Every finding on record at Lexington Park Nursing & Post Acute Center

Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff propelled Resident (R) 49, R29, R28, and R24 through the hallway in wheelchairs without having foot pedals, requiring the residents to hold their feet up while being pushed. Findings included:- Review of the Electronic Medical Record (EMR) revealed the following: 1. The EMR for R49 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and polyosteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage and bone in five or more joints simultaneously). R49's Annual Minimum Data Set (MDS), dated 02/20/26, documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe impairment in thinking and memory. The assessment documented that she used a wheelchair for mobility. She required supervision or touching assistance when eating and required substantial to maximum assistance for all transfers and her other activities of daily living (ADL). R49's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/20/26, documented she had the presence of inattention and disorganized thinking. R49's Communication CAA, dated 02/20/26, documented she had an impaired ability to make herself understood through verbal and non-verbal expression of ideas and wants. R49's Care Plan dated 09/03/25, documented staff were to propel her in her wheelchair. Staff were also instructed to use the sit-to-stand lift (a mechanical aid designed to help individuals with limited mobility move from a seated to a standing position) if she was weaker than usual or transfer seemed unsafe. An observation on 04/27/26 at 08:16 AM revealed staff wheeled R49 in hallway in her wheelchair without foot pedals attached. R49 had to hold her feet in the air. Further observation revealed the wheelchair foot pedals were in R49's room, lying on the floor under the air conditioning unit close to her bed. Observed on 04/28/26 at 07:48 AM, Certified Medication Aide (CMA) R pushed R49 in her wheelchair from the nurse's station area to the resident's room without foot pedals on the wheelchair. On 04/28/26 at 07:53 AM, CMA R stated that the charge nurse informed the staff they were allowed to push residents in their wheelchair without foot pedals if a resident could hold their feet up. On 04/28/26 at 08:32 AM, Licensed Nurse (LN) G said resident preference and ability determined whether foot pedals were required to be used. LN G also stated that if the resident had a lower BIMS cognition score, then foot pedals were to be used. On 04/28/26 at 08:36 AM, Administrative Nurse D stated residents should have foot pedals on the wheelchair if they cannot propel themself and resident preference was a determining factor on whether foot pedals were to be used on the wheelchair. Administrative Nurse D also said the facility did not have a policy related to wheelchair safety. 2. R29's EMR documented diagnoses which included sciatica (nerve pain and irritation in the lower back down the legs), sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), acute and chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R29's admission MDS, dated 04/06/26, documented a BIMS score of 15, which indicated intact cognition. The assessment documented R29 had no falls. The MDS documented R29 required assistance with wheelchair mobility. R29's Care Plan, dated 04/24/26, documented R29 could propel herself short distances in her wheelchair but required staff assistance for longer distances such as to the therapy room or the unit scale. R29's Care Plan, dated 04/24/26, documented R29 needed staff to assist her with transferring and mobility, but she was working with therapy to increase her strength and coordination to help with independence. R29's Medicare A Progress Note, dated 04/28/26 at 11:41 AM, documented R29 had weakness and required assistance with care. Observed on 04/28/26 at 09:20 AM, Consultant HH pushed R29's wheelchair to her room without any foot pedals on the chair. R29's feet were dragging on the floor. 3. R24's EMR documented diagnoses which included unspecified dementia, restlessness and agitation, and restless leg syndrome. R24's Annual MDS, dated 02/20/26, documented a BIMS of five, indicating severe cognitive impairment. The MDS documented that R24 used a wheelchair for mobility. R24 required partial to moderate assistance for transfers and toileting hygiene and required supervision to touching assistance for bathing. R24's Care Plan documented an intervention, dated 06/23/22, for staff to check on R24 frequently because she had poor safety awareness. Another intervention, dated 04/11/22, instructed staff to help R24 propel with her wheelchair. Observed on 04/27/26 at 10:16 AM, CNA N pushed R24 to his room in his wheelchair without foot pedals. The foot pedals were sitting on the floor outside his room by the door. On 04/28/26 at 07:53 AM, CMA R stated that the charge nurse informed the staff that they were allowed to push residents in their wheelchair without foot pedals as long as a resident was capable of holding their feet up. On 04/28/26 at 08:32 AM, Licensed Nurse (LN) G said resident preference and ability determined whether foot pedals were required to be used. LN G also stated if a resident had a lower BIMS cognition score, then foot pedals were to be used. On 04/28/26 at 08:36 AM, Administrative Nurse D stated residents should have foot pedals on the wheelchair if they cannot propel themself and resident preference was a determining factor on whether foot pedals were to be used on the wheelchair. Administrative Nurse D also said the facility did not have a policy related to wheelchair safety. The facility did not provide a policy related to wheelchair safety and transporting residents by wheelchair.

Based on observation, interview, and record review, the facility failed to adequately store medications and/or biologicals when staff failed to lock an unattended medication cart. Findings included:- An observation on 04/28/2026 at 08:47 AM revealed the 100-hall medication cart sitting across from the nurse's station was unlocked. There were no staff present at the nurse station or within sight of the medication cart. The keys for the cart rested on top of the unattended cart. During an interview on 04/28/2026 at 09:10 AM, Certified Medication Aide (CMA) S stated the medication cart was to be locked when unattended and the key was never to be left on the cart while it was unattended. During an interview on 04/28/2026 at 09:35 AM, Licensed Nurse (LN) H stated the medication cart was never supposed to be left unlocked and unattended and if she found it like that, she would lock it and go find the staff member responsible for the cart. During an interview on 04/28/2026 at 09:38 AM, Administrative Nurse D stated the facility policy directed staff to never leave the cart unlocked and always have the key on them. The facility policy stated that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview, and record review, the facility failed to display accurate posted nurse staffing information which contained all the required data. Findings included:- On 04/27/2026 at 07:43 AM, an observation revealed a daily staffing sheet hanging on the wall near the nursing station at the facility. The Daily Nursing Staffing Information sheet, dated 04/27/26, listed the number of employees and the hours but lacked the facility name and did not post the daily nursing staff total hours. On 04/29/26 at 09:15 AM, Administrative Nurse D reported he had not noticed the nursing daily staff sheet did not have total numbers on the daily sheet and said that he was aware it should be posted on the daily nursing staffing sheet. Administrative Nurse D further stated he was unaware the facility name needed to be on the daily nurse staffing sheet. Administrative Nurse D stated he will make the necessary corrections for the daily nurse staff posting. The facility Daily Nurse Staff Posting policy with a revised date of 11/28/17 documented the facility will post the full-time equivalent number of nursing personnel responsible for providing direct care, daily for each shift. The policy documented general guidelines, which stated at the beginning of each shift the number of licensed nurses (RNs and LPNs) and the number of unlicensed personnel (CMAs, CNAs, and nurses aid trainees) who provide direct care to residents will be posted using the daily nurse staffing form. Shift posting information shall include only the number of full-time equivalents on duty for that day for that shift. Daily posting shall be recorded on each facility's daily nurse staffing form, which will be retained for 18 months.

The facility had a census of 77 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure nonpharmacological symptom management and a specified duration of use for Resident (R) 19 and R18's use of as-needed (PRN) psychotropic (alters mood or thoughts) medication. The facility further failed to ensure an appropriate indication of use or a documented physician rationale and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) and for not attempting a gradual dose reduction (GDR) for R33 and failed to ensure R18's PRN antipsychotic medication had the required 14-day stop date. This placed the residents at risk of receiving unnecessary psychotropic medications. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease with heart failure, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic respiratory failure, atrial fibrillation (rapid, irregular heartbeat), dependence on supplemental oxygen, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and pseudobulbar affect (a condition which is characterized by an uncontrollable reaction of laughter or crying that is disproportionate to the event). R19's Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had severe cognitive impairment with no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by gross impairment in reality perception), or behaviors. R19 required partial/moderate assistance with functional activities such as dressing, and transfers, and substantial/maximum assistance with toileting hygiene, bathing, and bed mobility. R19 was not ambulatory. The MDS further documented R19 had a condition or chronic condition that may result in a life expectance of less than six months and received hospice care (special care to people who are near the end of life). R19 received scheduled and PRN pain medication. R19 took an antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and received oxygen therapy. The Psychotropic Drug Use Care Area Assessment, dated 05/21/24, documented R19 received psychotropic medications and received an antidepressant and antianxiety medication. R19's Care Plan dated 05/23/24 documented R19 had mood and behavior problems, took Ativan (lorazepam- antianxiety medication) for targeted behavior of racing thoughts; Buspar (antianxiety medication) for a targeted behavior for yelling out; Cymbalta (an antidepressant) for depression and a targeted behavior of self-isolation, and Wellbutrin (antidepressant) with a target behavior of crying. The care plan directed staff to watch for side effects of medications and listed things that made the resident feel down or depressed such as missing family, and friends, and not having their own home. The care plan directed staff to help R19 feel better were calling friends and family on the phone, reading a book, and watching TV. The Physician Order, dated 12/19/23, directed staff to administer lorazepam 0.5 milligrams (mg) by mouth every four hours as needed (PRN) for anxiety related to anxiety disorder. The target behavior listed racing thoughts, and nonpharmacological interventions should be applied before administration. The Consultant Pharmacist (CP) Review, dated 01/08/24 and 06/13/24, documented R19 had an order for PRN Ativan though noted the resident was on hospice services. The CP documented that per Centers for Medicare and Medicaid Services (CMS) regulations, for PRN psychotropic use greater than 14 days, the prescriber must document a clinical rationale in the medical record for the continuance of the PRN agent and indicate the duration that the medication should be continued. The CP recommended re-evaluating the need to continue the PRN order at that time. If continued use is warranted, please provide a clinical rationale as well as the duration below. The physician's response to the CP review on 01/08/24 recorded the rationale for use was the medication was beneficial, and wrote the duration was no stop order or discontinue date. The response lacked a rationale or supporting data as to the benefit and lacked a specified duration. The physician's response to the CP review on 06/13/24 recorded that the rationale for use was hospice and lacked a specified duration of use. R19's April 2024 Electronic Medication Administrative Record (EMAR) revealed the use of PRN lorazepam 14 times that lacked documentation of nonpharmacological interventions used prior to administration. R19's May 2024 EMAR revealed the use of PRN lorazepam 14 times and lacked documentation of nonpharmacological interventions used prior to administration. R19's June 2024 EMAR revealed the use of PRN lorazepam 27 times and recorded the use of nonpharmacological interventions twice. R19's 07/01/24 to 07/15/24 EMAR revealed the use of PRN lorazepam 23 times and recorded nonpharmacological interventions only 11 times. On 07/15/24 at 02:56 PM, observation revealed staff pushed R19 to the dining room in a wheelchair for an activity involving food, drink, and music. On 07/17/24 at 08:00 AM, Certified Nurse Aide (CNA) M reported when R19 was upset, she tried to reassure her calmly, offered to lay her in bed, provided drinks, sat with her, and brought the resident to the nurse's station area. CNA M stated if interventions were not successful, the charge nurse would be notified. On 07/16/24 at 02:42 PM, Licensed Nurse (LN) H reported R19's mood and anxiety had been up and down. LN H stated the physician frequently saw R19. LN H reported R19's crying episodes had been less with the start of medication for pseudobulbar affect. LN H stated nonpharmacological interventions used for R19 would include turning on audiobooks, activity attendance if not too upset, sitting with the resident, massaging her hands, and doing her nails. LN H also reported the CNAs were good at redirecting conversations and hospice provided music therapy. On 07/17/24 at 08:00 AM, Administrative Nurse D reported the physicians made the decisions related to the use of medications. The pharmacist reviewed the resident's medical record and gave recommendations which were sent to the physician for review. Administrative Nurse D said the nurses and unit directors also reviewed the recommendations for orders. Administrative Nurse D stated nonpharmacological interventions should be attempted and documented before administration of PRN lorazepam. The facility's Unnecessary Medications policy, dated 11/28/17, documented that each resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in excessive doses including duplicate therapy for excessive duration or without adequate monitoring or without adequate indications for this use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. The facility failed to ensure nonpharmacological symptom management and a specified duration of use for R19's PRN psychotropic antianxiety medication. This placed the resident at risk of receiving unnecessary psychotropic medication and related side effects. R33's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), atrial fibrillation (rapid, irregular heartbeat) and acquired absence of left leg below knee. R33's Quarterly Minimum Data Set (MDS), dated [DATE], documented R33 had severe cognitive impairment, had no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception) or behavioral symptoms. R33 required substantial/maximal assistance with functional abilities and mobility. The MDS further documented R33 received scheduled and PRN pain medication, an antipsychotic, anticoagulant (class of medication to prevent blood clotting), opioid (medication to treat pain), and hypoglycemic (class of medication used to reduce blood sugar). R33 received an antipsychotic on a routine basis, with no gradual dose reduction (GDR) attempt, and a physician documented that a GDR was clinically contraindicated on 03/19/24. R33's Psychotropic Drug Use Care Area Assessment, dated 11/02/23, documented R33 received an antipsychotic and antianxiety (class of medications that calm and relax people) medication. R33's Care Plan, dated 04/25/24, documented a mood and/or behavior problem. R33 received Abilify (antipsychotic) for a targeted behavior of anger and Ativan (an antianxiety medication) for a targeted behavior of pacing. The care plan further directed staff with behavior management. The Physician Order, dated 01/30/24, directed staff to administer Abilify 15 milligrams (mg) in the morning related to major depressive disorder. The Consultant Pharmacist (CP) review, dated 01/09/24, documented R33 was currently receiving Abilify 15 mg daily for depression and had a diagnosis of dementia. The CP noted that while depression was a Food and Drug Administration (FDA) approved indication for this medication (adjunctive treatment for depression), the use of antipsychotics in this patient population was strongly discouraged given the adverse side effects associated with their use. Periodic risk versus benefit assessments were recommended for continued use. The CP recommended considering a trial reduction to Abilify 10 mg at that time to ensure the lowest effective dose was being utilized and minimize the risk for adverse effects. If no changes were warranted, please provide clinical rationale. The physician responded disagree but did not provide a clinical rationale. The CP Review, dated 03/10/24, documented to consider a trial reduction to Abilify 10 mg daily at that time to ensure the lowest effective dose was being utilized and minimize the risk for adverse effects. If no changes were warranted, please provide a clinical rationale below. The physician responded disagree and noted the patient was stable but did not provide a rationale that addressed the benefits of continued use, and at the same dose, despite the risk. On 07/15/24 at 03:13 PM, observation revealed R33 sitting in the dining room enjoying a second root beer float and music-listening activity. On 07/17/24 at 07:57 AM, Administrative Nurse D stated antipsychotic medication was reviewed with the physician and the physician determined the diagnosis. Administrative Nurse D confirmed the CP had recommended a GDR and risk versus benefit documentation for the use of psychotropic medications. The facility's Unnecessary Medications policy, dated 11/28/17, documented that each resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in excessive doses including duplicate therapy for excessive duration or without adequate monitoring or without adequate indications for this use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. The facility failed to ensure R33 who had dementia and received an antipsychotic medication had a CMS-approved indication for use and an attempted GDR or the required physician documentation. This placed the resident at risk of receiving unnecessary psychotropic medication and related complications. 32358 - R18's Electronic Medical Record (EMR) documented R18 had diagnoses of major depressive disorder (a major mood disorder that causes persistent feelings of sadness) and dementia (a progressive mental disorder characterized by failing memory, and confusion). R18's Quarterly Minimum Data Set (MDS), dated [DATE], documented R18 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented that R18 received an antipsychotic, antianxiety (class of medications that calm and relax people), and antidepressant (class of medications used to treat mood disorders) medication daily during the observation period. R18's Care Plan, revised 06/20/24, documented that R18 received Ativan (antianxiety medication) and Haldol (antipsychotic medication). The care plan instructed staff to monitor R18 for signs of depression such as having trouble going to sleep or staying asleep, sleeping all the time, decreased appetite and weight loss, crying, or making statements about not wanting to go on or feeling useless. Staff were to notify the nurse and physician if R18 exhibited these behaviors. The Physician Orders, dated 08/21/23 at 02:00 PM, instructed staff to administer R18 Haldol 1 milliliter (ml) of 2 milligrams (mg) per ml liquid every eight hours PRN for nausea. The order lacked a 14-day stop date. The orders instructed staff to administer Ativan tablet, 1 mg, every four hours PRN without a stop date. On 02/27/24 the Consultant Pharmacist (CP) drug regimen reviews documented R18 currently took Haldol 1 ml of every eight hours PRN with a diagnosis of nausea but per Centers of Medicare and Medicaid Services (CMS) guidelines, only the Food and Drug Administration (FDA) approved indications for schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), Tourette's syndrome (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds) and Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder) are allowed for the continued use of antipsychotics in residents with dementia. The physician responded only PRN, no change. On 06/15/24 the CP documented that R18 had an order for PRN Ativan and noted that R18 received hospice services. The CP documented that per CMS regulations for PRN psychotropics medication use greater than 14 days, the prescriber must document a clinical rationale in the medical record for the continuance of the PRN agent and indicate the duration that the medication should be continued. The physician's response did not indicate the duration and rationale for the continued use of Ativan. On 07/15/24 at 03:28 PM, observation revealed R18 sat in a recliner in her room, visited with staff in a polite voice, and had no signs or symptoms of pain. On 06/04/24 at 03:20 PM, Administrative Nurse D verified R18's Ativan lacked a stop date and stated it should have one. Administrative Nurse D verified R18's Haldol had a diagnosis of nausea and stated the resident received hospice services and their standing orders had Haldol with a diagnosis of nausea. The facility's Unnecessary Medications Policy, revised 11/28/17, documented that antipsychotic medications are indicated for the treatment of schizophrenia, Tourette's syndrome, and Huntington's disease. The use of antipsychotic medications for any other diagnosis must include physician documentation of the rationale. The facility failed to ensure a 14-day stop date as required for R18's PRN antipsychotic, Haldol. The facility further failed to place a stop date or a physician rationale for extended use with a specified duration on R18's PRN Ativan. This placed the resident at risk for unnecessary psychotropic medications.

The facility had a census of 77 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)45, R36, and R73 or their representative with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R45's Electronic Medical Record (EMR) documented R45 had a diagnosis of malignant neoplasm (an abnormal mass of tissue that forms when cells grow and divide more than they should or do not die when they should) of the supraglottic (upper part of the larynx or voice box), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), atherosclerotic heart disease (a type of disease that affects the heart or blood vessels), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R45's Quarterly Minimum Data Set (MDS), dated [DATE], documented R45 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident required substantial to maximal staff assistance with toileting and personal hygiene. R45's Care Plan, dated 07/10/24, documented R45 had a feeding tube and would receive feeding and pleasure food; R45 would notify staff when she would like a meal or pleasure food. R45 received tube feeding through the pump as a continuous feeding overnight. R45 had an additional diet order of regular with thin liquids as tolerated. The Progress Note, dated 06/11/24 at 11:49 PM, documented R45 became short of breath and R45 stated she felt like she had something in her throat that was blocking her airway. Staff obtained the resident's oxygen levels and obtained a reading of 71% (normal 95% to 100%) on 3.5 liters of oxygen. Staff administered a breathing treatment and the resident's oxygen levels came up to 78%. Her heart rate was 116 (normal 60-100 beats per minute), and her respirations were 32 (normal 12-16 breaths per minute). The nurse practitioner was contacted, and the resident was sent to the hospital via ambulance. The Progress Note, dated 06/12/24 at 03:09 PM, documented the resident was admitted to hospital. The Progress Notes. dated 06/14/24 at 03:44 PM, documented the resident returned to the facility and was readmitted . R45's clinical record lacked evidence the resident or representative was provided the bed hold policy when she was transferred to the hospital. On 07/16/24 at 08:10 AM, observation revealed R45 sat on the side of her bed with oxygen on per nasal cannula. Continued observation revealed License Nurse (LN) H administered 120 milliliters (ml) of water, crushed Levaquin (antibiotic) 750 milligrams, and Nutra Source Fiber (liquid nutrition) mix and followed with 120 ml of water. On 07/16/24 at 03:30 PM, Social Service X verified she had not provided the resident, or her representative with the bed hold policy when she was transferred to the hospital on 06/12/24. On 07/16/24 at 04:00 PM, Administrative Staff A verified the resident had not been provided the bed hold policy when she was transferred to the hospital on 06/12/24. The facility's Bed-Hold Policy, dated November 28, 2017, documented a written notice, that specifies the duration of the bed-hold policy, would be provided at the time of transfer of a resident for hospitalization or therapeutic leave. A resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan would return to the facility to their previous room if available or immediately upon the first availability of a bed. During the admission process, the facility would review the bed-hold policy with the resident and/or representative, The facility failed to provide R45 or her representative with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. 32358 - R36's Electronic Medical Record (EMR) documented R36 had a diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). R36's Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented the resident required partial to moderate staff assistance with most activities of daily living (ADLs) and received oxygen therapy. R36's Care Plan, revised 07/04/24, instructed staff to monitor R36's body language and facial expressions for signs or symptoms of pain, cough, and shortness of breath. Staff were to listen to her lungs for any sounds of wetness or wheezing and notify the physician if they were heard. The Progress Note, dated 01/04/24 at 05:23 AM, documented R36 was admitted to the hospital. The Progress Note, dated 04/16/24 at 12:55 PM, documented R36 was admitted to the hospital. R36's clinical record lacked evidence the resident or representative was provided the bed hold policy when she was transferred to the hospital on 01/04/24 or 04/16/24. On 07/16/24 at 08:00 AM, observation revealed R36 self-propelled in a wheelchair down the hall from the dining room to her room. She wore oxygen at two liters, per nasal cannula, with no signs or symptoms of respiratory distress or pain. On 07/16/24 at 12:09 PM Administrative Staff A verified the resident or representative was not provided the facility bed hold policy when she was transferred to the hospital on 01/04/24 and 04/16/24. Administrative Staff A stated the social service designee was responsible for providing the bed hold policy to the resident or representative and it should have been provided. The facility's Bed-Hold Policy, revised 11/28/17, documented a written notice that specifies the duration of the bed-hold policy would be provided to the resident or resident representative upon transfer to hospital or therapeutic leave. The facility failed to provide R36 or her representative with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. - R73's Electronic Medical Record (EMR) documented R73 had a diagnosis of an anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory, confusion), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). R73's Annual Minimum Data Set (MDS), dated [DATE], documented R73 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented the resident required substantial to maximal staff assistance with most activities of daily living (ADLs) and had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue). R73's Care Plan, revised 04/11/24, documented R73 had physically and verbally aggressive behavior, had a history of paranoia and accusing others of taking her things, and instructed staff to leave her alone in a safe place if she had these behaviors. The care plan documented if the behaviors persisted despite time alone or redirection to call her representative and let her talk to him. The Progress Note, dated 05/03/24 at 02:12 PM, documented R73 was admitted to the behavioral health hospital. R73's clinical record lacked evidence the resident or representative was provided the bed hold policy when she was transferred to the hospital. On 07/16/24 at 12:09 PM Administrative Staff A verified the resident or representative was not provided the facility bed hold policy when she was transferred to the hospital. Administrative Staff A stated the social service designee was responsible for providing the bed hold policy to the resident or representative and it should have been provided. The facility's Bed-Hold Policy, revised 11/28/17, documented a written notice that specifies the duration of the bed-hold policy would be provided to the resident or resident representative upon transfer to hospital or therapeutic leave. The facility failed to provide R73 or her representative with written information regarding the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

The facility had a census of 59 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview 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)18, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R18's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). R18's Admission Minimum Data Set Assessment (MDS), dated [DATE], documented R18 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R18 required extensive staff assistance with activities of daily living (ADL) except supervision with eating. The MDS documented R18 received an antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication for two days and an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication for seven days during the seven-day lookback period. R18's Psychotropic Drug Care Area Assessment (CAA), dated 02/23/23, documented R18 had diagnoses of depression and anxiety. R18's Psychosocial Care Plan, revised 03/09/23, documented R18 received Seroquel (antipsychotic medication) for targeted behavior of yelling at staff, and instructed staff to watch R18 for side effects of her medication. The Discharge From Hospital Physician Order Sheet, dated 02/16/23, instructed staff to administer Seroquel tablet, 12.5 milligram (mg) every night for the diagnosis of major depressive disorder. The Pharmacist Recommendation, dated 03/06/23, documented the pharmacist indicated R18's diagnoses for Seroquel was an inappropriate diagnosis and recommended it be changed to an appropriate diagnosis. The recommendation asked for a gradual dose reduction of the medication and the physician replied he disagreed, and instructed he would manage R18's Seroquel dosage. The physician did not respond to the inappropriate diagnosis for Seroquel. The Physician Order Sheet, dated 03/08/23, instructed staff to administer Seroquel tablet, 12.5 milligram (mg) twice a day for the diagnosis of major depressive disorder. On 03/20/23 at 12:18 PM, observation revealed R18 in the therapy room. R18 visited politely with staff. On 03/27/23 at 02:56 PM, Administrative Nurse D verified the resident's Seroquel had an inappropriate diagnosis. The facility's Unnecessary Medications Policy, revised 11/28/17, documented antipsychotic medications are indicated for the treatment of Schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) , Tourette's (neurological condition that causes unwanted, involuntary muscle movements and sounds known as tics) and Huntington's (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder). The facility's Drug Regimen Review Policy, revised 11/28/17, documented the pharmacist would report any irregularities to the attending physician, the facility's medical director and the director of nursing. The facility would act upon the pharmacist recommendations. 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 R18's antipsychotic medication. This placed the resident at risk for receiving an unnecessary psychotropic medication.

The facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect during dining for Resident (R) 3, R12 and R20. This placed the residents at risk for an undignified dining experience. Findings included: - On 03/20/23 at 11:45AM, observation of dining service revealed R3, R12 and R20 sat in Broda chairs (a wheelchair that provides supportive positioning through a combination of tilt, recline and is adjustable) across from the 200 hallway nurse's desk. Further observation revealed staff sat on chairs beside each resident. Staff, while feeding R3, R12 and R20, discussed personal problems with each other and discussed other residents who resided on the 200 hallway while assisting the residents with their meal. On 03/21/23 at 08:20AM, observation revealed R3, R12 and R20 each sat in a Broda chairs across from the 200 hallway nurse's desk. Staff sat on chairs next to each resident. Staff, while feeding R3, R12 and R20, discussed their personal lives with each other and discussed work related topics with each other but did not engage R3, R12, or R20 in conversation during the meal. On 03/21/23 at 12:10PM, observation revealed R3, R12 and R20 each sat in Broda chairs across from the 200 hallway nurse's desk with a staff member seated beside each resident. While feeding R3, R12 and R20, staff discussed discussed personal issues with each other and discussed other residents while assisting the residents with their meal. On 03/28/23 at 10:00AM, Administrative Nurse D verified staff were to speak with the residents when feeding them and acknowledged it was a dignity concern for staff to discuss personal issues and other residents when assisting residents with their meals. The facility's undated Resident Rights policy, stated the facility staff will promote care in a manner to promote and enhance dignity and respect. The facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff assisted R3, R12 and R20 with their meals and spoke to other staff during the dining instead of speaking and interacting with the residents being assisted. This placed the affected residents at risk for an undignified dining experience.

The facility had a census of 59 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to post the actual working hours for nursing staff directly responsible for resident care per shift as required. Findings included: - On 03/20/23 at 08:30 AM, upon entrance into the facility, observation revealed the facility lacked a Daily Nurse Staffing Report posted in the facility. On 03/21/23 at 07:30 AM, observation revealed the facility lacked a Daily Nurse Staffing Report posted in the facility. On 03/27/23 at 08:30 AM, observation revealed the facility lacked a Daily Nurse Staffing Report posted in the facility. On 03/27/23 at 02:05 PM, Administrative Nurse D verified the facility had not posted the Daily Nurse Staffing Report on the dates documented above. Administrative Nurse D stated it was something the facility was working on. The facility's Posting Direct Care Daily Staff Numbers policy, dated November 28, 2017, recorded the facility would post the full-time equivalent number of nursing personnel responsible for providing direct care, daily for each shift. At the beginning of each shift, the number of licensed nurses (Registered Nurses and Licensed Practical Nurses) and the number of unlicensed nursing personnel (Certified Medication Aide, Certified Nurse Aide, nurse aide trainees) who provide direct care to residents would be posted using the Daily Nurse Staffing forms. The facility failed to post the daily staffing hours for the nursing personnel directly responsible for resident care per shift as required.

The facility identified a census of 59 residents. Based on observations, record reviews, and interviews, the facility failed to ensure proper hand hygiene was performed during meal serving and failed to prevent cross-contamination during peri-care (involves washing the genital and rectal areas of the body or peri-area) and foley catheter (tube inserted into the bladder to drain urine into a collection bag) care for Resident (R) 206. This deficient practice increased the risk of illness and infection for all residents on the affected unit. Findings included: - On 10/11/21 at 12:06 PM, Licensed Nurse (LN) H wore gloves and pushed dining cart into the dining room. She scratched her arm then rolled silverware and wrapped food bowls and cups. LN H then pushed the dining cart onto the South unit without changing gloves and/or performing hand hygiene. LN H delivered a tray to a resident then doffed (removed) her gloves. She returned to the dining room, performed hand hygiene, touched her uniform then delivered lunch to a resident at a table. On 10/11/21 at 12:28 PM, LN H served a resident lunch, brought a dirty dish to the dirty dish cart, grabbed a clean plastic cup and got the resident water. LN H returned to the serving area and grabbed another plate to serve. No hand hygiene was observed. On 10/13/21 at 09:50 AM, LN I and Certified Nurse Aide (CNA) N entered R206's room, shut the door, then both performed hand hygiene and donned (put on) gloves. LN I lowered R206's head of the bed (HOB), raised bed to waist level, removed blankets, then rolled R206 to his right side with assistance from CNA N. LN I cleaned R206's peri-area, removed soiled brief, placed a clean brief, then put barrier cream (cream used to protect the skin) on R206's buttocks. No hand hygiene was performed after peri-care and before applying barrier cream. CNA N used right hand to help spread barrier cream, did not doff soiled glove before touching R206's thigh. LN I doffed gloves and performed hand hygiene then donned new gloves. LN I performed foley catheter care appropriately. After catheter care, LN I did not doff gloves and perform hand hygiene before she touched his blankets and pillows. LN I doffed gloves, elevated HOB, lowered bed, and placed call light within reach. LN I and CNA N performed hand hygiene. On 10/13/21 at 01:52 PM, CNA M stated hand hygiene was performed before and after each resident contact, before and after serving a meal tray, upon entering and exiting resident rooms, and after doffing gloves. She stated during peri-care, she changed her gloves and performed hand hygiene when moving from dirty to clean surfaces during the procedure. On 10/13/21 at 01:56 PM, LN G stated hand hygiene was performed before and after care, after doffing gloves, before serving trays and in between serving to different residents. She stated during peri-care, she changed gloves and performed hand hygiene after done with cleaning soiled areas and before touching clean areas. ON 10/13/21 at 02:00 PM, Administrative Nurse D stated he expected hand hygiene to be performed per the facility policy. He stated hand hygiene was performed before and after cares, after doffing dirty gloves, and before donning new gloves. He stated gloves were changed after each resident contact during meal service. He expected staff to change gloves and perform hand hygiene after cleaning a soiled area and before touching clean items. The facility's Hand Hygiene policy, dated 11/28/17, directed hand hygiene was performed before and after contact with the resident, after contact with body fluids or visibly contaminated surfaces and surfaces in the resident's environment, and after removing personal protective equipment including gloves. The facility failed to ensure proper hand hygiene was performed during meal serving and failed to prevent cross-contamination during peri-care and foley catheter care for Resident (R) 206. This deficient practice increased the risk of illness and infection for all residents on the affected unit.

The facility identified a census of 59 residents. The sample included 16 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to follow the Consulting Pharmacist (CP) recommendation to notify the physician when resident (R)16's blood glucose reading was over the 300 milligrams per deciliter (mg/dl- a unit for measuring concentration of glucose in the blood) parameter. This placed R16 at risk for complications related to increased blood glucose levels. Findings included: - The electronic medical record (EMR) for R16 documented diagnoses of type II diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic [CONDITION(S)] (a disease where nerve damage is caused by long-term high blood sugar levels), and Type II DM with diabetic peripheral angiopathy (a condition that involves damage to cells in the blood vessels caused by high levels of glucose), and Type II DM with diabetic chronic kidney disease. The Annual Minimum Data Set (MDS) dated [DATE] for R16 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. She required extensive assistance of two staff for activities of daily living (ADLs) and used a wheelchair for mobility. During the look back period she received injections and/or insulin (a hormone which regulates blood sugar) seven of seven days. The Quarterly MDS dated [DATE] documented R16 had a BIMS score of 10, which indicated moderate cognitive impairment. She required extensive assistance of two staff with her ADLs. She required the use of a wheelchair for mobility that staff propelled. She received injections and/or insulin seven of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 05/21/21 documented that R16 had a BIMS of 15 and required extensive assistance of two staff with her ADLs. The Nutrition Care Plan updated 08/05/21 instructed staff to follow R16's accu-check ( a blood glucose measuring system) and insulin orders and to notify primary physician if her blood sugar was outside of the parameters. Under the Orders tab, the Orders Summary Report dated 10/11/21 documented an order for blood glucose monitoring four times a day related to type II DM with diabetic chronic kidney disease, notify physician if blood glucose was greater than 400mg/dl or less than 70 mg/dl with a start date of 04/30/21. The Orders tab documented an ordered dated 06/29/21 for [MEDICATION(S)] R U-500 Kwik Pen (insulin) to inject 100 units subcutaneously (SQ-under the skin) four times a day related to type II DM with diabetic chronic kidney disease. Hold insulin if blood glucose was less than 110mg/dl or meal refused. Notify physician if blood glucose was greater than 300 mg/dl or less than 70mg/dl. The Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) for the month of June 2021 for R16 documented blood glucose reading greater than 300mg/dl on 13 of 120 opportunities without the physician being notified. The July 2021 MAR/TAR for R16 documented blood glucose readings greater than 300mg/dl on nine of 124 opportunities without the physician being notified. The August 2021 MART/TAR for R16 documented blood glucose readings greater than 300mg/dl on 24 of 124 opportunities. The CP made nursing recommendations for the months of June, July, and August of 2021 to please ensure nursing staff are notifying the physician for blood sugar readings outside of parameters (above 300mg/dl or below 70 mg/dl) and documenting this in the chart. On 10/12/21 at 10:30 AM R16 sat in her wheelchair as staff propelled her down the hallway to the east dining room for a meeting. In an interview on 10/13/21 at 01:19 PM, Licensed Nurse (LN) J stated that typically staff go by the order for blood glucose monitoring parameters to notify the physician when R16's blood glucose reading is over 400mg/dl, because R16 typically had readings over 300mg/dl. LN j stated staff would be calling the physician all the time. LN J also stated that Administrative Nurse E received the CP's nursing recommendations and would act upon them and notify staff in their morning huddle of the recommendations. In an interview on 10/13/21 at 01:27 PM, Administrative Nurse E stated that R16's [MEDICATION(S)] order should have that parameter to notify they physician when blood glucose level is greater than 400mg/dl or below 70mg/dl and not 300mg/dl. She stated she was the one that put the order in the MAR on 06/29/21 and the system automatically populated the parameter to 300mg/dl (that is the parameter for all other residents except for R16). R16's parameter was changed to 400mg/dl due to the fact that she often times has blood glucose readings greater than 300mg/dl and that was agreed on by her primary physician and the endocrinologist (a doctor that specializes in glands and the hormones). Administrative Nurse E stated R16's special instructions on her dashboard, stated blood glucose greater 400mg/dl or below 70 mg/dl. She further stated that she received the CP's nursing recommendations and acted upon them and then would notify staff and educate them if needed on the changes. In an interview on 10/13/21 at 02:21PM, Administrative Nurse D stated that he received the CP's recommendations and gave them to the unit managers. The unit managers reviewed them and signed off on them. If a nurse received a new order or recommendation, they entered it into the computer. The following day after the recommendations were received, they l addressed them in the morning huddle with staff and educated/reminded them they needed to remember to notify the physician when the blood glucose was out of parameters. he further stated R16 historically had a vast variance in her blood sugars. The facility policy Pharmacy Services revised April 27, 2018, documented: The facility will provide pharmaceutical services to meet the needs of each resident. The facility will obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility; determines that drug records are in order. The facility failed to ensure that nursing staff followed the CP's repeated recommendation that staff needed to notify the physician as ordered when R16's blood glucose readings were greater than 300mg/dl, which had the potential for unnecessary complications related to insulin usage and increased blood glucose levels.

The facility identified a census of 59 residents. The sample included 16 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to notify the physician when resident (R)16's blood glucose reading was over the 300 milligrams per deciliter (mg/dl- a unit for measuring concentration of glucose in the blood) parameter. The facility also failed to ensure that lab was obtained as ordered for R33. This placed R16 at risk for complications related to increased blood glucose levels, and R33 at risk for possible unwarranted and unnecessary medication administration. Findings included: - The electronic medical record (EMR) for R16 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] for R16 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. She required extensive assistance of two staff for activities of daily living (ADLs) and used a wheelchair for mobility. During the look back period she received injections and/or insulin (a hormone which regulates blood sugar) seven of seven days. The Quarterly MDS dated [DATE] documented R16 had a BIMS score of 10, which indicated moderate cognitive impairment. She required extensive assistance of two staff with her ADLs. She required the use of a wheelchair for mobility that staff propelled. She received injections and/or insulin seven of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 05/21/21 documented that R16 had a BIMS of 15 and required extensive assistance of two staff with her ADLs. The Nutrition Care Plan updated 08/05/21 instructed staff to follow R16's accu-check (a blood glucose measuring system) and insulin orders and to notify primary physician if her blood sugar was outside of the parameters. Under the Orders tab, the Orders Summary Report dated 10/11/21 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Orders tab documented an ordered dated 06/29/21 for [MEDICATION(S)] R U-500 Kwik Pen (insulin) to inject 100 units subcutaneously (SQ-under the skin) four times a day related to type II DM with diabetic chronic kidney disease. Hold insulin if blood glucose was less than 110mg/dl or meal refused. Notify physician if blood glucose was greater than 300 mg/dl or less than 70mg/dl. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2021 MAR/TAR for R16 documented blood glucose readings greater than 300mg/dl on nine of 124 opportunities without the physician being notified. The August 2021 MART/TAR for R16 documented blood glucose readings greater than 300mg/dl on 24 of 124 opportunities. On 10/12/21 at 10:30 AM R16 sat in her wheelchair as staff propelled her down the hallway to the east dining room for a meeting. In an interview on 10/13/21 at 01:19 PM, Licensed Nurse (LN) J stated that typically staff go by the order for blood glucose monitoring parameters to notify the physician when R16's blood glucose reading is over 400mg/dl, because R16 typically had readings over 300mg/dl. LN J stated staff would be calling the physician all the time. In an interview on 10/13/21 at 01:27 PM, Administrative Nurse E stated that R16's [MEDICATION(S)] order should have stated that parameter to notify they physician when blood glucose level was greater than 400mg/dl or below 70mg/dl and not 300mg/dl. She stated that she was the person that put the order in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's parameter was changed to 400mg/dl due to the fact that she often times has blood glucose readings greater than 300mg/dl and that was agreed on by her primary physician and the endocrinologist (a doctor that specializes in glands and the hormones). Administrative Nurse E stated R16's special instructions on her dashboard, stated blood glucose greater 400mg/dl or below 70 mg/dl. In an interview on 10/13/21 at 02:21PM, Administrative Nurse D stated that staff nurses input new medication orders into the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The unit managers reviewed orders the next day to make sure they were entered correctly. The nurse should remember to notify the physician when the blood glucose was out of parameters, he further stated R16 historically had a vast variance in her blood sugars. The facility policy Vital Signs Monitoring dated November 28, 2017 documented: The physician will establish parameters for all vital signs. These parameters will be placed on the TAR. When vital signs are outside the physician specified parameters, notification of the physician will be made and documented in the clinical record. The facility failed to ensure that nursing staff notified the physician as ordered when R16's blood glucose readings were greater than 300mg/dl, which had the potential for unnecessary complications related to insulin usage and increased blood glucose levels. - The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented R33 had a Brief Interview for Mental Status (BIMS) score 15 which indicated intact cognition. R33 received antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication seven days, antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications, and diuretic (medication to promote the formation and excretion of urine) medications seven days of the seven-day lookback period. The Quarterly MDS dated [DATE], documented R33 had a BIMS score of 14 which indicated intact cognition. R33 received antianxiety, antidepressant, and diuretic medications seven days of the seven-day lookback period. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 08/27/21, documented R33 had a BIMS score of 15 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Mood/Behavior Care Plan dated 05/21/19, directed staff to review R33's status and notify the doctor if there were any changes in order to see if medications should have been reduced. The Orders tab of R33's EMR documented a discontinued laboratory order with an order date of 02/03/21 for vitamin B12 every six months on the fourth, an active laboratory order with an order date of 02/24/21 for vitamin B12 every three months on the fourth, and an order with a start date of 02/25/21 for vitamin B12 1000 milligrams once a day for supplement. The Medication Regimen Review (MRR) in January 2021 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MRR in February 2021 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's medical record revealed a vitamin B12 level was obtained on 02/04/21. The medical record lacked evidence a vitamin B12 level was obtained as ordered in 12 weeks from 02/19/21 or six months from 02/02/21. Review of R33's Lab Administration Report for August 2021 revealed missed laboratory administration on 08/04/21. On 10/12/21 at 02:05 PM, R33 laid in bed and played on her tablet. She appeared comfortable and without signs of distress or discomfort. She stated she was doing good. On 10/13/21 at 01:56 PM, Licensed Nurse (LN) G stated pharmacy reviews were the responsibility of the Director of Nursing (DON). On 10/13/21 at 02:00 PM, Administrative Nurse D stated the charge nurse and/or unit manager were responsible for placing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not provide a policy on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to obtain laboratory services for R33. This deficient practice placed R33 at increased risk for unwarranted physical complications and unnecessary medication use.

The facility identified a census of 81 residents. The sample included 23 residents. Based on observation, record review, and interview the facility failed to ensure that medications were available for administration as ordered for Resident (R) 52, R59, R57, R17, R16, R35, and R65. Findings included: - The Electronic Medical Record (EMR) for R52 included [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. R52 required limited staff assistance of one person for all Activities of Daily Living (ADLs). The Quarterly MDS dated [DATE] documented a BIMS score of seven which indicated severe cognitive impairment. R52 required limited staff assistance of one staff member for all ADLs except eating which required set-up assistance only. The Care Area Assessment (CAA) for [MEDICAL CONDITION] (medications which affect thinking and/or mood) drugs dated 03/08/2019 documented the resident was taking an antidepressant medication. The Mood/Behavior Care Plan dated 05/20/19 documented R52 took [MEDICATION NAME] for depression, [MEDICATION NAME] (used to treat high blood pressure) for night terrors, and [MEDICATION NAME] for pseudobulbar affect. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Medication Administration tab in the EMR lacked documentation that [MEDICATION NAME] was administered as prescribed on six shifts in (MONTH) 2019. [MEDICATION NAME] was not administered as prescribed on one shift in (MONTH) 2019. [MEDICATION NAME] was not administered as prescribed on one shift in (MONTH) 2019. [MEDICATION NAME] was not administered as prescribed on one shift in (MONTH) 2019. The comment in the Medication Administration Record [REDACTED]. On 12/18/19 at 09:38 AM R52 was sitting in the dining room waiting for an activity to start. She sat upright in her wheelchair. She smiled when greeted. She ate a snack from a bowl without difficulty, and had no problem drinking liquid from an adapted cup. On 12/23/19 at 10:00 AM Certified Medication Aide (CMA) R stated that if a resident does not have a medication in the medication cart and it is time to give it, she will call the pharmacy to have the medication sent immediately. If it arrives in time, she will give it. If it's too late to give, she will tell the nurse, and document why it was not given. How long she waits when a medication is not available depends on the issue. If the pharmacy is out of the medication, CMA R will call another pharmacy. This facility uses a pharmacy which is not open 24 hours. They do have after hours, and the facility uses several local pharmacies as back-up. If a medication is unavailable in the middle of the night, CMA R looks for a generic medication or calls the physician to let them know it was unavailable. She stated that nurses and CMAs order the medications. It usually takes one to two days to get medication after they are ordered, but sometimes insurance won't release medication early. If the order is for immediate delivery, it usually takes one to two hours to get it. If a medication is not available CMA R calls the physician and the pharmacy. She stated that a medication might not be available because the pharmacy might be out because of high demand, or because of insurance issues. If the medication is over the counter, she will check in stock meds or ask central supply for it. On 12/23/19 at 10:09 AM Licensed Nurse (LN) G stated that if a resident doesn't have a medication in the medication cart and it is time to give it, she calls the pharmacy and orders the medication to be delivered immediately. A back-up pharmacy can be used if necessary. This facility uses a pharmacy which is not open 24 hours. It usually takes an hour or two to get the medication delivered. If the med isn't available, LN G reports it to Administrative Nurse D. A medication is usually ordered seven days before the resident is out. If the medication is an over the counter medication it can be taken from stock or someone can go to a local pharmacy to pick it up. On 12/23/19 at 11:05 AM Administrative Nurse D stated that if a resident does not have a medication in the medication cart and it is time to give it, nurses will call the pharmacy and order it to be delivered immediately. If the pharmacy doesn't have it, staff can get it from an after-hours pharmacy. If it is an over the counter medication, the staff checks the overflow or occasionally they go to a local pharmacy to get it. The CMAs and nurses can fax medication orders in to the pharmacies. Medication is delivered daily at around eight pm. Medication usually comes the same day, if it is ordered before two pm. The medication bubble packs are marked indicating when to reorder. The facility's Medication Administration policy dated 03/2011 stated that medications are to be administered in accordance with written orders of the attending physician. The facility failed to ensure that facility medications were available to administer to this resident as ordered by the physician. This deficient practice placed R52 at risk for an increase in her depression, and increased symptoms of pseudobulbar affect and [MEDICAL CONDITION]. -The Electronic Medical Record (EMR) for R59 included [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. R59 required limited staff assistance of one person for all Activities of Daily Living (ADLs) except eating which required set-up assistance only. The Quarterly MDS dated [DATE] documented a BIMS score of nine which indicated moderate cognitive impairment. R59 required limited staff assistance of one person for all ADLs except eating which required set-up assistance only. The Care Area Assessment (CAA) for ADLs dated 06/10/19 documented that R59 had a decline in ADL self-performance and an increased need for staff assistance. He required limited to extensive assistance for ADLs. He required limited assist of one staff for dressing, bathing, and locomotion. He required extensive assistance of one staff for toileting. The Black Box Warning Care Plan dated 05/20/19 documented that information about the medications R59 takes with black box warnings were located on the electronic Medication Administration Record. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Medication Administration tab in the EMR lacked documentation that [MEDICATION NAME] was administered as prescribed on six shifts in (MONTH) 2019. The comment in the Medication Administration Record [REDACTED]. On 12/18/19 at 07:35 AM R59 was observed being wheeled by an aide to the dining room for breakfast. R59 ate breakfast independently from a regular plate without difficulty. He drank coffee without difficulty from a regular cup. No signs of distress were noted. On 12/23/19 at 10:00 AM Certified Medication Aide (CMA) R stated that if a resident does not have a medication in the medication cart and it is time to give it, she will call the pharmacy to have the medication sent immediately. If it arrives in time, she will give it. If it's too late to give, she will tell the nurse, and document why it was not given. How long she waits when a medication is not available depends on the issue. If the pharmacy is out of the medication, CMA R will call another pharmacy. This pharmacy used by the facility is not open 24 hours. They do have after hours agents, and the facility uses several pharmacies as back-up. If a medication is unavailable in the middle of the night, CMA R looks for a generic medication or calls the physician to let them know it was unavailable. She stated that nurses and CMAs order the medications. It usually takes one to two days to get medication after they are ordered, but sometimes insurance won't release medication early. If the order is for immediate delivery, it usually takes one to two hours to get it. If a medication is not available CMA R calls the physician and the pharmacy. She stated that a medication might not be available because the pharmacy might be out because of high demand, or because of insurance issues. If the medication is over the counter, she will check in stock meds or ask central supply for it. On 12/23/19 at 10:09 AM Licensed Nurse (LN) G stated that if a resident doesn't have a medication in the medication cart and it is time to give it, she calls the pharmacy and orders the medication to be delivered immediately. A back-up pharmacy can be used if necessary. The facility uses a pharmacy which is not open 24 hours a day. It usually takes an hour or two to get the medication delivered. If the medication is not available, LN G reports it to Administrative Nurse D. A medication is usually ordered 7 days before the resident is out. If the medication is an over the counter medication it can be taken from stock or someone can go to a local pharmacy to pick it up. On 12/23/19 at 11:05 AM Administrative Nurse D stated that if a resident does not have a medication in the medication cart and it is time to give it, nurses will call the pharmacy and order it to be delivered immediately. If the pharmacy doesn't have it, staff can get it from an after-hours pharmacy. If it is an over the counter medication, the staff checks the overflow or occasionally they go to the local pharmacy to get it. The CMAs and nurses can fax medication orders in to the pharmacies. Medication is delivered daily at around 08:00 PM. Medication usually comes the same day, if it is ordered before 02:00 PM. The medication bubble packs are marked indicating when to reorder. The facility's Medication Administration policy dated 03/2011 stated that medications are to be administered in accordance with written orders of the attending physician. The facility failed to ensure that medication was available to administer to this resident as ordered by the physician. This deficient practice placed R59 at risk for adverse consequences. Findings included: - The '[DIAGNOSES REDACTED]. The resident's 03/22/19 Admission Minimum Data Set (MDS) assessment revealed the resident had intact cognition, no depression and no behaviors. He required extensive assistance of two staff for most activities of daily living (ADLs), with no limitations in range of motion. He was not in pain at the time of the assessment and received antidepressant and antibiotic medications for seven days of the assessment. He received anticoagulant (medication that increases the time it takes for blood to clot) medication five days of the assessment. The Urinary Incontinence Care Area assessment dated [DATE] documented R57 had some bladder incontinence, required a Hoyer lift (total body mechanical lift used to transfer residents) for transfers and used a bed pan or urinal. The Nutrition Care Area assessment dated [DATE] documented R57 eats and drinks independently The Incontinence Care Plan created 05/21/19 documented the resident was incontinent of bladder at times. The Nutrition Care Plan created 05/21/19 documented the resident could eat independently with setup. The physician's orders [REDACTED].) and [MEDICATION NAME] (used to lower cholesterol and triglycerides in the blood) dated 05/24/19 20 mg at bedtime. Review of the Medication Administration Record [REDACTED]. 12/18/19 at 10:23 AM revealed R57 sat in the hallway in a wheelchair. R57 was interacting with staff and getting ready to go to kickball activity. Resident was participating in activity and laughing with peers. On 12/18/19 at 10:23 AM Licensed Nurse (LN) G stated, the nurses or the medication aides reorder medications. The medications should be reordered one week before running out. If the nurses or CMAs call the pharmacy and they can't get it, then our pharmacy will call a local pharmacy, or we will pull it from the emergency kit. If a medication isn't readily available, we will call the pharmacy and get a STAT (immediately) order for delivery. A medication would not be available if it wasn't delivered from the pharmacy yet, the family supplies it and hasn't brought it in yet or there is an issue with the resident's insurance. If a medication is not available, the nurses call the physician, family and pharmacy. If the facility runs out of over the counter medications (OTC), someone from the facility will go to the local pharmacy to get them. On 12/23/19 at 09:25 AM Certified Medication Aide (CMA) R stated, nurses reorder controlled substances and the CMA's reorder the other medications. Medications should be reordered within one week of running out, there is a mark on the bubble pack (packaging in which a medication is sealed between a cardboard backing and clear plastic cover) that indicates when to reorder. If a medication is not available, she will call the pharmacy and place a STAT order. Sometimes medications aren't available because the pharmacy doesn't have them in stock or there's an issue with insurance. She notifies the pharmacy, physician, Social Services and the Director of Nursing if a medication is not available. On 12/23/19 at 11:05 AM Administrative Nurse D stated, if a medication is not available and it's a prescription, the nurses call the pharmacy and get a STAT delivery. If it's an OTC, someone from the facility will go to the local pharmacy to pick it up, if we don't have it in our medication room. The medication aides fax the orders to pharmacy and the nurses fax the order in for new admissions. The medications usually come the same day we order them. The bubble pack is marked indicating when the medication should be reordered. The facility's Ordering and Receiving Medications from Provider Pharmacy policy dated 03/11 stated refill medications are ordered five days in advance of need to assure an adequate supply is on hand. If medications are needed before the next regular delivery, transmit the order to the pharmacy and call the pharmacy to let them know the order is needed immediately. The facility failed to ensure medications were available to administer to R57 as ordered by the physician. - The '[DIAGNOSES REDACTED]. The resident's 05/03/19 Annual Minimum Data Set (MDS) assessment revealed the resident had intact cognition, no depression, and no behaviors. She required extensive assistance of one to two staff for most activities of daily living (ADLs), with no limitations in range of motion. She had an indwelling catheter. She was not in pain at the time of the assessment and received antianxiety, antidepressant, anticoagulant, antibiotic and diuretic medications for seven days of the assessment. The Activities of Daily Living Care Area Assessment (ADL) dated 05/17/19 documented R17 is cognitively intact and requires extensive assistance for all ADLs. She received psychoactive medications. The Mood/Behavior Care Plan created 05/21/19 documented the resident takes Klonopin (medication used to prevent and control [MEDICAL CONDITION] and anxiety) for anxiety. The ADL Care Plan created 05/21/19 documented the resident requires extensive assistance with most of her ADLs. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Observation on 12/18/19 at 10:34 AM revealed R17 lying in bed with her eyes open, remote control to TV in her right hand and call light within reach. On 12/18/19 at 10:23 AM Licensed Nurse (LN) G stated, the nurses or the medication aides reorder medications. The medications should be reordered one week before running out. If the nurses or CMAs call the pharmacy and they can't get it, then our pharmacy will call a local pharmacy, or we will pull it from the emergency kit. If a medication isn't readily available, we will call the pharmacy and get a STAT order for delivery. A medication would not be available if it wasn't delivered from the pharmacy yet, the family supplies it and hasn't brought it in yet or there is an issue with the resident's insurance. If a medication is not available, we call the physician, family and pharmacy. If the facility runs out of over the counter medications (OTC), someone from the facility will go to the local pharmacy to get them. On 12/23/19 at 09:25 AM Certified Medication Aide (CMA) R stated, nurses reorder controlled substances and the CMA's reorder the other medications. Medications should be reordered within one week of running out, there is a mark on the bubble pack (packaging in which a medication is sealed between a cardboard backing and clear plastic cover) that indicates when to reorder. If a medication is not available, she will call the pharmacy and place a STAT order. Sometimes medications aren't available because the pharmacy doesn't have them in stock or there's an issue with insurance. She notifies the pharmacy, physician, Social Services and the Director of Nursing if a medication is not available. On 12/23/19 at 11:05 AM Administrative Nurse D stated, if a medication is not available and it's a prescription, the nurses call the pharmacy and get a STAT delivery. If it's an OTC, we will go to the local pharmacy to pick it up, if we don't have it in our medication room. The medication aides fax the orders to pharmacy and the nurses fax the order in for new admissions. The medications usually come the same day we order them. The bubble pack is marked indicating when the medication should be reordered. The facility's Ordering and Receiving Medications from Provider Pharmacy policy dated 03/11 stated refill medications are ordered five days in advance of need to assure an adequate supply is on hand. If medications are needed before the next regular delivery, transmit the order to the pharmacy and call the pharmacy to let them know the order is needed immediately. The facility failed to ensure medications were available to administer to R17 as ordered by the physician. - The '[DIAGNOSES REDACTED]. The resident's 10/18/19 Annual Minimum Data Set (MDS) assessment revealed the resident had intact cognition, mild depression and no behaviors. She required supervision of one person for most activities of daily living (ADLs), with no limitations in range of motion. She was not in pain at the time of the assessment and received antidepressant medications for seven days of the assessment. The Fall Care Area Assessment (ADL) dated 11/01/19 documented R16 has a history of falling and remains at risk due to visual deficit, unsteady gait, medications and previous falls The Antiplatelet Care Plan created 05/21/19 instructed staff to observe the resident for signs and symptoms of bleeding. The Fall Care Plan created 05/21/19 instructed the staff to check R16's blood pressure if she gets dizzy while she is laying, then sitting and then standing to see if her blood pressure drops. Let the physician know if this happens. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. 12/18/19 at 10:30 AM R16 was in room lying in bed with her eyes open and covers pulled up. Staff knocked before entering room to tell resident she was next for a shower. Resident stated she was ready. 12/18/19 at 12:55 PM R16 was in her room sitting on her bed eating bacon, toast and drinking orange juice. Resident is listening to TV and stated everything is going good and she has no concerns. On 12/18/19 at 10:23 AM Licensed Nurse (LN) G stated, the nurses or the medication aides reorder medications. The medications should be reordered one week before running out. If the nurses or CMAs call the pharmacy and they can't get it, then our pharmacy will call a local pharmacy, or we will pull it from the emergency kit. If a medication isn't readily available, we will call the pharmacy and get a STAT order for delivery. A medication would not be available if it wasn't delivered from the pharmacy yet, the family supplies it and hasn't brought it in yet or there is an issue with the resident's insurance. If a medication is not available, we call the physician, family and pharmacy. If the facility runs out of over the counter medications (OTC), someone from the facility will go to the local pharmacy to get them. On 12/23/19 at 09:25 AM Certified Medication Aide (CMA) R stated, nurses reorder controlled substances and the CMA's reorder the other medications. Medications should be reordered within one week of running out, there is a mark on the bubble pack (packaging in which a medication is sealed between a cardboard backing and clear plastic cover) that indicates when to reorder. If a medication is not available, she will call the pharmacy and place a STAT order. Sometimes medications aren't available because the pharmacy doesn't have them in stock or there's an issue with insurance. She notifies the pharmacy, physician, Social Services and the Director of Nursing if a medication is not available. On 12/23/19 at 11:05 AM Administrative Nurse D stated, if a medication is not available and it's a prescription, the nurses call the pharmacy and get a STAT delivery. If it's an OTC, we will go to the local pharmacy to pick it up, if we don't have it in our medication room. The medication aides fax the orders to pharmacy and the nurses fax the order in for new admissions. The medications usually come the same day we order them. The bubble pack is marked indicating when the medication should be reordered. The facility's Ordering and Receiving Medications from Provider Pharmacy policy dated 03/11 stated refill medications are ordered five days in advance of need to assure an adequate supply is on hand. If medications are needed before the next regular delivery, transmit the order to the pharmacy and call the pharmacy to let them know the order is needed immediately. The facility failed to ensure medications were available to administer to R16 as ordered by the physician. - The '[DIAGNOSES REDACTED]. The resident's 09/27/19 Annual Minimum Data Set (MDS) assessment revealed the resident had intact cognition, no depression and had no behaviors. She was independent with set up assistance for most activities of daily living (ADLs), with no limitations in range of motion. Resident did not have any weight loss or gain during the assessment period. She was not in pain at the time of the assessment and received antianxiety, antidepressant and diuretic medications for seven days of the assessment. The Fall Care Area Assessment (ADL) dated 10/11/19 documented R35 is at risk for falls due to hx of falls, medications and poor balance at times. The ADL Care Area assessment dated [DATE] documented R35 is either independent or needs supervision only for ADLs. Will continue current care plan. The ADL Care Plan created 05/21/19 informed staff R35 has [MEDICAL CONDITION] and she is able to read the newspaper and watch television. She is working with therapy and needs assistance of one staff member for most of her ADLs. The physician's orders [REDACTED]. due to [MEDICAL CONDITION] or other eye diseases). Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] was not available for administration on 12/04/19. Thera Tab was not available for administration on 06/30/19, 07/06/19, 09/08/19, 09/10/19, 09/11/19 and 11/2019. Xalantan was not available for administration on 06/18/19. 12/19/19 at 02:35 PM R35 was in bed resting with her eyes closed. 12/18/19 at 02:44 PM R35 was in dining room playing bingo with peers. On 12/18/19 at 10:23 AM Licensed Nurse (LN) G stated, the nurses or the medication aides reorder medications. The medications should be reordered one week before running out. If the nurses or CMAs call the pharmacy and they can't get it, then our pharmacy will call a local pharmacy, or we will pull it from the emergency kit. If a medication isn't readily available, we will call the pharmacy and get a STAT order for delivery. A medication would not be available if it wasn't delivered from the pharmacy yet, the family supplies it and hasn't brought it in yet or there is an issue with the resident's insurance. If a medication is not available, we call the physician, family and pharmacy. If the facility runs out of over the counter medications (OTC), someone from the facility will go to the local pharmacy to get them. On 12/23/19 at 09:25 AM Certified Medication Aide (CMA) R stated, nurses reorder controlled substances and the CMA's reorder the other medications. Medications should be reordered within one week of running out, there is a mark on the bubble pack (packaging in which a medication is sealed between a cardboard backing and clear plastic cover) that indicates when to reorder. If a medication is not available, she will call the pharmacy and place a STAT order. Sometimes medications aren't available because the pharmacy doesn't have them in stock or there's an issue with insurance. She notifies the pharmacy, physician, Social Services and the Director of Nursing if a medication is not available. On 12/23/19 at 11:05 AM Administrative Nurse D stated, if a medication is not available and it's a prescription, the nurses call the pharmacy and get a STAT delivery. If it's an OTC, we will go to the local pharmacy to pick it up, if we don't have it in our medication room. The medication aides fax the orders to pharmacy and the nurses fax the order in for new admissions. The medications usually come the same day we order them. The bubble pack is marked indicating when the medication should be reordered. The facility's Ordering and Receiving Medications from Provider Pharmacy policy dated 03/11 stated refill medications are ordered five days in advance of need to assure an adequate supply is on hand. If medications are needed before the next regular delivery, transmit the order to the pharmacy and call the pharmacy to let them know the order is needed immediately. The facility failed to ensure medications were available to administer to R35 as ordered by the physician. Findings included: - R65's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. and end stage [MEDICAL CONDITION] (when the kidneys' function reaches an advanced state and no longer work as they should to meet the body's needs). The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of nine, which indicated moderately impaired cognition. She required limited to extensive staff assistance with her Activities of Daily Living (ADLs). The Swallowing/Nutritional Status Care Area assessment dated [DATE] documented R65 had end stage [MEDICAL CONDITION]. The Pain Care Plan dated 12/09/19 documented the staff administered pain medications as ordered by the physician. The physician's orders [REDACTED].

The facility identified a census of 81 residents. The sample included 23 residents. Based on observations, interviews and record review the facility failed to document physician ordered daily weights for Resident (R) 31 and R 35. The facility failed to document physician ordered urine output from an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) for R 17. The facility failed to document weekly skin assessments for R66's pilonidal cyst (abnormal pocket in the skin that usually contains hair and skin debris). Findings included: - The [DIAGNOSES REDACTED]. The resident's 08/09/19 Annual Minimum Data Set (MDS) assessment revealed the resident had intact cognition, no depression and no behaviors. She required limited to extensive assistance of one person for most Activities of Daily Living (ADLs), with no limitations in range of motion. She received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant (medicines that increase the time it takes for blood to clot), and diuretic (medication to promote the formation and excretion of urine) medications for seven days of the assessment. The Nutrition Care Area assessment dated [DATE] documented R31 takes a diuretic daily. The Nutrition care plan initiated 05/20/19 directed staff to monitor R31's weight as ordered. The Order tab of the EMR revealed the resident had a physician order [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed no daily weight documented on (MONTH) 29th and 30th. No daily weight documented on (MONTH) 14th and 27th. No daily weight documented on (MONTH) 5th, 6th, 18th, 21st and 29th. No daily weight documented on (MONTH) 1st, 2nd, 8th, 11th, 16th, 20th, 22nd, 23rd, 24th, 30th and 31st. No daily weight documented on (MONTH) 1st, 3rd, 4th, 6th, 7th, 8th, 9th, 11th, 13th, 18th and 25th. Observation on 12/18/19 at 12:50 PM revealed R31 was in her room sitting in a chair watching television. She appeared to be in a pleasant mood. No indications of pain or distress noted. On 12/23/19 at 09:28 AM Certified Nursing Aide (CNA) M stated the CNAs obtain the weighs. The CNAs know which people and how frequently to get the weights because the nurse tells them, and the CNAs have a communication book. The CNAs document the weights on a piece of paper and give them to the nurses. The nurses document the weights in the EMR. On 12/23/19 at 09:35 AM Licensed Nurse (LN) G stated the CNAs obtain the weights but she will help get them if needed. The nurses tell the CNAs which weights to get, and the CNAs also have a communication book that tells them. If there are parameters on weights it will be on the physician order. If there is a three-pound weight gain or loss, the nurses and/or CNAs will reweigh and notify the physician. If there is a blank spot in the Treatment Administration Record (TAR) that would indicate the order wasn't done. If she notices a weight hasn't been done, she will remind the CNAs or go get herself. If a weight is not obtained or is outside of the parameters, she notifies the physician. On 12/23/19 at 11:05 AM Administrative Nurse D stated CNAs get the weights then tell the nurses what the weight is. The nursing staff either CNAs or nurses can put it in the computer. Parameters for weights should be put in the order. Frequency of weights will be in orders or tasks. A blank indicates the weight was not done. He expects staff to get the weights as ordered and there should be no blanks. The facility Weight Monitoring Policy dated (MONTH) 28, (YEAR) documented additional weights will be obtained based on physician orders. A nurse is responsible for recording the weight on the TAR. The facility failed to document daily weights for R 31 which has the potential to place R31 at risk for complications from CKD. - The [DIAGNOSES REDACTED]. The resident's 09/27/19 Annual Minimum Data Set (MDS) assessment revealed the resident had intact cognition, no depression and had no behaviors. She was independent with set up assistance for most Activities of Daily Living (ADLs), with no limitations in range of motion. She was not in pain at the time of the assessment and received antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) and diuretic (medication to promote the formation and excretion of urine) medications for seven days of the assessment. The Nutrition Care Area assessment dated [DATE] documented R35 takes a diuretic daily. The Nutrition care plan initiated 05/20/19 directed staff to monitor R35's weight as ordered. The Order tab of the EMR revealed the resident had a physician order [REDACTED].>Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed no daily weight documented on (MONTH) 9th, 14th, and 24th. No daily weight documented on (MONTH) 2nd, 9th 23rd and 30th. No daily weight documented on (MONTH) 6th, 12th, 21st and 25th. No daily weight documented on (MONTH) 16th, 20th, 23rd, 24th and 31st. No daily weight documented on (MONTH) 4th, 5th, 7th, 8th, 9th, 13th, 14th, 16th, 18th, 19th, and 25th. Observation on 12/19/19 10:25 AM revealed R35 was in bed resting with her eyes closed. On 12/23/19 at 09:28 AM Certified Nursing Aide (CNA) M stated the CNAs obtain the weighs. The CNAs know which people and how frequently to get the weights because the nurse tells them, and the CNAs have a communication book. The CNAs document the weights on a piece of paper and give them to the nurses. The nurses document the weights in the EMR. On 12/23/19 at 09:35 AM Licensed Nurse (LN) G stated the CNAs obtain the weights but she will help get them if needed. The nurses tell the CNAs which weights to get, and the CNAs also have a communication book that tells them. If there are parameters on weights it will be on the physician order. If there is a three-pound weight gain or loss, the nurses and/or CNAs will reweigh and notify the physician. If there is a blank spot in the Treatment Administration Record (TAR) that would indicate the order wasn't done. If she notices a weight hasn't been done, she will remind the CNAs or go get herself. If a weight is not obtained or is outside of the parameters, she notifies the physician. On 12/23/19 at 11:05 AM Administrative Nurse D stated CNAs get the weights then tell the nurses what the weight is. The nursing staff either CNAs or nurses can put it in the computer. Parameters for weights should be put in the order. Frequency of weights will be in orders or tasks. A blank indicates the weight was not done. He expects staff to get the weights as ordered and there should be no blanks. The facility Weight Monitoring Policy dated (MONTH) 28, (YEAR) documented additional weights will be obtained based on physician orders. A nurse is responsible for recording the weights in the TAR. The facility failed to document daily weights for R 35 which has the potential to cause a decline in her well-being from [MEDICAL CONDITION]. - The [DIAGNOSES REDACTED]. The resident's 05/03/19 Annual Minimum Data Set (MDS) assessment revealed the resident had intact cognition, no depression, and no behaviors. She required extensive assistance of one to two staff for most Activities of Daily Living (ADLs), with no limitations in range of motion. She had an indwelling catheter. She was not in pain at the time of the assessment and received antianxiety, antidepressant, anticoagulant, antibiotic and diuretic medications for seven days of the assessment. The Nutrition Care Area assessment dated [DATE] documented R17 takes a diuretic daily. The Urinary Care Area assessment dated [DATE] documented R17 takes a diuretic and has an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). The Foley care plan initiated 05/21/19 directed staff to empty R17's catheter drainage bag every shift and as needed. The Order tab of the EMR revealed resident had a physician order [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed no urine output documented on evening shift on the 1st, 7th, 8th, 10th and day shift on the 23rd and 25th. No urine output documented on night shift on (MONTH) 4th, 6th 13th and 14th and on day shift in (MONTH) on 6th, 12th and 17th. No urine output documented in (MONTH) on night shift on the 2nd, 5th and 30th and on day shift on the 14th and 30th. There was no urine output documented in (MONTH) on night shift on the 1st and 27th and the 23rd and 26th on day shift. Observation on 12/18/19 at 10:34 AM revealed R17 lying in bed with her eyes open, remote control to TV in right hand and call light within reach. No leakage of catheter noted. Catheter approximately ¼ full at this time. Observation on 12/19/19 at 10:35 AM revealed R17 in her room in bed watching TV. Call light in reach. No indications of catheter leaking. Catheter approximately ¼ full at this time. The facility policy Catheter Drainage Bag dated (MONTH) 28, (YEAR) documented urine output is to be recorded in the clinical record. On 12/23/19 at 09:28 AM Certified Nursing Aide (CNA) M stated the CNAs empty the catheters. She checks the catheters every two hours to see if it needs emptied. The CNAs document the output on a piece of paper and give it to the nurse so the nurse can document it in the computer. The nurse always asks the CNAs for the output. On 12/23/19 at 09:35 AM Licensed Nurse (LN) G stated the CNAs empty the catheters but she will help them if she needs to. The CNAs check the catheters frequently, so they don't get too full. The nurses document the output in the computer. If there was one missing, she would go get it herself or call the CNA to get the amount. If there is a blank in the TAR, that would indicate the order wasn't done. On 12/23/19 at 11:05 AM Administrative Nurse D stated CNAs empty catheters. The output should be checked according to the order. Nurses put the output amounts in the computer. The parameters should be in the order if there are parameters. If output is not documented, the nurses should be documenting the reason why. If there is a blank in the TAR that indicates the order wasn't done. The facility failed to document indwelling urinary catheter urine outputs for R 17 which has the potential to cause urinary complications. Findings included: - The [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated intact cognition. R66 required limited to extensive staff assistance with her Activities of Daily Living (ADLs). She had frequent bladder incontinence and was always incontinent of bowel. She was at risk 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). The facility provided her with pressure reducing devices for her bed and wheelchair. The Pressure Ulcer Care Area Assessment (CAA) dated 12/02//19 documented R66 required assistance with her ADLs and mobility. A pressure reduction mattress was provided The Skin/Pressure care plan revised 12/11/19 documented R66's skin was moist, and staff assisted her with repositioning. The staff completed wound assessments weekly until open skin areas healed. A nursing progress note dated 12/05/19 documented R66 had two small open wounds just above her coccyx. The areas were actively bleeding, and wound care was performed. The nurse documented report of the wounds was passed to the next shift through shift change report. The EMR documented a physician's orders [REDACTED]. The EMR lacked initial measurements of the wounds and weekly wound assessments thereafter. On 12/19/19 at 09:20 AM R66 rested in her bed, on her left side with a support pillow offloading her coccyx from the mattress. A low air loss mattress was inflated on her bed and wheelchair cushion was present. R66 stated the staff are treating a wound on her coccyx and repositioning her frequently. An observation on 12/19/19 at 10:26 AM revealed a scarred, recessed area above R66's coccyx. The area was not open and had rolled skin edges. The base of the area was solid with no drainage noted. On 12/23/19 at 10:09 AM Licensed Nurse H stated when a new wound is observed the nurse assesses and documents the findings, which include measurements of the wound. The nurse reports the wounds to the unit manager. The unit manager does weekly wound assessments. On 12/19/19 at 10:26 AM Consultant Nurse GG stated R66 had surgery for [REDACTED]. The area has opened a few times in the past but, is not open at the present time. On 12/23/19 at 10:39 AM Administrative Nurse [NAME] stated the nurses communicate new wound findings with her. She then performs weekly wound assessments and documents. She verified she did not receive a communication note regarding the new wounds and did not do follow up assessments. On 12/23/19 at 11:05 AM Administrative Nurse D stated he expected nurses to notify the unit manager after assessing the wound. The nurses do wound measurements with the initial assessment of the wound. The facility's Wound Assessment, Prevention and Treatment policy dated 11/28/17 documented when a skin issue is identified, an assessment of the wound is done immediately, including measurements of the wound. The wound nurse completes weekly assessments of the skin issue. The facility failed to provide weekly wound assessments documenting the type of skin injury, current interventions, and the progression of R66's wounds, which had the potential for further skin integrity breakdown.

The facility identified a census of 81 residents. The sample included 23 residents. Based on observations, interviews, and record review the facility failed to provide ongoing communication and collaboration with the [MEDICAL TREATMENT] (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) facility for Resident (R)65, sampled for [MEDICAL TREATMENT]. Findings included: - R65's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. an advanced state and no longer work as they should to meet the body's needs) . The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of nine, which indicated moderately impaired cognition. She required limited to extensive staff assistance with her Activities of Daily Living (ADLs). She received [MEDICAL TREATMENT] treatments. The Swallowing/Nutritional Status Care Area assessment dated [DATE] documented R65 had end stage [MEDICAL CONDITION] and received [MEDICAL TREATMENT] treatments. The [MEDICAL TREATMENT] care plan dated 11/20/19 documented R65 received [MEDICAL TREATMENT] treatments three times weekly. Staff monitored her for symptoms of fluid overload and assisted her in following dietary recommendations made from the [MEDICAL TREATMENT] center. The facility coordinated laboratory monitoring with the [MEDICAL TREATMENT] center. Review of the EMR's progress notes from 11/18/19 through 12/19/19 lacked documentation regarding communication between the [MEDICAL TREATMENT] facility and the facility. On 12/19/19 at 09:00 AM R65 sat in her room and addressed Christmas cards. She stated she has [MEDICAL TREATMENT] treatments on Mondays, Wednesdays, and Fridays. She does not stop at the Program of All-Inclusive Care for the Elderly (PACE) facility prior to or after finishing [MEDICAL TREATMENT] treatments. On 12/23/19 at 10:09 AM Licensed Nurse H stated residents are sent to [MEDICAL TREATMENT] with a communication paper and medical records staff scans the information into the EMR, when the resident returns. On 12/23/19 at 10:24 AM Medical Records Staff Y stated she has scanned [MEDICAL TREATMENT] communication papers into EMRs before but, did not see communication sheets in R65's EMR. On 12/23/19 at 10:39 AM Administrative Nurse [NAME] stated residents are sent to [MEDICAL TREATMENT] with a communication paper. The PACE program keeps the communication papers and calls the facility with updates. On 12/23/19 at 11:05 AM Administrative Nurse D stated the communication papers are sent with the residents when leaving for the [MEDICAL TREATMENT] center. The communication papers are returned to the facility and the information is entered and/or scanned into the EMR. The facility's [MEDICAL TREATMENT] policy dated (MONTH) 28, (YEAR) lacked documentation for providing communication and collaboration with the [MEDICAL TREATMENT] facility. The facility failed to provide ongoing communication and collaboration with the [MEDICAL TREATMENT] facility regarding [MEDICAL TREATMENT] care, health status and services for R65, which had the potential of unwarranted adverse complications, related to her health status and the [MEDICAL TREATMENT] procedure.

The Facility identified a census of 73 residents. Based on observation and interview, the facility failed to ensure medication were appropriately stored and labeled in 3 of 3 medication rooms. Findings Included: - On [DATE] at 8:30 AM review of medication storage room [ROOM NUMBER] revealed Phyto- plex anti-fungal powder expired on [DATE]. Licensed nursing staff K removed this item from the medication storage room. On [DATE] at 8:45 AM review of medication storage room [ROOM NUMBER] revealed [MEDICATION NAME] 1.5gm/ml expired [DATE]. Two Normal Saline intravenous fluid bags expired [DATE]. Licensed nursing staff L removed these items from the medication storage room. On [DATE] at 9:00 AM review of medication storage room [ROOM NUMBER] revealed Wet to Dry dressing kit expired (YEAR). One box of Juven ,[DATE] supplement expired [DATE]. Licensed nursing staff HH removed these items from the medication storage room. The facility failed to provide a request policy for Storage and labeling of Medications. The facility failed to ensure medication were appropriately stored and labeled in 3 of 3 medication rooms.

The facility identified a census of 73 residents. The sample included 31 residents with 11 residents reviewed for abuse. Based on record review and interview, the facility failed to ensure staff provided care and services according to the resident's written plan of care for 2 sampled residents (#227, #229). Findings included: - The (MONTH) (YEAR) electronic medical record for resident #227 documented the following pertinent diagnosis, dementia (progressive mental disorder characterized by failing memory, confusion), dysphonia (difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.), generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and [MEDICAL CONDITION] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, mask like faces, shuffling gait, muscle rigidity and weakness). The quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. The resident required extensive assistance with majority of all Activities of Daily Living (ADLs) and documented 1 non-injury fall since admission. The quarterly MDS assessment dated [DATE] documented little change in cognition or functional ability but recorded 2 non-injury falls since admission. The care plan dated 5/2/18 dated documented the resident could not live by him/herself. Staff were to provide supervision to when completing personal hygiene and assist the resident with dressing and bathing. The resident had a history of [REDACTED]. One to two staff were to provide assist to the resident with transfers and provide 1 person assist to help the resident reposition in bed every 2 hours. The resident required a low bed and a mattress next to the ground to minimize the risk of injury if he/she rolled out of bed. The facility reported investigation dated 5-1-18 documented the following: On 4/26/18 direct care staff N observed discoloration on the residents left arm. Direct care staff N asked direct care staff O to verify the discoloration was new. Direct Care staff 0, (who had worked with the resident the day before) confirmed the discoloration was new. Licensed nursing staff H was notified and assessed and interviewed the resident. The resident gave a description of direct care staff P and stated he/she was in his/her room last night and felt the staff member hated him/her because the staff member treated him/her like a dog last night. Direct care staff P, was immediately suspended. The staff assessed the resident to have the following new skin conditions: Discoloration to proximal lateral left arm measuring 15cm x 1cm, circular purple discoloration measuring 4cm X 5cm, circular discoloration to his left elbow measuring 6cm x 6cm, 3 circular discolorations on his/her proximal forearm near his elbow measuring 2cm x 2cm, and discoloration on his/her right posterior hand measuring 3cm x 3cm. The resident also reported discomfort to shoulders and neck. The facility investigation recorded licensed nursing staff H notified the Director of Nursing (DON), the residents primary care provider, the resident's Durable Power of Attorney (DPOA) and the local law enforcement. Administrative staff D interviewed direct care staff P who stated that he/she had entered the residents room first at 3:30 AM and observed the resident on the floor. Direct care staff P reportedly obtained the mechanical lift and sling and lifted the resident off the floor. During the transfer, direct care staff P stated that the residents weight shifted, and the sling pinched the resident. Direct Care P stated he lowered the resident back down, adjusted the sling and then assisted the resident back into bed using the lift. Direct care staff P stated that at approximately 5:30 AM he/she observed the resident on the fall mattress next to his/her bed. Direct care staff P stated that he/she could not get the sling under the resident, so he/she placed the sling on the floor and rolled the resident off the mattress onto the sling. Direct care staff P then used the mechanical lift and assisted the resident back into bed. Direct care staff P did not tell the nurse about these occurrences. Direct care staff P admitted he/she did not have assistance from another staff member when operating the lift. The investigation concluded the large discoloration that is linear in nature to the residents left proximal left arm is likely from the bed frame or floor when the resident rolled out of bed. The other discolorations to his/her left arm, left hand and right hand are likely from direct care staff P trying to adjust the residents in the mechanical lift sling. Direct care staff N's notarized witness statement dated 4/26/18, documented around 6:30 AM I went into the resident's room to get him up for the day. The resident laid with his/her left side by the wall. When I sat him/her up I saw his/her left arm bruised from his/her shoulder to his/her elbow and a few more below his/her elbow. I laid him/her back down. I got direct care staff O because he/she was the first one I saw right out of his/her room. I asked direct care staff O if he/she could come take a look at the resident's arm. We sat the resident up and direct care staff O saw the residents arm and said the bruises were all new. Direct care staff O reported to the charge nurse. While Licensed nursing staff H assessed the resident, he/she revealed his/her shoulder and neck were hurting. Direct care staff O's notarized witness statement dated 4/26/18 documented, I worked with the resident on Wednesday, the 25th. As I was getting the resident dressed there were no bruising on his/her left arm. When I saw the bruises on 4/26/18, I immediately reported to the nurse. Licensed nursing staff H's notarized witness statement dated 4/26/18 documented at approximately 6:35 AM on (MONTH) 26th, (YEAR), this writer was summoned to the resident's room per reports of bruising. Direct care staff N was present assisting the resident with morning ADLs. The resident stated his/her shoulders and neck hurt and gave a description of a staff member that had been in his/her room last night. The skin assessment revealed the following: the upper outer left arm, 15cm length x 1cm width line shaped discoloration approximately 4.5cm diameter circular in shape discoloration, light purple in color. Left elbow was approximately 6cm in diameter, circular in shape, purple and pink discoloration. Distal to elbow on left upper forearm, 3 circular purple discolorations measuring approximately 2cms each, with approximately 2.5cm between the 3 circular discolorations. Back of the left hand 2 cm in diameter discoloration. Right hand with dark purple discoloration, circular in shape measuring approximately 3 cm in diameter. Staff administered the scheduled [MEDICATION NAME] (narcotic pain medication) for the resident's complaint of pain. In a notarized witness statement dated 4/26/18 licensed nursing staff I stated On 4-25- to 4-26, I was the night shift nurse for the north unit. Direct care staff P was one of my certified nursing assistants for the night shift. I was counting narcotics with the day shift nurse licensed nursing staff H on 4-26, when direct care staff O told us that the resident had bruising to his/her left arm. I did not know of any incidents or concerns that occurred during the night shift. On 11/5/18 at 4:00 PM, administrative staff D stated I do not remember the resident's specific injuries. If he/she had a skin tear or bruising, staff should have monitored at least weekly, but I do not know exactly on that resident. In a notarized witness statement dated 4/26/18 direct care staff P stated I worked with the resident on 4-25 to 4-26 during the night shift. At around 03:30 AM we heard the resident hollering help. When I entered the room, the resident laid on the floor near the foot of his/her bed. I went to get the lift and put the sling under him/her. I started to lift the resident up and his/her weight shifted, the resident said the sling was pinching him/her, so I put him/her down. After repositioning him/her in the sling I assisted him/her back to bed. During rounds at approximately 5:30 AM, the resident sat on his/her fall mattress with his/her back leaning against his/her bed. I went to get the lift. I was not able to get the sling under the resident with him/her being on the mattress. I placed the sling in the floor next to the fall mattress and rolled the resident slowly off the mattress onto the sling which I placed on the ground. Then I assisted the resident back to bed using the lift. The facility's policy Abuse Neglect and Exploitation dated 11/28/17 defined neglect as failure of staff to provide goods or services which are reasonably necessary to ensure safety and well-being and to avoid physical or mental harm or illness. The facility failed to provide on-going monitoring and supervision to ensure staff provided care to this cognitively impaired resident as directed in the written plan of care to prevent multiple bruises. - Resident #229 electronic medical record (EMR) documented the facility admitted the resident on 8/27/18 with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment dated [DATE] documented the resident had a Brief interview for Mental status score of 12 which indicated moderately impaired cognition. The resident had no behaviors during the seven-day assessment period. He/she required extensive assistance of two staff with most activities of daily living (ADLS) such as bed mobility, transfers, ambulation, dressing and toileting. The MDS recorded the resident had an indwelling Foley catheter, was incontinent of bowel and had unhealed pressure sores. The care plan for ADLS, dated 7/25/18 documented the resident required extensive assistance with repositioning and directed to use 2 staff with bed mobility or repositioning every 2 hours. Review of a facility reported occurrence recorded: On 7/26/18 the resident reported to direct care staff member R, that on the evening shift of 7/25/18 a (description of staff member S) hit or punched him/her during cares and direct care staff S stated, I did not hit you that hard. Staff member R informed licensed nurse LL and the resident repeated his/her story that staff member S punched him/her in his/her lower back, but could not tell whether it was a fist or palm that hit him/her. Resident # 229 stated this occurred while staff member S was assisting him/her to roll back and forth to change his/her incontinent brief. Direct care Staff R notarized witness statement dated 7/26/18 documented: while checking vital signs the resident stated that he/she had pain in his/her right side. (Resident) then stated that the (description of direct care staff S) had hit or punched him/her while changing him/her (in the night) and when I (resident) said something to him/her about it, (direct care staff S) stated he/she did not hit him/her that hard. I then reported to the nurse and she immediately went to talk to the resident and reported the issue. Licensed nursing staff LL notarized witness statement dated 7/26/18 documented: This writer was called to (residents) room by (direct care staff R) The patient stated that the (direct care staff S) on the evenings had punched him in the side. He/she did not know if it was (showed open hand) or (showed closed hand). The resident stated it happened when staff member rolled him/her back and forth to change his/her brief. The resident stated, he/she was not rolling fast enough for (direct care S) so he/she punched me over. When (resident) told him/her (direct care staff S) stated I did not hit you that hard. The resident complained of pain on his/her right side, there was no discoloration. The area was tender to the touch. The resident was given a pain relief pill. Direct care Staff S notarized witness statement dated 7/26/18 documented: On 7/25/18 I was working the evening shift on the east unit, I was assigned to care for (resident #229). Approximately 8:00 P.M. on 7/25/18 I went to change (residents) clothes and brief, I had to roll him/her, so I used a draw sheet and it was too difficult. When I started to turn him/her I heard a pop which sounded like cracking your knuckles. I went to get another direct care staff member, to assist me. Interviewed on 11/05/18 at 3:35 PM licensed nurse HH stated when he/she notified the director of nursing and told the nurse on duty to send that direct care staff S away immediately. Interview on 11/5/18 at 4:13 P.M. administrative licensed nurse D stated: The facility reported the incident to the State Agency and the local law enforcement. We investigated the allegations and during the investigation identified the resident required a two person assist. (Direct care staff S) denied the allegations profusely but accepted that the resident could have been perceived him/her as being rough. The facility's policy Abuse neglect and Exploitation Policy revised 11/28/17, defined neglect as the failure of staff to provide goods or services which are reasonably necessary to ensure safety and well-being and to avoid physical or mental harm or illness. The facility failed to provide on-going monitoring and supervision to ensure 2 staff provided care to this dependent resident as directed in the written care plan.

The facility has a census of 40 residents. The sample included 6 residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to provide an environment free from chemical restraint when resident #45 received an antipsychotic intramuscular injection without documented behaviors. Findings included: - The (MONTH) (YEAR) electronic medical record for the resident documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 03, which indicated severely impaired cognition and no behaviors documented. The admission Care Area Assessment (CAA) dated 9/22/18 for cognition documented that significant changes be communicated with the Physician. The CAA dated 9/22/18 did not trigger for mood or behaviors. The care plan dated 9/28/18 directed staff to provide step by step instructions while completing tasks. The care plan lacked behavioral monitoring and non-pharmalogical interventions. The (YEAR) Physicians Order Sheet (POS) recorded [MEDICATION NAME] (antipsychotic medication to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 20 milligram per milliliter given intramuscular one time daily for one day for agitation. Review of the nurse's progress notes dated 10/30/18 at 2:55 AM documented the resident was agitated and talked about two people being murdered and that resident became resistive to care and made a fist like he/she wanted to hit care givers. The resident was then laid down and allowed staff to [MEDICATION NAME] 20 mg intramuscular (IM) medication without a problem. According to www.fda.gov, [MEDICATION NAME] had a black box warning of increased mortality in elderly patients with dementia-related [MEDICAL CONDITION]. The product had a warning that the [MEDICATION NAME] injection can cause severe cutaneous adverse reactions, such as Stevens-Johnso[DIAGNOSES REDACTED], some are fatal. All [MEDICATION NAME] can be associated with metabolic changes that may increase cardiovascular/[MEDICAL CONDITION] risk. The nurse's progress note lacked documentation of non-pharmalogical interventions attempted prior to administered antipsychotic medication. On 10/31/18 at 8:35 AM, physician KK stated staff were to try non-pharmalogical interventions before calling him/her for medication. The facility failed to provide a policy on antipsychotic medication use. The facility failed to provide an environment free from chemical restraint when resident #45 received an antipsychotic intramuscular injection without documented behaviors or evidence of anything less invasive therapies.

The facility identified a census of 73 residents. The sample included 31 residents with 3 residents reviewed for quality of care. Based on observation, record review and interview, the facility failed to assess, monitor and follow up on 2 residents documented injuries. Resident #32's upper left arm bruising and resident #227's multiple bruises to his/her left arm with neck and shoulder discomfort. Findings included: - The (MONTH) (YEAR) electronic medical record (EMR) documented for resident # 32 [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] documented a brief interview for mental status (BIMs) of 99 which indicated sever cognitive impairment. The resident required extensive 2-person assistance with all activities of daily living (ADL's) such as bed mobility, transfers, and toileting. The admission care area assessment (CAA) date 1/8/18 documented the resident had dementia and required extensive assistance for ADL's. The care plan dated 1/8/18 directed staff to be patient with resident as he/she may not be able to communicate needs, introduce oneself before attempting cares and explain what you are doing, ask simple question, and approach in a calm manner. Review of the facility reported investigation dated 8/23/18 documented that direct care staff O noticed and reported bruising on the resident's upper left arm. License nursing staff H assess the resident and reported the bruising to the primary physician and the resident's durable power of attorney (DPOA). The resident was not able to state how the bruising occurred. During interview staff O indicated that the resident could be resistive and combative and sometimes would swing out while cares were being done. The resident wore arm sleeves for skin protection. The EMR did not contain documentation of assessment, monitoring or follow up care for the bruising. A skin assessment dated [DATE] documented discoloration to the left arm. Interview of nursing staff J revealed that skin bruising is assessed and monitored by the nursing staff to determine if the bruise is healing or getting worse and should be charted in the progress notes. At a minimum this would be done during the resident's bi-weekly baths. Interview with administrative nursing staff K revealed that the aide staff make notations on a skin form when they inspect the resident's skin during cares but that this form is not scanned into the EMR. Nurse K did not provide the requested skin assessment forms. Interview with administrative staff D revealed that the resident's EMR did not contain documentation of follow-up care for the resident's upper left arm bruise. The facility did not provide requested quality of care and assessment policy. The facility failed to provide follow-up assessment, care and monitoring of the bruises to this cognitively impaired dependent resident's upper left arm. - The (MONTH) (YEAR) electronic medical record for resident #227 documented the following pertinent diagnosis, Dementia (progressive mental disorder characterized by failing memory, confusion), Dysphonia (difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.), Generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and [MEDICAL CONDITION] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderately impaired cognition. The resident required extensive assistance with majority of all Activities of Daily Living (ADL's). The MDS documented 1 non-injury fall since admission. The quarterly MDS assessment dated [DATE] documented little change in cognition or functional ability but had 2 non-injury falls since admission. The care plan dated 5/2/18 dated documented the resident could not live by his/herself. Staff were to provide supervision to when completing personal hygiene and assist the resident with dressing and bathing. The resident had a history of [REDACTED]. The staff were to provide 1-2 person assist to the resident with transfers and provide 1 person assist to help the resident reposition in bed every 2 hours. He/she had a low bed and a mattress next to the ground to minimize the risk of injury if he/she rolled out of bed. The facility reported investigation dated 5-1-18 documented the following: On 4/26/18 direct care staff N observed discoloration on the residents left arm. Direct care staff N asked direct care staff O to verify the discoloration was new. Direct Care staff 0, (who had worked with the resident the day before) stated the discoloration was new. Licensed nursing staff H was notified and assessed and interviewed the resident. The resident gave a description of direct care staff P and stated he/she was in his/her room last night and felt the staff member hated him/her because the staff member treated him/her like a dog last night. Direct care staff P, was immediately suspended. The resident was observed to have the following new skin conditions: Discoloration to proximal lateral left arm measuring 15cm x 1cm, circular purple discoloration measuring 4cm X 5cm, circular discoloration to his left elbow measuring 6cm x 6cm, 3 circular discolorations on his/her proximal forearm near his elbow measuring 2 cm x 2cm, and discoloration on his/her right posterior hand measuring 3cm x 3cm. The resident also reported discomfort to shoulders and neck. Licensed nursing staff H notified the Director of Nursing (DON), the residents primary care provider, the resident Durable Power of Attorney (DPOA) and the Topeka police department. Administrative staff D interviewed direct care staff P who stated that he/she had entered the residents room first at 0330 and observed the resident on the floor. Direct care staff P got the mechanical lift and sling and lifted the resident off the floor. During the transfer, direct care staff P stated that the residents weight shifted, and the sling pinched the resident. Direct Care P stated he lowered the resident back down, adjusted the sling and then assisted the resident back into bed using the lift. At approximately 0530 AM, Direct care staff P stated that at 0530 the resident was observed on the fall mattress next to his/her bed. Direct care staff P stated that he/she could not get the sling under the resident, so he/she placed the sling on the floor and rolled the resident off the mattress onto the sling. Direct care staff P then used the mechanical lift and assisted the resident back into bed. Direct care staff P did not tell the nurse about these occurrences. Direct care staff P admitted he/she did not have assistance from another staff member when operating the lift. The video camera was reviewed. The video cameras were reviewed. The investigation concluded the large discoloration that is linear in nature to the residents left proximal left arm is likely from the bed frame or floor when the resident rolled out of bed. The other discolorations to his/her left arm, left hand and right hand are likely from direct care staff P trying to adjust the residents in the mechanical lift sling. Direct care staff N's notarized witness statement dated 4/26/18, documented around 6:30 AM I went into the resident's room to get him up for the day. The resident lays with his/her left side by the wall. When I sat him/her up I saw his/her left arm bruised from his/her shoulder to his/her elbow and a few more below his/her elbow. I laid him/her back down. I got direct care staff O because he/she was the first one I saw right out of his/her room. I asked direct care staff O if he/she could come take a look at the resident's arm. We sat the resident up and direct care staff O saw the residents arm and said they were all new. Direct care staff O went to get the nurse right after. The nurse, licensed nursing staff H, came to his room and started assessing the residents arm and asking him/her questions. While licensed nursing staff H was checking the resident, he/she also said his/her shoulder and neck were hurting. Direct care staff O's notarized witness statement dated 4/26/18 documented, I worked with the resident on Wednesday, the 25th. As I was getting the resident dressed there were no bruising on his/her left arm. When I saw the bruises, I immediately went to tell the nurse about them. Licensed nursing staff H's notarized witness statement dated 4/26/18 documented at approximately 6:35 AM on (MONTH) 26th, (YEAR), this writer was summoned to the resident's room per reports of bruising, upon entering the room, the resident was sitting on the toilet in the bathroom without his/her shirt on. Direct care staff N was present assisting the resident with morning ADLs. This writer asked the resident what was going on. Resident stated his shoulders and neck hurt, Resident gave a description of a staff member and stated the staff member had been in his/her room last night. Resident stated I think he/she hates me because he/she treated me like dog last night. The writer examined the resident for skin issues. Noted to the upper outer left arm, 15 cm length x 1cm width line shaped discoloration approximately 4.5cm diameter circular in shape discoloration, light purple in color. Left elbow was approximately 6cm in diameter, circular in shape, purple and pink discoloration. Distal to elbow on left upper forearm, 3 circular purple discolorations measuring approximately 2cms each, with approximately 2.5cm between the 3 circular discolorations. Back of the left hand 2 cm in diameter discoloration. Right hand with dark purple discoloration, circular in shape measuring approximately 3 cm in diameter. Scheduled [MEDICATION NAME] was given. I noticed the DON and administrator immediately. In a notarized witness statement dated 4/26/18 licensed nursing staff I stated on 4-25- to 4-26, I was the night shift nurse for the north unit. Direct care staff P was one of my certified nursing assistants for the night shift. I was counting narcotics with the day shift nurse licensed nursing staff H on 4-26, when direct care staff O told us that the resident had bruising to his/her left arm. I did not know of any incidents or concerns that occurred during the night shift. Since I had given report to licensed nursing staff H, he/she went to assess the situation. Later that day, when I was home, I informed that the resident had concerns about direct care staff P's care toward him/her. I did not recall any incident between them. I was also informed that direct care staff P had assisted the resident off the floor twice that night, but he/she did not report this to me at that time. In a notarized witness statement dated 4/26/18 direct care staff P stated I worked with the resident on 4-25 to 4-26 during the night shift. At around 0330 we heard the resident hollering help. When I entered the room, the resident was laying on the floor near the foot of his/her bed. I went to get the lift and put the sling under him/her. I started to lift the resident up and his/her weight shifted to the left and the sling pinched him/her. The resident said the sling was pinching him/her, so I put him/her down and repositioned him/her in the sling and assisted him/her back to bed. When I left the room to carry on with my work dugites. I went to check on the resident during rounds at 0530 and he was sitting on his/her fall mattress with his/her back learning against his/her bed. I went to get the lift. I was not able to get the sling under the resident with him/her being on the mattress. I placed the sling in the found next to the fall mattress and rolled the resident slowly off the mattress onto the sling which was placed on the ground. Then I assisted the resident back to bed using the lift. The resident did not have any concerns. The facility policy titled Abuse, Neglect, and Exploitation dated 11/28/17 documented physical abuse to includes but is not limited to hitting, slapping, pinching and kicking. The facility is responsible for employee screening, training and prevention, identification, investigation, protection, and reporting of abuse, neglect or exploitation. The clinical record lacked documentation related to follow up assessments of the resident's new skin concerns or discomfort in the neck and shoulders. On 11/05/18 at 04:00 PM administrative staff D stated I do not remember the resident's specific injuries. If he had a skin tear or bruising it should have been monitored at least weekly, but I do not know exactly on that resident. The facility failed to perform follow up assessments related to multiple new skin conditions and discomfort in the resident's neck and shoulders.

The facility identified a census of 73 residents. The sample included 31 residents, 5 reviewed for medication administration and monitoring. Based on record review and interview, the facility failed to insure timely lab reviews related to the residents use of anticoagulant (medication having the effect of inhibiting the coagulation of the blood) medication (#58). Findings included: - The residents electronic medical record documented the following pertinent Diagnosis: [REDACTED]. body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and [MEDICAL CONDITION] (condition of elevated blood lipid levels). The significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The resident required extensive assistance with the majority of the resident's activities of Daily Living (ADL's). The resident received an insulin injection (a horAmone produced in the pancreas that regulates the amount of glucose in the blood), Antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), Antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), Anticoagulant (A medication that is used to prevent the formation of blood clots) and an Opioid (an [MEDICATION NAME] compound that binds to one or more of the three opioid receptors of the body.) 7/7 days. The Care Area Assessments (CAA) dated 10/16/18 for ADL functional and rehabilitation potential documented the resident to have a BIMS of 15. The resident required extensive assistance for most ADL's and the resident took psychoactive medications. The quarterly MDS assessment dated [DATE] documented the resident to have a BIMS of 11, indicating the resident had mild cognitive impairment. The resident required extensive assistance with the majority of ADL's. The resident received an insulin injection, Antianxiety, Antidepressant, Anticoagulant, and an Opioid 7/7 days. The resident received a Diuretic (medication to promote the formation and excretion of urine) 1/7 days. The care plan last reviewed on 9/20/18 documented the resident had limited ability to complete ADL's independently and instructed staff to provide the resident with assistance. Documentation reveled the resident took medications with black box warnings; including an anticoagulant, [MEDICATION NAME] (A drug taken to prevent the blood from clotting and to treat blood clots and overly thick blood). Staff were instructed to monitor the resident for side effects such as bleeding, and obtain labs as ordered. Review of the physician orders [REDACTED]. Diagnosis: [REDACTED]. Review of the resident's laboratory results reveled a time frame of 2 months where the resident did not have a [MEDICATION NAME] ratio and international normalized ratio (PT/INR) (A lab used to monitor the anticoagulant effects of the medication [MEDICATION NAME]) obtained, 7/10/18 to 9/13/18. Review of the consultant pharmacist recommendations reveled in (MONTH) of (YEAR) a recommendation was made for the facility to obtain routine INR monitoring related to [MEDICATION NAME] administration. The pharmacist documented the last INR was obtained 7/10/18. On 11/01/18 at 04:08 PM licensed nursing staff J stated that PT/INR lab results are usually obtained every week and if the results have been consistent, then sometimes the doctor will go 2 weeks. Staff J stated that he/she was not sure why the resident did not have a PT/INR drawn from 7/10/18- 9/13/18, stating that was a large gap in time between the two labs. Staff J stated that it should have been drawn sooner. On 11/05/18 at 11:36 AM administrative staff D stated that he/she was aware that there had been a gap in PT/INR monitoring identified for this resident. Staff D stated that it should not have been that long between PT/INR monitoring and that a PT/INR should have been obtained. Staff D stated that the facility will be making adjustments on this issue. The facility provided policy titled Laboratory, Radiology and Other Diagnostic Services revised (MONTH) 28th, (YEAR) documented the facility must provide or obtain laboratory, radiology and other diagnostic services to residents as ordered. The policy lacked any specific information related to [MEDICATION NAME] monitoring. The facility failed to adequately monitor the resident's medication regimen related to a period of 2 months with no PT/INR laboratory results obtained.

The facility identified a census of 73 residents. Based on observation and interview, the facility failed to ensure that residents received mail on Saturdays. Findings included: - On 10/31/18 interview of members of the resident council revealed that the residents did not receive mail on Saturdays. On 11/1/18 at 3:00 PM interview of activity staff Z revealed that mail is not delivered to the facility on the weekends. Activity staff Z stated, the mail is delivered to the facility's business office on Mondays, is sorted and then delivered to the residents. On 11/5/18 at 8:30 AM interview of administrative staff A stated, he was not aware that the residents mail needed to be delivered on the weekends. Then created a Mail Deliver on Saturday Policy dated 11/3/18 which indicated that mail would be delivered on every Saturday starting this date forward. The facility failed to ensure that mail was delivered to the residents on the weekends.

The facility identified a census of 79 residents and the sample included 1 resident. Based on observation, record review, and staff interview the facility failed to provide proper treatment and [MEDICAL CONDITION] care for 1 of 1(#1) resident reviewed in the sample. Findings included: - Resident #1 had [DIAGNOSES REDACTED]. The admission Minimum Data Set had an assessment reference date of 5/5/11, and an admission date of [DATE], listed the residents Brief Interview for Mental Status score of 15, the resident was cognitively intact. The resident required supervision in some activities of daily living with total dependence of one staff member for eating. The resident had a gastrostomy tube, received oxygen therapy, and [MEDICAL CONDITION] care. The care plan dated 4/28/11 listed the resident had a [MEDICAL CONDITION]. Provide [MEDICAL CONDITION] care as ordered. Oxygen (O2) by [MEDICAL CONDITION] mask as ordered. Monitor O2 saturation. The Physicians Order Sheet (POS) dated 4/28/11 and not signed listed [MEDICAL CONDITION] care twice daily and as needed (PRN) , may suction PRN . The nurses notes (NN) dated 5/7/11 at 9:00 A.M. recorded the nurse came to have the licensed nurse B unhook the peg tube for the resident to go to the bathroom, at 9:15 A.M. the certified nurses aide told the nurse the resident lip synced he/she could not breathe. The nurse went in to check the resident. The resident was noted attempting to cough up phlegm. The nurse attempted to clean the lumen of the [MEDICAL CONDITION]. The nurse attempted to take it out and the [MEDICAL CONDITION] came out. The nurse cleaned and gently reinserted. The resident coughed out bright red blood. The NN dated 5/7/11 at 10:05 A.M. recorded licensed nurse C was alerted to the resident's room regarding [MEDICAL CONDITION] care. On assessment the [MEDICAL CONDITION] was out, with bright red blood being coughed out of the site. The writer suctioned the outer area, and the resident's mouth. The writer obtained a [MEDICAL CONDITION] care kit and a new lumen and attempted to place a new lumen unsuccessfully. The resident now was having difficulty breathing. Staff obtained an order to transport the resident to the hospital for [MEDICAL CONDITION] placement. Interview on 5/18/11 1 :24 P.M. with direct care staff A he/she confirmed the notarized statement of the account of the events on the day of 5/7/11. The resident's call light was going off, the resident needed to go to the bathroom. He/she got the nurse to unhook the feeding tube, and took the resident to the bathroom and cleaned him/her up. Staff sat the resident in a chair to change the bedding, the resident stated he/she couldn't breathe, I asked if he/she wanted me to get the nurse, he/she said yes, I informed the nurse that the resident was having trouble breathing. The nurse came to the room with me, and stated she had not done anything with a [MEDICAL CONDITION] for [AGE] years, she tried to clean the [MEDICAL CONDITION], at that point I left to take care of another resident. The hospital history and physical dated 5/7/11 recorded the resident was an [AGE] year old with a history of head and [MEDICAL CONDITION], a complex history, he/she had a [MEDICAL CONDITION], and he/she was currently at one of the nursing home facilities. Someone there intended to clean his/her [MEDICAL CONDITION] but instead of removing the inner cannula they removed the entire apparatus, and he/she began hemorrhaging, and was brought here. The hemorrhaging was brought under control, the [MEDICAL CONDITION] apparatus was replaced. A chest x-ray showed some infiltrate in the right lower, and right middle lung lobe, this probably represented blood. It was thought that he/she should be watched to be sure there was no more bleeding and to be sure he/she does not have any [MEDICAL CONDITION] issues related to what is probably some blood in his/her lung. Impression : Tracheal Hemorrhage. Hemorrhage at his/her [MEDICAL CONDITION] site secondary to improper removal of the entire [MEDICAL CONDITION] apparatus. The inner cannula should have been removed but instead the entire apparatus was removed. It was subsequently replaced, and hemeostasis was achieved. The right lower lobe/right middle lobe infiltrate, probably represented blood into his/her lower respiratory tract. . Plan: The patient will be admitted and monitored for pneumonia symptoms or any additional [MEDICAL CONDITION] site hemorrhaging. Anticipate he/she would be able to return to the nursing home facility in the next 24-48 hours, signed by hospital physician A. The NN dated 5/9/11 at 7:40 PM recorded the resident was readmitted from the hospital per ambulance cart, the resident transferred to bed by walking. Vital signs temperature 98.3, pulse 92, respirations 20, blood pressure (b/p) 136/76 oxygen saturation 96%. O2 per [MEDICAL CONDITION] mask, warm aerosol at 30% feeding tube in place, feeding tube patent no problems with [MEDICAL CONDITION], resident cooperative, able to cough up some sputum through [MEDICAL CONDITION]. The resident was alert and oriented, denies discomfort at this time. Diminished lung sounds in base, skin warm/dry, resident can makes needs known by mouthing words or use of erase board. The family was at bedside. The social service note dated 5/10/11, note not timed recorded a meeting was held on 5/9/11 with the daughter, the director of nursing and social services. The daughter wanted to make sure that [MEDICAL CONDITION] training was put in place so that staff can care for the resident. [MEDICAL CONDITION] training was set up for 5/10/11 and held for nursing staff on 5/10/11. Review of the inservice provided to facility staff revealed on 5/10/11 at 1:00 P.M. an outside source came and provided a general inservice on [MEDICAL CONDITION] information. The information consisted of the kit to use, how suctioning should be performed, the use of heated aerosol. The inservice provided the opportunity for participants to view and practice with supply items. Observation of the resident 5/17/11 3:30 P.M. revealed the resident in his/her room resting in bed, [MEDICAL CONDITION] attached to humidified concentrator, and tube feeding running. The resident was sleeping. Interview on 5/18/11 at approximately 9:45 A.M. consultant A, who provided the inservice confirmed the inservice was conducted on 5/10/11 at 1:00 P.M.The inservice was a general inservice about equipment and [MEDICAL CONDITION] care, he/she did not inservice staff on the facility policy/procedure. Review of the attendance sheet for the inservice revealed 15 licensed staff members of the facility attended the inservice. Review of an employee list provided by the facility revealed the facility employed 23 licensed staff on a full time or as needed basis. Review of the staffing assignments for the facility from 5/9/11 thru 5/16/11 revealed 8 shifts of care for this resident were assigned to staff who had not attended the [MEDICAL CONDITION] inservice. Interview on 5/18/11 at 2:29 P.M. with licensed staff A confirmed the facility policy and procedure was not inserviced to the staff that attended the inservice, and not all licensed staff of the facility attended the inservice that was provided. The facility failed to ensure this resident received the care and services needed to prevent tracheal hemorraghe. The facility failed to provide care to this resident utilizing trained nurses in [MEDICAL CONDITION] care.

The facility identified a census of 78 residents. The sample included 21 residents. Based on observation, interview, and medical record review the facility failed to provide care for 1 of 4 sampled residents with pressure ulcers to prevent the development of pressure ulcers for resident #165. Findings included: - Resident #165's [DIAGNOSES REDACTED]. The admission Minimum Data Set 2.0, (MDS), dated 04/08/10 recorded the resident with no memory impairment. The MDS also documented the resident as continent of bowel and usually continent of bladder, briefs used with a scheduled toileting plan. The resident required limited assistance of 1 person for transfers, dressing and hygiene. The resident was independent with bed mobility. The MDS further documented no pressure ulcers, no turning or repositioning program for pressure ulcers and the resident as independent with bed mobility. The Resident Assessment Protocol, (RAP) for activities of daily living dated 4/09/10 admission assessment recorded the resident required 1 person limited assistance with transfers, dressing and toileting. The RAP also recorded the resident required 1 person extensive assistance for bathing. The admission assessment dated [DATE] recorded a red/excoriated area on the residents buttocks. Review of the Braden Screen completed on 3/29/10 recorded a score of 15, high risk for development of pressure ulcers. Review of the Braden Screen dated 4/09/10 recorded a score of 15 identifying the resident as high risk for the development of pressure ulcers. Review of the Care Plan dated 04/09/10 recorded a problem for altered skin integrity related to occasional incontinence. The Care Plan directed staff to monitor the resident ' s skin during times of bathing, toileting and dressing and to report any changes in skin integrity to the charge nurse and physician. The Care Plan also directed staff to apply a preventive ointment to the resident ' s perineal area after each incontinent episode and after toileting and it directed staff to toilet the resident at least every 2 hours and check for incontinence. The Wound Skin Report dated 07/8/10 recorded a stage 2 pressure ulcer that measured 2.0 centimeters(cm) x 2.0 cm with no depth or exudate and no odor on the right buttocks. Also the report recored a stage 2 pressure ulcer on the left buttocks that measured 4.0 cm x 1.5 cm with no depth, no exudate and no odor. The Wound Skin Report also recorded a stage 2 pressure ulcer on the residents left heel that measured 3.0 cm x 4.0 cm no depth, no exudate and fluid filled intact skin. On 7/15/10 the wound report measured the wound on the right buttocks as 1.0 cm x1.0 cm a stage 2 pressure ulcer, no depth and the left buttocks was closed. The heel stage 2 measured 3.0 cm x 4.0 cm with no exudate and no depth with skin intact and light brown. Review of the Wound Skin Report dated 07/22/10 recorded the wound on the right buttocks as closed. Review of the nurse ' s notes and the physician's orders [REDACTED]. Review of theTreatment Administration Record for July and August 2010 revealed the facility failed to document any treatments to the area on the resident ' s right buttocks that was identified on the Wound Skin Report. Observation on 08/11/10 at 9:05 A.M.revealed direct care staff G and licensed staff A used the stand lift to toilet the resident. The resident was incontinent of a bowel movement in his/her brief. Observation revealed an open area with no dressing on the resident ' s right buttocks. Licensed staff A assessed the area on the resident ' s right buttocks as an open area which measured 5.0 cm x 0.2 cm superficial, red in color and staff A could not determine the amount of drainage from the area. The area on the left buttocks was observed as healed. The resident did have a pressure reduction cushion on the wheelchair and had a pressure reduction mattress on the bed. Frequent observation on 08/11/10 from 10:30AM through 3:00P.M., a duration of 4 hours and 30 minutes, revealed the staff did not toilet or reposition the resident. During an interview on 08/11/10 at 2:00 A.M. direct care staff G reported he/she toileted the resident one time at 10:00 A.M. on his/her shift. Direct care staff G further reported he/she usually did not work with this resident, but was pulled over from another unit to work on this unit, therefore he/she was not familiar with this resident. He/she reported not repositioning the resident today during his/her shift as the resident could make position changes on his/her own. During an interview on 8/11/10 at 9:32 A.M. licensed staff A reported he/she would call the physician to report this resident had an open stage 2 pressure ulcer. Observation on 08/12/10 at 10:20AM revealed the resident had an open stage 2 pressure ulcer on his/her left heel. Licensed staff A assessed the area which measured 0.3 cm x 0.8 cm pink and superficial with a white area surrounding the open center measuring 0.3cm and superficial. The facility failed to toilet this incontinent resident as directed on the resident ' s care plan and failed to effectively relieve pressure to promote healing of pressure ulcers. The clinical record lacked evidence to show that the development of the reoccurring pressure ulcer in this physically dependent resident was unavoidable and the resident developed a stage 2 pressure ulcer on the right buttocks.