Every finding on record at Good Samaritan - Hutchinson Village

The facility identified a census of 51 residents. The sample included 14 residents. Based on record review and interview, the facility failed to ensure the required annual performance reviews were completed at least once every 12 months for one Certified Medication Aide (CMA) and three Certified Nurse Aides (CNA).Findings included:- Review of the requested facility performance reviews noted the following staff lacked an annual review:CMA T's, hired on 01/11/08, last performance evaluation was completed on 05/31/24. The facility lacked evidence that a performance review was completed in the last 12 calendar months upon request. CNA NN's, hired on 12/19/14, last performance evaluation was completed on 05/31/24. The facility lacked evidence that a performance review was completed for CNA NN.CNA O was hired on 07/26/24. The facility lacked evidence that a performance review was completed for CNA O.CNA MM was hired on 11/19/24. The facility lacked evidence that a performance evaluation was completed for CNA MM.On 12/02/25 at 12:35 PM, CNA O stated she had not had a performance evaluation yet, and her anniversary date was in July.On 12/03/25 at 11:57 AM, Administrative Nurse D stated that the facility has had quite a bit of turnover in staff recently, and she had gotten behind in getting the performance evaluations completed. Administrative Nurse D stated that she and Administrative Nurse E had been working on getting the performance evaluations completed and caught up on staff.The facility's Performance Management policy dated 07/08/25 documented the performance management process was designed to encourage ongoing, meaningful conversations between employees and leaders. These connections should take place throughout the calendar year and be personalized to each employee's role and responsibilities. Performance management conversations should clarify role expectations, reinforce contributions, and provide ongoing feedback related to performance, behaviors, and development. Performance management conversations may also inform decisions related to career growth, development opportunities, recognition, as well as other decisions (i.e., merit, promotion, employee relations decisions, etc.). Eligible employees will receive a notification from One Source when their self-evaluation were available. Once submitted, leaders will receive a notification to complete their step of the evaluation process in One Source, which includes providing performance feedback and ratings for their employees based on role expectations, quality of work, behaviors, and contributions. Leaders should schedule one-on-one meetings with employees to share feedback, discuss performance and development opportunities, and review the performance rating.

The facility had a census of 51 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage. This placed the 51 residents at risk for food-borne illness. Findings included: - On 12/01/25 at 08:20 AM, the walk-in refrigerator and freezer did not have thermometers inside.The November 2025 Temperature Log directions directed staff to obtain temperatures in the morning and afternoon. The log lacked recorded temperatures for both the morning and the afternoon on 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/05/25, 11/09/25, 11/13/25, 11/14/25, 11/22/25, and 11/27/25. The log documented the one temperature on 11/20/25 in the afternoon temperature, but lacked a morning temperature. On 12/02/25 at 11:40 AM, observation used dish rags sat next to clean pitchers in the dishwasher room. The magnetic knife holder above the make table had dried food on it. The toaster had a copious amount of dried bread particles on it and on the controls. On 12/01/25 at 08:20 AM, Dietary Staff BB verified the lack of thermometers in the walk-in cold storage. On 12/02/25 at 11:40 AM, Consultant GG verified the findings and stated staff were to ensure food equipment and shelves were kept clean. The facility's Food Supply Storage, Food and Nutrition Services policy, dated 03/07/25, stated internal temperatures of all refrigerators and freezers were to be recorded two times daily on the temperature log. The facility's General Sanitation, Food, and Nutrition policy, dated 06/27/25, stated the location stored, prepared, and distributed food under sanitary conditions at all times. All food contact surfaces would be washed, rinsed, and sanitized after each use and when working with one kind of food to another. Fixed or immobile equipment was cleaned with detergent and hot water.

The facility had a census of 51 residents. Based on observation, interview, and record review, the facility failed to remove or dispose of expired medication in the facility's north medication room. Findings included: - On 12/01/25 at 03:07 PM, inspection of the facility's north medication room revealed:Three unopened bottles of magnesium chloride pills, with an expiration date of 10/2025. A box of 100 bisacodyl suppositories, with an expiration date of 09/2025. On 12/01/25 at 03:07 PM, Administrative Nurse E verified the expiration dates and stated staff were to remove expired medications from service. The facility's Medication Acquisition, Receiving, Dispensing and Storage policy, dated 03/04/25, stated nursing staff would routinely check for expired medications, and necessary disposal would be done in accordance with state/pharmacy regulations.

The facility identified a census of 51 residents. The sample included 14 residents with Resident (R) 6 reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a collaboration of care between R6's hospice provider and the facility, which included the information on what hospice services would be provided to the residents, as well as how often hospice staff would visit the facility.Findings included:- R6's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (HTN- elevated blood pressure), and chronic kidney disease (CKD- a long-term condition where the kidneys become damaged and cannot filter blood well, causing waste buildup).R6's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R6 required partial to moderate assistance from staff for her functional abilities and activities of daily living (ADL). R6 was on a hospice care program.R6's Care Plan revised on 09/10/25, directed staff to monitor, document, and report to the provider as needed any signs and symptoms of cardiac issues, chest pain, etc. The plan of care directed staff to assess for shortness of breath and cyanosis.R6's Care Plan lacked a care area specific to her hospice care and collaboration with the hospice provider that directed staff on what medications, durable medical equipment (DME), supplies provided by hospice, and how often hospice would visit the facility/resident.R6's Orders tab documented a physician's order dated 08/02/25 to admit to hospice.R6's EMR contained a scanned document IDG Report dated 08/02/25 that contained the hospice provider's information, plan of care, medication orders, the list of hospice staff that would visit R6 and how often, supplies and equipment provided.On 12/02/25 at 02:00 PM, R6 attended an activity in the activity room with other residents.On 12/02/25 at 09:30 AM, Certified Medication Aide (CMA) R stated a resident's chart should state whether they were on hospice or not. CMA R stated the nurses would typically tell staff when a resident was placed on hospice care, and hospice usually supplied briefs and other supplies. CMA R stated the care plan should contain information about hospice.On 12/03/25 at 08:15 AM, Administrative Nurse D stated that staff, including herself, had dropped the ball on ensuring that R6's care plan was updated to include her being admitted to hospice care. Administrative Nurse D stated the facility was going through a turnover in staffing, and not all tasks had been completed as they should have been. Administrative Nurse D stated that the hospice care area would be added to R6's care plan.The facility's Hospice-Provided Services policy dated 11/01/24 documented a coordinated comprehensive plan of care shall be jointly developed by the location and hospice. Hospice participation in the care plan conference and input from the hospice representative were required. The plan of care must include directives for managing pain and other symptoms associated with hospice care and must be revised and updated as necessary to reflect the resident's current clinical, psychosocial, and spiritual condition. Location employees would address the discipline-specific resident needs in the care plan. The hospice team and location employees must communicate with each other when any changes are made to the resident's plan of care. Location employees would assist nursing and the hospice in monitoring the resident's pain and reporting the resident's needs. for example, issues of pain may exacerbate mood and behavior, and all employees should help in monitoring and communicating resident condition changes so appropriate interventions can be implemented. The hospice information/documentation should be integrated into the electronic medical record (EMR). Hospice documentation received from the hospice agency will be scanned and retrieved in OnBase in a timely manner. Progress notes related to hospice services for nursing or social work may be completed in PointClickCare (PCC)/EMR using the PN - Hospice. CNA documentation related to the direct care of the hospice resident will be completed in PCC - POC/EMR only when car is provided by Society employees. When hospice employees provide activities of daily living (ADL) care, it will be documented on hospice forms and scanned into OnBase or copied.

The facility reported a census of 53 residents. Based on observation, record review and interview, the facility failed to follow proper food handling practices to prevent the outbreak of foodborne illness. Findings included: - During the initial tour of the kitchen on ,d+[DATE]/ at 08:30 AM, the refrigerator had the following areas of concerns: 1. One open bag of hotdogs, that lacked an opened date 2. One bag of turkey lunch meat that lacked an opened date and lack a use by date. On [DATE] at 08:30 AM, observation of the dry storage area revealed three bags of hot dog buns with a used by date of [DATE]. In addition, there was one dented can of sliced beets and one dented can of fancy sauerkraut. Interview on [DATE] at 11:47 AM, Dietary staff I reported when the facility received a can with a dent from the vendors, staff need to take a picture of it and send it to the certified dietary manager, so the facility could get credit for the dented can, or just throw the dented cans of food in the trash. Food, including the breads should not be used if the date is past the use by date. Staff should have an opened date on all opened food items. On [DATE] at 11:50 AM, Dietary Staff G reported staff were to monitor the bread every Thursday, and if the bread was expired, staff should remove the bread. Staff should not use food items from dented cans. Staff should have open dates on all refrigerated items. The policy for Food -Supply Storage-Food and Nutrition Services dated [DATE], documented the purpose was to ensure that food is stored properly. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly. The used by dates are checked on a regular basis; foods/fluids that have expired or are otherwise unsafe for use are discarded. The facility failed to follow proper food handling practices to prevent the outbreak of foodborne illness.

The facility reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, by not having a dignity bag for the indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) collection bag. Findings included: - The Physician's Orders dated 10/10/23 revealed R4 had a diagnosis of urinary retention (the lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R4 had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 10/12/23, revealed R4 arrived at the facility from the hospital with an indwelling catheter. The Care Plans dated 10/12/23 documented R4 would remain free from catheter-related trauma through review date. Monitor for signs and symptoms of discomfort on urination and frequency. Observations on 11/13/23 at 10:10 AM revealed R4's indwelling urinary catheter collection bag stored directly on the floor. The catheter bag lacked a dignity bag and was visible to residents and staff in the hall. Observation on 11/14/23 at 01:13 PM, revealed R4's indwelling urinary catheter collection bag laid directly on the floor. The catheter bag lacked a dignity bag. On 11/20/23 at 01:40 PM, Interview with Administrative Nurse B, reported her expectations regarding catheter care is for the urinary collection bag to be in a dignity bag. The facility's policy for Catheter: Care, Insertion, Removal, Drainage bags, dated 04/25/23, documented that every effort is made to keep a resident's catheter covered or out of sight. Catheter bags should be covered when up in chair and out in public or visible from door/hall. These bags should be changed when visibly soiled The facility failed to ensure R4 was treated with dignity when a privacy bag was not provided for indwelling catheter bag.

The facility reported a census of 53 with 12 residents in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow recommendation of the pharmacist for Resident (R)17, related to Abnormal Involuntary Movement scale (AIMS- a clinician-rated scale to assess severity of dyskinesias [the inability to execute voluntary movements]) testing and on R6 and R24 regarding as needed (PRN) lorazepam (a medication used for severe agitation) to obtain a new prescription every 14 days. Findings include: - Review of the R17's signed Physician Orders dated 09/11/23, revealed the diagnosis of unspecified dementia moderated without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). Review of the Discharge Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) revealed a score of staff assessment for mental status with memory problems. R17 received seven days of antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications and seven days of antidepressant (class of medication used to treat mood disorders and relieve symptoms of depression) medications. Review of the Significant Change MDS dated [DATE], revealed a BIMS score of four, indicating severely impaired cognition. R17 did not receive antipsychotic medication, and received antidepressant, anticoagulant (blood thinner) and seven days of diuretic(medication to promote the formation and excretion of urine). Review of the Care Plan dated 07/12/23 revealed R17 with impaired cognitive function related to forgetfulness, short- and long-term memory loss, confusion, and hallucinations (sensing things while awake that appear to be real, but the mind created). R17 received antipsychotic medication therapy related to dementia with potential for behavioral symptoms. Review of the Pharmacy reviews dated 01/05/23 revealed the recommendation for staff to complete an Assessment of Involuntary Movement (AIMS) test. R17 on olanzapine (an antipsychotic medication to treat severe agitation). Pharmacy review dated 02/07/23 requested an AIMS test to be completed on R17 for psychotropic medication. Pharmacy review dated 03/06/23 requested AIMS test to be completed for R 17 for psychotropic medication. The facility did not act upon the consulting pharmacist recommendations for the AIMs assessment until 08/01/23. Interview on 11/15/23 at 12:56 PM, Consultant Staff H reported the expectations regarding the pharmacy recommendations would be a response from the facility or the resident's physician. If a recommendation was not responded to, the consultant pharmacist would repeat the request. Interview on 11/20/23 at 02:00 PM, Administrative Nurse B reported the facility should follow up pharmacy recommendations in a timely manner. The facility's undated policy for Psychotropic Medications Rehab/Skilled revealed if a physician prescribes an antipsychotic for the resident, a registered nurse must complete the 'Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in their electronic records. The facility failed to follow up on the pharmacist recommendation related to an AIMS assessment on R 17 while the resident received a psychotropic medication. 36881 - Review of Resident (R) 24's undated physician orders included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and dementia (- progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The resident had a condition or chronic disease that may result in a life expectancy of less than six months. She received medications which included antidepressant, diuretic and opioid, for seven days of the look back period and antianxiety medication for two days of the look back period. The Quarterly MDS, dated [DATE], documented changes from above assessment included the resident did not receive antianxiety medication during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/07/23, documentation included the resident had gradual progression of dementia. Her BIMS score of 03 indicated severe cognitive impairment, and she required staff to provide cues and reorientation. She received medications which included scheduled Seroquel (antipsychotic), Lexapro (antidepressant), and Ativan (antianxiety medication as needed (PRN). The Care Plan dated 10/09/23, directed staff to consult with pharmacy and the health care provider related to the resident received antipsychotic medication to consider dosage reduction when clinically appropriate. The Physician Orders, dated 10/04/23, included the following psychoactive medication orders: 1. Lorazepam/Ativan, 0.5 milligrams (MG) (Lorazepam-antianxiety medication), give one tablet by mouth, every three hours, as needed for anxiety/agitation, ordered 04/11/2023. 2. Seroquel Tablet, 25 MG (Quetiapine Fumarate-antipsychotic), give 12.5 mg, by mouth, two times a day for agitation, ordered 08/02/2023. 3. Divalproex Sodium Capsule Delayed Release Sprinkle (anticonvulsant/mood stabilizer), 125 MG, give 2 capsules by mouth, two times a day, related to bipolar disorder and major depressive disorder, dated 07/30/23. Review of the Monthly Pharmacy Medication Review, dated 02/07/23 through 11/07/23, revealed the following concerns: 1. On 05/01/2023, the consultant pharmacist identified an irregularity related to the use of Lorazepam/Ativan PRN (as needed), beyond a 14-day period. The pharmacist recommendation included requested documentation for the continued use of Lorazepam beyond the Centers for Medicare and Medicaid Services (CMS) 14 day recommended time period for PRN use, indication of the intended duration of use, and reevaluation every six months. The facility lacked evidence of any follow-up on the pharmacy recommendation. 2. On 06/05/2023, the consultant pharmacist recommended a gradual dose reduction (GDR) in the resident's psychoactive medication regimen in accordance with the CMS guidelines. The pharmacist identified the resident as receiving three different psychoactive medications without a GDR since the most recent order dates as follows: a. Escitalopram 20 mg daily, by mouth, ordered 10/28/19. b. Divalproex 125 mg, by mouth, at 07:00 AM and 01:00 PM, and 250 mg, PO at 07:00 AM and 09:00 PM, ordered 01/26/22. c. Seroquel 12.5 mg, by mouth, twice daily, ordered 09/15/22. d. Lorazepam 0.5 mg PO every 3 hours, PRN anxiety, ordered 09/15/22. The physician follow-up on the pharmacist's recommendation, dated 06/28/23, (23 day after the recommendation), was not timely. On 11/15/23 at 12:14 PM, Administrative Nurse B stated the pharmacist reviewed the resident's medication regimen monthly. Administrative Nurse B reported the recommendations should be followed up within 10 days of the facility receiving the recommendations. She confirmed the lack of follow up on the 05/01/2023 recommendations and excessive time frame beyond the expected follow up for the 06/05/23 identified irregularities. Additionally, Administrative Nurse B stated the anti-anxiety medication used PRN, should be ordered for a maximum of 14 days regardless if the resident had a renewal every 14 days for PRN orders, even if the resident received hospice services. On 11/15/23 at 12:57 PM, Consultant H reported regarding the Lorazepam, the consultant pharmacist usually sent a note if the Lorazepam is longer than 14 days to either discontinue (D/C) the medication or provide a rational for its extended use. If the resident is on Hospice, the physicians usually do not respond to the request. The facility policy Medication: Drug Regimen Review dated 02/10/23, documentation included the purpose of the medication regimen review was to prevent medication errors that could cause harm to a resident or result in resident hospitalization and to identify potential adverse events. The facility failed to act upon the identified irregularities by the consulting pharmacist on 05/01/23 and failed to act on the pharmacists recommendation in a timely manner on 06/05/23 for the resident. 31078 - R6's signed physician orders dated 10/31/23 revealed the following diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had verbal and physical behaviors towards others. The resident required partial assist of one staff for toilet, transfers, and the resident was mobile with the use of a wheelchair. The resident was frequently incontinent. The resident received scheduled and as needed pain medication for complaints of pain at 5/10 scale. She had two or more falls with no injuries noted. She did not receive psychotropic medications. The Discharge assessment dated [DATE] revealed the resident had a unwitnessed fall with fractured hip on 07/26/23 and was sent to the hospital for care. The resident returned on 07/31/23. The Significant Change in Status MDS dated [DATE], revealed a decline in cognition with a score of 10, indicating moderate cognitive impairment. The resident had no behaviors. She required partial assist with daily care. The resident was frequently incontinent. The resident had a unstageable pressure injury to the heel and was being treated with skin prep. The resident received Hospice Services. Review of the physician orders included: Lorazepam 0.5 milligram (mg), oral (PO) every 12-hour, as needed (PRN), with a start date of 03/03/23. The order lacked a stop date. Lorazepam 0.5 mg, PO twice a day (BID), as needed, for anxiety, with a start date of 04/04/23. The order lacked a stop date. Lorazepam 0.5 mg, BID on PRN basis, start on 06/12/23. The order lacked a stop date. Lorazepam Oral Tablet 0.5 mg, 1 tablet every 6 hours, as needed, for anxiety/restlessness, with a start date of 10/13/23. The order lacked a stop date. Review of the Consulting Pharmacist monthly medication review revealed the following: On 04/01/23, the resident receives an as needed (PRN) order for anxiolytic without a stop date- lorazepam 0.5 mg PO every 12-hour PRN with start date 03/03/23 Recommend discontinuing Lorazepam. On 04/14/23, the physician declined to discontinue (DC) the lorazepam medication, however, the attending physician failed to document the rationale in the resident's medical record. On 05/01/23, the resident receiving PRN Lorazepam 0.5 mg, PO, BID, as needed, for anxiety, started on 04/04/23. Please DC. The physician failed to respond to the recommendation. On 07/03/23, the resident receiving Lorazepam on PRN basis with no stop date that started on 06/12/23. The physician replied on 07/12/23, the physician declined the recommendation, however, the attending physician failed to document the rationale in the resident's medical record. On 11/20/23 at 01:30 PM, Licensed Nurse (LN) O reported the resident has Alzheimer's and gets agitated. She received medications for behaviors. The resident has an as needed lorazepam to take when she gets agitated and that usually works well. On 11/12/23 at 12:56 PM, Interview with Consultant D regarding recommendations, she would make recommendation to the physician and would expect a response from the facility or physician. If Consultant D did not receive a response, she would repeat the request. The facility and physician failed to follow recommendation of the pharmacist for R6 regarding the stop date of Lorazepam, or a documented rationale related to the prn lorazepam.

The facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for Residents (R6 and R24). Findings included: - R6's signed physician orders dated 10/31/23 revealed the following diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had verbal and physical behaviors towards others. The resident required partial assist of one staff for toilet, transfers, and the resident was mobile with the use of a wheelchair. The resident was frequently incontinent. The resident received scheduled and as needed pain medication for complaints of pain at 5/10 scale. She had two or more falls with no injuries noted. She did not receive psychotropic medications. The Discharge assessment dated [DATE] revealed the resident had a unwitnessed fall with fractured hip on 07/26/23 and was sent to the hospital for care. The resident returned on 07/31/23. The Significant Change in Status MDS dated [DATE], revealed a decline in cognition with a score of 10, indicating moderate cognitive impairment. The resident had no behaviors. She required partial assist with daily care. The resident was frequently incontinent. The resident had a unstageable pressure injury to the heel and was being treated with skin prep. The resident received Hospice Services. Review of the physician orders included: Lorazepam 0.5 milligram (mg), oral (PO) every 12-hour, as needed (PRN), with a start date of 03/03/23. The order lacked a stop date. Lorazepam 0.5 mg, PO twice a day (BID), as needed, for anxiety, with a start date of 04/04/23. The order lacked a stop date. Lorazepam 0.5 mg, BID on PRN basis, start on 06/12/23. The order lacked a stop date. Lorazepam Oral Tablet 0.5 mg, 1 tablet every 6 hours, as needed, for anxiety/restlessness, with a start date of 10/13/23. The order lacked a stop date. Review of the Consulting Pharmacist monthly medication review revealed the following: On 04/01/23, the resident receives an as needed (PRN) order for anxiolytic without a stop date- lorazepam 0.5 mg PO every 12-hour PRN with start date 03/03/23 Recommend discontinuing Lorazepam. On 04/14/23, the physician declined to discontinue (DC) the lorazepam medication, however, the attending physician failed to document the rationale in the resident's medical record. On 05/01/23, the resident receiving PRN Lorazepam 0.5 mg, PO, BID, as needed, for anxiety, started on 04/04/23. Please DC. The physician failed to respond to the recommendation. On 07/03/23, the resident receiving Lorazepam on PRN basis with no stop date that started on 06/12/23. The physician replied on 07/12/23, the physician declined the recommendation, however, the attending physician failed to document the rationale in the resident's medical record. On 11/20/23 at 01:30 PM, Licensed Nurse (LN) O reported the resident has Alzheimer's and gets agitated. She receives medications for behaviors. The resident has an as needed lorazepam to take when she gets agitated and that usually works well. On 11/12/23 at 12:56 PM, Interview with Consultant D regarding recommendations, she would make recommendation to the physician and would expect a response from the facility or physician. If Consultant D did not receive a response, she would repeat the request. The facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for R6. 36881 - Review of Resident (R) 24's undated physician orders included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and dementia (- progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The resident had a condition or chronic disease that may result in a life expectancy of less than six months. She received medications which included antidepressant, diuretic and opioid, for seven days of the look back period and antianxiety medication for two days of the look back period. The Quarterly MDS, dated [DATE], documented changes from above assessment included the resident did not receive antianxiety medication during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/07/23, documentation included the resident had gradual progression of dementia. Her BIMS score of 03 indicated severe cognitive impairment, and she required staff to provide cues and reorientation. She received medications which included scheduled Seroquel (antipsychotic), Lexapro (antidepressant), and Ativan (antianxiety medication as needed (PRN). The Care Plan dated 10/09/23, directed staff to consult with pharmacy and the health care provider related to the resident received antipsychotic medication to consider dosage reduction when clinically appropriate. The Physician Orders, dated 10/04/23, included the following psychoactive medication orders: 1. Lorazepam/Ativan, 0.5 milligrams (MG) (Lorazepam-antianxiety medication), give one tablet by mouth, every three hours, as needed for anxiety/agitation, ordered 04/11/2023. 2. Seroquel Tablet, 25 MG (Quetiapine Fumarate-antipsychotic), give 12.5 mg, by mouth, two times a day for agitation, ordered 08/02/2023. 3. Divalproex Sodium Capsule Delayed Release Sprinkle (anticonvulsant/mood stabilizer), 125 MG, give 2 capsules by mouth, two times a day, related to bipolar disorder and major depressive disorder, dated 07/30/23. Review of the Monthly Pharmacy Medication Review, dated 02/07/23 through 11/07/23, revealed the following concerns: 1. On 05/01/2023, the consultant pharmacist identified an irregularity related to the use of Lorazepam/Ativan PRN (as needed), beyond a 14-day period. The pharmacist recommendation included requested documentation for the continued use of Lorazepam beyond the Centers for Medicare and Medicaid Services (CMS) 14 day recommended time period for PRN use, indication of the intended duration of use, and reevaluation every six months. The facility lacked evidence of any follow-up on the pharmacy recommendation. 2. On 06/05/2023, the consultant pharmacist recommended a gradual dose reduction (GDR) in the resident's psychoactive medication regimen in accordance with the CMS guidelines. The pharmacist identified the resident as receiving three different psychoactive medications without a GDR since the most recent order dates as follows: a. Escitalopram 20 mg daily, by mouth, ordered 10/28/19. b. Divalproex 125 mg, by mouth, at 07:00 AM and 01:00 PM, and 250 mg, PO at 07:00 AM and 09:00 PM, ordered 01/26/22. c. Seroquel 12.5 mg, by mouth, twice daily, ordered 09/15/22. d. Lorazepam 0.5 mg PO every 3 hours, PRN anxiety, ordered 09/15/22. The physician follow-up on the pharmacist's recommendation, dated 06/28/23, (23 day after the recommendation), was not timely. On 11/15/23 at 12:14 PM, Administrative Nurse B stated the pharmacist reviewed the resident's medication regimen monthly. Administrative Nurse B reported the recommendations should be followed up within 10 days of the facility receiving the recommendations. She confirmed the lack of follow up on the 05/01/2023 recommendations and excessive time frame beyond the expected follow up for the 06/05/23 identified irregularities. Additionally, Administrative Nurse B stated the anti-anxiety medication used PRN, should be ordered for a maximum of 14 days regardless if the resident had a renewal every 14 days for PRN orders, even if the resident received hospice services. On 11/15/23 at 12:57 PM, Consultant H reported regarding the Lorazepam, the consultant pharmacist usually sent a note if the Lorazepam is longer than 14 days to either discontinue (D/C) the medication or provide a rational for its extended use. If the resident is on Hospice, the physicians usually do not respond to the request. The facility policy Medication: Drug Regimen Review dated 02/10/23, documentation included the purpose of the medication regimen review was to prevent medication errors that could cause harm to a resident or result in resident hospitalization and to identify potential adverse events. The facility failed to monitor for adverse reactions of psychotropic medications for this resident to ensure no unnecessary medicaton usage.

The facility reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program, related to one resident, Resident (R) 4, related to urinary catheter care and placement, to help prevent contamination and the spread of infection. Findings included: - The Physician's Orders dated 10/10/23 revealed R4 had the following diagnosis of urinary retention (the lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R4 had a indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Care Area Assessment (CAA) dated 10/12/23 revealed R4 arrived at the facility from the hospital with the indwelling catheter. The Care Plans dated 10/12/23, revealed urinary incontinence, R4 will remain free from catheter-related trauma through review date. Monitor for signs and symptoms of discomfort on urination and frequency. Observations on 11/13/23 at 10:10 AM, revealed the resident had an indwelling urinary catheter laid directly on the floor. The catheter collection bag lacked a barrier from the bag to the floor. Observation on 11/14/23 at 01:13 PM, revealed the catheter collection bag laid directly on the floor. Observation on 11/14/23 at 01:29 PM, revealed certified nurse's aide (CNA) J entered R4's room to applied gloves, emptied the collection bag, and placed the collection bag onto the recliner, that caused the indwelling urinary bag to rest directly on the floor. CNA J did not use an alcohol swab to clean the port after emptying the catheter bag. On 11/20/23 at 01:40 PM, Interview with Administrative Nurse B reported staff should wipe the ports of the collection bag with alcohol before reattaching the port to the tip. Staff should keep the urinary bag off the floor for infection control purposes. The facility policy, dated 04/25/23 for Catheter: Care, Insertion, Removal, Drainage bags revealed when emptying the catheter bag place a moisture resistant barrier beneath the measuring container and avoid placing the container on the floor. Open the drainage port and allow urine to drain into the measuring container placed underneath. When done clean drainage port tip with alcohol wipe and replace in the holder The facility failed to maintain an effective infection control program, related to one resident, Resident (R) 4, related to urinary catheter care and placement, to help prevent contamination and the spread of infection.

The facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment by failing to implement interventions prevent Resident (R) 106, with moderately impaired cognition, from having repeated falls. Findings included: - R106's signed Physician Orders dated 10/31/23 revealed the following diagnoses: peripheral vascular disease (PVD is an abnormal condition affecting the blood vessels), atrial fibrillation (rapid irregular heart rate), bradycardia (slow heart rate), shortness of breath, unsteadiness on feet, chronic respiratory failure with hypoxia (inadequate supply of oxygen). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident was occasionally incontinent of urine and continent of bowel. The resident had no complaints of pain. The resident was short of breath and received oxygen (O2) per nasal cannula (NC). The Significant Change in Status MDS dated [DATE], revealed a BIMS of 10, indicating moderately impaired cognition. The resident used a walker and wheelchair for mobility and required moderate assistance with his daily care. He had no complaints of pain. The resident was short of breath and dependent on the use of O2. He had one no injury fall since the last assessment. The resident received an anticoagulant (blood thinner), diuretic (water pill), and required oxygen therapy. The Care Area Assessment (CAA) dated 10/31/23 revealed the following: The Cognitive loss/dementia CAA revealed R106 had occasional confusion and forgetfulness. He was easily re-directed and answered questions appropriately. R 106 required continuous oxygen. The Activities of daily living (ADL)Functional Rehabilitation Potential CAA revealed R106 was recently hospitalized for Pneumonia and Covid, then re-hospitalized on acute on chronic respiratory failure with hypoxia. He required skilled therapy due to returning to the facility weak and deconditioned. R106 required continuous O2 therapy. He required limited to extensive assist for cares. The resident was unable to ambulate, however he could propel himself in a wheelchair. R106's Care Plan dated 11/01/2023 included the resident required assistance with all decision making. Staff were to communicate with the resident/family regarding resident's capabilities and needs. Staff were to break tasks into one step at a time. Staff were to encourage the resident to make sure the recliner is down after transferring. Ensure dysem (a slip resistant material) to be in the resident's recliner. Remind resident not to bend over to pick up dropped items. Encourage use of a grabber or to ask for assistance. The resident received a non-injury fall on 10/03/23. The resident required extensive assistance with his walker for transfers and one staff limited assistance with ambulation. Staff were to make sure the resident wore gripper socks. The resident had a fall on 11/09/23, and staff was to re-educate the resident to use a call light for assistance, proper use of equipment (walker) and what not to use (rolling desk chair) to assist with ambulation. Staff were to monitor the resident for significant changes in gait, mobility, and positioning device, standing/sitting balance and lower extremity joint function. Give resident verbal cues to lower his lift chair so the seat is level, and he is not at risk. for sliding out. Staff was to review bowel and bladder continence status and establish and/or review toileting plan based on the resident's needs, dated 12/13/22. The Incident notes on 10/03/2023 at 01:19 PM revealed the resident fell when he transferred from his wheelchair to the toilet while Certified Nursing Assistant (CNA) N was in the room. The resident was impulsive and would not listen and wait for help to transfer and lost his balance and fell to floor. Three staff assisted the resident up and placed the resident on the toilet. The Incident notes for 11/09/2023 at 12:55 AM, revealed the resident yelled out for, help, help, help. Staff went to resident's room and found him on the floor sitting on his buttocks in-front of his recliner. He needed to go to the toilet, and did not use his call light, but instead tried to stand up without assistance and sit in his rolling computer chair so he could scoot himself into the bathroom. The rolling computer chair moved, and he fell . Staff intervention was to re-educate the resident to use a call light for assistance, however the resident's MDS indicated he had moderately impaired cognition. On 11/09/2023 at 02:58 PM, social service notes documented staff visited with the son related to his recliner chair. The resident would lift his chair up but would then slide out of his chair. He did not like the cushion in the chair and would refuse to leave the dysem in the chair. The Incident notes for 11/17/2023 revealed the resident fell from his recliner. He had a large knot formed on his left forehead and a laceration to his left temple. Staff lifted the resident with a full lift to his bed. The resident transferred to the emergency room for evaluation The resident had no fracture. Staff removed the chair remove from his reach and placed the remote on the desk. The resident was not happy about not being able to move his legs up by himself but understood after a brief teaching. (His MDS indicated he had moderate cognitive impairment). On 11/18/23 a fall risk assessment completed and had a score of 20, indicating a high risk for falls. On 11/20/2023 at 01:22 AM, staff re-educated the resident regarding not able to have his remote to his recliner due to his fall. However, he had moderate cognitive impairment.) Observation on 11/13/23 at 01:33 PM, the resident was up walking in his room with his brief pulled down to his knees. He was bent over walking and had his O2 cannula on. (The resident was not to be up without assistance per his care plan.) His lift chair was in the high standing position with the remote sitting directly in the chair. No dysem was seen in chair. Observation on 11/14/23 at 2:00 PM, the resident was in his room and leaned over his recliner with the reacher directly on the floor between his legs. He attempted to lean over and scoot the grabber reacher with his foot.) On 11/15/23 at 07:20 AM, the resident sat sleeping in his recliner in upright standing position. The resident had legs hanging down with his feet on the floor. Non-skid socks in place with no shoes on. On 11/15/23 at 08:30 AM, staff delivered the resident his breakfast tray and placed the tray on the bed side table behind the resident. The tray was out of reach of resident. The resident attempted to stand to get his breakfast tray and he had his lift chair in the high standing position. On 11/14/23 at 10:30 AM, certified nurse's aide (CNA) F reported the resident was one assist with his care. The resident would always sit in his recliner and would raise the chair to the standing position. Staff should check him often because he will get up on his own. On 11/20/23 at 07:20 AM CNA F reported the resident refused to get in his bed and he sleeps in his recliner at night. Staff have taken his controls for his lift chair away after the resident had two falls this past weekend. He was always lifting his chair and standing when he had the controls. He cannot stand on his own with the chair in the low position. On 11/20/23 at 10:30 AM, Licensed Nurse (LN)C reported the resident was on day three of a fall follow-up. The resident has not attempted to get up by himself since the remote to his chair was taken from his reach. The resident was upset and angry about the remote and wanted to be able to reposition his chair as he wanted. We have talked to him about raising his recliner and have visited with the son about a different chair. Until the resident is able to get a different chair, staff would not let him have his remote. On 11/20/23 at 1:00 PM, Administrative Nurse B reported the resident was upset about not having his remote to the chair. The resident reported to her he could breathe better with the chair up some. Administrative Nurse B reported she had met with the resident's family earlier and discussed the resident. The family reported they already this day had to take his car keys from him and did not want him to lose power over his chair also, so they requested the remote be given back to the resident. They were aware of his fall risk and were okay to give the remote back. So that is what she did. She gave him his remote and visited with him to use his call light and is going to assure the staff check on him as they should be. Review of the facility policy named Fall Prevention and Management dated 03/29/23 revealed a Proactive Approach before a fall occurs care plan the appropriate interventions, including personalizing all risk areas. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-hour Report, care plan, Kardex and stand-up meetings. Communicate any identified environmental changes and/or referral needs. The facility failed to provide a safe environment by failing to implement interventions to prevent Resident (R) 106, with moderately impaired cognition, from having repeated falls.

The facility reported a census of 53 residents which included 12 residents sampled for reviewed for transmission of Minimum Data Set, (MDS) assessments. Based on interview and record review, the facility failed to electronically transmit Resident (R)51's Discharge Return not Anticipated MDS, tracking no later than 14 days after the assessment Reference date (ARD) of 08/23/23, and/or seven days after the completion date of the MDS as required. Findings included: - On 11/20/23 at 12:30 PM, review of Resident (R)51's Discharge Return not Anticipated Minimum Data Set' (MDS), dated [DATE], revealed the MDS had not been electronically transmitted to Centers for Medicare and Medicaid Services (CMS) after the assessment Reference date (ARD) of 08/23/23, and/or seven days after the completion date of the MDS as required. On 11/20/23 at 12:50 PM, Administrative Nurse Q confirmed the facility failed to electronically submit the MDS as noted above. She reported a corporate nurse completed the assessment and she was not aware of the reason it was not electronically transmitted. She reported she exported assessments every week on Wednesdays. She reported the facility used the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, (RAI) manual for guidance related to the electronic transmission of the MDS. The 3.0 RAI Manual, dated 10/01/20, documentation included the MDS tracking must be no later than 14 days after the assessment Reference date (ARD) and/or seven days after the completion date of the MDS. The facility failed to electronically transmit the resident's Discharge Return not Anticipated MDS, tracking no later than 14 days after the assessment Reference date (ARD) and/or seven days after the completion date of the MDS.

The facility reported a census of 53 residents. The sample of 12 residents included one resident sampled for personal hygiene related to bathing. Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good personal hygiene for Resident (R)24, related to bathing and hair care. Findings included: - Review of Resident (R) 24's undated Physician's Orders, documentation included diagnoses of morbid (severe) obesity, communication deficit, weakness, and dementia (progressive mental disorder characterized by failing memory). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Staff reported she preferred a tub bath. She required extensive assistance of staff for bed mobility, personal hygiene, and was totally dependent on staff for transfers, locomotion, toilet use, and one staff assist with bathing. The resident was always incontinent of bowel and bladder. She had a condition or chronic disease that may result in a life expectancy of less than six months and received hospice services. The Quarterly MDS, dated [DATE], documented no changes from the above. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/07/23, documentation included the resident exhibited gradual progression of dementia. She received hospice services and required staff to provide cues and reorientation. The Care Plan, dated 10/25/23, directed staff the resident required extensive assistance of staff for grooming and bathing. The hospice nurse aides visited the resident one to two times weekly. On 11/13/23 at 04:15 PM, the resident family member stated she had concerns that the resident did not get bathed as she should at least two times a week as she had requested. Additionally, she stated she was not sure if the resident's hair washed with each bath as she had requested, since she no longer goes to the beauty shop for shampoos. Review of the Tasks for bathing in the electronic medical record (EMR) Task Bathing scheduled for Tuesdays and Fridays. Review of the bathing tab from 10/17/23 thru 11/13/23 revealed the resident received five of the eight minimally required bathing opportunities as follows: 1. R24 received a shower on 10/30/23. 2. R24 received bed baths on 10/17/23, 10/20/23, and 11/03/23. 3. R24 received sponge baths on 11/07/23 and 11/10/23. The resident lacked a bathing opportunity from the facility staff from 10/20/23 until 10/30/23, a total of 10 days. On 11/14/23 at 10:39 AM, the resident sat in her highbacked reclining chair. The resident's hair was oily and laid flat against her head. On 11/14/23 11:18 AM, CNA Q stated the bath aide should provide residents with their scheduled showers/baths. Residents' showers or bathing opportunities should be documented in the EMR. CNA Q stated the resident gets her hair washed in beauty shop once a week, but residents that do not go to the beauty shop should get their hair washed on bathing days, at least two times a week. On 11/14/23 at 01:06 PM, Certified Nurse Assistant (CNA) Q assisted the resident from the dining room to her room and provided incontinence care. CNA Q confirmed the resident's hair appeared to be unkept. She stated she thought the beautician was to shampoo the resident's hair. CNA Q stated the resident received hospice services which should provide two additional baths to the facility provided baths. The facility should provide two baths a week which should include washing the resident's hair unless they go to the beauty shop. In addition, the facility staff should document any offers of bath or refusals of care in the EMR. On 11/14/23 at 12:30 PM, Social Service Staff P, verified the resident's representative called the business office on 11/01/23, and requested the resident not go to the beauty shop any longer. The resident should receive her shampoos with her baths by the facility staff at least twice a week. She notified the beautician that the resident would not be getting her hair done in the beauty shop but failed to notify the nursing staff. On 11/14/23 at 01:45 PM, Administrative Nurse B reviewed the EMR and confirmed the above findings. She stated although the resident received hospice services, those services did not replace the required services of the facility which included a minimum of two baths a week. Administrative Nurse B confirmed the staff should offer to provide baths and/or refusals of care. and should be documented in the resident's EMR. The facility policy for Bathing, dated 08/24/22, lacked address of bathing frequency of residents. The facility failed to ensure necessary services to maintain good personal hygiene with bathing and hair care for the resident.

The facility census totaled 51 residents residing on two halls, North and South. The South Unit had 14 cognitively impaired residents and one Resident, (R) 1, who stated a Certified Nurse Aide (CNA) on duty was rough with her. Based on observation, interview, and record review, the facility failed to provide a safe environment for 14 residents when CNA E reported to work tearful and stated she did not want to be there, which led to the CNA being rough/loud with R1, causing bruises/scratches during a transfer, and making the resident attend a meal when she stated she did not feel well. This put the 14 residents on the South Unit at risk for abuse. Findings included: - Resident (R) 1's signed physician orders dated 11/10/22 revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The resident required limited assistance of one staff for transfers and ambulation with a walker or wheelchair. The Quarterly MDS dated [DATE] revealed a BIMS score of 06, indicating severe cognitive impairment. The resident required limited assistance of one staff with transfers and used a walker or wheelchair for mobility. Medications included the use of an antidepressant. Review of the resident's Care Plan dated 07/25/23 revealed R1 had impaired cognitive function, short and long-term memory loss, forgetfulness, low motivation, and poor safety awareness. The resident had behavioral symptoms of delusional thoughts, hallucinations, increased confusion, and made false accusations of staff. The 08/04/23 at 03:33 PM Nurse Progress Note revealed Licensed Nurse (LN) C checked on R1's due to the resident having some emesis (vomiting). R1 told the nurse that a Certified Nursing Assistant (CNA) (E) threw her into her wheelchair last night on 08/03/23. LN C went and got management to hear R1's complaint. LN D did an assessment and found three scratch marks on the resident's right lower leg. The resident's right forearm had several purple and red discolorations (age unknown). The resident had no complaints of discomfort or pain noted at that time. Review of the Notarized Witness Statement from CNA E revealed she went to get the resident ready for supper and R1 accused CNA E of being rough with her before she had even gotten near her. CNA E stated she stood back and told R1 she was not going to touch her and she would stand there if R 1 needed help. R1 then continued saying CNA E was being rough with her after she was in her chair. CNA E pushed R1 out of the room and told the nurse what happened. CNA E then left the building due to frustration and poor mental health. CNA E stated she left for the safety of the residents and herself because she did not feel she would be able to properly care for them at that time. Review of the Notarized Witness Statement from LN F dated 08/04/23 revealed CNA E arrived at work for second shift on 08/03/23. She arrived with high anxiety and was emotional. She wanted to go home as soon as her shift started. and was stressed over having to work with someone she had never worked with before and over personal issues. Around dinner time for the residents, CNA E was crying in a stock room and stated she needed to go home because she loved the residents and did not want to come off as mean to them but did not know if she could help it. Shortly after crying in the stock room, she grabbed her things and told the nurse she was leaving and did not return the rest of the shift. On 08/15/23 at 10:30 AM, the resident sat in her room, in a chair. The resident had a very faint discoloration, which measured approximately two centimeters in diameter on her right forearm. No other injuries were seen or reported by the resident. The resident was calm with no behaviors noted. Interview on 08/15/23 at 10:30 AM R1 reported an aide on the evening shift was upset with her because she was going to eat in her room. CNA E entered her room, told her she was going to go to the dining room for supper, was rough with her and threw her into her wheelchair. It bruised both of her arms where the staff member grabbed her. The resident reported CNA E was very loud and rude to her. R 1 had never seen CNA E act like that but stated CNA E had been upset all shift before supper. She was pregnant and tearful when she provided care. R1 had not seen her since. Interview on 08/15/23 at 01:25 PM CMA H reported he only worked with CNA E a couple of times and did not notice anything about her demeanor with the residents. Interview on 08/15/23 at 11:20 AM LN C reported she was not working the day the incident happened, but the next day she went to the resident's room and the resident told her about CNA E being mean the night before. LN C said the resident reported she did not feel well and was going to stay in her room for supper. CNA E came in her room and told her she was getting up for supper rudely and transferred her to her wheelchair just throwing her in the chair. The resident showed the nurse some bruising on her arms. The nurse then contacted a person in management to come see the resident. Interview on 08/15/23 at 11:45 AM, LN D reported she went to R1's room to visit with her about an incident that happened the night before. She reported CNA E was rude and rough with her when transferring her to her wheelchair for supper. R1 then showed LN D three scratch marks on the right lower leg, and the right forearm had several purple/red in color discolorations (age unknown). The resident had no complaints of discomfort or pain noted at this time. Interview on 08/15/23 at 02:00 PM, Administrative Nurse B reported a couple of weeks ago she was informed that a resident had a concern about a staff member about possible abuse. At that time LN D interviewed the resident and then called her and Administrative Staff A. Administrative Nurse B then called CNA E and suspended her. Law Enforcement was notified and the officer, administrator, director of nursing, and the residents family member talked to the resident. R1 told the officer a CNA had roughly put her in her wheelchair. At that time a case number was given. Social Service interviewed other residents and R1. CNA E stated she did not touch her because the resident stated she was rough. Two other residents said a person who met the alleged perpetrator description was rude to them but was not rough. CNA E also stated she left in the middle of her shift because she was having some mental issues and did not want to be mean to anyone. Review of the facility policy named Abuse and Neglect dated 07/06/23, revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, location employees, other residents, volunteers, employees of other agencies serving the resident, family members or legal guardians. The facility failed to provide a safe environment for 14 residents when CNA E reported to work tearful and stated she did not want to be there, which led to the CNA being rough/loud with R1, causing bruises/scratches during a transfer, and making the resident attend a meal when she stated she did not feel well.

The facility census totaled 50 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow consultant pharmacist recommendations to add Not to Exceed (NTE) cautions to Resident (R)16 and R17's orders for acetaminophen (medication used to treat minor pain and fever) to reduce the potential for liver damage, failed to add manufacturer's instructions for administration of [MEDICATION(S)] (topical anti-[CONDITION(S)] gel used for pain relief) for R16, failed to follow recommendations to discontinue the use of as needed (PRN) [MEDICATION(S)] (sedative medication) for R29, and failed to respond to the recommendation to attempt a Gradual Dose Reduction (GDR) of [MEDICATION(S)] (an antidepressant) and [MEDICATION(S)] (an antipsychotic) for R28. Findings included: - Resident (R) 16's Electronic Health Record (EHR) under the Medical Diagnosis tab revealed a diagnosis of pain. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment and received both scheduled and as needed (PRN) pain medications. The Quarterly MDS dated [DATE] revealed a BIMS score of 11 and R16 received both scheduled and PRN pain medications. The Pain Care Area Assessment (CAA) dated 03/01/21 revealed R16's pain management included scheduled [MEDICATION(S)] (medication used to treat moderate to severe pain, containing acetaminophen) and Tylenol (acetaminophen) as needed for pain. The Care Plan dated 12/03/18 revealed R16 was on pain medication therapy related to chronic pain to her left foot and hand and occasional headaches, secondary to allergies. A review of the Physician Orders included the following: An order dated 10/29/21 for [MEDICATION(S)] Gel 1 percent, apply to left foot topically two times daily for pain. An order dated 02/09/18 for [MEDICATION(S)] 10-325 milligrams (mg), give one tablet by mouth two times daily for pain. An order dated 09/30/17 for Tylenol 325 mg, give two tablets by mouth every four hours as needed for pain. A review of the consultant pharmacist's Medication Regimen Review (MRR) revealed: A recommendation dated 02/10/21 to add a NTE caution of a maximum of three grams per 24 hours for Acetaminophen which was not addressed by the facility. A recommendation dated 11/15/21 to update directions for [MEDICATION(S)] topical gel using a dosing card as supplied by the manufacturer which was not addressed by the facility. An observation on 01/11/22 at 09:15 AM revealed R16 did not show signs or symptoms of having pain while she watched television in her room. In an interview on 01/12/22 at 08:14 AM, Certified Medication Aide (CMA) K stated R16 did not usually complain of having pain. In an interview on 01/12/22 at 03:45 PM, Administrative Nurse B stated she expected the pharmacist recommendations for the Acetaminophen NTE warning and directions for application of [MEDICATION(S)] to be added as recommended by the consultant pharmacist. In an interview on 01/13/22 at 8:00 AM, Consultant Pharmacist I stated she expected the facility to respond to her recommendations for NTE for Tylenol and the manufacturers' administration instructions for [MEDICATION(S)]. The Pharmaceutical Services policy dated 05/19/21 revealed, A licensed pharmacist will be employed or services obtained to .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to follow the consultant pharmacist recommendation to add a caution and directions for use of medications for R16. - R17's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/08/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 05/04/21 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R17 received no antipsychotic medications in the seven-day look back period. The 11/08/21 Quarterly MDS documented R17 received antipsychotic medications daily in the seven-day look back period. The 01/06/22 Care Plan for R17 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order dated 11/04/19 for Tylenol 325 milligrams (mg), take two by mouth (PO) every four hours as needed, and an order dated 12/28/21 for [MEDICATION(S)] (antipsychotic medication) 0.5 mg PO daily. Lacked documentation of [MEDICATION(S)] (antipsychotic medication). Review of the monthly Pharmacy Medication Record Review (MRR) for January 2021 through December 2021 documented the following recommendations, which lacked facility documentation of physician follow-up and/or response: 03/10/21, MRR recommendation to add Not To Exceed (NTE) three grams of acetaminophen in 24 hours warning to Tylenol order. 11/15/21, MRR recommendation to change the inappropriate diagnosis of hallucinations for the medication [MEDICATION(S)], to an approved diagnosis, such as [CONDITION(S)], [CONDITION(S)], or [CONDITION(S)]. On 01/11/22 at 09:06 AM an observation revealed R17 sitting in a wheelchair in her room watching TV with the window curtains open and a blanket over her lap. On 01/11/22 at 01:48 PM Licensed Nurse (LN) L stated the floor nurse could complete orders on the MRR once signed by the physician but LN L did not send the MRR's to the physicians. He stated he believed the Director of Nursing took care of that. On 01/12/22 at 01:35 PM Administrative Staff B confirmed the facility would re-send a fax two or three times and as a last resort would hand deliver the MRR to the physician. If the physician's response was not in the Pharmacy Consult notebook or folders, there probably was not a physician's response. On 01/13/22 at 08:00 AM Consultant Staff I confirmed the recommendations made and lack of follow-up, and that she would expect the physician to address her recommendations. Consultant Staff I stated she would make recommendations numerous times and had contacted the then current DON who informed her of the lack of response by the physicians and at that time she decided to pick her battles and that the facility had documented someplace else the NTE for acetaminophen products. The Pharmaceutical Services policy dated 05/19/21 documented, A licensed pharmacist will be employed, or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to adequately monitor the use of medications for R17 by not responding to the consultant pharmacist recommendations. - R28's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/28/21 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R28 received antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 11/28/21 [CONDITION(S)] Drug Use Care Area Assessment (CAA) documented R28 had a history of depression with mood/behavior. R28 received scheduled [MEDICATION(S)] (antipsychotic medication), [MEDICATION(S)] (antidepressant medication), and [MEDICATION(S)] (antianxiety medication). The 11/01/21 Quarterly MDS documented R28 received an antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 01/05/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 11/13/20 for [MEDICATION(S)] (antipsychotic medication) 25 milligrams (mg) PO daily, an order on 01/14/21 for [MEDICATION(S)] (antianxiety medication) 0.5 mg PO daily, an order on 04/15/21 for [MEDICATION(S)] (respiratory inhalant corticosteroid) inhale daily, and an order dated 04/28/21 for [MEDICATION(S)] (antidepressant medication) 30 mg PO daily. Review of the monthly Pharmacy Medication Record Review (MRR) for January 2021 through December 2021 documented the following recommendations, which lacked facility documentation of physician follow-up and/or response: 01/15/21, R28 received a medication containing an inhaled corticosteroid, [MEDICATION(S)]. A recommendation was made to update the order to include rinsing the mouth with water and do not swallow after use. 05/07/21, R28 received [MEDICATION(S)] 25 mg PO daily since 11/13/20. A recommendation was made to attempt a Gradual Dose Reduction (GDR). 10/19/21, R28 received [MEDICATION(S)] 0.5 mg PO daily, [MEDICATION(S)] 30 mg PO daily since 03/29/18, and [MEDICATION(S)] 25 mg PO daily. A recommendation was made to attempt a GDR for [MEDICATION(S)] from 30 mg PO daily down to 15 mg PO daily. On 01/11/22 at 02:06 PM, R28 sat in her room in the recliner visiting with her spouse. On 01/11/22 at 01:48 PM Licensed Nurse (LN) L stated the floor nurse could complete orders on the MRR once signed by the physician but LN L did not send the MRR's to the physicians. He stated he believed the Director of Nursing took care of that. On 01/12/22 at 01:35 PM Administrative Staff B confirmed the facility would re-send a fax two or three times and as a last resort would hand deliver the MRR to the physician. If the physician's response was not in the Pharmacy Consult notebook or folders, there probably was not a physician's response. On 01/13/22 at 08:00 AM Consultant Staff I confirmed the recommendations made and lack of follow up, and that she would expect the physician to address her recommendations. Consultant Staff I stated she would make recommendations numerous times and had contacted the then current DON who informed her of the lack of response by the physicians and at that time she decided to pick her battles. The Pharmaceutical Services policy dated 05/19/21 documented, A licensed pharmacist will be employed, or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to adequately monitor the use of medications for R28 by the failure to ensure the physician responded to the recommendations made by the consultant pharmacist to ensure the lowest effective dose received and ensure minimal side effects. F756 E - R29's Electronic Health Record (EHR) under the Medical Diagnosis tab revealed a diagnosis of anxiety (a feeling of worry, nervousness, or unease). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R29 did not receive an antianxiety medication during the seven day look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 and R29 did not receive an antianxiety medication during the seven-day look back period. The Care Plan dated 03/24/21 documented R29 was on hypnotic therapy related to anxiety. Interventions included to monitor R29's condition based on clinical practice guidelines or clinical standards of practice related to the use of [MEDICATION(S)] PRN. The 04/06/21 Physician's Orders for R29 documented an order for [MEDICATION(S)] 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Further review revealed the order discontinued on 10/20/21. The 10/20/21 Physician's Orders for R29 documented an order for [MEDICATION(S)] 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Review of the Electronic Medication Administration Record (EMAR) from March 2021 to December 2021 revealed R29 received PRN [MEDICATION(S)] 16 times. The May 2021 MRR documented R29 had a PRN order for [MEDICATION(S)] which had been in place for greater than 14 days without a stop date since 04/02/21. A recommendation was made to either discontinue the PRN [MEDICATION(S)] or that the provider provide a rationale for the extended use of the medication. The July 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for [MEDICATION(S)] which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN [MEDICATION(S)] or that the provider provide a rationale for the extended use of the medication. The August 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for [MEDICATION(S)] which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN [MEDICATION(S)] or that the provider provide a rationale for the extended use of the medication. Observation on 01/11/22 at 09:37 AM revealed R29 was alert, oriented, and calm. He did not appear to be anxious. On 01/12/22 at 01:35 PM Administrative Nurse B stated she expected a PRN [CONDITION(S)] medication to have a 14-day stop date on the order. On 01/13/22 at 08:00 AM Consultant Pharmacist I stated she would definitely expect the facility to follow up on her recommendations to discontinue PRN [MEDICATION(S)] which had no stop date. The facility's Pharmaceutical Services policy dated 05/19/21 documented A licensed pharmacist will be employed or services obtained to . Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to follow the consultant pharmacist's recommendation to discontinue the use of PRN [MEDICATION(S)] after 14 days.

The facility census totaled 50 residents with 12 included in the sample. Based on interview and record review the facility failed to ensure one of five Certified Nurse Aide's (CNA) 12- hour annual mandatory in-service training included dementia training. Findings included: - On 01/12/22, the surveyor provided Administrative Staff A a list of five CNAs employed by the facility in excess of 12 months requesting documentation of the annual mandatory in-service trainings. Four of the five staff had the required education; however, CNA M lacked record of completed dementia training in the last 12 months from hire date. On 01/12/22 Administrative Staff A reported she could not find evidence of dementia training for CNA M. The 10/15/19 facility policy Competency and Mandatory Education Requirements revealed employees were responsible to attain and maintain competency and complete mandatory education required within their specific job description. The facility failed to ensure one of five CNA's 12-hour annual mandatory in-service training included the required dementia training.

- R28's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/28/21 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R28 received antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 11/28/21 [CONDITION(S)] Drug Use Care Area Assessment (CAA) documented R28 had a history of depression with mood/behavior. R28 received scheduled [MEDICATION(S)] (antipsychotic medication), [MEDICATION(S)] (antidepressant medication), and [MEDICATION(S)] (antianxiety medication). The 11/01/21 Quarterly MDS documented R28 received an antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 01/05/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order on 11/13/20 for [MEDICATION(S)] (antipsychotic medication) 25 milligrams (mg) by mouth (PO) daily, an order on 01/14/21 for [MEDICATION(S)] (antianxiety medication) 0.5 mg PO daily, and an order dated 04/28/21 for [MEDICATION(S)] (antidepressant medication) 30 mg PO daily. Review of the monthly Pharmacy Medication Record Review (MRR) for January 2021 through December 2021 documented the following recommendations, which lacked facility documentation of physician follow up/response: 05/07/21, R28 received [MEDICATION(S)] 25 mg PO daily since 11/13/20. A recommendation was made to attempt a Gradual Dose Reduction (GDR). 10/19/21, R28 received [MEDICATION(S)] 0.5 mg PO daily, [MEDICATION(S)] 30 mg PO daily since 03/29/18, and [MEDICATION(S)] 25 mg PO daily. A recommendation was made to attempt a GDR for [MEDICATION(S)] from 30 mg PO daily down to 15 mg PO daily. On 01/11/22 at 02:06 PM R28 sat in her room in the recliner visiting with her spouse. On 01/11/22 at 01:48 PM Licensed Nurse (LN) L stated the floor nurse could complete orders on the MRR once signed by the physician. On 01/12/22 at 01:35 PM Administrative Staff B confirmed she would expect the MRR's recommendations to be responded to in a timely manner. The Pharmaceutical Services policy dated 05/19/21 documented, A licensed pharmacist will be employed, or services obtained to: .Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon and follow-up documentation maintained). The facility failed to adequately monitor the use of [CONDITION(S)] medications for R28 by the failure to ensure the physician responded to the recommendations made by the consultant pharmacist to ensure the lowest effective dose received and ensure minimal side effects. The facility reported a census of 50 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure two of five residents did not receive unnecessary medications when the facility administered as needed (PRN) [CONDITION(S)] medication to Resident (R)29 beyond 14 days without a renewed physician order or rationale provided by the physician stating why R29 should continue receiving [MEDICATION(S)] (antianxiety medication) on a PRN basis. The facility also failed to follow the recommendation to respond to a request for a Gradual Dose Reduction (GDR) for [MEDICATION(S)] (an antipsychotic drug) and [MEDICATION(S)] (an antidepressant drug) to ensure the lowest effective dose for R28. Findings included: - R29's Electronic Health Record (EHR) under the Medical Diagnosis tab revealed a diagnosis of (a feeling of worry, nervousness, or unease). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R29 did not receive an antianxiety medication during the seven day look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 and R29 did not receive an antianxiety medication during the seven day look back period. The Care Plan dated 03/24/21 documented R29 was on hypnotic therapy related to anxiety. Interventions included to monitor R29's condition based on clinical practice guidelines or clinical standards of practice related to the use of [MEDICATION(S)] PRN. The 04/06/21 Physician's Orders for R29 documented an order for [MEDICATION(S)] 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Further review revealed the order discontinued on 10/20/21. The 10/20/21 Physician's Orders for R29 documented an order for [MEDICATION(S)] 0.5 mg one tablet by mouth daily PRN for anxiety, with no stop date noted. Review of the Electronic Medication Administration Record (EMAR) from March 2021 to December 2021 revealed R29 received PRN [MEDICATION(S)] 16 times. The May 2021 MRR documented R29 had a PRN order for [MEDICATION(S)] which had been in place for greater than 14 days without a stop date since 04/02/21. A recommendation was made to either discontinue the PRN [MEDICATION(S)] or that the provider provide a rationale for the extended use of the medication. The July 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for [MEDICATION(S)] which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN [MEDICATION(S)] or that the provider provide a rationale for the extended use of the medication. The August 2021 MRR documented REPEATED RECOMMENDATION from 05/05/21: Please respond promptly to assure facility compliance with Federal regulations. R29 had a PRN order for [MEDICATION(S)] which had been in place for greater than 14 days without a stop date since 03/23/21. A recommendation was made to either discontinue the PRN [MEDICATION(S)] or that the provider provide a rationale for the extended use of the medication. Observation on 01/11/22 at 09:37 AM revealed R29 was alert, oriented, and calm. He did not appear to be anxious. On 01/11/22 at 09:39 AM R29 stated he took medication for anxiety when he needed it, which kept his moods good. On 01/12/22 at 01:10 PM Certified Nurse Aide (CNA) F stated she monitored, documented, and notified the charge nurse for R29's behaviors, which included if he isolated himself, appeared sad, or sighed loudly. CNA F stated R29 was cognizant, independent, and able to make his requests known. On 01/11/22 at 03:36 PM Licensed Nurse (LN) D stated behavior monitoring for a resident taking antipsychotic medication was documented in a Mood/Behavior note under Progress Notes. On 01/12/22 at 01:35 PM Administrative Nurse B stated she expected a PRN [CONDITION(S)] medication to have a 14-day stop date on the order. On 01/13/22 at 08:00 AM Consultant Pharmacist I stated she would definitely expect the facility to follow up on her recommendations to discontinue PRN [MEDICATION(S)] which had no stop date. The facility's [CONDITION(S)] Medications policy dated 12/01/21 documented PRN orders for [CONDITION(S)] drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, her or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility failed to ensure R29 did not receive unnecessary medications by not ensuring the prescribing physician provided a rationale to extend the use of PRN [MEDICATION(S)] beyond the 14 day limit for use of PRN [CONDITION(S)] medications.

The facility census totaled 50 residents, with four residents reviewed for accidents. Based on observation, interview, and record review the facility failed to provide appropriate assistance for transfers to R3, R1 and R2. Due to these incorrect transfers, R3 endured two right rib fractures when assisted to the commode by Certified Medication Aide (CMA) E and Certified Nurse Aide (CNA) D without the care planned full lift for transfers, CNA D used the sit-to-stand lift for R1 alone resulting in a fall with a right humerus fracture and R2 experienced a fall with closed head injury when CNA M did not ensure she had a hold of his gait belt while he ambulated. Findings included: - Resident (R) 3's pertinent diagnoses from Physician's Orders in the Electronic Medical Record (EMR) dated 10/19/21 revealed weakness and multiple fractures (broken bones) of ribs on the right side. The 10/18/21 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident was totally dependent on two staff for transfers with an impairment to one-side of her lower extremity (limb) and she used a wheelchair for mobility. The 10/18/21 Activities of Daily Living (ADL) Care Area Assessment (CAA) revealed R3 experienced a fall at home resulting in a right ankle fracture, non-weight bearing (NWB, must avoid putting any of your body weight on the area for a designated amount of time) at this time with physical therapy. She required extensive assistance with most ADL and staff used the full lift for transfers. The 10/12/21 ADL Care Plan revealed the resident required the full lift [for toileting] with a bedpan and slide board for transfer to commode. The 10/10/21 Hospital Admit paperwork revealed after her fall at home, she had a right ankle fracture, but no rib fractures. The Daily Skilled Notes revealed on 10/17/21 at 07:45 AM staff used the full lift to get the resident up to the toilet (commode). The 10/18/21 at 09:51 PM Communication Other Note documented by Licensed Nurse (LN) G revealed R3 was tearful, and stated she was having pain because the aides lifted her up by her arms rather than that lift to the commode. The 10/18/21 facility's Investigation revealed at approximately 10:50 PM Administrative Nurse C received a call from LN G stating R3 was upset about her care regarding a transfer. Social Services Designee (SSD) F interviewed R3 on 10/19/21 at approximately 09:00 AM, revealing when CNA D and CMA E assisted R3 for toileting and insisted she use the commode (and not the bed pan as R3 requested). R3 stated CNA D and CMA E lifted her under her arms and did not use a gait belt or a mechanical full lift. Administrative Nurse B and Administrative Nurse C interviewed R3 who stated she was upset with cares given on 10/18/21. The facility sent the resident to the emergency room (ER) for pain reported to her right rib area. The ER diagnosed R2 with acute (new) minimally displaced fractures of the right posterior (back) seventh and eighth ribs. The initial conclusion for the facility investigation, based on the initial interviews with CNA D and CMA E where they reported they provided care for R3's safety when they found her standing in front of the commode after she had finished toileting The administration staff viewed camera footage from 10/18/21 between 05:00 PM to 11:00 PM and noted CMA E and CNA D did not take the full lift into R3's room, which contradicted the involved CNA and CMA's notarized statements/interviews from 10/19/21 where they both stated they used the full lift to transfer R3. After CMA E watched the camera footage, she admitted they did not use the lift for R3's transfer on 10/18/21. Observation of R3 on 10/25/21 at 03:35 PM revealed the resident seated on her commode with a cast noted to her right lower leg. At 03:38 PM CMA E and CNA W assisted the resident back to her recliner with use of a slide board (a piece of equipment that can be used if a person is not able to use their legs to complete a transfer between surfaces). Interview with R3 on 10/25/21 at 03:40 PM revealed on 10/18/21 CMA E said she did not need the gait belt for the transfer and CNA D and CMA E picked her up, holding her under her arms, to transfer her from her recliner to the commode. R3 said she felt they broke her ribs, and she screamed and put weight on her fractured right lower extremity. When they transferred her back from the commode to her recliner, R3 said they did the same transfer again, but their grip tightened, and they quickly placed her on the edge of her recliner. She then stated. They really hurt me doing these things. R3 said she went to the hospital the next day because she felt she could not breathe and found she had two fractured ribs on her right side. She felt forced to do this incorrect transfer and said it was not something she wanted to do or had done before. Interview with CMA E on 10/25/21 at 04:34 PM revealed on 10/18/21, she and CNA D transferred R3 with the full lift to the commode, and R3 complained of pain in her leg and ribs. CMA E said the staff then removed the sling once she was on the commode, gave her privacy, and upon return, they found the resident standing on her left leg trying to wipe herself with tissue. CMA E said they ran over to the resident and one held her right leg and completed a pivot transfer without the use of a gait belt. CMA E stated they held her underneath her arms and on her back, but she did not complain of pain. CMA E said R3 refused the lift for the transfer from the commode back to the recliner because she said it was too painful to use it. Interview with LN G on 10/27/21 at 08:39 AM revealed on 10/18/21 R3 asked for a pain pill around 06:30 PM and then requested toileting, so he told CNA D. At 09:40 PM, R3 started crying saying CMA E and CNA D lifted her to the commode and off the commode, and that thing. He gathered that the CNA's had transferred R3 wrong, and not with the lift, so he spoke with the CNAs. LN G said the CNAs stated they used the lift for the transfer. Interview with SSD F on 10/26/21 at 02:32 PM revealed she was asked to talk with R3 on 10/19/21, and the resident brought up the incident on her own without prompting, and R3 said she knew staff were supposed to use the lift for her transfers. R3 reported CMA E and CNA D lifted her up by the arms and placed her on the commode. SSD F said R3 was not happy about that, and R3 felt worried, and was very tearful. Interview with Administrative Nurse C on 10/25/21 at 04:18 PM revealed she received a call from LN G on 10/18/21 around 10:50 PM stating the resident was upset. The resident stated CMA E and CNA D did not use the full lift for a transfer to the commode. The next morning, SSD F interviewed R3 and found that CMA E and CNA D did not transfer her correctly and without a gait belt. Administrative Nurse C interviewed R3 who reported the same story. She then interviewed the CNAs involved and both stated they used the full lift to transfer R3 to the commode on 10/18/21, and then the resident stood up by herself, completing personal care. R3 wanted back in the recliner quickly, so the staff transferred her by her underarms with no gait belt back to the recliner. The next day, R3 complained of right-side rib pain, and was sent to the emergency room . The ER found she had two acute rib fractures. Interview Administrative Nurse B and Administrative Nurse C on 10/26/21 at 10:32 AM revealed they watched the video footage and verified the two staff involved (CNA D and CMA E) did not bring a full lift to R3's room for the transfer 10/18/21. Administrative Nurse B and Administrative Nurse C expected staff to transfer residents per the resident's care plan, expected staff to use a full lift for R3, and to use a gait belt for non-lift transfers. Administrative Nurse B and Administrative Nurse C said they completed corrective action with the CNA's and stated the incident seemed isolated, until the video was viewed . we thought the failure was that R3 refused the correct transfer, but now we know that the failure was the CNA's not transferring R3 correctly. They stated the facility had not retrained all nursing staff regarding transfers since the incident. The 04/06/21 Mobility Support and Positioning: Mobility-Rehab/Skilled policy revealed staff were to follow any specific lift/transfer instructions for the resident and check the Kardex/service-plan prior for the type and amount of assistance needed, including gait belt. The facility failed to identify appropriate causal factors related to the incident experienced by R3 due to incorrect transfer. R3 endured two right rib fractures when assisted to commode by CMA E and CNA D without the care planned full lift for transfers. - Resident (R) 1's pertinent diagnoses from Physician's Orders in the Electronic Medical Record (EMR) dated 09/04/21 revealed dementia (a progressive mental disorder characterized by failing memory, confusion), pain, and fracture (broken bone) of the upper end of the humerus (upper arm bone). The 07/19/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of three, indicating severely impaired cognition. The resident required total dependence of two staff for assistance with transfers and had impairment to both upper and lower extremities (arms/legs). She experienced one non-injury fall and one minor injury fall during the review period. The 07/19/21 Falls Care Area Assessment (CAA) revealed the resident had a previous fall with a history of stroke (sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain resulting in weakness or paralysis of one side of the body). The 08/16/21 Significant Change MDS revealed a BIMS of three. The resident required extensive assistance of two staff for transfers, had impairment to one side of her upper extremity, and no falls noted during the review period. The 08/16/21 Falls CAA revealed R1 had a history of falls. The 09/01/17 Comprehensive Care Plan revealed a revision dated 04/07/20 noting the resident required two staff assistance with the sit-to-stand lift. The 07/12/21, 08/11/21, and 09/03/21 Fall Tools assessments revealed the resident was at medium risk for falls. The facility CP 5417 investigation revealed on 09/03/21at approximately 05:45 PM Certified Nurse Aide (CNA) D assisted R1 to bed with the sit-to-stand lift (without a second staff member), placed the resident on the side of bed with her legs down, and after removing the sit-to-stand, CNA D lifted the residents legs into bed. As she lifted the resident's legs, R1 slid sideways out of the bed landing on her right side. CNA D then notified Licensed Nurse (LN) H to assess the resident, but no injuries were found, and they assisted the resident back to bed with the full lift. The next morning on 09/04/21, when Certified Nurse Aide (CNA) R went into resident room for morning cares, she noted the resident could not move her right arm. She notified LN I, who assessed the resident and found a large bruise to the resident's right shoulder/arm, R1 was diaphoretic (sweating), and had pain with movement. The facility sent the resident to the emergency room (ER) at approximately 09:20 AM where R1 was diagnosed with a fracture of the right humerus. The facility reeducated CNA D to follow the residents care plan for operating the sit-to-stand lift with two staff. Interview with LN H on 10/27/21 at 08:17 AM revealed CNA D came to her and said the resident slid off the bed to the floor after she transferred the resident with the sit-to-stand lift to bed. LN H assessed R1 and she had no pain or injury noted. LN H said the sit-to-stand lift required two staff assistance for transfers. Interview with LN I on 10/27/21 at 08:32 AM revealed after CNA R informed her R1's arm was bruised, she assessed her, and noted R1 cried out in pain with her right upper arm bruised/swollen and sweating profusely. LN I sent R1 out to the ER and was diagnosed with a right humerus fracture. LN I said the sit-to-stand lift should have two staff members to assist with transfers. Interview with Administrative Nurse B and Administrative Nurse C on 10/27/21 at 10:47 AM revealed the sit-to-stand lifts for resident transfers always required two staff assistance. The 04/06/21 Mobility Support and Positioning: Mobility-Rehab/Skilled policy revealed staff were to follow any specific lift/transfer instructions for the resident and check the Kardex/service-plan prior for the type and amount of assistance needed. The facility failed to ensure the safe transfer to R1 when only one CNA (CNA D) operated the sit-to-stand lift for R1, who fell which resulted in a right humerus fracture. - Resident (R) 2's pertinent diagnoses from Physician's Orders in the Electronic Medical Record (EMR) dated 10/08/21 revealed abnormalities of gait (manner or style of walking)/mobility, weakness, pain and injury of the head. The 05/03/21 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The resident required one staff assistance for walking in corridor and locomotion on the unit. His gait was unsteady, he utilized a walker for ambulation, and was at risk for falls with no falls noted in the review period. The 05/03/21 Cognitive Loss/Dementia Care Area Assessment (CAA) revealed R2 as alert and oriented to person and place, with brief moments of confusion/forgetfulness with safety awareness. The 05/03/21 Activities of Daily Living (ADLs) CAA revealed R2 required extensive to limited assistance from staff for all ADLs. R2 required staff assistance with use of a walker and gait belt for transfer. The 05/03/21 Falls CAA revealed the resident was at medium risk for falls with no falls noted since admission. The 07/26/21 Quarterly MDS revealed a BIMS of 12. The resident required extensive one staff assistance for locomotion on the unit. His gait was unsteady, and he utilized a walker for ambulation, with no falls noted in the review period. The 04/28/21 Cognitive Care Plan revealed a revision 05/12/21 that resident needed assistance with all decision making; staff provided the resident with cues and supervision as needed. The 04/28/21 Fall Care Plan revealed the resident was at risk for falls related to poor balance/unsteady gait and required extensive one staff assistance transfers. A revision on 10/07/21 revealed staff needed to be aware of what the resident was doing while transferring, to hold on to the gait belt at all times, give the resident cues, and maintain a contact guard assist (CGA, the assisting person has one or two hands holding on to a person's body to help steady and balance) while he ambulated/transferred. The Fall Tools assessments revealed on 04/29/21 the resident was considered a medium risk for falls and on 10/08/21 he was considered a high risk for falls. The 09/29/21 Therapy to Nursing Communication Form revealed R2 required one staff assistance with use of a gait belt and walker for ambulating to the dining room. The CP 6203 facility investigation revealed on 10/07/21 at approximately 07:50 AM Certified Nurse Aide (CNA) M ambulated R2 to the dining room with his walker and used a gait belt. Upon entering the dining room, CNA M stopped with the resident to obtain his temperature, assisted to sanitize his hands, and placed his breakfast order with Dietary Aide K. During this process, the resident attempted to continue to ambulate to the table without staff assistance, became unsteady, and fell to the floor on his right side with his face down. Licensed Nurse (LN) L assessed R2 and noted he had lethargy (unresponsiveness), hit the right side of his head on the floor, and had a raised area noted to the right side of his forehead (suspected hematoma, a collection of blood trapped in the tissues of the skin, resulting from trauma). The resident went to the emergency room (ER) and admitted due to a diagnosis of a closed head injury (caused by a rapid forward or backward movement/shaking of the brain inside the bony skull that results in bruising/tearing of brain tissue and blood vessels). The revision 10/07/21 to the 09/29/21 Therapy to Nursing Communication Form revealed to clarify (the previous order), R2 should be CGA. Observation of R2 on 10/27/21 at 09:22 AM revealed he sat in his recliner watching television with no bumps noted on his forehead. Interview with R2 on 10/27/21 at 09:24 AM revealed he ambulated with his walker and a gait belt to the dining room with CNA M and she stopped to talk to Dietary Aide K. CNA M let go of his gait belt, so he attempted to walk to his table, but fell and had to go to the hospital to get checked out. R2 said now the staff held the gait belt and stayed with him when he ambulated. Interview with CNA M on 10/27/21 at 08:36 AM revealed she ambulated with R2 with his walker and gait belt to the dining room and then she assisted Dietary Aide K to get the residents meal ticket. CNA M said she thought she held on to R2's gait belt (while talking to Dietary staff), but she did not remember and then the resident fell . Interview with LN L on 10/27/21 at 09:28 AM revealed he sat at the nurse's station was notified of a resident fall in the dining room while CMA M assisted the dietary staff to find R2's meal ticket. CNA M said she held onto the resident's gait belt, but the resident kept walking. Interview with Administrative Nurse B and Administrative Nurse C on 10/27/21 at 10:47 AM revealed they expected staff who assisted with resident ambulation to the dining room, to take the resident to their table, then sanitize their hands, and get their meal order so the resident was not standing or waiting. Administrative Nurse B and Administrative Nurse C said in this incident the CNA should have completed CGA, held on to the resident's gait belt per therapy's orders, and paid attention to what the resident was doing. The 04/06/21 Mobility Support and Positioning: Mobility-Rehab/Skilled policy revealed staff were to follow any specific lift/transfer instructions for the resident and check the Kardex/service-plan prior for the type and amount of assistance needed, including gait belt. The facility failed to ensure the CNA provided appropriate assistance to R2 while assisting R2 to walk to dine and R2 experienced a fall with closed head injury.

The facility census totaled 50 residents with three residents (R) reviewed for facility reportable incidents. Based on interview and record review the facility failed to complete four facility reported incident investigations (lacked attestation signature and date) and did not submit the investigations within the required five-day timeframe to the State Mandated reporting agency, as directed by federal regulation. Findings included: - Review of facility reported incident Investigations revealed the following four did not contain an attestation signature and date, and were not submitted to the State Mandated reporting agency, within the five-day timeframe, as required: 1. The unsigned/undated completed CP 5417 for R1's fall with fracture (broken bone) due to unsafe transfer with the sit-to-stand lift on 09/03/21 was submitted to the State Agency by email on 09/15/21 at 12:51 PM, eight business days after incident. 2. The unsigned/undated completed CP 6203 for R2's fall with closed head injury (caused by a rapid forward or backward movement/shaking of the brain inside the bony skull that results in bruising/tearing of brain tissue and blood vessels) due to incorrect staff assistance for transfer/ambulation on 10/07/21 was submitted to the State Agency by email on 10/18/21 at 05:05 PM, seven business days after incident. 3. The unsigned/undated completed CP 6560 for R4's fall with two fractured (broken bone) ribs and a lumbar (lower back bone) compression fracture (when forced together bone surfaces caused a bone to break) when he ambulated unassisted on 10/19/21 was submitted to the State Agency by email on 11/02/21, ten business days after incident. 4. The unsigned/undated CP 6710 for R5's fall with a right sided cerebral bleed (bleeding from a blood vessel in the brain) when he attempted to transfer unassisted on 10/24/21 was submitted to the State Agency by email on 11/02/21, seven business days after incident. Interview with Administrative Staff A on 10/28/21 at 01:27 PM revealed he did not know why the investigations were not signed or dated and stated when he received them from the staff completing them, he just uploads and sends the investigations to the State Agency. The 12/23/20 Abuse and Neglect policy revealed the results of all investigations would be reported to the officials in accordance with state law, including to the state survey and certification agency within five working days of the incident, or sooner as designated by state law. The administrator or director of nursing services would sign the report. The facility failed to complete four facility reported incident investigations (lacked attestation signature and date) and did not submit the investigations within the required five-day timeframe to the State Mandated reporting agency, as directed by federal regulation.

The facility census totaled 50 residents with three residents (R) reviewed for reportable incidents. Based on interview and record review the facility failed to thoroughly investigate an allegation of R3's incorrect transfer which resulted in two right rib fractures (broken bone), when the facility did not view the video footage until the surevyor asked about video footage, one week after the allegation. Findings included: - The 10/18/21 facility reported CP 6509 investigation revealed at approximately 10:50 PM Administrative Nurse C received a call from LN G stating R3 was upset about her care regarding a transfer. R3 stated CNA D and CMA E lifted her under her arms and did not use a gait belt or a mechanical full lift. The facility sent the resident to the emergency room for pain reported to her right rib area. The ER diagnosed the resident with acute (new) minimally displaced fractures of the right posterior (back) seventh and eighth ribs. The initial conclusion for the facility investigation, based on the initial interviews with CNA D and CMA E where they reported they provided care for R3's safety when they found her standing in front of the commode after she had finished toileting. The investigation noted that a state surveyor in the facility on 10/25/21 (seven days after the incident) at approximately 02:40 PM, requested to see any video footage of the date/time the incident occurred, and Administrative Nurse C notified Administrative Staff A of the request. Administrative Nurse C did not know the cameras were working and had not viewed the footage prior to completing the investigation. The administration staff then viewed the camera footage from 10/18/21 between 05:00 PM to 11:00 PM and noted CMA E and CNA D did not take the full lift into R3's room, which contradicted the involved CNA and CMA's notarized statements/interviews from 10/19/21 where they both stated they used the full lift to transfer R3. Interview Administrative Nurse B and Administrative Nurse C on 10/26/21 at 10:32 AM revealed they watched the video footage last night (10/25/21, a week after the allegation) and verified the two staff involved (CNA D and CMA E) did not bring a full lift to R3's room for the transfer 10/18/21 and stated, they [CNA D and CMA E] lied. Both Administrative Nurse B and Administrative Nurse C did not know the hallway cameras worked, so they did not think to watch the footage until the state surveyor mentioned watching the cameras to ensure staff actually used the lift. Administrative Nurse B and Administrative Nurse C said they completed corrective action with the CNAs and stated the incident seemed isolated, until the video was viewed . we thought the failure was that R3 refused the correct transfer, but now we know that the failure was the CNA's not transferring R3 correctly. The 12/23/20 Abuse and Neglect policy revealed the location will have evidence that all alleged or suspected violations are thoroughly investigated. The investigation team will determine whether further investigation is needed. Resources are available as aids in how to investigate different types of allegations. The facility failed to thoroughly investigate an allegation of R3s incorrect transfer that resulted in two right rib fractures.

The facility reported a census of 55 residents with three selected for review of falls. Based on interview and record review the facility failed to provide one of three residents with adequate supervision and assistive devices to prevent accidents allowing a fall on 05/01/20 which resulted in a fracture for Resident (R) 1, when staff failed to use a gait belt during a transfer, as care planned. Findings included: - Review of R1's Discharge Documentation from a local hospital electronically signed on 05/05/20 documented the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R1 required limited physical assistance of one staff for transfers. Review of the Significant Change MDS dated [DATE] documented a BIMS score of 14 indicating intact cognition. R1 required extensive assistance of one staff with transfers, no falls since admission or prior assessment. Review of the Care Plan dated 02/27/19 documented R1 required assist of one staff, a gait belt (belt used to help transfer a person from one place to another), and a walker to rise from seated position. Review of a Progress Note dated 05/01/20 at 03:04 PM documented that R1 was sitting on the floor with her back against the dresser/next to the foot of the bed. Direct care staff E was taking R1s vitals. Resident was not wearing gait belt. Walker was upright to the right of the resident. Direct care staff G reported she was assisting the resident to the bathroom and when the resident was in a standing position direct care staff G went to move the wheelchair out of the way. R1 started walking, lost her balance, and fell . R1 had pain and staff transported the resident to the hospital for evaluation. Review of Progress Notes documented R1 admitted to the hospital on [DATE] for a spine fracture to S5, L3 and T7 (sacral, lumbar, and [MEDICATION NAME] vertebra), on 05/05/20 R1 returned to the facility, and on 05/26/20 R1 admitted to hospice. Review of the Complaint investigation Witness Statement for the incident on 05/01/20 revealed Direct Care staff D, Direct Care staff E, Direct Care Staff F, and Licensed Nurse C documented R1 did not have a gait belt in place at the time of the incident. Interview on 08/18/20 at 10:10 AM with Direct care staff D revealed that R1 did not have a gait belt on at the time of the incident. Staff D stated there had been on-going education during staff huddles about the use of gait belts for residents who are not independent., Interview on 08/18/20 at 9:10 AM with Licensed Nurse (LN) C revealed she knocked on R1's door and found R1 sitting on the floor with her legs extended out in front of her. LN C stated R1 did not have a gait belt on at the time she had the fall in her room, when Staff G was helping R1 from her wheelchair to her recliner. LN C stated there have been ongoing huddles talking about care plans and non-independent residents (with transfers or walking) that staff needed to use a gait belt on the resident. Interview on 08/18/20 at 8:57 AM with Administrative Nurse B revealed her expectations were that staff were to follow the care plan and use a gait belt if directed in the care plan. Review of the Gait-Transfer Belt-Rehab/Skilled policy dated 06/15/20 documented Gait belts are used with assisted ambulation unless medically contraindicated. The facility failed to use a gait belt during a transfer, as care planned, and the resident fell and sustained a spinal fracture. The facility identified and corrected the deficient practice on 05/05/20 when the facility audited all care plans to ensure accuracy of transfers, audited to ensure the staff implemented the care plans correctly, and educated all direct carestaff on care plans, gait belts, transfers, and kardex. The facility further provided education in the form of daily huddles regarding gait belt, transfers, care plans, and kardex regarding the following a resident's care plan and knowing how a resident transfers from one place to another. The facility assigned educational modules over gait belt use and transfers and not staff were allowed to work until completion of their education and training. Due to the facilities actions to identify and correct on 05/05/20, the deficient practice was deemed past non-compliance at a scope and severity of G.

The facility census totaled 59 with 20 residents sampled and one resident sampled for nutrition. Based on observation, interview, and record review the facility failed to maintain adequate nutritional status and prevent avoidable weight loss for cognitively impaired Resident (R) 41 when staff failed to follow recommendations for dietary supplements ordered repeatedly by the Registered Dietician (RD). R41 lost a total of 27.5 pounds (lbs.) or 15.28% of her total body weight from 09/12/19 to 01/23/20, a 133-day time period. Findings included: - Review of R41's signed Physician order [REDACTED]. (disease of the blood vessels and the arteries that supply the brain). Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognition. She showed no signs or symptoms of a swallowing disorder and required extensive assistance of 2 persons with eating. The MDS identified the resident with no or unknown weight loss. The resident was 62 inches tall and weighed 178 pounds. The MDS did not identify a restorative nursing program for eating. Review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, which indicated severely impaired cognition. She continued to show no signs or symptoms of a swallowing disorder, required extensive assistance of one staff with eating, and weighed 159 pounds. According to the MDS, R41 did not experience recent weight loss. The resident received a restorative dining/eating program two of seven days during the observation period. Review of the Nutritional Status Care Area Assessment (CAA) dated 09/18/19 revealed the resident would benefit from improved intake of 75% or greater of at least two meals daily to meet needs and maintain a weight of 160-170 lbs. The CAA noted difficulty with maintaining R41's weight due to current sleeping and eating patterns, meal refusals, and periods of lethargy (sluggishness, lack of energy). R41's Care Plan included the following interventions related to weight loss: 1. An intervention dated 09/12/19 directed staff to provide partial assistance with meals, use plate guards, and mugs with lids. 2. An intervention dated 09/13/19 directed staff to weigh R41 weekly, monitor her for chewing and swallowing difficulties, and for coughing and choking. 3. An intervention dated 09/19/19 directed staff to provide a restorative nursing program due to limited physical mobility and weakness. 4. A 09/24/19 revision included R41 should receive staff assistance with eating if she became too fatigued to feed herself. The care plan also directed staff to monitor R41 at each meal or snack time to see if she required assistance. 5. An intervention dated 09/25/19 instructed staff to provide eight ounces of Instant Breakfast (IB) three times daily between meals. 6. An intervention dated 10/15/19 noted R41 required a texture modified diet. The intervention lacked the texture required by the resident. 7. An intervention dated 10/18/19 noted R41's impaired ability to manage hot beverages and soups related to her [DIAGNOSES REDACTED]. 8. An intervention dated 12/12/19 instructed staff to encourage fluid/food intake per prescriber (from a 09/22/19 order). The Care Plan lacked evidence of review/revision related to weight loss and nutritional status in the time period from 12/12/19-01/27/20. The physician's orders [REDACTED].>1. A 09/18/19 order for pureed texture foods with regular consistency fluids. 2. A 09/22/19 order to encourage fluid and food intake. 3. A 01/15/20 order for [MEDICATION NAME] (a medication used to treat depression and used to stimulate the appetite) 7.5 milligrams (mg) at bedtime for weight loss. 4. A 01/22/20 order to increase the [MEDICATION NAME] to 15 mg at bedtime for weight loss. Review of the Physicians Orders revealed lack of further interventions to address weight loss from 09/22/20 -01/29/20. On 09/26/19, the Registered Dietician (RD) completed a Dietician Assessment and noted R41's weight loss of 8.6% since admission (14 days). In response to the weight loss, the RD recommended use of an appetite stimulant, a juice-based supplement three times daily, and fortification of foods with extra butter added to potatoes and vegetables. The RD also recommended a discussion with R41's spouse about the possibility of enteral (tube) feedings. On 09/26/19, a Nutritional Status Note written by the RD identified R41 with inadequate caloric, fluid, and protein intake. A Mini Nutritional assessment dated [DATE] identified R41 as malnourished (poorly nourished). On 01/09/20, the RD completed another Dietician Assessment and noted R41's weight of 145 lbs., a weight loss of 13.5 lbs. or 8.5% in a 30-day time period. The resident's weight was 145 lbs. resulting in an unplanned or unintentional weight loss of 13.5 lbs. or 8.5% in 30 days. After a discussion with the Certified Dietary Manager, a change in her supplements were made for better consumption (no specific changes were noted). The anti-depressant she started had no effect on her intake. The RD recommended a re-evaluation. The clinical record lacked documented changes to R41's supplement. Review of the Communication/Visit with the Physician notes revealed: 1. On 09/18/19 the resident was lethargic, but her vital signs were within normal limits. She slept most of the day, but could be awakened at times and answered questions appropriately. Per her husband's request salt was given, but was ineffective. She ate less than 10% of her lunch. 2. On 09/20/19 the resident returned to the facility with an order for [REDACTED]. 3. On 09/20/19 doctor's office returned the call. They were advised that R41 could not receive speech therapy due to her not qualifying for Medicare and was Medicaid pending. 4. On 01/11/20 a fax was sent to R41's doctor requesting to change the anti-depressant to an appetite stimulant. Review of the resident's weights in the Vital Signs tab in the electronic charting system revealed the following: 09/12/19 02:22 PM 180.0 lbs. 10/16/19 11:21 AM 161.0 lbs. (10.56% weight loss in 34 days) 12/11/19 01:30 PM 158.5 lbs. (11.94% weight loss in 90 days) 01/23/20 01:37 AM 152.5 lbs. (15.28% weight loss in 133 days) Review of R41's Meal log from 12/31/19 - 01/29/20 (90 meals over 30 days) revealed the resident consumed: 11 of 90 meals 0-25% 21 of 90 meals 26-50% 11 of 90 meals 51-75% 31 of 90 meals 76-100% The resident refused seven of 90 meals. Three of 90 meals were listed as not available. Four of 90 meals were not documented. Only two meals were documented on 01/01, 01/03, 01/14, and 01/15/20. According to R41's Care Plan the resident received three snacks daily (84 potential snacks from 01/01/2019-01/29/2019). Review of R41's snack log from 01/01/20-01/29/20 revealed documentation for 54 snacks. 19 out of 54 documented as sleeping. 34 out of 54 documented as accepted, but lacked intake amount. One out of 54 documented as not available. On 01/27/20 at 08:36 AM unidentified staff brought R41 out to the dining room in her wheelchair and served the resident a pureed diet. The staff assisted her with the meal. On 01/28/2020 at approximately 11:45AM, unidentified staff and R41 sat in the dining room. An unidentified direct care staff member assisted R41 with her pureed meal. After cueing the resident would open her eyes and eat spoonful's of food with no observable swallowing issues. R41 did not participate in self feeding, but responded to staff cueing. On 01/29/2020 at 08:20AM, R41 was at her dining table in her wheelchair with her eyes closed, waiting for breakfast. She waited approximately 17 minutes for staff assistance and her meal to arrive. The staff woke and cued R41 several times for food and fluid intake. The resident continued to respond well to staff cueing, but did not participate in staff cueing. Interview with Licensed Nurse (LN) [NAME] on 01/29/20 at approximately 10:00AM revealed if the Dietician recommended supplements for a resident, the staff contacted the doctor for an order. LN [NAME] did not know if that ever took place for R41 and confirmed R41 did not have an order for [REDACTED].>Interview with Certified Nurse Aide (CNA) J on 01/29/20 at 11:07AM revealed if R41 was sleeping the staff would take her nutritional shake back to the kitchen and R41 would not receive another nutritional shake until the next shift. CNA J did not know if the CNAs were required to log if the shakes were received. Interview with LN D on 01/29/19 at 10:03 AM said R41 received house supplements and could drink them independently when she was awake. She reported they do not document consumption amounts and said the CNAs only documented whether R41 received them or not. If R41 chose to eat in her room she would receive assistance as needed by the CNAs. Interview with Certified Dietary Manager (CDM) CC on 01/29/20 at approximately 04:00PM revealed they were monitoring R41's weight loss and addressed it with instant breakfast mixed with vitamin D milk, which did not require a doctor's order. CDM CC said the staff offered the drink to R41 three times daily. CDM CC could not verify the intake amount of R41 and stated the facility only documented whether she accepted, refused, or was sleeping. CDM CC could not confirm if R41 drank 100% of the supplement. Interview with Administrative Nurse B on 01/30/20 at 11:07AM revealed she expected the staff to re-approach R41 with her supplement when she was sleeping or refused them. The resident always needed assistance with meals, but reported that some days she could feed herself. She noted the resident was on [MEDICATION NAME]/[MEDICATION NAME] five times a day. This medication treated her [MEDICAL CONDITION] and one of the side effects of that medication was nausea. She discussed this concern with her doctor, but no changes were made. Electronic interview with Administrative Nurse B on 02/04/20 at 12:42 PM revealed R41's weight loss as unusually rapid and significant, and related it to her [DIAGNOSES REDACTED]. Administrative Nurse B relied on her RISK Team (a team of people who work to identify and attempt to prevent potential hazards) the Dietary Manager and Consultant, and the resident's physician to make the best decisions for R41 regarding nutritional interventions. Multiple attempts to reach the resident's physician on 02/04/20 at approximately 01:00PM and on 02/06/20 at 09:10AM where a request for an electronic email interview. The emailed interview questions sent on 02/06/20 at 09:12AM and as of 02/10/20 the physician had not responded. Review of the facility's policy Nutrition and Hydration dated (MONTH) of 2019 revealed the facility would maintain acceptable parameters of nutritional status such as usual or desirable body weight ranges and electrolyte balance unless the resident's clinical condition demonstrates that it is not possible or resident preference indicate otherwise. The facility failed to maintain an adequate nutritional status for cognitively impaired R41 when staff failed to follow recommendations for dietary supplements ordered by the RD, to prevent the severe weight loss of 15.28% in 133 days.

The facility reported a census of 68 residents with 3 residents reviewed for change of condition with hospitalization . Based on interview and record review the facility failed to assure 1 of 3 residents reviewed received adequate monitoring for resident #1 who received an anticoagulant (blood thinning) medication. The facility failed to monitor and report potential signs and symptoms of anticoagulant therapy complications, such as, black, tarry stools. The anticoagulant medication therapy required [MEDICATION NAME] time (PT - lab used to measure bleeding time) and international normalized ratio (INR- used to monitor individuals who received blood-thinning medication) laboratory monitoring, as ordered by the physician. The facility failed to obtain the ordered labs for over 2 months after the order date. The resident displayed changes which included black, tarry stools, increased lethargy (drowsy, listless), decreased oxygen saturation (the percent of oxygen in the blood) and noticeable change in level of consciousness. The resident admitted to a hospital intensive care unit with an INR greater than 9 (therapeutic range less than 3) and died later that night. This deficient practice placed the resident in immediate jeopardy. (#1) Findings included: - Review of resident #1's [DIAGNOSES REDACTED].'s disease (progressive mental deterioration characterized by confusion and memory failure), [MEDICAL CONDITION] (rapid, irregular heart beat), hypertension (elevated blood pressure), heart failure (a condition with low heart output and the body becomes congested with fluid), dementia (progressive mental disorder characterized by failing memory, confusion), [MEDICAL CONDITIONS] disease (conditions that affect the circulation of blood to the brain) and [MEDICAL CONDITION] and [MEDICAL CONDITION] (inability to move half the body). Review of the [DATE] annual Minimum Data Set (MDS) revealed the resident had short and long-term memory problems, with severely impaired cognitive skills for daily decision making. The resident required total dependence on 1 to 2 staff for most activities of daily living (ADLs). The resident did not have a condition or chronic disease that might result in a life expectancy of less than 6 months. The resident received daily anticoagulant therapy in the 7 day observational period. Review of the quarterly MDS dated [DATE] revealed the resident had no change in from the previous assessment. Review of the [DATE] cognitive loss/dementia care area assessment (CAA) revealed the resident answered questions in one word answers, such as yes or umhumm. The resident had also had a [MEDICAL CONDITION] ([MEDICAL CONDITION]- [MEDICAL CONDITION]/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) with left-sided [MEDICAL CONDITION]/[MEDICAL CONDITION] with resulting [MEDICAL CONDITION] (condition with disordered or absent language function). He/she had long and short-term memory loss. The resident received [MEDICATION NAME] (anticoagulant medication used to thin blood), in which the dosage would change based upon the PT/INR lab results. Review of the [DATE] care plan revised on [DATE] revealed the resident received a anticoagulant therapy related to a [DIAGNOSES REDACTED]. Monitor/document/report to health care provider as needed (PRN) any signs or symptoms of anticoagulant complications: blood tinged or frank 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. Staff were to complete lab as ordered. Black box warning (BBW- labeling of drugs associated with serious adverse reactions) for [MEDICATION NAME]: observe for major or fatal bleeding. Potential adverse effects include hematuria (blood in the urine) and/or hemorrhage (bleeding). Review of the [DATE] medication review report signed by the physician revealed the resident had an order for [REDACTED]. Review of the resident's lab results for [MEDICATION NAME] time (PT - lab used to measure bleeding time) revealed the resident had a high PT (outside of the normal range of 12XXX,[DATE].9 seconds) on the following dates: [DATE]: PT 48.5 seconds [DATE]: PT 41 seconds [DATE]: PT 28.8 seconds [DATE]: PT 21.7 seconds [DATE]: PT 24.0 seconds Review of the international normalized ratio (INR- no unit of measure, a ratio based on results of a PT and used to monitor individuals treated with the blood-thinning medication; normal INR range: 2XXX,[DATE].0) lab results revealed the following: [DATE]: INR 5.2 (high) [DATE]: INR 4.2 (high) [DATE]: INR 2.7 [DATE]: INR 1.89 [DATE]: INR 2.14 Review of the nurse's note dated [DATE] at 5:08 p.m. revealed the physician called to order no change in the dose of [MEDICATION NAME] and to recheck the resident's PT/INR on [DATE]. The resident's clinical record lacked evidence of any other labs after [DATE] for resident #1. Review of the electronic Medication Administration Record [REDACTED] [DATE]-31, 2016. [DATE]-31, 2017. February ,[DATE], 2017. Review of the pharmacy consultant reviews revealed the pharmacist reviewed the resident's medications monthly from [DATE]-[DATE] and noted on [DATE] the lack of the PT/INR results from a [DATE] lab ordered. The consultant recommended to follow-up with the lab and have the results forwarded to the facility so that results could be shared with the prescriber for potential changes in [MEDICATION NAME] therapy. Review of the fax communication to the physician from administrative nursing staff K on [DATE] (14 days after the pharmacist recommendation) revealed the facility needed a current PT/INR order for resident #1. The communication sheet lacked a response from the physician. Review of the bowel charting for resident #1 for [DATE]-[DATE] revealed the resident had bowel movements (BM) every ,[DATE] days that ranged between small to large. The charting revealed the amount of BM and the size of the BM were the only descriptions on the report. Further review of the bowel charting revealed the direct care staff could document the size (small, medium, large) and the consistency (formed/normal, soft, putty like, loose/liquid or hard) and whether the resident was continent or incontinent. The charting did not give a section to chart the color of the stool or include tarry or sticky as a consistency. Review of the nurse's note by licensed nursing staff D dated [DATE] at 3:50 a.m. revealed the resident was not acting his/her usual self and the following vital signs were documented: blood pressure (BP) ,[DATE] millimeters of mercury (mmHg), pulse 92, respirations 22, oxygen (O2) saturation 86% on room air. Staff D reported placing supplemental oxygen on the resident and O2 saturation came up to 93%. Staff D assessed the resident's lung fields and noted only slight rhonchi (coarse rattling respiratory sounds, usually caused by secretions in [MEDICATION NAME] airways) and staff D would continue to monitor. Normal ranges for vital signs: Blood pressure ,[DATE] mm/Hg to ,[DATE] mm/Hg; Respirations: 12 - 18 breaths per minute; pulse ; O2 95% - 100% , and pulse 60 to 100 beats per minute . Review of the nurse's note dated [DATE] at 4:12 a.m. revealed licensed nursing staff D notified the on-call for physician I, and reported to physician J the resident's change in condition. Staff D reported the resident's O2 saturation level was at 86% on room air, and then after placing 02 on the resident, his/her O2 saturations came up to 93%. Staff D reported the resident had not been acting in his/her usual manor and was more limp. Physician J wanted to know the resident's code status (the resident had a do not resuscitate (DNR)) and physician J instructed the nurse to talk to the family of the resident in the morning and see what they wanted done. Physician J instructed staff to stabilize the resident until morning. Review of the nurses notes dated [DATE] at 5:50 a.m. revealed licensed nursing staff D checked on the resident and his/her O2 saturation level was at 94% with O2 on at 3 liters (L) per nasal cannula with no other vital signs obtained. Review of the nurse's note dated [DATE] at 5:55 a.m. revealed licensed staff D attempted to notify the resident's DPOA (durable power of attorney - representative of the resident able to make health care decisions for the resident) of the resident's condition and left message to call the facility back. The resident's clinical record lacked evidence of other nurses notes between [DATE] at 5:55 a.m. and [DATE] at 10:34 a.m. (approximately 4 ½ hours) Review of the nurse's note dated [DATE] at 10:34 a.m. revealed licensed nursing staff C called and spoke with the family of resident #1 and advised the family member the resident had trouble breathing that morning and exhibited lethargy. Staff C documented licensed nursing staff D placed supplemental oxygen on the resident last night, and the resident had a low grade fever of 99.0 degrees Fahrenheit. Staff C documented he/she called 911 to send the resident to the emergency room (ER), per phone order from physician I's office. Review of the ER report revealed the resident was unresponsive and confused when he/she admitted on [DATE]. The staff started oxygen for the resident. The resident's vital signs were: blood pressure ,[DATE] millimeters of mercury (mmHg), oxygen saturation 100%, on 2 liters per minute (L/M). The resident arrived per emergency medical services (EMS) with reports from the facility the resident started having low oxygen saturations in the mid 80's last night and the resident had a history of [REDACTED]. The resident presented with lethargy. Glasgow coma score 12, (scoring system used to describe the level of consciousness in a person with [MEDICAL CONDITION] and a score of ,[DATE] indicated moderate [MEDICAL CONDITION]). Current symptoms were moderate with gradual onset of symptoms of last night and associated with a fever. The note listed medications (including [MEDICATION NAME]) the resident received daily with no dose documented. The complete blood count (CBC) collection result from the emergency roiagnom on [DATE], (normal range): Hemoglobin (Hgb- red blood cell, serving as the oxygen-carrying protein in the blood) 5.3 grams per deciliter (g/DL) (critical) (11XXX,[DATE].3 g/DL) and hematocrit (Hct - ratio of the volume of red blood cells to the total volume of blood) measured 19.4 % (31XXX,[DATE].9) PT greater than 90.0 seconds (9XXX,[DATE].5) and INR measured greater than 9.0 (0XXX,[DATE].1) Partial [MEDICAL CONDITION] time (PTT) measured 87.7 seconds (23XXX,[DATE].0) The [DATE] ER report revealed the resident required intensive care and admitted to the intensive care unit. The same ER report revealed the final [DIAGNOSES REDACTED]. The ER report further revealed the resident received a blood transfusion of fresh frozen plasma (FFP- the liquid portion of the blood that contains all coagulation factors from the blood and was indicated for patients with a coagulopathy who are bleeding or at risk of bleeding) for low hemoglobin and [MEDICAL CONDITION]. Review of the nurse's note dated [DATE] at 6:49 p.m. revealed the facility received a call from the ER nurse, who stated the resident admitted to hospital intensive care unit (ICU) with a [DIAGNOSES REDACTED]. The facility received a call from a local hospice group and notified the resident admitted to hospice for pneumonia and an INR greater than 9. Review of the nurse's note dated [DATE] at 4:58 p.m. revealed the facility called the hospice group and verified the resident died at 6:45 p.m. on [DATE]. The [DATE] facility investigation revealed the following: Licensed nursing staff L on [DATE] revealed he/she took the physician's PT/INR order on [DATE] and did not put it on the treatment administration record (TAR) for lab to be drawn. Staff L did not know what happened that he/she did not get the order on the TAR. The notarized witness statement of administrative nursing staff N dated [DATE] reported on Wednesday [DATE], physician I went to the facility to see the resident. Staff N reported the management team discussed resident #1 that morning about the PT/INR labs needed. Staff N faxed to physician I's office mid-morning on [DATE] and asked about an order for [REDACTED]. Interview with direct care staff G on [DATE] at 10:44 a.m. revealed if the staff saw the resident was not acting his/her usual or displayed signs of distress, he/she reported to the nurses. Staff G reported the resident took all of his/her medications regularly. Staff G stated the resident had gone to the hospital but was unsure as to why. Staff G stated the resident was on anticoagulant medication and the resident took those in the evening, after his/her shift. Staff G stated when a resident was on anticoagulant medication the resident should be monitored for bleeding and within the last 2 weeks the facility had changed the protocol so only licensed nurses could administer [MEDICATION NAME]. Interview with direct care staff H on [DATE] at 12:15 p.m. revealed the staff provided total care for the resident. Staff H reported he/she reported to the licensed nurse C the resident's respirations were odd and the resident's skin was paler. Staff H stated he/she did not see any bleeding from the resident when the resident left the faciity on [DATE]. Staff H stated the resident was not responsive. Interview with direct care staff E on [DATE] at 9:10 a.m. revealed the resident acted a little out of it around 3:00 a.m. on [DATE] and staff E took vital signs and noticed the resident's oxygen saturation levels were in the 80's. Staff E reported the finding to licensed nursing staff D, who then assessed the resident and called the physician. Staff E said the physician instructed the nurse to wait and call the resident's physician in the morning. Staff E stated he/she took the resident's oxygen saturation levels ,[DATE] times, however, staff only took a full set of vitals once at 3:30 a.m. on [DATE]. Staff E stated the resident's oxygen levels were within normal limits on the oxygen and stated the resident seemed out of it and was awake but not verbal. Interview with direct care staff R on [DATE] at 6:07 a.m. revealed the resident required 2 person staff assistance with toileting and the resident had very black, dark and sticky stools that were hard to wipe off. Staff stated he/she did not report the stool to the nurse because that was the resident's normal bowel movement for the past few months Interview with direct care staff S on [DATE] at 6:08 a.m. revealed he/she would report if the resident's stool looked different than it normally had. Staff stated the resident had black, dark and sticky stool most of the time and most of them were medium sized amounts. Staff stated he/she did not report the black, dark and sticky stool to the nurse because it was the resident's normal and he/she would just let the nurse know the resident had a BM and then chart it on the BM charting. Interview with direct care staff H on [DATE] at 11:30 a.m. revealed the resident had tarry, black and sticky bowel movements. Staff H stated he/she reported this to the nurse. Staff stated the resident had had the black, tarry and sticky stools for months and the nurse would just say it was the medication. Staff H said the BM charting did not have an other button, in order to chart the color, and only allowed the selection of formed, soft, putty, hard, or liquid/loose. Staff H stated he/she thought other staff charted the black and tarry as normal since the resident had been having the black tarry stools for a few months. Interview with licensed nursing staff C on [DATE] at 2:05 p.m. revealed the resident had a history of [REDACTED]. Staff C stated he/she received report from licensed nursing staff D and was told to wait to call as long as the resident was stable. Staff C stated he/she called the DPOA and PCP and explained the situation and asked for permission to send the resident out. Staff C stated the resident was sent out via EMS. Staff C stated he/she did not know what happened with the lab order from [DATE] not entered into the system. Interview with licensed nursing staff D on [DATE] at 5:25 a.m. revealed the resident was sleeping when he/she came on shift. Staff D stated there were no issues reported at beginning of his/her shift regarding resident #1. Staff D stated the aides performed a turn and reposition around 3:00 a.m. on [DATE] and reported to staff D the resident was not acting right. Staff D checked the resident's vitals and noted his/her oxygen level was lower, in the 80's and then staff D applied oxygen 2L/M. Staff D called the on-call physician J to report the change in condition. Physician J instructed staff D to keep the resident comfortable and stable through keeping the resident's oxygen saturation levels within normal limits, and to contact the resident's family in the morning to see what they wanted done. Staff D reported, physician J did not want the resident sent to the hospital. Staff D reported he/she tried to contact the family at the end of his/her shift. Staff D obtained and documented the resident's oxygen saturation levels 2 times after the 3:30 am set, and they were WNL with the administered oxygen. Staff D reported the resident never woke up on his/her shift. The resident had episodes in the past where he/she used to use oxygen and had breathing treatments. Interview with licensed nursing staff C on [DATE] at 12:31 p.m. revealed the staff looked at the type of BM a resident had and stated the resident usually had a dark BM and they were kind of soft and sometimes they were formed, but the majority were soft. Staff stated the resident did not have black or tarry stool and the staff did not change the resident that morning. Interview with licensed nursing staff L on [DATE] at 6:00 a.m. revealed administrative staff B asked him/her about the missing order entry for the PT/INR for resident #1 from [DATE] in February of 2017. Staff L stated he/she did not know why he/she did not put in the order entry for the lab. Staff L stated they assess the abdomen on admission, on skilled, and when no BM for 3 days or if the resident complained of pain. Staff L stated the resident did not have any complaints that he/she knew of. Staff L stated on [DATE] the resident acted differently and licensed nursing staff C reported the resident acted differently to licensed nursing staff D. Staff L said he/she thought staff C reported the resident had more labored breathing, increased lethargy, and fatigue. Interview with administrative staff A [DATE] at 8:00 a.m. verified the PT/INR lab from the [DATE] order was not drawn because staff did not enter the order into treatment administration record, so it did not trigger for lab to be done. Staff A stated the nurse practitioner and the doctor saw the resident and they did not catch the missing PT/INR, either. Staff A reported the facility did education on orders and had a new system in place, to ensure physician telephone orders were put into the system. Staff A stated the facility were conducting daily audits on PT/INR and had 8 residents on them now. Staff A stated the facility had checks and balances that did not work in the instance of the [DATE] lab order for resident #1. Staff A stated this was the facility's first instance of missing a lab and it would be the last. Staff A reported the facility had a lot of illnesses and when a resident was on an antibiotic and they received [MEDICATION NAME] it could increase the PT and INR, so now staff ran a report for both antibiotics and anticoagulant every 3 days. Interview with administrative nursing staff B on [DATE] at 2:45 p.m. revealed the residents PT/INR fell through the cracks. Staff B stated he/she missed the pharmacy review recommendations in February 2017. Staff B stated the facility was at fault for not checking the PT/INR for resident #1. Staff B stated he/she planned to ask each physician for parameters for INR for each resident because the facility did not have a facility parameter for INR. Staff B stated he/she remembered obtaining vitals on the resident on the morning of [DATE] but did not chart those and did not know why licensed staff C had not charted the resident's vitals either. Staff B expected vitals to be charted in the resident's clinical record. Interview with administrative staff A on [DATE] at 12:02 p.m. revealed he/she expected the nursing staff to monitor for change in condition for residents and he/she expected vital signs to be documented. Staff A stated the facility failed to enter the lab order, run the lab, and the DON failed to see the pharmacist review. Staff A reported he/she expected vital signs to be recorded and entered in the resident's clinical record and expected an assessment to be completed for the resident when he/she transferred to the hospital. Interview with consultant pharmacy staff Q on [DATE] at 9:38 a.m. revealed staff Q reviewed medications monthly and in [DATE] the pharmacist staff had reviewed resident #1's medications and lab and saw a PT/INR from December, but in February 2017 saw the repeat PT/INR had not been drawn. Staff Q stated when he/she finished his/her reviews; he/she put it on the director of nursing (DON) report and gave a report to leadership, including the administrator and assistant director of nursing (ADON) of the facility. Interview with physician I on [DATE] at 8:54 a.m. revealed he/she felt the lack of current PT/INR played a role in the events on [DATE] and stated in the past month he/she had not seen anything with the resident that would lead the physician to believe that death was expected. Physician I stated the INR should remain less than 3. Physician I said the resident was non-verbal with severe dementia and difficult to assess, due to the advanced dementia and non-verbal status. The physician I stated if the oxygen saturation levels were the only thing out of the normal limits for the resident, then he/she would only expect the staff to monitor the oxygen saturations. Interview with physician N on [DATE] at 8:20 a.m. revealed the resident presented to the emergency department on [DATE] less alert, with dementia, and low oxygen saturation levels. Physician N stated his/her staff found an unexpected finding of a high INR and low hemoglobin and stated the resident had GI blood loss. Physician N [MEDICAL CONDITION] or blood loss caused the resident's death. Physician N stated the resident did have a fecal impaction, positive fecal occult lab test (lab test used to check stool samples for hidden blood) and received a blood transfusion of fresh frozen plasma and received intravenous (IV) Vitamin K (fat soluble vitamin used to thicken the blood). Physician N stated black, tarry stools were indicative of GI blood loss. Physician N stated INRs should be monitored. Review of the facility policy on physician orders dated ,[DATE], revised on ,[DATE], revealed physician orders were critical component to providing quality care to resident and accurate processing of physician orders was important. Orders were processed and transcribed into point click care (PCC- online electronic charting) immediately upon receipt of an order. All orders must be noted by the licensed nurse who processed the order. Once the order was entered in to PCC, depending on the category, the order populated the appropriate electronic documentation location within the application: eMAR, eTAR. Review of the facility policy titled laboratory services from ,[DATE], revised on ,[DATE], revealed the policy existed to assure quality and timeliness of laboratory. Laboratory services were done only when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with State law, including scope of practice laws. Laboratory results were noted by a licensed nurse and scanned and indexed into the resident's electronic medical record. The facility failed to monitor the resident on anticoagulant therapy for signs and symptoms of anticoagulant therapy complications, which included a BBW for [MEDICATION NAME] to observe for major or fatal bleeding (black, tarry stools) and by not completing a physician prescribed PT/INR lab ordered on [DATE]. The resident displayed changes in his/her health status. The resident transferred to the ER and died with an elevated INR level of greater than 9 on [DATE]. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] when the facility put into place 18 steps to ensure proper follow through of systems were completed in a timely manner for order entry of PT/INR and the tracking or residents on [MEDICATION NAME] therapy, and appropriate notification of resident change in condition and proper assessments were completed. The plan included 5 day a week monitoring of residents on [MEDICATION NAME], weekly auditing, monthly quality assessment and performance improvement (QAPI) meetings, staff education, staff competencies, review of policies and procedures for assessment and noticing subtle change in conditions of residents, order entry, head to toe assessments, lab orders, notification of physician of lab orders, and pharmacy consultant reviews to be reviewed within 72 hours by the director of nursing with follow up. The deficient practice remained at the scope and severity of a G.

The facility reported a census of 68 residents with 3 residents reviewed for change of condition with hospitalization . Based on interview and record review the facility failed to ensure 1 of 3 residents reviewed received adequate assessment before being transferred to the emergency room for a change in condition for resident #1. The facility failed to obtain any vital signs for the resident after 5:55 a.m. on [DATE] and only completed one set of full vitals at 3:30 a.m. on [DATE]. The resident displayed changes of increased lethargy (drowsy, listless), decreased oxygen saturation (the percent of oxygen in the blood) and a noticeable change in level of consciousness. The resident admitted to a hospital intensive care unit and died later that night. Findings included: - Review of resident #1's [DIAGNOSES REDACTED].'s disease (progressive mental deterioration characterized by confusion and memory failure), [MEDICAL CONDITION] (rapid, irregular heart beat), hypertension (elevated blood pressure), heart failure (a condition with low heart output and the body becomes congested with fluid), dementia (progressive mental disorder characterized by failing memory, confusion), [MEDICAL CONDITIONS] disease (conditions that affect the circulation of blood to the brain) and [MEDICAL CONDITION] and [MEDICAL CONDITION] (inability to move half the body). Review of the [DATE] annual Minimum Data Set (MDS) revealed the resident had short and long-term memory problems, with severely impaired cognitive skills for daily decision making. The resident required total dependence on 1 to 2 staff for most activities of daily living (ADLs). The resident did not have a condition or chronic disease that might result in a life expectancy of less than 6 months. The resident received daily anticoagulant therapy in the 7 day observational period. Review of the quarterly MDS dated [DATE] revealed the resident had no change from the previous assessment. Review of the [DATE] cognitive loss/dementia care area assessment (CAA) revealed the resident answered questions in one word answers, such as yes or umhumm. The resident had also had a [MEDICAL CONDITION] ([MEDICAL CONDITION]- [MEDICAL CONDITION]/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) with left-sided [MEDICAL CONDITION]/[MEDICAL CONDITION] with resulting [MEDICAL CONDITION] (condition with disordered or absent language function). He/she had long and short-term memory loss. The resident received [MEDICATION NAME] (anticoagulant medication used to thin blood), in which the dosage would change based upon the [MEDICATION NAME] time (PT - lab used to measure bleeding time) and international normalized ratio (INR- used to monitor individuals who received blood-thinning medication) lab results. Review of the [DATE] care plan revised on [DATE] revealed the resident received anticoagulant therapy related to a [DIAGNOSES REDACTED]. Monitor/document/report to health care provider as needed (PRN) any signs or symptoms of anticoagulant complications which included any significant or sudden changes in vital signs. Review of the nurse's note by licensed nursing staff D dated [DATE] at 3:50 a.m. revealed the resident was not acting his/her usual self and the following vital signs were documented: blood pressure (BP) ,[DATE] millimeters of mercury (mmHg), pulse 92, respirations 22, oxygen (O2) saturation 86% on room air. Staff D reported placing supplemental oxygen on the resident and oxygen saturation came up to 93%. Staff D assessed the resident's lung fields and noted only slight rhonchi (coarse rattling respiratory sounds, usually caused by secretions in [MEDICATION NAME] airways) and staff D would continue to monitor. (Normal ranges for vital signs: Blood pressure ,[DATE] mm/Hg to ,[DATE] mm/Hg; Respirations: 12 - 18 breaths per minute; O2 95% - 100% , and pulse 60 to 100 beats per minute .) Review of the nurse's note dated [DATE] at 4:12 a.m. revealed licensed nursing staff D notified the on-call for physician I, and reported to physician J the resident's change in condition. Staff D reported the resident's O2 saturation level was at 86% on room air, and then after placing 02 on the resident, his/her O2 saturations came up to 93%. Staff D reported the resident had not been acting in his/her usual manor and was more limp. Physician J wanted to know the resident's code status (the resident had a do not resuscitate (DNR)) and physician J instructed the nurse to talk to the family of the resident in the morning and see what they wanted done. Physician J instructed staff to stabilize the resident until morning. Review of the nurses notes dated [DATE] at 5:50 a.m. revealed licensed nursing staff D checked on the resident and his/her O2 saturation level was at 94% with O2 on at 3 liters (L) per nasal cannula with no other vital signs obtained. Review of the nurse's note dated [DATE] at 5:55 a.m. revealed licensed staff D attempted to notify the resident's DPOA (durable power of attorney - representative of the resident able to make health care decisions for the resident) of the resident's condition and left message to call the facility back. The resident's clinical record lacked evidence of other nurses notes or vital signs recorded for resident #1 between [DATE] at 5:55 a.m. and [DATE] at 10:34 a.m. (approximately 4 ½ hours), after which the resident left the facility by ambulance. Review of the nurse's note dated [DATE] at 10:34 a.m. revealed licensed nursing staff C called and spoke with the family of resident #1 and advised the family member the resident had trouble breathing that morning and exhibited lethargy. Staff C documented licensed nursing staff D placed supplemental oxygen on the resident last night, and the resident had a low grade fever of 99.0 degrees Fahrenheit. Staff C documented he/she called 911 to send the resident to the emergency room (ER), per phone order from physician I's office. Review of the ER report revealed the resident was unresponsive and confused when he/she admitted on [DATE]. The staff started oxygen for the resident. The resident's vital signs were: blood pressure ,[DATE] millimeters of mercury (mmHg), oxygen saturation 100%, on 2 liters per minute (L/M). The resident arrived per emergency medical services (EMS) with reports from the facility the resident started having low oxygen saturations in the mid 80's last night and the resident had a history of [REDACTED]. The resident presented with lethargy. Glasgow coma score 12, (scoring system used to describe the level of consciousness in a person with [MEDICAL CONDITION] and a score of ,[DATE] indicated moderate [MEDICAL CONDITION]). Current symptoms were moderate with gradual onset of symptoms of last night and associated with a fever. The note listed medications (including [MEDICATION NAME]) the resident received daily with no dose documented. The [DATE] ER report revealed the resident required intensive care and admitted to the intensive care unit. The same ER report revealed the final [DIAGNOSES REDACTED]. Review of the nurse's note dated [DATE] at 6:49 p.m. revealed the facility received a call from the ER nurse, who stated the resident admitted to hospital intensive care unit (ICU) with a [DIAGNOSES REDACTED]. The facility received a call from a local hospice group and notified the resident was admitted to hospice for pneumonia and an INR greater than 9 (normal INR range: 2XXX,[DATE].0, no unit of measure, a ratio based on results of a PT and used to monitor individuals treated with the blood-thinning medication). Review of the nurse's note dated [DATE] at 4:58 p.m. revealed the facility called the hospice group and verified the resident died at 6:45 p.m. on [DATE]. Interview with direct care staff H on [DATE] at 12:15 p.m. revealed the staff provided total care for the resident. Staff H reported he/she reported to the licensed nurse C the resident's respirations were odd and the resident's skin was paler. Staff H stated he/she did not see any bleeding from the resident when the resident left the faciity on [DATE]. Staff H stated the resident was not responsive. Interview with direct care staff E on [DATE] at 9:10 a.m. revealed the resident acted a little out of it around 3:00 a.m. on [DATE] and staff E took vital signs and noticed the resident's oxygen saturation levels were in the 80's. Staff E reported the finding to licensed nursing staff D, who then assessed the resident and called the physician. Staff E said the physician instructed the nurse to wait and call the resident's physician in the morning. Staff E stated he/she took the resident's oxygen saturation levels ,[DATE] times, however, staff only took a full set of vitals once at 3:30 a.m. on [DATE]. Staff E stated the resident's oxygen levels were within normal limits on the oxygen and stated the resident seemed out of it and was awake but not verbal. Interview with licensed nursing staff C on [DATE] at 2:05 p.m. revealed the resident had a history of [REDACTED]. Staff C stated he/she received report from licensed nursing staff D and was told to wait to call as long as the resident was stable. Staff C stated he/she called the DPOA and PCP and explained the situation and asked for permission to send the resident out. Staff C stated the resident was sent out via EMS. Interview with licensed nursing staff D on [DATE] at 5:25 a.m. revealed the resident was sleeping when he/she came on shift. Staff D stated there were no issues reported at beginning of his/her shift regarding resident #1. Staff D stated the aides performed a turn and reposition around 3:00 a.m. on [DATE] and reported to staff D the resident was not acting right. Staff D checked the resident's vitals and noted his/her oxygen level was lower, in the 80's and then staff D applied oxygen 2L/M. Staff D called the on-call physician J to report the change in condition. Physician J instructed staff D to keep the resident comfortable and stable through keeping the resident's oxygen saturation levels within normal limits, and to contact the resident's family in the morning to see what they wanted done. Staff D reported, physician J did not want the resident sent to the hospital. Staff D reported he/she tried to contact the family at the end of his/her shift. Staff D obtained and documented the resident's oxygen saturation levels 2 times after the 3:30 am set, and they were WNL with the administered oxygen. Staff D reported the resident never woke up on his/her shift. The resident had episodes in the past where he/she used to use oxygen and had breathing treatments. Interview with licensed nursing staff L on [DATE] at 6:00 a.m. revealed on [DATE] the resident acted differently and licensed nursing staff C reported the resident acted differently to licensed nursing staff D. Staff L said he/she thought staff C reported the resident had more labored breathing, increased lethargy, and fatigue. Interview with administrative nursing staff B on [DATE] at 2:45 p.m. revealed he/she remembered obtaining vitals on the resident on the morning of [DATE] but did not chart those and did not know why licensed staff C had not charted the resident's vitals either. Staff B expected vitals to be charted in the resident's clinical record. Interview with administrative staff A on [DATE] at 12:02 p.m. revealed he/she expected the nursing staff to monitor for change in condition for residents and he/she expected vital signs to be documented. Staff A reported he/she expected vital signs to be recorded and entered in the resident's clinical record and expected an assessment to be completed for the resident when he/she transferred to the hospital. Interview with physician N on [DATE] at 8:20 a.m. revealed the resident presented to the emergency department on [DATE] less alert, with dementia, and low oxygen saturation levels. Physician N stated his/her staff found an unexpected finding of a high INR and low hemoglobin and stated the resident had GI blood loss. Physician N [MEDICAL CONDITION] or blood loss caused the resident's death. Review of the 4 page facility policy and procedure on change in condition evaluation (CICE), dated [DATE] and revised on ,[DATE], revealed nursing judgment should be used to determine the urgency when contacting the provider. In the event the situation required calling 911, the change in condition evaluation (CICE) would not be used. If the resident received skilled services and condition change required monitoring, it was not necessary to complete both the Daily Skilled note and the CICE. Staff would make a note on the Daily Skilled Note to see the CICE for that shift and complete the CICE. The nursing staff could initiate a CICE, notify the provider of the change in condition, and after speaking to the provideruse the CICE to guide the change of shift report. If nursing shifts changed and a new nurse took over the care of the resident experiencing a change in condition, the first nurse should save and sign and lock the form and the next nurse should open a new CICE. The facility failed to ensure staff performed timely and adequate assessments, which included vital signs monitoring for resident #1. The resident received an anticoagulant (blood thinning) medication, experienced a change in condition before being transferred to the emergency room . The resident required emergency treatment, hospitalization and died .

The facility had a census of 73 residents, with 3 residents selected for sample. The sampled residents each experienced falls within the past seven months. Based on observation, interview and record review, the facility failed to provide 2 of 3 sampled residents with adequate supervision , including assessment of root cause analysis after each fall and development/implementation of appropriate fall prevention interventions after each fall, to prevent additional falls. (Residents #1 and #2) Resident #2 had severe cognitive impairment and experienced repeated falls. The facility consistently failed to complete root cause analyses of the falls and utilize those findings to develop/implement appropriate interventions to prevent additional falls. The resident required transportation to the hospital/or clinic after two falls, experienced a fractured rib as a result of one fall and a closed head injury with a fractured facial bone as the result of an additional fall. Findings included: -Resident #2's clinical record included a 2/15/16 Quarterly MDS (Minimum Data Set) which identified the resident with severe cognitive impairment (Brief Interview for Mental Status score of 4), independent with transfers, the need for stand by staff assistance for ambulation, balance impairments in all areas but able to stabilize without staff assistance, no functional limitations in range of motion of the upper or lower extremities, used a walker and a wheelchair as mobility devices, total continence of bowel and bladder, and experienced two no injury falls since the prior assessment. The 5/9/16 Significant Change MDS identified resident #2 with severe cognitive impairment (Brief Interview for Mental Status score of 4), the need for extensive assistance of one staff for transfers and ambulation, impaired balance in all areas and only able to stabilize with staff assistance, functional limitations in range of motion on one side of the upper extremities, used a walker and wheelchair as mobility devices, experienced two or more no injury falls and two or more injury - not major injury falls since the prior assessment , and experienced occasional bladder incontinence. CAAs (Care Area Assessments) completed on 5/16/16 included: Cognitive Loss: Described resident #2's [DIAGNOSES REDACTED]. ADLs (Activities of Daily Living) did not trigger for further assessment. Falls: Described the resident as at risk for falls, with physical symptoms of weakness, balance problems, overall decline in physical and cognitive function, and lower extremity weakness. According to the CAA, staff repeatedly instructed the resident to ask for assistance with transfers and ambulation and the resident failed to do so. Fall risk assessments completed for resident #2 identified the resident as low risk for falls on 1/15/16, medium risk on 2/11/16, 2/29/16, 5/6/16 and 6/10/16, and high risk on 3/23/16, 5/25/16 and 6/8/16. The current care plan included: 3/31/16 intervention: Impaired Cognitive Function as evidenced by short and long term memory loss and poor safety awareness. The care plan directed staff to present the resident with only one thought, idea, question or command at a time and reorient/supervise as needed. (Reviewed on 3/31/16) 5/16/16 intervention: ADL self-care performance deficit: Directed staff to provide assistance of one for transfers and use a wheelchair for mobilization. According to the care plan, the resident required extensive assist of one for toileting and safe transfers. 11/19/15 intervention: Resident is at risk for falls related to poor safety awareness, impulsive, activity intolerance, leg weakness, pain, and loss of balance with ambulation. The care plan directed staff to encourage the resident to call for assistance, remind the resident not to bend over to pick up dropped items, and ensure the resident wore proper foot wear. A revision on 11/19/15 directed staff to review bowel and bladder continence status and establish and/or review toileting plans based on the resident's needs. A revision on 3/28/16 directed staff to monitor the resident at 7:30 - 8:30 p.m. and assist with dressing for bed. Progress Notes described resident #2's multiple falls, which included: 1/15/16: Described an incident which occurred at 3:30 a.m. in which staff heard a noise coming from the resident's room and then found the resident on his/her knees on the floor. The Fall Investigation for the 1/15/16 fall noted the resident stated he/she woke up and needed to go to the bathroom quickly. The resident failed to put his/her shoes on correctly and failed to call for staff assistance. The facility completed a root cause analysis of the fall which included the resident's need to get to the bathroom. Fall prevention interventions after the fall included to educate the resident on how to put shoes on correctly and to use the call light for assistance. The fall investigation did not address reviewing the resident's toileting plan. 2/29/16: Described an incident which occurred at 10:46 a.m. in which resident #2 fell to the floor upon exit from his/her bathroom. Although requested, the facility could not provide any evidence of an investigation of this fall, including a root cause analysis and evidence of development/implementation of appropriate interventions to prevent additional falls. The fall investigation did not address reviewing the resident's toileting plan. 3/23/16: Described an incident which occurred at 8:30 p.m. in which staff found the resident on the floor near his/her bed. According to the documentation, the resident tried to get out of bed to go the bathroom when he/she slipped and fell . The Fall Investigation included a root cause analysis of weak legs, only had on TED (compression stockings) hose, slid out of bed. The root cause failed to mention the resident's reason he/she attempted to get out of bed which was to toilet. The documentation revealed no evidence of development/implementation of appropriate interventions in an attempt to prevent additional falls. The fall investigation did not address reviewing the resident's toileting plan. 3/24/16: Described an incident which occurred at 8:00 p.m. when staff found the resident on the floor of his/her room near the bathroom. The Fall Investigation included a root cause analysis of was walking with compression stockings only, possible weakness. The root cause failed to mention the resident's reason for ambulation and/or why he/she was on the floor near the bathroom. The fall investigation did not address reviewing the resident's toileting plan. 4/17/16: Described an incident which occurred at 1:30 a.m. in which the resident attempted to sit on his/her electric scooter and fell to the floor. The Fall Investigation lacked evidence of a root cause analysis to determine why the resident sat on the scooter at 1:30 a.m The fall investigation did not address reviewing the resident's toileting plan. A fax sent to the facility from the mid-level practitioner on 4/18/16 noted a fracture of the 11th rib as a result of the 4/17/16 fall. 5/6/16: Described an incident in which staff found the resident on the floor of his/her room. The Fall Investigation included the root cause analysis of didn't use call light, ambulating without assistance of front wheeled walker. The root cause failed to mention the resident's reason he/she attempted ambulation. 6/10/16: Described an incident which occurred at 5:05 p.m. in which staff found the resident on the floor near the bathroom door. The resident reported he/she hit his/her head during the fall. The Fall Investigation described the resident's fall which occurred when the resident ambulated to the bathroom without staff assistance, and then fell on the way out of the bathroom. According to the investigation, Resident will need to be toileted more often. The Fall Investigation revealed no evidence of a root cause analysis of the fall, and no evidence the facility changed the resident's toileting plan to include more frequent toileting. As a result of the fall with a blow to the head, the facility sent the resident to the hospital for further assessment. Discharge instructions from the hospital on [DATE] included [DIAGNOSES REDACTED]. During an observation on 7/5/16 at 4:50 p.m., resident #2 stood in the middle of his/her room, unattended by staff, and leaned on the walker. Survey staff notified Direct Care Staff C of the resident's location in the room on 7/5/16 at 4:50 p.m., and Direct Care Staff C responded with Oh, (he/she) always does that. Staff C failed to immediately go to the room to guide the resident to a more safe location. During an observation on 7/6/16 at 10:00 a.m., resident #2 slept while seated in an easy chair in his/her room, across the room from his/her bed. The resident's call light remained attached to the bed and not within the reach of the resident. The resident remained seated in the chair, without access to his/her call light, until 11:40 a.m., a time period of 1 hour and 40 minutes. During an observation on 7/6/16 at 11:40 a.m., Direct Care Staff D assisted the resident from the easy chair to a standing position. The resident leaned heavily on a walker in order to ambulate to the bathroom. The resident had an unsteady, wobbly gait during ambulation. Staff D left the resident unattended in the bathroom for a few minutes but remained in the adjacent room. Upon opening the bathroom door a few minutes later, Direct Care Staff D found resident #2 standing in front of the toilet, attempting to pull up his/her pants/brief. Staff D intervened and assisted the resident and then ambulated him/her for a short distance in the hallway before the resident became fatigued and required the wheelchair for transport to the dining room. During an observation on 7/6/16 at 1:32 p.m., the door to resident #2's room remained closed. The resident failed to respond to knocks on the door. When survey staff opened the door slowly and looked inside, resident #2 stood alone in the bathroom with the door wide open. The resident leaned over unsteadily and attempted to pull his/her slacks up. Survey staff immediately summoned help and staff entered the room and assisted the resident with ambulation to his/her bed. During an interview on 7/5/16 at 4:50 p.m., Direct Care Staff C reported resident #2 frequently transferred without assistance and refused to call for help. Staff C recalled the resident experienced a broken nose in one fall and described the resident's balance as horrible. Direct Care Staff C could not verbalize any interventions taken by staff to prevent falls other than they checked on the resident a lot and when we have a chance. During an interview on 7/6/16 at 11:50 a.m., Direct Care Staff D reported he/she did not assist resident #2 to the easy chair after breakfast that morning, and stated the resident most likely transferred to the chair without staff assistance. Staff D reported the resident experienced multiple falls in the past. Direct Care Staff D could not verbalize any interventions implemented to prevent falls other than checking on the resident whenever we go down the hall. During an interview on 7/6/16 at 1:30 p.m., Direct Care Staff E reported he/she did not assist resident #2 to the chair after breakfast that morning and didn't know how the resident got into the chair. During an interview on 7/6/16 at 2:50 p.m., Licensed Nurse E reported resident #2 experienced multiple falls in the past because he/she refused to call for assistance and got up from the bed or chair independently. Nurse E described the resident as very unsteady . Licensed Nurse E could not verbalize interventions put in place to prevent falls except he/she advised staff to check on him/her every time they went down the hallway. During an interview on 7/12/16 at 5:00 p.m., Administrative Nurse B confirmed the clinical record lacked evidence staff completed a root cause analysis and/or developed and implemented appropriate new fall prevention interventions after falls on 1/15/16, 2/29/16, 3/23/16, 3/24/16, 4/17/16, 5/6/16 and 6/10/16. Administrative Nurse B also confirmed the resident experienced fractures as a result of falls which occurred on 4/17/16 and 6/10/16. The facility's 5/16 Fall Prevention and Management policy and procedure included, .Proactive approach requires identifying a potential risk and taking steps to mitigate (eliminate) the risk before actual harm occurs. In a fall prevention program, a proactive approach will include the post-fall investigation to determine the cause of the fall (root cause analysis), identifying risk factors and taking steps (interventions) to prevent the fall from happening again. The policy/procedure defined root cause analysis as a method of problem solving used for analysis identifying the root causes of faults or problems. Root cause analysis in nursing is a structured method used to analyze serious adverse events such as falls. The facility failed to provide resident #2 with adequate supervision, including assessment of root cause analysis after each fall, and development/implementation of appropriate fall prevention interventions after each fall to prevent additional falls. Resident #2 had severe cognitive impairment and experienced repeated falls. The facility consistently failed to complete root cause analyses of the falls and then develop/implement appropriate interventions to prevent additional falls. The resident experienced a fractured rib as a result of one fall and a closed head injury with a fractured facial bone as the result of an additional fall. - Resident #1's clinical record included dictated notes from a 6/12/16 physician's visit which identified the resident with multiple medical diagnoses, including Multiple Sclerosis/MS (a progressive disease of the nerve fibers of the brain and spinal cord) and a fracture of the right radius (one of the bones going from the wrist to the elbow). The 8/12/15 Admission MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 14), the need for stand -by assistance of one staff for transfers and ambulation, impaired balance in all areas but able to stabilize without staff assistance, no functional limitations in range of motion of the upper or lower extremities, used a walker and wheelchair as mobility devices, had a history of [REDACTED]. The 5/2/16 Quarterly MDS identified the resident with no change in cognition, range of motion or balance from the 8/12/15 MDS, and two or more no injury falls since the prior assessment. CAAs (Care Area Assessments) completed on 8/17/15 included: ADLs (Activities of Daily Living): Described the resident's leg weakness and legs giving out unexpectedly which resulted in repeated falls. The resident frequently failed to ask staff for assistance with transfers. Falls: Described the resident's lower extremity weakness and balance issues as related to the [DIAGNOSES REDACTED]., and how the falls occurred most often when his/her legs gave out during ambulation. The resident experienced a fall in the facility on 8/9/15. Fall Risk Assessments included: 8/24/15 = 15 = medium risk 12/19/15 = 11 = low risk 2/4/16 = 20 = high risk 4/28/16 = 16 = high risk 5/13/16 = 11 = low risk 5/26/16 = 15 = medium risk 6/22/16 = 16 = high risk The care plan included: Impaired cognition evidenced by forgetfulness/poor safety awareness (5/10/16) ADL self-care performance deficit related to disease process, impaired balance and dragged (his/her) feet when walking at times, MS, inability to perform ADL tasks independently and safely. The care plan directed staff to supervise ambulation and transfers and to use a walker for ambulation. The care plan also noted the resident's fluctuating needs based on fluctuating medical condition due to the [DIAGNOSES REDACTED]. Falls: At risk for falls related to impulsivity and not asking or waiting for assist; gait/balance problems secondary to feet/toes dragging at times, and a history of falls. The care plan included multiple fall prevention interventions and included the physician's report which stated falls were expected and clinically unavoidable secondary to MS. Progress Notes included multiple entries related to falls, including: 2/4/16 at 10:31 a.m.: Described an incident in which staff found the resident on the floor in his/her room. The Fall Investigation identified the root cause of the fall as resident became dizzy and weak in the legs without notice. Review of the clinical record revealed no evidence staff developed/implemented new fall interventions after the 2/4/16 fall in an attempt to prevent additional falls. 2/28/16 at 11:00 a.m.: Described an incident in which the resident fell lost his/her balance and fell in his/her room. The Fall Investigation revealed staff failed to complete a root cause analysis. Review of the clinical record revealed no evidence staff developed/implemented new interventions after the 2/28/16 fall in an attempt to prevent additional falls. 4/28/16 at 1:50 p.m.: Described an incident in which staff found the resident on the floor in his/her room. The fall investigation revealed staff failed to complete a root cause analysis of the fall. Review of the clinical record revealed no evidence staff developed/implemented new interventions after the 4/28/16 fall in an attempt to prevent additional falls. 5/21/16 at 3:35 p.m.: Described an incident where the resident fell to the floor in his/her room while getting items out of the closet without staff assistance. The Fall Investigation identified the root cause analysis of the fall as MS (multiple sclerosis). Review of the clinical record revealed no evidence staff developed/implemented new interventions after the 5/21/16 fall in an attempt to prevent additional falls. 5/26/16 at 11:45 a.m.: Described an incident in which staff found the resident on the floor of his/her room near the recliner. The resident complained of right wrist pain after the fall. A note written at 4:05 p.m. that same day described the resident's return from the clinic with a [DIAGNOSES REDACTED]. The Fall Investigation lacked evidence staff completed a root cause analysis of the fall. During an observation on 7/6/16 at 7:15 a.m., Direct Care Staff E assisted resident #1 with ambulation from the recliner to the bathroom. The resident required assistance to rise from a seated to a standing position. The resident used a walker and assistance of one staff for ambulation to the bathroom. He/she walked with a slightly stooped forward posture and a steady gait. During the observation, the resident was alert and oriented and able to verbalize his/her needs. During an interview on 7/5/16 at 4:45 p.m., Direct Care Staff C reported resident #1 required assistance of one staff and a gait belt for all transfers. Staff C recalled the resident experienced multiple falls since admission. Staff C could not verbalize interventions implemented by staff to prevent the resident from additional falls. During an interview on 7/6/16 at 11:50 a.m., Direct Care Staff D reported resident #1 liked to walk as much as possible but knew when he/she was too weak to walk. According to Staff D, the resident frequently tried to get up independently and refused to call for staff assistance. Staff D could not verbalize interventions implemented to prevent falls other than keeping a close eye on the resident. During an interview on 7/6/16 at 1:25 p.m., resident #1 described himself/herself as a very independent person and stated he/she intentionally transferred and ambulated without staff assistance in spite of the facility's requests that he/she call for assistance. According to the resident, That's just the way I am and no one is going to change me. During an interview on 7/12/16 at 5:00 p.m., Administrative Nurse B confirmed the clinical record lacked evidence staff completed a root cause analysis and/or developed and implemented appropriate new fall prevention interventions after falls on 2/4/16, 2/28/16, 4/28/16, 5/21/16 and 5/26/16. Administrative Nurse B also confirmed the resident experienced a fracture as a result of a fall which occurred on 5/26/16. According to Administrative Nurse B, resident #1 had the cognitive ability to know to call for assistance prior to transfers and ambulation, but refused to do so, and experienced many falls as a result of the refusal to ask for assistance. The facility's 5/16 Fall Prevention and Management policy and procedure included, .Proactive approach requires identifying a potential risk and taking steps to mitigate (eliminate) the risk before actual harm occurs. In a fall prevention program, a proactive approach will include the post-fall investigation to determine the cause of the fall (root cause analysis), identifying risk factors and taking steps (interventions) to prevent the fall from happening again. The policy/procedure defined root cause analysis as a method of problem solving used for analysis identifying the root causes of faults or problems. Root cause analysis in nursing is a structured method used to analyze serious adverse events such as falls. The facility failed to provide resident #1 with adequate supervision (assessment of root cause analysis after each fall, development/implementation of appropriate fall prevention interventions after each fall) to prevent additional falls.

The facility had a census of 71 residents with 19 selected for sample and 3 residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents sampled for pressure ulcers received necessary treatment and services to prevent the development of pressure ulcers, promote healing, and prevent infections. The facility failed to complete thorough skin assessments for resident #69 upon admission and daily with the use of an orthopedic leg immobilizer. Resident #69 developed an unstageable pressure ulcer to the right lower leg as a result of pressure from the leg immobilizer. The facility also failed to ensure staff implemented care planned interventions for resident #116 in order to promote healing of an unstageable pressure ulcer to his/her right great toe that was present on admission to the facility. Findings included: - Review of resident #69's electronic medical record signed physician orders [REDACTED]. Resident #69's 4/18/14 Admission MDS (minimum data set) assessment revealed the resident had intact cognition and required limited assistance of 1 person for bed mobility, transfers, and toilet use. The resident used a walker and wheelchair for mobility and was continent of urine. According to the assessment, the resident was at risk for pressure ulcer development and had no unhealed pressure ulcers. Resident #69's 4/22/14 pressure ulcer CAA (care area assessment) summary revealed the resident had mobility limitations due to weakness following a recent illness. Review of resident #69's MDS assessments revealed the facility completed an entry record on 5/22/14 after a hospitalization and a readmission/return MDS on 5/29/14 which indicated the resident had intact cognition and required extensive assistance of 2 persons for bed mobility and transfers; and walking did not occur. The assessment stated the resident was continent of urine. The facility identified the resident as at risk for pressure ulcers and indicated the resident had 1 unhealed stage 2 pressure ulcer discovered on 5/26/14, with the most severe tissue type described as eschar (dead, necrotic tissue). According to the assessment the resident had no pressure ulcers present on admission. Pressure ulcer treatment included pressure relief devices for the chair/bed, turning repositioning program, pressure ulcer care, and application of ointments/medications. Resident #69's 6/19/14 30 day MDS revealed the resident had intact cognition and required extensive assistance of 2 for bed mobility, transfers, and toilet use. The assessment identified the resident as at risk for pressure ulcer development and had 1 unstageable pressure ulcer with coverage of the wound bed with slough and/or eschar. The wound measured 5.8 cm (centimeters by 3.0 cm with no depth. The pressure ulcer was not present on admission to the facility. The facility used pressure relief devices for the resident's chair/bed, turning/repositioning program, nutrition/hydration interventions, pressure ulcer care and application of ointments and medications as treatment. Resident #69's 5/22/14 nursing care plan stated the resident had the ability to assist with turning and getting in and out of bed with the assistance of turning bars on the bed. The resident requires a mechanical lift with assistance of 2 staff for transfers. The care plan also indicated the resident was at risk for pressure ulcer development. The care plan directed staff to turn and reposition every 2 hours. A 6/24/14 revision to the care plan identified an unstageable pressure ulcer to the resident's right calf and instructed staff to check the skin under the resident's brace, no less than daily for any concerns and notify the nurse immediately of any new areas of skin breakdown, redness, blister, bruises, or discoloration. The resident also had a pressure relief device for his/her chair. According to the care plan the resident had a history of [REDACTED]. The nursing care plan lacked interventions related to the resident's leg immobilizer and skin care beneath the immobilizer after returning to the facility on [DATE] with the brace. The re-admission data collection tool dated 5/22/14 for resident #69 stated the facility admitted the resident from the hospital following a femur and humerus fracture (broken leg and arm). The assessment indicated the resident had a right femur (long leg bone) fracture with an immobilizer (leg brace) in place with no pressure areas. Resident #69's admission physician orders [REDACTED]. to the upper thigh. The admission nursing physical exam for the resident stated he/she had a right fractured femur with an immobilizer in place. Resident #69's nurses/progress notes included the following: Documentation on 5/22/14 lacked evidence of an assessment of the resident's skin under the immobilizer. On 5/25/14 at 1:04 p.m., the nurse noted the right leg continued in the immobilizer with swelling to the skin that remained indented to both lower extremities. On 5/26/14 at 9:22 a.m., the note stated the resident had swelling that indented to both lower extremities without pain. The resident had facial grimacing with transfers and had the immobilizer present to the right lower extremity. A nurse's note on 5/26/14 at 10:58 a.m. indicated staff only removed the brace to dress the resident; otherwise, it remained on all the time. On 5/26/14 at 2:54 p.m. documentation indicated the resident voiced his/her right calf had a burning sensation and upon assessment the nurse visualized a 1.6 cm (centimeter) by 1.1 cm blackened area to the right calf, under the leg brace. The RN (registered nurse) Wound Care Assessments for resident #69 included the following: Documentation on 5/26/14 revealed the resident had an unstageable pressure ulcer to the right calf that measured 3.2 by 1.3 cm with 1.1 cm blackened area to the right of the calf under the edge of the brace where the straightening rods of the brace rubbed with surrounding red/purple, non blanchable (redness of the skin that does not turn white or purple when pressed on) area. According to the note the brace should be left on until the right leg fracture healed. The resident complained the area burned. The note also described the wound as 100% eschar and placed [MEDICATION NAME] (special type of wound dressing). During an observation on 7/9/14 at 1:43 p.m., Licensed Nurse Y entered resident #69's room and changed the pressure ulcer dressing. Visualization of the wound revealed black eschar approximately 4 cm x 2 cm with slight redness to outer surrounding edges and dark brown bloody drainage to the dressing. During an observation on 7/14/14 at 9:41 a.m. direct care staff Z assisted resident #69 with the bedpan. After using the bedpan, staff AA applied the brace padded with sheepskin to the right lower leg. During an interview on 7/14/14 at 10:19 a.m., direct care staff AA stated that the resident has one pressure ulcer to the right lower leg and that he/she would make sure there is no drainage to the dressing and that the bandage is secure. The staff then stated that there is a pad that is placed underneath the leg before the brace is applied but cannot remember what it is called. The staff further reported that the resident's right leg needs to be propped up and elevated in the bed or the recliner, and to make sure that the leg rest is provided in the wheelchair. During an interview on 7/14/14 at 11:52 a.m., licensed staff T stated the staff will advise him/her when they see something red on a resident and he/she would assess it. If there is a pressure ulcer or a risk for developing into a pressure ulcer, the nurse should advise the director of nursing and the physician, and follow the protocol for skin care. During an interview on 7/14/14 at 3:40 p.m., administrative nurse B verified resident #69's record lacked evidence of any skin checks or assessments under the resident right leg brace from his/her admission on 5/22/14 until staff discovered the wound on 5/25/14. Nurse B further added the CNAs (certified nurse's aides) should be looking at the resident's skin when they provide care to the resident and the nurses should be assessing the resident three times a day for skin issues. An interview on 7/16/14 at 3:50 p.m. with Physician DD verified the resident had recent development of a pressure ulcer, but had not yet assessed the resident and could not comment on the status of the pressure ulcer. The facility's March 2007 Pressure Ulcer policy stated the center would utilize prevention and assessment interventions to ensure that a resident entering the center without pressure ulcers would not develop a pressure ulcer unless their condition demonstrated that was unavoidable. The policy further stated each resident should have a head to toe assessment performed by a licensed nurse during the admission process. Residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes in their skin condition. The facility failed to provide resident #69 with daily skin assessments under the orthopedic splint from readmission into the facility for a total of 4 days even though the resident wore a brace on the right lower leg continuously. The resident developed an unstageable avoidable pressure ulcer on the right lower leg. - Review of resident #116's signed medication review report, dated 6/9/14, revealed the following Diagnosis: [REDACTED]. Review of the resident's admission MDS (Minimum Data Set) dated 5/29/14 revealed a BIMS (Brief Interview for Mental Status) score of 07, indicating severe cognitive impairment. The resident required extensive assistance for bed mobility, transfers, walking in his/her room, and locomotion on/off the unit. The assessment reported the resident had one unstageable pressure ulcer present upon admission. The assessment indicated an admission date of [DATE]. Review of the ADL(activities of daily living) Functional/Rehabilitation Potential CAA (Care Area Assessment) dated 5/29/14 revealed the resident required extensive assistance with ADLs of 1 staff. The resident had an an unstageable pressure ulcer to the left great toe (the pressure ulcer was actually on the right great toe) upon admission to the facility. The resident required extensive assistance with transferring, bed mobility, and he/she had declining physical function due to a lung mass. The resident used his/her wheelchair for mobility. Review of the Nutritional Status CAA dated 5/29/14 revealed the resident had an unstageable wound to the tip on the right great toe, the wound surface was necrotic. The resident received a mechanically altered, pureed diet with nectar consistency liquids. Review of the Pressure Ulcer CAA dated 5/29/14 revealed the resident had an unstageable pressure wound to the tip of the right great toe, that measured 1.6 cm x 1.6 cm (centimeters) on admission. The wound was open to air and the resident's shoe was kept off of the foot. Review of resident #116's care plan, initiated 5/22/14, directed staff to assist the resident to turn/reposition every 2 hours with the assistance of 1 staff, provide a pressure relieving recliner, monitor nutritional status, serve diet as ordered, monitor and record intake, the resident was not wear a shoe on the right foot and only a non-skid sock, and notify the nurse immediately of any new areas of skin breakdown. Review of a Braden Scale (score of pressure ulcer risk) dated 5/22/14 revealed a score of 20, indicating the resident was not at risk for pressure ulcers. Review of a Fax Communication to the Physician dated 6/5/14 revealed an order for [REDACTED]. During an observation on 7/9/14 at 8:40 a.m., 8:55 a.m., and 9:10 a.m. the resident rested flat in bed with his/her shoes on both feet. At 9:18 a.m. the resident sat on the edge of his/her bed, with shoes in place. Social services staff F entered the resident's room with a wheelchair and the resident transferred him/herself to the wheelchair. During an observation on 7/10/14 at 12:05 p.m. licensed nursing staff I removed the resident's right foot sock. The tip of the resident's right great toe had a black area the approximate size of a dime, open to air. Staff I reported the resident received [MEDICATION NAME] treatments twice a day. During an interview on 7/10/14 at 3:50 p.m. with direct care staff J revealed the resident had shoes, but did not like to wear them. Staff J reported the resident wore non-skid socks. Staff J reported he/she was unsure about interventions for the resident's pressure ulcer other than elevating the resident's foot and whatever the resident requested. During an interview on 7/10/14 at 4:35 p.m. with licensed nursing staff N revealed he/she was unsure of the type of footwear the resident should wear and would need to review the care plan. During an interview on 7/14/14 at 12:37 p.m. with direct care staff K revealed he/she was unsure about interventions for care of the resident's foot wound. Staff K reported the resident wore socks during the day. During an interview on 7/14/14 at 1:00 p.m. with licensed nursing staff I revealed resident #116 wore socks throughout the day. During an interview on 7/14/14 at 2:23 p.m. with administrative nursing staff B revealed the resident had the wound on admission, and the wound was classified as a pressure ulcer. Staff B reported he/she monitored the wound weekly for improvement. Staff B reported he/she expected the staff to follow the care plan. Review of the facility's policy for Pressure Ulcers, dated 9/2012, revealed a resident who had a pressure ulcer received the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcer from developing. The facility failed to ensure resident #116 wore non-skid socks on the right foot instead of shoes, as care planned. The resident had an unstageable pressure ulcer on the right great toe that was present on admission to the facility.

The facility census totaled 69 residents with 27 included in the sample. Based on observation, interview and record review, the facility failed to develop and implement a plan on how to manage the severe pain for 2 of 4 sampled residents reviewed for pain (#1 and #89), failed to develop, implement, and revise interventions for 3 of 5 sampled residents with skin issues other than pressure ulcers (#23, #27 and #49) and failed to monitor the [MEDICAL TREATMENT] site after [MEDICAL TREATMENT] and coordinated the care for the resident between both the facility and the [MEDICAL TREATMENT] provider for 1 of 1 sampled resident who received [MEDICAL TREATMENT] services. (#1) For residents #1 and #89, the facility assessed the residents' pain, but failed to develop, implement, and monitor or modify a pain management plan for either resident. Both residents experienced excruciating pain and/or incapacitating distress because of the facility's failure to address the residents' pain. This failure placed both residents #1 and #89 in immediate jeopardy in regard to severe, unrelieved, pain. For resident #27, the facility failed to follow the care plan regarding brief usage and failed to give protein supplements between meals. The resident's wound increased in size and developed drainage. Findings included: - Review of a cumulative [DIAGNOSES REDACTED].#89 with [MEDICAL CONDITION] ([MEDICAL CONDITION]--a disease of the lungs that included asthma),[MEDICAL CONDITION](Gastro-[MEDICAL CONDITION] Reflux Disease-acid reflux), constipation, irregular heart rate, [MEDICAL CONDITION] (elevated fats located in the blood), DM (Diabetes Mellitus--diabetes),[MEDICAL CONDITION](Hypertension--high blood pressure), CAD ([MEDICAL CONDITION]-buildup of plaque in the coronary arteries, leading to reduced blood flow), [MEDICAL CONDITION] (low oxygen levels in the blood), and lethargy. Review of the admission MDS (Minimum Data Set-a required assessment) dated 2/19/13 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11/15 (indicated moderately impaired cognition), exhibited daily behavioral symptoms not direct toward others (included verbal/vocal symptoms like screaming, disruptive sounds), and that the behaviors significantly intruded on the privacy or activity of others, received PRN (as needed) pain medications, received non-medication intervention for pain, identified the resident had pain almost constantly, that made it hard for the resident to sleep at night, limited his/her day-to-day activities because of pain, and identified the resident rated the pain intensity at a 7 on a 0-10 pain scale with zero being no pain and ten as the worst pain the resident could imagine. Review of the quarterly MDS dated [DATE] identified the resident with short-term memory problems and moderately impaired cognition. It also identified the resident received PRN (as needed) pain medications, received non-medication interventions for pain, had pain almost constantly that made it hard for the resident to sleep at night, and the resident limited his/her day-to-day activities because of the pain. The resident also described the pain intensity as a 10 on a scale of 0-10 with 0 being no pain and ten as the worst pain he/she could imagine. The resident's rating of the pain intensity increased from the previous assessment. Review of the Pain CAA (Care Area Assessment- a further assessment) dated 2/21/13 identified the resident had chronic lower back pain that at times was excruciating, and kept him/her awake at night at times. The CAA identified the resident described the pain as almost always present. The CAA identified the resident had explained he/she had 2 prior back surgeries that were not successful and the Doctor wanted to do a 3rd surgery but could not guarantee it would relieve the pain so the resident refused the 3rd surgery. The CAA identified the resident had MEDICATION ORDERS FOR [REDACTED]. The CAA identified the resident had taken both the [MEDICATION NAME] and the Tylenol during the assessment period, but not the [MEDICATION NAME]. The assessment failed to identify if the medication had been effective at relieving the resident's pain or what non-medication interventions, if any, the staff attempted and what worked for the resident at relieving his/her pain. Review of the resident's care plan, dated 2/27/13, revealed it lacked a pain management plan. According to the facility's policy on "Routine Daily Practice", dated 7/2012, the care plans "should reflect resident centered items that are unique to that resident's care." The policy identified the treatment of [REDACTED]. Review of the undated care plan interventions located in the computer kiosks on each hall revealed the following intervention: Explain to the resident that staff will assist with cares as soon as they are available. Review of the facility's undated comprehensive pain assessment, completed by a licensed practical nurse, identified that the resident verbalized pain at the back and left groin. The resident rated the pain as a 9 on a scale of 0-10 (with 0 as no pain and 10 as the worst pain ever). The resident rated the pain at its least at a 6 and at its worst at a 9. The resident identified a tolerable level of pain was a 3-4. The staff had failed to complete the remaining 4-page comprehensive pain assessment. Review of the May 2013 MAR (Medication Administration Record) identified the resident had been in the hospital for 7 days, from 5/13/13 until 5/21/13. Prior to the resident's hospitalization , the resident's orders for pain included PRN use of Tylenol, [MEDICATION NAME] (a non-narcotic pain medication) and [MEDICATION NAME] (a narcotic pain medication). According to the MAR, the staff had given the resident 4 doses of Tylenol between 5/1 through 5/13, twice for an increased temperature above 100 degrees Fahrenheit and once for "aching, not feeling well", and staff failed to document why on the last dose. The front of the MAR indicated [REDACTED]. Finally, the staff administered 14 doses of [MEDICATION NAME] to the resident during the same timeframe. The reasoning showed that the resident identified back pain that ranged from an 8-10 on a pain scale of 0-10. The staff failed to document the effectiveness of the [MEDICATION NAME] after each administration, but the resident did identify twice that the medication had not been effective, and on 6 other times staff documented the resident as "resting" but did not get a verbal report from the resident. Only once did the staff document that the resident reported the medication as effective in reducing the pain level. After the resident returned from the hospital on [DATE], the physician ordered [MEDICATION NAME] (a narcotic pain medication) for the resident. Between the dates of 5/21/13 and 5/31/13, the staff documented the administration of 25 doses of [MEDICATION NAME], mostly for back and leg pain, but also for "general" or "over-all" pain. When staff documented the resident's rating of the pain, the resident rated the pain between 8-10 on a scale of 0-10. Again, staff failed to follow up on the effectiveness of each dose given, but on the doses staff did follow up on, the resident reported little relief of the pain on 11 of the doses. The staff documented the resident rested well after 5 of the doses of [MEDICATION NAME]. Staff also documented the administration of PRN Tylenol twice, both times after the resident reported a pain level of 10, once for leg pain and once for general pain. The resident reported the Tylenol did not ease the pain much once and the other time staff documented the resident rested. Review of the June 2013 MAR indicated [REDACTED]. On 05/28/2013 at 3:25 p.m., observation revealed the resident sat in a wheelchair in his/her room. The resident stated they had back pain and activated the call light. At 3:28 p.m., direct care staff entered the room and the resident reported to the direct care staff that he/she had back pain of 8-9. The staff left the room, saying they would go tell the direct care staff that passed the medications. By 4:05 p.m., or 37 minutes later, observation revealed staff had not brought the resident a pain pill. On 6/3/13 at 6:47 a.m., observation revealed Direct care staff X entered the resident's room to assist the resident up for the day. While assisting the resident, staff X asked the resident how he/she felt, and the resident responded "Not so good, I hurt." Staff X asked if the resident had told Direct care staff BB (who passed medications that morning) that he/she hurt. The resident confirmed that he/she had not asked for a pain pill. Staff X told the resident that he/she would let staff BB know that the resident needed a pain pill after he/she helped the resident up. Staff X then asked the resident how long he/she had been hurting, and the resident replied "at least a couple of weeks." Staff X asked if the resident had told the nurses and the resident confirmed that he/she had, but the nurses did not think it was that big a deal. Staff X said he/she would tell the Licensed nurse K about the resident's pain, also. At 6:59 a.m., Direct care staff G entered the room and together with staff X rolled the resident over in bed. The resident cried out "Oh! Oh, my hip!!" Staff G rolled the resident back onto his/her back and asked the resident if he/she had gotten his/her medicines yet this morning. The resident stated that he/she had not. Staff G then told the resident "We are going over again, this time slower" and the resident agreed. Even rolling the resident slower, the resident cried out "Oh, my hip!" and staff G said "I know honey" but kept going with pulling the resident's slacks up and positioning a sling underneath the resident. As staff X and G assisted the resident into a sling and used the mechanical lift to transfer the resident from the bed into the wheelchair, the resident yelled out "OH, my hip! I can't take any more of this!" Staff G said "We are going to get you in the chair and we will make it quick, ok?" The resident kept repeating, "Oh, my hip, oh! My hip!" Once in the wheelchair, the aides finished dressing the resident. The staff then left the resident seated up in a wheelchair in his/her room. Once staff G and X left the room, they immediately went into another room, without telling the charge nurse or the Direct care staff who passed medications about the resident's pain. On 6/3/13 at 8:03 a.m. observation revealed Licensed Nurse K talked with the resident in his/her room. The resident told Nurse K that he/she hurt. Nurse K told the resident that someone else would be bringing him/her a pain pill. At 8:19 a.m. observation revealed the resident started calling out for help while seated in a wheelchair in his/her room. Social Service staff NN went in to talk to the resident and the resident stated that he/she was having a burning pain. Staff NN then activated the resident's call light and left the room. After staff NN left the room, staff NN went to Direct care staff BB, who stood by a medication cart down the hall from the resident's room and told staff BB that the resident was hurting. As staff NN walked by Nurse K, staff NN told the Nurse K that the resident had pain. Observation revealed at 8:20 a.m., 1 hour and 30 minutes after staff were first made aware that the resident had pain, Direct care staff BB gave the resident a pill. Staff BB told the resident it was a pain pill. On 6/3/13 at 11:47 a.m., observation revealed Direct care staff P brought the resident back to his/her room. The resident asked the staff member something for pain and reported the pain at an 8. Staff P stated that he/she would go tell staff BB. No one returned to the room to talk to the resident about his/her pain until staff X and G assisted the resident into bed at 12:10 p.m. Observation on 6/4/13 at 7:35 a.m. revealed the resident sat in a wheelchair in the commons area near the nurse ' s station, with no staff in the direct area. The resident identified he/she had pain and rated it an 8 and said it was "all over." The resident did not recall if he/she had gotten a pain pill yet. The resident reported pain again at 7:44 a.m. of pain and now rated the pain at 9, identified the pain in his/her arm and said it was "getting worse." Resident continued to sit in the commons area until 7:46 a.m., when Direct care staff F walked by and the resident called him/her over and explained he/she had pain. Staff F said that he/she would try to find someone. Staff F returned at 7:48 a.m. and told the resident that he/she had already had a pain pill, then left the resident without offering other alternatives to relieve pain. On 6/4/13 at 8:32 a.m., observation revealed the resident sat in a wheelchair in the dining room, eating breakfast independently. Observation on 6/4/13 at 9:20 a.m. revealed Direct care staff P assisted the resident from the dining room to the commons area by the nurse's station. The resident told the nurse that he/she was not feeling well and staff P said he/she would let Licensed Nurse D know that the resident was not feeling well. The resident reported that his/her back hurt and rated the pain at an 8. The resident reported he/she had no pain relief from the previous pain pill. The resident stated "My God I hurt." Observation at 9:23 a.m. revealed Administrative Nurse C assisted the resident back to his/her room, then left the resident in his/her room. On 6/4/13 at 9:26 a.m. observation revealed the resident sat in a wheelchair in his/her room with the call light attached to the wheelchair. The resident stated Nurse C had said he/she would tell Nurse D that the resident was hurting. At 9:39 a.m., when no staff returned to talk to the resident about his/her pain, the resident activated his/her call light. After 3 minutes, then again 3 minutes after that the call light re-paged to the Direct care staff, without response. The resident reactivated the call light at 9:45 a.m. At 9:47 a.m., Nurse C answered the resident's call light to report to the resident that it was not time for another pain pill. On 6/3/13 at 7:03 a.m., the resident stated he/she had not slept well at all the night before. The resident reported that his/her back and legs hurt him/her. The resident reported a history of 2 back surgeries and that the doctors wanted to do a 3rd surgery on his/her back. The resident had asked them if they could guarantee that it would take away the pain, and the doctors said they could not guarantee it so the resident said he/she was not going through another surgery, so he/she dealt with a lot of pain. He/she said it hurt to stay in any one position for too long. On 6/3/13 at 6:04 a.m., Direct care staff Y stated the resident would call out for help during the night because he/she hurts. Staff Y stated that the staff usually went in and repositioned the resident and that seems to help. 6/3/13 at 8:35 a.m., Direct care X confirmed that the resident had pain quite a bit of the time. When he/she tells us he/she is hurting, the staff let the medication aide (direct care staff that pass medications) know that the resident would like a pain pill. On 6/3/13 at 1:57 p.m. Direct care staff G stated the resident has pain a lot in his/her back, legs and shoulders. Staff G stated that the direct care staff let the nurses know about the resident's pain and they come down and look him/her over. On 6/4/13 at 4:11 p.m. Direct care staff HH stated that the resident "likes to complain about pain a lot" and that it was hard to believe that the resident really had all that pain. Staff HH called the resident a "hypochondriac" (a person who is abnormally anxious about their health). Staff HH stated the resident's pain "travels--sometimes it is in (his/her) shoulder, sometimes it is in (his/her) back--(he/she) never has it in the same place two times in a row. I think (he/she is saying (he/she) is in pain for the attention." On 6/3/13 at 5:52 a.m., Licensed nurse Z stated the resident complained about pain during the night, but staff would go in and reposition the resident and it seems to help for a while. On 6/4/13 at 3:30 p.m. Licensed nurse EE identified the resident had quite a bit of pain. When that happened, Nurse EE stated he/she would go down and assess the resident and then tell the medication aide to give a PRN pain pill and that usually helped. On 6/6/13 at 11:00 a.m., Administrative Nurse C confirmed they were aware there were concerns with the facility's handling of the resident's pain. On 6/4/13 at 10:25 a.m., Physician KK stated that pain for residents was not a topic that had been discussed at the last Quality Assessment and Assurance meeting that he/she could remember. Physician KK reported the only time the group had discussed pain is "when it had been a real problem." Review of the facility's policy on pain management, last revised on 1/09, revealed that a registered nurse would assess the resident's pain level and together with the physician and the interdisciplinary team develop interventions which could be non-pharmacological as well as pharmacological. The registered nurse would review the resident's response to the medication interventions and work closely with the physician to assist in the individualized pain management plan. The policy identified the care plan team and nurses "must continually monitor and evaluate the pain management plan." The policy directed the facility staff to develop a care plan including pain, goal and interventions. The care plan was to define what pain scale the resident and staff used as well as the level of pain that the resident could tolerate. The policy directed staff to document the effectiveness of the pain management plan at least monthly. The policy directed staff to document the summarization of pain analysis on a specific form. The form was to be completed quarterly for ongoing pain and for resident on a pain management program. Staff were to document medication changes, status of pain control, resident's general condition noting any significant changes, cognitive status, behavior manifestations or occurrence of new pain and the resident's acceptance of pain level. The facility failed to develop, implement and modify a pain management program for a resident with a history of back surgeries and with multiple reports of pain. The resident's pain was severe enough that it interfered with the resident's sleep patterns at night and the assessment identified the resident had to change his/her day-to-day activities. The facility's failure to address this severe, on-going, excruciating pain placed the resident in immediate jeopardy. The immediate jeopardy was considered abated on June 7 th at 12:49 p.m. when the facility provided evidence they had completed a comprehensive pain assessment by a registered nurse, the development of a pain management care plan that included staff to evaluate and document the resident's pain every 30 minutes, the use of warm moist packs when the resident identified he/she had pain, discussion with the physician to determine if routine narcotic medication would be effective on the morning of 6/7/13, and the education of staff on all 3 shifts regarding the newly-developed plan to address the resident's pain. The deficient practice remained at a scope and severity of a D. - Review of resident #1's admission MDS (minimum data set) dated 3/5/13 revealed a BIMS (brief interview for mental status) score of 15 (cognitively intact). The resident required total assist of two staff members for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. The resident required set up help and supervision with meals. The assessment identified the resident received PRN (as needed) pain medication and received non-medication interventions for pain. The pain assessment portion of the assessment indicated the resident had no pain indicators in the last 5 days of the assessment. Review of the resident's ADL (activities of daily living) CAA (care area assessment) dated 3/11/13 revealed the resident required total assist with all ADLs. The resident had severe obesity with deformities of his/her feet and muscle weakness of the legs. The resident required re-positioning routinely to prevent the development of pressure areas. The resident required a 28-30 inch wheelchair for positioning/mobility, and the staff documented the plan to use a 26 inch wheelchair for transportation purposes out of the facility only. Review of the admission MDS CAA revealed the pain CAA did not trigger. Review of resident #1's current care plan on 6/5/13 at 2:25 p.m. revealed the facility failed to address pain in the care plan. Review of resident #1's undated pain assessment, located in the resident ' s record at the nurse ' s station, revealed staff had not completed or signed the assessment. Review of a second pain assessment for resident #1, dated 6/5/13, revealed the resident had pain in both feet that staff documented the resident reported "hurts bad, the right foot worse". The resident indicated pain in the bottom of both feet and rated the pain as 9.7 on a scale of 1-10 (1=no pain 10=worst pain ever). The resident reported his/her pain at its least at 8 and rated his/her pain at its worst as greater than 10. Review of the [MEDICAL TREATMENT] communication sheet dated 5/30/13 revealed the [MEDICAL TREATMENT] staff documented "Pt (patient) complains of extreme foot pain 90 minutes into treatment, pt requests to end treatment". On 6/5/13, review of the resident's May and June 2013 MAR (medication administration record) revealed the resident had physician's orders [REDACTED]. of 3,000 mg of [MEDICATION NAME] per day. On 5/30/13 at 4:07 p.m., observation revealed the resident cried out in pain. The resident cries were heard from the hall way while observation of the facility staff revealed they walked past the resident ' s room. At 4:36 p.m. Direct care staff H entered the resident ' s room. While repositioning the resident's feet on a pillow the resident displayed facial grimacing and had verbal complaints of pain. Staff H told the resident he/she would tell the nurse that the resident was in pain and left the room. Observation of staff H until 4:45 p.m. revealed he/she did not report resident #1's complaints of pain to the charge nurse. On 6/03/13 at 9:00 a.m. observation revealed the resident cried out in pain and yelled for help. Direct care staff G entered the resident's room and spoke with the resident. The resident reported he/she had foot and leg pain. Direct care staff G told the resident he/she would tell the nurse. Staff G left the resident ' s room and continued to provide care to other residents. Staff G failed to report to the charge nurse the resident's complaints of pain and discomfort. On 6/3/13 observation at 11:00 a.m. revealed direct care staff BB administered Tylenol 325 mg 2 tablets to the resident for complaints of break through pain. Staff BB failed to ask the resident to rate his/her pain level using the facility approved pain scale. On 6/3/13 at 11:25 a.m. direct care staff II entered the resident's room and had a conversation with the resident. The resident complained of pain. Staff II reassured the resident he/she would tell the charge nurse the resident was in pain. Observation of staff II after he/she left the resident ' s room revealed he/she left the unit and went to a facility provided activity. The charge nurse was not informed by staff II the resident had complaints of pain. On 6/3/13 at 12:57 p.m. observation revealed the resident yelled "Please help me, please help me " repeatedly. Administrative nurse C and licensed nurse K entered the room to provide wound care. The licensed nursing staff failed to ask the resident if he/she was in pain prior to rolling him/her onto his/her left side to complete the dressing change. Observation revealed the resident had facial grimacing and verbal complaints of pain to his/her legs and feet while Licensed staff C and K performed the dressing change. Licensed staff C and K failed to assess the resident for pain prior to the initiation of the wound care. On 6/3/13 at 2:45 p.m. observation revealed the resident yelled " Help me please, help me. " Direct care staff G and H entered the room and adjusted the resident's feet on a pillow. The resident winced in pain and discomfort when staff moved his/her foot . The staff asked the resident how he/she was doing and the resident reported that his/her feet hurt really bad, and then started to cry. After the staff left the room, observation revealed neither staff G nor staff H reported the resident's pain to licensed nurse K. On 6/3/13 at 8:01 a.m. interview revealed the resident had pain in his/her legs and feet that was so bad that he/she was unable to tolerate it anymore. On 6/3/13 at 10:45 a.m. interview with licensed nurse K revealed the direct care staff had not reported complaints of pain to him/her by the resident. Staff K revealed the resident cried out in pain frequently and the resident ' s family member had reported the resident " liked " [MEDICATION NAME] (a strong narcotic pain medication) and the resident wanted to go back to the hospital to get more [MEDICATION NAME]. Staff K revealed the resident had been on several different pain medications at different times and he/she still complained of pain. Licensed nurse K revealed he/she was unsure what caused the resident to have increased pain in the legs and feet. Staff K revealed the facility required the licensed staff to complete a pain assessment upon admission, quarterly and with a change in condition and confirmed that the resident had not been seen by a pain specialist. Staff K revealed that upon assessment the resident had reported his/her pain as a 10. On 6/3/13 at 11:00 a.m. Direct care staff BB revealed the charge nurse had told him/her the resident complained of pain at a level of 6. The charge nurse had advised him/her to give the resident Tylenol for break thru pain. Staff BB confirmed he/she had not asked the resident to rate his/her pain prior to administering the medication. On 6/4/13 at 12:44 p.m., interview with the resident's family member revealed the resident had received [MEDICATION NAME] in the hospital and the he/she preferred the resident not receive [MEDICATION NAME] anymore but he/she was not the DPOA (durable power of attorney). The family member revealed the resident had pain and complained of his/her legs and feet hurting so badly at times he/she was unable to finish [MEDICAL TREATMENT]. The family member reported the resident had begged to be taken off the [MEDICAL TREATMENT] machine and sent back to the facility due to the high level of pain. The family member revealed the facility needed to do something to control the resident's pain so the resident could complete the [MEDICAL TREATMENT] treatments. On 6/5/13 at 4:53 p.m. Administrative nurse C revealed the resident had a history of [REDACTED]. Staff C confirmed the resident should be assessed for pain upon admission, quarterly, and with a significant change in status. Administrative nurse C confirmed the resident complained of pain and yelled out frequently. Staff C confirmed the facility had received an order to obtain a consult with a pain specialist on 5/23/13 and had failed to schedule that appointment. Staff C confirmed the care plan team had met on 6/5/13 and failed to address the resident's pain indicators. Administrative nurse C confirmed the facility failed to address the resident's pain indicators or develop interventions to aid in relieving the resident's pain. Staff C stated that the care plan team had reviewed resident ' s care plan reviewed and updated the resident ' s care plan on 6/5/13. On 6/4/13 at 11:01 a.m. physician KK revealed the facility had not discussed the resident's pain indicators and treatment with him/her. Physician KK was unaware the resident was having uncontrolled pain issues and revealed he/she would act on the resident ' s behalf as needed to ensure the resident was assessed by a pain specialist and, if needed, review the resident medications for possible changes to ensure the resident received adequate pain control. Review of the facility's Pain Management policy, dated 1/09, revealed the following: " All residents will receive interdisciplinary consultations on assistance in managing pain. When a resident is identified as being in pain, the social worker, as part of the Interdisciplinary Team, will assess the psychosocial well-being of the resident. Individualized approaches will be developed to address the resident's pain management needs in a holistic manner. The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological. The registered nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan. " Review of the facility's Pain Data Collection and Management policy, dated 11/09 revealed the following: "A pain management plan can include, but not be limited to, a medical regime. The analysis should help determine what other methods or alternatives of pain control/relief may be implemented prior to contacting a physician. The Care Team and nurses must continually monitor and evaluate the pain management plan." The procedure for the policy included the development of a care plan that included pain, the goal and interventions. The policy directed staff to define on the care plan what pain scale was to be used and include the level of pain that the resident was able to tolerate. The policy also directed staff to document the effectiveness of the pain management plan at least monthly. If the current pain management was not effective or the resident had new onset of pain, then staff were to re-assess. Staff were also to document summarization of pain analysis quarterly for ongoing pain and for residents on a pain management program. Staff were to document medication changes; status of pain control, resident's general condition noting any significant changes (either improvement or decline), changes in elimination pattern, cognitive status, behavior manifestations or occurrence of new pain and the resident's acceptance of pain level. The facility failed to adequately assess the resident's pain, develop a pain management program in an effort to control the resident's pain to promote the residents comfort and well-being. The level of the resident's pain interfered with the resident's day-to-day activities when he/she could not finish [MEDICAL TREATMENT] services. The facility's failure to address the resident severe, constant pain placed the resident in immediate jeopardy. The immediate jeopardy was considered abated on June 7 th at 12:49 p.m. when the facility provided evidence they had completed a comprehensive pain assessment by a registered nurse, developed a pain management care plan that included the non-pharmacological intervention of ice to the resident's feet for 20 minutes then re-applied 2-3 hours later, the change

The facility census totaled 69 residents with 27 included in the sample. Based on observation, interview and record review, the facility failed to provide the necessary services to prevent the development of pressure ulcers for 1 of 3 residents sampled for pressure ulcers. (#1) Resident #1 came into the facility without pressure ulcers and the resident developed two stage 3 (wounds that involve the subcutaneous tissue such as ligaments and tendons). Findings included: - Review of a physician's orders [REDACTED]. Review of the admission MDS (Minimum Data Set-a required assessment) dated 3/5/13 revealed a BIMS (Brief Interview for Mental Status) score of 15 (indicated the resident with intact cognition). The assessment showed the resident had mood indicators of trouble falling asleep or sleeping to much for 12-14 days and no behaviors. The resident required total assist of two staff members for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene,and bathing. The resident required set up help and supervision with meals. The assessment identified the resident received PRN (as needed) pain medication and received non-medication interventions for pain. The pain section of the assessment was marked "No" for the question "have you had pain or hurting at any time in the last 5 days?" The MDS identified the resident at risk for pressure ulcers, did not have a pressure ulcer, had a surgical wound and moisture associated skin damage. The assessment showed the resident used a pressure relieving device to the chair, bed, was on a turning and repositioning program, and received surgical wound care. The medication section of the assessment showed the resident received an antibiotic during the 7 day look back period and received [MEDICAL TREATMENT] services. Review of the resident's ADL (Activities of Daily Living) CAA (Care Area Assessment-a further assessment) dated 3/11/13 revealed the resident required total assist with all ADLs, except able to feed self. He/she has severe obesity, he/she had a [MEDICAL CONDITION] (an opening cut directly into the trachea from the neck to facilitate breathing-also called a "trach") due to [MEDICAL CONDITION]. [MEDICAL CONDITION] had healed. He/she also had a feeding tube (a tube placed directly into the stomach) while on the trach. H/she no longer had the feeding tube and had the ability to eat without difficulty, but still had a very slow healing wound from the [DEVICE] stoma (area the tube entered the stomach) site that required dressing changes twice a day. He/she had deformities of his/her feet and muscles due to disuse of legs. H/she was unable to stand at all times. He/she was working with therapies for his/her personal goal to return to home. He/she is also a new patient on [MEDICAL TREATMENT] 3 times weekly. He/she had a trapeze bar (an overhead bar used to help with bed mobility) on his/her bed and assist bars and is working with therapy to improve bed mobility with these items. although as of now he/she is total assist with bed mobility. he/she requires a Medilift (Mechanical lift) for all transfers. He/she does need repositioned routinely to prevent pressure areas, He/she is unable to do this him/herself at this time. Staff were doing bed baths. He/she had his/her own personal wheelchair (w/c) that was too small for him/her, so (the facility) did not use it. The facility identified the resident required a 28-30 inch w/c for positioning /mobility. The facility identified the size of the bariatric wheelchair able to fit in the transportation van was a 26 inch wheelchair. The facility acknowledged this wheelchair was too small for the resident, so they planned to only use the wheelchair for "transportation purposes out of the facility only." Urinary Incontinence and Indwelling Catheter CAA, dated 3/11/13, identified the resident as functionally incontinent of bladder due to severe obesity and the resident's non-ambulatory status. It also identified the resident had a decreased sensation of need to void. The CAA identified staff checked and changed the resident every 2 hours and then applied skin barrier. The resident had massive skin folds due to severe obesity and recent loss of over 200 pounds. The assessment identified the resident had chronic history of moisture related skin damage under abdominal folds, perineal area and inner thighs. It identified the resident at risk of skin breakdown and urinary tract infections. Review of the nutritional status CAA dated 3/11/13 revealed the resident had severe obesity with a recent weight loss of 200 pounds prior to admission. The resident consumed 100% of the ordered diet. The resident had a chronic history of hoarding food and eating foods not on his/her diet. The resident also received [MEDICAL TREATMENT]. Fluid contributes to fluctuation in weight. Other contributing [DIAGNOSES REDACTED]. The resident received a regular consistent carbohydrate diet and was able to feed self. Staff were to provide large protein portions, provide no seconds and no substitutions. Review of the pressure ulcer CAA dated 3/11/13 revealed the resident at risk for skin breakdown due to impaired mobility, incontinent of bowel and bladder, dependence on staff for all care needs and severe obesity, which fluctuated due to [MEDICAL TREATMENT] and fluid retention. The CAA identified the resident had an abdominal wound related to a surgery for [REDACTED]. The surgical wound was clean, red beefy appearance. and staff did wound treatment daily as ordered. The resident had massive abdominal folds as residual of losing over 200 pounds prior to admission. At risk for skin breakdown to feet and heels. The resident's legs turn to the lateral side as the resident said the abdominal folds kept the legs from straightening out. Staff were to reposition the resident every 2 hours, check and change the resident for incontinence every 2 hours, use a pressure relieving mattress to bed and chair. Review of the care plan for altered skin integrity, dated 4/11/13, revealed the resident had a stage 2 open area to the left inner gluteal and directed staff to provide the treatment as ordered by the physician, to monitor the status of the ulcer and surrounding skin and dressing, to document the size and progress on the wound flow sheet. It also directed staff to keep the skin clean, dry and moisturized, provide support surfaces as appropriate, pillows for positioning , monitor for pain, provide non-pharmacological interventions and/or medication treatment as ordered, complete a Braden scale for predicting pressure ulcer risk, notify dietary for interventions as appropriate, notify rehabilitation coordinators (therapists) for re-evaluation for mobility status, keep physician informed, involve/educate resident and/or family members. Review of the care plan for risk for impaired skin integrity, dated 5/7/13, related skin damage under right abdominal apron, skin will remain clear and intact through next 30 days, inspect skin daily during care, report changes to licensed nurse, observe skin condition, complete Braden scale for predicting pressure sore risk 5/7/13, moisturize skin, keep dry, pad and/or protect fragile skin, position body with pillows/support device, apply protective barrier/cream to areas exposed to moisture/incontinence, check and change every 2 hours. Keep towel between abdominal fold on the right side, scored 3 or lower on the Braden scale (identified as severe risk), turn and reposition in bed every 2 hours, pressure redistribution surface on support with pillow, restorative nursing referral for wheelchair skin protection, keep linen dry and wrinkle free, lift do no slide resident, use assistive devices to decrease frictions, have resident help using traction bar, [MEDICAL TREATMENT] chair too small is not able to be repositioned during [MEDICAL TREATMENT]. Review of the resident's care plan for skin integrity, updated on 5/15/13, identified the resident had two stage 3 pressure ulcers to the sacrum (large bone at the base of the spine). The care plan identified the most probable cause for the development of the pressure ulcers were the result of sitting for 4 hours in a [MEDICAL TREATMENT] chair without the option of being repositioned at the [MEDICAL TREATMENT] center. The recliner used at the [MEDICAL TREATMENT] center was a "tight fit" for the resident as evidenced by the development of pressure wounds and worsening of a stage 3 . The care plan directed the staff to treat the wound as ordered by the wound doctor. It also directed staff that for wound management, to coordinate care efforts with the [MEDICAL TREATMENT] center to minimize risk of further skin breakdown. The care plan directed staff to perform a thorough head-to-toe skin assessment every time the resident returned from [MEDICAL TREATMENT], and to not wait until the end of the shift but complete it at the time of return and document the results on the treatment record. The care plan included that staff anticipated that due to the current pressure wounds and high risk for development of more wounds were unavoidable related to the seating at the [MEDICAL TREATMENT] unit and the inability to be repositioned while hooked to the [MEDICAL TREATMENT] machine. The care plan directed staff to reposition the resident every 2 hours, support position with pillows, the resident's "massive" abdominal girth and abdominal apron had a tendency to hang mostly to the right side and the resident was often reluctant to turn off of the right side. On 5/16/13 staff updated the care plan and wrote in the following: right calf laceration 5/16/13 occurred at [MEDICAL TREATMENT], monitor the right calf sutured laceration every shift, cover with 4 x 4 (inch) gauze dressing and secure with miplex or tape until healed, observe for signs/symptoms of infection that include redness, swelling. On 5/20/13, staff updated the care plan to include: left and right buttocks wound. Right and left buttocks wound near sacrum apply santyl/foam (type of dressing) daily to sacrum, turn side to side every 2 hours, limit wheelchair to 2 hours at a time, only place on back for 20 minutes. On 5/28/13, staff updated the care plan to include: apply santyl/foam daily to right buttocks, apply foam only every other day and PRN (as needed) to left buttocks. On 6/3/13. staff updated the care plan to include: skin tears/abrasions left foot 2nd toe and 4 th digit related to bumping feet on the transportation van--keep toes covered during transport. Review of the nutritional care plan. dated 5/15/13, revealed the care plan identified the resident ate independently in the northern reflections dining room and staff were to provide the resident with room trays when the resident requested, staff were to provide a sack lunch for the resident to take to [MEDICAL TREATMENT] 3 times weekly, identified the resident ate inappropriate food/candy/snacks in room that were brought in by family, educate family and resident when eats food outside of diet guidelines. The care plan identified the physician ordered the resident to have consistent carbohydrate, renal diet with high protein, low salt, low calcium, low potassium and low phosphorous and a 2000 cc (cubic centimeters) per day fluid restriction. The diet ordered staff to not provide second servings, to provide a supplement can called nephro twice a day, obtain the resident's weight 3 times a week (at the [MEDICAL TREATMENT] center) and staff were to enter the weights in the computer for monitoring fluctuations. Review of the skin observation record initiated on 3/03/13 revealed reddened skin to the resident's back, buttocks and hip, specifically, the resident's left-sacrum. On 3/3/13 staff documented the resident had raw skin on the back and sacrum. It lacked documentation of an investigation to determine what caused the "raw skin" or what interventions the staff planned to promote healing and prevent it from getting worse. On 4/16/13 staff documented the resident had open skin on the front of the left foot foot and the right ankle. It lacked documentation of an investigation to determine what caused the open skin or what interventions the staff planned to promote healing and prevent it from getting worse. On 4/16/13 staff documented the resident had open skin on the back and sacrum. It lacked documentation of an investigation to determine what caused the open skin or what interventions the staff planned to promote healing or prevent it from getting worse. Review of the nurse's notes revealed the resident was hosptalized on [DATE] and returned to the facility on [DATE]. Review of the undated initial nursing assessment of the resident upon re-admission after a hospitalization on [DATE] revealed the resident's Braden score of 13 (indicated moderate risk for skin breakdown). The assessment revealed the resident was readmitted to the facility with a pressure ulcer to the coccyx area, and an open lesion to the left inner groin area, a surgical wound to right chest wall and to the abdomen, and the resident had 1-2+ [MEDICAL CONDITION] ([MEDICAL CONDITION]=collection of fluid in the skin, 1-2+ = a slight indentation when a finger is pressed into the skin, the indentation rebounds within 15 seconds). Review of Physician JJJ's progress notes revealed the following: On 5/20/13: Sacral ulcer now covered with 100% slough with debrided left buttocks skin tear, right buttocks ulcer. New treatment plan sacrum foam today start santyl/foam daily. Bilateral buttock wounds foam 2 x/weekly (2 times weekly) and PRN. Turn side to side every 2 hours limit wheelchair to 2 hours at a time, 20 minute break. On 5/27/13: Sacrum wound measurements (length x width x depth) 5.5 cm (centimeters) x 2.7 cm x 0.1 cm, right buttock 2.1 cm x 1.5 cm x 0.1 cm, left buttock 2.5 cm x 2.4 cm. Review of the facility's skin assessments revealed the following: On 6/3/13: Left buttock: This wound has separated from original sacrum wound. Wounds are to left inner buttocks, with measurements of 1.8 cm x 1.0 cm with 100% slough (stringy clumps of yellow or white material) in the wound bed. Staff documented this wound as unstageable, slough progress towards healing decreasing in size interventions include turning and repositioning, support surfaces, moisture incontinent protection, friction and sheet management. On 6/3/13: Sacrum: 3.8 cm x 3.0 cm, no depth 100% slough. Staff documented this was non-stageable, had a decrease in size, pressure ulcer to sacrum improving as evidenced by decrease in less sloughing, treatment of [REDACTED]. On 6/3/13 Right buttock: 1.0 cm x 0.06 cm, 100% slough. Documentation revealed the area had decreased in size, superficial wound due to a trauma abrasion, covered with foam dressing. Review of the push tool (a method of monitoring the healing progression of a wound) revealed the staff measured the area on the right buttock on 5/20/13 and 5/28/13 and the resident's score was 14. The score on 6/3/13 was 11, which indicated the wound was healing. On 6/3/13 at 7:11 a.m. observation of the resident revealed he/she laid flat in bed on his/her back with his/her eyes closed. Observation of the resident's left foot revealed it hung off the side of the bed with a bunny boot (a type of heel protection device) and the right foot laid on the bed. On 6/3/13 12:57 p.m. Administrative Nurse C and Administrative Nurse K prepared to assist the resident to lie on his/her side to observe the dressings on the resident's sacral and buttocks area. As Nurse C and K rolled the resident onto his/her side, observation revealed one of the dressings came loose, so Nurse C changed the dressing. The wound was at the top right coccyx and measured 3.8 cm x 3 cm and had pink tissue. At the bottom left of the coccyx observation revealed there were 2 separate foam dressings. Nurse C revealed the resident had developed two stage 3 pressure ulcers after admission to the facility. Upon investigation the facility determined the areas were caused by going to the [MEDICAL TREATMENT] center and sitting for 4 hours without being repositioned. The facility switched [MEDICAL TREATMENT] centers and purchased a Roho cushion (a type of pressure relief cushion) and the areas had started making progress. On 6/6/13 at 12:50 p.m. interview with administrative nurse LLL revealed the resident literally went to the [MEDICAL TREATMENT] center one day and came back with the pressure area. The facility had contacted the [MEDICAL TREATMENT] center and the [MEDICAL TREATMENT] center stated that the resident could not be moved while hooked up to [MEDICAL TREATMENT] not even to be just lifted with the lift and set back down. The [MEDICAL TREATMENT] center refused to allow the resident to have a bed that the facility offered to provide for the resident on [MEDICAL TREATMENT] days. Nurse LLL stated the facility had even called the hospital and they do not do [MEDICAL TREATMENT]. Nurse LLL revealed the facility then ordered the resident a Roho cushion (a type of pressure relief cushion) after the breakdown happened. Prior to the breakdown, the resident had a gel cushion in the wheelchair. Nurse LLL revealed the Roho cushion relieved the resident of the discomfort from sitting for longer periods. The facility had identified the resident at moderate risk for the development of pressure ulcers. The facility failed to assess the resident's length of sitting time in the gel cushion prior to sending the resident to the [MEDICAL TREATMENT] center. On 6/4/13 at 11:01 a.m. interview with Physician KK revealed he/she had no knowledge of the resident's pressure ulcers other than he/she knew the facility had a resident with some wounds and he/she advised them to follow their policy for turning and reposition. He/she had not been asked to look at the resident for the facility to help manage wound. Review of the facility's policy on Pressure Ulcer Practice Guidelines, dated 9/10, revealed the following: Prevention strategies should be developed and implemented at the time of admission based upon the initial assessments of the causative factors that contribute to the resident's risk for skin breakdown. Prevent strategies are ongoing and will be individualized based on the areas or the level of risk determined. Include these prevention strategies on the resident's care plan. The facility failed to determine the resident's pressure relief needs to accommodate the length of time needed for sitting in a chair for [MEDICAL TREATMENT]. The resident did not have a pressure ulcer upon admitting to the facility, but developed them after the resident sat for long periods of time at [MEDICAL TREATMENT]. The resident developed two stage 3 pressure ulcers.

The facility census totaled 69 residents with 27 residents sampled. Of those, 3 residents were sampled for nutrition, including weight loss. Based on observation, interview and record review the facility failed to ensure 1 of 3 sampled residents (#89) received snacks as planned, was offered foods the resident liked, and had 3 meals per day. The resident experienced a significant weight loss of 5.3% in less than 1 month when the resident's weight went from 236.6 pounds on 5/21/13 down to 224.0 on 6/7/13. Findings included: - Review of resident # 89's cumulative [DIAGNOSES REDACTED]. glucose, there ' s not enough insulin made or the body can ' t respond to the insulin, and lethargy. Review of the admission MDS (Minimum Data Set-a required assessment) dated 2/19/13 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11/15 (indicated moderately impaired cognition), required limited assistance of 1 staff for eating, had no issues with swallowing. It indicated the resident received a mechanically altered diet, and had a steady weight of 268 pounds. It also revealed the resident had no natural teeth or tooth fragments. Review of the quarterly MDS dated [DATE] identified the resident had short-term memory problems and moderately impaired cognition, had no issues with swallowing, chewing, and did not have any weight loss, weight was 266 pounds. Review of the Nutritional CAA (Care Area Assessment- a further assessment) dated 2/25/13, identified the resident had a high BMI, and was a new admission to the facility. It also revealed the resident was admitted with a diet of mechanical soft level II diet and the resident was not happy with that diet so it was recently upgraded to mechanical soft level 3 providing a more regular type diet. The CAA revealed the resident had no further concerns regarding the upgraded diet. The resident also had a [DIAGNOSES REDACTED]. Review of the care plan, dated 2/27/13, revealed a concern with eating and directed staff to provide set up to partial assistance in southern charm dining room, provide a mug with lid for hot liquids as accepted. It also revealed the resident received a level 3 diet as ordered with scheduled hydration between meals. It did not include any supplementation to prevent weight loss. Review of the care plan the aides used revealed it lacked any direction of the type of assistance the resident needed with meals or planned hydration between meals. Review of the dietician's assessment, dated 5/30/13 revealed the resident received a mechanical soft diet, and had a recent weight loss that was acceptable. The assessment identified the resident required 2400cal/day, and 2488cc's/day to maintain weight/minimum hydration status. The assessment lacked indication the resident was on a planned weight loss program. Review of the dietitian notes dated 5/29/13 revealed the resident had a significant weight loss in 3 months. The resident had a BMI (Body Mass Index) or body fat was 33.9% and weight loss was acceptable since he/she had [MEDICAL CONDITION]. The notes indicated staff asked nursing to report weight loss of 10% in 3 months and BMI is acceptable. The notes lacked indication the resident was on a planned weight loss program. The notes also revealed the resident did not like ground meat and had a low [MEDICATION NAME]. Recommend regular meat cut up be served to meet his protein needs and will provide with prune juice to aide with constipation. Review of the resident ' s dietary card revealed a level 3 diet, and not to serve the resident chicken or turkey. It also indicated the resident was to receive prune or tomato juice for each meal and needed mugs with lids for hot liquids. It did not indicate the resident on a weight loss program or to receive supplement to prevent weight loss. Review of the computerized dining record revealed from 5-5-13 to 6-4-13 the resident was offered nourishment between breakfast and lunch twice and refused it one of those times. There was also documentation the resident received a supplement of fruit with supper meal one time. Review of the weight report revealed the following weights: 2-12-13 - 266.2 2-18-13 - 267.5 2-27-13 - 268.7 3-4-13 - 267.4 3-11-13 - 265.9 3-18-13 - 268.1 4-5-13 - 267.7 5-6-13 - 265.5 5-21-13 - 236.6 6-5-13 - 224.4 6-7-13 - 224.0 The documented weights revealed the resident had the greatest weight loss between 5/6/13 and 5/21/13, when the resident had been hospitalized for [REDACTED]. The resident ' s weight went from 236.6 pounds on 5/21/13 (the day the resident returned to the hospital) to 224 pounds on 6/7/13, evidence of a 12.6 pound weight loss in a 2 ? week time-frame. Review of the dining record included the following documentation: The resident refused evening meal on 5/10, 5/12, and was not available for the evening meal on 5/13. The record lacked documentation for breakfast on 5/5, noon meal on 5/11, noon meal on 5/13, 5/22, noon and evening meal on 5/23, noon and evening meal on 5/25, and the noon meal on 5/27. An observation on 6-3-13 at 8:25 a.m. direct care staff G and X were providing care for the resident when direct care staff N knocked on the door and informed staff the resident had an appointment and needed to leave at 8:45 a.m. Direct care staff G reported the resident had not eaten breakfast yet and they would hurry. At 8:42 a.m. direct care staff N knocked on the door again, took the resident out of the room, down the hall and out of the building without breakfast. An observation on 6-3-13 at 11:07 a.m. revealed the resident had returned to the facility. The resident sat in the wheel chair, turned on the call light and direct care staff F answered the light. The resident asked staff to take him/her to " chow " , because he/she was hungry. On 6-3-13 at 11:15 a.m. Staff F returned to the resident ' s room to answer the call light again. The resident asked to go to "chow". Direct care staff F responded, "You want to go to chow?" The resident said "I didn't get any breakfast." Direct care staff F then stated "Did you have a doctor's appointment?" and the resident said yes. Direct care staff X then assisted the resident to the dining room. On 6/3/13 at 11:23 a.m., direct care staff X brought the resident a plate of meatloaf, buttered bread and what looked like cauliflower (but was creamed potato), a glass of ice water and a glass of orange juice. The resident started to eat independently. On 6/3/13 at 11:47 a.m., observation revealed the mid-morning snacks had not been passed out to the residents. The snacks sat in a cooler with the lid open and melting ice. The snacks were covered in clear plastic wrap with a sticker that had the resident names on it. The cooler had 13 different resident ' s snacks including fortified cookie and nutritional supplements. One of the glasses was sugar free punch for resident #89. On 6/3/13 at 12:07 p.m., observation of the resident's noon plate revealed the staff had not served the resident a vegetable (Aztec corn or alternate of wax beans), gelatin salad, or the black forest cake. The resident only ate half the meatloaf, ? of the potatoes, and none of the bread. The resident drank most of the orange juice and none of the ice water. The staff also failed to provide the resident with tomato or prune juice as planned. Observation on 6/4/13 at 4:30 p.m., revealed the mid-afternoon snacks sat in a cooler on an over-the-bed table by the nurse's station. Observation revealed that a 4oz glass of pink juice/ punch covered in clear plastic wrap had a label that identified it as resident #89 ' s. The glass was full and staff had written on the label, "Refused--does not like the punch" and the glass remained in the cooler. On 6/5/13 at 11:10 a.m., observation revealed the mid-morning snacks sat in a cooler on an over-the-bed table down the SW hallway. Licensed nurse staff D stated the staff was "still working on those." Staff D then looked at the glasses in the cooler and said "Here is (resident #89's). I will go give it to him/her." Staff D then took the glass of pink punch with a protein supplement mixed in it into the resident's room, where the resident lay in a low bed on his/her back. Staff D left it on the bedside table and walked out. When asked if the resident was able to drink that independently, staff D said "No, I will go back in and help him." Staff D walked into the room and then said "Well, (gender) looks sleepy. (Name)? Would you like your snack, (name)?" The resident asked staff D what it was, and staff D said a drink. The resident asked him/her what kind of drink, and staff D said "Some kind of juice--maybe fruit juice or fruit punch?" The resident asked him/her what color it was and he/she said pink. The resident said "I don't want it. I don't like it." Staff D tried to talk the resident into it and he/she refused to take it. An observation on 6/5/13 at 7:10 p.m., revealed unpassed snacks from the mid-afternoon where in a cooler at the nurse's station on a table. Observation revealed that a glass of pink juice/punch labeled for the resident had not been passed. An observation on 6/6/13 at 10:30 a.m., revealed an over the bed table had a cooler with snacks in it, including a glass of pink juice/punch labeled for the resident. During an interview on 6/3/13 at 7:03 a.m., resident #89 reported he/she really did not like eating ground meat, but they kept giving it to him/her. The resident also said he/she never liked chicken or turkey, but liked beef or pork. The resident stated even though he/she did not like chicken he/she still got served it at times. He/she said he/she went ahead and ate it rather than go hungry. The resident also reported the staff gave him/her juice in his/her room, didn ' t like the flavor of it but they kept giving it to him/her even though he/she had told the staff he/she didn ' t like it. During an interview on 6/3/13 at 6:04 a.m., direct care staff Y reported he/she did not know what kind of diet the resident received since the resident had never asked for snacks at night. During an interview on 6/3/13 at 8:35 a.m., direct care staff X reported the resident received ground meat but does not really like it. During an interview on 6/3/13 at 1:57 p.m. direct care staff G reported the resident received ground meat which he/she did not like and so staff had to really encourage the resident to eat. During an interview on 6/4/13 at 4:11 p.m. direct care staff HH reported the resident received a mechanical soft diet that included ground meat. Staff HH reported the resident did not have any trouble eating and was not losing weight. During an interview on 6/5/13 at 11:40 a.m., direct care staff LL reported the same person who passes out room trays was also supposed to pass out the snacks and were also supposed to document the amount of the snack taken in. During an interview on 6/4/13 at 3:30 p.m., licensed nursing staff EE reported the resident was not at risk for losing weight and did not have any trouble eating as far as he/she knew. During an interview on 6/3/13 at 11:48 a.m. administrative staff C reported the snacks were to be passed out between 10 and 10:30 a.m. Staff C confirmed staff was late in passing the snacks today. Staff C again confirmed they were supposed to be passed out between meals. During an interview on 6/6/13 at 11:00 a.m. administrative staff C agreed staff should have passed out the snacks and it was not getting done. Staff C also said that staff was not following the dietary card, but that was the dietary department. When told staff had not ensured the resident had eaten breakfast the previous Monday, nor had they ensured that he/she had eaten everything offered for the noon meal, staff C said he/she could see the surveyors concern. Staff C did report the resident recently had a medication change to increase his/her appetite. The surveyor and staff C questioned why an appetite stimulant would be initiated when the facility failed to provide food items the resident liked and failed to ensure the resident received 3 meals a day. During an interview on 6/5/13 on 3:42 p.m. dietary staff T reported the resident started on [MEDICATION NAME] (an antidepressant) to increase his/her appetite, was started on 2-cal on June 3rd and super cereal (a high calorie cereal) was started right after admission. Staff T also reported the resident received Protein shots in drinks in between the 2-cal. He/she also reported the juice between meals was for hydration because the resident reported he/she did not like to drink. Staff T also confirmed the resident did not like to eat ground meats. Staff T reported that if the resident did not like the juice staff should have called the kitchen or let the nurse know, not write on the label. Staff T said now that he/she knew the resident did not like it he/she can make sure the resident did not get the " pink juice " anymore. During an interview on 6-5-13 at 3:45 p.m. consultant staff MM reported he/she had written several days ago for staff to stop serving a ground meat, but to serve regular meat and make sure they cut it up into small pieces. He/she agreed staff had not followed the recommendations yet. Staff MM reported it was nursing ' s responsibility to bring residents to the dining room for meals and to pass the snacks that were provided between meals. During an interview on 6/4/13 at 10:25 a.m., Physician KK reported weight loss was discussed at QA (Quality Assurance) meetings. They usually discuss who had recent weight losses and how the facility had altered their diets or what additives were done and how the residents had responded. A policy was requested from the facility on the morning of 6-11-13 and none provided. The facility failed to provide a resident with foods he/she liked, failed to ensure the resident had 3 meals a day and failed to ensure nutritional interventions were in place to prevent an avoidable, significant weight loss of 5.3% in 1 month for resident #89.

The facility census totaled 70 residents with 24 residents included in the sample. Of those, 4 resident's were reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure 3 out of 4 sampled residents received the necessary treatment and/or services to promote healing and prevent new sores from developing by the failure to consistently reposition residents #33, #27 and #76 as planned. Resident #76 acquired 2 deep tissue unstageable pressure ulcers after admission to the facility. Findings include: - Review of signed physician orders [REDACTED]. hypercholestremia, fractured right acetabulum and pelvis. Review of the admission MDS (minimum data set) a required assessment with an ARD (assessment reference date) of 1/30/12 identified the resident as cognitively impaired with a BIMS (brief interview for mental status) score of 9 (8-12 moderately impaired). The resident required total assist with all ADL's (activities of daily living),including repositioning with assist of two staff, was non-ambulatory and on bedrest during the assessment period. The assessment identified the resident as being high risk for pressure ulcers though had none present during the look back period. Review of the pressure ulcer CAAs ( care area assessments) dated 2/2/12 indicated the resident needed total assist with bed mobility and was at risk for skin breakdown and was frequently incontinent of bowel. "(Resident) is a new admit to facility and fell at home resulting in a right acetabular fracture and a right pelvic fracture. (Gender) is currently on bedrest as is unable to transfer using a mechanical lift, using a foam wedge between legs to remind (gender) that (gender) cannot move (gender) legs. Observing for indications of skin breakdown. Currently has a Foley catheter observing for placement of tubing. Since this observation period pressure area noted on right and left heel, refer to treatment record". Review of the resident's admission Braden scale (an assessment to determine pressure ulcer risk) dated 1/24/12 included a score of 14 indicating moderate risk for skin breakdown. Review of the resident's admission skin assessment dated [DATE] identified the resident without any skin breakdown on admission. Review of the admission care plan approaches dated 1/24/12 instructed staff to give bed baths daily, bed rest only, directed licensed staff to monitor skin every shift, and to offload the resident's heels. The resident was not to be positioned on his/her right side due to fractures of right hip and pelvis. Staff were to use positioning devices/pillows per therapy. The approaches instructed direct care staff to reposition the resident every 2 hours, offload the resident's heels, and use positioning devices/ pillows per therapy recommendations. Review of the resident's comprehensive care plan dated 2/8/12 identified alteration in skin integrity related to right and left pressure ulcers on heels manifested by slow healing of ulcers. The goal included the resident "will have timely healing within the disease process". Approaches included, "Bed rest only and skin to be monitored every shift by licensed nurses. Observe skin daily with care/ bath for residents at risk. Report any changes, concerns to the nurse. Reposition every 2 hours, heels to be offloaded. Do not position on right side due to fractures of the right hip and pelvis. Use positioning devices/pillows per therapy recommendations. Monitor status of ulcers, surrounding skin and dressing. Provide treatment as ordered. Keep physician informed." Review of physician orders [REDACTED]. Record review of the wound flow sheet revealed the resident had developed pressure areas on both heels on 2/1/12. The areas measured 1.4 cm (centimeters) by 1.8 cm on left heel and 1.8 cm by 2.4 cm on right heel. The areas were dark in color with skin intact and no drainage. Record review of the wound flow sheet on 2/8/12 revealed an increase in size of wounds. The left heel measured 2.7 cm by 4.0 cm, the right heel measured 2.8 cm by 3.2 cm. The resident's record lacked evidence that staff notified the physician of the worsening areas of pressure. Record review of the wound flow sheet for 2/14/12 revealed pressure area on left heel now measured 2.4 cm by 3.0 cm, the right heel measured 2.2 cm by 3.0 cm and the sites fading in color around the edges. The resident's treatment record from 1/24/12 though 1/31/12 instructed nurses to observe for skin conditions every week. The treatment record failed to include the care plan approaches that were developed upon admission that "the licensed nursing staff to monitor skin every shift with heels to be offloaded." The licensed nursing staff initialed they monitored the heels weekly. The residents treatment record dated 2/1/12 through 2/29/12 instructed the nurse to monitor both heels every shift due to deep tissue injury. The nurses failed to initial treatment completion on 2/3/12 and 2/15/12. Review of further information provided by the facility on 2/20/12 indicated the staff received positioning education from therapy department on 2/2/12, a day after the discovery of the pressure areas on both heels. Review of the printed kiosk report from 1/24/12 to 2/9/12 revealed no documentation that direct care staff repositioned the resident every 2 hours as planned (prior to the development of pressure ulcers.) Review of the printed kiosk(computerized charting device) report dated 2/9/12 through 2/16/12 revealed the direct care staff documented that staff repositioned the resident every 2 hours as planned (after the development of the pressure ulcers.) On 2/14/12 at 2:24 p.m. observation revealed the resident in bed with husband at bedside feeding the resident a cookie. The resident was on his/her back at that time with both heels elevated off the bed. Observation of licensed nursing staff K on 2/15/12 at 9:30 a.m. as he/she inspected the resident's skin for pressure ulcers revealed a black area approximately the size of a nickel on both heels. The resident's heels were elevated on a cushion and the resident positioned on his/her left side. Interview with licensed nursing staff U on 2/14/12 at 4:20 p.m. revealed the resident had a pressure ulcer on both of his/her heels. He/she stated the resident was on bedrest and direct care staff repositioned the resident with his/her heels off loaded. He/she also stated the wound nurse checked heels daily and documented on wound sheet in the treatment book. During an interview on 2/15/12 at 3:00 p.m. with licensed nursing staff T revealed that the resident was on bedrest per physician order [REDACTED]. He/she stated the resident was to be turned every two hours to the back and the left side. The resident was not to be turned to the right side at any time. The direct care staff were to give the resident bed baths daily and change him/her as needed. The nursing staff used a foam wedge between the residents legs for positioning and to keep the resident's heels off the bed. Licensed nursing staff T stated the direct care staff had a care plan update book informing them of the care the resident required. He/she produced the book directing the staff to reposition the resident every two hours and offload heels as instructed. During an interview on 2/16/12 at 4:00 p.m. administrative nursing staff M reported the resident had no breakdown on admission but experienced a lot of pain and the staff did not want to move her. Staff M confirmed the resident developed unstageable deep tissue areas on both heels. Staff M stated that He/she had a temporary care plan that he/she revised in his/her computer with the nurses having access to it on their handheld devices and kiosk. He/she acknowledged there was no paper copy of a temporary care plan showing any preventative measures to prevent skin breakdown other than what was on the kiosk. Interview on 2/16/12 at 4:15 p.m. with medical records staff KK revealed the direct care staff obtained the care plan interventions from the kiosk, and documented in the kiosk after care was given. On 2/16/12 during an interview with administrative nursing staff M at 5:00 p.m. he/she confirmed that the interventions that he/she had added in the kiosk should have been added to the wound treatment sheet for documentation. Interview with administrative nursing staff D on 2/16/12 at 5:15 p.m. revealed that he/she confirmed the resident had developed 2 pressure areas 7 days after admission. He/she also confirmed the documentation should have been the same from the kiosk to the treatment sheet. He/she confirmed the nursing staff are not consistent in documenting on the treatment sheet. The Policy called Pressure Ulcer Practice Guidelines dated 9/2010 included: Movement or Management of Tissue Load Staff should implement resident specific turning and positioning programs based upon an individualized assessment. This includes a consistent program for changing the resident's position and realigning the body. Staff should collaborate with restorative nursing and therapy staff for residents presenting with positional challenges. Staff should avoid massaging over bony prominences: maintain head of bed less than 30 degrees in an effort to prevent breakdown of skin integrity. Staff should use support surfaces (mattresses, wheelchair cushions, etc.) to decrease ischemia of bony prominences. The facility failed to consistently monitor and provide repositioning to promote the healing and prevent the worsening of two potentially avoidable, unstageable pressure ulcers for resident #76. - Review of resident #33's signed physician's orders [REDACTED]. Review of the most current significant change in status MDS (minimum data set 3.0, a required assessment) with an ARD (assessment reference date) of 6-1-2011 revealed the resident scored a 7 on the BIMS (brief interview for mental status) which indicated the resident had moderate cognitive impairment, needed extensive to total assistance with daily care, the resident had a stage 2 (open) ulcer and stage 4 (involving muscle or bone) ulcer and at risk for developing further pressure ulcers. Review of the resident's most current quarterly MDS with an ARD of 2-1-2012 revealed the resident had severe cognitive impairment in decision making, needed total assistance to complete activities of daily living including bed mobility, received Hospice services and had two stage 4 (involving muscle or bone) pressure ulcers. The Pressure Ulcer CAA (Care Area Assessment), dated 6-2-11 revealed the resident in end-stage [MEDICAL CONDITION], and with 2 pressure ulcers, dependent on staff for bed mobility. Review of the care plan dated 2-8-2012 identified the resident with skin breakdown and directed staff to reposition the resident every 2 hours, provide leg cushion with pillow on top to place under the resident's knees so that the resident's feet floated in the air, do not put pressure on heels and use a foot cradle on foot of bed to keep covers from resting on the resident's feet. On 2-15-12 at 9:40 a.m. observation revealed direct care staff P and H provided incontinent care as the resident laid in bed. Staff P and H positioned the resident on his/her left side, so the resident faced the window. Staff P and H placed a foam wedge under the resident's legs to keep the resident's heels off the bed. Observation revealed staff used a foot cradle at the end of the bed. Further observations that day at 9:50 a.m., 10:20 a.m., 11:00 a.m., 11:27 a.m., 12:24 p.m., and 12:37 p.m. revealed the resident remained on his/her left side, facing the window, with a pillow at the resident's back to prevent the resident from turning over. On 2-15-12 at 12:42 p.m., when asked to show the resident's skin, Licensed Nurse I and direct care staff P rolled the resident onto his/her back. The resident experienced bowel incontinence. Staff I and P provided perineal care, and afterwards observation revealed a reddened area on the resident's left upper buttock. The resident remained in bed on his/her left side without a position change for over 2 and 1/2 hours. Observation on 2-15-12 at 2:00 p.m. revealed the resident lay on his/her back. Additional observations that day at 2:20 p.m., 3:18 p.m., 3:55 p.m., 4:11 p.m., 4:26 p.m., and 4:40 p.m. revealed the resident remained in the same position on his/her back. At 5:00 p.m., observation of the resident revealed the resident then laid on his/her right side. Staff failed to provide a position change for the resident for over 2 and 1/2 hours. On 2-15-2012 at 8:30 a.m., direct care staff reported the resident received Hospice services and identified staff were to place the piece of foam under the resident's legs is to keep his/her heels off the bed "because he/she has sore on them." Staff P also reported that staff repositioned the resident every 2 hours from side to side and on his/her back but stated the resident experienced the most comfort on his/her back." On 2-15-2012 at 5:00 p.m., direct care staff J reported that he/she had just repositioned the resident "about 10 minutes ago." At that time staff J also reported that staff last turned the resident just before shift change. Staff J reported that staff were to reposition the resident every 2 hours. On 2-16-2012 at 3:49 p.m., Administrative Nurse M reported that staff were to reposition residents at risk for the development of pressure ulcers every 2 hours. Nurse M identified the direct care staff all know what is expected, and did not believe that staffing was an issue if repositioning failed to get done. During an interview on 2-16-12 at 4:12 p.m., Licensed Nurse K reported that when a resident is planned for repositioning every 2 hours staff are to do one at shift change because the staff do rounds then and follow up with additional repositioning every 2 hours after that. Nurse K reported that the expectation included the charge nurse completing visual rounds. When resident #33 yelled out or talked a lot, then "sometimes he/she is hurting and just needs repositioned and that will usually help him/her." Review of the facility's Pressure Ulcer Policy, dated 9/10, revealed " Movement or management of tissue load -- Staff should implement resident specific turning and positioning programs based upon an individualized assessment. This includes a consistent program for changing the resident's position and realigning the body." The facility failed to provide timely repositioning assistance to a dependent resident with pressure ulcers. - Review of resident #27's physician orders [REDACTED]. Review of the significant change of condition MDS (minimum data set, 3.0 a required assessment) with a ARD (assessment reference date) of 10/20/11 identified the resident with a BIMS (Brief Interview for Mental Status) score of 2/15 (severely impaired cognition), required extensive assistance of one staff with bed mobility, transfers, at risk for pressure ulcers and with a stage 4 pressure ulcer (involving muscle or bone). Review of the ADL (Activities of Daily Living) CAA (care area assessment) dated 10/27/11 indicated the resident required extensive assistance with ADLs. Review of the care plan, dated 1/18/12 revealed the resident had a pressure ulcer and directed staff to reposition the resident at least every 2 hours, all pressure areas treated and measured only at the physician ' s office, to report any redness or ulceration immediately to the nurse, treat special skin problems as ordered by the physician, keep skin clean and dry and apply moisturizing lotion as needed, heels up off the bed using (a specialized) device, and to lay the resident down or sit in the recliner after meals with (a specialized) cushion in the wheelchair or in the recliner duet to the history of skin breakdown. On 2/15/12 at 2:20 p.m., observation revealed the resident sat in a recliner in his/her room. The resident stated he/she wished someone would answer the phone, which had just been ringing and was not in reach. The resident also reported that he/she had been up all day in the wheelchair going to the doctor's office and back. Further observations at 3:00 p.m., 3:14 p.m., 3:29 p.m., 3:50 p.m., 4:18 p.m., and 4:40 p.m. revealed the resident remained in his/her room, seated in a recliner, without a position change. At 5:05 p.m. direct staff X entered the resident's room to assist the resident up into the wheelchair for the evening meal. Staff failed to reposition the resident for over 2 and 1/2 hours as planned. Interview with Licensed Nurse U, on 2/14/12 at 2:36 p.m., revealed that staff were to turn the resident every 2 hours. On 2/16/12 at 1:00 p.m. interview with Administrative Nurse D revealed the expectations of staff included assisting residents to turn at least every 2 hours. Review of the facility's Pressure Ulcer Policy, dated 9/10, revealed " Movement or management of tissue load -- Staff should implement resident specific turning and positioning programs based upon an individualized assessment. This includes a consistent program for changing the resident's position and realigning the body." The facility failed to provide timely repositioning services for a resident that required extensive assistance and at risk for the development of pressure ulcers.

The facility census totaled 78 residents. The sample included the review of 3 residents with pressure sores. Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing through a failure of staff to adequately monitor the skin under a leg immobilizer, use clean technique while changing a dressing on pressure sores, a failure to follow the manufacturer's recommendations and use too many linens over an air mattress overlay and a failure to provide timely repositioning services for 3 of 3 sampled residents (#1, #2, and #3). Resident #3 developed two pressure sores on their lower leg when staff failed to adequately monitor the resident's skin while the resident used a leg immobilizer, a type of full-leg brace. Findings included: - Review of the recapitulation of orders, dated 7/5/11, identified resident #3 with the following Diagnoses: [REDACTED]. Review of the significant change MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 8/3/11 identified resident #3 with a BIMS (Brief Interview for Mental Status) score of 6/15 (indicating severe cognitive impairment), no behaviors, dependent on one staff for bed mobility, transfers, dressing, toilet use, personal hygiene, at risk for the development of pressure ulcers, with 2 stage II pressure ulcers, on a pressure reducing device for the chair, bed, on a turning/repositioning program, and received ulcer care. Review of the Pressure Ulcer Care Area Assessment (CAA) dated 8/8/11 identified "Resident has new Stage 2 pressure ulcer related to impaired mobility and complicated by recent [MEDICAL CONDITION] knee which required bed rest for several days. Resident repositioned every 2 hours, receiving nutritional supplement of [MEDICATION NAME]. Lab (laboratory tests) indicated [MEDICATION NAME] low at 3.0. Does have one wound that has closed on the left ischium. Area to buttocks has a history of being fragile and has had previous off and on open area. Pressure relief mattress to bed and in w/c (wheelchair). Resident is incontinent of B&B (bowel and bladder) and is a check and change every 2 hours." The care plan, last reviewed on 8/10/11 directed staff on 7/23/11 that the resident had two Stage II (open) areas, on the R (right) and L (left) Ischium (area on buttock), both 0.5cm (centimeters) x 0.5cm in size, to reposition the resident every 2 hours, identified the resident's skin as fragile and the resident received arginade (protein supplement to support healing) 1 packet twice a day for 30 days as a supplement for wound healing, for staff to monitor skin during routine cares and report any changes to charge nurse. The charge nurse was to assess and inform physician and treat as ordered, keep the heels up off bed using "heels up" device and heel protectors, and that staff were to help the resident up last, and assist the resident 1st down after meals. Review of the nurse's notes, dated 8/31/11 at 7:45 a.m. revealed documentation that a bath aide noted open areas on the back of the resident's left leg where the knee brace rubbed on the back of left leg above the heel. The facility faxed the following note to the resident's physician on 8/31/11: "Res (resident) has pressure areas on Lt (left) back of heel (2) areas 2.2 x 3.5cm. Eschar (dark scab) with serous (clear)drainage et (and) Lt side of heel 2.5cm x 1.5 cm black area also. Areas cleansed et covered with A/B (antibiotic) ung (ointment) and [MEDICATION NAME] dressing. Cushioned with gauze - do you want to see (the resident) before the next appointment on 9/6/11?" The physician returned the fax on 9/1/11 to continue the treatment and that they planned to see the resident on 9/6/11. On 9/6/11, the resident saw the physician in their office. The physician wrote the following orders to staff "DC (discontinue) the brace in 1 week, monitor skin closely, recheck as needed." Observation on 9/13/11 at 10:30 a.m. revealed nurse aides F and G assisted the resident into bed. The resident wore a leg immobilizer that extended from the hip to the ankle on their left leg. Once the resident lay in bed, Nurse B entered the room and together Nurse B and Nurse Aide F removed the leg immobilizer from the resident's leg by removing the Velcro straps which held the brace in place. Nurse B then picked up the resident's leg and looked at the dressing on the back of the leg. Nurse B removed the dressing, and then laid the leg with the uncovered wounds, on top of the immobilizer. Nurse B identified the wounds on the back of the leg as "not open, but scabbed over." When asked how the wounds formed, Nurse B stated the nurses were supposed to be checking the skin under the brace and they hadn't picked up the leg to look under it and it was found not that long ago. Nurse B went out and looked at the treatment record and identified staff found the areas on 8/31/11. Review of the facility's policy on "Cast Care" (also used for brace applications) last revised on 1/09 revealed staff were to "1. Observe area around cast every day for exudate, foul odor, swelling, numbness, tingling, pain and skin condition. 3. Observe areas around cast edges for signs of impaired circulation. Pad any rough edges that may cause skin irritation. 5. Check heels, ankles, elbows or other areas or bony prominences for redness. Provide skin care and implement ways to relieve pressure on these areas." Staff failed to follow their policy and thoroughly monitor the resident's skin under and around an immobilizer, and the resident developed two pressure sores from the immobilizer rubbing on the back of the lower leg, near the heel. On 9/13/11 at 10:45 a.m., observation revealed Nurse B stood out in the hall, from a nearby treatment cart, retrieved a pair of scissors, a large roll of Meplix (tape), packages of 4x4 (inch) gauze, and individual packages of Kerlix (a non-stick bandage). Nurse B then returned to the room and placed all the items onto the top of a dresser without placing a barrier down to provide a clean field. This provided the opportunity for contamination of the items used for the dressing change. Nurse B then applied clean gloves and opened the 2nd drawer of the dresser. From the drawer, Nurse B obtained a spray bottle of wound cleanser. Nurse B stated they thought there was a package of Curasorb (a type of Calcium Alginate--used to absorb wound drainage) in the drawer, but there wasn't, so they were going to have to leave the room to go back to the treatment cart. Nurse B removed their left glove only, and left the room. The nurse soon returned to the room, still wearing the right glove and said the treatment cart lacked any packages of Curasorb, also, so they were going to have to go to the supply room to get more. Nurse B left, still wearing the right glove. A few minutes later, the nurse returned to the room with a box of Curasorb, and still wearing the right glove, which Nurse B used to open the door to the room and the handles of the 2nd drawer on the dresser before they opened the package and removed an individualized packet of calcium alginate. The nurse then reapplied a clean left glove, and gathered all the materials for the dressing change off the dresser top and transferred them to the bed, again without placing a clean barrier down first. The scissors lay directly on the covers of the bed; the wound cleanser tip also touched the bed linen, thereby providing the opportunity for contamination. The Nurse then used some of the 4x4 gauze and used the wound cleanser to clean the wounds on the left leg. Without changing gloves, the nurse then took the contaminated scissors and opened a packet of calcium alginate and cut two small circles out of the small square and placed the circles (now touched with the contaminated scissors and unclean gloves) directly on the wound beds. The nurse then placed the remaining calcium alginate back in the package and back on the bed. The nurse then used the scissors to cut a large section of Meplix, and with the same potentially dirty gloves, opened the package of Kerlix and placed the Kerlix, then 4x4 gauze over the wound, then used the Meplix to hold the padded dressing in place. The nurse then gathered the items on the bed and placed them back in the second drawer of the dresser, removed their gloves, washed their hands, and left the room. Review of the facility's policy on Wound Dressing Change, last revised on 3/2008 revealed it provided guidance to staff to create a clean field with equipment/dressing wrappers. The facility failed to provide the necessary service of thorough skin monitoring for a resident with a leg brace. The resident developed 2 pressure sores from the immobilizer rubbing. The facility also failed to promote healing and prevent infection through a failure to provide a dressing change while using clean technique and prevent potential contamination of the equipment used during the dressing change, including gloves and scissors. - Review of a physician's recapitulation of orders dated 6/24/11 identified resident #2 with the [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 8/17/11 identified resident #2 with a BIMS (Brief Interview for Mental Status) score of 6 out of 15 (indicating severe cognitive impairment), no behaviors, dependent on two staff for bed mobility, transfers, toilet use, required extensive assistance with personal hygiene, frequently incontinent of bowel and bladder, at risk for the development of pressure ulcers, with two unhealed pressure ulcers, on a turning/repositioning program, and received ulcer care. Review of the care plan, dated 8/24/11, directed staff to monitor for any signs or symptoms of infection in any of the resident's current wounds, to provide the resident with wound healing supplements, such as vitamins & dietary foods/drinks, to keep the resident's right stump and left leg elevated, keep pressure off left heel, use heel protectors, protect the resident's legs from hitting objects or lift mechanisms during transferring with midi lift (total lift), keep the resident's skin clean and dry, apply moisturizing lotion, monitor skin with cares and report any changes to nurse and reposition the resident every 2 hours. Observation on 9/12/11 at 1:45 p.m. revealed nurse aides D and E assisted the resident from a wheelchair into bed with the use of a mechanical lift. The aides situated the resident on their back in bed, raised the resident's head and legs, and then left the resident to rest. The resident remained in this position without a position change through observations at 2:45, 3:25 p.m. and 4:15 p.m. Staff failed to follow the care plan and reposition the resident every 2 hours. Observation on 9/13/11 at 10:45 a.m. revealed staff assisted the resident up out of bed and into the wheelchair with the use of a mechanical lift. The resident then left the building to attend a physician's visit. At 12:10 p.m. on the same day, observation revealed the resident had returned to the facility and remained in the wheelchair. The resident sat in the dining room, eating their lunch. At 12:45 p.m., observation revealed the resident remained seated in the wheelchair, but now sat next to their bed in their room, with their eyes closed. The resident remained there without a position change through observations at 1:30 p.m. and 1:52 p.m. At 2:12 p.m., nurse aides G and F entered the room to assist the resident into bed. Nurse aide G stated "I bet you are ready to go to bed, aren't you (resident's name)? You have been up since, what, 10:45 this morning?" The aides used a mechanical lift and assisted the resident into bed, then removed the resident's incontinent brief. Observation of the resident's buttocks revealed they both contained large red and white raised areas where the resident sat on creases in their slacks or the incontinent brief. On 9/13/11 at 2:15 p.m., Nurse aide F stated they were supposed to reposition the resident every 2 hours, but that the resident had a doctor's appointment that morning and that was why they had sat up for over 2 hours. When asked if staff could have assisted the resident into bed when they brought the resident back to their room after lunch at 12:45 p.m., Staff F said they could, but they had other people that were supposed to go to bed first. The facility failed to provide the timely repositioning services to a dependent resident at risk for the development of pressure sores, as planned. - Review of the physician's orders [REDACTED]. Review of the quarterly MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 8/3/11 identified resident #1 with severely impaired cognition, no behaviors, dependent on two staff for bed mobility, transfers, toilet use, personal hygiene, with an indwelling catheter, incontinent of bowel, at risk for the development of pressure ulcers, with 2 stage IV pressure ulcers, on a pressure reducing device for chair and bed, and on a turning /repositioning program. The care plan, dated 8/10/11, identified the resident had multiple pressure ulcers, including one on the left clavicle and left outside of the chin, both of which had closed, plus one on the right iliac crest (hip) and one on the left sacrum (buttock) and directed staff to reposition the resident every 2 hours, to observe the resident's skin daily with cares/during bath, to report any changes or concerns to nurse, ensure the resident wore wrist splints for contractures, monitor any reddened areas or skin breakdown when applying splints-assure that splints are not too tight, apply "neck" pillow to crook of right arm to protect arm from resting on chin, to use the large soft cushion behind the resident's knees, and to wear heel protectors when in bed. The care plan lacked any guidance to staff to use an air mattress. On 9/13/11 at 1:15 p.m., nurse aide F identified the facility placed an air mattress overlay on top of the mattress on the resident's bed. Staff F pulled back the sheets to show the overlay and stated they covered it with a bottom sheet, then an incontinent pad, then made the bed with the top sheet and a bed spread. When asked what setting the resident required the air mattress to be at to provide optimum pressure relief, Staff F said they didn't know, "I don't mess with those settings." Observation on 9/13/11 at 1:20 p.m. revealed nurse aides F, G and nurse N assisted the resident into bed from the wheelchair with the use of a mechanical lift. Staff F placed another cloth incontinent pad on top of the made bed, then assisted the resident into bed, positioned the resident with positioning pillows, and covered the resident with a blanket. Review of the manufacturer's recommendations for the air mattress overlay revealed the following guidance regarding bed linens: "This device incorporates a waterproof cover that is moisture vapor permeable; therefore it is recommended to limit bed linens to one cotton sheet in order to maximize the system's performance. NOTE: Only "breathable" incontinent pads are recommended for use with this device." The facility failed to follow the manufacturer's recommendations regarding the use of bed linens on the air mattress overlay. On 9/13/11 at 8:40 a.m., Administrative Nurse A stated they lacked knowledge what level the air mattress should be set at for the resident, and did not know which staff set it. The facility failed to provide the necessary treatment and services and follow the manufacturer ' s guidelines for the number of linens used over an air mattress overlay or monitor the air level used in the overlay to maximize its performance in order to promote healing of the resident's pressure sores and prevent new sores from developing.