Every finding on record at Greeley County Hospital Ltcu

The facility had a census of 15 residents. Based on observation, interview, and record review, the facility failed to use appropriate barriers while sorting soiled laundry.Findings included:- On 11/06/25 at 08:37 AM, while on tour of the laundry department, Housekeeping Staff V stated the soiled laundry was sorted using only gloves for personal protective equipment (PPE) and said staff did not wear a gown or other barriers.On 11/06/25 at 09:48 AM, Housekeeping Staff U stated the laundry staff had not been using a clothing barrier while sorting soiled laundry, and there was the potential of transferring infectious material to the clean laundry while sorting and folding clean laundry.The facility's Laundry Washer Dryer Room Procedures, dated 10/02/24, documented to use of gloves when touching dirty/soiled laundry. The policy lacked the use of a PPE gown or apron barrier to prevent the transfer of potentially infectious material from sorting soiled laundry onto clean laundry for folding and sorting.

The facility had a census of 15 residents. Based on observation, interview, and record review, the facility failed to offer a pneumococcal (type of bacterial infection) PVC20 immunization for Residents (R) 6, R12, and R10 per the guidance from the Centers for Disease Control and Prevention (CDC).Findings included:- R6's Electronic Health Record (EHR) documented that R6 received one Pneumovax Prevnar 13 dose on 04/17/17. The facility lacked documentation that R6 had been offered or refused any further pneumococcal vaccinations.R12's EHR documented that R12 received one Pneumovax Prevnar 13 dose on 01/05/18. The facility lacked documentation that R12 had been offered or refused any further pneumococcal vaccinations.R10's EHR documented that R10 received one Pneumovax Prevnar 13 dose on 11/17/22. The facility lacked documentation that R10 had been offered or refused any further pneumococcal vaccinations. On 11/06/25 at 09:34 AM, Administrative Nurse E reported the facility had been working on the pneumonia immunizations and had been reviewing the pneumococcal status of the current residents, but had not offered the currently required pneumococcal vaccinations as required by the CDC. Administrative Nurse E reported updating the physician's standing orders to include the update for pneumococcal immunizations.The facility's Influenza and Pneumonia Immunization policy, dated 08/27/24, documented that the Advisory Committee on Immunization Practices recommends vaccinating persons who are at high risk for complications from influenza and/or pneumonia, including those [AGE] years of age and older, who are residents of nursing homes. Recognizing the major impact and mortality of influenza and/or pneumonia disease on residents of nursing homes, and the effectiveness of vaccines in reducing healthcare costs and preventing illness, hospitalization, and death, this facility has adopted the following policy statement: Pneumonia vaccines will be administered per CDC-recommended guidelines.

The facility had a census of 15 residents. The sample included eight residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use for Resident (R) 12's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing). Findings included: - R12's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).R12's admission Minimum Data Set (MDS) dated [DATE] recorded R12 had a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition. The MDS recorded the resident used a walker and wheelchair for mobility and required substantial to maximal assistance with sit-to-stand, chair/bed to chair transfer, and toilet transfer. The MDS recorded R12 required partial to moderate assistance to walk ten feet once standing. The MDS recorded the resident received antipsychotic medications during the observation period.The Psychotropic Drug Use Care Area Assessment (CAA) dated 11/04/25 recorded R12 had a history of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The CAA recorded R12 received an antipsychotic, antidepressant (a class of medications used to treat mood disorders), and a sedative (a medication that induces sedation by reducing irritability or excitement).R12's Care Plan dated 07/09/25 recorded R12 had impaired cognitive function, dementia, or impaired thought process due to dementia. The care plan documented R12 used psychotropic (a medication that alters mood or thoughts medication Seroquel (an antipsychotic medication) due to depression and dementia. The care plan directed staff to monitor for side effects and effectiveness every shift, and monitor for side effects such as unsteady gait, tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk), shuffling gait, rigid muscles, shaking, frequent falls refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea and vomiting, and behavior symptoms not usual to that person. The care plan documented the staff would monitor and record occurrences of targeted behaviors, symptoms, and document per facility protocol. The care plan did not document the targeted behaviors for Seroquel.The Physician's Order initial order date of 06/11/25 and 10/23/25 directed the staff to administer Seroquel 25 milligrams (mg), one time a day, related to major depressive disorder and anxiety.On 11/05/25 at 08:30 AM, observation revealed R12 sat in a wheelchair in her room. Continued observation revealed Certified Medication Aide (CMA) R administered the resident's morning medications. On 11/05/25 at 10:00 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, when R12 first received the medication that was ordered 12/29/23 with a diagnosis of dementia with behaviors, which the admitting nurse chose that diagnosis for the medication use. Administrative Nurse D stated the resident returned from her recent hospital stay, and on 10/23/25, the nurse apparently chose the diagnosis of major depressive disorder and anxiety. Administrative Nurse D stated she would speak with the physician and get an appropriate diagnosis for the use of Seroquel.The facility's Antipsychotic Medication policy, dated 04/28/25, documented any resident who used an antipsychotic medication receives a gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs to ensure the resident does not receive unnecessary medications and at the lowest possible dose is administered for the shortest amount of time. The policy documented all physician orders for antipsychotic medications would be clear and accurate and would include a diagnosis, condition, or indication for use, and the consultant pharmacist would review the appropriateness of all medication orders for medications to be administered by clinical staff. The policy documented each resident who had a new order for an antipsychotic medication would be assessed and periodically reassessed during their stay to determine the effectiveness of the medication. The policy documented the staff would revise the care plan as indicated and report to the physician any findings that indicated a change in medication regimen may be indicated.

The facility had a census of 15 residents. The sample included eight residents, including one resident reviewed for accidents. Based on observation, interview, and record review, the staff failed ensure fall interventions were implemented to prevent a fall which resulted in transport to a local hospital and subsequent hip fracture and hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) for Resident (R) 12. Findings included: - R12's Electronic Medical Record (EMR) documented the resident had diagnoses of atrial fibrillation (rapid, irregular heartbeat), dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and nondisplaced subtrochanteric fracture of right femur (broken thigh bone). R12's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R12 had a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS recorded the resident used a walker and wheelchair for mobility and required substantial to maximal staff assistance with sit-to stand, and chair/bed-to-chair transfer, toilet transfer. The MDS documented R12 required staff supervision or touch assistance to walk ten feet, once standing.R12's admission MDS dated [DATE] recorded R12 had a BIMS of seven. The MDS recorded the resident used a walker and wheelchair for mobility, required substantial to maximal staff assistance with sit-to-stand, and chair/bed-to-chair transfer, and toilet transfer. The MDS documented R12 required partial to moderate staff assistance to walk ten feet, once standing. R12's Fall Care Area Assessment (CAA) dated 11/04/25 documented R12 fell more than once during the quarter, received an antidepressant medication daily, and required staff assistance with transfers and activities of daily living (ADL) due to safety concerns and ADL assistance.R12's Fall Care Plan dated 07/09/25 documented R12 was a high fall risk, related to poor balance, unsteady gait, and the fall assessments. A 06/07/24 intervention noted R12 had a chair sensor alarm, used to notify staff when the resident tried to get out of bed on her own. The care plan included a staff intervention to make sure the alarm was moved between the recliner and the wheelchair. The care plan documented staff would ensure the floor was dry, clear of clutter, call light was within reach, needed items were within reach, and the resident had on appropriate footwear. The care plan documented staff would make sure sensor alarms were working and connected when in use and remind the resident to use the call light before standing or when assistance was needed. R12's ADL Care Plan dated 07/09/25 revealed one staff to assist R12 with transfers with a gait belt and walker and the resident may use a wheelchair if needed. The ADL care plan documented staff would check on the resident at midnight, 04:00 AM, and 08:00 AM. If the resident was incontinent the staff would assist the resident with cares and offer to assist R12 to the bathroom if R12 was not incontinent. The TRIPS - Fall Risk assessment dated [DATE] recorded a score of 85 (a score of 45 or higher indicated a high fall risk).The TRIPS - Fall Risk Assessment dated 10/30/25 recorded a score of 75. The Nurses Note dated 09/27/25 at 12:45 PM documented staff found R12 lying on the floor in front of her bathroom, positioned on her right side. R12 was alert, holding the back of her head and stated her head hurt. Upon assessment of R12'as head, staff noted a raised area to the back of her head, approximately 2.0 centimeter (cm) with no bleeding or bruising present. The nurse documented R12's range of motion was within normal limits and R12 denied pain or injury to any other area. R12 had on regular socks and her shoes were in front of her recliner, where she previously sat, and her call light was attached to the recliner. The staff assisted the resident to a wheelchair without difficulty, toileted R12, and pushed her to the dining room for lunch. The resident did not express distress and neuro checks were initiated. At approximately 12:30 PM, the hematoma to back of her head was larger and measured 4.0 cm. R12 was in the dining room eating lunch, alert and oriented per baseline. The staff sent the resident to the emergency room for evaluation of the hematoma and gave report to the emergency department nurse. The staff notified the Durable Power of Attorney (DPOA). The Nurse's Notes dated 09/27/25 at 03:07 PM documented R12 had a fractured left hip and transported a local hospital for surgery.The Nurse's Notes dated 10/10/25 at 02:56 PM documented R12 admitted back to the facility from the hospital at 11:05 AM (13 days after her fall). The Fall Investigation Report dated 10/03/25 documented: following assessment, staff interviews, and review of the environment, the facility could not determine what directly led to R12's fall, as it was unwitnessed. The investigation noted the resident was found alert, on the floor, in front of her bathroom, wearing plain socks with shoes located by her recliner. The wheelchair/recliner pad alarm was at the foot of the bed and was not in use at the time, and no environmental hazards were identified in the resident's room. The investigation documented R12 sustained a head hematoma, monitored per facility protocol with neuro checks initiated, and staff notified the physician and responsible party. The investigation documented the root cause remained undetermined, with contributing factors documented as: ambulation without non-skid footwear and the absence of an active chair alarm. The investigation documented the corrective actions implemented included: reinforcement of staff education on fall prevention practices, proactive toileting assistance, ensuring proper use of alarms, and resident encouragement to wear appropriate footwear. On 11/05/25 at 08:00 AM, observation revealed Certified Medication Aide (CMA) R assisted R12 to transfer from the toilet to her wheelchair with use of a gait belt. Continued observation revealed CMA R placed the chair pad alarm in the seat of the resident's wheelchair before the transfer.On 11/06/25 at 09:05 AM, Administrative Nurse D stated the medical records documented the resident had a fall on 09/27/25 at 11:45 AM and after investigating it was determined R12 did not have the chair pressure pad alarm in the recliner when she fell, and the alarm was located at the end of the bed. Administrative Nurse D stated she re-educated nursing and Certified Nurse Aides (CNA) staff on ensuring staff assisted residents to wear appropriate footwear before ambulating. Administrative Nurse D also stated they reinforced the fall prevention policy, including ensuring alarms were used as ordered and correctly placed, and reviewed the importance of offering toileting assistance proactively to reduce unassisted transfers.The facility's Fall Prevention Program policy, dated 04/28/25, documented anyone admitted to the facility was considered at risk for falls. The policy documented on admission, quarterly, and with any significant change in status the following shall occur. The fall Nurse Coordinator would complete the TRIPS Fall Risk Assessment. The evaluation included history or falls, blood pressure, ambulatory aid, oxygen use, gait, and mental status. The staff would update the care plan and monitor the interventions at each care plan and document such on the Fall intervention Monitor Form. The policy documented Physical Therapy would assess all residents on admission, with any significant change of health status, and at minimum every six months. The charge nurse would evaluate and investigate the fall and implement any immediate interventions deemed necessary, complete the Fall Assessment-TRIPS in the computer electronic medical records program, obtain a set of vitals, notify the physician of the fall, monitor, and document for 72 hours post fall.

The facility had a census of 15 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified the lack of specific parameters for Resident (R) 1's use of as-needed (PRN) opioid (a class of drug used to reduce moderate to severe pain) and diuretic (a medication to promote the formation and excretion of urine) use and R12's unapproved diagnosis for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality).Findings included: - R1's Electronic Medical Record (EMR) included diagnoses of constipation (difficulty passing stools), pain, functional dyspepsia (indigestion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), acquired absence of right leg above the knee, pain in the left leg, and polyneuropathy (a condition that affects multiple peripheral nerves). R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R1 had intact cognition and rejection of care behavior that occurred one to three days during a seven-day look-back period. R1 had a functional range of motion to lower extremity on one side, required substantial to maximal assistance with toileting hygiene, chair-to-bed transfers, and bed-to-chair transfers. R1 required partial to moderate assistance with upper body dressing and personal hygiene. R1 had occasional incontinence of urine and bowel. The MDS further documented that R1 had not received scheduled pain medication regimen but received PRN pain medication and non-medication interventions for pain. R1 had frequent pain, which occasionally affects sleep, and the pain level score of eight out of ten. (Pain scale rating zero for no pain and ten being the worst pain felt). R1 received a diuretic and an opioid. The Pain Care Area Assessment (CAA) dated 04/16/25 documented that R1 had pain frequently, utilized PRN medication daily, had polyneuropathy, and chest pain. R1's Care Plan dated 10/28/25 documented that R1 was on pain medication therapy related to complaints of chronic pain, polyneuropathy, and depression. The Care Plan directed staff to administer pain medication as ordered by the physician and oxycodone (opioid medication) five milligrams (mg) PRN every three hours for pain. The Black Box Warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration) for documented Bumetanide (diuretic medication) was a potent diuretic that could lead to diuresis with water and electrolyte (minerals that help keep the body's fluid levels in balance, necessary to help the muscles, heart, and other organs work properly) depletion. Therefore, careful medical supervision is required, and the dose and dosage schedule have to be adjusted to the individual patient's needs. The Physician Order dated 09/23/24 directed staff to administer oxycodone (opioid) five mg by mouth every three hours as needed for pain. Take one to three tablets every three hours PRN. The order lacked parameters related to specifics for the level or type of pain and how many tablets to give based on the level or type of pain. The Physician Order dated 08/26/25 directed staff to administer bumetanide 0.5 mg by mouth every 24 hours as needed for edema. The order lacked specific guidelines related to edema. The Physician Order dated 09/17/25 directed staff to administer bumetanide one mg by mouth one time a day for a diuretic. The September 2025 Medication Administration Record (MAR) revealed R1 received five to ten mg of oxycodone three to six times a day. The October 2025 MAR revealed R1 received ten mg of oxycodone two to six times a day. The Progress Note dated 09/15/25 documented that R1 informed the nurse that bumetanide two mg was making her cramp all over and wanted the physician notified that she wanted the dose decreased back to one mg. R1 stated she would refuse the two mg dose if the dose was not lowered. The Monthly Medication Regimen Review dated 12/17/24 through 09/24/25 lacked a recommendation or clarification on the specific parameters related to the PRN use of oxycodone and bumetanide. On 11/04/25 at 04:19 PM, R1 was sitting in the dining room for another resident's birthday celebration. On 11/05/25 at 04:44 PM, R1 reported that the pain she experienced was leg pain. R1 also reported edema in her stump and could not follow orders to wear the stump shrinker to utilize the prosthesis (artificial body part). On 11/05/25 at 08:09 AM, Certified Medication Aide (CMA) R explained that the charge nurse on duty was notified if R1 needed or requested PRN medication, and the charge nurse determined what medication to administer to R1. On 11/06/25 at 09:05 AM, Licensed Nurse (LN) G reported that R1 determined what dose of oxycodone she wanted. LN G reported that R1 usually complained of pain all over her body when LN G asked about pain. LN G stated R1 had changes to the dose of bumetanide, and R1 would let staff know if she wanted the PRN bumetanide. LN G stated the order for oxycodone and bumetanide lacked parameters or specified edema (swelling) or pain levels related to their use. On 11/06/25 at 10:51 AM, Administrative Nurse D reported the physician's order lacked specific criteria for administration of PRN dosing. The facility's Pharmacy Services policy, dated 04/28/25, documented that it was the policy of the facility to provide pharmacy services in accordance with State and Federal Regulations. - R12's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R12 admission Minimum Data Set (MDS) dated [DATE] recorder R12 had a Brief Interview for Mental Status (BIMS) of seven, indicating moderately impaired cognition. The MDS recorded the resident used a walker and wheelchair for mobility and required substantial to maximal assistance with sit to stand, and chair/bed to chair transfer, toilet transfer, with partial to moderate assistance to walk ten feet once standing. The MDS recorded the resident received antipsychotic medications (class of medications used to treat major mental conditions which cause a break from reality) during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA) dated 11/04/25 recorded R12 had a history of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The CAA recorded R12 received an antipsychotic, antidepressant (a class of medications used to treat mood disorders) and a sedative (a medication that induces sedation by reducing irritability or excitement). R12's Care Plan, dated 07/09/25 recorded R12 had impaired cognitive function, dementia, or impaired thought process due to dementia. The care pan documented R12 used psychotropic (a medication that alters mood or thoughts) medication, Seroquel (antipsychotic medication), due to depression and dementia. The care plan directed staff to monitor for side effects and effectiveness every shift, and monitor for side effects such as unsteady gait, tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea and vomiting, and behavior symptoms not usual to that person. The care plan documented the staff would monitor and record occurrences of targeted behaviors symptoms and document per facility protocol. The care plan did not document the targeted behaviors for Seroquel. The Physician's Order, initial order date 06/11/25 and 10/23/25, directed the staff to administer Seroquel 25 milligrams (mg), one time a day related to major depressive disorder and anxiety. On 11/05/25 at 08:30 AM, observation revealed R12 sat in a wheelchair in her room. Continued observation revealed Certified Medication Aide (CMA) R administered the resident's morning medications. On 11/05/25 at 10:00 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, when she first received the medication that was ordered 12/29/23 with a diagnosis of dementia with behaviors, which the admit nurse chose that diagnosis for the medication use. Administrative Nurse D stated the resident returned from her recent hospital stay and on 10/23/25 the nurse apparently chose the diagnosis of major depressive disorder and anxiety. Administrative Nurse D stated she would speak with the physician and get an appropriate diagnosis for the use of the Seroquel. Administrative Nurse D verified the pharmacist consultant did not address the physician's diagnosis for the Seroquel with his monthly reviews. The facility's Antipsychotic Medication policy, dated 01/26/24, documented any resident who used an antipsychotic medication receives gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs to ensure the resident does not receive unnecessary medications and at the lowest possible dose is administered for the shortest amount of time. The policy documented all physician orders for antipsychotic medications would be clear and accurate and would include a diagnosis, condition or indication for use, and the consultant pharmacist would review the appropriateness of all medication orders for medications to be administered by clinical staff. The policy documented each resident who had a new order for an antipsychotic medication would be assessed and periodically reassessed during their stay to determine the effectiveness of the medication. The policy documented the staff would revise the care plan as indicated and report to the physician any findings that indicated a change in medication regimen may be indicated. The Pharmacy Services policy, dated 04/28/25, documented the facility would provide pharmacy services in accordance with State and Federal regulations. The facility would employ or obtain services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility, establishes a system of records of receipts and disposition all controlled drugs in sufficient detail to enable an accurate reconciliation. Determines that drug records are in order and that an account of all controlled drugs is maintained.

The facility had a census of 15 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to obtain parameters for as needed (PRN) medication related to opioid (a class of drug used to reduce moderate to severe pain) and diuretic (a medication to promote the formation and excretion of urine) use.Findings included:- R1's Electronic Medical Record (EMR) included diagnoses of constipation (difficulty passing stools), pain, functional dyspepsia (indigestion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), acquired absence of right leg above the knee, pain in left leg, and polyneuropathy (a condition that affects multiple peripheral nerves).R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R1 had intact cognition and rejection of care behavior that occurred one to three days during a seven-day look-back period. R1 had a functional range of motion to lower extremity on one side, required substantial to maximal assistance with toileting hygiene, chair-to-bed transfers, and bed-to-chair transfers. R1 required partial to moderate assistance with upper body dressing and personal hygiene. R1 had occasional incontinence of urine and bowel. The MDS further documented that R1 had not received scheduled pain medication regimen but received PRN pain medication and non-medication interventions for pain. R1 had frequent pain, which occasionally affected sleep, and the pain level score of eight out of ten. (Pain scale rating zero for no pain and ten being the worst pain felt). R1 received a diuretic and an opioid.The Pain Care Area Assessment (CAA) dated 04/16/25 documented that R1 had pain frequently, utilized PRN medication daily, had polyneuropathy, and chest pain.R1's Care Plan dated 10/28/25 documented that R1 was on pain medication therapy related to complaints of chronic pain, polyneuropathy, and depression. The Care Plan directed staff to administer pain medication as ordered by the physician and oxycodone (opioid medication) five milligrams (mg) PRN every three hours for pain. The Black Box Warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration) for documented Bumetanide (diuretic medication) was a potent diuretic that could lead to diuresis with water and electrolyte (minerals that help keep the body's fluid levels in balance, necessary to help the muscles, heart, and other organs work properly) depletion. Therefore, careful medical supervision is required, and the dose and dosage schedule have to be adjusted to the individual patient's needs.The Physician Order dated 09/23/24 directed staff to administer oxycodone (opioid) five mg by mouth every three hours as needed for pain. Take one to three tablets every three hours PRN. The order lacked parameters related to specifics for the level or type of pain and how many tablets to give based on the level or type of pain.The Physician Order dated 08/26/25 directed staff to administer bumetanide 0.5 mg by mouth every 24 hours as needed for edema. The order lacked specific guidelines related to edema.The Physician Order dated 09/17/25 directed staff to administer bumetanide one mg by mouth one time a day for a diuretic.The September 2025 Medication Administration Record (MAR) revealed R1 received five to ten mg of oxycodone three to six times a day.The October 2025 MAR revealed R1 received ten mg of oxycodone two to six times a day.The Progress Note dated 09/15/25 documented that R1 informed the nurse that bumetanide two mg was making her cramp all over and wanted the physician notified that she wanted the dose decreased back to one mg. R1 stated she would refuse the two mg dose if the dose was not lowered.On 11/04/25 at 04:19 PM, R1 was sitting in the dining room for another resident's birthday celebration.On 11/05/25 at 04:44 PM, R1 reported the pain she experienced was leg pain. R1 also reported edema in her stump and could not follow orders to wear the stump shrinker to utilize the prosthesis (artificial body part).On 11/05/25 at 08:09 AM, Certified Medication Aide (CMA) R explained the charge nurse on duty was notified if R1 needed/requested PRN medication, and the charge nurse determined what medication to administer to the resident.On 11/06/25 at 09:05 AM, Licensed Nurse (LN) G reported that R1 determined what dose of oxycodone she wanted. LN G reported that R1 usually complained of pain all over her body when LN G asked about pain. LN G stated R1 had changes to the dose of bumetanide, and R1 would let staff know if she wanted the PRN bumetanide. LN G stated the order for oxycodone and bumetanide lacked parameters or specified edema (swelling) or pain levels related to their use.On 11/06/25 at 10:51 AM, Administrative Nurse D reported the physician's order lacked specific criteria for administration of PRN dosing.The facility's Administration of PRN (As Needed) Medications policy, dated 11/06/25, documented that medication would be administered by qualified staff only and would be administered only as prescribed by a licensed practitioner in this State. All medications would be administered in a safe and effective manner. Due to the complexity and length/amount of instructions, some medications may be labeled use as directed. Refer to the MAR for instruction details.

The facility had a census of 16 residents. The sample included nine residents with two reviewed for accidents. Based on observation, record review, and interview the facility failed to ensure an environment free from accidents for Resident (R)3, when staff served her a hot beverage in the wrong cup. R3 spilled the hot beverage on her abdomen, which caused a second-degree burn (potentially painful burn that affects the first and second layer of the skin) and placed the resident at risk for increased pain. Findings included: - R3's Electronic Health Record (EHR) revealed diagnoses of multiple sclerosis (MS-a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control), major depressive disorder (major mood disorder which causes persistent feelings of sadness), dysphagia (swallowing difficulty), and weakness. R3's Admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed the resident required set-up assistance with eating. R3's Hot Liquid assessment dated [DATE], documented a score of three and a score of two that indicated a risk of spills from hot liquid. The assessment documented the resident was to have hot liquids in a cup with lids. R3's Care Plan, dated 06/27/24, recorded R3 required staff assistance with most activities of daily living (ADL) care. The care plan documented the resident had a self-care performance deficit with contractures (abnormal fixation of a joint or muscle) and could feed herself. The plan documented that staff would assist with cutting up her food. The plan directed staff to serve hot liquids in a lidded cup, due to R3's documented risk of spills from hot liquids. R3's Care Conference dated 07/10/24, documented the resident had honey-thickened liquids, preferred water only, and used a Kennedy cup (a lightweight, easy to grip, no-spill cup that only dispensed liquids as the resident sucked on the straw) with meals. R3's EHR recorded a Progress Note, dated 07/25/24 at 09:14 AM, that documented R3 dropped her Styrofoam cup of hot cocoa, and the lid came off; this caused the cocoa to spill onto R3's abdomen. Staff called the clinic, and no new orders were obtained at that time. Staff made an appointment for R3 to see the physician in the morning. The Progress Note, dated 07/25/24 at 11:26 AM, documented R3 went to the hospital to see the physician. R3's abdomen was assessed and had redness that remained on the upper abdomen under the breast area. The area was 0.6 centimeters (cm) with round, raised, fluid-filled blisters in the middle of the burned area. The physician ordered medication for the burned area. The late entry Progress Note, dated 07/25/24 at 11:40 AM, documented R3 had a hot liquid spill incident. The staff were educated, and a report was sent to the state agency. The note documented the burn occurred because the resident was in isolation for positive COVID-19 (highly contagious respiratory virus) status and dietary staff served her meals and liquids in disposable containers. R3's hot liquids were served in a Styrofoam cup. The note recorded that dietary staff were operating under old COVID-19 guidelines where disposable plates and cups were used. The Progress Note, dated 07/26/24 at 11:01 AM, documented R3 continued to have burns to the top of her abdomen under the breast. The area was red with one blister present, approximately 1 cm, round, and fluid-filled. Staff applied bacitracin (a topical antibiotic ointment) and Telfa (non-stick dressing) dressing. The Progress Note, dated 07/27/24 at 12:09 AM, documented R3 had a dressing in place on the abdomen on the burns. R3's skin continued to be blistered. The resident denied discomfort. The Progress Note, dated 07/27/24 at 09:55 AM, documented that staff applied bacitracin ointment topically one time a day for blisters to R3's abdomen and covered with a nonadherent gauze dressing until healed. The note documented the resident's skin continued with redness to the right upper abdomen under her breast with one large fluid-filled clear blister to the inner upper abdomen. When the dressing change was completed, R3 complained the area was tender to touch. The Physician Notes, dated 07/30/24 at 03:43 PM documented R3's provider visited to follow up on the burn to R3's abdomen but issued no new orders. R3's Skin assessment dated [DATE], documented a faded area with slight redness to the upper mid-abdomen. The area was small, scaly, and had a scab healing. The assessment noted no open areas. R3's Hot Liquid Assessment, dated 08/08/24 (14 days after the hot liquid burn), documented the resident had a neurological diagnosis, a psychiatric diagnosis, poor muscular control, and low mobility. The assessment documented the resident had experienced burns from a previous spill and would benefit from a burn-proof protector during the consumption of hot liquids. The assessment documented the resident could not manage hot liquids independently and was at risk for hot liquid spills. On 08/28/24 at 07:50 AM, observation revealed R3 sat in a wheelchair at the dining room table dressed in street clothes. Continued observation revealed the resident had three drinks in Kennedy cups. On 08/27/24 at 09:30 AM, Administrative Nurse D verified she was on vacation when the incident occurred. Administrative Nurse D stated the resident was diagnosed with COVID-19 on 07/15/24 and was in her room on isolation precautions. Administrative Nurse D verified the dietary staff prepared a room tray for the resident that included a Styrofoam cup with a lid and a straw but due to the resident's limited mobility, hand contractures, and weakness, she put a hole in the cup when she grabbed it and the lid popped off resulting in the liquid leaking on her abdomen. This caused burns. Administrative Nurse D verified the resident was supposed to have a Kennedy cup, not a Styrofoam cup, and that is the reason she sustained the burns to her abdomen. Administrative Nurse D instructed the dietary department it was ok for an isolation resident to have the Kennedy cups instead of the Styrofoam and they could sanitize the cup. Administrative Nurse D verified the facility completed a hot liquid assessment upon admission on 06/27/24. Administrative Nurse D stated that after R3's burn incident, the facility utilized a new Hot Liquid Assessment that used more information to identify residents at risk for burns and spills. The facility's Hot Beverage policy dated 08/14/24 , documented that all hot beverages served to residents in their room or dining room would be in insulated mugs and the temperature should not exceed 160 degrees Fahrenheit. The facility failed to provide R3 with the correct Kennedy cup to prevent hot liquid accidents resulting in R3 spilling the hot liquid on her abdomen which caused a second-degree burn and placed the resident at risk for increased pain. The facility completed all corrective actions, to include staff education, by 08/15/24, prior to the onsite survey. Therefore, the deficient practice was deemed past noncompliance at a G scope and severity.

The facility had a census of 16 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter 1 indicated no licensed nurse coverage on the following dates: 10/08/23, 10/09/23, 10/15/23, 10/22/23, 10/28/23, 11/05/23, 11/11/23, 11/16/23, 11/23/23, 11/24/23, 12/03/23, 12/17/23, and 12/30/23. A review of the facility's licensed nurse payroll data for the dates listed above revealed a licensed nurse was on duty 24 hours a day, seven days a week. On 08/27/24 at 11:30 AM, Administrative Nurse D verified the facility had submitted nursing hours and data for the PBJ that lacked the coverage of the agency and hospital RN coverage. Administrative Nurse D verified the nurse clock in hours and the facility had nurse coverage on all the days documented above. The Mandatory Submission of Uniformed Staffing Information, dated 08/29/24 documented the facility complete submission of staffing information-based payroll data in a uniform format as specified by regulatory requirements. The facility would electronically submit to the Centers for Medicare and Medicaid Services (CMS). The data would include the category of work for each person on direct care staff, including, but not limited to if the individual is a registered nurse (RN)), licensed practical nurse (LPN), certified nursing assistant, therapist, or other type of medical personnel as specified by CMS. The Director of Nursing (DON) would review that monthly to ensure accurate reporting and notify the designated person assigned to data submission as to any corrections needing to be made. Prior to the end of the quarter submissions, the DON would again review entire quarterly submissions to ensure accurate reporting and notify the designated person assigned data submission as to any corrections needing to be made. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 16 residents. The sample included nine residents with two reviewed for skin issues. Based on observation, interview, and record review the facility failed to perform weekly skin assessments and follow-up documentation of non-pressure related skin issues found for Resident (R) 9, placing R9 at risk for further skin issues. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of dermatitis (swelling and irritation of the skin), history of venous thrombosis (a clot that developed within a blood vessel) absence of the right leg above the knee, and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented that R9 was independent with eating and required staff assistance with dressing toileting and mobility. The MDS documented R9 was at risk for pressure ulcers (localized injury to the skin or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) but had no skin issues. R9's Care Plan, dated 11/02/23 and revised on 04/24/24, stated the resident required skin inspection (weekly and as needed) and directed staff to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. The Progress Note, dated 07/01/24 documented an open wound approximately one centimeter (cm) by 0.5cm, on R9's lower left leg just below the knee. The note stated the site had been oozing clear fluid and the nurse covered it with a 2x2 gauze and band-aid. R9's EMR had no follow-up note or assessment of the skin issue and the next skin assessment was dated 07/26/24, three and half weeks later. The Skin Assessment, dated 07/26/24, documented a scabbed area to the top of R9's left second toe, measuring 1 cm x 0.5 cm, and a band-aid was applied. R9's EMR had no follow-up note or assessment of the skin issue and the next skin assessment was dated 08/13/24, over two weeks later. A review of the documented Skin Assessments revealed four separate weeks without an assessment (07/07-13/24, 07/14-20/24, 07/28/24 - 08/03/24, 08/04-10/24.) On 08/29/24 at 08:59 AM, observation revealed R9 was in bed. Administrative Nurse D performed a skin check and found no skin issues on R9's left leg and toe. On 08/27/24 at 08:05 AM, Administrative Nurse D verified staff had not documented skin assessments weekly and she verified staff should have followed up on the documented skin issues of 07/01/24 and 07/26/24. The facility's Skin Assessment policy, dated 08/29/24, stated all residents would receive a head-to-toe skin assessment on admission and weekly thereafter. Any skin issues identified should be documented on the assessment form. The facility failed to perform weekly skin assessments and follow-up documentation of skin issues found for R9. This placed R9 at risk for further skin issues due to the lack of routine skin assessments and follow-up of identified skin issues.

The facility had a census of 16 residents. The sample included nine residents. Based on observation, interview, and record review the facility failed to label and date one vial of insulin (a hormone that lowers the level of glucose in the blood) for Resident (R) 15, placing R15 at risk of receiving expired or ineffective insulin. Findings included: - On [DATE] at 09:24 AM, observation in the facility's medication storage room revealed one Fiasp (fast-acting insulin) insulin vial which had been accessed, but not dated at that time. On [DATE] Medlineplus.Gov documented unrefrigerated unopened vials, cartridges, and pens of insulin aspart solution (Fiasp) can be used within 28 days, but after that time they must be discarded. On [DATE] at 09:24 AM, Administrative Nurse D verified the vial should have been dated when opened and first accessed. The facility's Medication Labeling and Storage policy, dated [DATE], stated medications would be labeled and stored in accordance with facility requirements and state and federal laws. Multi-dose vials that have been opened or accessed would be dated and discarded within 28 days unless the manufacturer specified a different date for that vial. The facility failed to date R15's vial of insulin when opened, placing her at risk of receiving ineffective insulin.

The facility had a census of 18 residents. The sample included eight residents. Based on observation, record review and interview the facility failed to promote an environment free of hazards for Resident (R)8 who smoked cigarettes but was not assessed for safe smoking practices by the facility. This placed the resident at risk for avoidable injuries and fire related hazards Findings included: - R8's diagnoses include cerebrovascular disease (CVA-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) major depressive disorder (major mood disorder) , hyperkalemia (greater than normal amounts of calcium in the blood), hypertension (elevated blood pressure), and gastro-esophageal reflux disease (backflow of stomach contents to the esophagus). R8's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented R8 was independent with activities of daily living (ADLs), used a cane or walker for mobility and required staff supervision in the facility. R8's Activities of Daily Living Care Plan, dated 03/22/23, directed staff to assist the resident to use a wheelchair for independent locomotion as needed for weakness and being unsteady. The care plan recorded R8 had limited physical mobility and right-handed weakness post CVA. R8's Smoking Care Plan dated 03/22/23, directed staff to instruct R8 about smoking risk and hazards and about cessation aids that were available to quit smoking. The care plan further stated the resident could smoke unsupervised and instructed the resident was able to keep the lighter and cigarettes at bedside. R8's clinical record lacked evidence the facility assessed R8 for safe smoking practices including safe storage of smoking materials . On 06/05/23 at 12:45 PM, observation revealed R8 sat in a wheelchair in enclosed patio. Further observation revealed R8 took a cigarette and lighter out of her shorts pocket and lit a cigarette. R8 smoked the cigarette and placed the lighter back in her shorts pocket. R8 propelled herself into the facility independently. On 06/06/23 at 09:20 AM, Administrative Nurse D verified R8 was the only resident in the facility who smoked and said R8 could smoke any time. Administrative Nurse D said R8 kept her cigarettes and lighter in her room. Administrative Nurse D verified the facility lacked a safe smoking assessment for the resident and said staff would complete one. The Smoking Assessment policy, dated June 6, 2023, documented the facility would allow residents to smoke in designated areas on the property if the facility is adhered to by the resident. When the resident requests to smoke, the Care Plan Team will assess the resident's capabilities and deficits to determine appropriate supervision and assistance. Smoking will be allowed in designated outdoor areas in the facility that are not near flammable substances or where oxygen is used. Residents, resident representatives, and visitors will be informed of the facility's smoking policy at the time of admission. The purpose of this policy is to ensure an assessment is complete when a resident request to smoke or use other smoking materials to ensure precautions are taken for every resident's safety as well as the safety of others in the facility. Smoking is not a right, but a privilege and with all privilege and with all privileges come responsibilities. If this Smoking Policy is not followed, the facility reserves the right to exclude the residents from smoking either temporarily or permanently. The Smoking Policy documented if any resident chose to smoke, they will be assessed by a member of the Interdisciplinary team using the Smoking Safety Screen Assessment. The facility failed to promote a safe environment for R8 and all the residents residing in the facility, placing the residents at risk for smoke or fire.

The facility identified a census of 16 residents. Based on record review, observation, and interview, the facility failed to provide sufficient nurse staffing with the appropriate competencies and skill sets to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for Resident (R)1 which resulted in R1 falling and breaking her left hip. On 07/26/23 at 02:15 AM, Certified Medication Aide (CMA) R sat at the nurse's station and heard someone yelling. CMA R went down the hallway and found R1 in her room by her bed. R1 stated, I fell , and I can't get up and R1 stated she was trying to reach her call light, which was noted to be at the end of her bed. CMA R called the hospital to get one of the nurses to come help with R1's assessments and neurological checks. R1 told the hospital nurse her left hip hurt. The two hospital nurses who responded to the incident provided a few routine checks of R1's range of motion and then decided to take R1 to the emergency room . CMA R notified R1's son about the fall and R1 went to the emergency room . R1 sustained a broken left hip and transferred to a higher level of care for surgical repair of her left hip R1 sustained a broken left hip and was sent to a higher level of care for surgical repair of her left hip. This deficient practice placed R1 at risk for falls, injury, and pain. Findings included: - R1's Electronic Medical Record, documented R1 had diagnoses of Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (major mood disorder), and adult failure to thrive. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of eight which indicated severely impaired cognition. The MDS documented R1 required limited to extensive assistance of one person for all of her activities of daily living. The MDS documented R1 had two or more falls during the look back period without injury. The Activity of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA), dated 11/24/22, documented R1 required limited assistance with ADL's due to severe visual impairment. The CAA documented R1 was a high fall risk. The Cognitive Loss/Dementia CAA, dated 11/24/22, documented R1 was a one assist with transfers and ambulation due to vision issues and had a history of falls. The Fall Care Plan, dated 11/21/22, documented R1 was a high risk for falls due to gait/balance problems. The care plan documented R1 would be free from minor injury and would not sustain serious injury. The care plan directed staff to anticipate and meet R1's needs, ensure R1's call light was within reach, promptly respond to all requests for assistance, ensure R1 was wearing appropriate footwear during the day and non-skid socks at night when ambulating or mobilizing in her wheelchair. The Fall Risk Assessment, dated 05/30/23, documented R1 had a fall risk score of 85 which indicated she was a high fall risk. The EMR lacked any nursing documentation regarding R1's fall. The Witness Statement, dated 07/26/23, documented CNA M was in another resident's room performing 02:00 AM rounds when CMA R came and told CMA M that R1 had fallen. CMA M finished with the resident she was working with and offered her assistance. The two emergency room nurses came to R1's room. CNA M stated she helped get R1 up to her wheelchair. CNA M stated R1 stated she was trying to reach for her call light when she had fallen. CNA M stated the previous CNA had forgotten to give R1 her call light. The Witness Statement, dated 07/26/23, documented CMA R was sitting at the nurses station when she heard R1 yelling, I fell and I can't get up. CMA R asked R1 what had happened and R1 stated that she was trying to get her call light at the end of the bed. CMA R stated that an agency CNA had put R1 to bed the previous evening and did not put R1's call light next to her but left it at the end of the bed. CMA R called the hospital for a nurse to come over and check R1 out. Two emergency room nurses came over. R1 complained of her left hip hurting. The nurses did some range of motion with R1. The two nurses suggested that R1 be taken to the emergency room . CMA R stated that she notified R1's Durable Power of Attorney (DPOA) of the fall. R1 was unavailable for observation or interview. On 07/31/23 at 01:00 PM, Administrative Nurse D stated that there had not be a Licensed Nurse (LN) on the evening of 07/25/23 through the morning of 07/26/23. Administrative Nurse D stated that the LN that was scheduled was called away due to an emergency, so the facility had the nurses at the hospital provide nursing coverage. Administrative Nurse D stated that the LN provided assessments and medication administration to the Skilled residents of the facility and the CMA provided medication administration to the other residents in the facility. Administrative Nurse D stated that once the Skilled residents' medications were administered a CMA and CNA could handle the twenty-nine residents in the building and call a nurse over from the hospital if needed. Administrative Nurse D verified that there was not a LN in the facility supervising and caring for the residents in the facility at the time of R1's fall. Administrative Nurse D stated that the facility would normally staff one LN, one CMA, and one CNA for the night shift. Administrative Nurse D stated that not having a LN on shift didn't happen a lot but it did happen and they have used the hospital nurses as coverage before. Administrative Nurse D stated that R1 rarely slept in her bed but would rather sleep out in the living area in a recliner. The night of 07/25/23 thru 07/26/23, R1 had requested to go to bed. Administrative Nurse D stated that CMA R and CNA M did rounds at 12:00 AM and just looked in on R1 and did not go in her room to ensure that her call light was in reach. Administrative Nurse D stated that she had educated CMA R and CNA M to ensure that they understood the importance of going into the residents rooms and laying eyes on them to ensure the residents were safe. Administrative Nurse D stated the facility did not have a staffing policy. The facility Fall Policy, dated 10/12/22, documented in the event a fall occurs the charge nurse will evaluate and investigate the fall and implement any immediate interventions deemed necessary, complete the Fall Assessment, obtain a set of vital signs, follow procedures in the neuro check policy, notify the physician of the fall, and monitor and document for 72 hours post fall. In an attempt to prevent falls, the following shall occur: orientation to place (room, equipment, bathroom, etc.), residents shall be assessed for toileting needs, shoes or slippers shall be used for ambulation and provided if the resident does not have any, bed shall be maintained in lowest position, rooms shall be free from excess equipment and furniture, routine nursing rounds shall be done for assessment of needs, gait belts will be available for assistance with ambulation, needs for assistive devices and assistance shall be communicated to other departments participating in resident care, and utilization of bed and chair alarms for residents when deemed appropriate. The facility did not provide a staffing policy. The facility failed to provide sufficient nurse staffing with the appropriate competencies and skill sets to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for R1 which resulted in R1 falling and breaking her left hip. This deficient practice placed R1 at risk for falls with injury and pain.

The facility identified a census of 16 residents. Based on record review, observation, and interview, the facility failed to provide sufficient nurse staffing with the appropriate competencies and skill sets to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for Resident (R)1 which resulted in R1 falling and breaking her left hip. On 07/26/23 at 02:15 AM, Certified Medication Aide (CMA) R sat at the nurse's station and heard someone yelling. CMA R went down the hallway and found R1 in her room by her bed. R1 stated, I fell, and I can't get up and R1 stated she was trying to reach her call light, which was noted to be at the end of her bed. CMA R called the hospital to get one of the nurses to come help with R1's assessments and neurological checks. R1 told the hospital nurse her left hip hurt. The two hospital nurses who responded to the incident provided a few routine checks of R1's range of motion and then decided to take R1 to the emergency room. CMA R notified R1's son about the fall and R1 went to the emergency room. R1 sustained a broken left hip and transferred to a higher level of care for surgical repair of her left hip R1 sustained a broken left hip and was sent to a higher level of care for surgical repair of her left hip. This deficient practice placed R1 at risk for falls, injury, and pain. Findings included: - R1's Electronic Medical Record, documented R1 had diagnoses of Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (major mood disorder), and adult failure to thrive. The Quarterly Minimum Data Set (MDS), dated 05/27/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of eight which indicated severely impaired cognition. The MDS documented R1 required limited to extensive assistance of one person for all of her activities of daily living. The MDS documented R1 had two or more falls during the look back period without injury. The Activity of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA), dated 11/24/22, documented R1 required limited assistance with ADL's due to severe visual impairment. The CAA documented R1 was a high fall risk. The Cognitive Loss/Dementia CAA, dated 11/24/22, documented R1 was a one assist with transfers and ambulation due to vision issues and had a history of falls. The Fall Care Plan, dated 11/21/22, documented R1 was a high risk for falls due to gait/balance problems. The care plan documented R1 would be free from minor injury and would not sustain serious injury. The care plan directed staff to anticipate and meet R1's needs, ensure R1's call light was within reach, promptly respond to all requests for assistance, ensure R1 was wearing appropriate footwear during the day and non-skid socks at night when ambulating or mobilizing in her wheelchair. The Fall Risk Assessment, dated 05/30/23, documented R1 had a fall risk score of 85 which indicated she was a high fall risk. The EMR lacked any nursing documentation regarding R1's fall. The Witness Statement, dated 07/26/23, documented CNA M was in another resident's room performing 02:00 AM rounds when CMA R came and told CMA M that R1 had fallen. CMA M finished with the resident she was working with and offered her assistance. The two emergency room nurses came to R1's room. CNA M stated she helped get R1 up to her wheelchair. CNA M stated R1 stated she was trying to reach for her call light when she had fallen. CNA M stated the previous CNA had forgotten to give R1 her call light. The Witness Statement, dated 07/26/23, documented CMA R was sitting at the nurses station when she heard R1 yelling, I fell and I can't get up. CMA R asked R1 what had happened and R1 stated that she was trying to get her call light at the end of the bed. CMA R stated that an agency CNA had put R1 to bed the previous evening and did not put R1's call light next to her but left it at the end of the bed. CMA R called the hospital for a nurse to come over and check R1 out. Two emergency room nurses came over. R1 complained of her left hip hurting. The nurses did some range of motion with R1. The two nurses suggested that R1 be taken to the emergency room. CMA R stated that she notified R1's Durable Power of Attorney (DPOA) of the fall. R1 was unavailable for observation or interview. On 07/31/23 at 01:00 PM, Administrative Nurse D stated that there had not be a Licensed Nurse (LN) on the evening of 07/25/23 through the morning of 07/26/23. Administrative Nurse D stated that the LN that was scheduled was called away due to an emergency, so the facility had the nurses at the hospital provide nursing coverage. Administrative Nurse D stated that the LN provided assessments and medication administration to the Skilled residents of the facility and the CMA provided medication administration to the other residents in the facility. Administrative Nurse D stated that once the Skilled residents' medications were administered a CMA and CNA could handle the twenty-nine residents in the building and call a nurse over from the hospital if needed. Administrative Nurse D verified that there was not a LN in the facility supervising and caring for the residents in the facility at the time of R1's fall. Administrative Nurse D stated that the facility would normally staff one LN, one CMA, and one CNA for the night shift. Administrative Nurse D stated that not having a LN on shift didn't happen a lot but it did happen and they have used the hospital nurses as coverage before. Administrative Nurse D stated that R1 rarely slept in her bed but would rather sleep out in the living area in a recliner. The night of 07/25/23 thru 07/26/23, R1 had requested to go to bed. Administrative Nurse D stated that CMA R and CNA M did rounds at 12:00 AM and just looked in on R1 and did not go in her room to ensure that her call light was in reach. Administrative Nurse D stated that she had educated CMA R and CNA M to ensure that they understood the importance of going into the residents rooms and laying eyes on them to ensure the residents were safe. Administrative Nurse D stated the facility did not have a staffing policy. The facility Fall Policy, dated 10/12/22, documented in the event a fall occurs the charge nurse will evaluate and investigate the fall and implement any immediate interventions deemed necessary, complete the Fall Assessment, obtain a set of vital signs, follow procedures in the neuro check policy, notify the physician of the fall, and monitor and document for 72 hours post fall. In an attempt to prevent falls, the following shall occur: orientation to place (room, equipment, bathroom, etc.), residents shall be assessed for toileting needs, shoes or slippers shall be used for ambulation and provided if the resident does not have any, bed shall be maintained in lowest position, rooms shall be free from excess equipment and furniture, routine nursing rounds shall be done for assessment of needs, gait belts will be available for assistance with ambulation, needs for assistive devices and assistance shall be communicated to other departments participating in resident care, and utilization of bed and chair alarms for residents when deemed appropriate. The facility did not provide a staffing policy. The facility failed to provide sufficient nurse staffing with the appropriate competencies and skill sets to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for R1 which resulted in R1 falling and breaking her left hip. This deficient practice placed R1 at risk for falls with injury and pain.

The facility had a census of 16 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff administered nasal spray to Resident (R)2 in the dining room with other residents in full view of the procedure. This placed the resident at risk for an undignified experience. Findings included: - On 06/06/23 at 07:55 AM, observation revealed R2 sat at the dining room table and Certified Medication Aide (CMA) M administered fluticasone propionate (anti-allergy nasal spray) nasal spray and morning medications to the resident's nostril while 15 other residents were in the dining room in full view of the nasal administration. On 06/08/23 at 09:20 AM, Administrative Nurse D stated she expected the nurse to administer the nasal spray to the resident in another, private area. The facility's Resident Rights policy dated February 23, 2023, documented each resident residing in the facility has the right and would be afforded the right to a dignified existence self-determination, and communication with and access to persons and services inside and outside the facility without interference. The policy documented each resident would be treated with dignity and would be allowed and encouraged to make choices, to be able to have access to friends and family of choices at times the resident chooses, and to services providers of the residents choice both inside and outside the facility and be free from abuse, neglect and misappropriation of personal property. The facility failed to promote care for R2 in a manner to maintain and enhance dignity and respect, placing the residents at risk for an undignified experience.

The facility had a census of 16 residents. The sample included eight residents with one reviewed for hospitalization . Based on observation, interview, and record review the facility failed to inform Resident (R) 11 of the facility's bed hold policy when she was transferred to the hospital. This deficient practice placed R11 at risk to make uninformed decisions regarding her care. Findings included: - R11's Electronic Medical Record documented diagnoses of pain, right leg above knee amputation (surgical removal of a limb), heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), anemia (condition in which the blood doesn't have enough healthy red blood cells), polyneuropathy (malfunction of many peripheral nerves throughout the body), hypertension (high blood pressure), cellulitis (bacterial skin infection), and a history of blood clots. R11's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R11 was independent with eating, hygiene, and locomotion, but required staff assistance with dressing, toileting, and transfers. R11's medical record documented R11 was hospitalized [DATE] to 03/13/23. R11's clinical record lacked evidence she received a bed hold notice for the above hospitalization . The facility was unable to provide evidence R11 received a bed hold notice. On 06/06/23 at 07:09 AM, observation revealed R11 at the dining table and Certified Medication Aide (CMA) R administered medication to her. On 06/08/23 at 09:22 AM, Administrative Nurse D verified staff had not provided a bed hold notice to the resident. Upon request the facility did not provide a Bed Hold Notice policy. The facility failed to inform R11 of the facility's bed hold policy or provide the notice when R11 was transferred to the hospital, placing R11 at risk to make uninformed decisions regarding her care.

The facility had a census of 16 residents. The sample included eight residents with one reviewed for vision. Based on observation, interview, and record review the facility failed to ensure availability of eye drops as prescribed by the physician for Resident (R) 14. This deficient practice placed R14 at risk for eye discomfort or further reduction in vision. Findings included: - R14's Electronic Medical Record documented diagnoses of glaucoma (group of eye conditions that can cause blindness), dry eye syndrome (condition that occurs when your tears aren't able to provide adequate lubrication for your eyes) and ocular pain (physical discomfort in the eye's surface or deep within the eye, ranging from a slight irritation to severe pain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented a mood score of 14, indicating significant depression (common and serious medical illness that negatively affects how you feel, the way you think and how you act), and was independent with all activities of daily living. The MDS documented R14 received pain medication as needed and reported frequent severe pain. The Medication Care Plan, dated 03/29/23, directed staff to administer medications as ordered, monitor for side effects and effectiveness, and provide a pharmacy review monthly or per protocol. The Physician Order, dated 04/28/2023, directed staff to administer Refresh Optiv Mega-3 Ophthalmic Solution 0.5-1-0.5 % (carboxymethylcellu lose-glycerinpolysorbate 80) Instill one drop in left eye every hour for dry eyes. The order was changed to one drop both eyes every two hours while awake, 05/19/23. The Medication Administration Record (MAR) documented the eye drops were not administered as ordered 57 opportunities in April, 128 times in May, and none the first five days of June 2023. The Optometrist Note, dated 01/11/23, stated R14 had a history of 20 eye surgeries. R14 was blind in the right eye and had blurry vision in his left eye. The Optometrist Note, dated 04/12/23, recorded R14 had bilateral, corneal opacity, of the left eye (OS) with recent worsening. The note recorded a plan to refer to a corneal specialist. The note also recorded corneal edema (swelling), in both eyes and severe stage glaucoma in the right eye (OD). The Medication Note, dated 04/19/23 at 04:00 PM, documented Refresh Optiv Mega-3 Ophthalmic Solution eye drops were on back order from pharmacy. The Medication Note, dated 06/6/23 at 04:02 PM, documented Refresh Optiv Mega-3 Ophthalmic Solution was on back order. The 06/06/23 at 07:49 PM late entry note documented that on 05/19/23 and on 06/02/23, during R14's eye physician appointments, R14 told his physician that he was out of the Refresh Optiv Mega-3. The staff with him reported it was on backorder and was not sure when it would be available. R14 asked the physician if he could use the PRN (as needed) Systane eye drops until the prescription eye drops were available. The physician agreed to that. On 06/06/23 at 07:36 AM, observation revealed Certified Medication Aide (CMA) R administered medications to R14 including Systane Ultra 0.3-0.4%, one drop in each eye. On 06/05/23 at 12:10 PM, R14 stated one staff always administered his eye drops late and he usually had to go ask for them. On 06/05/23 at 03:25 PM, CMA S stated the Refresh Megs Optiv 3 eye drops were not in from the pharmacy yet and stated R14 had not received them since last month, 05/09/23. CMA S stated R14 received the eye drops hourly then the order was switched to every two hours. She stated staff administer the PRN Systane eye drops as an alternative. On 06/07/23 at 08:13 AM, Administrative Nurse D verified staff should have notified the optometrist the ophthalmic solution had not been delivered or administered when they did not receive it the first week or two after it was ordered. She stated the transportation aide heard R14 discuss it with his optometrist during the appointment. Administrative Nurse D verified the lack of facility documentation regarding physician awareness of the lack of administration due to not receiving the medication from pharmacy. Administrative Nurse D stated she had contacted the pharmacist who verified they had not reported the issue to the optometrist. The facility's Administration of Medications policy, dated 12/15/22, stated the charge nurse or CMA should administer medications as ordered by the physician. The facility failed to ensure availability of eye drops as prescribed by the physician for R14, placing R14 at risk for eye discomfort, and further decline in visual function.

The facility had a census of 16 residents. The sample included eight residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's failed to ensure the Consultant Pharmacist identified and reported an inappropriate indication for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R)13 and failed to notify the director of nursing of missing administration of prescribed eye drops for R14. This placed the residents at risk for unnecessary medications and related side effects. Findings included: - R13 ' s Physician Order Sheet (POS), documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear.) R13 ' s Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition with inattentive behaviors and disorganized thinking. The MDS recorded the resident was independent with bed mobility, locomotion on the unit, dressing and personal hygiene. The MDS documented R13 received an antipsychotic medication seven days during the lookback period. R13's Cognitive loss/Dementia Care Area Assessment, dated 08/31/22 recorded the resident had a diagnosis of dementia with confusion. R13's Psychotropic [affects mood or thought] Care Plan, dated 03/13/23 directed staff to monitor the resident's behaviors. R13 would pace, wander, and disrobe. R13 had inappropriate response to verbal communication, and violence/aggression towards staff/others. The Physician Order, dated 09/01/22, directed the staff to administer R13 ' s Zyprexa (antipsychotic medication) 5 (mg) milligrams, one time a day, for a diagnosis of dementia without behavioral disturbance. The Pharmacy Consult review on 03/24/23 recommended the physician attempt a gradual dose reduction (GDR). The physician replied the physician could address the recommendations at the next psychiatric appointment. On 06/06/23 at 07:50 AM, observation revealed the R13 sat at the dining room table, nicely groomed and dressed. While R13 ate breakfast, Certified Medication Aide (CMA) R administered R13 ' s morning medications. On 06/08/23 at 09:20 AM, Administrative Nurse D verified the inappropriate diagnosis of dementia without behavioral disturbance for R13's use of the Zyprexa medications. Administrative Nurse D further acknowledged there were no recommendations from the pharmacist for an appropriate indication for the use of the Zyprexa. The facility's Psychotropic Medication Monitoring policy, dated October 17, 2022, documented the facility would use and administer psychotropic medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation, and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dose, side effects, risk and/or benefits. The policy documented upon admission to the facility a resident who had physician ordered psychoactive medication and a diagnosis of dementia, the Director of nursing and staff would obtain an approved diagnosis from the physician for the antipsychotic medication and a specific behavior for the medication use. The facility's Drug Regimen Review policy, dated October 28, 2022, documented the consultant pharmacist would perform a drug regimen review on each resident living in the facility at the of the resident ' s admission to the facility and at least monthly and when requested by a team member of the facility. The review would include but not limited to: Irregularities of any drug that met criteria for an unnecessary drug. Documentation of any/all irregularities on a separate, written report that is sent to the attending physician and the DON and lists: resident ' s name, relevant drug, irregularity identified. Attending physician must document that identified irregularity had been reviewed and what, if any, action had been taken to address the irregularity and document rational for decision(s). The pharmacist would assist in management of the resident ' s medical regimen including Psychotropic drugs defined as any drug that affects brain activity associated with mental process and behavior' with recommendation of Gradual Dose Reduction as appropriate. The facility failed to ensure the Consultant Pharmacist identified and reported to the facility Director of Nursing (DON), medical director, and physician the inappropriate indication for R13's use of Zyprexa. This placed the resident at risk for inappropriate use of an antipsychotic medication. 26768 - R14's Electronic Medical Record documented diagnoses of glaucoma (group of eye conditions that can cause blindness), dry eye syndrome (condition that occurs when your tears aren't able to provide adequate lubrication for your eyes) and ocular pain (physical discomfort in the eye's surface or deep within the eye, ranging from a slight irritation to severe pain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented a mood score of 14, indicating significant depression (common and serious medical illness that negatively affects how you feel, the way you think and how you act), and was independent with all activities of daily living. The MDS documented R14 received pain medication as needed and reported frequent severe pain. The Medication Care Plan, dated 03/29/23, directed staff to administer medications as ordered, monitor for side effects and effectiveness, and provide a pharmacy review monthly or per protocol. The Physician Order, dated 04/28/2023, directed staff to administer Refresh Optiv Mega-3 Ophthalmic Solution 0.5-1-0.5 % (carboxymethylcellu lose-glycerinpolysorbate 80) Instill one drop in left eye every hour for dry eyes. The order was changed to one drop both eyes every two hours while awake, 05/19/23. The Medication Administration Record (MAR) documented the eye drops were not administered as ordered 57 opportunities in April, 128 times in May, and none the first five days of June 2023. The Medication Note, dated 04/19/23 at 04:00 PM, documented Refresh Optiv Mega-3 Ophthalmic Solution eye drops were on back order from pharmacy. The Pharmacist Consultant Reviews, dated 04/23/23 and 05/23/23, documented no irregularities and lacked notation of the numerous times R14's prescribed eye drops were not administered. The Medication Note, dated 06/6/23 at 04:02 PM, documented Refresh Optiv Mega-3 Ophthalmic Solution was on back order. The 06/06/23 at 07:49 PM, late entry note documented on 05/19/23 and on 06/02/23, during R14's eye physician appointments, R14 told his physician that he was out of the Refresh Optiv Mega-3. The staff with him reported it was on backorder and was not sure when it would be available. R14 asked the physician if he could use the PRN (as needed) Systane eye drops until the prescription eye drops were available. The physician agreed to that. On 06/06/23 at 07:36 AM, observation revealed Certified Medication Aide (CMA) R administered medications to R14 including Systane Ultra 0.3-0.4%, one drop in each eye. On 06/05/23 at 03:25 PM, CMA S stated the Refresh Megs Optiv 3 eye drops were not in from the pharmacy yet and stated R14 had not received them since last month, 05/09/23. CMA S stated R14 received the eye drops hourly then the order was switched to every two hours. She stated staff administer the PRN Systane eye drops as an alternative. On 06/07/23 at 08:13 AM, Administrative Nurse D stated she had contacted the pharmacist who verified they had not reported the issue to the optometrist or notified the director of nursing or physician of the missing administration documentation. The facility's Drug Regimen Review policy, dated 10/28/22, stated the consultant pharmacist would document any irregularities on a separate written report to the attending physician and the director of nursing and would include medication ordered but not administered. The facility's failed to ensure the Consultant Pharmacist identified and notified the facility of R14's missing administrations of the eye drops as prescribed, placing R14 at risk for eye discomfort, and further decline in visual function.

The facility had a census of 16 residents. The sample included eight residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facilty failed to provide an acceptable indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for Resident (R) 13 who received an antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) medication. This placed the resident at risk for unnecessary antipsychotic medication and related side effects. Findings included: - R13' s Physician Order Sheet (POS), documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R13's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition with inattentive behaviors and disorganized thinking. The MDS recorded the resident was independent with bed mobility, locomotion on the unit, dressing and personal hygiene. The MDS documented R13 received an antipsychotic medication seven days during the lookback period. R13's Cognitive loss/Dementia Care Area Assessment, dated 08/31/22 recorded the resident had a diagnosis of dementia with confusion. R13's Psychotropic [affects mood or thought] Care Plan, dated 03/13/23, directed staff to monitor the resident's behaviors. R13 would pace, wander, and disrobe. R13 had inappropriate response to verbal communication, and violence/aggression towards staff/others. The Physician Order, dated 09/01/22, directed the staff to administer Zyprexa (antipsychotic medication) 5 milligrams (mg), one time a day, for a diagnosis of dementia without behavioral disturbance. The Pharmacy Consult review on 03/24/23 recommended the physician attempt a gradual dose reduction (GDR). The physician replied the physician could address the recommendations at the next psychiatric appointment. R13's clinical record lacked evidence of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use for Zyprexa. On 06/06/23 at 07:50 AM, observation revealed the R13 sat at the dining room table, nicely groomed and dressed. While R13 ate breakfast, Certified Medication Aide (CMA) R administered R13 ' s morning medications. On 06/08/23 at 09:20 AM, Administrative Nurse D verified the inappropriate diagnosis of dementia without behavioral disturbance for R13's use of the Zyprexa medications. The facility's Psychotropic Medication Monitoring policy, dated October 17, 2022, documented the facility would use and administer psychotropic medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation, and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dose, side effects, risk and/or benefits. The policy documented upon admission to the facility a resident who had physician ordered psychoactive medication and a diagnosis of dementia, the Director of nursing and staff would obtain an approved diagnosis from the physician for the antipsychotic medication and a specific behavior for the medication use. The facilty failed to provide an acceptable indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for R13's Zyprexa. This placed the resident at risk for adverse medication effects.

The facility had a census of 16 residents. The sample included eight residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for Resident (R)3 and R5 This placed the residents at risk for inadequate nutrition. Findings included: - On 06/07/23 at 10:30 AM, observation revealed Dietary Staff (DS) CC prepared two pureed diets. Dietary Staff CC placed two serving (3 ounces) of pork chops in a food blender with approximately 16 tablespoons of pork juice. She then blended to the pureed texture and emptied the pureed pork chops in a metal pan and placed in the oven. DS CC placed two servings of Au Grauten potatoes, which she said stated was two ounces and added two tablespoons of potato juice/broth, in a food blender, blended to the pureed texture and emptied in a metal pan and placed in the oven. Dietary Staff CC placed two servings of carrots, approximately two-ounce servings in a food blender and added one package of broth to add flavor and blended to the puree texture. DS CC placed two dinner rolls, in a food blender and added approximately one teaspoon of milk and one teaspoon of butter and blended to the puree texture. On 06/06/23 at 10:35AM, Dietary Staff CC stated she was aware of the amount of liquid she needed to achieve the correct puree texture and did not have a specific recipe to follow for the above pureed food . On 06/07/23 at 03:20 PM, DS BB verified the dietary staff were expected to use a pureed recipe when preparing a pureed diet at the facility. DS BB stated she had just started the Dietary Manager job at the facility and the last Dietary Manager did not have specific paper copies available for each food pureed. DS BB verified the amount of the food and ingredients in a recipe should be followed to achieve the correct nutritional food value and texture and stated she was looking into getting recipes for the foods pureed. The facility's Puree Diet policy, dated January 17, 2020, recorded a resident may require a puree diet if they had trouble chewing and swallowing foods. The policy documented to ensure complete and balanced nutrition while maintaining a puree diet the staff would ensure foods are properly prepared and served by following the Quality in Quantity recipe book, add necessary thickener and appropriate liquid of nutritive value and flavor to obtain desired consistency, portions per recipe, heat or chill the pureed food to safe serving temperatures pureed food shall be prepared into a smooth mashed potato consistency, and appearance is smooth like pudding. The facility failed to prepare pureed diets using professional standards to maintain nutritive and palatable value for R3 and R5. The placed the residents at risk for inadequate nutrition.

The facility had a census of 16 residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to provide mail delivery for residents on Saturdays. Findings included: - On 06/06/23 at 02:38 PM, observation revealed Social Services Designee (SSD) X delivered mail to Resident (R) 11 and had her sign a form. On 06/06/23 at 02:38 PM, SSD X stated hospital administrative staff picked up mail at the post office, then notified facility staff of any resident mail. SSD X verified no staff retrieved and delivered the mail on weekends. On 06/07/23 at 12:52 PM, during the interview for resident council, R1 stated the facility did not deliver mail to the residents on Saturdays as there was no administrative staff on duty to go to the post office to get it. On 06/06/23 at 02:55 PM, Administrative Nurse D verified facility staff did not deliver mail to residents on Saturdays. She stated the hospital administrative staff got the mail from the post office during weekdays, and brought the mail to facility staff; those staff did not work weekends so there was no one to go to the post office on Saturdays. The facility's Right to Send and Receive Mail policy, dated 06/06/23, stated residents would receive all mail unopened and mail would be delivered to the resident on the day it was received by the facility. The facility would arrange for mail pick up on the day the mail is delivered to the post office box. The facility failed to provide services for mail delivery on Saturdays.

The facility had a census of 28 residents. The sample included 12 residents of which 1 was reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to prevent the development of 2 Stage 3 pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) (a sore that extends into the tissue beneath the skin forming a small creator, fat may show in sore, but not muscle, tendon or bone) for 1 of 1 sampled residents. (#10) Findings included: - Resident #10's physician orders, dated 11/2/18, documented [DIAGNOSES REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 7/11/18, recorded the resident had severe cognitive impairment, inattention and altered level of consciousness which fluctuated, and needed total assistance of 1 or 2 staff for bed mobility, transfers, toilet use, dressing, bathing, personal hygiene, and eating. The MDS further documented the resident had impaired functional range of motion in the lower extremity on one side, and was at risk for pressure ulcers. The MDS further recorded the resident had no pressure ulcer, used pressure reducing devices for chair, and was on a turning/repositioning program. The (CAA) Care Area Assessment, dated 7/12/18, for pressure ulcers recorded the resident was at risk for skin breakdown, had no open or red areas, received a skin assessment weekly by a nurse, and required assistance with repositioning every 2 hours and as needed. The quarterly MDS, dated [DATE], recorded the resident had severe cognitive impairment, and needed total assistance of 1 to 2 staff for bed mobility, transfers, dressing, toileting, personal hygiene, bathing and eating. The MDS further documented the resident had 2 stage 3 pressure ulcers, interventions included a pressure reducing device for his/her chair, a turning/repositioning program, and pressure ulcer care. The care plan, dated 6/25/18, documented a weekly skin assessment would be completed by a nurse. The care plan directed staff to notify the nurse of any skin issues. The 7/11/18 care plan lacked direction to staff for care of the leg immobilizer. The care plan, dated 10/2/18, lacked instruction for the prevention, care, and treatment of [REDACTED]. The skin observation tool, dated 7/11/18, recorded the resident had a bruised discoloration from an incident on 7/4/18 (when [MEDICAL CONDITION] femur occurred), increased bruising and swelling all the way down the left leg and knee, and had an immobilizer (device to restrict movement) to left knee. The medical record lacked documentation of of a physician order [REDACTED]. The 7/18/18 skin observation tool recorded an abrasion to the lower leg/heel from the knee immobilizer rubbing on the resident's skin, which measured 1 cm (centimeter) (in length) x 1 cm (in width). Weekly Wound Observations documented the following: (Wound #1) 7/21/18: Stage 3 pressure ulcer, acquired 7/18/18, worsening with slough (dead tissue, usually cream or yellow in color), 10 % necrotic tissue (pertaining to the death of tissue in response to disease or injury), moist, yellow center, and black all around the edges. The pressure ulcer had small amount of purulent drainage (producing or containing pus). Measured 1.5 cm x 0.5 cm x 0.5 cm. 7/24/18: Acquired Stage 3 pressure ulcer, upper heel, with slough tissue, moist, 90% necrosis in the wound bed, a moderate amount of serosanguous (bloody drainage) drainage, and measured 2 cm x 1 cm x 2 cm. 7/31/18: Pressure ulcer was caused by immobilizer, staff applied heel protector, the heel floated on a pillow during the night, and applied padding to the brace. Stage 3 pressure ulcer worsening, slough tissue present, moist, 60% necrosis and or slough. The assessment documented the drainage was purulent, moderate amount with odor, and infection suspected due to green/yellow drainage. Standing order for Stage 3 ulcer treatment, not improving. 8/20/18: Left heel Stage 3 pressure ulcer, unchanged, moist, bloody moderate amount drainage, measured 2 cm x 1.5 cm x 0.2 cm, peri-wound pink/healthy irregular shape with some rolling edges. The wound bleeds with irrigation, and drainage was bloodier since the new brace was placed, and was digging into the wound. Staff removed the brace, floated heels on a pillow when in bed. 9/11/18: pressure ulcer Stage 3, improving, [MEDICATION NAME], granulation tissue (tissue formed during wound healing) present, slough was 20%, measured 1 cm x 0.5 cm x 0.2 cm. The edge was slightly rolled but defined. Floating heels on pillows and wearing sheep skin padded half cast. 10/20/18: documented, on 10/12/18 resident seen by physician, left leg in half cast wrapped with ace bandages. The pressure ulcer #1 was healed. Weekly Wound Observation documented the following: (Wound #2) The facility lacked assessment of wound #2 until 9/11/18. 9/11/18: on 8/19/18 family aware of skin issues involving the rigid splint which caused the left outer ankle Stage 3 pressure ulcers, which started as a blister that broke open. The wound worsened since discovery, granulation tissue present, had slough, 5% necrosis, serosanguous moderate amount drainage, and measured 7 cm x 1.3 x 0.2 cm. 10/20/18 Left outer ankle, Stage 3, improving, had granulation tissue, 30% necrotic, a small amount of serosanguous drainage, and measured 6 cm x 2 cm x 0.3 cm. Treatment continued, heels and ankles floated with pillow while in bed. 10/29/18 Pressure ulcer Stage 3, healing, [MEDICATION NAME] and granulation tissue present, wound bed much improved, with no necrotic tissue or slough noted at this time, but had small amount serosanguous drainage. Measured 5 cm x 2.2 cm x 0.3 cm. Peri-wound red and irritated from border gauze adhesive, and well defined and slightly rolled edges. 11/6/18 pressure ulcer Stage 3, improving, [MEDICATION NAME] and granulation tissue present, moist, and had small amount of serosanguous drainage. Measured 6.5 cm x 2.2 cm x 0.3 cm. On 11/14/18 at 7:07 AM, observation revealed the resident seated in his/her wheelchair, in the dining room, without the leg immobilizer. On 11/14/18 at 8:48 AM, Nurse G removed the resident's dressing which consisted of a foam covering and alginate rope (calcium-alginate dressing which forms a soft gel that absorbs when it comes into contact with wound drainage). The dressing had a moderate amount of serosanguinous (semi-thick reddish) drainage. Nurse G irrigated the wound with normal saline, the wound bed was beefy red with no eschar (dead tissue) and measured 5.8 (cm) centimeters x 2 cm x 0.4 cm. Nurse G then placed alginate rope into the wound, covered with a foam dressing and secured with rolled gauze. Nurse G and Nurse Aide M placed the immobilizer onto the left leg from the upper thigh to the lower leg and placed a pillow under the resident's left leg. On 11/13/18 at 1:38 PM, Nurse Aide O verified the pressure ulcer on the resident's leg was obtained from the braces the resident had in the past, and the care plan did not address the pressure area or how often to reposition the resident. On 11/13/18 at 1:44 PM, Nurse H verified the resident had several different splints for his/her leg due to his/her leg fracture and the first brace used for the resident had a stabilizer bar which rubbed the skin and caused the first pressure sore. On 11/13/18 at 1:53 PM, Administrative Nurse D verified the resident's care plan, which was reviewed in (MONTH) (YEAR), did not address the facility acquired pressure ulcer from a splint used for the resident's 7/4/18 leg fracture. Administrative Nurse D verified the care plan did not address how to care for the fracture, the splint or the pressure ulcer. Administrative Nurse D also verified the lack of documentation for the use and care of the leg immobilizer or skin assessment prior to the pressure ulcer development except for 7/18/18 when staff observed an abrasion. The facility's Skin Assessments policy, dated 9/18/2017, documented any skin issues identified should be documented on the assessment form and the nurse would update the resident's care plan with the focus, goal and interventions put in place regarding the skin issue. The facility's Standing Orders, dated 3/29/17, documented if a resident developed a Stage I pressure ulcer, staff would remove the pressure. The facility failed to develop and implement timely and effective interventions to prevent the development of 2 facility acquired Stage 3 pressure ulcers, 1 to the left ankle and 1 to the left heel, for cognitively impaired Resident #10. This placed the resident at risk for further skin breakdown, infections and pain.

The facility had a census of 30 residents. The sample included 15 residents of which 5 were reviewed for abuse toward others. Based on observation, record review and interview, the facility failed to thoroughly investigate and report to the state agency, incidents of resident to resident abuse, which placed all residents in the facility in immediate jeopardy for abuse. The facility further failed to protect Residents' #20, #18, #21, #23, #14, #24, #26, and 9 unidentified residents. Findings included: - Resident #10's (POS) physician order sheet, dated 6/12/17, documented the resident had [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 8/16/16, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 1, which indicated severely, impaired cognition. The assessment revealed the resident required limited assistance of 1 staff for dressing, set-up assistance and supervision for eating, supervision and 1 staff assistance for personal hygiene, and was independent with locomotion and ambulation. The assessment further revealed the resident had no behaviors, no rejection of care and or wandering, and received 7 days of antipsychotic (used to treat [MEDICAL CONDITION] and other mental emotional conditions) and antidepressant (used to treat mood disorders and relieve symptoms of depression) medications. The quarterly MDS, dated [DATE], recorded the resident had a BIMS of 00, which indicated severely impaired cognition and the resident was independent with all (ADLs) Activities of Daily Living except for limited assistance of 1 staff for dressing, toileting, and eating. The assessment revealed the resident had disorganized thinking, physical and verbal behaviors towards others, rejection of care, wandering, and 6 days of antipsychotic medication use. The 8/16/16 (CAA) Care Area Assessment for Antipsychotic Medication stated the resident received antipsychotic medications daily. The Behavior CAA did not trigger. The care plan, dated 9/6/16 and reviewed on 5/15/17, documented the resident used [MEDICAL CONDITION] medications related to behavior management and directed staff to monitor and record occurrence of target behaviors, such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence and aggression towards staff and others, and document per facility protocol. The care plan further documented the resident had a psychosocial well-being problem related to depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) with behavioral disturbances (condition exhibiting one or more specific emotional and/or behavioral difficulties over a long period of time) and anxiety, and documented the resident would get agitated and yell. The care plan directed staff to redirect the resident to appropriate behaviors, monitor the effectiveness of the medication, and document any negative behaviors. The 6/4/16 at 4:22 PM, incident report recorded Resident #20 followed Resident #10 into the dining room, Resident #10 then turned around and shoved his/her walker into Resident #20. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 9/21/16 at 12:02 PM, incident report recorded Resident #20 was eating his/her meal with his/her fingers and Resident #10, stated in an angry tone, hey, use your spoon. Resident #20 did not respond and continued to eat with his/her fingers when Resident #10 reached over with his/her right fist and hit the resident on the knuckles of his/her left hand. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident. The 1/31/17 Medication Regimen Review documented Resident #10 received [MEDICATION NAME] (an antipsychotic) 2.5 (mg) milligrams at bedtime, requested a gradual dose reduction or a risk versus benefit statement from the physician, and the physician discontinued the medication on 2/7/17. The 2/9/17 at 4:19 PM, nurse's note documented Resident #10 frequently yelled at other residents that walked near him/her to just leave me alone or get the {h***} out of here and occasionally shook his/her walker at other residents until that resident left from his/her area of sight. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 3/13/17 at 5:02 PM, nurse's note documented Resident #10 sat at the dining room table when another unidentified resident wheeled up close to him/her, and Resident #10 swung his/her arm at the resident. The note further documented no contact was made between the residents and the other resident left the area. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 3/14/17 at 10:36 AM, nurse's note documented Resident #10 pushed his/her walker into Resident #20's upper legs and yelled,get {him/her} away from me! The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 3/22/17 at 12:24 PM, nurse's note documented Resident #10 sat next to Resident #18 at the dining table. The note stated Resident #10 picked up his/her fork and raised it up toward Resident #18 when Resident #18 reached for Resident #10's pudding. The note further documented staff were able to intervene before Resident #10 could bring the fork down onto Resident #18's hand. The clinical record lacked evidence the facility reviewed or implemented intervention to prevent further behaviors. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 3/28/17 at 9:25 AM, nurse's note documented Resident #10 rolled up a magazine and swung it at Resident #18 as he/she wheeled his/her wheelchair up to the dining room table. The note further documented no contact was made between the residents and Resident #18 was taken away from the table. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 4/4/17 at 5:21 PM, nurse's note documented staff heard Resident #10 yelling at Resident #18 and witnessed Resident #10 hit Resident #18 twice on the back and staff separated the residents. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident. The 4/6/17 at 1:32 PM, nurse's note documented staff faxed communication to the physician regarding the resident's behavior on 4/4/17, no new orders were written, and a [DIAGNOSES REDACTED]. The 4/16/17 at 4:48 PM, nurse's note documented Resident #10 yelled out, I'm warning you, you better get out of here, put his/her left hand on Resident #21's right upper chest and pushed the resident so hard, Resident #21's wheelchair flew backwards. The note further documented Resident #21 wheeled away from the dining room. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident. The 4/19/17 at 7:32 AM, nurse's note documented Resident #18 sat in his/her wheelchair next to Resident #10. Resident #10 turned towards Resident #18, raised his/her right hand and hit Resident #18 twice on his/her right shoulder and pushed him/her, which caused Resident #18's wheelchair to move backwards. Resident #10 yelled out, I said get {him/her} away from me! The note documented staff told Resident #10 not to hit other residents, and Resident #10 stated, then get {him/her} out of here! The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident. The 4/19/17 at 4:15 PM, fax communication to the physician regarding Resident #10's aggressive behaviors documented the physician asked nursing staff if the resident was generally aggressive. The nursing staff further documented to the physician that Resident #10 was aggressive towards other residents and staff. The fax documented the physician diagnosed the resident with [MEDICAL CONDITION]. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 4/21/17 physician order directed staff to administer [MEDICATION NAME] ([MEDICAL CONDITION] medication) 2.5 mg, by mouth, at bedtime, for [MEDICAL CONDITION]. The 60 day physician visit, dated 5/11/17, documented the resident had confusion, as usual, and staff reported some behaviors and medication refusals. The physician directed staff to increase the resident's [MEDICATION NAME] to 5 mg, by mouth, at bedtime. The 5/13/17 at 2:22 PM, nurse's note documented the resident was upset most of the morning, frequently looked for his/her father, became easily agitated, yelled at staff, and occasionally verbally threatened that he/she should just kill someone. (Review of the medical record lacked documentation Social Services was involved after the resident verbally threatened to kill someone). The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 6/5/17 at 12:28 PM, nurse's note documented Resident #10 was outside calling another unidentified resident names and telling him/her to get out of here. The note stated when staff went outside to intervene, Resident #10 pushed his/her walker towards staff and yelled, get the {h***} out of here, you {b****}. Staff assisted the other resident inside the building. The record lacked documentation of the other resident's name. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. On 6/15/17 at 1:10 PM, observation revealed Resident #20 stood in the dining room and no nursing staff present. Further observation revealed Resident #10 ambulated with his/her walker toward the dining room, approximately 5 feet from Resident #20. Resident #10 yelled, get out of my way, get out of my face. Continued observation revealed neither resident made contact with each other and staff were unaware of the incident. On 6/14/17 at 2:45 PM, Nurse Aide C stated the resident became physically aggressive to staff and residents, and staff tried to redirect the resident. On 6/19/17 at 11:08 AM, Licensed Nurse E stated staff would notify the physician when the resident had a change in behavior, but he/she did not know of any incidents of aggressive behavior to residents. On 6/20/17 at 1:10 PM, Administrative Nurse A stated he/she and Administrative Staff O, were responsible for investigating and reporting to the state agency. On 6/23/17 at 3:00 PM, Social Service Staff J stated, he/she was not involved when residents had physical altercations, and the nurses handled the situation. Social Service J further stated, when residents would get into arguments, he/she would talk to each resident, find out both sides of the story, and notify the family of the conflict. On 6/28/17 at 5:06 PM, Administrative Nurse A stated staff who witnessed any resident to resident altercation, should separate and assess the residents for injury, and monitor the residents closely. Administrative Nurse A further stated, staff notify the physician and ask for guidance on how to handle the resident. Administrative Nurse A verified he/she had no policy and procedure in place for staff intervention to keep residents apart after a resident to resident altercation. The facility's 6/30/2011, Reporting To State Policy indicated the facility shall identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident/patient property was more likely to occur. The policy stated if there is an incident of abuse that is putting a resident in immediate danger, first remove the resident from the situation, report the incident immediately to the charge nurse, Director of Nursing, risk manager, all suspected abuse incidents or any incident of unknown origin. All alleged violations involving mistreatment, neglect or abuse including all injuries of unknown origin must be reported to the state survey and certification agency immediately, but not to exceed 24 hour after discovery of the incident. Review of the 6/30/11 facility policy for Abuse, Neglect and Exploitation contained only 6 of the 7 components which are federally mandated. Further review of the facility policy, revealed it lacked the component of protection. The facility failed to thoroughly investigate, report, and protect the other residents in the facility from abuse by Resident #10. The facility abated the immediate jeopardy on 7/7/17 when the facility completed staff education on policies of Behavior Management and Monitoring, [MEDICAL CONDITION] Medication use, and Abuse. The Director of Nursing completed chart reviews of the residents in the facility with dementia on 6/30/17 and implemented interventions specific to each resident's behavior. The deficient practice remained at the scope and severity of an F. - Resident #14's (POS) physician order sheet, dated 4/14/17, documented the resident had [DIAGNOSES REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 4/3/16, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 5, which indicated severely, impaired cognition. The assessment revealed the resident had verbal and physical behaviors toward others, and rejection of cares 4 to 6 days, of the look back period of 7 days. The assessment further documented the resident was totally dependent on 2 staff for bed mobility, transfers and dressing, was totally dependent on 1 staff for locomotion on and off the unit, and received antipsychotic and antidepressant medications. The quarterly MDS, dated [DATE], recorded the resident had a (BIMS) Brief Interview for Mental Status score of 2, which indicated severely, impaired cognition. The assessment revealed the resident was dependent upon 2 staff for bed mobility, toileting, dressing, and dependent upon 1 staff for locomotion on and off the unit. The assessment further revealed the resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), rejection of care 1 to 3 days, and received 7 days of antipsychotic (used to treat [MEDICAL CONDITION] and other mental emotional conditions), and antidepressant (used to treat mood disorders and relieve symptoms of depression) medications. The annual MDS, dated [DATE], recorded the resident had a BIMS of 00, which indicated severely, impaired cognition. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting, dressing, and extensive assistance of 1 staff for locomotion on and off the unit. The assessment further revealed the resident had physical and verbal behaviors towards others and received antipsychotic and antidepressant medication. The 4/4/17 (CAA) Care Area Assessment for antipsychotic medications recorded the resident received antipsychotic medications daily. The CAA for Behavioral Symptoms documented the resident's behaviors improved. The care plan, dated 9/6/16 and reviewed on 4/11/17, recorded the resident had behaviors, and became agitated easily, yelled, cursed and did not like being told what to do. The care plan further recorded the resident received medication for his/her behaviors and directed staff to suggest help and offer choices with all cares. The 1/6/15 physician order directed staff to administer [MEDICATION NAME] HCL (an antidepressant), 100 (mg) milligrams, by mouth, at bedtime for the [DIAGNOSES REDACTED]. The 4/5/16 at 11:17 AM, nurse's note documented Resident #14 verbally attacked Resident #18, stated he/she was crazy, and did not have a brain in his/her head. The note further documented staff moved the resident to another dining room table. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 9/17/16 at 1:12 PM, nurse's note documented the resident was in his/her wheelchair, wheeled up to another resident (unidentified by the facility), grabbed the wheelchair and would not let go. The note further documented staff asked the resident to let go of the wheelchair, and Resident #14 swung at staff. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 12/3/16 at 1:56 PM, nurse's note documented Resident #14 sat in his/her wheelchair in the hallway when Resident #23 came out of his/her room. Resident #14 asked Resident #23 if he/she had seen any of his/her family. The note further documented both resident's kicked and yelled at each other, and staff intervened and separated them. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident. The 12/29/16 at 7:49 PM, nurse's note documented the resident threatened to kill everyone with a gun. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 3/1/17 at 7:32 AM, nurse's note documented the resident transferred to a behavioral unit for evaluation for increased behaviors. The 3/16/17 nurse's note documented the resident returned from the behavioral unit and was cooperative and friendly. The 3/16/17 physician orders, upon readmission, directed staff to administer [MEDICATION NAME] (an antianxiety medication), 0.5 mg, by mouth, three times a day, for anxiety and paliperidone [MEDICATION NAME] (an antipsychotic medication) suspension, 1.5 (ml) milliliters, (IM) intramuscularly, every 30 days for adult personality disorder. The 3/21/17 at 2:22 PM, nurse's note documented Resident #14 tried to hit another resident (unidentified by the facility) who sat by him/her in the dining room. The note further documented staff intervened and no physical contact was made between the residents. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. On 6/20/17 at 1:10 PM, Administrative Nurse A stated he/she and Administrative Staff O, were responsible for investigating and reporting to the state agency. On 6/23/17 at 3:00 PM, Social Service Staff J stated he/she was not involved when residents have physical altercations, and the nurses handle the situation. Social Service J further stated, when residents argued, he/she would talk to each resident, find out both sides of the story, and notify the family of the conflict. On 6/28/17 at 5:06 PM, Administrative Nurse A stated the staff, who witnessed any resident to resident altercation, separated and assessed the residents for injury, and closely monitored the residents. Administrative Nurse A further stated, staff notified the physician and asked for guidance on how to handle the resident. Administrative Nurse A verified he/she had no policy and procedure in place for staff intervention to keep residents apart after a resident to resident altercation. The facility's Abuse and Neglect policy, dated 6/30/11, documented the resident had the right to have an abuse free environment and it is staff responsibility to provide it for the residents 24 hours a day. The undated Resident Right's Policy stated the resident had the right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation and misappropriation of property by anyone. The facility failed to thoroughly investigate report and protect other residents in the facility from abuse by Resident #14. The facility abated the immediate jeopardy on 7/7/17 when the facility completed staff education on policies of Behavior Management and Monitoring, [MEDICAL CONDITION] Medication use, and Abuse. The Director of Nursing completed chart reviews of the residents in the facility with dementia on 6/30/17 and implemented interventions specific to each resident's behavior. The deficient practice remained at the scope and severity of an F. - Resident #18's (POS) physician order sheet, dated 5/11/17, documented the resident had [DIAGNOSES REDACTED]. more intense and persistent than what may normally be felt from time to time). The quarterly (MDS) Minimum Data Set assessment, dated 2/26/16, recorded the resident had severely impaired cognition, inattention and disorganized thinking behavior that was present continuously, altered level of consciousness that fluctuated, physical symptoms toward others and rejection of cares 1 to 3 days of the 7 day look back period. The MDS further documented the resident was totally dependent on 2 staff for bed mobility, transfers, and dressing, required extensive assistance of 1 staff for dressing, eating and toileting, and received antipsychotic medication (used to treat [MEDICAL CONDITION] and other mental emotional conditions). The annual MDS dated [DATE], recorded the resident had a (BIMS) Brief Interview for Mental Status Score of 00, which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of 2 staff for transfers, toileting, dressing, and extensive assistance of 1 staff for locomotion on and off the unit. The assessment revealed the resident wandered, had physical and verbal behaviors toward others, received 7 days of antipsychotic medications, and the mood score indicated no depression. The 5/15/17 (CAA) Care Area Assessment for antipsychotic medication and behavior documented staff monitored the resident for the use of [MEDICATION NAME] (medication used to treat the symptoms of psychotic conditions), and reported any changes of the resident's condition to the physician. The CAA further directed staff to ensure daily routines remained as consistent as possible, provide the resident with activities that kept him/her from becoming frustrated and bored, and if he/she became frustrated, allow the resident time to calm down, and then reapproach later. The care plan, dated 9/6/16 and reviewed on 4/9/17, documented the resident received [MEDICAL CONDITION] medications related to behavior management and directed staff to monitor and record occurrence of target behaviors, such as wandering, inappropriate response to verbal communication, violence, aggression towards staff and others, and document per facility protocol. The care plan further documented the resident had aggressive behaviors, wandered around the facility in his/her wheelchair, and needed staff assistance making safe decisions. The care plan lacked documentation of the specific behaviors the resident displayed towards staff and other residents, or interventions staff were to implement in the case of those behaviors. The 4/5/16 at 10:19 AM, nurse's note documented Resident #18 sat at the dining room table and became agitated with Resident #14. The note further documented Resident #18 doubled up his/her fist and moved towards Resident #14 when staff intervened and moved the resident to another table. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 4/26/16 at 2:07 AM, nurse's note documented Resident #18 grabbed Resident #24's arm and squeezed, which caused Resident #24 to express discomfort. The note further documented, staff intervened and the resident let go. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 6/12/16 at 10:16 AM, nurse's note documented Resident #18 became agitated, reached out with his/her fist, and hit Resident #24 on the forearm. The note further documented, staff moved Resident #18 in his/her wheelchair so he/she was unable to reach Resident #24. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 9/15/16 at 4:41 PM, nurse's note documented while Resident #18 propelled him/herself down the hallway, the resident punched at another resident (unidentified by facility), but no contact was made. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 5/4/17 at 10:08 AM, nurse's note documented Resident #20 napped on the couch with his/her head resting on the back of the couch. The note documented Resident #18 propelled him/herself up to the couch, reached out with his/her fist, and hit Resident #20 in the back of his/her head. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The medical record lacked documentation of a thorough investigation of the incident or report to the state agency. The 6/1/17 physician order sheet directed staff to administer [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITION] and other mental emotional conditions), 5 (mg) milligrams, by mouth, at bedtime, for the [DIAGNOSES REDACTED]. On 6/14/17 at 12:53 PM, observation revealed Resident #18, sat in his/her wheelchair in the dining room, after breakfast, with his/her head down and eyes closed. On 6/15/17 at 9:17 AM, observation revealed Resident #18 sat in the dining room, and in a raised voice stated what the {h***}, as 2 staff members offered him/her something to eat and drink. Observation revealed a family member joined the resident at the table, and no further outbursts were observed. On 6/16/17 at 2:30 PM, Nurse Aide G stated the resident required assistance with all cares, but was able to propel him/herself around the facility. Nurse Aide G further stated, when the resident hit or kicked another resident, he/she separated the residents, notified the charge nurse, and informed the director of nursing. On 6/16/17 at 3:30 PM, Nurse Aide M stated the resident's behavior depended on what type of day he/she had, and the resident had periods of agitation and rejection of care. On 6/20/17 at 1:10 PM, Administrative Nurse A stated he/she and Administrative Staff O, were responsible for investigating and reporting to the state agency. On 6/28/17 at 5:06 PM, Administrative Nurse A stated staff who witnessed any resident to resident altercation, separated and assessed the residents for injury, and closely monitor the residents. Administrative Nurse A further stated staff notified the physician and asked for guidance on how to handle the resident. Administrative Nurse A verified he/she had no policy and procedure in place for staff intervention to keep residents apart after a resident to resident altercation. The facility's Abuse and Neglect policy, dated 6/30/11, documented the resident had the right to have an abuse free environment and it is staff's responsibility to provide it for the residents 24 hours a day. The undated Resident Right's Policy stated the resident had the right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation and misappropriation of property by anyone. The facility failed to thoroughly investigate, report, and protect the other residents in the facility from abuse by Resident #18. The facility abated the immediate jeopardy on 7/7/17 when the facility completed staff education on policies of Behavior Management and Monitoring, [MEDICAL CONDITION] Medication use, and Abuse. The Director of Nursing completed chart reviews of the residents in the facility with dementia on 6/30/17 and implemented interventions specific to each resident's behavior. The deficient practice remained at the scope and severity of an F. - Resident #21's quarterly (MDS) Minimum Data Set assessment, dated 5/20/16, recorded the resident had severe cognitive impairment, inattention and disorganized thinking behavior that fluctuated, experienced delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal behavior directed toward others daily, and wandered 1 to 3 days of the 7 day look back period. The MDS further recorded the resident required limited assistance of 1 staff for bed mobility, transfers, and locomotion on and off the unit, required extensive assistance of 2 staff for walking in the corridor, and received antianxiety medication. Resident #21's quarterly (MDS) Minimum Data Set assessment, dated 3/15/17, recorded the resident had severe cognitive impairment, physical and verbal behaviors directed toward others 4 to 6 days of the 7 day look back period, other behaviors not directed toward others, and wandering 4 to 6 days of the look back period. The MDS further recorded the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and extensive assistance of 1 staff for locomotion on and off unit, eating, and personal hygiene. The MDS recorded the resident used a wheelchair for mobility, was occasionally incontinent of bladder and bowel function, and received antipsychotic and antidepressant medications. The 9/12/16 (CAA) Care Area Assessment for [MEDICAL CONDITION] drug use, directed staff to monitor for effectiveness and adverse reactions to medications. The 5/26/16 care plan informed staff, the resident had [DIAGNOSES REDACTED].

The facility had a census of 30 residents. The sample included 15 residents of which 5 were reviewed for abuse toward others. Based on observation, record review and interview, the facility failed to provide a safe environment free from physical and verbal abuse. Resident #10 displayed physical and verbal abuse toward Residents' #20, #18, #21, and 2 unidentified residents, which placed the residents in immediate jeopardy. Resident #14 displayed physical and verbal abuse toward Residents' #18, #23, and 2 unidentified residents, which placed the residents in immediate jeopardy. Resident #18 displayed physical and verbal abuse toward Residents' #14, #24, #20, and 1 unidentified resident, which placed the residents in immediate jeopardy. Resident #21 displayed physical and verbal abuse toward Residents #18, and 4 unidentified residents, which placed the residents in immediate jeopardy. Resident #23 displayed physical and verbal abuse toward Residents' #20 and #26, which placed the residents in immediate jeopardy. Findings included: - Resident #10's (POS) physician order sheet, dated 6/12/17, documented the resident had [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 8/16/16, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 1, which indicated severely impaired cognition. The assessment revealed the resident required limited assistance of 1 staff for dressing, set-up assistance and supervision for eating, supervision and 1 staff assistance for personal hygiene, and was independent with locomotion and ambulation. The assessment further revealed the resident had no behaviors, no rejection of care and or wandering, and received 7 days of antipsychotic (used to treat [MEDICAL CONDITION] and other mental emotional conditions) and antidepressant (used to treat mood disorders and relieve symptoms of depression) medications. The quarterly MDS, dated [DATE], recorded the resident had a BIMS of 00, which indicated severely impaired cognition and the resident was independent with all (ADLs) Activities of Daily Living except for limited assistance of 1 staff for dressing, toileting, and eating. The assessment revealed the resident had disorganized thinking, physical and verbal behaviors towards others, rejection of care, wandering, and 6 days of antipsychotic medication use. The 8/16/16 (CAA) Care Area Assessment for Antipsychotic Medication stated the resident received antipsychotic medications daily. The Behavior CAA did not trigger. The care plan, dated 9/6/16 and reviewed on 5/15/17, documented the resident used [MEDICAL CONDITION] medications related to behavior management and directed staff to monitor and record occurrence of target behaviors, such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence and aggression towards staff and others, and document per facility protocol. The care plan further documented the resident had a psychosocial well-being problem related to depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) with behavioral disturbances (condition exhibiting one or more specific emotional and/or behavioral difficulties over a long period of time) and anxiety, and documented the resident would get agitated and yell. The care plan directed staff to redirect the resident to appropriate behaviors, monitor the effectiveness of the medication, and document any negative behaviors. The 6/4/16 at 4:22 PM, incident report recorded Resident #20 followed Resident #10 into the dining room, Resident #10 then turned around and shoved his/her walker into Resident #20. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 9/21/16 at 12:02 PM, incident report recorded Resident #20 was eating his/her meal with his/her fingers and Resident #10, stated in an angry tone, hey, use your spoon. Resident #20 did not respond and continued to eat with his/her fingers when Resident #10 reached over with his/her right fist and hit the resident on the knuckles of his/her left hand. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 1/31/17 Medication Regimen Review documented Resident #10 received [MEDICATION NAME] (an antipsychotic) 2.5 (mg) milligrams at bedtime, requested a gradual dose reduction or a risk versus benefit statement from the physician, and the physician discontinued the medication on 2/7/17. The 2/9/17 at 4:19 PM, nurse's note documented Resident #10 frequently yelled at other residents that walked near him/her to just leave me alone or get the {h***} out of here and occasionally shook his/her walker at other residents until that resident left from his/her area of sight. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The 3/13/17 at 5:02 PM, nurse's note documented Resident #10 sat at the dining room table when another unidentified resident wheeled up close to him/her, and Resident #10 swung his/her arm at the resident. The note further documented no contact was made between the residents and the other resident left the area. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 3/14/17 at 10:36 AM, nurse's note documented Resident #10 pushed his/her walker into Resident #20's upper legs and yelled,get {him/her} away from me! The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 3/22/17 at 12:24 PM, nurse's note documented Resident #10 sat next to Resident #18 at the dining table. The note stated Resident #10 picked up his/her fork and raised it up toward Resident #18 when Resident #18 reached for Resident #10's pudding. The note further documented staff were able to intervene before Resident #10 could bring the fork down onto Resident #18's hand. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The 3/28/17 at 9:25 AM, nurse's note documented Resident #10 rolled up a magazine and swung it at Resident #18 as he/she wheeled his/her wheelchair up to the dining room table. The note further documented no contact was made between the residents and Resident #18 was taken away from the table. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The 4/4/17 at 5:21 PM, nurse's note documented staff heard Resident #10 yelling at Resident #18 and witnessed Resident #10 hit Resident #18 twice on the back and staff separated the residents. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 4/6/17 at 1:32 PM, nurse's note documented staff faxed communication to the physician regarding the resident's behavior on 4/4/17, no new orders were written, and a [DIAGNOSES REDACTED]. The 4/16/17 at 4:48 PM, nurse's note documented Resident #10 yelled out, I'm warning you, you better get out of here, put his/her left hand on Resident #21's right upper chest and pushed the resident so hard, Resident #21's wheelchair flew backwards. The note further documented Resident #21 wheeled away from the dining room. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 4/19/17 at 7:32 AM, nurse's note documented Resident #18 sat in his/her wheelchair next to Resident #10. Resident #10 turned towards Resident #18, raised his/her right hand and hit Resident #18 twice on his/her right shoulder and pushed him/her, which caused Resident #18's wheelchair to move backwards. Resident #10 yelled out, I said get {him/her} away from me! The note documented staff told Resident #10 not to hit other residents, and Resident #10 stated, then get {him/her} out of here! The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 4/19/17 at 4:15 PM, fax communication to the physician regarding Resident #10's aggressive behaviors documented the physician asked nursing staff if the resident was generally aggressive. The nursing staff further documented to the physician that Resident #10 was aggressive towards other residents and staff. The fax documented the physician diagnosed the resident with [MEDICAL CONDITION]. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 4/21/17 physician order directed staff to administer [MEDICATION NAME] ([MEDICAL CONDITION] medication) 2.5 mg, by mouth, at bedtime, for [MEDICAL CONDITION]. The 60 day physician visit, dated 5/11/17, documented the resident had confusion, as usual, and staff reported some behaviors and medication refusals. The physician directed staff to increase the resident's [MEDICATION NAME] to 5 mg, by mouth, at bedtime. The 5/13/17 at 2:22 PM, nurse's note documented the resident was upset most of the morning, frequently looked for his/her father, became easily agitated, yelled at staff, and occasionally verbally threatened that he/she should just kill someone. (Review of the medical record lacked documentation Social Services was involved after the resident verbally threatened to kill someone). The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 6/5/17 at 12:28 PM, nurse's note documented Resident #10 was outside calling another unidentified resident names and telling him/her to get out of here. The note stated when staff went outside to intervene, Resident #10 pushed his/her walker towards staff and yelled, get the {h***} out of here, you {b****}. Staff assisted the other resident inside the building. The record lacked documentation of the other resident's name. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. On 6/15/17 at 1:10 PM, observation revealed Resident #20 stood in the dining room and no nursing staff present. Further observation revealed Resident #10 ambulated with his/her walker toward the dining room, approximately 5 feet from Resident #20. Resident #10 yelled, get out of my way, get out of my face. Continued observation revealed neither resident made contact with each other and staff were unaware of the incident. On 6/14/17 at 2:45 PM, Nurse Aide C stated the resident became physically aggressive to staff and residents, and staff tried to redirect the resident. On 6/19/17 at 11:08 AM, Licensed Nurse E stated staff would notify the physician when the resident had a change in behavior, but he/she did not know of any incidents of aggressive behavior to residents. On 6/23/17 at 3:00 PM, Social Service Staff J stated, he/she was not involved when residents had physical altercations, and the nurses handled the situation. Social Service J further stated, when residents would get into arguments, he/she would talk to each resident, find out both sides of the story, and notify the family of the conflict. On 6/28/17 at 5:06 PM, Administrative Nurse A stated staff who witnessed any resident to resident altercation, should separate and assess the residents for injury, and monitor the residents closely. Administrative Nurse A further stated, staff notify the physician and ask for guidance on how to handle the resident. Administrative Nurse A verified he/she had no policy and procedure in place for staff intervention to keep residents apart after a resident to resident altercation. The facility's 6/30/2011, Reporting To State Policy indicated the facility shall identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident/patient property was more likely to occur. The policy stated if there is an incident of abuse that is putting a resident in immediate danger, first remove the resident from the situation, report the incident immediately to the charge nurse, Director of Nursing, risk manager, all suspected abuse incidents or any incident of unknown origin. All alleged violations involving mistreatment, neglect or abuse including all injuries of unknown origin must be reported to the state survey and certification agency immediately, but not to exceed 24 hour after discovery of the incident. Review of the 6/30/11 facility policy for Abuse, Neglect and Exploitation contained only 6 of the 7 components which are federally mandated. Further review of the facility policy, revealed it lacked the component of protection. The facility failed to provide a safe environment from physical and verbal abuse for Residents #20, #18, #21, and 2 unidentified residents, from Resident #10, placing the residents in immediate jeopardy. The facility abated the immediate jeopardy on 7/7/17 when the facility completed staff education on policies of Behavior Management and Monitoring, [MEDICAL CONDITION] Medication use, and Abuse. The Director of Nursing completed chart reviews of the residents in the facility with dementia on 6/30/17 and implemented interventions specific to each resident's behavior. The deficient practice remained at the scope and severity of an H. - Resident #14's (POS) physician order sheet, dated 4/14/17, documented the resident had [DIAGNOSES REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated 4/3/16, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 5, which indicated severely impaired cognition. The assessment revealed the resident had verbal and physical behaviors toward others, and rejection of cares 4 to 6 days, of the look back period of 7 days. The assessment further documented the resident was totally dependent on 2 staff for bed mobility, transfers and dressing, was totally dependent on 1 staff for locomotion on and off the unit, and received antipsychotic and antidepressant medications. The quarterly MDS, dated [DATE], recorded the resident had a (BIMS) Brief Interview for Mental Status score of 2, which indicated severely impaired cognition. The assessment revealed the resident was dependent upon 2 staff for bed mobility, toileting, dressing, and dependent upon 1 staff for locomotion on and off the unit. The assessment further revealed the resident experienced hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), rejection of care 1 to 3 days, and received 7 days of antipsychotic (used to treat [MEDICAL CONDITION] and other mental emotional conditions), and antidepressant (used to treat mood disorders and relieve symptoms of depression) medications. The annual MDS, dated [DATE], recorded the resident had a BIMS of 00, which indicated severely, impaired cognition. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, toileting, dressing, and extensive assistance of 1 staff for locomotion on and off the unit. The assessment further revealed the resident had physical and verbal behaviors towards others and received antipsychotic and antidepressant medication. The 4/4/17 (CAA) Care Area Assessment for antipsychotic medications recorded the resident received antipsychotic medications daily. The CAA for Behavioral Symptoms documented the resident's behaviors improved. The care plan, dated 9/6/16 and reviewed on 4/11/17, recorded the resident had behaviors, and became agitated easily, yelled, cursed and did not like being told what to do. The care plan further recorded the resident received medication for his/her behaviors and directed staff to suggest help and offer choices with all cares. The 1/6/15 physician order directed staff to administer [MEDICATION NAME] HCL (an antidepressant), 100 (mg) milligrams, by mouth, at bedtime for the [DIAGNOSES REDACTED]. The 4/5/16 at 11:17 AM, nurse's note documented Resident #14 verbally attacked Resident #18, stated he/she was crazy, and did not have a brain in his/her head. The note further documented staff moved the resident to another dining room table. The 9/17/16 at 1:12 PM, nurse's note documented the resident was in his/her wheelchair, wheeled up to another resident (unidentified by the facility), grabbed the wheelchair and would not let go. The note further documented staff asked the resident to let go of the wheelchair, and Resident #14 swung at staff. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 12/3/16 at 1:56 PM, nurse's note documented Resident #14 sat in his/her wheelchair in the hallway when Resident #23 came out of his/her room. Resident #14 asked Resident #23 if he/she had seen any of his/her family. The note further documented both resident's kicked and yelled at each other, staff intervened and separated them. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 12/29/16 at 7:49 PM, nurse's note documented the resident threatened to kill everyone with a gun. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 3/1/17 at 7:32 AM, nurse's note documented the resident transferred to a behavioral unit for evaluation for increased behaviors. The 3/16/17 nurse's note documented the resident returned from the behavioral unit and was cooperative and friendly. The 3/16/17 physician orders, upon readmission, directed staff to administer [MEDICATION NAME] (an antianxiety medication), 0.5 mg, by mouth, three times a day, for anxiety and paliperidone [MEDICATION NAME] (an antipsychotic medication) suspension, 1.5 (ml) milliliters, (IM) intramuscularly, every 30 days for adult personality disorder. The 3/21/17 at 2:22 PM, nurse's note documented Resident #14 tried to hit another resident (unidentified by the facility) who sat by him/her in the dining room. The note further documented staff intervened and no physical contact was made between the residents. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. On 6/23/17 at 3:00 PM, Social Service Staff J stated he/she was not involved when residents have physical altercations, and the nurses handle the situation. Social Service J further stated, when residents argued, he/she would talk to each resident, find out both sides of the story, and notify the family of the conflict. On 6/28/17 at 5:06 PM, Administrative Nurse A stated the staff, who witnessed any resident to resident altercation, separated and assessed the residents for injury, and closely monitored the residents. Administrative Nurse A further stated, staff notified the physician and asked for guidance on how to handle the resident. Administrative Nurse A verified he/she had no policy and procedure in place for staff intervention to keep residents apart after a resident to resident altercation. The facility's Abuse and Neglect policy, dated 6/30/11, documented the resident had the right to have an abuse free environment and it is staff responsibility to provide it for the residents 24 hours a day. The undated Resident Right's Policy stated the resident had the right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation and misappropriation of property by anyone. The facility failed to provide an environment free from abuse and initiate interventions to prevent abuse by Resident #14, who displayed physical and verbal abuse toward Residents #23, #18, and 2 other unidentified residents, placing them in immediate jeopardy. The facility abated the immediate jeopardy on 7/7/17 when the facility completed staff education on policies of Behavior Management and Monitoring, [MEDICAL CONDITION] Medication use, and Abuse. The Director of Nursing completed chart reviews of the residents in the facility with dementia on 6/30/17 and implemented interventions specific to each resident's behavior. The deficient practice remained at the scope and severity of an H. - Resident #18's (POS) physician order sheet, dated 5/11/17, documented the resident had [DIAGNOSES REDACTED]. more intense and persistent than what may normally be felt from time to time). The quarterly (MDS) Minimum Data Set assessment, dated 2/26/16, recorded the resident had severely impaired cognition, inattention and disorganized thinking behavior that was present continuously, altered level of consciousness that fluctuated, physical symptoms toward others and rejection of cares 1 to 3 days of the 7 day look back period. The MDS further documented the resident was totally dependent on 2 staff for bed mobility, transfers, and dressing, required extensive assistance of 1 staff for dressing, eating and toileting, and received antipsychotic medication (used to treat [MEDICAL CONDITION] and other mental emotional conditions). The annual MDS dated [DATE], recorded the resident had a (BIMS) Brief Interview for Mental Status Score of 00, which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of 2 staff for transfers, toileting, dressing, and extensive assistance of 1 staff for locomotion on and off the unit. The assessment revealed the resident wandered, had physical and verbal behaviors toward others, received 7 days of antipsychotic medications, and the mood score indicated no depression. The 5/15/17 (CAA) Care Area Assessment for antipsychotic medication and behavior documented staff monitored the resident for the use of [MEDICATION NAME] (medication used to treat the symptoms of psychotic conditions), and reported any changes of the resident's condition to the physician. The CAA further directed staff to ensure daily routines remained as consistent as possible, provide the resident with activities that kept him/her from becoming frustrated and bored, and if he/she became frustrated, allow the resident time to calm down, then reapproach later. The care plan, dated 9/6/16 and reviewed on 4/9/17, documented the resident received [MEDICAL CONDITION] medications related to behavior management and directed staff to monitor and record occurrence of target behaviors, such as wandering, inappropriate response to verbal communication, violence, aggression towards staff and others, and document per facility protocol. The care plan further documented the resident had aggressive behaviors, wandered around the facility in his/her wheelchair, and needed staff assistance making safe decisions. The care plan lacked documentation of the specific behaviors the resident displayed towards staff and other residents, or interventions staff were to implement in the case of those behaviors. The 4/5/16 at 10:19 AM, nurse's note documented Resident #18 sat at the dining room table and became agitated with Resident #14. The note further documented Resident #18 doubled up his/her fist and moved towards Resident #14 when staff intervened and moved the resident to another table. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The 4/26/16 at 2:07 AM, nurse's note documented Resident #18 grabbed Resident #24's arm and squeezed, which caused Resident #24 to express discomfort. The note further documented, staff intervened and the resident let go. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The 6/12/16 at 10:16 AM, nurse's note documented Resident #18 became agitated, reached out with his/her fist, and hit Resident #24 on the forearm. The note further documented, staff moved Resident #18 in his/her wheelchair so he/she was unable to reach Resident #24. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 9/15/16 at 4:41 PM, nurse's note documented while Resident #18 propelled him/herself down the hallway, the resident punched at another resident (unidentified by facility), but no contact was made. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further behaviors. The 5/4/17 at 10:08 AM, nurse's note documented Resident #20 napped on the couch with his/her head resting on the back of the couch. The note documented Resident #18 propelled him/herself up to the couch, reached out with his/her fist, and hit Resident #20 in the back of his/her head. The clinical record lacked evidence the facility reviewed or implemented interventions to prevent further abuse. The 6/1/17 physician order sheet directed staff to administer [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITION] and other mental emotional conditions), 5 (mg) milligrams, by mouth, at bedtime, for the [DIAGNOSES REDACTED]. On 6/14/17 at 12:53 PM, observation revealed Resident #18, sat in his/her wheelchair in the dining room, after breakfast, with his/her head down and eyes closed. On 6/15/17 at 9:17 AM, observation revealed Resident #18 sat in the dining room, and in a raised voice stated what the {h***}, as 2 staff members offered him/her something to eat and drink. Observation revealed a family member joined the resident at the table, and no further outbursts were observed. On 6/16/17 at 2:30 PM, Nurse Aide G stated the resident required assistance with all cares, but was able to propel him/herself around the facility. Nurse Aide G further stated, when the resident hit or kicked another resident, he/she separated the residents, notified the charge nurse, and informed the director of nursing. On 6/16/17 at 3:30 PM, Nurse Aide M stated the resident's behavior depended on what type of day he/she had, and the resident had periods of agitation and rejection of care. On 6/28/17 at 5:06 PM, Administrative Nurse A stated staff who witnessed any resident to resident altercation, separated and assessed the residents for injury, and closely monitor the residents. Administrative Nurse A further stated staff notified the physician and asked for guidance on how to handle the resident. Administrative Nurse A verified he/she had no policy and procedure in place for staff intervention to keep residents apart after a resident to resident altercation. The facility's Abuse and Neglect policy, dated 6/30/11, documented the resident had the right to have an abuse free environment and it is staff's responsibility to provide it for the residents 24 hours a day. The undated Resident Right's Policy stated the resident had the right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation and misappropriation of property by anyone. The facility failed to provide an environment free from abuse and initiate interventions to prevent abuse by Resident #18, who displayed physical and verbal abuse toward Residents #20, #14, #24 and 1 unidentified resident, placing them in immediate jeopardy. The facility abated the immediate jeopardy on 7/7/17 when the facility completed staff education on policies of Behavior Management and Monitoring, [MEDICAL CONDITION] Medication use, and Abuse. The Director of Nursing completed chart reviews of the residents in the facility with dementia on 6/30/17 and implemented interventions specific to each resident's behavior. The deficient practice remained at the scope and severity of an H. - Resident #21's quarterly (MDS) Minimum Data Set assessment, dated 5/20/16, recorded the resident had severe cognitive impairment, inattention and disorganized thinking behavior that fluctuated, experienced delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal behavior directed toward others daily, and wandered 1 to 3 days of the 7 day look back period. The MDS further recorded the resident required limited assistance of 1 staff for bed mobility, transfers, and locomotion on and off the unit, required extensive assistance of 2 staff for walking in the corridor, and received antianxiety medication. Resident #21's quarterly (MDS) Minimum Data Set assessment, dated 3/15/17, recorded the resident had severe cognitive impairment, physical and verbal behaviors directed toward others 4 to 6 days of the 7 day look back period, other behaviors not directed toward others, and wandering 4 to 6 days of the look back period. The MDS further recorded the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and extensive assistance of 1 staff for locomotion on and off unit, eating, and personal hygiene. The MDS recorded the resident used a wheelchair for mobility, was occasionally incontinent of bladder and bowel function, and received antipsychotic and antidepressant medications. The 9/12/16 (CAA) Care Area Assessment for [MEDICAL CONDITION] drug use, directed staff to monitor for effectiveness and adverse reactions to medications. The 5/26/16 care plan informed staff, the resident had [DIAGNOSES REDACTED]. The care plan directed staff to redirect the resident as needed when he/she yelled out, and report when the resident was very anxious, and/or had increased negative behaviors, so the nurse could administer antianxiety medication to the resident. The 3/22/17 care plan update informed staff the resident was disoriented to place, wandered aimlessly, and instructed staff to distract him/her by offering pleasant diversions, structured activities, food, conversation, television, and books. The care plan further instructed the staff to monitor/document for physical/nonverbal indicators of stress and frustration level. The care plan lacked documentation to direct staff how to approach the resident's behaviors and interventions to use to prevent resident to resident altercations. The 5/27/16 at 10:29 AM, progress note documented Resident #21 ran into another resident while seated in his/her wheelchair (upon request the facility failed to identify the other resident) and had been wandering. The 6/5/16 at 4:00 PM, progress note documented Resident #21 had an altercation with another resident (upon request facility failed to identify the other resident) in which the other resident grabbed his/her neck and the aide had to break up the altercation. Th

The facility had a census of 30 residents. The sample included 15 residents, of which 3 residents were reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure 1 of 3 residents (#23) remained free of entrapment. This deficient practice placed Resident #23 in immediate jeopardy. The facility failed to implement safety precautions for Resident #10, who spilt hot coffee on him/herself, and a second burn incident occurred when the facility failed to follow new interventions after the first incident, placing the resident at risk for further injury. Findings included: - Resident #23's quarterly (MDS) Minimum Data Set assessment, dated 8/20/16, recorded the resident had severe cognitive impairment. The MDS recorded the resident was independent with bed mobility, transfers, walking in room and corridor, and locomotion on and off unit. He/she required minimal assistance of 1 staff for personal hygiene and dressing. The MDS further recorded the resident's balance during transition and walking was steady at all times, had no falls since the prior assessment, and exhibited wandering daily. He/she had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and exhibited verbal behavioral symptoms directed toward others. The 11/18/15 (CAA) Care Area Assessment summary for falls documented the resident was at risk because he/she got confused at night and wanders. The CAA for cognitive loss summary indicated he/she goes into other residents rooms at night when wandering and had behaviors of cursing and yelling at other residents. The 11/23/15 care plan instructed the staff to keep the resident's bed in the lowest position to minimize injury if the resident should fall out of bed, and to keep bed wheels locked so the bed did not move while transferring in and out of bed. The care plan further directed staff to remind the resident not to pick things up off the floor, as this is a high risk activity. There were no further care plan updated from 11/23/15 to the time of the fall. Review of the resident's progress notes revealed, an unwitnessed fall on 9/29/16 at 8:45 PM, and to refer to assessments for further information. The Fall Assessment, dated 9/29/16 at 8:45 PM, recorded the resident's family member summoned staff to his/her room. Upon entering the room, the resident was found on the floor on his/her knees, next to the bed. The resident's head was lodged between the mattress and night stand, and the resident was not responding to any stimuli. The note further documented staff dislodged, repositioned the resident, and he/she yelled out at that time. The resident had a crease to his/her face, the resident's muscle tone was flaccid (weak, soft and flabby), and he/she was not responding to stimuli. The note stated the resident was unable to maintain an upright position on his/her own and muscle tone was flaccid. Staff lifted the resident into a recliner due to unresponsiveness via 4 man lift. After approximately 30 minutes, the resident began to show signs of responsiveness and attempted to lean forward in the recliner, but did not have enough muscle control to keep him/her from pitching forward out of the recliner. The nurse on duty notified the family contact person, by phone on 9/29/16 at 10:46 PM and faxed the fall report to the physician on 9/30/16, the time of the fax was unknown. Review of the medical record revealed no new interventions were placed on the care plan to prevent further entrapment and the root cause of the fall was not determined. On 6/19/17 at 4:00 PM, Staff Nurse B explained the resident was found with his/her knees on the floor, and his/her face downward and lodged between the night stand and mattress. The resident was dislodged, and had a crease to his/her face from the pressure from the mattress, and assessed for injuries. He/she verified the resident was not verbalizing or opening eyes, had no injuries to extremities, and was monitored per protocol for unwitnessed fall. On 6/19/17 at 4:10 PM, Staff Nurse B, verified he/she did not notify the physician of the resident's unresponsiveness, and the crease to his/her face from being lodged between the mattress and night stand, via phone, but faxed the information instead. On 6/19/17 at 1:10 PM, Administrative Nurse A verified he/she expected the nursing staff to notify the physician in an event of an unresponsive episode involving a resident and not to fax the information to the doctor who would not review the communication until his/her office opened. He/she stated the definition of entrapment was not clear to him/her, related to this situation because it did not involve the bed rail and no interventions were initiated. The facility's Notification of Changes Policy, dated 2/9/17, states the nurse would immediately notify the resident's physician and the resident representative of accidents involving the resident, which results in injury and the potential for requiring physician intervention. The intent of the policy was to provide appropriate and timely information about changes relevant to a resident's condition, or accident that may require physician intervention. The facility failed to ensure a safe environment free of hazards, and to provide immediate physician notification and root cause analysis of an incident involving an entrapment for Resident #23, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 6/23/17, when the facility completed face to face training to all direct care staff, administrative staff, care team members, housekeeping, and maintainance staff on command strip placemet (18 inch gap between furniture) and visual monitioring. Training provided to all charge nurses/ CMAs/MDS Cooridinator on Restraints and Side Rails which includes entrapment and what to do in case of entrapment. This deficient practice remained at the scope and severity of a D. - Resident #10's quarterly (MDS) Minimum Data Set assessment, dated 5/19/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 00, which indicated severely impaired cognition. The assessment revealed the resident was independent with all (ADL's) Activities of Daily Living except for limited assistance of 1 staff for dressing, toileting, and eating. The quarterly MDS, dated [DATE], documented the resident had a BIMS of 1 which indicated severely impaired cognition.The assessment revealed the resident was independent and staff provided set up assistance for eating. The 8/24/16 care plan recorded the resident had trouble handling regular silverware and used big handled silverware, a plate guard (helps prevent food from being pushed off of a dinner plate), and cups with handles to assist the resident with not spilling his/her drinks. The 12/6/16 facility incident report documented staff gave the resident a cup of coffee at the dining room table, the resident grabbed the coffee cup, lifted the cup to take a drink, the cup slipped out of the resident's hand and spilled onto the resident's thigh and knee. The incident report further stated the staff immediately assisted the resident in changing his/her pants. The report documented the resident's left thigh and knee had slight redness, staff to monitor and instructed to provide the resident's coffee in a styrofoam cup with a lid, to prevent possible spilling and burns. The medical record lacked documentation of continued skin assessments after the incident, or staff notification to the physician. The 5/16/17 at 7:40 AM, nurse's note stated the resident was at the breakfast table and a dietary aide gave the resident a full cup of hot coffee. The note further stated the resident picked up the cup of coffee and dropped the cup, spilling it on him/herself. The staff immediately dried off the resident, took him/her to the bathroom, and removed the resident's clothes. The resident's inner thighs, right chest area and both hands were reddened. The note further stated the staff notified the physician and by 11:00 AM, most of the redness was gone. The medical record lacked documentation of an incident report, or continued skin assessments after the incident. On 6/15/17 at 1:17 PM, observation revealed the resident, seated at the dining room table, with a styrofoam cup with no lid, cold chocolate milk and a snack. On 6/19/17 at 11:08 AM, Licensed Nurse E stated after the first time the resident spilled his/her coffee, staff were to provide the resident's drinks in styrofoam cups, but the dietary aide was not told. Licensed Nurse E stated the dietary manager was supposed to tell his/her staff about the cups. On 6/19/17 at 11:41 AM, Dietary Staff L, indicated the resident had adult sippy cups for his/her juice and water and he/she did not provide the resident coffee. On 6/19/17 at 11:57 AM, Dietary Staff K stated the incident with the coffee was an accident and the resident does well with cups with handles. On 6/20/17 at 12:00 PM, Administrative Nurse A stated the facility had not assessed the resident after the first time the resident spilled his/her coffee, to make sure the resident could hold a cup with hot coffee. Administrative Nurse A further stated the nurse should have documented how the resident's skin looked and better follow up. Upon request a policy for accidents or hot liquids was not provided by the facility. The facility failed to implement safety precautions for Resident #10, who spilt hot coffee on him/herself, and a second burn incident occurred when the facility failed to follow new interventions after the first incident, placing the resident at risk for further injury.

The facility had a census of 24 residents. The sample included 10 residents. Based on observation, record review, and interview the facility failed to document supplement intake for 3 of the 3 residents reviewed for nutrition, (#11,#10, #14), and failed to implement dietary interventions to prevent further weight loss for Resident #10, who had significant weight loss. Findings included: - Resident #10's quarterly (MDS) Minimum Data Set assessment, dated 4/16/14, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 3, which indicated severely impaired cognitive function. The MDS indicated the resident was independent with bed mobility, transfers, walking, and required supervision with dressing, eating and hygiene. The MDS indicated the resident received scheduled pain medication, displayed signs of pain 3-4 days, and received antipsychotic and antidepressive medications 7 days of the look back period. The significant change (MDS) Minimum Data Set 3.0 assessment, dated 9/12/14, indicated short term memory problems, severely impaired decision making skills, was independent with bed mobility, transfers, walking, and required supervision with dressing, eating and hygiene. The MDS indicated the resident weighed 142 (#) pounds. The MDS did not indicate the resident received a therapeutic diet nor had weight loss and no dental or swallowing concerns. The 9/12/14 (CAA) Care Area Assessment summary for nutrition indicated the resident had poor memory, depression, and needed to be told when it was meal time. The 6/29/14 care plan for nutrition directed the staff to provide a regular diet, continue offering snacks, and provide encouragement at all meals to increase food and fluid intake. The care plan indicated the resident was able to choose the foods that he/she liked at each meal and the family requested smaller portions at meals. The care plan update on 8/30/14 directed the staff to offer 8 oz. magic milk at breakfast and supper. The care plan update on 9/17/14 instructed the staff to provide 8 oz. magic milk with lunch and supper (the 2 meals the resident ate better). The resident's weight record revealed the following: 5/4/14 - 154.5# 6/8/14 - 147# 7/20/14 - 139.6# (16.4# or 10.5% weight loss in 104 days) The clinical record lacked evidence the staff notified the dietician or implemented any additional weight loss interventions. 8/3/14 - 141.4# The clinical record lacked evidence the staff notified the dietician or implemented any additional weight loss interventions. 8/31/14 - 143.4# The clinical record stated the resident was hospitalized [DATE] through 8/25/14. The 4/18/14 Nutritional assessment, by the (CDM) Certified Dietary Manager, indicated the resident received a regular diet and snacks (BID) twice daily, averaged 71% food intake, ate independently, was alert but confused and weighed 156#. The 6/4/14 dietary note to the physician reported a significant weight loss of 5.17% in one month and the physician responded, OK, but did not order new dietary interventions. The clinical record lacked evidence the facility notified the (RD) Registered Dietician regarding the resident ' s weight loss. The 7/14/14 Nutritional assessment, by the CDM, indicated the resident weighed 142# (a loss of 14# in 90 days) and the physician gave no new orders. The 7/24/14 dietary note sent to the physician indicated the resident had weight loss of 11.36% in 6 months and the physician responded, OK, but did not order new dietary interventions. The 8/29/14 (RD) Registered Dietician note indicated the resident ate independently, refused some meals or had eaten very little since the hospital return. The RD recommended 8 oz. magic milk at breakfast and supper, monitor intake and weight. (40 days after the staff identified a significant weight loss of 10.5% over the previous 3 months) On 9/16/14 at 11:45 AM, observation revealed the resident sat at the dining table, and independently ate a ground turkey sandwich, chocolate pudding, pasta salad, brownie, potato salad, 240 (ml) milliliters coffee, and 180 ml water. Further observation revealed the resident ate less than 25%, and did not drink the supplement or the water. When staff encouraged him/her to eat more, the resident stated he/she couldn't eat any more, but he/she did not know why. On 9/17/14 at 11:45 AM, observation revealed the resident at the dining table with the following beverages: 120 ml supplement, 120 ml orange juice, 240 ml water, 240 ml coffee. Further observation revealed the resident ate 100% of the pumpkin pie, 25% of the Reuben sandwich, 25% of the broccoli and 10% of the sweet potatoes. The resident drank 100% of the supplement, and 50% of the other beverages. On 9/17/14 at 9:11 AM, Dietary Manager C stated the resident received 8 (oz.) ounces of magic milk (1/2 cup of whole milk with a 1/2 cup of dairy creamer), and a ground meat diet, which was initiated on 6/10/14. (The clinical record lacked indication of why the diet was changed) He/She stated the staff had not been documenting the supplements correctly so dietary and nursing were unable to determine the amount of supplement actually consumed by the resident. On 9/17/14 at 4:55 PM, Administrative Nurse B stated supplements should be listed and documented by the staff on the intake clipboard and dietary staff were to put new nutritional interventions or changes on the care plan between meetings. He/She verified the resident's intake record lacked documentation of numerous meals during July through September 2014. On 9/18/14 at 9:38 AM, observation revealed Nurse Aide J documented food and fluid intake from the breakfast meal. He/she stated if a resident had a supplement he/she just documented that together with the other fluids. On 9/22/14 at 3:40 PM, Administrative Nurse B verified the facility had not provided new interventions to prevent further weight loss from April through July 2014, when the resident lost a significant amount of weight. On 9/23/14 at 9:40 AM, Physician M, stated when the resident lost weight he/she looked for a possible cause and ordered blood lab work. He/She stated the resident's mental state had declined this past year, which could be affecting his/her intake, the resident was admitted to the geri psychiatric unit for about 3 weeks and had several medication changes. Physician M stated the dietary department usually made suggestions for dietary interventions and the physician then evaluated or ordered the interventions. He/She stated he/she would expect the facility to notify the RD of significant weight loss and have the RD recommend interventions. The facility's 3/22/12 policy for significant weight loss directed the staff to review the food intake records to estimate the average percentage of food/fluid intake in the past 2-4 weeks, review the care plan for pertinent information and request/implement nutrition interventions based on the individual case. The policy defined significant weight loss as the following: 5% weight loss in 1 month. 7.5% weight loss in 3 months. 10% weight loss in 6 months. The facility failed to provide interventions to prevent further weight loss after the staff notified the physician of a significant weight loss of 5.17%, in 1 month, on 6/4/14, and the resident continued to experience weight loss, 8.67% in 3 months. The facility failed to document Resident #10's intake of supplements and all meals to monitor the amount actually consumed by the resident to determine additional interventions needed to prevent further weight loss. - Resident #14's annual (MDS) Minimum Data Set 3.0 assessment, dated 4/17/14, indicated the resident was cognitively impaired with a (BIMS) Brief Interview for Mental Status of score of 0, required total staff assistance with all (ADLs) Activities of Daily Living, had no swallowing problems and no natural teeth. The MDS indicated the resident's height of 65 inches, weight 133 (#) pounds, weight loss, and received a mechanically altered diet. The quarterly 7/18/14 MDS indicated the same except short/long term memory loss, severely impaired decision making, held food in his/her mouth, coughing/choking with swallowing, and a weight of 120#. The 4/30/14 (CAA) Care Area Assessment summary for nutrition indicated, due to Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), the resident required total staff assistance with meals, received a pureed diet, had dentures and required total care with ADLs. The 7/23/14 care plan for nutrition directed the staff to provide the resident a ground meat diet, allow options and choices at meals and snacks, and encourage him/her to drink fluids. The care plan indicated the resident was able to let the staff know what he/she liked and disliked, intake usually averaged 26%, and weight was 115.8#. The care plan lacked information as to the level of dietary assistance required and lacked information regarding supplements or snacks. Review of the medical record revealed the following: The 1/27/14 Nutritional assessment indicated the resident weighed 140.5#, received a pureed diet, snacks (BID) twice daily, and the resident does not swallow as well or eat independently. The 2/11/14 (CDM) Certified Dietary Manager note to the physician stated the resident's diet changed from pureed to ground and the weight loss of 5.88% in one month. 3/2/14 weight - 138#. The 3/11/14 CDM note to the physician recommended to discontinue [MEDICATION NAME] (supplemental protein) shakes (started 8/20/12) as the resident had been gaining weight. The physician ordered the staff to discontinue the [MEDICATION NAME] shakes. The 3/28/14 CDM note to the physician requested offering 8 (oz) ounce magic milk (TID) three times daily, at meals and the physician approved the request. 4/6/14 weight - 132.5#. The 4/10/14 annual (RD) Registered Dietician Nutritional assessment indicated the resident received a ground diet, weighed 132.5#, averaged 65% intake, received total assistance from staff with meals and a concern with weight loss. The RD's assessment indicated the resident's estimated daily dietary needs included: 1500-1600 calories, 60 grams protein, 1506 (ml) milliliter fluids. 5/4/14 weight - 131.5#. The 5/8/14 memo from the RD to the CDM directed the staff to provide 8 oz magic milk TID at meals and 8 oz magic milk at the afternoon snack to prevent further weight loss. The 5/14/14 CDM note to the physician indicated a weight loss of 15.4# in 6 months, stated the resident received magic milk, 8 oz. TID, and the RD requested to add magic milk to snacks as well. The physician approved the request. The 6/6/14 physician ordered the diet changed to pureed. 6/8/14 weight - 128# (a 10# or 7.2% loss in 90 days) The 6/23/14 CDM note to the physician requested approval to offer magic milk 8 oz at 3:00 PM, along with the TID magic milk. (The same recommendation as the physician had signed 5/14/14) and the RD also requested a swallow study. The physician approved both requests. 6/29/14 weight - 128.5#. 7/6/14 weight - 124#. The 7/11/14 physician order [REDACTED]. 7/12/14 weight - 120.6#, with new scales. The 7/14/14 dietary note to the physician indicated the resident had weight loss of 5.78% in one month. The note indicated the resident received Magic Milk, 8 oz TID, with meals and at 3:00 PM. 7/20/14 weight - 115.8#. The 7/24/14 note to the physician indicated the resident's weight down 8.81% in a month and 19.86% in 6 months. The note indicated the resident received Magic Milk 8 oz TID with meals and at 3:00 PM and had a current weight of 115.8#. The 7/29/14 physician progress notes [REDACTED].# in 2.5 months. 8/3/14 weight - 112.2#, a 6.96% loss in less than 30 days. The 8/13/14 dietary note to the physician reported a weight loss of 7.62% in one month and indicated the new scale had been used for at least one month and the resident weighed 111.4#. 9/7/14 weight - 111.6#, a 19.13% loss in 180 days. The 9/12/14 Registered Dietician note indicated the resident's weight 111.6#, up 0.2# over 1 month, and down 16.4# in 3 months. The note indicated the resident's intake was 55%, the resident continued to receive magic milk TID and at 3:00 PM. The RD recommendations to DC magic milk and offer 120 (ml) milliliter, med pass or 2 cal (QID) four times daily, add 1 packet Benecal (protein/calorie supplement) to the meal best consumed by the resident, and monitor intake and weight. Review of the Dietary Intake records from 7/1/14 to 9/17/14 revealed numerous meals that the staff had not documented any intake or fluids: 35 meals in July, 16 meals in August, and 14 meals of the first 16 days of September 2014. The 9/12/14 memo from the RD to the dietary manager stated: Need to document amount consumed of any intervention item such as magic milk, [MEDICATION NAME] shakes, med pass or 2 cal. The 9/17/14 physician's orders [REDACTED]. On 9/16/14 at 11:45 AM, observation revealed the resident seated at the dining table with 180 ml chocolate supplement, 180 ml water, 120 ml apple juice, but further observation revealed the resident made no attempt to independently drink. Continued observation revealed staff sat next to the resident and assisted him/her with drinking the supplement after pouring some into a medicine cup. At 11:55 the staff served a meal of pureed pizza, pasta salad, and a brownie. Observation revealed the resident barely opened his/her mouth for small sips and he/she opened his/her mouth better for bites of food. The resident ate approximately 50 % of the food, 100% of the supplement and apple juice and 50% of the water. The resident closed his/her eyes and did not take anymore sips or bites. On 9/17/14 at 9:11 AM, Dietary Manager C stated in 2012 the resident had weight loss and [MEDICATION NAME] was started, then discontinued when his/her weight became stable. He/she stated, in April 2014, the resident received magic milk (1/2 cup whole milk with 1/2 cup of dairy creamer), a ground diet, which was changed on 6/10/14. Dietary Manager C stated the dietary department provided no other changes in the resident's diet until 9/16/14. He/She stated the RD makes recommendations and the CDM sends the paper work to the physician. He/she stated on 9/17/14 Benecal, 1 packet, was added to breakfast and either 2 cal QID or 120 ml med pass. He/She stated the staff had not been documenting the supplements correctly so dietary and nursing were unable to determine the amount of supplement actually consumed by the resident. On 9/17/14 at 4:55 PM, Administrative Nurse B stated supplements are to be listed and documented by the staff on the intake clipboard and dietary staff are to put new nutritional interventions or changes on the care plan between meetings. He/She verified the resident's intake record lacked documentation of numerous meals during July through September 2014. On 9/18/14 at 938 AM, observation revealed Nurse Aide J documenting food and fluid intake from the breakfast meal. He/she stated if a resident had a supplement he/she just documented that together with the fluids. The facility's 3/22/12 policy for significant weight loss directed the staff to review the food intake records to estimate the average percentage of food/fluid intake in the past 2-4 weeks, review the care plan for pertinent information and request/implement nutrition interventions based on the individual case. The facility failed to document Resident #14's intake of supplements and all meals to monitor the amount actually consumed by the resident to determine additional interventions needed to prevent further weight loss. - Resident #11's physician order, dated 9/12/14, indicated the resident had a [DIAGNOSES REDACTED]. enough iron). The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 7/19/14, indicated the resident had no swallowing problems, height 64(in) inches, weight 102(#) pounds, received a mechanically altered diet, and had physician prescribed (verified incorrect per interview below) weight loss regimen. The 7/23/14 care plan indicated the resident received a pureed diet, he/she enjoyed sweets, and used a plate guard with every meal. The care plan indicated the resident's meal intake averaged about 66%, instructed the staff to encourage the resident to drink fluids, and to serve the resident ground meat per family request. Review of the resident's 2014 weight record revealed the following: 7/14 - 101.4# 7/21 - 100.4# 7/26 - 101# 8/3 - 100# 8/9 - 97.8# 8/17 - 99# 8/23 - 97# 8/31 - 103.6# 9/6 - 99.8# 9/14 - 94# The CDM documentation revealed the following: 1) 4/18/14 the resident received a 4 (oz) ounce protein shake twice daily. 2) 5/14/14 fax to the physician from the CDM indicated he/she would like to stop the protein shakes and offer the resident magic milk (half and half milk with whole milk) 8 oz. three times daily and the physician approved the request. 3) 6/4/14 the resident received magic milk 8 oz. three times daily and 2 cal (a nutritionally complete, high-calorie formula designed to meet the increased protein and calorie needs), 60 (ml) milliliters, supplement twice daily. 4) 7/30/14 fax to the physician from the CDM indicated the resident was refusing to drink the 2 cal, 60 ml, and he/she requested the resident continue to receive magic milk twice daily and the physician approved the request. Review of the daily intake log revealed no documentation of the resident's supplement consumption separately from the other fluid intake, and lacked documentation of food or fluid consumption for the resident as follows: July -19 times August- 14 times September - 1 time (through 9/18/14) The 9/12/14 memo from the dietician to the CDM instructed the staff to document the amount consumed by the resident, of each individual intervention. Review of the meal/supplement intake record revealed staff had not started the dietician recommendation as of 9/18/14. (6 days after the recommendation) The 9/15/14 at 4:40 AM nurse's notes indicated the resident had lost 5.8 lbs in one week. On 9/18/14 at 7:45 AM, observation revealed the resident seated in a wheel chair at the dining room table, using a red plate with a plate guard. Observation revealed the staff assisting the resident with his/her breakfast meal of 240 (cc) cubic centimeters of magic milk, 240 cc orange juice, 240 cc water, and pureed sausage and biscuit. Continued observation revealed the resident consumed 80% of magic milk, 100% orange juice, and few bites of pureed sausage and biscuit with assistance from the staff. On 9/18/14 at 8:00 AM, Dietary Staff C verified the missing documentation of food and fluid intake on the above months and stated he/she expected the staff to document the consumption of interventions. On 7/22/14 at 12:05 PM, Administrative Nurse B verified the resident's 7/19/14 MDS incorrect and stated the resident was not on a physician prescribed weight loss regimen. The facility failed to document Resident # 11's consumption of nutritional supplement, who continued to have weight loss.

The facility reported a census of 25 with 12 sampled for review, 3 were reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 (#17) residents. The facility also failed to ensure the resident environment remained as free of accident hazards as possible. The facility reported 9 residents as independently mobile and cognitively impaired. This included potentially hazardous chemicals stored in areas accessible to residents and water temperatures in 6 resident rooms and in commons areas that exceeded 120 degree F (Fahrenheit). (#29, #2, #17, #23, #18, and #6). Findings included: - The signed Physician order [REDACTED]., essential hypertension, cerebral aneurysm nonruptured, chronic airway obstruction, dyspepsia, constipation, neurogenic bladder, osteoarthrosis, insomnia, edema, history of venous thrombosis and embolism, long term use of anticoagulants. The 9/29/2011 Annual MDS (minimum data set) assessment for resident #17 identified the resident as cognitively intact and required supervision for transfers. Resident #17 sustained no falls since admission or since the prior assessment. The 12/30/2011 Quarterly MDS assessment for resident #17 identified the resident as cognitively intact with unsteady balance and required limited assistance of one staff member for bed mobility, transfers, and ambulation. Resident #17 sustained no falls since admission or since the prior assessment. Resident #17's 9/30/2011 CAAs (care area assessment) summary for falls indicated he/she had a history of [REDACTED]. Record review of resident 17's fall risk assessment completed on 12/30/2011 revealed a score of "10" indicating the resident had a high fall risk. Record review of resident 17's fall risk assessment completed on 4/3/2012 revealed a score of "18" indicating the resident remained a high fall risk. Resident #17's 4/3/2012 nursing care plan indicated the resident used a front wheeled walker with supervision in his/her room and used a wheel chair for long distances. The 4/3/2012 care plan indicated resident #17 refused restorative therapy. Resident #17's 4/3/2012 nursing care plan lacked revision to include resident's current need of limited assistance with mobility based on 12/30/2012 Quarterly MDS assessment. Record review of nurse's notes for 3/12/2012 at 8:55 p.m. MST (Mountain Standard Time) indicated resident #17 attempted to get out of bed without assistance and fell . The resident sustained [REDACTED]. Staff transported resident #17 to the emergency roiagnom on a cart at 9:15 p.m. MST (Mountain Standard Time). Record review of the emergency room documentation for 3/12/2012 indicated the laceration above resident #17's left eyebrow measured 2.5 centimeters and the doctor repaired the laceration using Dermabond adhesive. During an observation on 4/4/2012 at 8:50 a.m. MST (Mountain Standard Time), direct care staff K and L assisted resident #17 out of bed and to the bathroom. Resident #17 used his/her four- wheeled walker, took short steps, and shuffled the left foot on the floor. During an interview on 4/5/2012 at 7:45 a.m. MST, resident #17 recalled he/she slipped off the edge of his/her bed and hit his/her head on the bedside drawer last month. During an interview on 4/4/2012 at 2:10 p.m. MST, direct care staff N verified staff reminded resident #17 to use the call light to get assistance in order to prevent falls and staff had not used any other interventions to prevent falls for resident #17. During an interview on 4/5/2012 at 10:00 a.m. MST, administrative nursing staff C verified that resident #17 had a high fall risk and the care plan lacked interventions to prevent falls. During an interview on 4/4/2012 at 5:15 p.m. MST, administrative nursing staff A indicated that staff should evaluate each fall and initiate interventions to prevent future falls. The 2/21/2008 fall policy and procedure indicated that all residents admitted to this facility had a risk for falls due to age, diagnoses, medications, and changes in environment. In the event that a fall occurred, staff should implement the necessary changes to the resident's plan of care immediately. The facility failed to assess and put an effective plan in place to prevent falls for this resident, who the facility identified as a high fall risk. This resident sustained [REDACTED]. - Observations on 4/2/12 at 10:30 a.m. MST (Mountain Standard Time) revealed two 12 ounce cans of Lysol disinfectant spray with a warning label of "keep out of reach of children" and "eye irritant" and a 13 ounce spray bottle of 3M non-acid disinfectant bathroom cleaner with a warning label of "may cause eye, skin, nose, and throat irritation" in the unlocked south hall shower room. During an interview on 4/2/12 at 10:45 a.m. MST, Direct Care Staff R reported the shower room usually remained locked and confirmed staff failed to keep the potentially hazardous chemicals in the shower room out of access to residents. Observations on 4/2/12 at 1:00 p.m. MST revealed in a mechanical room, unlocked and unattended by staff, with the doorway propped open on the south hallway with the following chemicals found within easy reach: o a full, 1 quart container of Crew toilet bowl cleaner with a warning label to "keep out of reach of children" o a 1/8 full, 3.17 quart container of Bath Mate acid free cleaner with a warning label of "eye irritant" and "keep out of reach of children" o a full, 17 ounce container of Dymon Grease Gun cleaner with a warning label of "keep out of reach of children," "eye irritant," and "skin irritant" o a full, 17 ounce container of Ozone penetrating lube with a warning label of "harmful vapors" and "keep out of reach of children" o a 1/4 full, 20 ounce container of Powder cleanser double strength with chlorine bleach with a warning label of "eye irritant" and "keep out of reach or children" o a full, 17.7 ounce container of Rose Shineup furniture polish with the warning label of "keep out of reach of children" o a 1/4 full, 48 fluid ounce container of Rug Doctor carpet cleaner with a warning label of "keep out of reach of children" o a full, 23 ounce container of Power foam Bravo with a warning label of "corrosive skin and eye irritant, burns" and "keep out of reach of children" o a full, 19 ounce container of Kaboom Foam cleanser with a warning label of "eye irritant" and "keep out of reach of children" o a 3/4 full, 16.5 ounce container of Fall Misty 11 disinfectant and deodorizer with a warning label to "keep out of reach of children" o a 1/2 full, 18 ounce container of Century water based solvent with a warning label of "keep out of reach of children" o and a full, 19 ounce container of Glass Betco spray with a warning label of "skin and eye irritant," "harmful if swallowed" and "keep out of reach of children." During an interview on 4/2/12 at 1:15 p.m. MST, Administrative Nursing Staff B confirmed staff failed to keep residents safe by not securing potentially hazardous chemicals out of residents' reach. The facility's 4/3/12 "Housekeeping Chemicals and Their Safe Use" policy instructed "all staff (as) responsible to ensure the safe storage of all chemicals in their area and will not allow patients to have access to the bottles of chemicals." Observations on 4/2/12 between 10:32 a.m. and 10:54 a.m. MST revealed common sink water temperatures (the activity area sink, the shower room sink, the east kitchenette sink, and the south hallway sink) between 121.6 degrees F and 124.5 degrees F. Further observations in residents #29, #2, #17, #23, #18, and #6's rooms between 2:08 p.m. to 3:27 p.m. MST revealed water temperatures between 123.9 degrees F and 128.0 degrees F. During an interview on 4/4/12 at 1:37 p.m., Housekeeping/Maintenance/Laundry Staff S reported maintenance staff randomly checked resident rooms and common sinks water temperatures weekly with a dial thermometer. Staff S reported a lack of awareness of how to calibrate the dial thermometer. During a tour and an interview on 4/4/12 at 2:21 p.m., Housekeeping/Maintenance/Laundry Staff S checked water temperatures between two thermometers in the facility and noted one thermometer with a blue sleeve reached 104.0 degrees F and the other with a red sleeve reached 112.0 degrees F. Staff S stated he/she usually used the lower reading dial thermometer with a blue sleeve for all random common and resident room water temperature checks. Review of the facility's weekly random water temperature checks revealed between 2/1/12 and 3/29/12 that common sinks and random room water temperatures reached between 111.0 degrees F and 118.0 degrees F. During an interview on 4/5/12 at 11:00 p.m. MST, Housekeeping/Maintenance/Laundry Staff S reported he/she checked resident 29's water temperature which reached 124.0 degrees F with the red sleeved, dial thermometer. During an interview on 4/5/12 at 8:57 a.m. MST, Housekeeping/Maintenance/Laundry Staff S reported he/she recalibrated the dial thermometer and noted the activity area water temperature reached 124.0 degrees minutes prior to the interview. Staff S confirmed the facility failed to keep water temperatures at a safe range below 120 degrees F. The facility failed to ensure the residents' environment remained free of accident hazards related to safe water temperatures in residents #29, #2, #17, #23, #18, and #6's rooms and common areas and for 9 cognitively impaired, independently mobile residents when staff stored potentially hazardous chemical products in areas accessible to the residents

The facility reported a census of 25 residents with 12 residents sampled for review including one resident with nutritional concerns. Based on observation, interview and record review, the facility failed to ensure that one sampled resident maintained acceptable parameters of nutritional status. Resident #9 experienced a severe weight loss of 6.6% over a one month period and an 8.2% weight loss over a 3 month period. The facility failed to assess and implement interventions to address the weight loss. Findings included: - The signed Physician order [REDACTED]. The 12/25/2011 Quarterly MDS (minimum data set) assessment for resident #9 identified the resident as rarely or never understood. Resident #9's functional status revealed a total dependence on the assistance of one for oral hygiene and eating. Resident #9 tended to hold food in his/her mouth, did not have a reported weight loss, consumed a therapeutic diet, and had mouth pain or difficulty with chewing. Resident #9's height measured 59 inches. Resident #9's 6/25/2011 CAAs (care area assessment) summary for nutritional status indicated he/she needed soft foods and assistance with meals. Resident #9's 4/4/2012 nursing care plan indicated he/she needed to have weight monitored, may need to have a reduced calorie diet, and had a goal of no significant weight gain. Resident #9's care plan also included the weights of 149.5 pounds on 1/8/2012, 145.5 pounds on 2/19/2012, and 137 pounds as the current weight. The care plan lacked specific goals or interventions related to the resident's weight gain or loss. The care plan mentioned a reduced calorie diet, however, did not include specific goals or interventions to achieve these goals. Dietary Consultant J ' s progress notes on 1/19/12 revealed resident #9 had a " significant weight loss of 4 pounds in one week " and recommended " no change in (the resident ' s) diet. The 3//15/2012 progress note also documented the resident had weight loss. A nutritional assessment completed by dietary staff H on 3/26/12 identified a weight loss of 12 pounds in 90 days with a current weight of 135 pound. The assessment also stated the resident had a food intake of 52% of meals and received snacks twice daily. Record review of Physician orders [REDACTED]. The Physician orders [REDACTED]. Record review of resident #9 ' s laboratory tests indicated the resident had a total protein of 6.5 grams per deciliter on 10/4/11 (normal range 6.4-8.2 g/dL) and an [MEDICATION NAME] level of 3.4 g/dL (normal 3.4-5.0 g/dL). Resident #9 ' s weekly weight record revealed the following weights: * 12/25/11 147 lbs.(pounds) * 01/01/12 146.5 lbs. * 01/08/12 149.5 lbs. * 01/15/12 145.5 lbs. * 01/22/12 147 lbs. * 01/29/12 146 lbs. * 02/05/12 150 lbs. * 02/12/12 146 lbs. * 02/19/12 145.5 lbs. * 02/26/12 144.5 lbs. * 03/04/12 141.5 lbs. * 03/11/12 138 lbs. * 03/18/12 138 lbs. * 03/25/12 135 lbs. Calculation of resident #9 ' s weight loss revealed a 1 month weight loss from 02/26/12 (144.5 lbs.) to 03/25/12 (135 lbs.) of 9.5 lbs., a 6.6% weight loss. The resident had a 3 month weight loss from 12/27/11 to 3/25/12 of 12 lbs, an 8.2% weight loss. During an observation on 4/4/2012 at 10:00 a.m. MST (Mountain Standard Time), resident #9 received assistance with eating breakfast, took small bites of egg, chewed each bite for several minutes, and required encouragement to continue eating without offering substitutes. During an observation on 4/4/2012 at 12:00 p.m. MST, resident #9 received assistance with eating lunch, took small bites of turkey with gravy, mashed potatoes and spinach, chewed each bite for several minutes and required encouragement to continue eating without offering substitutes. During an interview on 4/4/2012 at 5:15 p.m. MST, administrative nursing staff A verified resident #9 had weight loss and staff failed to implement interventions related to the weight loss. During an interview on 4/4/2012 at 3:15 p.m. MST, dietary staff H verified he/she completed resident #9's Nutritional Assessments and did not realize the significance of the weight loss. Dietary staff reported he/she saw resident #9's weekly weights, but only calculated the percentage of weight loss quarterly. Dietary staff H further verified he/she completed the nutritional portion of resident #9's care plan and that portion did not reflect the resident's current condition and did not contain the interventions to address the resident's weight loss. During an interview on 4/5/2012 at 2:10 p.m. MST, consultant staff J verified that he/she came monthly, reviewed resident #9's medical record, and consulted with staff regarding the resident's nutritional condition and needs. Dietary staff J further verified that during his/her review of resident #9's information on 3/15/2012, he/she may not have considered that resident #9 had a significant weight loss considering the resident remained above his/her ideal body weight of 98 pounds. Based on the weights recorded from 2/5/2012 to 3/25/2012 which indicated a steady weight loss, resident #9 should have received a supplement to support his/her nutritional needs. The facility failed to ensure that one sampled resident maintained acceptable parameters of nutritional status. Resident #9 experienced a severe weight loss of 6.6% over a one month period and an 8.2% weight loss over a 3 month period. The facility failed to implement effective interventions to address resident #9 ' s weight loss and the resident continued to lose weight. The clinical record lacked evidence to show this weight loss was unavoidable.

The facility reported a census of 23 residents with 15 residents sampled. Based on observation, interview and record review, the facility failed to ensure resident #1 remained free of neglect. The facility policy for abuse and neglect defined neglect as, " failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. " The facility staff failed to provide the services to treat and/or prevent pressure ulcers including nutritional support, frequent change of position, treatments including cleaning and dressing pressure ulcers, and pressure relief devices. The facility also failed to provide pain management and end of life services, including the option for hospice management, and services to prevent a decline in range of motion. This placed resident #1 in immediate jeopardy as the resident developed 12 pressure ulcers which included four stage IV ulcers (bone and/or tendon exposed) and one stage III (muscle exposed). The resident also experienced severe pain and a decline in range of motion. Findings included: - A 5/21/10 hospital return nursing assessment showed resident 1 had returned from a hospital stay with the following ulcers: o Left buttock: 3 cm (centimeter) decubitus (pressure) ulcer o Right buttock: 2 cm decubitus ulcer o Right lateral ankle: 1 cm wound o [MEDICATION NAME] (a type of pressure ulcer dressing) over a red bony prominence on the mid back. Hospital return orders from the same date included an order for [REDACTED]. Physician orders [REDACTED]. Current physician's order [REDACTED]. A 9/14/10 quarterly MDS showed the resident had moderate pain and one stage IV pressure ulcer. A 9/29/10 wound assessment showed the following ulcers: o Right lateral ankle: 2 cm o Right lateral foot beside 5th toe: a small darkened area o Left buttocks: 1.5 cm open area o Coccyx: 4 cm x 3 cm ulcer o Middle upper back: 2 cm peeling area A 10/8/10 wound assessment showed the following: o Right lateral foot by the toe: " small discoloration " o Left buttocks: 1 cm open area o Coccyx: 4 cm ulcer A 10/23/10 wound assessment showed the following ulcers: o Right lateral ankle: 1 cm ulcer o Left buttock: 1 cm ulcer o Coccyx: 4 cm ulcer o Upper back: 3 mm (millimeter) x 2.5 cm ulcer o Right hand: blisters An 11/4/10 fax to the physician showed the resident had two stage III pressure ulcers on the knuckles of the right hand. An 11/4/10 physical therapy consultation stated, " Resident family have decided to take comfort measures for resident at this time. Is unable to assist with transfers feeding or ADLs (activities of daily living). Resident is on comfort measures only. No RA (restorative assistant) services requested for this time. " The record showed the resident had not received restorative services since 9/27/10. On 1/13/11 at 8:47 am mountain time, restorative aide K stated she did not do any daily cares with resident 1 and did not place any splints in the resident ' s hand. She stated that since the resident started on comfort care, she had not performed any restorative services for this resident. On 1/18/10 at approximately 2 pm mountain time, the director of nursing B reported the resident had declined in range of motion over the previous year resulting in worsened contractures. Registered dietician notes from 11/16/10 identified the resident as at nutritional risk and had multiple ulcers. The dietician offered no new recommendations but identified the resident received Ensure supplement (a supplement different from the protein shake) twice daily. The record lacked a physician order [REDACTED]. The record included the following laboratory values that indicated the resident had poor protein stores: o Total protein blood levels - 9/13/10 -- 6.8, normal 6.4 - 8.2 10/18/10 -- 6.9 1/2/11-- 5.9 o Blood [MEDICATION NAME] levels - 10/18/10 3.0, normal 3.4-5.0 1/3/11 -- 1.9 On 1/13/11 at 8:30 am Mountain Time, nurse aide R reported the kitchen sent out Ensure at the 3 pm and 8 pm snack times along with a food-type snack. She stated that if the resident could eat the food snack, staff did not offer the Ensure. She stated the staff did not record the intake of the Ensure. The treatment records for December 2010 showed the resident had received the protein shakes as ordered twice daily but lacked any evidence of the amount of the supplement the resident consumed. The record lacked any further dietary changes or recommendations to assist in wound healing. Physician orders [REDACTED]. On 1/12/11 at 4:30 pm Mountain Time, licensed nurse G reported the facility lacked a policy regarding comfort care to guide staff on how to care for a resident on comfort care. A 12/14/10 significant change MDS showed the resident had poor communication abilities, poor memory and moderately impaired decision-making abilities. The assessment showed the resident required extensive to total assistance for all activities of daily living and was bedfast. The assessment listed a [DIAGNOSES REDACTED]. The MDS listed 1 stage I pressure ulcer, 2 stage II ulcers not present on admission, and 2 stage IV pressure ulcers that were present on admission. The MDS showed a stage IV ulcer at 1.7 cm- x 1.4 cm x 0.5 cm deep. It stated that two ulcers had worsened since prior assessment, and one worsened stage III since prior assessment. Regarding pain, the assessment stated the resident had symptoms of pain but had not received a routine pain medication. A 12/14/10 pain CAA (care area assessment) showed the resident had pain secondary to pressure ulcers, arthritis, and contractures. The resident could not express the location of pain but would yell out or grimace. The assessment showed the resident ' s contractures and immobility could contribute to the resident ' s pain and directed staff to document if there was inadequate pain relief in order for the physician to change the resident ' s pain regimen. A 12/14/10 pressure ulcer CAA stated the resident continued to break down and identified a high risk for pressure ulcers. The assessment instructed staff to monitor and report any change of conditions in the ulcers to the physician and continue to follow physician orders [REDACTED]. A 12/15/10 care plan included the following interventions: o On comfort cares as the doctor does not think that my health will hold up much longer. o I need frequent repositioning in bed. o My wounds should be measured at least once per week with my shower and noted in the nurses notes. o Nurse should also do a weekly skin assessment with my shower. o Help me change position every 2 hours. o I am to be moved side to side and never on my back o I also need to have bunny boots and pillows to prop my feet on while in bed to keep from having pressure sores on by ankles and feet. o I sleep on an air pressure relief mattress. o I get a high protein high fiber shake twice per day with snacks that is to help with wound healing. o Get [MEDICATION NAME] two times per day for wound healing. o Offer me frequent drinks when you come to complete cares for me. o I have frequent episodes of pain and this can be a reason for my hollering out, so if you hear me ask me if I hurt anywhere. o I have scheduled pain medication and I do have some medication ordered that I can use as needed for pain Physician standing orders signed 12/16/10 included the following for routine decubitus care -- o Stage I: Appearance, redness or inflammations that does not disappear after removing pressure. Care: Remove pressure, manage incontinence, reposition every 2 hours in bed and every 1 hour in chair, encourage dietary compliance to maintain nutritional status, apply [MEDICATION NAME] and change every third day. o State II appearance: partial thickness, loss of skin layers, may look blistered and red, painful, bottom of wound is moist and pink. Care: with drainage, contact physician, irrigate with normal saline and 23 gauge syringe, sprinkle with [MEDICATION NAME] powder and cover with non-adherent dressing daily. Without drainage, contact physician. Cleanse with normal saline, cover with [MEDICATION NAME] and non- adherent dressing. o Stage IIl, or IV. Notify physician. o For use by resident as needed for positioning or skin integrity: Air mattress, foam cushions or gel cushions, Geri chair or Geri recliner without table, heel, elbow, arm protectors or sheepskin. o Obtain swab specimen for culture and sensitivity on any draining wound or eye, after conferring with provider via communication sheet or phone call. o Facility policy is to give supplements per physician order. Wound assessments from 12/21/10 (over 2 months after the last thorough assessment) showed the following: o Right lateral ankle: 3 cm x 2 cm o Right lateral lower leg: 2 cm x 1 cm o Right lateral foot by 5th toe: 2.5 cm x 2 cm o Left buttocks: 1 cm x 1.2 cm o Coccyx 5 cm x 3 cm o Middle upper back: 8.5 cm x 8.5 cm red area o Right hand fourth finger: 0.25 cm x 0.5 cm o Right had fifth finger: 1 cm x 1 cm x 0.25 cm deep Wound assessments from 12/28/10 showed the following: o New ulcer to the front of the left thigh: 3 cm x 2 cm with purulent drainage o Right lateral ankle worsened to 7 cm x 5 cm with purulent drainage o Right lateral lower leg worsened to 6 cm x 5 cm o Right lateral foot by 5th toe worsened to 5 cm x 3 cm o Two new open areas to the left buttocks each measuring 3 cm x 1 cm o Left buttocks worsened to 2 cm x 1 cm and tunneling to the coccyx ulcer o Coccyx ulcer not measured o Middle upper back: reddened area worsened to 8.9 cm x 8.9 cm o Right hand fourth finger worsened to 2.1 cm o Right hand fifth finger worsened to 2 cm x 2 cm The record lacked evidence the physician or the resident ' s family had knowledge of the new and /or worsened ulcers. Treatment records for December 2010 and January 2011 showed no treatments done to any pressure ulcers except weekly [MEDICATION NAME] flush to the large, stage IV coccyx ulcer. On 1/12/11 at 3 pm Mountain Time, licensed nurse L confirmed the resident did not receive any treatments to the multiple pressure ulcers. On 1/13/11 at 11:24 am mountain time, the physician reported he thought the nurses had followed the standing orders for wound treatments. When survey staff DD described the wound to the right lateral leg, the physician reported he did not know the ulcer had gotten worse. A pain management log showed the resident received [MEDICATION NAME] 5/500 mg (milligrams) 2 tablets, prn (as needed) as ordered by the physician as follows: o November 2010 the staff assessed the resident ' s pain at an eight on a 1-10 pain scale on 5 occasions and administered the [MEDICATION NAME]. All follow-up assessments showed pain relief with a zero rating. o December 2010: staff assessed the resident ' s pain between 7-9 on the same scale 8 times and administered [MEDICATION NAME]. All follow-up assessment showed pain relief with a zero rating. The record showed the resident did not receive any other pain medications. Interviews with nursing staff B, E, F, K, N, and O during the dates of the survey, 1/11/11 - 1/19/11 revealed staff did not provide frequent position changes or restorative cares as the resident had pain with every movement. On 1/13/11 at 9:09 am Mountain Time, social services staff F reported the resident received comfort cares only. She stated she had contacted the family when the doctor ordered comfort care but had not offered the possibility of receiving hospice services. Observations of the resident on the dates of the survey, 1/11/11 - 1/19/11, showed an extremely thin resident with multiple contractures. The resident ' s right hand was contracted into a fist, the right elbow contracted up against the resident ' s chest, and the right shoulder contracted against the resident ' s side. The resident ' s right leg was contracted with the knee bent placing the lower leg over the left leg in a figure 4. The resident ' s left leg was contracted into a straight, stiff position. The left arm was contracted with the hand against the chest and the left hand contracted with the thumb against the palm of the hand and the fingers straight out. Frequent observations on 1/12/11 between 9:20 am and 12 noon mountain time, a period of 2 hours and 40 minutes, showed the resident lay slightly on the right side with the coccyx against the mattress and a body pillow against the resident ' s back. The resident had a pillow between the lower portion of the right leg and the thigh of the left leg, placing further pressure on these areas. From 12 noon until 1:30 pm mountain time on 1/12/11, the resident lay on his/her back. Frequent observations on 1/12/11 from 1:30 pm and 4:15 pm mountain time, a period of 2 hours and 45 minutes, showed the resident again lay on his/her right side with the coccyx against the mattress and a body pillow against the resident ' s back. The resident had a pillow between the lower portion of the right leg and the thigh of the left leg, placing further pressure on these areas. At 4:15 pm, nursing staff O reported the resident had lay on his/her back prior to 4:15 pm and positioned the resident again to the right side. When asked regarding cleaning or splints to the contracted right hand, the aide reported the restorative aide cleaned the hand and put a wash cloth in it daily. She stated she did not know why the resident did not have a washcloth or splint in the hand but did not place one. On 1/13/11 at 8:47 am mountain time, restorative aide K stated she did not do any daily cares with resident 1 and did not place any splints in the resident ' s hand. She stated that since the resident started on comfort care, she had not performed any restorative, placed splints or cleaned the resident ' s hand. On 1/13/11 at 7:40 am mountain time, aides placed the resident on his/her back for breakfast. The resident grimaced with any movement. The resident reported he/she had pain and refused to allow staff to move either arm away from the chest. Frequent observations through 11:00 am Mountain Time, 3 hours 20 minutes, showed the resident remained on his/her back. A thorough skin assessment, requested by survey staff DD, on 1/13/11 at 1:38 PM Mountain Time by licensed nurses G and M revealed the following: o Right side of spine - stage I ulcer measuring 12 cm x 11 cm o Right side of spine - stage II ulcer measuring 3 cm x 1 cm o Right side of spine - second stage II ulcer measuring 4 cm x 1 cm o Left buttocks - horseshoe shaped stage IV ulcer measuring 1.6 cm x 0.8 cm x 0.7 cm o Medial left buttocks - stage II ulcer measuring 1.7 cm x 0.5 cm o Third open area to left buttocks - stage II ulcer measuring 1.2 cm x 4.4 cm x 0.2 cm o Right foot by 5th toe - an unstagable ulcer measuring 2 cm in diameter with black and yellow eschar o Right lateral lower ankle - a stage IV ulcer with the tendons exposed measuring 3.7 cm x 2 cm x 1 cm o Right lateral lower leg - a stage IV ulcer with the tendons exposed measuring 6.3 cm x 1.7 cm x 0,7 cm o Left thigh - a stage III ulcer with the muscle exposed measuring 1.7 cm in diameter and 0.8 cm deep o Coccyx - a stage IV ulcer with the tailbone exposed measuring 9 cm x 6 cm x 3.4 cm o Inside right hand - unable to completely visualize due to pain, however, the area was moist and when nurse G removed her finger, it had sloughed skin tissue on it. . In summary, the facility failed to provide the services to treat and/or prevent pressure ulcers including nutritional support, frequent change of position, treatments including cleaning and dressing pressure ulcers, and pressure relief devices. The facility also failed to provide pain management and end of life services, including the option for hospice management, and services to prevent a decline in range of motion. This placed resident #1 in immediate jeopardy as the resident developed 12 pressure ulcers which included four stage IV ulcers (bone and/or tendon exposed) and one stage III (muscle exposed). The resident also experienced severe pain and a decline in range of motion. The facility abated the immediate jeopardy on 1/18/11 at 9:40 am mountain time by implementing mandatory staff education regarding pressure ulcers, positioning, pain assessment and treatment, equipment and nutritional issues, implementing treatments to the resident ' s wounds, implementing routine pain medication for the resident, having the resident evaluated by a registered dietician and physical therapist and notifying the physician and family of the resident ' s condition and designating the Director of Nursing as the responsible party to ensure all interventions are implemented. The deficiency remains at a G level.

The facility reported a census of 23 residents with 15 residents sampled. The sample included 2 of 2 residents on comfort care. Based on observation, interview, and record review, the facility failed to provide pain management and end of life services, including the option for hospice management, for 1 of the 2 residents identified as on comfort cares. (#1) Findings included: - A 9/14/10 quarterly MDS showed resident #1 had moderate pain. Physician orders [REDACTED]. A 12/14/10 significant change MDS showed the resident had poor communication abilities, poor memory and moderately impaired decision-making abilities. The assessment showed the resident required extensive to total assistance for all activities of daily living and was bedfast. The assessment listed a [DIAGNOSES REDACTED]. The MDS listed 1 stage I pressure ulcer, 2 stage II ulcers not present on admission, and 2 stage IV pressure ulcers that were present on admission. The MDS showed a stage IV ulcer at 1.7 cm- x 1.4 cm x 0.5 cm deep. It stated that two ulcers had worsened since prior assessment, and one stage III had worsened since prior assessment. Regarding pain, the assessment stated the resident had symptoms of pain but had not received a routine pain medication. A 12/14/10 pain CAA (care area assessment) showed the resident had pain secondary to pressure ulcers, arthritis, and contractures. The resident could not express the location of pain but would yell out or grimace. The assessment showed the resident ' s contractures and immobility could contribute to the resident ' s pain and directed staff to document inadequate pain relief so the physician could change the resident ' s pain regimen. A 12/15/10 care plan included the following interventions: o On comfort cares as the doctor does not think that my health will hold up much longer. o I have frequent episodes of pain and this can be a reason for my hollering out, so if you hear me ask me if I hurt anywhere. o I have scheduled pain medication and I do have some medication ordered that I can use as needed for pain A pain management log showed the resident received [MEDICATION NAME] 5/500 mg (milligrams) 2 tablets, prn (as needed) as ordered by the physician as follows: o November 2010 the staff assessed the resident ' s pain at an eight on a 1-10 pain scale on 5 occasions and administered the [MEDICATION NAME]. All follow-up assessments showed pain relief with a zero rating. o December 2010: staff assessed the resident ' s pain between 7-9 on the same scale 8 times and administered [MEDICATION NAME]. All follow-up assessment showed pain relief with a zero rating. The medication administration records for December 2010 and January 2011 showed the resident did not receive any other pain medications, including routine pain medications as outlined in the care plan. Interviews with nursing staff B, E, F, K, N, and O during the dates of the survey, 1/11/11 - 1/19/11 revealed staff did not provide frequent position changes or restorative cares as the resident had pain with every movement. As a result the resident had a decline in range of motion as written at F 318 in this report, and had developed multiple stage II, stage III and stage IV pressure ulcers as written at F 314 in this report. On 1/13/11 at 9:09 am Mountain Time, social services staff F reported the resident received comfort cares only. She stated she had contacted the family when the doctor ordered comfort care but hand not offered the possibility of receiving hospice services. Observations of the resident on the dates of the survey, 1/11/11 - 1/19/11, showed an extremely thin resident with multiple contractures. The resident ' s right hand was contracted into a fist, the right elbow contracted up against the resident ' s chest, and the right shoulder contracted against the resident ' s side. The resident ' s right leg was contracted with the knee bent placing the lower leg over the left leg in a figure 4. The resident ' s left leg remained in a fixed, extended position. The left arm was contracted with the hand against the chest and the left hand contracted with the thumb against the palm of the hand and the fingers straight out. On 1/13/11 at 7:40 am mountain time, aides placed the resident on his/her back for breakfast. The resident grimaced with any movement. The resident reported he/she had pain and refused to allow staff to move either arm away from the chest. Frequent observations through 11:00 am Mountain Time, 3 hours 20 minutes, showed the resident remained on his/her back. In summary, the facility failed to provide pain management and end of life services, including the option for hospice management, for resident #1.

The facility reported a census of 29 residents with 5 sampled. Based on observation, interview and record review, the facility failed to provide treatment and assessments of a wound for resident 1002 and failed to provide dressing changes for stage IV pressure ulcers by a licensed nurse (1001). Findings included: - A 2/23/11 significant change MDS (minimum data set) assessment identified resident 1002 with short term memory problems and moderately impaired decision-making abilities. The assessment showed the resident had some skin conditions other than pressure ulcers or stasis ulcers. A hospital return assessment dated [DATE] showed the resident had a 2.4 cm (centimeter) x 2.8 cm blood filled blister on the left shin. A 2/18/11 weekly skin assessment showed the resident had a 0.8 cm x 0.4 cm scab on the left shin. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The medication administration records showed the area as healed on 2/28/11 with no further treatments. A 3/11/11 Weekly skin assessment showed the resident had a large, dried scab area involving the scab and dry, scaly skin around the area with a measurement of 3 cm diameter. The record lacked evidence of physician notification or the initiation of treatments to the wound. ` On 3/14/11 at 1:25 pm, nurse aide E assisted the resident with cares. The resident had a large, raised scabbed area to the left shin. Nurse aide E reported the resident had returned from the hospital with the wound. The area had no dressing. On 3/15/11 at 7:50 am during observations, the resident again had no dressing on the left leg. On 3/15/11 at 1 pm, licensed nurse B reported she had assessed the area on the shin and stated the area needed some type of dressing as the area was dry. She stated she would notify the physician for orders. In summary, the facility failed to provide ongoing assessments and treatments of a wound to resident 1002 ' s left shin. The resident went 21 days without a wound assessment and 15 days without treatment. - This deficient practice also affected resident 1001 as a medication aide performed dressing changes, including the packing of two stage IV pressure ulcers, for resident 1001 without adequate training.

The facility reported a census of 23 residents with 15 residents sampled. The sample included 1 resident with pressure ulcers. Based on observation, interview and record review, the facility failed to provide the services to treat and/or prevent pressure ulcers including nutritional support, frequent change of position, treatments including cleaning and dressing pressure ulcers, and pressure relief devices for resident #1. Findings included: - A 5/21/10 hospital return nursing assessment showed resident 1 had returned from a hospital stay with the following ulcers: o Left buttock: 3 cm (centimeter) decubitus (pressure) ulcer o Right buttock: 2 cm decubitus ulcer o Right lateral ankle: 1 cm wound o Duoderm (a type of pressure ulcer dressing) over a red bony prominence on the mid back. Hospital return orders from the same date included an order for [REDACTED]. Physician orders [REDACTED]. Current physician's order [REDACTED]. A 9/14/10 quarterly MDS showed the resident had one stage IV pressure ulcer. A 9/29/10 wound assessment showed the following ulcers: o Right lateral ankle: 2 cm o Right lateral foot beside 5th toe: a small darkened area o Left buttocks: 1.5 cm open area o Coccyx: 4 cm x 3 cm ulcer o Middle upper back: 2 cm peeling area A 10/8/10 wound assessment showed the following: o Right lateral foot by the toe: " small discoloration " o Left buttocks: 1 cm open area o Coccyx: 4 cm ulcer A 10/2/10 wound assessment showed the following ulcers: o Right lateral ankle: 1 cm ulcer o Left buttock: 1 cm ulcer o Coccyx: 4 cm ulcer o Upper back: 3 mm (millimeter) x 2.5 cm ulcer o Right hand: blisters An 11/4/10 fax to the physician showed the resident had two stage III pressure ulcers on the knuckles of the right hand. Registered dietician notes from 11/16/10 identified the resident as at nutritional risk and had multiple ulcers. The dietician offered no new recommendations but identified the resident received Ensure supplement (a supplement different from the protein shake) twice daily. The record lacked a physician order [REDACTED]. On 1/13/11 at 8:30 am Mountain Time, nurse aide R reported the kitchen sent out Ensure at the 3 pm and 8 pm snack times along with a food-type snack. She stated that if the resident could eat the food snack, staff did not offer the Ensure. She stated the staff did not record the intake of the Ensure. The treatment records for December 2010 showed the resident had received the protein shakes as ordered twice daily but lacked any evidence of the amount of the supplement the resident consumed. The record lacked any further dietary changes or recommendations to assist in wound healing. Physician orders [REDACTED]. A 12/14/10 significant change MDS showed the resident had poor communication abilities, poor memory and moderately impaired decision-making abilities. The assessment showed the resident required extensive to total assistance for all activities of daily living and was bedfast. The assessment listed a [DIAGNOSES REDACTED]. The MDS listed 1 stage I pressure ulcer, 2 stage II ulcers not present on admission, and 2 stage IV pressure ulcers that were present on admission. The MDS showed a stage IV ulcer at 1.7 cm- x 1.4 cm x 0.5 cm deep. It stated that two ulcers had worsened since prior assessment, and one stage III had worsened since prior assessment A 12/14/10 pressure ulcer CAA stated the resident continued to break down and identified a high risk for pressure ulcers. The assessment instructed staff to monitor and report any change of conditions in the ulcers to the physician and continue to follow physician orders [REDACTED]. A 12/15/10 care plan included the following interventions: o On comfort cares as the doctor does not think that my health will hold up much longer. o I need frequent repositioning in bed. o My wounds should be measured at least once per week with my shower and noted in the nurses notes. o Nurse should also do a weekly skin assessment with my shower. o Help me change position every 2 hours. o I am to be moved side to side and never on my back o I also need to have bunny boots and pillows to prop my feet on while in bed to keep from having pressure sores on by ankles and feet. o I sleep on an air pressure relief mattress. o I get a high protein high fiber shake twice per day with snacks that is to help with wound healing. o Get [MEDICATION NAME] two times per day for wound healing. Physician standing orders signed 12/16/10 included the following for routine decubitus care -- o Stage I: Appearance, redness or inflammations that does not disappear after removing pressure. Care: Remove pressure, manage incontinence, reposition every 2 hours in bed and every 1 hour in chair, encourage dietary compliance to maintain nutritional status, apply Duoderm and change every third day. o Stage II appearance: partial thickness, loss of skin layers, may look blistered and red, painful, bottom of wound is moist and pink. Care: with drainage, contact physician, irrigate with normal saline and 23 gauge syringe, sprinkle with [MEDICATION NAME] powder and cover with non-adherent dressing daily. Without drainage, contact physician. Cleanse with normal saline, cover with Duoderm and non- adherent dressing. o Stage IIl, or IV. Notify physician. o For use by resident as needed for positioning or skin integrity: Air mattress, foam cushions or gel cushions, Geri chair or Geri recliner without table, heel, elbow, arm protectors or sheepskin. o Obtain swab specimen for culture and sensitivity on any draining wound or eye, after conferring with provider via communication sheet or phone call. o Facility policy is to give supplements per physician order. Wound assessments from 12/21/10 (over 2 months after the last thorough assessment) showed the following: o Right lateral ankle: 3 cm x 2 cm o Right lateral lower leg: 2 cm x 1 cm o Right lateral foot by 5th toe: 2.5 cm x 2 cm o Left buttocks: 1 cm x 1.2 cm o Coccyx 5 cm x 3 cm o Middle upper back: 8.5 cm x 8.5 cm red area o Right hand fourth finger: 0.25 cm x 0.5 cm o Right had fifth finger: 1 cm x 1 cm x 0.25 cm deep Wound assessments from 12/28/10 showed the following: o New ulcer to the front of the left thigh: 3 cm x 2 cm with purulent drainage o Right lateral ankle worsened to 7 cm x 5 cm with purulent drainage o Right lateral lower leg worsened to 6 cm x 5 cm o Right lateral foot by 5th toe worsened to 5 cm x 3 cm o Two new open areas to the left buttocks each measuring 3 cm x 1 cm o Left buttocks worsened to 2 cm x 1 cm and tunneling to the coccyx ulcer o Coccyx ulcer not measured o Middle upper back: reddened area worsened to 8.9 cm x 8.9 cm o Right hand fourth finger worsened to 2.1 cm o Right hand fifth finger worsened to 2 cm x 2 cm The record lacked evidence the physician or the resident ' s family had knowledge of the new and /or worsened ulcers. Treatment records for December 2010 and January 2011 showed no treatments completed to any pressure ulcers except weekly [MEDICATION NAME] flushes to the large, stage IV coccyx ulcer. On 1/13/11 at 11:24 am mountain time, the physician reported he thought the nurses had followed the standing orders for wound treatments. When survey staff DD described the wound to the right lateral leg, the physician reported he did not know the ulcer had gotten worse. On 1/12/11 at 3 pm Mountain Time, licensed nurse L confirmed the resident did not receive any treatments to the multiple pressure ulcers. On 1/13/11 at 11:24 am mountain time, the physician reported he thought the nurse ' s had followed the standing orders for wound treatments. Frequent observations on 1/12/11 between 9:20 am and 12 noon mountain time, a period of 2 hours and 40 minutes, showed the resident lay slightly on the right side with the coccyx against the mattress and a body pillow against the resident ' s back. The resident had a pillow between the lower portion of the right leg and the thigh of the left leg, placing pressure against a stage IV ulcer on the lateral right leg and a stage III ulcer on the top of the left thigh. The wounds had no dressings or coverings and when staff removed the pillow, the pillow covering had a large area of wound drainage and pieces of sloughed tissue on it. From 12 noon until 1:30 pm mountain time on 1/12/11, the resident lay on his/her back. Frequent observations on 1/12/11 from 1:30 pm and 4:15 pm mountain time, a period of 2 hours and 45 minutes, showed the resident again lay on his/her right side with the coccyx against the mattress and a body pillow against the resident ' s back. The resident had a pillow between the lower portion of the right leg and the thigh of the left leg, placing further pressure on these areas. At 4:15 pm, nursing staff O reported the resident had lay on his/her back prior to 4:15 pm and positioned the resident again to the right side. When asked regarding cleaning or splints to the contracted right hand, the aide reported the restorative aide cleaned the hand and put a wash cloth in it daily. She stated she did not know why the resident did not have a washcloth or splint in the hand but did not place one. On 1/13/11 at 8:47 am mountain time, restorative aide K stated she did not do any daily cares with resident 1 and did not place any splints in the resident ' s hand. She stated that since the resident started on comfort care, she had not performed any restorative, placed splints or cleaned the resident ' s hand. On 1/13/11 at 7:40 am mountain time, aides placed the resident on his/her back for breakfast. Frequent observations through 11:00 am Mountain Time, 3 hours 20 minutes, showed the resident remained on his/her back. A thorough skin assessment, requested by survey staff DD, on 1/13/11 at 1:38 PM Mountain Time by licensed nurses G and M revealed the following: o Right side of spine - stage I ulcer measuring 12 cm x 11 cm o Right side of spine - stage II ulcer measuring 3 cm x 1 cm o Right side of spine - second stage II ulcer measuring 4 cm x 1 cm o Left buttocks - horseshoe shaped stage IV ulcer measuring 1.6 cm x 0.8 cm x 0.7 cm o Medial left buttocks - stage II ulcer measuring 1.7 cm x 0.5 cm o Third open area to left buttocks - stage II ulcer measuring 1.2 cm x 4.4 cm x 0.2 cm o Right foot by 5th toe - an unstagable ulcer measuring 2 cm in diameter with black and yellow eschar o Right lateral lower ankle - a stage IV ulcer with the tendons exposed measuring 3.7 cm x 2 cm x 1 cm o Right lateral lower leg - a stage IV ulcer with the tendons exposed measuring 6.3 cm x 1.7 cm x 0,7 cm o Left thigh - a stage III ulcer with the muscle exposed measuring 1.7 cm in diameter and 0.8 cm deep o Coccyx - a stage IV ulcer with the tailbone exposed measuring 9 cm x 6 cm x 3.4 cm o Inside right hand - unable to completely visualize due to pain, however, the area was moist and when nurse G removed her finger, it had sloughed skin tissue on it. . In summary, the facility failed to provide the services to treat and/or prevent pressure ulcers including nutritional support, frequent change of position, treatments including cleaning and dressing pressure ulcers, and pressure relief devices.

The facility reported a census of 29 residents with 5 sampled for review. Based on observation, interview and record review, the facility failed to provide pressure reduction surfaces, routine wound assessments and treatments as ordered by the physician for two of 3 sampled residents reviewed for pressure ulcers. (1017, 1007) Findings included: - A 1/21/11 annual MDS (minimum data set) assessment identified resident 1017 with cognitive impairment, required total assistance with all activities of daily living, including turning and repositioning, had had a risk of developing pressure ulcers. Pressure ulcer Care Area Assessments dated 1/21/11 stated, " Has no documented pressure ulcers at this time. Remains at high risk secondary to decreased mobility and incontinence. To have change of position every 2 hours. Weekly skin assessments with shower. " The 2/21/11 care plan included interventions for staff to assist with position changes every 2 hours. Wound care flow sheets showed on 2/28/11, the resident had developed a 1 cm (centimeter) x 1 cm pressure ulcer to the left heel with DuoDerm treatment to the heel. The record lacked any further assessments of the ulcer. On 3/7/11, one week following the development of the heel ulcer, licensed nursing staff faxed the physician of the development of the ulcer to the heel. On 3/15/11 at 10 am, licensed nurse C found the fax in the nursing room and not in the chart. The fax did not contain any physician response and licensed nurse C confirmed the facility had not received a response from the physician regarding the resident ' s pressure ulcer. The 1/14/11 Policy for Pressure Ulcers stated, " Nursing staff need to initiate measures to prevent or reduce the potential for shearing or friction during transfers, elevation and repositioning. Nursing staff will initiate Pressure redistributing devices. The Pressure redistributing devices will be used for the bed, wheel chair and/or chair, such as gel type surfaces or overlays. " On 3/14/11 at 1:38 pm, nurse aides E and F assisted the resident with repositioning. The resident had a heel protector half-way up the left leg with an ulcer to the left heel exposed. The resident had a small, approximately 1 cm x 1 cm area on the left heel. Eschar covered the area, including the wound bed, thus making the wound unstagable. The ulcer had no dressing/treatment in place. The right heel had no pressure reduction devices in place. Staff did not reposition the heel protector over the ulcer on the left heel during cares. The resident also did not have a pressure reduction mattress on the bed. When staff assisted the resident to move up in bed, staff pulled the resident up, dragging his/her heels across the sheet and mattress causing shear and friction to the heels. On 3/14/11 at 2 pm, licensed nursing staff B reported only two residents utilized pressure reduction mattresses and confirmed resident 1017 did not use one. On 3/14/11 at 3:04 pm, nurse aide F repositioned the resident. The resident continued to have no pressure relief to the right heel and no dressing on the ulcer on the left heel. On 3/15/11, the Skin Assessment showed licensed nursing staff had performed a wound assessment to the left heel and applied a DuoDerm dressing to the wound. The record lacked any evidence of a physician's order [REDACTED]. In summary, the facility failed to provide ongoing assessments, pressure reduction devices or consistent treatments to a pressure ulcer on resident 1017 ' s left heel. - This deficient practice also affected resident 1007 as the facility failed to provide ongoing assessments of a stage II pressure ulcer and failed to follow physician's orders [REDACTED].

The facility reported a census of 26 residents with three sampled for review of pressure ulcers. Based on observation, interview and record review, the facility failed to provide timely position changes and pressure reduction to prevent pressure ulcers for one of the 3 residents identified with pressure ulcers (17) Findings included: - A 1/21/11 annual MDS (minimum data set) assessment identified resident 17 with cognitive impairment, required extensive to total assistance with transfers and bed positioning, and had a risk for pressure ulcers. A 2/21/11 care plan identified a risk for pressure ulcers. A 3/20/11 update showed the resident had a stage II pressure ulcer to the left heel and directed staff to apply heel protector and to change the resident ' s position every 2 hours. A 3/23/11 update showed the resident required [MEDICATION NAME] wound treatment to the left heel. Weekly skin assessments showed the resident healed a stage I pressure ulcer to the right hip on 3/14/11. The assessments showed the resident had a healing stage II ulcer to the left heel and staff used wet to dry dressings per physician's order [REDACTED]. On 4/19/11 at 11:30 am, licensed nursing staff B reported the resident required a heel protector to both heels in order to prevent breakdown and/or pressure ulcers. At 11:50 am on 4/19/11, nurse aide C stated the resident should have a heel protector on both heels but had not had one on the right heel all morning. She stated the staff should place pillow under his/her hip to assist with repositioning and place a bone-shaped pillow under the heels to provide pressure relief to the heels. Frequent observations of the resident on 4/19/11 from 9:50 am MDT (mountain daylight time) and 12:50 MDT revealed the resident lay in bed on his/her back and slightly to right side. A chair in the corner of the room across from the resident contained an extra pillow and a bone shaped pillow. The resident did not have a heel protector on the right heel. The heel lay against the sheet slightly to the right outer side. Although staff provided cares at 11:55 am, staff did not provide a change of position nor did the staff attempt to provide pressure relief with pillows. During cares at 11:55 am, the resident ' s right heel had a large, approximately 5 cm (centimeter) deep, dark, red area on the outer right heel. The skin blanched but had a boggy feel. Assessment by licensed nurse B at 1 pm confirmed this. The nurse stated the boggy feel can indicate underlying tissue damage. In summary, the facility failed to provide pressure relief to the right heel and failed to provide timely position changes to prevent the development of pressure ulcers for resident 17.