Every finding on record at Heritage Grove Estates

Based on record review and interviews, the facility failed to ensure the nurse aides received the required number of in-service training hours per year. Findings included:- Review of the employee records revealed the following:Certified Nurse Aide (CNA) M employee file documented a hire date of 08/28/2014. The file lacked evidence of the required 12-hour in-service. The facility was unable to provide the documentation upon request.CNA N file documented a hire date of 06/28/2023. The file lacked evidence of the required 12-hour in-service. The facility was unable to provide the documentation upon request. On 07/22/2026 at 07:50 AM, Administrative Nurse D stated the facility was unable to find out if CNA M and CNA N had completed any of the 12-hour in-service required hours. On 07/22/2026 at 9:00 AM, Administrative Nurse D stated the facility had recently been bought, and they presently have new owners. Administrative Nurse D stated the employee's personnel files had been located, but they lacked documentation of the in-service hours, and the online training program lacked any documented in-service training hours for either employee. Administrative Nurse D verified the nurse aides were to have the 12 hours in-service hours each year, and said the facility was implementing a new program to track the employees continuing education hours. The facility's Required Training, Certification and Continuing Education of Nurse Aide, policy dated 2025, documented the facility would comply with State and Federal regulations and requirements as they pertain to the training certification, and continuing education of its nurses' aides. The facility would provide at least 12 hours of in-service training annually, based on employment date. Not calendar year. Documentation of in-services would be forwarded to the Human Resource Director and maintained in the employee's personnel file. It is the responsibility of the employee to attend required in-service training courses to maintain employment status with the facility.

Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to sanitize multi-resident use equipment between resident use. Staff also failed to utilize adequate infection control measures when providing urinary catheter care for Resident (R) 15. The facility also failed to establish a water management program to prevent the growth of Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other water-borne pathogens. Findings included:- 1. On 07/20/2026 at 02:00 PM, observation revealed R15 sat in a wheelchair in the family area by the nurses' station. Staff asked the resident if he would like to go to his room and sit in his recliner, and he replied: That sounds good, let's go. Certified Nurse Aide (CNA) MM propelled R15 in a wheelchair to his room, while CNA P retrieved a full-body lift machine. Both aides donned a gown and applied gloves and assisted R15 to transfer, using a full lift machine, from wheelchair to a recliner. CNA P doffed the gown and discarded gloves in the trash can, left the room (without washing her hands), and took the full lift machine down the hall to the cubby where they were stored when not in use, then went to another resident's room to provide care. CNA P did not sanitize the full lift machine after using it. CNA MM placed the urinary catheter bag on a trash can next to the left side of R15's recliner, with the uncovered bag touching the floor, retrieved a graduated cylinder from the resident's bathroom, and placed it on the floor, without placing a barrier underneath the graduated cylinder. CNA MM unclipped the catheter spout from the bag, opened it, let the dark yellow urine drain into the graduated cylinder, closed the spout clip, then attached it to the holder on the urinary bag. CNA MM took the graduated cylinder to the bathroom, poured the urine into the toilet, placed the graduated cylinder on the toilet back, without rinsing it. CNA MM removed and discarded the gown and gloves, tied up the bag, and left the room without washing her hands. At 02:15 PM, when CNA P was asked the procedure for putting away a lift after using it for a resident, she stated: We put it in the room and plug it in. 2. On 07/21/2026 at 07:57 AM, observation revealed Certified Medication Aide (CMA) R used a blood pressure cuff to check a resident's blood pressure, did not sanitize it, and checked another resident's blood pressure with the same cuff. CMA R popped out medications from pill cards without using hand hygiene before the procedure. CMA R verified the observations and stated she typically did not sanitize the blood pressure cuff after use. 3. On 07/21/2026 at 8:25 AM, observation revealed Administrative Nurse E provided wound care for R29's left lateral leg wound without wearing a gown as required. 4. On 07/21/2026 at 08:50 AM, observation revealed CMA R entered R1's room (who was on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high-contact care) to administer R1 his medications. R1 was leaning to the left against the wall and down in bed. CMA R, without donning a gown or applying gloves, assisted R1 in repositioning in bed. 5. On 07/21/2026 at 01:00 PM, observation revealed R3 in bed on her back. CNA R and Administrative Nurse E entered R3's room (who was on EBP) and transferred the resident with a full lift machine from her bed to a wheelchair. CNA R removed and discarded the gown and gloves, took the full lift machine, without sanitizing it, out of the resident's room down the hall to the place where they are stored, and came back to the room. CNA R stated he generally does sanitize the lift once he gets it back to the storage area; he would go back and do it later. CNA R propelled the resident in a wheelchair to the dining room. 6. On 07/22/2026 at 7:54 AM, observation revealed CMAS took the blood pressure machine into the dining room and checked R49's blood pressure(the amount of force your blood uses to get through your arteries). CMAS rolled the cart back to her medication cart and did not sanitize the cuff (an inflatable sleeve wrapped around the upper arm). CMA S verified she had not sanitized the blood pressure cuff after using it to check R49's blood pressure and stated typically the blood pressure cuff should be sanitized after each use, with the wipes staff have in the medication cart. 7. Record review revealed a lack of documentation that the facility had a water management program. On 07/22/2026 at 12:34 PM, Administrative Nurse D stated staff should place a resident's catheter bag towards the bottom of the bed, not touch the floor, place a barrier on the floor, then put the graduated cylinder (a device used to measure the volume of a liquid) on it. Staff should unhook the spout from the catheter bag holder, wipe with an alcohol wipe, place the spout in the graduated cylinder, unclip the closure to the drainage spout, and let the urine drain into the graduated cylinder. Administrative Nurse D stated staff should close the drainage spout, use an alcohol wipe on the spout tip, then place it back into the spout holder, then take the graduated cylinder, empty the urine in the toilet, then wash it and place it back in a plastic bag. Administrative Nurse D stated all resident shared equipment should be sanitized between uses. Administrative Nurse D stated staff should wash their hands when entering a resident's room and before exiting the room. Administrative Nurse D stated if a resident is on EBP for having a wound, staff should wear a gown and apply gloves. On 07/22/2026 at 11:22 AM, Administrative Staff A verified the facility lacked documentation regarding a water management program to prevent the growth of Legionella and other waterborne pathogens. Administrative Staff A stated the facility maintenance executive left last Friday with no notice. The facility's updated Infection Prevention and Control Program Policy states that documented hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All reusable items and equipment requiring special cleaning, disinfection, or sterilization should be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. The facility's updated EBP Policy documented implementation of EBP makes gowns and gloves available immediately near or outside of the resident's room. Personal Protective Equipment (PPE) for EBP was only necessary when performing high-contact care activities. High-contact resident care activities include:dressingbathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use; central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters, urinary catheters, and wound care. The facility's undated Water Management Program Policy documented that it was the policy of the facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens. The policy documented that a water management team had been established to develop and implement the facility's water management program, including how Legionella and other water-borne pathogens grow and spread. Education is consistent with each team member's role. The maintenance director would maintain documentation that describes the facility's water system.

Based on record reviews and interviews, the facility failed to provide regular in-service education based on the outcome of performance reviews. This placed the residents at risk of impaired care. Findings included:- The facility's employment records documented nine nurse aides were employed at the facility for at least one year. The facility's in-service records documented that 2 of those nurses' aides reviewed had not completed in service education on the outcome of performance reviews for competencies. Certified Nurse Aide (CNA) M, hired 08/28/2014, lacked competency review and in-services based on performance evaluations.CNA N, hired 06/28/2023, lacked competency review and in-services based on performance evaluations On 07/22/2026 at 09:00 AM, Administrative Nurse D stated the facility had recently been bought, and they presently have new owners. Administrative Nurse D stated the employee's personnel files had been located but they lacked documentation of the current yearly competencies and in-services based on performance evaluations. The facility's Required Training, Certification and Continuing Education of Nurse Aide, policy dated 2025, documented the facility would comply with State and Federal regulations and requirements as they pertain to the training certification and continuing education of its nurses' aides. In-service training would be provided by qualified personnel and would be based on the needs of the residents in the facility and any area of weakness determined in the nurse aides performance reviews and facility assessment. Documentation of in-services would be forwarded to the Human Resource Director and maintained in the employee's personnel file. It is the responsibility of the employee to attend required in-service training courses to maintain employment status with the facility.

Based on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Findings included:- On 07/22/2026 at 02:30 PM, a review of staffing for background checks was completed for facility staff. Upon request and review, the facility was unable to provide evidence that a criminal background check had been completed for Maintenance Staff U, who had worked at the facility since 06/23/2026. On 07/22/2026 at 03:00 PM, Administrative Staff A stated the facility would obtain criminal background/record checks on all employees prior to the employee working at the facility. Administrative Staff A verified she could not find a criminal record check for Maintenance Staff U. The facility's Background Investigation dated 2025, documented job references, drug screenings, licensure verification, and criminal record checks are conducted on all personnel making application for employment with the facility. Driving record checks are conducted when the job in question requires the employee to drive as part of their assigned duties. The Human Resource department will conduct all applicable background investigations on each individual making application for employment with the company and on any current employee if such background investigation is appropriate for the position for which the individual has applied. The company would not conduct a background investigation without applicants or employees advanced consent. Applicants or employees who do not consent to a background investigation would not be considered for the position that the company has determined to require the completion of a background investigation. If the background investigation discloses any material misrepresentation or omission by the applicant or employee on the application form or reveals information indicating that the individual may not be appropriate for hire, the company would investigate the matter further. Upon completion of the investigation, if the company determines that the applicant or employee's background makes him/her unsuitable for the position he/she is seeking, the applicant will not be employed, if already employed, would be terminated.

Based on observation, record review, and interview, the facility failed to provide Resident (R) 6, R8, and R44 and/or their representatives with a written notification of transfer for facility-initiated transfers and a bed hold policy upon transfer to the hospital. The facility further failed to notify the long-term care ombudsman (LTCO) of R6, R8, and R44's transfers to the hospital. Findings included:- 1. R6's Discharge Minimum Data Set (MDS), dated 05/19/2026, documented a planned discharge to an acute hospital with a return anticipated.R6's Entry MDS, dated 05/20/2026, documented a re-entry to the facility from an acute hospital.R6's Discharge MDS, dated 06/15/2026, documented an unplanned discharge to an acute hospital with a return anticipated.R6's Entry MDS, dated 06/19/2026, documented a re-entry to the facility from an acute hospital.On 07/21/2026 at 11:46 AM, the bed hold, written notification of transfer, and LTCO notification were requested from the facility for R6. The facility was unable to provide the requested information regarding R6's transfers to the hospital on [DATE] and 06/15/2026. - 2. R8's Discharge MDS, dated 04/27/2026, documented an unplanned discharge to an acute hospital with a return anticipated.R8's Entry MDS, dated 05/01/2026, documented a re-entry to the facility from an acute hospital.On 07/21/2026 at 11:46 AM, the bed hold, notification of transfer, and LTCO notification were requested from the facility for R8. The facility was unable to provide the requested information regarding R8's transfer to the hospital on [DATE]. 3. R44's Discharge MDS, dated 11/19/2025, documented an unplanned discharge to an acute hospital with a return anticipated.R44's Entry MDS, dated 11/24/2025, documented a re-entry to the facility from an acute hospital.On 07/21/2026 at 11:46 AM, the bed hold, written notification of transfer, and LTCO notification were requested from the facility for R44. The facility was unable to provide the requested information regarding R44's transfer to the hospital on [DATE].On 07/21/2026 at 01:21 PM, Administrative Staff A stated that she was unable to find any record of the bed holds, written notification of transfer, or notification to the ombudsman for R6, R8, and R44's transfers to the hospital. She stated that the facility did have a packet that nursing staff was supposed to complete when a resident was transferred to the hospital, but that had not been done. Administrative Staff A stated the facility had a change in ownership back in February 2026 and the prior administrator and staff had not completed the bed hold, notice of transfer, and ombudsman notification. She stated she had been at the facility since June 2026 and had not realized it was not completed, and she had not assigned that task to any certain staff member yet, but going forward a Performance Improvement Plan (PIP) would be initiated that outlined which staff were responsible for each item.The facility's Transfer and Discharge policy dated 2026 directed the facility to provide a transfer/discharge notice to the resident and resident's representative in a language and manner in which they can understand. The facility provided a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated. The Social Services Director, or designee, provided copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable.The facility's Bed Hold Notice policy, dated 2026, directed in the event of an emergency transfer of a resident, the facility provided a written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility documented multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility kept a signed and dated copy of bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.

:Based on observation, record review, and interview, the facility failed to complete the Care Area Assessment (CAA), analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for Resident (R) 30 and R31, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs.Findings included:- 1. R30's admission MDS, dated 05/05/2026, triggered CAAs for the following: Communication, Functional Abilities, Urinary Continence and Indwelling Catheter, Nutritional Status, Pressure Ulcer/Injury, and PainR30's CAA Worksheet, dated 05/13/2026, documented the triggered CAA areas lacked completion with an analysis of findings.-2. R31's admission MDS, dated 06/29/2026, triggered CAAs for: Cognitive Loss/Dementia, Visual Function, Functional Abilities, Urinary Continence and Indwelling Catheter, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, and Pressure Ulcer/Injury.R31's CAA Worksheet, dated 06/29/2026, documented the Nutritional Status CAA had been completed. R31's remaining triggered CAA areas were completed on 07/02/2026 by Administrative Nurse F lacked completion with an analysis of findings.On 07/22/2026 at 11:45 AM, Administrative Nurse F stated she had been hired in June 2026 and completed the MDSs for the residents. She stated the MDS triggered the CAA, and she completed the CAA worksheet. Administrative Nurse F stated she had never documented anything in the analysis of finding area and was unaware that she needed to.On 07/22/2026 at 12:35 PM, Administrative Nurse D stated that the MDS would trigger the CAA area and either the MDS Coordinator, social services, or dietary staff would complete the CAA, and they should be documenting information regarding items checked on the CAA worksheet to assist with the development or revision of the care plan.The facility's MDS 3.0 Completion policy, dated 2026, directed the responsibility for completion of each CAA was clearly assigned. Staff documented the key findings based on the CAA review, including the nature of the condition, complications and risk factors that affected the care planning decision, factors that were considered in developing the care plan interventions, and the need for referrals or evaluation by appropriate health professionals.

Based on observation, record review, and interview, the facility failed to apply the standards of practice when staff recorded an incorrect opened date on Resident (R) 28 and R73 insulin pens in response to the survey. Findings included:- On 07/20/2026 at 08:10 AM, observation of the North Treatment Cart Hall 2 revealed R28's Lantus (long-acting insulin) flex pen were labeled with that day's date. R73's Humalog (rapid-acting insulin) flex pen, two Lantus Solostar flex pens, and one Lantus flex pen were labeled with that days date. Further observation of the insulin pens revealed they were not full, and some were half empty. On 07/20/2026 at 08:35 AM, Licensed Nurse (LN) G verified the nurses should date the insulin pens when they were opened and mark with the discard date. LN G verified that the dates had not been on the insulin pens, and when she realized the survey team was in the facility, she went ahead and labeled the pens with that days date. LN G stated she was an agency nurse and did not know when the pens had actually been opened.On 07/20/2026 at 03:15 PM, Administrative Nurse D stated if R28 and R73 insulin pens did not have a date on them, and they were opened and in use, the nurse should not date them when she is going to use them; she should discard the opened undated insulin pens and get new pens to use and date them when she opens them and first uses them.The facility's Insulin Pen policy dated 2026, documented the facility would use insulin pens in order to improve the accuracy of insulin dosing, provided increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Insulin pens must be clearly labeled with the resident's name, physician's name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. If the label is missing, the pen will not be used; a new pen must be ordered from the pharmacy. Once opened, clearly labeled insulin pens may be stored at room temperature in a locked medication cart.

Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 8's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R8. Findings included:- R8's Electronic Medical Record (EMR) documented diagnoses of encephalopathy (a broad term for any brain disease that alters brain function or structure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and PTSD.R8's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R8 needed partial to substantial staff assistance with cares. The MDS documented an active diagnosis of PTSD.R8's Psychosocial Well Being Care Area Assessment (CAA) dated 06/19/2026 documented her memory appeared great; her mood also appeared great. The CAA did not mention R8's PTSD.R8's Care Plan dated 04/08/2026 documented her psychosocial history was that her memory appeared great and her mood also appeared great. The care plan directed staff that social services was to assist as needed. R8's Care Plan lacked a care area to address her PTSD, any triggers that might cause re-traumatization, and interventions if re-traumatization would occur.R8's Social Services- Initial Assessment and History dated 04/08/2026 in the assessments tab of the EMR documented a diagnosis of PTSD. The assessment lacked any goal or interventions related to R8's PTSD.R8's EMR lacked evidence of assessment to identify her history of trauma and/or triggers which may cause re-traumatization. The EMR lacked goals and interventions to minimize or eliminate the effect of the trigger on the resident.On 07/21/2026 at 087:52 AM, R8 laid in her bed resting.On 07/22/2026 at 07:45 AM, Social Services X stated that on admission, an initial assessment and history were done on each resident. Social Services X stated that the facility did not have an assessment specific to trauma-informed care. Social Services X stated that R8 did have a diagnosis for PTSD, and a care plan area should have been added to the care plan to address R8's PTSD and any triggers that could possibly cause any re-traumatization.On 07/22/2026 at 12:35 PM, Administrative Nurse D stated that social services did an assessment on each resident on admission that should address if they had PTSD, and it should trigger it to be added to the care plan. Administrative Nurse D stated she could not say for certain why R8's PTSD was not triggered for a care area on the care plan, but she should have information that lists the trauma history, her possible triggers and interventions to minimize the triggers.The facilities Trauma-Informed Care policy documented The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan. While most triggers are highly individualized, some common triggers may include but are not limited to: experiencing a lack of privacy or confinement in a crowded or small space; exposure to loud noises or bright/flashing lights; certain sights, such as objects that are associated with their abuser; sounds, smells, and physical touch. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery.

Based on record review and interview, the facility failed to provide appropriate and adequate narcotic drug reconciliation when staff failed to accurately record controlled substance doses on the narcotic count record and further failed to immediately report a discrepancy in Resident (R) 60's count. Findings included:- On 07/20/2026 at 09:15 AM, Observation in the south medication room refrigerator revealed an emergency medication kit (e-kit) without an expiration date or documentation regarding what was in it. Certified Medication Aide (CMA) R opened it by putting in the code. The e-kit had 12 milliliters (mL) of lorazepam (a class of medications that calm and relax people) oral concentrate for R60. CMA R verified it had no expiration date and stated it belonged to R60, who had recently passed away. CMA R stated that usually when a resident passes, their medications would be returned to the pharmacist when he came to the facility. R60's Controlled Drug Record revealed that on 06/30/2026 at12:00 PM, staff administered lorazepam, 0.25 ml to R60, and the amount remaining was 14.75. The next entry was 07/05/2026, without a time, 0 amount administered, and amount remaining 12 ml. The Narcotic Count Sheet, from 06/30/2026, had missing signatures on July 3, 7, 8, 14, and 15 in the nurse going off signature line. On 07/21/2026 at 11:25 M, Administrative Nurse D verified missing documentation on the narcotic count sheet and the discrepancy in the count on the controlled drug record. Administrative Nurse D stated she was unaware of the discrepancy in the count and stated staff should count narcotics every shift with the on-going and off-going nurse or CMA. Administrative Nurse D stated staff should have reported to administration when there was a discrepancy in the count. Administrative Nurse D verified the resident had passed away on 06/30/2026 and stated the pharmacist should have picked up the medication. The facility's undated Controlled Substance Administration and Accountability Policy documented the controlled drug record serves the dual purpose of recording both narcotic disposition and patient administration. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify that controlled substances that are destroyed are appropriately documented and medications removed from either the automated dispensing system or medication cart/cabinet have a documented physician order. Any discrepancies which cannot be resolved must be reported immediately as follows. Notify the DON, charge nurse, or designee and the pharmacy. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff who were working when the discrepancy was noted. The DON, charge nurse, or designee must also report any loss of controlled substances, or theft is suspected, to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, state board of nursing, state board of pharmacy, and possibly the state licensure board for nursing home administrators. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies.

Based on observation, interview, and record review, the facility failed to label Resident (R)1, R28, R39, and R73s insulin flex pens when initially opened for use. Findings included:- On 07/20/2026 at 08:10 AM, observation of the North Treatment Cart Hall 2 revealed R28's Lantus (long-acting insulin) flex pen was not labeled with the correct date opened or the correct discard date. R73's Humalog (rapid-acting insulin) flex pen, two Lantus Solostar flex pens, and one Lantus flex pen were not labeled with the correct date opened or the correct discard date. On 07/20/2026 at 08:35 AM, License Nurse (LN) G verified the nurses should date the insulin pens when they were opened and mark with the discard date. LN G verified the dates marked on the pen were not the accurate dates they were opened. On 07/20/2026 at 09:00 AM, observation of the North Treatment Cart Hall 1 revealed R1's Novolog (rapid acting insulin) flex pen was not labeled with the date opened or the discard date. R39's Humalog insulin flex pen was not labeled with the date opened or the discard date. On 07/20/2026 at 09:05 AM, LN H verified the nurses should date the insulin pens when they are opened and indicate the discard date. On 07/20/2026 at 03:15 PM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date they were opened and the date of discard. Medlineplus.gov directs open, unrefrigerated Novolog, Humalog, and Lantus can be used within 28 days; after that time, they must be discarded. The facility's Medication Storage policy dated 2025, documented the facility would ensure all medications housed on the premises would be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on observation, record review and interviews, the facility failed to ensure the collaboration of care between Resident (R) 8 and R27's hospice provider and the facility which included the hospice provider contact information, the services the hospice provider would provide to the resident, the supplies, equipment and medications the hospice provider would provide for R8 The facility failed to ensure the hospice provider provided the current hospice plan of care (POC) for R8 and failed to ensure R27's most recent hospice certification and POC was provided. Findings included:- 1. R8's Electronic Medical Record (EMR) documented diagnoses of encephalopathy (a broad term for any brain disease that alters brain function or structure), chronic respiratory failure (a long-term condition where the lungs cannot properly oxygenate the blood or remove carbon dioxide), and atrial fibrillation (rapid, irregular heartbeat).R8's Significant Change Minimum Data Set (MDS) dated [DATE] documented R8 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R8 was receiving hospice services.R8's Functional Abilities Care Area Assessment (CAA) dated 06/11/2026 documented R8 had an activities of daily living (ADL) self-care performance deficit and needed assist with self-care tasks to include bathing, transfers, personal hygiene tasks, bed mobility, dressing, eating, toilet use, and locomotion related to limited mobility, chronic respiratory failure and dependence on oxygen, functional bowel and bladder incontinent, limited mobility, deconditioning, and psychotropic medication use. R8's Care Plan revised on 07/01/2026, documented R8 received hospice services. R8's Care Plan directed staff to: encourage the resident to make simple decisions related to his care to give the resident a sense of functional ability and control; evaluate the needs of the patient and caregiver for additional resources that hospice could provide; hospice certified nursing assistance to visit twice per week and would provide showers and/or bed baths; the hospice nurse to visit once per week and as needed; and poor skin integrity to be expected related to end of life terminal prognosis. R8's care plan lacked staff direction on how to contact the hospice provider, the supplies hospice would provide, the durable medical equipment (DME) that hospice would provide or the medications that hospice would provide.R8's Orders tab of the EMR documented a physician's order dated 06/30/2026 for hospice services related to encephalopathy.R8's hospice provider binder lacked the hospice's POC that should contain the following information: the most recent hospice plan of care specific to each patient; hospice election form; physician certification and recertification of the terminal illness specific to each patient; names and contact information for hospice personnel involved in hospice care of each patient; instructions on how to access the hospice's 24-hour on-call system; hospice medication information specific to each patient.; hospice physician and attending physician (if any) orders specific to each patient.On 07/21/2026 at 07:52 AM, R8 laid in her bed resting. -2. R27's EMR documented diagnoses of chronic respiratory failure, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R27's Quarterly MDS dated 06/30/2026 documented she had a BIMS score of six, which indicated severely impaired cognition. R27 received hospice services.R27's Care Plan revised on 10/25/2025 documented she received hospice services. R27's Care Plan directed staff to respect do not resuscitate (DNR) wishes; hospice would attend family care meetings; medications provided by hospice; DME provided by hospice; skilled nursing to visit one to two times per week and as needed (PRN); chaplain to visit one to two times per month PRN; Social Service/Counselor to visit one to two times per month and PRN.R27's Orders tab of the EMR documented a physician's order dated 10/16/2024 to admit to the facility with hospice services for acute to chronic respiratory failure.R27's hospice provider binder at the nurse's station contained past certification and recertification periods since her admission on [DATE] to 05/26/2026. R27's hospice binder lacked the most recent recertification signed by the hospice medical director and lacked the current hospice POC.On 07/22/2026 at 08:57 AM, R27 sat at the dining table eating breakfast.On 07/22/2026 at 10:45 AM, Licensed Nurse (LN) I stated that each resident on hospice had a binder that was in the cabinet at the nurse's station. The hospice provider was responsible for maintaining the information in the binder. LN I stated the residents' care plan should reflect the information, supplies, and visits provided by hospice.On 07/22/2026 at 12:35 PM, Administrative Nurse D stated that each resident had their own hospice binder at the nurse's station, and the hospice provider was responsible for making sure all the information in the binder was current and correct, including any recertifications and POC. Administrative Nurse D stated that all hospice residents' facility care plans should indicate the hospice provider, how to contact hospice, the supplies provided by hospice, medications supplied, and how often hospice staff would make visits.The facility's Services Agreement for R7's hospice dated 04/17/2026 documented the hospice POC means a written, patient-specific care plan established, maintained, reviewed and modified, if necessary, as frequently as the patient's condition required but no less than every 15 calendar days established by the Interdisciplinary Group with Attending Physician involvement: Initially completed by a hospice registered nurse within forty-eight (48) hours after the election of hospice care. Established within five (5) calendar days after the election of hospice care; identification of the patient's/family's problems and needs for physical, psychosocial, emotional, and spiritual care; the scope and frequency of services needed to meet the patient and family's needs and by whom the service would be provided, prescribed and required medical equipment, supplies, medications, treatments and the level of care; realistic and achievable goals; all physician orders; a comprehensive assessment of each hospice patient's needs; and maintained in the hospice patient's medical record.The facilities Hospice Agreement for R27's hospice provider dated 02/11/2026 documented: Hospice shall maintain professional, financial, and administrative responsibilities for the services provided by Facility. Admission/Assessments -Hospice shall maintain responsibility for admitting patients to the Hospice program. Hospice shall perform a Patient/Family Assessment on all Patients in accordance with policies and regulations. Hospice shall notify Facility, either orally or in writing, of each Hospice Patient authorized by Hospice for admission. Hospice shall furnish the Facility with a copy of the Patient/Family Assessment. Assessing Continued Eligibility -Hospice shall have sole authority for assessing a Hospice Patient's continued eligibility for Hospice Services and for discharging a Hospice Patient from Hospice. Professional Management Responsibility. Hospice shall retain financial, administrative, and professional management responsibility for the contracted services. Hospice shall ensure that Facility services are furnished in a safe and effective manner, by persons meeting the qualifications necessary to provide effective Hospice care, in accordance with the Patient's Interdisciplinary Plan of Care, and other requirements of regulatory and accrediting bodies. Continuity of Care -Hospice shall ensure the continuity of patient and family care in the home, outpatient, and inpatient settings. The Hospice maintains responsibility for coordination of discharge planning for Hospice Patients, as appropriate, in collaboration with Facility's Social Services Department. Hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. It was the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the facility resident were in his or her own home.

Based on observation, interview, and record review, the facility failed to post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift. Findings included:- On 07/20/2026 at 08:30 AM, upon entrance into the facility, a Daily Nurse Staffing Sheet was observed posted on the bulletin board across from the North nurse's station, dated 07/20/2026 and documented the date, the nurse and aides names who were on duty and the hours they worked, but lacked a breakdown of the Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified medication Aide(CMA) and Nurse Aides (NA) who were working each shift with amount of calculated hours they worked each shift. On 07/21/2026 at 07:30 AM, observation revealed the facility posted the Daily Nurse Staffing Report with the nurse and aides names who were on duty and the hours they worked. On 07/22/2026 at 7:20 AM, observation revealed the facility posted the Daily Nurse Staffing Report with the nurse and aides names who were on duty and the hours they worked. On 07/22/2026 at 08:10 AM, Administrative Nurse D and Administrative Staff A verified the Daily Nurse Staffing Report should be posted daily with the RN, LPN, CMA, and NA total hours worked per shift with the number of staff for each shift, and the facility census. The facility's Nursing Staffing Posting policy, dated 2025, documented the facility would make sure nurse staffing information is readily available in a readable format to residents, staff, and visitors at any given time. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:Facility nameThe current dateFacility's current censusThe total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. (RN, LPN, and Certified Nurse Aides) The facility would post the Nurse Staffing Sheet at the beginning of each shift.The information would be presented in a clear readable format and in a prominent place readily accessible to residents, staff, and visitors. Nursing schedules and posting information would be maintained in the Human Resources Department for review for a minimum of 18 months or as required by State law, whichever is greater.

The facility identified a census of 64 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision for cognately impaired Resident (R)1, a resident with a risk for elopement and falls, to prevent an elopement. On 01/26/25, R1 self-propelled in his wheelchair down a hallway to a locked door with a keypad. The door was not latched and R1 left the unit and proceeded out a set of double doors that exited the building. When R1 opened the double doors, an alarm sounded at the nurse ' s station, but the staff turned the alarm off without checking the door. Per interview and investigation, R1 exited the facility building at 05:58 AM and entered the Assisted Living (AL) building at 07:02 AM. The weather ranged from 22 degrees Fahrenheit (F) to 23 degrees F. AL staff contacted the nursing staff in R1 ' s building and nurses from R1s unit came to get him. The lack of supervision and response to the door alarms placed R1 in immediate jeopardy. Findings Included: - R1 ' s Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), need for assistance with personal care, Alzheimer ' s disease (progressive mental deterioration characterized by confusion and memory failure), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS documented R1 used a wheelchair and was independently mobile. The MDS further documented R1 required partial to moderate assistance for bathing, upper body dressing, personal hygiene, ability to move from a seated position to standing, and transfers. The MDS documented no wandering behavior. The Falls Care Area Assessment (CAA), dated 10/14/24, documented R1 had a risk for falls related to impaired balance, taking scheduled antidepressant medication, high fall risk score, and decreased cognition. The CAA further documented staff assisted the resident with functional abilities and transfers as indicated. The Cognitive Loss/Dementia CAA dated 10/14/24, documented R1 had a BIMS score of three, diagnosis of Alzheimer's disease, and vascular dementia. R1's Care Plan with an initiated date of 10/03/23 documented R1 required limited to extensive assistance. R1 ' s Care Plan with an initiated date of 10/03/23 documented R1 had a fall and safety risk related to cognition, impulsiveness, decreased safety awareness, impaired balance, impaired mobility, and weakness. R1 ' s Care Plan with an initiated date of 02/22/24 documented R1 was an elopement risk related to a high-risk score on an elopement assessment and unpredictable behaviors. An intervention with an initiated date of 10/15/24 documented R1 ' s elopement risk as high. Review of the Elopement Assessment 2013 dated 01/10/25 documented R1 had a moderate risk for elopement. R1 ' s Health Status note dated 01/26/25 documented Certified Medication Aide (CMA) R reported R1 was at the facility ' s [assisted living] apartments at 07:11 AM, unassisted, per phone a call received by an apartment Certified Nurse Aide (CNA). The note further documented Licensed Nurse (LN) G and LN H went to assist R1 back to the facility. The note documented R1 wore a short-sleeved T-shirt, sweatpants, socks, and shoes. The note recorded R1 was a poor historian, unable to recall where he was going, and was cold to the touch. The Facility Incident Report with a signed date of 01/28/25, documented on the morning of 01/26/25, staff reported seeing R1 in the facility hallways at approximately 06:00 AM to 06:15 AM. The investigation documented that at approximately 07:11 AM CMA R received a phone call from AL staff informing them R1 was in the dining room of the AL building. The investigation further recorded CMA R and LN G went to the AL to get R1 and brought R1 back to the Health Center where he resided. The investigation notes documented that upon review of the camera system, R1 was observed going out of the northwest therapy door of the Health Center at 05:58 AM. R1 was in his wheelchair with sweatpants, a t-shirt, and tennis shoes on. The investigation note documented there was no exterior footage of the building, and there was a path through the snow to the AL building across the parking lot. Upon review of the camera system in the AL, R1 was observed at the south door of the AL building at 07:02 AM and entered the AL facility at 07:04 AM into their dining room. The note further recorded Dietary BB was in the AL dining room and turned to see R1 behind her, and per Dietary BB ' s report, R1 asked where he could sit to eat. Dietary BB told R1 he could sit anywhere and then realized R1 did not look familiar. Dietary BB stayed with R1 and contacted nursing staff via the facility communication system. Dietary staff noted R1 ' s hands to be red and cold. The investigation note further documented CMA R and LN G arrived at the AL at approximately 07:11 AM to get R1. LN H and LN J met CMA R and LN G in route to return R1 to the building via wheelchair and LN J assumed resident care. The investigation documented R1 was assessed with no injury noted, R1 was reported as alert and oriented to self and situation and reported being hungry. R1 ' s cognition was recorded as being at baseline and skin was cool to touch. Vital signs upon reentry to the facility at approximately 07:15 AM were temperature (T) 94.1F taken via ear thermometer, pulse (P) 59 beats per minute (BPM), blood pressure was 99 millimeters of mercury (mmHg) over 48 mmHg, and respirations 16 breaths per minute. The investigation documented staff applied a jacket and warm blankets to R1 and placed him on one-to-one supervision. At approximately 07:40 AM vitals were T 95.8F per ear thermometer, P 67 BPM, blood pressure 146/69 mmHg. At approximately 09:00 AM vitals included R1 ' s temperature was 96.1 degrees F via ear thermometer, pulse was 66 BPM, respirations were 16 breaths per minute, and blood pressure was 146/68 mmHg. The investigation recorded R1 ' s family and provider were notified, and no new orders were received. The investigation documented per guidelines a normal temperature via ear thermometer was 96.4 degrees F to 100.2 degrees F and cold skin could have a direct effect on the accuracy of the thermometer. R1 did not present with signs or symptoms to suspect hypothermia (medical emergency that occurs when the body's core temperature drops below 95 F). The investigation documented R1 was alert and oriented to self and occasionally situation. R1 is a one-to-one transfer and used a wheelchair for mobility. R1 was able to propel himself in his wheelchair, was a high elopement risk, and was care planned as such. The investigation further documented elopement fliers were at the nurse ' s stations with R1 ' s photo. The investigation further documented per the camera system, R1 exited the north hall by therapy by pushing the door to the therapy hallway open; the door had not properly latched when last used and did not require the key code to be pushed open due to not being latched completely. R1 then pushed open the exterior door, which sounded an alarm at the north nurses ' station. When the alarm sounded at 05:58 AM, per camera time, LN I deactivated this alarm from the nurses ' station without going to check on the location of the alarm. Per the investigation note, the entrance R1 exited the facility from was an entrance that staff used, and LN I thought it was staff entering and exiting the building as residents should not be able to access the door in the therapy hall. According to Wunderground.com the temperature at 06:00 AM on 01/26/25 was 23 degrees F and the temperatures dropped to 22 degrees F at 07:00 AM. Dietary BB ' s Notarized Witness Statement, dated 01/28/25, documented at approximately 07:05 AM, R1 appeared behind Dietary BB in the dining room. R1 was in a wheelchair and asked where he could sit for a meal. Per the witness statement, R1 told Dietary BB he was locked out and had been outside for quite a while. R1 was able to tell Dietary BB where his room was. Dietary BB contacted the nurses in R1 ' s building and the nurses came to get R1. Dietary BB ' s witness statement documented R1 looked very cold, especially his hands. CMA R ' s Witness Statement, dated 01/26/25, documented CMA R received a phone call at 07:11 AM from AL staff and was asked if CMA R knew R1. CMA R went to the south hall to ask if staff had seen R1 and to check his room. The witness statement document R1 was not in his room. LN G and CMA R went to the AL dining room where R1 sat, and CMA R and LN G brought R1 back to the Health Center. LN G ' s Witness Statement, dated 01/26/25, documented during report a CMA received a call from AL staff that R1 was in their dining room. LN G and CMA R went to get R1 per the witness statement. Witness statement documented that R1 was cold to the touch and hungry. The statement documented two other nurses met LN G on the way back to the Health Center and assumed care for R1. The witness statement further documented LN G contacted Administrative Staff A, another nurse contacted Administrative Nurse D, and other staff performed room checks to ensure other residents were present. A document titled Written Warning #1 with a signed date of 01/26/25, documented an audible alert went off at the nurses ' station at 05:57 AM on 01/26/24 and LN I did not immediately go to the door indicated on the annunciator system (provides an indication of the location and type of alarm that has been activated). The document recorded LN I did not check both inside and outside the door to determine who or why the door alarm sounded. LN I turned the alarm off and proceeded with his tasks. The document further recorded that under no circumstances should a door alarm be deactivated until the source of the activation was determined. Moving forward, LN I was to check both inside and outside the door to determine who or why the door alarm sounded. On 01/29/25 at 01:38 PM, an observation made outside where R1 exited the facility revealed R1 exited through the double doors to a sidewalk with three paths. The path leading southwest curves around and is attached to a facility road and parking area. The road and parking area continued south and eventually led to a pond on facility property. The sidewalk also connected to a main road that traveled east and [NAME] on the South side of the facility. The posted speed for the main road was 35 miles per hour (mph). The second path from the exit doors went down concrete stairs and connected to the same parking lot and facility roadway as the Southwest path. The third path went North alone the building then turned East. The sidewalk had a rail that traveled along the edge. There was some snow left on the sidewalk and a thin trail was noted in the snow that appeared to be a track from R1 ' s wheelchair. The sidewalk turned North and connected to a crosswalk that joined to the entrance of the AL building. The area of the sidewalk that connects to the crosswalk was covered with snow. There was a grass area that continued East from this sidewalk and eventually joined at another sidewalk with a ramp that connected to the same facility road with the crosswalk. There was snow in the grass and another thin line that appeared to be a track from R1 ' s wheelchair. From the second sidewalk exit ramp, R1 could have used this to cross the road and enter the front door of the AL building. This was the path Administrative Staff A stated he believed R1 took to get to the AL. The facility roads connected to other roads off the facility property to the East and [NAME] sides of the facility. The facility was surrounded to the North, East, and [NAME] by residential housing, and to the South a main road with small businesses across that street and some residential housing and small apartment buildings. On 01/29/25 at 05:11 PM, R1 sat in the dining room in his wheelchair. R1 fed himself at the table with staff seated nearby. R1 did not appear to be in any distress. On 01/29/25 at 05:47 PM, LN I was unavailable for Interview. On 01/29/25 at 12:12 PM, Dietary BB stated she was in the AL dining room and turned around to see R1 in a wheelchair behind her. Dietary BB stated she didn ' t know where R1 came from and thought R1 may have been a new resident to the AL. Dietary BB stated R1 wheeled himself to a table and stated the room he stayed in and further said that he had been locked outside for a while. Dietary BB asked where he was, and she stated R1 pointed across the road. Dietary BB stated she called the nursing staff, and they came over to get him. Dietary BB stated R1 ' s hands were red, and believed R1 may have been outside quite a while. Dietary BB stated she didn ' t touch R1s hands but stated that just looking at him she could tell R1 was cold. Dietary BB stated R1 had on a t-shirt, sweatpants, socks, and shoes. She further stated R1 did not have a coat, gloves, or hat on. On 01/29/25 at 01:50 PM, Administrative Staff A stated residents were not supposed to able to get back to the therapy hall and believed the door that led to the therapy hall, did not latch properly when it was last closed and that allowed R1 to get through the door without using the keypad. Administrative Staff A stated the nurse on duty turned off the alarm at the nurses ' station when the alarm sounded without checking the source. Administrative Staff A further stated the facility had a company coming out to see about eliminating the ability for staff to turn off the alarms at the desk. Administrative Staff A stated staff were educated on elopement, what to do, the policy, and door alarms. Administrative Staff A stated all but a few staff were educated and those left would be educated before they could work their next shift. Administrative Staff A stated signs have been posted to remind staff they were not allowed to turn off alarms without checking the source. Administrative Staff A stated maintenance was notified about the door and came in to inspect and make adjustments. Administrative Staff A stated they had no further issues with the door since maintenance inspected it. On 01/29/25 at 02:02 PM, CMA R stated she was working the med cart when she received a call from the AL. CMA R stated she was asked if R1 was their resident. CMA R stated she notified LN G and looked on the unit for R1 before going to the AL with LN G to bring him back. CMA R stated R1 was really cold, she stated they put his foot pedals on his wheelchair and brought him back to the building and the nurses that worked on his hall took over care. CMA R stated she felt R1 ' s skin and he felt cold, and he looked white. She stated staff put blankets on R1 they took from the dryer to help warm him. CMA R stated she believed R1 was normally confused and was an elopement risk prior to him exiting the facility. On 01/29/25 at 02:09 PM, LN G stated CMA R told her R1 was in the AL and they both went to the AL to bring him back. LN G stated R1 was at a dining room table in the AL, he responded to his name, and he said he was cold and hungry. LN G stated that R1 was cold to touch. LN G further stated LN H and LN J took over his care as she and CMA R brought R1 back. LN G stated she contacted Administrative Staff A to inform him of the situation. LN G stated R1 was red and looked cold. She stated dietary staff in the AL told her R1 had knocked on the door and told them he was locked out. LN G stated when Administrative Staff A arrived, they performed a head check for all residents, information and education packets were handed out to staff and an in-service was done the following day. LN G stated they went over education for an elopement, the facility policy, and door alarms. She stated signs have been put in place reminding staff they must physically check every door when alarms go off. LN G stated staff were always expected to check door alarms when they went off. On 01/29/25 at 02:23 PM, LN H stated she went with LN J to get R1 and met LN G and CMA R as they were bringing him back. LN H stated she got him some blankets and some hot chocolate in the dining room. She stated she did rounds to check other residents to ensure they were all accounted for. LN H stated R1 looked nervous, felt cold, and was shivering. She stated when she saw him his hands were cold and looked purple. LN H stated that R1 had on a short-sleeved shirt, pants, socks, and shoes. LN H stated R1 appeared to be at his baseline. LN H stated the facility had three types of thermometers, one for oral, one that could be used in the ear, and one to scan a resident ' s forehead. LN H stated LN J used the ear thermometer on R1 and she didn ' t believe it would have been an accurate reading as his skin was a cold. LN H stated R1 was placed on a one-to-one observation after the incident and was unsure when the facility would discontinue it. LN H stated the facility provided elopement education, went over the policy with staff, and provided education on door alarms. LN H stated signs were put up to remind staff not to shut off alarms without checking to see what caused it first. On 01/29/25 at 02:45 PM, Administrative Nurse D stated she and Administrative Staff A did the investigation; however, she was the one who typed up the investigation documents that were provided. Administrative Nurse D stated LN I shut off the door alarm from the desk. Administrative Nurse D stated the first door R1 went through to get into the therapy hall was supposed to be secure. She stated it ' s supposed to lock so residents cannot access that area without staff. Administrative Nurse D stated the double doors R1 exited the facility through are used by staff, so it didn ' t alert LN I to check that door when the alarm went off. Administrative Nurse D stated maintenance came in to fix the door R1 was able to get through, but that did not latch properly. Administrative Nurse D stated maintenance normally does monthly checks on the doors; however, since the incident maintenance has been checking them daily, three times per day, each shift, and will continue that for two weeks. She stated if there are no further issues with the doors after two weeks, they will return to monthly checks. Administrative Nurse D stated that R1 may possibly be moved to memory care; however, until that happens, he would remain on one-to-one observation until the two-week door inspections were completed, and no issues were found. Administrative Nurse D stated there were no poor outcomes for R1 after the incident. Administrative Nurse D stated the facility ordered a rectal thermometer in case a situation like this occurred in the future so staff could obtain a more accurate temperature and an ear temperature would not have been as accurate in this situation. Administrative Nurse D stated Administrative Staff A provided immediate education for all staff related to elopement, the policy, and door alarms. Administrative Nurse D stated the few staff that had not completed the education were set to receive it before working their next shift and that the majority of staff had already completed the education. On 01/29/25 at 03:13 PM, Maintenance U stated from his understanding, the door R1 went through did not latch properly and that allowed him to get through the door. Maintenance U stated he came in that morning and inspected the door and did not find anything wrong with it; however, he made some adjustments to it. Maintenance U stated he checked the doors three times per day once for each shift and would continue that for two weeks. He stated he had never had any issue with the door prior to this incident. He further stated the facility was working on making changes to the alarm system to prevent staff from being able to turn off alarms at the nurses ' station. The facility ' s undated Missing Resident policy documented it is the policy of this facility to protect the safety of our residents through early assessment of their risk for exit-seeking behaviors. Once identified we take steps to mitigate that risk through an individualized care plan and good communication between staff, visitors, and families regarding supervision needs. All residents at risk for elopement will be identified through assessment. All staff members should be aware of those residents at risk for elopement and this procedure. All exit doors are alarmed with audible alerts, in the care of a door alarm sounding, staff will immediately go to the door indicated on the enunciator system and check both inside and outside the door to determine who/why the door alarm sounded. Under no circumstances will a door alarm be deactivated until the source of the activation has been determined. On 01/29/25 at 06:04 PM, Administrative Staff A and Administrative Nurse D received the Immediate Jeopardy (IJ) Template and was informed that the facility failed to respond to door alarms in order to prevent cognitively impaired R1 from exiting the facility without staff supervision or knowledge and entering an unsafe location placed R1 in IJ. The facility identified and completed the following corrective actions: A new elopement risk assessment was completed for the resident on 01/26/25 The nurse involved received corrective actions for not following elopement procedures and received education on 01/26/25. Maintenance assessed and adjusted the door and checked door alarms on 01/26/25. Staff education on policy, elopements, and door alarm response was completed on 01/26/25. A QAPI meeting related to elopements was completed on 01/27/25. Signs posted on door alarm mechanism at each nursing station to ensure all alarms are on and reminder that under no circumstances will an alarm be turned off until the source of the activation has been determined completed by 01/27/25. An all-staff in-service completed 01/27/25. Reviewed elopement risk posters to ensure all were up to date and completed by 01/27/25. The resident ' s care plan was updated to include interventions and monitoring of wandering completed on 01/28/25. The surveyor verified the above corrective actions were completed prior to the onsite survey on 01/29/25, therefore the deficient practice was cited as past noncompliance and existed at a scope and severity of J.

The facility identified a census of 57 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident's rights training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 08/06/24 at 01:15 PM the training record on file at the facility for agency Certified Nurses Aid (CNA) M and agency Licensed Nurse (LN) G revealed the following: CNA M's facility-provided credentialing file lacked documented training completed for resident rights. The file noted he was provided abuse, neglect, and exploitation (ANE), dementia, and infection control training. LN G's facility-provided credentialing file lacked documented training completed for resident rights. The file noted she was provided abuse, neglect, and exploitation (ANE), and dementia training. 08/07/24 at 07:04 AM Administrative Nurse D stated the facility relied on the contracted agency to provide the required education for the agency nursing staff. She stated the facility had not ensured the agency staff had the education and/or training required for direct care staff. The facility was unable to provide a policy related to required education for direct care staff. The facility failed to ensure the completion of the required resident's rights training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 57 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 08/06/24 at 01:15 PM the training record on file at the facility for agency Certified Nurses Aid (CNA) M and agency Licensed Nurse (LN) G revealed the following: CNA M's facility-provided credentialing file lacked documented training completed for communication. The file noted he was provided abuse, neglect, and exploitation (ANE), dementia, and infection control training. LN G's facility-provided credentialing file lacked documented training completed for communication. The file noted she was provided abuse, neglect, and exploitation (ANE), and dementia. 08/07/24 at 07:04 AM Administrative Nurse D stated the facility relied on the contracted agency to provide the required education for the agency nursing staff. She stated the facility had not ensured the agency staff had the education and/or training required for direct care staff. The facility was unable to provide a policy related to required education for direct care staff. The facility failed to ensure the completion of the required communication training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 57 residents. The sample included 15 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 41's dignity was maintained. This deficient practice placed R41 at risk for impaired dignity and decreased psychosocial well-being. Findings included: - R41's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R41 had severely impaired cognition. The MDS documented R41 was dependent on staff assistance for activities of daily living (ADLs). The MDS documented R41 had bilateral lower extremity impairment of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). R41's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/15/24 documented R41 had a diagnosis of dementia. R41 had memory loss and disorganized thinking. R41's Care Plan dated 03/11/24 documented he preferred his shower twice weekly in the evening. The plan of care documented that staff would break down the tasks into segments for R41 to be more manageable. The plan of care for R41 documented that staff would establish and maintain a routine and would reorient and reassure him as needed. The plan of care also documented staff would support and assist him with problem-solving. On 08/05/24 at 09:09 AM R41 was transferred from his bed to a shower chair with the assistance of Certified Nurse Aide (CNA) O and CNA P with a Hoyer lift (total body mechanical lift). R41 was dressed in a gown that was open in the back, he was unable to sit upright on the shower chair. CNA O placed a small blanket from R41's bed around his waist to his knees. CNA O and CNA P attempted to reposition him on the shower chair by lifting him under his arms and legs. CNA O stated R41 was unable to sit upright on the shower chair, and he usually was given a shower on the bath bed, but another unit was using it at that time. CNA O stated she would have to pull R41 down the hallway backward because R41's feet would get caught under the shower chair or drag on the floor. CNA O pulled R41 down the hallway to the shower room backwards with CNA P attempting to hold R41's feet from dragging on the floor. On 08/07/24 at 09:07 AM, CNA N stated should never be pulled backward down the hallway on a shower chair. CNA N stated a resident should be covered when in the hallways. On 08/07/24 at 09:12 AM, Licensed Nurse (LN) H stated a resident should never be pulled backward, if a person's legs are too long, they should have been put in a reclining shower chair. LN H said residents should be covered appropriately. On 08/07/24 at 10:43 AM, Administrative Nurse D stated if a resident was unable to be pushed forward in the shower chair then it would be safer to pull the resident backward Administrative Nurse D stated she expected the staff to follow the residents' care plan. The facility's Right to Dignity policy dated 11/29/19 documented the facility would promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality. All staff would provide dignity to each resident by maintaining the resident's privacy of body which included. Keeping the resident covered while transporting the resident outside the resident's room. The residents would be undressed and dressed inside the bathing room rather than being transported without full clothing unless otherwise care planned, and a resident has requested it. The facility failed to ensure R41's right to be treated with respect, and dignity when pulled in the hallway backward on a shower chair. This deficient practice placed R41 at risk for negative psychosocial outcomes and decreased dignity.

The facility identified a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination for Resident (R)41. This deficient practice placed R41 at increased risk for respiratory infection and complications. Findings included: - R41's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R41 had severely impaired cognition. The MDS documented R41 was dependent on staff assistance for activities of daily living (ADLs). The MDS documented R41 had bilateral lower extremity impairment of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). R41's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/15/24 documented R41 had a diagnosis of dementia. R41 had memory loss and disorganized thinking. R41's Care Plan dated 07/09/24 documented that staff would change the oxygen tubing weekly and as needed. The plan of care documented that staff would monitor the oxygen concentrator to ensure proper operation and clean the filters weekly and as needed. The plan of care documented that staff would monitor his oxygen saturation every shift and report any changes to the physician. The care plan documented the facility would provide education regarding the use of oxygen and would demonstrate proper placement of the oxygen equipment. R41's EMR under the Orders tab revealed the following physician orders: Titrate oxygen via nasal cannula to maintain oxygen saturation above 90 percent every shift dated 06/11/24. On 08/05/24 at 09:09 AM R41 laid on his back on the bed. The bed was in a low position R41 was not wearing an oxygen nasal cannula. A nasal cannula and oxygen tubing were wrapped tightly around the back of a Broda chair (specialized wheelchair with the ability to tilt and recline) in the room. Another nasal cannula and oxygen tubing were draped over the oxygen concentrator next to his bed. On 08/06/24 at 12:24 PM, R41's nasal cannula and oxygen tubing were hung over the top of the oxygen concentrator and rested on the floor behind the concentrator. A black bag was attached to the oxygen concentrator. On 08/06/24 at 02:23 PM, R41 lay on his bed with his eyes closed and a nasal cannula was intact on his face. Oxygen tubing and a nasal cannula were draped over the back of the Broda chair and not placed in the black bag that was attached to the back of the Broda chair. On 08/06/24 at 09:10 AM, Certified Nurse Aide (CNA) N stated all oxygen nasal cannulas should be stored in a bag when not in use. CNA N stated the oxygen nasal cannulas are changed weekly. On 08/06/24 at 09:12 AM, Licensed Nurse (LN) H stated all of the residents who are on oxygen therapy are given containers and bags for oxygen cannulas and nebulizers. LN H stated all oxygen should be placed in bags or canisters when not in use for sanitation, and never wrapped around handles of oxygen canisters or draped over chairs. On 08/06/24 at 10:43 AM, Administrative Nurse D stated she expected the oxygen nasal cannulas to be stored in a sanitary manner. Administrative Nurse D stated the nasal cannulas are changed weekly and a black bag was provided to store the nasal cannula when not in use. Administrative Nurse D said it should never be placed on the floor or draped over a chair. The facility was unable to provide a policy related to sanitary storage of oxygen equipment when not in use. The facility failed to ensure R41's oxygen tubing was stored in a sanitary manner to decrease exposure and contamination. This placed R41 at increased risk for respiratory infection and complications.

The facility identified a census of 57 residents. The sample included 15 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to ensure a form of communication was established between the facility and the dialysis center for Resident (R) 3. This deficient practice placed R3 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R3's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dependence on renal dialysis, end-stage renal disease (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), and a need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R3 received hemodialysis services during the observation period. R3's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 06/06/24 documented during the assessment period, R3 required staff assistance for activities of daily living (ADLs). R3 received renal dialysis on Monday, Wednesday, and Friday. R3's Care Plan dated 05/29/24 documented that staff would observe, monitor, and assess the arteriovenous (AV-a surgically created connection between an artery and a vein) for signs or symptoms of infection, compromise, and impairment. R3's EMR under the Orders tab revealed the following physician orders: Dialysis on Monday, Wednesday, and Friday at 10:30 AM dated 05/29/24. R3's clinical record reviewed from 05/29/24 to 08/06/24 lacked evidence of consistent communication between the facility and the dialysis provider. On 08/06/24 at 12:58 PM, R3 walked around in his room without difficulty. On 08/06/24 at 01:55 PM, Licensed Nurse (LN) I stated the facility did not send communication sheets with R3 to dialysis. LN I stated the dialysis provider would call the facility if there had been a change, if lab work had been obtained, or any other changes. LN I stated the facility did not notify the dialysis provider of any pre-dialysis assessments on the days R3 went for dialysis treatment. On 08/06/24 at 02:46 PM, Administrative Nurse D stated she believed that the facility system was to send a dialysis communication sheet with any resident who received dialysis though the dialysis provider did not always return the communication sheets. Administrative Nurse D stated she would have to check with Administrative Nurse E. On 08/06/24 at 03:20 PM Administrative Nurse E stated the facility had stopped sending dialysis communication sheets with the residents to their dialysis providers due to the provider not returning the communication sheet. The facility's undated Hemodialysis Policy documented the facility was to provide excellence in care and services to residents with End-Stage Renal Disease (ESRD) receiving hemodialysis at a certified renal dialysis unit off-site. Coordination of care included Information transmitted to the dialysis unit by the facility prior to dialysis, and information transmitted to the facility by the dialysis unit after dialysis. The facility staff would initiate a written communication form that would accompany the resident off-site to the dialysis unit and return, completed by the dialysis unit staff for every visit. The facility failed to ensure a form of communication was established between the facility and the dialysis center for R3. This deficient practice placed R3 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 56 residents. The sample included 14 residents with two residents reviewed for pressure injuries. Based on observation, record review, and interview, the facility failed to ensure preventive measures were in place for Resident (R)40 who developed a facility acquired pressure injury to his coccyx (small triangular bone at the base of the spine) area and further failed to implement treatment orders, and routinely monitor the wound. R40's pressure injury evolved into a stage three (full thickness, extending into tissue beneath the skin) pressure ulcer. The facility further failed to ensure preventive measures were in place for R32 who developed a pressure injury to her left heel and further failed to monitor the wound routinely. This deficient practice placed her at risk of worsening and further development of skin related injuries. Findings included: - R40's Electronic Medical Record (EMR) recorded diagnoses of low back pain, reduced mobility, hypertension (HTN, high blood pressure) and venous insufficiency (poor circulation). R40's Admission Minimum Data Set (MDS) dated [DATE] recorded R40 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. He had no rejection of cares, required extensive assistance of two staff for bed mobility, and extensive assistance from one staff for transfers and dressing. He required supervision to limited assistance with other activities for daily living (ADL). The MDS documented the resident did not have any pressure injuries and was not at risk for development. The MDS recorded R40 had a pressure reducing device for his chair but not for his bed and was not on a turning/repositioning program. The Pressure Ulcer Care Area Assessment (CAA) dated 11/20/22 recorded R40 had minimal potential for pressure ulcers as he was able to shift his own weight. He had occasional urinary incontinence and ambulated with assistance. His Braden score (formal assessment used to predict risk for pressure ulcers) was 20, which indicated no risk. The Care Plan dated 11/14/22 documented R40 required limited assistance with ADL. An intervention dated 11/14/22, revealed R40 required minimal assistance from one staff for dressing, and one to one assistance with a gait belt and walker for toileting. The care plan was updated on 01/25/23 to reflect R40 required two staff assistance with a sit to stand lift for transfers as of 01/25/23. The care plan lacked information regarding assistance required for bed mobility. The care plan lacked direction or interventions related to skin care and or wound and/or pressure ulcer prevention or treatment. A Skin assessment dated [DATE] recorded no site or type for skin concerns and no measurements though the additional comments section recorded the resident continued to be treated for dry, flaky to his coccyx (area of skin right over tailbone). R40's January 2023 Medication/Treatment Administration Record MAR/TAR) recorded an order for a skin assessment weekly on Friday by the day shift (07:00 AM to 03:00 PM shift) but lacked evidence of any treatments orders for R40's coccyx, prior to 01/20/23. A Health Status Note dated 01/10/23 at 01:56 PM documented R40 had an open area to his left buttock. The note recorded the wound nurse and R40's family were notified. The area was cleansed with wound cleanser and a Mepilex (absorbent, bordered foam dressing) applied. Staff notified Consultant HH. The note recorded Licensed Nurse (LN) K spoke with R40's representative and the facility therapy staff about using a commode and all agreed (the note lacked further detail regarding the commode). The EMR lacked evidence of an order for the Mepilex or any ongoing treatments established at this time. The Skin and Wound Evaluation dated 01/10/23 but remained in progress (not locked) at the time of survey lacked data under the describe section regarding the type of wound, location, acquired in house or present on admission, how long the wound was present and the exact date of the wound. The next section B. Wound Measurements recorded and area of 1.7 centimeters (cm), 1.8 cm length, 1.3 cm width and no depth, undermining, or tunneling. The Section C. Wound Bed was left blank. The section D. Exudate [drainage] was left blank, section E. Peri Wound [skin surrounding wound] was blank except the change in temperature [degrees] section which recorded 0.0. section F. Wound Pain was completely blank, section G. Orders was completely blank, section H. Treatment was also blank as well as the last section I. Progress. The January 2023 MAR/TAR recorded on 01/13/23, R40 refused his weekly skin assessment. A Health Status Note' dated 01/13/23 recorded R40 refused his shower that day and the certified nurse Aide (CNA) reported the resident had loose stools that day. A Antibiotic Stewardship Note dated 01/16/23 recorded the resident tested negative for Covid-19 (contagious respiratory virus). A Dietary Note documented by the registered dietician (RD), Consultant II, dated 01/18/23 recorded R40 weight from 01/08/23 reflected a five percent loss in one month, believed to be due to his diuresis. The note recorded a recommendation which directed to discontinue the order for liquid protein and start Med-Pass (high calorie nutritional supplement) instead. The note lacked evidence the RD was aware of any skin concern. A Skin assessment dated [DATE] recorded no site or type for skin concerns and no measurements though the additional comments section recorded an open area to the left buttock, and bilateral buttocks were red. The January 2023 MAR/TAR recorded an order dated 01/20/23 which directed to cleanse coccyx area with normal saline daily, pat dry. Apply Medihoney (medical grade honey used to promote wound healing) to wound, apply sacral (area of skin on coccyx/tailbone) border. Change as needed (PRN) if soiled. in the morning for coccyx wound. This order was discontinued on 01/30/23. The Skin and Wound Evaluation dated 01/20/23 and locked on 01/20/23 documented a stage 3 full thickness pressure wound to the coccyx, facility acquired, but lacked how long the wound was present and the exact date of the wound. The next section B. Wound Measurements recorded an area of 0.9 centimeters (cm), 0.9 cm length, 0.8 cm width and 0.5 cm depth, with no undermining, or tunneling. The wound bed was pink or red granulation tissue (new tissue that forms on a healing wound), no evidence of infection. There was no drainage. The periwound had edges that were not attached (edge appeared as a cliff) and was excoriated (redness of the skin causes by exposure to urine, feces, body fluids, exudate, and/or friction) and was fragile. The pain and orders section were left blank. The treatment section recorded none on dressing appearance, cleansing solution of normal saline, autolytic debridement (using the body's own defense mechanisms and fluids to liquefy eschar, slough, and other forms of necrotic tissue), and a foam primary dressing. The treatment section recorded additional cares of cushion, incontinence management, mobility aids provided, moisture barrier, and nutritional supplements only. The turning/reposition program was not marked. A Health Status Note dated 01/21/23 at 06:53 AM recorded staff received new orders to cleanse the coccyx area with normal saline, pat dry, apply Medihoney, a sacral border, and to change as needed for soiling. The Skin and Wound Evaluation completed on 01/23/23, remained in progress (not locked) at the time of survey and lacked data under the describe section regarding the type of wound, location, acquired in house or present on admission, how long the wound was present and the exact date of the wound. The next section B. Wound Measurements recorded an area of 0.cm, 1.2 cm length, 0.4 cm width and no depth, undermining, or tunneling. The Section C. Wound Bed was left blank. The section D. Exudate [drainage] was left blank, section E. Periwound was blank except the change in temperature [degrees] section which recorded 0.0. section F. Wound Pain was completely blank, section G. orders was completely blank, section H. Treatment was also blank as well as the last section I. Progress. The Physician Progress Note dated 01/23/23 recorded the resident was assessed by Consultant HH due to increased confusion and dysarthria (difficulty speaking). The note lacked evidence the wound was reported to Consultant HH or assessed at that time. A Skin assessment dated [DATE] recorded no site or type for skin concerns and no measurements but indicated in the additional comments the left buttocks had an open area. The Skin and Wound Evaluation dated 01/27/23 and locked on 01/30/23 recorded R40 had a pressure wound, stage three (full thickness skin loss) on his coccyx, acquired in-house. The question regarding how long the wound was present and the exact date were left blank. The wound measured 0.7 cm in area, 0.7 cm in length, 0.7 cm width and had no depth, undermining, or tunneling. The wound bed was 100 percent (%) epithelial tissue (tissue which forms the external skin) with the surface intact. The rest of the section including evidence of infection was left blank. The section regarding drainage was also blank. The peri-wound (area around the wound) was attached, epithelized ( new pink, shiny tissue), and fragile. The assessment recorded under the treatment section, R40 had a cushion, incontinence management, mattress with pump, mobility aids, moisture barrier and nutrition supplementation only. The turning/reposition program was not marked. The wound was progressing according to the assessment. The January 2023 MAR/TAR recorded an order dated 01/30/23 which directed to cleanse coccyx area with normal saline daily, pat dry. Apply Medihoney to wound, apply foam border. Change as needed (PRN) if soiled. in the morning for coccyx wound. Cleanse coccyx area with NS daily, pat dry. Change PRN if soiled. in the morning for coccyx wound. The Skin/Wound Note dated 01/30/23 recorded the R40's pressure ulcer to the left buttock was improving. The note recorded the first wound picture was taken on 01/10/23 with resident permission. Measurement per the wound application was a 1.7 cm opening with suspected deep tissue injury (SDTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) to bilateral buttocks. The following week, the deep tissue injury (DTI, pressure ulcers defined as purple or maroon localized area of discolored intact skin or blood?filled blister) did not improve, though the resident had been refusing to sleep in his bed due to his concerns with breathing. The nurse and resident discussed the importance of shifting weight while in any chair, but especially his recliner. Occupational Therapy (OT) was able to assist the resident with using a ROHO (pressure relief cushion that is made of soft, flexible air cells connected by small channels) cushion for better relief while in the recliner. The resident was agreeable and felt it helped. R40 agreed to sleep on the air flow mattress to assist in improving the wound. Upon reassessment on 01/27/23, the area was completely epithelialized and continued to have treatment with cleanser and Medihoney with bordered foam to site. The DTI to the bilateral buttocks needed continued treatment, though was also improving. Nursing continued to treat site as ordered and PRN. A Skin assessment dated [DATE] recorded no site or type for skin concerns but indicated in the additional comments no new skin issues were observed and the area to the coccyx was followed by the wound nurse. On 02/02/23 at 09:36 AM R40 laid on his right side on the bed. R40's bed was in lowest position and had a low air mattress. R40 refused to allow observation of pressure area dressing change. On 02/02/23 at 01:40 PM Certified Medication Aide (CMA) R stated she would report any skin related changes to the charge nurse. On 02/02/23 at 02:16 PM Licensed Nurse (LN) I stated the physician would be notified of any newly identified skin issues, along with the director of nursing, the facility wound nurse, and the family. LN I was uncertain what preventative measures should be placed, or in place, for prevention of pressure injuries. On 02/02/23 at 03:11 PM Administrative Nurse E stated she reviewed all assessment in each of the residents' clinical record to complete the MDS for each resident. Administrative Nurse E stated the facility wound nurse reviewed all wounds and skin related issues. On 02/02/23 at 03:37 PM Administrative Nurse D stated the MDS coordinator prints off the last 24-hour charting from the progress notes to review in the morning department head meeting. Administrative Nurse D stated all new items are discussed and followed up by each department head or unit managers. Administrative Nurse D stated the facility wound nurse follows all the wounds and skin issues. The facility's Skin Protocol for Residents at risk for Pressure Ulcers policy dated 02/19/18 documented the purpose of this policy was to assure that residents who entered the facility without a pressure ulcer would not develop a pressure ulcer unless their clinical condition demonstrated they were unavoidable. Upon admission, quarterly a significant change, readmission and annually, all residents would have a pressure risk assessment completed. For residents determined at risk would have the appropriate interventions based on the needs and preferences of the resident in the resident's care plan. The facility failed to ensure preventive measures were in place for R40 who developed a facility acquired pressure injury to his coccyx area and further failed to implement treatment orders, and routinely monitor the wound. R40's pressure injury evolved into a stage three pressure ulcer. - R32's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), need for assistance with personal care, and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R32 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R32 was at risk of pressure ulcers and had one unhealed pressure ulcer. The MDS documented R32 had a pressure reducing device in her chair, pressure ulcer care and application of medication/ointments to other then feet. The MDS lacked documentation pressure reducing mattress, turning, or repositioning, or nutritional interventions. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R32 was dependent on two staff members assistance for ADLs. The MDS documented R32 was at risk for pressure ulcers and documented no unhealed pressure ulcers. R32's Pressure Ulcer Care Area Assessment (CAA) dated 09/28/22 documented R32 had the potential for pressure related to hospice status with declined nutritional intake. R32's Care Plan lacked documentation related to pressure ulcer prevention or care. A Skin assessment dated [DATE] documented R32's skin was warm, dry, and intact. A Health Status Note dated 09/19/22 at 01:35 PM recorded a discolored area on R32's left inner heel. The note documented facility wound nurse, hospice nurse and physician were notified of area. A Health Status Note dated 09/20/22 at 05:31 PM documented an order was received for Betadine (topical antiseptic used to disinfection of the skin) to a lesion on the left inner heel and directed to avoid pressure to area until resolved for skin. Review of the EMR under Orders tab revealed physician orders dated 09/20/22 apply Betadine to lesion on left inner heel and avoid pressure to the area until resolved every day. Review of the Treatment Administration Record (TAR) for September 2022 documented an order to apply Betadine to left heel started on 09/20/22, changed time of administration and restarted on 09/22/22. The TAR lacked evidence the Betadine was applied on 09/21/22. The clinical record lacked documentation preventive and/or offloading measures were implemented to prevent further pressure to left heel. R32's Skin & Wound Evaluation dated 09/30/22 labeled as in progress and not completed documented a pressure area to the left heel, stage two: partial-thickness skin loss with exposed dermis (the thick layer of living tissue below the epidermis (outer layer of skin) which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures) area measured 1.2 centimeters (cm) in length and 1.0 cm in width. R32's Skin assessment dated [DATE] documented left heel/right toe dressing was in place, followed by wound nurse. The assessment lacked measurements and wound assessment. R32's Skin & Wound Evaluation dated 10/05/22 but unlocked and in progress documented a pressure area to left heel, stage two, partial-thickness skin loss with exposed dermis, acquired in house, 0.5 cm in length and 0.8cm in width. The assessment area was blank regarding additional care for preventive measures related to pressure. R32's Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel (with current treatment & followed by wound nurse). The assessment lacked wound measurements and preventive measures in place to reduce and prevent pressure. R32's Skin assessment dated [DATE] documented a red area to peri area, treatment in place no other skin issues. The assessment lacked documentation of left heel ulcer, wound measurements, preventive measures in place to prevent pressure. R32's Skin assessment dated [DATE] documented redness under breasts and peri area with a treatment in place. The assessment lacked documentation of left heel pressure ulcer, or preventive measures in place to reduce pressure. R32's Skin & Wound Evaluation dated 10/28/22 labeled in progress and unlocked, documented a pressure area to left heel, stage two, partial-thickness skin loss with exposed dermis, acquired in house 0.2cm in length and 0.5cm in width. R32's Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel with current treatment, Thrombo-Embolic-Deterrent (T.E.D. hose- specialized compression stockings designed to help manage swelling of the feet/legs) in use. The assessment lacked documentation of wound measurements, preventive measure in place to reduce pressure. The clinical record lacked an order for T.E.D. hose and documentation of application of T.E.D. hose. R32's Skin & Wound Evaluation dated 11/04/22 unlocked and in progress documented a pressure, stage two partial-thickness skin loss with exposed dermis, to left heel, in house acquired, 0.3cm in length 0.6cm in width, and 0.6 cm in depth. The assessment lacked preventive measures in place to reduce pressure. R32's Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel w with current treatment. The assessment lacked wound measurements and preventive measures in place to reduce pressure. R32's Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel with current treatment. The assessment lacked wound measurements and preventive measures in place to rescue pressure. A Skin & Wound Evaluation dated 11/15/22 but unlocked and in progress, documented a pressure area, stage two partial-thickness skin loss with exposed dermis, left heel, acquired in house, 0.1cm in length, 0.6cm in width, and 0.3cm in depth. The assessment lacked documentation of preventive measures in place to reduce pressure. A Skin assessment dated [DATE] documented no new skin issues noted, continue with area to left heel. The assessment lacked wound assessment and current preventive measures and pressure reducing measures in place to prevent further skin related injuries. A Skin assessment dated [DATE] documented no new skin issues, skin intact. The assessment lacked wound documentation of left heel and preventive measures in place to reduce pressure. A Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel with current treatment, A Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel with current treatment. The assessment lacked measurement of left heel pressure ulcer, and preventive measures in place to reduce pressure. Review of R32's Order Summary revealed an order dated 12/17/22 which instructed to take pictures of wound to left heel with wound phone that weekend for monitoring/reporting and notify facility wound nurse if needed. The clinical record lacked a photo of left heel pressure area. R32's Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel with current treatment. The assessment lacked wound assessment of left heel pressure ulcer, and preventive measures in place to reduce pressure. R32's Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel with current treatment. The assessment lacked a wound assessment of left heel pressure ulcer and preventive measures in place to reduce pressure to prevent further pressure related injuries. R32's Skin assessment dated [DATE] documented a stage two pressure ulcer to left heel with current treatment, The assessment lacked a wound assessment for pressure ulcer on left heel and preventive measures in place to prevent further pressure related injuries. R32's Skin assessment dated [DATE] documented no new skin issues. The assessment lacked a wound assessment of pressure ulcer on left heel and preventive measures in place to prevent further pressure resalted injuries. R32's Skin assessment dated [DATE] documented stage two pressure ulcer to left heel with current treatment, The assessment lacked a wound assessment of pressure ulcer on left heel and preventive measures in place to prevent further pressure related injuries. On 02/02/23 at 10:08 AM R32 sat in a wheelchair next to the bed. R32 wore non-skid socks, R32 had a bed cradle on the foot of the bed which also had a low air loss mattress. R32's leg drainage bag on her leg contained light amber urine. On 02/02/23 at 01:40 PM Certified Medication Aide (CMA) R stated she would report and any skin related changes to the charge nurse. On 02/02/23 at 02:16 PM Licensed Nurse (LN) I stated the physician would be notified of any newly identified skin issues, along with the director of nursing, the facility wound nurse and the family. On 02/02/23 at 03:11 PM Administrative Nurse E stated she reviewed all assessment in each of the residents' clinical record to complete the MDS for each resident. Administrative Nurse E stated the facility wound nurse reviewed all wounds and skin related issues. On 02/02/23 at 03:37 PM Administrative Nurse D stated the MDS coordinator prints off the last 24-hour charting from the progress notes to review in the morning department head meeting. Administrative Nurse D stated all new items are discussed and followed up by each department head or unit managers. Administrative Nurse D stated the facility wound nurse follows all the wounds and skin issues. The facility's Skin Protocol for Residents at risk for Pressure Ulcers policy dated 02/19/18 documented the purpose of this policy was to assure that residents who entered the facility without a pressure ulcer would not develop a pressure ulcer unless their clinical condition demonstrated they were unavoidable. Upon admission, quarterly a significant change, readmission and annually, all residents would have a pressure risk assessment completed. For residents determined at risk would have the appropriate interventions based on the needs and preferences of the resident in the resident's care plan. The facility failed to ensure preventive measures were in place for R32 who developed a pressure injury to her left heel and further failed to monitor the wound routinely. This deficient practice placed her at risk of worsening and further development of skin related injuries.

The facility reported a census of 56 residents. The sample included 14 residents with seven residents reviewed for accidents/hazards. Based on observation, record review, and interview, the facility to ensure Resident (R)41 remained free from avoidable accidents when staff left R41, who required one-to-one assistance, alone in the bathroom to perform hygiene tasks, which resulted in a fall for R41. As a result, R41 sustained a cut to the back of her head which required emergent treatment and surgical staples to close the wound. The facility further failed to identify and implement appropriate interventions, investigate for causal factors, and follow residents' plan of care to prevent avoidable accidents and falls. This placed those affected residents, R19, R28, R44, and R29, at risk for fall related injuries and complications. Findings included: - The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of unsteadiness on feet, macular degeneration (progressive deterioration of the retina), abnormalities of gait and mobility, vertebral fracture of lumbar region (broken bone of the spinal region), and dorsalgia (back pain). R41's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated she required extensive assistance from one staff member for bed mobility, transfers, dressing, toileting, and bathing. The MDS noted she required supervision and set-up assistance for personal hygiene. The MDS noted she used a walker and wheelchair for mobility. The MDS noted no falls since admission. R41's Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 11/28/22 noted staff would assist the resident with ADLs as needed and her needs would be care planned. R41's Falls CAA dated 11/28/22 indicated she had a history of falls, used assistive devices, and was assessed to be a fall risk. The CAA noted R41 had two falls before her admission in June. A review of R41's Falls Care Plan initiated 11/15/22 indicated she was at risk for falls related to impaired balance, mobility, and weakness. The plan instructed staff to encourage R41 to use her call light for assistance and work with therapy services (11/15/22). On 01/25/22 a note was added to R41's care plan indicating her walker had been removed from service and taken to maintenance to service the brakes. The update noted an armchair was added at the sink for personal cares and instructed staff to check on R41 frequently. A review of R41's ADL Care Plan, initiated 11/15/22, indicated she transferred with a gait belt. R41's Care Plan instructed staff R41 required one-to-one moderate assistance with ambulation, bathing, dressing, grooming, transfers, and toileting. A review of R41's Fall Assessment completed by Licensed Nurse (LN) H on 11/15/22 revealed a score of 14, indicating she was a high risk for falls. A review of R41's Fall Assessment completed by Licensed Nurse (LN) H on 11/28/22 revealed a score of one, indicating R41 was a low fall risk. The re-assessment did not accurately document and account for R41's impaired mobility, instability while turning, previous fall history, medications, and diagnosis. A review of R41's EMR revealed a Health Status note on 01/14/23 indicated staff found R41 lying on the floor in her bathroom. The note indicated R41 lost her balance and fell sideways on her left side. The note documented the resident had a BIMS of 15, but she was more forgetful the last couple of weeks. A review of R41's EMR under Incident Note on 01/25/23 revealed R41 fell while completing personal hygiene at the sink in her room on 01/14/23. The note indicated staff assisted R41 to sit on her rolling walker at the sink, and then the staff left her alone while R41 brushed her teeth. R41 reported to staff she attempted to scoot her walker backwards and fell on her head. The note indicated R41 had a two-centimeter (cm) laceration (wound to the skin) on the back of her head. R41 was transferred to an acute care facility and required surgical staples to close the wound. The note indicated she also had a 2 cm by 1.5 cm hematoma (collection of blood trapped in the tissues of the skin, resulting from trauma) on the back of her head. On 02/02/23 at 10:00 AM an observation of R41's room revealed a wheelchair stationed next to her sink, and a grab bar was in her toilet area . On 02/02/23 at 01:36 PM Certified Medication Aid (CMA) R noted R41 should never be left alone in the bathroom or during cares because she was a high fall risk. She stated that residents who were on one-to-one assist required staff to be with them at all times during tasks. CMA R stated R41 forgets to call for help sometimes and tried to do things for herself. On 02/02/23 at 02:20 PM Licensed Nurse (LN) H stated all residents received a fall assessment upon admission and then another assessment two weeks later. She stated the assessments should be completed every year, quarterly, and after a change or fall occurs. She stated fall assessments included reviewing a resident's previous falls, diagnoses, level of assistance, and recent changes in cognition. She stated she did not look at the resident's previous assessments, she just reviewed their status as the assessment were completed. She stated if a significant change occurred in the resident risks, she would notify the interdisciplinary team (IDT). She stated the nurses could review the care plans and make suggestions for new interventions to the IDT. On 02/02/23 at 02:50 PM Administrative Nurse E stated the facility's MDS assessment used the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated the inaccurate data could completely change the care a resident received. On 02/02/23 at 03:10 PM in an interview with Administrative Nurse D, she stated staff were expected to always monitor residents on one-to-one assistance during cares and were expected to follow the plan of care for each resident. A review of the facility's Fall Prevention policy revised 09/2018 indicated residents will be provided services and care that ensures the environment remains free from accident hazards and adequate supervision to prevent accidents. The policy noted that every team member is responsible for checking the resident's education care plan and ensuring the interventions are in place. The policy noted that assessments, interventions, and education will be used to provide a fall reduction program for each resident. The facility failed to safely monitor and assist R41 during morning hygiene as guided by her care plan. This deficient practice resulted in an injury fall requiring R41 to transfer to an acute care facility for treatment and surgical staples to the back of her head. -The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (a condition with low heart output and the body becomes congested with fluid), macular degeneration (progressive deterioration of the retina), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). R19's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS noted she required limited assistance for transfers, toileting, bed mobility, personal hygiene, and bathing. R19's Fall Care Area Assessment (CAA) dated 08/12/22 noted she had a potential for falls use to use of assistive device, incontinence, psychotropic medication (medication capable of affecting the mind, emotions, and behaviors), and cognitive impairment. R19's Activities of Daily Living (ADLs) CAA dated 08/12/22 indicated that she needed assistance with some ADLs and incontinence. The CAA noted she had history of hallucinations (seeing or hearing things that are not real). A review of R19's Care Plan for Falls initiated 08/01/19 indicated that she would have a fall assessment completed upon admission and two weeks after admission (08/01/19). The plan instructed staff to encourage R19 to use her call light (08/01/19) and remind her to wear her rubber-soled house shoes or tennis shoes ()08/01/19). The care plan lacked direction on the use of a electric lift recliner. A review of R19's Care Plan for ADLs initiated 08/01/19 indicated that R19 may transfer independent with her walker (08/01/19) , dress independently (08/01/19), toilets self but may require cueing (08/01/19), and preferred to get up between 10:00AM and 11:AM (02/01/22). The care plan lacked direction regarding the use of the electric lift chair. A review of R19's EMR revealed a Health Status note on 09/01/22 revealed that R19 was found yelling, sitting on the floor of her room in front of her recliner. The note indicated that R19 was unable to explain to staff what she was doing before the fall. The note indicated that R19 had no socks or shoes on at the time of the fall. A review of R19's EMR revealed a Incident note on 09/10/22 indicated that R19's recliner tipped upward resulting in her sliding onto the floor. The note indicated R19 could not figure out the recliner buttons and slid out of the chair onto the floor. The note indicated that R19 had no injuries and the resident representative was notified. The note indicated that the representative informed staff that she knew how to use the chair lift recliner. The note included an intervention to provide resident education on recliner use and encourage R19 to use the call light. A review of R19's EMR on 02/02/23 revealed no documentation of education or safety risk assessment for the use of the electric lift- reclining chair. A review of R19's EMR revealed an Incident note dated 10/14/22 indicated that R19 was found on her floor next to her bed in a pool of urine due to an incontinence episode. The note indicated the R19 tripped over a fan cord attempting to go to the restroom. The note listed that staff should ensure her floor is free from clutter, educate R19 to call for assistance, and remind her to wear socks and shoes when walking. R19's EMR lacked evidence staff implemented personalized interventions in order to prevent future falls. On 01/31/23 at 10:49AM R19 reported that she has fallen out of her chair a few times but could not remember if she received education on how to use the remote. She stated that the facility did label the remote after she had slid out of the chair onto the floor. R19 was in her bed reading a book. R19's lift recliner chair sat opposite of her bed. The chair had the brown (slick) covering still on it. On 02/02/23 at 01:36PM in an interview with Certified Medication Aid (CMA) R, she stated that direct staff have access to review the residents care plan. She stated that the resident should be monitored and assisted based on the level of care listed within the care plan. She stated that direct care can tell the nurse if a change is needed for care or the resident does not maintain the level of care listed in the care plan. She stated that all resident should have education provided on how to use the recliner/lift chairs but not sure where it would be documented. On 02/02/23 at 02:20PM in an interview with Licensed Nurse I, she stated that residents should not use the electric chairs until given education but not sure where it was documented. She stated that all staff have access to the care plans and can view it when needed. She stated that he was familiar with some of the residents sliding out of their chairs and stated that the facility would educate them on how to use the remotes. She stated that R19 is more independent and sometimes does not ask for help before transferring or walking. A review of the facility's Fall Prevention policy revised 09/2018 indicated that residents will be provided services and care that ensures the environment remains free from accident hazards and adequate supervision to prevent accidents. The policy noted that every team member is responsible for checking the resident's education care plan and ensuring the interventions are in place. The policy noted that assessments, interventions, and education will be used to provide a fall reduction program for each resident. The facility failed to provide individualized fall interventions to prevent R19's repeated falls. This deficient practice placed both residents at risk for preventable accidents and related injuries. - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of chronic fatigue, dysphagia (difficulty swallowing), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), diverticulitis (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), acute kidney failure, and need for assistance with personal care. R28's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated that she required extensive assistance from two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS indicated that she had a history of falls before her admission but no falls since being admitted . R28's Fall Care Area Assessment (CAA) completed 01/30/22 noted she had a history of falls, a foley catheter (tube inserted into the bladder to drain urine into a collection bag), and wound vacuum tubing. The CAA noted she had an assessment score of 13 indicating a high risk for falls. A review of R28's Care Plan initiated 01/18/23 for Falls indicated she was at risk for falls related to poor balance, impaired mobility, and weakness. On 01/28/23 an intervention for a fall was created for staff to reassess R28's ability to safely use her electric/lift recliner chair. A review of R28's EMR under Health Status revealed a note on 01/28/23 that R28 was found by dietary staff lying on her right side in front of the recliner on the floor. The note indicated that the recliner was positioned in the high (all the way forward) position indicating the resident slid off it. The note indicated that the slick brown cover of the recliner was removed, and the resident was placed back on it. R28 reported in the note that she messed up with the recliner remote and fell . A review of R28's EMR on 02/02/23 at 08:00AM revealed no safety risk assessment or documented education for her lift recliner. On 02/01/23 at 09:01AM R28 stated that she did have a fall out of her recliner but not sure what caused it. She was not sure if she received education on how to use it safely upon admitting to the facility. The recliner sat next to her bed. The slick brown cover was removed. She stated that she currently felt safe using the chair but not sure if she had training before she fell . On 02/02/23 at 01:36PM in an interview with Certified Medication Aid (CMA) R, she stated that she has heard of the resident sliding out of the electric recliners but has not seen it. She stated that the residents with the chair are supposed to be assessed before the use the recliner for safety but did not know where it was documented. She stated that R28 sometimes forgets her limitations and can has fallen before. She stated that the residents should not be using the recliners until they are shown how to use them, and the nurse assesses them. On 02/02/23 at 03:10PM in an interview with Administrative Nurse D, she stated that staff were expected to monitor residents on one to one assistance at all times during cares. She stated that the resident should be assessed for safety related to the electric recliners. She stated that the assessment should be in the EMR under Lift Recliner Assessment. A review of the facility's Fall Prevention Protocol dated 09/2018 indicated that all resident will be assessed for safety within their environment for accident hazards. The policy noted the all casual risk factors for falling will be assessed and care planned with interventions appropriate to the situation. The policy noted that the use all assistive devices will be assessed for safety and appropriateness to each resident's function. The facility failed to ensure R28 could safely maneuver the controls of her electric lift recliner resulting in a non-injury fall. This deficient practice placed R28 at risk for preventable fall and injuries. -The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement), acute kidney failure, and history of total knee replacement surgery. R44's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS indicated that he required limited assistance from one staff for transfers, bed mobility, dressing, personal hygiene, toileting, and bathing. The MDs indicated no falls. A review of R44's Activates of Daily Living (ADLs) Care Area Assessment completed 11/07/22 noted he had been hospitalized due to progressive weakness and being unable to get out of his recliner. The CAA noted that staff would assist him as needed. R44's Falls CAA completed 11/07/22 noted that he was a fall risk related to his urinary incontinence, use of assistive devices, and cognitive impairment. The CAA noted his Fall Assessment score was 18 indicating a high fall risk. A review of R44's Care Plan for Falls initiated 10/27/22 instructed staff to encourage him to use his call light. On 11/14/22 a new intervention was added to R44's plan for staff to provide instructions and education to R44 related to safe measures but did not state what those measures were. A review of R44's Care Plan for ADLs initiated 10/27/22 indicated that he required one to one moderate assist for transfers, ambulation, dressing, grooming, toileting, and bathing. The plan noted the he required a gait belt with all transfers. A review of R44's Fall Assessment completed on 10/28/22 revealed a score of 18 indicating he was a high risk for falls. A review of R44's Fall Assessment completed on 11/09/22 revealed a score of 22 indicating he was a high risk for falls. A review of R44's Fall Assessment completed on 11/15/22 revealed a score of eight indicating a low to moderate risk for falls. The assessment did not accurately account for R44's safety awareness and judgement, incontinence, unstable gait, fall history, and medications which caused his fall risk to lower. A review of R44's EMR revealed a Health Status note dated 11/4/22 that indicated R44 was found by staff laying on his stomach with his right arm underneath him on the floor. The note revealed his head was directly underneath the air conditioning unit. The note revealed R44 did not have socks or shoes on. The note revealed R44 had an abrasion to the left side of his forehead and one on his knee. The note revealed that R44 was trying to turn down the room's heater. R44's EMR lacked evidence interventions were implemented as a result of the fall to prevent future falls. R44's EMR revealed a Health Status note on 11/08/22 indicated that R44 was found by staff sitting on the floor outside of his bathroom with his pants unbuttoned. R44's walker was found inside his bathroom. He was not wearing slippers or non-skid socks. The note revealed that R44 was not sure what he was doing at the time of his fall. R44's EMR lacked evidence a root cause analysis was completed or interventions implemented to prevent future falls. On 02/02/23 at 01:36PM Certified Medication Aid (CMA) R noted that direct staff have access to review the residents care plan. She stated that the resident should be monitored and assisted based on the level of care listed within the care plan. She stated that direct care can tell the nurse if a change is needed for care or the resident does not maintain the level of care listed in the care plan. She stated that during each fall episode the direct care staff will notify the nurse immediately. She stated that staff will stay with the resident until help arrives and then assist the nurse. On 02/02/23 at 02:20PM Licensed Nurse H stated that all resident will receive a fall assessment upon admission and then another assessment two weeks later. She stated that assessments should be completed every year, quarter, and after a change or fall occurs. She stated that fall assessments include reviewing a resident's previous falls, diagnoses, level of assistance, and recent changes in cognition. She stated that she does not look at the resident's previous fall assessments she just reviews their current status as the assessment is being completed. She stated that if a significant change occurs in the resident risks, she would notify the interdisciplinary team (IDT). She stated that nurses can review the care plans and make suggestions for new interventions to the IDT. On 02/02/23 at 02:50PM Administrative Nurse E stated that the facility's MDS assessment use the data collected from nursing assessments (including fall assessments) the provide care plans and information that drives the resident's care. She stated that inaccurate data could completely change the care a resident receives. A review of the facility's Fall Prevention policy revised 09/2018 indicated that residents will be provided services and care that ensures the environment remains free from accident hazards and adequate supervision to prevent accidents. The policy noted that every team member is responsible for checking the resident's education care plan and ensuring the interventions are in place. The policy noted that assessments, interventions, and education will be used to provide a fall reduction program for each resident. The facility failed to provide individualized fall interventions to prevent R44's repeated falls. This deficient practice placed both residents at risk for preventable accidents and related injuries. 41037 - R29's Electronic Medical Record (EMR) recorded diagnoses of cerebral infarction (stroke- occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia and hemiparesis following cerebral infarction (weakness or the inability to move on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). R29's Admission Minimum Data Set (MDS) dated [DATE] Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. She had verbal behaviors directed towards others for one to three days of the look back period. Significantly interfered with her participation in activities and significantly intruded on the privacy or activity of others and disrupted cares and the living environment. R29's Quarterly MDS dated [DATE] recorded R29 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R29 required extensive assistance of one to two staff for most activities of daily living (ADL), extensive assistance of two staff for bed mobilty, but was totally dependent on two staff for toileting and transfers. The MDS recorded R29 had no behaviors. The MDS recorded R29 was frequently incontinent of urine but was continent of bowel. The MDS documented R29 had trialed a toileting program since admission but was not currently on a toileting program. R29 had two or more falls since the previous assessment, one with injury. The MDS documented r29 received an antipsychotic medication (medication used to treat major mental disorders), an antidepressant (medication used to treat depression) and a diuretic (medication which promotes the formation and excretion of urine) all seven of the look back days. The MDS documented a gradual dose had been attempted on 11/14/22. The Falls Care Area assessment dated [DATE] recorded R29 had potential for falls due to a history of falls. Use of psychotropic (alters mood or thought) medication and stroke issues. She had cognitive impairment. Her fall assessment score was 13. The CAA documented R29 did not ambulate and required two staff assist with transfers with a gait belt and she sued a wheelchair for mobility. The Care Plan documented R29 had safety/fall risk due to impaired mobility. The plan recorded interventions dated 08/29/22 which directed staff to assure lighting was appropriate, encourage family participation, encourage resident to sue the call light for staff assistance, An update was added on 11/08/22 which directed staff to place a fall mat at the bedside and recorded the resident would work with therapy to gain strength and balance. An update on 12/29/22 directed staff to place a body pillow on R29's right side when she was in bed. The Care Plan dated 08/29/22 recorded R29 required extensive assistance with ADL. The plan lacked direction to staff on the amount of assistance required for bed mobility but an intervention dated 08/2922 directed staff R29 required two staff assistance for transfers and directed staff to encourage R29 to stand up tall and look up and to allow R29 time to do it. A Health Status Note dated 01/13/23 at 06:52 AM documented at 06:30 AM the Certified Nurse Aide (CNA) requested the nurse to come to the resident's room. The CNA stated that she was attempting to sit R29 up on the edge of the bed and when she did, the resident slid off the bed onto the floor on her buttocks. The bed was locked and in mid position. The resident had socks and slippers on. R29 denied pain. The nurse assessed R29 and no apparent injuries were observed. R29's pupils were round and reactive to light. The resident was alert per her normal. R29 was able to move extremities through full range of motion. The note recorded staff would pass on to day shift nurse to notify Consultant HH's office when the office opened per protocol. Staff notified R29's representative. The note recorded the fall was witnessed, and the resident did not hit her head. Staff would assess orthostatic blood pressure for three days. The facility was unable to provide an investigation or witness statement from the CNA present during the attempted transfer and fall. On 02/01/23 at 09:15 AM R29 sat in a wheelchair, next to her bed with a bedside table in front of R29. She had a soft touch call light on the bedside table. On 02/02/23 at 01:40 PM Certified Medication Aide (CMA) R stated R29 had a few falls and interventions in place for R29 was toileting every two hours and body pillow in bed when R29 was in her bed. CMA R stated the frall interventions should be listed on the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change). On 02/02/23 at 01:55 PM Licensed Nurse (LN) G stated all the fall interventions for R29 would be listed on the Kardex for all the staff caring for her would be able to review. LN G stated the nurse would complete a fall assessment after each fall and place a new intervention on the resident's Care Plan. LN G stated the administrative staff would review the fall documentation and interventions. On 02/02/23 at 03:37 PM Administrative Nurse D stated the MDS coordinator would print the last 24 hour progress note entries for each resident in the facility and the administrative team reviewed the notes every morning meeting. Administrative Nurse D stated the administrative team reviewed every fall and any new interventions to ensure the Care Plan was updated and no neglect or abuse occurred. Administrative Nurse D stated was not sure if R29's Care Plan was currently up to date, the administrative team was reviewing resident's Care Plans every Wednesday. A review of the facility's Fall Prevention Protocol dated 09/2018 indicated that all residents will be assessed for safety within their environment for accident hazards. The policy noted all casual risk factors for falling will be assessed and care planned with interventions appropriate to the situation. The policy directed the interdisciplinary team would develop a plan for services to improve or maintain the resident's standing and sitting balance and other interventions to reduce resident's risk for falls. The plan would include specific, individualized information about the resident's routines and habits. The policy stated every team member was responsible for checking the care plan of the residents who were at risk for falls when beginning each day and throughout the assigned shift. The facility failed to ensure staff followed the R29's plan of care which included her need for extensive assistance of two staff for transfers and which lacked direction on bed mobility which resulted in a fall for R29. The facility further failed to investigate the occurrence, identify causal factors and implement relevant interventions related to the fall. This placed the residnet at risk for further falls and related injuries.

The facility reported a census of 66 residents and the sample was 6. Based on observation, record review, and interview the facility failed to provide supervision for 1 (#2) resident with a low blood sugar who fell and received multiple fractures and failed to prevent a cognitively impaired resident (#1) from leaving the facility unsupervised. Findings included: - Resident #2's closed record revealed a quarterly Minimum Data Set (MDS) 3.0 dated 4/21/13 which recorded the resident with a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment and required limited assistance with bed mobility, transfer, dressing and extensive assistance with toileting and personal hygiene. The Care Area Assessment (CAA) dated 10/19/12 for falls recorded the resident had the potential for falls due to use of psychoactive medications, on narcotic medications, used assistive device, had oxygen tubing, and had urinary incontinence. The care plan dated 4/21/13 recorded the staff would monitor for signs of [DIAGNOSES REDACTED], (low blood sugar) including nervousness, sweating, weakness, palpitations and trembling. Monitor for signs of hyperglycemia, (high blood sugar) including increased thirst and urination, blurred vision, weight loss, and dry mouth or skin. The care plan also indicated the resident needed stand by assistance with transferring safely in and out of chairs. The resident had a history of [REDACTED]. A fall risk assessment on 1/19/13 documented the resident was a low to moderate risk for falls. A nurse's note dated 5/21/13 at 3:56 A.M. documented the resident had increased confusion at 11:45 P.M. and a direct care staff told the nurse to go to the resident's room. The resident was noted on the floor face down in a pool of blood. The resident was very confused, diaphoretic, (sweating) and thrashing body around. Resident refused ice pack to his/her bloody nose. Blood sugar was tested at 52 (normal range was 60-100) and the resident drank a high calorie, high protein drink with encouragement. A nurse's note dated 5/21/13 at 8:30 A.M. revealed an order to send the resident to the emergency room . The emergency room (ER) report dated 5/21/13 at 2:57 P.M. documented the resident was diagnosed with [REDACTED]. A phone interview with direct care staff E on 6/3/13 at 4:14 P.M. stated he/she was with the resident on the night of 5/20/13. Staff E stated at 11:40 P.M. the nurse had asked this staff member to give the resident a health shake. He/she usually gave the shake and the resident had never had a problem with drinking them. Direct care staff E stated when he/she came back 10 minutes later the resident was mumbling to him/herself, eyes did not focus, the resident was shaking and he/she had not touched the shake. When he/she tried to get him/her to drink it he/she started to throw him/herself back. Staff E went to get the nurse to tell him/her that the resident was acting odd. He/she left the resident on the side of the bed because he/she had always sat on the side of the bed and was fine. About 5 minutes later when we walked back into the room the resident was on the floor in a puddle of blood from his/her nose. Staff helped get the resident cleaned up and encouraged him/her to drink a shake. The resident's blood sugar was checked and it was low at 52 so I went and got another shake and got the resident to drink it. The resident refused ice packs to his/her nose even though the bleeding had stopped. The resident stated he/she was not in any pain and did not say he/she wanted to go to the hospital. Interview with licensed staff D on 6/3/13 at 2:21 P.M. stated and would expect the resident to be assessed by the nurse he/she would expect the staff to put the call light on and not leave the resident when in that condition. The resident had a history of [REDACTED]. Interview with direct care staff H on 6/3/13 at 2:40 P.M. stated the resident did have low blood sugar reactions where he/she would rock his/her body back and forth and his/her whole body would shake. When this would happen this staff would push the call light and wait for someone to come and assist him/her. Staff H would not have left him/her there by him/herself when he/she was too unsteady. Interview with licensed staff I on 6/3/13 at 3:38 P.M. stated the resident had already fallen when the day shift had started and after the nurse gave staff report, he/she went to the resident's room. The first thing the resident said was that he/she wanted to go to the hospital. I called the doctor and got the order to send him/her to the ER. He/she had a history of [REDACTED]. If the resident was incoherent I would expect the staff to put the call light on and stay with the resident until help came. Interview with administrative staff A on 6/3/13 at 4:32 P.M. stated the aide told the nurse something was wrong with the resident and asked him/her to come and assess. I would not have expected the aide to do anything differently. The facility failed to provide supervision when this resident had a change in condition, and the resident fell and sustained multiple facial fractures and a fracture of the wrist. - Resident 1#'s quarterly Minimum Data Set (MDS) 3.0 dated 5/9/13 recorded the resident with a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. The MDS recorded the resident required limited assistance with all Activities of Daily Living (ADLs) and needed supervision with eating. The Care Area Assessment (CAA) dated 8/7/13 for behaviors recorded the resident had attempted to exit the building, and had swung at staff with his/her walker, attempting to hit staff with it. The CAA dated 8/7/12 for psychosocial well being recorded the resident wandered with his/her walker, and attempted to go out of the exit door one time. The care plan dated 5/3/13 recorded the resident's memory was poor, and he/she was on medication to help with agitation. Interventions in place were to calm the resident, to have staff talk in a low tone, offer to call the resident's children on phone, and to redirect with snacks, the resident loves ice cream. The care plan also indicated the resident was a potential fall risk and a risk for elopement. An elopement risk assessment dated [DATE] resulted in a high risk score of 11. An elopement risk assessment dated [DATE] resulted in a high risk score of 13. A nurses note dated 4/24/13 at 8:19 P.M. recorded on 4/23/13 at 7:20 P.M. this resident walked out the south exit door to look for his/her spouse. The resident walked around the building with his/her walker on the sidewalk to the front entrance. Observation on 5/30/13 at 3:15 P.M. revealed the south exit door was opened after a 15 second push on the door bar. This exit faced busy traffic with a speed limit of 35 miles per hour (mph). There is a fence that has opens to the driveway entrance of the building. Across this driveway is an unfenced pond. Observation on 6/3/13 at 9:03 A.M. revealed the resident sat in his/her recliner while he/she ate breakfast. Observation on 6/3/13 at 3:45 P.M. revealed the resident walked in the hallway with his/her walker, steadily at an average pace. Interview with the resident on 5/30/13 2:54 P.M. he/she stated I leave when they let me leave, I have family that visit sometimes. Interview with administrative licensed staff B on 5/30/13 at 1:58 P.M. stated the resident went out with a family member earlier in the day. At 7:20 P.M. the resident walked out the alarmed door while the staff were busy with other residents. By the time the door alarm was checked the resident had walked around the building, and the staff did not see anyone at the door, and went back to their jobs. The resident was a wander risk and his/her picture was posted at the nurses desk and reception's desk. Interview with administrative staff A on 5/30/13 at 2:29 A.M. stated we noticed the resident was more exit seeking after being out of the facility during the day. Interview with Administrative licensed staff C on 5/30/13 at 2:35 P.M. stated the intervention for this was an inservices for the employees. Not just peek out the door when the alarm sounded, but to go out and look around the building. Interview on the phone with secretary staff G on 6/3/13 at 11:16 A.M. stated while at the reception desk he/she received a phone call on 4/23/13 from a family member who just drove by the nursing home and was concerned because he/she saw an older person in the parking lot that did not have a coat on and it was chilly that night. (confirmed temperature of 44 degrees from the National Weather Service website) The staff saw the resident walking up the sidewalk with a walker towards the welcome center. The staff called for help and someone came right away. The resident was cold and confused, but physically seemed Ok. We have pictures of the elopement risk residents at the desk. Interview on the phone with direct care staff F on 6/3/13 at 11:40 A.M. stated when he/she came in from taking the trash out he/she heard the alarm sounding. Staff F went over to the panel and turned off the alarm and then walked to the door to look out. He/she did not see any one outside so he/she went back to work, and gave a shower. Many family members use that door and make the alarm sound all the time. That's the only door that sounds all the time. Interview with licensed staff D on 6/3/13 at 2:33 P.M. stated the resident was in independent living first and every time he/she went out for an appointment the staff need to reorient him/her to the resident's room. When the door alarms go off he/she checked the camera to see who was going out and if there was no one there he/she would have staff count face to face to make sure we were not missing anyone. Interview with direct care staff H on 6/3/13 at 2:40 P.M. stated the resident was considered an elopement risk. When his/her family came in and visited, then they left, he/she would want to go with them. When a door alarm goes off, staff H would go immediately find which door it was. The alarm going off was always the south door because that's the one the visitors use, and its not locked. Interview with Administrative staff A on 6/3/13 at 4:32 P.M. stated the staff were with other residents. My expectation would be for the staff to take a head count after an unexplained door alarm sounded to make sure all residents were accounted for. The undated facility elopement policy documented if a resident was not discovered outside after an alarm sounded, a head count of all residents will be completed to account for all the residents. The facility failed to follow the facility policy for elopement and failed to ensure the safety and supervision of this cognitively impaired resident who left the facility without staff knowledge.

The facility had a census of 60 residents of which 4 were sampled. Based upon observation, record review and interview the facility failed to provide supervision to prevent falls for 3 (#1, #2, #3) of the 4 sampled residents. Findings included: - Resident #1's current medical [DIAGNOSES REDACTED].(a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, forward flexion of the trunk, loss of postural reflexes and muscle rigidity and weakness), and vascular dementia (progressive mental disorder characterized by failing memory, and confusion). The resident's significant change Minimum Data Set 3.0 ((MDS) dated [DATE] identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS recorded the resident required limited staff assistance with walking in the room and totally dependent upon staff for locomotion on/off the unit. The MDS coded the resident was unsteady and could only stabilize with human assistance when moved from seated to standing position, walking, moving on and off the toilet, and surface to surface transfers. The MDS identified the resident was frequently incontinent of urine and had 1 non major injury fall and 1 major injury fall since the prior assessment. The resident's urinary incontinence Care Area Assessment (CAA) dated 11/14/12 included the resident was frequently incontinent of urine, the resident required staff assistance with toileting and transfers and staff prompted the resident to toilet approximately every hour plus or minus 30 minutes. The resident's fall CAA dated 11/14/12 documented the resident had several falls the past 2 to 3 weeks, one fall resulted in a fractured right humerus (arm) and the resident continued to be at a fall risk due to bowel and bladder incontinence, the use of psychoactive medication and a [DIAGNOSES REDACTED]. The resident's fall risk assessment dated [DATE] identified the resident scored 15 (high risk for falls). The resident's fall risk assessment dated [DATE] the resident scored 4 (low to moderate fall risk) and on 10/28/12 the resident scored 16 (high risk for falls). The facility performed a voiding diary from 10/31/12 through 11/2/12. Further review of the resident's clinical record lacked evidence the facility analyzed the data to determine the resident's voiding pattern. The resident's care plan dated 7/21/11 addressed the resident was at risk for falls. Interventions prior to 10/27/12 included 1 staff transferred the resident using a gait belt, staff propelled the resident in the wheelchair, and staff prompted the resident to toilet approximately every 2 hours and per the resident while the resident was awake, and the resident activated the call light at night. Review of the facility's fall interventions effective 12/3/12 included: staff implemented orthostatic blood pressure checks (blood pressure drops suddenly when a person stands up or stretches) each shift for 3 days; performed a complete blood count and chemistry basic panel; copied a list of medications so the provider could review the resident's medications and comment on findings on his/her next rounds; staff informed the physician of the last therapeutic level if residents were on medications that required therapeutic drug levels; staff notified the nurse on call, and staff entered the resident's vitals in the resident's clinical record. Further review of the fall interventions included staff would choose 1 or 2 appropriate interventions. Interventions included 3 day voiding diary to determine continence changes, staff assistance, and low bed. A nurse's note dated 10/27/12 timed 3:40 P.M. documented the resident laid on the floor in front of the sink in his/her room and staff observed the resident had a skin tear on his/her right arm that measured 7 centimeters (cm), bruising on the back of his/her right arm that measured 10 cm by 3 cm, bruise on his/her right thumb that measured 3 cm x 4 cm, and a bruise on his/her left elbow that measured 2 cm x 2 cm. A nurse's note dated 10/28/12 timed 1:52 P.M. documented that at approximately 1:00 P.M. the resident sat on the floor in his/her room. The resident stated he/she went to the bathroom and was going to bed and fell . The note included staff observed a bump on the resident's right arm and at 1:15 P.M. staff transferred the resident to a local emergency (ER) for a right arm displaced fracture (broken bone). A nurse's note dated 10/28/12 timed 4:40 P.M. documented the resident returned from the ER with a splint and sling on his/her right arm and the resident was not a surgical candidate. Interventions added to the resident's plan of care on 10/28/12 included 1 staff assisted the resident with activities of daily living and transfers and the pharmacist would review the resident's medications. A nurse's note dated 10/31/12 and timed 2:41 P.M. documented that at approximately 1:20 P.M. a therapist called down the hall and said the resident was on the floor. The note included the resident was positioned on his/her back, the resident's feet were next to his/her bed and the resident's head was in the middle of his/her room. The note included the resident stated he/she sat on the side of his/her bed, slid off to the floor and hit his/her head falling backwards. The note included the intervention that staff would offer to toilet the resident every hour. On 10/31/12 the facility added the intervention that staff provided hourly visual check and offered to toilet the resident to the resident's care plan. On 11/5/12 the facility added the intervention for staff to place the resident in the lobby area by the nursing station for frequent visual observation when the resident became restless. A nurse's note dated 11/6/12 timed 5:45 P.M. documented staff alerted the nurse the resident was on the floor. The note included the resident laid on the floor on his/her left side, the resident's knees were bent, staff placed the resident in a wheelchair and placed the resident by the nurses' desk for observation. A nurse's note dated 11/7/12 timed 11:39 A.M. documented the investigation into the resident's fall in his/her room on 11/6/12 the resident told staff the reason he/she fell was because he/she was bored and wanted to go across the hall to see his/her friend. The note included the intervention for the resident to visit his/her friend before and after supper each day. A nurse's note dated 12/9/12 timed 3:06 P.M. documented staff observed the resident in the doorway of his/her bathroom and noted an abrasion on the resident's right elbow that measured approximately 1/2 inch long. On 12/9/12 the resident's care plan included staff assessed the resident for signs/symptoms of a urinary tract infection. A nurse's note dated 12/12/12 timed 3:50 P.M. documented that at 2:55 P.M. staff observed the resident on the floor in his/her room and interventions included staff assessed the resident's room for safety and ensured the paths were clear. A nurse's note dated 12/25/12 timed 3:52 P.M. documented staff observed the resident on the floor in his/her bathroom, the resident's buttock in front of the toilet and the resident was fully clothed. The note included the resident stated he/she tripped on the trash can in his/her bathroom, bumped his/her right side (rib cage) and complained of pain to that area. The note included the incident occurred at 2:45 P.M. The note included the facility received a physician's orders [REDACTED]. A nurse's note dated 12/25/12 and timed 6:36 P.M. documented x-ray staff telephoned the facility and informed them the resident's eight and ninth right lateral ribs were fractured (broken). Fall interventions dated 12/25/12 included the resident's physician made medication changes to the resident's regimen, the facility re-educated staff regarding the resident's fall/safety interventions placed on the resident's Kardex and staff toileted the resident before and after meals and as needed. On 1/17/13 at 9:15 A.M. the resident sat in the wheelchair in his/her room. During interview with the resident at that time the resident stated several times he/she needed to punch a time card at 8:00 A.M. On 1/17/13 at 10:00 A.M. and 10:50 A.M. the resident sat in the wheelchair in his/her room. On 1/17/13 at 12:30 P.M. the resident sat in the wheelchair at the dining room table. On 1/17/13 at 12:40 P.M. consultant staff M wheeled the resident from the dining room to his/her room. At 12:42 P.M. observation revealed the resident in a low bed. Further observation revealed the resident had green tape around the handle of his/her wheelchair. During interview with consultant staff M at that time he/she stated he/she did not toilet the resident. Consultant staff M stated the resident was continent of urine during the day, incontinent of urine during the night and was able to state when he/she needed to urinate. On 1/18/13 at 9:10 A.M. direct care staff K ambulated with the resident from the dining room to the resident's room. Direct care staff K assisted the resident in the recliner and did not toilet the resident. During interview with direct care staff K at that time staff stated his/her first day on the unit was 1/15/13 and he/she did not know the resident's toileting schedule. On 1/17/13 at 1:50 P.M. licensed nurse E stated all residents at risk for falls had a low bed, and green tape on the handle of his/her wheelchair or on his/her walker. On 1/17/13 at 2:30 P.M. licensed nurse D stated the resident was at risk for falls, and staff toileted the resident before and after meals. Licensed nurse D stated residents at risk for falls had a low bed, and green tape on the handle of his/her wheelchair or on his/her walker. On 1/17/13 at approximately 4:00 P.M. direct care staff O stated staff toileted the resident every 2 hours. On 1/18/13 the resident sat in the recliner in his/her room at 9:15 A.M. and 9:30 A.M. On 1/18/13 at approximately 10:30 A.M. the resident's friend (an alert and oriented resident) stated staff had not brought the resident for his/her visit this A.M. During interview with nursing administrative staff C on 1/18/13 at approximately 10:45 A.M. staff stated the resident was at risk for falls, utilized a low bed and staff toileted the resident before and after meals. Nursing administrative staff C stated the facility recently developed fall interventions for all residents. Administrative staff C stated the facility performed 3 day voiding patterns upon admission, annually and after a resident experienced a significant change. Administrative staff C stated the facility compared the data from the most current voiding diary to the previous diary and did not always complete a new continence evaluation. During interview with administrative staff A on 1/18/13 at approximately 11:00 A.M. staff stated one of the interventions the facility had in place to minimize the resident's falls was for the resident to visit his/her friend once a day before supper. After checking the resident's care plan administrative staff A confirmed the care plan included the resident was to visit his/her friend before and after supper each day. The facility failed to provide interventions as planned for this cognitively impaired resident with a history of falls which resulted in a fractured right arm and fractured ribs. The facility failed to toilet the resident after meals, failed to analyze the data of the 3 day voiding diary, failed to ensure the resident visited his/her friend, and failed to provide assistance with transfers adn ADL's as planned. - Review of resident #2's Physician order [REDACTED]. The resident's admission Minimum Data Set 3.0 ((MDS) dated [DATE] identified the resident scored 1 (severely impaired cognition) on the Brief Interview for Mental Status, the resident was independent with bed mobility, transfers, and walking in the room/corridor, required staff supervision with locomotion on/off the unit, dressing, personal hygiene and toilet use. The MDS recorded the resident as unsteady but able to stabilize without human assistance when moved from seated to standing position, turning around and facing the opposite direction while walking, moving on/off the toilet, and surface to surface transfers. The MDS coded the resident utilized a walker, was occasionally incontinent of urine, and had not fallen since admission/reentry or prior assessment. The resident's urinary Care Area Assessment (CAA) dated 12/4/12 documented the resident was occasionally incontinent of urine, was able to take himself/herself to the bathroom but sometimes notified staff he/she needed to use the bathroom. The CAA included staff assisted the resident with pericare as needed and the facility would not develop a urinary incontinence care plan for the resident. The resident's fall CAA dated 12/4/12 documented the resident utilized a walker and the nurse's note dated 11/27/12 included the resident ambulated with a walker and the resident's gait was strong and steady. The resident's fall risk assessment dated [DATE] identified the resident scored 4 (low to moderate fall risk). The resident's fall risk assessment dated [DATE] identified the resident scored 20 (high risk for falls). The resident's clinical record revealed the facility performed the resident's 3 day voiding diary from 11/24/12 through 11/26/12. Further review lacked evidence to support the facility analyzed the data from the 3 day voiding diary to determine the resident's voiding pattern. The resident's fall care plan initiated on 11/16/11 included staff assisted the resident with transfers and mobility as needed and monitored the resident for functional decline. Review of the facility's fall interventions effective 12/3/12 included: staff implemented orthostatic blood pressure checks (blood pressure drops suddenly when a person stands up or stretches), each shift for 3 days; performed a complete blood count and chemistry basic panel; copied a list of resident's medications so the provider could review the resident's medications and comment on findings on his/her next rounds; staff informed the physician of the last therapeutic level if residents were on medications that required therapeutic drug levels; staff notified the nurse on call, and staff entered the resident's vitals in the resident's clinical record. Further review of the fall interventions included staff would choose 1 or 2 appropriate interventions. The interventions included 3 day voiding diary to determine continence changes, staff assistance, and low bed. A nurse's note dated 12/8/12 and timed 7:33 P.M. documented that at approximately 6:00 P.M. the resident attempted to sit in a chair next to the medication cart and fell on to his/her buttock. A nurse's note dated 12/8/12 and timed 10:00 P.M. documented at approximately 9:30 P.M. the resident laid on his/her right side inside the doorway of his/her room, the resident stated he/she attempted to go to the restroom, and staff observed a knot on the resident's forehead. The note included staff wrote a physician's orders [REDACTED]. The care plan listed the intervention dated 12/8/12 for staff to offer toileting before bedtime. A nurse's note dated 12/9/12 and timed 6:20 A.M. documented the resident complained of chest pain and the facility transferred the resident to a local emergency room (ER) for evaluation and treatment. A nurses's note dated 12/9/12 and timed 11:45 A.M. documented the resident returned to the facility with [DIAGNOSES REDACTED]. A nurse's note dated 12/11/12 and timed 7:21 A.M. documented at 5:50 A.M. the resident laid on the floor, and the facility transferred the resident to a local ER. The care plan listed the intervention dated 12/11/12 that the physician would review the resident's medications. A nurse's note dated 12/22/12 and timed 11:28 A.M. documented the resident was on the floor and the resident's legs extended into the hallway. The note included the resident complained of left shoulder and lower back pain. The note included the facility ordered a CBC, BMP and initiated orthostatic blood pressures per facility protocol. A nurse's note dated 1/3/13 and timed 7:44 P.M. documented the resident was alert to person only, propelled self independently via his/her wheelchair, staff also assisted the resident with mobility, the resident ambulated with 1 to 1 staff assistance, the resident's gait was slow, unsteady at times and the resident was continent and incontinent of urine. A nurse's note dated 1/7/13 A.M. documented at 5:00 A.M. the resident sat on the floor mat next to his/her bed, the resident was unable to state why he/she sat on the mat due to short term memory loss and dementia, the resident was incontinent of urine, and staff assisted the resident to the bathroom. A nurse's note dated 1/10/13 and timed 10:18 A.M. documented the facility completed the investigation of the resident's fall on 1/7/13 at 5:00 A.M. and intervention included staff would toilet the resident at 5:00 A.M. A nurse's note dated 1/10/13 and timed 7:25 P.M. documented the resident was alert to person only, utilized the wheelchair, staff assisted the resident to propel the wheelchair, the resident ambulated short distances independently, and the resident's gait was slow and unsteady at times. The note included the resident required frequent nursing observation due to being impulsive at times and attempted to ambulate without nursing assistance. The resident's clinical record lacked evidence the facility thoroughly assessed the causal factors of the resident's falls. On 1/17/13 at 9:15 A.M., 10:00 A.M. ,10:50 A.M., 11:15 A.M. and 11:30 A.M. the resident sat in his/her wheelchair in the activity room of the facility. At 11:30 A.M. observation revealed the resident non-interviewable. At 11:32 A.M. the resident propelled himself/herself from the activity room to the dining room. Further observation revealed green tape on the handle of the resident's wheelchair. On 1/17/13 at 2:30 P.M. direct care staff H and P transferred the resident from the wheelchair to the toilet. During interview with direct care staff H at that time staff stated the resident was probably continent because direct care staff I toileted the resident at approximately 2:00 P.M. Direct care staff H stated the resident had declined in the last couple of weeks, now utilized a wheelchair, was incontinent of urine and required staff assistance with toileting. Observation on 1/18/13 at 7:40 A.M. revealed the resident had a low bed and a fall mat was in the resident's room. On 1/18/13 the resident sat in his/her wheelchair at the dining room table at 7:30 A.M., 7:45 A.M., 8:00 A.M. 8:15 A.M., 8:30 A.M., 9:00 A.M., 9:15 A.M., and 9:30 A.M. At 9:40 A.M. staff transferred the resident from the dining room to the activity room. On 1/17/13 at 1:50 P.M. licensed nurse E stated all residents at risk for falls had a low bed, and green tape on the handle of his/her wheelchair or on his/her walker. During interview with nursing administrative staff C on 1/18/13 at approximately 10:45 A.M. staff stated the resident was at risk for falls, one of the falls resulted in the resident fracturing his/her finger, the resident utilized a wheelchair and walker, the resident had experienced a decline in ambulation and urinary incontinence and confirmed the resident's care plan did not reflect the resident's decline in ambulation and urinary incontinence. The facility failed to timely assess and provide effective interventions for the prevention of falls for this resident with a history of falls that resulted in a fracture. - Review of resident #3's current computerized list of medical [DIAGNOSES REDACTED]. The resident's significant change Minimum Data Set 3.0 ((MDS) dated [DATE] identified the resident scored 6 (severely impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and totally dependent upon staff for locomotion on/off the unit. The MDS identified the resident was unsteady and only able to stabilize with human assistance when moved from seated to standing position, on/off the toilet, and surface to surface transfers and had fallen once since the last assessment. The resident's fall Care Area Assessment (CAA) dated 12/19/12 included the resident required the assistance of 2 staff with transfers with a gait belt, the resident utilized a low bed, and a fall mat next to his/her bed. The CAA included the resident fell on [DATE], and was at risk for further falls due to a decrease in his/her cognitive/physical status and impulsivity. The resident's fall risk assessment dated [DATE] identified the resident scored 16 (high fall risk). The resident's fall risk assessment dated [DATE] identified the resident scored 17 (high risk for falls). The resident's fall care plan initiated on 5/16/12 included the resident was at risk for falls and staff assisted the resident with transfers and mobility. A nurse's note dated 5/31/12 and timed 8:14 P.M. documented the resident sat on the floor beside his/her bed and staff observed the resident had a skin tear on his/her right lower arm that measured 5 centimeters (cm). The note included the resident stated he/she attempted to transfer himself/herself into his/her wheelchair. A nurse's note dated 6/4/12 timed 11:17 A.M. documented the resident fell twice on 5/31/12; at 4:00 P.M. and 4:45 P.M. The note included at 4:45 P.M. the resident reached for his/her telephone which was on the floor and the intervention included staff ensured the resident's telephone was within reach. A nurse's note dated 6/26/12 timed 4:27 P.M. documented the resident laid in the middle of his/her room on his/her back, the resident had a skin tear on his/her nose that measured 4 cm, the resident's nose appeared broken and the resident had a lump on the central posterior of his/her head. The note included the facility transferred the resident to a local emergency room (ER). A nurse's note dated 6/27/12 timed 10:53 A.M. documented the resident returned to the facility at approximately 8:00 P.M. on 6/26/12 with a [DIAGNOSES REDACTED]. A nurse's note dated 9/20/12 and timed 6:26 P.M. documented staff left the resident unattended on the toilet in the south bathroom and the resident fell . The care plan revealed the intervention dated 9/21/12 that staff would not leave the reisdent unattended inthe bathroom. A nurse's note dated 11/14/12 and timed 12:00 P.M. documented the resident on the floor, the resident legs extended in front of him/her and the resident stated he/she was attempting to get situated. A nurse's note dated 11/15/12 and timed 11:33 A.M. documented the investigation of the resident's fall on 11/14/12 revealed the resident stated he/she was in bed prior to the fall, the resident attempted to remove his/her pants, and he/she fell . The intervention included staff would offer to remove the resident's pants prior to the resident napping. A nurse's note dated 11/19/12 and timed 12:06 A.M. documented staff found the resident on the floor. A nurse's note dated 11/21/12 timed 2:20 P.M. documented the facility completed the investigation regarding the resident's fall on 11/19/12 and the intervention included the facility would place a body pillow to aide in positioning when the resident was in bed. A nurse's note dated 11/25/12 and timed 12:29 P.M. documented staff observed the resident on the floor of his/her room and the resident stated he/she attempted to toilet himself/herself. The care plan revealed the intervention dated 11/25/12, staff would toilet the reisdetn prior to placing the reisdent in the recliner. A nurse's note dated 12/5/12 and timed 1:06 A.M. documented that on 12/4/12 at 8:25 A.M., staff found the resident on his/her knees facing his/her wheelchair, the resident was confused, staff observed the resident's right wrist had a fluid filled blister and his/her right knee had a light red area. The care plan revealed on 12/4/12 the facility started the resident on an antiiotic for a urinary tract infection. A nurse's note dated 12/9/12 and timed 4:41 P.M. documented the resident asked to go to the bathroom, the staff requested the assistance of another staff and when staff entered the resident's room, the resident was on the floor on his/her knees. The care plan lacked a new intervention after this fall. A nurse's note dated 12/16/12 timed 3:58 P.M. documented dietary staff observed the resident sitting on the fall mat beside his/her bed. The care plan lacked a new intervention after this fall. On 1/17/13 at 9:15 A.M. the resident sat in the high back wheelchair in his/her room. Further observation revealed green tape on the handle of the resident's wheelchair. On 1/17/13 at 12:50 P.M. direct care staff H and I transferred the resident from his/her wheelchair to the bed. Observation revealed the resident was fully dressed (jacket, shirt and pants), direct care staff H asked the resident if he/she wanted his/her jacket removed, but did not offer to remove the resident's pants as planned. Further observation revealed staff did not place a body pillow, as planned, after staff placed the resident in bed. Observation also revealed the resident's telephone sat on top of his/her television which was on the opposite side of the room and not within reach of the resident as planned. On 1/17/13 at 1:55 P.M. the resident remained in bed, the resident's telephone was not within reach and no body pillow in place as planned. On 1/18/13 at 8:10 A.M. and 9:00 A.M. the resident sat in the wheelchair in his/her wheelchair, and staff had not placed the resident's call light and telephone within reach. On 1/17/13 at 1:50 P.M. licensed nurse E stated all residents at risk for falls had a low bed, and green tape on the handle of his/her wheelchair or on his/her walker. Licensed nurse E stated the resident was at risk for falls. On 1/17/13 at 4:25 P.M. direct care staff J confirmed staff did not place a body pillow when the resident was in bed. On 1/18/13 at approximately 9:15 A.M. licensed nurse stated G stated the resident utilized a body pillow when napping. At that time licensed nurse entered the resident's room and confirmed there was no body pillow in the resident's room. On 1/18/13 at approximately 9:30 A.M. direct care staff I stated staff had not placed the body pillow when the resident napped for some time. During interview with nursing administrative staff C on 1/18/13 at approximately 10:45 A.M. staff stated the resident was at risk for falls, the resident's fall interventions included a body pillow, staff offered to remove his/her pants when napping and staff ensured the resident's telephone was within reach. The facility failed to place the body pillow as care planned to aid in positioning, failed to offer to remove the resident's pants and failed to ensure the resident's telephone was with reach for this resident with a history of falls and a fractured nose as planned.

The facility reported a census of 54 residents and the sample was 3. Based on observation, record review, and staff interview, the facility failed to provide interventions for the prevention of falls as planned for 1 (#3 ) out of 3 residents reviewed for falls. Findings included: - Resident #3 had [DIAGNOSES REDACTED]. The admission Minimum Data Set 3.0 with an assessment reference date of 2/6/12 recorded a Brief Interview for Mental Status ( BIMS) score of 5 (severely impaired), needed limited assistance with bed mobility and personal hygiene, needed extensive assistance with transfer and toileting, used a walker and a wheel chair, the test of balance recorded the resident was not steady when moving from seated to standing, with turning, when moving on/off toilet, and when transferring from surface to surface, only able to stabilize with assistance, was always incontinent of bladder, and frequently incontinent of bowel, had a fall history, and had a non- injury fall since admission. The Care Area Assessment (CAA) dated 2 /9/12 for falls recorded the resident had a history of [REDACTED]. The resident continued to be a potential for fall risk due to use of psychotropic medications, assistive devices, and with the [DIAGNOSES REDACTED]. The CAA dated 2/9/12 for incontinence recorded the resident needed extensive assistance with toileting and that the staff would check/change approximately every 2 hours during the day and every 4 hours at night. The CAA dated 2/9/12 for activities of daily living recorded the resident was currently receiving therapy , had a decline and had to move to long term care, was able to transfer self but was a high fall risk and needed assistance of 1 for safe transfers. The 3 day voiding diary started on 1/31/12 and finished on 2/2/12 was incomplete. The temporary care plan dated 1/31/12 recorded the resident needed assistance with transfers and dressing/grooming, had altered bladder function, initiated 3 day voiding diary, was a fall/safety risk, for the call light to be in reach, low boy bed, encourage family participation, floor mat, transfer 1:1 with gait belt , and used wheel chair and walker. The Comprehensive care plan dated 2/7/12 recorded the resident could transfer him/herself but needed stand by assistance for safe transfers. The care plan recorded the resident was incontinent of bladder/bowel and needed assistance with toileting, and for the staff to check/change the resident approximately every 2 hours +/- 30 minutes for incontinence during the day and every 4 hours at night. The care plan for safety/falls recorded "I have had recent falls and continue to be potential for falls due to use of psychoactive meds (medications), bowel/bladder incontinence and some cognitive impairments." Interventions included low boy bed with fall matt, and for the staff to not leave the resident alone in his/her room unattended. Nurses notes (NN) dated 1/31/12 at 3:00 P.M. recorded the facility admitted the resident , the resident used his/her walker short distances with 1:1 assist with gait belt, admitting [DIAGNOSES REDACTED]. The resident was incontinent of bowel/bladder, "but will also attempt to use bathroom," resident was 1:1 assist with transfer, dressing/toileting, and repositioning, had good long term memory, poor short term memory. NN dated 2/3/12 at 7:15 A.M. the staff found the resident sitting in an empty room on the floor next to wheel chair. The resident said he/she slipped out of bed which was in the highest position. The resident was undressed, had no injuries, was just confused. The Fall Reduction Intervention dated 2/3/12 recorded for the facility to identify the reason why the resident was getting up, to have the call light in reach, bed in lowest position, visual checks at specific time intervals (15 minute checks for 72 hours after a fall), and to redirect the resident. NN 2/4/12 the resident continued on fall precautions with 15 minute rounds. NN 2/19/12 at 2:45 P.M., the staff answered the resident's call light and the resident was sitting on the floor in his/her room in front of the wheel chair. The resident said he/she attempted to pick up the cordless phone on the bed, and slid out of the chair. No injury noted, the staff transferred the resident to the wheel chair and then took him/her to the activity room to watch TV. The Fall Reduction Intervention dated 2/19/12 recorded the new intervention to monitor closely during post fall period. NN 2/21/12 at 10:15 A.M. the staff found the resident at approximately 9:45 A.M. in another room on the floor next to the wheel chair, alert/oriented times 2 with redeveloped confusion. The resident had used the rest room. No injuries noted, the staff notified the physician with a new order for orthostatic blood pressures daily for one week. The Fall Reduction Interventions dated 2/21/12 recorded the facility requested medication dose reduction, and for the staff to toilet immediately when assisted to the room after meals, to assist to regular chair or bed when in room, and to monitor closely during post fall period. NN 2/21/12 at 9:00 P.M. the resident transferred with 1:1 assist, shaky on feet, alert/oriented x 3 with periods of confusion. The bed was in low position, call light in reach, staff encouraged the resident to use the call light, and sometimes he/she used it. Observation on 2/23/12 at 12:29 P.M. 12:39 the resident wheeled him/herself from the dining room to his/her room. Staff stopped him/her on the way to his/her room and asked the resident if he/she could give him/her a shower. At 12:50 P.M. the resident wheeled him/herself into his/her bathroom, and transferred to the toilet with the wheel chair in the door opening. The resident was alone in his/her room. At 12:55 P.M. the resident wheeled him/herself out of the bathroom, had only a brief on and was barefoot. The resident complained about urine odor in his/her bathroom, and on inspection the toilet was not flushed and there was bowel movement smear on the toilet seat. The resident said he/she was going to go to bed, the bed was in low position with floor mat in front, and the resident closed his/her door. At 1:20 P.M. direct care staff E entered the resident ' s room and the resident said he/she just got into bed. The staff checked the resident ' s brief that was soiled with bowel movement, and assisted the resident with use of a gait belt to the wheel chair and then to the bathroom after putting slippers on. Interview on 2/23/12 at 2:10 P.M. with direct care staff F said they try not to keep the resident in his/her room by him/herself, not let him/her wheel him/herself into his/her room by themselves, as the resident was new here and was still trying to transfer by him/herself. The staff said they encouraged the resident to use his/her call light, they got him/her into activities, and tried to keep him/her from falling. The facility failed to provide interventions as planned for this resident with a history of falls.

The facility had a census of 71 residents. The sample included 17 residents of which 5 were reviewed for bladder functioning. Based on observation, interview and record review the facility failed to improve or prevent decline in normal bladder function for one (#23) resident, and failed to assess and/or provide toileting as planned for 3 (#68, #120, #56) residents of the sample. Findings included: Resident #23 Physician's History and Physical dated 4/16/10,revealed [DIAGNOSES REDACTED]. The (MDS) Minimum Data Set 2.0 ,quarterly review dated 12/26/09 indicated the resident had memory loss, mental function varied over the course of the day. The MDS also indicated the resident required assistance with activities of daily living,and was occasionally incontinent of urine. The (RAPS) Resident Assessment Protocol dated 12/26/09,did not address the causative factors for the occasional incontinence. The 11/3/09 care plan indicated licensed nursing staff to do 72 hour bladder study quarterly and as needed. The care plan also indicated that staff should toilet the resident every 2 hours. The (MDS) Minimum Data Set 2.0,quarterly review dated 3/22/10,revealed the resident had memory loss and mental function varied over the course of the day. The MDS also indicated the resident required assistance with activities of daily living,was frequently incontinent of urine. The updated care plan dated 3/22/10 had no new interventions added to incontinence care plan. The (MDS) Minimum Data Set 2.0,quarterly review dated 6/14/10,indicated the resident had memory loss and mental function varied over the course of the day. The MDS also indicated the resident required assistance with activities of daily living,and was totally incontinent of urine. The updated care plan dated 6/14/10 had no new interventions added to the incontinence care plan. Frequent observations on 8/25/10 from 7:22 AM to 10:07 AM, (duration of 2 hours and 45 minutes) the resident sat in his/her wheelchair and staff did not assist the resident to the toilet. Observation on 8/25/10 at 10:07 AM revealed direct care staff A transferred the resident to his/her bed and removed the urine soaked incontinence brief. The staff did not attempt to toilet this resident. On 8/25/10 at 10:25 AM direct care staff A stated the staff do not attempt to toilet this resident,they only check and change him/her. Direct care staff O on 8/25/10 at 4:48 PM transferred the resident to his/her bed and removed a urine soaked incontinent breathe staff did not attempt to toilet this resident. On 8/25/10 at 5:10 PM interview with Licensed staff B indicated the staff only change the resident. The resident was usually wet and the staff should check and change the resident every 2 hours. On 8/26/10 at 7:59 AM interview with Licensed staff A indicated the staff developed the bladder plan for each resident by doing a 3 day voiding diary,the MDS coordinator developed a toileting plan and then care planned it. The staff did not complete a full 72 hour bladder study and lacked evidence of an assessment to determine the type of urinary incontinence. The clinical record lacked evidence the decline in incontinence was unavoidable. The facility failed to develop an individualized toileting plan to prevent decline in incontinence. - Resident #120 admitted to the facility, with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set, dated dated [DATE], identified the resident had a cognitive impairment, and memory problems with periods of [MEDICAL CONDITION] and disordered thinking. It identified the resident required extensive assistance for toileting, hygiene, and bathing, and identified the resident as occasionally incontinent of bowel and frequently incontinent of bladder. The resident assessment protocol summary, (RAPS) dated 7/22/10, documented incontinence as a problem, however the (RAPS), failed to address the causative factors for the incontinence. The care plan, dated 7/22/10, addressed toileting and incontinence and listed the interventions: monitor for signs and symptoms of urinary tract infections, perform a 72 hour bowel and bladder assessment with evaluation on admission, quarterly and as needed, [MEDICATION NAME] after each incontinent episode, staff assist with toilet use, and personal hygiene, staff will prompt toileting upon awakening, before and after meals, at bedtime and as needed. The clinical record revealed the resident was admitted with a foley catheter in place, due to a pressure ulcer located on the right and left inner buttocks. The clinical record revealed a bladder assessment on admission, noting the foley catheter, however, failed to evidence any further assessment after removal of the catheter on 7/28/10. On 8/26/10 at 1:58 P.M. licensed staff E validated, "Here is the voiding diary for when the resident was admitted . The resident came in with a catheter. We just did not do another voiding diary when the catheter was discontinued. We didn't update the care plan either, but we will right away." The 7/26/10 dated physician's orders [REDACTED]. Straight catheterize twice each day for residual until less than 200cc (cubic centimeters), then stop. Document in nurses medication administration record." Frequent observations, on 8/23/10, from 1:40 P.M. thru 4:45 P.M., revealed the resident in the recliner without an opportunity to toilet afforded to the resident. Frequent observations, on 8/24/10 from 8:14 A.M. thru 12:00 P.M., (duration of three hours and 46 minutes), revealed the resident in bed and staff did not toilet. The resident at 12:00 P.M. observation revealed the staff transferred the resident to the wheelchair and took to lunch without toileting. Frequent observations, on 8/24/10 from 1:30 P.M. to 4:30 P.M., (duration of three hours) revealed the resident in the recliner in the resident's room, and staff did not attempt to toilet the resident. At 4:30 P.M., the surveyor requested direct care staff do a skin check. Direct care staff K and L then proceeded to stand the resident up at the bedside, pull the residents pants down, state "he/she is dry" pull the resident's pants back up, and sat the resident in the wheelchair. Staff then took the resident to the restroom and placed them on the commode. Interview with direct care staff K and L revealed, "This resident is not on a toileting or repositioning program. " Frequent observations, on 8/25/10, from 6:55 A.M. thru 9:00 A.M., (duration of two hours and five minutes) revealed the resident laid in bed on his/her right side, and staff did not offer a toileting opportunity. On 8/25/10 at 9:22 A.M. observation of staff provided perineal care, revealed resident's brief saturated with urine, and the bed pad under the resident wet. Staff did not toilet the resident at this time. Frequent observations, on 8/26/10 from 7:01 A.M. thru 10:30 A.M., (duration of three hours and twenty nine minutes), revealed the resident positioned on the right side in the bed and staff did not toilet this resident. On 8/25/10 at 10:45 A.M., interview with direct care staff I stated, "I would normally change (him/her),... We just check (him/her) and change (his/her) brief. We don't try to toilet(him/her) because (he/she) fights too much". On 8/26/10 at 7:10 A.M., interview with licensed staff C, " We don't have anyone on a scheduled plan right now." On 8/26/10 at 7:50 A.M., interview with direct care staff D "We don't have anybody on a turning or toileting program right now." The facility failed to complete a comprehensive bladder assessment to determine this resident's individual toileting needs, and failed to provide toileting opportunities to promote urinary continence for this dependent resident as planned. - This deficient practice of not providing toileting as planned also affected resident #56. - Resident #68 had [DIAGNOSES REDACTED]. The 4/12/10 Annual Assessment MDS (minimum data set) revealed the resident had memory loss, moderately impaired cognitive skills for daily decision making, needed extensive assistance with activities of daily living, including total assistance with toileting, and was frequently incontinent of bladder. The 4/20/10 RAPS (Resident Assessment Protocol Summary) for bowel and bladder stated the " resident is toileted by staff and cleanliness of perineal area (is done) each time (the resident is) incontinent to avoid skin related problems " ... " (The resident is) frequently incontinent (and) pads (and/or) briefs (are) used. " The RAPS for ADL (activities of daily living) recorded total dependence for toilet use. These RAPS did not address the causative factors for the incontinence. The 7/5/10 Quarterly Assessment MDS revealed the resident had memory loss, moderately impaired cognitive skills for daily decision making, needed total assistance with activities of daily living, including toileting, was totally incontinent of bladder and was on a scheduled toileting plan. The clinical record lacked further assessment of the resident ' s urinary status including the type of incontinence, the frequency or pattern of the incontinence, or other factors which could contribute to the resident ' s urinary incontinence status. The facility ' s Bladder and Bowel assessment dated [DATE] indicated that the resident had multiple daily episodes (of bladder incontinence) with little or no control. The 7/1/10 Care Plan included interventions to " apply moisture barrier cream prn (as needed), cleanse perineal area with soap and water following each incontinent urination or bowel movement ...toilet (resident) upon awakening, before and after meals, at bedtime and as (resident) needs " . On 8/24/10 at 4:40 P.M., observation revealed the resident laid in bed. Direct Care Staff L and B checked the resident ' s brief for incontinence, which was dry. The staff did not toilet the resident before the transfer to a wheelchair and took the resident to the dining room. At 7:14 A.M. on 8/25/10, the resident was observed sitting in a wheelchair in his/her room. Staff took the resident taken to the dining room at 7:58 A.M. and returned to the room at 8:55 A.M. The staff did not check the resident for incontinence or toilet the resident. At 9:34 A.M. on 8/25/10, Licensed Staff C transferred the resident from the wheelchair to the bed and checked the resident ' s incontinence brief. The resident was not incontinent and the staff did not toilet the resident. At 12:23 P.M. on 8/25/10, Direct Care Staff I checked the resident ' s brief for incontinence. The resident ' s incontinent brief was saturated with a large amount of dark, amber urine. The staff did not toilet the resident prior to the transfer to a wheelchair and took the resident to the dining room. At 1:23 P.M. on 8/25/10, Direct Care Staff I took the resident via wheelchair from the dining room to the hallway outside of the resident ' s room. Staff did not toilet the resident. At 3:04 P.M. on 8/25/10, Direct Care Staff I and L transferred the resident from the wheelchair to the bed. The incontinent brief contained a medium amount of dark, amber urine. Perineal care was provided and barrier ointment was applied. Staff did not toilet the resident. During an interview on 8/26/10 at 9:10 A.M. Direct Care Staff I stated (the staff change the resident ' s brief) every 2 hours. Staff reported that each day they are given a sheet that indicated the resident ' s needs. The sheet indicates that the resident ' s toileting is 2:1 assist. On 8/26/10 at 10:51 A.M. Direct Care Staff H stated that " only one (resident) is on a toileting program and the other residents are check and change if they are not able to tell you (when they need to urinate)...(incontinence) is not tracked unless there is a Bladder and Bowel Assessment form in the book " . During an interview on 8/26/10 at 9:28 A.M., Licensed Staff B stated that the (direct care) staff have a sheet that is given each morning that indicated specific cares ...all residents are change-of-position " every 2 hours and toileted before and after meals. During an interview on 8/26/10 at 9:37 A.M., Licensed Staff D stated that the (direct care) staff " does not ' have access to the chart. If they (direct care staff) have questions, the nurse will direct them ...there is a book at the nurse stations for each resident that pertains to the resident ' s bladder and bowel ...every morning before work the nurse tells (direct care staff) for each person that has a change or something new. " The facility failed to toilet this resident as planned.

The facility reported a census of 71 residents with sample size of 17. Based on observation, record review, and staff interview, the facility failed to have a system in place to prevent unavoidable weight loss for two of three residents reviewed for weight loss. (#68, #27). Findings included: - Resident #68 had diagnoses of [MEDICAL CONDITION], hypertension, peripheral [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), unsteady gait, dementia, Alzheimer ' s, and depression as listed on the Physicians Order Sheet dated 8/1/10. The 4/12/10 Annual Assessment MDS (minimum data set) recorded memory loss, moderately impaired cognitive skills for daily decision making with staff to provide set up and supervision for eating. Weight was recorded at 153 pounds. The 7/5/10 Quarterly Assessment MDS recorded memory loss, moderately impaired cognitive skills for daily decision making, needed total assistance with activities of daily living with staff to provide setup and supervision for eating. Weight was recorded at 152 pounds. The Resident Assessment Protocol for Nutrition dated 4/20/10 recorded the resident had chewing and swallowing problems accompanied by dementia. Dietary and nursing were to ensure the resident had adequate meals and/or snacks and encouragement given to consume them. Mechanically altered and therapeutic diet were recorded for nutritional approaches. The care plan dated 7/1/10 included interventions, " Pureed diet, nectar thick liquids, determine food preferences, instruct (resident) about dietary modifications. Weights are monitored and reviewed and recommendations made as needed. Dietician consult and recommendations as needed. Encourage (resident) at mealtimes and assist with set up as needed. " Revision to the care plan dated 8/13/10 included, " Level 2 wt (weight) loss protocol, CIB (Carnation Instant Breakfast) shake BID (twice daily) at lunch and dinner, feed resident as needed. " The facility ' s policy and procedure for Weight Loss indicated Level 2 as " snacks between meals and/or before bedtime " . Recorded weights for resident #68: 8/25/10 - 140.0 pounds 8/18/10 - 139.5 pounds 8/11/10 - 141.0 pounds 8/4/10 - 143.5 pounds 7/7/10 - 149.1 pounds 6/9/10 - 152.4 pounds 5/13/10 - 151.2 pounds 4/27/10 - 152.7 pounds Consisting of a 12.7 pound weight loss in 4 months. Observation on 8/25/10 at 7:58 A.M. revealed that resident was served oatmeal, thickened juice, water and milk and ate approximately 30 percent of the meal with assistance by Licensed Staff C and Licensed Staff D. At 1:10 P.M. on 8/25/10 resident #68 received tomato soup, mashed potatoes, and green beans. The labels on the resident ' s drinks were labeled " water nectar " , " oj nectar " , and " milk nectar " . Direct Care Staff I assisted the resident to eat. The resident was removed from the dining hall at 1:23 P.M. by Direct Care Staff I. The resident consumed approximately 2 bites of green beans, 4 bites of mashed potatoes, 50% of the tomato soup, 50% of the water, 25% of the juice, and 0% of the milk. Resident interview at 1:27 P.M. on 8/25/10 revealed the resident stated " No " when asked by this surveyor " Are you full? " At 1:28 P.M. Direct Care Staff I stated, "I think is he/she was really sleepy. He/She seemed to be done eating. He/She was tired." Record review of Standing Orders for Consultant B revealed that " residents with intake <75% may have fortified food such as super cereal, super pudding and health shakes with meals daily " . The facility recorded daily food intake for breakfast, lunch, and dinner for this resident. Average weekly intake (to include seven days) for the resident were: week of 7/19/10 = 69%; week of 7/26/10 = 70%; week of 8/2/10 = 53%; week of 8/9/10 = 40%; and week of 8/16 = 47%. Nutritional Progress Notes dated 8/13/10 revealed that Administrative Staff C recorded resident had weight decrease of 4% in 30 days ... " resident eats approx. 60% at all meals. Dietary will start a Level 2 wt (weight loss) protocol with CIB (Carnation Instant Breakfast) shake BID (twice daily) at lunch and dinner ... " Registered dietician noted dated 8/17/10 recorded, " resident needs to be fed by staff ...current weight 141 pounds, decrease of 8 pounds in past month " . The clinical record lacked evidence that staff implemented the physician ' s standing orders and the dietary recommendations. In interview on 8/26/10 at 3:43 P.M. with Administrative Staff C revealed that the facility does not ' Bt contact the dietician until the resident has had a significant weight loss, which was defined as 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. Administrative Staff C stated that the resident did not have a significant weight loss and that the resident was on a pureed diet and received assistance to eat. 8/25/10 at 1:29 P.M. Direct Care Staff Q stated that resident #68 did not receive a nutritional supplement, but that the resident does go to " snacks " in the dining room. Record review of laboratory results revealed that the resident ' s current [MEDICATION NAME] level on 7/27/09 was 3.4 g/dL (grams/deciliter) with a reference range of 3.4-5.7 g/dL. On 8/24/10 at 4:58 P.M. Direct Care Staff B stated the resident received thickened fluids with morning snack, lunch, afternoon snack (either at dining hall or in the room) and resident received water, milk, and juice at meals. The clinical record lacked evidence the 12 pounds weight loss was unavoidable. - Resident #27 had a [DIAGNOSES REDACTED]. The annual MDS (minimum data set) dated 1/17/2010, recorded the resident's cognitive status as; modified independence with difficulty in new situations - function that varied over the course of the day, extensive one person physical assist with bed mobility and transfer, total dependence with toileting and dressing, extensive one person assist with personal hygiene, wore glasses, ate independently, walk in room activity did not occur, leaves 25% or more of food uneaten at most meals, needs cuing, dietary supplement between meals, insufficient fluids; did not consume all or almost all liquids during the last 3 days, and urinary tract infection in the last 30 days. The quarterly MDS dated [DATE] recorded memory loss, cognitive status as modified independence with some difficulty in new situations, mental function varied over the course of the day, extensive one person physical assist with bed mobility and transfer, total dependence with toileting and dressing, extensive one person assist with personal hygiene, walked in room activity did not occur, wore glasses, ate independently, and urinary tract infection in the last 30 days. The RAPS (resident assessment protocol) dated 1/17/2010 for Nutritional Status revealed the resident received a regular diet, consumed 50 - 75% of meals on a regular basis and had no significant changes in weight in the last 90 days. Dehydration/Fluid status revealed the resident did not consume most of his/her liquids that the staff offered, staff offered fluid between meals to help in the prevention of dehydration and the resident currently showed no signs of dehydration. The Care Plan dated 1/21/2010 and reviewed on 7/5/10 revealed the staff identified the resident as a potential risk for weight loss and dehydration related to debility. The staff should monitor the resident's appetite, assess oral status and proper fit of dentures, dietician consult, and verbally encourage the resident at meal time to consume foods and fluids. The staff will offer fluids between meals, and monitor weight and skin turgor. The weight record showed the following: 1/5/10 112.8 pounds 2/19/10 112 pounds 3/26/10 111.4 pounds 4/27/10 112.7 pounds 5/13/10 112.1 pounds 6/9/10 108.4 pounds 7/7/10 108.5 pounds 8/11/10 104.6 pounds 8/18/10 111.2 pounds 8/25/10 99.3 pounds The record had a re-weigh on 8/26/10 of 109.6 pounds per surveyor request. The dietary Food Intake Record, undated, for Days 1- 4 showed the amount of food eaten by resident #27 over a four day time frame: Breakfast 40% (percent), 30%, 30%, 40% Beverage 40% 40% 25% 30% Lunch 25% 40% 25% Beverage 25% 50% 40% Dinner 25% 20% 30% Beverage 50% 20 % 25% The facility Standing Orders dated 5/17/10 revealed residents with an intake less than 75% may have fortified foods such as super cereal, super pudding, and health shakes with meals daily. Non diabetic residents may have Carnation Instant Breakfast, Boost, Ensure or the house supplement twice daily. Resident #27's had no [DIAGNOSES REDACTED]. An interview with Dietary staff C on 8/26/10 at 2:00 P.M. staff stated the resident is [AGE] years old and it was discussed among the staff not to give him/her supplements at his/her age. Dietary staff C stated in a second interview on 8/26/10 at 3:39 P.M. the resident slept all day except for meals. Dietary Staff C stated they didn't want to supplement a shake for his/her meals because the resident would get more nutrition out of his/her meals. An interview with Licensed Nursing Staff D on 8/25/10 at 3:29 P.M. revealed inservices provided for the staff educating on the importance of nutrition and hydration. Licensed Nurse Staff D trained the staff on the importance of protein in the residents diets. Observation on 8/25/10 at 9:35 A.M. revealed resident #27 eating his/her morning meal. The resident had eaten 100% of the food on his/her plate but was not offered more. Observation on 8/26/10 at 9:35 A.M. revealed resident #27 eating his/her morning meal. The resident ate a few bites of his/her morning meal and staff did not encourage the resident to eat more nor was he/she offered something different for his/her morning meal. Staff then assisted the resident back to his/her room at 9:45 A.M. An observation on 8/26/10 at 6:00 P.M. revealed resident #27 eating his/her evening meal. The resident ate half of his/her dessert and only approximately 5% of his/her cereal. The staff did not offer the resident a supplement or a substitute for his/her uneaten cereal. Observation on 8/26/10 at 12:45 P.M. revealed resident #27 eating his/her noon meal. The resident ate approximately 25% of his/her noon meal and staff did not offer the resident a supplement or a substitute. The facility failed to have a system in place to monitor the resident's intake, to follow the care plan to encourage the resident at meal times, and failed, per standing order, to provide the resident with fortified food to prevent weight loss.