Every finding on record at Ignite Medical Resort Carondelet LLC

Based on interview and record review, the facility failed to develop an ongoing person-centered discharge plan, when the facility issued a 30-day discharge letter to one sampled resident (Resident #2), discharging the resident to a homeless shelter who required medication and care oversight out of five sampled residents. The facility census was 111 residents. Review of the facility's Discharge Policy dated April 2023 showed:-A resident's discharge potential was assessed by Social Services upon admission.-When the Interdisciplinary Team (IDT - a group of facility staff, including nursing, medicine, therapy, and social work, work together with the resident to develop and implement a person-centered discharge plan) meet to discuss the discharge, the physician was contacted.-Social Services met with the resident to set up outside services and equipment.-A discharge form was completed by the IDT that explained the resident's care needs when at home. A policy regarding discharge planning was requested on 6/25/26, was informed by the Administrator that the facility does not have a Discharge Planning Policy, only the Discharges Policy. 1. Review of Resident #2's undated admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:Hemiparesis (severe muscle weakness, stiffness, or total loss of movement on one side of the body) affecting the right dominant side.-Hemiplegia (a form of paralysis that affects one entire side of the body) affecting the right dominant side.-Contracture (permanent tightening or shortening of muscle, tendons, skin, or other soft tissue that causes joints to become stiff and restricts normal movement) of right upper arm.-Aphasia (a neurological disorder caused by brain damage that impairs a person's ability to speak, write, and understand language).-Syncope (fainting or passing out due to a sudden, temporary drop in blood flow to the brain) and Collapse (when a person falls down for no obvious reason).-Unsteadiness on feet. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff) dated 5/26/26, showed the resident was cognitively intact. Review of the resident's Care Plan dated 3/1/26, showed he/she:-May need help reading instructions, pamphlets or other written materials.-Had impaired cognitive function.-Had a deficit and limitations in his/her Activities of Daily Living (ADL - necessary and routine task required for personal care, health, and independent living).-Limitation in physical mobility due to weakness and uses a wheelchair for mobility.-Was at risk for falls.-Wishes to remain at the facility for long term care (LTC).--Care Plan meeting on 4/10/26, to discuss discharge goals (wishes to remain LTC), goals of care and treatment preference.--Evaluate his/her motivation to return to the community quarterly, annually and as needed.--Identify, discuss and address limitations, risk, benefits, and needs for maximum independence. Review of the resident's Care Management note dated 6/2/26 at 12:08 P.M., showed:-The resident's plan for living arrangements had not changed.-Upon discharge the resident plans to remain LTC at the facility.-Significant change in mood since last review.-Alternate discharge placement not discussed. Review of the resident's Social Service Note dated 6/8/26 at 1:05 P.M., showed:-Director of Care Transitions (DCT)/Social Services and the Administrator met with the resident.-During the meeting the resident was given formal notice of 30-day discharge.-The resident was educated on the 30-day discharge notice and his/her right to appeal.-The resident expressed that he/she would like referrals sent out to locate an alternative location. Review of the Notice of Discharge Letter dated 6/8/26 showed:-Hand delivered to the resident.-After careful evaluation and consultation with the attending physician, the facility concluded that the safety of individuals at the facility was endangered by the resident and the resident's health had improved sufficiently so the resident no longer needs services provided by the facility.-The reason the safety of individuals in the facility was endangered by the resident barricading doors and refusing to allow staff to enter his/her room to provide care.-Additionally, the resident does not meet the level of care required for LTC facility and his/her needs can be met in the community.-The effective date of the discharge was 7/8/26.-The location to which he/she will be discharged was to the homeless shelter unless he/she had planned to move elsewhere. Review of the resident's Progress Note dated 6/8/26 at 3:26 P.M., showed:-Staff were working on finding the resident placement where he/she was able to be more independent per his/her wishes.-The resident wants to administer all his/her medications and complain when he/she was not able to take medications on his/her own except controlled substances, which makes it unreasonable for him/her to be under this level of care since he/she was wanting independence and continued to refuse care. During an interview on 6/24/26 at 1:08 P.M., Ombudsman A said it was not a safe discharge or considered a permanent location when the facility discharges a resident to a homeless shelter or a motel. During an interview on 6/24/26 at 2:35 P.M., the resident said he/she:-Had appealed the discharge letter and the hearing was set for 7/8/26.-He/she wanted to discharge from the facility to another facility and was willing to move anywhere. He/she needed a change.-Did not want to discharge to his/her parents' home.-Social Services was sending out referrals to other facilities.-Waiting to see if one of the facilities would take him/her. During an interview on 6/24/26 at 3:03 P.M., the Administrator said:-The facility had been trying to find placement for the resident, but no other facilities would accept the resident because of his/her behaviors.-He/She gave the discharge letter to the resident with the Social Services Director (SSD). -The resident's Preadmission Screening and Resident Review (PASRR - used to help ensure individuals with serious mental disorder and/or developmental disabilities are not inappropriately placed in nursing homes for long term care and receive the services they need in their residential setting) was done when the resident admitted to the facility.-A new PASRR has not been done to show the resident's improvements.-Placed a call to the resident's parents to see if the resident could discharge them to their home.-Parents said no, they were done with the resident because of his/her behaviors.-Part of the reason for the discharge was the resident's behavior and the other was the resident no longer meets LTC needs.-The resident can care for him/herself.-According to regulations he/she can discharge a resident to a homeless shelter.-He/she wrote the discharge letter and was responsible for the discharge decision. During an interview on 6/25/26 at 12:43 P.M., SSD said:-IDT meet weekly to go over the resident's care and discuss different interventions to get the resident to let staff care for him/her.-The IDT had discussed discharging the resident to another facility.-The resident wants to stay in an LTC.-He/She meets with the resident weekly to go over the referrals that have been sent out and the referrals response.-The other facilities were not taking the resident because of the residents' behaviors. During an interview on 6/30/26 at 10:33 A.M., the Nurse Practitioner (NP) said:-He/She sees the resident twice a week for care.-The resident needs medication management and was not compliant with schedule II medications.-The resident wants to self-administer all medications.-The resident was not compliant with staff caring for the resident and does most care him/herself.-The resident does have behavior problems toward others.-He/She does not agree with the resident discharging to a homeless shelter.-He/She was not included in the discharge planning meeting and was told after the discharge letter was given to the resident.-The resident was independent with some things but still needs assistance and protective oversight like setting up his/her medications in a pill box for self-administration.-The resident can walk some but not for long periods of time, will use wheelchair when tired or weak.-The resident does have limited use of his/her right dominant side due to a stroke.-He/She was not onboard with this discharge and does not approve of this discharge. 3039039

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) received physician ordered pain medications when the resident's narcotic pain medication was not administered for four consecutive days out of five sampled resident. The facility census was 125 residents. The Administrator and the Director of Nursing (DON) was notified of the past noncompliance which began on 4/7/26. The facility immediately completed education to ensure physician orders were complete with all nursing staff. The deficiency was corrected on 4/7/26. Review of the facility undated Medication Administration Policy showed:-It was the policy of the facility to ensure safe, accurate, and timely medication administration using a liberalized medication pass approach, allowing flexibility in administration times while maintaining clinical appropriateness, physician intent, and resident safety in accordance with federal and state regulations. -To promote resident-centered care by reducing rigid medication schedules while ensuring medications are administered safely, effectively and in accordance with physician orders. -This policy applies to all licensed nursing staff responsible for medication administration.-Missed or delayed medications--Assess impact--Notify physician if needed--Document reason, action, and outcome.-Controlled substances.--Follow double-check procedures.--Report discrepancies immediately.-Resident rights.--Right to refuse.--Right to be informed.--Respect preferences when safe. 1.Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnosis including muscle weakness. Review of the resident's Medication Administration Record (MAR) dated 4/1/26 through 4/30/26 showed the following physician order:-Tramadol (narcotic pain medication used to treat moderate to moderately severe chronic pain in adults) Oral Tablet 50 milligrams (mg), give 50 mg by mouth two times a day for moderate pain, with an order date of 4/3/26 at 3:15 P.M.-Tramadol was not documented as administered 4/3/26 P.M. through 4/7/26. Review of the resident's Control Record dated 4/8/26 through 4/18/26 showed:-Tramadol tablet 50 mg, give 50 mg by mouth, two times a day for moderate pain, ordered 4/3/26.-Pharmacy dispensed 28 tablets of Tramadol on 4/7/26.- The 28 tablets of Tramadol were received on 4/8/26 and signed for by the Licensed Practical Nurse.-Tramadol was signed out for administration on 4/8/26 at 6:00 P.M. Review of the resident's Progress Note dated 4/3/26 at 3:17 P.M. showed:- Tramadol Oral Tablet 50 MG, give 50 mg by mouth two times a day for moderate pain.- The order was entered by nursing. Review of the resident's Progress Note dated 4/7/26 at 1:03 P.M. showed:-The resident stopped Nurse Practitioner (NP) in the hallway to let him/her know he/she was having pain all over due to his/her stroke, which was typical for him/her.-He/She was taking Tramadol in the past with good effect and would like to get back on it.- A trial of Tramadol 50 mg twice daily (BID) if ok with the Doctor. During an interview on 4/28/26 at 2:48 P.M. the resident said:-He/She complained about his/her medications in the past, but the staff had resolved his/her concerns. -He/She has arranged through meeting with the facility staff, NP and the doctor to self-administer all his/her medications except the controlled medications. -He/She was getting his/her Tramadol, it was just coming late. -He/She no longer had concerns. During an interview on 4/28/26 at 4:55 P.M. DON said:-There was an order for the resident to have Tramadol on 4/3/26 which was not signed by the physician until 4/7/26.-The medication could not be sent from the pharmacy until after the physician signed the order. During an interview on 4/30/26 at 11:05 A.M. the NP said:-Prescriptions for controlled medications such as Tramadol must be signed by the physician.-The physician has authority to sign for controlled medications, he/she did not. -The resident does well when his/her pain is controlled. -He/She normally does not get involved when controlled medications are ordered.-He/She does know the medication cannot be sent from the pharmacy until the order has been signed by the physician. CMP 2986685

Based on interview and record review, the facility failed to develop an appropriate discharge plan, when the facility issued a Notice of Medicare (a federal health insurance program) Non-Coverage (NOMNC - a mandatory document provided to beneficiaries by skilled nursing facilities when their covered services are ending) to one sampled resident (Resident #1) out of seven sampled residents. The facility census was 134 residents.Review of the facility's Discharge policy, dated April 2023, showed:-A resident's discharge potential was assessed by Social Services upon admission.-When the Interdisciplinary Team (IDT - a group of facility staff, including nursing, medicine, therapy, and social work, work together with the resident to develop and implement a person-centered discharge plan) meet to discuss the discharge, the physician was contacted.-Social Services met with the resident to set up outside services and equipment.-A discharge form was completed by the IDT that explained the resident's care needs when at home. A policy regarding Discharge Planning was requested but not received. 1. Review of Resident #1's face sheet, undated, showed:-The resident was admitted to the facility on [DATE].-The resident was diagnosed with:--Hemiplegia (severe muscle weakness, stiffness, or total loss of movement on one side of the body).--Aphasia (a language disorder caused by brain damage, usually from a stroke or injury, that impaired a person's ability to speak, understand, read, or write).--Unsteadiness on feet. Review of the resident's initial Minimum Data Set (MDS - a health status screening and assessment tool used for all residents of long-term care nursing facilities) dated 3/1/26, showed the resident was cognitively intact. Review of the resident's Care Plan (a written, step-by-step outline of a person's specific medical, personal, and social needs who cannot live independently), dated 3/1/26, showed:-The resident wished to remain at the facility for long term care.--Evaluate the resident's motivation to return to the community quarterly, annually and as needed.-Identify, discuss and address limitations, risk, benefits and needs for maximum independence. -The resident had impaired cognitive function.-The resident had a deficit and limitations in her Activities of Daily Living (ADL - necessary and routine tasks required for personal care, health, and independent living).-The resident was at risk for falls. Review of the facility's Progress Notes, created by the Director of Care Transitions (DCT), dated 3/4/26, showed:-The Initial Care Management meeting was held.-The resident's plan for living arrangements have not changed.-There were no environmental barriers impacting the discharge plan.-There were no remaining medical education needs for the resident.-Stairs were a functional barrier at discharge.-Bathing was an ADL barrier for the resident. Review of the facility's NOMNC, signed by the resident on 3/5/26, showed:-The resident's Medicare Coverage was ending on 3/7/26.-The following information was to be completed by the provider and was given to the resident blank:--Notice delivered by (name and title).--Call date/time.--Spoke with: name, phone number, relation to resident.--Date NOMNC mailed to representative.--Provider signature, title, and date. During an interview on 4/10/26 at 10:04 A.M., the resident said:-He/She had issues with staff not giving him/her medications.-All the medication issues were resolved. -He/She talked to the DCT who talked to the nurses.-He/She got frustrated and yelled at the staff.-He/She did not want to be kicked out of the facility without cause or for displaying anger on account of the staff lied and said he/she cussed them. -He/She recognized their need to be in a safe place, to have shelter, food, showers and care.-The Administrator and the DCT helped him/her get his/her medication and staff issues resolved. -The Administrator and DCT said he/she could not stay at the facility and find somewhere else to go.-The DCT was working on transferring him/her to another facility. -He/She was unsure about going to that facility as she needed to research it.-He/She was unsure if they were trying to put him/her Long-Term Care (LTC) or in an Assisted Living Facility (ALF).-He/She did not want to move again.-He/She liked it in the facility. -He/She did not receive a discharge notice but was told he/she had to leave.-He/She told the Administrator he/she did not want to move. During an interview on 4/10/26 at 10:58 A.M., the DCT said: -The resident received a NOMNC.-Medicare was paying for the resident's stay and he/she was past his/her last covered day.-He/She also had Medicaid (a federal and state program that provided free or low-cost health coverage to those with limited income and resources).-He/She sent a referral to another facility. -Due to the resident's behaviors, that facility will not accept the resident. -The resident was not given a letter of discharge.-He/She and the Administrator discussed LTC, patient liability, semi private room, and the differences between that and therapy with the resident.-The resident had the right to go back to the community.-The resident accepted going to the other facility and he/she wanted to look it up on line and said he/she was ok with it.-He/She was sending out referrals to other facilities. -There is no plan for the resident to stay here.-Right now, the goal is to move forward with a transfer.-A discharge notice had not been issued. During an interview on 4/10/26 at 12:25 P.M., the Administrator said:-He/She was actively looking for placement for the resident.-The resident was not appropriate to be safe towards staff and other residents.-The DCT continued to send out referrals.-The resident had to accept the referrals.-The resident accepted the referral to the other facility. -The resident had stated he/she did not want to be here.-The resident did not need long term care according to the resident's level of care (LOC - defined the intensity, frequency, and type of medical or support services a person needed based on their health status).-The resident was independent with most of his/her cares.-He/She did not want to do a 30-day discharge for the resident.-The resident has not made any payment. -If the resident did not accept placement, he/she will get a 30-day discharge based on offering him/her safe placement and he/she declined.-Documentation was kept on the risk management side, not in electronic progress notes. During a follow up interview on 4/10/26 at 2:10 P.M., the DCT said:-He/She had the resident's consent to send out referrals to other facilities.-He/She did not ask the resident what his/her preferences were for other transfers. -The resident stated he/she wanted to go back to an LTC facility.-The resident is not dis-included from proper discharge planning.-He/She had conversations in passing with the resident but did not always make a note about it. During a follow up interview on 4/10/26 at 2:10 P.M., the Administrator said:-We were planning to discharge the resident.-The resident can go back to the motel he/she was living in for six months prior to being hospitalized and admitted to this facility.-Care plan says she initially planned to stay long term care.-The Care Plan has not been updated.-The resident received education on the discharge planning process.-He/She would expect to have the care plan updated with discharge planning.-Sending the resident to a hotel would not be a safe discharge. -He/She will not send the resident to a hotel if he/she did not wish to go to a hotel. Complaint #2969722

Based on interview and record review, the facility failed to provide medical related social services by not planning for and referring one resident (Resident #1) out of three sampled residents, to potential community services necessary for the resident to have a successful and appropriate discharge back to the community. The facility census was 134 residents. Review of the facility's Discharges policy, dated April 2023, showed:-A resident's discharge potential was assessed by Social Services upon admission.-When the Interdisciplinary Team (IDT - a group of facility staff, including nursing, medicine, therapy, and social work, work together with the resident to develop and implement a person-centered discharge plan) meet to discuss the discharge. -Social Services met with the resident to set up outside services and equipment.-A discharge form was completed by the IDT that explained the resident's care needs when at home. 1. Review of Resident# 1's face sheet, undated, showed:-The resident was admitted to the facility on [DATE].-The resident was diagnosed with the following diagnoses:--Hemiplegia (severe muscle weakness, stiffness, or total loss of movement on one side of the body).--Aphasia (a language disorder caused by brain damage, usually from a stroke or injury, that impaired a person's ability to speak, understand, read, or write).--Unsteadiness on feet. Review of the resident's initial Minimum Data Set (MDS - a health status screening and assessment tool used for all residents of long-term care nursing facilities) dated 3/1/26, showed the resident was cognitively intact. Review of the resident's Care Plan (a written, step-by-step outline of a person's specific medical, personal, and social needs who cannot live independently), dated 3/1/26, showed:-The resident wished to remain at the facility for long term care.--Evaluate the resident's motivation to return to the community quarterly, annually and as needed.-Identify, discuss and address limitations, risk, benefits and needs for maximum independence. -The resident had impaired cognitive function.-The resident had a deficit and limitations in her Activities of Daily Living (ADL - necessary and routine tasks required for personal care, health, and independent living).-The resident was at risk for falls. Review of the facility's Progress Notes, created by the Director of Care Transitions (DCT), dated 3/4/26, showed:-The Initial Care Management meeting was held.-The resident's plan for living arrangements had not changed.-There were no environmental barriers impacting the discharge plan.-There were no remaining medical education needs for the resident.-Stairs were a functional barrier at discharge.-Bathing was an ADL barrier for the resident.-NOTE: there was no documentation of:--Referrals to needed services from outside entities.--Assisting the resident with identifying community placement options. During an interview on 4/10/26 at 10:04 A.M., the resident said:-He/She recognized their need to be in a safe place, to have shelter, food, showers and care.-The Administrator and DCT said he/she could not stay at the facility and he/she needed to find somewhere else to go.-The DCT was working on transferring him/her to another facility. -He/She was unsure about going to that facility as he/she needed to research it.-He/She was unsure if they were trying to put him/her in a Long-Term Care (LTC) facility, housing, or in an Assisted Living Facility (ALF).-He/She had not received any information from the facility regarding getting assistance from outside agencies. During an interview on 4/10/26 at 10:58 A.M., the DCT said: -The resident received a Notice of Medicare Non-Coverage (NOMNC).-Medicare was paying for the resident's stay and he/she was past his/her last covered day.-He/She also had Medicaid (a federal and state program that provided free or low-cost health coverage to those with limited income and resources).-He/She sent a referral to another facility. -Due to the resident's behavior, that facility did not accept the resident. -The resident was not given a letter of discharge.-He/She and the Administrator discussed LTC, patient liability, semi private room, and the differences between that and therapy with the resident.-He/She did not give any other referrals to available community resources to the resident.-The resident had the right to go back to the community.-He/She was sending out referrals to other facilities. -Right now, the goal is to move forward with a transfer.-A discharge notice had not been issued. During an interview on 4/10/26 at 12:25 P.M., the Administrator said:-He/She was actively looking for placement for the resident at other facilities.-The DCT continued to send out referrals.-The resident had to accept the referrals.-The resident accepted the referral to the other facility. -The resident had stated he/she did not want to be here.-The resident did not need LTC according to the resident's level of care (LOC - defined the intensity, frequency, and type of medical or support services a person needed based on their health status) and could live in the community.-There were no other referrals to outside agencies as some of them require the resident to be in LTC for at least three months.-He/She had no plans for the resident to remain at the facility that long.-If the resident did not accept placement he/she will be issued a 30-day discharge based on offering him/her safe placement and he/she declined. During a follow up interview on 4/10/26 at 2:10 P.M., the DCT said:-He/She had the resident's consent to send out referrals to other facilities.-He/She did not ask the resident what his/her preferences were for other transfers. -The resident stated he/she wanted to go back to an LTC facility.-The resident was not dis-included from proper discharge planning.-He/She had conversations in passing with the resident but did not always make a note about it. Complaint #2969722

Based on observation and interview, the facility failed to ensure there was negative airflow in the restrooms of the following resident rooms H7, H6, H5, H4, H2, H1, G8, G5, G7, G9, G12, G14, D8, D7, D4, D5, D3, D2, and D1. This practice potentially affected 23 residents who resided in those rooms. The facility census was 105 residents. *Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn to the vent, then negative air flow was present; if the paper fell, then negative airflow was absent. 1. Observation on 1/12/26, with the Facility Maintenance Director and the Senior [NAME] President of Facility Services showed the following:-At 2:31 P.M. there was the absence of negative air flow in the restroom of resident room H7.-At 2:33 P.M. there was the absence of negative airflow in the restroom of resident room H6.-At 2:36 P.M. there was the absence of negative airflow in in the restroom of resident room H5.-At 2:38 P.M. there was the absence of negative airflow in the restroom of resident room H4.-At 2:39 P.M. there was the absence of negative airflow in the restroom of resident room H2.-At 2:44 P.M. there was the absence of negative airflow in the restroom of resident room H1.Observation on 1/13/26, with the Facility Maintenance Director and the Senior [NAME] President of Facility Services showed the following:-At 9:02 A.M. there was the absence of negative airflow in the restroom of resident room G6.-At 9:04 A.M. there was the absence of negative airflow in the restroom of resident room G8.-At 9:06 A.M. there was the absence of negative airflow in the restroom of resident room G5.-At 9:08 A.M. there was the absence of negative airflow in the restroom of resident room G7.-At 9:23 A.M. there was the absence of negative airflow in the restroom of resident room G9.-At 9:25 A.M. there was the absence of negative airflow in the restroom of resident room G12.-At 9:27 A.M. there was the absence of negative airflow in the restroom of resident room G14.-At 2:25 P.M. there was the absence of negative airflow in the restroom of resident room D8.-At 2:32 P.M. there was the absence of negative airflow in the restroom of resident room D7.-At 2:35 P.M. there was the absence of negative airflow in the restroom of resident room D4.-At 2:38 P.M. there was the absence of negative airflow in the restroom of resident room D5.-At 2:41 P.M. there was the absence of negative airflow in the restroom of resident room D3.-At 2:44 P.M. there was the absence of negative airflow in the restroom of resident room D2. -At 2:47 P.M., there was the absence of negative airflow in the restroom of resident room D1.During an interview on 1/14/26 at 11:01 A.M., the Facility Maintenance Director said:-He/She had not checked for negative airflow since he/she started.-He/She was not told to check for negative airflow in the resident rooms.

Based on observation and interview, the facility failed to maintain the ceiling vents in the A Hall shower room free from a heavy buildup of dust; and failed to maintain the table top fans in the following areas free from a heavy buildup of dust: Resident room B10, Resident #33's room, Resident room B4, Resident room C5, and Resident #101's room. This practice potentially affected at least 30 residents who used the shower room and resided in those areas. The facility census was 105 residents. 1. Observation on 1/13/26 at 11:22 A.M., with the Facility Maintenance Director showed a heavy buildup of dust on two ceiling vents in the A Hall shower room. During an interview on 1/13/26 at 11:23 A.M., the Facility Maintenance Director said:-He/She needed to develop a schedule for cleaning those ceiling vents.-He/She had not had a chance to develop a schedule because he/she only took over as the Director in December 2025.Observation on 1/13/26 at 11:33 A.M., with the Facility Maintenance Director showed:-A heavy buildup of dust on the tabletop fan in resident room B5. -At the time, there were no residents present to interview about the dust buildup in the fan.Observation on 1/13/26 at 11:53 A.M., with the Facility Maintenance Director showed a heavy buildup of dust on the fan in Resident #33's room.During an interview on 1/13/26 at 11:53 A.M., Resident #33, a resident identified by the quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning), dated 4/18/25, who was cognitively intact said the facility staff cleaned his/her fan every now and then, but would prefer they cleaned the fan more often.Observation on 1/13/26 at 11:56 A.M., with the Facility Maintenance Director showed:-A heavy buildup of dust on the tabletop fan in resident room B4.-At the time, there were no residents present to ask about the dust buildup in the fan.Observation on 1/13/26 at 1:28 P.M., with the Facility Maintenance Director showed:-A heavy buildup of dust on the fan in resident room C5. -At the time, there were no residents present to interview about the dust buildup in the fan.Observation on 1/13/26 at 1:32 P.M., with the Facility Maintenance Director showed a heavy buildup of dust on the fan in Resident #101's room.During an interview on 1/13/26 at 1:32 P.M., Resident #101, a resident identified by the quarterly MDS dated [DATE] who was cognitively intact, said it has been a while since they cleaned the fan on his/her side of the room and he/she would appreciate it if the facility staff cleaned his/her fan a little bit more. 2685006

Based on observation, interview, and record review, the facility failed to ensure a resident's food preferences were honored, and alternative menu choices were provided for three sampled residents (Resident #95, #110, and #112), out of 21 sampled residents and had the potential to affect all residents who were bed bound, did not eat in the dining room area, and who ate meals in their room. The facility census was 105 residents. Review of the facility policy titled Meal Service revised dated May 2024 showed:-Meals were served three times per day. Snacks were served as ordered and at bedtime.-The dietary department delivers trays to the nursing units and dining rooms.-All nursing personnel and other available facility staff help with delivering trays and feeding residents as needed.-Residents were encouraged to eat in the dining room.-Individual preferences of residence regarding seating arrangements and where they eat were accommodated as much as possible.-When the tray was delivered, the staff ensures that the correct tray was given to the correct resident and the diet on the card matches what was on the tray.-Trays were delivered to residents at the same table at the same time.-If a resident does not like the food served, a substitute was offered.-If a resident does not eat and does not want a substitute, staff would alert the nurse for appropriate follow up. 1. Review of Resident #95's Face Sheet showed he/she was admitted on [DATE] with diagnoses which included, difficulty in walking, dysphagia (inability or difficulty swallowing) and muscle weakness. Review of the resident's Care Plan dated 3/14/25 showed:-The resident had the potential for alterations in nutrition and hydration related to being at risk for malnutrition and acute illness. Interventions instructed the nursing staff to:--Monitor and document as needed if the resident refused to eat. Review of the resident's progress notes showed there was no documentation of the resident refusing meals or meal preferences. During an interview on 1/11/26 at 4:19 P.M., with the resident while in the room and in his/her bed said:-He/She did not get to make choices about meal items and staff just brought him/her whatever they wanted. -His/her sister brought in food at times, but it was not on a regular schedule. -He/she preferred the food be hot or at least warm. During an interview on 1/12/26 at 8:20 A.M., with the resident while in the room and in his/her bed said he/she did not get to choose menu items, food was cold, and he/she was not offered an alternative by the person serving the tray. Observation on 1/13/26 at 9:29 A.M., showed the resident:-Was in the room in the bed with his/her breakfast tray on the bedside table in front of him/her.-He/She did not have the oatmeal listed on the resident's meal ticket dated 1/13/26. -The meal ticket section labeled dislikes and other were both blank. During an interview on 1/13/26 at 9:29 A.M. the resident said:-He/she did not choose the menu items.-He/she was told they were out of oatmeal and was not offered an alternative.-No alternative menu was offered to resident. Observation on 1/14/26 at 8:45 A.M., showed:-The resident was provided with a breakfast meal tray in his/her room.-Oatmeal was listed on meal ticket but not provided.-The dislikes and other section on meal ticket were blank.-He/She refused the meal due to it being cold and not having menu items he/she wanted.-No alternative menu was offered. During an interview on 1/16/26 at 10:40 A.M., Certified Nursing Assistant (CNA) G said:-He/she knew what the resident's preferences and choices were by looking at the meal ticket or chart.-Updates to the resident's preferences could be found in the resident's electronic medical record.-He/she found out what the resident's preferences were by asking the nurse.-If a resident refused a meal, he/she would offer alternatives and go to the kitchen to order.-Choices and preferences were communicated to dietary by telling dietary.-He/she had been told by dietary that they were out of items in the past. During an interview on 1/16/26 at 11:11 A.M., Licensed Practical Nurse (LPN) C said:-The meal ticket should have information about the resident's preferences and choices.-Resident's choices and preferences were updated by notifying the Dietary Manager and writing a progress note.-Resident's food preferences were documented on the meal ticket, under dietary orders and in progress notes.-If the resident refused a meal staff was supposed to try to encourage, notify the dietician to give supplement and offer alternatives.-If a resident refused meals due to a lack of choice, the CNA's should let the resident know there were alternatives and offer them.-He/she had never been told that menu items were not available so he/she doesn't know what the procedure would be. During an interview on 1/16/26 at 11:55 A.M., the Executive Chef said:-He/she knew of updates to resident's diets and preferences by a progress note being made in the electronic medical record that synced with the software he/she used to create food orders and print meal tickets.-Residents were offered alternatives everyday with every meal.- the same alternative menu that was in the dining room was placed in each resident room and it was also included in the resident's welcome/admission packet. -Residents could get items that were not on the menu.-Cooks and servers were responsible for making sure that all the items listed on the meal ticket were providing on the room trays. During an interview on 1/16/26 at 12:06 A.M., the Chief Nursing Officer (CNO) said:-Resident preferences were assessed during care plan meetings, and the monthly meetings with the dietician.-Updates to resident's preferences were made by putting them in the diet order listing report daily, if on therapy they put it in an order, care plan it, it should be on the meal ticket, the residents electronic medical record notes synced to the dietary menu software.-Residents were aware that alternatives were available and had an alternative menu.-Residents were made aware by the CNA's that alternatives were available.-Residents were given an alternative menu in their welcome/admission packet. 2. During an initial interview on 1/11/26 Resident #110 who ate in his/her room said no one asked them what they wanted to eat, they just got whatever was brought to them. Observation on 1/13/2026 at 1:30 PM of the resident's lunch meal ticket did not offer alternatives nor was there a menu available. 3. During an initial interview on 1/11/26 Resident #112 who ate in his/her room said no one asked them what they wanted to eat, they just got whatever was brought to them. Observation on 1/13/2026 at 8:45 AM of the resident's breakfast meal ticket did not offer alternatives nor was there a menu available. 4. Observation of the dining room on 1/11/26 1:20 P.M., showed: no alternative menus on the menu board or available to the residents. Observation of the dining room on 1/12/26 at 9:30 A.M., showed no alternative menus on the menu board or available to the residents. Observation of the dining room on 1/13/26 at 9:57 A.M., showed no alternative menus on the menu board or available to the residents. 5. During interview on 1/14/26 at 2:00 P.M. the Executive Chef said:-When the resident initially admitted to the facility, he/she would talk with the resident and let them know the alternative menu was in the welcome packet.-The cook and the server were supposed to make sure the residents had all the items on the meal ticket.-The resident could tell nursing staff or dietary staff if they wanted something else. During an interview on 1/15/26 at 2:15 P.M., CNA A said the CNA's would contact the kitchen and let them know if a resident wanted something else to eat. During an interview on 1/16/26 at 9:15 A.M., CNA B said the CNAs asked the residents what they wanted to eat, or the resident could call the kitchen themselves. During an interview on 1/16/26 at 9:30 A.M., LPN A said the residents could tell the charge nurse or the CNA on the floor what they wanted to eat. During an interview on 1/16/26 at 11:37 A.M., the Assistant Chief Nursing Officer (ACNO) said: -The residents would let the nursing staff know what they wanted to eat and then they would refer it to dining. -Sometimes the Executive Chef would come around, and the residents would let him/her know also. During an interview on 1/16/26 at 12:04 P.M., the CNO said:-The CNA's or the Executive Chef would go around and ask the residents what they wanted to eat.-The alternate menu was in the welcome packet.-The resident could get an alternate meal anytime.-The resident should have had an alternate menu.

Based on observation and interview, the facility failed to remove the dust on the vents and ceiling lights all throughout the kitchen and over-serving area; failed to ensure the walls did not have holes in them and the metal trim was falling off on a corner; failed to ensure there was a drain cover over the drain in the dish machine room; failed to ensure a large bag of bread crumbs was not open and the flour bin door was open; and failed to ensure the dining room floors were mopped. This deficient practice potentially affected all residents who ate the food from the kitchen and ate or walked through the dining room. The facility census was 105 residents. 1. Observation on 1/11/26 1:20 P.M., of the dining room showed there was dried spilled residue all throughout the sitting area. Observation on 1/11/26 1:53 P.M., during the initial kitchen walk-through showed:-Dust on the vents and ceiling lights throughout the kitchen and over-serving area. -The flour bin door was open.-A large bag of breadcrumbs was open. Observation on 1/12/26 9:30 A.M., of the dining room showed:-There was dried spilled residue all throughout the sitting area.-There was a new fresh liquid spill on the floor by a support column in the middle of the floor. Observation on 1/13/26 9:57 A.M., of the dining room showed:-There was dried spilled residue all throughout the sitting area.-There was dried spilled residue next to the support column in the middle of the floor in the same area as the liquid spill observed on 1/12/26. Observation on 1/13/26 2:47 P.M., of the dining room showed:-There was dried spilled residue all throughout the sitting area.-There was dried spilled residue next to the support column in the middle of the floor. Observation on 1/14/26 8:52 A.M., of the dining room showed:-There was dried spilled residue all throughout the sitting area.-There was dried spilled residue next to the support column in the middle of the floor. Observation on 1/14/26 from 9:36 A.M. through 12:30 P.M., during the lunch meal preparation showed:-There were holes in the wall adjacent to the serving area in the walkway on top of the trim molding.-The metal trim was coming off the corner adjacent to the bread rack. -The dish machine room had no drain cover over the drain.-The area around the piping under the prewash sink in the dish machine room was not sealed and there was a large hole with wall debris spilling out on to the floor.-There was a black substance potentially mold on the piping and around the hole under the prewash sink in the dish machine room. -There was dust on the black fan in the dish machine room.Observation on 1/14/26 1:58 P.M., of dining room showed:-There was dried spilled residue all throughout the sitting area.-There was dried spilled residue next to the support column in the middle of the floor. During an interview on 1/14/26 at 2:00 P.M. the Executive Chef said:-Staff swept and mopped the kitchen every day. -Once a week staff deep clean, power wash the floors and pull the racks out of the cooler. -The holes in the walls and the drain cover should have been reported to maintenance in the tracking system.-The dining room should be swept and mopped after every meal.-Housekeeping would clean the dining room with a scrubber every other day. During an interview on 1/16/26 at 10:54 A.M. the House Keeping Supervisor said:-Dietary swept and mopped the dining room floors daily.-Once a week the house keeping staff would use the scrub machine on the dining room floor.

Based on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP, infection control measures, primarily in long-term care, requiring gowns and gloves for all high-contact care activities for residents with multidrug-resistant organisms (MDROs), wounds, or indwelling devices, expanding beyond standard precautions to prevent transmission while allowing residents more freedom than contact precautions.) were implemented for two sampled residents (Resident #4 and #14) who were on EBP; failed to ensure handwashing was done after completing dirty tasks during resident care for two sampled residents (Resident #4 and #14); failed to ensure infection control practices to prevent cross-contamination with proper placement of medical devices to include suprapubic catheter (a urinary catheter that is inserted into the bladder from a small cut in your stomach, just above your pubic bone) drainage bag that was placed underneath a wheelchair was dragging on the floor, and failed to ensure Enhanced Barrier Precaution (EBP) performed to prevent cross contamination during incontinence care and treatment care for one sampled resident (Resident #7) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Infection Control policy and procedure updated May 2024, showed This facility will facilitate safe care of all residents and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to pro- vide a safe, sanitary, and comfortable environment and to help pre- vent the development and transmission of communicable diseases and infections. This facility will follow Standard Precautions for Infection Control and Prevention to protect residents, staff and visitors to ensure staff do not carry infectious pathogens on hands or via equipment during resident care. The policy showed:-Contact precautions will be used to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or environment and requires the use of appropriate personal protective equipment (PPE-gowns gloves goggles, facemasks) including a gown and gloves prior to or upon entering the room. Prior to leaving the resident's room, the PPE will be removed and hand hygiene performed.-This facility will follow the Enhanced Barrier Precautions Policy for all MDRO infections.-Personal Protective Equipment includes but is not limited to gloves, gowns, masks, goggles, if skin or clothing is likely to be exposed to blood or body fluids.-Certain PPE may be required when working in the facility, including the use of facemasks or eye protection during a respiratory virus pandemic including but not limited to gloves worn before and removed after contact with blood or body fluid, mucous membranes, or non-intact skin; gloves changed and hand hygiene performed before moving from a contaminated­ body site to a clean-body site during resident care; gown worn for direct resident contact if the resident has uncontained secretions or excretions or with contaminated or potentially contaminated items; appropriate mouth, nose, and eye protection is worn for resident care or procedures that are likely to contaminate mucous membranes, or generate splashes or sprays of blood, body fluids, secretions or excretions.-Donning PPE order-put on gown, then mask, then gloves. Ensure gown is secured behind neck and with tie behind back. PPE should be appropriately discarded after resident care prior to leaving room followed by hand hygiene.-Hand Hygiene refers to both washing with plain or anti-microbial soap and water and use of alcohol gel. When hands are not visibly soiled, alcohol gel is preferred method of hand hygiene.-Perform hand hygiene: Before and after contact with a resident, immediately after touching blood, body fluids, non-intact skin, mucous mem­ branes or contaminated items (even when gloves are worn during contact), Immediately after removing gloves, when moving from contaminated body sites to clean body sites during resident care, after touching objects and medical equipment in immediate resident care area. Review of the facility foley Catheterization of Urinary Bladder revised on April 2023 showed:-Hang collection bag (drainage bag) appropriately to the side of the bed and keeping the bag below the resident bladder and off the floor. 1. Review of Resident #14's Face Sheet showed the resident was admitted on [DATE] with diagnoses that included:-Cerebral Palsy (a permanent neurological disorder caused by damage to the developing brain, affecting movement, posture, and muscle coordination).-Aphasia (a language disorder resulting from brain damage that impairs the ability to understand or express spoken or written language).-Cancer.-Acid reflux.-Malnutrition.-Seizure disorder (a sudden burst of electrical activity in the brain, it can cause changes in behavior, movements, feelings and levels of consciousness).-Dysphagia (difficulty swallowing).-Gastrostomy tube (a flexible tube inserted through the abdominal wall directly into the stomach, creating a surgical opening (stoma) for delivering nutrition, fluids, and medicine when a person cannot eat or swallow properly, providing essential enteral feeding and hydration).-Urine retention.-Anemia (low iron levels).-Depression. Review of the resident's Care Plan updated 10/28/25, showed the resident was on EBP related to his/her gastrostomy tube. Interventions showed staff would:-Provide EBP as indicated.-Involved the use of PPE, specifically gowns and gloves during high contact resident care activities (prolonged resident care activities). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/31/25, showed the resident:-Was alert with cognitive incapacity.-Had impairment on both upper and lower extremities.-Needed total assistance for bathing, dressing, grooming, toileting, eating and mobility. Review of the resident's Physician's Order Sheet (POS) dated January 2026, showed:-An order for gastrostomy care and feeding. -The resident was on EBP due to his/her gastrostomy tube. Observation on 1/13/26 at 11:50 A.M., showed:-There was an EBP sign on the resident's door frame with a box containing PPE (gowns and gloves) in the hallway. -The resident was in bed awake and was watching tv. He/She was alert and oriented to self and was non-verbal. -Certified Nursing Assistant (CNA) F and Licensed Practical Nurse (LPN) C entered the resident's room without putting on a gown. -CNA F put on gloves without sanitizing his/her hands. -LPN C sanitized his/her hands then went to the resident and checked the placement of his/her gastrostomy tube by measuring the length with a ruler. He/She told CNA F he/she would come back after the resident's incontinence care was completed. -LPN C washed his/her hands, left the resident's room and sanitized his/her hands. -CNA F removed his/her gloves and left the resident's room without washing or sanitizing his/her hands. Observation on 1/13/25 at 11:59 A.M., showed:-CNA F entered the resident's room with supplies without putting on a gown or washing/sanitizing his/her hands. He/She sat the supplies down then left the resident's room to get gloves. -CNA F re-entered the resident's room and put on the gloves without handwashing/sanitizing his/her hands or putting on a gown, and began providing incontinence care, and cleaning the resident.-CNA F turned the resident to the side to complete cleaning the resident, rolled the soiled bed pad (which was under the resident) and his/her brief up, then without de-gloving, washing or sanitizing his/her hands, he/she took a clean pad and placed it under the resident, on top of the soiled bed pad. -The resident continued to use the bathroom, so CNA F removed his/her soiled gloves then without sanitizing or washing his/her hands, he/she re-gloved and used the call light to request assistance.-CNA G came into the resident's room with a gown and gloves on. He/She held the resident to the side while CNA F cleaned the resident's bottom again. When he/she finished, he/she rolled the soiled pad, and sheet up against the resident's bottom. CNA F then removed his/her gloves and without washing or sanitizing his/her hands, he/she left the resident's room. -CNA F re-entered the resident's room with clean linen, without wearing a gown, or washing/sanitizing his/her hands, put on gloves and put the clean sheet and bed pad on the bed under the resident. CNA F and CNA G both rolled the resident over to his/her opposite side and CNA G removed the soiled linen from under the resident. -CNA F and CNA G both finished cleaning the resident's bottom before rolling the resident onto the clean pad.-Without removing gloves and washing/sanitizing their hands, CNA F and CNA G put the resident's clean brief on. -CNA G then placed the soiled linen in a trash bag, removed his/her gloves and washed his/her hands. -CNA F then put the resident's gown on, then removed his/her gloves and washed his/her hands. -CNA F and CNA G both re-gloved and repositioned the resident in bed and made the resident comfortable. CNA G then de-gloved, de-gowned and washed his/her hands. -CNA F pulled the resident's trash, de-gloved and then exited the resident's room without washing his/her hands. During an interview on 1/13/26 at 12:22 P.M., CNA G said:-The resident had an EBP sign on his/her door, and so he/she was supposed to wear a gown upon entering his/her room.-He/She did not know which resident was on EBP so it was better to wear the gown than not to. During an interview on 1/13/26 at 12:25 P.M. CNA F said:-The EBP protocol was, if there was an EBP sign on the door, they were to put on the gown with gloves prior to entering the room.-He/She did not know why or that the resident was on EBP and he/she had not initially looked at the door to see the sign.-Regarding handwashing, he/she was supposed to change gloves and wash his/her hands during incontinence care when changing to another part of the body, before he/she touched anything else in the resident's room, before he/she left the resident's room and whenever he/she went from a dirty task to a clean task. -He/She did not wash or sanitize between the dirty and clean tasks because he/she was moving fast and was a little frustrated that the resident began using the bathroom again after he/she had cleaned the resident up. Observation on 1/13/26 at 12:29 P.M., showed:-LPN Z came into the resident's room without putting on a gown. He/She washed his/her hands, gloved and informed resident that he/she was going to feed him/her via his/her gastrostomy tube. -LPN Z measured the resident's gastrostomy tube and checked placement and residual fluid prior to feeding the resident. After feeding the resident he/she rinsed the supplies, de-gloved and washed his/her hands. During an interview on 1/13/26 at 12:30 P.M. LPN Z said:-He/She did not gown because he/she did not know the resident was on EBP. -When a resident was on EBP, all nursing staff were supposed to sanitize/wash their hands, gown and glove prior to or upon entering the resident's room. -He/She had not paid close attention to the identifier on the resident's door. -He/She had taken care of the resident since he/she was admitted to the facility and did not know that he/she was supposed to be on EBP. During an interview on 1/16/26 at 12:04 P.M., the Chief Nursing Officer (CNO) said:-EBP should be worn with a resident who had a feeding tube.-A gown should have been worn while providing care to a resident with a feeding tube.-Hand hygiene should be completed between clean and dirty processes and between glove changes. 2. Review of Resident #4's Face Sheet showed the resident was admitted on [DATE], with diagnoses that included:-Diabetes (a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar).-Anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells)-Atrial fibrillation (AFib is an irregular and often very rapid heart rhythm).-Kidney failure.-Seizures.-Cholecystitis (inflammation of the gallbladder),-Prostatic hyperplasia (enlargement of the prostate gland causing urinary problems like frequent urination). Review of the resident's Care Plan updated 11/4/25, showed the resident was on EBP for wounds, a urinary catheter and nephrostomy tube. Interventions showed staff was to:-Provide EBP as indicated.-Involved the use of PPE, specifically gowns and gloves during high contact resident care activities (prolonged, direct contact). Review of the resident's annual MDS dated [DATE], showed the resident:-Was alert and oriented with some cognitive loss.-Was dependent on staff for bathing, dressing, toileting, eating and mobility.-Had a urinary catheter (a thin, flexible tube inserted into the bladder to drain urine out of the body). Review of the resident's POS dated January 2026, showed:-Physician's orders for wound care, catheter care and nephrostomy care. -The resident was on enhanced barrier precautions for wound care. Observation on 1/13/26 at 11:33 A.M., showed:-There was an EBP sign on the resident's door frame with a box containing PPE (containing gowns and gloves) in the hallway. -The resident was in bed awake without odors. -The resident's catheter collection bag was at the side of his/her bed below his/her bladder and his/her nephrostomy bag (a surgical opening from the kidney's urine-collecting area (renal pelvis) directly to the skin, usually in the back, to allow urine to drain externally via a tube (nephrostomy tube) into a bag, bypassing a blockage from kidney stones, tumors, or injury and preventing kidney damage) was laying on his/her bed with minimal fluid in it and in the tubing. During an interview on 1/13/26 at 11:33 A.M. the resident said:-He/She was doing well and had no issues regarding staff care and services. -He/She did not recall if the staff wore gowns when providing care. -He/She was satisfied with his/her care. During an observation on 1/13/26 at 11:35 A.M. showed the resident:-Pulled his/her call light and CNA F responded and asked the resident what he/she needed. The resident requested to be re-positioned in bed on his/her side. CNA F exited the resident's room and obtained gloves from the box of gloves that was on the railing in the hallway. CNA F then, without sanitizing his/her hands or putting on a gown, gloved then re-entered the resident's room and began repositioning the resident. When he/she was done, he/she removed his/her gloves and without sanitizing or washing his/her hands, CNA F exited the resident's room. During an interview on 1/13/26 at 11:37 A.M. CNA F said:-He/She was supposed to wear a gown with residents who were on EBP.-He/She did not normally work that hall and did not know all the residents who were on EBP.-He/She did not know the resident was on EBP.-He/She was supposed to wash or sanitize his/her hands upon entering the resident's room prior to putting on gloves and upon leaving after removing his/her gloves. During an interview on 1/16/25 at 12:40 P.M., the CNO said he/she expected the nursing staff to follow EBP protocol whenever providing direct care to residents who were on EBP. 3. Review of Resident #7's admission Record Sheet showed he/she admitted with the following diagnoses: -Malignant Neoplasm of the bladder (cancer of bladder). -Retention of Urine (is when your bladder doesn't empty completely or at all). Review of the resident suprapubic Care plan revised on 10/5/25 showed:-Check placement of the tubing each shift. -Provide Enhanced Barrier Precautions as indicated. Involved the use of PPE, specifically gowns and gloves, during high contact resident care activities (i.e., prolonged direct contact) revised on 7/23/25.-The resident had a suprapubic urinary catheter related to Obstructive and reflux of uropathy (is a condition in which the flow of urine is blocked).-Monitor, record and report to the physician any signs and symptoms of urinary infection. Review of the resident's Quarterly MDS dated [DATE], showed he/she:-Was cognitively intact.-Was able to understand others and make his/her needs known.-Required total assistance from staff for toileting.-Was admitted with an indwelling catheter. Review of the resident's POS dated 12/1/25 showed:-He/she was on EBP for an indwelling catheter every shift, dated 10/31/24.-Nursing staff were to provide indwelling catheter care every shift, dated 10/8/25.-Nursing staff were to change the Suprapubic catheter (use an 18 French Fr, a measurement of the outer diameter of a catheter), change every month at bedtime starting on the 6th and ending every month on the 7th, dated 12/6/25. -Monitor the Suprapubic catheter site for signs and symptoms of infection, including redness, drainage, and swelling every shift for new Suprapubic catheter site. Was dated 4/2/25. Observation on 1/12/26 at 11:21 A.M., of the resident showed. -He/She was sitting in a wheelchair in the hallway close to the nursing station. -An unknown nurse was standing next to the medication cart administrating medication to the resident. -The resident's catheter drainage bag and part of the tubing was dragging on the ground underneath his/her wheelchair.-The catheter tubing had a thick yellow substance in drainage tube. Observation on 1/14/26 at 12:00 P.M. of the resident showed: -He/she was sitting in a wheelchair in the hallway. -The catheter drainage bag was under his/her wheelchair and was dragging on the ground. Observation on 1/15/26 at 9:45 A.M. of the resident's Suprapubic catheter care showed: -The resident did not have Enhanced Barrier Precaution signage posted on the outside of his/her room door frame - CNA C entered the resident's room and sanitized his/her hands then placed gloves on his/her hands. -CNA C did not apply a gown or mask. -CNA C emptied the resident's catheter drainage bag of clear yellow urine into a graduate container. -CNA C provided incontinent care for the resident after he/she changed gloves. -CNA C did not wear PPE of a gown or mask while draining the catheter drainage bag of urine and during personal incontinent care for the resident. During an interview on 1/15/2026 12:14 P.M., CNA C said:-The CNA's completed incontinent care and emptied the resident's catheter drainage bag.-The resident's catheter drainage bag should be placed underneath the wheelchair secure, so it was not touching or dragging on the ground.-If the catheter drainage bag was found on the ground, he/she would clean the drainage bag with bleach wipes and then reposition the drainage bag so it was not touching the ground. -He/she was not aware the resident was on EBP.-If a resident was on EBP staff should wear a gown, gloves and mask when they provided direct contact care such as incontinence care and emptying the catheter drainage bag. During an interview on 1/16/26 at 9:11 A.M., CNA D said:-The resident's catheter bag should be secure underneath his/her wheelchair and should not be dragging on the ground. -The resident was on EBP and the CNA who provided any direct care should wear a gown, gloves and mask during the direct care process. During an interview on 1/16/2026 at 9:31 A.M., LPN B said:-The resident's catheter drainage bag should be placed securely underneath the resident's wheelchair and should never be touching the ground.-If found on the ground then the catheter drainage bag needed to be cleaned or replaced. -The resident should be on EBP due to the Suprapubic catheter. He/she would expect EBP signage on the door frame of the resident's room. -All staff were required to wear a gown, gloves and mask during any direct care provided for the resident. During an interview on 1/16/26 at 10:35 A.M., with Infection Control Preventionist (ICP) and the [NAME] President of Clinical Operations (VPCO) said: -He/she would be responsible to ensure infection precaution signage was posted on the resident's door and door frame with the type of precaution the resident was on. -Would expect a resident with a Suprapubic catheter be placed on EBP and staff should wear PPE of gown, gloves and mask if case splatter during any direct care provided. -The resident's catheter drainage bag should be secure and placed so it did not drag or touch the ground. -He/she would expect all care staff to preform hand hygiene before and after resident care, between a dirty to clean process, and between each glove changes. During an interview on 1/16/26 at 12:04 P.M., the CNO said: -He/she would expect care staff to perform hand hygiene upon entering and exiting a resident room, from a dirty to clean process, and between each glove change. -The resident's catheter drainage bag should be secured under the wheelchair and not dragging on the ground.-If found dragging on ground he/she would expect care staff to change the dirty drainage bag and with clean drainage bag. -He/she would expect EBP signage to be posted by the ICP for those residents at risk. -The resident was to be on EBP. -He/she would expect care staff to apply a gown, gloves and mask for any direct care provided including incontinent care and catheter care.

Based on observation and interview, the facility failed to maintain the inner area of the climate control units in resident rooms A9, A1, B11, D3, free from debris; failed to ensure the restroom ceiling vent covers in the restrooms of resident rooms A14, C8, C3, and D11, were firmly attached to the ceiling; failed to ensure the hand rail in the restroom of resident room A5, was firmly attached to the wall; and failed to ensure the wall guard in C12 was firmly attached to the wall. This practice potentially affected at least 15 residents who resided in or used those areas. The facility census was 105 residents. 1. Observation on 1/13/26 between 11:02 A.M. and 2:41 P.M., with the Facility Maintenance Director of the climate control units, showed:-The presence of an ointment bottle, a fork and a small medication cup were inside the climate control unit in resident room A9, with the grate cover for the climate control unit missing.-There was a heavy buildup of dust and cobwebs in the climate control unit in resident room A1.-There was a heavy buildup of dust and cobwebs in the climate control unit in resident room B11.-There was a large amount of dust and debris inside of the climate control unit in resident room D3.During an interview on 1/14/26 at 11:10 A.M., the Facility Maintenance Director said the climate control units should be checked once per month for debris buildup.2. Observation on 1/13/26 between 10:56 A.M. and 2:25 P.M., with the Facility Maintenance Director of the restroom ceiling vents, showed:-The ceiling vent in the restroom of resident room A14 was loose and not firmly attached to the ceiling.-The ceiling vent in the restroom of resident room C8 was loose and not firmly attached to the ceiling.-The ceiling vent in the restroom of resident room C3 was absent from the ceiling.-The ceiling vent in the restroom of resident room D11 was loose and not firmly attached to the ceiling.During an interview on 1/14/26 at 11:08 A.M. the Facility Maintenance Director said he/she had checked those vents in the past.3. Observation on 1/11/26 at 3:15 P.M.; 1/13/26 at 9:20 A.M., and on 1/13/26 at 12:51 P.M., showed a handrail that was not firmly attached to the wall of the restroom in resident room A5.4. Observation on 1/14/26 at 11:31 A.M. showed the wall guard in resident room C12 was peeling away from the wall with some of the screws protruding from the guard as it was detached from the wall.During an interview on 1/14/26 at 11:31 A.M., the Facility Maintenance Director said:-He/She was unaware of the loose wall guard in resident room C12.-He/She thought the facility staff (nurses and housekeepers) were really good about placing those items in The Equipment Lifecycle System (TELS(R)--Platform connects your teams to the data that matters - work orders, assets, compliance, and capital planning - all in one place).2685006

Based on observation, interview and record review, the facility failed to meet professional standards of practice when administering insulin (a hormone that regulates blood sugar), without cleansing the insulin pen rubber septum with alcohol prior to applying the pen needle and injecting insulin for two supplemental residents (Resident #75 and #115) out of 6 supplemental residents. The facility census was 105 residents. Review of the facility's Injections Policy last reviewed/revised in May 2023 showed there was no instruction given to clean pen septum prior to drawing up insulin.1. Review of Resident #75's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus (DM a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).Review of the resident's Physician's Order Sheet (POS) showed:-Humalog (a fast-acting insulin used to control high blood sugar) 20 units every day before meals.Observation on 1/14/26 at 11:58 A.M., showed:-Licensed Practical Nurse (LPN) F applied needle, drew up insulin, discarded due to wrong amount drawn, removed needle, did not wipe pen septum with alcohol, replaced needle, primed insulin and drew up 20 units of insulin.2. Review of Resident #115's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus.Review of the resident's POS showed:- Novolog (a rapid acting prescription insulin used to control high blood sugar) FlexPen 100 UNIT/milliliter (ML) Solution pen-injector--Inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units; 351 - 400 = 6 units Greater than 400 give and notify MD; notify provider for less than 70 , subcutaneously before meals and at bedtime for Diabetes Mellitus.- Lantus (a long-acting insulin used to control high blood sugar) SoloStar 100 UNIT/ML Solution pen-injector--Inject 10 units subcutaneously two times a day for DM; Hold if blood glucose less than 60, give and notify provider if greater than 400.Observation on 1/15/26 at 8:28 A.M., showed LPN D did not clean the Novolog or Lantus insulin pen septum with alcohol prior to applying pen needle, priming and drawing up medicine.3. During an interview on 1/15/26 at 9:02 A.M., LPN D said:-The facility policy on infection control when injecting insulin was to clean the resident's skin with alcohol, check skin, wipe insulin pen with alcohol and then apply needle.-Insulin pens should be wiped with alcohol prior to applying the needle and injecting into the resident.-Contamination risk could have been prevented when using the insulin pens by performing hand hygiene, applying any appropriate Personal Protective Equipment (PPE) such as gloves, and wiping all insulin injection pens and the resident's skin with alcohol. -The risk of not cleaning the insulin pens with alcohol prior to use is anywhere from minor to severe infection.During an interview on 1/15/26 at 9:51 A.M. the Chief Nursing Officer (CNO) said:-The facility policy for using insulin pens was to wipe the pen with alcohol before attaching the needle and cleanse the site with alcohol prior to administration.-He/She would expect nurses to clean the insulin pens with alcohol prior to attaching the pen needle.-Contamination was prevented with injector pens by swabbing the pen and skin with alcohol prior to administration.-The risks of not doing this could result in bacteria being passed or cross contamination and can range from mild to severe.

Based on observation, interview and record review, the facility failed to ensure multiple shower refusals were reviewed and documented for a potential reason for the shower refusals, and failed to review and document preferences for bathing or shower days and preferred shower times, for one sampled resident (Resident's #19), who refused 5 out 5 showers since his/her admission; and failed to ensure one sampled resident (Resident #12) who required staff assistance with activities of daily living (ADL's) had the call light placed within his/her reach out of 21 sampled residents. The facility resident census of 105 residents. The facility's Bathing/Shower Program policy was requested and not received at time of exit. Review of the facility's Call Light-Ability to Use policy last revised/reviewed in January 2024, showed:-The call light system is provided as a tool for residents to communicate with staff.-Residents will be evaluated for ability to use call light on admission, quarterly and annually.-If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided.-Staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room. 1.Review of Resident #19's admission Record showed he/she was admitted on [DATE] with a diagnosis of adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability) and need for assistance with personal cares. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/3/25 showed he/she:-Was cognitively intact.-Was able to understand others and make his/her needs known. Review of the facility's binder that indicated the resident's assigned shower days and time schedule dated 7/21/25 showed:-Residents were assigned their showers by room number.-The resident's room was assigned for a shower during the evening/night shift on Monday and Thursday.-A note on the binder indicated the Certified Nursing Assistant's (CNA's) were to report any skin changes and refusal of showers to the charge nurse. If a resident refused a shower, the CNA would document on the resident's shower sheet the resident had refused a shower. The shower sheet was to be signed by the resident or guest for any refusal of shower for assigned shower times and day. Review of the resident's Care Plan for ADL's dated 12/4/25 showed:-He/She had ADL self-care performance deficits, needed assistance with cares, required assistance with shower or bathing. -The resident had delirium (a sudden, serious change in mental state, causing confusion, disorientation, and reduced awareness, with symptoms like difficulty focusing, memory problems, hallucinations, agitation, or drowsiness, often fluctuating over hours or days, and typically linked to an underlying medical issue, infection, medication, or substance withdrawal).-The resident had delusions (a fixed, false belief held with strong conviction despite evidence to the contrary, not shared by the person's culture, and often involving misinterpretations of reality).-Known noncompliance with medical treatment. Review of resident's Skin monitoring: CNA shower Review sheet forms dated 12/8/25 to 12/31/25 showed:-The resident was offered showers during evening/night shift as assigned by room number. -On 12/8/25 he/she refused the shower as it was too late to take shower: and was signed by the resident. will shower next time. -On 12/11/25 he/she refused the shower and indicated he/she liked taking showers in the morning and the shower sheet was signed by the resident. -On 12/15/25 he/she refused a shower, and the shower sheet was signed by the resident.-On 12/18/25 the resident refused a shower, the shower sheet did not have the resident's signature for refusal of the shower. -On 12/23/25 the resident was in hospital. -There was no documentation on the shower sheet that the refusal of the shower had been addressed or the resident had been educated by the licensed nurse for noncompliance. Review of the resident's medical record dated 12/8/25 to 12/31/25 showed:-There was no documentation related to the residents refusal of his/her evening shift shower.-There was no documentation of any new interventions put in place related to bathing preferences and refusal of shower on the evening shift. Review of the resident's Care Plan dated 12/19/25 showed:-The resident was resistive to care, refusing care and medication and treatments.-Interventions included:--Encourage the resident to comply with cares.--Educate the resident and family, inform family member and the resident of outcomes from not complying with recommended treatment and cares.--Give clear explanation of all care activities prior to and as they occur during each contact with the resident. Review of the resident's care plan dated 12/30/25 showed:-History of refusal of care, treatments and medications. -There were no new interventions that indicated new approaches to encourage taking showers.-There were no new interventions that indicated the facility had offered to change his/her shower day and time to match his/her preference. Review of resident's Skin Monitoring: CNA Shower Review Sheets dated 1/1/26 to 1/8/26 showed:-The resident was assigned to evening/night shift for showers.-On 1/1/26 and on 1/5/26 no shower was given due to resident being in the hospital. -On 1/8/26 there was documentation the resident had refused a shower during the evening shift. --There was no resident signature for refusal of the shower. --There was no documentation on the shower sheet that the refusal of the shower had been addressed, or the resident had been educated by the licensed nurse for potential outcomes of noncompliance with bathing. Review of the resident's medical record dated 1/1/26 to 1/10/26 showed:-There was no documentation related to the resident's refusal of the evening shift shower.-There was no documentation of any new interventions put in place related to bathing preferences. Review of the resident's nurse Health Status Note dated 1/11/26 at 6:46 P.M., showed nursing reported to the Chief Nursing Officer (CNO) about the resident refusing showers on the assigned days and time. Observation on 1/12/26 at 3:22 P.M., of the resident showed: -There were no lingering odors noted in the resident's room. -The resident was clean, and he/she denied any care issues at that time. During an interview on 1/15/26 at 12:00 P.M., the resident said:-He/she had received a shower on Tuesday when his/her daughter was at the facility. -He/she was not aware he/she was assigned certain shower days and time. -He/she had wash cloths and towels available in his/her room to provide sponge baths at the bathroom sink. Review of the resident's Health Status Note dated 1/13/26 at 1:17 P.M. showed:-Staff called and spoke with the family regarding the resident ongoing refusal of showers and challenges with bathing.-The resident was referred to Social Services and Psychiatric Services. Review of the resident's Social Services note dated 1/14/26 at 5:56 P.M., showed: -Social Services called to talk to the resident's family member about setting up a care plan meeting. -The family member said he/she had been helping the resident with showers. -The family member preferred to help the resident with showers. -He/she didn't want the resident to refuse showers from care staff. -The family member would talk to the resident about allowing staff to provide care also. During an interview on 1/15/26 at 12:14 P.M., CNA C said:-If the resident refused a shower he/she would offer again later that shift, then notify the charge nurse the resident had refused.-He/She would have the resident sign the shower sheet.-The resident was assigned to the evening night shift for showers. During an interview on 1/16/26 at 9:11 A.M., CNA D said: -The resident was scheduled for nights shift showers. -Day shift showers did not populate as an option for the resident on the resident care task.-The resident's family member would give the resident baths also. -If the resident refused a shower or care, he/she would let the charge nurse know and the nurse would follow-up with the resident on why refused. During an interview on 1/16/26 at 9:31 A.M., Licensed Practical Nurse (LPN) B said:-For a shower refusal, the staff would try to offer a shower later that shift after first refusal, then if refused second time would then ask the resident why and would have the resident sign that he/she had refused the shower.-Nurse would let management know so they could follow-up with family members to encourage the resident to shower. -Nursing management would be responsible for changing the resident's shower days. -It was discussed during morning clinical meeting that the resident preferred a different time or days. -The resident was able to and provided some of his/her own personal body care at the bathroom sink, provided own sponge bath.-The night nurse would be responsible to document the resident refusal of a shower and any follow-up action taken. -He/she had not seen the resident unclean in the morning shift change. During an interview on 1/16/26 at 12:04 P.M., CNO said: -The resident had a history of refusal of cares by staff to include night/evening showers.-The resident's shower days and times were assigned by their room number.-Shower sheets were to be reviewed by the charge nurse every shift. -The resident care plan meeting reviewed the resident's preference on showering and then determined if there was a need to change the shower schedule.-The resident's shower should be documented by the assigned CNA as given or refused. -If a resident refused a shower he/she would expect the CNA to document on the shower sheet refused and have the resident sign that he/she had refused the shower that day. -If staff noted ongoing refusal of showers, then he/she would expect the CNA to notify the charge nurse to address with the resident and discuss the refusal of the showers with care team during the morning clinical meetings. -The resident's family member expressed concern related to the resident refusing staff assistance with his/her showers. The family indicated they would like to provide the resident shower when they visited. -He/she would expect shower/bathing provided by a family member be documented on the resident's shower sheet and/or in the nursing progress notes. -The clinical administrative staff were more focused on the resident's mental health changes and physical changes, then they were going to address the resident's refusal of care and his/her care preferences. 2. Review of Resident #12's admission Face Sheet showed he/she was admitted to the facility with diagnoses that included:-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Muscle weakness.-Need for assistance with personal care.-Difficulty walking. Review of the resident's Quarterly MDS dated [DATE] showed the resident:-Was able to express ideas and wants.-Had the ability to understand others.-Was moderately cognitively impaired.-Required either moderate or maximal assistance with self-care.-Required either moderate or maximal assistance with transfers, mobility, and walking up to 10 feet.-Had a diagnosis of Dementia.-Had a history of falls. Observation on 1/11/26 at 2:22 P.M., showed:-The resident was in bed.-The resident's call light was behind his/her nightstand and not within reach. Observation on 1/12/16 at 3:34 P.M., showed:-The resident was in bed.-The resident's call light was draped over the back of his/her nightstand and not within reach. During an interview on 1/12/26 at 3:24 P.M., the resident said:-Staff kept him/her in bed most of the time due to frequent falls.-The night shift staff purposefully placed his/her out of reach during the shift.-He/She was not able to get up on his/her own to go to the bathroom because he/she could not walk very far and had to wait until staff came into the room to check on him/her. Observation on 1/13/26 at 9:32 A.M., showed:-The resident was in his/her wheelchair in his/her room.-The resident's call light was behind his/her nightstand and not within reach. Observation on 1/13/26 at 10:03 A.M., showed the Assistant Chief Nursing Officer (ACNO):-Completed wound care and incontinent care on the resident.-The resident chose to stay in bed when asked.-The call light was not placed within reach. Observation on 1/14/26 at 8:17 A.M., showed:-The resident was in his/her wheelchair in his/her room.-The resident's call light was behind his/her nightstand and not within reach. Review of the resident's care plan last updated on 1/14/26 showed:-He/She had a communication problem related to difficulty understanding and expressing self at times.--Staff were to ensure/provide a safe environment by having the call light within reach.-He/She had an ADL self-care performance deficit and limited physical mobility related to Dementia, limited range of motion, and generalized weakness.--Staff were to encourage the resident to use the call light for assistance.--Staff were to educate the resident on the need to call for assistance when transferring, ensure the resident's call light was within reach and encourage him/her to use it. Observation on 1/14/26 at 11:41 A.M., showed:-The resident was in bed sleeping in his/her room.-The resident's call light was behind his/her nightstand and not within reach. During an interview on 1/16/26 at 10:12 A.M., CNA E said:-The resident required assistance from staff with cares and transfers.-He/She knew what the resident's assistance needs were based on information at the nurse's station and by asking the nurse.-He/She knew when the resident needed assistance by doing rounds and when the resident used the call light because he/she can use it.-He/She made sure the call light was within reach by making sure it was close by the resident and telling him/her that it was there.-Call lights were checked every time they entered the room and during rounds.-All nursing and other staff were responsible for making sure that call lights were within reach after cares had been provided.-Call lights should be placed within reach by being hooked to the bed or linens.-If a call light was found to be out of reach, he/she should place it within the resident's reach as soon as possible.-Staff should ensure call lights were within reach before leaving the room.-He/She identified the resident's call light was behind his/her nightstand.-The call light should not have been behind the nightstand. During an interview on 1/16/26 at 11:11 A.M., LPN C said:-The resident required assistance from staff with cares and transfers.-He/She knew what assistance was needed for the resident by looking at the resident's Electronic Health Record (EHR) under therapy, task, and MDS tabs and under the progress notes.-He/She would know if the resident was in need of assistance because he/she usually yelled out or using the call light.-The CNA's would check under interventions in the resident's EHR or ask the nurse to find out what assistance a resident needed.-Call lights should be checked when going in and coming out of the resident's room.-Everyone was responsible for making sure that call lights were within reach at all times.-All nursing staff was responsible for implementing the resident's interventions.-Call lights should be within reach before leaving the room by attaching it to the linens or bed rail in a position where the resident could reach it.-He/She attended an in-service one week ago that included the topics of call light placement.-Risks for not having the call light within reach at all times were fall and injury. During an interview on 1/16/26 at 12:05 P.M., the CNO said:-He/She would expect the resident's call light to always be within reach.-All nursing staff were responsible for making sure that call lights were within reach.-Staff should check that call lights were within reach before leaving a resident's room.-If staff saw a call light was not within reach, he/she would expect staff to place it within reach by securing it to the linens or wrap it around the bed rail.-He/She would expect the resident's care plan to be followed and interventions implemented.-Staff could find information about the resident's assistance needs and intervention information in the Kardex (a quick reference tool in the resident chart that has summarizes resident data a such as medications, care plans and critical information), care plan, during wound rounds and orders.-He/She would expect residents who are dependent on staff for all care and transfers to have their call light within reach at all times. -Staff received training on call light accessibility every month during an in-service, during new employee orientation and as needed. Complaint # 2703939

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #93) had access to an adaptive call light device and that the call light was within reach; and failed to implement ordered pressure injury prevention interventions, including the application of Prevalon boots while in bed. This failure placed the resident at risk for unmet needs, delayed assistance, and increased risk for pressure injury development out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Call Light-Ability to Use policy revised January 2024 showed:-The call light system was provided as a tool for residents to communicate with staff.-Residents would be evaluated for ability to use call light on admission, quarterly and annually.-If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) would be provided.-If residents are determined to be cognitively unable to use call lights, residents will be monitored for needs by staff members during rounds and while delivering care.-Staff members would ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room.Review of the facility's ADL (Activities of Daily Living) policy revised April 2023 showed:-The facility would provide each resident with care, treatment and services according to the resident's individualized care plan. -Based on the individual resident's comprehensive assessment, facility staff would ensure that each resident's abilities in activities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrated that the decline was unavoidable, including:--Communication including using speech, language or other functional communication systems specific to the needs of the individual resident.Review of the facility's Physician Orders policy revised May 2023 showed:-Orders may be called, hand-written, faxed, or electronically generated by physician.-The physician's order must be documented completely with sufficient content to clearly convey.-Orders that are unclear must be clarified prior to implementation.Review of the facility's Statement of Resident Rights dated June 2013 showed the resident:-Had the right to receive the services specified in the service plan.-Had the right to be free of neglect.1. Review of Resident #93's Face Sheet showed he/she was admitted on [DATE] with diagnoses that included:-Protein-calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat).- Palliative Care (specialized medical support focused on relieving symptoms and stress from serious illnesses).-Cognitive communication deficit.-Difficulty in walking.-Legal blindness.-Senile Degeneration of Brain (age-related cognitive decline, now typically called dementia characterized by progressive loss of memory, thinking, and daily function).-Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated December 2025 showed the resident:-Had some difficulty communicating some words or finishing thoughts.-Usually understood others but missed some part/intent of message.-Had severely impaired vision.-Was severely cognitively impaired.-Was completely dependent for all ADL's.-Was completely dependent for all transfers and changes in position.-Was incontinent of bowel and bladder.-Was at risk of developing pressure ulcer/injury.Review of the resident's Physician Order Sheet (POS) dated January 2026 showed a physician's order for Prevalon boots to be worn when in bed.Review of the resident's Care Plan dated January 2026 showed:-Resident was vision impaired and legally blind. Interventions showed staff would:--Keep call light and other key items within reach.--Tell resident where items were placed, be consistent.-Resident had self-care deficits related to chronic health conditions, significant changes in ability to participate, recent hospice (a specialized, holistic, and compassionate form of end-of-life care focused on providing comfort, dignity, and quality of life rather than curative treatment for patients with a terminal prognosis of six months or less) admission for senile degeneration of brain. Interventions showed staff would:--Encourage the resident to use bell to call for assistance.-Resident was at risk for falls related to conditions, reduced function, legally blind and recent falls. Interventions showed staff would:--Ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance, initiated on 5/1/23.--Provide soft touch call light for resident use, initiated on 6/23/23.-Resident had risk for impaired skin integrity related to immobility and incontinence. Interventions showed staff would:--Apply bunny boots to bilateral feet for pressure relief, initiated 6/27/23.Observation on 1/11/26 at 3:52 A.M. showed the resident:-Was in bed resting with no Prevalon boots applied.-The standard call light was on the floor between the bed and nightstand and not within the resident's reach. -There was no adaptive call light present.Observation on 1/12/26 at 12:11 P.M. showed the resident:-Was in bed sleeping with no Prevalon boots applied.-The standard call light was tied to the lower bed frame and not within the resident's reach. -There was no adaptive call light present.Observation on 1/13/26 at 12:04 P.M. showed the resident:-Was in bed resting with no Prevalon boots applied.-The standard call light was tied to the lower bed frame and not within the resident's reach.-There was no adaptive call light present.Observation on 1/14/26 at 8:24 A.M. showed the resident:-Was in bed sleeping with no Prevalon boots applied.-The standard call light was tied to the lower bed frame and not within the resident's reach.-There was no adaptive call light present.Observation on 1/16/26 at 9:15 A.M. showed the resident:-Was in bed resting with no Prevalon boots applied.-The standard call light was tied to the lower bed frame and not within the resident's reach.-There was no adaptive call light present.During an interview on 1/16/26 at 11:00 A.M., Certified Nursing Assistant (CNA) H said:-The resident had limitations with mobility and positioning and required total assistance from staff.-He/she knew what the resident's interventions for cares and assistance were because he/she had been taking care of the resident for a long time and just knew.-He/she could find this information in the resident's electronic medical record or by asking the charge nurse.-He/she would know if the resident needed assistance by the call light being activated and by randomly doing rounds.-The call light should always be within reach and attached to the siderail, bed linens or the resident's clothing.-The call light should be placed within the resident's reach before leaving the room.-He/She did not know if the resident required a standard or adaptive soft touch call light. The resident could use regular but should probably have a soft touch.-He/she was not sure if the resident should have heel protecting boots on while in bed and would get this information by asking the charge nurse.-A resident should wear heel protecting boots while in bed.-Pressure injury interventions were listed in the resident's care plan.-The nursing staff were responsible for implementing interventions and documenting the interventions completed.-He/she had received training on call light placement and interventions regarding assistive devices during an in-service one week ago. Topics included call light placement, making sure call lights were within reach and to use preventative devices as ordered.During an interview on 1/16/26 at 11:11 A.M., Licensed Practical Nurse (LPN) C said:-The resident was bed bound and required total assistance.-He/she would know if the resident required assistance because the resident usually yelled out and by doing rounds and at meals.-The call light should be placed on the resident's bed linens and within reach at all times.-He/she was not sure which type of call light the resident should have. He/she would check the MDS and care plan for that information.-He/she believed that since the resident was bed bound they would require heel protector boots being worn. He/she would find out this information by asking hospice, asking the wound nurse, checking MDS, progress notes or the care plan.--The CNA's could find out this information by checking interventions in Point of Care (POC- enables care staff to document activities of daily living at or near the point of care) or by asking the nurse. -He/she received training through in-services that were held one week ago which included the topics of call light placement and the application of assistive devices. He/she also training on the first Thursday of each month and as needed. During an interview on 1/16/26 at 12:05 P.M., the Chief Nurse Officer (CNO) said:-He/she would expect the call light to be within reach of the resident at all times.-All direct care staff was responsible for making sure that call lights were within reach at all times.-Staff should place call lights within reach before leaving the room.-If staff saw that a call light was out of reach, they should make sure it was within reach and secured to the resident's linens or wrapped around the bedrail.-He/she would expect the nursing staff to follow the resident's care plan and implement all interventions.-He/she would expect that physician's orders to be followed at all times.-He/she would expect that a resident with an order for Prevalon boots have them on at all times while in bed as ordered.-Staff could find information about the resident's interventions by checking the care plan, during wound rounds, and looking at the resident's orders.-He/she would expect staff document the interventions and there should be an order in the chart to monitor for placement, a care plan note, and it should be listed in the tasks section in POC.-He/she would expect a resident who was totally dependent on staff for cares and transfers always have their call light within reach. -All direct care staff was responsible to make sure call lights were within reach.-Staff received training on call light accessibility and pressure injury prevention (heel protectors) every month, during orientation and as needed. -There was also a town hall training session on 1/8/26.

Based on observation, interview, and record review, the facility failed to ensure there were physician orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that treats sleep disorders by delivering a steady stream of air through a pressurized mask) for one sampled resident (Resident #18) out of 23 sampled residents. The census was 105 residents. Review of the facility policy titled Physician Orders revised dated May 2023 showed:-Orders may be called, handwritten, fax, or electronically generated by physician. -The physician's orders must be documented completely with sufficient content to clearly convey the provider's intent. Indication for PRN (as needed) orders should be included in the order.-After the authorized provider had completed the orders, the Registered Nurse (RN) or Licensed Practical Nurse (LPN) was responsible to promptly and accurately transcribe all written orders. The RN or LPN must include his/her signature, the date and time of the transcription and credentials.-Orders that were unclear must be clarified prior to implementation.1. Review of Resident #18's face sheet dated 12/29/25 showed he/she admitted to the facility with the following diagnoses:-Acute respiratory failure (a sudden, life-threatening condition where the lungs cannot adequately supply oxygen to the blood (hypoxemia) or remove carbon dioxide (hypercapnia).-Shortness of breath.-Obstructive sleep apnea (a chronic disorder characterized by repeated, temporary pauses in breathing (apneas) or shallow breaths (hypopneas) during sleep caused by the upper airway collapsing or becoming blocked, despite ongoing breathing efforts).-Heart failure.-Need for assistance with personal care.-Hypoxemia.Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/14/26 showed: -He/She was cognitively intact.-He/She was dependent on staff for self-care.-He/She was independent for functional cognition.-He/She was dependent on a motorized wheelchair.- CPAP was not marked yes.-Respiratory failure was not marked yes. Review of the resident's current physician orders dated January 2026 showed no orders for the resident being on a CPAP prior to 1/15/26. Review of the resident's Care Plan dated January 2026 showed no mention of or interventions that indicated the use of a CPAP prior to 1/15/26. Review of the resident's Oxygen Saturation daily documentation records showed the staff documented the resident used a CPAP starting on 1/2/26.Observation on 1/12/26 at 10:09 A.M. showed the CPAP was on the nightstand next to the resident's bed. Observation on 1/13/26 at 10:48 A.M. showed the CPAP was on the nightstand next to the resident's bed. Observation on 1/15/26 at 1:00 P.M. showed the CPAP was on the nightstand next to the resident's bed. During an interview on 1/15/26 at 2:35 P.M. Certified Nursing Assistant (CNA) A said: -The resident wore a CPAP every night.-Staff assisted putting the CPAP on him/her at night. -He/She believed the nurses were responsible for cleaning it.-He/She thought there should be orders for the CPAP.Observation on 1/16/26 at 8:45 A.M. showed the CPAP was on the nightstand next to the resident's bed and the mask was lying on the bed. During an interview on 1/16/26 at 9:15 A.M. CNA B said:-He/She had not worked with the resident since he/she came back from the hospital.-He/She did not remember the resident having a CPAP before going to the hospital.-He/She did not know who was responsible for cleaning the CPAP. During an interview on 1/16/26 at 9:30 A.M. LPN A said:-He/She could not remember if the resident had a CPAP machine.-He/She believed the night nursing staff would know more about the CPAP machine. -If a resident did need a CPAP machine the nurses would be responsible for cleaning it.-CAN's would not clean the machine.-The resident should have had an order for the CPAP.-The first time the resident had a CPAP machine, there should have been an order for it.-He/She could not remember when the resident came back from the hospital.-The CPAP should have been documented in the Care Plan and the MDS. During an interview on 1/16/26 at 10:00 A.M., the MDS/Care Plan Coordinator said:-The resident did not have the CPAP when he/she moved into the facility.-He/She thought maybe the family had brought the CPAP in.-The first time he/she heard about the resident having a CPAP was on 1/15/26.-The CPAP should have been documented in the Care Plan and the MDS.During an interview on 1/16/26 at 10:46 A.M., the resident said:-He/She had the CPAP machine since 2016.-He/She had to wear it every night.-He/She needed staff to put it on him/her every night.-He/She was able to take it off by himself/herself. During an interview on 1/16/26 at 11:37 A.M., the Assistant Chief Nursing Officer (ACNO) said: -He/She just found out on 1/15/26 that resident had a CPAP machine. -When the resident admitted and readmitted to the facility he/she did not have the machine. -He/She didn't think the resident had it for very long.-There should have been an order since he/she had it in his/her room.-He/She would need assistance to put the CPAP on, and the nursing staff would have helped.-Nurses were responsible for cleaning it and it should have been cleaned daily.-The CPAP should have been documented in the Care Plan and the MDSDuring an interview on 1/16/26 at 12:04 P.M., the Chief Nursing Officer (CNO) said:-There should be orders when a resident wore a CPAP.-Nursing staff was responsible for making sure the orders were in.-The resident wore a CPAP.-He/She did not know when the CPAP came into the building.-He/She was waiting to hear from the resident's spouse to see when the machine came into the building. -He/She just learned about the CPAP on 1/15/26. -The resident did not necessarily need help putting it on since he/she was able to take it off by him/herself. -The Charge Nurse would record the Oxygen saturation data for the resident while wearing the CPAP.

Based on observation, interview and record review, the facility failed to ensure dialysis (a medical treatment that filters waste products and excess fluid from the blood when the kidneys fail, acting as an artificial kidney to keep the body in balance) orders for monitoring the dialysis site were complete to show the thrill (the buzzing vibration felt on the skin over a vascular access (like an AV fistula) from rapid blood flow), and bruit (the whooshing sound heard with a stethoscope, both indicating the access was working properly) would be checked daily; failed to monitor the resident's dialysis site according to the facility protocol; failed to document that the monitoring was completed; and failed to develop a care plan that included how the facility would monitor the resident's dialysis site for one sampled resident who received dialysis (Resident #57) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Dialysis policy and procedure dated April 2023 showed:-Any line dressings will be done at dialysis unless specifically ordered to be done at the facility. The dressing may be reinforced.-The dialysis site Central Venous Catheter (CVC access for dialysis is a temporary or bridging method for hemodialysis using a soft tube inserted into a large vein (neck, chest, groin) to quickly access the bloodstream, featuring two ports for blood removal and return, ideal for urgent situations but carrying higher infection/clotting risks than permanent access) will be checked daily for signs and symptoms of infection or bleeding.-The dialysis site fistula (a surgically created connection between a patient's artery and vein, typically in the arm, to provide durable, long-term access for hemodialysis, allowing for efficient blood flow for cleaning by the dialysis machine),) will be monitored daily for thrill and bruit.-For residents with fistulas, documentation in the medical record will reflect arm precautions if applicable. Arm precaution includes no blood pressure on the fistula arm, no intravenous lines, and no application of pressure on the arm with the fistula.-Communication with the dialysis center will be done by nursing, dietary and/or social services.-The resident's care plan will reflect their dialysis needs.1. Review of Resident #57's Face Sheet showed the resident was admitted with diagnoses including end stage renal disease (the blood, affecting body chemical balance, blood pressure, and red blood cell production), dependence on dialysis, diabetes, high blood pressure and high cholesterol.Review of the resident's Care Plan dated 12/8/25, showed the resident received dialysis in-house on Monday, Wednesday and Friday. Interventions showed:-Check and change the dressing at the access site per physician's orders and document.-Encourage the resident to go for the scheduled dialysis appointments. -Monitor the Dialysis site for bleeding when returning from dialysis.-Monitor labs and report to the doctor as needed.-Monitor vital signs (blood pressure, temperature, respirations and oxygen) as ordered, and notify the doctor of significant abnormalities.-Monitor/document/report as needed any signs or symptoms of infection to the access site: redness, swelling, warmth or drainage.-NOTE: The care plan did not show where the resident's dialysis access site was or the type of access site the resident had. It did not show how the facility was to monitor the access site.Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/12/25, showed the resident:-Was alert and oriented with minimal cognitive decline.-Needed only supervision with bathing, dressing, toileting, grooming, mobility.-Had lower extremity limitations and used a wheelchair for mobility.-Received dialysis services.Review of the resident's Physician's Order Sheet (POS) dated January 2026, showed physician's orders for:-In house dialysis on Monday, Wednesday and Friday at 3:30 P.M. (ordered 1/13/25).-Remove dressing from the dialysis access site the next day after dialysis treatment (3/1/25).-CVC Location Right chest (1/9/25).-The physician's orders did not show how the facility was to monitor the dialysis CVC, there were no physician's orders to show the resident had a permanent dialysis site such as a fistula, where it was located or how to care for/monitor that site.Observation and interview on 1/13/26 at 10:29 A.M., showed the resident was in his/her room in his/her wheelchair dressed for the weather without odors. He/She had a right below knee amputation with a prosthetic. The resident's left forearm showed the resident had red bruising and several puncture wounds at the dialysis site (fistula site). The resident also had tubing coming from his/her right chest (CVC site) that was covered with a white cotton 4x4 pad. The resident said:-He/She was a dialysis patient and had both a fistula and a CVC.-He/she was not supposed to receive dialysis through the CVC, but yesterday at dialysis they had a hard time getting his/her fistula to work so since he/she still had the CVC they used that to give his/her dialysis treatment. -Normally they used the fistula to give his/her dialysis treatment, and the puncture wounds and bruising was from dialysis staff trying to access the fistula.-He/She still had the CVC but they were eventually going to remove it. Until then, he/she was not supposed to get the CVC wet and the facility staff was not supposed to do anything with it.-The nurses would check to see if there was any bruising or bleeding from the CVC and that was it.-The nursing staff usually removed the bandage from his/her fistula then checked it to make sure it wasn't red or bruised after he/she returned from dialysis.-Sometimes Licensed Practical Nurse (LPN) E would feel his/her fistula, but they did not check it every day and not all of the nurses checked it.-He/She had not seen any of the nurses use a stethoscope to listen to his/her fistula.During an interview on 1/15/26 at 10:39 A.M., the resident was sitting in his/her wheelchair in his/her room and said:-The nurse did not check his/her dialysis site yesterday, because he/she was not the nurse who normally worked on his/her unit, but today LPN E was working, and he/she normally checked his/her fistula. -LPN E had not come in to check his/her dialysis site yet.During an interview on 1/15/26 at 3:08 P.M., LPN E said: -He/She only worked on one of the resident's dialysis days, Monday.-He/She visually checked the resident's CVC site to ensure the CVC was not wet and showed no signs of trauma, bruising or draining. -He/She did the same with the resident's fistula, he/she checked to see that there are no signs of infection.-The resident's fistula had been doing well but yesterday they poked him/her so much in dialysis, that he/she had some significant bruising at his/her fistula site.-He/She documented monitoring of both the fistula and CVC sites on the Medication Administration Record (MAR).-The nurse who was monitoring the areas were supposed to document a progress note if there were any changes to the site noticed.-When he/she checked the resident's fistula, sometimes he/she would feel it to ensure it was flowing and was not clogged. -He/she did not usually listen to the resident's fistula to ensure it was working properly.-The physician's orders did not show they were to check the thrill and bruit or how they were to monitor the resident, but he/she would find out what they were supposed to do.During an interview on 1/16/26 at 9:36 A.M., Dialysis Patient Care Technician (PCT) said: -Once the resident completed his/her dialysis treatment and went back into the facility, the nursing staff was not to touch the resident's dialysis site. -The nursing staff was allowed to change or remove the bandage at the resident's CVC site if it was wet or soiled.-They were not to do anything else but look at the site and report signs and symptoms of infection.-For the resident's fistula, the nursing staff could remove the bandage after he/she came back from dialysis and then ensure there were no signs or symptoms of infection.-They taught the resident in dialysis how to monitor their thrill and bruit to make sure it was not clogged.-If the facility nursing staff noticed any concerns or problem with the resident's CVC or fistula, they were supposed to notify dialysis immediately so it could be addressed.During an interview on 1/16/26 at 9:42 A.M., Dialysis Registered Nurse (RN) said:-CVC dressings were to be changed by the facility nurse only if they got wet or dirty.-Facility nursing staff should monitor the CVC site daily to see if the CVC site got wet or dirty.-If the resident took a shower the nurses were to cover the resident's CVC site. -If the CVC site got wet or dirty, the facility nursing staff was to clean the area immediately and notify dialysis because the area could get infected and sepsis (a life-threatening medical emergency caused by the body's extreme, dysregulated immune response to an infection, resulting in tissue damage, organ failure, and potential death) could occur, otherwise, the facility staff was not to touch the CVC site.-With the fistula, the facility nurse should remove the tape/dressing on the access site 24 hours after dialysis treatment.-The facility nurse staff should look at the fistula site daily to ensure there were no signs and symptoms of infection. -If the resident had an issue with the fistula access site on days the dialysis staff were in the building, the nursing staff should bring the resident to dialysis so they could assess and treat the concern.-If the resident had an issue when the dialysis staff were not in the building, the facility staff were to notify dialysis immediately by telephone or text application.-He/She did not know what the facility protocol was for checking the resident's thrill and bruit daily while in the facility, but they checked the thrill and bruit at dialysis on the days the resident was there.-They communicated to the facility on the days the resident had dialysis regarding the resident's treatments and if there were any concerns or issues noted.During an interview on 1/16/26 at 10:25 A.M., LPN E said:-The protocol for monitoring the resident's dialysis access sites was to visually monitor both the CVA site and the fistula by looking to see if there are any signs or symptoms of infection.-The dialysis center would check the thrill and bruit.-They were to document that they looked at the sites on the resident's MAR.During an interview on 1/16/26 at 12:04 P.M., the Chief Nursing Officer said:-Nursing staff were supposed to monitor for signs/symptoms, bleeding on every shift.-He/She would expect to the nurse to check for bruit / thrill if they had one.-Nursing staff should notify dialysis and clinical (nursing staff) of any issues.-Nursing staff should be doing more than looking at a dialysis site, it should be assessed properly for the type of access site they had.

Based on observation, interview and record review, the facility failed to ensure follow-up dental appointments were made, which resulted in delay in dental treatment for one sampled resident (Resident #77) who was at risk for dental pain and infection out of 21 sampled residents. The facility Census of 105 residents. Review of the facility's Physician Order Policy dated May 2023 showed:-To clarify requirement and assure that all physicians orders were valid and safe for resident care. -Licensed nursing staff were responsible to promptly and accurately transcribe all written order. Review of the facility's Dental Services policy revised on April 2023 showed:-The admitting nurse performs a dental assessment on each resident upon admission. -If dental care is needed the nurse informs the resident and responsible party. -If the resident would like to use the facility dentist, that dentist will be notified.If the feels that there is a dent emergency, then the attending physician is notified for possible transfer to the emergency room. -Documentation by the dentist is recorded in the resident chart.-Nursing will document dental issue in the nursing note. 1. Review of Resident #77's admission Record showed the resident admitted to the facility on [DATE] with diagnoses of Anemia (a common blood condition characterized by a shortage of healthy red blood cells or a low level of hemoglobin) and cirrhosis of the liver (a serious, progressive liver disease where healthy liver tissue is replaced by scar tissue (fibrosis) due to long-term injury, impairing its ability to filter blood, process nutrients, and perform other vital functions, often leading to liver failure if untreated). Review of the resident's Physician Order Sheet (POS) dated 7/30/25 showed: -Dental referral due to poor dentition ( a state of inadequate or unhealthy teeth) and cracked teeth.-Dental Consult as needed order dated 2/17/24.Review of the resident's handwritten doctor progress notes dated 8/7/25 showed:-Diagnosis of poor dentition.-Had a dental visit and the resident was referred for a dental consult for surgery with sedative for Edentulation (the loss of all or most natural teeth). -Pending denture appointment after removal of teeth.Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/29/25 showed he/she:-Was cognitively intact.-He/she was able to understand others and make his/her needs known.-Had nothing documented under dental for broken or missing teeth.Review of the resident's Oral/dental Health Care Plan dated 9/10/25 showed: -The resident had oral/dental health problems related to poor dentition/cracked teeth.--Coordinate arrangements for dental care, transportation as needed/as ordered.--Provide mouth care as per Activity of daily living (ADL) and personal hygiene.--Monitor/document/report as needed any signs/symptom of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth), ulcers in mouth, or lesions.Review of the resident's medial record dated 10/1/25 to 1/11/26 showed: -The resident did not have any additional documentation related to follow-up dental appointment made or reason for a delay in dental treatment. -Had no documentation or nursing assessment related to ongoing dental pain and discomfort. Review of the resident's Nurse Practitioner (NP) encounter note dated 1/12/2026 showed:-Visit Type was an Acute/Follow-Up.-Had a diagnosis of dental abscess, and poor dentition.-New treatment order for dental abscess for the resident to start on Clindamycin (an antibiotic used to treat serious bacterial infections) 300 milligrams (mg) three times a day for five days. --There was no documentation of what type of infection or where.-Schedule the resident for poor dentition follow-up with a local hospital oral surgeon. Review of the resident's order notes dated 1/12/26 at 9:45 P.M., by the NP showed: -The resident was experiencing discomfort. patient said, that his/her mouth was hurting, and he/she couldn't really chew because each time he/she chewed it was cutting up his/her cheeks. -An order was given for follow-up with a dentist and order for magic mouthwash (made of Benadryl, Maalox, lidocaine) for pain.During an interview on 1/12/26 at 10:55 A.M., the resident said:-He/she had complaints of mouth pain, include gums, tongue and jaw, -He/she had difficulty eating due to the mouth pain. -Would like to have dental care and maybe a mouth guard due to his/her sharp jagged teeth. -Received regular schedule pain medication, but no special mouth wash treatment or pain medication for mouth pain. Review of the resident's physician's order note dated 1/12/26 at 12:14 P.M., showed an order for magic mouthwash given every day for five days. During an interview on 1/14/26 at 8:50 A.M., the resident said:-He/she continued to complain of mouth pain.-He/she was not aware of new orders for pain medication or mouthwash treatments.-The teeth he/she had left were very sharp, it felt like his/her gums and tongue were getting cut.-Difficulty in drinking also due to mouth pain. During an interview on 1/14/26 at 9:00 A.M., Licensed Practical Nurse (LPN) F said: -He/she had not assessed the resident for any mouth pain. -He/she was aware the resident had missing and jagged teeth.-The resident had no current treatment for mouth pain.-The resident was on antibiotic for a wound infection in the groin area. -The resident had to get approval from his/her cancer doctor before his/her broken teeth could be removed. -The dentist was at the facility yesterday; it was possible the resident was seen by the dentist then. -The resident did not have an order for mouth rinse or special medication for sore mouth, -He/she was not aware of the resident's current complaints of mouth pain, and his/her gums and tongue hurting. Review of the resident's POS on 1/14/26 at 9:27 A.M., with the [NAME] President of Clinical Operations showed he/she did not find the resident's physician order for mouth/teeth treatment such as a magic mouthwash for dental pain transcribed to the resident's POS. During an interview on 1/14/26 at 10:20 A.M., the Social Services Designee (SSD) said: -He/she found a note that the resident was seen at the dental clinic in October 2025.--The facility did not have documentation from the dental visit and any recommendation needed -The dental provider was going to send a copy to the facility. -The facility did not have the December 2025 documentation for the visit. -He/she did not find SSD follow-up notes or follow-up appointments note in the resident's progress notes. -He/she would expect the Prior SSD to have obtained a copy of the dental visits in October and document any additional referrals or treatments ordered. -Nursing would be responsible for obtaining the physician order and transcribe to the order on the POS. Observation and interview on 1/14/26 at 10:25 A.M., of the resident's mouth showed:-He/she was assessed by facility Regional Nurse and observed to have very few teeth left, which were jagged, broken and sharp. No open mouth sores noted at that time. -The resident had complaints of pain on the right side of the mouth and jaw. -The resident said it did hurt to chew, but he/she needed to eat. Review of the resident's Health Status Note dated 1/14/26 at 2:45 P.M., showed: -The resident continued on antibiotic, Clindamycin HCl Oral Capsule 300 mg give 300 mg by mouth three times a day for infection. -The resident had no complaints or adverse reactions noted on this shift.-NOTE: there was no documentation that the resident had received magic mouth wash for mouth pain. Review of the resident's POS transcribed on 1/14/26 showed:-The resident had order for Magic Mouthwash (made of Benadryl, Maalox, lidocaine 1:1:1 part) give 5 milliliters (ml) every six hours as needed for mouth pain for five days. May substitute for peroxide sore mouth cleanser until Magic Mouthwash arrives. -Clindamycin HCl Oral Capsule 300 mg give 300 mg by mouth three times a day for mouth/tooth abscess infection prevention.During an interview on 1/16/26 at 9:11 A.M., Certified Nursing Assistant (CNA) D said: -The resident had complained of oral pain, and he/she had informed the charge nurse. -The resident's oral pain started after his/her last dental appointment. -He/she was not aware was a special oral care treatment for the resident. During an interview on 1/16/26 at 9:31 A.M., LPN B said the dental care/pain process was to call the provider, assess, refer to dental clinic to be seen, and antibiotic as needed.During an interview on 1/16/26 12:04 P.M. the Chief Nursing Officer (CNO) said: -When a resident reported dental pain, he/she would expect the nursing staff to assess the resident's mouth and contact the resident's physician or further orders. Make a referral to the dental clinic for elevation and treatment as needed.-He/she would expect the nursing staff complete a pain assessment as needed. -The nurse would be responsible to address complaints of pain including dental pain to contact the resident's physician for any orders and follow-up needed. -Nursing staff would be responsible for documenting any referrals needed in the progress note. -Nursing staff would be responsible for contacting the dental clinic after the visit for any recommendations and dental treatment plan. -Social Services would be responsible to schedule dental appointments, transportation and any schedule for additional follow-up appointments. -He/she would expect the resident to have documentation of any additional dental appointment sand recommendations for treatment in the resident's progress note by Social Services and by nursing staff. -The resident should not have had to wait 4-5 months to receive follow-up dental treatments for ongoing dental issues.

Based on observation, interview and record review, the facility failed to ensure a comfortable and homelike environment for 64 sampled residents out of 73 sampled residents with room temperatures ranging from 81.8 degrees Fahrenheit ( F) to 87.0 F and halls A, B, C, D and F temperatures ranged from 81.5 F to 82.8 F. The facility had failed to have a comprehensive monitoring system including documentation for the air temperatures to maintain documentation for all ongoing maintenance for cooling units in the facility and to conduct random monitoring. This had the potential to affect all residents in the building. The facility census was 116 residents. Review of the facility's Emergency Operations Plan policy dated 4/1/23 showed: -Temperature thresholds: --Each facility shall establish and implement policies and procedures in a written plan to provide for the health, safety, welfare and comfort of all residents when the heat index/apparent temperature as established by the National Oceanic and atmospheric Administration, inside the facility exceeds 80 degrees F. Review of the facility Temperature policy revised March 2024 showed: -The facility temperature will be maintained between 71-81 degrees F. -There may be brief periods of time when the inside temperature falls out of this range in the event of inclement weather, power outages, or other unforeseen circumstances, -In these aforementioned instances, facility staff will take immediate and appropriate steps to ensure resident comfort. -During heat waves or excess heat, additional fluids will be offered or made available unless contraindicated. Review of the facility Direct Supply Logbook Documentation for temperatures: test and log air temperatures dated marked done on-time by the facility Director of Environmental Services/Maintenance (DOM) on May 17, 2024, showed: -Steps: --All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71-81 degrees F. or at a more restrictive range required by state or local requirements. Exceptions to this range may be available for brief periods of unseasonably warm or cold temperatures; however, the variance in temperatures must not adversely affect resident or patient health and safety. -Instructions: --Take environmental temperature readings approximately 36 inches from the floor. --Using a digital thermometer take random location temperatures throughout the building. --The time of day that the temperatures are taken should vary to ensure that the desired temperature range is achieved under a variety of conditions. --While meeting the requirement for the indoor air temperature, it is also important to consider the effective air temperature and the impact that humidity and air movement in the building may be having on comfort. --If air temperature monitoring tests are not within acceptable ranges, immediately create a high priority TELS work order. Review of the Weather Underground's website for local weather for the city and state where the facility was located from 6/8/24 through 6/10/24, showed the daily high temperatures and heat index were: -On 6/8/24; Daily high temperature of 86 F. -On 6/9/24; Daily high temperature of 80 F. -On 6/10/24; Daily high temperature of 80 F. 1. Observation and interview on 6/9/24 at 2:25 P.M., Director of Maintenance (DOM) said: -He/She does not keep regular facility temperature logs unless there was a problem. -The facility runs off a boiler system and air handler/chiller unit. -It runs about 20 degrees cooler then outside. -It will never get as cool as some residents would like it to. -Observed with the DOM the unit information screen/gage showing the unit was working and the water temperature going through the unit was 65.3 degrees F. -The air from the cold water in the system will stay the same throughout the facility. -The outside temperature was 83 degrees F. -Each room in the facility has a wall unit that can adjust the room temperature. -The facility had two wall units down at this time and new parts came in 6/8/24 and would be installed on 6/10/24. -One unit was in room H-4 and there was no resident in that room. -The other unit was at the common area at the end of hall E that was not used by residents unless going to the vending machine. -He/She had ordered a total of eight new motors and fans one each for those units and six extra since weather will be getting hotter. Observation on 6/9/24 from 3:38 P.M. to 4:14 P.M. showed: -The A hallway was 81.5 F. -The B hallway was 82.8 F. -Resident room A5 was 81.8 F, Resident #1 said the room was hotter than the hallway and he/she was hot. Resident #2 nodded his/her head in an up and down motion when asked if he/she were hot. -Resident room B10 was 83.9 F, Resident #10 was in bed and asleep. -Resident room B6 was 86.0 F, the room air unit was turned off and the window was opened about 2 inches. During an interview on 6/9/24 at 3:40 P.M., Family Member A said: -The resident room was hot. -He/she had just told the DOM and the Med Records/Central Supply person who was Manager on Duty (MOD) for the shift on 6/9/24 at 3:47 P.M., the room was too hot. During an interview on 6/9/24 at 3:47 P.M., the DOM said: -Had just been told by resident 1's family member that the air conditioning unit was not turning on in room A-5. -He/She checked for a work order and did not find one. -He/She will repair it tomorrow morning. During an interview on 6/9/24 at 3:54 P.M., Certified Nursing Assistant (CNA) A said: -Felt that resident 1's room was hot since the 17th of May. -Did not report to anyone because both residents in the room were not hot. -His/Her face was swollen up on Friday 5/24/24, due to the facility being too warm for him/her. -Resident 1 told him/her on Friday 5/24/24, the room was too hot. -He/She called and told the Clinical Staffing Coordinator, the MOD on Saturday morning 5/25/24, that the temperature in facility was too hot for him/her. -He/She was back on duty on 5/27/24, and the facility was cooler then. -Resident 10 in room B-10-1 had told him/her on 6/8/24, that it was hot. -He/She told Licensed Practical Nurse (LPN) C, only works as needed (PRN) that resident 10 was hot. -He/She did not believe LPN C told anyone else about resident 10 being hot. During an interview on 6/9/24 at 4:20 P.M., LPN A said: -He/she was not aware that the room window in B6 was opened. -Room windows should not be open. Observation on 6/9/24 from 4:22 P.M. to 4:46 P.M., showed: -The C Hall was 81.9 F. -LPN B was passing medications, was sweating and wiping his/her neck and face with a cloth. He/She said no residents had told him/her yet that it was hot and he/she had not asked them if they were comfortable. He/She had told the MOD the C hall was too hot. The MOD told him/her the air conditioning was being worked on at this time. -Resident room C10 was 86.9 F, there was an oscillating floor fan near Resident #5's bed. -The D hall was 83.1 F. -Resident room D7 was 87 F. Resident #7 was in bed. He/she had an oscillating floor fan near his/her bed and a small fan on the overbed table blowing on him/her. He/She was covered with a sheet and wearing oxygen. He/She said it was uncomfortable to breathe and it was too hot. Resident #8 had a small fan near his/her bed and said if the thermostat by the door setting gets turned down lower than 90 F the air conditioning wall unit in the room shuts off. -Resident room F8 was 83.1 F. The wall air unit was not turned on. Resident #9 had a thick blanket pulled up around him/her and said it was hot. During an interview on 6/9/24 at 5:17 P.M., the Director of Nursing (DON) had arrived at the facility and said: -Had contacted the air conditioning company that the facility contracted with and the company was sending a technician. -He/she had staff start moving residents from the hotter rooms to the cooler areas. -He/she had staff checking on all residents providing cold drinks and fans to those who wanted fans. -Activated the Emergency Disaster Plan including: --Room moves. --Nursing assessments of residents. --Hydration rounds. --Offering fans. --Cooling locations in the therapy gym and private dining area. During an interview on 6/9/24 from 6:01 P.M., the DOM said: -He/She had checked the Chiller at 4:34 P.M. and it was not running. -He/she had taken a picture of the information gages and it showed the Chiller had shut off at 3:15 P.M., probably due to a power surge. -The water in the Chiller was 80 Degrees F. -He/She contacted the air conditioning company, and they had a technician on the way. Observation on 6/9/24 from 6:06 P.M. to 6:25 P.M. with the MOD showed: -Resident Room A1 was 81.5 F., the wall unit was not working. Resident #22 said he/she was hot and there was a fan near his/her bed. -Resident Room A3 was 82.3 F. -Resident Room A5 was 82.5 F. Resident #2 was asleep with no apparent signs of distress at this time. -Resident Room A6 was 82.4 F, the wall unit was not working. -Resident Room A8 was 85.1 F. There were no residents in this room. During an observation on 6/9/24 from 7:17 P.M. to 8:19 P.M. with the Regional Resource [NAME] President (RRVP) showed: -Resident Room A7 was 82.5 F. -Resident Room A9 was 82.2 F. -Resident Room A10 was 82.0 F. -Resident Room A11 was 82.4 F, the wall unit was turned off. -Resident Room A14 was 82.0 F. -Resident Room B1 was 82.5 F. Resident #6 said the temperature was much better than earlier. -Resident Room B2 was 83.5 F. -Resident Room B3 was 83.5 F. -Resident Room B4 was 83.4 F. -Resident Room B5 was 83.7 F. Resident #39 and Resident #40 both said the temperature is a little warm but better than earlier. -Resident Room B6 was 84.2 F. -Resident Room B7 was 83.7 F. -Resident Room B8 was 83.0 F. -Resident Room B9 was 83.0 F. Resident #44 said the temperature was a little warm but ok with it. -Resident Room B10 was 83.1 F. Resident #10 and #11 both said the temperature was ok and better than earlier. -Resident Room B11 was 84.2 F. Resident #46 next to the window with curtain open said he/she was hot. -Resident Room B12 was 84.2 F. -Resident Room C1 was 82.8 F. Resident #51 said he/she was comfortable and temperature better than earlier. -Resident Room C2 was 82.0 F, resident belongings were on top of the wall unit and it was turned off. -Resident Room C4 was 81.7 F. -Resident Room C3 was 84.5 F, the room window was open. Resident #54 was next to the window and said he/she was hot. -Resident Room C6 was 85.4 F. Resident #55 and Resident #56 both said the temperature was better than earlier and it was cooling off some. -Resident Room C5 was 83.6 F. -Resident Room C8 was 83.2 F. -Resident Room C7 was 82.5 F. -Resident Room C10 was 88.0 F. Resident #5 said the temperature was better than earlier and waiting to be moved to another room. Hospitality Aide A said Resident #6 was out moved to another room onto B hall. -Resident Room C9 was 83.1 F. -Resident Room C12 was 82.7 F. Resident #62 and Resident #63 both said the room is cooling down and they were comfortable. -Resident Room E11 was 83.5 F. the wall unit was turned off and the RRVP turned the unit on. Observation on 6/9/24 from 8:00 P.M. to 8:30 P.M., with the DOM showed: -Resident room D3 was 86.7 F, the window was open, and the wall unit and thermostat were off. Resident #12 said it was warm. He/she had short sleeved shirt and shorts on and was up in his/her wheelchair. -Resident room D2 was 86.5 F, the window was open and wall unit and thermostat were off. The wall unit was set at 63 F. Resident #13 said he/she was really hot, there was no point in telling anyone. he/she had no shirt on. He/she said the wall unit was giving no air. -Resident room D4 was 86.9 F, the wall unit and the thermostat were off. Both residents were in bed and uninterviewable. -Resident room D5 was 84.3 F, the window as open, the wall unit and the thermostat were off. Resident #14 had a personal fan directly on him/her and said he/she had told the nurse it was too hot. -Resident Room D6 was 87.2 F, the wall unit and the thermostat were off. Resident #15 said it was a little hot. His/her shades were drawn, and the wall unit was off. He/she had told the direct care facility staff it was too hot more than once over the last couple of days. -Resident Room D7 was 86.5 F, the window was open, the wall unit was off, and the thermostat was off. Resident #16 said that the heat had a been a problem for several days since it was getting hotter. He/she had told the facility staff, and nothing was done. Resident #7 said the hospital aide had tried to adjust the thermostat and the thermostat shut completely off. Resident #7 said it was too hot and something needed to be done. -Resident Room D11 was 84.8 F, the window was open, the wall unit and the thermostat were off. Resident #17 said the air had never worked. He/she had told several staff, but no one had come to work on it. He/she spends time outside of his/her room because of the heat. -Resident Room D8 was 88.5 F, the wall unit and the thermostat were not working. Resident #18 said he/she was hot and was wearing oxygen. He/she said it had been uncomfortable for 2-3 days and he/she began to feel sick the night of 6/8/24. He/she had told the facility staff. Resident #20 said he/she was hot and had told everyone that had come thru the room. He/she was given a fan just a bit ago. The DOM said the wall unit was not working. -Resident Room D9 was 84.7 F, the wall unit and the thermostat were off. Resident #19 said it was not working and it was too hot. He/she said it was his/her choice if the unit was off and he/she did not mind it a little hot. He/she said the DOM had fixed the wall unit about two months ago and put a new motor in, the motor had stopped working. During an interview on 6/9/24 at 8:33 P.M., CNA C said: -The facility rooms and hall had been hot for about 3 days. -It was alarming hot in the building. -He/she had turned down thermostats in rooms that seemed hot and or for residents that had complained of heat. During an interview on 6/9/24 at 8:35 P.M., CNA D said only one resident had complained to him/her about it being too hot. He/she told the nurse. During an interview on 6/9/24 at 9:00 P.M., the Mechanical Contractor said: -The facility had purchased a new unit a few months back, there was nothing wrong with the unit itself. -The unit had a phasing issue (a power blip - a short outage) when it lost a phase of power. -He/she restored the unit through a hard reset in the navigator controls. -He/she was unable to determine what cause the phasing issue and could not see how long the power outage was. -When the unit was down it could not provide cooling to the units inside. During an interview on 6/9/24 at 9:30 P.M., the DOM & the RRVP said: -The only way all the wall units and thermostats on the D Hall were off was because someone (a human) would have had to turn them off. -There was no plan in place to check every wall unit and every thermostat unless a resident or facility staff person reported there was a problem. During an interview on 6/13/24 at 2:55 P.M. The DON and CCO said: -They were notified on 6/9/24 that state surveyor was in building about increased facility temperatures. -Put their heat plan in to action. -Called the facility environmental response team for that day to bring in fans and lowered the temperature in the cooling rooms in facility. -Moved the residents from D Hall, the hottest area at that time, to other rooms if the resident chose to. -Room D-8 air unit was not working, had to convince one resident to move to a cooler room. -Room D-8 air unit was repaired. -Enacted guardian rounds which consisted of: --Checking all rooms to be sure all air units were functioning. --Some room air units were turned off, mostly by the resident, turned the units back on. --Room temperatures and the Chiller checked every hour. --Offered hydration rounds. --Providers were notified. --Resident assessments were done every 8 hours for respiratory residents and every 12 hours for other residents. -On 6/9/24 about 7:30 P.M. The contracted heating/air conditioning company arrived: --Deemed an unexpected loss of power to the Chiller unit. --Reset the unit no repairs made to the unit. --The unit was up and running by 8:20 P.M. on 6/9/24. -RRVP in-serviced the DON and the facility DES concerning: -- monitoring all room temperatures and the Chiller every hour till rooms and facility temperatures were within the acceptable range of 71 degrees F. to 81 degrees F. --Providing hydration to residents and fans were needed. --Moving residents to cooler rooms and areas. --Checking that room windows were closed, and air units turned on. -The DON started in-servicing the staff on shift on 6/9/24 -Rooms D-8, 9, and 11 were the only rooms above 81 degrees F. at 12:00 A.M. on 6/10/24 and residents had been moved out of those rooms, -Rooms D-8 and D-11 were below 81 degrees F at 1:00 A.M. on 6/10/24. -Room D-9 was below 81 degrees at 3:00 A.M. on 6/10/24 -The resident in D-9 wants his/her room hot and likes the room air unit turned off. The resident was educated not to turn the air unit off in the room and to let staff know if cool and the staff will adjust the air in room so the staff will be aware of the room temperature. -The facility staff have done hourly room temperature checks on D Hall and random temperature room checks on the other halls till today, 6/13/24 at 9:00 A.M. and will continue to monitor while the weather is warmer. MO00237318 & MO00236930

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #316) received timely perineal care (peri-care: washing of a person's genitals and anal area) to keep the resident dry and repositioned to prevent the development of an open area to his/her tailbone and failed to ensure a resident who admitted to the facility with pressure ulcers had an admission skin assessment to include a description of the wounds, wound measurements, appropriate type and stage of wounds, and treatment orders for all wounds within six hours of admission and failed to administer antibiotics (a medicine that stops the growth or destroys bacteria) for an infected wound as ordered by the physician for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy, dated 5/2023, titled Wound Policy and Procedure showed: -At the time of admission, staff were to review the discharge records from the previous facility for information related to wounds and skin integrity. -Staff were to perform a full body inspection and note all wounds within six hours of a resident's admission to the facility. -Staff were to complete, upon admission, a comprehensive assessment of any wounds to include location, length, width, depth, appearance of wound base, drainage characteristics, appearance of wound edges, and a description of the skin surrounding the wound. Review of the facility's policy, titled Skin Integrity, dated 5/2023, showed: -Staff were to examine each resident's total body skin at each bath and report any abnormalities. -Staff were to begin a bowel and bladder management program for residents that were incontinent. 1. Review of Resident #316's Face Sheet showed he/she was admitted on [DATE] with a need for assistance with personal hygiene. Review of the resident's Nursing Evaluation, dated 1/19/24, showed the resident did not have any wounds to his/her tailbone or buttocks. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool used for care planning), dated 1/24/24, showed the resident: -Was cognitively intact. -Was dependent on staff for toileting and hygiene. -Was dependent on staff for lower body dressing. -Required moderate assistance to roll left and right. -Was occasionally incontinent (lack of the ability to control) of urine. -Was frequently incontinent of stool. -Had a diagnosis of neurogenic bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem). -Was paraplegic (partial or complete inability to move the lower half of the body and both legs). Review of the resident's Physical Therapy note, dated 1/27/24, showed the resident required maximum assistance for bed mobility. Review of the resident's undated Care Plan showed: -The resident used briefs and staff were to change the brief as needed and clean his/her peri-area each time. -Staff were to check every two to three hours, and as needed, for incontinence. -Staff were to toilet the resident every four to six hours during the daytime hours to promote continence. -Staff were to turn and reposition the resident every two to three hours. Observation and interview on 1/29/24 at 9:00 A.M. showed: -The resident was lying in bed flat on his/her back. -He/she was uncomfortable and didn't feel well. -Staff had not transferred him/her out of the bed at any time on 1/28/24. -He/she had asked staff to get him/her out of bed that morning but he/she was still waiting. A written request was made to the Administrator on 1/29/24 at 9:35 A.M. for bath sheets and full body skin assessments for the resident since admission. One skin assessment dated [DATE] was received at time of exit. No bath sheets were provided at time of exit. During an interview on 1/29/24 at 10:41 A.M., the resident said he/she still wanted to get out of bed but was desperate for a urinal (a bottle for urination) as he/she felt he/she would burst. Observation on 1/29/24 at 10:41 A.M. showed: -The resident remained in bed lying flat on his/her back. -Physical Therapist (PT) A entered the room and gave the resident a urinal. -The resident asked the PT to get out of bed and the PT said he/she would notify the care staff. During an interview on 1/29/24 at 10:49 A.M., Assistant Director of Nursing (ADON) A said he/she did not have any bath sheets for the resident. Observation on 1/29/24 at 11:22 A.M., 11:57 A.M., 12:15 P.M., 12:54 P.M., and 1:49 P.M., showed the resident remained in bed lying flat on his/her back. During an interview on 1/29/24 at 1:49 P.M., the resident said: -Staff had still not come to get him/her out of bed. -He/She had used his/her call light and asked several staff members to get out of bed. During an interview on 1/29/24 at 3:14 P.M., the resident said: -Staff had just got him/her out of bed and into his/her wheelchair. -Staff had refused to get him/her out of bed on 1/28/24 and told him/her to go in his/her brief and they would clean him/her afterward. -He/She had new pain on his/her buttocks near the spine. During an observation and interview on 1/30/24 at 8:56 A.M.: -Certified Nursing Assistant (CNA) A was standing in the resident's room. -CNA A said he/she was waiting for another staff member to assist him/her reposition the resident. -The resident said he/she was not able to turn side to side without help. Observation on 1/30/24 at 8:57 A.M. showed: -CNA A returned to the resident's room with the Staffing Coordinator. -The two staff members rolled the resident and removed his/her brief. -The resident had open areas on both sides of his/her tailbone; both had loose skin with black crusting stool-like substance around the edges with beefy red wound beds, no significant depth seen in either wound, both estimated to be half an inch long by half an inch wide. During an interview on 1/30/24 at 10:47 A.M. the resident, CNA A, Licensed Practical Nurse (LPN) A, and Physician A said: -CNA A said the resident had not needed his/her brief changed at all that day. -CNA A said he/she had first seen the wounds on the buttocks at 8:57 A.M. that day. -The resident said he/she started feeling pain on his/her tailbone on 1/28/24 but couldn't see back there. -The resident said he/she had urinated in his/her brief while waiting for the urinal earlier that morning because he/she couldn't wait any longer. -LPN A and Physician A were in the room to assess the resident's skin impairment. -LPN A told CNA A that the resident's brief was wet and had soaked through to the resident's pants. -LPN A said he/she was first told about the wound on the resident's buttocks that day. -Physician A said the resident's wound happened because he/she had been lying in urine. -Physician A said he/she believed the residents frequently sat in urine soaked briefs because of staffing issues at the facility. -Physician A said the resident's skin impairment was moisture associated. Review of the resident's Wound Assessment Details Report documented by LPN A, dated 1/30/24, showed: -The resident had a facility acquired moist associated wound measuring 3.2 centimeters (cm) long by 2.5 cm wide, with depth unknown. -An attached photo that showed the two open areas on the resident's buttocks. During an interview on 1/30/24 at 12:17 P.M., PT B said: -The resident could not turn from side to side, he/she required maximum assistance. -When physical therapy sees residents in the morning, the residents are usually soiled and the PTs have to perform peri-care and change the brief. During an interview on 1/30/24 at 1:26 P.M., CNA E said: -He/She was working with the resident that day. -He/She asked residents what they could and couldn't do to know what assistance to provide. -He/She would reposition a resident when he/she had repeatedly seen in the same position. -CNAs were expected to document any wounds in the resident's electronic chart and notify the nurse. -He/She was not aware the resident had any wounds on his/her buttocks. During an interview on 1/30/24 at 1:40 P.M., Certified Medication Technician (CMT) A said: -He/She was working with the resident that day. -CNAs were to report any wounds to their nurse and the wound nurse. During an interview on 1/30/24 at 2:38 P.M., LPN D said: -He/She expected the CNAs to observe the resident's skin each time peri-care was performed. -He/She expected the CNAs to report any new wounds to him/her and the wound nurse. During an interview on 1/30/24 at 3:06 P.M., Registered Nurse (RN) A said: -He/She was caring for the resident that day. -He/She was unaware the resident had a wound on his/her buttocks. -If the CNAs were providing peri-care as ordered, they would have found the wound on the resident's buttocks much earlier. During an interview on 1/31/24 at 1:48 P.M., the Director of Nursing (DON) said: -The resident's physician labeled the resident's buttocks wounds as moisture associated. -He/She expected staff to know what residents were not able to reposition themselves. -He/She expected staff to share each resident's mobility status during shift report so the staff were aware of what residents needed assistance. -He/She expected CNAs that found a new wound to report it to the charge nurse and chart it in the resident's electronic record. -If a wound was found during bathing, he/she expected the bath sheet to reflect the wound. -If the CNAs were checking and changing the resident's brief like they were supposed to, the CNAs would have found the wound much earlier. 2. Review of Resident #319's Face Sheet showed he/she was admitted [DATE] with the following diagnoses: -Osteomyelitis (inflammation of the bone) of vertebra (small bones that form the spine), sacral (a triangular bone located at the base of the spine) and sacrococcygeal region (includes the sacral area and the tailbone). -Pressure ulcer of the right buttock. -Pressure ulcer of the sacral region. -Local Infection of the skin and underlying tissue. -Pressure ulcer of the left buttock. Review of the resident's medical record showed no documentation of a skin assessment or wound assessment upon admission to the facility. The first documented skin/wound assessment was on 1/23/24. Review of the resident's undated Medication Review Report showed the physician ordered: -Weekly skin checks on 1/19/24. -Ampicillin-Sulbactam Sodium (an antibiotic) 9 grams (g) to be given intravenously (IV-through the vein) every eight hours for an infected wound on 1/19/24. -Vancomycin 1 g to be given IV in the afternoon for an infected wound on 1/19/24. -Wound care for each wound on 1/23/24. Review of the resident's MDS dated [DATE], showed: -The resident was cognitively intact. -The resident had one Stage III pressure ulcer (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone). -The resident had one Stage IV pressure ulcer (wound depth extends to muscle, tendon, or bone). -The resident had taken antibiotics prior to admission and at the facility. Review of the resident's undated care plan showed staff: -Documented the resident was at risk for skin breakdown. -Were to provide skin and wound treatments as ordered. -Documented the resident was receiving IV medications. -Added on 1/23/24 that the resident had four wounds: a left heel Deep Tissue Injury (DTI-a purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing [when forces moving in opposite directions are applied to tissues in the body]); a Stage III pressure ulcer to the right buttock; a right heel DTI; and a Stage IV pressure ulcer to the sacral region. Review of the resident's Wound Summary report dated 1/23/24 showed: -A non-infected DTI of the left heel identified on 1/23/24 with measurements and descriptions. -An infected Stage III pressure ulcer to the right buttock identified on 1/23/24 with measurements and descriptions. -A non-infected DTI of the right heel identified on 1/23/24 with measurements and descriptions. -An infected Stage IV pressure ulcer to the sacral area identified on 1/23/24 with measurements and descriptions. Review of the resident's Treatment Administration Record (TAR), dated January 2024, showed: -Staff signed that a skin assessment was completed on 1/22/24 (record not received at time of exit). -The physician entered an order for wound care to the sacral area starting on 1/19/23 and ending on 1/23/24. This was marked as completed 3 out of 8 opportunities. -The physician entered an order for all wounds, including the resident's left heel, right heel, right buttock and sacral area on 1/23/24. -Staff documented the administration of Vancomycin 4 out of 9 opportunities. -Staff documented the administration of Ampicillin-Sulbactam Sodium 17 out of 32 opportunities. Review of the resident's Physician's Note, dated 1/25/24, showed: -Staff had missed two doses of Vancomycin. -The physician discussed with the Assistant Director of Nursing (ADON) the importance of ensuring the resident received his/her antibiotics as ordered as it was imperative the resident received them to clear up his/her infection. Observation on 1/25/24 at 11:11 A.M. showed the resident's: -Right buttock had a wound approximately 1.5 inches x 1.5 inches with some tissue thickness loss and a pink wound bed, no drainage noted. -Sacral area had a large wound, approximate the size of a fist, with significant depth. Unable to see wound bed coloring or characteristics. Review of the resident's Physician's Note, dated 1/28/24 at 11:30 A.M. showed: -The physician saw the resident -The physician was concerned as the resident had missed his/her antibiotics for over 48 hours. During an interview on 1/30/24 at 10:22 A.M., Physician A said: -LPN A was the wound nurse. -LPN A would go in the room and do a full body assessment, then come out and notify him/her of any findings. -He/She would then assess the wound and give orders for wound care. During an interview on 1/30/24 at 1:40 P.M., CMT D said: -He/She expected staff to follow the physician's orders -He/She believed the facility expectation was to call the physician and notify them each time a resident missed a dose of a medication. -Every resident was to have a full body skin assessment the day of admission. During an interview on 1/31/24 at 1:48 P.M., the DON said: -He/She expected physician's order to be followed. -Staff were to perform a full body skin assessment of each resident upon admission. MO00229757, MO00229876, MO00230433.

Based on observation, interview, and record review, the facility failed to maintain appropriate staffing numbers to adequately provide resident care and meet resident needs. This had the potential to affect all residents who resided at the facility. The census was 122 residents. A policy regarding staffing by acuity was requested and not received at time of exit. 1. Review of the working staff schedules, dated 1/1/24 to 1/30/24 showed: -The facility had seven halls where residents resided; A-D were long term care, F-H were rehabilitation. -Each hall was assigned one Certified Nursing Assistant (CNA) each shift. -Nurses were each assigned to two halls per shift. -On 1/1/24 (holiday), two halls (F and G) did not have a CNA assigned during the day, and one hall (G) did not have a CNA at night. -On 1/2/24, two halls (D and G) did not have a CNA assigned at night. -On 1/3/24, two halls (C and H) did not have a CNA assigned during the day, and one hall (F) did not have a CNA at night. -On 1/5/24, one hall (F) did not have a CNA assigned during the day, and one hall (D) did not have a CNA at night. -On 1/6/24 (weekend), one hall (A) did not have a CNA assigned during the day, and two halls (D and G) did not have a CNA at night. -On 1/7/24 (weekend), two halls (A and F) did not have a CNA assigned until 12:00 P.M. during the day, and two halls (D and F) did not have a CNA at night. -On 1/9/24, one hall (H) did not have a CNA assigned during the day, and one hall (F) did not have a CNA at night. -On 1/10/24, one hall (D) did not have a CNA assigned at night. -On 1/11/24, one hall (G) did not have a CNA assigned at night. -On 1/13/24 (weekend), two halls (G and D) did not have a CNA assigned at night. -On 1/14/24 (weekend), two halls (B and H) did not have a CNA assigned during the day. -On 1/15/24, two halls (C and F) did not have a CNA assigned during the day. -On 1/18/24, one hall (H) did not have a CNA assigned during the day, and one hall (G) did not have a CNA assigned at night. -On 1/20/24 (weekend), one hall (G) did not have a CNA assigned at night and one hall (D) did not have a CNA until 11 P.M. -On 1/21/24 (weekend), one hall (G) did not have a CNA assigned at night. -On 1/22/24, two halls (D and H) did not have a CNA assigned until 1:00 P.M., and one hall (B) did not have a CNA assigned at night. -On 1/23/24, two halls (D and G) did not have a CNA assigned and a third hall (H) did not have a CNA assigned until 1:00 P.M. during the day. -On 1/26/24, two halls (F and H) did not have a CNA assigned during the day, and two halls (B and H) did not have a CNA assigned at night. -On 1/27/24 (weekend), the rehab unit had a nurse scheduled from 12:00 P.M. to 7:00 P.M. then another nurse from 11:00 P.M. to 7:00 A.M. leaving multiple hours with no nurse for those halls, and three halls (D, F, and G) did not have a CNA assigned during the day. -On 1/28/24 (weekend), all three rehab halls (F, G, and H) had CNAs until 4:00 P.M. during the day with night shift coming on duty at 7:00 P.M., and one hall (A) did not have a CNA assigned at night. -On 1/30/24, one hall (F) did not have a CNA assigned during the day. Review of the facility's Device Activity Report (shows what room/date/time/duration of activation for call lights used in the facility) from 1/19/24-1/22/24 showed: -On 1/19/24, room: --D1's bed call light alarmed for 15 minutes (min) and 14 seconds (sec) starting at 12:15 A.M. --D1's bed call light alarmed for 15 min and 14 sec starting at 12:30 A.M. --A3's bed call light alarmed for 16 min and 37 sec starting at 12:47 A.M. --F6's bed call light alarmed for 16 min and 15 sec starting at 1:01 A.M. --A3's bed call light alarmed for 15 min and 37 sec starting at 1:03 A.M. --A5's bed call light alarmed for 17 min and 51 sec starting at 1:18 A.M. --A5's bed call light alarmed for 17 min and 51 sec starting at 1:36 A.M. --H7's bed call light alarmed for 16 min and 47 sec starting at 1:48 A.M. --G14's bed call light alarmed for 23 min and 54 sec starting at 1:55 A.M. --H7's bed call light alarmed for 16 min and 47 sec starting at 2:04 A.M. --B2's bed call light alarmed for 15 min and 59 sec starting at 3:45 A.M. --D7's bed call light alarmed for 21 min and 27 sec starting at 8:00 A.M. --A5's bed call light alarmed 17 min and 11 sec starting at 9:16 A.M. --A5's bed call light alarmed for 17 min and 11 sec starting at 9:33 A.M. --B2's bed call light alarmed for 22 min and 7 sec starting at 9:37 A.M. --D1's bed call light alarmed for 19 min and 8 sec starting at 9:58 A.M. --B2's bed call light alarmed for 22 min and 7 sec starting at 9:59 A.M. --D1's bed call light alarmed for 19 min and 8 sec starting at 10:17 A.M. --F6's bed call light alarmed for 25 min and 32 sec starting at 11:56 A.M. --F6's bed call light alarmed for 25 min and 32 sec starting at 12:22 P.M. --G3's bed call light alarmed for 21 min and 12 sec starting at 3:17 P.M. --G3's bed call light alarmed for 21 min and 12 sec starting at 3:38 P.M. --D1's bed call light alarmed for 16 min and 37 sec starting at 3:47 P.M. --D1's bed call light alarmed for 16 min and 37 sec starting at 4:04 P.M. --B8's bathroom call light alarmed for 17 min and 52 sec starting at 4:05 P.M. --C9's bed call light alarmed for 18 min and 58 sec starting at 4:15 P.M. --B8's bathroom call light alarmed for 17 min and 52 sec starting at 4:34 P.M. --H7's bed call light alarmed for 16 min and 54 sec starting at 4:35 P.M. --H7's bed call light alarmed for 16 min and 54 sec starting at 4:52 P.M. --H8's bed call light alarmed for 17 min and 44 sec starting at 4:54 P.M. --F5's bed call light alarmed for 22 min and 52 sec starting at 5:33 P.M. --F5's bed call light alarmed for 22 min and 52 sec starting at 5:56 P.M. --B2's bed call light alarmed for 15 min and 3 sec starting at 6:12 P.M. --D4's bed call light alarmed for 18 min and 44 sec starting at 6:23 P.M. --H8's bed call light alarmed for 26 min and 48 sec starting at 6:46 P.M. --D8's bed call light alarmed for 16 min and 6 sec starting at 7:12 P.M. --C9's bed call light alarmed for 18 min and 58 sec starting at 7:16 P.M. --H7's bed call light alarmed for 19 min and 59 sec starting at 7:53 P.M. --C1's bed call light alarmed for 17 min and 13 sec starting at 7:54 P.M. --C1's bed call light alarmed for 17 min and 13 sec starting at 8:11 P.M. --H7's bed call light alarmed for 19 min and 59 sec starting at 8:13 P.M. --D1's bed call light alarmed for 22 min and 37 sec staring at 8:27 P.M. --F13's bed call light alarmed for 24 min and 33 sec starting at 8:39 P.M. --B2's bed call light alarmed for 15 min and 3 sec starting at 8:42 P.M. --D1's bed call light alarmed for 22 min and 37 sec starting at 8:50 P.M. --B7's bed call light alarmed for 15 min and 17 sec starting at 9:23 P.M. --D4's bed call light alarmed for 18 min and 44 sec starting at 9:28 P.M. --H7's bed call light alarmed for 17 min and 53 sec starting at 9:29 P.M. --B2's bed call light alarmed for 23 min and 54 sec starting at 9:42 P.M. --H7's bed call light alarmed for 17 min and 53 sec starting at 9:47 P.M. --G14's bed call light alarmed for 24 min and 31 sec starting at 9:59 P.M. --B2's bed call light alarmed for 23 min and 54 sec starting at 10:06 P.M. -On 1/20/24, room: --B11's bed call light alarmed for 16 min and 6 sec starting at 1:53 A.M. --F3's bed call light alarmed for 15 min and 12 sec starting at 2:07 A.M. --B11's bed call light alarmed for 16 min and 6 sec starting at 2:09 A.M. --F3's bed call light alarmed for 15 min and 12 sec starting at 2:22 A.M. --A5's bed call light alarmed for 16 min and 8 sec starting at 6:39 A.M. --A5's bed call light alarmed for 40 min and 30 sec starting at 7:26 A.M. --F6's bed call light alarmed for 23 min and 19 sec starting at 8:47 A.M. --F8's bathroom call light alarmed for 18 min and 6 sec starting at 8:52 A.M. --A4's bed call light alarmed for 18 min and 56 sec starting at 8:56 A.M. --H3's bed call light alarmed for 16 min and 42 sec starting at 8:57 A.M. --F5's bed call light alarmed for 15 min and 9 sec starting at 8:57 A.M. --A5's bed call light alarmed for 17 min and 33 sec starting at 9:06 A.M. --F8's bathroom call light alarmed for 18 min and 6 sec starting at 9:10 A.M. --F6's bed call light alarmed for 23 min and 19 sec starting at 9:11 A.M. --F5's bed call light alarmed for 15 min and 9 sec starting at 9:12 A.M. --H3's bed call light alarmed for 16 min and 42 sec starting at 9:14 A.M. --H8's bed call light alarmed for 25 min and 28 sec starting at 9:18 A.M. --A5's bed call light alarmed for 17 min and 33 sec starting at 9:23 A.M. --H3's bed call light alarmed for 16 min and 36 sec starting at 9:54 A.M. --B2's bed call light alarmed for 16 min and 55 sec starting at 10:21 A.M. --F13's bed call light alarmed for 16 min and 21 sec starting at 10:22 A.M. --F13's bed call light alarmed for 16 min and 21 sec starting at 10:38 A.M. --C10's bed call light alarmed for 15 min and 39 sec starting at 10:47 A.M. --A4's bed call light alarmed for 18 min and 56 sec starting at 10:55 A.M. --F4's bed call light alarmed for 18 min and 11 sec starting at 10:56 A.M. --C10's bed call light alarmed for 15 min and 39 sec starting at 11:03 A.M. --F5's bed call light alarmed for 18 min and 11 sec starting at 11:14 A.M. --C10's bed call light alarmed for 23 min and 55 sec starting at 11:21 A.M. --B7's bed call light alarmed for 23 min and 45 sec starting at 11:28 A.M. --B8's bed call light alarmed for 19 min and 31 sec starting at 11:32 A.M. --C10's bed call light alarmed for 23 min and 55 sec starting at 11:45 A.M. --B7's bed call light alarmed for 23 min and 45 sec starting at 11:51 A.M. --B8's bed call light alarmed for 19 min and 31 sec starting at 11:52 A.M. --F6's bed call light alarmed for 22 min and 59 sec starting at 11:54 A.M. --C2's bed call light alarmed for 21 min and 9 sec starting at 12:02 P.M. --F6's bed call light alarmed for 22 min and 59 sec starting at 12:17 P.M. --C2's bed call light alarmed for 21 min and 9 sec starting at 12:23 P.M. --C2's bed call light alarmed for 21 min and 59 sec starting at 12:53 P.M. --G14's bed call light alarmed for 22 min and 23 sec starting at 12:54 P.M. --H13's bed call light alarmed for 19 min and 28 sec starting at 12:55 P.M. --A3'd bed call light alarmed for 17 min and 35 sec starting at 1:10 P.M. --C2's bed call light alarmed for 21 min and 59 sec starting at 1:15 P.M. --A3's bed call light alarmed for 17 min and 35 sec starting at 1:27 P.M. --B1's bed call light alarmed for 15 min and 15 sec starting at 1:28 P.M. --C2's bed call light alarmed for 16 min and 55 sec starting at 2:07 P.M. --H8's bed call light alarmed for 19 min and 2 sec starting at 2:27 P.M. --H8's bed call light alarmed for 19 min and 2 sec starting at 2:45 P.M. --B8's bed call light alarmed for 20 min and 52 sec starting at 2:51 P.M. --B8's bathroom call light alarmed for 19 min and 54 sec starting at 2:57 P.M. --C7's bed call light alarmed for 42 min and 15 sec starting at 2:59 P.M. --F2's bed call light alarmed for 17 min and 18 sec starting at 3:11 P.M. --B8's bed call light alarmed for 20 min and 52 sec starting at 3:12 P.M. --B1's bed call light alarmed for 26 min and 48 sec starting at 3:13 P.M. --B8's bathroom call light alarmed for 19 min and 54 sec starting at 3:17 P.M. --H3's bed call light alarmed for 20 min and 56 sec starting at 3:41 P.M. --H13's bed call light alarmed for 21 min and 5 sec starting at 4:00 P.M. --H3's bed call light alarmed for 20 min and 56 sec starting at 4:02 P.M. --C2's bed call light alarmed for 16 min and 55 sec starting at 4:54 P.M. --C8's bed call light alarmed for 18 min and 3 sec starting at 5:14 P.M. --B8's bed call light alarmed for 19 min and 32 sec starting at 6:31 P.M. --F6's bed call light alarmed for 17 min and 48 sec starting at 6:33 P.M. --F6's bed call light alarmed for 17 min and 48 sec starting at 6:51 P.M. --C2's bed call light alarmed for 15 min and 10 sec starting at 6:54 P.M. --C2's bed call light alarmed for 15 min and 10 sec starting at 7:09 P.M. --A7's bed call light alarmed for 22 min and 54 sec starting at 7:11 P.M. --H13's bed call light alarmed for 21 min and 5 sec starting at 7:30 P.M. --B8's bed call light alarmed for 19 min and 32 sec starting at 8:31 P.M. --A2's bed call light alarmed for 20 min and 58 sec starting at 8:47 P.M. --C7's bed call light alarmed for 15 min and 15 sec starting at 8:49 P.M. --F6's bed call light alarmed for 19 min and 18 sec starting at 8:58 P.M. --G14's bed call light alarmed 20 min and 17 sec starting at 8:59 P.M. --C7's bed call light alarmed for 15 min and 15 sec starting at 9:05 P.M. --A2's bed call light alarmed for 20 min and 58 sec starting at 9:08 P.M. --F6's bed call light alarmed for 19 min and 18 sec starting at 9:17 P.M. --C2's bed call light alarmed for 16 min and 6 sec starting at 10:20 P.M. --A2's bed call light alarmed for 15 min and 16 sec starting at 10:25 P.M. --A2's bed call light alarmed for 15 min and 15 sec starting at 10:40 P.M. -On 1/21/24, room: --D1's bed call light alarmed for 17 min and 14 sec starting at 12:52 A.M. --D1's bed call light alarmed for 17 min and 14 sec starting at 1:09 A.M. --A5's bed call light alarmed for 19 min and 16 sec starting at 2:34 A.M. --A5's bed call light alarmed for 19 min and 16 sec starting at 2:53 A.M. --F8's bed call light alarmed for 16 min and 30 sec starting at 3:42 A.M. --F5's bed call light alarmed for 21 min and 46 sec starting at 5:25 A.M. --F2's bed call light alarmed 20 min and 36 sec starting at 5:28 A.M. --F5's bed call light alarmed for 21 min and 46 sec starting at 5:47 A.M. --F2's bed call light alarmed 20 min and 36 sec starting at 5:48 A.M. --A5's bed call light alarmed for 16 min and 44 sec starting at 7:42 A.M. --A5's bed call light alarmed for 16 min and 44 sec starting at 7:59 A.M. --B8's bed call light alarmed for 25 min and 46 sec starting at 8:03 A.M. --C1's bed call light alarmed for 15 min and 40 sec starting at 8:32 A.M. --C1's bed call light alarmed for 15 min and 40 sec starting at 8:47 A.M. --F6's bed call light alarmed for 21 min and 59 sec starting at 9:13 A.M. --F6's bed call light alarmed for 21 min and 59 sec starting at 9:35 A.M. --D4's bed call light alarmed for 19 min and 55 sec starting at 9:36 A.M. --G5's bathroom call light alarmed for 16 min and 24 sec starting at 9:52 A.M. --A5's bed call light alarmed for 25 min and 34 sec starting at 10:00 A.M. --G5's bathroom call light alarmed for 16 min and 24 sec starting at 10:09 A.M. --B1's bed call light alarmed for 24 min and 53 sec starting at 10:33 A.M. --C6's bed call light alarmed for 16 min and 6 sec starting at 10:37 A.M. --H13's bed call light alarmed for 15 min and 32 sec starting at 10:47 A.M. --C6's bed call light alarmed for 16 min and 6 sec starting at 10:53 A.M. --D8's bed call light alarmed for 17 min and 18 sec starting at 11:05 A.M. --H9's bed call light alarmed for 26 min and 45 sec starting at 11:09 A.M. --C7's bed call light alarmed for 18 min and 38 sec starting at 11:15 A.M. --D4's bed call light alarmed for 19 min and 55 sec starting at 11:26 A.M. --F2's bed call light alarmed for 17 min and 14 sec starting at 11:35 A.M. --H5's bed call light alarmed for 20 min and 10 sec starting at 11:42 A.M. --B8's bed call light alarmed for 25 min and 46 sec starting at 11:48 A.M. --H5's bed call light alarmed for 20 min and 10 sec starting at 12:02 P.M. --C2's bed call light alarmed for 22 min and 23 sec starting at 12:02 P.M. --H13's bed call light alarmed for 15 min and 32 sec starting at 12:43 P.M. --D8's bed call light alarmed for 17 min and 18 sec starting at 12:52 P.M. --A3's bed call light alarmed for 16 min and 48 sec starting at 1:08 P.M. --A3's bed call light alarmed for 16 min and 48 sec starting at 1:25 P.M. --F13's bed call light alarmed for 21 min and 20 sec starting at 1:30 P.M. --D6's bed call light alarmed for 19 min and 28 sec starting at 1:31 P.M. --D8's bed call light alarmed for 20 min and 0 sec starting at 1:32 P.M. --A9's bed call light alarmed for 17 min and 41 sec starting at 1:37 P.M. --D6's bed call light alarmed for 19 min and 28 sec starting at 1:51 P.M. --F13's bed call light alarmed for 21 min and 20 sec starting 1:51 P.M. --D8's bed call light alarmed for 20 min and 0 sec starting at 1:52 P.M. --A9's bed call light alarmed for 17 min and 41 sec starting at 1:55 P.M. --C7's bed call light alarmed for 18 min and 38 sec starting at 2:24 P.M. --F2's bed call light alarmed for 17 min and 14 sec starting at 2:33 P.M. --D8's bed call light alarmed for 21 min and 36 sec starting at 3:44 P.M. --G3's bed call light alarmed for 21 min and 26 sec starting at 3:59 P.M. --D8's bed call light alarmed for 21 min and 36 sec starting at 4:06 P.M. --G3's bed call light alarmed for 21 min and 26 sec starting at 4:20 P.M. --F13's bed call light alarmed for 22 min and 5 sec starting at 4:27 P.M. --A5's bed call light alarmed for 21 min and 54 sec starting at 5:27 P.M. --A5's bed call light alarmed for 21 min and 54 sec starting at 5:49 P.M. --A5's bed call light alarmed for 19 min and 53 sec starting at 6:33 P.M. --A6's bed call light alarmed for 20 min and 54 sec starting at 6:33 P.M. --A5's bed call light alarmed for 19 min and 53 sec starting at 6:53 P.M. --F5's bed call light alarmed for 40 min and 14 sec starting at 6:53 P.M. --A6's bed call light alarmed for 20 min and 54 sec starting at 6:54 P.M. --D7's bed call light alarmed for 18 min and 48 sec starting at 7:21 P.M. --F6's bed call light alarmed for 22 min and 44 sec starting at 9:39 P.M. --H13's bed call light alarmed for 16 min and 1 sec starting at 9:58 P.M. --F6's bed call light alarmed for 22 min and 44 sec starting at 10:02 P.M. --H13's bed call light alarmed for 16 min and 1 sec starting at 10:14 P.M. --B2's bed call light alarmed for 23 min and 17 sec starting at 10:16 P.M. --D7's bed call light alarmed for 18 min and 48 sec starting at 10:26 P.M. -On 1/22/24, room: --H13's bed call light alarmed for 16 min and 51 sec starting at 1:50 A.M. --C5's bed call light alarmed for 15 min and 50 sec starting at 4:31 A.M. --C5's bed call light alarmed for 15 min and 50 sec starting at 4:47 A.M. --A5's bed call light alarmed for 25 min and 3 sec starting at 5:52 A.M. --C10's bed call light alarmed for 19 min and 5 sec starting at 5:52 A.M. --C10's bed call light alarmed for 19 min and 5 sec starting at 6:11 A.M. --H8's bed call light alarmed for 16 min and 5 sec starting at 6:24 A.M. --B1's bed call light alarmed for 23 min and 51 sec starting at 7:22 A.M. --F5's bed call light alarmed for 15 min and 33 sec starting at 7:29 A.M. --A5's bed call light alarmed for 15 min and 54 sec starting at 7:42 A.M. --F5's bed call light alarmed for 15 min and 33 sec starting at 7:44 A.M. --H9's bed call light alarmed for 21 min and 23 sec starting at 8:29 A.M. --H9's bed call light alarmed for 21 min and 23 sec starting at 8:50 A.M. --H7's bed call light alarmed for 18 min and 59 sec starting at 10:13 A.M. --H7's bed call light alarmed for 16 min and 48 sec starting at 11:27 A.M. --F2's bed call light alarmed for 19 min and 44 sec starting at 12:26 P.M. --F2's bed call light alarmed for 19 min and 44 sec starting at 12:46 P.M. --F5's bed call light alarmed for 24 min and 30 sec starting at 1:31 P.M. --A3's bed call light alarmed for 19 min and 49 sec starting at 2:22 P.M. --G14's bed call light alarmed for 22 min and 5 sec starting at 2:35 P.M. --H10's bed call light alarmed for 15 min and 14 sec starting at 2:36 P.M. --G14's bed call light alarmed for 22 min and 5 sec starting at 2:58 P.M. --A3's bed call light alarmed for 19 min and 49 sec starting at 4:21 P.M. --F5's bed call light alarmed for 24 min and 40 sec starting at 5:02 P.M. --H10's bed call light alarmed for 24 min and 6 sec starting at 5:07 P.M. --D1's bed call light alarmed for 18 min and 54 sec starting at 5:13 P.M. --H5's bed call light alarmed for 20 min and 25 sec starting at 5:57 P.M. --B2's bed call light alarmed for 16 min and 2 sec starting at 6:04 P.M. --B1's bed call light alarmed for 16 min and 30 sec starting at 6:04 P.M. --B6's bed call light alarmed for 18 min and 24 sec starting at 6:26 P.M. --C2's bed call light alarmed for 17 min and 44 sec starting at 6:41 P.M. --G14's bed call light alarmed for 17 min and 19 sec starting at 6:55 P.M. --H8's bed call light alarmed for 17 min and 24 sec starting at 7:10 P.M. --D1's bed call light alarmed for 18 min and 54 sec starting at 7:11 P.M. --G14's bed call light alarmed for 17 min and 19 sec starting at 7:12 P.M. --C8's bed call light alarmed for 16 min and 3 sec starting at 7:22 P.M. --H8's bed call light alarmed for 17 min and 24 sec starting at 7:27 P.M. --D4's bed call light alarmed for 26 min and 13 sec starting at 7:43 P.M. --D4's bed call light alarmed for 26 min and 13 sec starting at 8:09 P.M. --C2's bed call light alarmed for 22 min and 24 sec starting at 8:32 P.M. --C1's bed call light alarmed for 22 min and 55 sec starting at 8:58 P.M. --C1's bed call light alarmed for 22 min and 55 sec starting at 9:21 P.M. --D8's bed call light alarmed for 15 min and 16 sec starting at 10:39 P.M. --D8's bed call light alarmed for 15 min and 16 sec starting at 10:54 P.M. --D5's bed call light alarmed for 15 min and 21 sec starting at 11:10 P.M. --D5's bed call light alarmed for 15 min and 21 sec starting at 11:26 P.M. --H13's bed call light alarmed for 25 min and 6 sec starting at 11:39 P.M. Review of the Facility Assessment Tool, dated 1/23/24, showed: -An average daily census of 120 residents. -An average of two residents admitted per weekend. -An average census of 32 residents on the rehabilitation (rehab) unit. -An average census of 84 residents on the long-term care unit. -121 residents required some to maximum assistance from staff for dressing. -121 residents required some to maximum assistance from staff for bathing. -94 residents required some to maximum assistance from staff for transferring. -100 residents required some to maximum assistance from staff for toileting. -109 residents spent most of their time in a chair. 2. Review of Resident #49's Admission Minimum Data Set (MDS-a federally mandated assessment tool compleed by facility staff for care planning), dated 3/14/23, showed the resident was dependent on staff for toilet hygiene, showering, lower body dressing, and toilet transfers. Review of the resident's Quarterly MDS, dated [DATE], showed the resident: -Had moderate cognitive impairment. -Was occasionally incontinent of urine and frequently incontinent of bowel. During an interview on 1/23/24 at 10:31 A.M., the resident said he/she had soiled their brief, asked for staff assistance, and staff had refused. Continuous observation on 1/23/24 from 10:31 A.M. to 10:57 A.M. showed: -The resident used his/her call light for assistance at 10:31 A.M. -No staff were in the hallway. -No staff responded to the call light during this time. 3. Review of Resident #316's Admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Was dependent on staff for toileting hygiene. -Was dependent on staff for lower body dressing. -Required moderate assistance to roll left and right. -Was occasionally incontinent (lack of the ability to control) of urine. -Was frequently incontinent of stool. Observation on 1/29/24 at 9:00 A.M. showed: -The resident was lying in bed flat on his/her back. -The resident's face was shiny and hair was disheveled. -The resident was in a hospital gown. During an interview on 1/29/24 at 9:00 A.M., the resident said: -He/she was uncomfortable and didn't feel well. -Staff had not transferred him/her out of the bed at any time on 1/28/24. -He/she had asked staff to get out of bed that morning but he/she was still waiting. During an interview on 1/29/24 at 10:41 A.M., the resident said he/she still wanted to get out of bed but was desperate for a urinal (a bottle for urination) as he/she felt he/she would burst. Observation on 1/29/24 at 10:41 A.M. showed: -The resident remained in bed lying flat on his/her back. -Physical Therapist (PT) A entered the room and gave the resident a urinal. -The resident asked PT A to get him/her out of bed; PT A said he/she would notify the care staff. Observation on 1/29/24 at 11:22 A.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 11:57 A.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 12:15 P.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 12:54 P.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 1:49 P.M. showed the resident remained in bed lying flat on his/her back. During an interview on 1/29/24 at 1:49 P.M., the resident said: -Staff had still not come to get him/her out of bed. -He/she had used his/her call light and asked several staff members to get out of bed. During an interview on 1/29/24 at 3:14 P.M., the resident said: -Staff had just got him/her out of bed and into his/her wheelchair. -Staff had refused to get him/her out of bed on 1/28/24 and told him/her to defecate in his/her brief and they would clean him/her afterward. Observation on 1/30/24 at 8:56 A.M. showed Certified Nursing Assistant (CNA) A was standing in the resident's room. During an interview on 1/30/24 at 8:56 A.M.: -CNA A said he/she was waiting for another staff member to assist him/her reposition the resident. -The resident said he/she was not able to turn side to side without help. Observation on 1/30/24 at 8:57 A.M. showed: -CNA A returned to the resident's room with the Staffing Coordinator. -The two staff members rolled the resident and removed his/her brief. During an interview on 1/30/24 at 10:47 A.M.: -CNA A said the resident had not needed his/her brief changed at all that day. -The resident said he/she started feeling pain on his/her tailbone on 1/28/24 but couldn't see back there. -The resident said he/she had urinated in his/her brief while waiting for the urinal earlier that morning because he/she couldn't wait any longer. -Licensed Practical Nurse (LPN) A told CNA A that the resident's brief was wet and had soaked through to the resident's pants. -LPN A said he/she was first told about the wound on the resident's buttocks that day. 4. During an interview on 1/24/24 at 2:47 P.M., CNA A said sometimes there was not enough staff to complete resident cares. During an interview on 1/24/24 at 3:06 P.M., LPN E said he/she felt the facility was understaffed. During an interview on 1/25/24 at 6:45 A.M., CNA S said: -There was supposed to be one CNA per hall at night. -There were only three CNAs working the long-term unit (halls A, B, C, and D) the previous night and they all had to assist with D hall as there was no CNA assigned. -He/she did not feel like there was enough staff. -Management had never had a conversation with him/her about staffing. -When staff did not come to work, management did not always find a replacement, so they worked short-staffed. -The rehabilitation units needed additional CNAs because those residents required a lot of assistance. During an interview on 1/25/24 at 6:45 A.M., CNA H said: -He/she had approximately 23-24 residents assigned to him/her each night. -Approximately half of those needed assistance with cares and transfers. -There were two to three CNAs scheduled to cover four halls at night. -When providing cares, it frequently took 30 minutes to complete and he/she could not answer any other call lights during that time. During an interview on 1/26/24 at 9:21 A.M., CNA M said: -There were 25 residents on his/her assigned hall. -Approximately 18-20 residents on his/her hall were incontinence and 9-10 residents required the use of a mechanical lift. -Some resident cares took 45 minutes to complete and he/she could not answer call lights during that time. -He/she has had residents that waited 45 minutes to an hour for help because he/she was busy with another resident. -He/she felt overwhelmed with the workload. -He/she had talked to management but nothing had changed in regard to staffing. -When he/she required assistance, he/she had to leave his/her assigned hall to find someone to help. During that time, no other staff member covered his/her hall or monitored the residents. -He/she was to perform four baths a night but he/she believed it impossible. -It took him/her approximately 20 minutes to give a shower and during that time no one was watching the residents on his/her assigned hall. -Other staff would occasionally find him/her while he/she was providing cares and say a call light has been on for a long time but they won't answer the call light themselves. During an interview on 1/26/24 at 10:25 A.M., the Director of Nursing (DON) said if a CNA does not come to work, the residents they were assigned to care for are split up among the rest of the CNAs. During an interview on 1/29/24 at 11:01 A.M., the Staffing Coordinator said: -He/she was not sure how many residents required a full body mechanical lift. -A full body mechanical lift required two staff members to operate. -When a mechanical lift was needed, the CNAs were to get a CNA from another hall to assist. -The facility frequently had only three CNAs for halls A, B, C, and D because of call-ins. During an interview on 1/29/24 at 11:01 A.M., the DON said he/she frequently received complaints about lack of staffing on nights and weekends but that was normal. During an interview on 1/30/24 at 8:24 A.M., PT C said: -He/she was occasionally asked to help with resident cares outside of therapy sessions due to staffing issues. -Therapists frequently found residents in soiled briefs when they went to get them for their therapy appointment. -Therapists would assist the residents in personal hygiene and brief changing prior to starting the therapy session. During an interview on 1/30/24 at 9:28 A.M., Certified Medication Technician (CMT) E said: -He/she was always late passing medications because they are all due at the same time. -He/she would try to assist a resident with their call light on but frequently cannot as he/she was responsible for passing medication timely. During an interview 1/30/24 at 10:10 A.M., CNA G said: -He/She was working on the A hall by himself/herself. -He/She usually transferred the residents using the full body lift by himself/herself because there was usually no one available to assist him/her to transfer the resident. -There was not enough staff to be able to transfer residents that need a full body lift with two people. -There were four to five residents on the hall that need a full body lift to transfer. -He/She was aware that they were supposed to have two persons to transfer residents using a full body lift. -He/She transferred the resident because the resident was ready to lay down and needed incontinence care and he/she could not find anyone to help him/her. Observation on 1/30/24 at 10:47 A.M showed the Administrator in Training (AIT) and Staffing Coordinator were passing breakfast on the F hall. During an interview on 1/30/24 at 11:31 A.M., the Staffing Coordinator said: -Therapy helpe

Based on observation, interview, and record review, the facility failed to ensure staffing sheets were posted daily, visible, and accessible to residents and visitors at the beginning of each shift including facility name, date, census, and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 122 residents. Review of the facility's policy, dated April 2023, titled Posting of Nursing Hours showed: -Each day staff were to post, at the facility entrance, the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) scheduled; the name of the facility; the census of the facility; and the total number of hours for each position. -Staff were to post the staffing sheet to be accessible for residents, family members, and visitors. -Staff were to instruct residents on the location of the daily staffing sheet at admission. 1. Observation on 1/23/24 at 11:25 A.M. showed: -No staffing sheet was posted at the main entrance. -One staffing sheet was found in the facility; located on the F hall, dated 10/12/23. Observation on 1/24/24 at 10:45 A.M. showed no staffing sheet was posted at the main entrance. Observation on 1/24/24 at 3:23 P.M. showed: -The staffing sheet was filled out vertically but posted horizontally making it difficult to read. -The staffing sheet was posted to the left and behind the receptionist. During an interview on 1/26/24 at 10:25 A.M., the Director of Nursing (DON) said the staffing coordinator was responsible for posting daily staffing sheets. During an interview on 1/26/24 at 2:44 P.M., Family Member A said: -He/she had no idea how many staff or residents were in the building. -He/she had never seen any staff posting. Observation on 1/29/24 at 11:15 A.M. showed: -The staff posting was to the left and approximately one and a half feet behind the receptionist. -The posting was not able to be read when standing at the receptionist's desk. During an interview on 1/29/24 at 12:25 P.M., Family Member B said he/she had never seen any posting showing how many residents or staff were in the building.

Based on observation, interview, and record review, facility staff failed to accurately identify the root cause for falls, failed to implement and analyze the effectiveness of fall prevention interventions in accordance with the resident's plan of care, failed to implement new individualized interventions to help prevent future falls, failed to follow the facility's policy after a fall occurs to perform a complete assessment of the resident and document in the resident's medical record those findings, and failed to notify the resident's physician of each fall for one resident (Resident #35) out of 17 sampled residents. The resident experienced four falls in a two month time period which resulted from the resident sliding off his/her pressure reducing air mattress, and after sustaining the fourth fall, the resident was found unresponsive on the floor between the resident's bed and the wall. Additionally, facility staff failed to ensure two sampled residents' (Residents #20 and #30) and three supplemental residents' (Residents #203, #204, and #205) low air loss mattresses were inflated to the correct weight for safety, failed to have a system in place to monitor the low air loss mattress settings, and failed to educate the staff on low air loss mattresses. The facility census was 110 residents. Record review of the facility's Fall Investigation and Management Policy, with a revision date of [DATE], showed: -Policy: Staff will investigate each fall that occurs to ensure that risk from falls is decreased for the individual resident and that collective information about falls is used to improve the overall performance of the ministry according to current standards of practice and in conjunction with state and federal guidelines; -The charge nurse on duty at the time of the fall should complete nursing documentation of the fall in the medical record, a Resident Incident Report form, and an Investigation Quality Assurance (QA) form, as soon as possible after the fall had occurred; -Falls should be reported to the Director of Nursing (DON) as soon as possible; -The original incident report and the accident investigation QA form are to be forwarded to the DON's office; -The DON or delegate, reviews the reports and is responsible for the investigation, takes any immediate corrective action necessary, and forwards the incident report to Medical Records (MR); MR logs the incident then forwards the report to the Facility Administrator for review; -Administrative Nursing staff will review the fall incident report and interview the staff necessary; -Causative factors should be addressed to improve resident safety outcomes; -The DON and QA Team should attempt to make determination of the cause for the fall, whether the fall was preventable or not preventable, and if the investigation of the fall was completed; -The QA Team/Safety Committee should review (randomly and as trends develop) falls, incident reports, health conditions that may have contributed to the fall, and daily routines of the residents who fell during the previous quarter; -Responsibilities: Direct care staff is responsible to report a fall immediately to their supervisor; -Licensed nurses are responsible to thoroughly document the fall incident in the medical record, on the Fall Incident Report, and on the Accident Investigation QA form; -The DON is responsible for the overall quality of care on the unit, and is responsible therefore to manage fall assessments, interventions, and follow-up, and to assist, monitor and supervise nursing staff to ensure that this policy is followed; -The DON is responsible for developing in-service material to educate nursing personnel and responsible for the overall management of the prevention program. Record review of the facility's Resident Fall Follow Up policy, with a revision date of [DATE], showed: -Policy: Residents who have sustained a fall will be thoroughly assessed and provided with care that maintains the highest practicable physical, mental, and psychosocial well being; -A resident found on the floor should not be moved until a licensed nurse has assessed them; -The assessment should include but is not limited to the following items: --Vital signs, including a blood glucose test if the resident is diabetic; --Determine if an injury occurred as a result of the fall; --Assess for a head injury, determine level of consciousness, check pupil reaction to light; --Assess for pain, pain intensity, and location of pain; --The assessment for possible injury may require an extensive head to toe evaluation; --Assess for joint trauma and ask the resident to move his/her extremities; --Assess for bruising, skin tears, swelling, or bleeding; --If no injury is identified, assist resident with appropriate persons or assistive devices to either a bed or chair to complete the assessment; and --Attempt to identify contributing factors for the fall; -Documentation in the resident's medical record should include and must be completed by the nurse in charge on the shift the fall occurred prior to going off duty: --Was the current intervention in place and operational? Why was the intervention not effective?; --Was the fall witnessed? What is the actual or probable cause of the fall; --All components of the nursing assessment; --The resident's physician and family must be notified of the fall; --What happened immediately after the fall occurred? What actions did the nursing staff take to mitigate a future fall; -The licensed nurse should complete a fall risk assessment on the resident; -Post fall nursing care and documentation includes: --For a non injury fall- Vital signs with nursing assessment will be documented in the resident's medical record during the shift the fall occurred and every shift for 24 hours; and -For a fall with potential for head trauma- Neurological checks should be completed every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, then every two hours for six hours; -The resident's Physician and family should be notified of any changes in the resident's condition. 1. Record review of Resident #35's Profile Face Sheet showed the resident: -Was originally admitted to the facility on [DATE] and re-admitted on [DATE]; -Chose to have Cardio Pulmonary Resuscitation (CPR) administered in the event of cardiac or respiratory arrest. Record review of the resident's Fall Risk Assessment, dated [DATE], showed: -The resident was confused or disoriented; -The resident was assessed as having altered elimination of bowel and bladder; -The resident had the ability to successfully change his/her body position with multiple attempts; -The resident was at high risk for falls. Record review of the resident's initial Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Needed extensive assistance from a staff member to perform bed mobility, transfers, dressing, toileting, and bathing; -Was not steady and only able to stabilize his/her balance when assisted to move on or off the toilet, when moved from sitting to standing position, and to turn around while standing; -Had no impairment of the upper or lower extremities; -Used a walker and wheelchair for mobility devices; -Active medical [DIAGNOSES REDACTED]. -had a history of [REDACTED]. -Had a pressure reducing device for the bed and chair; -Was on a turning and repositioning program; -Medications received during the previous seven days included antidepressants, anticoagulants (medication to thin the blood to prevent blood clots), antibiotics, and diuretics (medication which increases the body's elimination of fluid); -Received Physical Therapy (PT) and Occupational Therapy (OT) treatment and services; -An active discharge plan was in place for the resident to return to the community. Record review of the resident's PT Treatment and Progress Note, dated [DATE], showed the resident: -Demonstrated increased functional gain in bed mobility with improved activity tolerance; -Required increased verbal instruction for walker placement management when ambulating with assistance; -Could ambulate using a walker with assistance for up to 50 feet in distance; -Required up to maximum assistance from two staff members to perform sit to stand transfers; -Had a good prognosis for future progress; -Demonstrated a higher physical level of functioning, with slow yet steady gains in therapy services. Record review of the resident's Activities of Daily Living (ADL's) Functional Potential Care Plan, with an initiation date of [DATE], showed: -The resident needed set up assistance with eating; -Extensive assistance needed with transfers and required assistance from two staff members for transfers; -The resident used a wheelchair for mobility and could ambulate short distances; -The resident needed extensive assistance with one staff member for bed mobility; -He/she was incontinent of bladder and continent of bowel; -Extensive assistance needed for toileting, bathing, and dressing; -Encourage resident to self perform ADL's and provide assistance as needed; -Allow extra time for the resident to perform ADL tasks. Record review of the resident's Fall Care Plan, dated [DATE], showed: -The resident had the potential for falls related to a history of falls, impaired mobility, poor safety awareness, and use of anti-depressant medications; -Interventions to keep the resident free of injury related to a fall included: --OT evaluation and treatment as ordered; --PT evaluation and treatment as ordered; --Encourage resident to call for assistance with transfers; --Keep floors and walkways free of spills or clutter; --Encourage the resident to use his/her rolling walker for short distances and wheelchair for long distances; --A fall risk evaluation to be completed quarterly; --Keep the resident's bed at the appropriate height for the resident; --Provide adequate lighting for the resident and keep the resident's call light within reach --Assist the resident to wear non-skid footwear; -An intervention to check the low air loss (LAL) mattress settings for proper function was not documented on the care plan by the nursing staff. Record review of the resident's Medical Record for a reported fall, dated [DATE], showed staff documented: -At 5:30 A.M., the resident slid off his/her bed mattress and was found in his/her room sitting on the floor on the left side of the bed with his/her bed linens underneath his/her buttocks; -Interventions that were in place at time of fall included: --The resident had on gripper socks; --The resident was last toileted at 3:00 A.M.; --The resident's bed was in low position; --Antidepressants, diuretics, antibiotics, and cardiovascular medications were administered to the resident within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 5:30 A.M. and showed: --Staff identified the root cause for the fall was the resident slid off of his/her LAL mattress due to having a draw sheet underneath the resident; -New interventions to be implemented to prevent future falls included a PT screen for falls and bolsters to be applied to the resident's LAL mattress; -A new intervention to check the LAL mattress settings for proper function was not considered or documented by the nursing staff; -The resident's Fall Risk Care Plan was updated on [DATE] with interventions that included: --A PT screen for falls; --Bolsters applied to the resident's LAL mattress; -The resident's primary care physician (PCP) and family were notified of the incident on [DATE]; -The DON was notified of the incident on [DATE]. Record review of the resident's Fall Risk Assessment, dated [DATE], showed: -The resident was confused or disoriented; -The resident was unable to rise or change his/her body position without assistance; -The resident was at high risk for falls. Record review of the resident's Medical Record for a reported fall, dated [DATE], showed staff documented: -At 12:30 A.M. the resident sustained [REDACTED]. -Interventions in place at time of fall included: --The resident had on socks; --The resident was last toileted at 11:30 P.M.; --The resident's bed was in low position; --The resident had a LAL mattress with bolsters; --Antidepressants, diuretics, antibiotics, and cardiovascular medications were administered to the resident within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 12:30 A.M. and showed: --Staff identified the root cause for the fall was the resident rolled out of his/her bed due to the resident being disoriented; -The resident's bed wheels were locked; -The resident's blood glucose level at 5:00 P.M. (seven and a half hours before the fall occurred) was 111; -Other factors that contributed to the resident's fall included a [DIAGNOSES REDACTED].>-New interventions to be implemented to prevent future falls included a PT screen for falls and padded floor mats were to be placed on the floor next to the resident's bed while the resident was in his/her bed; -A new intervention to check the LAL mattress settings for proper function was not considered or documented by the nursing staff; -The resident's Fall Risk Care Plan was updated on [DATE] with interventions that included: --A PT screen for falls; --Floor mats to be placed next to the resident's bed when the resident is in bed; -The resident's PCP and family were notified of the incident on [DATE]. Record review of the resident's quarterly MDS Assessment, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance from one staff member to perform bed mobility, transfers, dressing, bathing, and personal hygiene; -Not steady when moving from a seated position to a standing position and required assistance to stabilize balance from a human; -Able to use a wheelchair as a mobility device; -Always incontinent of urine; -Frequently incontinent of bowel; -Not on a toileting program; -Had the following medical Diagnoses: [REDACTED]. --Depression; -Assessed as having two or more falls that resulted in no injury since admission to the facility; -Received non-pharmacological pain interventions; -Limited in doing day to day activities due to the resident's pain; -66 inches in height and weighed 150 pounds; -Had a pressure reducing device for his/her chair and bed. Record review of the resident's Fall Risk Assessment, dated [DATE], showed: -The resident had symptomatic depression; -The resident had altered bowel and bladder elimination; -The resident was able to rise or change his/her body position successfully with one attempt; -The resident had no risk or was at low risk for falls. Record review of the resident's Medical Record for a reported fall, dated [DATE], showed staff documented: -At 6:00 A.M. the resident sustained [REDACTED]. -The resident lay on the floor on his/her left side between the resident's bed and faced the wall in his/her room; -The resident said that he/she attempted to roll to his/her side but slid out of the bed to the floor; -The the licensed nurse on duty assessed the resident, then two nursing staff assisted the resident up to a chair; -Staff did not document they completed a head to toe assessment of the resident's condition or skin assessment; -Interventions that were in place at time of fall included: --The resident had on off load boots; --The resident was found to be wet when he/she was last toileted (staff did not document when the resident was last toileted); -The resident had a LAL mattress with bolsters and did not have an assist bar on the side of the bed where the resident rolled off onto the floor; -Antidepressants and diuretic medications were administered to the resident within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 6:00 A.M., and showed: --Staff identified the root cause for the fall was the resident rolled out of his/her bed due to the resident's slippery mattress on his/her bed; -The resident's bed wheels were not locked; -The resident's blood glucose level with no time documented for the test was 111; -Other factors that contributed to the resident's fall included a [DIAGNOSES REDACTED]. -Initial interventions to prevent future falls/incidents from occurring included: --Nursing staff were to ensure that the resident's bed was in a low position and the wheels were locked; --Padded floor mats were to be placed on the floor while the resident was in the bed; -Staff did not document current care plan interventions that were in place at time of the fall; -Staff did not document an evaluation of current interventions or new interventions to prevent the resident from falling; -Staff did not update the resident's Fall Risk Care Plan with any new interventions to prevent the resident from falling after the fall on [DATE]; -A new intervention to check the LAL mattress settings for proper function was not considered or documented on the care plan by the nursing staff; -The nurse on duty documented that the resident's Nurse Practitioner was notified of the fall and no new orders were received at that time; -The nurse on duty documented that the resident's family was notified of the fall on [DATE]. Record review of the resident's Neurological Check form, dated [DATE], showed staff documented: -Staff performed neurological checks on the resident at 12:00 P.M., which showed the resident: --Was alert and oriented to person; --Was awake and could open his/her eyes spontaneously and purposely; --Pupils in both eyes were round and reactive to light; --Had normal power and strength in his/her right and left hands, right and left arms, and in the right and left legs; --No abnormal results were assessed at that time. Record review of the resident's Medical Record for a reported fall, dated [DATE], showed: -At 5:15 A.M. the resident sustained [REDACTED]. -The resident was a full code status and CPR was initiated by Licensed Practical Nurse (LPN) A and LPN B per facility protocol; -Documentation showed the resident rolled or slid out of the bed during or just prior to the incident; -Interventions that were in place at time of fall/incident included: --The resident had on off load boots; --The resident was incontinent of urine when he/she was last toileted at 4:50 A.M.; -The resident had a LAL mattress with bolsters and the bed was in the low position; --Antidepressants, cardiovascular, and diuretic medications were administered to the resident, within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 5:15 A.M., and showed: --Staff identified the root cause for the fall was the resident was non-ambulatory and required assistance with all Activities of Daily Living (ADL's), which included transfers; -Certified Nursing Assistant (CNA) L last checked on the resident between 4:15 A.M. and 4:50 A.M. -The resident's bed wheels were locked; -The resident's blood glucose level was documented as not applicable; -Other factors that contributed to the resident's fall included a [DIAGNOSES REDACTED]. -Current care planned interventions that were in place at time of the fall showed the following: --Bed in low position; --LAL mattress with bolsters; -Staff did not document an evaluation of current interventions; -Due to the resident's death, the Fall Risk Care Plan was not updated with any new interventions after the fall on [DATE]; -The resident's PCP, Nurse Practitioner, facility Medical Director, and family were notified by telephone by LPN B. During an interview on [DATE] at 9:45 A.M., the Administrator and DON said: -LPN B discovered the resident's body upon entering the resident's room at approximately 5:15 A.M. to administer the resident's morning medications; -LPN B found the resident's body on his/her left side between the resident's bed and wall; -LPN B and LPN C performed CPR to the resident until the paramedics arrived; -The paramedics arrived and one paramedic told the nurses to stop CPR so that he/she could assess the resident for an apical pulse; -The paramedic then instructed the nurses to cease CPR efforts because the resident had no vital signs; -The paramedics called the police to the facility due to a suspicious death; -The Staffing Coordinator notified the Administrator by telephone at approximately 6:45 A.M. on [DATE], that the police were investigating the resident's suspicious death; -When the Administrator arrived at the facility, the paramedics had already left; -The nursing staff called the facility's Medical Director and the resident's PCP but both were unavailable and voicemail messages were left for them; -The police needed the resident's PCP to sign paperwork regarding the resident's cause of death before the resident's body could be released to the funeral home; -The resident's Nurse Practitioner was notified and stated that the resident's PCP would be at the facility as soon as possible to complete the necessary paperwork; -The resident's family members were notified and began to show up at the facility; -Due to the suspicious death investigation, the police would not allow any nursing staff or family members to enter the resident's room until evidence had been properly collected to rule out the resident's death as a possible homicide; -After the police obtained the needed evidence, two nursing staff members went into the resident's room to make the resident's body presentable before the resident's family members were allowed to view the body; -The resident's body then was released to a funeral service provider per family choice; -The Administrator was the only upper management personnel at the facility on the date of the event; -The DON and Assistant Director of Nursing (ADON) returned to work on ,[DATE]; -The ADON found the incident report, dated [DATE], that LPN C slid under the ADON's office door, when he/she returned to work on [DATE]; -The incident report was sent to the corporate office on [DATE] and an investigation was initiated; -The Administrator made a self-report to the State Agency on [DATE]; -LPN B and CNA L were suspended from work until the facility Administrator and management nursing staff completed a thorough investigation. During an interview on [DATE] at 10:05 A.M., LPN B said: -He/she had worked at the facility as a LPN since February of 2015; -He/she was currently certified in CPR as a healthcare professional; -At the start of his/her shift on [DATE] at 7:00 P.M., it was reported during the change of shift verbal report, that the resident sustained [REDACTED]. -He/she needed to perform post follow-up fall documentation for the resident, which included neurological checks per facility policy; -The resident did not have any complaints that evening or during the night; -He/she entered the resident's room at 5:15 A.M. with the resident's morning medications and observed that the resident was not in his/her bed; -He/she went back out into the hallway to see if CNA L already assisted the resident with getting up for the day, but he/she could not find the resident; -Upon re-entering the resident's room, the resident's body was observed to be between the resident's bed and the wall, lying on his/her left side, with his/her face up against the wall; -LPN B attempted to move the foot of the bed away from the wall to assess the resident but the bed was too difficult to move by himself/herself; -The resident's arm was cool to touch and LPN B observed that the resident was not breathing; -He/she then went out into the hallway to find other nursing staff to assist him/her with confirming the resident's code status, calling 911, bringing the crash cart to the resident's room; -LPN A and LPN B re-entered the resident's room and LPN A helped move the resident's bed away from the wall and roll the resident over on his/her back to initiate CPR; -CPR was continued until the Paramedics arrived and instructed the nurses to cease CPR in order to assess the resident for a pulse; -The resident had no vital life signs and was pronounced dead at that time by the paramedics; -He/she requested help with providing the resident with post mortem care while he/she attempted to contact the resident's PCP and family members; -He/she could not remember if the resident's bed wheels were locked prior to moving the bed away from the wall when he/she discovered the resident's body; -He/she did not perform any neurological checks on the resident during the night; -The resident had a LAL mattress with bolsters, but the padded floor mats were not in place on the floor while the resident was sleeping in bed that night. During an interview on [DATE] at 1:30 P.M., LPN A said: -He/she worked on the night shift when the resident was found on the floor unresponsive in the early morning hours of [DATE]; -LPN B was in the hall waving his/her arms for help and said the resident was not breathing; -The resident was a full code status; -He/she went with LPN B to the resident's room; -The head of the resident's bed was against the wall and the foot of the bed was pushed away from the wall; -The resident was on his/her left side on the floor against the wall with his/her face and body against the wall; -He/she moved the bed to access the resident to perform CPR and the bed moved easily. -The resident was unresponsive; -CPR was performed until the paramedics arrived and instructed to cease CPR; -The paramedics pronounced the resident's time of death; -There were no fall mats on the floor; -The bed was in a low position. During an interview on [DATE] at 1:44 P.M., CNA K said: -He/she provided care for the resident in the past month; -The resident was at risk for falls; -The resident had a LAL mattress with bolsters; -The resident was capable of performing limited bed mobility. During an interview on [DATE] at 2:14 P.M., CNA D said: -The resident had bruising all down the left side of his/her body from under his/her arm and down his/her side; -The bruising was red, blue, dark purple. During an interview on [DATE] at 3:05 P.M., the Maintenance Staff said: -Staff did not report any malfunctioning LAL mattresses, except around the beginning of November when one mattress would not inflate. During a phone interview on [DATE] at 3:45 P.M., the homicide detective at the local police department, said: -The resident's PCP signed the resident's death certificate and documented the resident's cause of death as cardiac arrest; -After further investigation of the resident's death, it was no longer classified as a homicide; -No associated police report was filed regarding the resident's death. During an interview on [DATE] at 4:08 P.M., the DON said: -After the resident fell on [DATE], he/she expected neurological checks to be completed per the facility protocol; -He/she could only locate one set of neurological checks that staff completed for the resident, dated [DATE] at 12:00 P.M During an interview on [DATE] at 4:15 P.M., CNA F said: -He/she worked at the facility as a CNA for 2 years; -He/she worked the day shift on [DATE], which began at 7:00 A.M.; -A CNA working on the B Hall of the facility asked for his/her assistance on the B hallway; -When he/she entered the room staff already moved the resident's body back onto the bed; -He/she observed that the resident had a skin tear on his/her right hand that continued up the resident's right arm; -The resident also had bruising noted to his/her left side of the face and in the area of the resident's left shoulder blade; A phone call to the resident's PCP on [DATE] at 4:30 P.M., was not returned. During an interview on [DATE] at 4:45 P.M., the resident's Nurse Practitioner said: -Staff did not notify him/her of the resident's fall that occurred on [DATE]; -He/she would have expected the nursing staff to implement a new intervention to prevent the resident from falling on [DATE] such as a bed alarm or chair alarm; -He/she would have expected floor mats to be put on the floor while the resident was in bed; -Due to the resident's compensated cardiovascular system and limited mobility, the fall on [DATE] definitely could have caused or been a contributory factor in the resident's death. During an interview on [DATE] at 5:10 P.M., the ADON said: -He/she expected the nurse to complete a head to toe assessment of the resident when the resident fell on [DATE]; -The nurse should have completed neurological checks on the resident per the facility protocol. During an interview on [DATE] at 6:05 P.M., LPN C said: -He/she found the resident on [DATE] at 6:00 A.M., on his/her left side on the floor between the resident's bed and the wall; -The resident said he/she tried to roll himself/herself over in the bed and slid off of the mattress onto the floor; -The resident's bed wheels were not locked; -The resident was assessed as having no injury and the resident was assisted up into a chair by two staff members; -He/she completed neurological checks at 6:00 A.M., 6:15 A.M., 6:30 A.M. and 6:45 A.M. and documented those checks in the resident's electronic medical record but his/her documentation did not save in the record; -The resident's bed wheels were not locked after getting the resident up in a chair; -He/she did not inform the day shift nurse during nursing report of the new intervention to lock the bed wheels; -He/she did not update the resident's Fall Care Plan with any new fall prevention interventions; -He/she did not perform a thorough head to toe assessment or skin assessment on the resident; -The resident's Nurse Practitioner and family were notified of the resident's fall the morning of [DATE]; -He/she never received inservice training on operating a LAL mattress or the proper settings for a LAL mattress. During an interview on [DATE] at 6:55 P.M., CNA A said: -The resident was a two person assist with transfers; -The resident was alert and oriented; -He/she believed the resident had a low air loss mattress but was unsure if the resident had bolster mattresses; -The resident would slide down in his/her bed frequently, but he/she did not see the resident slide to the sides of his/her bed; -Many of the residents slide down in their low air loss beds. During an interview on [DATE] at 7:02 P.M., CNA B said: -He/she worked with the resident during the day on [DATE]; -He/she worked a double shift that day starting at 7:00 A.M.; -He/she was unaware the resident fell out of his/her bed that morning; -He/she was unaware of any new interventions put into place for the resident that day; -Around noon time on [DATE], the resident complained his/her foot was hurting so he/she told the charge nurse; -The resident had a LAL mattress with bolsters; -He/she never received inservice training on operating a LAL mattress or the proper settings for a LAL mattress; -One side of the resident's bed was up against the wall; -The bed should be in a low position and the bed should be in a locked position when the resident was in bed. During an intervi

See event ID H9GZ11 Based on observation, interview, and record review, the facility staff failed to provide protective oversight related to falls/accident prevention for one sampled resident, failed to accurately identify the root cause for each fall, failed to implement and analyze the effectiveness of the fall prevention interventions in accordance with the resident's plan of care, failed to implement new individualized interventions to help prevent future falls from occurring, failed to follow the facility's policy after a fall occurs to perform a complete assessment of the resident and document in the resident's medical record those findings, and failed to notify the resident's Physician of a fall that occurred. The resident experienced four falls in a two month time period which resulted from the resident sliding off his/her pressure reducing air mattress, and ultimately after sustaining the fourth fall the resident was found on the floor, in the resident's room, between the resident's bed and the wall. Despite efforts to revive the resident, the Paramedics pronounced the resident dead with no vital life signs shortly after arriving on the scene at the facility; for one sampled resident (Resident #35) out of 17 sampled residents; and failed to ensure two sampled residents (Resident #20 and #30) and three supplemental residents (#203, #204, and #205) low air loss mattresses were inflated to the correct weight for safety; failed to have a system in place to monitor the low air loss mattress settings; and failed to educate the staff on the low air loss mattresses. The facility census was 110 residents. Record review of the facility's Fall Investigation and Management Policy, with a revision date of [DATE], showed: -Policy: Staff will investigate each fall that occurs to ensure that risk from falls is decreased for the individual resident and that collective information about falls is used to improve the overall performance of the ministry according to current standards of practice and in conjunction with state and federal guidelines; -The charge nurse on duty at the time of the fall should complete nursing documentation of the fall in the medical record, a Resident Incident Report form, and an Investigation Quality Assurance (QA) form, as soon as possible after the fall had occurred; -Falls should be reported to the Director of Nursing (DON) as soon as possible; -The original incident report and the accident investigation QA form are to be forwarded to the DON's office; -The DON or delegate, reviews the reports and is responsible for the investigation, takes any immediate corrective action necessary, and forwards the incident report to Medical Records (MR); MR logs the incident then forwards the report to the Facility Administrator for review; -Administrative Nursing staff will review the fall incident report and interview the staff necessary; -Causative factors should be addressed to improve resident safety outcomes; -The DON and QATeam should attempt to make determination of the cause for the fall, whether the fall was preventable or not preventable, and if the investigation of the fall was completed; -The QA Team/Safety Committee should review (randomly and as trends develop) falls, incident reports, health conditions that may have contributed to the fall, and daily routines of the residents who fell during the previous quarter; -Responsibilities: Direct care staff is responsible to report a fall immediately to their supervisor; -Licensed nurses are responsible to thoroughly document the fall incident in the medical record, on the Fall Incident Report, and on the Accident Investigation QA form; -The DON is responsible for the overall quality of care on the unit, and is responsible therefore to manage fall assessment, intervention, and follow-up, and to assist, monitor and supervise nursing staff to ensure that this policy is followed on the unit; -The DON is responsible for developing in-service material to educate nursing personnel and responsible for the overall management of the prevention program. Record review of the facility's Resident Fall Follow Up policy, with a revision date of [DATE], showed: -Policy: Residents who have sustained a fall will be thoroughly assessed and provided with care that maintains the highest practicable physical, mental, and psychosocial well being; -A resident found on the floor should not be moved until a licensed nurse has assessed them; -The assessment should include but is not limited to the following items: --Vital signs, including a blood glucose test if the resident is diabetic; --Determine if an injury occurred as a result of the fall; --Assess for a head injury, determine level of consciousness, check pupil reaction to light; --Assess for pain, pain intensity, and location of pain; --The assessment for possible injury may require an extensive head to toe evaluation; --Assess for joint trauma and ask the resident to move his/her extremeties; --Assess for bruising, skin tears, swelling, or bleeding; --If no injury is identified, assist resident with appropriate persons or assistive devices to either a bed or chair to complete the assessment; and --Attempt to identify contributing factors for the fall; -Documentation in the resident's medical record should include and must be completed by the nurse in charge on the shift the fall occurred prior to going off duty: --Was the current intervention in place and operational? Why was the intervention not effective?; --Was the fall witnessed? What is the actual or probable cause of the fall; --All components of the nursing assessment; --The resident's physician and family must be notified of the fall; --What happened immediately after the fall occurred? What actions did the nursing staff take to mitigate a future fall; -The licensed nurse should complete a fall risk assessment on the resident; -Post fall nursing care and documentation includes: --For a non injury fall- Vital signs with nursing assessment will be documented in the resident's medical record during the shift the fall occurred and every shift for 24 hours; and -For a fall with potential for head trauma- Neurological checks should be completed every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, then every two hours for six hours; -The resident's Physician and family should be notified of any changes in the resident's condition. 1. Record review of Resident #35's Profile Face Sheet showed the resident: -Was originally admitted to the facility on [DATE] and re-admitted on [DATE]; -Had chosen to have Cardio Pulmonary Resuscitation (CPR-a procedure given to a person to manually circulate the blood in the body and provide rescue breathing in the event that the heart and breathing stops) administered in the event of cardiac or respiratory arrest. Record review of the resident's Fall Risk Assessment, dated [DATE], showed: -The resident was confused or disoriented; -The resident was assessed as having altered elimination of bowel and bladder; -The resident had the ability to successfully change his/her body position with multiple attempts; and -The resident had a high risk for falls. Record review of the resident's initial Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) Assessment, dated [DATE] showed the resident: -Was not cognitively impaired; -Felt it was very important to choose his/her own bedtime, to have family or close friend involved with plan of care, to read books or newspaper, to be able to listen to music, and to be able to go outside for fresh air when the weather was good; -Needed extensive assist from a staff member to perform bed mobility, transfers, dressing, toileting, and bathing; -Was not steady and only able to stabilize his/her balance when assisted to move on or off the toilet, when moved from sitting to standing position, and to turn around while standing; -Had no impairment of the upper or lower extremities; -Used a walker and wheelchair for mobility devices; -Active medical [DIAGNOSES REDACTED].>--Coronary Artery Disease (CAD- narrowing of the coronary arteries); --Congestive Heart Failure (CHF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body); --Hypertension (HTN- high blood pressure) --Urinary Tract Infection (UTI- a bacterial infection within the urinary system of the body); and --Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin); -Had a non-injury fall within the last month prior to admission to the facility; -Had a non-injury fall within the previous two to six months prior to admission to the facility; -Had a pressure reducing device for the resident's bed and chair; -Was on a turning and repositioning program; -Had been administered medications during the previous seven days that included: --Antidepressants; --Anticoagulants ( medication to thin the blood to prevent blood clots) --Antibiotics; --Diuretics (medication which increases the body's elimination of fluid); -Started receiving Physical Therapy (PT) treatment and services on [DATE]; -Started receiving Occupational Therapy (OT) treatment and services on [DATE]; and -An active discharge plan was in place for the resident to return to the community. Record review of the resident's PT Treatment and Progress Note, dated [DATE] showed the resident: -Demonstrated increased functional gain in bed mobility with improved activity tolerance; -Required increased verbal instruction for walker placement management when ambulating with assistance; -Could ambulate using a walker with assistance for up to 50 feet in distance; -Required up to max assist from two staff members to perform sit to stand transfers; -Had good prognosis for future progress; -Demonstrated a higher physical level of functioning, with slow yet steady gains in therapy services. Record review of the resident's Activities of Daily Living (ADL) Functional Potential Care Plan, with an initiation date of [DATE], showed: -The resident needed set up assistance with eating; -Extensive assistance needed with transfers and required assistance from two staff members for transfers; -The resident used a wheelchair for mobility and could ambulate short distances; -The resident needed extensive assistance with one staff member for bed mobility; -He/she was incontinent of bladder and continent of bowel; -Extensive assistance needed for toileting, bathing, and dressing; -Encourage resdient to self perform ADL's and provide assistance as needed; -Allow extra time for the resident to self perform ADL tasks. Record review of the resident's Fall Care Plan, dated [DATE], showed: -The resident had the potential for falls related to a history of falls, impaired mobility, poor safety awareness, and use of anti-depressant medications;; -Interventions to keep the resident free of injury related to a fall included: --OT evaluation and treatment as ordered; --PT evaluation and treatment as ordered; --Encourage resident to call for assistance with transfers; --Keep floors and walkways free of spills or clutter; --Encourage the resident's use of his/her rolling walker for short distances and wheelchair for long distances; --A fall risk evaluation to be completed quarterly; --Keep the resident's bed at the appropriate height for the resident; --Provide adequate lighting for the resident and keep the resident's call light within reach; --Assist the resident to wear non-skid footwear; -An intervention to check the LAL mattress settings for proper function was not documented on the care plan by the nursing staff. Record review of the resident's Medical Record for a reported fall dated [DATE], showed: -At 5:30 A.M. resident had slid off his/her bed mattress and was found in his/her room, sitting on the left side of the bed, on the floor, with his/her bed linens underneath his/her buttocks; -Interventions that were in place at time of fall included: --The resident had on gripper socks; --The resident was last toileted at 3:00 A.M.; --The resident's bed was in low position; --Antidepressants, diuretics, antibiotics, and cardiovascular medications were administered to the resident, within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 5:30 A.M. and showed: --A root cause for the fall was identified as the resident slid off of his/her LAL mattress due to having a draw sheet underneath the resident; -New interventions that were to be implemented to prevent future falls included a PT screen for falls and bolsters to be applied to the resident's LAL mattress; -A new intervention to check the LAL mattress settings for proper function was not considered or documented by the nursing staff; -The resident's Fall Risk Care Plan was updated on [DATE] with interventions that included: --A PT screen for falls; --Bolsters applied to the resident's LAL mattress; -The resident's primary care physician (PCP) and family were notified of the incident on [DATE]; -The DON at the facility was notified of the incident on [DATE]. Record review of the resident's Fall Risk Assessment, dated [DATE], showed: -The resident was confused or disoriented; -The resident was unable to rise or change his/her body position without assistance; -The resident had a high risk for falls. Record review of the resident's Medical Record for a reported fall dated [DATE], showed: -At 12:30 A.M. the resident sustained [REDACTED]. -Interventions that were in place at time of fall included: --The resident had on socks; --The resident was last toileted at 11:30 P.M.; --The resident's bed was in low position; -The resident had a LAL mattress with bolsters; --Antidepressants, diuretics, antibiotics, and cardiovascular medications were administered to the resident, within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 12:30 A.M. and showed: --A root cause for the fall was identified as the resident rolled out of his/her bed due to the resident being disoriented in the bed; -The resident's bed wheels were locked; -The resident's blood glucose level at 5:00 P.M. (seven and a half hours before the fall occurred) was 111; -Other factors that contributed to the resident's fall included a [DIAGNOSES REDACTED].>-New interventions that were to be implemented to prevent future falls included a PT screen for falls and padded floor mats were to be placed on the floor next to the resident's bed, while the resident was in his/her bed; -A new intervention to check the LAL mattress settings for proper function was not considered or documented on the care plan by the nursing staff; -The resident's Fall Risk Care Plan was updated on [DATE] with interventions that included: --A PT screen for falls; --Floor mats to be placed next to the resident's bed, when the resident is in his/her bed; and -The resident's PCP and family were notified of the incident on [DATE]. Record review of the resident's quarterly MDS Assessment, dated [DATE] showed that the resident was: -Not cognitively impaired; -Assessed as needing extensive assistance and required physical assistance from one staff member to perform bed mobility, transfers, dressing, bathing, and personal hygiene; -Not steady when moving from a seated position to a standing position and required assistance to stabilize balance from a human; -Able to use a wheelchair as a mobility device; -Always incontinent of urine; -Frequently incontinent of bowel; -Not on a toileting program; -Had the following medical Diagnoses: [REDACTED]. --Depression; -Assessed as having two or more falls that resulted in no injury since admission to the facility; -Receiving non-pharmacological pain interventions; -Limited in doing day to day activities due to the resident's pain; -66 inches in height and weighed 150 pounds; -Had a pressure reducing device for his/her chair and bed. Record review of the resident's Fall Risk Assessment, dated [DATE], showed: -The resident had symptomatic depression; -The resident had altered bowel and bladder elimination; -The resident was able to rise or change his/her body position successfully with one attempt; and -The resident had no risk or was a low risk for falls. Record review of the resident's Medical Record for a reported fall dated [DATE], showed: -At 6:00 A.M. the resident sustained [REDACTED]. -The resident was observed to be on his/her left side, lying on the floor, between the resident's bed and facing the wall in his/her room; -The resident stated that he/she was attempting to roll to his/her side but slid out of the bed to the floor; -The resident was assessed by the licensed nurse on duty, then assisted up to a chair by two nursing staff members; -No documented head to toe assessment of the resident's condition or skin assessment could be found in the resident's medical record; -Interventions that were in place at time of fall included: --The resident had on off load boots; --The resident was found to be wet when he/she was last toileted and the time that the resident was last toileted was not documented by the staff; -The resident had a LAL mattress with bolsters and had no assist bar on the side of the bed where the resident rolled off onto the floor; --Antidepressants and diuretic medications were administered to the resident, within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 6:00 A.M. and showed: --A root cause for the fall was identified as the resident rolled out of his/her bed due to the resident's slippery mattress on his/her bed; -The resident's bed wheels were not locked; -The resident's blood glucose level with no time documented for the test was 111; -Other factors that contributed to the resident's fall included a [DIAGNOSES REDACTED]. -Initial interventions to prevent future falls/incidents from occurring included: --The nursing staff was to ensure that the resident's bed wheels were locked and in the low position; --Padded floor mats were to be placed on the floor while the resident was in the bed; -Current care planned interventions that were in place at time of the fall showed no documentation by the nursing staff; -No evaluation of current interventions or new interventions to prevent the resident from falling was documented; -The resident's Fall Risk Care Plan was not updated with any new interventions to prevent the resident from falling after the fall on [DATE]; -A new intervention to check the LAL mattress settings for proper function was not considered or documented on the care plan by the nursing staff; -The nurse on duty documented that the resident's Nurse Practitioner was notified of the fall and no new orders were received at that time; and -The nurse on duty documented that the resident's family was notified of the fall on [DATE] and stated that they were glad that the resident was not hurt and were planning to come in town to visit him/her very soon. Record review of the resident's Neurological Check form, dated [DATE], showed: -Neurological checks were performed on the resident at 12:00 P.M., which showed the resident: --Was alert and oriented to person; --Was awake and could open his/her eyes spontaneously and purposely; --Pupils in both eyes were round and reactive to light; --Had normal power and strength in his/her right and left hands, right and left arms, and in the right and left legs; and --No abnormal results were assessed at that time; -Per facility policy, neurological checks should have been performed and documented on [DATE] for the following times: --6:00 A.M., 6:15 A.M., 6:30 A.M., 6:45 A.M.; --7:15 A.M., 7:45 A.M., 8:15 A.M., 8:45 A.M.; --9:45 A.M., 10:45 A.M. 11:45 A.M., 12:45 P.M.; --Then every shift for 72 hours; -Only 1 set of neurological checks were documented by the nursing staff out of 13 opprotunities until the resident's time of death. Record review of the resident's Medical Record for a reported fall dated [DATE], showed: -At 5:15 A.M. the resident sustained [REDACTED]. -The resident was a full code status and CPR was initiated by Licensed Practical Nurse (LPN) A and LPN B per facility protocol; -Documentation showed that the resident had rolled or slid out of the bed during or just prior to the incident; -Interventions that were in place at time of fall/incident included: --The resident had on off load boots; --The resident was found to be wet at 4:50 P.M., when he/she was last toileted; -The resident had a LAL mattress with bolsters and the bed was in low position; --Antidepressants, cardiovascular, and diuretic medications were administered to the resident, within eight hours prior to the incident; -A Post Fall Investigation Worksheet was completed on [DATE] at 5:15 A.M. and showed: --A root cause for the fall was identified as the resident was non-ambulatory and required assistance with all Activities of Daily Living (ADL's), which included transfers; -Certified Nursing Assistant (CNA) L last checked on the resident between 4:15 A.M. and 4:50 A.M. -The resident's bed wheels were locked; -The resident's blood glucose level was documented as not applicable; -Other factors that contributed to the resident's fall included a [DIAGNOSES REDACTED]. -Current care planned interventions that were in place at time of the fall showed the following: --Bed in low position; --LAL mattress with bolsters; -No evaluation of current interventions or new interventions to prevent the resident from falling was documented; -A new intervention to check the LAL mattress settings for proper function was not considered or documented by the nursing staff; -The resident's Fall Risk Care Plan was not updated with any new interventions after the fall on [DATE], due to the resident's death; -The resident's PCP, Nurse Practitioner, facility Medical Director, and family were notified by telephone by LPN B. During an interview on [DATE] at 9:45 A.M. the Administrator and DON said: -The Administrator was the only upper management staff member that was present in the facility on [DATE]; -The DON and ADON returned to the facility to work on [DATE]; -On [DATE], an incident report dated [DATE], had been discovered, that had been slid under the ADON's office door by LPN C; -On [DATE], the discovered incident report was sent to the facility's corporate office for review; -On [DATE] the Administrator made a self-reported complaint to the State Agency regarding the resident's death -The resident's body had been discovered by LPN B, upon entering the resident's room at approximately 5:15 A.M., with the resident's morning medications; -LPN B found the resident's body between the resident's bed and wall, on his/her left side; -LPN B and LPN C performed CPR to the resident until the paramedics arrived; -The paramedics arrived and one paramedic told the nurses to stop CPR so that he/she could assess the resident for an apical pulse; -The paramedic then instructed the nurses to cease CPR efforts because the resident had no vital life signs; -The paramedics called the police to the facility due to a suspicious death; -The Staffing Coordinator notified the Administrator by telephone at approximately 6:45 A.M. on [DATE], that the police were investigating the resident's suspicious death; -When the Administrator arrived at the facility the paramedics had already left the facility; -The nursing staff had called the Medical Director of the facility and the resident's PCP, but both were unavailable and voicemail messages were left for them; -The police needed the resident's PCP to sign paperwork regarding the resident's cause of death before the resident's body could be released to the funeral home; -The resident's Nurse Practitioner was notified and stated that the resident's PCP would be at the facility as soon as possible to complete the necessary paperwork; -The resident's family members were notified and began to show up at the facility; -Due to the suspicious death investigation, the police would not allow any nursing staff or family members to enter the resident's room until evidence had been properly collected to rule out the resident's death as a possible homicide; -After the police had obtained the needed evidence, two nursing staff members went into the resident's room to make the resident's body presentable before the resident's family members were allowed to view the body; -The resident's body then was released to a funeral service provider per family choice; and -LPN B and CNA L had been suspended from work until a thorough investigation had been completed by the facility Administrator and management nursing staff. During an interview on [DATE] at 10:05 A.M., LPN B said: -He/she had been working at the facility as a LPN since February of 2015; -He/she was currently certified in CPR as a healthcare professional; -At the start of his/her shift on [DATE] at 7:00 P.M., it was reported during the change of shift verbal report, that the resident had sustained an unwitnessed non-injury fall early that morning; -He/she needed to perform post follow-up fall documentation for the resident, which included neurological checks per facility policy; -The resident had no complaints that evening or during the night; -He/she entered the resident's room at 5:15 A.M. with the resident's morning medications and observed that the resident was not in his/her bed; -He/she went back out into the hallway to see if the resident had already been assisted with getting up for the day by CNA L, but could not find the resident; -Upon re-entering the resident's room, the resident's body was observed to be between the resident's bed and the wall, lying on his/her left side, with his/her face up against the wall; -LPN B went over and attempted to move the foot of the bed away from the wall to assess the resident; -The resident's arm was cool to touch and LPN B observed that the resident was not breathing; -He/she then went out into the hallway to find other nursing staff to assist him/her with confirming the resident's code status, calling 911, bringing the crash cart to the resident's room, while LPN A and B went to initiate CPR; -LPN A and LPN B re-entered the resident's room and LPN A helped with moving the resident's bed away from the wall and to roll the resident over on his/her back to initiate CPR; -CPR was continued until the Paramedics arrived and instructed the nurses to cease CPR in order to assess the resident for a pulse; -The resident had no vital life signs and was pronounced dead at that time by the paramedics; -He/she requested help with providing the resident with post mortem care while he/she attempted to contact the resident's PCP and family members; -He/she could not remember if the resident's bed wheels were locked prior to moving the bed away from the wall when he/she discovered the resident's body; -He/she had not performed any neurological checks on the resident during that shift when the resident's body was discovered; -The resident had been lying on a LAL mattress with bolsters but the padded floor mats were not in place on the floor, while the resident was sleeping in bed that night. During an interview on [DATE] at 1:30 P.M., LPN A said: -He/she was working on the night shift when the resident was found on the floor unresponsive on [DATE] in the early morning hours; -LPN B was in the hall waving his/her arms for help and said the resident was not breathing; -The resident was a full code status; -He/she went with LPN B to the resident's room; -The resident's head of the bed was against the wall and the foot of the bed was pushed away from the wall; -The resident was laying on his/her left side on the floor against the wall with his/her face and body against the wall; and -He/she moved the bed to access the resident to perform CPR and the bed moved easily. -The resident was unresponsive; -CPR was performed until the paramedics arrived and instructed to cease CPR; -The paramedics pronounced the resident's time of death; -There were no fall mats on the floor; and -The bed was in a low position. During an interview on [DATE] at 1:44 P.M., CNA K said: -He/she had cared for the resident in the past month; -The resident was at risk for falls; -The resident had a LAL mattress with bolsters; and -The resident was capable of performing limited bed mobility. During an interview on [DATE] at 2:14 P.M., CNA D said: -He/she had performed post-mortem care on the resident on [DATE]; -The resident had bruising all down the left side of his/her body from under the arm down the side; -The bruising was red, blue and purple; -The left side of his/her face was indented; -His/her mouth was twisted to the side. During an interview on [DATE] at 3:05 P.M., the Maintenance Staff said: -No complaints had been reported in the facility regarding malfunctioning LAL mattresses except for one mattress that would not inflate, sometime around the beginning of the month of November. During a phone interview on [DATE] at 3:45 P.M.,the homicide detective at the local police department, said: -The resident's PCP had signed the resident's death certificate and documented the resident's cause of death being cardiac arrest; -After futher investigation of the resident's death was no longer classified as a homicide; and -No associated police report had been filed regarding the resident's death. During an interview on [DATE] at 4:08 P.M., the DON said: -After the resident fell on [DATE], he/she expected neurological checks to be completed per the facility protocol. -He/she could only locate one set of neurological check that had been completed for the resident. During an interview on [DATE] at 4:15 P.M., CNA F said: -He/she had been working at the facility as a CNA for 2 years; -He/she had worked during the day shift on [DATE] and his/her shift began at 7:00 A.M.; -A CNA working over on the B Hall of the facility came and asked for his/her assistance over on the B hallway; -When he/she entered the room the resident's body had already been moved back onto the bed; -He/she observed that the resident had a skin tear on his/her right hand that continued up the resident's right arm; -The resident also had brusing noted to his/her left side of the face and in the area of the resident's left shoulder blade; -The CNA helped provide post mortem care to the resident to make the resident's body presentable for the resident's family to view the body; -CNA F helped wipe dried green mucous or sputum off of the resident's face, combed the resident's hair, and attempted to close the resident's eye lids; -The resident's body was cold to touch when he/she provided post mortem care to the resident. A phone call was placed to CNA L on [DATE] at 4:25 P.M., but no phone call was returned by the CNA. A phone call was placed to the resident's PCP on [DATE] at 4:30 P.M., using the Physician's answering service but no phone call was returned. During an interview on [DATE] at 4:45 P.M., the resident's Nurse Practitioner said: -He/she had not been notified of the resident's fall that occ

Based on observation, interview and record review, the facility staff failed to have a wound care policy and systems in place for the prevention and treatment of developing pressure ulcers and to identify individuals at risk for developing pressure ulcers; to complete a skin assessment and to inspect the resident's skin regularly; to have the Registered Dietician (RD) screen and assess the nutritional status of every individual at risk of pressure ulcers, and to have the RD's recommendations put in place once the resident's physician agrees to the recommendations; to provide an individualized repositioning strategy for the prevention of pressure ulcers based on the condition of the resident and the support surface in use; to assess the need for pressure-redistributing devices for residents with reduced mobility and who are at risk of pressure ulcer development; for assessing, monitoring, and measuring the wounds at least weekly and documenting the findings; and to observe for changes in the pressure ulcer that may indicate a change in the treatment of the pressure ulcer for four sampled residents of 36 residents identified by the facility as having pressure ulcers (Residents #1, #15, #17, and #21); to provide pressure ulcer treatment until prompted, to prevent infection, and to prevent new pressure ulcers from developing for one sampled resident (Resident #1) with multiple pressure ulcers; to notify the resident's physician of a newly identified pressure ulcer in a timely manner, resulting in a six day delay from the resident receiving treatment for one sampled resident (Resident #17); to obtain a physician's orders [REDACTED].#21) who acquired a Stage II (partial thickness skin loss) and Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer on his/her buttocks/thighs; and to follow physician's orders [REDACTED].#15), out of 21 sampled residents. The facility census was 103 residents. Record review of the National Pressure Ulcer Advisory Panel (NPUAP) Quick Reference Guide titled "Pressure Ulcer Prevention &Treatment" dated 2009, showed the following: -A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (a strain in the structure of a substance produced by pressure, when its layer are laterally shifted in relation to each other) -Stage I pressure ulcer: Non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. -Stage II pressure ulcer: Partial thickness skin loss. Partial thickness loss of dermis (the lower or inner layer of the two main layers of cells that make up the skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. -Stage III pressure ulcer: Full thickness skin loss. Full thickness tissue loss. Subcutaneous (beneath the skin) fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (separation of tissue from the surface under the edge of the wound) and tunneling (a break in the surface of the body or organ in which the entry and exit wounds are the same size). The depth of the Stage III pressure depends upon the anatomical location. The bridge of the nose, ear, occipital (eye socket), malleolus (ankle bone) do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity (fatty tissue) can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. -Stage IV pressure ulcers: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead hard dark brown or black tissue) may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. Stage IV ulcers can extend into muscle and/or supporting structures making osteo[DIAGNOSES REDACTED] (infection of the bone) possible. Exposed bone/tendon is visible or directly palpable. -Unstageable pressure ulcer: Depth unknown. Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Stage cannot be determined. Stable eschar on the heels serves as "the body's natural cover" and should not be removed. -Suspected Deep Tissue Injury (SDTI): Depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Pressure Ulcer Prevention Recommendations: -Establish and document all risk assessments that includes a comprehensive skin assessment. -Skin Assessment: Educate professionals on how to undertake a comprehensive skin assessment that includes techniques for identifying blanching response, localized head, [MEDICAL CONDITION], and induration (hardness). Inspect the skin regularly. -Skin care: Use skin [MEDICATION NAME] to hydrate dry skin in order to reduce risk of skin damage. Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage. Nutrition for Pressure Ulcer Prevention. -Refer each individual with nutritional risk and pressure ulcer risk to a Registered Dietician (RD). -Provide nutritional support to each individual with nutritional risk and pressure ulcer risk, following the nutritional risk and pressure ulcer risk, the following the nutrition cycle. This support should include: -- Nutritional assessment. --Estimation of nutritional requirements. --Comparison of nutrient intake with estimated requirements. --Provision of appropriate nutrition intervention, based on he appropriate feeding route. --Monitoring and evaluation of nutritional outcome, with reassessment of nutritional status at frequent intervals while an individual is at risk. Repositioning for the Prevention of Pressure Ulcers -Repositioning frequency will be determined by the individual's tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessments of the individual's skin condition. -Limit the time an individual spends seated in a chair without pressure relief. When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities (the bone and area you sit on). As the loaded in such cases in relatively small, the pressure will be high; therefore, without pressure relief, a pressure ulcer will occur very quickly. Support Surfaces: -Prevention in individuals at risk should be provided on continuous basis during the time that they are at risk. -The use of support surfaces to prevent heel pressure ulcers: --Ensure that the heels are free of the surface of the bed. --Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles Tendon (the tendon above the heel). The knee should be in slight flexion. --Use a pillow under the calves so that heels are elevated (floating). --Inspect the skin of the heels regularly. -Use of support surfaces to prevent pressure ulcers while seated: --Use a pressure-redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development. Pressure Ulcer Assessment: -Assess the pressure ulcer initially and re-assess it at least weekly, document findings. A two-week period is recommended for evaluating progress toward healing. However, weekly assessments provide an opportunity for health care professional to detect for a change in treatment. -With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment. -Assess and accurately document physical characteristics such as location, Stage, size, tissue types, wound bed and periwound condition, wound edges, sinus tracts (a narrow, elongated channel in the body that allows the escape of fluid), undermining, tunneling, exudate (drainage), necrotic tissue, odor, presence/absence of granulation tissue and eptihelialization (good tissue). --Length and width: Select a uniform, consistent method for measuring wound length and width to facilitate meaningful comparisons of wound measurements across time. --Wound depth, tunneling, and undermining: Select a consistent,uniform method of measuring depth. Methods for Monitoring Healing: -Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within two weeks. Signs of deterioration should be addressed immediately. Cleansing: -Cleanse the pressure ulcer and surrounding skin at the time of each dressing change. --Cleanse healing, clean pressure ulcers with normal saline (salt water). --Cleanse surrounding skin. 1. Record review of Resident #1's interdisciplinary notes dated 9/26/14, at 8:40 P.M. showed: --The resident: -admitted to the facility at 5:20 P.M.; -Was alert to self only; -Was able to answer simple questions; -Had a peripherally inserted central catheter (PICC line an intravenous (IV the process of giving medication directly into a resident's vein) access that can be used for a prolonged period of time); -Had dressings on his/her left foot; -Had no complaints of pain; -Had tube feeding (no specific formula was mentioned) started; --The facility staff received report from the resident's previous facility that the resident: -Was usually alert and oriented and able to have a full conversation, but since he/she had been sick he/she had been more lethargic; -Had [DIAGNOSES REDACTED]. -Was receiving IV and tube feeding antibiotics (a medicine (such as [MEDICATION NAME] or its derivatives) that inhibits the growth of or destroys microorganisms); -Had a temperature for the last three days and was being treated at the facility; --Had his/her son bring medications from the previous facility and insisted the resident be sent to the hospital emergency room for evaluation because of complaints of pain and a cough with congestion; and --Was sent to the hospital emergency room at 7:00 P.M. Record review of the hospital paperwork dated 9/26/14 showed the resident: -Had altered mental status (any measure of arousal other than normal) and fever; -Had a [DIAGNOSES REDACTED]. ability to produce or comprehend language due to [MEDICAL CONDITION]) and dysphagia (inability or difficulty swallowing) and a percutaneous endoscopic gastronomy (PEG tube is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate); -Was able to open his/her eyes to his/her name but did not offer any other interaction; -Had [MEDICAL CONDITION] (swelling of an extremity that when pressure is applied to the swollen area by depressing the skin with a finger causes an indentation that persists for some time after the release of the pressure) to both upper extremities; -Had necrotic eschar area to the left heel; -Had a pressure ulcer to the left Achilles tendon (heel tendon that runs just above the heel); -Had a stage II-III pressure ulcer on the sacrococcygeal (affecting the sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) and coccyx (tailbone)); -Had a consult for multiple wounds that included the following: --The sacrum had multiple (no specific number listed) Stage II pressure ulcers with a pink wound base in the sacrococcygeal area; --The right heel had an Unstageable ulcer that measured 1.5 centimeters (cm) x 1.5 cm; --The left heel had an Unstageable ulcer that measured 4.5 cm x 4.0 cm; ---The physician was able to express pus (an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during infection) from beneath the left heel wound; and --The left Achilles had a Stage IV wound that measured 4.0 cm x 2.5 cm with tendon exposed. Record review of the resident's transfer admitting orders from the hospital dated 9/30/14 showed the resident had a [DIAGNOSES REDACTED]. Record review of the resident's undated Physician order [REDACTED]. -To coccyx: apply [MEDICATION NAME] (a pressure ulcer treatment that promotes debridement of eschar and other necrotic tissue) every six hours for wound care and as needed for soiling; and -To left calf: apply [MEDICATION NAME] ( is used with other treatments to help prevent and treat wound infections) /Xeroform (a type of medical Vaseline dressing consisting of finely woven mesh) every 12 hours wrap with loose Perplex (a soft thick absorbent wrap dressing). Record review of the resident's undated POS showed the resident had the following wound orders with no date: -To right heel: paint [MEDICATION NAME] ([MEDICATION NAME]-iodine used as a wound care treatment) daily; -To left heel: paint [MEDICATION NAME] daily; -To left medial (situated in the middle) foot: paint [MEDICATION NAME] daily; and -Boots on at all times. Record review of the resident's interdisciplinary notes dated 10/1/14 showed: -The resident had wounds on bilateral (both) lower extremities; -The resident was seen by the wound doctor; -New orders for left calf Silva/Thermoform every 12 hours wrap with loose gauze (a thin, translucent fabric with a loose open weave) and to paint [MEDICATION NAME] to the right and left heel and Achilles daily; and -No documentation regarding the pressure ulcer on the left medial foot. Record review of the resident's interdisciplinary notes dated 10/3/14 showed the resident: -Was turned every two hours; -The ordered treatments were completed; -Had bilateral boots in place; and -Had a low air loss mattress. Record review of the resident's physician visit progress notes dated 10/8/14 showed: -The resident had multiple pressure ulcers; -The resident had the pressure ulcers covered and the physician did not visualize them; and -The treatment plan was to continue with current wound care. Record review of the resident's interdisciplinary notes dated 10/8/14 showed the resident: -Was seen by the wound doctor; -Was to continue the treatments as follows: --[MEDICATION NAME] paint to right heel; --[MEDICATION NAME] paint to left heel; --[MEDICATION NAME] paint to left foot; --Silva/Thermoform gauze to left Achilles; and --Heel lift boots on at all times. Record review of the resident's Minimum Data Set (MDS a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/8/14 showed the resident: -Was able to make himself/herself understood and understand others; -Required total assistance from one or two staff members for his/her Activities of Daily Living (ADLs); -Had impaired range of motion to both left and right upper and lower extremities; -Used a wheelchair propelled by staff for mobility; -Had an indwelling catheter (a tube passed through the urethra into the bladder to drain urine) (the catheter was not ordered to be placed until 11/16/14); -Was always incontinent of bowel function; -Weighed 135 pounds; -Was receiving a tube feeding as the only nutritional approach; -Was not at risk for developing pressure ulcers; -Had one Stage II pressure ulcer that was present at the time of admission; -Had one Stage IV pressure ulcer that was present at the time of admission; -Had three Unstageable pressure ulcers that were present at the time of admission; -Had measurements of length 4.5 cm x width 4.5 cm x depth 2.0 cm of the largest surface area pressure ulcer; -Had slough indicated as the most severe tissue type for any pressure ulcer present; -Had open lesion(s) other than ulcers, rashes, or cuts; and -Had the following skin and ulcer treatments indicated: --Pressure reducing device for the chair; --Pressure reducing device for the bed; --Turning/repositioning program; --Nutrition or hydration intervention to manage skin problems; --Pressure ulcer care; --Application of nonsurgical dressings (with or without topical medications) other than to feet; and --Applications of ointments/medications other than to feet. Record review of the resident's interdisciplinary notes dated 10/9/14 showed: -A care plan meeting was held with facility staff and family present; -The wound care doctor's notes were given to the family at the care plan meeting; and -The plan of care for the pressure ulcers was going to be developed and followed by the wound care team. Record review of the facility wound report dated 10/10/14 showed the resident: -Had the following pressure ulcers: --Left Achilles was a Stage IV that measured 4.5 cm x 4.5 cm x 1.0 cm was stable and had Silva/Thermoform ordered twice a day; --Left Heel was Unstageable that measured 4.5 cm x 6.5 cm x 2.0 cm was stable and had [MEDICATION NAME] ordered daily; --Left Medial Foot was Unstageable that measured 2.5 cm x 1.5 cm x 0.1 cm was stable and had [MEDICATION NAME] ordered daily; --Right heel had two areas listed as Unstageable that measured 2.5 cm x 2.5 cm x 0.1 cm and 1.5 cm x 1.5 cm x 0.0 cm were stable and had [MEDICATION NAME] ordered daily; and --Coccyx was a Stage II was listed as resolved. Record review of the facility wound report dated 10/17/14 showed the resident: -Had the following pressure ulcers: --Left Achilles was a Stage IV that measured 3.8 cm x 2.8 cm x 0.8 cm was stable and had Silva/Thermoform ordered twice a day; --Left Heel was Unstageable that measured 4.5 cm x 6.5 cm x 2.0 cm was stable and had [MEDICATION NAME] ordered daily; --Left Medial Foot was Unstageable that measured 2.5 cm x 1.5 cm x 0.1 cm was stable and had [MEDICATION NAME] ordered daily; --Right heel had two areas listed as Unstageable that measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm were stable and had [MEDICATION NAME] ordered daily; and --Coccyx was a Stage II was listed as resolved. Record review of the resident's interdisciplinary notes dated 10/20/14 showed the resident was sent to the hospital emergency room for evaluation and there was no documentation of a skin assessment before the resident left the facility. Record review of the resident's hospital paperwork dated 10/20/14 to 10/29/14 showed the resident: -Had pink, dry oral mucosa (the mucous membrane lining the inside of the mouth); -Had warm and dry skin; -Had boggy (spongy) heels; -Had healed pressure ulcers on the coccyx; -Had pressure ulcers to the left lower extremity; -Had pressure ulcers on both heels wrapped in Perplex; -Had pressure ulcers on the left heel (not staged), right heel (not staged), and coccyx (Stage I); -Was at high risk for wounds; -Had an ulcer on the left shin with Silva and conforming gauze; -Had an ulcer on the left heel with eschar/necrotic tissue with gauze and wrapped with Perplex; -Had an ulcer on the right heel that had black eschar that was boggy with gauze and wrapped with Perplex; -Had a consult for wound management in the hospital; -Was to be repositioned every two hours from side to side; -Was to have [MEDICATION NAME] to the left heel, left foot and right heel ulcers daily cover with Perplex; -Was to have heel protection at all times; -Was to have [MEDICATION NAME] AG (a dressing that has silver in it to promote wound healing) to the left Achilles to be changed every three days; -Was to have the following treatments upon discharge from the hospital back to the facility: --[MEDICATION NAME] topically to the left heel, left foot, and right heel ulcers daily and cover with Perplex; --[MEDICATION NAME] AG to the left Achilles changed every three days; and --[MEDICATION NAME] AG dressing on the sacral wounds to be changed every two days and as needed. Record review of the resident's interdisciplinary notes dated 10/30/14 showed there was no documentation of the resident returning back to the facility. Record review of the resident's Pressure Ulcer/skin Prevention Care Plan dated 10/30/14 showed: -The resident had impaired skin integrity related to wounds on the left Achilles, left heel, left medial foot, right heel, and coccyx; -A goal that the resident would be free from signs and symptoms of infection and will demonstrate optimal healing; -Interventions that included: --Provide treatment as ordered; --Provide pain management with dressing changes; --Assess and document wound size, depth, color, and drainage present every week; --Assist/teach the resident to reposition self to eliminate pressure (the resident was totally dependent on staff for all repositioning); --Heel/elbow protectors on when in bed (The resident did not have elbow protectors on); --Pressure relieving mattress on bed, low air loss mattress on bed; --Pressure relieving cushion to chair, wedge cushion; --Keep skin clean and dry; and --Provide peri-care after each incontinence episode and apply skin protectant; -An indwelling catheter was inserted for wound healing on 11/12/14 (was the only update added to the care plan after its development on 10/30/14); and -It did not address the healed and new wounds that developed at the facility. Record review of the resident's interdisciplinary notes dated 10/31/14 showed the resident was back in the facility and had bilateral boots in place. Record review of the facility wound report dated 10/31/14 showed the resident: -Had the following wounds: --Left Achilles was a Stage IV that measured 3.8 cm x 2.8 cm x 0.8 cm was stable and had Silva/Thermoform ordered twice a day; --Left Heel was Unstageable that measured 4.5 cm x 6.5 cm x 2.0 cm was stable and had [MEDICATION NAME] ordered daily; --Left Medial Foot was Unstageable that measured 2.5 cm x 1.5 cm x 0.1 cm was stable and had [MEDICATION NAME] ordered daily; --Right heel had two areas listed as Unstageable that measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm were stable and had [MEDICATION NAME] ordered daily; and --Coccyx had Moisture Associated Skin Damage (MASD skin damage caused by excess moisture including incontinence) that measured 3.0 cm x 2.0 cm x 0.0 cm was new and had Calzyme (used as a mild antiseptic to prevent infections) ordered. Record review of the resident's physician visit note dated 11/5/14 showed no documentation of any wounds. Record review of the facility wound report dated 11/7/14 showed the resident: -Had the following wounds: --Left Achilles was a Stage IV that measured 3.8 cm x 2.8 cm x 0.8 cm was stable and had Silva/Thermoform ordered twice a day; --Left Heel was Unstageable that measured 4.5 cm x 7.5 cm x 2.0 cm was stable and had [MEDICATION NAME] ordered daily; --Left Medial Foot was Unstageable that measured 2.5 cm x 1.5 cm x 0.1 cm was stable and had [MEDICATION NAME] ordered daily; --Right heel had two areas listed as Unstageable that measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm were stable and had [MEDICATION NAME] ordered daily; and --Coccyx had MASD that measured 1.5 cm x 1.0 cm x 0.0 cm was new and had Calzyme ordered. Record review of the resident's interdisciplinary notes dated 11/11/14 showed a late entry for the resident: -The resident was admitted with the following wounds: --Left Achilles measured 3.8 cm x 2.8 cm x 0.8 cm with tendon exposed that had black tissue with orders for Silva/Thermoform daily; (not the dressing ordered by the hospital) --Left heel measured 4.5 cm x 7.5 cm x 2.0 cm with black eschar present with orders for [MEDICATION NAME] daily to heel; --Left medial foot measured 2.5 cm x 1.5 cm x 0.1 cm with black eschar present with orders for [MEDICATION NAME] daily; -No documentation of the right heel wound, measurements and treatment; and -No documentation of the coccyx wound, measurements and treatment. Record review of the resident's interdisciplinary notes dated 11/12/14 showed: -The resident's left heel wound had necrotic tissue present, no odor, redness or swelling present in the wound bed, the wound measured 4.5 cm x 7.5 cm x 2.0 cm and to continue current treatment of [MEDICATION NAME] to the heel daily; -MASD of his/her buttocks that measured 3.0 cm 2.0 cm x 0 cm to continue with the Calzyme twice a day and as needed for soiling (not what was ordered from the hospital); and -Had an order to consult the wound doctor for the sacral wound. Record review of the resident's physician visit notes date 11/12/14 showed no documentation of any wounds. Record review of the facility wound report dated 11/14/14 showed the resident: -Had the following wounds: --Left Achilles was a stage IV that measured 3.8 cm x 2.8 cm x 0.8 cm was stable and had tendon exposed with granulation tissue on wound edges had Silva/Thermoform ordered twice a day; --Left Heel was Unstageable that measured 4.5 cm x 7.5 cm x 2.0 cm was stable and had eschar and had [MEDICATION NAME] ordered daily; --Left Medial Foot was Unstageable that measured 2.5 cm x 1.5 cm x 0.1 cm was stable and had eschar and had [MEDICATION NAME] ordered daily; --Right heel had two areas listed as Unstageable that measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm were stable and had eschar and had [MEDICATION NAME] ordered daily; and --Coccyx had MASD measured 2.0 cm x 1.0 cm x 0.0 cm was new and had pink/red area a catheter was place for healing and had Calzyme ordered. Record review of the resident's telephone orders dated 11/16/14 showed an order for [REDACTED]. Record review of the resident's interdisciplinary notes dated 11/18/14 showed the resident: -Had wounds on the bottom of his/her left foot, right heel, coccyx, and left calf; and -Was being followed by the wound nurse and the wound doctor. Record review of the resident's interdisciplinary notes dated 11/19/14 showed the resident: -Was seen by the wound doctor; -Had the left heel debrided (the removal of dead tissue), had dark red granulated tissue with blood clots, the wound was tender to touch, measured 5.5 cm x 8.0 cm x 2.0 cm; -Had eschar present in the left medial foot wound that measured 2.5 cm x 1.5 cm x 0.1 cm; -Had two wounds on the right heel with eschar present that measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm; -Had two open areas with granulated tissue present in the coccyx wound bed that measured 1.0 cm x 1.0 cm x 0.0 cm and 1.0 cm x 1.0 cm x 0.0 cm; and -Had new orders for Silva/Thermoform to the left Achilles and the left heel twice a day wrap with Perplex. Record review of the resident's physician visit notes dated 11/21/14 showed no documentation of any wounds. Record review of the facility wound report dated 11/21/14 showed the resident: -Had the following wounds: --Left Achilles was a Stage IV that measured 3.8 cm x 2.8 cm x 0.8 cm was stable and had tendon exposed with granulation tissue on wound edges had Silva/Thermoform ordered twice a day; --Left Heel was Unstageable that measured 5.5 cm x 8.0 cm x 2.0 cm was stable and had been debrided with a scalpel and tweezers by the wound doctor for drainage and foul odor from the wound, the wound was dark red, painful to touch, no drainage, no odor, and no swelling and had a new treatment of Silva/Thermoform twice a day and as needed for soiling was ordered; --Left Medial Foot was Unstageable that measured 2.5 cm x 1.5 cm x 0.1 cm was stable and had eschar and had [MEDICATION NAME] ordered daily; --Right heel had two areas listed as Unstageable that measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm were stable and had eschar and had [MEDICATION NAME] ordered daily; and --Coccyx had MASD with two open areas that measured 1.0 cm x 1.0 cm x 0.0 cm and 1.0 cm x 1.0 cm x 0.0 cm was new and had two pink/red areas on the sacral area a catheter was placed for healing and had Calzyme ordered. Record review of the resident's interdisciplinary notes dated 11/26/14 showed the resident: -Was seen by the wound doctor; -Coccyx wound that measured 2.0 cm x 2.0 cm x 0.0 cm continue with the Calzyme; -Left Achilles wound that measured 3.8 cm x 2.8 cm x 0.8 cm with tendon exposed continue with the Silva/Thermoform twice a day; -Left heel wound measured 5.5 cm x 8.0 cm x 2.0 cm had soft necrotic tissue with exposed tendon continue with the [MEDICATION NAME]; -Left medial foot measured 2.5 cm x 1.5 cm x 0.1 cm with eschar continue with the [MEDICATION NAME]; and -Right heel measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm with necrotic tissue continue with the [MEDICATION NAME]. Record review of the facility wound report dated 11/28/14 showed the resident: -Had the following wounds: --Left Achilles was a Stage IV that measured 3.8 cm x 2.8 cm x 0.8 cm was stable and had tendon exposed with granulation tissue on wound edges had Silva/Thermoform ordered twice a day; --Left Heel was Unstageable that measured 5.5 cm x 8.0 cm x 2.0 cm was stable and dark red, painful to touch, no drainage, no odor, and no swelling and had an order for [REDACTED]. --Left Medial Foot was Unstageable that measured 2.5 cm x 1.5 cm x 0.1 cm was stable and had eschar and had [MEDICATION NAME] ordered daily; --Right heel had two areas listed as Unstageable that measured 2.0 cm x 2.0 cm x 0.1 cm and 1.0 cm x 1.0 cm x 0.0 cm were stable and had eschar and had [MEDICATION NAME] ordered daily; and --Coccyx had MASD with two open areas that measured 2.0 cm x 2.0 cm x 0.0 cm and 1.0 cm x 1.0 cm x 0.0 cm was new and had two pink/red areas on the sacral area a catheter was place for healing and had Calzyme ordered. Record review of the resident's POS dated 12/1/14 to 12/31/14 showed: - The resident: --Had an order to complete a skin assessment weekly every Saturday; --Had an order for [REDACTED]. --Had an order for [REDACTED]. --Had an order for [REDACTED]. -Instructions to place a (-) sign if the resident had no new skin impairment and to place a (+) sign if the resident had new skin impairment and to document this on the skin assessment form; -No orders for the left medial foot wound; -No orders for the right heel wounds; and -The RD recommendations for Vitamin C 500 milligrams (mg) twice a day and Prostat liquid (sugar free) twice a day, continue weekly weights, and attempt to titrate Nepro up five cubic centimeters (cc)'s frequently to assess tolerance were not addressed (from his/her 12/14/14 visit). Rec

Based on observation, interview and record review, the facility staff failed to prevent or manage ongoing pain by not recognizing when the resident was experiencing pain and to identify when pain could be anticipated, by addressing the pain when experienced by the resident, by evaluating the existing pain and the cause, and to manage or prevent pain consistent with current clinical standards of practice for one sampled resident (Resident #1); to follow physician's orders [REDACTED]. shin below the knee, and to wrap the resident's left leg to reduce swelling for one sampled resident (Resident #15); to obtain a physician's orders [REDACTED]. [REDACTED]. of care and services provided to the resident between the facility and the [MEDICAL TREATMENT] clinic, including notification of critical lab values and the amount of fluid removed, and to include the medications that were given to the resident during [MEDICAL TREATMENT] on the resident's Medication Administration Record [REDACTED]#14), out of 18 sampled residents. The facility census was 103 residents. Record review of the National Pressure Ulcer Advisory Panel (NPUAP) Quick Reference Guide titled "Pressure Ulcer Prevention &Treatment" dated 2014, showed the following: -Pressure ulcers are painful; -Pain occurs both during procedures and at rest; -Assess for pressure ulcer related pain in adults using a scale that is valid and reliable; -Incorporate the individual's cognitive ability into the selection of a pain assessment tool; -Pain assessment tools may not provide sufficient information to guide interventions. Investigate other aspects in order to provide more effective, individualized interventions; -Incorporate the individual's body language and nonverbal cues into the assessment of pain; -Evaluate factors that increase pain frequency and/or intensity when conducting an assessment of pain; -Assess for deterioration of the ulcer or possible infection when the individual reports increasing intensity of pain over time; -Position the individual off the pressure ulcer whenever possible; -Organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow, and set priorities for treatment; -Administer pain medication regularly, in the appropriate dose, to control chronic pain; -Reposition the resident as a means to reduce pain; -Use adequate pain control measures, including additional dosing, prior to commencing wound care procedures; and -Work with the multi-disciplinary health care team to develop a holistic plan to manage chronic pressure ulcer pain. 1. Record review of Resident #1's wound consultation report dated 9/29/14, showed he/she: -Presented in the hospital with multiple pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); -Had a [DIAGNOSES REDACTED]. -Had [MEDICATION NAME] (a controlled narcotic medication substance Schedule II; among the most powerful medications for the relief of severe pain) and [MEDICATION NAME] (a topical, antibacterial cream) cream initiated for treatment to his/her wounds. Record review of the resident's Physician order [REDACTED]. -Tylenol (used to relieve many kinds of minor aches and pains) 160 milligram (mg)/5 milliliters (ml)-650 mg per tube every 6 hours as needed (PRN) for pain; -[MEDICATION NAME]/APAP (a narcotic medication used to relieve pain, with potential side effects of constipation) 5/325 mg, give one tablet per tube every six hours PRN for pain; -Pressure ulcer treatments for the coccyx to be done every six hours, -Pressure ulcer treatments for the left calf to be done every 12 hours; and -Pressure ulcer treatment for [REDACTED]. Record review of the resident's interdisciplinary notes dated 10/3/14, showed the resident would "occasionally scream for no reason." Record review of the resident's interdisciplinary notes dated 10/8/14 at 6:41 A.M., showed: -The resident was given PRN pain medication for pain with dressing change to the left lower extremity; and -No documentation of a pain assessment prior to the resident's dressing change. Record review of the resident's physician visit notes dated 10/8/14 at 12:30 P.M., showed: -The resident had minimal movement of extremities; -A single line drawn through the areas that were not assessed including pain; -An assessment of "multiple wounds" with the plan to continue wound care; -No documentation of assessment of the resident's pain; and -No documentation of a plan for pain or potential pain. Record review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/8/14, showed he/she: -Required total assistance with turning and repositioning; -Had range of motion limitations to both left and right upper and lower extremities; -Was not receiving scheduled pain medication; -Was receiving PRN pain medications; and -Did not show any signs or symptoms of pain during the five day look back period. Record review of the resident's interdisciplinary notes dated 10/9/14, showed: -The resident had a care plan meeting with the resident and family present in addition to facility staff; -The resident had no behaviors; -The resident had no pain; and -No documented pain interventions. Record review of the resident's interdisciplinary notes dated 10/10/14, showed he/she: -Was calling out his/her children's names and crying; -Said "he/she was waiting for his/her children to all come so he/she could die;" -Complained of pain in his/her leg and feet; and -Was medicated but continued to yell frequently. Record review of the resident's telephone orders dated 10/13/14, showed a physician's orders [REDACTED]. Record review of the resident's interdisciplinary notes dated 10/20/14, showed he/she had several episodes of emesis (vomiting) with discomfort. Record review of the resident's telephone orders dated 10/20/14, showed he/she: -Had a physician's orders [REDACTED]. -Had an order for [REDACTED]. -Had an order to send him/her to the emergency room (ER) for evaluation and treatment of [REDACTED]. Record review of the resident's hospital transfer orders dated 10/30/14, showed he/she: -Had a physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. -Had an order for [REDACTED]. Record review of the resident's interdisciplinary notes dated 10/31/14 at 7:33 A.M., showed he/she: -Was given the PRN [MEDICATION NAME] and PRN [MEDICATION NAME] at bedtime on 10/30/14; and -Was given the PRN [MEDICATION NAME] at 6:25 A.M. on 10/31/14 for complaints of left heel pain; -Rated his/her pain a ten out of a range from zero to ten, with ten being the worst pain possible; -Had increased pain in left lower extremity and posterior leg; and -Had a new physician's orders [REDACTED]. Record review of the resident's interdisciplinary notes dated 11/1/14, showed he/she: -Was seen by the nurse practitioner; and -Had a new pain medication order for [MEDICATION NAME] (a powerful opioid (narcotic pain killer)) patch 12 micrograms (mcg), change his/her patch every 72 hours for pain. Record review of the resident's physician visit note dated 11/5/14, showed he/she: -Complained of intermittent right knee and left lower extremity pain; -Had pain and joints with arthritic changes circled on his/her assessment; and -Was assessed for pain and had a plan for [MEDICATION NAME] ([MEDICATION NAME]) trans-dermal patch (a thin, adhesive, patch worn on the skin that delivers medicine through the skin and into the bloodstream) and to monitor for over sedation. Record review of the resident's interdisciplinary notes dated 11/6/14 at 6:47 P.M., showed he/she was yelling and crying uncontrollably. Record review of the resident's telephone orders dated 11/6/14, showed he/she: -Had a physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. Record review of the resident's interdisciplinary notes dated 11/7/14, showed he/she: -Had swelling in the left upper extremity; -Had pain with movement of the left upper extremity; and -Was medicated two times during the 7:00 P.M. to 7:00 A.M. shift. Record review of the facility's educational offering record/attendance sheet dated 11/10/14, showed: -The topic was filling out pain sheets; -The education included pain sheets were to be filled out each time a PRN medication was given; -The attendance sheet included four Certified Medication Technicians (CMTs); -The attendance sheet did not have a presenter's name; and -The attendance sheet did not have any licensed nurse's signatures; and -The facility had more than four CMTs employed. Record review of the resident's interdisciplinary notes dated 11/11/14, showed he/she: -Was being followed in the "patient at risk" (PAR) meeting by facility staff; and -Had no mention of pain or pain management in the PAR meeting notes. Record review of the resident's physician visit note dated 11/12/14, showed he/she: -Was without the [MEDICATION NAME] and staff stated the resident did not complain of pain; and -Had well controlled pain with PRN pain medications. Record review of the resident's interdisciplinary notes dated 11/12/14 at 1:25 P.M., showed he/she: -Had been in his/her room yelling and crying in the morning; -Was given the PRN [MEDICATION NAME] and [MEDICATION NAME] at 10:00 A.M.; and -Was seen by the physician and had the [MEDICATION NAME] discontinued as a result of having pain controlled without the patch. Record review of the resident's interdisciplinary notes dated 11/18/14, showed: -The resident was followed in the PAR meeting; and -No documentation of his/her pain or pain management in the PAR meeting notes. Record review of the resident's physician visit note dated 11/19/14, showed he/she: -Had one episode of crying out occasionally related to pain; -Had an "x" across pain; -Had agitation - likely multifactorial pain - not a consistent issue; -Had no medication changes; and -Was to continue the use of the PRN [MEDICATION NAME]. Record review of the resident's interdisciplinary notes dated 11/19/14, showed: -The resident was seen by the wound physician; -The resident's left heel wound was debrided (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue); -The resident's left heel wound was tender to the touch; and -No documentation that the resident was medicated for pain before the wound treatment was done. Record review of the resident's interdisciplinary notes dated 11/25/14, showed: -The resident was followed in the PAR meeting; and -No documentation of pain or pain management in the PAR meeting notes. Record review of the resident's interdisciplinary notes dated 11/26/14, showed: -The resident was seen by the wound physician; -The resident had a wound on the left Achilles that had tendon (a band of fibrous connective tissue that usually connects muscle to bone) exposed; -The resident had a wound on the left heel that had tendon exposed; and -No documentation of being medicated for pain before the wound treatment was done. Record review of the resident's pain evaluation dated 11/29/14, showed: -The reason for the evaluation was a quarterly evaluation; -The location of the pain was knees and all over; -The type of pain scale used was faces zero to five; -The resident and/or the resident's family was educated on pain the management interventions available; -In the last five days the resident had received a scheduled pain medication; -In the last five days the resident had received a PRN pain medication; -In the last five days the resident had received non-medication interventions for pain; -The pain evaluation interview should not be conducted as the resident is "rarely/never understood;" -In the last five days the resident had non-verbal sounds including crying, whining, gasping, moaning, or groaning; -In the last five days the resident had vocal complaints of pain such as that hurts, ouch, or stop; -In the last five days the resident had facial expressions such as grimaces, winces, wrinkled forehead, furrowed brow, or clenched jaw; -Pain interventions being used included [MEDICATION NAME] (pain medications) medications and repositioning; and -This was the only pain evaluation form found or provided by the facility staff for the resident. Record review of the resident's pain care plan dated 11/29/14, showed he/she had a potential for pain related to daily pain as evidenced by crying out and complaining of pain, and he/she would demonstrate pain control as evidenced by verbalizing satisfaction with level of comfort, the ability to participate in activities of daily living without discomfort, and the early detection of pain for timely intervention to prevent escalation. His/her interventions included: -Provide [MEDICATION NAME] as ordered and assess for adverse side effects; -Assess pain his/her level as evidenced by reported pain, restlessness, pupil dilation, perspiration, changes in vital signs form baseline data; -Report uncontrolled pain to the provider; -Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity, or severity, and precipitating factors of pain; -Teach the use of non-pharmacological techniques (e.g. relaxation, guided imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities, before pain occurs or increases, and along with other pain relief measures; -Medicate before an activity as needed to increase participation, but evaluate for sedation/safety; -Provide non-pharmacological interventions prior to [MEDICATION NAME]; -Monitor for non-verbal signs of pain such as grimacing, irritability, moaning, body language, guarding, daily; and -Observe for side effects of medications such as falling, constipation, and drowsiness. Record review of the resident's POS dated 12/1/14 to 12/31/14, showed had physician's orders [REDACTED]. -[MEDICATION NAME] (Tylenol) 160 mg/5 ml, take 4 ml per tube every six hours as needed; -[MEDICATION NAME]/APAP 7.5-325, take 10 ml per tube every four hours as needed; and -[MEDICATION NAME] 12 mcg, change every 72 hours if the family was agreeable; -Biofreeze (a topical over-the-counter gel for pain relief) to the right knee four times daily as needed; and -Pressure ulcer treatments to the left Achilles and left heel every 12 hours, left medial foot and right heel daily. Record review of the resident's Medication Administration Record [REDACTED] -Received Tylenol a total of ten times during the month of December 2014; -Did not have supporting documentation for the reason the medication was given on the back of the MAR indicated [REDACTED] -Received [MEDICATION NAME]/APAP a total of 28 times during the month of December 2014; -Did not have supporting documentation for the reason the medication was given on the back of the MAR indicated [REDACTED] -Received [MEDICATION NAME] a total of nine times during the month of December 2014; -Did not have supporting documentation for the reason the medication was given on the back of the MAR indicated [REDACTED] -Did not receive the Biofreeze during the month of December 2014; and -Received pressure ulcer treatments as ordered every 12 hours and daily. Record review of the resident's undated [MEDICAL CONDITION] (medications used to alter brain chemistry in order to modify a person's emotional or cognitive (thinking) functions) tool showed he/she: -Received [MEDICATION NAME] a total of nine times during December 2014; -Received [MEDICATION NAME] for the behavior of yelling out and crying all nine times during December 2014; and -Was "resting quietly" after the medication was given all nine times during December 2014. Record review of the resident's undated pain monitoring sheet showed he/she: -Received Tylenol a total of five times during the month of December 2014; -Was "resting quietly" after the medication was given all five times during December 2014; -Received [MEDICATION NAME] a total of 19 times during the month of December 2014; and -Was "resting quietly" after the medication was given all 19 times during December 2014. Record review of the resident's interdisciplinary notes dated 12/2/14, showed: -The resident was followed in the PAR meeting; and -No documentation of pain or pain management in the PAR meeting notes. Record review of the resident's physician visit notes dated 12/3/14 at 11:00 A.M., showed he/she had chronic pain that was "well controlled." Record review of the resident's interdisciplinary notes dated 12/5/14, showed he/she: -Has continued to have pain; and -Continued to cry with position changes. Record review of the resident's December 2014 MAR for the date of 12/5/14, showed he/she: -Did not receive any Tylenol any time during the day; and -Did not receive any [MEDICATION NAME] any time during the day. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/5/14, showed he/she did not receive any: -Tylenol at any time during the day; and -[MEDICATION NAME] any time during the day. Record review of the resident's interdisciplinary notes dated 12/7/14, showed he/she: -Was crying and moaning; -Was complaining that his/her left leg was hurting; and -Was medicated and was "resting" in his/her room with no sign or distress. Record review of the resident's December 2014 MAR for the date of 12/7/14, showed he/she: -Did not receive Tylenol any time during the day; -Received [MEDICATION NAME] two times with no times listed and no supporting documentation why the pain medication was given during the day, and no follow-up evaluation for effectiveness; -Received [MEDICATION NAME] one time at 8:50 A.M. for complaints of left lower extremity pain; and -Was "resting and calm" at 9:30 A.M. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/7/14, showed he/she: -Did not receive Tylenol any time during the day; -Received [MEDICATION NAME] at 4:50 A.M. for complaints of left lower extremity pain; -Was "resting quietly" at 5:50 A.M.; -Received [MEDICATION NAME] at 8:50 A.M. for complaints of leg pain; -Had a follow-up evaluation at 10:30 A.M. that showed the resident was "resting and calm; -Received [MEDICATION NAME] at 11:30 P.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 12:00 A.M. that showed he/she was "resting quietly." Record review of the resident's interdisciplinary notes dated 12/8/14, showed he/she: -Was crying and moaning; and -Was complaining of left leg pain. Record review of the resident's December 2014 MAR for the date of 12/8/14, showed he/she: -Received Tylenol one time at 5:20 A.M. with no documentation why the pain medication was given and no follow-up evaluation for effectiveness; -Received [MEDICATION NAME] at 8:45 A.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 9:30 A.M. showing he/she was "resting quietly with his/her eyes closed." Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/8/14, showed he/she: -Received Tylenol at 5:20 A.M. for left lower extremity pain; and -Had a follow-up evaluation (there was no time listed when done) that showed the medication was "effective." Record review of the resident's interdisciplinary notes dated 12/10/14, showed: -The resident was seen by the wound physician; -The resident had a wound on the left Achilles with the tendon exposed; -The resident had a wound on the left heel with the tendon exposed; and -No documentation of the resident being medicated for pain before the wound treatment was done. Record review of the resident's December 2014 MAR for the date of 12/10/14, showed he/she: -Did not receive any Tylenol any time during the day; and -Did not receive any [MEDICATION NAME] any time during the day. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/10/14, showed he/she: -Did not receive any Tylenol any time during the day; and -Did not receive any [MEDICATION NAME] any time during the day. Record review of the resident's interdisciplinary notes dated 12/12/14, showed he/she: -Was crying; -Was complaining of pain; -Rated the pain a nine of a scale of one to ten with ten being the worst pain possible; -Was given PRN pain medication; and -Was "resting quietly." Record review of the resident's December 2014 MAR for the date of 12/12/14, showed he/she: -Received Tylenol one time at an unreadable time during the day and had no follow-up evaluation for effectiveness; and -Did not receive any [MEDICATION NAME] any time during the day. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/12/14, showed he/she: -Received Tylenol at 8:30 P.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 9:30 P.M. that showed he/she was "resting quietly." Record review of the resident's interdisciplinary notes dated 12/15/14, showed he/she: -Had pain with any movement; and -Had no mention of being given any pain medication at any time during the shift. Record review of the resident's December 2014 MAR for the date of 12/15/14, showed he/she: -Did not receive any Tylenol any time during the day; and -Received [MEDICATION NAME] one time at 3:20 P.M. and had no supporting documentation why the pain medication was given during the day and no follow up evaluation for effectiveness. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/15/14, showed he/she: -Did not receive any Tylenol any time during the day; -Received [MEDICATION NAME] at 3:20 P.M. for complaints of leg pain; -Had a follow-up evaluation at 4:30 P.M. that showed the medication was "effective;" -Received [MEDICATION NAME] at 11:15 P.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 12:15 A.M. that showed the resident was "resting quietly." Record review of the resident's interdisciplinary notes dated 12/16/14, showed he/she: -Was given PRN [MEDICATION NAME] for left lower extremity pain; -Was "resting quietly;" -Had a wound on the left heel with the tendon exposed; -Had pain when the left heel was touched; -Had a wound on the left Achilles with the tendon exposed; and -Had pain when the left Achilles was touched. Record review of the resident's December 2014 MAR for the date of 12/16/14, showed he/she: -Received Tylenol at 5:10 A.M. and had no supporting documentation why the pain medication was given or follow-up evaluation for effectiveness; and -Did not receive any [MEDICATION NAME] any time during the day. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/16/14, showed he/she: -Did not receive any Tylenol any time during the day; -Received [MEDICATION NAME] at 5:10 A.M. and had no supporting documentation for the pain medication; -Had a follow-up evaluation at 6:00 A.M. that showed he/she was "resting quietly;" -Received [MEDICATION NAME] at 11:45 P.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 12:45 A.M. that showed he/she was "resting quietly." Record review of the resident's interdisciplinary notes dated 12/20/14, showed he/she: -Was crying; -Was given PRN pain medication one time during the shift; and -Was "resting quietly." Record review of the resident's December 2014 MAR for the date of 12/20/14, showed he/she: -Received Tylenol one time at 8:00 P.M. and had no supporting documentation for why the pain medication was given and had no follow-up evaluation for effectiveness; and -Did not receive Tylenol any time during the day. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/20/14, showed he/she: -Received Tylenol at 8:00 P.M. for left lower extremity pain and had a follow-up evaluation for the effectiveness; -Received [MEDICATION NAME] at 12:15 A.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 1:15 A.M. that showed he/she was "resting quietly." Record review of the resident's interdisciplinary notes dated 12/23/14, showed he/she: -Was crying before the wound treatment; -Was given PRN pain medication; and -Had only brief relief. Record review of the resident's December 2014 MAR for the date of 12/23/14, showed he/she: -Did not receive Tylenol any time during the day; -Received [MEDICATION NAME] at 8:30 A.M. for complaints of heel pain (did not indicate which heel); -Was "resting" after follow-up evaluation; -Received [MEDICATION NAME] at 2:00 P.M. for heel pain (did not indicate which heel); and -Did not have a follow-up evaluation for effectiveness. Record review of the resident's undated December 2014 pain monitoring sheet for the date of 12/23/14, showed he/she: -Did not receive any Tylenol any time during the day; -Received [MEDICATION NAME] at 8:30 A.M. for complaints of leg pain and had no follow-up evaluation for effectiveness; and -Received [MEDICATION NAME] at 2:00 P.M. for complaints of leg pain and had no follow-up evaluation for effectiveness. Record review of the resident's interdisciplinary notes dated 12/25/14 at 7:21 A.M., showed he/she: -Was calling out for family; -Was out of PRN [MEDICATION NAME]; -Was given Tylenol with no effect; -Was given PRN [MEDICATION NAME] after being delivered at 6:05 A.M. with no effect; -Was awake much of the night from pain; and -Was crying and screaming that his/her legs hurt. Record review of the resident's December MAR for the date of 12/24/14 and 12/25/14, showed: -No documentation of any pain medication being given from 12/24/14 at 7:00 P.M. to 12/25/14 at 7:00 A.M. Record review of the resident's Interdisciplinary notes dated 12/25/14 at 6:39 P.M., showed he/she: -Was given PRN Tylenol at 9:00 A.M.; -Was reassessed and found to be "resting and calm;" -Was given PRN Tylenol at 4:00 P.M.; -Was reassessed and found to be "resting and calm;" -Was given PRN [MEDICATION NAME] at 6:45 P.M. (this time is later than the time the note was written) for leg pain; -Rated the leg pain a ten on a scale of one to ten with ten being the worst pain possible; and -Was in his/her room with "no signs of distress." Record review of the resident's December 2014 MAR for the date of 12/25/14, showed he/she: -Received Tylenol at 9:00 A.M. and had no supporting documentation why the pain medication was given, and had no follow-up evaluation for effectiveness; -Received Tylenol at 3:30 P.M. and had no supporting documentation why the pain medication was given and had no follow-up evaluation for the effectiveness; and -Received [MEDICATION NAME] at 6:45 P.M. and had no supporting documentation why the pain medication was given and had no follow-up evaluation for the effectiveness. Record review of the resident's undated pain monitoring sheet for the date of 12/25/14, showed he/she: -Received [MEDICATION NAME] at 6:05 A.M. for leg pain; -Had a follow-up evaluation at 6:45 A.M. that showed the medication was "not effective;'" -Received Tylenol at 9:00 A.M. for leg pain; -Had a follow-up evaluation at 9:30 A.M. that showed he/she was "in room resting;" -Received Tylenol at 3:30 P.M. for complaints of left lower extremity pain; -Had a follow-up evaluation at 4:00 P.M. that showed he/she was "resting quietly;" -Received [MEDICATION NAME] at 6:45 P.M. for complaints of left lower extremity pain; -Had a follow-up evaluation at 7:45 P.M. that showed the medication was "effective;" -Received [MEDICATION NAME] at 11:25 P.M. for complaints of leg pain; and -Had a follow-up evaluation at 12:25 A.M. that showed the resident was "resting quietly." Record review of the resident's interdisciplinary notes dated 12/26/14, showed he/she: -Was crying in pain at 9:30 A.M.; -Complained of pain in his/her legs; -Rated the pain in his/her legs a ten on a scale of one to ten with ten being the worst pain possible; -Was given PRN [MEDICATION NAME] at 9:30 A.M.; -Was reassessed at 10:00 A.M.; -Was found to be "resting with no signs of discomfort;" -Was complaining of pain in left lower extremity at 2:30 P.M.; -Rated the pain an eight on a scale of one to ten with ten being the worst pain possible; -Was reassessed at 3:00 P.M.; and -Was found to be "resting in bed with no signs of discomfort." Record review of the resident's undated pain monitoring sheet for the date of 12/26/14, showed he/she: -Received [MEDICATION NAME] at 4:30 A.M. for complaints of left lower extremity pain and had no follow-up evaluation for effectiveness; -Received [MEDICATION NAME] at 9:30 A.M. for complaints of left lower extremity pain; -Had a follow-up evaluation at 10:00 A.M. that showed he/she was "resting in room;" -Received [MEDICATION NAME] at 2:30 P.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 3:00 P.M. that showed he/she was "resting in chair." Record review of the resident's December 2014 MAR for the date of 12/28/14, showed he/she did not receive any: -Tylenol any time during the day; and -[MEDICATION NAME] any time during the day. Record review of the resident's interdisciplinary notes dated 12/29/14, showed he/she: -Had complaints of pain; -Rated the pain a six on a scale of one to ten with ten being the worst pain possible; -Was crying, saying his/her legs hurt; -Was given PRN [MEDICATION NAME] at 3:30 P.M.; and -Was reassessed at 4:00 P.M. and found to be "resting in bed with no signs of distress or discomfort." Record review of the resident's December 2014 MAR for the date of 12/29/14, showed he/she: -Did not receive any Tylenol any time during the day; and -Received [MEDICATION NAME] one time at 3:30 P.M., and had no supporting documentation why the pain medication was given and no follow-up evaluation for the effectiveness. Record review of the resident's undated pain monitoring sheet for the date of 12/29/14, showed he/she: -Received [MEDICATION NAME] at 3:30 P.M. for complaints of left lower extremity pain; -Had a follow-up evaluation at 4:00 P.M. that showed he/she was "resting and calm;" -Received [MEDICATION NAME] at 8:00 P.M. for complaints of left lower extremity pain; and -Had a follow-up evaluation at 9:00 P.M. that showed he/she was"resting quietly." Record review of the resident's interdisciplinary notes dated 12/30/14, showed the facility staff had a family meeting to discuss the decline of the resident's condition, and no documentation pain or pain management was discussed. Record review of the resident's physician visit note dated 12/31/14 at 11:15 A.M., showed he/she: -Had pain; -Had issues with pain bei

Based on observation, interview and record review, the facility staff failed to maintain acceptable parameters of nutritional status for one sampled resident (Resident #1) who had a feeding tube (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube), by not maintaining body weight and protein level, by not recognizing, evaluating, and addressing the needs of the resident already experiencing impaired nutrition, by not identifying risk factors for, and causes of, impaired nutritional status, for a resident who experienced significant weight loss and had multiple pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s) which healing can be affected by the resident's nutritional status); to notify the physician regarding the Registered Dietitian (RD) recommendations for two sampled residents (Resident #1 and #17); and to follow RD recommendations for one sampled resident (Resident #3) who had a significant weight loss and a pressure ulcer, out of 18 sampled residents. The facility census was 103 residents. Record review of the facility policy dated 5/8/12 and revised on 8/5/14 titled "Weights," showed the following procedure: -New residents will be weighed weekly for the first four weeks and then monthly. -Recorded weights will be monitored by the RD and reported to the nurse manager. -Determine the amount of weight loss or gain. -Weight loss or gain of greater than 5% in a month, 10% over three months and/or 3% weight loss in 30 days are identified as at risk and interventions are put in place. -Notification of the attending physician and family of the resident's loss or gain will be documented in the medical record. 1. Record review of Resident #1's hospital transfer admission orders [REDACTED] -Fever (an abnormally high body temperature); -Urinary tract infection (UTI - an infection of one or more structures in the urinary system); -[MEDICAL CONDITION] ([MEDICAL CONDITION]; a bacteria that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon); -Multiple wounds; -[MEDICAL CONDITION] ([MEDICAL CONDITION], stroke); -Left [MEDICAL CONDITION] (paralysis/weakness affecting one side of the body); -Dysphagia (inability or difficulty swallowing); -Hypertension (HTN; high blood pressure); -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin); -History of renal transplant (a surgical procedure to place a functioning kidney from a donor into a person whose kidneys no longer function properly); -Nothing to eat by mouth (NPO); and -Enteral Tube Feeding (a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing) of Glucerna 50 milliliters (ml)/hour (hr) with 200 ml water flush every four hours. Record review of the resident's interdisciplinary notes dated 9/30/14, showed he/she was NPO with Enteral feeding tube present with Glucerna 1.2 running at 50 cubic centimeters (cc)/hr with 200 ml water flushes every four hours. Record review of the resident's weights showed no admission weight on 9/30/14. Record review of the resident's telephone orders dated 10/1/14 showed: -A physician's order to discontinue the Glucerna and water flushes; and -Start Glucerna 1.2 at 65 cc/hr with routine water flushes of 150 cc every four hours via Enteral tube. Record review of the resident's interdisciplinary notes dated 10/1/14, showed he/she received: -Tube feeding of Glucerna 1.2 at 50 cc/hr without difficulties; and -200 cc water flushes every four hours. Record review of the resident's telephone orders showed a physician's order dated 10/2/14 for [MEDICATION NAME] (a commonly used medication for the treatment of [REDACTED]. Record review of the resident's interdisciplinary notes dated 10/3/14, showed he/she: -Had no signs or symptoms of nausea or vomiting; and -Was administered fluids via the Enteral tube, tolerated them well. Record review of the resident's weight dated 10/3/14 showed he/she weighed 135 pounds. Record review of the resident's interdisciplinary notes dated 10/4/14, showed he/she: -Was vomiting around 2:00 A.M.; -Had the tube feeding held "for a couple of hours;" -Had a residual (amount of tube feeding left in the stomach) of 5 cc's at 6:00 A.M.; and -Had the tube feeding turned back on at 6:10 A.M. Record review of the resident's interdisciplinary notes dated 10/5/14, showed he/she: -Had a residual amount of tube feeding of 100 cc's at 5:40 A.M. and the tube feeding was turned off; -Had tube feeding turned back on at 6:56 A.M.; and -Had no emesis (vomiting) noted on the 7:00 A.M. through 7:00 P.M. shift. Record review of the resident's interdisciplinary notes dated 10/7/14, showed his/her weight was "stable," he/she continued to have Glucerna at 65 cc/hr, and was to be seen by the dietitian for recommendations. Record review of the resident's telephone orders dated 10/7/14, showed: -A physician's order to stop Glucerna 1.2; and -Start Glucerna 1.5 at 50 cc/hr for 22 hours daily as tolerated. Record review of the resident's physician visit notes dated 10/8/14, showed: -Emesis on same day after medications were "pushed;" and -The resident with nausea, and would have dietary re-evaluate. Record review of the resident's interdisciplinary notes dated 10/8/14, showed the resident had Glucerna at 65 cc/hr and his/her tube flushed as ordered. Record review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/8/14, showed he/she: -Had a feeding tube in place; -Required total assistance with eating; and -Had a weight of 135 pounds. Record review of the resident's lab work drawn on 10/09/14, showed an [MEDICATION NAME] level (the main protein in human blood) of 3.6 (normal reference range 3.4-5.0). Record review of the resident's weight dated 10/10/14, showed he/she weighed 134 pounds. Record review of the resident's interdisciplinary notes dated 10/15/14, showed he/she continued to have emesis. Record review of the resident's telephone orders dated 10/15/14, showed: -A change in feeding due to increased residuals; and -an order for [REDACTED]. Record review of the resident's weight dated 10/17/14 showed he/she: -Weighed 124 pounds; and -Had a significant weight loss of 8% in one week. Record review of the resident's interdisciplinary notes dated 10/20/14, showed he/she: -Had brown/green emesis on his/her shirt/towel; -Had an order to send to the hospital for evaluation and treatment for [REDACTED]. -Had no tube feeding from 7:00 A.M. through 7:00 P.M.; and -Was sent to the hospital for evaluation at 7:17 P.M. Record review of the resident's telephone orders dated 10/20/14, showed new orders for: -An x-ray of the kidneys, ureter (tubes made of smooth muscle fibers that propel urine from the kidneys to the urinary bladder), and bladder (KUB); and -[MEDICATION NAME] (a medication that prevents vomiting) 25 milligrams (mg)/ml Intramuscular (IM); an injection of a substance directly into a muscle) every four hours as needed for nausea/discomfort; and -Send the resident to the hospital for evaluation and treatment for [REDACTED]. Record review of the resident's interdisciplinary notes dated 10/21/14, showed a late entry for 10/20/14 at 7:00 A.M. through 7:00 P.M. saying he/she: -Had "several" episodes of emesis; -Had his/her tube feeding held; -Had [MEDICATION NAME] as ordered with no effect; -Had new orders for [MEDICATION NAME] and a KUB; -Was given the [MEDICATION NAME] IM and the KUB was ordered; -Had more emesis after the IM injection; and -Had the KUB done. Record review of the resident's hospital transfer form with admission orders [REDACTED] -Tube feeding of [MEDICATION NAME] 30 cc/hr; -200 cc water flushes every six hours; and -A goal of tube feeding 70 cc/hr. Record review of the resident's lab work dated 10/31/14, showed he/she: -Had a low [MEDICATION NAME] level of 3.1 (normal reference range 3.4-5.0); and -A low [MEDICATION NAME] level can be caused by a poor nutritional state, not taking in enough protein, or losing protein. Record review of the resident's interdisciplinary notes showed: -No notes dated before 10/31/14, stating he/she had returned from the hospital; and -On 10/31/14, he/she received [MEDICATION NAME] at 30 cc/hr via his/her feeding tube and had no nausea/vomiting. Record review of the resident's interdisciplinary notes dated 11/1/14, showed he/she was seen by the nurse practitioner and had a new order to change the tube feeding to Nepro 20 cc/hr with a 200 cc water bolus every six hours, and to hold one bolus if the resident had any emesis. Record review of the resident's lab work dated 11/3/14, showed he/she: -Had a low [MEDICATION NAME] level of 3.1 (normal reference range 3.4-5.0). Record review of the resident's physician visit notes dated 11/5/14, showed he/she: -Had a recent hospital admission for nausea/vomiting; -Had resolved nausea/vomiting; and -Was to continue the Nepro tube feeding and diet by mouth. Record review of the resident's weight dated 11/7/14, showed he/she: -Weighed 128 pounds; and -Had a significant weight loss of 5.5% in one month. Record review of the resident's interdisciplinary notes dated 11/11/14, showed he/she: -Was being followed in the "patient at risk" (PAR) meeting for Enteral feeding; -Had a stable weight; and -Was tolerating the tube feeding. Record review of the resident's physician visit dated 11/12/14, showed the resident: -Denied nausea/vomiting; and -Was to continue [MEDICATION NAME] medication as needed for complaints of nausea/vomiting. Record review of the resident's weight dated 11/14/14, showed he/she: -Weighed 121 pounds; and -Had a significant weight loss of 5.8% in one week. Record review of the resident's physician visit note dated 11/17/14, showed the resident was to continue the tube feeding increasing the rate per dietary. Record review of the resident's interdisciplinary notes dated 11/18/14, showed he/she: -Was being followed in the PAR meeting for weight loss; -Was receiving Nepro for tube feeding; -Was down to 121 pounds from 128; -Was to have his/her tube feeding increased to 25 cc/hr to increase calorie intake; and -Had episodes of vomiting in the past. Record review of the resident's telephone orders showed a new order to increase the tube feeding of Nepro to 25 cc/hr. Record review of the resident's weight dated 11/21/14, showed he/she weighed 120 pounds. Record review of the resident's interdisciplinary notes dated 11/25/14, showed he/she: -Was being followed in the PAR meeting for Enteral feeding; -Was continuing to receiving Nepro tube feeding through the tube without difficulties; -Was continuing to lose weight with an increased feeding; and -Was to be assessed for another increase in the tube feeding by 5 cc's. Record review of the resident's weight dated 11/28/14, showed he/she weighed 120 pounds. Record review of the resident's feeding tube care plan dated 11/29/14, showed he/she had a problem that identified a feeding tube was necessary for nutritional needs related to dysphagia (difficulty in swallowing), with a goal that his/her nutritional needs would be met by the tube feedings, and the following interventions: -Check placement of the tube before each feeding by two means; -Give 30 cc's of water before and after each feeding; -Keep his/her head of bed elevated to 45 degrees during feeding and 30 minutes after; -Administer the tube feeding formula as ordered; -Administer tube feed water flush as ordered; -Monitor tolerance of the tube feeding; -Monitor labs as per physician orders; -Monitor for signs and symptoms of dehydration (a dangerous lack of water in the body resulting from inadequate intake of fluids or excessive loss); -Monitor for signs and symptoms of aspiration (breathing in fluid or foreign material, especially stomach contents or food); and -This care plan did not address that he/she had actual significant weight loss. Record review of the resident's tube feeding care plan dated 11/29/14, showed a problem of being at risk for tube feeding dislodgement and aspiration, with a goal that the feeding tube would remain patent (unobstructed) and in the correct position, with the following additional interventions: -Obtain vital signs; -Auscultate (the act of listening for sounds within the body) lung sounds daily as indicated; and -He/she had no other care plans regarding the tube feeding or any updates indicating any changes to the tube feeding orders. Record review of the resident's Physician's Order Sheet (POS) dated 12/1/14-12/31/14, showed the following physician's orders: -Flush his/her tube with 200 cc of water every six hours; -Dated 10/30/14 for a pureed diet with nectar thick liquids, and enteral tube feeding not listed under the diet order area; -Had an Enteral tube feeding listed with the medications with a beginning date of 10/31/14, a physician's order for Nepro (a nutritional drink for people on [MEDICAL TREATMENT]) 20 cc/hr per tube, and the 20 cc had a diagonal line through it and 25 cc was handwritten above it with "change on 11/19/14" handwritten under the order; -Dated 12/3/14 to increase his/her tube feeding by 5 cc/hr as tolerated and to do weekly weights; and -Dated 12/3/14 for "tube feeding 30 cc/hr as tolerated" in the list of medications. Record review of the resident's Medication Administration Record [REDACTED] -Had a physician's order to flush his/her tube with 200 cc water every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. --Had three blank boxes during the whole month with no explanation as to why the boxes were blank; -Had a physician's order dated 10/31/14 for Nepro 20 cc/hr per tube, and a line through the 20 cc with 25 cc handwritten above the order; -Had two time frames and initials present: --At 7:00 A.M. to 7:00 P.M.; ---Initials signifying the tube feeding was infusing during this time frame from 12/1/14 to 12/5/14; --At 7:00 P.M. to 7:00 A.M.; ---Initials signifying the tube feeding was infusing during this time frame from 12/1/14 to 12/4/14; and -Had discontinued (dc'd) 12/3/14 handwritten next to the initials with a line through the rest of the row. -Had a physician's order dated 12/3/14 for weekly weights with four days indicated and no weights listed in the days indicated; -Had a physician's order dated 12/3/14 for Nepro 30 cc/hr per tube, with two time frames and initials present; --7:00 A.M. to 7:00 P.M.; ---Initials signifying the tube feeding was infusing during this time frame from 12/4/14 to 12/8/14; --7:00 P.M. to 7:00 A.M.; ---Initials signifying the tube feeding was infusing during this time frame from 12/3/14 to 12/8/14; -Had "order changed" next to the initials with a line through the rest of the row. Record review of the resident's physician visit note dated 12/3/14, showed the resident had continued weight loss despite minimum oral intake and tube feeding. Record review of the resident's nutritional status care plan dated 12/3/14, showed he/she: -Had a problem of being at risk for weight loss related to his/her tube feeding for nutrition; -Had a goal of maintaining current weight within three to five pounds; and -Had only one intervention, to consult the dietitian. Record review of the resident's weight dated 12/5/14, showed he/she: -Weighed 120 pounds; and -Had a significant weight loss of 12.5% in two months. Record review of the resident's MAR indicated [REDACTED] -Had a physician's order dated 12/9/14 for Nepro 30 cc/hr per tube from 6:30 P.M. to 7:30 A.M.; --6:30 P.M. on and 7:30 A.M. off had initials from 12/9/14 to 12/17/14; ---Had seven blank boxes during this time frame, with no explanation as to why the boxes were blank; -Had a physician's order dated 12/9/14 for Nepro 30 cc/hr per tube from 9:30 A.M. to 11:30 A.M.; --9:30 A.M. on and 11:30 A.M. off had initials from 12/9/14 to 12/17/14; ---Had one initial circled and 10:00 written under the circled initials; -Had a physician's order dated 12/9/14 for Nepro 30 cc/hr per tube from 1:30 P.M. to 4:30 P.M.; --1:30 P.M. on and 4:30 P.M. off had initials from 12/9/14 to 12/17/14; ---Had two blank boxes during this time frame, with no explanation as to why the boxes were blank. Record review of the resident's POS dated 12/1/14-12/31/14, showed a physician's order dated 12/11/14 for Nepro 30 cc/hr per tube from 6:30 P.M. to 7:30 A.M., Nepro 30 cc/hr per tube from 9:30 A.M. to 11:30 A.M., and Nepro 30 cc/hr per tube from 1:30 P.M. to 4:30 P.M. Record review of the resident's weight dated 12/12/14, showed he/she weighed 121 pounds. Record review of the resident's nutrition services progress note written by the RD and dated 12/14/14, showed he/she: -Weighed 120 pounds; -Had an Enteral feeding of Nepro given via pump from 6:30 P.M. to 7:30 A.M., 9:30 A.M. to 11:30 A.M., and 1:30 P.M. to 4:30 P.M.; -Had an oral diet of pureed food with nectar thick liquids; -Had a poor oral intake of 0-25%; -Had calorie needs estimated at 2138 kcal, protein needs of 89 grams, fluid needs of 1636 cc's; -His/her current tube feeding was providing 972 kcal, protein 44 grams, fluids 393 cc water plus 800 cc water flush for a total fluid intake of 1193 cc's; -His/her current tube feeding was well below estimated needs; and -Had recommendations to add Vitamin C 500 mg twice a day, Prostat liquid twice a day, continue weekly weights, and attempt to titrate his/her Nepro tube feeding up frequently to assess his/her tolerance. Record review of the resident's telephone orders dated 12/17/14, showed a new physician's order to increase his/her tube feeding to Nepro 35 cc/hr from 6:30 P.M. to 7:30 A.M., Nepro 35 cc/hr from 9:30 A.M. to 11:30 A.M., and Nepro 35 cc/hr from 1:30 P.M. to 4:30 P.M. Record review of the resident's MAR indicated [REDACTED] -Had "changed 12/17/14" written next to the initials; -Had a physician's order dated 12/17/14 for Nepro 35 cc/hr per tube from 6:30 P.M. to 7:30 A.M.; --6:30 P.M. on and 7:30 A.M. off had initials from 12/18/14 to 12/31/14, and six blank boxes during this time frame, with no explanation as to why the boxes were blank; -Had a physician's order dated 12/9/14 for Nepro 35 cc/hr per tube from 9:30 A.M. to 11:30 A.M.; --9:30 A.M. on and 11:30 A.M. off had initials from 12/18/14 to 12/31/14, and three blank boxes during this time frame, with no explanation as to why the boxes were blank; -Had a physician's order dated 12/9/14 for Nepro 35 cc/hr per tube from 1:30 P.M. to 4:30 P.M.; --1:30 P.M. on and 4:30 P.M. off had initials from 12/18/14 to 12/31/14; and had two blank boxes during this time frame, with no explanation as to why the boxes were blank. Record review of the resident's weight showed: -On 12/19/14, he/she weighed 119 pounds; and -On 12/26/14, he/she weighed 117 pounds. Record review of the resident's interdisciplinary notes dated 12/29/14, showed he/she: -Was eating less than 25% of each meal; and -Had one emesis after the morning meal. Record review of the resident's POS dated 12/1/14-12/31/14, showed the following: -A physician's order dated 12/31/14 for dietary to review his/her tube feeding regarding weight loss; -The resident had two tube feeding orders listed in the list of medications with different rates; and -The resident did not have any physician's orders that addressed the RD's recommendations for "Vitamin C 500 mg twice a day, Prostat liquid twice a day, continue weekly weights, and attempt to titrate Nepro up frequently to assess tolerance." Record review of the resident's physician visit note dated 12/31/14, showed the resident still had weight loss, and his/her tube feeding was being held at the current rate due to the staff reporting emesis. Record review of the resident's POS dated 1/1/15 to 1/31/15, showed he/she: -Had a physician's order dated 10/30/14 for a pureed diet with nectar thick liquids; -Did not have an Enteral tube feeding listed under the diet order area; -Had a physician's order to flush his/her tube with 200 cc of water every six hours; -Had a physician's order dated 10/31/14 for Nepro 20 cc/hr per tube; and -Had no other order for tube feeding on the POS. Record review of the resident's weight dated 1/1/15, showed he/she: -Weighed 117 pounds; and -Had a significant weight loss of 15.4% in three months (since admission to the facility). Record review of the resident's MAR indicated [REDACTED] -Had a physician's order to flush the tube with 200 cc of water every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -All boxes for all times for all days from 1/1/15 to 1/9/15 had initials present; -Had a physician's order dated 10/31/14 for Nepro 20 cc/hr per tube at 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.; --Had initials on 1/1/15 for 7:00 P.M. to 7:00 A.M.; --Had initials on 1/2/15 for 7:00 A.M. to 7:00 P.M.; --Had "see new orders" written next to the initials; -Had no physician's order for Nepro 35 cc/hr per tube on the MAR (the last tube feeding order from the month of December); -Had a physician's order dated 1/2/15 for Nepro 40 cc/hr per tube from 6:30 P.M. to 7:30 A.M.; --Had initials from 1/3/15 to 1/9/15; ---Had three blank boxes during that time frame, with no explanation as to why the boxes were blank; -Had a physician's order dated 1/2/15 for Nepro 40 cc/hr per tube from 9:30 A.M. to 11:30 A.M.; --Had initials from 1/3/15 to 1/9/15; ---Had one initial circled with nausea/vomiting (n/v) during that time frame; -Had a physician's order dated 1/2/15 for Nepro 40 cc/hr per tube from 1:30 P.M. to 4:30 P.M.; --Had initials from 1/3/15 to 1/9/15; ---Had one initial circled with nausea/vomiting (n/v) during that time frame. Record review of the resident's interdisciplinary note dated 1/4/15, showed he/she ate less than 25% of each meal. During an observation of the resident on 1/5/15 at 1:50 P.M.: -He/she was in bed on his/her left side; -He/she had less than 100 cc's of tube feeding solution in a bag that was dated 1/4/15 at 10:45 P.M., and labeled with Nepro 40 cc/hr; -His/her tube feeding pump was turned off at this time; and -The tube feeding tubing was hanging uncapped on the pole and the cap was on the floor. Observations of the resident on 1/6/15, showed: -At 6:30 A.M., he/she was up in his/her wheelchair (tilt in space), and had a tube feeding of Nepro 40 cc/hr infusing via pump with 200 cc in the bag; -At 12:15 P.M., he/she was up in his/her wheelchair in a reclining position being pushed to the dining room by a staff member; and -At 12:30 P.M., he/she was being returned back to the resident's room by the charge nurse for medication, then returned back to the dining room by staff. Record review of the resident's interdisciplinary notes dated 1/6/15, showed he/she ate less than 25% of his/her meals. Observations of the resident on 1/7/15 at 9:00 A.M., showed: -He/she was in bed laying on his/her back; -His/her bag of tube feeding solution was dated 1/5/15 at 8:30 P.M., and labeled Nepro 40 cc/hr. Observations of the resident on 1/7/15 at 10:40 A.M., showed: -He/she continued to be in bed on his/her back; -His/her bag of tube feeding solution was dated 1/7/15 at 9:30 A.M., and infusing via a pump; -No identification of the tube feeding solution or rate on the bag the solution was infusing from; and -Another bag hanging on the pole, with no identification of a date or time on the bag, with a graduate (a device used to measure water to be used for flushes) and piston syringe (used to administer the tube feeding flush and medications through his/her tube) inside the bag. Record review of the resident's physician visit note dated 1/7/15 at 1:00 P.M., showed the resident: -Continued to have tube feeding increased despite nausea and vomiting; -Had difficulty tolerating tube feeding secondary to nausea and vomiting, advance as tolerated; and -Had malnutrition. During an observation of the resident on 1/7/15 at 3:05 P.M., he/she: -Was in bed on his/her right side; and -Had tube feeding infusing via pump at 40 cc/hr. During an observation of the resident on 1/8/15 at 8:20 A.M., showed he/she was sitting in his/her wheelchair reclined back in a common area of the facility with no tube feeding infusing at that time. During an interview on 1/8/15 at 8:30 A.M., the Director of Nursing (DON) said: -The Dietitian was in the building at least twice a week; -There was no reason why any resident was not seen in a timely manner regarding dietary concerns; -The Dietitian's recommendations were given to the charge nurses, DON, Assistant Director of Nursing (ADON), and Dietary Manager; -It was the responsibility of the charge nurses to call the physician and obtain orders for the dietary recommendations or a reason as to why the physician did not want to approve the recommendations; -It was the responsibility of the ADON to follow-up to make sure all dietary recommendations had orders or a reason explaining why the physician did not give the order; and -All the dietary orders should be correct and being followed by the facility staff. During an observation of the resident on 1/8/15 at 10:05 A.M., showed he/she was in his/her room sitting in his/her wheelchair reclined back, with his/her tube feeding infusing at 40 cc/hr via pump. During an interview on 1/8/15 at 10:25 A.M., Dietary Director A said: -Copies of the RD recommendations are given to the Dietary Director, DON, ADON, and the charge nurse; -He/she attended the PAR meetings; -He/she contacted the Dietitian as needed; -The charge nurses were responsible for obtaining orders from the physician for the recommendations; -The Dietary Director would get a copy of the orders if the order pertained to the resident's diet; -Dietitian services changed in the middle of October 2014 and a new RD started coming to the facility; and -The RD was in the building three times a week. During continuous observations of the resident on 1/8/15 from 10:50 A.M. to 2:00 P.M., showed: -At 10:50 A.M., had his/her tube feeding of Nepro infusing at 40 cc/hr via pump; -At 11:30 A.M., he/she was asking for water, had his/her tube feeding of Nepro infusing at 40 cc/hr via pump, had no verbalizations of nausea, and had no vomiting; -At 12:35 P.M., had his/her blood sugar checked as ordered with a high result of 282, had insulin given as ordered, and had no verbalizations of nausea and no vomiting; -At 12:40 P.M., had oral care provided by charge nurse, and had no verbalizations of nausea and no vomiting; -At 1:00 P.M., had his/her tube feeding of Nepro infusing at 40 cc/hr via pump, and had no verbalizations of nausea and no vomiting; -At 1:15 P.M., had his/her tube feeding of Nepro infusing at 40 cc/hr via pump; and --A staff member brought a meal room tray into the room, and set it on the dresser across the room from the resident and out of reach; --The staff member left the room; --He/she had no verbalizations of nausea and no vomiting; -At 1:20 P.M.: --A staff member entered the room; --The staff member picked up the room tray sitting on the dresser across from the resident which was not within the resident's reach; --The staff member took the glass of thickened water off the tray and placed it on the dresser across from the resident, out of the resident's reach; --The staff member said to the resident, "They said to leave you alone."; --The staff member left the room, leaving his/her meal tray out of the resident's reach; --The resident had no verbalizations of nausea and had no vomiting; -At 1:40 P.M.; --A staff member brought the resident's roommate into the room from the dining room; --The staff member did not address the resident or acknowledge the resident in any way; --The glass of thickened water remained on the dresser across the room from the resident and not within his/her reach; -At 1:50 P.M., his/her tube feeding of Nepro was infusing at 40 cc/hr via pump; -At 1:55 P.M., there was a charge nurse outside of room in hallway; and -At 2:00 P.M., his/her tube feeding of Nepro was infusing at 40 cc/hr via pump. During an interview on 1/9/15 at 1:15 P.M., Certified Nursing Assistant (CNA) B said: -The resident was to be up in the dining room for meals; -A tray was to be offered to the resident at every meal; and -The total amount of the meal the resident ate was to be reported to the charge nurse. During an observation of the resident on 1/9/15 at 1:35 P.M., he/she: -Was sitting in his/her wheelchair; -Had a totally empty bag attached to the tube feeding pump; -Had tubing that was empty past the tube feeding pump; -Had a charge nurse come into his/her room and add one can of Nepro to the empty bag, then could not get the tube feeding solution to advance into the tubing, and had to get a new bag and tubing set up to be able to administer the tube feeding to the resident. During an interview on 1/12/15 at 12:20 P.M., Licensed Practical Nurse (LPN) B said: -The tube feeding schedule of being off for two hours around all meal times started around the end of December (2014); -The resident was eating when that was started; -Since the Nepro tube feeding was started, the resident had not had any emesis; -The resident tolerated the Nepro; -The tube feeding was being advanced about every two weeks; -The only symptom the resident ever had if he/she was not tolerating the tube feeding was nausea and vomiting; -The RD was in the building two to three days a week; -The RD would see the resident and complete a recommendation sheet and leave it at the desk; -It was the charge nurse's responsibility to obtain physician's orders if dietary recommendations were left for a resident; -The physicians are pretty open to the recommendations and usually go along with them; and -New orders are placed on the POS, MAR, and Treatment Administration Record (TAR) as appropriate, and a copy is given to the Dietary Manager if it is diet related. During an interview on 1/12/15 at 10:35 A.M., the RD said: -He/she was in the building three times a week; -He/she would get a copy of the monthly weights from the Dietary Manager; -He/she would give a copy of the dietary recommendations to the DON, ADON, Dietary Manager and leave a copy on the charge nurse's desk; -Nursing staff pass supplements unless ordered with meals, and then they are the dietary staff's responsibility; -He/she was asking staff about specific residents and recommendations; -He/she was being told by staff that the resident was not tolerating the tube feedings; -The resident had not eaten more than 25% of his/her meals since he/she started in November of 2014; -Staff continued to say the resident was not tolerating the tube feedings; -Increasing the time the resident was receiving tube feeding may have been beneficial for the resident; -The resident needed "gut rest" and have his/her tube feedings off between two to four hours; -Nepro was the best option for the resident; -He/she saw resident with tube feedings at least monthly; -With the changes in management structure, the facility processes were not up to par; and -There had to be a better system for dietary recommendations being addressed and followed. During an interview on 1/14/15 at 9:00 A.M., Physician A said: -The resident was not tolerating tube feedings of Glucerna and [MEDICATION NAME]; -The resident was able to tolerate the Nepro better; -Staff had to advance the Nepro slowly as the staff was reporting the resident was not tolerating it and was continuing to have nausea and vomiting; -He/she would expect to be notified if the resident was not tolerating tube feedings. -He/she would expect to have orders followed; -He/she would expect to have medications given as ordered for nausea and vomiting; -He/she did not think about changing the times of the tube feeding and no one mentioned it or suggested it; -The resident continued to lose weight since his/her admission; and -The resident's nutritional needs were not being met at this time. During an interview on 1/14/15 a

Based on observation, interview and record review the facility staff failed to provide adequate supervision and protective oversight, complete an investigation after each fall to determine the root cause of the fall and put individualized interventions in place; failed to complete fall risk assessments and neurological checks (neurochecks-a check used to check for injury or issues with the brain after a fall) after each un-witnessed fall and failed to develop an individualized interdisciplinary care plan with appropriate interventions to instruct staff on how to keep the resident safe from further injury from falls for the resident care plan in accordance with the resident's condition for one sampled resident (Resident #7) who had numerous falls at the facility and suffered a hip (broken hip bone) fracture from a fall and for one sampled resident (Resident #17) who was diagnosed with [REDACTED].#6) who had two falls, and failed to ensure resident medications were properly stored and inaccessible to residents and visitors by leaving resident medication cards on top of the medication cart unattended by nursing staff. The total resident sample was 20 residents. The facility census was 111 residents. Record review of the undated facility policy for Fall Management showed facility staff should identify residents at risk for falling and initiate interventions promoting decreased risk of injury related to falls by: -Conducting a fall risk assessment upon admission/re-admission, quarterly, and as needed; -Conducting interdisciplinary assessments related to actual/risk of falls on an ongoing basis; -Implementing general interventions for all residents to prevent injury from fall (e.g., non-slip footwear, clear and lighted traffic ways); -Adding individualized interventions to care plans of those residents assessed to be at risk for falls; -Monitoring residents for 72 hours after a fall including documentation of the following --Neuro checks. --Signs of injury; --Pain; -Notifying family or significant other; -Faxing alert information to the primary care provider; -Repeating the fall risk assessment; -Implementing fall precaution interventions immediately after a fall; and -Modifying the resident's individualized care plan. 1. Record review of Resident #7's Post Fall Investigation Report dated 3/19/13 at 3:30 P.M., showed: -The resident was wet (incontinent of his/her urine), agitated and restless. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her wheelchair previous to the fall. -Other factors which contributed to the fall: --The resident was trying to reach for clothing on a shelf in the closet. -There were no safety devices in place (fall interventions). -What the resident said happened: --He/she was trying to reach in his/her closet and fell . -The analysis/conclusion of what happened: --The resident was trying to reach in his/her closet for clothing and fell . -The evaluation of present interventions and new interventions: --"Re-educated call light use". -This was fall number 1 for this resident. Record review of the resident's Neurological Assessment Flow Sheet dated 3/19/13 showed the resident's neurological checks had been completed. Record review of the resident's Interdisciplinary Progress Notes dated 3/19/13 at 3:30 P.M. showed: -The resident had a non-injury fall. -New orders were obtained for an occupational therapy (OT) evaluation and a physical therapy (PT) evaluation. -The resident's alarm had been sounding and the resident was found on the floor in front of his/her door. -The resident's wheelchair was in front of him/her. -The resident was assessed, was restless, and was transferred back into his/her wheelchair. -There was no staff documentation to show the resident's physician or family member had been notified. Record review of the PT and OT Progress and Discharge Summary Reports showed the resident was not referred to the therapy department on 3/19/13. Record review of the resident's Post Fall Investigation Report dated 3/29/13 at 6:00 A.M., showed: -The resident was wet, agitated and restless. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her wheelchair previous to the fall. -Other factors which contributed to the fall: --Being left alone in his/her wheelchair. -The resident had a bed alarm. -What the resident said happened: --He/she did not remember. -The analysis/conclusion of what happened: --No information had been documented by the staff. -The evaluation of present interventions and new interventions: --The staff added a wheelchair cushion to prevent sliding. -No neurochecks were completed. -This was fall number 2 for this resident. Record review of the resident's Interdisciplinary Progress Notes dated 3/29/13 at 8:00 A.M. showed: -At approximately 6:00 A.M., the staff that was taking care of this resident summoned the nurse to the resident's room. -The resident was observed sitting on the floor next to his/her bed. -The resident was assessed with [REDACTED]. -The resident was encouraged to call for help when he/she needed assistance. -A chair alarm was placed and would be used now. -The resident's physician had been notified. -The staff did not document the resident's family had been notified. Record review of the resident's Post Fall Investigation Report dated 3/29/13 at 9:20 A.M., showed: -The resident was restless. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her wheelchair previous to the fall. -Other factors which contributed to the fall: --The resident had right sided weakness. -The resident had a low bed. -What the resident said happened: --He/she was trying to get up. -The analysis/conclusion of what happened: --The wheelchair was not locked and the resident was trying to get up alone. -The evaluation of present interventions and new interventions: --A "gripper" seat (a cushion that would grip the wheelchair seat and prevent slipping) and physical therapy/occupational therapy would evaluate the resident. -No neurochecks were completed. -This was fall number 3 for this resident and the resident's previous fall was 3 hours and 20 minutes before this fall. Record review of the resident's Interdisciplinary Progress Notes dated 3/29/13 at 8:15 A.M. (related to the fall investigation report dated 3/29/13 at 9:20 A.M.) showed: -The certified nursing assistant (CNA) told the nurse the resident had a fall. -The resident was sitting on his/her bottom on the floor beside his/her bed with his/her feet in front of him/her. -The resident stated he/she was trying to get up. -The resident's alarm sounded at the time of the fall. -The resident was assessed and had no injury. -The resident was assisted back into his/her wheelchair. -The resident had a temperature of 101.0 degrees Fahrenheit (F) and was given Tylenol. -The resident was wheeled to the dining room and seemed to slip forward in his/her seat. -A "gripper pad" was suggested for his/her wheelchair but central supply was not here at this time to obtain the gripper cushion. -The Director of Nursing (DON) was notified. -New lab orders were received including a urinalysis was to be completed. -The staff did not document that the resident's family and physician had been notified. Record review of the resident's Interdisciplinary Progress Note dated 4/1/13 at 6:40 P.M., showed: -At approximately 9:30 A.M., the resident had non-injury fall. -The nurse was on the hall and heard the resident's personal alarm sounding. -The resident was found on the floor sitting up in front of his/her wheelchair with the wheelchair cushion on the floor. -The resident was asked if he/she was trying to get up and he/she stated "no, that damn cushion" and he/she pointed to the wheelchair cushion. -The wheelchair was unlocked. -The resident's wheelchair was switched by the therapy department so the resident would lean back further. -The resident received a new wheelchair cushion. -Staff did not document that they notified the resident's family member. -The staff did not document that the resident had a gripper cushion in place at the time of this fall. --This was fall number 4 for this resident which was two days after the resident's previous fall. Record review of the resident's medical record showed the staff did not complete a Post Fall Investigation form for the resident's fall on 4/1/13. Record review of the resident's Neurological Assessment Flow Sheet dated 4/1/13 showed the resident's neurological checks had been completed. Record review of the resident's Patient At Risk Meeting form dated 4/4/13 showed: -The resident had a fall on 4/1/13 at 9:30 A.M. -The form had a check mark on interventions, history of falls, and care plan. -The document was not signed or initialed by any staff members. -The form did not contain any other information related to the resident's falls, fall interventions, or the root cause of the resident's falls. Record review of the resident's Post Fall Investigation Report dated 4/7/13 at 3:30 P.M., showed: -The resident was agitated and restless. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her bed previous to the fall. -The resident was wet. -There were no fall interventions in place. -Other factors which contributed to the fall: --The resident was waiting for someone to help him/her then attempted to get out of bed by himself/herself. -The resident had a low bed. -What the resident said happened: --He/she was trying to get out of bed and into his/her wheelchair to change positions. -The analysis/conclusion of what happened: --The resident's call light was on but he/she did not wait for staff assistance. -The evaluation of present interventions and new interventions: --"low bed, floor matts". --This was fall number 5 for this resident which was six days after the resident's previous fall. Record review of the resident's Neurological Assessment Flow Sheet dated 4/7/13 showed the resident's neurological checks had been completed. Record review of the resident's Interdisciplinary Progress Notes dated 4/7/13 at 3:40 P.M., showed: -The CNA informed the nurse the resident was on the floor. -The resident was sitting beside his/her bed on the floor and smelled of feces. -The resident's call light was on. -The resident was asked why he/she was trying to get out of bed and stated he/she was just trying to move around. -The resident was asked if he/she needed to go to the restroom and he/she said no. -The resident was assessed, cleaned up, and put back into bed. -The resident's alarm did not sound. -The alarm was replaced and no new orders were obtained from the physician other than a low bed and floor mats. Record review of the resident's physician's Progress Notes dated 5/3/13, 5/21/13, 5/28/13, 6/4/13, 6/5/13, 6/17/13, and 6/21/13 did not address any of the resident's falls. Record review of the resident's OT Progress notes and Discharge Summary dated 5/6/13 through 6/3/13 showed: -The resident had been seen by therapy for training related to his/her power wheelchair. -The resident had right sided weakness and cognitive deficits. Record review of the resident's physician's orders [REDACTED]. -Hypertension (HTN-high blood pressure). Record review of the resident's Letters of Guardianship of an Incapacitated Person dated 6/5/13 showed the resident: -Had been assigned a legal guardian as his/her responsible party. Record review of the resident's Interdisciplinary Notes dated 6/21/13 at 7:13 A.M., showed: -The resident had been up most of the night. -The resident was noted to be pulling dirty brief off and throwing the brief onto the floor. -The resident had been non-complaint with cares. Record review of the resident's Post Fall Investigation Report dated 6/25/13 at 1:55 P.M., showed: -The resident was wet, agitated and restless. -The resident did not have an alarm on his/her wheelchair. --A wheelchair alarm had been added as an intervention after the resident's fall on 3/29/13 but the wheelchair alarm was not in place when this fall occurred. -The resident was in his/her wheelchair and the wheelchair brake was locked. -Other factors which contributed to the fall: --No information had been documented by the staff. -The resident had a low bed and mats on the floor. -What the resident said happened: --His/her "legs gave out". -The analysis/conclusion of what happened: --No information had been documented by the staff. -The evaluation of present interventions and new interventions: --No information had been documented by the staff. --This was fall number 6 for this resident. Record review of the resident's Neurological Assessment Flow Sheet dated 6/25/13 showed the resident's neurological checks had been completed. Record review of the resident's Interdisciplinary Notes dated 6/25/13 at 3:56 P.M., showed: -The resident was found on the floor in his/her room. -The resident stated he/she was using his/her walker to change the television station and fell . -The resident stated he/she was not hurt. -Neurochecks were started on the resident. -There was no staff documentation that showed the resident was assessed, or that the physician had been notified. -This was fall number 7 for this resident which was six two hours after the resident's previous fall. Record review of the resident's Interdisciplinary Notes dated 6/25/13 at 4:01 P.M., showed: -The resident's family member was notified that the resident had been found on the floor. -Maintenance was not in the building to fix the resident's remote control to his/her television. Record review of the resident's medical record showed no record of a Fall Investigation Report being completed by the facility staff or that neurochecks had been completed for the resident's fall on 6/25/13 at 3:56 P.M. Record review of the resident's Interdisciplinary Notes dated 7/6/13 at 7:16 P.M. showed: -A CNA told the nurse he/she had not seen the resident fall but had heard the resident fall. -The resident was sitting on the floor in his/her room on his/her left buttock with his/her pants down around his/her ankles. -The resident was asked what happened and he/she responded "I fell god damn trying to clean my ass". -Range of motion was performed and the resident complained of right hip pain. -The nurse practitioner was called and an x-ray of the right hip was ordered. -The resident's family member was notified. --This was fall number 8 for this resident which was eight days after the resident's previous fall. Record review of the resident's medical record showed no record of a Fall Investigation Report being completed by the facility staff for the resident's major injury fall on 7/6/13. Record review of the resident's Interdisciplinary Notes dated 7/7/13 at 3:48 P.M., showed: -The mobile x-ray company called and stated the resident had a mildly displaced fracture of the (right) femoral neck (broken hip bone). Record review of the resident's discharge assessment Minimum Data Set (a federally mandated tool required to be completed by facility staff) dated 7/7/13 showed the resident had a major injury fall. Record review of the resident's hospital History and Physical dated 7/7/13 showed the resident: -Had suffered a right hip fracture after a fall at the facility. -Had his/her pants around his/her legs when he/she fell to the floor at the facility. -Had an acute right femoral neck fracture. Record review of the resident's hospital Operative Report dated 7/7/13 showed the resident: -Had a right hip hemiarthroplasty (an artificial hip joint replacement). Record review of the resident's Patient at Risk Meeting form dated 7/11/13 showed: -On 7/6/13, the resident was found on the floor by a staff member. -The form had a check mark on interventions, history of falls, the resident's family and physician had been notified, care plan and an investigation had been completed. -Written at the bottom of the form: The resident was attempting to clean himself/herself up with his/her pants down around his/her ankles. The resident had a x-ray performed and was found to have a hip fracture. The intervention was to send the resident to the hospital. -The form did not contain any other information related to the resident's falls, fall interventions, or the root cause of the resident's falls. Record review of the resident's Interdisciplinary Notes dated 7/13/13 at 3:44 P.M., showed: -The resident was readmitted to the facility with a [DIAGNOSES REDACTED]. -The resident was alert and oriented to 1-2. (Alert and oriented to himself/herself and sometimes to place but not to time). Record review of the resident's Fall Risk assessment dated [DATE] showed the resident was a high fall risk. Record review of the resident's OT Progress and Discharge Summary dated 7/15/13 through 7/25/13 showed: -The resident had been seen by therapy related to his/her right hip fracture. -The resident was a fall risk, had right sided weakness and cognitive deficits, decreased safety awareness and was impulsive. Record review of the resident's OT Progress and Discharge Summary dated 7/15/13 through 10/06/13 showed: -The resident was seen by therapy related to his/her right hip fracture. -The resident had right hip precautions but was unable to grasp instructions related to his/her right hip. -The resident had severe pain in the right hip and had trouble bearing weight on his/her right hip. Record review of the resident's physician's Admit History and Physical dated 7/16/13 showed: -The resident was recently hospitalized due to a right hip fracture and the hip fracture was repaired. -Had the following Diagnoses: [REDACTED]. --Weakness. -Cognitive impairment and debility. Record review of the resident's physician's Progress Notes dated 7/17/13, 7/22/13, 7/23/13, 7/25/13, 8/13/13, 8/15/13, 8/16/13, 8/21/13, 8/26/13, 8/28/13, 8/30/13, 9/2/13, 9/6/13, 9/16/13, 9/24/13, 10/4/13, and 10/5/13 did not address any of the resident's falls. Record review of the resident's Interdisciplinary Notes dated 7/23/13 at 3:02 P.M. showed: -The resident was alert and oriented to self, place but not oriented to time. -The resident had been trying to got up at times without assistance. -A bed alarm was in place. Record review of the resident's Interdisciplinary Notes dated 7/26/13 at 1:31 P.M., showed the resident: -Was sent to the hospital related to a right lower leg arterial occlusion (blood flow in the artery to the leg stopped). Record review of the resident's hospital History and Physical dated 7/26/13 showed the resident: -Had a right lower extremity arterial occlusion. -Had right hip and thigh pain. Record review of the hospital Consultation completed by Physician A dated 7/26/13 showed the resident: -Had broken his/her right hip after a fall at the facility on 7/7/13. -Was unable to give an accurate history related to his/her confusion and dementia. -Was unable to straighten his/her right leg and kept his/her hip in a flexed position. -had a history of [REDACTED]. Record review of the resident's hospital Consultation report dated 7/27/13 showed the resident: -Had a diminished (blood) flow through his/her right leg. -Had a recommendation to amputate (remove) his/her right leg above the knee. -Had his/her right leg in a flexed position and the leg could not be flexed straight out due to contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to passive stretching). Record review of the resident's x-ray Result dated 8/4/13 showed: -The resident's right hip was dislocated (when the head of the thighbone (femur) slips out of its socket in the hip bone (pelvis). Record review of the resident's hospital Operative Report completed by the Physician A dated 8/5/13 showed: -The resident went to the operating room. -The resident's right hip was attempted to be repaired. -The resident's right hip repair was unable to be completed. -The procedure was aborted. Record review of the resident's Post Fall Investigation Report dated 8/13/13 at 9:00 P.M., showed: -The resident was agitated, combative and restless. -The resident was in his/her bed previous to the fall. -The resident had a low bed and an alarm (staff did not document what type of alarm or if the alarm was on his/her bed at the time of the fall). -The resident had an assist bar (a device that enables the resident to sit up or turn in his/her bed) on the left side of his/her bed. -Other factors which contributed to the fall: --The resident was restless and had lower right sided extremity weakness. -What the resident said happened: --He/she was reaching for his/her soda and slid out of bed. -The analysis/conclusion of what happened: --The staff did not document an analysis or conclusion about the fall. -The evaluation of present interventions and new interventions: --"Floor mats" and "battery put in alarm". ---Floor mats were originally added as a fall intervention for this resident on 4/7/13 and were not in place at the time of this fall. -This was fall number 9 for this resident. Record review of the resident's Neurological Assessment Flow Sheet dated 8/13/13 showed the resident's neurological checks had been completed. Record review of the Interdisciplinary Notes dated 8/14/13 at 4:40 A.M., showed: -The resident had been found sitting on the floor bedside his/her low bed. -The resident stated he/she had slid out of bed reaching for his/her soda. -The resident was assessed and the physician was called. -The resident did not have mats or a working bed alarm in place at the time of the fall. -The resident was confused, combative, and restless at times. -The resident was re-educated on call light use. -The resident was assessed with [REDACTED]. -The staff did not document that the resident's family member had been notified. Record review of the resident's physician's Progress Notes dated 8/14/13 showed the staff had reported a non-injury fall and the resident recalled the fall. Record review of the resident's POS dated 8/15/13, 9/2013, and 10/15/13 showed the resident had the following Diagnoses: [REDACTED]. -Peripheral vascular disease (disease of the arteries and veins of the extremities). -A dislocated right hip. -Urinary retention (unable to urinate). -Chronic anemia (a decrease in hemoglobin in the blood to levels below the normal range). -HTN. -Dementia. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Had moderately impaired cognition. -Required the assistance of two staff members for transfers. -Required the assistance of one staff member for bathing, hygiene and dressing. -Was incontinent of bowel. -Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine). -Had no falls. Record review of the resident's Care Plan dated 8/30/13 showed: -The following fall care plan: --The resident had a history of [REDACTED]. -The resident had multiple falls related to being impulsive. ---Encourage the resident to use his/her call light. ---Request a PT/OT evaluation as needed. ---Provide activities that minimize the potential for falls. ---Keep room free from spills or clutter. ---Keep personal items within reach. ---Wear non-skid footwear. ---Place a fall mat beside his/her bed and keep the bed in the lowest position. ---Place the resident's walker and wheelchair beside his/her bed. -The staff did not document the new interventions after each fall or that the resident used a bed alarm. Record review of the resident's Activity of Daily Living (ADL) Daily Care List used by the CNA's to know how to care for the resident dated 8/30/13 showed: -The resident was very impulsive and would forget to use his/her call light for assistance. -The resident was intermittently confused, verbally abusive at times, and used foul language. -The resident required staff checks every two hours and as needed. -The staff did not document the resident was a fall risk or any interventions that were in place including fall mats, bed alarms, or assist bars. Record review of the resident's Post Fall Investigation Report dated 9/12/13 at 11:30 P.M., showed: -The resident was agitated, restless, and unable to explain why he/she was on the floor. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her bed previous to the fall. -The resident had an assist bar on the left side of his/her bed. -The resident had a Foley catheter and a clean incontinent brief on. -Other factors which contributed to the fall: --The resident had right sided weakness. -The resident had a low bed. -The analysis/conclusion of what happened: --The staff did not document the analysis/conclusion of the fall. -The evaluation of present interventions and new interventions: --The staff did not document any present intervention or new interventions. -No neurochecks were completed. -This was fall number 10 for this resident which was seventeen days after the resident's previous fall. Record review of the Interdisciplinary Notes dated 9/13/13 at 3:40 A.M., showed: -The resident was lying on the floor next to his/her low bed with his/her head at the foot of the bed. -The resident was trying to pull himself/herself with the assist bar that was located on his/her bed. -The resident was agitated at the time and was unable to tell the nurse why he/she was on the floor. -The resident's call light was not in reach at the time of the incident. -The resident was "now" in a low bed with mats on the floor and an alarm in place. -The physician was notified. -The staff did not document the resident's family member had been notified. Record review of the Interdisciplinary Notes dated 9/14/13 at 8:22 P.M., showed: -The resident had been calling (out) for assistance when he/she needed something. -The resident was very impulsive. Record review of the resident's Interdisciplinary Notes dated 9/24/13 at 1:33 A.M., showed: -The resident was found sitting on his/her mat on the floor beside his/her bed. -The resident was alert and easily agitated which was normal for the resident. -The resident was assessed and had no injury. -The family and physician were notified. -The staff did not document the cause for the fall, if new interventions were put into place, or if all of the current interventions were still in place. -This was fall number 11 for this resident which was eleven days after the resident's previous fall. Record review of the resident's medical record showed no record of a Fall Investigation Report or the Neurological Flow Sheet being completed by the facility staff for the resident's fall on 9/24/13. Record review of the resident's Post Fall Investigation Report dated 10/04/13 at 12:01 A.M., showed: -The resident's behavior was unknown at the time of the fall. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her wheelchair previous to the fall. -The resident was dry (no incontinent episode). -Other factors which contributed to the fall: --"Confusion". -The resident had a low bed and floor mats. -What the resident said happened: --"I don't know". -The analysis/conclusion of what happened: --The staff did not document the analysis/conclusion of the fall. -The evaluation of present interventions and new interventions: --The staff did not document any present intervention or new interventions. -No neurochecks were completed. -This was fall number 12 for this resident which was ten days after the resident's previous fall. Record review of the resident's Interdisciplinary Note dated 10/4/13 at 3:15 A.M., showed: -The resident was found calling out with his/her legs slightly folded sideways resting his/her back against the bed. -The resident had raised the low bed to a higher position. -The resident was assessed with [REDACTED]. -The resident's family and physician were notified. -The resident was alert and oriented to himself/herself, to place, and situation. -The Post Fall Investigation report dated 10/4/13 showed the resident was confused and could not explain to the staff why he/she fell . -The staff did not document any new interventions or if the previous interventions were in place at the time of the fall. Record review of the resident's Post Fall Investigation Report dated 10/13/13 at 6:05 A.M., showed: -The resident's behavior was unknown at the time of the fall. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her bed previous to the fall. -The resident had an assist bar on the left side of his/her bed. -The resident was wet and had last been toileted at 3:00 A.M. --Previous staff documentation showed the resident had a Foley catheter. -The resident had a low bed, floor mats and an alarm. -What the resident said happened: --He/she was trying to reach for a book. -The analysis/conclusion of what happened: --The resident was confused related to his/her disease process. -The evaluation of present interventions and new interventions: --The staff educated the resident on the use of his/her call light. -This was fall number 13 for this resident which was nine days after the resident's previous fall. Record review of the resident's Neurological Assessment Flow Sheet dated 10/13/13 showed the resident's neurological checks had been completed. Record review of the resident's Interdisciplinary Notes dated 10/13/13 at 8:24 A.M., showed: -The resident was found sitting on his/her floor mat, facing the nightstand, holding onto the assist bar on his/her bed. -The resident was assessed with [REDACTED]. -The resident's family and physician were notified. -The resident was reoriented to the importance of using his/her call light. Record review of the resident's Fall Risk assessment dated [DATE] showed the resident was a high fall risk. Record review of the resident's Post Fall Investigation Report dated 11/01/13 at 1:00 A.M., showed: -The resident's behavior was unknown at the time of the fall. -The resident had an alarm but the staff did not document what type or the placement of the alarm. -The resident had been in his/her bed previous to the fall. -The resident had an assist bar on the left side of his/her bed. -The resident had a low bed, floor mats and an alarm. -What the resident said happened: --The resident had sat up and slipped off the bed onto the floor mat. -The analysis/conclusion of what happened: --The resident had sat up and slipped off the bed onto the floor mat. -The evaluation of present interventions and new interventions: --The staff educated the resident to use his/her assist bar on his/her bed. -This was fall number 14 for this resident which was eighteen days after the resident's previous fall. Record review of the resident's Neurological Assessment Flow Sheet dated 11/1/13 showed the resident's neurological checks had been completed. Record review of the resident's Interdisciplinary Notes dated 11/1/13 at 4:41 A.M., showed: -The resident had been found on the floor calling out for help. -The resident said he/she pulled himself/herself up using the assist bar and slid out of bed. -The staff did not document the resident's family and physician had been notified. -The staff did not document any new interventions or if the previous interventions were in place at the time of the fall. Observation on 11/4/13 at 1:12 P.M., showed: -The resident's room. -A roller walker was folded up and positioned to the right of the resident's night stand. -The resident's bed was a high/low (a bed that could be adjusted to a high or low posi