Every finding on record at Medicalodges Wichita

The facility reported a census of 45 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for one of the five Certified Nurse Aides (CNA) reviewed. Findings included:- Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concern: Certified Nurse Aide (CNA) M, hired 09/04/24, lacked an annual performance review in her personnel file. On 09/30/25 at 11:41 AM, Administrative Staff A stated the facility had not completed all the annual evaluations. The facility's Employee Handbook included: Staff performance evaluations shall be completed on an annual basis within two weeks of an employee's anniversary date and include the staff member's strengths and weaknesses.

The facility reported a census of 45 residents. Based on observation, interview, and record review the facility failed to ensure adequate infection control practices related to the handling, processing, and storage of resident clothing and linen. Findings included: - On 09/30/25 at 01:45 PM, the tour of the laundry area with Laundry Staff V revealed the following concerns:The soiled linen sorting area had an overflow of laundry in three barrels in the corner, which resulted in direct contact with the walls.Six uncovered pillows, which included one with a torn, unsanitary vinyl cover, were stacked on top of an overflowing linen barrel with bagged, unmarked clean clothing.The inside door of the dryer, which came in direct contact with clothes during the processing of clean laundry, had an unsealed, worn surface and rust colored substance with an irregular, unsealed, and unsanitary surface.A folding table with peeling and missing laminate, which exposed a porous, unsealed, and unsanitary surface which comes in direct contact with clean laundry during the processing of clean laundry.On 09/30/25 at 01:45 PM, Laundry Staff V stated the bagged unmarked clothing was clean but was not able to identify who the clothing belonged to because they were not marked with the resident's names. She reported the facility stored the clean, unmarked, bagged clothing in the area while awaiting identification. Additionally, she reported she did not know if the pillows were clean or soiled. She said pillows should be sanitized with sani-wipes and stored in a bag separate from the soiled linen to prevent cross-contamination.On 09/30/25 at 02:35 PM, Housekeeping/Laundry Staff W and Maintenance Staff U joined the tour of the laundry and confirmed the above findings and the need for repairs to provide a safe, comfortable, and sanitary environment for the facility staff and residents. Housekeeping/Laundry Staff W stated the vinyl floor peeling and crack in the laundry floor was related to a prior flood from a washer drain and would require repair to ensure a safe and sanitary area.On 09/30/25 at 02:45 PM, Housekeeping/Laundry Staff W agreed the above-noted storage and linen processing issues presented infection control concerns.On 09/30/25 at 03:03 PM, Administrative Nurse F reported she made observations related to processing linen and resident clothing to prevent infection and cross contamination by watching handwashing and the handling and delivery of linen on the units, but did not include rounds in the laundry to determine compliance with infection control measures in that area. She stated she expected the housekeeping and/or maintenance department heads to make rounds within their own departments to determine compliance.The facility policy Infection Control Surveillance, dated 11/2023, documented inspection rounds should be performed in all areas of the facility to monitor compliance with infection prevention and control measures.

The facility reported a census of 45 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately, to prevent the potential for food-borne bacteria in one of one kitchen and one of two dining rooms.Findings included:- During an initial tour of the kitchen, on 09/25/25 at 09:37 AM, the following areas of concern were noted in the kitchen:Three of three two-door reach-in refrigerators had dried-on food and fluids on the fronts, and the rubber strips around the perimeter of the doors contained an unknown black substance.One two-door reach-in refrigerator had spilled liquid on the inside bottom shelf.A stainless-steel cart used to store clean cookie sheets had food debris on the bottom. The bottom shelf of a preparation table holding oils, syrups, uncooked pasta, etc., had food debris.Two of two covered trash cans had dried-on food debris on the fronts.A beige, plastic cart used to deliver drinks to residents in the dining room had black, rubbed-in debris on the top.The microwave had dried-on food debris on all sides and the top of the oven. During an initial tour of the kitchenette in the dining room, on 09/25/25 at 09:37 AM, the following areas of concern were noted:The wooden counter had eight of eight cabinet doors with deep grooves.The microwave had dried-on food debris on all sides and the top of the oven. On 09/30/25 at 03:31 PM, Dietary Staff BB confirmed the areas of concern needed to be addressed and stated the areas would be added to the cleaning schedule.The facility policy for Sanitation of Dining and Food Service Areas, undated, included: The Dining Services Manager will record the necessary cleaning and sanitation tasks for the department. All staff shall be trained on the frequency of cleaning and be held responsible for the completion of the tasks.

The facility reported a census of 45 residents. The sample of 15 residents included five residents reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure the accurate administering of multiple medications as ordered by the physician for one resident, Resident (R)17, related to pain medication and medications to treat constipation.Findings included:- R17's Electronic Health Records (EHR) undated Physician Orders (POS) documented diagnoses which included lymphocytic leukemia (malignant disease affecting bone marrow) of B-cell type, pain, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and constipation R17's 08/29/25 Significant Change in Status Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. The MDS noted R17 received scheduled pain medications and opioids (narcotic pain medication) and reported occasional pain; she did not experience constipation. The Psychotropic Drug Use Care Area Assessment (CAA), dated 09/08/25, documented the resident was at risk for pain based on reported symptoms, including pain that interferes with sleep and limits day-to-day activities. The current interventions included as-needed (PRN) opioid and non-opioid medications. R17's Care Plan dated 09/09/25, directed staff to give medications as ordered. The plan noted R17 used her fingers to clean stool from her rectum even when the stool was soft. She had pain in her right hand and shoulder, and the staff should be responsive, empathetic, and listen to the resident's concerns. The plan directed staff to monitor for non-verbal cues for pain (facial grimacing, guarding, moans, limited participation).R17's EHR recorded Physician Orders (POS) for medications, which included:Gabapentin oral tablet (medication used to treat nerve pain),100 milligrams (MG), give one tablet by mouth, two times a day for neuropathy, ordered 09/05/25.Senna-S oral tablet, 8.6-50 MG (laxative), give two tablets by mouth two times a day, for constipation, ordered 09/05/25. Review of R17's Medication Administration Record(MAR) and Treatment Administration Record (TAR) dated 09/01/25 through 09/30/25 lacked evidence the facility administered the following medications as ordered by the physician:Gabapentin was not given on 09/25/25 at 04:00 PM.Senna-S was not administered at 05:00 PM on 09/15/25, 09/18/25, 09/25/25, and 09/28/25. On 09/30/25 at 09:48 AM, the resident lay in bed. She reported to Certified Medication Aide (CMA) R that her feet hurt. CMA R stated the resident had neuropathy in her feet and received routine medication for the pain. R17 reported her pain rated at a two on a 0-10 scale (pain scale where zero represents no pain and 10 represents the worst pain imaginable). CMA R said she would report R17's pain to the nurse and see what R17 could have to help. On 10/01/25 at 04:08 PM, Administrative Nurse D confirmed the above findings. She verified the nurse and/or CMA should document on the MAR when medications were administered. Administrative Nurse D said the lack of documentation on the MAR indicated the medication was not administered as ordered by the physician. Administrative Nurse D stated R17 always complained of constipation, said R17 reports needing to go all the time, and will attempt to dig out the stool on her own. The facility's policy titled Medication Administration General Guidelines, dated 01/2024, documented the medications are administered in accordance with the prescriber's written order.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the residents of the facility to prevent possible food-borne illnesses. Findings included: - On 02/13/24 at 08:36 AM, a kitchen tour with Dietary Staff BB identified the following concerns: 1. An uncovered trash can/ barrel uncovered, at the handwashing station. 2. A gallon bottle of opened Worchester sauces with a sticky brown hardened rim around the exterior of the gallon jug. 3. The floor soiled with a black substance and debris throughout the kitchen and dish room. 4. A pot rack had rusted legs. 5. A commercial can opener, with a pointed spike that enters the sealed container of food, had black debris hardened on the spike and metal within the bracket used for storage. 6. Eleven flat baking sheets had a brown substance on the cooking surface of the pan, which was reported to be in direct contact with the food. On 02/13/24 at 08:36 AM, kitchen tour with Dietary Staff BB confirmed the above findings. He stated the identified areas of concern should be corrected to provide safe sanitary food preparation for the residents. On 02/14/24 at 11:45 AM, the commercial vent hood over the stove in the food preparation area had a bubbled appearance and missing paint on the exterior of the hood. Dietary Staff CC confirmed and stated the hood had been like that and should be fixed to prevent flaking paint in the food during food prep. The facility lacked a policy to address the repair and maintenance of the kitchen to provide a safe and sanitary operation during food preparation. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the residents of the facility.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary environment for residents and staff in the facility kitchen for the residents of the facility to help prevent the development and transmission of infections. Findings included: - On 02/13/24 at 08:36 AM, during the kitchen tour with Dietary Staff BB identified the following concerns: 1. The dish room hand washing sink with an uncovered trash barrel/can which lacked a foot operated lid closure to prevent the staff from having to touch the lid to dispose of paper towels. 2. The food prep area with a barrel trash at the handwashing sink, with an uncovered trash barrel/can which lacked a foot operated lid closure to prevent the staff from having to touch the lid to dispose of paper towels 3. The kitchen and dish room floor with black substance and debris throughout. 4. The dish room had approximately 30 four-inch tiles missing with black substance build up on floor, which could not be sanitized. 5. A metal shelving unit with soiled vinyl/linoleum covered the bottom shelf which contained eight dish racks. The legs of the shelving unit had rust which could not be sanitized. 6. A food preparation area had a hanging rack for pots and pans with rusty poles, which were unable to be sanitized. 7. The commercial spike can opener had black debris hardened on the spike and inside the metal bracket mounted on the food prep counter which stored the can opener. On 02/13/24 at 08:46 AM, Dietary Staff BB confirmed the above findings and stated the identified concerns prevented the areas from being sanitized. The facility lacked a policy to address to appropriate trash/garbage disposal in the kitchen to prevent cross contamination. Additionally, the facility lacked a policy to address the repair and maintenance of the kitchen equipment to prevent cross contamination and the spread of infection The facility failed to provide a safe, functional, sanitary environment for residents and staff in the facility kitchen to prevent possible contamination.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to maintain all mechanical and electrical equipment in safe operating condition in the kitchen. Findings included: - On 02/13/24 at 08:36 AM, kitchen tour with Dietary Staff BB revealed the following identified concerns: 1. Eight dish racks stacked on a metal stand that had soiled vinyl linoleum which covered the shelf. The shelf had rust on the legs. 2. A commercial spike can opener had a build-up of hardened black debris on the spike which enters the sealed can of food, and metal black dried hard substance within the bracket which housed the can opener. 3. The upright poles attached to the pot rack were rusted. On 02/13/24 at 08:45 AM, Dietary Staff BB confirmed the above findings and stated the equipment needed to be cleaned and maintained for safe operation. On 02/14/24 at 11:45 AM, the commercial stove hood had bubbled peeled paint. Dietary Staff CC confirmed the above finding and stated the stove hood had been like that for a while. Dietary Staff BB confirmed the above finding and stated the equipment needed to be cleaned and maintained for safe operation. The facility lacked a policy to address repair and maintenance of equipment in the kitchen in safe operation condition. The facility failed to maintain all mechanical and electrical equipment in safe operating condition in the kitchen.

The facility reported a census of 47 residents. Based on observation, interview, and record review the facility failed to ensure a safe and sanitary environment for residents and staff in the facility kitchen. Findings included: - On 02/13/24 at 08:36 AM, kitchen tour with Dietary Staff BB, revealed the dish room floor with approximately 30, four-inch tiles missing with black substance build up on the bare concrete where the floor tiles were missing. On 02/13/24 at 08:55 AM, Maintenance Staff U, joined the kitchen tour and confirmed the above finding. He stated the tile had been missing for a while. The facility usually placed a rubber mat over the missing tile. Maintenance Staff U confirmed the area was a trip hazard and was unsanitizable. On 02/14/24 at 10:42 AM, during additional tour of the kitchen, two wall tiles laid on the windowsill in food prep area. On 02/14/24 at 10:54 AM, Dietary Staff BB and dietary staff CC confirmed the above finding, and reported they did not know why or how long the tiles had been lying in the windowsill. The facility lacked a policy to address maintenance and repair related to the kitchens safe and sanitary environment. The facility failed to ensure a safe and sanitary environment for residents and staff in the facility kitchen.

The facility reported a census of 43 residents one main kitchen that served all residents that received meals. Two residents received nutrition via feeding tubes. The facility failed to store food in a sanitary manner in the main kitchen. Findings Included: - Tour of the kitchen on 03/21/22 at 08:10 AM in the dry storage area revealed a large bag of Cheetos laid open on the shelf. Observation in the freezer revealed a bag of hamburger patties open with no closure, a bag with five fish fillets with no date, and a box of pizza dough left open to air. Interview on 03/23/22 at 01:10 PM with Certified Dietary Manager N verified she expected the staff to date all items when opened and all opened items should have proper closures. The facility policy Food Storage revised in 2011 stated food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Wrap food properly and never leave food items uncovered and not labeled. The facility failed to store food in a sanitary manner in the main kitchen.

The facility reported a census of 43 residents. Based on observation, interview, and record review the facility failed to ensure nursing staff used Personal Protective Equipment (PPE) appropriately, by the failure to change gloves between dirty and clean tasks when providing care for Residents (R) 23 and R9. The facility further failed to clean a glucometer (instrument used to calculate blood glucose) after use to reduce the risk of spread of infectious diseases. Findings Included: - On 03/21/22 at 08:50 AM, observation revealed Certified Medication Aid (CMA) J and Administrative Nurse I entered R23's room and informed R23 of care to be provided. Both staff performed hand hygiene and donned gloves, positioned R23 with shorts down and brief open lying on his side. While Administrative Nurse I held R23 on his side, CMA J cleaned the bowel movement (BM) off of R23 with gloved hands and wipes, then cleaned R23's front side, CMA J continued with the same gloved hands to close R23's brief, pull up his shorts, and cover him with a blanket. CMA J then continued, with dirty/same gloved hands, to adjust her mask. CMA J then moved the lift sling to R23's wheelchair and moved the wheelchair to a position in front of R23's nightstand. CMA J then removed the gloves and performed hand hygiene. On 03/21/22 at 09:20 AM, observation revealed CMA J and Administrative Nurse I performed hand hygiene and entered R9's room. Informed R9 of care to be provided and positioned R9 on his side with his brief open. Administrative Nurse I cleaned R9's BM with gloved hands and wipes, retrieved a tube of barrier cream, and applied it to R9. With the same gloved hands, she then scratched her head, adjusted R9 in bed, adjusted the resident's hospital gown, adjusted R9's feeding tube, and placed the bed control within R9's reach. Administrative Nurse I then placed the wipes and barrier cream tube in the resident's nightstand drawer and then removed her gloves and performed hand hygiene. On 03/21/22 at 08:50 AM CMA J confirmed she was educated on infection control procedures and donning and doffing of PPE. She confirmed she should have changed her gloves between dirty and clean fields. On 03/21/22 at 09:20 AM Administrative Nurse I confirmed she should have changed her gloves between clean and dirty fields. She stated she was educated on infection control procedures of donning and doffing PPE. On 03/22/22 at 07:38 AM Administrative Nurse H confirmed all staff were trained in donning and doffing PPE and she completed competency audits with several staff. She would expect all staff to perform hand hygiene between glove use as well as change gloves from dirty to clean fields. On 03/23/22 at 08:26 AM Administrative Nurse B stated her expectation would be that all staff use PPE appropriately with changing gloves to be at the top of the list. The facility Infection Management Process policy revised December 2019 documented the staff were educated on proper hand hygiene. The facility failed to ensure staff changed gloves between dirty and clean tasks when providing cares for R23 and R9. - Observation on 03/22/22 at 07:52 AM revealed Licensed Nurse (LN) O checked the blood sugar for R10 using a glucometer (instrument used to calculate blood glucose). The nurse donned gloves and cleaned the resident's finger with alcohol. LN O then used a lancet (sharp object to pierce the skin to obtain a blood sample) to draw blood and placed a small drop of blood onto the glucometer strip. LN O then cleaned the resident's finger and LN O took gloves off and took the glucometer out of the resident's room. LN O then put the glucometer in the box filled with cotton balls and lancets before cleaning the machine. On 03/22/22 at 8:00 AM LN O reported staff used the glucometer for all residents receiving blood sugar checks and she probably should have cleaned it before she put it away. Observation on 03/22/22 at 08:02 AM Administrative Nurse B walked up to the medication cart and gave the nurse a towelette to clean the glucometer. Nurse O then cleaned the machine. On 03/22/22 at 08:02 AM Administrative Nurse B reported the glucometer should be cleaned between each use. The facility policy for Infection Management Process dated 12/2019 revealed glucometers will be properly sanitized between each use. The device will be wiped with products that kill c-diff spores and blood borne pathogens. Staff will be educated on appropriate dry time before using. The facility failed to clean a glucometer after use to reduce the risk of spread of infectious diseases.

The facility census totaled 43 residents, with 13 sampled, including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to initiate a physician's order for a dose reduction for an antipsychotic medication for six months for Resident (R) 33. The facility further failed to limit the time frame of an as needed (PRN) [CONDITION(S)] medication for R28. Findings Included: - R28's Physician's Orders Sheet dated 03/21/22 documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 01/18/22 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. R28 received an antianxiety medication on one day in the seven-day look back period. The 03/21/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders in the electronic health record (EHR) documented the following orders for [MEDICATION(S)] 0.5 milligrams (mg) as needed (PRN): Order dated 01/10/22 and discontinued on 02/01/22, for a total of 22 days. Order dated 02/01/22 and discontinued on 03/21/22, for a total of 48 days. On 03/21/22 at 02:14 PM R28 sat in her wheelchair outside of her room and used her legs to move her wheelchair toward the dining room. Several staff through the area stopped and spoke to R28, offered her assistance, snacks, and drinks. On 03/22/22 at 01:43 PM Certified Medication Aid (CMA) J stated R28 took her medications crushed and usually take her medications. She stated when R28 was upset or anxious she would move through the facility in her wheelchair and try to stand up without assistance. On 03/22/22 at 03:09 PM Administrative Staff B stated she expected the nursing staff to be mindful of the PRN orders for the residents and assist with keeping them at the 14-day limit. Telephone attempts to interview the consulting pharmacist on 03/23/22 and 03/24/22 at 12:34 PM with no contact made. The facility's Medication Regimen Review and Reporting policy revised 09/2018 documented the nursing center would follow up on recommendations to verify that appropriate action was taken. Recommendations would be acted upon within 30 calendar days. The facility failed to adequately monitor the use of [CONDITION(S)] medications for R28 by the failure to limit the PRN antianxiety medication to 14 days to ensure the lowest effective dose received and ensure minimal side effects. - R33's signed Physician Orders dated 02/02/22 revealed the following diagnoses: major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and [CONDITION(S)] (progressive mental disorder characterized by failing memory, confusion). The 05/13/21 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident had no behaviors and had rejection of care one to three days of the observation period and did not receive [CONDITION(S)] medications in the seven-day review period. The 02/02/22 Quarterly MDS revealed R33 had verbal behaviors one to three days of the observation period. The resident received psychotic medication daily in the seven-day review period. The Care Area Assessment (CAA) dated 05/13/21 had all appropriate triggers. The Care Plan dated 02/17/22 revealed the resident received therapeutic [CONDITION(S)] medications. The resident received [MEDICATION(S)] (antipsychotic) for agitation verbal aggression mood/behavior and psychosocial problems and could be manipulative, passive/aggressive and attention seeking. The resident needed to develop a trusting, therapeutic relationship with others. Staff to allow the resident to express her emotions without judgement or criticism. Staff to encourage the resident to participate in activities of her choice. Assist the resident to develop more appropriate methods of coping and interacting with staff. Staff to intervene as necessary to protect the rights and safety of others. Speak to the resident in a calm voice, divert attention. Remove from the situation and take to alternate location as needed. Refer the resident to have psychological referral. The 06/15/21 Physician Orders revealed [MEDICATION(S)] Tablet 25 milligrams (MG) give one tablet by mouth at bedtime related to major depressive disorder. The Consulting Pharmacist Monthly Medication Regimen Report revealed a pharmacist request for a gradual dose reduction (GDR) of [MEDICATION(S)] 25 mg to 12.5 mg on 10/13/21. Physician reported the resident's condition was stable and agreed to decrease with a signed order to decrease the medication. The Medication Administration Record for the months of 10/21, 11/21, 12/21, 01/22, 02/22 and 03/22 revealed the [MEDICATION(S)] dose remained unchanged at 25 mg. The resident received [MEDICATION(S)] 25 mg every day since the order was to be decreased to 12.5 mg. Observation on 03/21/22 at 01:20 PM revealed the resident walked down the hall and came across a dietary staff standing with a cart by the elevator. The resident made very rude comments to the staff before the staff got on the elevator. The resident walked off as if nothing happened. The resident declined an interview on 03/21/22 at 09:30 AM. On 03/22/22 at 10:24 AM Certified Medication Aide (CMA) J stated she would report to the nurse if the resident had behaviors. She would also report if she saw the resident with increased sleepiness or not acting herself. On 03/22/22 at 01:40 PM Licensed Nurse (LN) E reported the resident would have behaviors like yelling and cursing if you told her she could not do something or have something. When she has behaviors the nurse charts them in the nurse's notes. The Certified Nursing Assistants (CNA) will chart it and then tell us and we will assess the resident. On 03/22/22 at 04:00 PM the pharmacy consult and the physician order was given to Administrative Nurse L and Administrative Staff A and told Administrative Nurse L about the medication error. On 03/23/22 at 11:30 AM Administrative Nurse B reported she was made aware of the medication error and contacted the physician. Administrative Nurse B reported she obtained a new order to decrease the medication and to monitor for resident behaviors. Attempted to interview the pharmacist on 03/23/22 at 12:17 PM and on 03/24/22 with no contact made. The facility policy Medication Regimen Review and Reporting dated 09/18 revealed the nursing care center followed up on the recommendations to verify appropriate action was taken. Recommendations shall be acted upon within 30 calendar days. The facility failed to initiate a doctor's orders for a dose reduction of an antipsychotic medication for six months for R33.

The facility census totaled 43 residents with 13 sampled including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to initiate a physician's order for a dose reduction for an antipsychotic medication, as recommended by consulting pharmacist, for six months for Resident (R) 33. The facility further failed to limit the time frame of an as needed (PRN) [CONDITION(S)] medication, as recommended by the consulting pharmacist, for R28. Findings Included: - R28's Physician's Orders Sheet dated 03/21/22 documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 01/18/22 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. R28 received an antianxiety medication on one day in the seven-day look back period. The 03/21/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders in the electronic health record (EHR) documented the following orders for [MEDICATION(S)] 0.5 milligrams (mg) as needed (PRN): Order dated 01/10/22 and discontinued on 02/01/22 for a total of 22 days Order dated 02/01/22 and discontinued on 03/21/22 for a total of 48 days Review of the monthly pharmacy Medication Record Review (MRR) for 01/21/22 with the recommendation PRN [CONDITION(S)] orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the prn order. Please address the noncompliant PRN [MEDICATION(S)] order. Review of R28's EHR lacked documentation from the provider for a rationale to continue use of PRN for longer than the 14 days. On 03/21/22 at 02:14 PM R28 sat in her wheelchair outside of her room and used her legs to move her wheelchair toward the dining room. Several staff through the area stopped and spoke to R28, offered her assistance, snacks, and drinks. On 03/22/22 at 01:43 PM Certified Medication Aid (CMA) J stated R28 took her medications crushed and that she would usually take her medications. She stated when R28 was upset or anxious, she would move through the facility in her wheelchair and try to stand up without assistance. On 03/22/22 at 03:09 PM Administrative Nurse B stated the consultant pharmacist would email the recommendations to her and her Assistant Director of Nursing. Administrative Nurse B would print them off, the medical records staff would complete the nursing portion, and the nurse practitioner for the provider would sign and complete physician portion. She stated she expected the nursing staff to be mindful of the PRN orders for the residents and assist with keeping them at the 14-day limit. Unable to interview pharmacist with attempts made to contact the Consulting Pharmacist on 03/23/22 and 03/24/22 at 12:34 PM. The facility's Medication Regimen Review and Reporting policy revised 09/18 documented that the nursing center would follow up on recommendations to verify that appropriate action was taken. Recommendations would be acted upon within 30 calendar days. The facility failed to adequately monitor the use of [CONDITION(S)] medications for R28 by the failure to limit the PRN antianxiety medication to 14 days, as recommended by the consulting pharmacist, to ensure the lowest effective dose received and ensure minimal side effects. - Resident (R)33's signed Physician Orders dated 02/02/22 revealed the following diagnoses: major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and [CONDITION(S)] (progressive mental disorder characterized by failing memory, confusion). The 05/13/21 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident had no behaviors, had rejection of care one to three days of the observation period, and did not recieve [CONDITION(S)] medications in the seven day review period. The Quarterly MDS dated [DATE] revealed verbal behaviors one to three days of the observation period. The resident received an antipsychotic medication seven days of the observation period. The Care Plan dated 02/17/22 revealed the resident received therapeutic [CONDITION(S)] medications. The resident received [MEDICATION(S)] (antipsychotic) for agitation, verbal aggression mood/behavior and psychosocial problems and could be manipulative, passive/aggressive and attention seeking. The Physician Orders dated 06/15/21 revealed [MEDICATION(S)] Tablet 25 milligrams (MG) give one tablet by mouth at bedtime related to major depressive disorder. The Consulting Pharmacist Monthly Medication Regimen Report revealed a pharmacist request for a gradual dose reduction (GDR) of [MEDICATION(S)] 25 mg to 12.5 mg on 10/13/21. Physician reported the resident's condition was stable and agreed to decrease with a signed order to decrease the medication to 12.5 mg. The Consulting Pharmacist Medication Regimen Reviews dated 11/11/21, 12/21/21, 01/21/22 and 02/20/22 made no mention of the [MEDICATION(S)] dose not being decreased as ordered on 10/13/21. The Medication Administration Record dated 10/21, 11/21, 12/21, 01/22, 02/22 and 03/22 revealed the [MEDICATION(S)] dose remained unchanged at 25 mg. The resident received [MEDICATION(S)] 25 mg every day since the order was to be decreased to 12.5 mg. Observation on 03/21/22 at 01:20 PM revealed the resident walked down the hall and came across a dietary staff standing with a cart by the elevator. The resident made very rude comments to the staff before the staff got on the elevator. The resident walked off as if nothing happened. The resident declined an interview on 03/21/22 at 09:30 AM. On 03/22/22 at 10:24 AM Certified Medication Aide (CMA) J stated she would report to the nurse if the resident had behaviors. She would also report if she saw the resident with increased sleepiness or not acting herself. On 03/22/22 at 01:40 PM Licensed Nurse (LN) E reported the resident would have behaviors like yelling and cursing if you told her she could not do something or have something. When she has behaviors the nurse charts them in the nurse's notes. The Certified Nursing Assistants (CNA) will chart it and then tell us and we will assess the resident. On 03/22/22 at 04:00 PM, Administrative Nurse L reviewed the physician order and agreed the medication should have been decreased. On 03/23/22 at 11:30 AM Administrative Nurse B reported she was made aware of the medication error and contacted the physician. Administrative Nurse B reported she obtained a new order to decrease the medication and to monitor for resident behaviors. She received the pharmacy consults monthly but missed the order for the medication. Attempted to interview the pharmacist on 03/23/22 at 12:17 PM and on 03/24/22 with no contact made. The facility policy Medication Regimen Review and Reporting dated 09/2018 revealed the consultant pharmacist reviewed the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication and ensure the medications each resident received were clinically indicated. The facility failed ensure the Consultant Pharmacist identified continued use of an antipsychotic medication without a GDR and the facility failed to implement the physician order for a GDR in response to the pharmacist's recommendation.

The facility reported a census of 43 resident, with 13 residents included in the sample, and two residents reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure they had a system in place to change oxygen tubing, nebulizer tubing, and cleaning of respiratory equipment in a timely manner for Residents (R) 148 and R25. Findings included: - The 12/22/21 signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Them12/29/21 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Plan of Care dated 12/22/21 indicated R148 had a potential for respiratory distress related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan lacked any further direction to staff regarding changing oxygen and nebulizer tubing and/or cleaning of respiratory equipment. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the (MAR) and Treatment Administration Record (TAR) from 12/22/21 to 03/17/22 indicated a lack of documentation for staff to clean the nebulizer after each use, and/or when to change the resident's nebulizer mask and or tubing. Observation on 03/22/22 at 08:04 AM revealed the resident's nebulizer had leftover fluid in the base and was still connected to the mask. The mask had crusty material observed to the inside the mask. The date on the tubing was noted as 01/17/22 (over two months prior). Observation on 03/23/22 at 09:25 AM revealed R148 received a breathing treatment per mask and after completing the treatment R148 laid the mask and tubing on her nightstand. Observation on 03/23/22 at 10:10 AM the resident's nebulizer remained laid on the bedside table in the same position and no signs the staff had disconnected and rinsed the equipment. Interview on 03/22/22 at 09:35 AM with R148 revealed she removed the nebulizer mask after the treatment was complete. R148 stated the staff did not come into her room and rinse the equipment out. Interview on 03/22/22 at 01:06 PM with Certified Medication Aide (CMA) J revealed the nurse provided the nebulizer treatment and cleaned the equipment after each use. CMA J stated they changed the tubing weekly and marked the tubing with a piece of tape or on the tubing itself. Interview on 03/23/22 at 07:33 with Licensed Nurse (LN) E revealed the nebulizer should be cleaned after each use and the tubing and mask should be changed on a weekly basis. Interview on 03/23/22 at 12:35 PM Administrative Nurse B stated she expected the licensed nurse to rinse the nebulizer out after each use, place it on a paper towel in the resident's room, and expected the staff to change out the tubing and mask weekly. She further expected the information be placed on the care plan and MAR/TAR. The facility failed to provide a policy regarding respiratory care as requested on 03/23/22. The facility failed to ensure a system to change R148 oxygen tubing, nebulizer tubing, and cleaning of respiratory equipment. - Review of R25's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 01/20/22 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had shortness of breath with exertion, sitting, and at rest. The Baseline Care Plan dated 03/21/22 revealed the resident had a potential for respiratory distress related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medical Record dated 03/10/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation 03/22/22 at 08:07 AM revealed oxygen tubing in the resident's room with no markings to indicate the last time staff changed out the tubing. Interview on 03/22/22 at 01:12 PM with Certified Nurse Aide (CNA) J revealed they changed the oxygen tubing out weekly and did not mark the tubing. Interview on 03/23/22 at 07:46 AM with Licensed Nurse (LN) E revealed the oxygen tubing changes should be documented on either the MAR/TAR when staff competed the task. Interview on 03/23/22 at 12:40 PM with Administrative Nurse B revealed she expected the tubing to be changed weekly and documented on the (MAR/TAR) and plan of care. The facility failed to provide a policy regarding respiratory care as requested on 03/23/22. The facility failed to ensure a system in place to change oxygen tubing, nebulizer tubing, and cleaning of respiratory equipment in an timely manner.

The facility census totaled 43 residents with 13 included in the sample, and one reviewed for urinary catheter. Based on observation, interview, and record review the facility failed to provide necessary services to decrease the risk of a urinary tract infection when staff failed to ensure Resident (R) 29 urinary catheter tubing did not come in contact with the floor. Findings included: - R29's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/25/21 Significant Change in Status Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of one staff for daily care. The resident had a urinary catheter and received hospice care. The 01/25/22 Quarterly MDS revealed no significant changes in status since assessment on 10/25/21. The 10/25/21 Urinary Incontinence Care Area Assessment (CAA) revealed the resident continued to require an indwelling urinary catheter for neuropathic bladder. Staff change the catheter monthly and as needed (PRN) per physician orders. The 09/30/21 Care Plan revealed the resident had an indwelling urinary catheter related to [CONDITION(S)]. Staff were to position the catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor/record/report to nurse signs of a urinary tract infection ([CONDITION(S)]): pain, burning, blood tinged urine, cloudiness, no output, deepening or urine color, increased pulse, increasing temp, urinary frequency. Staff to provide catheter care every shift. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/22/22 at 07:55 AM revealed the resident sat in a wheelchair in the dining room for breakfast. The resident's urinary catheter tubing drug on the floor. Observation on 03/22/22 at 08:00 AM revealed the resident moved to different table in the dining room by Certified Nurse Aide (CNA) K. The catheter tubing drug on the floor as they went by, with the urinary catheter bag hung under the chair. On 03/22/22 at 08:00 AM CNA K reported he knew the catheter tubing needed to be off of the floor. On 03/22/22 at 01:20 PM CNA M reported she did not know the tubing drug on the floor early that morning. On 03/23/22 at 10:15 AM Licensed Nurse (LN) L reported the catheter tubing should always remain off the floor. LN L reported Hospice staff must have changed the resident's urinary collection bag but acknowledged the bag should have been off the floor. The facility did not provide a policy regarding catheter care, as requested on 03/23/22 at 08:00 AM. The facility failed to provide necessary services to decrease the risk of a urinary tract infection when staff failed to ensure Resident (R) 29 urinary catheter tubing did not come in contact with the floor.

The facility reported a census of 43 with 13 residents included in the sample. Based on observations, interviews, and record review the facility failed to ensure Resident (R) 148 received appropriate assessments and foot care. Findings include: - The 12/22/21 signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/29/21 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 12/29/21 stated the resident was independent with ADLs except required some assistance for balance with mobility. The 12/22/21 Care Plan indicated R148 needed assistance of one staff member with dressing and personal cares. The care plan lacked information to provide diabetic foot care. Review of the Medical Record from 12/22/21 to 03/17/22 lacked an admission skin assessment and weekly skin assessments. Observation on 03/21/22 at 09:23 AM, R148 removed a sock from her left foot revealing long toenails which curved towards the her little toe. Observation on 03/22/21 at 08:02 AM revealed R148 ambulating in the hallway with gripper socks on both feet with no complaints of pain. Interview on 03/22/22 at 07:11 AM with Certified Nurse Aide (CNA) G revealed she informed the nurse about R148's nails about two and half weeks ago, but had not seen her toenails since then. Interview on 03/23/22 at 07:33 AM with Licensed Nurse (LN) E indicated the skin assessment should be completed on admission and weekly. LN E did not hear R148 complain about her toenails. Interview on 03/22/22 at 02:50 PM with Social Services Designee (SSD) C revealed SSD C set up the appointments with the podiatrist, but due to COVID, he has not came to the facility for about eight months. On 03/23/22 at 12:35 PM Administrative Nurse B stated she expected the nurses to complete a skin assessment upon admission and then weekly. The facility's Wound Prevention and Management policy revised on 12/2018 stated the facility's Licensed Nurse was responsible for weekly assessments of skin for all residents and should document findings in the Skin Condition Note in the electronic medical record. The facility failed to complete an admission skin assessment including the feet of diabetic R148, complete weekly skin assessments, and to provide appropriate foot care.

The facility reported a census of 43 resident with 13 residents included in the sample and two residents reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure Resident (R)148's plan of care included changing of nebulizer tubing, and cleaning of respiratory equipment in a timely manner. Findings included: - The 12/22/21 signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/29/21 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Plan of Care dated 12/22/21 indicated R148 had potential for respiratory distress related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan lacked any further direction to staff regarding changing nebulizer tubing and/or cleaning of respiratory equipment. Review of the Medication Administration Record (MAR) revealed R148 received a nebulizer treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR and Treatment Administration Record (TAR) from 12/22/21 to 03/17/22 lacked documentation for staff to clean the nebulizer after each use, and/or when to change the resident's nebulizer mask and or tubing. Observation on 03/22/22 at 08:04 AM revealed the resident's nebulizer had leftover fluid in the base still connected to the mask and crusty material observed inside the mask. The date on the tubing was noted as 01/17/22. Interview on 03/23/22 at 12:35 PM Administrative Nurse B stated she would expect the information related to changing tubing and cleaning the nebulizer to be placed on the care plan. The facility failed to provide a policy regarding respiratory care as requested on 03/23/22. The facility failed to ensure the plan of care included to change R148's nebulizer tubing, and or direction to staff on cleaning of respiratory equipment.

The facility reported a census of 43 residents with 13 sampled, including one for hospitalization . Based on observation, interview, and record review the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 28. Findings Included: - Review of R28's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on 01/15/22 and returned to the facility on [DATE]. Review of R28's Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge to R28's Office of the State Long-Term Care Ombudsman. On 03/21/22 at 02:14 PM R28 sat in her wheelchair outside of her room and used her legs to move her wheelchair toward the dining room. Several staff through the area stop and spoke to R28, offered her assistance, snacks, and drinks. On 03/22/22 at 02:09 PM Social Service Designee (SSD) C confirmed he did not send a notice to the Office of the State Long-Term Care Ombudsman when a resident discharged to the hospital. On 03/22/22 at 03:09 PM Administrative Nurse B confirmed no notice was sent to the Office of the State Long-Term Care Ombudsman when the resident transferred to the hospital. She stated she did not know that a notice was needed. On 03/23/22 at 10:15 AM Administrative Nurse B stated if no policy was provided, the facility used the Regulation for their policy. The facility failed to send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman when R28 transferred to the hospital.

The facility had a census of 43 residents with three reviewed for Beneficiary Protection Notification. The facility failed to provide notification (CMS form ) prior to ending Medicare Part A coverage for Resident (R) 99, which did not provide the resident the opportunity to dispute the decision to discontinue therapy services. Findings included: - On the Beneficiary Notice Discharge List R99 discharged from Part A skilled therapy on 02/09/22. Review of R99's record revealed the facility failed to have prior notification of the discharge date of therapy. The record lacked completion of CMS form signed by the resident or representative prior to the resident's discharge. On 03/23/22 at 08:36 AM Administrative Nurse I reported she was responsible for the beneficiary notices when residents discharged from therapy services. She stated she met with the director of therapy services every morning to discuss resident progress and therapy progress. When discharge was coming up for a resident, she then talked to Social Services Designee (SSD) C who then worked with the resident and family to make discharge plans whether staying in the facility or going home. He set up services such as home health visits if the resident was going home. She reported when R99 discharged she just returned from vacation and missed getting it done. No discharge notice was given to the resident with the information about an appeal listed on the discharge. The resident then discharged to an Assisted Living facility. The facility failed to provide notification (CMS form ) prior to ending Medicare Part A coverage for Resident (R) 99, which did not provide the resident the opportunity to dispute the decision to discontinue therapy services.

The facility had a census of 43 residents with 13 included in the sample. Based on observation, interview and record review the facility failed to ensure the resident's dignity by the failure to place the catheter drainage bag in a dignity bag and away from public view for Resident (R) 29. Findings include: - R29's 02/02/22 signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/25/22 Significant Change in Status Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance from one staff for daily care, had a urinary catheter, and received hospice care. The 01/25/22 Quarterly MDS revealed no significant changes in status since the 10/25/22 MDS assessment. The 10/25/22 Urinary Incontinence Care Area Assessment (CAA) revealed the resident continued to require an indwelling urinary catheter and the staff change the catheter monthly and as needed (PRN) per physician orders. The 09/30/22 Care Plan revealed the resident had an indwelling urinary catheter and staff were to position the catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 03/21/22 at 11:29 AM revealed the resident's catheter bag hung on the side of bed, not in a dignity bag and urine visible in the bag. The bag was visible from the hallway outside the resident's room to anyone who passed by. Observation on 03/21/22 at 02:58 PM revealed the resident remained in bed, with the catheter bag hung on the side of the bed without a dignity bag. On 03/22/22 at 07:55 AM, the resident sat in a wheelchair in the dining room for breakfast. The resident's urinary catheter tubing resting on the floor, with the drainage bag hung mostly out of the dignity bag, not fully covering the bag and urine visible in the bag. On 03/22/22 at 08:00 AM the resident moved to a different table in the dining room propelled by Certified Nursing Assistant (CNA) K. The catheter tubing drug on the floor as they moved to the other table and the bag was almost completely out of the dignity bag as it hung under chair. On 03/23/22 at 10:25 AM Licensed Nurse (LN) L entered the resident's room to look at the resident's catheter bag. The bag hung on the bed frame with urine visible in the bag. No dignity bag or privacy flap noted on the drainage bag. On 03/22/22 at 0:800 AM CNA K reported he would get a dignity bag for the resident's catheter. He was from an agency, but knew the catheter needed to be in a dignity bag. On 03/22/22 at 01:20 PM CNA M reported the catheter should be in a dignity bag. She reported she did not know the tubing drug on the floor that morning, but knew the dignity bag was torn and not covering the urine collection bag. On 03/23/22 at 10:15 AM LN L reported the catheter bags the facility used had a privacy flap over the bag, so there was no need for a dignity bag. LN L reported the hospice staff must have changed R29's urinary collection bag, but acknowledged the bag should have been covered either by the facility bag with the privacy flap or with the dignity bag and verified neither were in place. The facility did not have a policy regarding dignity bags for urinary catheter drainage bags. The facility failed to protect the dignity of R29 when staff did not ensure the use of a dignity bag to cover the urinary catheter bag that was visible to the public.

The facility identified a census of 45 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment after a significant change in status after Resident (R)19 admitted to hospice services on 07/24/20. Findings included: - Review of the signed Physician order [REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognitive function. The MDS documented R19 required supervision with the assistance of one staff member for most Activities of Daily Living (ADLs) and had an unsteady gait (manner or style of walking). Review of R19's MDS information lacked a comprehensive assessment after the significant change occurred on 07/24/20, when R19 admitted to hospice services. Review of the physician's orders [REDACTED]. Review of the signed hospice document titled, Election of Hospice Medicare Benefit and Patient Authorization dated 07/24/2020 revealed consent from a legal representative for R19 to receive services hospice. An observation on 09/03/20 at 11:20 AM revealed R19 in her room seated on the side of her bed as the resident watched television. An interview on 09/02/20 at 01:08 PM with Administrative Nurse C stated the facility did not have a current in-house MDS coordinator and explained the nurses did the clinical review assessments and a corporate nurse completed the MDS offsite. An interview on 09/02/20 at 01:48 PM with Administrative Nurse B stated she communicated with the clinical reimbursement consultant regarding assessments and charting. When asked how the offsite consultant knew about non-scheduled comprehensive assessments such as when a significant change occurred, Administrative Nurse B stated she notified the offsite consultant. Administrative Nurse B stated she did not notify the offsite consultant regarding a significant change when R19 admitted to hospice care. An interview on 09/02/20 at 01:48 PM with Administrative Staff A stated the offsite clinical reimbursement consultant completed comprehensive assessments and confirmed R19 should have had a comprehensive assessment for a significant change when she signed on to receive hospice services. An email on 09/03/20 at 12:53 PM from Administrative Staff A stated the facility utilized the Resident Assessment Instrument RAI (comprehensive, standardized tool to assess residents in long-term care settings) manual for MDS comprehensive assessments regarding significant changes. The RAI indicated resident placement on hospice services did qualify as a significant change in status. The facility failed to complete a comprehensive assessment for a significant change after R19 admitted to hospice services.

The facility had a census of 40 residents. Based on interview and record review, the facility failed to provide one resident with sufficient preparation to ensure a safe and orderly discharge from the facility. The facility initiated an emergency discharge of resident #1 due to resident behaviors/practices which placed him/herself at risk as well as other facility residents. The facility failed to attempt to find alternate placement for the resident in a facility/setting which could meet the resident's physical/medical needs. The facility discharged the resident to a motel of the resident's choosing, and failed to ensure the resident had all ordered medications upon discharge. The facility also failed to contact other providers to ensure the resident received four times daily breathing treatments and had oxygen available to maintain oxygen saturation levels within acceptable ranges upon discharge from the facility, which placed the resident in immediate jeopardy. Findings included: - Resident #1's clinical record included signed physician's orders [REDACTED]. mellitus (adult onset diabetes which occurs when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), [MEDICAL CONDITION] ([MEDICAL CONDITION]-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and chronic [MEDICAL CONDITION] (long term inflammation and swelling of the lining of the airway, leading to narrowing and obstruction and generally resulting in daily cough). The 11/7/16 Admission Minimum Data Set (MDS) noted the resident's admission to the facility from an acute care hospital on [DATE], and identified the resident with a serious mental illness and/or intellectual disability. According to the MDS, resident #1 had moderate cognitive impairment (Brief Interview for Mental Status score of 12), no hallucinations or delusions, no physical or verbal behaviors directed toward others and no rejection of care. The resident required extensive assistance of 1 staff for bed mobility, transfers and toileting, lacked the ability to walk in his/her room or corridor, and had impaired balance in all areas and could only stabilize with staff assistance. The resident used a wheelchair for mobility, experienced frequent bowel and bladder incontinence, and used antipsychotic medication 5 of 7 days during the observation period. The 4/21/17 Quarterly MDS identified the resident with continued moderate cognitive impairment, no hallucinations or delusions, and rejection of care 1-3 days during the 7 day observation period. The resident required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use, assistance of one staff for ambulation in the room and corridor, impaired balance and could only stabilize with staff assistance, and he/she used a walker and a wheelchair for mobility. The resident experienced frequent bowel and bladder incontinence and shortness of breath or trouble breathing when laying flat. According to the MDS, the resident experienced 2 or more non-injury falls and 1 injury fall since the prior assessment. The MDS identified the resident with no family or significant other, no guardian and no legally authorized representative. Care Areas Assessments (CAAs) dated 11/13/16 included: Cognitive Loss/Dementia: Identified the resident with a Level 2 PASARR (preadmission screening and resident review intended to determine the services required to address a person's serious mental illness) and multiple psychiatric diagnoses. According to the CAA, the resident experienced moderate cognitive impairment. Activities of Daily Living (ADLs): Identified the resident with a desire to regain the ability to walk and then move to an assisted living facility. According to the CAA, the resident currently required a wheelchair and received restorative services to increase his/her walking skills. Urinary Incontinence: Identified the resident with frequent bladder incontinence and required extensive assistance of staff for toileting. Falls: Identified the resident with a history of falls and a fall risk score which noted the resident's high risk for falls. According to the CAA, the resident had not experienced falls since admission. The areas of Psychosocial, Moods and Behaviors did not trigger for further assessment. The 12/2/16 Care Plan included: Falls: Identified the resident as at risk for falls and noted falls which occurred on 1/27/17, 2/15/17, 3/5/17 and 4/12/17. [MEDICAL CONDITION] medications: [REDACTED]. Respiratory: Identified the resident with occasional difficulty breathing and directed staff to utilize supplemental oxygen as needed, monitor oxygen saturation levels every shift, and report respiratory problems to the physician. On 5/3/17, staff updated the care plan to include a new order for nebulizer treatments (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) four times daily for treatment of [REDACTED]. ADLs: Described the resident's ability to perform ADLs independently but personal choice not to do so. Due to those refusals, the resident required extensive staff assistance with dressing and toileting. According to the care plan, the resident used a wheelchair for mobility. Incontinence: Identified the resident with stress incontinence and directed staff to check and change the resident as needed and assist as needed with toileting. Discharge Plan: Described the resident's desire to go to an assisted living/group home upon discharge with no current, active discharge plan in place. physician's orders [REDACTED].>11/2/16 order for Aspirin 81 milligrams (mg) daily for preventative reasons 11/14/16 order for [MEDICATION NAME], a stool softener, 100 mg twice daily for constipation (difficulty passing stool). 12/10/16 order to wrap both lower legs in ACE wrap (a compression dressing) in the morning and remove at night 1/3/17 order for [MEDICATION NAME] 400 mg every 6 hours as needed for mild pain 1/26/17 order to check blood sugars four times daily and notify the physician if the blood sugars were less than 60 or greater than 500 2/27/17 order for Tylenol 325 mg (2 tablets) three times daily for pain 3/2/17 order for BioFreeze gel (an ointment used to treat aches and pain for muscles, joints, sprains and strains) to both lower legs, back and hips three times daily for pain. 3/2/17 order for [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION], nerve pain and/or restless leg syndrome) 300 mg at bedtime for muscle cramps and pain. 3/22/17 order for oxygen 2 liters via nasal cannula and titrate (adjust) as needed to keep oxygen saturation levels above 92%. 4/13/17 order for Atrovent inhaler three times a day for [MEDICAL CONDITION] 5/3/17 order for nebulizer treatments with [MEDICATION NAME], a medication used to relax the muscles in the airway and thereby increase air flow to the lungs, four times daily for treatment of [REDACTED]. Progress notes included: 5/9/17 at 12:57 a.m.: Described an incident which occurred during the evening hours of 5/8/17 in which staff found resident #1 in his/her bathroom, using an illegal drug which required an open flame/fire. According to the note, staff notified the police who then came to the facility, confiscated the drugs and drug paraphernalia, issued a citation and left the resident at the facility. Police advised staff of the inability to incarcerate the resident due to his/her dependence on the wheelchair. 5/9/17 at 10:06 a.m.: Described a meeting with resident #1, the facility Administrator, Director of Nursing, Assistant Director of Nursing and Social Services Designee. According to the note, staff reminded the resident of a contract he/she signed in December of 2016 after he/she tested positive for an illegal drug. According to the contract, the resident acknowledged plans to discharge the resident within 30 days if he/she was found to be under the influence of illegal drugs at any time in the future. The Administrator advised the resident of the safety risk posed to him/herself as well as other residents by use of illegal drugs within the facility, specifically due to the use of an open flame in his/her bathroom in a semi-private room in which the resident's roommate used oxygen. The Administrator advised the resident to decide what living arrangements he/she preferred upon discharge from the facility and to let the Administrator know of the choice by the end of the day. 5/9/17 at 4:56 p.m.: Described/summarized the events of the evening hours of 5/9/17 when staff found resident #1 smoking an illegal drug in his/her bathroom. According to the note, the resident's physician came to facility and wrote orders for an emergency discharge due to safety issues that had the potential to affect other residents in the building. The facility also moved the resident to a room closer to the nurse's station and placed the resident on every 15 minute checks to ensure his/her safety and the safety of other residents. 5/10/17 at 10:42 a.m.: Described the resident's discharge from the facility due to failure to comply with the conditions of a contract signed in December 2016 in which the resident agreed to refrain from use of illegal drugs. According to the note, staff sent all medications with the resident at the time of discharge, and provided the resident with a list of medications as well. Vital signs at the time of discharge were blood pressure 143/75 (normal), heart rate of 82 (slightly elevated), temperature of 97.8 (normal), respiratory rate of 20 (slightly elevated) and oxygen saturation level of 96% (normal). 5/10/17 at 4:21 p.m.: Described the resident's choice between going to a motel or a homeless shelter and his/her decision to go to a local motel. According to the note, the facility notified Adult Protective Services (APS) of the resident's discharge to the motel. 5/15/17 at 4:59 p.m.: Late Entry by social services staff which described notification of resident #1's caseworker from the State insurance plan regarding the resident's discharge to a motel due to safety concerns. The note lacked a date/time of notification of the caseworker. According to the entry, the caseworker's supervisor called the facility a few minutes later to object to the discharge and subsequently spoke to the facility Administrator. The facility provided a list of all medications sent with resident #1 upon discharge to the motel on 5/10/17. Comparison of that list of medications sent with the resident with a list of physician ordered medications revealed the facility failed to send the following: Aspirin 81 mg for daily use [MEDICATION NAME] 100 mg for twice daily use Atrovent inhaler for three times daily use Biofreeze gel for twice daily use Tylenol 325 mg (2 tablets) for three times daily use. [MEDICATION NAME] for nebulizer treatments ordered for four times daily from 5/3/17 - 5/13/17 The clinical record also lacked evidence the facility ensured the resident had the availability of oxygen upon discharge, equipment to ensure administration of nebulizer treatments, a means to complete blood sugar checks ordered four times daily by the physician, and the availability of a walker used by the resident for transfers and ambulation. Emergency Management System (EMS) records indicated EMS staff responded to a 911 call from a local motel on 5/11/17 at 11:19 a.m. Upon arrival at the motel, EMS found resident #1 on the floor, soiled with urine and feces, and with difficulty breathing. The resident told EMS staff he/she fell the previous night and laid on the floor the entire night and morning until a caseworker arrived and called 911. Initial physical examination by EMS revealed the presence of wheezes in both lungs, and oxygen saturation levels of 87% (normal range 94-99%). EMS staff applied oxygen and the resident reported decreased difficulty breathing and his/her oxygen saturation levels improved to 98% within 30 minutes of onset of treatment. EMS transported the resident to the hospital for further evaluation. Emergency Documentation dated 5/11/17 identified the resident's chief complaint as dismissed from nursing home yesterday to a motel. Found by caseworker this a.m. on the floor, short of air, chest pain and weak. No oxygen in motel room . Vital signs at the time of initial assessment in the emergency room included an oxygen saturation level of 79% on room air. An additional statement by emergency room staff included, Patient was up for dismissal and the social worker was attempting to arrange for patient to be transported home. Patient needs to be discharged with oxygen and some of the facilities cannot accommodate the need. When patient is taken off the oxygen, (his/her) oxygen saturation was 80-82% on room air, hypoxic (lack of adequate oxygen in the blood to sustain normal activities). Will arrange to admit the patient. As of 5/16/17 at 5:00 p.m., resident #1 remained hospitalized . During an interview on 5/15/17 at 2:56 p.m., Direct Care Staff D reported resident #1 required assistance of two staff for transfers, used a wheelchair for mobility, sometimes used a walker for transfers, and used oxygen at night. Staff D reported the resident experienced occasional falls and lacked the ability to get back up after a fall. During an interview on 5/15/17 at 3:00 p.m., Direct Care Staff E reported he/she worked the night he/she and another staff member found resident #1 in the bathroom smoking an illegal drug. According to Staff E, the charge nurse called the police and the resident admitted to use of the drug. Staff E reported the resident required assistance of two staff for transfers and toileting. Staff E reported the resident experienced occasional falls and lacked the ability to get back up after a fall. During an interview on 5/15/17 at 3:22 p.m., Direct Care Staff F reported resident #1 required assistance of one or two staff for transfers and toileting and the resident experienced frequent incontinence of bowel and bladder. Staff F reported the resident experienced occasional falls and lacked the ability to get back up after a fall. During an interview on 5/15/17 at 4:30 p.m., Administrative Staff A and Administrative Nurse B reported resident #1 had multiple psychiatric [DIAGNOSES REDACTED]. The resident had no problems from the time of admission in late October 2016 until December of 2016. Then, in mid to late December 2016, the resident left the facility with friends and, upon his/her return to the facility, told a staff member he/she used drugs during the outing. The facility notified the physician of the resident's reported drug use, obtained an order for [REDACTED]. The resident agreed to the conditions of the contract and signed it on 12/21/16. According to Administrative Staff A, the resident complied with the terms of the agreement until 5/9/17, at which time he/she obtained illegal drugs from a visitor and then proceeded to use those drugs in the bathroom of his/her semi-private room. Use of the drugs involved use of a lighter with an open flame, and therefore placed the resident and the roommate who used oxygen at risk of harm. When Staff A spoke with resident #1 the day after the incident, he/she admitted to use of the drug and the presence of an open flame, and acknowledged the safety risk to him/herself and other residents. After consultation with the resident's physician, the determined that resident #1's presence in the facility constituted a safety risk to him/herself and other residents and the physician wrote an order for [REDACTED]. The resident opted for a specific motel because he/she lived there at some point in time previously. Facility staff transported the resident to the motel on 5/10/17 before lunch, and sent medications, the resident's personal supply of snack food items and soda, and all personal belongings with him/her. Prior to discharge of the resident, Administrative Staff A reported the facility contacted the resident's caseworker through the State insurance plan, and asked for assistance in finding placement for the resident. The caseworker offered no suggestions for placement. Administrative Staff A reported the facility notified APS of the resident's discharge to the motel. During an interview on 5/16/17 at 10:55 a.m., Administrative Staff A reported the facility did not send oxygen with the resident or make arrangements for the resident to receive oxygen or nebulizer treatments upon transfer to the motel. During an interview on 5/16/17 at 11:45 a.m., Administrative Nurse B confirmed the facility did not sent oxygen with the resident or make arrangements for the oxygen upon discharge to the motel because he/she would have been in the same risk as here by blowing (him/herself) up when smoking. According to Nurse B, the facility did not contact a home health agency or other medical provider in an attempt to obtain oxygen services and nebulizer treatments for resident #1 upon discharge from the facility. During an interview on 5/16/17 at 11:57 a.m., Social Services Staff C reported he/she did not look for placement in another nursing home prior to discharge to the motel on 5/10/17 because the resident did not want to go to a nursing home. Staff C reported the resident wanted to go to an assisted living facility prior to the 5/8/17 incident, but was denied admission due to use of a wheelchair and need for assistance with care. Staff C reported he/she did not seek placement in assisted living facilities prior to discharge of the resident to the nursing home on 5/10/17. Although requested, Social Services Staff C could not provide any documentation related to attempts to secure placement for resident #1 in a facility equipped to handle the resident's mental health and physical needs after the 5/8/17 incident. During an interview on 5/16/17 at 12:10 p.m., Administrative Staff A confirmed the facility did not contact other nursing facilities in an attempt to secure placement prior to discharge to the motel on 5/10/17 because the resident verbalized a desire to not go to another nursing home. Staff A confirmed the clinical record lacked documentation related to the resident's refusal of the option to go to another nursing home. Staff A reported the facility had no options for discharge other than a homeless shelter or a motel after the rehab facility denied the resident's admission. On 5/16/17 at 2:48 p.m., Administrative Staff A sent email communication which noted staff failed to send over the counter medications such as Tylenol, Biofreeze and [MEDICATION NAME] with the resident at the time of discharge because, since they were over the counter, the resident had the responsibility to purchase those medications after discharge. Staff A also confirmed staff failed to send [MEDICATION NAME] with the resident at the time of discharge. According to Staff A, staff recalled placing the Atrovent inhaler in resident #1's medication bag at the time of discharge and lacked knowledge of why the inhaler was not included on the list of medications provided to the resident. On 5/17/17 at 10:13 a.m., Administrative Staff A sent email communication which described completion of a fall risk assessment for resident #1 on 4/20/17 and, according to that assessment, the resident had a moderate risk for falls. According to Staff A, the facility did not send a walker with resident #1 upon discharge to the motel even though the resident used a walker for occasional transfers while at the facility. Although requested, the facility could not provide policies and/or procedures related to involuntary discharge. The facility failed to provide resident #1 with sufficient preparation to ensure a safe and orderly discharge from the facility. The facility initiated an emergency discharge of resident #1 due to resident behaviors/practices which placed him/herself at risk as well as other facility residents. The facility failed to attempt to find alternate placement for the resident in a facility/setting which could meet the resident's physical/medical needs. The facility discharged the resident to a motel of the resident's choosing, and failed to ensure the resident had all ordered medications upon discharge. The facility also failed to contact other providers to ensure the resident received four times daily breathing treatments and had oxygen available to maintain oxygen saturation levels within acceptable ranges upon discharge from the facility. Within 24 hours of discharge to the motel, resident #1 fell and lacked the ability to get him/herself up off the floor, experienced low oxygen saturation levels, and required transport to the hospital via ambulance, with [DIAGNOSES REDACTED]. The physician admitted the resident to the hospital. The facility abated the immediate jeopardy on 5-18-17 at 4:49 p.m. when they provided education to all licensed nurses and facility administrative personnel on the facility's involuntary/emergency discharge process including referrals for alternate placement and documentation on the clinical record, equipment provided or arranged with another provider and all ordered medications provided or arranged to be provided upon discharge of the resident. The deficient practice remained at the scope and severity of a G.

The facility had a census of 52 residents. The sample included 27 residents of which 4 were reviewed for accidents. Based on observation, record review and interview, the facility failed to provide a safe environment for 2 of the 4 sampled residents reviewed for accidents. Cognitively impaired and independently ambulatory Resident #83, left the facility without staff knowledge. The staff located Resident #83 on a residential street approximately 2 blocks from the facility. The failure placed the resident in immediate jeopardy. Resident #27 had a mattress with a 6 inch gap between the rail and the mattress creating a wide enough gap to pose a risk of head entrapment between the bottom of the rail and mattress. Findings include: - Resident #83's admission (MDS) Minimum Data Set assessment, dated 12/3/14, revealed the resident had a severe cognitive impairment with a (BIMS) Brief Interview for Mental Status Score of 3. The MDS further revealed the resident had inattention, disorganized thinking, continuously, wandered daily and required assistance of 1 staff with transfers and walking. The MDS revealed the resident was not steady and only able to stabilize with staff assistance and received antipsychotic, antianxiety, and antibiotic medications. The Fall (CAAs) Care Area Assessment Summary, dated 12/3/14, revealed the resident was at risk for falls related to weakness, dementia (progressive mental disorder characterized by failing memory, confusion) with severe cognitive impairment, Urinary Tract Infection, pneumonia, anxiety, incontinence, daily use of psychotropic medications, and wandering/pacing behaviors. The 12/3/14 care plan directed the staff to monitor and check the resident's whereabouts every 15 minutes and ensure the resident's wanderguard was on and working at all times. The Fall Risk Assessment, dated 11/26/14, indicated the resident was a moderate fall risk. The clinical record lacked documentation of an elopement risk for Resident #83 until the 12/12/14 Elopement Risk Assessment tool was completed after the elopement and it scored the resident at high risk for elopement. The resident was admitted to the facility on [DATE] and review of the nurses notes from 11/26/14 to 12/12/14 indicated the resident wandered daily. The 11/28/14 at 2:36 AM nurses note, stated staff placed a wanderguard on the resident. Review of the medical record revealed no elopement risk assessment completed by the staff for the resident. The 12/13/14 at 1:14 AM nurses note, stated the South emergency exit door alarmed, Nurse J opened the first exit door to the foyer and the outside exit door, checked outside but was not able to see the resident. The nurses note stated the nurse assigned 1 staff member to go outside around the building to check for the resident and another staff to continue to check inside the rooms for the resident. The nurses note stated a staff member assisted the resident back into the facility and the resident had a functioning wanderguard on him/her. (Review revealed this was a late entry and the elopement occurred at approximately 9:30 PM on 12/12/14.) The 12/5/14 at 6:49 PM nurses note revealed the resident had opened a fire exit door at the North end of the building several times. On 12/9/14 at 1:27 PM, observation revealed the resident seated at the nurses station with a nurse seated at his/her side watching the resident. On 12/9/14 at 4:07 PM, observation revealed the resident ambulated in the hallway with a staff member at his/her side holding onto his/her arm with a wanderguard on his/her wrist. On 12/10/14 at 9:33 AM, observation revealed the staff guided the resident into his/her room holding onto the resident's arm. On 12/10/14 at 1:42 PM, observation revealed the resident ambulated independently in the hallway with a slow shuffling gait. On 12/10/14 at 2:58 PM, observation revealed the resident ambulated in the hallway with a staff member at his/her side holding onto his/her arm. On 12/12/14 Nurse Aide D stated in his/her notarized statement at around 9:30 PM he/she and another aide assisted a resident in a room, heard an alarm sound, and went to the South emergency exit door. Nurse Aide D stated he/she did not see any resident in the hallway or by the emergency exit door and opened the exit door and did not see any resident. Nurse Aide D stated he/she had left Resident #83 at the nurses station with the nurse while he/she checked on other residents. Nurse Aide D and Nurse Aide I split up and searched through rooms, restrooms, the dining room and the hallways but did not locate the resident. Nurse Aide D stated he/she saw the nurse in another resident's room and the nurse asked him/her what alarm was sounding. The nurse had Nurse Aide D stay in the resident's room and the nurse went to turn the alarm off. On 12/15/14 at 2:07 PM, Nurse Aide I stated at approximately 9:30 PM, he/she was in a resident's room and heard the exit door alarm sound. Nurse Aide I stated the aide that was in the room with him/her went to the first exit door, looked into the foyer but did not open the 2nd exit door to the outside, came back to the room and stated he/she did not see anyone outside. Nurse Aide I stated they looked in the residents' rooms and dining room searching for Resident #83 which took about 4 or 5 minutes. Nurse Aide I stated when he/she got to another resident's room, he/she asked the nurse where Resident #83 was and the nurse stated he/she was at the nurses station. Nurse Aide I stated the nurse asked him/her what alarm was sounding, the nurse went to the exit door, then called the upstairs nurse to come down and both nurses shut the alarm off. Nurse Aide I stated the nurses told him/her they had looked outside and then the nurse told him/her to go outside and look for the resident. Nurse Aide I stated he/she went outside to a residential street to the side of the building, and observed the resident in the middle of the street approximately 2 blocks from the facility. The aide ran to the resident and he/she was cold to the touch, wore 1 sock on 1 foot and the other was bare, a sweatshirt and sweatpants. Nurse Aide I stated the resident had been wandering up and down the hall, the staff had been taking turns watching the resident and the resident had been left at the nurses station with the nurse when the aides went into a room to assist another resident. On 12/15/14 at 2:27 PM, Nurse J stated he/she was seated at the nurses station, no time stated, with the resident and an alarm sounded in another resident's room. Nurse J stated he/she left the resident at the nurses station and helped another resident to the restroom. Nurse J stated he/she heard the door alarm when he/she came out of the resident's room. Then he/she went to the 1st exit door and shut off the alarm. The 2nd exit door still alarmed and he/she knew someone had tried to go outside. Nurse J stated he/she looked outside but it was foggy and he/she could not see anyone. Nurse J then asked another staff member to go outside and look for the resident. On 12/15/14 at 5:09 PM, Administrative Nurse A stated the first staff member who checked the doors at approximately 9:30 PM, should have gone outside and checked for a resident. Administrative Nurse A stated the staff failed to respond quick enough and he/she had talked with the aides who were working that night about how looking outside of the building is imperative probably more than looking inside of the building. Administrative Nurse A stated the facility needed to know where the resident was at all times. On 12/16/14 at 7:51 AM, Administrative Staff H stated the facility has not had an elopement drill in the last year. On 12/18/14 at 3:17 PM, Nurse Aide D stated he/she had worked at the facility approximately 3 months and had not had any training on elopement of residents. Nurse Aide D stated on the night Resident #83 eloped from the facility, he/she went to the South exit door, opened the exit door and looked for the resident but did not open the 2nd exit door to the outside. Nurse Aide D stated he/she was instructed after the elopement occurred of the importance of checking for residents outside of the building if an elopement is suspected. The weather conditions on the night of 12/12/14 at approximately 9:30 PM, was overcast and 48 degrees. The residential street where the resident was located had a speed limit of 30 miles per hour. The 8/20/2004 facility policy for Emergency Services/Disaster Plan for Missing Residents stated the staff member who discovered the resident missing should immediately notify the highest ranking supervisor in the facility. If the Administrator was not in the facility and a brief search did not locate the missing resident, the Administrator must immediately proceed to the facility to coordinate the search. Until the Administrator (or other designated individual) reached the facility, the charge person should continue a coordinated search. Time was of the essence. The facility failed to ensure safety for the resident when the staff failed to check outside the facility when a door alarm sounded, which allowed cognitively impaired Resident #83 to wander away from the facility for approximately 10 minutes when staff located him/her approximately 2 blocks from the facility on a residential street. The failure placed the resident in immediate jeopardy. The facility abated the Immediate Jeopardy on 12/16/14, when Administrative Staff provided an in service to all staff employed at the facility about policy and procedures for elopements and what to do when the door alarms sound. The nurse on duty the night of the elopement was terminated on 12/17/14. This deficient practice remained at the scope and severity of a D. - Review of resident #27's signed physician orders dated 12/4/14 revealed the following Diagnoses: [REDACTED]. Review of the annual MDS (minimum data set) dated 11/15/14 revealed a BIMS (brief interview for mental status) score of 12 indicating moderate cognitive impairment. The resident required extensive assistance of one staff with bed mobility, and extensive assistance of two with transfers and assistance of one with locomotion. No restraints were recorded on the assessment. Review of the CAA (care area assessment) dated 11/15/14 revealed no CAA for the use of side rails. Review of the care plan with a date of 12/17/13 revealed: The resident had a self-care deficit manifested by limitation in physical functioning. Approaches included; Make sure that residents 1/2 side rails are up as an enabler, to promote his/her independence. Review of the clinical record revealed a side rail assessment completed on 12/10/14 with the resident approved for the use of side rails. The assessment was completed 2 days after the side rails were discovered not to fit the bed in stage 1 of the survey. Observation on 12/8/14 at 2:22 p.m. revealed the side rail on the left side of bed had a 6 inch gap between the bottom of the rail and the mattress posing an entrapment risk. Observation on 12/10/14 at 10:00 a.m. revealed the resident lay in bed sleeping. The side rail on the furthest side of the bed had a gap of 6 inches between the rail and the mattress exceeding the FDA(federal drug administration) Guidance for Industry and FDA Staff- Hospital bed system Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/2006 limitation of 4 1/2 inches for head entrapment. The resident was on his/her back and in the middle of the bed. Observation on 12/10/14 at 10:50 a.m. revealed administrative nurse G looked at the side rails on the resident' s bed and saw the gap in the rails between the mattress and the bottom of the rails and agreed the gap was too large for safety reasons. Observation on 12/10/14 at 2:20 p.m. revealed the resident lay in bed with 1/2 side rails in the up position. The side rails fit the mattress and had no gaps between the mattress and the rails. On 12/10/14 at 10:50 a.m., the resident reported he/she wanted and needed his/her, side rails to be able to move in bed and did not want them taken from him/her. During an interview on 12/10/14 at 10:21 a.m., direct care staff Q reported he/she had never checked for gaps in the side rails and thought maybe maintenance checked that. During an interview on 12/10/14 at 1:30 p.m., direct care staff C reported the resident used the bars for movement but also required staff assistance. Staff C reported administration switched beds with different rails while the resident was at lunch. During an interview on 12/10/14 at 10:30 a.m. licensed nurse B reported not knowing any check staff do to the side rails looking for gaps. During an interview on 12/10/14 at 10:50 a.m. administrative nurse G reported there was no specific check done on the side rails. Nurse G reported that looking at the rails the resident needed to have different rails on the bed. During an interview on 12/15/14 at 5:12 p.m. administrative nurse A reported that all the old rails like the rail with the gap have been removed from the facility on 12/10/14 and rails replaced with correctly fitting rails. Review of the facility policy named Side Rail Use and assessment dated [DATE] revealed the use of side rails for positioning and mobility or the creation of a safe environment, taking into account each resident's medical/psychological needs, comfort and freedom of movement. The facility failed to monitor for the safe use of side rails for 1 resident by the failure to measure gaps between the rail and the mattress and determine if the gaps were of a safe width.

The facility reported a census of 56 residents with 5 residents sampled for nutrition. Based on observation, interview and record review the facility failed to ensure 5 of the 5 sampled resident maintained acceptable parameters of nutrition to prevent weight loss. (#26, #54, #71, #72 and # 76). Findings included: - The Review of resident #76's signed physician orders [REDACTED]. Review of resident #76 admission MDS (minimum data set) dated 3/4/13 revealed a BIMS (brief interview for mental status) with a score of 8 (moderately impaired). The functional status revealed the resident required extensive assist of one for eating. The resident received tube feedings and took nothing by mouth. The resident received >51% through feeding tube and more than 501 ml (milliliters) per day. On admission, the resident had a stage 1 or greater pressure ulcer. The resident was at risk of developing pressure ulcers. The resident has 2 unhealed pressure ulcers at stage 1 or higher of [MEDICATION NAME] tissue( 1 of 4 layer of tissue that covers the whole surface of the body), pressure relieving device for the bed and chair turning and positioning program and nutrition or hydration intervention to manage skin problems and receives pressure ulcer care with application of ointment to other than feet. Review of the quarterly MDS dated [DATE] BIMS of 1 (severely impaired). The resident was on a weight gain program. The resident was on a feeding tube and a mechanically altered diet, received 26-50% of the total calories/24 hr and 500 ml or less from [DEVICE]. The resident had no weight loss, and did not choke or cough while eating meal. Resident has 2- stage 1 pressure ulcers and receives pressure ulcer care with application of ointment to other than feet. Review of the Nutritional CAA (care area assessment) dated 3/9/13 revealed the resident received speech therapy and the body mass index was with in normal limits. Review of the feeding tube CAA revealed that the resident had a feeding tube and received [MEDICATION NAME] 1.5, 5 cans daily. Review of the Dehydration CAA revealed that the resident received [MEDICATION NAME] 1.5, 5 cans daily and 1000 ml free water flush. Review of the Pressure ulcer CAA revealed that on admission the resident had 2 stage 1 pressure ulcers on the coccyx and was at risk for pressure ulcers. Review of the care plan dated 7/29/13 revealed the resident was at risk for dehydration; staff was to provide water and fluids per [DEVICE] ([MEDICAL CONDITION] tube) as ordered and at meals. Staff was to take the resident to all meals the care plan meeting notes revealed that all disciplines attended and nursing revealed that the resident was doing well much improvement. There was no comment from dietary. There was no care plan for the prevention of pressure ulcers. Review of the Skin assessment dated [DATE] skin assessment on admission revealed a right and left gluteal fold blanchable (skin that turns white or purple when pressure is applied). On 2/25/13 on admit the resident s Braden scale (tool used to determine a resident ' s risk for pressure ulcer development) score 13 and 13-14 moderate risk. On 7/12/13, Braden scale 14. Review of the physician orders [REDACTED]. On 3/14/13 per nurses notes Overall skin assessment narrative, CNA notified nurse of open areas on the coccyx found two small pressure areas directly on coccyx about 1 cm by 2 cm no drainage noted stage 2 Applied temporary dressing until physician orders [REDACTED]. 3/14/13 Physician notified of the 2 open areas. We will consult wound specialist for orders PCP (primary care physician) agreed. No other measurements found in the chart Review of the 3/18/13 Dietary assessment revealed a score of 14 and below 17 indicated malnourishment. 3/20/13 Apply skin prep to coccyx cover with OpSite (clear surgical dressing) change every 3 days and as needed. Consult wound specialist if not healed by next week. On 3/22/13 skin assessment, coccyx 2 pressure ulcers dressing intact, no measurements. On 3/25/13, the physician phone order revealed an order to increase the [MEDICATION NAME] 1.5 to 6 cans daily with 1000 ml (milliliters) of water flushed total daily. On 4/11/13 review of the skin, assessment revealed pressure ulcers on coccyx. The monthly summary on 5/5/13 revealed poor skin turgor (degree of elasticity). On 5/11/13 review of the skin assessment blanchable redness to the sacrum. On 5/17/13, a phone order to clarify the speech therapy 3-5 times weekly to increase oral intake. Diet clarification obtained for pleasure feedings 3-5 times daily as tolerated, with single serving pureed food with water. On 6/7/13, a new physician order [REDACTED]. Continue with regular liquids offer small meals as tolerated and encourage oral intake at all meals. On 6/8/13 review of the skin assessment revealed blanchable area to the coccyx. On 6/22/13 review of the skin assessment revealed blanchable area to the coccyx. with fragile skin. On 6/26/13, new order to decrease [MEDICATION NAME] 1.5, to 1 can at 6:00 a.m. and 10:00 p.m. daily and flush with 250 cc water at 6:00 am and 10:00 p.m. crush medications and administer with food and liquid. The resident with a [DIAGNOSES REDACTED]. On 7/12/13 review of the skin, assessment revealed redness to the coccyx. Review of the nurses notes dated 7/12/13 revealed the resident went to the hospital on [DATE] and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was to receive no thin liquids. On 7/21/13 re view of the skin assessment revealed redness to the coccyx. On 7/22/13, the registered dietician assessment revealed the resident received inadequate oral intake, due to difficulty swallowing. The resident ' s weight was 143 pounds, down 5 pounds in 1 month and down 32 pounds in 3 months. The resident was on a pureed diet with pudding thick liquid. Recommendation to increase [MEDICATION NAME] 1.5 to 1 can three times a day to stabilize weight and increase oral intake and tube feeding. On 7/30/13, review of the skin assessment revealed no mention of coccyx. On 8/16/13, the facility obtained a phone order to increase the [MEDICATION NAME] 1.5 to three times daily. This was 25 days after the recommendation. On 8/21/13, staff added the order for the increase of [MEDICATION NAME] 1.5 to the TAR (treatment administration record) for administration. The facility failed to follow up for 30 days on the recommendation to increase the [MEDICATION NAME] 1.5 as recommended by the registered dietician on 7/22/13 No lab results for [MEDICATION NAME] or protein (laboratory values used to determine a resident ' s nutritional status) since admission. Review of the August TAR (Treatment Administration Record) revealed no signature for the [MEDICATION NAME] 1.5 or water flush on 8/10/13 at 10:00 p.m., 8/11/13 at 6:00 a.m. and 10:00 p.m., 8/12/13 at 6:00 a.m. on 8/15/13 at 6:00 a.m., and 8/16/13 at 6:00 a.m. Review of the resident's weight record revealed the following weights: 2/27 170 3/21 169 4/3 176 5/15 145 5/21 149 5/23 149 6/12 148 6/20 153 7/16 143 7/24 138 7/30 141 8/8 146 8/21 145 Review of the nurse's notes done 3 times daily. There was no mention of [MEDICAL CONDITION] on any of the days between 4/3 and 5/15/13. The review of the resident ' s records current and past revealed the resident had no meal intake sheets since admission, to record the % of the meal eaten. On 8/21/13 at 8:04 a.m., the resident was at the dining room table and received pureed eggs, pureed sausage, hot cereal, thickened water and milk. The resident ate all the eggs, all but 2 bites of the meat and 1/2 of the hot cereal. The resident took 2 sips of thickened water and drank about 1/4 of the milk. Each of the milk and water was 240 ml. On 8/22/13 at 7:56 a.m. the resident was at the table and served pureed eggs, pancake pureed with syrup and pureed bacon, 240 ml thickened milk and 240 ml thickened water. The resident ate the entire pancake and 1/2 of the meat, 1 bite of egg 1/3 of the milk and 1/4 of the water. At 12:30 p.m., staff took a tray to the resident ' s room of mashed potatoes, pureed meat, and a green vegetable. Direct care staff P was at the side of the bed assisting the resident with the meal. The resident ate 25 % of the meal and 120 cc water. On 08/22/2013 at 8:59 a.m., direct care staff P revealed the resident ate in the dining room, and could eat alone with occasional verbal cues and ate better at breakfast than any other meal. When asking the resident to come down to the dining room for the other meals the resident stated that he/she was not hungry, having ate a lot for breakfast. Staff offer the Mighty shakes in strawberry to the resident. All residents that eat in the dining room have meal intake sheets 8/22/13 4:53 p.m., direct care staff Q revealed the resident ate something at all three meals, but will leave a lot of food uneaten. The resident would eat snacks later on in the day. Staff member reported that staff would get a tray for him/her even when the resident said no. Staff would set the tray in front of the resident and sometimes he/she would eat some and other times not. On 8-21-13 at 12:23 p.m. direct care staff M reported that he/she did the weights for the facility all residents got weighed once a month, some were weekly, new resident got weighed every week for four weeks, if they are losing weight then the resident stayed on weekly weights. Staff member M reported that he/she used the wheel chair scale or Hoyer scale the restorative aide calibrates the scales once a month, but there is no log of the calibration. The dietary manager gave the schedule for monthly and weekly weights, then staff member M wrote down the weights then gave the list back to the to the dietary manager and then the dietary manager documented the weights in the computer. If the weights had a 4 pound difference, the dietary manager would ask for a reweigh. Staff member M turned the reweigh back into the dietary manager. Direct care staff M kept the weight book. The dietary manager would then do the care plan, and kept a copy of the weights. On review of the weight records,, the weights done between the first and the tenth of each month. On 8/20/13 at 11:20 a.m., licensed nursing staff G revealed the resident ate meals in the dining room on his/her own and then [DEVICE] feedings at night 2 times 6:00 a.m. and 10:00 p.m. Staff document the meals on the meal intake sheets. On 8/22/13 at 8:05 a.m. licensed nursing staff G reported that, it was the responsibility of the restorative aide to obtain residents weights. Then the restorative aide gave the weights to the dietary manager. The licensed nursing staff G revealed the director of nursing and the dietician got a copy of the weight list and that there was a weekly weight meeting. When there was a recommendation from the dietician, the nurses sent the recommendation to the physician and put the order on the TAR and the report sheet. Licensed nursing staff G was unaware when residents had a significant weight loss unless he/she looked it up in the computer and usually did not have the time, to do that. On 8/22/13 at 2:12 p.m., licensed nursing staff R resident went into the hospital due to pneumonia, but that hospitalization happened later than the weight loss. Licensed nursing staff R reported notifying administrative nursing staff A that some of the nurses did not sign for feeding, that is about the time he lost weight. The nurses on the first floor they come up and do the feedings for the residents. On 8-21-13 at 1:49 p.m., dietary staff L revealed when a resident admitted to the facility staff weighed the resident four times a month for the first month. If the resident was not at risk they go to monthly weights, but if it looked like the resident was losing weight and not eating the resident was put on every two week weights until they are leveled out on weight. Staff L reported there were weekly meetings involving weights, skin, falls, and once a month the risk committee look at everyone and who is at risk for weight loss, printed on a vital summary for six months, the committee did not review intake record at the meeting. Residents with tube feedings reviewed weekly and on weekly weights, the dietician notified at 5% weight loss. The dietician visited twice a month, reviewed any weight loss, the new people, and pressure ulcer reviewed once a month. When the dietician made recommendations, he/she gave the recommendations to Administrative nurse A and the floor nurses. It was their responsibility to act on the recommendation and bring it up at the risk meeting. Usually the committee just asked nurse A if the recommendation followed up on. They do not bring the chart to verify. Dietary L reveals that the review of the pressure ulcers are monthly. Room trays; the nurse determined who got a room tray. The nurse would let us know what they want for a room tray. If a resident does not want a tray, we do not send one. During a phone conversation on 8/21/13 at 2:39 p.m. Consultant N revealed he/she visited the facility every 2 weeks and requested a list of current weights, skin issues, tube feedings (review the second time of the month) if no change I will wait a month and reevaluate. Consultant N also requested a list of those who came from the hospital, MDS annual reviews, or any other concerns, if Consultant N made recommendations he/she usually checked back on the next visit. The Consultant N would look in the chart, if he/she did not see an order, he/she would check with nursing, look at the MAR (medication administration record), and talk to Administrative nurse A. Consultant N stated he/she had some problems with people who have come back from the hospital and getting the dieticians orders restarted. The residents not always weighed weekly. Nurse A thought the floor nurses were taking care of the recommendations but they were not. The last time Consultant N visited, the residents had no current weights. Direct care staff M began weighing the residents before he/she left the building. Administrative nurse A instructed to call the Consultant N with weights for tube feeders to tell if there was any weight loss but the dietician did not receive any call. With these not being weight and not calling it was three weeks until the dietician reviewed them again. With total tube feedings who continue to lose weight, " there should be another intervention tried before a month". The resident had a 31 pound weight loss since 3/2013 with recommendations made twice to increase the tube feedings though the resident continued to lose weight. The resident would probably be a candidate for continuous feeding though the facility was attempting to get some pumps for the tube feedings but had not gotten any at this time. During an interview 8-21-13 at 3:29 p.m., Administrative nurse A reported the facility received a new lift scale at the end of March or first of April, because staff kept getting weird weights. The facility had one scale direct care staff felt was not accurate, and it got disposed of it. In that, time we had identified significant weight losses on tube fed residents. Tube fed residents needed weekly weights. Dietary staff L was to compile a list of weights and bring them to the weekly risk meeting, when asked if Administrative staff A felt the lack of interventions and weekly weights had put residents receiving tube feedings at risk for harm Administrative nurse A stated " yes possibly " . "The dietician is available to be called at any time and I am the one responsible for calling consultant N and informing him/her of issues " Interview with physician V on 8/26/13 at 12:20 p.m. revealed that he/she was not aware of the pressure ulcer development. The wound nurse at the facility can assess the residents and there was no need for notification of a stage 2 or 3 ulcer, only stage 4. Physician V revealed he was aware of the weight loss and declined to comment on the weight loss. Review of the policy on Weekly Weights/Nutritional Risk dated 09/27/2004; Purpose to identify residents at risk for weight loss and poor nutrition. Procedure all weekly weights are documented in the treatment record. 1. All new admissions will be weighed with in four hours of admission and weekly for four weeks to establish a baseline weight and monitor for loss. 2. All residents with a physician's order [REDACTED]. 3. Weekly weights will be weekly on all residents receiving tube feedings. 4. Any resident who experiences a 5 pound weight loss or gain on routine monthly weights shall have weekly weights until three consecutive weekly weights show no loss or gain. Residents showing 5 pound or more weight loss or gain on monthly weights are reweighed within 24 hours prior to being placed on weekly weights. 5. Any resident who has not eaten at least 50% of one of three meals daily for 7 days shall have weekly weights until three consecutive weekly weights show no loss or gain Interview with Physician V on 8/26/13 at 12:20 revealed that the physician was aware of the weight loss. Physician V reported that he/she thought the weight loss was due to changing scales and or change in the staff. The facility failed to monitor and act upon a significant weight loss for this resident receiving nutrition by a feeding tube and by mouth, by the failure to monitor meal intake on the resident. The facility failed to follow recommendation of the registered dietician and notify the physician of the recommendation in a timely manner. - Review of resident # 54's admission MDS (minimum data set) dated 12/18/12 revealed the resident ' s metal status was moderately impaired. The resident had no [MEDICAL CONDITION], mood, or behavior problems. The resident is totally dependent on the staff to provide cares with 1 person assist for eating. The resident received 51% or more intake per tube feeding with over 501 cc/ day fluid intake. The resident had a formal assessment for skin breakdown and was at risk for pressure ulcer. The resident had pressure relieving devices in the bed, chair, turned and repositioned, hydration and nutrition program. Review of the quarterly MDS dated [DATE] revealed the resident ' s cognitive status was severely impaired. There was no change in the functional status. The resident had no weight gain or loss had a feeding tube and received the daily nutrition per the tube 51% or more total calories and >501 cc (cubic centimeters) fluid. The nutritional status CAA (care area assessment) did not trigger. The feeding tube CAA dated 12/18/12 revealed the resident required a feeding tube due to [MEDICAL CONDITION]. Review of the care plan with a date of 7/29/13 revealed the resident received 2 Cal 6 cans daily per [DEVICE]. Assess the resident ' s feeding tube for redness or drainage, change feeding tube dressing as ordered by the physician. Check the feeding tube for patency with each feeding flush the feeding tube per physician orders [REDACTED]. Elevate the head of the bed during feeding; make sure that the resident ' s tube feedings are on time and that the resident received the correct formula. Note if the resident had any diarrhea or vomiting and how the resident tolerated the tube feeding. On 7-31-13 actual stage 3 pressure ulcer to back, resident will have no further skin breakdown consult wound care physician, skin prep times 1 week then discontinue, Resolved 8-14-13 Resident is at risk for dehydration due to the use of a feeding tube. Resident will have adequate hydration as evidenced by having no significant weight change and by having labs be within normal limits in the next 90 days (initiated 12-19-12) No updates noted on current care plan. The resident received all hydration through the feeding tube; provide water and fluids via [DEVICE] as ordered Resident is on a feeding tube. Dress the site and make sure the tube is patent every day. Give 2 Cal 6 cans per day, assess the [DEVICE] site, change dressing as ordered, check for patency, flush per orders, flush with 60 ml before and after feedings, head of bed elevated during feeding, make sure feedings are on time and the correct formula, note how resident tolerates feedings. No care plan for weight loss found. Care plan summary dated 1-17-13 nurse summary stated no problems tolerating feeding well. Dietary signed but no note written. Care plan meeting date 3-21-13 nurse summary stated no concerns at this time, continue plan of care (no dietary staff signature on meeting notes or on signature attendance/participation as if not attended). No other care plan notes were in the care plan book. On 3-5-13, nurse ' s notes revealed the resident went to the hospital for evaluation, due to fever, coughing, wheezing. On 3-6-13 an order for [REDACTED]. Physician communication fax dated 5-16-13 to PCP from licensed staff revealed registered dietician recommendations: may we increase 2 Cal HN to 5 cans/day and decrease flushes of 250 cc to 2 times daily Response was " yes " (orders written on TAR for May) On 5/17/13 order received to increase 2, Cal HN 1 can to 5 times daily by [DEVICE]. Before and after feeding full strength flush the [DEVICE] with water 60 ml. On 6-14-13 physician order [REDACTED]. Physicians orders dated 7-24-13 directed staff to give 2 Cal HN (a type of liquid nutrition) 1 can per [DEVICE] every 4 hours. Review of the resident's monthly weights revealed the following: 1/9/13 137 2/6 /13 137 3/19/13 125 4/3/13 129 5/8/13 126 5/23/13 113 6/10/13 120 6/12/13 116 (reweigh) 7/5/13 116 7/6/13 116 reweigh 7/16/13 109 7/24/13 113 7/30/13 112 8/13/13 115, The resident had weight loss: 2/6/13 to 3/19/13 of 12 pounds 5/8/13 to 5/23/13 of 13 pounds 7/6/13 to 7/16/13 of 7 pounds The review of nutritional assessment on 12/26/12 revealed the resident received nutrition by [DEVICE] and took nothing by mouth. The resident ' s weight was 131 and 67 inches tall with a body mass index of 20. 5-23-13 at 412 pm risk meeting continues to be total care, [DEVICE] with [MEDICATION NAME] feedings tolerates well, no complicating, no skin issues at this time, weight stable, (no notes for June in chart indicating weight loss) On 7-11-13 at 1:20 p.m., risk meeting this am, weight loss reviewed, recent lengthy hospitalization will monitor. [DEVICE] in place, feedings tolerated and [DEVICE] flushes freely, no skin issues. On 7-18-13 3:18 p.m., reviewed skin issues, area to his back, interventions and treatments, seen by wound care physician, treatment in place reviewed presence of [DEVICE], no complications with feedings, weight reviewed, weight loss noted, awaiting blood cultures. No interventions noted. The nurse notes from January 2013 through present August 21 2013 revealed no mention of weight loss. Review of the local hospital's discharge instructions dated 3-6-13 included a handwritten note in large black print with an asterisk stating, "Please make sure the patient gets proper nutrition". Review of the physician progress notes [REDACTED]. On 2-11-13 physician V wrote - patient with history of motor vehicle accident with severe brain trauma. Has been stable for some time. Patient is nonverbal, no problems identified for weight loss. On 3-11-13 responds to verbal stimuli, is nonverbal, no weight loss problems identified. On 6-3-13 responsive to verbal stimuli per staff, blood pressure 127/57, no problem with weight loss identified. Review of the 12/ 2012 TAR (treatment administration record) had 2 Cal 4 times daily starting 12-17/12 with 7 missing signatures for 5:00 a.m. on the 21,22,25,26,29,30,31. On 12/17/12 signature for the 10:00 p.m. missing. Review of the January 2013 TAR had 2 Cal four times daily per [DEVICE], had 3 missing signatures on 1/4 at 5:00 a.m., 1/16 at 11:00 p.m. and 1/25 at 5:00 p.m. Review of the February 2013 TAR had 2 Cal four times daily per [DEVICE] had 2 missing signatures on 2/11 and 2/27 at 5:00 a.m. Review of the March 2013 TAR had 2 Cal ordered 4 times daily per [DEVICE] 2 missing signatures on 2/14 and 2/19 at 5:00 a.m. On 12/20/12 pre-[MEDICATION NAME] was 27 with in normal limits (no other lab for [MEDICATION NAME] in chart). Risk meeting notes revealed the following On 4-26-13 risk meeting notes weight stable, will continue to monitor. On 5-23-13 risk meeting, weight stable. On 7-11-13 risk meeting weight loss reviewed, On 7-18-13 1518 weight reviewed, weight loss noted. No notes in chart for June 2013 indicating weight loss. On 08/22/2013, 8:59 p.m., direct care staff P and S revealed the resident was not given anything by mouth and received feedings only by the nurses he cannot eat anything else. On 8/22/13 at 4:53 p.m., direct care staff Q the nurses feed him/her the only thing we do is oral care and ADL's. On 8/22/13, 9:15 am licensed nursing staff G the nurse from the other floor comes to feed the resident. The resident moved up to 2nd floor temporarily so the nurses came up from down stairs to feed the resident. The 1 first floor nurse makes all the physician calls. The chart stayed on the 2 nd floor. On 8/22/13, 4:32 pm licensed nursing staff R the resident originally came from the first floor and the nurse from st floor comes up, feeds him/her, and then call the doctors. The direct care staff from 2nd floor take care of the cares. On 8-21-13 at 1:49 p.m., dietary staff L revealed when a resident admitted to the facility staff weighed the resident four times a month for the first month. If the resident not at risk they go to monthly weights, but if it looked like the resident was losing weight and not eating the resident was put on every two week weights until they are leveled out on weight. Staff L reported there were weekly meetings involving weights, skin, falls, and once a month the risk committee look at everyone and who is at risk for weight loss, printed on a vital summary for six months, the committee did not review intake record at the meeting. Residents with tube feedings reviewed weekly and on weekly weights, the dietician notified at 5% weight loss. The dietician visited twice a month, reviewed any weight loss, the new people, and pressure ulcer reviewed once a month. When the dietician made recommendations they went to Administrative nurse A and the floor nurses. It was their responsibility to act on the recommendation and bring it up at the risk meeting. Usually the committee just asked nurse A if the recommendation followed up on. They do not bring the chart to verify. Dietary L reveals that review of the pressure ulcers are monthly. Room trays; the nurse determines who gets a room tray. The nurse would let us know what they want for a room tray. No if they do not want a tray we do not send one. During a phone conversation on 8/21/13 at 2:39 p.m. Consultant N revealed he/she visited the facility every 2 weeks and requested a list of current weights, skin issues, tube feedings(review the second time of the month) if no change I will wait a month and reevaluate. Consultant N also requested a list of those who came from the hospital, MDS annual reviews, or any other concerns, if Consultant N made recommendations he/she usually checked back on the next visit. The Consultant N would look in the chart, if he/she did not see an order, he/she would check with nursing, look at the MAR (medication administration record), and talk to Administrative nurse A. Consultant N stated he/she had some problems with people who have come back from the hospital and getting the dieticians orders restarted. The residents not always weighed weekly. Nurse A thought the floor nurses were taking care of the recommendations but they were not. The resident had no current weights the last time Consultant N visited; direct care staff began weighing the residents before he/she left the building. Administrative nurse A instructed to call the Consultant N with weights for tube feeders to tell if there was any weight loss but the dietician did not receive any call. With these not being weight and not calling it was three weeks until the dietician reviewed them again. With total tube feedings who continue to lose weight, " there should be another intervention tried before a month". The resident had a 25 pound weight loss since 2/2013 with recommendations made to increase the tube feedings though the resident continued to lose weight. The resident would probably be a candidate for continuous feeding though the facility was attempting to get some pumps for the tube feedings but had not gotten any at this time. During an interview 8-21-13 at 3:29 p.m., Administrative nurse A reported the facility got a new lift scale at the end of March or first of April, because staff kept getting weird weights. The facility had one scale direct care staff felt was not accurate, and it got disposed of it. In that, time staff had identified significant weight losses on tube fed residents. Tube fed residents needed weekly weights. Dietary staff L was to compile a list of weights and bring them to the weekly risk meeting, when asked if Administrative staff A felt the lack of interventions and weekly weights had put residents receiving tube feedings at risk for harm Administrative nurse A stated " yes possibly " . "The dietician is available to be called at any time and I am the one responsible for calling her and informing her of issues " Interview with physician V on 8/26/13 at 12:20 p.m. revealed that he/she was not aware of the pressure ulcer development. The wound nurse at the facility can assess the residents and there was no notification was necessary for a stage 2 or 3 ulcer, only stage 4. Physician V revealed he was aware of the weight loss and declined to comment on the weight loss. Review of the policy on Weekly Weights/Nutritional Risk dated 09/27/2004; Purpose to identify residents at risk for weight loss and poor nutrition. Procedure: All weekly weights will be documented in the treatment record. 1. All new admissions will be weighed with in four hours of admission and weekly for four weeks to establish a baseline weight and monitor for loss. 2. All residents with a physician's order [REDACTED]. 3. Weekly weights will be weekly on all residents receiving tube feedings. 4. Any resident who experiences a 5 pound weight loss or gain on routine monthly weights shall have weekly weights until three consecutive weekly weights show no loss or gain. Residents showing 5 pound or more weight loss or gain on monthly weights are reweighed within 24 hours prior to placement on weekly weights. 5. Any resident who has not eaten at least 50% of one of three meals daily for 7 days shall have weekly weights until three consecutive weekly weights show no loss or gain The facility failed to monitor and act upon a significant weight loss in a resident that was dependent on staff for nutrition by a feeding tube. The facility failed to monitor weights weekly and ensure the resident received the ordered nutrition needed to maintain his/her weight. - Review of the resident #26's face sheet revealed an admission date of [DATE]. Review of the signed physician's orders [REDACTED]. Review of resident #26's annual MDS (minimum data set) dated 11/30/12 revealed a BIMS (brief interview for mental status) score of 12 (mode

The facility reported a census of 56 residents with 5 residents sampled for nutrition. Based on observation, interview and record review the facility failed to ensure 5 of the 5 sampled resident maintained acceptable parameters of nutrition to prevent weight loss. (#26, #54, #71, #72 and # 76). Findings included: - The Review of resident #76's signed physician orders [REDACTED]. Review of resident #76 admission MDS (minimum data set) dated 3/4/13 revealed a BIMS (brief interview for mental status) with a score of 8 (moderately impaired). The functional status revealed the resident required extensive assist of one for eating. The resident received tube feedings and took nothing by mouth. The resident received >51% through feeding tube and more than 501 ml (milliliters) per day. On admission, the resident had a stage 1 or greater pressure ulcer. The resident was at risk of developing pressure ulcers. The resident has 2 unhealed pressure ulcers at stage 1 or higher of [MEDICATION NAME] tissue( 1 of 4 layer of tissue that covers the whole surface of the body), pressure relieving device for the bed and chair turning and positioning program and nutrition or hydration intervention to manage skin problems and receives pressure ulcer care with application of ointment to other than feet. Review of the quarterly MDS dated [DATE] BIMS of 1 (severely impaired). The resident was on a weight gain program. The resident was on a feeding tube and a mechanically altered diet, received 26-50% of the total calories/24 hr and 500 ml or less from [DEVICE]. The resident had no weight loss, and did not choke or cough while eating meal. Resident has 2- stage 1 pressure ulcers and receives pressure ulcer care with application of ointment to other than feet. Review of the Nutritional CAA (care area assessment) dated 3/9/13 revealed the resident received speech therapy and the body mass index was with in normal limits. Review of the feeding tube CAA revealed that the resident had a feeding tube and received [MEDICATION NAME] 1.5, 5 cans daily. Review of the Dehydration CAA revealed that the resident received [MEDICATION NAME] 1.5, 5 cans daily and 1000 ml free water flush. Review of the Pressure ulcer CAA revealed that on admission the resident had 2 stage 1 pressure ulcers on the coccyx and was at risk for pressure ulcers. Review of the care plan dated 7/29/13 revealed the resident was at risk for dehydration; staff was to provide water and fluids per [DEVICE] ([MEDICAL CONDITION] tube) as ordered and at meals. Staff was to take the resident to all meals the care plan meeting notes revealed that all disciplines attended and nursing revealed that the resident was doing well much improvement. There was no comment from dietary. There was no care plan for the prevention of pressure ulcers. Review of the Skin assessment dated [DATE] skin assessment on admission revealed a right and left gluteal fold blanchable (skin that turns white or purple when pressure is applied). On 2/25/13 on admit the resident s Braden scale (tool used to determine a resident ' s risk for pressure ulcer development) score 13 and 13-14 moderate risk. On 7/12/13, Braden scale 14. Review of the physician orders [REDACTED]. On 3/14/13 per nurses notes Overall skin assessment narrative, CNA notified nurse of open areas on the coccyx found two small pressure areas directly on coccyx about 1 cm by 2 cm no drainage noted stage 2 Applied temporary dressing until physician orders [REDACTED]. 3/14/13 Physician notified of the 2 open areas. We will consult wound specialist for orders PCP (primary care physician) agreed. No other measurements found in the chart Review of the 3/18/13 Dietary assessment revealed a score of 14 and below 17 indicated malnourishment. 3/20/13 Apply skin prep to coccyx cover with OpSite (clear surgical dressing) change every 3 days and as needed. Consult wound specialist if not healed by next week. On 3/22/13 skin assessment, coccyx 2 pressure ulcers dressing intact, no measurements. On 3/25/13, the physician phone order revealed an order to increase the [MEDICATION NAME] 1.5 to 6 cans daily with 1000 ml (milliliters) of water flushed total daily. On 4/11/13 review of the skin, assessment revealed pressure ulcers on coccyx. The monthly summary on 5/5/13 revealed poor skin turgor (degree of elasticity). On 5/11/13 review of the skin assessment blanchable redness to the sacrum. On 5/17/13, a phone order to clarify the speech therapy 3-5 times weekly to increase oral intake. Diet clarification obtained for pleasure feedings 3-5 times daily as tolerated, with single serving pureed food with water. On 6/7/13, a new physician order [REDACTED]. Continue with regular liquids offer small meals as tolerated and encourage oral intake at all meals. On 6/8/13 review of the skin assessment revealed blanchable area to the coccyx. On 6/22/13 review of the skin assessment revealed blanchable area to the coccyx. with fragile skin. On 6/26/13, new order to decrease [MEDICATION NAME] 1.5, to 1 can at 6:00 a.m. and 10:00 p.m. daily and flush with 250 cc water at 6:00 am and 10:00 p.m. crush medications and administer with food and liquid. The resident with a [DIAGNOSES REDACTED]. On 7/12/13 review of the skin, assessment revealed redness to the coccyx. Review of the nurses notes dated 7/12/13 revealed the resident went to the hospital on [DATE] and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was to receive no thin liquids. On 7/21/13 re view of the skin assessment revealed redness to the coccyx. On 7/22/13, the registered dietician assessment revealed the resident received inadequate oral intake, due to difficulty swallowing. The resident ' s weight was 143 pounds, down 5 pounds in 1 month and down 32 pounds in 3 months. The resident was on a pureed diet with pudding thick liquid. Recommendation to increase [MEDICATION NAME] 1.5 to 1 can three times a day to stabilize weight and increase oral intake and tube feeding. On 7/30/13, review of the skin assessment revealed no mention of coccyx. On 8/16/13, the facility obtained a phone order to increase the [MEDICATION NAME] 1.5 to three times daily. This was 25 days after the recommendation. On 8/21/13, staff added the order for the increase of [MEDICATION NAME] 1.5 to the TAR (treatment administration record) for administration. The facility failed to follow up for 30 days on the recommendation to increase the [MEDICATION NAME] 1.5 as recommended by the registered dietician on 7/22/13 No lab results for [MEDICATION NAME] or protein (laboratory values used to determine a resident ' s nutritional status) since admission. Review of the August TAR (Treatment Administration Record) revealed no signature for the [MEDICATION NAME] 1.5 or water flush on 8/10/13 at 10:00 p.m., 8/11/13 at 6:00 a.m. and 10:00 p.m., 8/12/13 at 6:00 a.m. on 8/15/13 at 6:00 a.m., and 8/16/13 at 6:00 a.m. Review of the resident's weight record revealed the following weights: 2/27 170 3/21 169 4/3 176 5/15 145 5/21 149 5/23 149 6/12 148 6/20 153 7/16 143 7/24 138 7/30 141 8/8 146 8/21 145 Review of the nurse's notes done 3 times daily. There was no mention of [MEDICAL CONDITION] on any of the days between 4/3 and 5/15/13. The review of the resident ' s records current and past revealed the resident had no meal intake sheets since admission, to record the % of the meal eaten. On 8/21/13 at 8:04 a.m., the resident was at the dining room table and received pureed eggs, pureed sausage, hot cereal, thickened water and milk. The resident ate all the eggs, all but 2 bites of the meat and 1/2 of the hot cereal. The resident took 2 sips of thickened water and drank about 1/4 of the milk. Each of the milk and water was 240 ml. On 8/22/13 at 7:56 a.m. the resident was at the table and served pureed eggs, pancake pureed with syrup and pureed bacon, 240 ml thickened milk and 240 ml thickened water. The resident ate the entire pancake and 1/2 of the meat, 1 bite of egg 1/3 of the milk and 1/4 of the water. At 12:30 p.m., staff took a tray to the resident ' s room of mashed potatoes, pureed meat, and a green vegetable. Direct care staff P was at the side of the bed assisting the resident with the meal. The resident ate 25 % of the meal and 120 cc water. On 08/22/2013 at 8:59 a.m., direct care staff P revealed the resident ate in the dining room, and could eat alone with occasional verbal cues and ate better at breakfast than any other meal. When asking the resident to come down to the dining room for the other meals the resident stated that he/she was not hungry, having ate a lot for breakfast. Staff offer the Mighty shakes in strawberry to the resident. All residents that eat in the dining room have meal intake sheets 8/22/13 4:53 p.m., direct care staff Q revealed the resident ate something at all three meals, but will leave a lot of food uneaten. The resident would eat snacks later on in the day. Staff member reported that staff would get a tray for him/her even when the resident said no. Staff would set the tray in front of the resident and sometimes he/she would eat some and other times not. On 8-21-13 at 12:23 p.m. direct care staff M reported that he/she did the weights for the facility all residents got weighed once a month, some were weekly, new resident got weighed every week for four weeks, if they are losing weight then the resident stayed on weekly weights. Staff member M reported that he/she used the wheel chair scale or Hoyer scale the restorative aide calibrates the scales once a month, but there is no log of the calibration. The dietary manager gave the schedule for monthly and weekly weights, then staff member M wrote down the weights then gave the list back to the to the dietary manager and then the dietary manager documented the weights in the computer. If the weights had a 4 pound difference, the dietary manager would ask for a reweigh. Staff member M turned the reweigh back into the dietary manager. Direct care staff M kept the weight book. The dietary manager would then do the care plan, and kept a copy of the weights. On review of the weight records,, the weights done between the first and the tenth of each month. On 8/20/13 at 11:20 a.m., licensed nursing staff G revealed the resident ate meals in the dining room on his/her own and then [DEVICE] feedings at night 2 times 6:00 a.m. and 10:00 p.m. Staff document the meals on the meal intake sheets. On 8/22/13 at 8:05 a.m. licensed nursing staff G reported that, it was the responsibility of the restorative aide to obtain residents weights. Then the restorative aide gave the weights to the dietary manager. The licensed nursing staff G revealed the director of nursing and the dietician got a copy of the weight list and that there was a weekly weight meeting. When there was a recommendation from the dietician, the nurses sent the recommendation to the physician and put the order on the TAR and the report sheet. Licensed nursing staff G was unaware when residents had a significant weight loss unless he/she looked it up in the computer and usually did not have the time, to do that. On 8/22/13 at 2:12 p.m., licensed nursing staff R resident went into the hospital due to pneumonia, but that hospitalization happened later than the weight loss. Licensed nursing staff R reported notifying administrative nursing staff A that some of the nurses did not sign for feeding, that is about the time he lost weight. The nurses on the first floor they come up and do the feedings for the residents. On 8-21-13 at 1:49 p.m., dietary staff L revealed when a resident admitted to the facility staff weighed the resident four times a month for the first month. If the resident was not at risk they go to monthly weights, but if it looked like the resident was losing weight and not eating the resident was put on every two week weights until they are leveled out on weight. Staff L reported there were weekly meetings involving weights, skin, falls, and once a month the risk committee look at everyone and who is at risk for weight loss, printed on a vital summary for six months, the committee did not review intake record at the meeting. Residents with tube feedings reviewed weekly and on weekly weights, the dietician notified at 5% weight loss. The dietician visited twice a month, reviewed any weight loss, the new people, and pressure ulcer reviewed once a month. When the dietician made recommendations, he/she gave the recommendations to Administrative nurse A and the floor nurses. It was their responsibility to act on the recommendation and bring it up at the risk meeting. Usually the committee just asked nurse A if the recommendation followed up on. They do not bring the chart to verify. Dietary L reveals that the review of the pressure ulcers are monthly. Room trays; the nurse determined who got a room tray. The nurse would let us know what they want for a room tray. If a resident does not want a tray, we do not send one. During a phone conversation on 8/21/13 at 2:39 p.m. Consultant N revealed he/she visited the facility every 2 weeks and requested a list of current weights, skin issues, tube feedings (review the second time of the month) if no change I will wait a month and reevaluate. Consultant N also requested a list of those who came from the hospital, MDS annual reviews, or any other concerns, if Consultant N made recommendations he/she usually checked back on the next visit. The Consultant N would look in the chart, if he/she did not see an order, he/she would check with nursing, look at the MAR (medication administration record), and talk to Administrative nurse A. Consultant N stated he/she had some problems with people who have come back from the hospital and getting the dieticians orders restarted. The residents not always weighed weekly. Nurse A thought the floor nurses were taking care of the recommendations but they were not. The last time Consultant N visited, the residents had no current weights. Direct care staff M began weighing the residents before he/she left the building. Administrative nurse A instructed to call the Consultant N with weights for tube feeders to tell if there was any weight loss but the dietician did not receive any call. With these not being weight and not calling it was three weeks until the dietician reviewed them again. With total tube feedings who continue to lose weight, " there should be another intervention tried before a month". The resident had a 31 pound weight loss since 3/2013 with recommendations made twice to increase the tube feedings though the resident continued to lose weight. The resident would probably be a candidate for continuous feeding though the facility was attempting to get some pumps for the tube feedings but had not gotten any at this time. During an interview 8-21-13 at 3:29 p.m., Administrative nurse A reported the facility received a new lift scale at the end of March or first of April, because staff kept getting weird weights. The facility had one scale direct care staff felt was not accurate, and it got disposed of it. In that, time we had identified significant weight losses on tube fed residents. Tube fed residents needed weekly weights. Dietary staff L was to compile a list of weights and bring them to the weekly risk meeting, when asked if Administrative staff A felt the lack of interventions and weekly weights had put residents receiving tube feedings at risk for harm Administrative nurse A stated " yes possibly " . "The dietician is available to be called at any time and I am the one responsible for calling consultant N and informing him/her of issues " Interview with physician V on 8/26/13 at 12:20 p.m. revealed that he/she was not aware of the pressure ulcer development. The wound nurse at the facility can assess the residents and there was no need for notification of a stage 2 or 3 ulcer, only stage 4. Physician V revealed he was aware of the weight loss and declined to comment on the weight loss. Review of the policy on Weekly Weights/Nutritional Risk dated 09/27/2004; Purpose to identify residents at risk for weight loss and poor nutrition. Procedure all weekly weights are documented in the treatment record. 1. All new admissions will be weighed with in four hours of admission and weekly for four weeks to establish a baseline weight and monitor for loss. 2. All residents with a physician's order [REDACTED]. 3. Weekly weights will be weekly on all residents receiving tube feedings. 4. Any resident who experiences a 5 pound weight loss or gain on routine monthly weights shall have weekly weights until three consecutive weekly weights show no loss or gain. Residents showing 5 pound or more weight loss or gain on monthly weights are reweighed within 24 hours prior to being placed on weekly weights. 5. Any resident who has not eaten at least 50% of one of three meals daily for 7 days shall have weekly weights until three consecutive weekly weights show no loss or gain Interview with Physician V on 8/26/13 at 12:20 revealed that the physician was aware of the weight loss. Physician V reported that he/she thought the weight loss was due to changing scales and or change in the staff. The facility failed to monitor and act upon a significant weight loss for this resident receiving nutrition by a feeding tube and by mouth, by the failure to monitor meal intake on the resident. The facility failed to follow recommendation of the registered dietician and notify the physician of the recommendation in a timely manner. - Review of resident # 54's admission MDS (minimum data set) dated 12/18/12 revealed the resident ' s metal status was moderately impaired. The resident had no [MEDICAL CONDITION], mood, or behavior problems. The resident is totally dependent on the staff to provide cares with 1 person assist for eating. The resident received 51% or more intake per tube feeding with over 501 cc/ day fluid intake. The resident had a formal assessment for skin breakdown and was at risk for pressure ulcer. The resident had pressure relieving devices in the bed, chair, turned and repositioned, hydration and nutrition program. Review of the quarterly MDS dated [DATE] revealed the resident ' s cognitive status was severely impaired. There was no change in the functional status. The resident had no weight gain or loss had a feeding tube and received the daily nutrition per the tube 51% or more total calories and >501 cc (cubic centimeters) fluid. The nutritional status CAA (care area assessment) did not trigger. The feeding tube CAA dated 12/18/12 revealed the resident required a feeding tube due to [MEDICAL CONDITION]. Review of the care plan with a date of 7/29/13 revealed the resident received 2 Cal 6 cans daily per [DEVICE]. Assess the resident ' s feeding tube for redness or drainage, change feeding tube dressing as ordered by the physician. Check the feeding tube for patency with each feeding flush the feeding tube per physician orders [REDACTED]. Elevate the head of the bed during feeding; make sure that the resident ' s tube feedings are on time and that the resident received the correct formula. Note if the resident had any diarrhea or vomiting and how the resident tolerated the tube feeding. On 7-31-13 actual stage 3 pressure ulcer to back, resident will have no further skin breakdown consult wound care physician, skin prep times 1 week then discontinue, Resolved 8-14-13 Resident is at risk for dehydration due to the use of a feeding tube. Resident will have adequate hydration as evidenced by having no significant weight change and by having labs be within normal limits in the next 90 days (initiated 12-19-12) No updates noted on current care plan. The resident received all hydration through the feeding tube; provide water and fluids via [DEVICE] as ordered Resident is on a feeding tube. Dress the site and make sure the tube is patent every day. Give 2 Cal 6 cans per day, assess the [DEVICE] site, change dressing as ordered, check for patency, flush per orders, flush with 60 ml before and after feedings, head of bed elevated during feeding, make sure feedings are on time and the correct formula, note how resident tolerates feedings. No care plan for weight loss found. Care plan summary dated 1-17-13 nurse summary stated no problems tolerating feeding well. Dietary signed but no note written. Care plan meeting date 3-21-13 nurse summary stated no concerns at this time, continue plan of care (no dietary staff signature on meeting notes or on signature attendance/participation as if not attended). No other care plan notes were in the care plan book. On 3-5-13, nurse ' s notes revealed the resident went to the hospital for evaluation, due to fever, coughing, wheezing. On 3-6-13 an order for [REDACTED]. Physician communication fax dated 5-16-13 to PCP from licensed staff revealed registered dietician recommendations: may we increase 2 Cal HN to 5 cans/day and decrease flushes of 250 cc to 2 times daily Response was " yes " (orders written on TAR for May) On 5/17/13 order received to increase 2, Cal HN 1 can to 5 times daily by [DEVICE]. Before and after feeding full strength flush the [DEVICE] with water 60 ml. On 6-14-13 physician order [REDACTED]. Physicians orders dated 7-24-13 directed staff to give 2 Cal HN (a type of liquid nutrition) 1 can per [DEVICE] every 4 hours. Review of the resident's monthly weights revealed the following: 1/9/13 137 2/6 /13 137 3/19/13 125 4/3/13 129 5/8/13 126 5/23/13 113 6/10/13 120 6/12/13 116 (reweigh) 7/5/13 116 7/6/13 116 reweigh 7/16/13 109 7/24/13 113 7/30/13 112 8/13/13 115, The resident had weight loss: 2/6/13 to 3/19/13 of 12 pounds 5/8/13 to 5/23/13 of 13 pounds 7/6/13 to 7/16/13 of 7 pounds The review of nutritional assessment on 12/26/12 revealed the resident received nutrition by [DEVICE] and took nothing by mouth. The resident ' s weight was 131 and 67 inches tall with a body mass index of 20. 5-23-13 at 412 pm risk meeting continues to be total care, [DEVICE] with [MEDICATION NAME] feedings tolerates well, no complicating, no skin issues at this time, weight stable, (no notes for June in chart indicating weight loss) On 7-11-13 at 1:20 p.m., risk meeting this am, weight loss reviewed, recent lengthy hospitalization will monitor. [DEVICE] in place, feedings tolerated and [DEVICE] flushes freely, no skin issues. On 7-18-13 3:18 p.m., reviewed skin issues, area to his back, interventions and treatments, seen by wound care physician, treatment in place reviewed presence of [DEVICE], no complications with feedings, weight reviewed, weight loss noted, awaiting blood cultures. No interventions noted. The nurse notes from January 2013 through present August 21 2013 revealed no mention of weight loss. Review of the local hospital's discharge instructions dated 3-6-13 included a handwritten note in large black print with an asterisk stating, "Please make sure the patient gets proper nutrition". Review of the physician progress notes [REDACTED]. On 2-11-13 physician V wrote - patient with history of motor vehicle accident with severe brain trauma. Has been stable for some time. Patient is nonverbal, no problems identified for weight loss. On 3-11-13 responds to verbal stimuli, is nonverbal, no weight loss problems identified. On 6-3-13 responsive to verbal stimuli per staff, blood pressure 127/57, no problem with weight loss identified. Review of the 12/ 2012 TAR (treatment administration record) had 2 Cal 4 times daily starting 12-17/12 with 7 missing signatures for 5:00 a.m. on the 21,22,25,26,29,30,31. On 12/17/12 signature for the 10:00 p.m. missing. Review of the January 2013 TAR had 2 Cal four times daily per [DEVICE], had 3 missing signatures on 1/4 at 5:00 a.m., 1/16 at 11:00 p.m. and 1/25 at 5:00 p.m. Review of the February 2013 TAR had 2 Cal four times daily per [DEVICE] had 2 missing signatures on 2/11 and 2/27 at 5:00 a.m. Review of the March 2013 TAR had 2 Cal ordered 4 times daily per [DEVICE] 2 missing signatures on 2/14 and 2/19 at 5:00 a.m. On 12/20/12 pre-[MEDICATION NAME] was 27 with in normal limits (no other lab for [MEDICATION NAME] in chart). Risk meeting notes revealed the following On 4-26-13 risk meeting notes weight stable, will continue to monitor. On 5-23-13 risk meeting, weight stable. On 7-11-13 risk meeting weight loss reviewed, On 7-18-13 1518 weight reviewed, weight loss noted. No notes in chart for June 2013 indicating weight loss. On 08/22/2013, 8:59 p.m., direct care staff P and S revealed the resident was not given anything by mouth and received feedings only by the nurses he cannot eat anything else. On 8/22/13 at 4:53 p.m., direct care staff Q the nurses feed him/her the only thing we do is oral care and ADL's. On 8/22/13, 9:15 am licensed nursing staff G the nurse from the other floor comes to feed the resident. The resident moved up to 2nd floor temporarily so the nurses came up from down stairs to feed the resident. The 1 first floor nurse makes all the physician calls. The chart stayed on the 2 nd floor. On 8/22/13, 4:32 pm licensed nursing staff R the resident originally came from the first floor and the nurse from st floor comes up, feeds him/her, and then call the doctors. The direct care staff from 2nd floor take care of the cares. On 8-21-13 at 1:49 p.m., dietary staff L revealed when a resident admitted to the facility staff weighed the resident four times a month for the first month. If the resident not at risk they go to monthly weights, but if it looked like the resident was losing weight and not eating the resident was put on every two week weights until they are leveled out on weight. Staff L reported there were weekly meetings involving weights, skin, falls, and once a month the risk committee look at everyone and who is at risk for weight loss, printed on a vital summary for six months, the committee did not review intake record at the meeting. Residents with tube feedings reviewed weekly and on weekly weights, the dietician notified at 5% weight loss. The dietician visited twice a month, reviewed any weight loss, the new people, and pressure ulcer reviewed once a month. When the dietician made recommendations they went to Administrative nurse A and the floor nurses. It was their responsibility to act on the recommendation and bring it up at the risk meeting. Usually the committee just asked nurse A if the recommendation followed up on. They do not bring the chart to verify. Dietary L reveals that review of the pressure ulcers are monthly. Room trays; the nurse determines who gets a room tray. The nurse would let us know what they want for a room tray. No if they do not want a tray we do not send one. During a phone conversation on 8/21/13 at 2:39 p.m. Consultant N revealed he/she visited the facility every 2 weeks and requested a list of current weights, skin issues, tube feedings(review the second time of the month) if no change I will wait a month and reevaluate. Consultant N also requested a list of those who came from the hospital, MDS annual reviews, or any other concerns, if Consultant N made recommendations he/she usually checked back on the next visit. The Consultant N would look in the chart, if he/she did not see an order, he/she would check with nursing, look at the MAR (medication administration record), and talk to Administrative nurse A. Consultant N stated he/she had some problems with people who have come back from the hospital and getting the dieticians orders restarted. The residents not always weighed weekly. Nurse A thought the floor nurses were taking care of the recommendations but they were not. The resident had no current weights the last time Consultant N visited; direct care staff began weighing the residents before he/she left the building. Administrative nurse A instructed to call the Consultant N with weights for tube feeders to tell if there was any weight loss but the dietician did not receive any call. With these not being weight and not calling it was three weeks until the dietician reviewed them again. With total tube feedings who continue to lose weight, " there should be another intervention tried before a month". The resident had a 25 pound weight loss since 2/2013 with recommendations made to increase the tube feedings though the resident continued to lose weight. The resident would probably be a candidate for continuous feeding though the facility was attempting to get some pumps for the tube feedings but had not gotten any at this time. During an interview 8-21-13 at 3:29 p.m., Administrative nurse A reported the facility got a new lift scale at the end of March or first of April, because staff kept getting weird weights. The facility had one scale direct care staff felt was not accurate, and it got disposed of it. In that, time staff had identified significant weight losses on tube fed residents. Tube fed residents needed weekly weights. Dietary staff L was to compile a list of weights and bring them to the weekly risk meeting, when asked if Administrative staff A felt the lack of interventions and weekly weights had put residents receiving tube feedings at risk for harm Administrative nurse A stated " yes possibly " . "The dietician is available to be called at any time and I am the one responsible for calling her and informing her of issues " Interview with physician V on 8/26/13 at 12:20 p.m. revealed that he/she was not aware of the pressure ulcer development. The wound nurse at the facility can assess the residents and there was no notification was necessary for a stage 2 or 3 ulcer, only stage 4. Physician V revealed he was aware of the weight loss and declined to comment on the weight loss. Review of the policy on Weekly Weights/Nutritional Risk dated 09/27/2004; Purpose to identify residents at risk for weight loss and poor nutrition. Procedure: All weekly weights will be documented in the treatment record. 1. All new admissions will be weighed with in four hours of admission and weekly for four weeks to establish a baseline weight and monitor for loss. 2. All residents with a physician's order [REDACTED]. 3. Weekly weights will be weekly on all residents receiving tube feedings. 4. Any resident who experiences a 5 pound weight loss or gain on routine monthly weights shall have weekly weights until three consecutive weekly weights show no loss or gain. Residents showing 5 pound or more weight loss or gain on monthly weights are reweighed within 24 hours prior to placement on weekly weights. 5. Any resident who has not eaten at least 50% of one of three meals daily for 7 days shall have weekly weights until three consecutive weekly weights show no loss or gain The facility failed to monitor and act upon a significant weight loss in a resident that was dependent on staff for nutrition by a feeding tube. The facility failed to monitor weights weekly and ensure the resident received the ordered nutrition needed to maintain his/her weight. - The Review of resident #71's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 2/19/13 revealed the

The facility census totaled 56 with 22 residents included in the sample. Based on observation, interview and record review the facility failed to implement new intervention and update the care plan for resident with pressure ulcer, accidents and significant weight loss for residents (#26, #72, #76, and #39). Finding included: - Review of the resident #26's face sheet revealed an admission date of [DATE]. Review of the physician's orders [REDACTED]. runny stools). Review of resident #26's annual MDS (minimum data set) dated 11/30/12 revealed a BIMS (brief interview for mental status) score of 12 (moderately impaired). The resident required limited assistance of one staff member for bed mobility, transfers, dressing, extensive assist of one staff member for toileting, personal hygiene, and bathing. The resident was independent with eating. The MDS revealed the resident had an indwelling suprapubic catheter and was occasionally incontinent of bowel. The resident's skin was intact and the resident required turning and reposition, had a pressure relieving device for chair, a pressure relieving device to the bed, and application of ointments to other than feet. Review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12. The resident required limited assistance of one staff member for bed mobility, and transfers. The resident was independent with eating. The resident required extensive assist of one staff member for toilet use, personal hygiene and bathing. The resident had a supra pubic catheter with occasional bowel incontinence. The MDS revealed the resident had a significant weight gain, received a therapeutic diet, and was at risk for developing a pressure ulcer. The MDS revealed the resident had a pressure relieving device to the wheelchair and bed. The resident was on a turning and repositioning program with nutritional interventions to manage skin problems. Review of the ADL (activities of daily living) CAA (care area assessment) dated 11/30/12 revealed the resident required extensive assistance of the staff for toilet use and personal hygiene. The resident required limited assistance with bed mobility, transfers, and dressing. The resident was independent with eating. Review of the nutritional CAA revealed the resident received a therapeutic diet. Review of the pressure ulcer CAA revealed the resident required limited assistance of staff for bed mobility, and was at risk for pressure ulcers. The resident had a pressure relieving mattress to his/her bed and wheelchair. The resident was on a scheduled repositioning program and had occasional bowel incontinence. Review of resident #26's care plan dated 03/20/13 revealed the resident was at risk for alteration in nutritional status. The care plan directed the staff to provide a low concentrated sweets diet. The care plan update on 8/1/13 directed the staff to discontinue the protein shakes and change to health shakes. A care plan updated on 8/19/13 directed the staff to give Pro stat (a protein supplement) 30 milliliters twice daily. Further review of the resident's care plan revealed the resident was obsessed with bulimia (an eating disorder) the care plan directed the staff to refer the resident to a psychologist for talk therapy and medication management. The facility failed to update the care plan to reflect the current dietary interventions to help reduce the resident's risk for weight loss. Review of the resident's care plan dated 12/5/12 revealed the resident was at risk for pressure ulcer related to bowel incontinence. The care plan revealed the resident chose to be independent with toileting, and had a pressure relieving cushion to his/her wheelchair. A care plan update on 8/21/13 revealed the resident had an actual superficial open area to the right buttocks, an air mattress to the resident's bed, and treatment per physician's orders [REDACTED]. . On 8/22/13 at 2:45 p.m., interview with Administrative nurse B revealed the care plan team develops the resident care plan within 21 days of admission. The care plan team meets weekly for at risk meetings make updates to the resident's care plan and the resident's care plan is reviewed at least every 90 days and updated with any new interventions. Staff B revealed the facility had new members to the care plan team that were still learning the care planning process. The facility failed to provide a policy in regards to updating care plan as requested on 8/22/13. The facility failed to updated the resident's care plan to accurately reflect new interventions to address the resident's pressure ulcers and weight loss. - Review of resident #72's admission MDS (minimum data set) dated 1/10/13 revealed the resident had a BIMS (brief interview for mental status) score of 7 (moderately impaired). The resident required total assist of two staff members for all ADLs (activities of daily living) including eating. The resident was totally incontinent of bowel and bladder, The resident had a feeding tube and received 25% of his/her nutritional intake via feeding tube. The resident had a stage 1 or greater pressure ulcer over bony a prominence, the resident was at risk for developing pressure ulcers, and currently had an unhealed stage 2 pressure ulcer. The resident had a pressure relieving device to the bed and chair, and turning and repositioning program, nutritional support and hydration to manage the resident's pressure ulcer. Review of the resident ADLs (activities of daily living) #72's CAA (care area assessment) dated 1/17/13 revealed the resident was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personally hygiene and bathing. Review of the resident urinary incontinence CAA dated 1/17/13 revealed the resident was totally dependent on staff for toileting use and totally incontinent of bowel and bladder. Review of the nutritional CAA dated 1/17/13 revealed the resident received a therapeutic diet, had a stage 1 pressure ulcer and the resident required being fed by staff. The registered dietician periodically reviewed the resident ' s diet. Review of the pressure ulcer CAA dated 1/17/13 revealed the resident was totally dependent on staff for all aspects of his/her ADLs, totally incontinent of and bladder, was at risk for developing pressure ulcers and had 2 actual stage one pressure ulcers. Review of the quarterly MDS dated [DATE] the resident had a BIMS score of 7. The resident was totally dependent on staff for all aspect of his/her ADLS and was totally incontinent of bowel and bladder. The resident received 26-50 % of his/her nutritional intake via the feeding tube, and 501 cc (cubic centimeters) day or more of fluid via tube feedings per day. The resident was at risk for developing pressure ulcers. The resident had pressure relieving devices to the bed and chair. The resident received turning, repositioning and hydration to manage skin breakdown. Review of the resident's care plan dated 7-31-13 revealed an actual stage 3 pressure ulcer. Interventions failed to address the current stage 3 pressure ulcer to the resident's coccyx and left ankle. The care plan failed to reflect the current intervention for the treatment of [REDACTED]. Review of the resident's care plan dated 1/23/13 revealed the resident had a feeding tube and staff needs to care for the resident's tube site. The care plan directed the staff to give 5 cans of 2-cal (a type of supplement) per day per feeding tube, arrange tube feedings around meal times, feed the resident by mouth, flush the feeding tube as ordered by the physician, so the tube will not get clogged, monitor the resident for signs and symptoms of dehydration such as dry sticky mouth, tiredness, thirst, decrease urine output, dry skin, poor skin tutor, constipation, dizziness, and irritability, monitor the resident's weight and labs as ordered by the physician, and staff to feed the resident a regular diet orally. The facility failed to updated the care plan to reflect the current dietary interventions and address the resident significant weight loss. On 8/22/13 at 2:45 p.m., interview with Administrative nurse B revealed the care plan team develops the resident care plan within 21 days of admission. The care plan team meets weekly for at risk meetings make updates to the resident's care plan and the resident's care plan is reviewed at least every 90 days and updated with any new interventions. Staff B revealed the facility had new members to the care plan team that were still learning the care planning process. The facility failed to provide a policy in regards to updating care plan as requested on 8/22/13. The facility failed to updated the resident's care plan to accurately reflect new interventions to address the resident's pressure ulcers and weight loss. - Review of resident #39's physician's orders [REDACTED]. Review of the annual MDS (minimum data set) dated 1/19/13 revealed a BIMS (brief interview for mental status) score 11 (moderate cognitive impairment) the resident required limited assist of one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was dependant on staff for locomotion off the unit and bathing, The resident was frequently incontinent of urine and remained continent of bowel, The resident had 2 or more non-injury falls since admission. The resident received an antipsychotic medication and an antianxiety medication during the 7 day look-back period. Review of the resident's quarterly MDS dated [DATE] revealed a BIMS score of 3 the resident required limited assist of one staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene extensive assist of one staff bathing The MDS was coded no falls since admission, the resident received an antipsychotic and an antidepressant all 7 days during the assessment period. Review of the cognitive CAA (care area assessment) dated 1/19/13 revealed the resident had a BIMS score of 11. The resident had risk factors that included the [DIAGNOSES REDACTED]. other factors included communication deficits in temporal orientation, required cues to recall information, indicators of paining the past 5 days, bladder incontinence and impaired vision. The resident does not have any strengths that would help him/her related to the resident's cognitive ability. Review of the ADLs (activities of daily living) CAA dated 1/19/13 revealed the resident was totally dependent on staff for bathing and locomotion off the unit. The resident required limited assistance of staff for bed mobility. transfers, dressing, toilet use, and personally hygiene. The resident remained independent with locomotion on the unit and eating. Review of the falls CAA dated 1/1913 revealed the resident had balance problems during the transitions, had a history of [REDACTED]. Review of the resident 7/28/13 fall risk assessment revealed a score of 14. The assessment indicated a score of 14 placed the resident at moderate risk for falls. On 8/22/13 at 2:45 p.m., interview with Administrative nurse B revealed the care plan team develops the resident care plan within 21 days of admission. The care plan team meets weekly for at risk meetings make updates to the resident's care plan and the resident's care plan is reviewed at least every 90 days and updated with any new interventions. Staff B revealed the facility had new members to the care plan team that were still learning the care planning process. The facility failed to provide a policy in regards to updating care plan as requested on 8/22/13. The facility failed to updated the resident's care plan to accurately reflect new interventions to address the resident's development of pressure ulcers, and significant weight loss. - Review of resident #76's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 3/4/13 revealed a BIMS (brief interview for mental status) with a score of 8 (moderately impaired cognition). The functional status revealed the resident required total dependence of 2 staff for bed mobility, transfer. The resident was admitted with 2 unhealed pressure ulcers at stage 1. The resident had a pressure relieving device for the bed and chair, and had a turning and positioning program. The resident received nutrition or hydration interventions to manage skin problems and received pressure ulcer care with application of ointment to other than feet. The resident was incontinent of bladder and bowel. Review of the quarterly MDS dated [DATE] recorded a BIMS of 1 (severely impaired). The resident required extensive assistance of 1 person for bed mobility and extensive assistance of 2 persons for transfers. The resident had a feeding tube and a received a mechanically altered diet; the resident had no weight loss. The resident had 2- stage 1 pressure ulcers and received pressure ulcer care with application of ointment to other than feet. The resident was always incontinent of bladder and bowel. Review of the Pressure ulcer CAA (Care Area Assessment) completed with the annual MDS dated [DATE] revealed that on admission the resident had 2 stage 1 pressure ulcers on the coccyx and was at risk for developing pressure ulcers. Review of the care plan with a date of 6/14/13 revealed the resident had an alteration in incontinence and at risk for pressure ulcer check and change, toileting program at times may ask to use the urinal. Review of the care plan dated 7/29/13 revealed the resident was at risk for dehydration; staff were to provide water and fluids per [DEVICE] ([MEDICAL CONDITION] tube) as ordered and at meals. Staff were to take the resident to all meals. The care plan meeting notes revealed that all disciplines attended and nursing revealed that the resident was doing well much improvement. There was no comment from dietary. Braden scale assessments (assessments used to determine a resident ' s risk for development of a pressure ulcer) dated 2/25/13 (on admission) revealed a score of 13 and 13-14 moderate risk. The 7/12/13 assessment revealed a score of 14. Review of the Skin assessment dated [DATE] skin assessment on admission revealed the right and left gluteal folds were blanchable (to press blood away and wait for return to determine blood circulation). On 3/14/13 per nurses notes: Overall skin assessment narrative, CNA notified nurse of open areas on the coccyx found two small pressure areas directly on coccyx about 1 cm (centimeters) by 2 cm no drainage noted stage, 2 (shallow open area). Applied temporary dressing until physician orders [REDACTED]. On 3/14/13 per the nurse's note: Physician notified of the 2 open areas. We will consult wound specialist for orders PCP (preferred care provider) agreed. No other measurements found in the chart. Review of a nurse's note dated 3/20/13 revealed an order to apply skin prep to coccyx cover with OpSite change every 3 days and as needed. Consult wound specialist if not healed by next week. Review of the resident's skin assessments reviewed the following: 3/22/13: coccyx-2 pressure ulcers dressing intact, no measurements documented 4/11/13: pressure ulcers on coccyx, no other information available The monthly summary on 5/5/13 revealed poor skin turgor (the expected resiliency of the skin caused by the outward pressure of the cells and interstitial fluid). 5/11/13: blanchable redness to the sacrum 6/8/13: blanchable area to the coccyx. 6/22/13: blanchable area to the coccyx with fragile skin. 7/12/13: redness to the coccyx. 7/21/13: redness to the coccyx. 7/30/13: no mention of coccyx. The clinical record lacked lab results for [MEDICATION NAME] or protein (labs used to help determine a resident ' s nutritional status) since admission. On 8/20/13 at 3:10 p.m., the resident was lying in bed on his/her left side. On 8/22/13 7:30 a.m., direct care staff P assisted the resident to the toilet, changed his/her brief and provided peri care. The resident ' s skin was pink with no open areas noted. On 8/22/13 4:53 p.m., direct care staff Q assisted the resident to the bathroom and changed the resident ' s brief. The resident ' s coccyx was without open areas. Review of the resident ' s records revealed the resident had no meal intake sheets since admission. On 8/21/13 at 8:04 a.m., the resident was at the dining room table and received pureed eggs, pureed sausage, hot cereal and thickened water and milk. The resident ate all the eggs, all but 2 bites of the sausage and 1/2 of the hot cereal. The resident took 2 sips of thickened water and drank about 1/4 of the milk. Each of the milk and water was 240 ml (milliliters). On 8/22/13 at 7:56 a.m. the resident was at the table and served pureed eggs, pancake pureed with syrup and pureed bacon, 240 ml thickened milk and 240 ml thickened water. The resident ate the entire pancake and 1/2 of the bacon, 1 bite of egg 1/3 of the milk and 1/4 of the water. On 8/22/13 at 12:30 p.m., staff took a tray to the resident's room that contained mashed potatoes, pureed meat, and a green vegetable. Direct care staff P was at the side of the bed assisting the resident with the meal. Resident ate 25 % of the meal and drank 120 cc (cubic centimeters) water. On 08/22/2013 at 8:59 a.m., direct care staff P and S revealed that the resident is incontinent of urine and is a check and change. The resident was at risk for breakdown but had none at this time. Staff put on the moisture barrier ointment with peri care. The resident moves around in the bed on his/her own. On 8/22/13 4:53 PM direct care staff Q revealed that sometimes the resident can stand and sometimes he/she cannot. The resident wore a brief and was incontinent of urine and bowel and when awake sometimes will tell the staff the need to go to the toilet. The resident received peri care every with the moisture barrier ointment with each incontinent change. On 8/21/13 at 10:15 a.m., the direct care staff monitors the resident ' s skin daily during routine care and reports any changes to the charge nurses. The charge nurses are responsible a weekly skin assessment for each resident to monitor the resident's skin for breakdown. It is the charge nurses responsibility to notify the physician for any skin issue and to obtain order to treat the skin issues. The resident's physician orders [REDACTED]. On 8/22/13 at 8:05 a.m., licensed nursing staff G revealed The resident is incontinent of bladder and bowel will let you know if he/he was incontinent no skin break down at this time it comes and goes. Direct care staff to monitor skin with all cares. On 8/22/13 at 2:12 p.m., licensed nursing staff R the resident does not really know he/she was going so he/she was a check and change. The resident had areas on the coccyx that open up and then heal. The resident has no open areas at this time. On 8/21/13 at 2:44 p.m. interview with Administrative nurse A revealed the resident had recently admitted to hospice related to his/her continued weight decline and skin breakdown. Staff A revealed he/she believed that the resident's weight loss and skin breakdown probably placed the resident at increased risk for serious health complications. On 8/25/13 at 12:40 p.m. interview Physician V revealed he/she was unaware the resident had a stage 3 pressure ulcer to his/her coccyx. Physician V revealed the facility employed a wound nurse and had a wound doctor that made weekly rounds who addressed the resident's wounds. Staff V revealed his/her expectation of the facility was to notify him/her of a stage 4 wound. All other wounds should be handled by the wound nurse and wound doctor. Physician V revealed he/she was aware the resident had a pressure ulcer and believed that the resident overall health condition resulted in the resident's significant weight loss and development of the stage 3 pressure ulcer. Physician V revealed he/she reviewed the wounds at the monthly QAA (quality assessment and assurance) meeting at the facility and Physician V revealed he/she had no concerns with the resident current condition. Review of the policy and procedure for Wound Care with the date of 2/22/2006 revealed all wound care and dressing changes would be done by the facility nurse. The facility nurse will be responsible for all skin treatments. Pressure ulcer documentation will be done at least weekly using the push tool. Procedure--All residents will have a skin condition note, including the Braden scale completed monthly by the charge nurse. Any resident who has a pressure ulcer who is receiving routine skin care treatment i.e., dressings topical applications, etc., shall have a skin condition note weekly by the treatment or charge nurse. All residents with pressure ulcers will have a documented, weekly, comprehensive assessment, including measurement, odor, color and draining of wound all the residents admitted with skin problems will have a comprehensive assessment and a skin condition note completed as part of the admission process. The nurse doing the treatment would document on the treatment sheet after completing the treatment. The facility failed to implement interventions to prevent existing stage 1 pressure ulcers from worsening into multiple stage 2 pressure ulcers.

The facility census totaled 56 with 22 residents included in the sample. Of those, 3 residents were reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to develop interventions to prevent the development of pressure ulcers for 3 of 3 residents. (#26, #72, and #76) Finding included: - Review of resident #26's face sheet revealed an admission date of [DATE]. Review of the physician's orders [REDACTED]., runny stools). Review of the annual MDS (minimum data set) dated 11/30/12 revealed a BIMS (brief interview for mental status) score of 12 (moderately impaired). The resident required limited assistance of one staff member for bed mobility, transfers, dressing, extensive assist of one staff member for toileting, personal hygiene, and bathing. The resident was independent with eating. The MDS revealed the resident had an indwelling suprapubic catheter and was occasionally incontinent of bowel. The resident's skin was intact and the resident required turning and reposition, had a pressure relieving device for chair, a pressure relieving device to the bed, and application of ointments to the body other than the feet. Review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12, required limited assistance of one staff member for bed mobility, and transfers, independent with eating, required extensive assist of one staff member for toilet use, personal hygiene and bathing. The resident had a supra pubic catheter with occasional bowel incontinence. The MDS revealed the resident had a significant weight gain, received a therapeutic diet, and was at risk for developing a pressure ulcer. The MDS revealed the resident had a pressure relieving device to the wheelchair and bed. The resident was on a turning and repositioning program with nutritional interventions to manage skin problems. Review of the ADL (activities of daily living) CAA (care area assessment) dated 11/30/12 revealed the resident required extensive assistance of the staff for toilet use and personal hygiene. The resident required limited assistance with bed mobility, transfers, and dressing. The resident was independent with eating. Review of the nutritional CAA revealed the resident received a therapeutic diet. Review of the pressure ulcer CAA dated 11/30/12 revealed the resident required limited assistance of staff for bed mobility, and was at risk for pressure ulcers. The resident had a pressure relieving mattress to his/her bed and wheelchair. The resident was on a scheduled repositioning program and had occasional bowel incontinence. Review of the care plan dated 03/20/13 revealed the resident was at risk for alteration in nutritional status. The care plan directed the staff to provide a low concentrated sweets diet. The care plan update on 8/1/13 directed the staff to discontinue the protein shakes and change to health shakes. A care plan updated on 8/19/13 directed the staff to give Pro stat (a protein supplement) 30 milliliters twice daily. Further review of the resident's care plan revealed the resident was obsessed with bulimia (an eating disorder). The care plan directed the staff to refer the resident to a psychologist for talk therapy and medication management. Review of the resident's care plan dated 12/5/12 revealed the resident was at risk for pressure ulcer related to bowel incontinence. The care plan revealed the resident chose to be independent with tilting, and a pressure reliving cushion to his/her wheelchair. A care plan update on 8/21/13 revealed the resident had an actual superficial open area (Stage 2) to the right buttocks, an air mattress to the resident's bed, and treatment per physician's orders [REDACTED]. Review of the resident's laboratory (lab) results dated 2/18/13 revealed an [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person ' s nutritional status) level of 3.0 g/dl (grams per deciliter), below the acceptable level range of 3.5 - 5.5 g/dl. Review of the lab dated 4/4/13 revealed protein 5.7 low (normal range 6.0- 8.5 g/dl) and [MEDICATION NAME] 3.1 (3-5 -5.5 g/dl) low with new orders recorded on 4/4/13 revealed protein shakes twice daily. Review of resident #26's skin assessment dated [DATE] revealed fragile red skin on the coccyx area from previous breakdown. Keep skin warm dry and clean. Apply barrier cream as needed. Staff failed to include these interventions on the care plan. Review of the nurse's note dated 7/14/13 at 6:25 a.m. revealed a 2 cm (centimeter) x 2 cm stage 2 pressure ulcer on the left buttock. Staff failed to promptly update the care plan and develop new interventions to help this area heal. Review of the skin assessment dated [DATE] revealed skin pink, warm, and dry with tiny red open spot on the left buttocks, and blanchable redness on the right buttocks. Apply barrier cream to bilateral buttocks; check and change, and encourage the resident to turn side to side in bed every two hours. The staff failed to include these interventions on the care plan. Review of a nurse's note dated 7/28/13 revealed the resident had a new stage 2 pressure ulcer on the coccyx. The wounds measured 1 cm (centimeter) in length x 1.0 cm in width x 1.5 cm in depth and a 4 inch area on the right side of the coccyx. The resident also had a 1 cm length x 1.0 width x 0.1 cm depth area to the left side of the coccyx. The area was sore and reddened. Further review of the nurse's note revealed the resident was a great risk for further break down. Teaching to the resident instructed him/her to remain off of the area however, the resident insisted on sitting on the area. Staff failed to update the care plan that included both the pressure ulcers or develop new interventions to help the areas heal. Review of the resident's record revealed staff sent a fax to the physician dated 7/28/13. The fax requested treatment orders for a pressure ulcer to both buttocks. Review of the skin assessment dated [DATE] revealed skin is pink, warm, and dry. Apply [MEDICATION NAME] dressing to buttocks. Three stage 2 spots one on the right cheek and two on the left cheek identified on the assessment. Staff failed to update the care plan to reflect this assessment. Review of the TAR for July 2013 revealed an order for [REDACTED]. Review of resident #26"s physician's orders [REDACTED]. On 8/21/13 at 7:15 a.m. observation of the resident revealed the resident lay in bed mid line on his/her back. The resident had pressure relieving mattress to the bed and a gel cushion noted to his/her wheelchair. On 8/21/13 at 1:45 p.m. observation revealed the resident had an air mattress to his/her bed. Observation of the wound revealed licensed nursing staff G removed the old wound dressing with a date of 8/19/13 visible on the dressing. Staff G confirmed the physician's orders [REDACTED]. Staff G cleansed the two areas to the right buttocks with normal saline and dabbed the area dry with gauze. The two open areas on the right buttocks were the size of a pea with red tissue, no drainage or odor noted to the areas. The surrounding tissue to the coccyx and left buttock was red in color. Staff G revealed the red areas were old scar tissue from previous breakdown to the resident buttocks and coccyx. On 8/21/13 at 2:55 p.m. interview with resident #26 revealed that since the survey started that he/she required an air mattress because of the wounds that he/she had on his/her buttocks. The resident revealed he/she turned and repositioned self in bed. The resident revealed he/she had bowel incontinence, wore an incontinent brief, needed help getting redressed, and cleaned him/herself after toileting. The resident revealed he/she had sores on his/her bottom before and the staff made him/her lay with a pillow under his/her hip to relief the pressure to his/her buttocks. On 8/21/13 at 2:44 p.m. interview with Administrative nurse A revealed he/she believed the facility was providing interventions to prevent the resident's skin breakdown. Staff A revealed he/she believed that the resident's weight loss and skin breakdown probably placed the resident at increased risk for serious health complications. On 8/25/13 at 12:40 p.m. interview with Physician V revealed he/she was unaware of the multiple stage 2 pressure ulcers to the resident's buttocks. Physician V revealed the facility employed a wound nurse and had a wound doctor that made weekly rounds that addressed the resident's wounds. Staff V revealed his/her expectation of the facility was to notify him/her of a stage 4 wound. Staff V revealed the wound nurse and rounding wound doctor was responsible for addressing all other areas and writing orders for treatment. Physician V confirmed he/she had not been aware of the 2 stage 2 pressure ulcers or had addressed them in the progress notes. Physician V denied knowledge of reviewing the facility's faxed requesting treatment for [REDACTED]. Physician V revealed the wounds were reviewed at the facility QAA (quality assessment and assurance) meeting monthly. Review of the facility's wound care policy last revised 2/22/06 revealed all wound care and dressing changes will be done by the facility charge nurse. All residents with pressure ulcers will have documentation weekly, and a comprehensive assessment including measurements, odor, color and drainage of wound. The facility failed to revise the care plan, conduct the weekly skin assessments, develop, implement new interventions, revise the care plan and conduct the treatments as frequently as ordered to prevent the development of two Stage 2 pressure ulcers. - Review of resident #72's admission MDS (minimum data set) dated 1/10/13 revealed the resident had a BIMS (brief interview for mental status) score of 7 (moderately impaired). The resident required total assist of two staff members for all ADLs (activities of daily living) including eating. The resident was totally incontinent of bowel and bladder, The resident had a feeding tube and received 25% of his/her nutritional intake via feeding tube. The resident had a stage 1 or greater pressure ulcer over bony a prominence, the resident was at risk for developing pressure ulcers, and currently had an unhealed stage 2 pressure ulcer. The resident had a pressure relieving device to the bed and chair, and turning and repositioning program, nutritional support and hydration to manage the resident's pressure ulcer. Review of the resident ADLs (activities of daily living) #72's CAA (care area assessment) dated 1/17/13 revealed the resident was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personally hygiene and bathing. Review of the resident urinary incontinence CAA dated 1/17/13 revealed the resident was totally dependent on staff for toileting use and totally incontinent of bowel and bladder. Review of the nutritional CAA dated 1/17/13 revealed the resident received a therapeutic diet, had a stage 1 pressure ulcer and the resident required being fed by staff. The registered dietician periodically reviewed the resident ' s diet. Review of the pressure ulcer CAA dated 1/17/13 revealed the resident was totally dependent on staff for all aspects of his/her ADLs, totally incontinent of and bladder, was at risk for developing pressure ulcers and had 2 actual stage one pressure ulcers. Review of the quarterly MDS dated [DATE] the resident had a BIMS score of 7. The resident was totally dependent on staff for all aspect of his/her ADLS and was totally incontinent of bowel and bladder. The resident received 26-50 % of his/her nutritional intake via the feeding tube, and 501 cc day or more of fluid via tube feedings per day. The resident was at risk for developing pressure ulcers. The resident had pressure relieving devices to the bed and chair. The resident received turning, repositioning and hydration to manage skin breakdown. Review of the resident's care plan dated 7-31-13 revealed an actual stage 3 pressure ulcer. Interventions failed to address the current stage 3 pressure ulcer to the resident's coccyx and left ankle. Review of the physician progress notes [REDACTED]. Review of the resident's physician fax sheet dated 8/9/13 revealed the facility requested an order for [REDACTED]. New orders received 8/9/13 revealed an order for [REDACTED]. Review of resident #72's record revealed a progress note from the wound clinic dated 8/14/13 identified a coccyx wound with a description of early stage 3, diarrhea, bowel incontinence, significant fecal, debility, and weight loss. Coccyx wound measurements 1.2 cm (centimeter) length x 0.6 cm width x 0.1 cm depth. Left lateral ankle wound measurement 0.8 cm length x 0.5 cm width. Observation On 08/21/2013 7:50 a.m. revealed the resident lay in bed with eyes open, air mattress with bolsters to the bed, heel protectors to both feet, and pillow between knees. Observation on 8/21/13 at 10:03 a.m. revealed licensed Staff Y removed the resident's soiled dressing to the coccyx. Observation of the wound revealed a quarter sized red beefy looking area to the resident's coccyx a foul odor noted during the dressing change and staff Y confirmed the odor was from the wound. Staff Y replaced the Xeroform (medicated wound dressing) dressing, covered the dressing with gauze and secured the gauze with tape. Staff Y failed to change his/her gloves between the removal of the soiled dressing and placement of the clean dressing. On 8/21/13 at 10:15 a.m. licensed staff Y revealed the resident developed the stage 3 wound while in the facility. The resident developed [MEDICAL CONDITION] on 8/2/13 and with the frequent loose stools he/she developed a wound to his/her coccyx. The resident required turning and repositioned every 2 hours and as needed. The resident was incontinent of bowel and bladder and wore attends. The expectation of the direct care staff was to report any changes in the resident's condition. The direct care staff monitor the resident's skin daily during routine care and report any changes to the charge nurses. The charge nurses are responsible for a weekly skin assessment for each resident to monitor the resident's skin for breakdown. The charge nurses are responsible for notification of the physician for any skin issue and to obtain orders to treat the skin issues. The resident's physician orders [REDACTED]. On 8/21/13 at 2:44 p.m. interview with Administrative nurse A revealed the facility had recently placed the resident on hospice related to his/her continued weight decline and skin breakdown. Staff A revealed he/she believed that the resident's weight loss and skin breakdown probably placed the resident at increased risk for serious health complications. On 8/25/13 at 12:40 p.m. interview Physician V revealed he/she was unaware the resident had a stage 3 pressure ulcer to his/her coccyx. Physician V revealed the facility employed a wound nurse and had a wound doctor that made weekly rounds who addressed the resident's wounds. Staff V revealed he/she would prefer not to comment on the resident current wound. Staff V revealed his/her expectation of the facility was to notify him/her of a stage 4 wound and all other wounds should be handled by the wound nurse and wound doctor. Physician V revealed he/she was aware the resident had a pressure ulcer and believed that the resident overall health condition resulted in the resident's significant weight loss and development of the stage 3 pressure ulcer. Physician V revealed the resident's wounds would be reviewed in the monthly QAA meeting at the facility and he/she had no concerns with the resident current condition. Review of the facility's wound care policy last revised 2/22/06 revealed all wound care and dressing changes will be done by the facility charge nurse. All resident with pressure ulcers will have documentation weekly and a comprehensive assessment including measurements, odor, color and drainage of wound. The facility failed to provide preventative treatment to prevent development of an avoidable pressure ulcers. For this cognitively impaired dependent resident. - Review of resident #76's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 3/4/13 revealed a BIMS (brief interview for mental status) with a score of 8 (moderately impaired cognition). The functional status revealed the resident required total dependence of 2 staff for bed mobility, transfer. The resident was admitted with 2 unhealed pressure ulcers at stage 1. The resident had a pressure relieving device for the bed and chair, and had a turning and positioning program. The resident received nutrition or hydration interventions to manage skin problems and received pressure ulcer care with application of ointment to other than feet. The resident was incontinent of bladder and bowel. Review of the quarterly MDS dated [DATE] recorded a BIMS of 1 (severely impaired). The resident required extensive assistance of 1 person for bed mobility and extensive assistance of 2 persons for transfers. The resident had a feeding tube and a received a mechanically altered diet; the resident had no weight loss. The resident had 2- stage 1 pressure ulcers and received pressure ulcer care with application of ointment to other than feet. The resident was always incontinent of bladder and bowel. Review of the Pressure ulcer CAA (Care Area Assessment) completed with the annual MDS dated [DATE] revealed that on admission the resident had 2 stage 1 pressure ulcers on the coccyx and was at risk for developing pressure ulcers. Review of the care plan with a date of 6/14/13 revealed the resident had an alteration in incontinence and at risk for pressure ulcer check and change, toileting program at times may ask to use the urinal. Review of the care plan dated 7/29/13 revealed the resident was at risk for dehydration; staff were to provide water and fluids per [DEVICE] ([MEDICAL CONDITION] tube) as ordered and at meals. Staff were to take the resident to all meals. The care plan meeting notes revealed that all disciplines attended and nursing revealed that the resident was doing well much improvement. There was no comment from dietary. Braden scale assessments (assessments used to determine a resident ' s risk for development of a pressure ulcer) dated 2/25/13 (on admission) revealed a score of 13 and 13-14 moderate risk. The 7/12/13 assessment revealed a score of 14. Review of the Skin assessment dated [DATE] skin assessment on admission revealed the right and left gluteal folds were blanchable (to press blood away and wait for return to determine blood circulation). On 3/14/13 per nurses notes: Overall skin assessment narrative, CNA notified nurse of open areas on the coccyx found two small pressure areas directly on coccyx about 1 cm (centimeters) by 2 cm no drainage noted stage, 2 (shallow open area). Applied temporary dressing until physician orders [REDACTED]. On 3/14/13 per the nurse's note: Physician notified of the 2 open areas. We will consult wound specialist for orders PCP (preferred care provider) agreed. No other measurements found in the chart. Review of a nurse's note dated 3/20/13 revealed an order to apply skin prep to coccyx cover with OpSite change every 3 days and as needed. Consult wound specialist if not healed by next week. Review of the resident's skin assessments reviewed the following: 3/22/13: coccyx-2 pressure ulcers dressing intact, no measurements documented 4/11/13: pressure ulcers on coccyx, no other information available The monthly summary on 5/5/13 revealed poor skin turgor (the expected resiliency of the skin caused by the outward pressure of the cells and interstitial fluid). 5/11/13: blanchable redness to the sacrum 6/8/13: blanchable area to the coccyx. 6/22/13: blanchable area to the coccyx with fragile skin. 7/12/13: redness to the coccyx. 7/21/13: redness to the coccyx. 7/30/13: no mention of coccyx. The clinical record lacked lab results for [MEDICATION NAME] or protein (labs used to help determine a resident ' s nutritional status) since admission. On 8/20/13 at 3:10 p.m., the resident was lying in bed on his/her left side. On 8/22/13 7:30 a.m., direct care staff P assisted the resident to the toilet, changed his/her brief and provided peri care. The resident ' s skin was pink with no open areas noted. On 8/22/13 4:53 p.m., direct care staff Q assisted the resident to the bathroom and changed the resident ' s brief. The resident ' s coccyx was without open areas. Review of the resident ' s records revealed the resident had no meal intake sheets since admission. On 8/21/13 at 8:04 a.m., the resident was at the dining room table and received pureed eggs, pureed sausage, hot cereal and thickened water and milk. The resident ate all the eggs, all but 2 bites of the sausage and 1/2 of the hot cereal. The resident took 2 sips of thickened water and drank about 1/4 of the milk. Each of the milk and water was 240 ml (milliliters). On 8/22/13 at 7:56 a.m. the resident was at the table and served pureed eggs, pancake pureed with syrup and pureed bacon, 240 ml thickened milk and 240 ml thickened water. The resident ate the entire pancake and 1/2 of the bacon, 1 bite of egg 1/3 of the milk and 1/4 of the water. On 8/22/13 at 12:30 p.m., staff took a tray to the resident's room that contained mashed potatoes, pureed meat, and a green vegetable. Direct care staff P was at the side of the bed assisting the resident with the meal. Resident ate 25 % of the meal and drank 120 cc (cubic centimeters) water. On 08/22/2013 at 8:59 a.m., direct care staff P and S revealed that the resident is incontinent of urine and is a check and change. The resident was at risk for breakdown but had none at this time. Staff put on the moisture barrier ointment with peri care. The resident moves around in the bed on his/her own. On 8/22/13 4:53 PM direct care staff Q revealed that sometimes the resident can stand and sometimes he/she cannot. The resident wore a brief and was incontinent of urine and bowel and when awake sometimes will tell the staff the need to go to the toilet. The resident received peri care every with the moisture barrier ointment with each incontinent change. On 8/21/13 at 10:15 a.m., the direct care staff monitors the resident ' s skin daily during routine care and reports any changes to the charge nurses. The charge nurses are responsible a weekly skin assessment for each resident to monitor the resident's skin for breakdown. It is the charge nurses responsibility to notify the physician for any skin issue and to obtain order to treat the skin issues. The resident's physician orders [REDACTED]. On 8/22/13 at 8:05 a.m., licensed nursing staff G revealed The resident is incontinent of bladder and bowel will let you know if he/he was incontinent no skin break down at this time it comes and goes. Direct care staff to monitor skin with all cares. On 8/22/13 at 2:12 p.m., licensed nursing staff R the resident does not really know he/she was going so he/she was a check and change. The resident had areas on the coccyx that open up and then heal. The resident has no open areas at this time. On 8/21/13 at 2:44 p.m. interview with Administrative nurse A revealed the resident had recently admitted to hospice related to his/her continued weight decline and skin breakdown. Staff A revealed he/she believed that the resident's weight loss and skin breakdown probably placed the resident at increased risk for serious health complications. On 8/25/13 at 12:40 p.m. interview Physician V revealed he/she was unaware the resident had a stage 3 pressure ulcer to his/her coccyx. Physician V revealed the facility employed a wound nurse and had a wound doctor that made weekly rounds who addressed the resident's wounds. Staff V revealed his/her expectation of the facility was to notify him/her of a stage 4 wound. All other wounds should be handled by the wound nurse and wound doctor. Physician V revealed he/she was aware the resident had a pressure ulcer and believed that the resident overall health condition resulted in the resident's significant weight loss and development of the stage 3 pressure ulcer. Physician V revealed he/she reviewed the wounds at the monthly QAA (quality assessment and assurance) meeting at the facility and Physician V revealed he/she had no concerns with the resident current condition. Review of the policy and procedure for Wound Care with the date of 2/22/2006 revealed all wound care and dressing changes would be done by the facility nurse. The facility nurse will be responsible for all skin treatments. Pressure ulcer documentation will be done at least weekly using the push tool. Procedure--All residents will have a skin condition note, including the Braden scale completed monthly by the charge nurse. Any resident who has a pressure ulcer who is receiving routine skin care treatment i.e., dressings topical applications, etc., shall have a skin condition note weekly by the treatment or charge nurse. All residents with pressure ulcers will have a documented, weekly, comprehensive assessment, including measurement, odor, color and draining of wound all the residents admitted with skin problems will have a comprehensive assessment and a skin condition note completed as part of the admission process. The nurse doing the treatment would document on the treatment sheet after completing the treatment. The facility failed to implement interventions to prevent existing stage 1 pressure ulcers from worsening into multiple stage 2 pressure ulcers.

The facility census totaled 60 residents with 3 residents included in the sample. Based on interview and closed record review, the facility failed to promptly notify the physician of a change in condition for one immune-compromised sampled resident (#1) who needed necessary treatment and services. This placed the resident in immediate jeopardy. Findings included: - Review of resident #1's record revealed an admission date of [DATE]. Review of the resident's physician's order [REDACTED]. The orders lacked a [DIAGNOSES REDACTED]. Review of resident #1's 5 day MDS (minimum data set) dated [DATE] revealed the resident had a BIMS (brief interview for mental status) score of 11 (moderately impaired). The MDS revealed the resident required limited assistance of one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required extensive assist of 2 staff member for bathing and the resident was independent with locomotion on and off the unit and eating. The resident was frequently incontinent of bowel and bladder. The MDS revealed oxygen usage for the resident. The MDS lacked a [DIAGNOSES REDACTED]. Review of the resident's temporary plan of care dated [DATE] revealed the resident required assist of 2 staff members for transfers, personal hygiene and toileting. The resident wheeled self in the wheel chair, wore glasses and had his/her own teeth. The resident had a history of [REDACTED]. Review of the resident's history and physical dated [DATE] revealed the resident was admitted to the hospital with [REDACTED]. Further review of the history and physical revealed the resident had no immunity related to a [DIAGNOSES REDACTED]. Review of resident #1's hospital transfer sheet dated [DATE] revealed it lacked a physician's orders [REDACTED]. Review of the Skilled Nurse's note dated [DATE] at 10:45 a.m. revealed the resident had bilateral coarse breath sounds with expiratory wheezes. The record noted the resident's vital signs as temperature 96.5 degrees Fahrenheit, heart rate 77 BPM (beats per minute), RR (respiratory rate) 18, BP (blood pressure) ,[DATE], and oxygen saturation at 94% on room air. According to the American Association of Critical Care Nursing, normal oxygen saturation values are 97% to 99% in the healthy individual. An oxygen saturation value of 95% is clinically accepted in a patient with a normal blood level. Review of the skilled nurse's notes on the following day, [DATE] at 5:18 p.m., revealed the resident had bilateral crackles in the lung with a temperature of 96.5 degrees Fahrenheit (F), RR- 20, heart rate 74 BPM and oxygen saturation of 91% on room air. Review of the skilled nurse's note dated on [DATE] at 8:18 a.m. revealed lung sounds were coarse bilaterally. The resident's temperature was 96.9 degrees Fahrenheit, oxygen saturation was 91% on room air, and heart rate 80 BPM, RR -18, BP- ,[DATE] and the resident denied pain. This indicated an increase in the resident's heart rate and a decrease in the oxygen saturation level. Review of the record revealed the nurse's notes lacked any documentation from nursing staff on [DATE]. Review of the physician's telephone order sheet dated on [DATE] at 10:00 a.m. revealed orders for a chest x-ray on [DATE] due to increased congestion/cough/sob (shortness of breath). The orders were given by physician C's office. The record did not indicate why staff obtained the order from Physician C, when Physician D was the resident Physician. Review of the mobile radiology service corporation form (yellow sheet) left for the facility dated [DATE] at 10:00 a.m., revealed the reason for the exam was cough with pain, a decreased oxygen saturation level of 81% on room air, fever, sob (shortness of breath) with activity and listed the attending physician as physician C. The form was timed 11:56 a.m. as the time of test completed. The nurse's notes lacked documentation of the resident receiving a chest x-ray, or the reasons for test. Review of the skilled nurse's note dated [DATE] at 2:49 p.m. revealed coarse breath sounds bilaterally with an occasional cough and SOA (shortness of air/breath). The note did not include vital signs documentation or physician notification of the newly documented cough, SOA, or results of the chest X-ray obtained on [DATE]. Review of the skilled nurse's notes dated [DATE] at 8:34 a.m. revealed the resident's lung sounds had bilateral crackles. The resident was alert to person, place, and time. The resident was on 3 liters of oxygen per nasal cannula per minute via a concentrator. The resident's vital signs were temperature 100.2 F, RR -28, HR-59, BP -,[DATE], and oxygen saturation was 95% on 3 liter per nasal cannula. Further review of the note revealed the resident was SOA with activity, Tylenol given for increased temperature, faxed x-ray report (taken on [DATE]) to Physician D, charge nurse left message regarding increased temperature and SOA and the resident was placed on oxygen at 3 liters per minute per nasal cannula. Review of the skilled nurse's notes dated [DATE] at 5:56 p.m. revealed Physician D called the nursing facility at 5:45 p.m. with orders to transfer the resident to the hospital. Review of the skilled nurse's notes dated [DATE] at 3:30 a.m. revealed the staff received information from the hospital staff that when the resident went to the hospital on [DATE], the physician admitted the resident to the hospital. Review of the x-ray results dated [DATE] revealed the patchy areas of increased density were observed in both upper lobes and both regions of the lungs. This may be secondary to bilateral [MEDICATION NAME], [MEDICAL CONDITION] scarring may have a similar appearance. However, there are no previous exams available for comparison. The Radiologist's recommendation revealed Short interval follow-up is suggested. The form was approved on [DATE] at 1:06 p.m., dictated on [DATE] at 12:42 p.m., and transcribed on [DATE] at 12:59 p.m. The final report of the chest x-ray faxed to the facility revealed a fax imprint on the top of the report dated [DATE] at 1:31 p.m. and stamped faxed [DATE] by licensed nurse F, but failed to identify whom nurse F faxed the results to. On [DATE] at 2:10 p.m. an interview with direct care staff H revealed they worked the night before the resident left to go to the hospital. Staff H identified the resident's family had visited and the family had talked with nurse F about the resident's respiratory condition. Staff H heard Nurse F tell the family member that an x-ray had been taken of the resident's chest, and the x-ray technologist had told Nurse F that the resident's lungs looked good and the x-ray was negative. Nurse F then told the family that the facility was just waiting on the final report to be faxed to the facility. Review of the record revealed a list of standing orders signed and dated on [DATE] by Physician C that failed to contain orders for oxygen or [MEDICATION NAME] treatment administered to the resident. Review of the resident's MAR (medication administration record) and TAR (treatment administration record) revealed it lacked any documentation the staff ever administered Oxygen or a breathing treatment. On [DATE] at 12:35 p.m. an interview with Administrative nurse B revealed the facility charge nurses are expected to notify the physician with any significant changes in the resident's status. Staff B confirmed the x-ray results had been faxed by Licensed nurse F on [DATE] who worked p.m. to 6 a.m. Administrative nurse B confirmed the fax failed to identify who the x-ray was sent to and the results had been sent after normal business hours for both Physicians C and D and would not have been seen by the physician until the next business day. Staff B revealed the facility's expectation of the charge nurses was to call abnormal lab results and/or radiology reports to the physician after normal business hours. Administrative nurse B also confirmed the standing orders in the resident's record did not include orders for a breathing treatment or oxygen which the resident received. Interview on [DATE] at 1:45 p.m. with Physician D revealed he/she was unaware the resident had been placed on oxygen, had an elevated temperature, or changes in his/her lung function until [DATE] th, 2013 when the facility faxed an x-ray and called his/her office. Physician D was informed by the facility charge nurse that the house physician had given the orders to the facility to obtain a chest x-ray on the resident. Physician D revealed he/she expected the house physician that gave the orders for the x-ray and was aware of the resident's change in condition would be responsible for following up on the results of the x-ray and ensure the resident received appropriate treatment. Further interview with Physician D revealed the facility should have contacted his/her office as soon as the resident began to run a low grade temperature and required oxygen with the resident's condition being as debilitated as it was. On [DATE] at 3:10 p.m. an interview with Administrative staff A and Administrative nurse B confirmed the facility had no documentation in the record to show which physician was faxed the x-ray results on [DATE], when the oxygen was initiated, the breathing treatment that was administered to the resident, and notification of the primary care physician of the resident change in status. Staff B confirmed the standing orders sheet in the resident ' s record was signed by Physician C, not the resident's attending physician, and the resident's record lacked the second page of standing orders that contained the orders with guidelines/parameters for the administration of oxygen or that of a breathing treatment. Administrative nurse B confirmed the facility had several residents in the facility that had upper respiratory infection and pneumonia during the period of time resident #1 developed symptoms of an upper respiratory infection. Staff B revealed he/she was under the impression from speaking with physician C, the facility had faxed the x-ray results to his/her office on [DATE] after normal business hours. Physician C's medical office was closed per routine on [DATE] and no one called the physician to make him/her aware of the abnormal x-ray results and Physician C did not see the x-ray report until the morning of [DATE]. On [DATE] at 4:55 p.m. an interview with Physician C revealed he/she saw the resident on [DATE] for an initial physician's visit upon the request of the facility. Physician C revealed a facility charge nurse contacted his/her medical office on [DATE] and obtained an order for [REDACTED]. Physician C revealed he/she was told by the facility the x-ray results had not come in until [DATE] and faxed to office for review. Physician C revealed he/she was uncertain if his/her medical office had ever received the x-ray results from the facility. Physician C revealed his/her duties included assisting the facility with contact physicians for orders and/or assuring treatment for [REDACTED]. Physician C revealed he/she was reluctant to give orders for physician D resident's but would have contacted Physician D personally to ensure the resident received treatment if he/she was unaware the facility had been unable to reach him/her. Further interview with Physician C revealed his/her expectations of the facility staff included notification of a significant change in condition and he/she considered a low grade temperature of 100.5 coupled with the use of oxygen to maintain oxygen saturation as a significant change in the resident's condition that required physician notification. Review of the facility's Clinical Resources for implementing Standards of Care policy last revised on [DATE] revealed immediate notification included any symptoms, sign, or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed including x-ray results with new or unsuspected findings (e.g. fracture, pneumonia, [MEDICAL CONDITION]). The facility ' s failure to promptly notify the physician and act on the significant changes in the immune-compromised resident placed the resident in Immediate Jeopardy for continued decline or complications due to the lack of medical treatment. On [DATE] at 1:45 p.m., Physician D stated the resident died from pneumonia 4 days after being admitted into the hospital. The immediate jeopardy was abated on [DATE] at 3:00 p.m. when the facility provided a copy of revised policies on the identification of a change in condition in a resident, the expected timeframe for physician notification with the changes, and documentation that all staff had been educated regarding the policy changes and the expectations. The facility's plan identified the DON (Director of Nurses) responsible for conducting daily monitoring of the nursing staff to ensure staff remained compliant with the new policies and expectations. The deficient practice remains at a scope and severity of a G.

2 The facility reported a census of 56 residents with 5 residents sampled for nutrition. Based on observation, interview and record review the facility failed to ensure 5 of the 5 sampled resident maintained acceptable parameters of nutrition to prevent weight loss. (#26, #54, #71, #72 and # 76). Findings included: - The Review of resident #76's signed physician orders [REDACTED]. Review of resident #76 admission MDS (minimum data set) dated 3/4/13 revealed a BIMS (brief interview for mental status) with a score of 8 (moderately impaired). The functional status revealed the resident required extensive assist of one for eating. The resident received tube feedings and took nothing by mouth. The resident received >51% through feeding tube and more than 501 ml (milliliters) per day. On admission, the resident had a stage 1 or greater pressure ulcer. The resident was at risk of developing pressure ulcers. The resident has 2 unhealed pressure ulcers at stage 1 or higher of [MEDICATION NAME] tissue( 1 of 4 layer of tissue that covers the whole surface of the body), pressure relieving device for the bed and chair turning and positioning program and nutrition or hydration intervention to manage skin problems and receives pressure ulcer care with application of ointment to other than feet. Review of the quarterly MDS dated [DATE] BIMS of 1 (severely impaired). The resident was on a weight gain program. The resident was on a feeding tube and a mechanically altered diet, received 26-50% of the total calories/24 hr and 500 ml or less from [DEVICE]. The resident had no weight loss, and did not choke or cough while eating meal. Resident has 2- stage 1 pressure ulcers and receives pressure ulcer care with application of ointment to other than feet. Review of the Nutritional CAA (care area assessment) dated 3/9/13 revealed the resident received speech therapy and the body mass index was with in normal limits. Review of the feeding tube CAA revealed that the resident had a feeding tube and received [MEDICATION NAME] 1.5, 5 cans daily. Review of the Dehydration CAA revealed that the resident received [MEDICATION NAME] 1.5, 5 cans daily and 1000 ml free water flush. Review of the Pressure ulcer CAA revealed that on admission the resident had 2 stage 1 pressure ulcers on the coccyx and was at risk for pressure ulcers. Review of the care plan dated 7/29/13 revealed the resident was at risk for dehydration; staff was to provide water and fluids per [DEVICE] (gastric tube) as ordered and at meals. Staff was to take the resident to all meals the care plan meeting notes revealed that all disciplines attended and nursing revealed that the resident was doing well much improvement. There was no comment from dietary. There was no care plan for the prevention of pressure ulcers. Review of the Skin assessment dated [DATE] skin assessment on admission revealed a right and left gluteal fold blanchable (skin that turns white or purple when pressure is applied). On 2/25/13 on admit the resident s Braden scale (tool used to determine a resident ' s risk for pressure ulcer development) score 13 and 13-14 moderate risk. On 7/12/13, Braden scale 14. Review of the physician orders [REDACTED]. On 3/14/13 per nurses notes Overall skin assessment narrative, CNA notified nurse of open areas on the coccyx found two small pressure areas directly on coccyx about 1 cm by 2 cm no drainage noted stage 2 Applied temporary dressing until physician orders [REDACTED]. 3/14/13 Physician notified of the 2 open areas. We will consult wound specialist for orders PCP (primary care physician) agreed. No other measurements found in the chart Review of the 3/18/13 Dietary assessment revealed a score of 14 and below 17 indicated malnourishment. 3/20/13 Apply skin prep to coccyx cover with OpSite (clear surgical dressing) change every 3 days and as needed. Consult wound specialist if not healed by next week. On 3/22/13 skin assessment, coccyx 2 pressure ulcers dressing intact, no measurements. On 3/25/13, the physician phone order revealed an order to increase the [MEDICATION NAME] 1.5 to 6 cans daily with 1000 ml (milliliters) of water flushed total daily. On 4/11/13 review of the skin, assessment revealed pressure ulcers on coccyx. The monthly summary on 5/5/13 revealed poor skin turgor (degree of elasticity). On 5/11/13 review of the skin assessment blanchable redness to the sacrum. On 5/17/13, a phone order to clarify the speech therapy 3-5 times weekly to increase oral intake. Diet clarification obtained for pleasure feedings 3-5 times daily as tolerated, with single serving pureed food with water. On 6/7/13, a new physician order [REDACTED]. Continue with regular liquids offer small meals as tolerated and encourage oral intake at all meals. On 6/8/13 review of the skin assessment revealed blanchable area to the coccyx. On 6/22/13 review of the skin assessment revealed blanchable area to the coccyx. with fragile skin. On 6/26/13, new order to decrease [MEDICATION NAME] 1.5, to 1 can at 6:00 a.m. and 10:00 p.m. daily and flush with 250 cc water at 6:00 am and 10:00 p.m. crush medications and administer with food and liquid. The resident with a [DIAGNOSES REDACTED]. On 7/12/13 review of the skin, assessment revealed redness to the coccyx. Review of the nurses notes dated 7/12/13 revealed the resident went to the hospital on [DATE] and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was to receive no thin liquids. On 7/21/13 re view of the skin assessment revealed redness to the coccyx. On 7/22/13, the registered dietician assessment revealed the resident received inadequate oral intake, due to difficulty swallowing. The resident ' s weight was 143 pounds, down 5 pounds in 1 month and down 32 pounds in 3 months. The resident was on a pureed diet with pudding thick liquid. Recommendation to increase [MEDICATION NAME] 1.5 to 1 can three times a day to stabilize weight and increase oral intake and tube feeding. On 7/30/13, review of the skin assessment revealed no mention of coccyx. On 8/16/13, the facility obtained a phone order to increase the [MEDICATION NAME] 1.5 to three times daily. This was 25 days after the recommendation. On 8/21/13, staff added the order for the increase of [MEDICATION NAME] 1.5 to the TAR (treatment administration record) for administration. The facility failed to follow up for 30 days on the recommendation to increase the [MEDICATION NAME] 1.5 as recommended by the registered dietician on 7/22/13 No lab results for [MEDICATION NAME] or protein (laboratory values used to determine a resident ' s nutritional status) since admission. Review of the August TAR (Treatment Administration Record) revealed no signature for the [MEDICATION NAME] 1.5 or water flush on 8/10/13 at 10:00 p.m., 8/11/13 at 6:00 a.m. and 10:00 p.m., 8/12/13 at 6:00 a.m. on 8/15/13 at 6:00 a.m., and 8/16/13 at 6:00 a.m. Review of the resident's weight record revealed the following weights: 2/27 170 3/21 169 4/3 176 5/15 145 5/21 149 5/23 149 6/12 148 6/20 153 7/16 143 7/24 138 7/30 141 8/8 146 8/21 145 Review of the nurse's notes done 3 times daily. There was no mention of [MEDICAL CONDITION] on any of the days between 4/3 and 5/15/13. The review of the resident ' s records current and past revealed the resident had no meal intake sheets since admission, to record the % of the meal eaten. On 8/21/13 at 8:04 a.m., the resident was at the dining room table and received pureed eggs, pureed sausage, hot cereal, thickened water and milk. The resident ate all the eggs, all but 2 bites of the meat and 1/2 of the hot cereal. The resident took 2 sips of thickened water and drank about 1/4 of the milk. Each of the milk and water was 240 ml. On 8/22/13 at 7:56 a.m. the resident was at the table and served pureed eggs, pancake pureed with syrup and pureed bacon, 240 ml thickened milk and 240 ml thickened water. The resident ate the entire pancake and 1/2 of the meat, 1 bite of egg 1/3 of the milk and 1/4 of the water. At 12:30 p.m., staff took a tray to the resident ' s room of mashed potatoes, pureed meat, and a green vegetable. Direct care staff P was at the side of the bed assisting the resident with the meal. The resident ate 25 % of the meal and 120 cc water. On 08/22/2013 at 8:59 a.m., direct care staff P revealed the resident ate in the dining room, and could eat alone with occasional verbal cues and ate better at breakfast than any other meal. When asking the resident to come down to the dining room for the other meals the resident stated that he/she was not hungry, having ate a lot for breakfast. Staff offer the Mighty shakes in strawberry to the resident. All residents that eat in the dining room have meal intake sheets 8/22/13 4:53 p.m., direct care staff Q revealed the resident ate something at all three meals, but will leave a lot of food uneaten. The resident would eat snacks later on in the day. Staff member reported that staff would get a tray for him/her even when the resident said no. Staff would set the tray in front of the resident and sometimes he/she would eat some and other times not. On 8-21-13 at 12:23 p.m. direct care staff M reported that he/she did the weights for the facility all residents got weighed once a month, some were weekly, new resident got weighed every week for four weeks, if they are losing weight then the resident stayed on weekly weights. Staff member M reported that he/she used the wheel chair scale or Hoyer scale the restorative aide calibrates the scales once a month, but there is no log of the calibration. The dietary manager gave the schedule for monthly and weekly weights, then staff member M wrote down the weights then gave the list back to the to the dietary manager and then the dietary manager documented the weights in the computer. If the weights had a 4 pound difference, the dietary manager would ask for a reweigh. Staff member M turned the reweigh back into the dietary manager. Direct care staff M kept the weight book. The dietary manager would then do the care plan, and kept a copy of the weights. On review of the weight records,, the weights done between the first and the tenth of each month. On 8/20/13 at 11:20 a.m., licensed nursing staff G revealed the resident ate meals in the dining room on his/her own and then [DEVICE] feedings at night 2 times 6:00 a.m. and 10:00 p.m. Staff document the meals on the meal intake sheets. On 8/22/13 at 8:05 a.m. licensed nursing staff G reported that, it was the responsibility of the restorative aide to obtain residents weights. Then the restorative aide gave the weights to the dietary manager. The licensed nursing staff G revealed the director of nursing and the dietician got a copy of the weight list and that there was a weekly weight meeting. When there was a recommendation from the dietician, the nurses sent the recommendation to the physician and put the order on the TAR and the report sheet. Licensed nursing staff G was unaware when residents had a significant weight loss unless he/she looked it up in the computer and usually did not have the time, to do that. On 8/22/13 at 2:12 p.m., licensed nursing staff R resident went into the hospital due to pneumonia, but that hospitalization happened later than the weight loss. Licensed nursing staff R reported notifying administrative nursing staff A that some of the nurses did not sign for feeding, that is about the time he lost weight. The nurses on the first floor they come up and do the feedings for the residents. On 8-21-13 at 1:49 p.m., dietary staff L revealed when a resident admitted to the facility staff weighed the resident four times a month for the first month. If the resident was not at risk they go to monthly weights, but if it looked like the resident was losing weight and not eating the resident was put on every two week weights until they are leveled out on weight. Staff L reported there were weekly meetings involving weights, skin, falls, and once a month the risk committee look at everyone and who is at risk for weight loss, printed on a vital summary for six months, the committee did not review intake record at the meeting. Residents with tube feedings reviewed weekly and on weekly weights, the dietician notified at 5% weight loss. The dietician visited twice a month, reviewed any weight loss, the new people, and pressure ulcer reviewed once a month. When the dietician made recommendations, he/she gave the recommendations to Administrative nurse A and the floor nurses. It was their responsibility to act on the recommendation and bring it up at the risk meeting. Usually the committee just asked nurse A if the recommendation followed up on. They do not bring the chart to verify. Dietary L reveals that the review of the pressure ulcers are monthly. Room trays; the nurse determined who got a room tray. The nurse would let us know what they want for a room tray. If a resident does not want a tray, we do not send one. During a phone conversation on 8/21/13 at 2:39 p.m. Consultant N revealed he/she visited the facility every 2 weeks and requested a list of current weights, skin issues, tube feedings (review the second time of the month) if no change I will wait a month and reevaluate. Consultant N also requested a list of those who came from the hospital, MDS annual reviews, or any other concerns, if Consultant N made recommendations he/she usually checked back on the next visit. The Consultant N would look in the chart, if he/she did not see an order, he/she would check with nursing, look at the MAR (medication administration record), and talk to Administrative nurse A. Consultant N stated he/she had some problems with people who have come back from the hospital and getting the dieticians orders restarted. The residents not always weighed weekly. Nurse A thought the floor nurses were taking care of the recommendations but they were not. The last time Consultant N visited, the residents had no current weights. Direct care staff M began weighing the residents before he/she left the building. Administrative nurse A instructed to call the Consultant N with weights for tube feeders to tell if there was any weight loss but the dietician did not receive any call. With these not being weight and not calling it was three weeks until the dietician reviewed them again. With total tube feedings who continue to lose weight, there should be another intervention tried before a month. The resident had a 31 pound weight loss since 3/2013 with recommendations made twice to increase the tube feedings though the resident continued to lose weight. The resident would probably be a candidate for continuous feeding though the facility was attempting to get some pumps for the tube feedings but had not gotten any at this time. During an interview 8-21-13 at 3:29 p.m., Administrative nurse A reported the facility received a new lift scale at the end of March or first of April, because staff kept getting weird weights. The facility had one scale direct care staff felt was not accurate, and it got disposed of it. In that, time we had identified significant weight losses on tube fed residents. Tube fed residents needed weekly weights. Dietary staff L was to compile a list of weights and bring them to the weekly risk meeting, when asked if Administrative staff A felt the lack of interventions and weekly weights had put residents receiving tube feedings at risk for harm Administrative nurse A stated yes possibly . The dietician is available to be called at any time and I am the one responsible for calling consultant N and informing him/her of issues Interview with physician V on 8/26/13 at 12:20 p.m. revealed that he/she was not aware of the pressure ulcer development. The wound nurse at the facility can assess the residents and there was no need for notification of a stage 2 or 3 ulcer, only stage 4. Physician V revealed he was aware of the weight loss and declined to comment on the weight loss. Review of the policy on Weekly Weights/Nutritional Risk dated 09/27/2004; Purpose to identify residents at risk for weight loss and poor nutrition. Procedure all weekly weights are documented in the treatment record. 1. All new admissions will be weighed with in four hours of admission and weekly for four weeks to establish a baseline weight and monitor for loss. 2. All residents with a physician's order [REDACTED]. 3. Weekly weights will be weekly on all residents receiving tube feedings. 4. Any resident who experiences a 5 pound weight loss or gain on routine monthly weights shall have weekly weights until three consecutive weekly weights show no loss or gain. Residents showing 5 pound or more weight loss or gain on monthly weights are reweighed within 24 hours prior to being placed on weekly weights. 5. Any resident who has not eaten at least 50% of one of three meals daily for 7 days shall have weekly weights until three consecutive weekly weights show no loss or gain Interview with Physician V on 8/26/13 at 12:20 revealed that the physician was aware of the weight loss. Physician V reported that he/she thought the weight loss was due to changing scales and or change in the staff. The facility failed to monitor and act upon a significant weight loss for this resident receiving nutrition by a feeding tube and by mouth, by the failure to monitor meal intake on the resident. The facility failed to follow recommendation of the registered dietician and notify the physician of the recommendation in a timely manner. - Review of resident # 54's admission MDS (minimum data set) dated 12/18/12 revealed the resident ' s metal status was moderately impaired. The resident had no [MEDICAL CONDITION], mood, or behavior problems. The resident is totally dependent on the staff to provide cares with 1 person assist for eating. The resident received 51% or more intake per tube feeding with over 501 cc/ day fluid intake. The resident had a formal assessment for skin breakdown and was at risk for pressure ulcer. The resident had pressure relieving devices in the bed, chair, turned and repositioned, hydration and nutrition program. Review of the quarterly MDS dated [DATE] revealed the resident ' s cognitive status was severely impaired. There was no change in the functional status. The resident had no weight gain or loss had a feeding tube and received the daily nutrition per the tube 51% or more total calories and >501 cc (cubic centimeters) fluid. The nutritional status CAA (care area assessment) did not trigger. The feeding tube CAA dated 12/18/12 revealed the resident required a feeding tube due to [MEDICAL CONDITION]. Review of the care plan with a date of 7/29/13 revealed the resident received 2 Cal 6 cans daily per [DEVICE]. Assess the resident ' s feeding tube for redness or drainage, change feeding tube dressing as ordered by the physician. Check the feeding tube for patency with each feeding flush the feeding tube per physician orders [REDACTED]. Elevate the head of the bed during feeding; make sure that the resident ' s tube feedings are on time and that the resident received the correct formula. Note if the resident had any diarrhea or vomiting and how the resident tolerated the tube feeding. On 7-31-13 actual stage 3 pressure ulcer to back, resident will have no further skin breakdown consult wound care physician, skin prep times 1 week then discontinue, Resolved 8-14-13 Resident is at risk for dehydration due to the use of a feeding tube. Resident will have adequate hydration as evidenced by having no significant weight change and by having labs be within normal limits in the next 90 days (initiated 12-19-12) No updates noted on current care plan. The resident received all hydration through the feeding tube; provide water and fluids via [DEVICE] as ordered Resident is on a feeding tube. Dress the site and make sure the tube is patent every day. Give 2 Cal 6 cans per day, assess the [DEVICE] site, change dressing as ordered, check for patency, flush per orders, flush with 60 ml before and after feedings, head of bed elevated during feeding, make sure feedings are on time and the correct formula, note how resident tolerates feedings. No care plan for weight loss found. Care plan summary dated 1-17-13 nurse summary stated no problems tolerating feeding well. Dietary signed but no note written. Care plan meeting date 3-21-13 nurse summary stated no concerns at this time, continue plan of care (no dietary staff signature on meeting notes or on signature attendance/participation as if not attended). No other care plan notes were in the care plan book. On 3-5-13, nurse ' s notes revealed the resident went to the hospital for evaluation, due to fever, coughing, wheezing. On 3-6-13 an order for [REDACTED]. Physician communication fax dated 5-16-13 to PCP from licensed staff revealed registered dietician recommendations: may we increase 2 Cal HN to 5 cans/day and decrease flushes of 250 cc to 2 times daily Response was yes (orders written on TAR for May) On 5/17/13 order received to increase 2, Cal HN 1 can to 5 times daily by [DEVICE]. Before and after feeding full strength flush the [DEVICE] with water 60 ml. On 6-14-13 physician order [REDACTED]. Physicians orders dated 7-24-13 directed staff to give 2 Cal HN (a type of liquid nutrition) 1 can per [DEVICE] every 4 hours. Review of the resident's monthly weights revealed the following: 1/9/13 137 2/6 /13 137 3/19/13 125 4/3/13 129 5/8/13 126 5/23/13 113 6/10/13 120 6/12/13 116 (reweigh) 7/5/13 116 7/6/13 116 reweigh 7/16/13 109 7/24/13 113 7/30/13 112 8/13/13 115, The resident had weight loss: 2/6/13 to 3/19/13 of 12 pounds 5/8/13 to 5/23/13 of 13 pounds 7/6/13 to 7/16/13 of 7 pounds The review of nutritional assessment on 12/26/12 revealed the resident received nutrition by [DEVICE] and took nothing by mouth. The resident ' s weight was 131 and 67 inches tall with a body mass index of 20. 5-23-13 at 412 pm risk meeting continues to be total care, [DEVICE] with bolus feedings tolerates well, no complicating, no skin issues at this time, weight stable, (no notes for June in chart indicating weight loss) On 7-11-13 at 1:20 p.m., risk meeting this am, weight loss reviewed, recent lengthy hospitalization will monitor. [DEVICE] in place, feedings tolerated and [DEVICE] flushes freely, no skin issues. On 7-18-13 3:18 p.m., reviewed skin issues, area to his back, interventions and treatments, seen by wound care physician, treatment in place reviewed presence of [DEVICE], no complications with feedings, weight reviewed, weight loss noted, awaiting blood cultures. No interventions noted. The nurse notes from January 2013 through present August 21 2013 revealed no mention of weight loss. Review of the local hospital's discharge instructions dated 3-6-13 included a handwritten note in large black print with an asterisk stating, Please make sure the patient gets proper nutrition. Review of the physician progress notes [REDACTED].>On 2-11-13 physician V wrote - patient with history of motor vehicle accident with severe brain trauma. Has been stable for some time. Patient is nonverbal, no problems identified for weight loss. On 3-11-13 responds to verbal stimuli, is nonverbal, no weight loss problems identified. On 6-3-13 responsive to verbal stimuli per staff, blood pressure 127/57, no problem with weight loss identified. Review of the 12/ 2012 TAR (treatment administration record) had 2 Cal 4 times daily starting 12-17/12 with 7 missing signatures for 5:00 a.m. on the 21,22,25,26,29,30,31. On 12/17/12 signature for the 10:00 p.m. missing. Review of the January 2013 TAR had 2 Cal four times daily per [DEVICE], had 3 missing signatures on 1/4 at 5:00 a.m., 1/16 at 11:00 p.m. and 1/25 at 5:00 p.m. Review of the February 2013 TAR had 2 Cal four times daily per [DEVICE] had 2 missing signatures on 2/11 and 2/27 at 5:00 a.m. Review of the March 2013 TAR had 2 Cal ordered 4 times daily per [DEVICE] 2 missing signatures on 2/14 and 2/19 at 5:00 a.m. On 12/20/12 pre-[MEDICATION NAME] was 27 with in normal limits (no other lab for [MEDICATION NAME] in chart). Risk meeting notes revealed the following On 4-26-13 risk meeting notes weight stable, will continue to monitor. On 5-23-13 risk meeting, weight stable. On 7-11-13 risk meeting weight loss reviewed, On 7-18-13 1518 weight reviewed, weight loss noted. No notes in chart for June 2013 indicating weight loss. On 08/22/2013, 8:59 p.m., direct care staff P and S revealed the resident was not given anything by mouth and received feedings only by the nurses he cannot eat anything else. On 8/22/13 at 4:53 p.m., direct care staff Q the nurses feed him/her the only thing we do is oral care and ADL's. On 8/22/13, 9:15 am licensed nursing staff G the nurse from the other floor comes to feed the resident. The resident moved up to 2nd floor temporarily so the nurses came up from down stairs to feed the resident. The 1 first floor nurse makes all the physician calls. The chart stayed on the 2 nd floor. On 8/22/13, 4:32 pm licensed nursing staff R the resident originally came from the first floor and the nurse from st floor comes up, feeds him/her, and then call the doctors. The direct care staff from 2nd floor take care of the cares. On 8-21-13 at 1:49 p.m., dietary staff L revealed when a resident admitted to the facility staff weighed the resident four times a month for the first month. If the resident not at risk they go to monthly weights, but if it looked like the resident was losing weight and not eating the resident was put on every two week weights until they are leveled out on weight. Staff L reported there were weekly meetings involving weights, skin, falls, and once a month the risk committee look at everyone and who is at risk for weight loss, printed on a vital summary for six months, the committee did not review intake record at the meeting. Residents with tube feedings reviewed weekly and on weekly weights, the dietician notified at 5% weight loss. The dietician visited twice a month, reviewed any weight loss, the new people, and pressure ulcer reviewed once a month. When the dietician made recommendations they went to Administrative nurse A and the floor nurses. It was their responsibility to act on the recommendation and bring it up at the risk meeting. Usually the committee just asked nurse A if the recommendation followed up on. They do not bring the chart to verify. Dietary L reveals that review of the pressure ulcers are monthly. Room trays; the nurse determines who gets a room tray. The nurse would let us know what they want for a room tray. No if they do not want a tray we do not send one. During a phone conversation on 8/21/13 at 2:39 p.m. Consultant N revealed he/she visited the facility every 2 weeks and requested a list of current weights, skin issues, tube feedings(review the second time of the month) if no change I will wait a month and reevaluate. Consultant N also requested a list of those who came from the hospital, MDS annual reviews, or any other concerns, if Consultant N made recommendations he/she usually checked back on the next visit. The Consultant N would look in the chart, if he/she did not see an order, he/she would check with nursing, look at the MAR (medication administration record), and talk to Administrative nurse A. Consultant N stated he/she had some problems with people who have come back from the hospital and getting the dieticians orders restarted. The residents not always weighed weekly. Nurse A thought the floor nurses were taking care of the recommendations but they were not. The resident had no current weights the last time Consultant N visited; direct care staff began weighing the residents before he/she left the building. Administrative nurse A instructed to call the Consultant N with weights for tube feeders to tell if there was any weight loss but the dietician did not receive any call. With these not being weight and not calling it was three weeks until the dietician reviewed them again. With total tube feedings who continue to lose weight, there should be another intervention tried before a month. The resident had a 25 pound weight loss since 2/2013 with recommendations made to increase the tube feedings though the resident continued to lose weight. The resident would probably be a candidate for continuous feeding though the facility was attempting to get some pumps for the tube feedings but had not gotten any at this time. During an interview 8-21-13 at 3:29 p.m., Administrative nurse A reported the facility got a new lift scale at the end of March or first of April, because staff kept getting weird weights. The facility had one scale direct care staff felt was not accurate, and it got disposed of it. In that, time staff had identified significant weight losses on tube fed residents. Tube fed residents needed weekly weights. Dietary staff L was to compile a list of weights and bring them to the weekly risk meeting, when asked if Administrative staff A felt the lack of interventions and weekly weights had put residents receiving tube feedings at risk for harm Administrative nurse A stated yes possibly . The dietician is available to be called at any time and I am the one responsible for calling her and informing her of issues Interview with physician V on 8/26/13 at 12:20 p.m. revealed that he/she was not aware of the pressure ulcer development. The wound nurse at the facility can assess the residents and there was no notification was necessary for a stage 2 or 3 ulcer, only stage 4. Physician V revealed he was aware of the weight loss and declined to comment on the weight loss. Review of the policy on Weekly Weights/Nutritional Risk dated 09/27/2004; Purpose to identify residents at risk for weight loss and poor nutrition. Procedure: All weekly weights will be documented in the treatment record. 1. All new admissions will be weighed with in four hours of admission and weekly for four weeks to establish a baseline weight and monitor for loss. 2. All residents with a physician's order [REDACTED]. 3. Weekly weights will be weekly on all residents receiving tube feedings. 4. Any resident who experiences a 5 pound weight loss or gain on routine monthly weights shall have weekly weights until three consecutive weekly weights show no loss or gain. Residents showing 5 pound or more weight loss or gain on monthly weights are reweighed within 24 hours prior to placement on weekly weights. 5. Any resident who has not eaten at least 50% of one of three meals daily for 7 days shall have weekly weights until three consecutive weekly weights show no loss or gain

2 The facility census totaled 56 with 22 residents included in the sample. Based on observation, interview and record review the facility failed to implement new intervention and update the care plan for resident with pressure ulcer, accidents and significant weight loss for residents (#26, #72, #76, and #39). Finding included: - Review of the resident #26's face sheet revealed an admission date of [DATE]. Review of the physician's orders [REDACTED].(loose runny stools). Review of resident #26's annual MDS (minimum data set) dated 11/30/12 revealed a BIMS (brief interview for mental status) score of 12 (moderately impaired). The resident required limited assistance of one staff member for bed mobility, transfers, dressing, extensive assist of one staff member for toileting, personal hygiene, and bathing. The resident was independent with eating. The MDS revealed the resident had an indwelling suprapubic catheter and was occasionally incontinent of bowel. The resident's skin was intact and the resident required turning and reposition, had a pressure relieving device for chair, a pressure relieving device to the bed, and application of ointments to other than feet. Review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12. The resident required limited assistance of one staff member for bed mobility, and transfers. The resident was independent with eating. The resident required extensive assist of one staff member for toilet use, personal hygiene and bathing. The resident had a supra pubic catheter with occasional bowel incontinence. The MDS revealed the resident had a significant weight gain, received a therapeutic diet, and was at risk for developing a pressure ulcer. The MDS revealed the resident had a pressure relieving device to the wheelchair and bed. The resident was on a turning and repositioning program with nutritional interventions to manage skin problems. Review of the ADL (activities of daily living) CAA (care area assessment) dated 11/30/12 revealed the resident required extensive assistance of the staff for toilet use and personal hygiene. The resident required limited assistance with bed mobility, transfers, and dressing. The resident was independent with eating. Review of the nutritional CAA revealed the resident received a therapeutic diet. Review of the pressure ulcer CAA revealed the resident required limited assistance of staff for bed mobility, and was at risk for pressure ulcers. The resident had a pressure relieving mattress to his/her bed and wheelchair. The resident was on a scheduled repositioning program and had occasional bowel incontinence. Review of resident #26's care plan dated 03/20/13 revealed the resident was at risk for alteration in nutritional status. The care plan directed the staff to provide a low concentrated sweets diet. The care plan update on 8/1/13 directed the staff to discontinue the protein shakes and change to health shakes. A care plan updated on 8/19/13 directed the staff to give Pro stat (a protein supplement) 30 milliliters twice daily. Further review of the resident's care plan revealed the resident was obsessed with bulimia (an eating disorder) the care plan directed the staff to refer the resident to a psychologist for talk therapy and medication management. The facility failed to update the care plan to reflect the current dietary interventions to help reduce the resident's risk for weight loss. Review of the resident's care plan dated 12/5/12 revealed the resident was at risk for pressure ulcer related to bowel incontinence. The care plan revealed the resident chose to be independent with toileting, and had a pressure relieving cushion to his/her wheelchair. A care plan update on 8/21/13 revealed the resident had an actual superficial open area to the right buttocks, an air mattress to the resident's bed, and treatment per physician's orders [REDACTED]. On 8/22/13 at 2:45 p.m., interview with Administrative nurse B revealed the care plan team develops the resident care plan within 21 days of admission. The care plan team meets weekly for at risk meetings make updates to the resident's care plan and the resident's care plan is reviewed at least every 90 days and updated with any new interventions. Staff B revealed the facility had new members to the care plan team that were still learning the care planning process. The facility failed to provide a policy in regards to updating care plan as requested on 8/22/13. The facility failed to updated the resident's care plan to accurately reflect new interventions to address the resident's pressure ulcers and weight loss. - Review of resident #72's admission MDS (minimum data set) dated 1/10/13 revealed the resident had a BIMS (brief interview for mental status) score of 7 (moderately impaired). The resident required total assist of two staff members for all ADLs (activities of daily living) including eating. The resident was totally incontinent of bowel and bladder, The resident had a feeding tube and received 25% of his/her nutritional intake via feeding tube. The resident had a stage 1 or greater pressure ulcer over bony a prominence, the resident was at risk for developing pressure ulcers, and currently had an unhealed stage 2 pressure ulcer. The resident had a pressure relieving device to the bed and chair, and turning and repositioning program, nutritional support and hydration to manage the resident's pressure ulcer. Review of the resident ADLs (activities of daily living) #72's CAA (care area assessment) dated 1/17/13 revealed the resident was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personally hygiene and bathing. Review of the resident urinary incontinence CAA dated 1/17/13 revealed the resident was totally dependent on staff for toileting use and totally incontinent of bowel and bladder. Review of the nutritional CAA dated 1/17/13 revealed the resident received a therapeutic diet, had a stage 1 pressure ulcer and the resident required being fed by staff. The registered dietician periodically reviewed the resident ' s diet. Review of the pressure ulcer CAA dated 1/17/13 revealed the resident was totally dependent on staff for all aspects of his/her ADLs, totally incontinent of and bladder, was at risk for developing pressure ulcers and had 2 actual stage one pressure ulcers. Review of the quarterly MDS dated [DATE] the resident had a BIMS score of 7. The resident was totally dependent on staff for all aspect of his/her ADLS and was totally incontinent of bowel and bladder. The resident received 26-50 % of his/her nutritional intake via the feeding tube, and 501 cc (cubic centimeters) day or more of fluid via tube feedings per day. The resident was at risk for developing pressure ulcers. The resident had pressure relieving devices to the bed and chair. The resident received turning, repositioning and hydration to manage skin breakdown. Review of the resident's care plan dated 7-31-13 revealed an actual stage 3 pressure ulcer. Interventions failed to address the current stage 3 pressure ulcer to the resident's coccyx and left ankle. The care plan failed to reflect the current intervention for the treatment of [REDACTED]. Review of the resident's care plan dated 1/23/13 revealed the resident had a feeding tube and staff needs to care for the resident's tube site. The care plan directed the staff to give 5 cans of 2-cal (a type of supplement) per day per feeding tube, arrange tube feedings around meal times, feed the resident by mouth, flush the feeding tube as ordered by the physician, so the tube will not get clogged, monitor the resident for signs and symptoms of dehydration such as dry sticky mouth, tiredness, thirst, decrease urine output, dry skin, poor skin tutor, constipation, dizziness, and irritability, monitor the resident's weight and labs as ordered by the physician, and staff to feed the resident a regular diet orally. The facility failed to updated the care plan to reflect the current dietary interventions and address the resident significant weight loss. On 8/22/13 at 2:45 p.m., interview with Administrative nurse B revealed the care plan team develops the resident care plan within 21 days of admission. The care plan team meets weekly for at risk meetings make updates to the resident's care plan and the resident's care plan is reviewed at least every 90 days and updated with any new interventions. Staff B revealed the facility had new members to the care plan team that were still learning the care planning process. The facility failed to provide a policy in regards to updating care plan as requested on 8/22/13. The facility failed to updated the resident's care plan to accurately reflect new interventions to address the resident's pressure ulcers and weight loss. - Review of resident #39's physician's orders [REDACTED]. Review of the annual MDS (minimum data set) dated 1/19/13 revealed a BIMS (brief interview for mental status) score 11 (moderate cognitive impairment) the resident required limited assist of one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was dependant on staff for locomotion off the unit and bathing, The resident was frequently incontinent of urine and remained continent of bowel, The resident had 2 or more non-injury falls since admission. The resident received an antipsychotic medication and an antianxiety medication during the 7 day look-back period. Review of the resident's quarterly MDS dated [DATE] revealed a BIMS score of 3 the resident required limited assist of one staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene extensive assist of one staff bathing The MDS was coded no falls since admission, the resident received an antipsychotic and an antidepressant all 7 days during the assessment period. Review of the cognitive CAA (care area assessment) dated 1/19/13 revealed the resident had a BIMS score of 11. The resident had risk factors that included the [DIAGNOSES REDACTED]. other factors included communication deficits in temporal orientation, required cues to recall information, indicators of paining the past 5 days, bladder incontinence and impaired vision. The resident does not have any strengths that would help him/her related to the resident's cognitive ability. Review of the ADLs (activities of daily living) CAA dated 1/19/13 revealed the resident was totally dependent on staff for bathing and locomotion off the unit. The resident required limited assistance of staff for bed mobility. transfers, dressing, toilet use, and personally hygiene. The resident remained independent with locomotion on the unit and eating. Review of the falls CAA dated 1/1913 revealed the resident had balance problems during the transitions, had a history of [REDACTED]. Review of the resident 7/28/13 fall risk assessment revealed a score of 14. The assessment indicated a score of 14 placed the resident at moderate risk for falls. On 8/22/13 at 2:45 p.m., interview with Administrative nurse B revealed the care plan team develops the resident care plan within 21 days of admission. The care plan team meets weekly for at risk meetings make updates to the resident's care plan and the resident's care plan is reviewed at least every 90 days and updated with any new interventions. Staff B revealed the facility had new members to the care plan team that were still learning the care planning process. The facility failed to provide a policy in regards to updating care plan as requested on 8/22/13. The facility failed to updated the resident's care plan to accurately reflect new interventions to address the resident's development of pressure ulcers, and significant weight loss. - Review of resident #76's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 3/4/13 revealed a BIMS (brief interview for mental status) with a score of 8 (moderately impaired cognition). The functional status revealed the resident required total dependence of 2 staff for bed mobility, transfer. The resident was admitted with 2 unhealed pressure ulcers at stage 1. The resident had a pressure relieving device for the bed and chair, and had a turning and positioning program. The resident received nutrition or hydration interventions to manage skin problems and received pressure ulcer care with application of ointment to other than feet. The resident was incontinent of bladder and bowel. Review of the quarterly MDS dated [DATE] recorded a BIMS of 1 (severely impaired). The resident required extensive assistance of 1 person for bed mobility and extensive assistance of 2 persons for transfers. The resident had a feeding tube and a received a mechanically altered diet; the resident had no weight loss. The resident had 2- stage 1 pressure ulcers and received pressure ulcer care with application of ointment to other than feet. The resident was always incontinent of bladder and bowel. Review of the Pressure ulcer CAA (Care Area Assessment) completed with the annual MDS dated [DATE] revealed that on admission the resident had 2 stage 1 pressure ulcers on the coccyx and was at risk for developing pressure ulcers. Review of the care plan with a date of 6/14/13 revealed the resident had an alteration in incontinence and at risk for pressure ulcer check and change, toileting program at times may ask to use the urinal. Review of the care plan dated 7/29/13 revealed the resident was at risk for dehydration; staff were to provide water and fluids per [DEVICE] (gastric tube) as ordered and at meals. Staff were to take the resident to all meals. The care plan meeting notes revealed that all disciplines attended and nursing revealed that the resident was doing well much improvement. There was no comment from dietary. Braden scale assessments (assessments used to determine a resident ' s risk for development of a pressure ulcer) dated 2/25/13 (on admission) revealed a score of 13 and 13-14 moderate risk. The 7/12/13 assessment revealed a score of 14. Review of the Skin assessment dated [DATE] skin assessment on admission revealed the right and left gluteal folds were blanchable (to press blood away and wait for return to determine blood circulation). On 3/14/13 per nurses notes: Overall skin assessment narrative, CNA notified nurse of open areas on the coccyx found two small pressure areas directly on coccyx about 1 cm (centimeters) by 2 cm no drainage noted stage, 2 (shallow open area). Applied temporary dressing until physician orders [REDACTED]. On 3/14/13 per the nurse's note: Physician notified of the 2 open areas. We will consult wound specialist for orders PCP (preferred care provider) agreed. No other measurements found in the chart. Review of a nurse's note dated 3/20/13 revealed an order to apply skin prep to coccyx cover with OpSite change every 3 days and as needed. Consult wound specialist if not healed by next week. Review of the resident's skin assessments reviewed the following: 3/22/13: coccyx-2 pressure ulcers dressing intact, no measurements documented 4/11/13: pressure ulcers on coccyx, no other information available The monthly summary on 5/5/13 revealed poor skin turgor (the expected resiliency of the skin caused by the outward pressure of the cells and interstitial fluid). 5/11/13: blanchable redness to the sacrum 6/8/13: blanchable area to the coccyx. 6/22/13: blanchable area to the coccyx with fragile skin. 7/12/13: redness to the coccyx. 7/21/13: redness to the coccyx. 7/30/13: no mention of coccyx. The clinical record lacked lab results for [MEDICATION NAME] or protein (labs used to help determine a resident ' s nutritional status) since admission. On 8/20/13 at 3:10 p.m., the resident was lying in bed on his/her left side. On 8/22/13 7:30 a.m., direct care staff P assisted the resident to the toilet, changed his/her brief and provided peri care. The resident ' s skin was pink with no open areas noted. On 8/22/13 4:53 p.m., direct care staff Q assisted the resident to the bathroom and changed the resident ' s brief. The resident ' s coccyx was without open areas. Review of the resident ' s records revealed the resident had no meal intake sheets since admission. On 8/21/13 at 8:04 a.m., the resident was at the dining room table and received pureed eggs, pureed sausage, hot cereal and thickened water and milk. The resident ate all the eggs, all but 2 bites of the sausage and 1/2 of the hot cereal. The resident took 2 sips of thickened water and drank about 1/4 of the milk. Each of the milk and water was 240 ml (milliliters). On 8/22/13 at 7:56 a.m. the resident was at the table and served pureed eggs, pancake pureed with syrup and pureed bacon, 240 ml thickened milk and 240 ml thickened water. The resident ate the entire pancake and 1/2 of the bacon, 1 bite of egg 1/3 of the milk and 1/4 of the water. On 8/22/13 at 12:30 p.m., staff took a tray to the resident's room that contained mashed potatoes, pureed meat, and a green vegetable. Direct care staff P was at the side of the bed assisting the resident with the meal. Resident ate 25 % of the meal and drank 120 cc (cubic centimeters) water. On 08/22/2013 at 8:59 a.m., direct care staff P and S revealed that the resident is incontinent of urine and is a check and change. The resident was at risk for breakdown but had none at this time. Staff put on the moisture barrier ointment with peri care. The resident moves around in the bed on his/her own. On 8/22/13 4:53 PM direct care staff Q revealed that sometimes the resident can stand and sometimes he/she cannot. The resident wore a brief and was incontinent of urine and bowel and when awake sometimes will tell the staff the need to go to the toilet. The resident received peri care every with the moisture barrier ointment with each incontinent change. On 8/21/13 at 10:15 a.m., the direct care staff monitors the resident ' s skin daily during routine care and reports any changes to the charge nurses. The charge nurses are responsible a weekly skin assessment for each resident to monitor the resident's skin for breakdown. It is the charge nurses responsibility to notify the physician for any skin issue and to obtain order to treat the skin issues. The resident's physician orders [REDACTED]. On 8/22/13 at 8:05 a.m., licensed nursing staff G revealed The resident is incontinent of bladder and bowel will let you know if he/he was incontinent no skin break down at this time it comes and goes. Direct care staff to monitor skin with all cares. On 8/22/13 at 2:12 p.m., licensed nursing staff R the resident does not really know he/she was going so he/she was a check and change. The resident had areas on the coccyx that open up and then heal. The resident has no open areas at this time. On 8/21/13 at 2:44 p.m. interview with Administrative nurse A revealed the resident had recently admitted to hospice related to his/her continued weight decline and skin breakdown. Staff A revealed he/she believed that the resident's weight loss and skin breakdown probably placed the resident at increased risk for serious health complications. On 8/25/13 at 12:40 p.m. interview Physician V revealed he/she was unaware the resident had a stage 3 pressure ulcer to his/her coccyx. Physician V revealed the facility employed a wound nurse and had a wound doctor that made weekly rounds who addressed the resident's wounds. Staff V revealed his/her expectation of the facility was to notify him/her of a stage 4 wound. All other wounds should be handled by the wound nurse and wound doctor. Physician V revealed he/she was aware the resident had a pressure ulcer and believed that the resident overall health condition resulted in the resident's significant weight loss and development of the stage 3 pressure ulcer. Physician V revealed he/she reviewed the wounds at the monthly QAA (quality assessment and assurance) meeting at the facility and Physician V revealed he/she had no concerns with the resident current condition. Review of the policy and procedure for Wound Care with the date of 2/22/2006 revealed all wound care and dressing changes would be done by the facility nurse. The facility nurse will be responsible for all skin treatments. Pressure ulcer documentation will be done at least weekly using the push tool. Procedure--All residents will have a skin condition note, including the Braden scale completed monthly by the charge nurse. Any resident who has a pressure ulcer who is receiving routine skin care treatment i.e., dressings topical applications, etc., shall have a skin condition note weekly by the treatment or charge nurse. All residents with pressure ulcers will have a documented, weekly, comprehensive assessment, including measurement, odor, color and draining of wound all the residents admitted with skin problems will have a comprehensive assessment and a skin condition note completed as part of the admission process. The nurse doing the treatment would document on the treatment sheet after completing the treatment. The facility failed to implement interventions to prevent existing stage 1 pressure ulcers from worsening into multiple stage 2 pressure ulcers.