Every finding on record at Kansas Soldiers Home

The facility identified a census of 51 residents. The sample included 12 residents, including one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to address and implement measures consistent with professional standards of practice to prevent the development of and promote the healing of pressure ulcers for Resident (R) 32 when staff failed to ensure R32 received pressure reducing interventions, repositioning, and physician involvement at the time the initial changes were identified. The resident developed Stage 3 pressure ulcers and was at risk for the development of new pressure ulcers, delayed healing, and worsening of existing ulcers. Findings included:- R32's Electronic Health Record (EHR) revealed diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), abnormalities of gait and mobility, and pain. R32's 07/25/25 admission Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented R32 required maximal assistance for toileting, oral care, personal hygiene, bed mobility, and transfers. The MDS documented R32 had impairment of both lower extremities. The MDS documented R32 was at risk for pressure ulcer development and documented no existing pressure ulcers or skin concerns. The MDS documented R32 did not have a pressure-reducing mattress, pressure-reducing cushion for his wheelchair, or a repositioning program. R32's 07/29/25 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R32 was at risk for pressure injury based on his Braden Scale score (a tool used to assess a patient's risk for developing a pressure injury) of 15 (07/18/25), which indicated a mild risk. The CAA noted R32 received psychotropic (alters mood or thoughts) medication use and limited mobility. Nursing would perform weekly skin assessments and assist as needed with repositioning for comfort. The CAA noted R32 would have a pressure reduction mattress, wheelchair cushion, and barrier cream in place for preventive measures. Review of R32's Braden Scale documented on 07/15/25 indicated R32 was at mild risk for pressure injury development with a score of 16. The assessment performed on 07/18/25 and 08/01/25 indicated R32 was at mild risk with a score of 15. R32's Care Plan dated 07/19/25 recorded he had an activities of daily living (ADL) deficit related to fatigue and limited mobility. The plan recorded an intervention dated 07/19/25, which instructed staff to know R32 required limited assistance from staff for bed mobility to turn and reposition. R32's 07/29/25 Care Plan documented R32 had the potential for pressure injury based on a Braden score of 15, limited mobility, and a Foley catheter (tube inserted into the bladder to drain urine). The plan instructed staff to provide education to the resident, family, and caregivers as to the causes of skin breakdown, including transfer and positioning requirements, importance of taking care during ambulating and mobility, good nutrition, and frequent repositioning. The plan instructed staff to follow facility policies and protocols for the prevention and/or treatment of skin breakdown. The plan instructed staff to inform the resident, family, and caregivers of any new area of skin breakdown and alert the family, interdisciplinary team, and resident of treatment refusals to determine why and try to find alternative methods. R32's Care Plan, revised 08/05/25, noted R32 had actual skin impairment on his buttock and directed staff to administer medications as ordered, including Arginaid (a nonprescription nutritional drink that supplies the amino acid L-arginine along with vitamins C and E) twice daily. An 08/05/25 intervention directed staff to perform weekly treatment documentation, including measurements of the skin breakdown width, length, depth, tissue type, and whether exudate (drainage) was present. R32's Care Plan lacked interventions related to frequency of repositioning, barrier cream, or pressure-reducing devices. R32's Physician Orders documented the following:Weekly Braden Assessment every Friday for four weeks, ordered 07/28/25.Weekly skin assessments every Wednesday for prevention of wounds, ordered 07/29/25. R32's Tasks in the EHR lacked documentation related to turning and repositioning. R32's 07/27/25 Bath and Skin Monitoring Sheet documented chafing (skin irritation caused by friction, often resulting in soreness or rawness) to his buttocks, and noted barrier cream was applied. R32's Weekly Skin Assessment dated 07/30/25 at 05:38 PM documented R32 had a rash on his buttocks, right and left gluteal (pertaining to the buttocks or buttocks muscles) folds, and several discolored areas. The assessment lacked measurements. R32's EHR lacked evidence staff notified the resident's physician of the skin condition noted on 07/30/25 and lacked evidence of treatments implemented in response to the changes to the resident's skin noted on 07/30/25. R32's Skin/Wound Note dated 08/04/25 at 02:26 PM documented Certified Nurse Aide (CNA) O reported R32 requested a dressing change. R32 had wounds to the right buttock and a scab area which measured 0.9 centimeters (cm) by 0.7 cm. R32 had a left buttock scab area that measured 0.5 cm by 0.5 cm and an open area on the left gluteal crease, which measured 3.3 cm by 2 cm, and a left gluteal cleft scab area that measured 0.5 cm by 0.4 cm. The left lateral buttock had an open area that measured 1.3 cm by 0.5 cm. R32's Weekly Wound Observation Tool dated 08/07/25 at 01:52 PM documented a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer to the coccyx (area over the tailbone) that measured 0.3 cm by 0.3 cm by 0.1 cm, with 90% slough (dead tissue, usually cream or yellow in color) and 10% granulation tissue (new tissue formed during wound healing). R32's Weekly Wound Observation Tool dated 08/07/25 at 01:56 PM documented a Stage 3 pressure ulcer to the right upper buttock that measured 1.2 cm by 2.5 cm by 0.1 cm, with 90% slough and 10% granulation tissue. R32's Weekly Wound Observation Tool dated 08/07/25 at 01:57 PM documented a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) pressure ulcer to the right lower buttock that measured 3.0 cm by 5.0 cm by 0.1 cm. During an observation and interview on 08/04/25 at 02:00 PM, R32 reported he had open areas for over a week now, and no one was helping him take care of them. R32 reported he had told the aides and the nurses, and reported some of the staff would place a patch on his buttock. Observation revealed a Mepilex (absorbent, bordered foam dressing) border dressing and body shield cream on the overbed table. During an observation on 08/04/25 at 02:11 PM, CNA O removed R32's brief when he assisted R32 with incontinent care. Observation revealed a pink square dressing on R32's lower right buttock. There was an open area on the right upper buttock, and the wound bed was yellow in color with a small amount of pink tissue, and depth was noted. Further observation revealed an open area on R32's coccyx. CNA O left the R32's room to notify Licensed Nurse (LN) H that R32 requested a dressing on his open areas. During an observation on 08/04/25 at 02:30 PM, LN H entered R32's room and assessed R32's open areas. R32 reported to LN H that he told other staff about his wounds on his buttocks last week. LN H removed the pink dressing from the right lower buttock, observed a wound approximately 3 cm by 5 cm with some depth, though no drainage was noted from the area. The right lower buttock area was red in color. LN H removed her gloves, reported, Administrative Nurse D was the wound nurse, and stated she would update her on the open area. During an observation on 08/06/25 at 07:48 AM, R32 laid in bed. There was a no low-air-loss mattress present on the resident's bed. R32's eyes were closed, and his breakfast tray was on the tray table, untouched. During an observation on 08/06/25 at 02:33 PM, R32 displayed on his phone the receipts from when he ordered the Mepilex border dressing and the set of three pressure reducing cushions from an online vendor site on 07/14/25 and 07/26/25. During an interview on 08/04/25 at 02:06 PM, CNA P reported R32 did have open areas on his buttocks, which were present since the previous week. During an interview on 08/04/25 at 02:45 PM, R32 reported he bought the Mepilex border dressing from a site on the computer and said that he told the staff for over a week now that he had sores on his buttocks. R32 had three types of pressure-reducing cushions for his electric wheelchair, and R32 reported he bought all the cushions online since the staff did not provide him with a cushion. During an interview on 08/06/25 at 02:22 PM, CNA M reported R32 had an open area on his buttocks since the previous week. She said she noted R32 had a dressing on and complained his buttock was sore. CMA M reported she told LN I that R32 was uncomfortable, and LN I entered R32's room. During an interview on 08/06/2025 at 02:40 PM, Administrative Nurse D reported she was the wound nurse and said she would measure the wound and document it on the wound tool notes in the EHR. Administrative Nurse D reported she had not assessed R32's areas that she was notified about on 08/04/25, as she had LN H complete the assessment in a progress note. Administrative Nurse D reported she did not have time to complete her own assessment. Administrative Nurse D said R32 should have had an air mattress already but confirmed the resident still did not have one on his bed. She reported the facility had air mattresses in stock. Administrative Nurse D reported she was unaware R32 complained to staff about the open areas on his buttocks and that the first day she was notified was on 08/04/25. Administrative Nurse D reported she expected the nurses to document and receive orders from a physician when a skin condition was observed. Administrative Nurse D reported R32's plan of care did not have interventions related to pressure reduction in place, prior to R32 obtaining pressure ulcers. The facility did not provide a policy for the prevention of pressure ulcers.

The facility reported a census of 51 residents. The facility identified five Certified Nurse Aides (CNA) employed for over 12 months during the review period. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for the five CNAs reviewed, to ensure adequate and appropriate care and services were provided to the residents of the facility. This placed the residents at risk for decreased quality of care. Findings included:- Review of employee files on 08/06/25 at 01:07 PM revealed a lack of performance evaluations signed by management for the five CNAs that had been employed over one year, that included CMA L date of hire 01/29/10, CMA R date of hire 05/08/23, CMA II date of hire 07/12/23, CMA JJ date of hire 05/28/15, and CMA KK date of hire 09/24/06.During an interview on 08/07/25 at 10:10 AM, Administrative Staff A reported he expected 100 percent compliance to have the annual performances evaluations completed annually.The facility did not provide a policy on annual performance evaluations.

The facility reported a census of 51 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.Findings included: - During a second tour of the kitchen on 08/5/25 at 10:30 AM, observation revealed three-barrel type trash cans that did not have a lid covering the trash cans. Dietary Staff DD did ask the staff to locate the lids to the trash cans, and all but one was found. On 08/0525 at 10:35 AM, observation revealed Dietary Staff DD washed her hands, then put on gloves, and pureed the food for five residents, which included country fried steak and asparagus. Dietary Staff DD followed the recipe. During the observation, Dietary Staff DD removed her soiled glove at the counter, put them in the trash barrel that did not have a lid, then reapplied new gloves without washing her hands. During the serving of the food on 08/06/25 at 11:00 AM, Dietary Staff CC removed her gloves, washed her hands, and donned new gloves. She then grabbed a plate with her gloved hands and then touched the hamburger buns package. Wearing the same gloves, she grabbed the breaded chicken with her gloved hand, turned, and then opened the tomato containers. Dietary Staff CC then removed her gloves, washed her hands, donned new gloves, and then proceeded to touch the tomatoes, plates, picked up a loaf of bread, and then went into the refrigerator for the prepared coleslaw. On 08/06/25 at 11:50 AM, Certified Dietary Manager BB stated the facility expected staff to provide food in a safe and healthy environment. CDM BB stated she provided training on food handling every year and met with her supervisors every Monday to discuss areas that staff needed to work on. The facility's policy Hand Washing, revised on 10/10/21, indicated staff will wash hands frequently as needed throughout the day, following proper hand washing procedure. After handling soiled equipment, during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks.

The facility reported a census of 51 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. This placed facility residents at risk for insect or rodent infestation.Findings included: - During a second tour of the kitchen on 08/5/25 at 10:30 AM observation revealed three-barrel type trash cans which did not have a lid. Dietary Staff DD did ask the staff to locate the lids to the trash cans and all but one was found.On 08/06/25 at 03:15 PM observation of the outside garbage bins with Certified Dietary Manager (CDM) BB revealed eight trash bins against the fence and two of the bins had lids up. The wind at the time of the observation was calm breeze and there were no strong winds noted.On 08/06/25 at 03:15 PM CDM BB said the bins were usually closed but maybe the wind lifted the lids. CDM BB said he had no idea why the lids were open at that time.The facility's policy Waste Disposal revised on 10/10/24 all garbage will be disposed of daily and in needed throughout the day. Trash will be deposited into a sealed container outside the premises.

The facility reported a census of 51 residents. The sample included 15 residents. Based on interviews, observation and record review, the facility failed to establish and maintain a consistent infection prevention and control program. Additionally the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to residents with catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), wounds, and/or surgical artificial openings entering the body to prevent the spread of infection. The facility further failed to provide catheter care using aseptic technique and failed to implement measures to prevent the growth of Legionella (a serious type of lung infection caused by inhaling water droplets or mist contaminated with Legionella bacteria) and other opportunistic water borne pathogens in the facility's water systems to prevent the spread of infections. These deficient practices had the potential to spread infections to the residents in the facility.Findings included:- Review of the facility Matrix, dated 08/05/25 revealed 11 residents with indwelling catheters and three residents with wounds. Upon request, the facility was unable to provide documentation or evidence of a water management program to mitigate Legionella and other water born pathogens.During an observation on 08/04/25 at 11:00 AM, initial tour of the facility revealed no evidence of EBP set up nor signage to indicate residents that required EBP personal protective equipment (PPE).During an observation on 08/04/25 at 01:58 PM, Certified Nurse Aide (CNA) O emptied Resident (R)32's indwelling catheter drainage bag. She donned gloves but did not wear a gown. CMA O then accessed the outlet access port, drained the urine and reinserted the outlet access into the holder port with cleansing it first. CNA O reported she did not know what EBP were. Observation revealed there was no signage regarding EBP or readily accessible PPE in or around the resident's room. CNA O confirmed the resident's door lacked signage to indicate the need for staff to wear PPE and the lack of assessable PPE in the room other than gloves.During an observation on 08/05/25 at 11:20 AM, R33 laid in the bed with an indwelling urinary catheter collection bag placed inside of a dignity bag. Further observation revealed there was no signage to inform those entering the room of required PPE, or gowns available in the room or surrounding area to be used when providing direct care and/or contact.On 08/06/25 at 01:24 PM, Administrative Nurse F confirmed the above findings. She stated she was not aware of the 04/01/2024 Center of Medicare and Medicaid Service (CMS) requirement for EBP to prevent infections for residents that had catheters, wounds and/or artificial openings in their body as noted above. Administrative Nurse F said catheter care should be provided each shift using aseptic technique to prevent cross contamination and the spread of infection. Administrative Nurse F reported she had not completed the July or August Infection Control Log. She stated she normally completed the documentation at the end of each month and did not track or trend infections more frequently to identify trends and patterns. She said she expected staff to clean the spout with an alcohol wipe before replacing the outlet when providing catheter care.On 08/07/25 at 10:46 AM, Administrative Nurse D, confirmed the above findings and stated she was not aware of the 04/01/2024 directive for the use of enhanced barrier precautions for residents with catheters, wounds, and/or artificial openings into their bodies. She stated catheter care should be provided each shift and should include cleaning the outlet tube with an alcohol wipe after emptying the drainage bag of urine and before replacing the tube in the sleeve to prevent cross contamination and the spread of infection. Administrative Nurse D said the infections in the facility should be tracked at the time the infection is identified to ensure timely interventions are implemented, not at the end of the month.The undated facility policy Infection Control, Program documentation included the function of the infection Control Program includes but is not limited to a system of surveillance designed to identify possible communicable disease or infection, tracking and trending infections before they can spread to another person in the facility and monitor the use of antibiotics. Staff providing direct care to residents should follow hand hygiene procedures.The facility did not have a policy related to prevention of Legionella.

The facility reported a census of 51 residents; the sample included 15 residents. Based on interview and record review, the facility failed to establish and infection prevention and control program which included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. This placed the residents at risk for infectious diseases.Findings included: - The facility Matrix, dated 08/05/25, noted seven residents who received antibiotics. Review of the infection control surveillance log dated 07/01/25 through 08/06/25 revealed the facility lacked documentation of tracking and trending of Resident (R) 33, with a diagnosis of recurrent urinary tract infection (UTI), who received gentamycin (antibiotic) bladder irrigations for prevention of urinary tract infection. The log lacked documentation of tracking and trending of R4, with diagnosis of UTI, for receiving amoxicillin (antibiotic), ordered 7/31/25, for seven days.On 08/06/25 at 01:24 PM, Administrative Nurse F confirmed the above findings. She stated R33 and R4 received antibiotics, which she failed to include on the Infection Control Log, dated 07/01/25 through 08/06/25. Administrative Nurse F reported she had not completed the July Infection Control Log to include antibiotic use in the facility. She stated she normally completed the documentation at the end of each month and did not track/trend antibiotic use daily. She reported the facility used McGeer's Criteria to determine the appropriateness of prescribed antibiotics. Upon Inquiry, she reported that the physician prescribed antibiotics, and the facility did not conduct formal reviews or audits to determine the appropriateness or effectiveness of the use of each antibiotic in the facility. On 08/07/25 at 10:46 AM, Administrative Nurse D stated the infections and antibiotics in the facility should be tracked when prescribed and reviewed for appropriate use.The undated facility policy Infection Control lacked address of the identified areas of concern.

The facility reported a census of 51 residents. The sample included 15 residents. Based on observation, interview and record review the facility failed to ensure a medication error rate of less that five percent. 35 medication administration opportunities were observed, and 22 errors identified resulting in a medication error rate of 52.94 percent. This placed the residents at risk for medication related complications and ineffective medication regimes.Finding included:- Resident (R) 2's July Medication Administration Record/Treatment Administration Record (MAR/TAR) documented 18 oral medications scheduled at 07:30 AM, two nasal spray medications were scheduled at 07:30 AM, as well as one inhaled medication. On 08/06/25 at 09:52 AM, observation revealed Certified Medication Aide T administered the 07:30 AM scheduled medications to R2, outside of the one hour before or after protocol. R2 received 18 late oral medications and one late inhaled medication. R2 declined the nasal spray. On 08/06/25 at 09:52 AM, CMA T stated he was trained by another certified medication aide and was told medications were only considered late after 10:00 AM. On 08/05/25 at 09:44 AM, Administrative Nurse D verified that the medications were scheduled for 07:30 AM and confirmed the facility did not have a liberalized medication pass time. Administrative Nurse D said she expected all medications to be administered on time; she expected staff to locate the residents to make sure all medications were passed on time. The facility policy Medication Administration dated 10/19/18, all administration of medications, the nurse shall keep in mind the following. Right drug, right dose, right time, right route, right indication, and right documentation.

The facility had a census of 51 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to provide services to meet professional standards of care related to medication administration. This placed the residents at risk for medication-related complications and ineffective medication regimes. Findings included:- During an observation on 08/05/25 at 08:45 AM, Certified Medication Aide (CMA) R was at the medication cart on the third floor. Observation revealed CMA R reviewed the computer screen with several residents' names highlighted in pink, indicating overdue medications. CMA R prepared medications without using the electronic Medication Administration Record (MAR) to verify the medication orders. CMA R stated she had prepared Resident (R)8's medications. Upon inquiry about the 14 residents that were highlighted pink and the preparation of the medications without looking at the MAR, CMA R shrugged her shoulders and walked away. During an observation and interview on 08/05/25 at 08:50 AM, Licensed Nurse (LN) H accessed the MAR in the Electronic Health Record (EHR) and noted 14 residents highlighted in pink; LN H reported the residents orders were all 07:30 AM scheduled medications and since it was just a little past 08:30 AM, the medications were not that late. LN H reported that the residents were independent, and it was hard to always administer medications on time. LN H reported the staff did not have time to chase after the residents. LN H reported that the medications were scheduled for a specific time, and if the MAR was pink, it meant the medications were late. LN H verified the facility did not have a liberalized mediation pass (allows long-term care residents to choose when they receive their medications, within a designated window, based on their individual schedules and preferences, rather than adhering strictly to a fixed schedule). During an observation on 08/06/25 at 09:52 AM, CMA T administered the 07:30 AM scheduled medications to R2. R2 received 18 late oral medications and one late inhaled medication. R2 declined the nasal spray.During an interview on 08/05/25 at 09:44 AM, Administrative Nurse D verified that the medications were scheduled for 07:30 AM and confirmed the facility did not have a liberalized medication pass time. Administrative Nurse D said she expected all medications to be administered on time; she expected staff to locate the residents to make sure all medications were passed on time. During an interview on 08/06/25 at 09:52 AM, CMA T stated he was trained by another certified medication aide and was told medications were only considered late after 10:00 AM. The facility policy Medication Administration dated 10/19/18 states that all administration of medications, the nurse shall keep in mind the following. Right drug, right dose, right time, right route, right indication, and right documentation.

The facility reported a census of 51 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observations, interview and record review the facility failed to obtain a consent form for a psychotropic 9alters mood or thoughts) medication for Resident (R) 3. This placed the residents at risk for adverse side effects of the medications and uninformed decisions.Findings included: - R3's Physician Orders dated 07/18/25 revealed the following diagnosis: major depressive disorder (major mood disorder, which causes persistent feelings of sadness). R3's Annual Minimum Data Set(MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated R3 received antidepressant medication (class of medications used to treat mood disorders).R3's Quarterly MDS dated [DATE] recorded a BIMS score of 14, which indicated intact cognition. The MDS documented R3 had no behaviors. The MDS noted R3 received an antidepressant medication. R3's Care Assessment Area dated 0/7/18/25 Psychotic Medication Use adverse effects (falls, sedation, and impaired balance) due to his daily use of psychotropic medication. R3's Care Plan documented the resident used antidepressant medication for depression and directed staff to monitor changes in behaviors, mood, cognition, suicidal thoughts, and social isolation. R3's Electronic Medical Record (EMR) revealed a Physician's Order for bupropion HCl (an antidepressant), give 150 mg (milligrams) by mouth one time a day, related to major depressive disorder. Observation on 08/06/25 at 08:10 AM, R3 sat in his wheelchair heading to the main dining room on the first floor. R3 had a device on the back of his wheelchair that alarmed if the resident tried to stand up without assistance. Observation on 08/0625 at 10:27 AM, R3 was in the commons area waiting for his shower. On 08/07/25 at 08:30 AM, Administrative Nurse D stated she only had consent forms for two other residents and confirmed there was no informed consent for R3's psychotropic medication. On 08/07/25 at 09:49 AM, Consultant Staff GG reported that the administrative nurse must have misunderstood regarding the informed consents for psychotropic medications. She said all psychotropic medication should have consent, and she had sent the form to the administrative nurse last month to complete. The facility did not provide a policy on informed consent.

The facility reported a census of 51 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) or document the rationale for Resident (R) 1. The deficient practice had the potential to lead to the residents receiving unnecessary medications.Findings included:- R1's Electronic Health Record (EHR) revealed diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and pain.R1's 10/22/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required supervision for bathing and was independent for all other activities of daily living (ADL). The MDS documented R1 had no behaviors. The MDS recorded R1 received antipsychotic and antidepressant (class of medications used to treat mood disorders) medication on a routine basis.R1's 10/25/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) R1 triggered related to the resident's potential need for assistance with ADLs. The CAA noted R1 had diagnoses of anxiety disorder and pain. He may be screened by therapy for a potential increase in ADL status, strength, balance, and mobility. He was at risk for incontinence, falls, and skin impairments. The CAA noted the care plan would address the resident's need for assistance with ADLs.R1's 06/30/25 Quarterly MDS documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented R1 had no behaviors. R1 required maximal assistance for bathing. R1 required moderate assistance for toileting and lower body dressing. The MDS recorded R1 received antipsychotic and antidepressant medications on a routine basis.R1's Care Plan documented on 08/29/23, staff instructed to administer Celebrex (medication commonly used to relieve pain and reduce inflammation)100 milligrams (mg) per order. The plan directed staff to monitor, record, and report to the nurse any resident complaints of pain or requests for pain treatment.R1's Physician's Orders documented an order for Celebrex oral capsule, one capsule, by mouth, one time a day for pain, date ordered 03/16/23.R1's Medication Regimen Review (MRR) on 09/10/24, documented a review was completed with no duplicate therapy or irregularities noted. The MRR noted R1 received Celebrex, and his creatinine (levels in the blood or urine can be measured to assess kidney function) was 1.78 milligram/deciliter (mg/dL) (Normal is 0.65-1.36 mg/dL) in May 2024 and the hemoglobin (Hgb-measure of blood that carried oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs) was 9.6 gram/dL. (Normal Hgb was 13.4-18.0 g/dL). R1's current creatinine was a little better but still elevated at 1.51. The consultant pharmacist recommended considering discontinuing the Celebrex 100 mg due to renal (kidney) or gastrointestinal involvement.R1's Physician Response to the 09/10/24 MRR, noted on 09/12/24, documented the physician's response of No to the recommendation but lacked a rationale. R1's Laboratory Results dated 05/13/25 noted R1's creatinine was 2.5 mg/Dl.During an observation on 08/06/25 at 08:00 AM, R1 was in his room eating his breakfast.During an interview on 08/07/25 at 08:30 AM, Administrative Nurse D reported she did not know if the physician was required to document a rationale for a pharmacy recommendation when not wanting to follow it.During an interview on 08/07/25 at 09:49 AM, Pharmacy Consultant Staff GG reported that the physician was not required to provide a rationale when not wanting to follow a recommendation, but only required one with gradual dose reductions for psychotropic medications.The facility's Drug Regimen Review dated October 10, 2024, documented to ensure residents at the Kansas Soldiers' Home maintain their highest practicable level of functioning and prevent or minimize adverse consequences related to medication therapy to the extent possible. Appropriate response from physician(s) concerning previous drug regimen review recommendations or drug irregularities.

The facility reported a census of 51 residents; the sample included 15 residents. Five residents were reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 1. This deficient practice placed R1 at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications.Findings included:- R1 's Electronic Health Record (EHR) revealed diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R1's 10/22/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required supervision for bathing and was independent for all other activities of daily living (ADL). The MDS documented R1 had no behaviors. The MDS recorded R1 received antipsychotic and antidepressant (class of medications used to treat mood disorders) medication on a routine basis. The MDS documented no gradual dose reduction.R1's 10/25/25 Psychotropic Drug Use Care Area Assessment (CAA) recorded R1 was at risk for adverse effects (falls, sedation, impaired balance, side effects outlined in the black box warning) due to his daily use of a psychotropic medication. Staff would monitor for signs and symptoms. The facility would review for possible gradual dose reduction if indicated. Staff would notify the physicians of any adverse reactions noted.R1's 06/30/25 Quarterly MDS documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented R1 had no behaviors. R1 required maximal assistance for bathing. R1 required moderate assistance for toileting and lower body dressing. The MDS recorded R1 received antipsychotic and antidepressant on a routine basis with no gradual dose reduction.R1's Care Plan dated 11/07/23 documented R1 used psychotropic medications, including aripiprazole (atypical antipsychotic medication), for major depressive disorder. The plan noted an intervention dated 11/07/23, which directed staff to administer medications as ordered; monitor and document for side effects and effectiveness. The plan further directed staff to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate; discuss with the physician and family regarding the ongoing need for use of medication. The plan directed staff to review behaviors, interventions, and alternate therapies attempted and their effectiveness per policy. The plan directed staff to provide education to the resident, family, and caregivers about risks, benefits, and the side effects and/or toxic symptoms of aripiprazole. Staff were instructed to monitor, document, and report any adverse reactions of psychotropic medications including unsteady gait, tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person.R1's Physician's Orders documented an order for mirtazapine oral tablet (an antidepressant), give 30 milligrams (mg) by mouth one time a day for depression and sleep date ordered 11/08/22.R1's Physician's Orders documented an order for aripiprazole oral tablet, give 1 mg tablet by mouth daily for depression, date ordered 06/11/25.R1's Medication Regimen Review reviewed from 08/31/24 through 07/30/25, lacked evidence that Pharmacy Consultant GG identified the aripiprazole diagnosis of depression or the lack of documentation for what symptoms the antipsychotic medication was being administered for.During an observation on 08/06/25 at 08:00 AM, R1 was in his room eating his breakfast, with no concerns noted.During an interview on 08/07/25 at 08:30 AM, Administrative Nurse D reported she did not know if depression was an acceptable diagnosis for R1's aripiprazole. Additionally, she reported that the managed symptoms of R1's behaviors should be in order. During an interview on 08/07/25 at 09:49 AM, Pharmacy Consultant Staff GG reported that depression was not an acceptable diagnosis for R1's antipsychotic medication, and the order was missing some components of managed symptoms of R1's behaviors.The facility did not provide a policy on psychotropic medications.

The facility reported a census of 51 residents; the sample included 15 residents. Based on observation, interviews, and record review, the facility failed to ensure an environment free from physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) when staff failed to assess and ensure safety regarding Resident (R) 28's use of a seatbelt on his motorized wheelchair. This deficient practice placed R28 at risk for complications related to restraints and impaired safety.Findings included:- Review of the Electronic Health Record (EHR) documented R28 had diagnoses which included chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and atrial fibrillation (rapid, irregular heartbeat).R28's 03/18/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented R28 required moderate assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS documented R28 was independent with wheelchair mobility and eating. The MDS documented R28 had impairment of both upper and lower extremities. The MDS documented R28 did not have a physical restraint.R28's 03/22/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R28 required assistance from staff related to his limited range of motion and impaired balance. Staff were to encourage R28 to participate in his daily care as he is able.R28's 06/11/25 Quarterly MDS documented a BIMS score of 14, which indicated intact cognition. The MDS documented R28 required moderate assistance for transfers. The MDS documented R28 was independent with wheelchair mobility. The MDS documented R28 had impairment of both upper and lower extremities. The MDS documented R28 did not have a physical restraint.R28's EHR lacked evidence the facility assessed R28's ability to release his seatbelt.R28's Care Plan dated 08/06/25, documented R28 used a maroon electric wheelchair for locomotion, date initiated 08/2024.R28's Physician Orders dated 08/06/25 did not address R28's seatbelt on the motorized wheelchair.R28's Progress Notes reviewed from 08/06/24 through 08/05/25 lacked mention of the seatbelt.During an observation on 08/04/25 at 01:21 PM, R28 had an engaged seatbelt on his electric wheelchair placed over his upper thighs. R28 reported that he could not undo the seatbelt independently as he could not reach it. R28 attempted to reach down with his right arm and could not reach the seatbelt. R28 reported that the staff would apply and release the seatbelt.During an observation on 08/05/25 from 01:20 PM through 03:45 PM, R28's seatbelt remained intact with no release until 03:45 PM. R28 was in bingo, then he independently went outside to sit in his wheelchair. R28 reported he had the electric wheelchair for about a year, and it has always had a seatbelt on it. R28 reported that he was told he had to wear the seatbelt. R28 said he did not have a choice to wear the seatbelt and reported that the staff was strict about the seatbelt.During an observation and interview on 08/05/25 at 03:42 PM, Certified Medication Aide (CMA) S reported R28 had to wear a seatbelt in the type of electric wheelchair he had, as it made R28 a high risk for injury. CMA S reported that not all residents required a seatbelt. CMA S verified that R28 was not able to undo his seatbelt independently. CMA S said it would be documented on the care plan if a resident required a seatbelt and went on to say it was ok to leave the seatbelt on longer than two hours. At 03:45 PM, CMA S entered R28's room and assisted R28 to the bathroom. CMA S released the seatbelt and assisted R28 to a standing position without a gait belt. R28 struggled to stand up independently, and CMA S pulled under R28's forearm to assist him up. During an interview on 08/05/25 at 03:50 PM, Licensed Nurse (LN) G reported that it was policy for the residents to wear a seatbelt in an electric wheelchair. LN G reported she was unaware who evaluated the seatbelt to see if a resident could release the seatbelt independently. LN G reported the seatbelt was a restraint if not released every two hours.During an interview on 08/05/25 at 04:32 PM, Administrative Nurse D and Administrative Nurse E reported that if a resident preferred to have the seatbelt on, the resident should be able to unbuckle the seatbelt, and it would be documented on the care plan. Administrative Nurse E reported that there were no residents currently who wore a seatbelt. Administrative Nurse D reported that the facility did not have a seatbelt safety assessment that would be completed.During an interview on 08/05/25 at 05:20 PM, Administrative Staff A reported that no resident had a seatbelt safety assessment completed, and no residents had a seatbelt care plan.The facility's policy Nursing Standards, Guidelines, Protocols, Procedures, and Position Statements, dated 10/10/24, the latest edition of Lippincott Nursing Procedure shall be used. Obtain a practitioner's order for a restraint.

The facility reported a census of 51 residents with 14 residents sampled which included one resident reviewed for catheters, and three residents reviewed for respiratory care and services related to respiratory equipment. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services regarding catheter care for R 49 and respiratory care and services for R 2, R 11, and R21 to prevent cross contamination and infection. Findings included: - Review of Resident (R)49's Physician Orders, (POS) dated 08/02/23, documentation included diagnosis of stage five chronic kidney disease and obstructive and reflux uropathy ( a disorder of the urinary tract that occurs due to obstructed urinary flow causing the back-up of urine into the kidneys). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident entered the facility on 07/27/23,with a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. He required staff limited assistance for toilet use. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/08/23, documented the resident at risk for complications related to his chronic urinary catheter use. Staff should provide him with assistance for management and monitor for signs and symptoms of complications. The Care Plan dated 08/16/23, revealed the resident had a potential for impairment related to his chronic indwelling catheter use. The staff should change the large catheter bag to a leg bag each morning between 5:00 AM to 6:00 AM and change back to the large catheter bag at bedtime. Staff were to observe for signs and symptoms of urinary tract infection (UTI) which included pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and/or change in behavior, initiated on 07/28/23. The POS, dated 09/01/23, documented a new medication order for an antibiotic of amoxicillin (antibiotic) tablet, 500 milligrams (MG), three times a day, for 10 days, by mouth, for UTI. On 08/29/23 at 10:01 AM, the resident sat at his bedside with his walker in front of him with his dignity bag attached to his walker. On 09/05/23 at 04:21 PM, during observation of catheter care and peri care provided by Certified Nurse Aide (CNA) E , noted CNA E laid the resident's catheter bag directly on the floor when she assisted the resident to the toilet. CNA E changed the residents brief and pants, and CNA E continued to place the catheter bag directly on the floor. On 09/05/23 at 04:34 PM, on inquiry, CNA E stated staff should not lay the catheter collection bag directly on the floor. She confirmed doing so would place the resident at risk for infection. On 09/05/23 at 05:00 PM, Licensed Administrative Nurse C stated the urine collection bag of the resident's indwelling catheter should not come in direct contact with the floor. The staff should suspend the urine collection bag below the bladder and off the floor to prevent cross contamination and/or urinary tract infection to prevent cross contamination and prevent UTIs. On 09/06/23 at 03:15 PM, Administrative Nurse B confirmed the facility policy for catheter care and related practices was referenced from the [NAME] Nursing Procedures as acceptable standard of practice. She stated the catheter urine collection bag should be maintained below the resident's bladder but not placed directly on the floor to prevent cross contamination and resulting UTI. The facility policy for Internal Management Policy or Procedure, dated 06/24/20, references the [NAME] Nursing Procedures seventh edition, Indwelling Urinary Catheter Care and Removal, page 387. Documentation included Don't place the drainage bag on the floor, to reduce the risk of contamination. The facility failed to provide necessary treatment and services regarding catheter care for the resident to prevent cross contamination and infection. 46960 - R2's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 08/06/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. The resident required extensive assistance of 2 staff for all cares except eating. The resident received oxygen. The 05/12/23 Quarterly MDS documented a BIMS of eight, indicating moderately impaired cognition. The resident received oxygen. The 08/06/23 Care Area Assessment (CAA) lacked documentation related to a nebulizer or oxygen use. The Care Plan dated 08/31/23, documented that the resident had altered respiratory status related to COPD and other disorders of the lungs, and instructed staff to administer medications as ordered, but lacked information specific to care of nebulizer equipment. The resident's Physician Orders included ipratropium-albuterol inhalation solution to be given once per day, and every four hours, as needed for difficulty breathing related to COPD, dated 03/16/23. The 06/01/23 to 08/31/23 electronic health record (EHR) Treatment Administration Record (TAR) lacked documentation for cleaning/maintenance of the resident's nebulizer equipment. On 08/30/23 at 11:04 AM, R2 was in bed with oxygen on. The nebulizer tubing and medication chamber was on top of the nebulizer machine. Moisture and a clear liquid remained in the medication chamber of the nebulizer. On 08/31/23 at 08:30 AM, R2 observed resting in bed wearing oxygen via nasal cannula. The nebulizer machine sat of top of the bedside table. There was no tubing/medication chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident receives a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that [NAME] Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer, to prevent possible cross contamination and infection. - R11's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), shortness of breath and obstructive sleep apnea [a condition in which the person cannot maintain an open airway while asleep]). The 01/10/23 Annual Minimum Data Set (MDS) documented Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident received oxygen. The MDS lacked documentation that resident received a continuous positive airway pressure (CPAP). The 08/27/23 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The resident received oxygen. The 01/10/23 Care Area Assessment (CAA) lacked documentation related to oxygen use, nebulizer medication administration, or CPAP use. R11's electronic health record (EHR) Physician Orders included ipratropium-albuterol inhalation solution to be given three times per day for shortness of air and continuous oxygen but lacked orders for CPAP. The Care Plan dated 08/30/23 documented on 01/24/22 that the resident has altered respiratory status. Administer medication/puffers as ordered. Staff instructed for the CPAP machine to use titrated pressure with full -face mask when sleeping. The physician's order included ipratropium-Albuterol solution, 3 milligrams per 3 milliliters, use 1 application, and inhale orally three times a day, for shortness of breath, dated 07/12/23. Review of the Treatment Administration Record from 07/12/23 to 08/31/23, lacked documentation of the care for the nebulizer equipment or the CPAP equipment. he 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for the care of nebulizer equipment or CPAP equipment. On 08/29/23 at 08:50 AM, R11 was in bed, the resident's nebulizer mask laid directly on the bed linens, and the nebulizer's medication chamber contained a clear liquid. On 08/30/23 at 11:55 AM, observation of R11's room revealed a nebulizer mask hung from the edge of the bed by an elastic strap. There was clear liquid inside the nebulizer medication chamber. On 08/30/23 at 03:04 PM, R11 observed sitting upright in bed receiving breathing treatment with nebulizer mask. R11 pressed the call light and unknown Certified Nurse Aide (CNA) responded to the call light and removed the nebulizer mask at the request of R11, then placed the nebulizer mask on top of the nebulizer machine on the resident's bedside table. The nebulizer was intact with an unknown clear liquid that remained in the nebulizer chamber. The CNA then left the room. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. It was unacceptable practice for nebulizer's to be left intact between treatments. On 08/31/23 at 08:41 AM, observation of R11's room revealed the nebulizer intact on the bedside table with unknown clear liquid in the nebulizer chamber. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that [NAME] Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer, to prevent possible cross contamination and infection. - R21's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 05/30/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required limited assistance of one staff for all cares except eating, which required setup and supervision. The 08/21/23 Quarterly MDS documented a BIMS of 15, indicating intact cognition. The 03/08/23 Care Area Assessment (CAA) lacked documentation related to the nebulizer medication use. R21's Physician Orders included: Ipratropium-albuterol inhalation solution, to be given four times, per day for shortness of air, ordered 05/23/23. Budesonide inhalation solution, to be given two times per day, for shortness of air, ordered 05/23/23. On 08/28/23 at 02:17 PM, observed R21's nebulizer mask outside the room, with the nebulizer mask stored directly on the handrail in the hallway. On 08/30/23 at 10:35 AM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 09/05/23 at 01:06 PM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that [NAME] Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer, to prevent possible cross contamination and infection.

The facility reported a census of 51 residents, with 14 residents sampled. Based on observation, interview and record review, the facility failed to provide Resident (R2) a bed of appropriate size for the safety and convenience of the resident. Findings included: - Resident (R)2's diagnosis included chronic obstructive pulmonary disease (COPD is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status score of eight, indicating moderately impaired cognition. The resident required extensive assistance for ADL's, other than eating. The resident was 73 inches tall. On 08/30/23 at 11:04 AM, the resident was in his bed, his legs in a bullfrog position. He was able to lower the bed to a flat position, and his body noted to hang off the top and bottom of the mattress with approximately three inches of combined clearance between his head and the headboard and his feet to the footboard. On 08/31/23 at 11:04 AM, the resident reported he must lay with his legs in a bullfrog position to be comfortable. He reported he wanted/needed a longer bed and had told staff that he needed a longer bed. The resident reported his height was 6 foot 3 inches (75 inches). On 08/30/23 at 03:35 PM, maintenance staff M reported the bed measurement from the headboard to the food board was 80 inches, and the mattress was 76 inches in length. The footboards could be removed from the bed from compromising the structural integrity of the bed. On 08/31/23 at 11:40 AM, Administrative Staff A reported he was not aware that the resident was uncomfortable in the bed. He reported the mattress was pinned to the bed frame, so there was no reason why the footboard could not be removed. On 09/05/23 at 12:57 PM, the resident reported he did not want the footboards removed because this would make his feet hand off the end of the bed. The facility did not provide a policy related to bed length. The facility failed to provide Resident (R2) a bed of appropriate size for the safety and convenience of the resident.

The facility reported a census of 51 residents with 14 residents sampled which included one resident reviewed for urinary catheters. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services regarding catheter care for one Resident (R)49, This deficient practiced placed R49 at risk for catheter related complications. Findings included: - Review of Resident (R)49's Physician Orders, (POS) dated 08/02/23, documentation included diagnosis of stage five chronic kidney disease and obstructive and reflux uropathy ( a disorder of the urinary tract that occurs due to obstructed urinary flow causing the back-up of urine into the kidneys). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident entered the facility on 07/27/23,with a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. He required staff limited assistance for toilet use. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/08/23, documented the resident at risk for complications related to his chronic urinary catheter use. Staff should provide him with assistance for management and monitor for signs and symptoms of complications. The Care Plan dated 08/16/23, revealed the resident had a potential for impairment related to his chronic indwelling catheter use. The staff should change the large catheter bag to a leg bag each morning between 5:00 AM to 6:00 AM and change back to the large catheter bag at bedtime. Staff were to observe for signs and symptoms of urinary tract infection (UTI) which included pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and/or change in behavior, initiated on 07/28/23. The POS, dated 09/01/23, documented a new medication order for an antibiotic of amoxicillin (antibiotic) tablet, 500 milligrams (MG), three times a day, for 10 days, by mouth, for UTI. On 08/29/23 at 10:01 AM, the resident sat at his bedside with his walker in front of him with his dignity bag attached to his walker. On 09/05/23 at 04:21 PM, during observation of catheter care and peri care provided by Certified Nurse Aide (CNA) E , noted CNA E laid the resident's catheter bag directly on the floor when she assisted the resident to the toilet. CNA E changed the residents brief and pants, and CNA E continued to place the catheter bag directly on the floor. On 09/05/23 at 04:34 PM, on inquiry, CNA E stated staff should not lay the catheter collection bag directly on the floor. She confirmed doing so would place the resident at risk for infection. On 09/05/23 at 05:00 PM, Licensed Administrative Nurse C stated the urine collection bag of the resident's indwelling catheter should not come in direct contact with the floor. The staff should suspend the urine collection bag below the bladder and off the floor to prevent cross contamination and/or urinary tract infection to prevent cross contamination and prevent UTIs. On 09/06/23 at 03:15 PM, Administrative Nurse B confirmed the facility policy for catheter care and related practices was referenced from the [NAME] Nursing Procedures as acceptable standard of practice. She stated the catheter urine collection bag should be maintained below the resident's bladder but not placed directly on the floor to prevent cross contamination and resulting UTI. The facility policy for Internal Management Policy or Procedure, dated 06/24/20, references the [NAME] Nursing Procedures seventh edition, Indwelling Urinary Catheter Care and Removal, page 387. Documentation included Don't place the drainage bag on the floor, to reduce the risk of contamination. The facility failed to provide necessary treatment and services regarding catheter care for the resident to prevent catheter related complications.

The facility reported a census of 51 residents with a sample of 14 residents, which included two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to thoroughly investigate falls to determine contributing factors and causes of falls to implement appropriate immediate interventions to prevent further falls for resident (R)1 and R 42 with multiple falls. Findings included: - Review Resident (R)1's Physician order Sheet, dated 08/02/23, documentation included diagnoses of lack of coordination, need for assistance with personal care, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late onset, behavioral disturbances, and hypertension (high blood pressure). The Significant Change in Status Minimum Data Set, (MDS) dated [DATE], documentation revealed the resident with a Brief Interview for Mental Status, score of two, indicating severe cognitive impairment. He required extensive assistance from staff with bed mobility, transfer, locomotion, dressing, toilet use. The resident did not ambulate during the assessment. His balance during transition was not steady. He was only able to stabilize with staff assistance. He had functional limitation in range of motion (ROM) of bilateral (both) lower extremities and used a wheelchair as an assistive device. The resident was frequently incontinent of bladder and always continent of bowel. He exhibited shortness of breath (SOB) or trouble breathing with lying flat and exertion (e.g., walking, bathing, transferring). He experienced two or more no injury falls. The resident received anti-anxiety medication for seven days of the look back period and antidepressant medication for one day of the look back period. The resident did not receive therapy nor restorative nursing program (RNP). He did use a bed and chair alarm daily. The Quarterly MDS dated [DATE], documented the changes which included a decreased BIMS score of 99, indicating a decline in mental status. He was occasionally incontinent of bowel. The resident did not experience SOB. He had two no injury falls and one fall with injury which was not major injury. The Care Area Assessment for Cognition/Dementia, Falls, and Psychoactive Drug Use, (CAA), respectfully, dated 11/28/22, documentation included the resident scored two on his BIMS. The resident stated that he just can't remember. He is at risk for further decline in cognition related to not feeling well. The resident does well with cueing, redirection, and reminders to complete tasks. Staff should keep his routine consistent and assist with Activities of daily living (ADL's). The resident is at risk for falls due to agitation, impulsiveness, incontinence, impaired balance, and medications. Staff to ensure he has appropriate footwear on while transferring. Staff to encourage him to utilize the call light for assistance and monitor for safety routinely. He was at risk for adverse effects (falls, sedation, impaired balance, side effects outlined in the black box warning) due to his use of a psychotropic medication. The Care Plan dated 08/22/23, directed staff that the resident was at risk for falls secondary to limited mobility. The care plan included that staff should provide medical adaptive equipment that included a Reacher (a handheld mechanical tool used to increase the range of a person's reach and grasp when grabbing objects) to assist the resident with grabbing items. Staff were to verify the resident's belt as appropriate. Verify belt is fastened properly not allowing pants to fall. Staff were to check each time the resident dressed and after every toileting. The resident had limited physical mobility and would maintain the ability to ambulate with walker with one staff assistance and guided staff that the resident could ambulate without assistive devices with impaired balance with one staff. He needed a four wheeled walker but would often refuse to use it. The care plan lacked guidance for the body alarm. The Morse fall scale, dated 12/27/22, 03/14/23, 03/21/23, 04/18/23 and 05/18/23 indicated R1 was at a high risk for falls. R1's electronic health record revealed the resident had multiple falls. From 03/04/23 to 06/27/23, the resident fell on 11 occasions. Review of the electronic records, on 04/04/23 at 11:20 PM, the resident's body alarm sounded like he was repositioning. After the alarm continued to sound, staff checked on R1, and the resident fell from his bed to the floor, with his upper body on the bed. On 10/24/22 at 08:15 PM, the resident fell while standing without assistance. The immediate intervention was to always place a pad alarm in bed and in the chair, even in the presence of staff. On 05/30/23 at 07:42 PM, an unidentified CNA assisted him to bed. He was found lying on his back by the north side of his bed. The root cause was the body alarm was in the resident's wheelchair, and not in his bed. On 06/11/23 at 12:30 AM, an unidentified certified Nurse aide (CNA) discovered the resident on the floor next to the bed. The root cause was the bed alarm appeared to be nonfunctional. Staff put the resident back to bed, however no documentation to reveal staff replaced the bed alarm with a functional body alarm. On 06/11/23 at 12:50 AM, shortly after first fall, staff discovered the resident on the floor, next to his bed. The root cause was a nonfunctional bed alarm. On 06/27/23 at 07:58 PM, the resident fell from his bed to the floor. The resident was incontinent and did not have his body alarm in place. Observation on 08/29/23 at 10:40 AM, R1 sat in recliner, no signs of discomfort. On 08/31/23 at 03:01 PM, R1 sat in a recliner by the nurse's station in visual field of staff. R1 made no attempts to get out of the recliner. On 09/05/23 at 01:31 PM, CNA F reported the resident would attempt to get out of his bed in the morning. If he gets up, the pressure alarm will activate. On 09/05/23 at 02:22 PM, Licensed Nurse (LN) G reported the resident underestimates what he can do, and he gets restless most of the time and tries to get up and out of bed on his own. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. The resident had intervention for the body alarm, and staff had to be reeducated because the alarm wasn't in place and another fall, staff did not answer the call light timely. Another fall occurred when staff didn't put the call light in place. The facility's policy for Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21, lacked guidance related to body alarms. The facility failed to ensure this resident had appropriate interventions related to his falls. 46960 - Resident (R)42's diagnoses from the Electronic Health Record (EHR) documented reduced mobility, polyosteoarthritis (degenerative changes to many joints characterized by swelling and pain) and fracture of the left femur (thigh bone). R42's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of six, which indicated severely impaired cognition. The resident required extensive assistance of one to two staff for all ADL's (activities of daily living). R42 had two or more falls since the prior assessment. R42's quarterly MDS, dated [DATE], documented a BIMS of 13, indicating intact cognition, and the resident required extensive assistance of one staff member for all ADL cares. The resident had two or more falls since the prior assessment. The Falls Care Area Assessment (CAA) dated 03/16/23, revealed that the resident was at increased risk for falls and injury due to impaired balance and staff were to ensure the ensured resident wore appropriate footwear. Staff encouraged R42 to utilize the call light for assistance. The care plan, dated 09/04/23, revealed the following: 1. The facility recognized the resident was an increased risk of falls on 03/02/22 related to deconditioning and balance problems and had the following interventions in place: continue to offer assistance even when declined by resident, be sure resident's call light is in reach and encourage resident to use it as needed and staff to go outside with resident when he goes outside to smoke. 2. The resident had a fall on 02/06/23. The care plan lacked appropriate interventions to possibly prevent further falls. 3. The resident had a fall on 02/17/23. The care plan lacked appropriate interventions to possibly prevent further falls. 4. The resident had a fall on 02/25/23. The care plan lacked appropriate interventions to possibly prevent further falls. 5. The resident had a fall on 03/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. 6. The resident had a fall on 04/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. 7. The resident had a fall on 04/30/23. The care plan lacked appropriate interventions to possibly prevent further falls. 8. The resident had a fall on 05/01/23. The care plan lacked appropriate interventions to possibly prevent further falls. 9. On 06/14/23 instructed staff to be one-on-one at all times to prevent falls. The Physician's orders documented on 06/14/23 for staff to be one-on-one at all times for fall prevention. The EHR assessments revealed fall risk screenings, dated 12/20/22, 02/06/23, 03/03/23, 03/30/23, 04/26/23 and 04/30/23 that indicated that resident was a high risk of falls. The Fall reports reviewed from 01/01/23 to 09/05/23 revealed the following: 1. On 02/06/23, R42 had a fall without injury. The immediate intervention was documented that resident was assisted up. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to encourage resident to wait for staff when going off the unit. However, the care plan lacked a corresponding entry to prevent future falls. 2. On 02/17/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented for staff to keep eyes on R42 when he came back from smoking until he returned to bed. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep an eye on resident when he came back from smoking to ensure needs were met. However, the care plan lacked a corresponding entry to prevent future falls. 3. On 02/25/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that vital signs were obtained and resident was assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to increase visual checks on resident to 30 minutes. However, the care plan lacked a corresponding entry to prevent future falls. 4. On 03/26/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the resident was assessed for injuries and assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to add pain medication or increase current regimen. However, the care plan lacked a corresponding entry to prevent future falls. 5. On 04/26/23, R42 had a fall with minor injury. The immediate intervention to prevent additional falls was documented that the staff were to leave door open and privacy curtain pulled back. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was for staff to keep door open and privacy curtain pulled back while awake. However, the care plan lacked a corresponding entry to prevent future falls. 6. On 04/30/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the staff assessed the resident for injury. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep resident in sight and to ensure safety measures are taken. However, the care plan lacked a corresponding injury to prevent future falls. 7. On 05/01/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was for staff to utilize a toileting schedule and to re-educate resident for use of call light. The fall report documented the addition to the care plan was to initiate one-on-one supervision with resident. However, the care plan did not reflect this entry until 06/14/23, which was 45 days later. On 09/05/23 at 04:01 PM, Administrative Nurse C reported when a resident fell , the nurse on duty was responsible for filling out a fall report and developing an immediate intervention to be implemented until the interdisciplinary team (IDT) could meet and determine the root cause of the fall. The IDT would develop a permanent intervention to be added to the care plan. Additionally stated that no documentation exists that outlines investigative process that the IDT used to determine root cause or development of care plan interventions. Administrative Nurse C confirmed the lack of care plan interventions for falls on 02/06/23, 02/17/23, 02/25/23, 03/26/23, 04/26/23, 04/30/23 and 05/01/23 and stated that the nurse on duty at the time of the fall could make addendums to care plan interventions, but ultimately it was the responsibility of Administrative Nurse C. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. If the nurse that was on duty at the time of the fall failed to add a care plan intervention or if the intervention was inappropriate, then Administrative Nurse C would correct it on the next business day. The facility's Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21 lacked guidance related to the investigation process. The facility failed to provide a safe environment when staff failed to appropriately and thoroughly investigate falls to determine root-cause to prevent further falls and initiate appropriate interventions to prevent further falls. This placed R42 at an increased risk for injury from falls.

The facility reported a census of 51 residents with a sample of 14 residents. Based on observation, interview, and record review, the facility failed to review and revise the care plan for Resident (R1) and R42, related to fall interventions. Findings included: - Review Resident (R)1's Physician order Sheet, dated 08/02/23, documentation included diagnoses of lack of coordination, need for assistance with personal care, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late onset, behavioral disturbances, and hypertension (high blood pressure). The Significant Change in Status Minimum Data Set, (MDS) dated [DATE], documentation revealed the resident with a Brief Interview for Mental Status, score of two, indicating severe cognitive impairment. He required extensive assistance from staff with bed mobility, transfer, locomotion, dressing, toilet use. The resident did not ambulate during the assessment. His balance during transition was not steady. He was only able to stabilize with staff assistance. He had functional limitation in range of motion (ROM) of bilateral (both) lower extremities and used a wheelchair as an assistive device. The resident was frequently incontinent of bladder and always continent of bowel. He exhibited shortness of breath (SOB) or trouble breathing with lying flat and exertion (e.g., walking, bathing, transferring). He experienced two or more no injury falls. The resident received anti-anxiety medication for seven days of the look back period and antidepressant medication for one day of the look back period. The resident did not receive therapy nor restorative nursing program (RNP). He did use a bed and chair alarm daily. The Quarterly MDS dated [DATE], documented the changes which included a decreased BIMS score of 99, indicating a decline in mental status. He was occasionally incontinent of bowel. The resident did not experience SOB. He had two no injury falls and one fall with injury which was not major injury. The Care Area Assessment for Cognition/Dementia, Falls, and Psychoactive Drug Use, (CAA), respectfully, dated 11/28/22, documentation included the resident scored two on his BIMS. The resident stated that he just can't remember. He is at risk for further decline in cognition related to not feeling well. The resident does well with cueing, redirection, and reminders to complete tasks. Staff should keep his routine consistent and assist with Activities of daily living (ADL's). The resident is at risk for falls due to agitation, impulsiveness, incontinence, impaired balance, and medications. Staff to ensure he has appropriate footwear on while transferring. Staff to encourage him to utilize the call light for assistance and monitor for safety routinely. He was at risk for adverse effects (falls, sedation, impaired balance, side effects outlined in the black box warning) due to his use of a psychotropic medication. The Care Plan dated 08/22/23, directed staff that the resident was at risk for falls secondary to limited mobility. The care plan included that staff should provide medical adaptive equipment that included a Reacher (a handheld mechanical tool used to increase the range of a person's reach and grasp when grabbing objects) to assist the resident with grabbing items. Staff were to verify the resident's belt as appropriate. Verify belt is fastened properly not allowing pants to fall. Staff were to check each time the resident dressed and after every toileting. The resident had limited physical mobility and would maintain the ability to ambulate with walker with one staff assistance and guided staff that the resident could ambulate without assistive devices with impaired balance with one staff. He needed a four wheeled walker but would often refuse to use it. The care plan lacked guidance for the body alarm. The Morse fall scale, dated 12/27/22, 03/14/23, 03/21/23, 04/18/23 and 05/18/23 indicated R1 was at a high risk for falls. R1's electronic health record revealed the resident had multiple falls. From 03/04/23 to 06/27/23, the resident fell on 11 occasions. Review of the electronic records, on 04/04/23 at 11:20 PM, the resident's body alarm sounded like he was repositioning. After the alarm continued to sound, staff checked on R1, and the resident fell from his bed to the floor, with his upper body on the bed. On 10/24/22 at 08:15 PM, the resident fell while standing without assistance. The immediate intervention was to always place a pad alarm in bed and in the chair, even in the presence of staff. On 05/30/23 at 07:42 PM, an unidentified CNA assisted him to bed. He was found lying on his back by the north side of his bed. The root cause was the body alarm was in the resident's wheelchair, and not in his bed. On 06/11/23 at 12:30 AM, an unidentified certified Nurse aide (CNA) discovered the resident on the floor next to the bed. The root cause was the bed alarm appeared to be nonfunctional. Staff put the resident back to bed, however no documentation to reveal staff replaced the bed alarm with a functional body alarm. On 06/11/23 at 12:50 AM, shortly after first fall, staff discovered the resident on the floor, next to his bed. The root cause was a nonfunctional bed alarm. On 06/27/23 at 07:58 PM, the resident fell from his bed to the floor. The resident was incontinent and did not have his body alarm in place. Observation on 08/29/23 at 10:40 AM, R1 sat in recliner, no signs of discomfort. On 08/31/23 at 03:01 PM, R1 sat in a recliner by the nurse's station in visual field of staff. R1 made no attempts to get out of the recliner. On 09/05/23 at 01:31 PM, CNA F reported the resident would attempt to get out of his bed in the morning. If he gets up, the pressure alarm will activate. On 09/05/23 at 02:22 PM, Licensed Nurse (LN) G reported the resident underestimates what he can do, and he gets restless most of the time and tries to get up and out of bed on his own. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. The resident had intervention for the body alarm, and staff had to be reeducated because the alarm wasn't in place and another fall, staff did not answer the call light timely. Another fall occurred when staff didn't put the call light in place. The facility's Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21 documented to revise care plan with updated interventions as it relates to the accident and/or incident. The facility failed review and revise this resident's care plan related to his multiple falls. 46960 - Resident (R)42's diagnoses from the Electronic Health Record (EHR) documented reduced mobility, polyosteoarthritis (degenerative changes to many joints characterized by swelling and pain) and fracture of the left femur (thigh bone). R42's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of six, which indicated severely impaired cognition. The resident required extensive assistance of one to two staff for all ADL's (activities of daily living). R42 had two or more falls since the prior assessment. R42's quarterly MDS, dated [DATE], documented a BIMS of 13, indicating intact cognition, and the resident required extensive assistance of one staff member for all ADL cares. The resident had two or more falls since the prior assessment. The Falls Care Area Assessment (CAA) dated 03/16/23, revealed that the resident was at increased risk for falls and injury due to impaired balance and staff were to ensure the ensured resident wore appropriate footwear. Staff encouraged R42 to utilize the call light for assistance. The care plan, dated 09/04/23, revealed the following: 1. The facility recognized the resident was an increased risk of falls on 03/02/22 related to deconditioning and balance problems and had the following interventions in place: continue to offer assistance even when declined by resident, be sure resident's call light is in reach and encourage resident to use it as needed and staff to go outside with resident when he goes outside to smoke. 2. The resident had a fall on 02/06/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 3. The resident had a fall on 02/17/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 4. The resident had a fall on 02/25/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 5. The resident had a fall on 03/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 6. The resident had a fall on 04/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 7. The resident had a fall on 04/30/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 8. The resident had a fall on 05/01/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. The EHR assessments revealed fall risk screenings, dated 12/20/22, 02/06/23, 03/03/23, 03/30/23, 04/26/23 and 04/30/23 that indicated that resident was a high risk of falls. The Fall reports reviewed from 01/01/23 to 09/05/23 revealed the following: 1. On 02/06/23, R42 had a fall without injury. The immediate intervention was documented that resident was assisted up. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to encourage resident to wait for staff when going off the unit. However, the care plan lacked a corresponding entry to prevent future falls. 2. On 02/17/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented for staff to keep eyes on R42 when he came back from smoking until he returned to bed. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep an eye on resident when he came back from smoking to ensure needs were met. However, the care plan lacked a corresponding entry to prevent future falls. 3. On 02/25/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that vital signs were obtained, and resident was assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to increase visual checks on resident to 30 minutes. However, the care plan lacked a corresponding entry to prevent future falls. 4. On 03/26/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the resident was assessed for injuries and assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to add pain medication or increase current regimen. However, the care plan lacked a corresponding entry to prevent future falls. 5. On 04/26/23, R42 had a fall with minor injury. The immediate intervention to prevent additional falls was documented that the staff were to leave door open and privacy curtain pulled back. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was for staff to keep door open and privacy curtain pulled back while awake. However, the care plan lacked a corresponding entry to prevent future falls. 6. On 04/30/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the staff assessed the resident for injury. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep resident in sight and to ensure safety measures are taken. However, the care plan lacked a corresponding injury to prevent future falls. 7. On 05/01/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was for staff to utilize a toileting schedule and to re-educate resident for use of call light. The fall report documented the addition to the care plan was to initiate one-on-one supervision with resident. However, the care plan did not reflect this entry until 06/14/23, which was 45 days later. On 09/05/23 at 04:01 PM, Administrative Nurse C reported when a resident fell , the nurse on duty was responsible for filling out a fall report and developing an immediate intervention to be implemented until the interdisciplinary team (IDT) could meet and determine the root cause of the fall. The IDT would develop a permanent intervention to be added to the care plan. Additionally stated that no documentation exists that outlines investigative process that the IDT used to determine root cause or development of care plan interventions. Administrative Nurse C confirmed the lack of care plan interventions for falls on 02/06/23, 02/17/23, 02/25/23, 03/26/23, 04/26/23, 04/30/23 and 05/01/23 and stated that the nurse on duty at the time of the fall could make addendums to care plan interventions, but ultimately it was the responsibility of Administrative Nurse C. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. If the nurse that was on duty at the time of the fall failed to add a care plan intervention or if the intervention was inappropriate, then Administrative Nurse C would correct it on the next business day. The facility's Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21 documented to revise care plan with updated interventions as it relates to the accident and/or incident. The facility failed to review and revise the care plan for this resident that had multiple falls.

The facility reported a census of 51 residents which included 14 selected for review. Based on interview and record review, the facility failed to fully complete comprehensive Minimum Data Set (MDS) assessment O-special treatments and programs and failed to complete Section V, Care Area Assessment Summary (CAA) for Resident (R)11 to include an analysis and rationale for care planned decisions. This placed the resident at risk for not accurately reflecting the resident's status and needs to develop an individualized comprehensive plan of care. Findings include: - R11's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), shortness of breath and OSA (obstructive sleep apnea - a condition in which the person cannot maintain an open airway while asleep). The 01/10/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive assistance of two staff for all cares except eating, which required setup and supervision. The resident received oxygen. The section O-special treatment and programs lacked documentation that the resident required a continuous positive airway pressure (CPAP) support. The 01/10/23 Care Area Assessment (CAA) lacked documentation related to the use of the resident's CPAP equipment. The 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for the CPAP equipment. On 08/29/23 at 08:50 AM, R11 observed resting in bed watching TV with the CPAP machine sitting on the bedside table with hose/mask intact and placed on top of the machine. On 08/30/23 at 11:55 AM, observation of R11's room revealed the CPAP machine sitting on the bedside table with hose/mask intact and placed on top of the machine. On 08/31/23 at 08:41 AM, observation of R11's room revealed the CPAP machine on the bedside table with hose/mask intact on top of the machine. On 09/06/23 at 11:29 AM, Administrative Nurse B confirmed that CPAP use was not on R11's most recent comprehensive MDS assessment. Administrative Staff A stated at 09/06/23 at 03:00 PM that the facility utilized RAI (resident assessment instrument) manual for guidance related to accuracy of MDS assessments. The facility failed to complete an accurate comprehensive admission assessment on the MDS for R11, related to the resident's CPAP use.

The facility reported a census of 51 residents with 14 selected for review. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident (R)21 and R11. This occurred with R21 when certified nurse aide (CNA) L entered R21's room without knocking, and R11 through the failure of the staff to place R11's call light within reach and R11's use of an air horn to alert staff to his need for assistance. Findings included: - On 08/28/23 at 02:29 PM, during interview with R21, CNA L opened the door and entered the resident's room without knocking or announcing himself and began rearranging items. R21 asked CNA L what he was doing, but no response was given by staff. When CNA L became aware of the presence of a surveyor in the room, he promptly left. R21 stated that CNA L would frequently enter his room unannounced and move items in his room despite protests from R21. R21 confirmed this would upset him. On 08/28/23 at 02:32 PM, CNA L confirmed that he entered R21's room without knocking or announcing himself. Further confirmed that he was supposed to knock and announce himself, then inform the resident of what he needed to do and approximately how long it would take. On 08/28/23 at 02:34 PM, Licensed Nurse (LN) G stated that every staff member should knock, announce themselves, inform the resident of what they needed to do and approximately how long it would take. On 08/28/23 at 03:00 PM, Administrative Nurse B stated that every staff member should knock on the resident's door, announce themselves, inform the resident of what they needed to do, and approximately how long it would take. Furthermore,on 08/30/23 at 11:55 AM during an interview with R11, observation revealed a canned air-horn intended for nautical use sat on R11's over-the-bed table. R11 stated that he is frequently placed in bed without being given his call light. Due to mobility issues while in bed, he cannot reach the wall box to call for assistance. R11 stated that this has caused him distress as he has become incontinent at times because he could not alert staff to his needs. R11 further explained that it negatively affected his pride and dignity when he had to use his own money to buy the air-horn to alert staff as he cannot discretely notify staff of his need for assistance. On 09/06/23 at 11:02 AM Certified Medication Aide (CMA) H stated that call lights should be placed where residents can easily reach them. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K stated that call lights should be placed close to residents where they can easily reach them. On 09/06/23 at 11:29 AM, Administrative Nurse B stated that call lights should be placed where residents can easily alert staff to their needs. The facility's Resident's Rights policy dated 04/10/19, documented that every resident in the facility has a right to a dignified existence and rights include but are not limited to privacy and confidentiality. The facility failed to protect the privacy and dignity of R21 when staff entered resident rooms without knocking, and of R11 by not placing the call light where he could easily access it.

The facility reported a census of 51 residents with 14 residents sampled, including three residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly store the nebulizer (a device for administering inhaled medications) and to correctly store distilled water used for oxygen humidification for to Resident (R)2, R11 and R21 in accordance with the standards of care. In addition, the facility failed to disassemble and clean the CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with obstructive sleep apnea [a condition in which a person cannot maintain an open airway while sleeping]) for R11. Findings included: - R2's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 08/06/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. The resident required extensive assistance of 2 staff for all cares except eating. The resident received oxygen. The 05/12/23 Quarterly MDS documented a BIMS of eight, indicating moderately impaired cognition. The resident received oxygen. The 08/06/23 Care Area Assessment (CAA) lacked documentation related to a nebulizer or oxygen use. The Care Plan dated 08/31/23, documented that the resident had altered respiratory status related to COPD and other disorders of the lungs, and instructed staff to administer medications as ordered, but lacked information specific to care of nebulizer equipment. The resident's Physician Orders included ipratropium-albuterol inhalation solution to be given once per day, and every four hours, as needed for difficulty breathing related to COPD, dated 03/16/23. The 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for cleaning/maintenance of the resident's nebulizer equipment. On 08/30/23 at 11:04 AM, R2 was in bed with oxygen on. The nebulizer tubing and medication chamber was on top of the nebulizer machine. Moisture and a clear liquid remained in the medication chamber of the nebulizer. On 08/31/23 at 08:30 AM, R2 observed resting in bed wearing oxygen via nasal cannula. The nebulizer machine sat of top of the bedside table. There was no tubing/medication chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident receives a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that [NAME] Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide a policy or procedure guide specific to nebulizer medication administration. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer. - R11's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), shortness of breath and obstructive sleep apnea [a condition in which the person cannot maintain an open airway while asleep]). The 01/10/23 Annual Minimum Data Set (MDS) documented Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident received oxygen. The MDS lacked documentation that resident received a continuous positive airway pressure (CPAP). The 08/27/23 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The resident received oxygen. The 01/10/23 Care Area Assessment (CAA) lacked documentation related to oxygen use, nebulizer medication administration, or CPAP use. R11's EHR Physician Orders included ipratropium-albuterol inhalation solution to be given three times per day for shortness of air and continuous oxygen but lacked orders for CPAP. The Care Plan dated 08/30/23 documented on 01/24/22 that the resident has altered respiratory status. Administer medication/puffers as ordered. Staff instructed for the CPAP machine to use titrated pressure with full -face mask when sleeping. The physician's order included ipratropium-Albuterol solution, 3 milligrams per 3 milliliters, use 1 application, and inhale orally three times a day, for shortness of breath, dated 07/12/23. Review of the Treatment Administration Record from 07/12/23 to 08/31/23, lacked documentation of the care for the nebulizer equipment or the CPAP equipment. he 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for the care of nebulizer equipment or CPAP equipment. On 08/29/23 at 08:50 AM, R11 was in bed, the resident's nebulizer mask laid directly on the bed linens, and the nebulizer's medication chamber contained a clear liquid. On 08/30/23 at 11:55 AM, observation of R11's room revealed a nebulizer mask hung from the edge of the bed by an elastic strap. There was clear liquid inside the nebulizer medication chamber. On 08/30/23 at 03:04 PM, R11 observed sitting upright in bed receiving breathing treatment with nebulizer mask. R11 pressed the call light and unknown Certified Nurse Aide (CNA) responded to the call light and removed the nebulizer mask at the request of R11, then placed the nebulizer mask on top of the nebulizer machine on the resident's bedside table. The nebulizer was intact with an unknown clear liquid that remained in the nebulizer chamber. The CNA then left the room. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. It was unacceptable practice for nebulizer's to be left intact between treatments. On 08/31/23 at 08:41 AM, observation of R11's room revealed the nebulizer intact on the bedside table with unknown clear liquid in the nebulizer chamber. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that [NAME] Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide a policy or procedure guide specific to nebulizer medication administration. The facility failed to provide respiratory care consistent with professional standards of care for R11, regarding the cleaning and storage of the nebulizer. - R21's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 05/30/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required limited assistance of one staff for all cares except eating, which required setup and supervision. The 08/21/23 Quarterly MDS documented a BIMS of 15, indicating intact cognition. The 03/08/23 Care Area Assessment (CAA) lacked documentation related to the nebulizer medication use. R21's Physician Orders included: Ipratropium-albuterol inhalation solution, to be given four times, per day for shortness of air, ordered 05/23/23. Budesonide inhalation solution, to be given two times per day, for shortness of air, ordered 05/23/23. On 08/28/23 at 02:17 PM, observed R21's nebulizer mask outside the room, with the nebulizer mask stored directly on the handrail in the hallway. On 08/30/23 at 10:35 AM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 09/05/23 at 01:06 PM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that [NAME] Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide a policy or procedure guide specific to nebulizer medication administration. The facility failed to provide respiratory care consistent with professional standards of care for R21, regarding the cleaning and storage of the nebulizer.

The facility census totaled 25 residents, with four residents included in the sample for abuse, neglect, and exploitation. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 was free from resident-to-resident abuse by R3 when the residents had three altercations, which led to R1 receiving a bloody nose and cut lip during one incident and a [CONDITION(S)] (requiring surgical repair) during another altercation. On 04/15/21, R3 shoved R1 and grabbed R1's wrist. On 05/17/21, R1 wandered into another resident's room, who started yelling at R1. R3 then entered the room and pushed R1, causing a bloody nose and a cut to the lip. Then on 06/10/21, R1 walked by R3's room and R3 pushed him down. R1 received a hip fracture, which required surgery. The facility failed to implement specific interventions to ensure R1 remained free from resident to resident abuse by R3, which placed R1 in immediate jeopardy. Findings included: - Review of R3's History and Physical dated 02/25/21 revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R3's Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. Total mood severity score of three, indicating minimal depression and no [CONDITION(S)], hallucinations, delusions, or behaviors exhibited during the seven-day review period. R3 wandered one to three days in the seven-day review period. R3 was independent with all activities of daily living (ADLs) and received antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression) daily during the seven-day review period. Review of the 02/28/21 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R3 had confusion and at times was not able to find his room. R3 wandered the hallways and did not understand why he was at the facility. R3 required frequent redirection due to statements of not being at the facility long. R3 believed he was supposed to be living with his daughter. Review of the 02/28/21 Behavioral Care Area Assessment (CAA) documented R3 wandered the halls and at times experienced exit-seeking behaviors, because he believed he was supposed to be living with his daughter. Review of the 05/21/21 Quarterly MDS documented a BIMS of six, indicating severely impaired cognition. R3 expressed physical behavioral symptoms one to three days in the seven-day review period. R3 was independent with all ADLs and received antidepressants and anti-anxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication daily during the seven-day review period. Review of the Care Plan last revised on 05/03/21, documented staff should identify the pattern of wandering, intervene, and distract R3 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. Staff were to remain in the lobby at all times to ensure R3 did not leave the unit unaccompanied, and the staff should ensure R3 remained an arms-length away from R4. Review of the 02/22/21Non-Medication Behavior Interventions Care Plan included non-pharmacological interventions of visiting, calling family, snacking, going to a quiet area, repositioning, fishing, and playing card games. Review of 03/01/21 Behavior Note documented R3 invaded the Certified Medication Aide's (CMA) personal space while continuing to ask about leaving the facility. R3 appeared to have increased frustration and refused validation or redirection and was visibly distraught. Review of a 03/01/21 SBAR Situation Note revealed facility staff contacted the physician regarding R3's increased agitation expressed via yelling at the staff. R3 was visibly irritated with staff, frustrated, speech clear concise, alert and oriented times one as norm. The physician ordered anti-anxiety medication, as needed (PRN), for the resident. Review of 03/02/21 Behavior Note revealed R3 was showing signs of paranoia with short-term memory loss and was unable to be redirected. Licensed Nursing (LN) staff instructed the Certified Nurse Aides (CNAs) to monitor R3 for aggression and wandering. Review of 04/15/21 Incident Note revealed R3 shoved another resident [R1] and grabbed his wrist. The immediate intervention listed was the separation of the residents. Staff wrote the root cause of the incident was R1 was talking to another resident, who did not want to engage in conversation with R1, and R3 decided he would take care of the situation. The Care Plan lacked any interventions regarding this incident. Review of 04/28/21 Behavior Note revealed R3 was angry with an unidentified resident for entering his and other residents' rooms and yelled at him. The other resident was redirected out of R3's room when R3 reported everyone is just tired of it he's always going where he doesn't belong, touching everything and he never listens. Review of 05/17/21 Incident Note - What Happened revealed R1 was wandering in other resident's rooms, and R3 responded to another resident [R2] yelling at R1. Upon R3s arrival, R1 took a defensive posture and R3 shoved R1 into the wall and door. This shove led to R1 sustaining a cut lip and nosebleed. Facility staff identified the root cause as R3's instinct to protect others, and the immediate intervention was to separate the residents. The Care Plan lacked any further intervention to prevent R3 and R1 from further resident-to-resident abuse. Review of Accident/Incident Witness Statement revealed CNA F wrote an undated, statement stating that R2 was attempting to get an electric razor back from R1 when R3 entered R2's room and pushed R1. Review of a 06/10/21 Incident Note revealed R3 shoved R1 to the ground causing R1 to hit his head on the railing. R3 reported R1 was in my face and R3 displayed agitated, anxious, and aggressive behaviors as evident by slamming a closed fist down on the medication cart. The facility staff identified the root cause as R3 being unable to remember being invited to leave the floor and felt like a prisoner. The staff placed an immediate intervention of advising R3 he could leave the facility with family or physician orders. They also attempted to contact R3's family, however they did not want to speak. Review of R1's 06/11/21 General Note revealed the acute care hospital contacted the facility and advised that R1 had a right hip fracture and may have surgery the next day. Review of an undated Witness Statement from LN G revealed R3 was looking for his room when he became agitated, pushed past the CNA staff, exited his room, pushed R1, then started pounding on the medication cart. Per interview with CNA A on 06/17/21 at 02:16 PM, R3 was sent to a behavioral health unit earlier that afternoon and was not expected to return for several weeks. She witnessed the 06/10/21 incident and reported that R3 pushed R1 like super hard and R1 flew and hit his head on the wall railing. She had never seen anyone being pushed that violently. She remembered another incident involving the two residents, which involved R3 shoving R1 when he wandered into another resident's room and R3 intervened for another resident who did not want R1 in his room. R3's behaviors usually included wandering, which became worse at night, but she had never seen him as agitated as he was on the evening of 06/10/21. She reported they were supposed to try and keep R1 and R3 apart, but there were times R1 could become adamant about getting into something. Staff were to also try redirecting R3 with calling his family and providing snacks. Interview with LN B on 06/17/21 at 02:41 PM revealed R1 would often wander into other resident's rooms and urinated in others' rooms or in the common's areas. R3 did not like that behavior and R3 felt like he had to take care of the other residents and staff. She knew on the 06/10/21 incident, that R3 was upset about not going to the store and R1 was just at the wrong place at the wrong time. She reported staff were to keep the two residents at arm's length, but that was not always possible or realistic. They could call R3's family to assist with redirection and after the incident on 06/10/21, certain staff were allowed to take R3 outside which seemed to appease R3 as well. Interview with Administrative Nurse C on 06/21/21 at 01:17 PM revealed the facility believed that attempting to prevent R1 from wandering would reduce any conflict between R1 and R3 since R3 did not seek R1 out for verbal or physical abuse. The facility was not able to put together a pattern between the two residents. The facility did implement taking R3 outside and one to one activities five days a week for R3 after the 06/10/21 incident but focused on trying to reduce the wandering of R1 prior to that regarding interventions. Review of the facility policy Abuse, Neglect, and Exploitation or Residents: Prevention, Identification, and Reporting Procedure revised on 05/12/17, documented Staff will intervene to protect the resident from harm and will be separated from the other resident. Staff will monitor behaviors and notify proper authorities. The facility failed to ensure R1 was free from resident-to-resident abuse by R3, when the residents had three altercations which led to R1 receiving a bloody nose and cut lip during one incident and a [CONDITION(S)] (requiring surgical repair) during another altercation. There were no interventions in place to prevent the initial resident-to-resident abuse, nor did the facility add interventions to prevent further abuse. The facility failed to implement specific interventions to ensure R1 remained free from resident-to -resident abuse by R3, that placed R1 in immediate jeopardy. On 06/21/21 at 01:50 PM, the Administrator and Administrative Nurse C was provided with the IJ template and notified that the failure to prevent R3 from pushing R1 causing a fracture, constituted immediate jeopardy at F600. The immediate jeopardy at F600 also constituted Substandard Quality of Care at 42 CFR 483.12. The immediate jeopardy was determined to first exist on 06/10/21 when the facility failed to ensure interventions were present to prevent escalation of resident to resident abuse from R3 towards R1. The facility presented an acceptable plan for removal of the immediate jeopardy on 06/21/21 at 05:16 PM. The survey team validated that the immediate jeopardy was removed on 06/22/21 at 09:15 AM following the facility's implementation of the plan for removal of the immediate jeopardy. The plan included developing a facility policy regarding Behavior Management and education of staff over behaviors and appropriate interventions. The deficient practice remained at a G (isolated with actual harm) scope and severity following the removal of the immediate jeopardy.

The facility had a census of 54 residents with three residents selected for sample. Based on observation, interview, and record review the facility failed to ensure one of three sampled residents the right to be free of neglect when staff placed the resident on a bedpan and failed to remove him from the bedpan for an extended period of time, most likely several hours. When staff found the resident on the bedpan and removed it, the resident had an area of skin discoloration in the shape of a bedpan across both buttocks. That area of reddish purple discoloration remained 11 days later. (Resident (R) 1) Findings included: - R1's clinical record included a comprehensive list of medical [DIAGNOSES REDACTED]. The 05/31/19 quarterly Minimum Data Set (MDS) identified the resident with moderate cognitive impairment (brief interview for mental status score of 11), the need for extensive assistance of two staff for bed mobility and transfers , and an inability to ambulate. According to the MDS, R1 used an indwelling bladder catheter (tube placed in the bladder to drain urine into a collection bag) and experienced frequent bowel incontinence. R1 required extensive assistance of two staff for toileting. The resident weighed 294 pounds (lbs.) and received hospice services. The 07/22/15 Care Plan noted the resident's enrollment in hospice. According to the care plan, the resident required use of a total mechanical lift for all transfers and had limited physical mobility. A 05/18/19 intervention directed staff to reposition the resident every two hours. Review of R1's Physician order [REDACTED]. A 05/24/19 Braden Skin Assessment (a standardized tool used to assess for risk of skin breakdown) identified R1 as at risk for skin breakdown. A Weekly Skin Assessment completed on 07/29/19 noted areas of discoloration on the R1's left and right lower legs. According to the assessment, staff did not note other skin concerns. A Weekly Skin Assessment completed on 08/10/19 identified areas of pressure on R1's right and left buttocks and described the areas as scabbing over. A Weekly Skin Assessment completed on 08/12/19 identified areas of pressure on R1's left and right buttocks which were in the shape of a bed pan. The assessment described the skin alteration as a red line, approximately 0.5 centimeters (cm) wide, going completely around buttock. R1's Progress Notes included a note written on 08/07/19 at 10:31 AM which described the presence of a dark purple raised area outlining R1's coccyx. Further description of the area of discoloration included, The dark purple area with surrounding redness was approximately half an inch wide going up lateral (pertaining to the side, away from the middle) aspect of each buttock, across the sacrum (large triangular bone between the two hip bones) and the perineum (area between the anus and scrotum) making an oblong rectangle shape. The area was firm to the touch with redness extending out from the raised purple areas. The note went on to describe a report that staff placed R1 on the bedpan at some point on Saturday (08/03/19) and inadvertently left him on the bedpan for an extended period of time. During an observation on 08/13/19 at 08:25 AM, Licensed Nurse (LN) G and an unidentified certified nurse aide (CNA) used a turn sheet to turn R1 onto his left side. R1's right buttock continued to have a reddish purple colored vertical line approximately 1/3 inch wide which started at the lower end of the buttock and extended upwards, and then across the sacrum area. LN G and the CNA then used the turn sheet to turn R1 onto his right side. Again, the left buttock had a reddish purple colored area, approximate 1/3 inch wide, which went from the sacrum area down his left buttock. When looking at the entirety of the area of discoloration, the area appeared to be the outline of the shape of a bedpan. At the time of the observation, the area of discoloration did not blanche (to press on a person's skin to push blood away and wait for return to determine blood circulation) and remained reddish purple with application of pressure. During an observation on 08/14/19 at 02:00 PM, LN G and Administrative Nurse D moved R1 into a right side-lying position. The area of discoloration on the left and right buttocks appeared slightly wider than on 08/13/19 and the surface of the area had small pin size areas of skin roughness which were not present the previous day. Administrative Nurse D applied pressure to the discolored areas on both the right and left buttocks and found them to blanche with pressure on this date, even though they failed to blanche on 08/13/19. At the time of this observation, the area of reddish purple colored discoloration remained in the shape of a bedpan 11 days after the original injury. During an interview on 08/13/19 at 08:00 AM, Administrative Nurse D reported an incident allegedly occurred on 08/03/19 when direct care staff found a bedpan inside R1's incontinence brief at approximately 06:00 PM. According to Administrative Nurse D, direct care staff found skin discoloration in the form of the outline of a bedpan on the resident's buttocks when they removed the bedpan. Administrative Nurse D said none of the staff working on the evening of 08/03/19 placed R1 on the bedpan, therefore those staff members theorized the staff from a previous shift placed the resident on the bed pan and then forgot to remove it. Administrative Nurse D stated the staff from the previous shifts also denied placing R1 on the bedpan and therefore it was unknown how long the resident remained on the bedpan. Administrative Nurse D reported she was not told of the incident until 08/07/19 . During an interview on 08/14/19 at 01:30 PM, Administrative Nurse D provided copies of all the notarized statements she obtained from staff members who worked on 08/03/19. According to Nurse D, all staff denied placing R1 on the bedpan at any time on 08/03/19, therefore she still did not know who was responsible for leaving the resident on the bed pan. Nurse D reported she did not know how staff could have provided care, including repositioning and catheter care, to R1 and not notice the bedpan inside of his incontinence brief . During an interview on 08/14/19 at 10:30 AM, R1 reported he used the bedpan for bowel movements only. According to the resident, he often fell asleep after staff placed him on the bedpan and never knew how long he sat on it. R1 could not recall anything unusual about being placed on the bedpan on 08/03/19 and said he did not know if he was on the bedpan 10 minutes or 10 hours. The facility utilized the Lippincott Nursing Procedures, Seventh Edition as the standard of all nursing processes and practices. In response to a request for a policy related to placement/removal of bedpan, the facility provided information from the Lippincott manual related to bedpan use. The information lacked guidance related to timely removal of the bedpan following resident use. The information also lacked information related to the risk of skin damage from the bedpan if staff left a resident on it for a prolonged period of time. The facility's Abuse, Neglect, and Exploitation of Residents: Prevention, Identification, and Reporting Procedure policy with a most recent revision date of 05/12/17 defined neglect as, The failure of any person to provide the degree of care which is reasonable. The facility failed to ensure one of three sampled residents the right to be free of neglect when staff placed the resident on a bedpan and failed to remove him from the bedpan for an extended period of time, most likely several hours. When staff found the resident on the bedpan and removed it, the resident had an area of skin discoloration in the shape of a bedpan across both buttocks. That area of reddish purple discoloration remained 11 days later.

The facility census totaled 53 residents. The sample included three residents reviewed for urinary incontinence. Based on observation, interview, and record review the facility failed to ensure Resident (R)3 did not have an avoidable decline in his current level of continence by the failure to assess and develop a toileting plan from the results of R3's voiding trial, failed to re-evaluate R3's urinary continence after an improvement in his/her physical functioning, and failed to assist R3 with toileting after his multiple requests to be toileted which resulted in the incontinence of urine and bowel. Findings included: - Review of R3's History and Physical dated 06/06/19 revealed the following Diagnoses: [REDACTED]. Review or R3's admission Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. R3 required extensive assist of two staff members for transfers, locomotion, and toileting. The resident required a wheelchair for all locomotion. The resident had frequent incontinence of urine, total incontinence of bowel and did not have a program in place to improve or maintain the resident's current level of urinary incontinence. Review of R3's urinary incontinence Care Area Assessment (CAA) dated 06/16/19 revealed R3 had urgency bladder incontinence related to impaired mobility and [MEDICAL CONDITION] bladder. The resident would remain free from skin breakdown due to incontinence and brief use. Further review of the CAA summary revealed facility staff would ensure the resident had an unobstructed path to the bathroom, monitor R3's voiding patterns, and develop a toileting plan. Review of R3's Care Plan last revised on 9/17/19 revealed the resident had urinary incontinence and required extensive assistance of two staff members for dressing, toileting, personal hygiene, and transfers. The care plan directed staff to check and change the resident every hour, upon rising in the morning, at bedtime, and as needed. The resident required assistance of two staff for a stand-pivot transfer with a gait belt related to toe-touch weight bearing status to the right lower extremity. Review of R3's Progress Note dated 06/03/2019 at 04:12 PM revealed the resident admitted to the facility from the hospital and he had incontinence of bowel and bladder. Review of the R3's Bowel and Bladder assessment dated [DATE] revealed the resident had a wet attend (incontinence product) 26 times and had a dry attend 37 times during the three-day voiding trial. The facility coded R3 as a strong urge/desire to void, however he lacked the ability to wait long to get to a bathroom. The resident remained dry for up to three hours. A notation in the notes section of the assessment revealed the resident was incontinent of bowel and bladder and the facility staff would check and change the resident every two hours. Review of R3's Progress Note dated 06/18/19 at 02:35 AM revealed the facility placed the resident on an hourly check, change, and repositioning program. Review of the Progress Note dated 08/15/19 at 12:42 PM revealed the resident transferred to his wheelchair and wheeled himself to the bathroom then transferred himself to the toilet. Review of the Progress Note dated 08/22/19 at 02:36 PM revealed staff heard the resident's personal alarm sound at 12:25 PM. Unidentified staff found R3 on the floor in his bathroom. The resident reported he tried to transfer himself to the toilet, turned to grab the sink, and lost his balance. Review of the Nursing Pocket Guide (a guide which informed the staff of each resident's transfer ability, toileting schedule, and special equipment required during care) for R3 updated on 09/11/19 revealed the facility failed to address toileting the resident and/or a toileting plan for the resident. An observation on 09/18/19 at 09:15 AM revealed Certified Nurse Aide (CNA) C and CNA D entered the resident's room and explained to the resident they needed to check and change his incontinent product. Both CNA C and CNA D removed the resident's old incontinent product, which staff C confirmed was wet with urine. CNA C and D cleaned the resident and placed a clean incontinence product on the resident. CNA C and D stated the resident's care plan directed them to check and change the resident every two hours and as needed. An observation on 09/18/19 at 11:45 AM revealed CNA E and CNA D assisted the resident to stand with the assistance of a gait belt and hand rails located next to the toilet. The resident followed CNA E's directions to pivot and sit on the toilet. The resident had a bowel movement and told the staff he finished and was ready to get up. CNA E provided peri-care, changed the resident's brief, and replaced R3's clothing. CNA D and E confirmed the resident's incontinence product was damp, but not wet and they assisted the resident back to his wheelchair. The resident did not have behaviors or refuse care during the observation. Interview on 09/18/19 at 09:20 AM with CNA C revealed the resident required a check and change program, every 2 hours, and as needed. CNA C revealed the resident was totally incontinent of bowel and bladder and required a brief for comfort and dignity. CNA C revealed the resident asked to go to the bathroom at times, put on his call light to tell the staff he had to go to the bathroom, and stated he could not wait and/or he needed to be changed. Further interview with CNA C on 09/18/19 at 11:15 AM revealed she did not know the resident's care plan advised staff to check and change the resident every hour. CNA C revealed she followed the nursing pocket guide to know what cares to provide to residents. CNA C confirmed the nursing pocket guide failed to include the R3's toileting program. Interview on 09/18/19 at 12:01 PM with CNA D revealed the resident required every two-hour check and change program. CNA D confirmed the resident attempted to transfer himself to the toilet without staff assistance several times since admission and his functional ability improved. CNA D revealed the resident asked her in the past to toilet him and CNA D did not know the resident's care plan advised staff to check and change the resident every two hours. CNA D confirmed staff did not toilet the resident until advised to do so by the nurse on 09/18/19. CNA D confirmed the nursing pocket guide failed to address the resident's incontinence and toileting schedule. Interview on 09/18/19 at 10:40 AM with Licensed Nurse (LN) F revealed the resident did not have a toileting plan. LN F stated the resident had impaired cognitive ability, was bed bound upon admission and placed on an every two-hour check and change program to manage his incontinence. Licensed F revealed R3 improved since admission and could bear weight and stand-pivot transfer with the assistance of two staff members and gait belt. LN F confirmed she did not know R3's care plan instructed staff to check and change the resident every hour. LN F further confirmed the resident asked to be toileted and informed staff in the past he just urinated on himself and needed to be changed. LN F revealed the Unit Manager G was responsible for review of the resident's three-day voiding trial and developed the resident's care plan from those results. Interview on 09/18/19 at 01:35 PM with Administrative Nurse G revealed she was responsible for the development of the R3's toileting program after she reviewed R3's voiding trial information. Administrative Nurse G stated the resident was bed bound and non-weight bearing upon admission to the facility and even though R3's voiding trial showed he had more episodes of continence than episodes of incontinence she placed R3 on a check and change, every 2 hour and as needed plan. Administrative Nurse G stated she did not think about offering the resident a bed pan, urinal or staff assistance to the toilet to help maintain or improve his current level of continence and to decrease his risk for decline. Administrative Nurse G stated she believed she placed the resident on an every one-hour toileting plan on 07/02/19 and confirmed she updated the resident's care plan. Nurse G denied she updated the resident's care plan on 09/17/19 with the new plan for the resident to be checked and changed every hour. Nurse G stated the facility should have completed a new voiding diary for the resident as he regained his functional abilities and the facility failed to do so. Interview on 09/18/19 at 02:00 PM with Administrative Nurse B revealed the facility failed to develop an appropriate toileting schedule for R3. Staff B revealed staff did not know the resident's toileting plan changed on 07/02/19 and confirmed failed to update the care plan until 09/17/19. Administrative Nurse B confirmed the nursing pocket guide failed to address the resident's toileting plan and the facility should have re-evaluated the resident as his physical functioning improved. Interview on 09/18/19 at 11:45 AM with Administrative Staff A revealed the facility should have addressed the resident's voiding patterns and developed an appropriate toileting plan to promote the resident's highest level of physical and mental functioning. Administrative Staff A confirmed the facility failed to implement an appropriate toileting plan upon R3's admission to the facility and failed to re-evaluate R3's continence with his improved physical functioning. Review of the undated policy Urinary Incontinence revealed an incontinent resident typically felt frustrated, embarrassed, and hopeless. Staff would assess elimination patterns, establish a voiding schedule and record the results. Review of the policy Care Plan, last revised April 4, 2019 revealed residents with incontinence of bladder and or bowel would receive appropriate treatment and services based on their comprehensive assessment to prevent urinary tract infections and to restore as much bladder and/or bowel function as possible. The facility failed to assess and develop a toileting pattern from the results of R3's voiding trial, failed to re-evaluate R3's urinary continence after an improvement in his/her physical functioning, and failed to assist R3 with toileting after his multiple requests to be toileted which resulted in the resident being incontinent of urine and bowel.

The facility census totaled 53 residents. The sample included three residents reviewed for urinary incontinence. Based on observation, interview, and record review the facility failed to ensure Resident (R)3 did not have an avoidable decline in his current level of continence by the failure to assess and develop a toileting plan from the results of R3's voiding trial, failed to re-evaluate R3's urinary continence after an improvement in his/her physical functioning, and failed to assist R3 with toileting after his multiple requests to be toileted which resulted in the incontinence of urine and bowel. Findings included: - Review of R3's History and Physical dated 06/06/19 revealed the following Diagnoses: [REDACTED]. Review or R3's admission Minimum Data Set (MDS) assessment dated [DATE] revealed R3 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. R3 required extensive assist of two staff members for transfers, locomotion, and toileting. The resident required a wheelchair for all locomotion. The resident had frequent incontinence of urine, total incontinence of bowel and did not have a program in place to improve or maintain the resident's current level of urinary incontinence. Review of R3's urinary incontinence Care Area Assessment (CAA) dated 06/16/19 revealed R3 had urgency bladder incontinence related to impaired mobility and [MEDICAL CONDITION] bladder. The resident would remain free from skin breakdown due to incontinence and brief use. Further review of the CAA summary revealed facility staff would ensure the resident had an unobstructed path to the bathroom, monitor R3's voiding patterns, and develop a toileting plan. Review of R3's Care Plan last revised on 9/17/19 revealed the resident had urinary incontinence and required extensive assistance of two staff members for dressing, toileting, personal hygiene, and transfers. The care plan directed staff to check and change the resident every hour, upon rising in the morning, at bedtime, and as needed. The resident required assistance of two staff for a stand-pivot transfer with a gait belt related to toe-touch weight bearing status to the right lower extremity. Review of R3's Progress Note dated 06/03/2019 at 04:12 PM revealed the resident admitted to the facility from the hospital and he had incontinence of bowel and bladder. Review of the R3's Bowel and Bladder assessment dated [DATE] revealed the resident had a wet attend (incontinence product) 26 times and had a dry attend 37 times during the three-day voiding trial. The facility coded R3 as a strong urge/desire to void, however he lacked the ability to wait long to get to a bathroom. The resident remained dry for up to three hours. A notation in the notes section of the assessment revealed the resident was incontinent of bowel and bladder and the facility staff would check and change the resident every two hours. Review of R3's Progress Note dated 06/18/19 at 02:35 AM revealed the facility placed the resident on an hourly check, change, and repositioning program. Review of the Progress Note dated 08/15/19 at 12:42 PM revealed the resident transferred to his wheelchair and wheeled himself to the bathroom then transferred himself to the toilet. Review of the Progress Note dated 08/22/19 at 02:36 PM revealed staff heard the resident's personal alarm sound at 12:25 PM. Unidentified staff found R3 on the floor in his bathroom. The resident reported he tried to transfer himself to the toilet, turned to grab the sink, and lost his balance. Review of the Nursing Pocket Guide (a guide which informed the staff of each resident's transfer ability, toileting schedule, and special equipment required during care) for R3 updated on 09/11/19 revealed the facility failed to address toileting the resident and/or a toileting plan for the resident. An observation on 09/18/19 at 09:15 AM revealed Certified Nurse Aide (CNA) C and CNA D entered the resident's room and explained to the resident they needed to check and change his incontinent product. Both CNA C and CNA D removed the resident's old incontinent product, which staff C confirmed was wet with urine. CNA C and D cleaned the resident and placed a clean incontinence product on the resident. CNA C and D stated the resident's care plan directed them to check and change the resident every two hours and as needed. An observation on 09/18/19 at 11:45 AM revealed CNA [NAME] and CNA D assisted the resident to stand with the assistance of a gait belt and hand rails located next to the toilet. The resident followed CNA E's directions to pivot and sit on the toilet. The resident had a bowel movement and told the staff he finished and was ready to get up. CNA [NAME] provided peri-care, changed the resident's brief, and replaced R3's clothing. CNA D and [NAME] confirmed the resident's incontinence product was damp, but not wet and they assisted the resident back to his wheelchair. The resident did not have behaviors or refuse care during the observation. Interview on 09/18/19 at 09:20 AM with CNA C revealed the resident required a check and change program, every 2 hours, and as needed. CNA C revealed the resident was totally incontinent of bowel and bladder and required a brief for comfort and dignity. CNA C revealed the resident asked to go to the bathroom at times, put on his call light to tell the staff he had to go to the bathroom, and stated he could not wait and/or he needed to be changed. Further interview with CNA C on 09/18/19 at 11:15 AM revealed she did not know the resident's care plan advised staff to check and change the resident every hour. CNA C revealed she followed the nursing pocket guide to know what cares to provide to residents. CNA C confirmed the nursing pocket guide failed to include the R3's toileting program. Interview on 09/18/19 at 12:01 PM with CNA D revealed the resident required every two-hour check and change program. CNA D confirmed the resident attempted to transfer himself to the toilet without staff assistance several times since admission and his functional ability improved. CNA D revealed the resident asked her in the past to toilet him and CNA D did not know the resident's care plan advised staff to check and change the resident every two hours. CNA D confirmed staff did not toilet the resident until advised to do so by the nurse on 09/18/19. CNA D confirmed the nursing pocket guide failed to address the resident's incontinence and toileting schedule. Interview on 09/18/19 at 10:40 AM with Licensed Nurse (LN) F revealed the resident did not have a toileting plan. LN F stated the resident had impaired cognitive ability, was bed bound upon admission and placed on an every two-hour check and change program to manage his incontinence. Licensed F revealed R3 improved since admission and could bear weight and stand-pivot transfer with the assistance of two staff members and gait belt. LN F confirmed she did not know R3's care plan instructed staff to check and change the resident every hour. LN F further confirmed the resident asked to be toileted and informed staff in the past he just urinated on himself and needed to be changed. LN F revealed the Unit Manager G was responsible for review of the resident's three-day voiding trial and developed the resident's care plan from those results. Interview on 09/18/19 at 01:35 PM with Administrative Nurse G revealed she was responsible for the development of the R3's toileting program after she reviewed R3's voiding trial information. Administrative Nurse G stated the resident was bed bound and non-weight bearing upon admission to the facility and even though R3's voiding trial showed he had more episodes of continence than episodes of incontinence she placed R3 on a check and change, every 2 hour and as needed plan. Administrative Nurse G stated she did not think about offering the resident a bed pan, urinal or staff assistance to the toilet to help maintain or improve his current level of continence and to decrease his risk for decline. Administrative Nurse G stated she believed she placed the resident on an every one-hour toileting plan on 07/02/19 and confirmed she updated the resident's care plan. Nurse G denied she updated the resident's care plan on 09/17/19 with the new plan for the resident to be checked and changed every hour. Nurse G stated the facility should have completed a new voiding diary for the resident as he regained his functional abilities and the facility failed to do so. Interview on 09/18/19 at 02:00 PM with Administrative Nurse B revealed the facility failed to develop an appropriate toileting schedule for R3. Staff B revealed staff did not know the resident's toileting plan changed on 07/02/19 and confirmed failed to update the care plan until 09/17/19. Administrative Nurse B confirmed the nursing pocket guide failed to address the resident's toileting plan and the facility should have re-evaluated the resident as his physical functioning improved. Interview on 09/18/19 at 11:45 AM with Administrative Staff A revealed the facility should have addressed the resident's voiding patterns and developed an appropriate toileting plan to promote the resident's highest level of physical and mental functioning. Administrative Staff A confirmed the facility failed to implement an appropriate toileting plan upon R3's admission to the facility and failed to re-evaluate R3's continence with his improved physical functioning. Review of the undated policy Urinary Incontinence revealed an incontinent resident typically felt frustrated, embarrassed, and hopeless. Staff would assess elimination patterns, establish a voiding schedule and record the results. Review of the policy Care Plan, last revised (MONTH) 4, 2019 revealed residents with incontinence of bladder and or bowel would receive appropriate treatment and services based on their comprehensive assessment to prevent urinary tract infections and to restore as much bladder and/or bowel function as possible. The facility failed to assess and develop a toileting pattern from the results of R3's voiding trial, failed to re-evaluate R3's urinary continence after an improvement in his/her physical functioning, and failed to assist R3 with toileting after his multiple requests to be toileted which resulted in the resident being incontinent of urine and bowel.

The facility census totaled 55 residents with 1 sampled for pressure ulcers. Based on observation, interview and record review the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer after admission. Resident #46 developed a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) on the coccyx after admission. The facility failed to thoroughly assess the wound at the time of discovery (measurements) and failed to assess for causative factors and implement appropriate pressure reduction interventions for a 5 day time period. At the end of 5 days, the pressure ulcer deteriorated to a Stage III (full thickness tissue loss; fat located beneath the skin may be visible but bone, tendon or muscle are not exposed). Finding included: - The signed recapitulation of the physician's orders [REDACTED].#46 included [DIAGNOSES REDACTED]. Review of the significant change MDS (minimum data set) dated 8/7/15 revealed a BIMS (brief interview for mental status) score of 4 indicating severely impaired cognition. The MDS indicated the resident required supervision with transfers, walking, locomotion, eating, toileting and personal hygiene but was independent in bed mobility. The MDS indicated the resident had occasional urinary incontinence and was always continent of bowel. According to the MDS, resident #46 was not at risk for pressure ulcer development, had no history of pressure ulcers and no current pressure ulcers. The CAA (care area assessment) dated 8/15/15 for cognition included the resident had a [DIAGNOSES REDACTED]. The CAA also described the resident as occasionally incontinent of urine. The CAA for pressure ulcers did not trigger for further assessment. The quarterly MDS dated [DATE] indicated the resident had severely impaired cognition with a BIMS score of 5 and needed supervision for all ADLS (activities of daily living) except personal hygiene which required limited assistance. The MDS indicated the resident had frequent bowel and bladder incontinence and had no pressure ulcer risk and no history of pressure ulcers or current ulcers. Review of the resident's care plan with a revision date of 11/13/15 revealed the resident had the ability to take his/her own showers, re-position self, and required no staff assistance to turn and reposition in bed. The care plan directed staff to provide assistance as necessary during times of increased fatigue and may occasionally need one assist. The resident required skin inspection weekly and with cares. Observe for redness and open areas and report changes to the nurse. The resident was able to ambulate to the bathroom with supervision and set up assistance from staff. On 1/9/16 the facility revised the care plan to address resident #46's pressure ulcer which directed staff to administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width and depth where possible. Report improvement and declines to the physician. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Apply new dressing per dr's orders when soiled or dislodged. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Resident received a regular diet with good sources of protein, vitamin C through the regular menu and received Arginade twice daily to help with healing. The care plan did not direct staff to follow a prompting/repositioning plan for the resident and did not include interventions related to use of pressure reduction devices. On 1/14/16 the facility again revised the care plan with interventions which directed staff to remind the resident to turn/reposition at least every 2 hours or more often as needed or requested, especially during the night time hours. Make frequent checks during the night and assist with position changes. The resident required an air mattress when in bed. Check function of air mattress to make sure it was properly working every shift. Treat pain as per Dr's orders prior to treatment/turning to ensure the resident's comfort. Monitor facial expressions and body language that may indicate resident is in pain and offer prn (as needed) Tylenol. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage) by the Wound Nurse. On 11/6/15 the facility completed an assessment used to determine the resident ' s risk of pressure ulcer development (Braden scale). According to that assessment, the resident was not at risk for development of pressure ulcers. According to weekly skin assessments completed between 11/4/15 and 1/5/16, resident #46 did not have any skin breakdown during the two month time period. Review of the nurses ' notes from 12/1/15 thru 1/9/16 revealed no documentation related to resident #46 ' s skin or areas of skin breakdown. Then, on 1/9/2016 at 8:45 a.m., a licensed nurse described a quarter sized open pressure ulcer on the top of the resident ' s coccyx, in between the buttocks. According to the note, the resident denied pain from the pressure ulcer. The nurse documented initiation of wound treatments with wound cleanser and a foam self-adhesive dressing over the pressure ulcer. This initial assessment of the coccyx pressure ulcer did not include specific would measurements or descriptions of surrounding tissue. On 1/10/16 at 7:24 a.m. a licensed nurse documented the presence of a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) open quarter sized pressure ulcer on the upper coccyx. According to the note, the pressure ulcer did not have a dressing over it at the time of the observation. Review of the clinical record revealed no evidence of assessment of the pressure ulcer or surrounding tissue in the 4 day time period between 1/10/16 and 1/14/16. The clinical record also lacked evidence of assessment for causative factors of the pressure ulcer and then timely intervention of appropriate pressure reduction devices to promote healing of the wound and prevent further tissue damage. The facility provided a Wound-weekly observation tool staff should use to document thorough assessments of newly developed pressure ulcers as well as weekly assessments of existing pressure ulcers. Review of the clinical record revealed no evidence the licensed nurse completed that assessment at the time he/she first identified the coccyx pressure ulcer on 1/9/16. According to documents found in the clinical record, staff completed the Wound - weekly observation tool for the first time on 1/14/16, five days after staff first noted the presence of the pressure ulcer. At the time of the 1/14/16 assessment, the licensed nurse identified a deterioration of the pressure ulcer which he/she now identified as a Stage (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) which measured 3.5 cm (centimeters) in length by 2 cm wide by 0.3 cm deep. Between 1/9/16 (day of discovery) until 1/14/16 the facility failed to thoroughly assess and identify causal factors for the pressure ulcer and then failed to develop and implement appropriate pressure reduction strategies to promote healing of the wound and prevent further skin breakdown. Review of the nurses ' progress notes revealed an entry dated 1/21/16 at 8:58 pm which included; the wound showed good evidence of healing and had granulation tissue (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process). The wound did not appear to be a stage three it appeared to be a stage 2 involving the dermis (thick layer of tissue just below the outer skin) and epidermis (outer layer of skin.). Review of the physician ' s progress notes revealed on 2/4/16 4:35 pm the physician visualized the wound as approximately 1.5 cm, healing now, wound clean and being treated. Resident lays on back at night. Review of the physician orders [REDACTED]. According to that faxed communication, staff applied [MEDICATION NAME] (foam adhesive dressing) over the pressure ulcer and started the resident on [MEDICATION NAME] (a protein supplement). The physician's assistant signed the fax on 1/14/16, 5 days after facility notification. On 1/14/16 a nurse obtained a telephone order from the physician for an air mattress to the resident's bed, a narcotic pain medication for wound pain at coccyx and Arginade twice a day supplement for wound healing. Observation on 2/3/16 at 7:58 am revealed the resident ambulated independently in the hallway. Observation at 8:15 am, 8:35 am, and 8:55 am revealed the resident continued to ambulate in the hallway. At 9:45 am observation revealed the resident coming out of his/her bathroom independently and resumed walking in the hallway. Observation on 2/3/16 at 2:10 pm revealed the resident ambulated in the on the 3rd floor. At 2:43 pm the resident ambulated on the 2nd floor and at 3:02 pm he/she used the bathroom in his/her room independently then resumed ambulating in the hallway. Observation of the dressing change to the open area on 2/3/16 at 4:54 pm revealed an open area of full thickness tissue loss (Stage III) and rolled wound edges located on the resident ' s coccyx/sacral midline, measuring the approximate size of a half dollar. At the time of the observation, resident #46 lay on the bed which had a pressure reduction mattress in place. The resident got out of bed immediately after the dressing change. Interview with direct care staff T revealed he/she will check the residents' skin during their baths or with any cares and notify the nurse of any redness or sores. Staff T said he/she was unaware of the resident's pressure ulcer until after it was found, he/she did not know what caused it since the resident walked around all the time. Interview with direct care staff U on 2/3/16 at 3:28 pm revealed he/she had not noticed any more incontinence with the resident and that the resident walked around like normal. Staff U reported they were to check resident ' s skin anytime they provided cares and would tell the nurse if anything was different and document as an alert on the electronic record. On 2/3/16 at 2:45 pm licensed nurse V reported he/she thought the area was caused by the resident scratching back there and he/she saw it on 1/9/16 and assessed it as a stage 2 pressure ulcer but did not complete the wound observation tool. Interview on 2/3/16 at 3:45 pm with licensed nurse Y revealed that he/she received a call on Saturday, 1/9/16 about the newly discovered pressure ulcer on the resident's coccyx. Nurse Y said he/she directed the nurse to clean the area, measure the area, and cover it with [MEDICATION NAME] dressing. Nurse Y said he/she told the nurse to document what was found and that nurse Y would do the weekly measurements on Friday as usual. Interview with licensed nurse F on 2/3/16 at 3:00 pm revealed that he/she assessed the area on 1/14/16, determined the cause of the pressure ulcerw as the resident sleeping on his/her back, and ordered an air mattress on 1/14/16. During an interview on 2/4/16 at 10:28 a.m., Physician FF reported he/she just visualized resident #46's pressure ulcer for the first time and considered it a Stage 3 area caused by pressure rather than trauma. Interview on 2/4/16 at 11:11 am licensed nurse W revealed a probable cause for the pressure ulcer of the resident slept flat on his/her back all night long. Interview on 2/8/16 at 11:31 am with administrative nurse C revealed he/she assumed supervisory duties on or about 1/25/16 and although he/she was made aware of the pressure ulcer he/she assumed the matter had been addressed and as of 2/8/16 had not visualized or assessed the resident's stage 3 pressure ulcer. Administrative nurse C said that would be his/her expectation for staff to complete the wound observation tool at the time of discovery and then weekly thereafter. The facility provided a policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol. Review of the policy revealed that the nurse shall assess and document/report the following: vital signs, full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue, pain assessment, resident's age and sex, resident's mobility status, current treatments including support surfaces and all active diagnoses. The facility failed to ensure resident #46 did not develop a pressure ulcer after admission. Resident #46 developed a Stage 2 pressure ulcer on the coccyx after admission. The facility failed to thoroughly assess the wound at the time of discovery (measurements) and failed to assess for causative factors and implement appropriate pressure reduction interventions for a 5 day time period. At the end of 5 days, the pressure ulcer deteriorated to a Stage III).

The facility had a census of 53 residents. The sample included 22 residents, including 2 residents reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to implement effective interventions to prevent the development of pressure ulcers for 1 (#62) of these 2 residents sampled for pressure ulcers. Findings included: - The admission Minimum Data Set (MDS) for resident #62, who was admitted on [DATE], dated 8-18-14, recorded the resident had a Brief interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, was independent with locomotion on and off the unit, and required extensive assistance of two staff for bed mobility. Furthermore, the resident experienced no impairment in range of motion (ROM) of the upper extremities, however did have impairment in the lower extremities bilaterally. The MDS included the resident was always incontinent of bowel and had an indwelling Foley catheter, was at risk for developing pressure ulcers, had three un-stageable pressure ulcers on admit, one stage IV pressure ulcer which was present upon admit and one stage I or higher pressure ulcer on admit. The MDS included the resident utilized a pressure reducing device for his/her chair and bed. Not on a turn and repositioning schedule. Review of the physician's orders [REDACTED]. have a negative effect on health, leading to reduced life expectancy and/or increased health issues), [MEDICAL CONDITION] (paralysis characterized by motor or sensory loss in the lower limbs and trunk), [MEDICAL CONDITION] bowel (dysfunction of the bowel caused by a lesion of the nervous system), [MEDICAL CONDITION] bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream). The resident's pressure ulcer care area assessment (CAA), dated, 8-18-14, included the resident admitted to the facility with skin concerns which included a pressure ulcer to his/her buttocks and toes. The CAA continued to show that the areas were improving since his/her admission. Staff assisted the resident with frequent position changes and supportive devices were in place to aide in the healing process. Staff applied foam boots to his/her feet while in bed, used a foot cradle and the RN/LPN completed weekly skin assessments. The Braden assessment recorded the resident was at high risk for the development of pressure ulcers. The resident's care plan, dated, 8-11-14, included the resident required assistance of 2 to move his/her lower body and was able to move his/her upper body in bed per self. The resident was independent with personal care after set-up. The care plan continued to document the resident needed to be repositioned side to side with a supportive pillow at their back side. Staff were to apply heel protectors while in bed and podus boots (usually prescribed for pressure ulcers and ankle foot contractures). The end of the heel was susceptible to ulceration without protection while up in the wheelchair. Staff were to change the resident's dressings as ordered by the physician. The RN (registered nurse)/LPNs (licensed practical nurse) were to perform weekly skin assessments, and direct care staff were to complete daily skin assessments. Skin assessments for the resident identified the following: On 8-11-14, the resident's admission skin assessment had a note which documented the resident had numerous skin problems. However, the assessment only identified the right big toe with reddened dry area 0.5 cm, (the only measurement), right below the right big toe and a scar to the right heel 0.5 cm (the only measurement). The skin assessment documented the visible tissue was improving. The wound to the sacrum was dry and a duoderm dressing was intact. (This was the only documentation found regarding the area on the sacrum). The resident's skin assessment dated [DATE], included an additional area to the posterior (back of) upper thigh which documented the area was improving. This was the only documentation found regarding this area. Left posterior buttock crease: (Not identified on the 08/11/14 admission assessment) 09/03/14 - present on admission, staged as a stage IV pressure ulcer. Visible tissue is improving with granulation tissue present. 09/08/14 - stage IV pressure ulcer to the left posterior buttock crease with granulation tissue present. 09/17/14 - stage IV pressure ulcer to the left posterior buttock crease, remained unchanged, with granulation tissue present. 09/25/14 - no documentation on this area. Right great toe: 09/03/14 - tip of right great toe, suspected deep tissue injury (SDTI) which the resident admitted with improving yet had necrotic (dead black) tissue present. The area was smaller than on admission. 09/08/14 - a pressure ulcer, SDTI, necrotic tissue present. The area was smaller than on admission. 09/17/14 - no documentation on this area. 09/25/14 - tip of right great toe was healed. Left great toe: 09/03/14 - area improving with necrotic tissue present. The area was smaller than on admission. 09/08/14 - area is improving with necrotic tissue present and the area was smaller than on admit. 09/17/14 - no documentation on this area. 09/25/14 - tip of left great toe was healed. Outside of left great toe: 09/03/14 - pressure ulcer, SDTI, which resident was admitted with is improving with necrotic tissue and the area was smaller than on admit. 09/08/14 - area improving with necrotic tissue present and the area was smaller than on admit. 09/17/14 - no documentation on this area. 09/25/14 - outside of the left great toe is healed. Treatment orders documented: Left great toe tip stage II pressure ulcer measuring 1.0 X 1.75 cm. 8-26-14 order to leave open to air. 9-30-14 order to cleanse with wound cleaner and pat dry. Apply triple antibiotic ointment and 4 X 4. Secure with [MEDICATION NAME]. 10-15-14 order to use safe-gel and cover with 4 X 4 and secure with [MEDICATION NAME]. The 09/25/14 skin assessment further revealed 2 new areas of development: Right upper foot at the bend of the resident's leg and foot - acquired on 09/24/14 - stage II - with granulation tissue present. On 09/25/14, a treatment order documented, *Dorsal (to the side or back) aspect of right foot, stage II pressure ulcer measuring 2.0 X 1.5 X 0.2 cm (centimeters). Apply duoderm with hydroactive gel. Change every 72 hours. Clean with wound cleaner. Middle of the left outer foot, acquired on 09/24/14 - stage II - with granulation tissue present. Treatment orders documented the following: Left plantar (bottom or underside) surface unstageable pressure ulcer with eschar measuring 1.0 X 0.9 X 0.2 cm. 10-15-14 order to use [MEDICATION NAME] cream and cover with 4 X 4 and secure with [MEDICATION NAME]. Skin assessments were unclear on what pressure ulcers the resident was admitted with and were not clear on when staff identified the other pressure ulcers. Furthermore, the clinical record lacked evidence the staff notified the physician of the pressure ulcers for timely intervention. The following areas were not identified on the skin assessments. Treatment orders documented the following: *Left second toe tip stage II pressure ulcer measuring 1.2 X 1.2 X 0.2 cm. 8-26-14 order to leave open to air. 9-30-14 order to cleanse with wound cleaner and pat dry. Apply triple antibiotic ointment and 4 X 4. Secure with [MEDICATION NAME]. 10-15-14 order to use safe-gel and cover with 4 X 4 and secure with [MEDICATION NAME]. *Right buttock stage II pressure ulcer measuring 3.5 X 1.5 X 0.2 cm. 10-15-14 order for duoderm. *Left superior gluteal fold stage III pressure ulcer measuring 3.0 X 3.0 X 3.0 cm. 8-12-14 order to cleanse with wound cleanser and pat dry with gauze. Pack with algicell cut to fit. Cover algicell with AU [MEDICATION NAME] foam and secure with [MEDICATION NAME]. Change every three days and as needed. 8-14-14 order to clean stage IV pressure ulcer wound with wound cleanser and pat dry with gauze. Pack with algicell AG strip and cover with [MEDICATION NAME] foam. Secure with [MEDICATION NAME]. 9-25-14 order to pack with plain packing strip wet with normal saline twice a day until healed. Cover with 4 X 4 and secure with [MEDICATION NAME]. 10-15-14 order for [MEDICATION NAME] AG packing soaked in normal saline. Cover with 4 X 4 and secure with [MEDICATION NAME]. *Left distal gluteal fold stage II pressure ulcer measuring 1.0 X 1.5 X 0.2 cm., identified on 9-08-14. 9-24-14 order to cleanse with wound cleaner and pat dry. Apply duoderm. Change every 3 days. 9-30-14 order to cleanse with wound cleaner and pat dry. Apply duoderm. Observation, on 10/15/14 at 8:20 am, revealed the resident in bed on the right side and propped with a wedge pillow. Direct care staff O and P assisted the resident to turn and reposition on the left side. It was noted, at that time, the resident turned and used the grab bars to pull him/herself up and over. At 9:30 am, it was noted the resident lying on his/her back in bed with the head of the bed up approximately 30 degrees. The resident had just finished eating breakfast of eggs, sausage, and toast. The resident took 100% (percent). Intermittent observation, at 9:45 am, 10:15 am, 10:30 am, 10:45 am, 10:00 am, 11:00 am, and 11:15 am revealed the resident remained in the same position. At 11:45 am, the resident had been repositioned, sitting up higher in the bed. The resident, at that time, stated he/she had been repositioned. Observation on 10/15/14 at 1:15 pm, of the treatment of [REDACTED]. Dorsal aspect of the right foot, stage II, measuring 2.0 cm x 1.5 cm x 0.2 cm. Dressed with duoderm. Right great toe pressure ulcer, stage II measuring 0.8 cm x 0.1 cm. Dressed with duoderm. (Previously documented as healed). Left great toe tip, stage II, 1.0 cm x 1.75 cm. Treated with safegel and covered with 4 x 4 and [MEDICATION NAME]. ( Previously documented as healed). Left second toe tip, stage II, measuring 1.2 x 1.2 x 0.2 cm. Treated with safegel and covered with 4 x 4 and [MEDICATION NAME]. Left plantar surface, unstageable eschar, measuring 1.0 x 0.9 x 0.2 cm. Treated with Silvadine cream and covered with 4 x 4 and [MEDICATION NAME]. Right buttock, stage II, measuring 3.5 cm x 1.5 cm by 0.2 cm. Dressed with duoderm. Left superior gluteal fold, stage III, measuring 3.0 cm x 3.0 cm x 3.0 cm. Treated with [MEDICATION NAME] AG packing soaked in saline covered by 4 x 4 and [MEDICATION NAME]. Staff took a culture of this wound. Left distal gluteal fold, stage II, measuring 1.0 cm x 1.5 cm x 0.2 cm. Covered with duoderm. Staff stated the aforementioned areas were not new areas. Also, during this observation, the following new pressure ulcers were found. Staff notified the physician and treatment orders were obtained. *Right buttock stage II pressure ulcer measuring 3.5 X 1.5 X 0.2 cm. 10-15-14 order to cover with duoderm. *Midline back at L 4 (lumbar area) stage II pressure ulcer measuring 3.0 X 4.0 X 0.2 cm 10-15-14 order to cover with duoderm. *Coccyx stage II pressure ulcer measuring 0.5 X 0.5 X 0.2 cm. 10-15-14 order to cover with duoderm. *Left superior inner thigh adjacent to peri-neum stage II pressure ulcer measuring 0.3 X 0.7 X 0.2 cm. 10-15-14 order to cover with duoderm. *Left distal inner thigh stage II pressure ulcer measuring 0.4 X 1.5 X 0.2 cm. 10-15-14 order to cover with duoderm. *Left upper outer thigh stage II pressure ulcer measuring 3.5 X 0.4 X 1.2 cm. 10-15-14 order to cover with duoderm. *Right little toe stage I pressure ulcer measuring 1.0 X 1.0 cm. 10-15-14 order to use safe-gel. Observation, on 10/16/14 at 1:30 pm, revealed the resident in the wheelchair, with a gel cushion in place. The resident, used his/her arms and lifted him/herself up in the chair, off of the gel cushion, and then resituating him/herself, sat back down in the wheelchair. On 10/15/14 at 1:14 pm, licensed nursing staff I stated the admission skin assessment had not been completed on admission. Staff I stated the wounds had been taken care of as they should and the weekly skin assessments had not been done and were not accurate. Staff I also stated the physician had not been notified of all of the open areas on the resident and the facility did not have orders for all of the areas, at that time. Staff member I also stated he/she was not sure of what all areas the resident had or what needed to be done for each of them. On 10-15-14 at 3:35 p.m., administrative nursing staff member B, stated the expectation was for nurses to take measurements at least weekly. Measurements need to be done each time staff change a dressing. Staff should also make a nurses note addressing the wound. Administrative nursing staff member B stated they were attempting to reduce staff at the facility and the expectation was that the unit coordinators would take over doing the wound assessments, however, that had not happened. Staff member B stated he/she was surprised the resident had developed additional wounds and did not realize the wounds progressed. On 10-16--14 at 3:45 p.m., licensed nursing staff J, stated that staff were to complete skin assessments weekly. When there was a new skin issue, the facility protocol was to make a nurses note, initiate standing orders, and fax the doctor. Nursing staff J stated staff did not start the [MEDICATION NAME] (a protein supplement ordered for wound healing) until 9-04-14 (over 3 weeks after admission) even though it was on the standing orders for pressure areas and should have been started the day of admit. On 10-15-14 at 11:23 a.m., physician staff E, stated that the facility needed to be more vigilant on watching for pressure ulcers and should receive more information on how to treat and prevent them. He/she stated that the nurses needed to document weekly and include measurements of wounds. The facility's undated policy, documented that a licensed nurse would perform a full-body skin assessment on the day of admission within 2-4 hours of entrance to the facility and again on the last day of the assessment period. A licensed nurse would also perform and document a skin assessment weekly on every elder of the facility. Weekly skin assessments would be done by the assigned shift and staff would notify the skin assessment coordinator of any reddened or open areas. Staff would complete daily wound documentation for active pressure wounds. The facility failed to promote healing of pressure ulcers and also failed to develop and implement interventions to prevent the development of new pressure ulcers for this dependent resident. Furthermore, the facility failed to consistently assess and document the condition of the resident's pressure ulcers to determine if physician notification and change of treatment was necessary. The resident developed 6 new stage II pressure ulcers, one new stage I pressure ulcer, and the existing pressure ulcers worsened.

The facility reported a census of 53 residents with 22 sampled for review and 3 residents reviewed for falls/accidents. The facility had 3 floors with resident rooms on the second and third floors. Based on observation, interview, and record review, the facility failed to ensure 3 of 3 residents sampled for falls/accidents received adequate supervision to prevent accidents. (#59, #35, and #43) Resident #59 sustained a fall with a right hip fracture on 10/8/14 after a readmission to the facility on [DATE]. The facility failed to implement appropriate fall prevention strategies when the resident returned to the facility with increased confusion. Findings included: - Resident #59 ' s 9/4/14 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 13 which indicated intact cognition and required limited assistance of one person for bed mobility, transfers, walking in his/her room and corridor, and with toilet use. According to the assessment, the resident ' s balance was unsteady and he/she had the ability to stabilize without assistance from others. Resident #59 had no functional limitations in range of motion and used a walker for mobility. The assessment also revealed the resident sustained [REDACTED]. Resident #59 ' s 9/10/14 ADL (activity of daily living) CAA (care area assessment) stated the resident had a UTI (urinary tract infection) prior to coming to the facility which contributed to several falls in the month prior to admission to the facility. The 9/10/14 Fall CAA indicated that resident #59 ' s fall risk assessment completed on admission revealed he/she was at a greater risk for falls due to weakness. The CAA further stated the resident required stand by assistance with ambulation, he/she utilized a walker, and staff encouraged appropriate footwear including non-slip socks at night. Resident #59 ' s 8/29/14 nursing care plan directed staff to provide stand by assistance with his/her four-wheeled walker for mobility. The care plan identified the resident as at risk for falls with a goal to be " free of falls " through the review date of 1/16/2015. The resident ' s 8/29/14 fall care plan stated the resident was at risk for falls due to his/her weak gait and instructed staff to assist with appropriate footwear, including non-slip socks at night, lock the wheelchair brakes prior to transfers, and to encourage him/her to use the bell to call for assistance. Review of the nursing care plan lacked revision related to fall prevention or an increased need for assistance after the resident returned to the facility from a hospital admission with acute delirium (sudden severe confusion, disorientation and restlessness), pneumonia (inflammation of the lungs), and CHF (congestive heart failure, a condition with low heart output and the body becomes congested with fluid) on 10/6/14. A care plan revision dated 10/9/14 (placed after the resident sustained [REDACTED]. Resident #59 ' s Morse Fall Scale dated 8/29/14 revealed a score of 65. According to the Morse scoring scale, scores above 45 indicated a high risk for falls. A Morse Fall Scale completed on 10/6/14 (following re-admission from the hospital) revealed a score of 75, also a high risk for falls. According to a 9/27/14 nurses ' progress note, the resident had 2-3 + pitting edema (fluid builds up in the extremities to such a degree that when the fluid-filled extremity is gently pushed with a finger, a depression will remain) in his/her legs, " crackles " (moist lung sounds when listening with a stethoscope) throughout the lungs, and the resident stated he/she had difficulty breathing. The resident ' s family transported him/her to the local hospital emergency room . A progress note dated 10/3/14 revealed resident #59 ' s family called and requested that he/she be placed on the second floor of the facility when he/she returned due to confusion and requested a room next to the nurses ' station. According to the note, the nurse notified administrative nurse C of the family ' s request. Review of the clinical record lacked follow-up regarding the family ' s request for a room change due to his/her condition. A nurses ' progress note dated 10/6/14 at 9:08 p.m. revealed staff readmitted the resident to a room on the third floor of the facility and documented the resident had confusion and was unaware of his/her location. According to the nurses ' note, staff placed a bed alarm in the resident ' s wheelchair for use when he/she was up. A nurses ' progress note on 10/7/14 stated resident #59 was restless most of the shift and would not stay in bed or sit in his/her chair, but wanted to wander around his/her room. According to a nurses ' progress note dated 10/8/14, staff found resident #59 on the floor at 9:10 p.m. laying on his/her right side with right hip pain. According to the note, he/she was in the recliner and was " up and down all shift " . The note stated the pressure alarm was left on the bed and was not sounding off. After notifying the physician, the physician ordered a transfer to the local hospital emergency room for evaluation and treatment for [REDACTED]. The facility ' s fall investigation stated that on 10/8/14 at approximately 9:10 p.m., resident #59 attempted to stand up without assistance, was unable to maintain his/her balance, and an un-witnessed fall occurred. Prior to the fall, the resident was restless and was in various locations and position changes, including the wheelchair and bed. According to the investigations, the care plan did not include a pressure alarm however, licensed nurse J instructed direct care staff to implement the alarm due to the resident ' s present fall risk and confusion. The investigation stated, when resident #59 fell the pressure alarm was not in place. The resident sustained [REDACTED]. The resident was a poor surgical candidate and he/she returned to the facility. A nurses ' progress note dated 10/10/14 revealed the resident returned to the facility at 1:45 p.m., admitted to a second floor room of the facility, oriented to person only and confused. The resident had an order for [REDACTED]. The resident was unavailable for observations. During an interview on 10/15/14 at 2:48 p.m., direct care staff X stated that when the resident returned from the hospital on [DATE], he/she required more assistance. Staff X stated that prior to the hospitalization resident #59 required stand-by assistance of one person, but after he/she came back from the hospital, he/she was not the same. According to staff X, they (direct care staff) received direction to assist the resident with one person instead of stand-by assist due to his/her confusion. Direct care staff X further stated that he/she was unaware of any fall precautions for this resident but did more visual checks because he/she had more confusion. Staff X stated that on the evening when resident #59 fell , he/she saw the resident sitting on the edge of the bed and the resident would not lie down. Staff X stated the alarm was on the bed and he/she fell about 20 minutes later. An interview on 10/16/14 at 2:34 p.m. with direct care staff Y revealed that on the evening when resident #59 fell , he/she assisted the resident to the recliner and was unaware that the resident needed a pressure alarm in place. During an interview on 10/15/14 at 3:26 p.m., licensed nurse J stated that after the resident returned to the facility on [DATE], his/her family discussed their desire for the resident to move to a private room on the second floor. According to nurse J, he/she informed the resident ' s family that no private rooms were available on the second floor and the resident returned to the third floor on 10/6/14. Licensed nurse J stated the resident required assistance of 2 persons when he/she returned to the facility on [DATE]. Nurse J stated the resident had increased confusion and did not know his/her limits. Licensed nurse J stated that on 10/8/14 staff observed the resident prior to the fall sitting in his/her recliner and was unsure if the alarm sounded. During an interview on 10/16/14 at 8:30 a.m., administrative staff A stated that licensed nurse J instructed direct care staff to implement a pressure alarm due to the resident ' s fall risk and increased confusion after readmission to the facility on [DATE], but failed to add the intervention to the resident ' s care plan. Administrative staff A confirmed that the pressure alarm was not in place at the time of resident #59 ' s fall on 10/8/14. An interview on 10/16/14 at 9:59 a.m. with administrative nurse B verified that resident #59 had increased confusion when re-admitted to the facility on [DATE] following a hospitalization for CHF and pneumonia. Nurse B further confirmed a nurses ' note dated 10/6/14 revealed placement of a bed alarm and confirmed the care plan lacked revision with the implementation of the alarm or the resident ' s need for increased assistance from staff due to his/her increased confusion and weakness following hospitalization . During an interview on 10/20/14 at 12:25 p.m., physician Z stated that when the facility readmitted resident #59 on 10/6/14, he/she had declined cognitively with increased confusion and required more assistance. Physician Z verified that the resident ' s CHF and pneumonia improved, however, he/she declined cognitively and there was discussion regarding moving the resident to the dementia floor (second floor of the facility). Physician Z further believed that it was made clear at the time of discharge that the resident had declined and required more assistance due to his/her dementia. On 10/20/14 at 5:01 p.m., administrative nurse B verified the facility placed resident #59 on the fall management program and indicated that restorative staff placed a yellow #1 (indicating which bed was occupied by a resident at high fall risk) on resident #59 ' s door on 10/7/14. The facility ' s 11/3/2010 revised Fall Protocol Policy stated the facility would put in place actions to provide adequate assessments and interventions to enhance the safety for the residents. The facility sill also identify resident at risk for falls with the fall risk assessment upon admission, readmission, quarterly, and with significant changes. If the resident scores 10 or above on the fall risk assessment the resident would be placed on the fall management program. The facility failed to implement appropriate fall prevention strategies for resident #59 after his/her readmission to the facility on [DATE] after a hospitalization . When readmitted to the facility on [DATE], the resident required more staff assistance and had increased confusion. Resident #59 fell on [DATE] and sustained a right fractured hip as a result of the fall. - Review of resident (#43's) Physician order [REDACTED]. The significant change MDS (Minimum data set), dated on 8/28/14, documented the resident has adequate hearing, sometimes understands others, sometimes others can understand the resident, speech is unclear. short term and long term memory impairment. moderately impaired for decisions regarding tasks of daily life. Required extensive assist of 2 staff with transfers and toilet use, limited assist of 2 staff members for walking and locomotion. No impairment in upper and lower extremities. always incontinent of urine and frequently incontinent of bowel. The CAA (care area assessment) for falls, dated on 8/28/14, revealed that the resident has had several falls during the look back period. Interventions such as frequent toileting, keeping walker close to bedside for utilization and assisting with repositioning in bed all put into place to help prevent future falls. The resident's room is close to the nurses station and he/she utilizes a pressure alarm to help remind him/her to not get up without staff assistance and to alert staff if he/she forgets. The restorative aide (RA) works with the resident 3 times a week. The CAA (care area assessment) for cognitive loss, dated on 8/28/14, revealed the resident has a [DIAGNOSES REDACTED]. The resident was unable to complete the BIMS interview, so the staff was interviewed. The staff stated that he/she knows where his/her room is and recognizes staff faces. His/her cognitive skills for decision making is moderately impaired. Due to the residents [DIAGNOSES REDACTED]. The CAA (care area assessment) for ADLs (activities of daily living) functional, dated on 8/28/14, revealed the resident required assistance with ADLs. He/She had several falls as noted on The Falls Management Program paperwork in residents chart. He/She is allowed to participate in his/her ADLs within his/her limits so that he/she can maintain his/her current ROM (range of motion) and independence. The plan of care, dated on 1/23/14, revealed the resident is at an increased risk for falls due to an unsteady gait. Please remind and assist him/her in wearing appropriate footwear, including non slip socks at night. He/She needs assistance with repositioning in bed to get comfortable. Turn him/her toward the wall when he/she can not get comfortable, this helps him/her not to get up repeatedly and prevents falls. Please make sure his/her night light is left on during the night time hours. When he/she utilizes the wheel chair, please make sure to remind him/her to lock the breaks prior to all transfers in or out of it. Monitor and report changes in anxiety, sleep patterns, behavior such as picking at his/her head and mood. Please offer him/her stand by assist with walker for transfers. The resident sometimes will miss his/her mark when he/she goes to sit down and miss the bed or chair falling on the floor, so please assist him/her with sitting down. The plan for toileting included: Tthe resident does not tell the staff when he/she needs to be toileted. The resident likes to go to the restroom before meals. He/She is on a P/V (planned voiding) schedule. Please take him/her to the restroom between 6:30 AM to 7:30 AM, 9:00 AM to 10:00 AM, 11:30 AM to 12:30 PM, 1:00 PM to 2:00 PM, 4:00 PM to 4:30 PM, 5:30 PM to 6:30 PM. Please check on him/her upon rising in the am, before returning to bed, before and after meals, activities and PRN. During the night time hours please prompt him/her to go to the restroom during position changes, and when awake. The plan of care, dated on 5/8/14, revealed the following interventions; place the resident in a room close to the nurse's station where there is increased staff supervision. The Plan of care, dated on 7/17/14, revealed the following interventions; the resident has been given a hi/lo bed due to him/her rolling out of bed. Visual checks will be done frequently to monitor him/her as he/she tends to get up on his/her own. The plan of care, dated on 10/7/14, revealed the following Interventions; to check on the resdient often. The resdient tries to adjust the bed and tries to get out of the bed by himself/herself. He/She needs supervision often and is not safe to use the bed controls without assistance due to his/her dementia. The health status note, dated on 3/3/14, revealed that the resident was found on the floor in his/her room. The resident was sitting on his/her buttock with the left leg bent out to the side and back and the right leg out forward. ROM (range of motion) within normal limits for the resident. The fall investigation, dated on 3/3/14, revealed the cause of the incident was unknown and no interventions were documented in the fall investigation report. The plan of care lacked the development of interventions. The health status note, dated on 3/15/14, revealed that staff witnessed the resident slipping off of the bed onto the floor. The resident was reaching for the water glass, and did not have his/her pressure alarm on. No injury noted from the fall. The fall investigation, dated on 3/15/14, revealed the cause of the incident was the resident slipped off the bed. The resident has unsafe gait for transfers and/or wheelchair seating problems. There were no interventions documented in the fall investigation report, and the care plan lacked any new interventions developed. The care plan lacked any new interventions developed.. The heath status note, dated on 5/11/14, revealed that the resident was found lying on the right side on the floor in front of the closet in his/her room. The resident complained of hitting the back of his/her head. There was no redness or raised areas to the back of the resident's head. AROM was within normal limits for this resident. The Morse fall assessment scale, dated on 5/11/14, revealed a score of 80, indicating the resident was a high fall risk. The fall investigation, dated on 5/11/14, revealed the cause of the incident was a loss of balance. There were no interventions documented in the fall investigation report, and the care plan lacked any new interventions developed. The incident note, dated on 7/10/2014, revealed at approximately 4:00 PM, the resident was attempting to get up from the bed with a CNA's (certified nurses assistant) assistance, the resident lost his/her balance and was lowered to the ground by the CNA. The resident did not hit his/her head on any apparatus. The staff will continue with 1 assistance. The care plan lacked any new interventions developed. The incident note, dated on 7/17/2014, revealed the resident had an unwitnessed fall at 9:20 AM. The resident was laying on his/her back on the floor and under him/her was a clothe bed pad. The fall was a non-injury fall. The clinical record lacked any evidence of the determination of the cause of the incident or interventions to prevent it's reoccurence. The incident note, dated on 7/30/2014, revealed that at approximately 4:00 PM, The resident was found lying on the floor in dining room. No injuries noted. The fall investigation, dated on 7/30/14, revealed the cause of incident was the resident lost his/her balance. The intervention was to increase staff assistance at all times. The intervention failed to instruct staff as to how they were to achieve the resident receiving assistance at all times. The Health Status Note, dated on 8/25/2014, revealed that the resident was found on floor in room by bed at 11:45 PM. The resident was getting out of bed without help. The resident had non skid socks on. The clinical record lacked any evidence of the determination of the cause of the incident or interventions to prevent it's reocurrence. The incident Note, dated on 10/7/2014, revealed staff went to check on the resident because the pressure alarm was alarming, and found that the resident had crawled out of his/her hi-lo bed. The fall investigation, dated on 10/7/14, revealed the cause of the incident was that the resident crawls out of bed. There was a skin tear to the left middle finger. The interventions included to increase staff assistance in the early morning with supervision, and to unplug the controls of the bed. The plan of care however, lacked the addition of this intervention to ensure all staff aware of the need to assist the resident early in the morning and to monitor whether the bed remained unplugged. On 10/15/2014 at 7:23 AM , observered the resident in the dining room with no staff in the dining room. On 10/14/2014 at 3:06 PM, observered direct staff U left the resident unattended in the bathroom to go get briefs out of the closet. On 10/15/2014 at 9:36 AM, direct care staff R stated that the resident is too have non-skid socks on at all times, the bed should be in the lowest position, with a floor mat beside the bed, staff should make sure the call light is within reach and he/she has a pressure alarm while in bed. The staff are not to leave the resident alone in the bathroom or dining room. The resident attempts to get out of bed all of the time. On 10/15/2014 at 1:30 PM, direct care staff Q, stated that the interventions for the resident falls included to keep the bed at the lowest position and have a mat at the side of the bed. A frequent toileting schedule, and a pressure alarm while in bed. The resident should not be left in the bathroom or dining room by himself/herself because of all of his/her falls. On 10/15/2014 at 3:06 PM, direct care staff S, stated that the resident interventions for falls included to have a pressure alarm when in bed, a mat beside the bed on the floor, and check on the resident every 10-15 minutes. The resident is not to be left alone in the bathroom and has to have staff in the dining room supervising him/her. On 10/15/2014 at 10:48 AM, licensed nursing staff K stated the inventions that have been put into place were the high low bed, staff moved the resident to a room close to the nurses station, a pressure alarm, and mat on the floor. The resident is not able to comprehend to stay in bed. When the resident is in bed, the staff disconnects the remote to move the bed up and down. The resident has a history of rolling out of bed. The resident is not to be left in the dining room by himself/herself. The reality is that the facility does not have staff to stay with the resident all of the time. It depends on the situation on the floor if the staff can stay with the resident. On 10/16/2014 at 12:55 PM, Administrative nursing staff B, stated that the nurse on duty needed to assess the resident when they have a fall, fill out an investigative fall packet, and turn the paper work into the DON (director of nursing) and then the nurse will put the intervention into the care plan. The nurse should develop interventions for the resident immediately. When the nurse puts it into the care plan they will mark it to be put on the kardex in the electronic chart for the CNA's to see. The resident should not be left by himself/herself in the dining room or the bathroom. The Fall protocol policy, dated on 7/19/2006, instructed the staff to investigate all falls at the time of the fall and then update the resident's plan of care with an appropriate fall intervention with each fall. The falls management program, dated on 10/2005, revealed that the program includes 2 primary approaches to the management of falls and injuries. The first is through an immediate response to a resident who fall. When a fall occurs, careful evaluation and investigation, along with immediate intervention during the first 24 hours, can help identify risk and prevent future incidents. The second approach is long term management. Here, screening at admission, quarterly, annually and change of condition are the key in identifying residents at high risk of a fall. In both approaches, a comprehensive falls assessment should be used to develop/ individualized care plan interventions. The facility failed to consistently assess and provide adequate supervision and/or assistive devices to prevent accidents for this cognitively impaired resident who had 7 falls between 3/2/14 and 10/7/14. - Review of resident (#35's) Physician order [REDACTED]. The Quarterly MDS (minimum data set), dated on 6/13/14, revealed the resident is able to understand others, be understood by others, has clear speech. The resident has a BIMS (brief interview of mental status) score of 9, indicating the residents cognition is moderately impaired. The resident is independent with no assist of staff for transfers, toileting, walking, locomotion, and dressing. The resident is occasionally incontinent of urine. The Significant change MDS, dated on 9/13/14, revealed the resident is able to understand others, be understood by others, has clear speech, has a BIMs score of 10 indicating that the resident cognition is moderately impaired. The resident is independent with no assist of staff with transfers, walking, locomotion, dressing, and toilet use. The resident is occasionally incontinent of bladder. The CAA (care area assessment) for falls, dated on 9/13/14, revealed that the fall Assessment, that was completed on 9/11/14, indicates resident is at a greater risk for falls. The resident is encouraged to allow staff to offer stand by assistance and contact guard with all transfers and ambulation. The resident wears appropriate footwear, including non slip socks at night or when in bed. He/She has demonstrated locking his/her wheelchair breaks prior to transferring and utilizing his/her call light when assistance is needed. Due to his/her [DIAGNOSES REDACTED]. The plan of care, dated on 1/27/14, revealed the resident was at an increased risk for falls. The resident has been educated on wearing appropriate footwear, including non slip socks, locking the wheelchair brakes prior to transfers and keeping the room free of debris. The resident has voiced understanding of these precaution measures. Please keep all personal items within reach and remind the resident to ask for assistance for items that are not within reach. to offer stand by assist due to the resident being at an increased risk for falls. Therapy has recommended that he/she walk with a FWW (front wheeled walker), contact guard with wheelchair following the resident. The resident chooses to utilize a wheel chair. The resident is independent with locomotion in wheelchair. The plan of care, dated on 7/29/14, revealed the following intervention; the resident will use a pressure alarm while in bed & in the wheelchair to prompt the resident to call staff for assistance when needed to be transferred into the wheelchair, the bed or the toilet related to a recent fall. (The resident is cognitively impaired). The Morse fall scale, dated on 1/14/14, revealed that the resident has a score of 65, indicating that the resident is high risk for falls. The Health Status Note, dated on 1/15/2014, revealed the resident self reported that when he/she was walking back from the bathroom, he/she went down on left knee. The resident voiced no complaints of discomfort and ROM (range of motion) was adequate and no injuries were noted. The fall investigation, dated on 1/15/14, documented the resident was walking back from the bathroom and reported that he/she went down on the left knee. The plan of care lacked any new intervention developed immediately following this fall. The Morse fall scale, dated on 3/28/14, revealed a score of 40, indicating the resident is at moderate risk for falls. The Incident note, dated on 4/22/2014, revealed that the resident had a fall this morning. The resident stated he/she became dizzy. The fall investigation, dated on 4/22/14, evidenced the cause of the incident was loss of balance due to dizziness. The intervention was to increase staff assistance during all transfers and to and from the toilet. (Staff assistance already an intervention dated 1/27/14). The Morse fall scale, dated on 9/11/14, revealed a score of 85, indicating that the resident is a high risk for falls. The Health Status Note, dated on 9/26/2014, documented the resident reports that he/she slipped off the toilet and hit his/her tail bone. The physical assessment was done and the resident noted to have a red area to the coccyx area. The note lacked documentation of the alarm sounding or how the resident got up. The incident Note, dated on 9/30/2014, revealed that at 1:00 PM, the restorative aide notified the nurse that the resident had reported a fall today to that staff. The fall investigation, dated on 9/30/14, revealed that the resident has an unsafe gait for transfers and/or wheelchair seating problems. The intervention for the fall was to increase staff assistance during ambulation. (already an intervention, dated 1/27/14). On 10/15/2014 8:56 AM, observation revealed, the resident propelling him/herself down the hallway to his/her room. The resident propelled himself/herself to the side of the bed and stood up out of the wheelchair and transferred self into the bed. The resident did not lock the wheelchair or call for assistance with the transfer, and the alarm did not sound. On 10/15/14 at 3:00 PM, observation revealed, the resident sitting in his/her wheelchair reading a book. The resident did not have a pressure alarm on. The resident transferred self without calling for assistance to the bed. The resident did not lock the wheels. On 10/14/2014 at 4:03 PM , direct care staff T, stated staff find out if the resident has any interventions for falls in the residents chart. At shift change, the staff will get notified of any new interventions. On 10/15/2014 at 9:17 AM, direct care staff R, stated the interventions for falls are in a book at the nurses station. The staff uses the avenue sheets to know what residents have fallen and what the interventions are. The staff will pass the sheets to the next shift during shift change. The resident has fallen due to not calling for assistance when transferring self. The resident does understand that he/she needs to call for help. On 10/15/2014 at 1:21 PM, direct care staff Q, stated the resident calls for assistance, but not when he/she transfers. The resident will call when he/she is finished with using the bathroom. The staff reminds the resident during rounds, to wear non-skid socks, and to use the call light at all times. On 10/15/2014 at 2:59 PM, direct care staff S, stated the resident has a pressure alarm, to remind him/her to use the call light. On 10/15/2014 at 10:30 AM, licensed nursing staff K, stated that the nurses do an incident report, fill out a fall packet and document in the nurses notes. The nurses should update the care plans every time there is a fall with a new intervention. On 10/16/2014 at 1:07 PM, Administrative nursing staff B, stated that the nurses are responsible for the interventions on the care plan. The falls will be investigated by administrative nursing staff B, and interventions will be initiated in the residents care plan. The Fall protocol policy dated on 7/19/2006, instructed the staff, that all falls will be investigated at the time of the fall and the resident's plan of care will be updated with an appropriate fall intervention with each fall. The falls management program, dated on 10/2005, revealed that the program includes 2 primary approaches to the management of falls and injuries. The first is through an immediate response to a resident who fall. When a fall occurs, careful evaluation and investigation, along with immediate intervention during the first 24 hours, can help identify risk and prevent future incidents. The second approach is long term management. Here, screening at admission, quarterly, annually and change of condition are the key in identifying residents at high risk of a fall. In both approaches, a comprehensive falls assessment should be used to develop/ individualized care plan interventions. The facility failed to consistently assess and provide adequate supervision and/or assistive devices to prevent accidents for this cognitively impaired resident who had 3 falls between 1/14/14 and 9/30/14.