Every finding on record at Mennonite Friendship Communities Inc

The facility had a census of 68 residents. The sample included six residents with one resident reviewed for involuntary discharge. Based on interviews and record review, the facility failed to ensure the involuntary discharge notice issued to Resident (R)1 or their representative contained a statement of appeal rights, the location to which the resident would be discharged and the contact information for the required state agencies (SA). The facility additionally failed to ensure the reason for the involuntary discharge was documented in the resident's medical record. This placed the resident at risk for impaired rights and inappropriate discharge. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included respiratory failure (severely impaired lung function) with hypoxia (inadequate supply of oxygen), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), weakness, and a need for assistance with personal careR1's Discharge - Return Not Anticipated Minimum Data Set (MDS) dated [DATE] documented R1 had a planned discharge from the facility to another long-term care facility on 06/27/25.R1's EHR under the Physician Orders did not contain an order to discharge from the facility.R1's EHR Resident Documents contained a scanned order, dated 06/26/25, to discharge R1 to a different long-term care facility on 06/27/25, signed by the provider on 06/25/25.Review of an untitled document dated 05/22/25, provided by Administrative Nurse D on 08/26/25 at 11:18 AM, revealed a letter sent to R1's representative, which informed R1's representative of a pending discharge on [DATE] for non-payment of services. The letter informed R1's representative she would need to find alternative living arrangements for R1 before 07/21/25 and offered assistance from facility staff. The letter contained contact information for the long-term care ombudsman (LTCO- an official appointed to investigate an individual's complaints). The letter contained a list of long-term care facilities in the area with telephone numbers. The letter did not contain the location to which R1 would be discharged , a statement of appeal rights (including name, address, and telephone number of the entity which receives such requests), nor information on how to initiate and/or submit an appeal or contact information for the SA. The letter was signed by Administrative Staff A.During an interview on 08/26/25 at 11:58 AM, Administrative Nurse D confirmed R1 was discharged for non-payment of services and provided supporting documentation that indicated R1 had been denied Medicaid services due to failure to submit required paperworkAdministrative Staff A was unavailable for interview on 08/26/25.The facility's Resident Rights policy, dated 01/30/12, did not address the discharge process.The facility's Admission, Transfer, and Discharge Policy policy, dated 11/2024, documented the facility would follow the regulations and policies regarding appropriate notification of discharge, including the right to appeal. If the facility staff mandated a transfer or discharge from the facility, documentation would be made in the clinical record (EHR) of the reason(s) for and conditions under which the transfer/discharge was mandated. This would include methods for transitioning care and responsibility from one clinician, organization, program, or service to another. The policy did not address providing a written discharge summary, recapitulation of stay, or medication reconciliation to the resident or the resident's representative.

The facility had a census of 68 residents. The sample included six residents with one resident reviewed for involuntary discharge. Based on interviews and record review, the facility failed to provide a written discharge summary, recapitulation of the stay or reconciliation of medications for Resident (R) 1 who discharged . This placed the resident at risk for impaired rights related to continuity of care and missed community healthcare services. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included respiratory failure (severely impaired lung function) with hypoxia (inadequate supply of oxygen), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), weakness, and a need for assistance with personal careR1's Discharge - Return Not Anticipated Minimum Data Set (MDS) dated [DATE] documented R1 had a planned discharge from the facility to another long-term care facility on 06/27/25.R1's EHR under the Physician Orders did not contain an order to discharge from the facility.R1's EHR Resident Documents contained a scanned order, dated 06/26/25, to discharge R1 to a different long-term care facility on 06/27/25, signed by the provider on 06/25/25.R1's EHR Resident Documents contained a Transfer / Discharge Instructions form dated 06/27/25, documented the resident was discharged to another facility. The form noted attachments included R1's demographic data, most recent diagnostic results, advanced directives (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves), immunization records, and a copy of the current medication administration record (MAR). The form reviewed ADL (activities of daily living such as walking, grooming, toileting, dressing, and eating) status, recent vital signs, and state agency contact numbers. Page three of the form regarding special care needed, antibiotics, transmission-based precautions and the list of other discharge paperwork was left blank. The form was signed by staff and R1's representative on 06/27/25.R1's EHR Progress Notes documented:On 05/27/25 at 10:04 AM, staff documented R1's provider requested a list of all medications ordered to be faxed prior to discharge.On 05/30/25 at 09:52 AM, staff documented they contacted R1's representative to inform them that R1's physician would not sign discharge orders unless R1 was being discharged to another long-term care facility. Staff documented they provided information to R1's representative about other long-term care facilities.On 06/23/25 at 08:32 AM, staff documented a referral was faxed to another long-term care facility at the request of R1's representative, then called the other long-term care facility to verify receipt of the referral.On 06/24/25 at 02:35 PM, staff documented R1's representative called to notify the facility that another long-term care facility had accepted R1; R1 would discharge on [DATE]. Staff contacted the receiving long-term care facility and verified the receiving facility would pick up R1 on 06/27/25.On 06/26/25 at 10:20 AM, staff documented the provider signed the discharge order on 06/25/25.On 06/27/25 at 11:25 AM, staff documented R1 was discharged to another long-term care facility on 06/27/25 at 11:22 AM, accompanied by staff from the receiving facility and R1's representative. Staff documented R1's EHR, under the Discharge Summary tab, contained documentation of discharge instructions, recapitulation, and education provided to R1 and/or R1's representative.R1's EHR Discharge Summary tab lacked evidence that the facility provided a written discharge summary, recapitulation of the stay, or medication reconciliation to R1 or R1's representative.During an interview on 08/26/25 at 11:18 AM, Administrative Nurse D revealed that prior to any discharge, the social services designee (SSD) would arrange for continuity of care, whether the discharge was to the community or to another facility. Administrative Nurse D said at the time of discharge, the SSD would ensure arrangements were made, and the nurse on duty would review the medications with the resident and/or their representative and perform a reconciliation of medications to clearly communicate when future doses were due. Administrative Nurse D reviewed R1's EHR during the interview and confirmed R1's EHR Discharge Summary tab lacked documentation of a written discharge summary, recapitulation of stay, and medication reconciliation provided to R1 or R1's representative. Additionally, Administrative Nurse D identified the Transfer / Discharge Instructions document in the EHR's Resident Documents as an old form that was formerly used for transfers to the hospital and confirmed it lacked a written discharge summary recapitulation of stay and medication reconciliation. Administrative Nurse D stated at the time of discharge, the Transfer / Discharge Instructions form was the appropriate form to have been used, and the nurse should have documented a discharge summary, recapitulation of stay, and medication reconciliation in the Progress Notes tab of R1's EHR. Administrative Nurse D confirmed R1's Progress Notes did not contain evidence a discharge summary, recapitulation of stay, or medication reconciliation was performed.During an interview on 08/26/25 at 11:58 AM, Administrative Nurse D confirmed R1 was discharged for non-payment of services and provided supporting documentation that indicated R1 had been denied Medicaid services due to failure to submit required paperworkThe facility's Resident Rights policy, dated 01/30/12, did not address the discharge process.The facility's Admission, Transfer, and Discharge Policy policy, dated 11/2024, documented the facility would follow the regulations and policies regarding appropriate notification of discharge, including the right to appeal. If the facility staff mandated a transfer or discharge from the facility, documentation would be made in the clinical record (EHR) of the reason(s) for and conditions under which the transfer/discharge was mandated. This would include methods for transitioning care and responsibility from one clinician, organization, program, or service to another. The policy did not address providing a written discharge summary, recapitulation of stay, or medication reconciliation to the resident or the resident's representative.

The facility had a census of 65 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards when staff left an activated steam table in an unlocked closet, with an unsecured gate, and the coffee station left accessible to residents with an unclosed gate. This placed the eight cognitively impaired independently mobile residents at risk for preventable accidents or injuries. Findings included: - On 01/13/25 at 10:10 AM observation revealed an activated steam table located in the 100-hall dining room in an unlocked open bifold door closet, with an unlocked combination padlock on the left-hand side of the trifold wooden white gate, in front of the closet. On 01/13/25 at 10:11 AM, Certified Nurse Aide (CNA) M verified that there was an activated steam table located in the 100-hall dining room in an unlocked bifold door closet, with an unlocked combination padlock on the left-hand side of the trifold wooden white gate. CNA M stated she was unaware who was responsible for keeping the gate locked, she never messed with it. CNA M stated it was probably dietary staff. 01/13/25 at 10:18 AM, Certified Dietary Manager (CDM) BB verified the left side of the gate should be secured with the combination padlock when the steam table was activated but she did not know the combination. CDM BB checked the water temperature in the first steam table pan on the left and it was 158.5 degrees Fahrenheit (F). The water temperature of the middle steam table pan was 160.1F. The third pan was empty. The CDM BB checked the top metal part of the steam table around the pans, and it was 98F. CDM BB stated she would not want a resident to touch it. CDM BB turned off the steam table and locked the gate. On 01/13/25 at 11:46 AM, an activated steam table was located in the southwest 100 hall dining room closet with the left-hand side of the white gate unlocked, without staff present. Resident (R) 31 sat in a chair at a table on the far side of the dining room. Observation revealed at 11:52 AM Dietary Staff (DS) DD propelled R22 into the dining room in a wheelchair to the same table, then left the dining room. At 11:55 AM R50 ambulated into the dining room and sat at the same table. At 11:58 AM R28 ambulated with a walker with an aide, sat at the same table, then left the dining room, with the gate still unlocked. Further observation revealed DS DD returned to the dining room and served the residents their noon meals. On 01/15/25 at 10:40 AM, Administrative Nurse D stated she expected staff to lock the gate in the southwest 100 hall dining room, when the steam table was activated or remain in the dining room when the steam table was activated. The facility's Use of Steam Table in Dining Area Policy, revised in 2020, documented that once the steam table is in the serving location, it is plugged in to help maintain food temperatures and must be continually staffed by an employee. A steam table is never left unattended in an area readily accessible to residents. The facility failed to ensure the resident environment remained free from accident hazards when staff left an activated steam table unsupervised and unlocked. This placed the eight cognitively impaired independently mobile residents at risk for preventable accidents or injuries. - On 01/14/25 at 03:55 PM, observation revealed no staff in the area or sight of the beverage station with the gate open. The beverage station area included a hot chocolate machine and a coffee dispensing machine with two push-button spigots. The kitchen door was closed and only one resident was at the very far end of the large room. On 01/14/25 at 04:00 PM, CDM BB obtained coffee temperatures from the coffee dispensers at 157F and 160F. CDM BB verified staff should place the security gate to close access to the beverage station area when they were not in the area to monitor access. The facility's Precautions for Handling Hot Beverages Policy, revised in 2020, documented that coffee and hot beverage equipment should be placed in areas that would be safe for residents. If self-serve stations are available, consider a dispenser to minimize spillage. The facility failed to ensure an environment free from accident hazards when staff left the beverage station gate open. This placed the eight cognitively impaired independently mobile residents at risk for preventable accidents or injuries.

The facility had a census of 65 residents. The sample included 16 residents. Based on record review and interview the facility failed to verify the Center for Medicare and Medicaid Services (CMS) received transmissions of the Minimum Data Set (MDS) containing the Resident Assessment Instruments (RAI) for two of 65 residents, R34 and R37. Findings included: - R34's Comprehensive MDS, dated [DATE], was completed and signed but not submitted to CMS. R37's Quarterly MDS, dated [DATE], was submitted but not received by CMS. On 01/14/25 at 01:00 PM, Licensed Nurse (LN) K verified the two resident's MDS had not been received by CMS and stated she was responsible to ensure they were submitted and accepted. The facility's MDS Process policy, dated 11/2022, stated staff were to transmit the MDS within seven days of completion. The facility failed to verify CMS received transmissions of the MDS containing the Resident Assessment Instruments for R34 and R37.

The facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication or required physician documentation for Resident (R) 38's and R27's use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and for the lack of a specific 14-day stop date for R38's as needed (PRN) Ativan (an antianxiety medication). This placed the residents at risk for inappropriate use of medication and related complications. Findings included: - The Electronic Medical Record (EMR) for R38 documented diagnoses of dementia without behavior disturbance (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition. R38 was dependent upon staff for toileting, lower body dressing, mobility, and transfers. R38 was always incontinent of bladder and frequently incontinent of bowel and had rejected care one to three days of the seven-day look-back period. R38 received an antipsychotic, an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medication used to treat mood disorders), and an opioid (a class of controlled drugs used to treat pain). R38's Care Plan, dated 12/17/24, initiated on 04/23/21, directed staff to administer medication as ordered, observe for nonverbal signs of anxiety, and determine any behavior cycles or events. The update, dated 02/14/23, directed staff to offer visits to a mental health center, and involve family. The update, dated 01/18/24, directed staff to listen to her frustrations and concerns, provide reassurance, and provide all care with two staff members. The update, dated 04/29/24, directed staff to offer reassurance if tearful or upset, and to encourage R38 to attend activities. R38's care plan directed staff to smile and compliment R38 to promote feelings of belonging and importance. The Physician's Order, dated 08/12/24, directed staff to administer Ativan (an antianxiety medication), 1 milligram (mg), one to two tablets, by mouth, every four to six hours, as needed, for anxiety. The EMR documented a stop date of 01/01/2035. The Physician's Order, dated 08/21/24, directed staff to administer Seroquel (an atypical antipsychotic medication), 100 mg, by mouth, twice per day, for depression. R38's EMR lacked evidence of a physician documented rationale which included the risks versus benefits for R38's Seroquel. The CP's monthly medication review (MMR) for R38 recorded on 07/15/24 documented R38 received PRN Ativan and did not have a specific stop date which was required, the physician responded with none. The 07/29/24 MRR documented R38 had a diagnosis of depression for her Seroquel which was not acceptable and asked the physician if there was a different diagnosis he wanted to use and if he wanted to reduce the medication. The physician documented do not reduce and had not provided an appropriate diagnosis or indication for the use of the Seroquel. The MRR dated 08/30/24 documented R38 received PRN Ativan and to please provide a specific stop date as the surveyors could question it if it was over six months to a year, due to the patient needing to be reassessed on a regular basis. The physician documented lifetime. The MRR for 09/29/24, 10/30/24, 11/28/24, and 12/30/24 did not make any recommendation or indication for continued use of Seroquel or a 14-day stop date for the PRN Ativan. On 01/14/25 at 07:45 AM, R38 received her medication without concern and was very pleasant and joked with staff. On 0/14/25 at 08:00 AM, Certified Nurse Aide (CNA) O stated R38 could be rude at times if staff failed to get what R38 wanted right away. CNA O further stated two staff go to her room to provide cares as she has accused staff of not providing care. On 01/15/25 at 09:55 AM, Licensed Nurse (LN) I stated, R38 had some behaviors and could be rude to staff. LN I stated R38 received Seroquel twice per day and had as needed anxiety medication if she needed it. LN I stated R38 went to a mental health professional every couple of months and staff charted if she had behaviors. On 01/15/25 at 10:47 AM, Administrative Nurse D stated she was unaware the diagnosis for R38's Seroquel was not an approved diagnosis, and would work with the physician to obtain a rationale for the diagnosis. Administrative Nurse D further stated, that the stop date for the as needed Ativan was not correct and was unsure if it was entered incorrectly. Administrative Nurse D stated the pharmacy had not reported any recommendations for the Seroquel diagnosis or the stop date for the PRN Ativan after the August 2024 review. The facility's Medication Review and Pharmacist Notification to Physician policy, dated 03/17/23, documented the consultant pharmacist documents in the resident's clinical record that the drug regimen review had been performed including a review of unnecessary drugs. The pharmacist provides monitoring of the resident's response to treatment and care, complications of adverse consequences of the treatments, irregularity of any event that was inconsistent with approaches to providing pharmaceutical services, and duration of medication. The licensed pharmacist reviewed each resident's medical and drug regimen at least monthly for skilled and long-term care residents. The licensed pharmacist would report any irregularities to the attending physician, the medical director, and the director of nursing. The physicians and director of nursing should provide timely responses to irregularities identified as a result of the resident's medication regimen review. The facility failed to ensure the CP identified and reported the lack of an appropriate indication for the use of Seroquel, an antipsychotic medication, and for the lack of a specific 14-day stop date for R38's PRN Ativan. This placed the resident's at risk for inappropriate use of medication and related complications. 26768 - R27's Electronic Medical Record documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and recurrent major depressive disorder (MDD - mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R27 had verbal behaviors, was independent with eating, wheelchair mobility, required supervision for walking, and moderate staff assistance for dressing and transfers. The MDS documented R27 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, and the physician documented a dose reduction was clinically contra-indicated. The Psychotropic Drug Use Care Plan, dated 10/22/24, directed staff to observe for nonverbal signs of anxiety, restlessness, trembling, or pacing. Administer Risperdal as ordered. See the Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) in the physician orders and follow pharmacy recommendations. R27's disruptive behavior problems related to inappropriate statements or questions towards staff and residents such as Are you a man or a woman, repetitive questions, yelling at staff, and taunting other residents. The care plan directed staff to remind R27 that this type of talk is inappropriate, reapproach him as needed, or try using different staff members. Staff were to assess whether R27 understood what he was doing, and all staff were to be consistent with the handling of behaviors. R27's care plan directed staff to have R27 sit with other men in the dining room, notify the provider of increased behaviors, and document the behaviors. Staff were to escort R27 to and from the dining room to help ensure that R27 did not make comments to other residents that were upsetting to them. The Physician Order, dated 08/28/23, directed staff to administer Risperdal (an antipsychotic drug), 0.5 milligrams (mg) (1/2 tab) at bedtime for recurrent MDD. The Consultant Pharmacist Recommendation, dated 08/28/23, requested clarification of the diagnosis for Risperdal and if using for a non-approved diagnosis requested thorough documentation describing what has been tried and failed and why the severity of the symptoms justified the use of the drug. The provider wrote the patient was admitted on these medications for dementia with behaviors and they were actively working on dose reduction as they had not seemed to be necessary at this time. No rationale for the continued use of Risperdal was written. The fax note to the physician, dated 12/02/23, stated R27 had some behaviors in the last month such as repetitively asking if you are a man or woman, looking down staff shirts, and saying, I can tell you're a woman. The spouse stated his psychotropic medications were decreased and she would like them changed back or changed to something a different medication. The Physician Order, dated 12/13/23, increased Risperdal to 0.5 mg twice daily for MDD. The Consultant Pharmacist Recommendation, dated 06/29/24, requested an approved diagnosis for Risperdal, or a GDR (gradual dose reduction). The physician had not provided a rationale for the continued use of Risperdal for dementia with behaviors. The Physician Order, dated 07/07/24, decreased Risperdal to 0.25 mg, twice daily, for dementia (progressive mental disorder characterized by failing memory, and confusion) with behaviors. The facility's fax to the physician, dated 09/06/24 fax to PCP stated no behaviors of psychosis, hallucinations, or harmful behaviors were documented. Do you want to re-evaluate if Risperdal should be continued? PCP responded- had been decreased in the past, and no rationale was written. Review of progress notes from 06/01/24 to 01/10/25 revealed one note documented personal sexual behavior on 09/02/24 at 01:29 AM, and a behavior note regarding a sexual comment on 12/07/24. The progress notes lacked any other behavior incidents. The Consultant Pharmacist Recommendation, dated 12/30/24, requested a GDR for Risperdal. The physician wrote that Risperdal was decreased. The Physician Order, dated 01/10/25, directed staff to decrease Risperdal to 0.5 mg (1/2 tab) at bedtime. The order was documented to be noted by a facility nurse on 01/10/25. The January 2025 Medication Administration Record (MAR) did not show any change in the dose of Risperdal starting 01/10/25 to 01/14/25. The MAR had documentated staff administered 0.5 mg (1/2 tab) twice daily on 01/11/25, 01/12/25, 01/13/25, and 01/14/25, which was four doses more than the physician ordered. The fax note to the physician, dated 01/14/25, stated R27's spouse would like to decline the Risperdal change, and stated she did not like the aggressive comments he has made. The Physician Order, dated 01/14/25, Risperdal 0.5 mg tablet 1/2 tab (0.25 mg) by mouth daily, twice daily For Dementia with Behaviors January 2025 Point of Care documentation for verbal behavioral symptoms directed toward others was all 0s. Physical hitting, kicking, pushing, scratching, grabbing, and sexual were all 0s. Other physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, disruptive sounds, and or rejection of care. All shifts documented no behaviors in January. On 01/13/25 at 02:52 PM, R27 sat in a recliner in his room. He asked the surveyor questions about education and religion but was not upset, angry, or confrontational. On 01/14/25 at 04:12 PM, Certified Nurse Aide (CNA) P assisted R27 to stand with a gait belt and walker. She provided incontinence care, changed gloves, and placed a clean brief on R27. The resident sat back down in his recliner to wait for his wife. The resident was pleasant and very cooperative. On 01/14/25 at 12:10 PM, Administrative Nurse D stated when the pharmacist consultant recommended documentation of behaviors the staff sent the request to the physician to reduce or discontinue the Risperdal due to a lack of behaviors. On 01/14/25 at 01:55 PM, Licensed Nurse (LN) H stated she had not observed the resident display angry or harmful behaviors. LN H stated the spouse reported the resident became verbally aggressive when visiting her at the independent living facility. LN H verified staff had not changed the MAR to reflect the 01/10/24 physician order to decrease the Risperdal. The order to keep the Risperdal dose at twice daily came on 01/14/25. She verified the resident had received Risperdal twice daily from 01/11/25 through 01/14/25 and should not have. On 01/15/25 at 09:55 AM, Administrative Nurse D verified staff should have followed the physician's order of 01/10/25 to decrease the dose of Risperdal. The facility's Psychotropic Medication Use policy, dated 11/2022, stated residents who used psychotropic drugs would receive a gradual dose reduction and behavioral interventions unless clinically contraindicated. This was to ensure the elder did not receive unnecessary medications and the lowest possible dose would be administered for the shortest amount of time. The elder's need for psychotropic medication would be monitored and when the medication could be lowered or discontinued. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. Behaviors for which these drugs are used must present a danger for elders or others, interfere with the staff's ability to provide care or cause the elder frightful distress due to paranoia, hallucinations, or delusions. The consultant pharmacist would review the appropriateness of all medication orders for medications to be administered by staff. The drug dosage must be periodically reduced with the goal of discontinuing it or replacing it with another less potent prescription. All antipsychotics would be tapered as a gradual dose reduction unless clinically contraindicated. After the first year a GDR would be attempted annually unless clinically contraindicated. For any elder receiving an antipsychotic to treat behavioral symptoms related to dementia, the GDR may be clinically contraindicated if the elder's target symptoms returned or worsened after the most recent attempt at a GDR and the physician has documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The Consultant Pharmacist Medication Review policy, dated 03/17/23, stated the consultant pharmacist would document in the resident's clinical record that the drug regimen review has been performed including a review of unnecessary drugs. The pharmacist would provide monitoring of the resident's response to treatment and care, complications of adverse consequences of the treatments, irregularity of any event that was inconsistent with approaches to providing pharmaceutical services, and duration of medication. The licensed pharmacist reviewed each resident's medical and drug regimen at least monthly for skilled and long-term care residents. The licensed pharmacist would report any irregularities to the attending physician, the medical director, and the director of nursing. The physicians and director of nursing should provide timely responses to irregularities identified as a result of a resident's medication regimen review. The facility failed to follow the consultant pharmacist's recommendation to obtain the physician's rationale for the continued use of the antipsychotic Risperdal for R27 who had a diagnosis of Alzheimer's dementia, placing R27 at risk for adverse effects of the antipsychotic medication.

The facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars outside of physician ordered parameters for one resident, Resident (R) 34. This placed the resident at risk for hyperglycemic (greater than normal amount of glucose in the blood) and hypoglycemic (less than normal amount of sugar in the blood) episodes and adverse effects related to medications. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose type 2, not enough insulin made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R34 had intact cognition. R34 was independent with all activities of daily living, except for supervision with showers. R34 received insulin (a hormone that lowers the level of glucose in the blood) daily. R34's Care Plan, dated 12/17/24, initiated on 12/04/24, directed staff to obtain Accu-checks (blood glucose monitoring test) as ordered, observe, and monitor, any signs and symptoms of hyperglycemia and hypoglycemia. The care plan directed staff to administer medications as ordered. The update, dated 09/19/24, documented R34 was very active in managing his own blood sugar routines and had a Dexcom blood glucose monitoring machine (a continuous glucose monitor that tracked your blood sugar without finger pricks). The nurses would help change Dexcom as needed and ordered. R34's Physician's Order, dated 07/02/24, directed staff to notify the physician if his blood sugar was less than 90 milliliters (ml) per deciliter (dl) or greater than 300 ml/dl, at 07:30 AM, 11:30 AM, 05:30 PM, and at hour of sleep (HS) for a total of four times per day for diabetes mellitus, type 2. The Physician's Order, dated 08/1/24 directed staff to administer Humalog (a rapid-acting insulin used to lower blood glucose) insulin sliding scale with meals: 131-180-2U 181-240-4U 241-300-6U 301-350-8U 351-400-10U for dm type 2 R34's Nurse Treatment Record, dated December 2024, documented the following days R34's blood sugar was out of parameters and the physician was not notified: 12/03/24 at HS- 301 ml/dl 12/06/24 at 0530 PM- 302 ml/dl 12/15/24 at 11:30 AM- 376 ml/dl 12/15/24 at HS- 303 ml/dl 12/16/24 at 11:30 AM- 320 ml/dl 12/16/24 at 05:30 PM- 312 ml/dl 12/21/24 at HS- 343 ml/dl 12/28/24 at HS- 354 ml/dl R34's Nurse Treatment Record, dated January 2025, documented the following days R34's blood sugar was out of parameters and the physician was not notified: 01/06/25 at 11:30 AM- 303 01/06/25 at HS- 316 01/09/25 at 11:30 AM- 302 01/14/25 at 1130 AM- 310 On 01/14/25 at 11:00 AM, R34 was at the treatment cart with his glucometer and it read 310 ml/dl. Licensed Nurse (LN) G administered 8 units of Humulog insulin to R34. On 01/14/25 at 12:15 PM, Licensed Nurse G stated R34 had orders to notify the physician if his blood sugars were out of the ordered parameters and verified that she should have contacted the physician when R34's blood sugar was out of parameters. Licensed Nurse G further stated R34 liked to be in control of his blood sugars. R34's physician felt he was on too much insulin but the family did not want anything changed at this time. On 01/15/25 at 11:02 AM, Administrative Nurse D stated nursing staff should follow the physician's orders and notify the physician when the blood sugars were out of parameters. The facility's Guidelines For Notifying Physician of Clinical Problems, dated 01/23, documented clinical care problems and significant changes in condition of residents must be communicated to the resident's physician, the resident's physician's designee, or the facility medical director in a timely efficient and effective manner. Staff are to notify the physician whenever there is a need to alter treatment significantly, a significant change in resident's condition, and should a resident develop a clinical problem that required physician intervention. The facility's Blood Glucose Monitoring policy, revised on 03/23, documented if the resident's test result was outside acceptable parameters, whether as ordered by the ordering physician or less than 50 ml/dl or greater than 400 ml/dl, by glucometer, and the resident is symptomatic requiring immediate intervention, care would be provided in accordance with the physician orders or standard, best practice procedure. If the resident had a diagnosis of hyperglycemia, insulin would be administered only upon the order of a physician. The facility failed to notify the physician as ordered when R34's blood sugar was out of the physician-ordered parameters. This placed the resident at risk for complications and adverse effects related to medications.

The Facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)38 and R27 had an approved diagnosis or a physician-documented rationale which included risks versus benefits for R38's use of Seroquel (antipsychotic - class of medications used to treat major mental conditions which cause a break from reality) and for R27's use of Risperdal (an antipsychotic medication) The facility further failed to ensure a 14-day stop date to be reassessed on a regular basis for R38. This placed the residents at risk for unnecessary medications and related complications. Findings included: - The Electronic Medical Record (EMR) for R38 documented diagnoses of dementia without behavior disturbance (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition. R38 was dependent upon staff for toileting, lower body dressing, mobility, and transfers. R38 was always incontinent of bladder and frequently incontinent of bowel and had rejected care one to three days of the seven-day look-back period. R38 received an antipsychotic, an antianxiety (a class of medications that calm and relax people, an antidepressant (a class of medications used to treat mood disorders), and an opioid (a class of controlled drugs used to treat pain). R38's Care Plan, dated 12/17/24, initiated on 04/23/21, directed staff to administer medication as ordered, observe for nonverbal signs of anxiety, and determine any behavior cycles or events. The update, dated 02/14/23, directed staff to offer visits to a mental health center, and involve family. The update, dated 01/18/24, directed staff to listen to her frustrations and concerns, provide reassurance, and provide all care with two staff members. The update, dated 04/29/24, directed staff to offer reassurance if tearful or upset. R38's care plan directed staff to encourage R38 to attend activities, smile, and compliment R38 to promote feelings of belonging and importance The Physician's Order, dated 08/12/24, directed staff to administer Ativan (an antianxiety medication), 1 milligram (mg), one to two tablets, by mouth, every four to six hours, as needed, for anxiety. The EMR documented a stop date of 01/01/2035. The Physician's Order, dated 08/21/24, directed staff to administer Seroquel, 100 mg, by mouth, twice per day, for depression. R38's EMR lacked evidence of a physician-documented rrationalewhich included the risks versus benefits for R38's Seroquel. On 01/14/25 at 07:45 AM, R38 received her medication without concern and was very pleasant and joked with staff. On 0/14/25 at 08:00 AM, Certified Nurse Aide O stated R38 could be rude at times if you don't get what she wants right away. CNA O further stated two staff go to her room to provide care as she has accused staff of not providing care. On 01/15/25 at 09:55 AM, Licensed Nurse (LN) I stated, R38 had some behaviors and could be rude to staff. LN I stated R38 received Seroquel twice per day, and did have as needed (PRN) anxiety medication if she needed it. LN I stated R38 did go to a mental health professional every couple of months and staff chart if she had behaviors. On 01/15/25 at 10:47 AM, Administrative Nurse D stated she was unaware the diagnosis for R38's Seroquel was not an approved diagnosis and would work with the physician to obtain a rationale for the diagnosis. Administrative Nurse D further stated, that the stop date for the PRN Ativan was not correct and was unsure if it was entered incorrectly. The facility's Psychotropic Medication Use policy, dated 11/22, documented residents would not receive psychotropic drugs pursuant to a PRN order unless that medication was necessary to treat a diagnosed specific condition that was documented in the clinical record. PRN orders for psychotropic drugs are limited to 14 days, except as provided, if the attending physician or prescribing practitioner believed that it is appropriate for the PRN order to be extended beyond 14 days. The physician was required to document their rationale in the resident's medical record and indicate the duration of the PRN order. All physician orders for antipsychotic medications would be clear and accurate and would include a diagnosis, condition, or indication for use; and the consultant pharmacist would review the appropriateness of all medication orders for medications to be administered by clinical staff. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition/behavior the antipsychotic medication would be prescribed only when indicated by assessment and medical necessity and after nonpharmacological interventions or alternatives have been considered or used all orders would be clear, and accurate and would in include a diagnosis, condition or indication for use, and the pharmacist would review the appropriateness of all medication orders. The facility failed to obtain an appropriate physician rationale or indication of the use of R38's Seroquel and failed to ensure a stop date for the PRN Ativan. This placed the resident at risk for unnecessary medications and related complications. 26768 - R27's Electronic Medical Record documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and recurrent major depressive disorder (MDD- mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R27 had verbal behaviors, was independent with eating, wheelchair mobility, required supervision for walking, and moderate staff assistance for dressing and transfers. The MDS documented R27 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, and the physician documented a dose reduction was clinically contra-indicated. The Psychotropic Drug Use Care Plan, dated 10/22/24, directed staff to observe for nonverbal signs of anxiety, restlessness, trembling, or pacing. Administer Risperdal as ordered. See the Black Box Warning (BBW - highest safety-related warning that medications can have assigned by the Food and Drug Administration) in the physician orders and follow pharmacy recommendations. Disruptive Behavior Problems related to inappropriate statements or questions towards staff and residents such as Are you a man or a woman, repetitive questions, yelling at staff, and taunting other residents. The care plan directed staff to remind R27 that this type of talk is inappropriate, reapproach him as needed, or try using different staff members. Assess whether he understands what he is doing, and all staff were to be consistent with the handling of behaviors. Staff were directed to have R27 sit with other men in the dining room. Staff were directed to notify the provider of increased behaviors and document the behaviors. Staff were to escort R27 to and from the dining room to help ensure that he was not making comments to other residents that were upsetting to them. The Physician Order, dated 08/28/23, directed staff to administer Risperdal (an antipsychotic drug), 0.5 milligrams (mg) (1/2 tab) at bedtime for recurrent MDD. The Consultant Pharmacist Recommendation, dated 08/28/23, requested clarification of the diagnosis for Risperdal and if using for a non-approved diagnosis requested thorough documentation describing what has been tried and failed and why the severity of the symptoms justified the use of the drug. The provider wrote the patient was admitted on these medications for dementia with behaviors and they were actively working on dose reduction as they did not seem to be necessary at this time. No rationale for the continued use of Risperdal was written. The fax note to the physician, dated 12/02/23, stated R27 had some behaviors in the last month such as repetitively asking if you are a man or woman, looking down staff shirts and said, I can tell you're a woman. The spouse stated his psychotropic medications were decreased and she would like them changed back or a different medication. The Physician Order, dated 12/13/23, increased Risperdal to 0.5 mg twice daily for MDD. The Consultant Pharmacist Recommendation, dated 06/29/24, requested an approved diagnosis for Risperdal, or a GDR-gradual dose reduction. The physician did not provide a rationale for the continued use of Risperdal for dementia with behaviors. The Physician Order, dated 07/07/24, decreased Risperdal to 0.25 mg, twice daily, for dementia with behaviors. The facility's fax to the physician, dated 09/06/24 fax to Primary Care Physician (PCP) stated no behaviors of psychosis, hallucinations or harmful behaviors documented. Do you want to re-evaluate if Risperdal should be continued? PCP responded- has been decreased in the past. No rationale written. Review of progress notes from 06/01/24 to 01/10/25 revealed one note documented personal sexual behavior on 09/02/24 at 01:29 AM, and a behavior note regarding a sexual comment on 12/07/24. The progress notes lacked any more behavior notes. The Consultant Pharmacist Recommendation, dated 12/30/24, requested a GDR for Risperdal. The physician wrote that Risperdal was decreased. The Physician Order, dated 01/10/25, directed staff to decrease Risperdal to 0.5 mg (1/2 tab) at bedtime. The order was documented as noted by a facility nurse on 01/10/25. The January 2025 Medication Administration Record (MAR) did not show any change in the dose of Risperdal starting 01/10/25 to 01/14/25. The MAR had documentation staff administered 0.5 mg (1/2 tab) twice daily on 01/11/25, 01/12/25, 01/13/25, and 01/14/25, which was four doses more than physician ordered. The fax note to the physician, dated 01/14/25, stated R27's spouse would like to decline the Risperdal change, and stated she did not like the aggressive comments he has made. The Physician Order, dated 01/14/25, Risperdal 0.5 mg tablet 1/2 tab (0.25 mg) by mouth daily, twice daily For Dementia with Behaviors January 2025 Point of Care documentation for verbal behavioral symptoms directed toward others was all 0s. Physical hitting, kicking, pushing, scratching, grabbing, and sexual were all 0s. Other physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming disruptive sounds, and rejection of care. All shifts documented no behaviors in January. On 01/13/25 at 02:52 PM, R27 sat in a recliner, in his room. He asked the surveyor questions about education and religion but was not upset, angry, or confrontational. On 01/14/25 at 04:12 PM, Certified Nurse Aide (CNA) P assisted R27 to stand with a gait belt and walker. She provided incontinence care, changed gloves, and placed a clean brief on R27. The resident sat back down in his recliner to wait for his wife. The resident was pleasant and very cooperative. On 01/14/25 at 12:10 PM, Administrative Nurse D stated when the pharmacist consultant recommended documentation of behaviors the staff sent the request to the physician to reduce or discontinue the Risperdal due to a lack of behaviors. On 01/14/25 at 01:55 PM, Licensed Nurse (LN) H stated she had not observed the resident display angry or harmful behaviors. LN H stated the spouse reported the resident became verbally aggressive when visiting her at the independent living facility. LN H verified staff had not changed the MAR to reflect the 01/10/24 physician order to decrease the Risperdal. The order to keep the Risperdal dose at twice daily came on 01/14/25. She verified the resident had received Risperdal twice daily from 1/11/25 through 01/14/25 and should not have. On 01/15/25 at 09:55 AM, Administrative Nurse D verified staff should have followed the physician's order of 01/10/25 to decrease the dose of Risperdal. The facility's Psychotropic Medication Use policy, dated 11/2022, stated residents who use psychotropic drugs would receive a gradual dose reduction and behavioral interventions unless clinically contraindicated. This was to ensure the elder did not receive unnecessary medications and the lowest possible dose would be administered for the shortest amount of time. The elder's need for psychotropic medication would be monitored and when the medication could be lowered or discontinued. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. Behaviors for which these drugs are used must present a danger for elders or others, interfere with the staff's ability to provide care, or cause the elder frightful distress due to paranoia, hallucinations, or delusions. The consultant pharmacist would review the appropriateness of all medication orders for medications to be administered by staff. The drug dosage must be periodically reduced with the goal of discontinuing it or replacing it with another less potent prescription. All antipsychotics would be tapered as a gradual dose reduction unless clinically contraindicated. After the first year a GDR would be attempted annually unless clinically contraindicated. For any elder receiving an antipsychotic to treat behavioral symptoms related to dementia, the GDR may be clinically contraindicated if the elder's target symptoms returned or worsened after the most recent attempt at a GDR and the physician has documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The facility failed to obtain the physician's rationale for the continued use of the antipsychotic Risperdal for R27 who had a diagnosis of Alzheimer's dementia, placing R27 at risk for adverse effects of the antipsychotic medication.

The facility had a census of 65 residents. The sample included 16 residents with six reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to follow physician orders when administering medication to Resident (R) 27, resulting in a medication error continuing for 4 days. This placed R27 at risk for adverse effects from the medication. - R27's Electronic Medical Record documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and recurrent major depressive disorder (MDD - mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R27 had verbal behaviors, was independent with eating, wheelchair mobility, required supervision for walking, and moderate staff assistance for dressing and transfers. The MDS documented R27 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, and the physician documented a dose reduction was clinically contra-indicated. The Psychotropic Drug Use Care Plan, dated 10/22/24, directed staff to observe for nonverbal signs of anxiety, restlessness, trembling, or pacing. Administer Risperdal as ordered. See the Black Box Warning (BBW - highest safety-related warning that medications can have assigned by the Food and Drug Administration) in the physician orders and follow pharmacy recommendations. Disruptive Behavior Problems related to inappropriate statements or questions towards staff and residents such as Are you a man or a woman, repetitive questions, yelling at staff, and taunting other residents. The care plan directed staff to remind R27 that this type of talk is inappropriate, reapproach him as needed, or try using different staff members. Assess whether he understands what he is doing, and all staff were to be consistent with the handling of behaviors. Staff were directed to have R27 sit with other men in the dining room. Staff were directed to notify the provider of increased behaviors and document the behaviors. Staff were to escort R27 to and from the dining room to help ensure that he was not making comments to other residents that were upsetting to them. The Physician Order, dated 01/10/25, directed staff to decrease Risperdal to 0.5mg 1/2-tab at bedtime. The order was documented as noted by a facility nurse on 01/10/25. The January 2025 Medication Administration Record (MAR) did not show any change in the dose of Risperdal starting 01/10/25 to 01/14/25. The MAR had documentation staff administered 0.5 mg (1/2 tab) twice daily on 01/11/25, 01/12/25, 01/13/25, and 01/14/25; which was four doses more than the physician ordered. The fax note to the physician, dated 01/14/25, stated R27's spouse would like to decline the Risperdal change, and stated she did not like the aggressive comments he has made. The Physician Order, dated 1/14/25, Risperdal 0.5 mg tablet 1/2 tab (0.25 mg) by mouth daily, twice daily For Dementia with Behaviors On 01/14/25 at 04:12 PM, Certified Nurse Aide (CNA) P assisted R27 to stand with a gait belt and walker. She provided incontinence care, changed gloves, and placed a clean brief on R27. The resident sat back down in his recliner to wait for his wife. The resident was pleasant and very cooperative. On 01/14/25 at 01:55 PM, Licensed Nurse (LN) H verified staff had not changed the MAR to reflect the 01/10/24 physician order to decrease the Risperdal. The order to administer the Risperdal dose twice daily came on 01/14/25. She verified the resident had received Risperdal twice daily from 1/11/25 through 01/14/25 and should not have. On 01/15/25 at 09:55 AM, Administrative Nurse D verified staff should have followed the physician's order of 1/10/25 to decrease the dose of Risperdal. The facility's Medication Administration policy, dated 05/2023, stated staff were to review all new medication orders and fax them to the pharmacy in a timely manner. Staff were directed to start all initial doses of medications within 24 hours or as instructed by the provider. The facility failed to follow physician orders when administering medication to R27, resulting in a medication error that continued for four days. This placed R27 at risk for adverse effects from the medication.

The facility had a census of 65 residents. The sample included 16 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 41. This placed the residents at risk for inadequate end-of-life care. Findings included: - R41's Electronic Health Record (EHR) revealed diagnoses of Chronic Obstructive Pulmonary Disease chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dysphagia (swallowing difficulty). R41's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R41 had a Brief Interview for Mental Status score of six which indicated severe cognitive impairment. The MDS recorded he required extensive staff assistance with transfers and activities of daily living (ADLs). The MDS documented the resident received hospice services. R41's facility Care Plan, dated 11/08/24, recorded R41 required extensive staff assistance with most ADL care. R41's Care Plan documented the resident had a terminal prognosis and required hospice services. The care plan directed the staff to provide comfort and encourage family and friends support system. The care plan directed staff to observe closely for signs of pain and administer medications as ordered. The facility care plan lacked instruction on the services provided by hospice including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. Review of R41's clinical record revealed the resident was admitted to hospice care on 07/27/23. The facility had a plan of care provided by hospice in the electronic health record. On 01/13/25 at 03:45 AM, R41 was dressed in street clothes and sat in a recliner in her room. On 01/15/25 at 09:00 AM, Administrative Nurse D verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The facility's Hospice Service policy, dated 6/2020, documented what each resident would receive, and the facility would provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility would provide continuity of care to provide residents who are terminally ill with the opportunity to receive comprehensive, interdisciplinary care that recognizes their spiritual needs and to assist the residents, family members, and friends to live as fully and completely as possible with meaning and dignity. Residents and family members may be offered hospice care upon request of the residents and families and/or guardians to meet the care and service needed. The physician would provide a written certification and request hospice care when the resident is determined to require hospice care. An individualized plan of care would be developed before hospice care begins, including an assessment of the resident's and family's needs for services. The interdisciplinary team would review and plan to implement the hospice care services, with advanced care planning, and would address the resident's wishes regarding treatment of acute illness, hospitalization treating acute illness, and hospitalization . The staff would provide and periodically review the resident plan of care, addressing services, and support that accommodate and honor the resident's choices and rights, manage pain and other physical, mental, and psychosocial symptoms, and strive to meet the resident's physical, mental, psychosocial, and spiritual needs. The interdisciplinary care plan would integrate the care and services provided by the facility and the hospice provider including resident, staff, and physician comfort with dealing with death. The care plan would communicate and/or provide the coordination of participants and agencies providing aspects of palliative care including the hospice providers and the facility would exchange information from respective care plan reviews, assessment updates, and resident and family conferences to ensure continued provision of changing necessary care and services. The care plan documented the facility would notify hospice when the resident experiences a significant change in physical, mental, social, emotional, cultural, and spiritual needs related to the terminal illness and related conditions related to the resident's well-being, comfort, and dignity throughout the dying process. The facility failed to coordinate care between the facility and the hospice provider for R41, who received hospice services. This deficient practice placed [NAME] at risk for inadequate end-of-life care.

The facility had a census of 65 residents. The sample included 16 residents of which one was reviewed for the G-Tube (Gastrostomy- surgical creation of an artificial opening into the stomach through the abdominal wall) feeding management. Based on observation, record review, and interview, the nurse failed to listen for the placement of the G-tube before administering medications and nutritional feeding for Resident (R)45. This placed the resident at risk for complications related to the feeding tube. Finding included: - R45's Electronic Health Record (EHR) revealed diagnoses of recorded a diagnosis of dysphasia (swallowing disorder), and cerebral infarct (damage to tissue in the brain due to loss of oxygen in the area). R 45's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R45 had short- and long-term memory loss with severely impaired cognition. The MDS recorded R45 required extensive assistance with transfers, bed mobility, dressing, toilet use, and personal hygiene. The MDS recorded the resident had a feeding tube. R45's Care Plan, dated 11/29/24, recorded R45 required a tube feeding for nutritional maintenance. The care plan directed the staff to administer tube feedings per physician order, assess tube placement, patency, and residual every shift including before and after meals and after administration of any fluids. The care plan documented staff could give medications as cocktail per physician order. The care plan recorded staff would report to the physician any side effects of abdominal pain from the abdominal binder, abdominal distention constipation or diarrhea. R45's Physician Order dated 12/26/24, directed the staff to administer Isosource (liquid nutritional supplement), 1.5 calorie per milliliter (ml), six ounces (oz) per G-Tube four times a day. The order directed staff to crush medications, and dissolve in water, then administer the medication with a total of 200 ml of water per feeding and medication administration. On 01/13/24 at 04:00 PM, Licensed Nurse (LN) I crushed the resident medications and added a small amount of water to dissolve the medications before administering per G-tube. LN I administered 50 ml of water followed by the following medications; Cyclobenzaprine (muscle relaxant) 5 milligram (mg) one tablet, Pepcid (antiacid) 40 mg, one tablet, Lopressor (lowers blood pressure) 100 mg one tablet, Tramadol (pain relief) 500 mg, one tablet. Then administer 6 oz of Isorsource 1.5 calorie per ml nutritional supplement followed by 50 ml of water, and approximately 100 ml of water with the nutritional supplement. LN G failed to listen for placement or check stomach residual prior to administration of medications and nutritional supplements. On 01/15/25 at 09:10 AM, Administrative Nurse D verified the nursing staff were to check placement prior to administering medication and feedings. Administrative Nurse D verified she would have a mini-in-service to re-educate the staff regarding the G-tube protocol including how and when to check placement. The facility's Enteral Tube Use and Care policy, dated 11/2022, documented the policy of the facility is to utilize feeding tubes in accordance with physician orders and current clinical standards of practice, with interventions to prevent complications to the extent possible. The policy documented to initiate bolus tube feeding clamp or pinch the distal end of gastrostomy tube, minimize the air flow potential until the syringe was attached. The policy documented to attach the syringe to the end of the tube, elevate the tube above the resident's abdomen, fill the syringe with formula, and allow the syringe to empty gradually, refilling until the prescribed amount has been delivered, and then flush with the prescribed amount of lukewarm water as ordered. The policy documented if the resident has continuous feeding to check for residual if the physician ordered it, and verify placement of tube by aspirating stomach contents. The Nurse failed to check R45's G-tube placement, prior to medication administration and nutritional feeding, as ordered, placing the resident at risk for complications related to the G-tube.

The facility had a census of 65 residents. The sample included 16 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician for blood sugars outside of physician ordered parameters for one resident, Resident (R) 34. This placed the resident at risk for hyperglycemic (greater than normal amount of glucose in the blood) and hypoglycemic (less than normal amount of sugar in the blood) episodes related to delayed physician involvement. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose type 2, not enough insulin made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R34 had intact cognition. R34 was independent with all activities of daily living, except for supervision with showers. R34 received insulin (a hormone that lowers the level of glucose in the blood) daily. R34's Care Plan, dated 12/17/24, initiated on 12/04/24, directed staff to obtain Accu-checks (blood glucose monitoring test) as ordered, observe, and monitor for any signs and symptoms of hyperglycemia and or hypoglycemia. The care plan directed staff to administer medications as ordered. The update, dated 09/19/24, documented R34 was very active in managing his blood sugar routines and had a Dexcom blood glucose monitoring machine (a continuous glucose monitor that tracked your blood sugar without finger pricks). The nurses would help change Dexcom as needed and ordered. R34's Physician's Order, dated 07/02/24, directed staff to notify the physician if his blood sugar was less than 90 milliliters (ml) per deciliter (dl) or greater than 300 ml/dl, at 07:30 AM, 11:30 AM, 05:30 PM, and at hour of sleep (HS) for a total of four times per day for diabetes mellitus, type 2. The Physician's Order, dated 08/1/24 directed staff to administer Humalog (a rapid-acting insulin used to lower blood glucose) insulin sliding scale with meals: 131-180-2U 181-240-4U 241-300-6U 301-350-8U 351-400-10U for dm type 2 R34's Nurse Treatment Record, dated December 2024, documented the following days R34's blood sugar was out of parameters and the physician was not notified: 12/03/24 at HS- 301 ml/dl 12/06/24 at 0530 PM- 302 ml/dl 12/15/24 at 11:30 AM- 376 ml/dl 12/15/24 at HS- 303 ml/dl 12/16/24 at 11:30 AM- 320 ml/dl 12/16/24 at 05:30 PM- 312 ml/dl 12/21/24 at HS- 343 ml/dl 12/28/24 at HS- 354 ml/dl R34's Nurse Treatment Record, dated January 2025, documented the following days R34's blood sugar was out of parameters and the physician was not notified: 01/06/25 at 11:30 AM- 303 01/06/25 at HS- 316 01/09/25 at 11:30 AM- 302 01/14/25 at 1130 AM- 310 On 01/14/25 at 11:00 AM, R34 was at the treatment cart with his glucometer and it read 310 ml/dl. Licensed Nurse (LN) G administered 8 units of Humulog insulin to R34. On 01/14/25 at 12:15 PM, LN G stated that R34 did have orders to notify the physician if his blood sugars were out of the ordered parameters. LN G verified that she should have contacted the physician when R34's blood sugar was out of parameters. LN G further stated R34 liked to be in control of his blood sugars. LN G stated the physician felt R34 was on too much insulin, but the family did not want anything changed at this time. On 01/15/25 at 11:02 AM, Administrative Nurse D stated nursing staff should follow the physician's orders and notify the physician when the blood sugars were out of parameters. The facility's Guidelines For Notifying Physician of Clinical Problems, dated 01/23, documented, clinical care problems and significant changes in condition of residents must be communicated to the resident's physician, the resident's physician's designee or the facility medical director in a timely efficient and effective manner. Staff are to notify the physician whenever there is a need to alter treatment significantly, a significant change in resident's condition, and should a resident develop a clinical problem that required physician intervention. The facility failed to notify the physician as ordered when R34's blood sugar was out of the physician-ordered parameters. This placed the resident at risk for hyperglycemic and hypoglycemic episodes related to delayed physician involvement.

The facility reported a census of 69 residents which included a sample of 17 residents. Based on observation, interview, and record review, the facility failed to handle, store, and process linen and biohazard waste (infectious waste deemed a threat to public health or environment) in a manner to prevent the cross contamination and spread of infection in resident (R)69's isolation room and one of four soiled utility rooms. Findings included: - On 03/08/23 at 11:00 AM, observed a red bag lined container, used for disposal of trash/used PPE in resident's (R)69's isolation room lacked a cover to contain the overflowing used personal protective equipment (PPE). Maintenance staff FF and GG PPE and entered the resident's room. After completing a maintenance task in the room, Maintenance Staff FF and GG removed their used/soiled PPE, placed it in the container, and shoved it down in the container with their ungloved hand. They agreed the used PPE should have been emptied and the lid closed to prevent cross contamination and the spread of infection. Staff FF and GG reported the housekeeping staff, and/or the nursing staff should remove the used PPE bags and blue soiled linen from the isolation rooms when full and take them to the soiled utility rooms for processing of linen and biohazardous waste. Furthermore, they confirmed the facility ran out of Bio-hazardous boxes due to supply issues and the increase of residents with COVID. On 03/08/23 at 11:15 AM, Housekeeping Staff V stated staff used red bags to dispose of trash from the isolation rooms and should be placed in the soiled utility room in a biohazardous box for disposal. The blue bags used to contain the soiled linens from the isolation rooms. She confirmed the housekeeping staff would pick up the soiled linen from the soiled utility room if the certified nurse aides (CNA) did not take the blue bags to the laundry from the isolation rooms. On 03/08/23 at 11:25 AM, Licensed Nurse (LN) H confirmed red bags were to be used to dispose of trash from the isolation rooms and should be placed in the soiled utility room in a biohazardous box for disposal. The blue bags were to be used to contain the soiled linens from the isolation rooms. She confirmed the housekeeping staff would pick up the soiled linen from the soiled utility room if the CNA's did not take the blue bags to the laundry from the isolation rooms. On 03/08/23 at 11:27 AM, during the tour of 300 hall's soiled utility room with LN I, observation revealed three full plastic bags laid directly on the floor. LN I reported blue bags contained soiled linen from isolation rooms and one red bag which contained trash/biohazardous waste from an isolation room. She stated bags with soiled linen nor trash should not be placed directly on the floor. The blue bags of linen should be in a linen cart and the trash should be contained in a biohazardous carton for disposal. On 03/08/23 at 11:33 AM, Housekeeping staff V verified three full plastic bags laid directly on the floor in the soiled utility room on 300 hall. She reported soiled linens were to be delivered to the laundry at the end of each shift by the certified nurse aides (CNAs). The other linen rooms were bigger and had barrels with lids, however this one was so small it does not have room for barrels like the other halls. The linen and trash should be in contained barrels and not on the floor to prevent the spread of infection. On 03/08/23 at 12:21 PM, CNA M confirmed the soiled linen from the isolation rooms should be contained in blue bags and the trash went in the red bags for transport to the soiled utility rooms on each unit. She stated the red bagged trash should then be placed in the biohazardous container for disposal and the blue bags should be placed in the closed laundry cart or barrel to prevent cross contamination and the spread of infection. Bagged trash or linen should never be placed directly on the floor in the soiled utility room. 03/09/23 10:06 AM, Administrative Nurse D verified the isolation rooms should have a red bag in a closed container for trash disposal of biohazardous waste and a container linen with a blue bag for soiled linen. The trash and linen should be in a closed container to prevent cross contamination and the spread of infection. The red and blue bags should be overfilled but closed and stored appropriately off the floor. The facility policy Infection Prevention and Control Plan, dated 06/2022, documentation included it is the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Laundry and direct care staff shall handle, store process, and transport linens to prevent the spread of infection. The facility failed to handle, store, and process linen and biohazard waste in a manner to prevent the cross contamination and spread of infection in resident (R)69's isolation room and one of four soiled utility rooms.

The facility reported a census of 69 residents with one central kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary by the staff's failure to date and reseal open food items and the failure to use gloves appropriately when serving food. Findings included: - On 03/07/23 at 07:47 AM, observation of the refrigerator located in the food service area of the kitchen revealed an approximately 3-inch stack of sliced cheese wrapped in plastic wrap. The cheese had no open date or use by date written on the packaging. Dietary staff CC verified the opened, undated cheese and disposed the cheese. On 03/07/23 at 08:05 AM, dietary staff DD observed passing room trays on 100 hall. After giving a resident her tray, she assisted the resident with setting up her food. She picked up the resident's toast, butter, and jelly with the same gloved hands used to pass out all room trays on the food cart. On 03/08/23 at 01:05 PM, dietary staff BB reported she had been told by her staff about the cheese found on initial tour and had reminded her staff about dating all food items prior to returning to storage. (Cold or dry storage). She also reported teaching the dietary staff about proper food handling and glove usage but would have to do more education. Review of the facility's Policy named Food Storage Dry, Refrigerated, and Frozen dated 2020, revealed all food items would be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Review of the facility's Policy named Use of Gloves in Food Service dated 11/2017, revealed gloves used to handle food are for single use only and will not be washed or re-used. Gloves will be used for handling of ready to eat foods if food is to be touched and utensils not used. The facility failed to store foods safely and sanitary by the staff's failure to date and reseal open food items and the failure to use gloves appropriately when serving food.

The facility census totaled 69 residents with 17 residents sampled, that included five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow physician's orders for Resident (R)12, related to physician ordered insulin. This failure placed the resident at risk for adverse effects related to medication use. Findings included: - R12's diagnoses from the Electronic Health Record (EHR) included diabetes mellitus, type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and dementia (progressive mental disorder characterized by failing memory, confusion). The 10/24/22 quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. R12 received insulin injections daily in the seven-day look-back period. The 01/22/23 annual MDS documented the resident had a BIMS of 15, indicating intact cognition. R12 received insulin injections daily in the seven-day look-back period. The 01/22/23 Care Area Assessment (CAA) lacked documentation related to insulin use. The 03/09/23 Care Plan lacked documentation specific to insulin administration. The Electronic Health Record (EHR) included the following physician orders: 1. Novolog Flexpen insulin 100 unit/mL (milliliter) - 10 units subcutaneous (an injection beneath the skin) three times daily, with meals, ordered 01/20/17. 2. Accucheck (a device to obtain the resident's blood sugar level) four times daily before each meal and at bedtime. Notify the physician if the resident's blood sugar was below 50 and/or over 400 milligrams/deciliter (mg/dL). Review of the physician's orders lacked an order with blood sugar parameters to withhold medication and notify the physician. Review of the 02/2023 to 03/2023 Medication Administration Record (MAR) revealed the following concerns: 1. On 02/07/23 at 04:49 PM, Novolog Flexpen was not administered with the resident's blood sugar documented of 97 mg/dL. 2. On 02/26/23 at 04:51 PM, Novolog Flexpen was not administered with the resident's blood sugar documented of 91 mg/dL. 3. On 03/02/23 at 12:06 PM, Novolog Flexpen was not administered with the resident's blood sugar documented of 112 mg/dL. 4. On 03/03/23 at 12:55 PM, Novolog Flexpen was not administered with the resident's blood sugar documented of 133 mg/dL. 5. On 03/07/23 at 10:50 AM, Novolog Flexpen was not administered with the resident's blood sugar documented of 98 mg/dL. The Progress Notes lacked documentation related to the physician notification of insulin having been held with rationale. On 03/09/23 at 11:51 AM, Licensed Nurse (LN) G revealed that there is a physician order to notify the physician if the blood glucose level was below 50 mg/dL or above 400 mg/dL and verified there was no order with parameters to hold the resident's insulin dose(s). Furthermore, LN G stated that if a nurse felt the insulin should be held, then staff should notify the physician for an order clarification. On 03/09/23 at 01:16 PM, Administrative Nurse D revealed that if R12's blood sugar was below 100 mg/dL, nurses would hold the scheduled insulin dose and feed the resident. Additionally, Administrative Nurse D revealed that no order exists in the EHR for staff to have parameters to hold R12's insulin dose(s). The facility's 06/01/18 Medication Administration policy documented that staff should execute hold orders only with a physician's order. The facility failed to follow physician's orders for R12 related to insulin not being administered as the physician ordered. This placed the resident at risk for adverse effects related to medication use.

The facility reported a census of 69 with 17 residents in the sample that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow up in a timely manner on the recommendations made by the pharmacist for Resident (R)12. This caused the resident to receive unnecessary medications for a total of 19 days. - R12's diagnoses from the Electronic Health Record (EHR) included diabetes mellitus, type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) and major depressive disorder (a major mood disorder). The 10/24/22 quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. R12 received an antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) and antidepressant medications (class of medications to treat depression [abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness]) daily in the seven-day look-back period. The 01/22/23 annual MDS documented a BIMS of 15, indicating intact cognition. R12 received antipsychotic and antidepressant medications daily in the seven-day look-back period. The 01/22/23 Psychotropic Care Area Assessment (CAA) documented R12 resident received antipsychotic and antidepressant medications daily in the seven-day look-back period. The 03/09/23 Care Plan instructed staff to review pharmacy consultant recommendations and to follow up as indicated. The Electronic Health Record (EHR) included the following physician orders: 1. Desvenlafaxine (an antidepressant medication) 50 mg (milligrams) to be given orally, one tablet by mouth every morning for psychotropic regimen, ordered 01/20/17. 2. Risperidone (an antipsychotic medication) 1 mg to be given orally, twice daily, for bipolar disorder, ordered 01/20/17. 3. Trazodone (an antidepressant medication) 50 mg to be given orally, daily for insomnia/depression, ordered 01/20/17. Review of the facility's pharmacy consultant's reviews revealed the following concerns: 1. On 06/29/22, the consultant pharmacist requested an order with parameters for abnormal blood sugar readings to be communicated to the physician. The physician ordered to contact the physician if the resident's blood sugar readings was under 50 or over 400 milligrams/deciliter (mg/dL). The physician signed the pharmacy consult on 07/18/22, a total of 19 days after the request was made. 2. On 08/31/22, the consultant pharmacist requested a reduction in dose(s) for the resident's psychotropic medications (desvenlafaxine, risperidone and/or trazodone). The physician ordered for the Desvenlafaxine to be reduced from 100 mg daily to 50 mg daily on 09/19/22, a total of 19 days staff administered the higher dosage. 3. On 08/31/22, the consultant pharmacist had a request related to famciclovir (antiviral medication) 250 mg for the resident's diagnosis of herpes simplex (a viral infection marked by watery blisters on the skin or mucous membranes of the lips, mouth, face, or genitals), whether the physician wanted the medication continued or discontinued. due to possible side effects of nausea and diarrhea. The physician discontinued the famciclovir on 09/19/22, a total of 19 days after the request was made. The Progress Notes lacked documentation related to physician notification from staff about pharmacy recommendations. On 03/09/23 at 11:51 AM, Licensed Nurse (LN) G revealed that when the pharmacist would send recommendations, the process was for Administrative Nurse D to send them to the charge nurse of each unit, the charge nurse(s) then send them to the respective physician, the time frame for completion from the physician should be approximately two to three days, if the nurse(s) doesn't get a response in a few days, the request should be resent to the physician. Furthermore, 19 days is too long to wait without resolution of the pharmacist's recommendation. On 03/09/23 at 01:16 PM, Administrative Nurse D stated that nurses should be expected to send the pharmacist's recommendation to the physician and to attempt contact if no response in three to five days. Additionally, physicians expected to respond to the pharmacist's recommendations in three to five days. Administrative Nurse D stated 19 days was too long to wait for resolution of pharmacist's recommendations. The facility's 11/2019 Medication Review policy documented that the licensed pharmacist would report any irregularities to the attending physician, medical director and the director of nursing (DON). The physicians and the director of nursing should provide timely responses to irregularities identified during the medication regimen review (MRR). The facility's 11/2019 Pharmacist Notification to Physician Procedure policy documented the following: 1. During the monthly MRR, the pharmacist would provide reports/recommendations to the DON and the medical director. 2. The charge nurse would send recommendation to the physician within three business days (via fax, in-person delivery or placed in a folder for physician to review during rounding). 3. If no response from the physician after seven business days, the recommendations would be re-faxed and the charge nurse would contact the physician via telephone to provide follow up. The facility failed to follow up in a timely manner on the recommendations made by the pharmacist for R12. This caused the resident to receive unnecessary medications for 19 days.

The facility reported a census of 77 residents, with one main kitchen. Based on observation, interview, and record review the facility failed to store foods and dishes in a safe and sanitary manner by the failure of staff to perform hand hygiene and use gloves appropriately in the kitchen and during meal service. Findings included: - On [DATE] at 08:35 AM during initial tour of the main kitchen the following were observed: In the walk-in refrigerator, noted one eight-ounce (oz) boost breeze with a use by date of [DATE], one eight oz boost breeze with a use by date of [DATE], one eight oz ensure plus with a use by date of [DATE]. Dietary Staff (DS) R removed these items. One stack of 12 different sized metal bowls were stacked upright. On [DATE] at 08:35 AM DS U stated, that is the way we always stack them. On [DATE] at 09:10 AM DS Y prepared spinach for the noon meal and had frozen spinach in a pan. DS Y then took an unopened bag of frozen spinach and placed it on top of the open raw spinach in the pan and cut it open to add to the open raw spinach. Placing the plastic bag from the freezer box onto the raw frozen open spinach. During an interview on [DATE] at 09:10 AM DS Y revealed she thought that was the way the spinach should be done. She stated the plastic from the unopened bag was hard to hold and placing it on the open spinach would stop the fluid from leaking everywhere. On [DATE] at 11:50 AM during the dining observation, DS V moved a trash can, picked up several straws and sugar packets, and placed them on the room trays. She then picked up and looked through the resident's meal tickets, placed her hands on the countertop, placed tickets on the meal trays, grabbed a stack of plates, and opened the gate to the serving area without hand hygiene. On [DATE] at 12:10 PM DS U pulled drinking glasses apart by holding the rim of the glasses before filling them with water and placed them on the tables for the residents. On [DATE] at 12:19 PM DS U stated they were not to touch the rims of the drinking glasses when serving, and she was unaware that she touched the rim of the glasses during serving. On [DATE] at 12:25 PM DS V revealed she would wash her hands once or twice during each meal service time. She stated she was unaware she moved a trash can and then proceeded to touch plates and attempt to serve. On [DATE] at 10:43 AM during a follow up visit to the main kitchen DS T prepared plated and pureed cake. DS T used gloved hands to plate pieces of cake, she then touched the handle of the spatula that was left sitting on the counter top, the lid to the blender, placed her hands on the counter top, and then proceeded to continue to pick up pieces of cake to place in the blender and on the plates using the same gloved hands. On [DATE] at 10:53 AM DS T stated she washed her hands just a little while ago but that she should probably have a plate or something on the countertop to place the used spatula and knife on. During an interview on [DATE] at 12:54 PM Certified Dietary Manager R expected all expired items be removed from use. She further stated that it was all staff responsibility to check expiration dates. DS R stated that all dishware should be stored inverted, and that she expected her staff to know this. Dietary Staff R stated that she also expected all her staff to know proper glove use and hand hygiene as the whole facility just had training on this subject, and that it was her responsibility to ensure her staff knew proper hand hygiene and glove use. DS R stated staff should not use gloved hands to touch any food items, they should always use a utensil and that utensil should be placed in the pan to which it was being used. The Proper Hand Washing and Glove Use policy dated 2020 documented that staff were to change gloves if they become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by the failure of staff dispose of expired food items and to perform appropriate hand hygiene and use gloves appropriately.

The facility had a census of 77 residents with 18 residents in the sample. Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments to Centers for Medicare & Medicaid Services (CMS) in a timely manner for four residents reviewed. Residents (R)9, R4, R2, and R5. Findings included: - Record review on 09/07/21 at 09:17 AM revealed: R5's Death in Facility MDS completed on 05/19/21 and no transmission date R2's Quarterly MDS signed as complete on 06/25/21 and no transmission date R4's Quarterly MDS signed as complete on 07/02/21 and no transmission date R9's Quarterly MDS signed as complete on 07/06/21 and no transmission date During an interview on 09/07/21 at 03:00 PM Administrative Nurse D acknowledged the assessments were not submitted to CMS in a timely manner. She reported she did not know if she transmitted the assessments or if the other MDS Coordinator or the DON transmitted them. During an interview on 09/07/21 at 03:10 PM Administrative Nurse A reported it was Administrative Nurse E who transmitted the MDS and Administrative Nurse A thought she did it weekly, but would check on why the assessments were not transmitted. Review of the facility's policy for MDS Process dated 11/19 revealed the facility would follow the 3.0 RAI [Resident Assessment Instrument] Manual for completion and submission of the MDS for each resident. According to the 3.0 RAI Manual, dated October 2019, all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date +14 days. All other MDS assessments must be submitted within 14 days of the MDS Completion Date + 14 days. The facility failed to transmit Minimum Data Set (MDS) assessments to CMS in a timely manner for four residents reviewed.

The facility had a census of 77 residents with 20 included in the sample. Based on observation, interview, and record review the facility failed place urinary drainage bags in dignity bags to keep the drainage bag away from public view for Residents (R) 38 and R 9. Findings included: - R38's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. The resident had an indwelling urinary catheter. The resident received diuretic medications. The Quarterly Minimum data set (MDS) dated [DATE] revealed a BIMS of 11 indicating moderate cognitive impairment. The resident had no changes in daily care. The resident had an indwelling urinary catheter. The resident received diuretic medications. The Urinary Incontinence/Catheter Care Area Assessment (CAA) dated 11/13/20 revealed the resident had an indwelling urinary catheter in place to assist with her [CONDITION(S)]. She required staff assist to maintain and manage the catheter. Licensed Nurse to change the catheter monthly per order. Review of the Care Plan dated 07/19/21 revealed the resident had a urinary catheter due to a [CONDITION(S)]. Interventions directed staff to change the catheter per order. Observation on 09/01/21 at 11:03 AM revealed the resident lying in bed waiting for the lunch meal. The resident had a catheter drainage bag with urine visible in the bag hanging on the side of the bed and no dignity bag used to cover the urine collection bag. The bag containing urine was visible from the hallway. Observation on 09/02/21 at 01:20 PM revealed the resident lying in bed in a semi- fowler (laying with head elevated) position. The resident's catheter bag hung from the side of the bed with no dignity bag in place and urine visible in the bag from the hallway. Observation on 09/07/21 at 07:19 AM revealed the resident's catheter bag hanging from side of bed without a dignity bag. Observation on 09/07/21 at 10:00 AM revealed the resident lay in bed watching television. Her catheter bag visibly hhanging on the side of the bed with no dignity bag on the drainage bag. During an interview on 09/02/21 the resident reported she had the catheter for a long while. Staff take care of all the care for it but did not remember a dignity bag being used. During an interview on 09/07/21 at 04:03 PM CNA H acknowledged no dignity bag was on the catheter drainage bag and she was not sure why. During an interview on 09/07/21 at 04:30 PM Licensed Nurse C reported all catheter bags were to be in a dignity bag with a tub underneath to prevent it from touching the floor. She was not aware of the resident not having a dignity bag. During an interview on 09/08/21 at 12:15 PM Administrative Nurse A reported all catheters always need to be kept off the floor and in a dignity bag. The Facility Policy for Catheter Care dated 11/19 revealed to keep drainage bag below level of the resident's bladder and keep the bag and tubing off the floor. Place the drainage bag into a cover bag for dignity both at bedside and in the wheelchair. The facility failed to place R 38's urinary drainage bag in a dignity bag. - R9's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, hygiene, dressing and bathing. The resident had an indwelling foley catheter. The Quarterly MDS dated [DATE] revealed a BIMS of three indicating severe cognitive impairment with no changes in daily cares. The resident continued with a catheter. The Urinary Incontinence/Indwelling Catheter CAA Care Area Assessment (CAA) dated 03/26/21 revealed the resident required total assistance for catheter management and care. Review of the Care Plan dated 07/21/21 revealed R9 had a suprapubic catheter (a catheter inserted into bladder through abdominal wall) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He had potential for infection and catheter related complications. Interventions included the following: Keep catheter bag below bladder level. Keep tubing and drainage bag from touching floor. Monitor urine appearance, amount, odor and clarity Maintain a closed, sterile, system, tubing free of kinks. Secure catheter tubing to upper leg with leg strap to prevent catheter begin pulled out. Change catheter monthly and as needed per physician orders Provide and encourage fluids of choice. Appointment with Urologist as scheduled and as needed. Observation on 09/01/21 at 08:32 AM revealed the resident lying in bed awake and restless. The resident had an indwelling catheter without a dignity bag and hanging off the end of the bed onto the floor. During an interview on 09/01/21 at 08:32 AM Certified Nursing Assistant (CNA) G reported residents with catheters usually had a dignity bag the drainage bag went in. She was unsure why the resident did not use one on his catheter. She did not remember seeing one used with the resident. During an interview on 09/07/21 at 10:45 AM CNA O reported the resident had a catheter staff emptied at the end of the shift and when needed. The (Licensed Nurse) LN took care of the catheter not the CNAs because it was a suprapubic catheter. During an interview on 09/07/21 at 3:55 PM LN C reported all catheter bags were to be in dignity bags and his bag should not have been on the floor. During an interview on 09/08/21 at 12:15 PM Administrative Nurse A reported all catheters always need to be kept off the floor and in a dignity bag. The Facility Policy for Catheter Care dated 11/19 revealed to keep drainage bag below level of the resident's bladder and keep the bag and tubing off the floor. Place the drainage bag into a cover bag for dignity both at bedside and in the wheelchair. The facility failed to place R9's urinary drainage bag in a dignity bag.

The facility reported a census of 77 residents with 20 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) 39. Findings included: - R39's Minimum Data Set (MDS) tracking form dated August 2021 revealed the resident discharged to the hospital on 07/31/20 and returned to the facility on [DATE]. Review of R39's Electronic Health Record (EHR) lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge and bed hold to R39's Office of the State Long-Term Care Ombudsman. Observation of 09/02/21 at 03:06 PM R39 sat in the day room in her wheelchair actively watching television, and the staff checked on R39 often. On 09/08/21 at 11:50 AM a request for logs of R39's transfers from the facility to the hospital in the time period July 2021 to August 2021, Medical Records staff K reported the facility failed to complete such transfer logs. She stated she had only the residents who discharged home or transferred to the hospital that did not live here on her log that she transmitted to the Office of the State Long-Term Care Ombudsman. Interview with Administrative Nurse A on 09/08/21 at 12:15 PM revealed she expected staff to send the logs of hospital transfers to the State Ombudsmen's office monthly. The 09/21 Administration policy documented staff will send a monthly summary of all discharges from the facility to the State and Regional Ombudsman. 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 R39 transferred to the hospital.

The facility reported a census of 77 residents with 20 sampled including one for hospitalization . Based on observation, interview, and record review the facility failed to provide a copy of the facility bed hold policy to Resident (R) 39 or her representative for her 07/31/21 facility-initiated hospitalization . Findings Include: - Review of R39's Minimum Data Set (MDS) tracking form dated August 2021 revealed the resident discharged to the hospital on 07/31/21 and returned to the facility on [DATE]. Review of R39's Electronic Health Record lacked evidence of written notification of the facility-initiated hospitalization transfer and bed hold to R39 or her representative. Observation of 09/02/21 at 03:06 PM R39 sat in the day room in her wheelchair actively watching television, and the staff checked on R39 often. On 09/08/21 at 11:37 AM Social Services Designee (SSD) Staff J stated the bed holds were done at the time of the admission to the nursing facility and the facility did not give a bed hold policy to the resident or representative at the time of hospitalization . She stated the life enhancement staff contacted the resident or their family for updates on anticipated return to the facility. On 09/08/21 at 11:40 AM Medical Record Staff K stated the life enhancement staff took care of the bed hold policy when residents were transferred to the hospital and stated they called the resident or representative to check on their plans to return to the facility. Medical Record Staff K stated the facility did hold the resident's bed for them. On 09/08/21 at 11:46 AM Life Enhancement/SSD Staff W stated the facility gave the resident or resident representative a copy of the bed hold policy at the time of admission to the facility, and if the resident was gone long enough, she called or emailed them to check on their plan to continue residence at the facility or not. On 09/08/21 at 11:49 AM Licensed Nurse X stated she did not give the bed hold policy to a resident at the time of a hospitalization transfer. On 09/08/21 at 12:15 PM Administrative Nurse A reported she thought Life Enhancement/SSD staff took care of the bed hold policies when residents transferred to the hospital and did not think nurses sent those out. Administrative Nurse A did not know the facility were not sending a copy of the bed hold policy to the resident or responsible party when a resident admitted to the hospital. The 06/18 Bed-Hold/ Readmission Policy documented all residents are made aware of facility's bed-hold policy and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence. The facility failed to provide a copy of the bed hold policy for R39 or her representative for her 07/31/21 hospitalization .

The facility census totaled 69 residents, with three residents (R) sampled for the assessment and safe use of bed rail and U-bars (a device used for bed mobility) to prevent accidental entrapment, serious injury, or death. The facility performed a Side Rail Assessment on 05/28/19, which indicated R1 was not an appropriate candidate for the use of side rails or a U-bar and the the facility failed to remove the U-bar from her bed at that time. On 09/25/20 the facility placed an air mattress on R1's bed with the continued use of the U-bar and did not conduct another Side Rail Assessment, which further failed to ensure the safety of the resident in use of the air mattress and the U-bar. On 11/15/2020 at approximately 05:00 AM, the facility staff found cognitively impaired and physically dependent, vulnerable R1 with her head lodged between the air mattress and the U-bar mounted to her bed and her body tangled in the blanket with her knees on the floor. These failures placed R1 in immediate jeopardy. Finings included: - A review of the 11/1/2020 physician's orders [REDACTED]. Review of R1's 07/21/20 Quarterly Minimum Data Set (MDS) revealed R1 had short and long term memory loss with moderately impaired decision making abilities. She required extensive assistance from two staff for bed mobility and transfers. Review of the 10/19/20 Annual MDS revealed R1 had short and long term memory loss with moderately impaired decision making abilities. She required extensive assistance from two staff for bed mobility and transfers. Review of R1's Fall Care Area Assessment (CAA) dated 10/19/20 revealed R1 could bear weight and required the use sit to stand mechanical lift for transfers. The resident recieved prescribed medication, which increased her risk of falls. Review of R1's Care Plan, last revised 11/17/20, revealed R1 had difficulty completing her Activities of Daily Living (ADL) and was at a high risk of falling. The Care Plan directed staff to provide extensive assistance with bed mobility and hand transfer bars (U-bars). The Care Plan alerted staff that R1 needed to be checked on frequently due to her memory impairment and seldom utilized the call light. R1 was to be monitored hourly and offered assistance as needed. On 11/17/20, staff revised the Care Plan to include R1 needed positioning in the center of her bed and body pillows were to be used for comfort and positioning. The Care Plan lacked interventions related to the use of the U-bar prior to the 11/17/2020 revision. Review of the 05/28/19 Side Rail Assessment revealed R1 was cognitively impaired, lack awareness to exit the bed safely, and was not a candidate for the use of a side rail or a U-bar. The medical record lacked documentation of another Side Rail Assessment until two days after staff found R1 between her mattress and the U-bar on 11/17/20. Review of the 11/17/20 Side Rail Assessment revealed no change from the 05/28/19 assessment; however, the facility removed the U-bars from the bed at that time. Review of the facility's Accident Investigation Report for R1's fall on 11/15/20 at 05:30 AM revealed the staff found R1 with her head between the mattress and the U-bar. She was face down with her body wrapped in her blankets, and her knees were on the floor. She had a small abrasion on her left elbow and a bruise to the back of her right hand. The resident could not explain what happened. The facility determined the causal factor as the staff had not positioned the resident in the center of her bed at 03:00 AM. The facility reported maintenance would remove the U-bar from the bed and revise the Care Plan. Review of the 11/15/20 at 09:28 AM Progress Note revealed at 05:15 AM, staff found R1 with her head between the mattress and the U-bar, face down with her body wrapped in her blankets, and her knees on the floor. The staff gently set free her head and then lifted R1 back into bed. They noted a small abrasion to the left elbow and a 4 centimeter (cm) bruise to the back of the right hand. The staff assessed R1's vital signs and neurological status, which were within R1's normal limits, and she denied any pain. Review of R1's Hospice Visit Notes on 11/18/20 revealed R1 did not demonstrate any outward signs of pain during the visit, but the hospice staff noted a green fading bruise to the right side of the resident's neck, which appeared linked to the most recent fall. The hospice staff called the durable power of attorney (DPOA) and updated them on R1's condition. The Hospice staff also reviewed the accident investigation report, dated 11/15/20, and noted that R1's head had been lodged between the U-bar and the mattress while her knees were on the floor. Review of the original Notarized Witness Statement written on 11/15/20 by Certified Nurse Aide (CNA) G revealed she went into R1's room for the 05:00 AM check and found her caught up in her blankets, dangling off the bed, with her head between the mattress and the bed rail. Review of the undated revised Notarized Witness Statement by CNA G revealed when she checked on R1 at 05:00 AM, she found her tangled in the blankets, legs off the bed, and her face between the mattress and the U-bar. R1's face was facing towards the interior of the room/door. CNA G ensured R1 was breathing and blinking her eyes. She then summoned Licensed Nurse (LN) D to help unravel R1 and get her onto the bed. CNA G reported R1's right cheek was up against the U-Bar. Review of the original Notarized Witness Statement dated 11/15/20 written by LN D revealed the resident had rolled off the edge of the bed and her head became lodged between the U-bar and the mattress, and noted her knees were on the floor and tangled in the blankets. Review of the undated revised Notarized Witness Statement by LN D revealed they found R1 with her face pressed against the U-bar and facing downward with her knees and legs on the floor. It appeared as if she had rolled out of bed. R1 did not display any signs or symptoms of pain or respiratory distress. LN D wrote R1's head was not lodged between the mattress and U-bar but R1 did have an indentation from the U-bar on her right cheek. LN D wrote R1 could move all her extremities and neck without any outward signs of discomfort and the staff utilized a gait belt to lift R1 into the bed. Interview on 12/07/20 at approximately 04:30 PM with Hospice Nurse (HN) E revealed the resident had a purple and green bruise to the right side of her neck, which measured 2 inches long by 1 inch wide when she visited the resident on Wednesday 11/18/20. HN E stated she reported the bruise to one of the facility charge nurses. Interview on 12/08/20 at 11:41 AM with CNA G revealed R1 was last physically given care on 11/15/20 around 03:00 AM. She revealed when she entered the room around 5:00 AM, she observed the resident with her head facing the floor between the air mattress and the U-bar. She clarified and stated, I can't say her head was entrapped or wedged, but I was unable to move her related to her weight and the fact she was wrapped up in a blanket with her knees/legs resting on the floor. She revealed she immediately checked to see if the resident was breathing because she was lying motionless and staring blankly at the floor. She reported calling the charge nurse to the room, and they lifted R1's head out of the space between the U-bar and the air mattress, placed R1 on the floor, and assessed her for injuries. She denied any bruising to R1's neck the last time she saw the resident. Interview on 12/08/20 at 11:20 AM with LN F revealed Bed Rail Assessments are done every three months. She revealed residents should not have a bed rail or U-bar if they are not cognitive enough to use it for positioning. LN F stated if a resident were caught between the mattress and the U-bar, she would remove them from the danger, assess them, contact the physician, and remove the U-bar immediately. Interview on 12/03/20 at approximately 05:30 PM with Administrative Nurse B revealed staff found R1 on 11/15/20 at approximately 05:00 AM during hourly rounds. After learning of the incident on 11/16/20, she assessed R1's mattress and U-bar and determined they had been installed properly. Administrative Nurse B reported that after having the witnessing staff clarify their statements, they determined that R1's head had not been entrapped due to being easily removed and during their investigation determined the causal factor for the incident was because R1 had not been placed in the center of the bed during the last check. She did not know why the side rail assessment had not been performed since 05/18/19 or why the U-bar had not been removed at that itme. Interview on 12/03/20 at approximately 5:15 PM with Administrative Staff A revealed Administrative Nurse B completed a total investigation of the incident and she determined the resident did not suffer any adverse effects related to the incident and they chose not to report it related to the outcome of that investigation. Interview with Licensed Physician C on 12/8/20 at approximately 02:20 PM revealed she preferred to be notified the day of a significant incident happened and not faxed by the facility. She revealed she considered R1's incident significant however the facility faxed her staff on 11/15/20 when the office was not opened. She revealed she had discussed the incident with the facility's Quality Assurance team members during a phone conference shortly after the fall on 11/15/2020. Review of the facility Assist Devices Policy last revised on 11/19 revealed Transfer Bar, (Grab bar, safety bar, U-bar) is a metal or plastic bar that attaches to the bed. Transfer bars are used to assist residents with turning, sitting, or standing position, allowing them more independence with bed mobility. The facility utilized a person-centered approach when determining the use of assistive devices such as side rails, transfer bars, and transfer poles. If after an attempted to the side/bed rails, transfer bars, has been made, and the alternatives do not meet the resident's needs, the facility shall: Evaluate the alternatives and document how these alternatives failed to meet the resident's assess needs. If there is no appropriate alternative, document reason. Assess the resident for risks of entrapment, and other risks associated with the use of side/bed rails, transfer bar, etc. The facility will ensure the correct installation and maintenance of assistive device. The facility failed to ensure an environment free of potential accident hazards, when the facility utilized a U bar side rail for a cognitively impaired, vulnerable R1 after a 05/2019 side rail assessment revealed the resident did not need bed rails. On 11/15/20 around 05:00 AM staff found the resident with her head face down between the U-bar and the air mattress, wrapped in a blanket with her knees on the floor which placed this resident at risk for serious injury and/or death related to entrapment/strangulation. The facility had not in-serviced staff regarding safety measures in positioning residents with air mattresses and U-bars. By not ensuring the appropriate assessments for use of a U-bar on a cognitively impaired and dependent resident with a history of falls, the facility put the resident at risk for strangulation, suffocation, bodily injury and/or death potentially on 11/15/20 when they found the resident tangled in her blanket, with her head lodged between the air mattress and the U-bar, with only her knees on the floor. Administrative Staff A and Administrative Nurse B were notified on 12/08/20 at 05:15 PM of the immediate jeopardy. The facility presented an acceptable plan for removal of the immediate jeopardy on 12/08/20. The removal plan included: a. A root cause analysis was conducted by staff on 11/15/2020. On November 16, the incident review team (a QAPI sub-committee) met to review incidents from the weekend which included the incident which involved a U-Bar. Investigation of incident was initiated on 11/16/20. The U-bar was reassessed on resident and removed from the resident's bed on 11/17/2020. b. Safety Committee (a QAPI sub-committee) reviewed incident on November 19th and assigned audits on all U-bars. c. Audits were conducted on November 20th and reviewed with maintenance director, DON, and Administrator. Maintenance staff on same day (20th) adjusted any U-Bars identified on the audit as a potential for safety hazard. d. QAPI audited U-Bars again on November 25th. Maintenance director made additional adjustments based on the audit of November 25th. e. On 12/04/20 the DON and Clinical Care Coordinator reviewed Side-rail/U-Bar assessments and care plans on all residents currently using U-Bars to ensure an assessment was completed according to policy and procedure and care plan matched assessment. f. Assistive Device policy and procedure was updated on 12/08/20 with new title, Adaptive Bed Equipment and to include completing quarterly assessments in addition to on admission, with a significant change and annually, maintenance to check adaptive bed equipment quarterly for proper fit and document the quarterly check in MFC's Worx-Hub system. MDS Coordinators are responsible to ensure assessments are completed prior to locking the MDS. g. Mini-in-service started on 12/08/20 for Direct Care staff, Licensed nurses, Environmental staff and MDS Coordinators' on the updated policy and procedure and education regarding adaptive bed equipment safety. h. On 12/09/20 the clinical team revised the Side-rail Assessment (see attachment); changing the name to Adaptive Bed Equipment Assessment, and revising assessment questions with interventions to consider. i. All residents using adaptive bed equipment will be reassessed on 12/09/20 using the new l Assessment and based on that assessment their care plans will be updated accordingly. j. A mandatory all staff Relias in-service has been assigned on Side-rails: A hidden Danger. Staff must complete this in-service by 12/16/2020. k. QAPI Committee met on 12/09/20 to develop the abatement plan of Correction. It was determined to conduct adaptive Bed Equipment audits weekly x 4 weeks then monthly x 3 months. These audits will be brought to QAPI monthly for review. The surveyor onsite verified the removal plan implementation on 12/10/20. The deficient practice remained at a D scope and severity following removal of the immediate jeopardy.

The facility census totaled 88 residents, with three residents sampled for lift use. Based on observation, interview, and record review, the facility failed to transfer resident (R) 1 in a safe manner by not correctly utilizing the sling and failing to repair broken/missing tile in the bathhouse, which resulted from a fall when the wheel of the sit-to-stand lift (a device for residents who have difficulty standing up on their own from a seated position used for transfers) became stuck in the floor where the tile was missing. R1 sustained a [MEDICAL CONDITION] as a result of the fall. Findings included: - Review of R1's [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Date Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R1 required extensive physical assistance of two or more staff members for transfers, bed mobility, dressing, and toilet use and was totally dependent on staff for bathing. The MDS documented no falls since prior assessment and received restorative services for range of motion. Review of the Care Area Assessment (CAA) dated 07/26/19 for Activities of Daily Living (ADL) documented R1 no longer ambulated due to bilateral lower extremity weakness, required assistance from two staff members, and used a sit-to-stand lift for all transfers. The Falls CAA documented bilateral lower extremity weakness, impaired gait/balance, and two staff members required to use the sit-to-stand lift. Review of R1's Care Plan dated 05/06/20 lacked information or instruction regarding the use of R1's unique sling with the sit-to-stand lift. Review of Therapy Notes dated 10/22/19 through 11/01/19 documented therapy educated nursing staff on the placement of R1's sling using the sit-to-stand lift. Documentation included return demonstration with nursing staff to ensure proper use of the sling with the sit-to-stand lift. The therapy notes included to continue training with nursing staff on the set-up and use of the new sling. Therapy also provided written instructions with pictures for nursing staff to ensure safe transfers. Review of the Transfer Instructions dated 11/01/19 to use R1's sling to transfer with the sit-to-stand lift stressed the importance of providing bilateral lower extremity support by using the leg straps on the sling during transfers. The information instructed staff to place sheepskin between leg straps and all four straps attached to the lift for transfers, and it was only acceptable to un-attach straps at the commode/toilet. The information for safety instructed staff to keep R1 over a transfer surface while pulling up pants to prevent R1 from sliding/slipping out of the sling. A review of the Nursing Note dated 07/17/20 at 01:35 PM documented the unidentified certified nurse assistant (CNA) requested the licensed nurse (LN) D to assess R1 who was sitting on the floor in front of her wheelchair in the bathhouse. The nurse document R1 stated she slid out her chair and did not complain of pain to her left leg until right after staff used the full body lift (a device used to transfer residents who cannot move their body on their own) to assist R1 off of the floor. The nurse documented, Approx 2 hours later resident complained of increased pain to left leg and right hip, call placed to PCP (primary care provider) and order received to sent to ER to eval and treat if indicated. Review of the Nursing Note for R1 dated 07/19/20 at 06:28 AM revealed on 07/18/20 she admitted to an acute care hospital. Review of the Nursing Note dated 07/21/20 at 04:34 PM document R1's return to facility with dressings to the left hip and noted R1 yelled out when staff transferred from her from the wheelchair to her bed with the Hoyer lift. Review of the Nursing Note for R1 dated 07/22/20 at 03:36 PM revealed a physician's orders [REDACTED]. Review of the Facility Investigation report dated 07/17/20 revealed the leg part of the sling had to be unhooked from the lift to position it under R1's leg and lacked information regarding the sling's position on R1 during the transfer and before the fall. Review of the Work Order dated 01/08/20 for the Meadowlark Lane/Southeast Bathing Suite documented, Floor has tiles missing. Review of the Work Order dated 07/18/20 for the Meadowlark Lane/Southeast Bathing Suite documented Installed some floor tile. Review of the Work Order dated 07/29/20 documented, There are multiple tile missing on the bathing suite floor that need repaired ASAP. We just had an accident involving a resident. The lift wheel got caught in a missing tile dip. Completion notes documented replacement of loose and broken tile on 07/25/20. An observation on 07/29/20 at 11:35 AM of the bathhouse revealed flooring that consisted of 2x2 inch tile, in which broken and missing tile was repaired or replaced with other tiles of similar colors. An observation on 07/29/20 at 11:55 AM revealed R1 resting in bed with family in the room. The family mostly kept the door closed and occasionally opened to communicate with staff. An observation on 07/29/20 at 06:20 PM revealed R1 was in bed on her back with eyes partially closed, covers on, and lights were down. An unidentified family member in R1's room stated R1 could not recover after the hip surgery and reported R1 had been unresponsive since they arrived a couple of hours prior. An interview on 07/29/20 at 04:37 PM with CNA K stated she told the nurse if something needed to be fixed and the nurse put in the work order for maintenance, and if it was urgent, the nurse also called maintenance. An interview on 07/29/20 at 04:58 PM with CNA J stated when something needed repaired or replaced, he notified the charge nurse who placed a maintenance request. An interview on 07/29/20 at 06:30 PM with CNA I stated he first noticed the tiles in the bathhouse were loose and cracked in May 2020 and noted the bath aid reported and complained about it several times. An interview on 07/29/20 at 06:40 PM with CNA H stated she first noticed the tile in disrepair a couple of months ago, and that she reported it to an unidentified staff member. An interview on 07/30/20 at 10:38 AM with CNA L stated she noticed broken tile in the bathhouse approximately three months ago. She described the tile as broken and partially missing. CNA L stated at the time there was no way around the broken tile because it was at the entrance to the bathtub, and exactly where the wheels to the lift had to roll over to position a resident into the bathtub. CNA L stated that sometimes wheels on the bath chair would catch on the broken tile during transfers to the tub. An interview on 07/30/20 at 10:44 AM with CNA G stated she used a sit to stand lift during transfers with R1 although R1 could not hold onto the lift very long and staff needed to be quick during transfers. R1 refused the full-body lift. CNA G stated she did not experience any other accidents with transferring R1 using the sit-to-stand lift. CNA G Stated there were missing tiles in the bathhouse for at least a couple of months before the incident and several broken/cracked tiles, including five or six missing tile pieces in the bathhouse at the time of the event. The missing tile on the floor was in front of where R1's wheelchair was parked in the bathhouse, and the bath chair was placed next to the wheelchair. CNA G explained there was no other place in the bathhouse that had enough space to transfer a resident using a lift. CNA G stated that other lifts have gotten caught up over the broken tile in the bathhouse, in which there were a total of five residents that required the use of a sit-to-stand lift for transfers to take a bath. She reported the missing tile and safety concerns several times to nursing and management, but maintenance did not repair the tile until after the incident with R1. When asked if the lift and sling were appropriate for R1, CNA G stated therapy worked with staff and R1 on the sit-to-stand lift with a special sling that went underneath each leg, but said staff had not been applying the sling correctly for transfers. CNA G reported they did not position the leg support parts of sling underneath R1's legs prior to the transfer in the bathhouse when R1 fell on to the floor. CNA G further explained the leg parts of the sling were just hooked onto the lift to keep them out of the way. CNA G stated when she transferred R1 from the bath chair to her wheelchair using the sit-to-stand lift, one of the lift wheels got stuck in the floor where the tile was missing, and she did not get R1 positioned far enough back in her wheelchair because the lift wheel was stuck and wouldn't move. CNA G stated her thigh was positioned underneath R1's bottom to keep her from falling out of her wheelchair, and they had to unhook the sling from the lift to get it positioned underneath R1's legs so they could use the lift to get her placed further back into her wheelchair. CNA G reported she was unable to get the sling positioned underneath R1's leg before she fell on to her bottom with both legs straight out in front of her. An interview on 07/30/20 at 11:09 AM with LN D stated she was on duty at the time of the incident. LN D explained unidentified CNA(s) notified her R1 slid out of her chair in the bathhouse because a wheel got stuck in the floor where the tile was missing. LN D stated that CNA G and CNA P had to jerk on the lift to try to free the wheel, which caused R1 to scoot further out of her wheelchair. LN D reported R1 used a sling that went through her legs to keep her from falling should she let go of the lift, but the staff did not tell her how they positioned R1's sling at the time of the incident. LN D stated that she believed the missing tile caused R1 to fall. An interview on 07/29/20 at 05:32 PM with LN E stated R1 used a sit-to-stand lift and refused to use the full lift. LN E said she knew about the broken/missing tile about a month before the incident and did not place a work order because unidentified staff told her that upper management knew about it. An interview on 07/30/20 at 01:07 PM with Therapy Staff F revealed CNA staff were to apply R1's leg straps with lambs' wool between sling material and thighs before transfers. When asked if it was ever acceptable to place the leg straps along the outside of R1's legs, Therapy Staff F stated all unit staff received extensive education for how to use R1's sling which included to never lift R1 away from any transfer surface without first applying the sling leg straps under R1's legs, and never place the sling on the outside of R1's legs. A phone interview on 07/29/20 at 7:04 PM Maintenance Staff M stated they were notified about the broken/missing tile 01/08/20 and contacted someone for a bid to replace the entire bathhouse flooring. Maintenance Staff M said, Somewhere it stalled out, and we never revisited. As workloads go, it was not on the front burner, and other things got put on top of it. Maintenance Staff M stated he did not view the broken/missing tile in the bathhouse as a safety hazard and did not see it as urgent to repair as it should have been. Maintenance Staff M stated after the incident with R1 in the bathhouse, he replaced the missing tiles and also replaced/repaired several cracked and loose tiles. Maintenance Staff M reported that fixing the broken/missing tile sooner would have prevented an accident from occurring. An interview on 07/29/20 at 5:48 PM with Administrative Nurse B stated in January or February 2020, staff reported issues with the bath chair and using lifts in the bathhouse due to broken/missing tile, in which she talked with maintenance about the concerns and the maintenance departments planned to replace the flooring in the bathhouse. An interview on 07/30/20 at 11:55 AM with Administrative Nurse B stated she nursing notified her via a phone call that R1 fell during the use of the lift to transfer her from bath chair to wheelchair because the lift wheel got stuck on the floor where the tile was missing. The staff could not get R1 positioned far enough back in her wheelchair. Administrative Nurse B stated R1 fell when staff had to unhook the sling from the lift to reposition the sling and explained the sling had a part that went up under R1's leg, and staff must not transfer R1 without the leg straps positioned correctly in her legs. Administrative Nurse B stated she was trained by therapy staff to position R1's sling under her legs for transfers. Upon further review of the facility's investigative report, the Administrative Nurse acknowledged the information was unclear and pursued clarification from therapy for proper sling position for R1, and from nursing staff for exactly how R1's sling was positioned prior to the incident. An interview on 07/30/20 at 12:55 PM with Administrative Nurse B and CNA G stated R1's sling was hooked up to the lift, but was not positioned under her legs during transfer when she fell . CNA G further explained the leg part of the sling needed to be unhooked so that she could get it positioned underneath her leg and hook it back up to keep R1 from falling, but R1 slid off of her chair onto her bottom with both legs straight out in front of her. CNA G stated they would have been able to get R1 back into her wheelchair, and R1 would not have slid down with her legs forward in front of her had the sling been positioned correctly in her legs. An interview on 07/30/20 at 11:18 AM with Administrative Nurse C stated R1 used the sit-to-stand lift with a special sling that involved the use of leg straps that went underneath each leg to prevent her from slipping out during transfers and reported that all unit staff were educated by therapy on how to use R1's sling properly. When asked if staff transferred R1 without using the leg straps, Administrative Nurse C stated it was never acceptable to use the sling without first positioning the leg straps. Administrative Nurse C stated sometime after she began her position on the unit in April 2020, she was informed of the broken/missing tile in the bathhouse and placed a work order for maintenance to repair. Administrative Nurse C stated she did not follow up on work orders after maintenance received them. Administrative Nurse C said she did not observe or look at the broken/missing tile in the bathhouse, but if the tile were intact, the fall would not have occurred. An interview on 07/29/20 at 06:40 PM with Administrator A stated the first work order for the tile was on 01/08/20, and maintenance staff were getting bids to replace all the tile flooring in that bathhouse. Administrator A stated she was unaware of any safety concerns staff had using lift equipment in the bathhouse with the missing tile and stated the missing tile was a safety issue and needed fixed pretty fast. An interview on 07/30/20 at 2:14 PM with Physician Extender N stated R1 fell out of her wheelchair and was diagnosed with [REDACTED]. Physician Extender N stated R1 had no history of upper leg or hip pain before the fall and stated the physician saw R1 in May 2020, and noted that R1 was doing well. Physician Extender N reported the fall and fracture contributed to R1's declined health status and receiving hospice services. An interview on 07/30/20 at 03:51 PM with Physician Extender O stated she saw R1 in the facility on 07/22/20. Physician Extender O stated the left [MEDICAL CONDITION] was caused by the fall when R1 fell out of her wheelchair on 07/17/20. Physician Extender O reported R1 declined severely after the fall, and on 07/22/20 she provided orders for hospice due to a significant decline in health status [REDACTED]. She reported the fall with fracture requiring surgery caused R1's body to go over the edge into the failure of different organ systems. Physician Extender O stated there was nothing else that would have caused such a decline in her health requiring hospice services during that period. The facility's policy titled, Lifts and Transfers, dated 05/23/19 documented nursing staff were to followed therapy's recommendations for transfers and staff should only transfer residents as determined by assessment and care planned. The facility's policy titled, Medicare-Sling Positioning, Lifting, and Transferring, dated December 2018, for positioning the sling from a seated position instructed, Gently raise resident's thigh, pulling the leg straps underneath. Repeat same procedure for other thigh. Crisscross the leg straps as shown with one strap passing through the other. Attach straps to adjacent sling support hooks. The policy said, Only a Licensed Nurse or Therapist can change the method of transfer of a resident. If a change is made, the licensed nurse must make the change to the resident's care plan, inform the Clinical Care and MDS Coordinators and send out an alert in POC (Point of Care is a mobile app that runs on wall kiosks and/or mobile devices that enables care staff to document care provided to residents) to inform the direct care staff of the change. Upon request on 07/30/20, the facility did not provide a policy for physical environment/safety hazards/maintenance repairs. The facility failed to ensure staff safely transferred R1 and failed to repair broken/missing tile in the bathhouse. R1 sustained a [MEDICAL CONDITION] as a result of an unsafe transfer by the misuse of a sling and using a sit-to-stand lift over a floor in disrepair with broken/missing tile.

The facility census totaled 99 residents with two of those residents identified with pressure sores. The sample for pressure sore review included two current residents and one discharged resident. Based on observation, interview and record review the facility failed to develop and implement timely and effective interventions to prevent the development of an avoidable stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) facility acquired heel pressure ulcer for resident #2 and failed to develop and implement effective interventions to prevent the development/worsening of a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling) heel pressure ulcer for resident #1. Findings included: - Review of the physician's office visit notes dated 9-1-17 identified Resident #2 with [DIAGNOSES REDACTED]. a right femur fracture (broken thigh bone). The facility admitted resident #2 to the facility on [DATE]. The admission minimum data set ((MDS) dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition, no behaviors and he/she required extensive assistance with transfers, locomotion off unit, dressing, personal hygiene and toilet use. The MDS showed the resident was frequently incontinent of urine. The MDS identified the resident at risk for pressure sore development, but had no pressure sores at the time of the assessment. The resident had a pressure reducing device for his/her chair and bed. The triggered Care Area Assessments (CAAs), dated 5-31-17 included: Activities of daily living (ADLs), the resident needed assist of 2 staff for bed mobility, transfers with sit to stand lift (a type of mechanical lift to assist staff in transferring a resident from one surface to another), dressing and toileting. The resident required a wheel chair as he/she did not ambulate at the time. The resident could only bear toe touch weight on the lower right extremity. Urinary Incontinence, the resident required assistance with toileting related to [MEDICAL CONDITION] femur. The resident was frequently incontinent related to functional mobility. Pressure ulcer, the resident 's immobility, advanced age, fragile skin, immobilizer on the right leg, incontinence, and diabetes all put the resident at risk for the development of pressure ulcers, skin breakdown, and bruising. The care plan dated 5-23-17 identified the following: The resident's ADLs were impaired related to the fractured femur. The care plan included physical therapy, occupational therapy, wheel chair for locomotion, assist with dressing and repositioning. Noted on 9-12-17 staff removed and repaired the brace on the resident's right leg. The 5-23-17 care plan identified the resident was incontinent of urine. Interventions directed staff to use moisture barrier, answer call light promptly, encourage fluids, observe for change in urine color, clarity and frequency. The 5-23-17 care plan recorded the resident was at risk for pressure ulcer development, skin breakdown, and bruising related to impaired immobility, advanced age, fragile skin, immobilizer on right leg, incontinence and diabetes. Interventions added on 6-8-17 included, pressure redistribution mattress and cushion in wheelchair and recliner, monitor nutrition and hydration, apply protective barrier after incontinent episodes, protect extremities during transfers. Use cushions and pillow for positioning and comfort, and keep pressure off heels. Care plan updates included: 6-27-17 the resident had an unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to the right heel; interventions dated 6-27-17 included a loss air mattress and refer to the wound clinic for treatment of [REDACTED]. Interventions included the addition of blue Posey boots (soft boot to relieve pressure on the heel) to both heels. Monitor to ensure staff put the boots on correctly to keep pressure from heels. 8-9-17 the left heel resolved. 8/23/27 the pressure ulcer to the right heel was debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). 9/6/17 May wear shoes when walking. Review of the Braden Risk Assessment (a tool for determining risk for development of a pressure ulcer) score completed on 5-19-17 revealed a score of 16. The Braden form noted a score of 17 or below indicated a risk for development of pressure ulcers. Review of the 6-23-17 physical therapy (PT) notes revealed the physical therapy assistant (PTA) removed the right lower extremity brace and repositioned all pads as the brace did not fit properly. 6-27-17 PT notes identified the resident had a quarter sized black spot on right heel. The physical therapy aide (PTA) noted the resident reported the nurse told him/her not to put pressure on the heel. 6-28-17 PT noted the resident had a dime sized bruise on the left heel, and nursing staff monitored it. The resident reported he/she was getting an air mattress today. 6/28/17 Skin evaluation form noted an area on the right heel 3.5 centimeters (cm) by 3.0 cm, but lacked further description. Staff applied skin prep and covered the heel with a padded dressing. A nurse's progress note dated 6/28/17 noted a non-blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation) area with dark center to bilateral (both) heels, dark areas to the right heel and a black spot to the left heel. 6-28-17 Staff sent a fax to the physician noting a black spot (appears to be a popped blister) on the bottom of the right heel which measured 2.5 cm by 2.5 cm in size and was tender to touch. Staff covered the area with a foam pad for comfort. The physician responded to consult with wound care clinic. Another fax dated 6-28-17 to the physician requested treatment at the wound clinic and noted the resident had a 3 cm x 3.5 cm dark area on right heel with a white non blanchable area 2.3 cm x 1.5 cm with dark center which measured 1.3 cm x 0.6 cm, also on the right heel. 6-29-17 PT notes identified communication with the nurse regarding the resident's report he/she was not to put pressure on the left lower extremity because of a potential breakdown area. The nurse told PT the resident was to have both heels offloaded (measures to prevent pressure on the heels when lying down or sitting) in the recliner, wheelchair or bed, had blue boots for pressure relief and, weight bearing to the left lower extremity was acceptable. A skin evaluation form dated 7-10-17 described the right heel area as 2.4 cm x 2.7 cm in size and reddish blackish in color. The resident denied pain and said it felt better. The skin evaluation form dated 7/16/17 revealed the area to the right heel was 1.2 cm wide and 1.0 cm deep. The area to the heel remained black in color with dry skin around the area. The skin evaluation form dated 7-24-17 noted the right heel area 1.8 x 1.2 cm, black in color and dry skin around the area. Review of the wound clinic physician order [REDACTED]. Wound clinic physician notes dated 7-25-17 identified the right heel wound was a stage 4 pressure wound (severe tissue damage which extends to the muscle and bone) and the left heel wound, a deep tissue injury, had resolved. The physician noted he/she debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) the right heel wound, and ordered a daily dressing change of an alginate dressing. The physician also noted to continue offloading the heels. The left heel wound was initially identified in 6-28-17 nurses' notes, and not noted again until this note 7/25/17 which identified the wound had healed. An e-mail was sent to licensed administrative licensed staff B on 10-10-17 specifically inquiring about information for the left heel. Information sent from staff B included only the 6-28-17 nurses' note and the 7-25-17 wound clinic note. 8-2-17 Wound clinic communication form noted daily alginate dressing changes (no location identified) and offload heels. 8-9-17 Skin evaluation form noted the right heel area was 1.2 cm by 1.0 cm by 0.3 cm, black in color, dry skin around area, and no drainage noticed. 8-9-17 Wound clinic noted, right heel had some callus (a toughened area of skin which has become relatively thick and hard in response to repeated friction, pressure, or other irritation) and [MEDICATION NAME] ([MEDICATION NAME] and platelets form a clot over an open area) on the wound, area debrided. Alginate dressing to right heel daily. Skin evaluation form dated 8-23-17 noted an area on the right heel which measured 1.0 cm by 0.9 cm by 0.5 cm, had a dry edge and scant (barely visible) drainage noted. 8-28-17 Skin evaluation form noted the area to the right heel was 0.9 cm by 0.9 cm by 0.2 cm, dry around edge with scant drainage noted. Wound clinic notes dated 9-6-17 noted to continue alginate dressing changes 3 times a week to right heel, and the resident could wear shoes when walking and remove the shoes when not walking. 9-6-17 Skin evaluation of right heel 0.7cm x 0.6cm x 0.2cm seen at wound clinic. 9-20-17 Skin Evaluation of right heel 0.4 cm x 0.4 cm, by 0.1 cm seen at wound. 10-4-17 Wound clinic notes for right heel dressing change completed, may wear shoes when walking, remove when not walking and offload both heels. Observation on 9-19-17 at 3:05 p.m. revealed the resident sitting in the recliner fully dressed in street clothes and wearing shoes and sock. The resident had his/her legs elevated with the recliner footrest; however the resident's heels had no offloading and his/her heels remained in contact with the footrest. Observation on 9-20-17 at 11:10 a.m. revealed the resident moving down the hall in a wheelchair unassisted. The resident wore shoes and socks. The resident said he/she had been to the wound clinic. Observation on 9-20-17 11:44 a.m. revealed the resident remained in the wheelchair in his/her room. The resident said he/she did not feel well, and displayed shortness of breath. The resident shared that the doctor said the wound looked better, but he/she wanted to see the resident again in 2 weeks. Observation on 9-21-17 at 2:15 p.m. revealed the resident sitting in the recliner wearing blue booties to offload his/her heels. The resident received oxygen via a nasal cannula and reported not feeling well again today. Interview on 9-21-17 at 2:03 pm with direct care staff E revealed the staff assisted the resident with most ADLs. They floated his/her heels when the resident was in bed or the recliner and removed the resident's shoes and put on the blue booties when the resident was not walking. Staff E said therapy approved the resident could wear his/her shoes for the purpose of walking, but otherwise he/she was to wear the blue booties. The resident got the pressure sore from a brace he/she used to have. The wound was about healed. Interview on 9-21-17 at 2:23 p.m. with direct care staff F revealed the resident currently had a healing pressure ulcer on his/her right foot. Staff F said he/she made sure the resident did not wear shoes when in the chair, or was not walking. The resident was to wear the blue booties in the chair and in the bed. Staff F said the resident used to have an immobilizer on the right leg and he/she thought it might have caused the pressure sore. Interview with licensed nurse D on 9-20-17 at 10:03 a.m. revealed the resident was currently at the wound clinic for evaluation. Unless the wound doctor changed the routine while he/she was at the wound clinic he/she will not be due for a dressing change again for 3 days. Interview with licensed nurse D on 9-21-17 at 2:10 p.m. revealed the wound started on the right heel from the immobilizer and the resident trying to walk with the immobilizer on. Staff D reviewed the electronic record notes and confirmed staff identified the pressure ulcer on 6-28-17. At that time the area was 3.5 cm by 3 cm and not open. Initially the treatment was skin prep. The wound clinic could not see the resident until 7-25-17. The wound clinic staff debrided the wound on the first visit to the clinic. Staff D reported the wound was almost healed at this time. Interview with licensed nurse C on 9-29-17 at 9:25 a.m. revealed the resident had a pressure ulcer to the right heel that was nearly healed. The resident had an immobilizer on when he/she first came and that might be what caused the pressure ulcer. The resident also had a pressure ulcer on the left heel. Staff C said he/she was not sure if the pressure ulcer on the left heel was present on admission, but said it healed. Interview with administrative licensed nurse B on 9-29-17 at 3:05 p.m. revealed the resident admitted to the facility with a [MEDICAL CONDITION] and the resident preferred being in bed rather than in the recliner. Staff B attributed the pressure ulcers to the amount of time the resident spent in bed. Staff B said staff identified the pressure ulcer on 6-28-17 and the resident was seen at the wound clinic. Staff B said the resident still had the wound on the right heel, but the wound on the left heel had healed. Staff B confirmed the resident was at risk for pressure ulcer development on admission however unsure if any preventative measures were implemented by staff prior to development of the pressure ulcer. Interview with physician H on 10-24-17 at 11:00 a.m. revealed he/she thought based on the location of the pressure ulcer it was highly unlikely the immobilizer caused the pressure ulcer. He/she explained pressure ulcers developed due to the pressure of the bone compressing the tissue between the bone and the surface the heel rested on. All of the tissue between the bone and the surface was compressed and damaged. A resident's heels must be offloaded to prevent the development of pressure ulcers to the heel. The damage of the pressure ulcer would have been all the way to the bone. The physician said pressure ulcers of the heel affect a resident's mobility which affects the resident's rehabilitation. This can lead to serious complications affecting the resident's overall health. Review of the undated facility provided policy titled Pressure Ulcer Prevention and Treatment, revealed prevention included staff assessment for risk of pressure sore development. Remove, modify or stabilize identified risk factors. Implement interventions to relieve/reduce pressure, shear and friction and promote circulation and mobility. Tissue tolerance testing, clinical assessment and the Braden score can be used to create a resident specific repositioning schedule to reduce the risk of development of pressure related skin impairment. The facility failed to implement care planned interventions to provide offloading of the immobile resident's heels, failed to develop a repositioning schedule and other preventative measures until the resident developed a deep tissue injury to the left heel and an avoidable stage 4 pressure ulcer to the right heel. - Review resident #1's hospital discharge notes dated 3-16-17 revealed [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (cancer that occurs in the prostate) and abscess (cavity containing pus and surrounded by inflamed tissue) of left lateral (pertaining to the side, away from the middle) neck. The facility admitted resident #1 on 3-17-17 and discharged the resident on 6-24-17. The admission minimum data set ((MDS) dated [DATE] identified the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, required assistance of 2 staff for bed mobility, transfers, dressing, toileting and one staff assistance for locomotion on and off the unit and personal hygiene. The resident had a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The MDS identified the resident at risk for pressure ulcers, but he/she had none at the time of the assessment. The MDS identified the resident had a pressure relieving device for the chair and bed. The triggered care area assessments (CAAs), dated 3-29-17 included: Urinary incontinence with a notation the resident had an indwelling catheter. Activities of daily living (ADLs) with an admission for physical therapy, occupational therapy and speech therapy, for a [DIAGNOSES REDACTED]. Psychosocial well-being with a patient health questionnaire (PHQ9 score indicating depression). The resident refused antidepressant medication because he/she felt the depression was related to the fracture and recovery. Pressure ulcer, the resident 's immobility, advanced age, fragile skin and takes aspirin all put the resident at risk for the development of pressure ulcers, skin breakdown, and bruising. Braden assessment score (a tool for assessing the risk for development of pressure ulcers) on 3-17-17 was 15 and a score below 17 indicated risk for pressure ulcer development. Review of the ADL care plan with a start date of 3-24-17 revealed the resident exhibited weakness from the left [MEDICAL CONDITION] and required staff assistance for mobility. Interventions to address the problem included, staff assistance with the walker and gait belt for transfers, weight bearing as tolerated to left lower extremity and not ambulatory at the time, related to the left heel. Staff to assist with mobility and positioning of left lower extremity. The resident was able to shift his/her weight and staff assisted with lifting and repositioning of both lower extremities. Physical therapy, occupational therapy and speech therapy were ordered. The 3-24-17 revised care plan identified a risk for pressure ulcers. Interventions directed staff to provide a pressure redistribution mattress and cushion in his/her recliner, monitor nutrition and hydration, monitor skin with bathing and care, notify the nurse of any skin issues, weekly skin monitoring, follow protocol for skin tears and dressing change to left hip. Monitor left heel for breakdown. On 4-6-17 staff added interventions for an off-loading boot. Review of clinical notes from the hospital stay, dated 3-10-17 revealed staff identified the resident's left heel displayed [DIAGNOSES REDACTED] and felt boggy (is used to describe something that, on physical examination, feels like it has fluid in it.). The staff noted the heels blanched (to press on a person's skin to push blood away and wait for return to determine blood circulation). Review of progress notes dated 3-17-17 revealed the facility admitted the resident to the facility for skilled level care after repair of the left [MEDICAL CONDITION]. Staff assessed the resident with [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) to the left lower extremity. The skin assessment noted multiple bruised areas to the resident's forearms but did not note any pressure areas. A progress note dated 3-18-17 at 12:47 p.m. noted the resident was admitted on skilled part A with physical therapy, occupational therapy and speech therapy for [DIAGNOSES REDACTED]. The resident stated he/she knew he/she had confusion, but it was improving. Staff noted the resident had 2+ [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissue demonstrated by application of pressure to the swollen area with a finger which causes an indentation that persists for some time) to both lower extremities and the pedal pulses(pulses found on top of the foot) were easily palpated (felt). CMS (Circulation, motion, sensory) were intact in the extremities. The resident's skin was warm and dry. Staff noted bruising but did not document location or a description of the bruising. The staff did not mention any pressure areas in the assessment note. The progress note dated 3-26-17 at 1:45 p.m. revealed staff completed a skin assessment and found a concern related to the resident's heel, and noted the area seemed to be a pressure ulcer 4.5 cm by 2.5 cm, and presented as a purple bruised area. Staff directed to keep the resident's heel floated and put a protector on the resident's heel, but the primary care physician was to address the issue the next morning. Review of a skin evaluation sheet dated 3-26-17 revealed staff floated the resident's heels and applied heel protectors and monitored for skin breakdown. Staff described a purple colored bruise 4.5 cm by 2.5 cm area to the right heel with the wound edge intact. A progress note documented the primary care physician saw the resident on 3-27-17 but did not write any new orders. A progress noted dated 3-28-17 at 10:55 a.m. noted the resident had a soft purple spot to the left heel. Staff encouraged the resident to keep his/her feet elevated and heels floated to prevent breakdown. The resident had soft pressure relieving boots. Progress notes dated 3-29-17 at 10:12 am revealed the resident had [MEDICAL CONDITION] to the right lower extremity and 3+ [MEDICAL CONDITION] to the left lower extremity. Therapy to start [MEDICAL CONDITION] (- swelling caused by accumulation of lymph0 treatments and wrap the left leg monitoring the soft purple area on the resident's left heel. The resident's heels were floated at all times and he/she wears soft pressure relieving boots. Progress note dated 3-30-17 at 3:53 p.m. revealed therapy would not apply [MEDICAL CONDITION] wraps or use any kind of compression stocking until the left heel area was healed. A progress note for 3-31-17 at 6:19 p.m. documented staff notified the primary care physician (PCP) the area on the resident's left heel increased in size and since the physician had not addressed the area at the appointment on 3-27-17 (5 days earlier) staff wanted to know what to do. The PCP gave orders to send the resident to the walk-in clinic. Staff sent the resident to the walk-in clinic. Staff at the walk-in clinic expressed more concern about the [MEDICAL CONDITION] in the resident's leg than the pressure ulcer. The staff at the clinic did a sonogram of the left lower leg to rule-out a [MEDICAL CONDITION] (clot that developed within a blood vessel), but did not address the pressure ulcer on the resident's left foot. Review of a skin evaluation sheet dated 3-31-17 revealed staff floated the resident's heels and applied heel protectors and monitored for breakdown. The resident had a 5.5 cm by 2.5 cm purple colored bruise to the right heel with intact skin. The staff noted the area increased in size and the outer edges of the wound seemed to be regenerating some new skin making those areas much more firm. A progress note on 3/31/17 at 6:56 p.m. revealed the left heel remained bruised. The resident continued to offload the heel when in a chair and wore the boots at night. Review of the skin evaluation sheet dated 4/2/17 revealed staff floated the resident's heels and applied heel protectors and monitored for breakdown. The resident had a 5 cm by 3 cm purple colored bruise to the right heel with intact edges. The staff noted the area had gotten wider and the outer edges of the wound seemed to be regenerating some new skin making those areas much more firm. On 4-2-17 the PCP wrote an order for [REDACTED]. A progress note dated 4-4-17 clarified orders from the walk-in clinic on 3-31-17, 4 days prior. The orders included use of a pressure relieving boot when up. Progress notes dated 4-4-17 at 7:22 p.m. noted PT gave the resident an off-loading boot, but it did not work as well as hoped, so they planned to try different types of offloading boots. A progress note dated 4-8-17 at 5:14 p.m. noted the resident still waited on PT for an off-loading boot. A progress noted dated 4-10-17 at 10:55 a.m. revealed the blood blister to the left heel remained but was healing well. A progress note dated 4-11-17 at 11:02 a.m. noted improvement of the heel, with pink, firm skin around the area. A progress note dated 4-12-17 noted an order for [REDACTED].>A progress noted dated 4-13-17 at 3:29 p.m. noted the left heel remained bruised and staff offloaded and used the blue boots at night. Still waiting for PT to get the offloading boot. 4-13-17 at 3:36 p.m. The left heel blister opened at the edges of the wound. The resident had dried blood on his/her sock. Staff assessed the area as stable with a hard scab and no dressing. Review of the 4-13-17 skin evaluation form for the left heel revealed was slightly wider and still purple in color. The outer edges of the wound seem to be regenerating some new skin making those areas much firmer. The resident said it was a little sore. The area measured at 6.8 cm by 2 cm, with the wound edge intact. The treatment continued the same, float heels, apply heel protectors and monitor for heel breakdown. Nurses Notes on the sheet included the left heel continued to heal nicely, the edges of the heel were hard and scabbed. New skin forming under the dermis, it was different in color compared to the rest of the area. Middle of wound continued to be soft, will continue to monitor daily. Review of the 4-16-17 skin evaluation form revealed staff remeasured, the left heel and the area was slightly wider and still purple in color. The outer edges of the wound seemed to be regenerating some new skin making those areas much firmer. Resident says it is a little sore. The area was measure as 6.8 cm by 2 cm, and bruised purple. The treatment continued the same; floated heels applied heel protectors, monitored heel for skin breakdown. 4-19-17 wound clinic notes revealed the physician felt the heel was doing acceptably well. The physician noted he/she was trying to find a compromise between not letting the resident do any physical therapy and keeping his/her heel completely off loaded. The physician noted he/she did not see that physical therapy had hurt the resident's heel a lot but said the therapy would hinder the healing of the heel. The physician felt it was important to establish some kind of strength to help the resident with his/her independence. 4-26-17 wound clinic notes revealed the physician started alginate dressings (a highly absorbent dressing used for wound healing0 daily to the left heel wound. 4-23-17 Skin evaluation form, left heel wound 5.5 cm x 2 cm. Float heels, applied heel protector, monitor for breakdown. 4-26-17 wound clinic notes included alginate 4-30-17 Skin evaluation form- left heel wound has decreased, new skin generating but has blackened center with flat edges. Has yellow tinged drainage. Wound 5 cm x 2 cm, undermining bruised purple. 5-3-17 Wound clinic notes indicated the heel wound bed had soft eschar (dead tissue). Sharp excisional debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) done to remove the eschar. Did not get all the way to the bottom of the wound because it would be difficult to manage if it started bleeding. Shoe altered so could try physical therapy for him/her. 5-4-17 Skin Evaluation - The pressure wound to the left heel measured 2.7 cm x 1.2 cm and the wound bed was reddish pink with rounded edges. The wound had yellowish brown drainage and a strong smell at the time of changing, but it was noted the odor could be from the dressing not being changed for a few days. 5-5-17 Skin Evaluation Form for left heel, wound bed was pink with center deeper, slough and loose skin around edges into the wound. Edges were flat. Yellowish/green brown drainage continued and staff noted an odor. The wound was 5 cm x 2 cm with wound edge intact, bruised and purple 5-10-17 wound clinic notes identified to continue the alginate treatment for [REDACTED]. 5-10-17 Wound clinic progress notes- the resident said he/she walked a little bit, but was confined to his/her room related to infection of a wound to the resident's neck. The left heel wound evidenced granulation around the margins with some [MEDICATION NAME] in the center of the wound. Sharp debridement was performed to the pressure wound on the heel. The physician noted he/she could identify the wound on the heel is a stage III possibly. The physician felt it was acceptable for the resident to continue with the current amount of weight bearing he/she was doing 5-10-17 physician's orders [REDACTED]. 5-14-17 The skin evaluation showed the left heel wound bed was 2.7cm by 1.2cm by 0.2cm and wound bed was reddish pink, rounded edges and yellow drainage continued with no pain voiced from the resident and treated with alginate. 5-18-17 physician's orders [REDACTED]. 5-29-17 Review of the skin evaluation sheet revealed the left heel wound bed was reddish pink with rounded edges. The wound continued to have a yellowish brown discharge with a strong smell but staff had not changed the dressing for several days, will monitor) [MEDICATION NAME] was applied to the wound then staff placed the alginate and secured the area with gauze. The wound measured 2.7 cm x 1.2 cm. 6-1-17 physician's orders [REDACTED]. 6-4-17 Skin evaluation sheet, left heel wound bed was identified as reddish pink with rounded edges. The wound was noted to continue to have a yellowish brown discharge with a strong smell but staff noted the dressing had not been changed for several days and could account for the strong odor. [MEDICATION NAME] was applied to the wound then staff placed the alginate and secured the area with gauze. The wound measured 2.7 cm by 1.2 cm by 0.2 cm. 6-9-17 Skin Evaluation Sheet. The wound bed was identified as reddish pink with rounded edges. The wound was noted to continue to have a yellowish brown discharge with a strong smell but staff noted the dressing had not been changed for several days and could account for the strong odor. [MEDICATION NAME] was applied to the wound then staff placed the alginate and secured the area with gauze. The wound measured 2.7 cm by 1.2 cm by 0.2 cm. 6-10-17 interdisciplinary team notes (IDT) noted the resident wore blue pressure relieving boots at night with cast shoe to left foot and sandal to right foot when standing, transferring or walking. 6-19-17 IDT notes, treatment to left heel, area is decreasing in size. Resident wore a boot when up. Blue boots (TRUNCATED)

The facility had a census of 107 residents. The facility utilized 2 vans, 1 bus and 1 car to transport residents. Three residents transported in facility vans/busses were selected for sample. Based on observation, interview and record review, the facility failed to ensure the resident environment remained free from potential hazards during transport when the facility failed to complete routine preventative maintenance checks of a platform lift used to raise/lower residents in a facility van. Resident #1 fell from the platform lift in a wheelchair from a height of approximately 3 feet during transfer from the bus to the ground. The resident sustained [REDACTED]. Facility failure to ensure completion of preventative maintenance checks on the lifts used during resident transports placed resident #1 in immediate jeopardy. The facility also failed to ensure completion of routine preventative maintenance checks for safety related to ramps used to load/unload residents into facility vans. Findings included: - Resident #1's clinical record included a 10/5/16 Admission Minimum Data Set (MDS) which identified the resident with no cognitive impairment, total dependence on two staff for transfers, an inability to ambulate, total dependence on staff for locomotion off the unit, functional limitations in range of motion on both sides of the lower extremities, and used a wheelchair. The 1/23/17 Quarterly MDS identified the resident with no changes in cognition, transfer/ambulation abilities or range of motion limitations. According to the MDS, the resident continued to use a wheelchair. Care Area Assessments (CAAs) completed on 10/10/16 included: Activities of Daily Living (ADLs): Described the resident's admission from another long term care facility with multiple medical issues, including chronic renal (kidney) failure. The resident required dialysis(a method of separating toxins from the blood via medical equipment) three times weekly. According to the CAA, the resident reported a history of a fractured (broken) leg 16 months prior and an inability to walk since that injury occurred. The resident used a sling type mechanical lift for transfers with assistance of two staff, and had the ability to propel the wheelchair short distances. The 1/17/17 Fall Risk Assessment identified the resident as high risk for falls. The 10/17/16 Care Plan included: Self-Care Deficit: Directed staff to transfer the resident with a full mechanical lift and assistance of two staff and to use a wheelchair for locomotion. Dialysis: Directed staff to transport the resident to and from dialysis three times weekly. Potential for Falls: Described the resident's risk for falls due to unsteady balance with transitions, medication side effects and potential drops in blood pressure after dialysis. On 3/22/17, the facility noted the resident's fall while at dialysis and subsequent transfer to the emergency room . Interdisciplinary (ID) notes included a 3/22/17 entry written at 10:09 a.m. which described a phone call from dialysis center staff who reported resident #1 fell from the wheelchair during transfer off the bus, landed face first on the ground and then became unresponsive and required bagging (supplemental ventilation/respiration). Dialysis staff reported they sent the resident to the emergency room of the local hospital. The facility's investigation of the 3/22/17 incident described resident #1's fall from a raised lift on a facility owned bus while seated in his/her wheelchair. The 3/22/17 Emergency Record from the local hospital described resident #1's fall out of a lift during a transport to the dialysis center and the resident fell on to his/her face. According to the documentation, emergency transport personnel found the resident barely breathing when they arrived on the scene. Emergency personnel gave the resident rescue breaths (assisted respiration) and the resident started breathing again. [DIAGNOSES REDACTED]. The physician in the hospital emergency room determined the resident required specialized care and staff then transferred him/her to a larger hospital in a nearby city. During an observation on 3/23/17 at 11:00 a.m., Administrative Nurse B and Transportation Staff C provided survey staff with a demonstration of the actual platform bus/lift from which resident #1 fell on [DATE]. The large multiple passenger white bus had a side door at the rear of the passenger side of the vehicle. Administrative Nurse B opened that door and Transportation Staff C stood inside the bus and used a control box to activate the mechanism on a large, heavy metal platform wheelchair lift. The control contained two buttons. When compressed, one button moved the lift from an upright position (as needed when stored inside the van) to a lowered/flat surface position. The other button controlled the raising/lowering of the platform from the height of the bus doorway to the level of the ground. The control box did not have a button to raise or lower the roll stop, a metal piece which extended across the width of the platform at the front edge of the lift platform to prevent a wheelchair from rolling off the edge. When Transportation Staff C pressed a button on the control, the platform changed from an upright position to a lowered position on which staff might load a wheelchair. Once lowered from an upright position to a flat surface position, the roll stop on the front/street facing side of the platform automatically raised/latched to prevent forward wheelchair movement. The other three sides of the lift also had permanently affixed raised edges approximately 1 inch in height to prevent wheelchairs from rolling off. Transportation Staff C lowered the platform to the ground. When the undersurface of the lift platform touched the ground, the roll stop automatically released downward and became a transition piece for ease of transfer from the lift platform onto the street/sidewalk/surface. Staff C demonstrated how a spring latch attached to a bar on the underside of the platform caused the roll stop to release/lower upon contact with the hard surface of the ground. Once the roll stop lowered, nothing prevented the wheelchair from moving forward off the front/street side of the platform. Transportation Staff C then raised the platform again, and the roll stop automatically went back to an upright position and latched to the lift platform. Administrative Nurse B pulled and pushed on the roll stop in an attempt to release it with the platform raised off the ground, and the roll stop did not release. Transportation Staff C demonstrated the height from which resident #1's wheelchair fell which was approximately 3 feet from the ground. Staff C also loaded resident #1's bariatric (extra-large) wheelchair onto the lift platform. Once on the platform, the wheelchair fit within the yellow striped decals as required in the manufacturer's operating manual, with approximately 1-2 inches between the front wheels of the wheelchair and the roll stop, which demonstrated how slight forward movement of the wheelchair had the potential to cause the wheelchair to go off the front of the platform with the roll bar in a down/collapsed position. During an interview on 3/23/17 at 8:45 a.m., Administrative Staff A reported Transportation Staff D drove the bus to transport resident #1 to dialysis on the day of the fall from the lift. Staff A reported the resident required transportation in the bus with the platform lift due to his/her large size and Transportation Staff D transported the resident with that bus and used that lift many times prior to the day of the fall. Administrative Staff A reported resident #1 somehow rolled off the front edge of the lift platform when the platform remained about half way up, and struck the ground with his/her body and head. According to Administrative Staff A, the resident sustained [REDACTED]. Administrative Staff A reported he/she took the bus/lift involved in the incident out of commission immediately after he/she learned of the resident's fall. During an interview on 3/23/17 at 9:54 p.m., Transportation Staff C confirmed Transportation Staff D frequently transported resident #1 to dialysis in the facility bus with the platform lift. Staff C reported staff typically only transported resident #1 in that particular bus and with that specific lift due to the resident's large size. On rare occasions, the facility used that bus/lift for other residents, but only rarely. Staff C denied any problems/mechanical issues with the lift prior to the previously described incident on 3/22/17. According to Staff C, administrative staff took the keys to the vehicle immediately after the incident and it could not be used until further notice. During an interview on 3/23/17 at 12:55 p.m., Transportation Staff D confirmed he/she drove resident #1 to the dialysis center early in the morning on 3/22/17. Once there, Staff D reported he/she lowered the lift platform to a flat surface position and rolled the resident's wheelchair onto the platform. Staff D recalled the roll stop on the front of the platform was in a raised position when he/she loaded the resident on to the platform. Staff D remained inside the bus and used the hand control to lower the resident. According to Transportation Staff D, the platform lowered approximately 12 inches when suddenly, with no advance warning, resident #1 fell off the front of the platform and onto the ground below. Staff D recalled the resident's abdomen hit the pavement first, followed by his/her head. Staff D immediately ran inside the dialysis center to get assistance, and staff at dialysis called 911. Emergency medical staff arrived within a few minutes and by that time Staff D saw that resident #1 was having problems breathing. Emergency staff then transported the resident to the hospital. Staff D reported he/she received training on how to properly use the platform lift prior to making unsupervised transportation runs, and felt comfortable with the lift. Staff D recalled he/she used extra caution with resident #1 due to the resident's large size and therefore drove the van slowly and maneuvered around corners slowly to avoid shifting of the wheelchair in transit. Staff D denied any problems with the lift prior to the 3/22/17 incident, and stated Everything always worked just fine. According to Staff D, the only explanation for the roll stop malfunction must be mechanical in nature because everything else happened just as it always did on previous transfers. The Operator's Manual for the Series 07 L915 Millennium Series Commercial Wheelchair Lift, the specific model of lift used on the facility transport bus, included specific recommendations related to maintenance and lubrication of the lift. Page 40 of the manual directed the owner to lubricate the pivot points approximately every 4 weeks or 100 cycles with alight penetrating type oil. According to instructions on page 40, maintenance and preventive maintenance must be performed at the recommended intervals by an authorized service representative who had attended and been certified by manufacturer. A warning on page 40 advised of the potential for serious bodily injury and/or property damage in the absence of adequate maintenance and lubrication procedures. On 3/23/17 at 2:00 p.m., survey staff requested documentation related to preventative safety/maintenance checks of the platform lift used during the 3/22/17 transfer. In response to that request, the facility provided an invoice dated 1/26/17 which showed a local service company repaired a leaking cylinder on the platform lift on that date. The invoice lacked evidence of a full inspection of the lift, including all latches and other mechanical safety features, on that date. On 3/28/17, Administrative Staff A sent an email which confirmed the facility lacked any documentation of safety/preventive maintenance checks of the platform lift used on 3/22/17, and specifically no documentation of safety checks as recommended by the lift manufacturer in the Owner's Manual for the lift. Although requested on 3/23/17, the facility did not provide a policy related to preventive maintenance expectations for lifts/equipment/vehicles used during transportation of residents. The facility failed to ensure the resident environment remained free from potential hazards during transport when the facility failed to complete routine preventative maintenance checks of a platform lift used to raise/lower residents in a facility bus. Resident #1 fell from the platform lift in a wheelchair during transfer from the van. The resident sustained [REDACTED]. Facility failure to ensure completion of preventative maintenance checks on a lift used during resident transports placed resident #1 in immediate jeopardy. The facility removed the bus/platform lift from use for all facility residents immediately after the 3/22/17 incident. The deficient practice was identified as past non-compliance and was corrected on 3/22/17. - Written/email communication with Administrative Staff A on 3/28/17 confirmed the facility used two smaller passenger vans to transport residents in addition to one larger van which contained a platform lift. During an interview on 3/23/17 at 9:54 a.m., Transportation Staff C confirmed the facility utilized two smaller vans to transport residents. Residents in wheelchairs who used the smaller vans for transport were loaded in and out of the vans via a ramp. Although requested on 3/23/17, the facility could not provide any evidence of safety checks/preventive maintenance checks of the ramps/small vans used to transport residents. Although requested on 3/23/17, the facility did not provide a policy related to preventive maintenance expectations for lifts/equipment/vehicles used during transportation of residents. The facility failed to have a system in place to ensure routine mechanical/safety/preventive maintenance checks of lifts/equipment/facility owned vehicles used to transport residents.

The facility had a census of 109 residents with 3 residents selected for sample. The three residents included in the sample utilized "Bed Buddies" (hot rice packs). Based on observation, interview and record review, the facility failed to provide 1 of 3 sampled residents with adequate supervision to prevent accidents when unlicensed staff applied an overheated rice pack/Bed Buddy to resident #1's shoulder, and then failed to monitor the rice pack after placement. Resident #1 sustained second degree burns to the left shoulder from placement of the rice pack. Findings included: - Resident #1's clinical record included an undated "Detailed Summary" report that identified the resident with multiple medical diagnoses, including flaccid [DIAGNOSES REDACTED] (paralysis of one side of the body). A 1/14/15 Admission MDS (Minimum Data Set) identified resident #1 with no cognitive impairment, the need for extensive assistance of two staff for bed mobility, total dependence on staff for transfers, an inability to ambulate, functional limitations in range of motion on one side of the upper and lower extremities, and no "burns" to the skin. A 60 day Medicare Part A MDS dated [DATE] identified resident #1 with no improvement or decline in ADL (activity of daily living) abilities since the previous MDS. According to this assessment, the resident had 2nd or 3rd degree burns. Pressure Ulcer CAAs (Care Area Assessments) completed on 1/14/15 noted resident #1's risk for pressure ulcer development, skin breakdown and bruising related to impaired mobility and left sided [DIAGNOSES REDACTED]. The CAA also noted resident #1's need for a full mechanical lift and assistance of two staff for transfers as well as his/her ability to "minimally assist" with bed repositioning. The undated admission care plan included a variety of interventions related to resident #1's need for staff assistance with bed mobility and transfers. On 2/6/15, staff reviewed/revised the care plan to include the intervention for use of a "Bed Buddy" every 2 hours for 20 minutes as needed for pain to affected areas. Physican's orders included a 2/6/15 order for a Bed Buddy every 2 hours for 20 minutes as needed for pain. An Admission Skin Assessment completed on 1/7/15 revealed no evidence of skin breakdown or injury on the back, shoulder or scapula (shoulder blade). Nurses Notes included the following entries related to an injury/burn to resident #1's left shoulder: o 2/25/15 at 3:22 a.m.: Described an "upper left shoulder fluid filled blister measuring 7 cm (centimeters) by 5 cm." with additional surrounding areas of redness. The entire dimensions of the affected skin (blister and reddened skin) measured 8.5 cm by 4.5 cm. According to the Nurses Note, resident #1 had no knowledge of how the injury occurred. The entry went on to describe placement of a "Bed Buddy" rice pack on the resident's shoulder the previous day. o 2/25/15 at 3:43 p.m.: Described an upper left shoulder fluid filled blister which measured 7 cm by 5 cm. The entry again noted the theory that the Bed Buddy caused the burn to the shoulder. According to the note, staff cleaned the affected area and covered it with "Xeroform", a type of gauze dressing, and secured it with tape. The note also described physician notification of the wound and requests for treatment orders. o 2/25/14 at 7:43 p.m.: Described the physician's orders [REDACTED]. Subsequent Nurses Notes in the time period from 2/26/15 to 3/9/15 describe the presence of a blister to resident #1's left upper shoulder. A Nurses Note dated 3/10/15 at 6:39 p.m. described the left shoulder wound with a "dark center and yellow periwound (area surrounding the wound) and some redness around the yellow." According to the Note, the resident had an appointment with his/her physician earlier that afternoon and that physician referred the resident to a local wound care center for treatment. Additional Nurses Note entries included: o 3/11/15 at 4:27 p.m.: Described the left shoulder blister as 5 cm by 3 cm with a dark center with a yellow area around the center and some redness around the yellow area. According to the note, resident #1 had some tenderness to the area during a dressing change. o 3/12/15 at 1:30 p.m.: Noted the presence of an open blister to the left shoulder and new treatment orders received from the "wound doctor." o 3/13/15 at 10:26 a.m.: Noted the presence of the wound to the left shoulder and described new physician's orders [REDACTED]. o 3/14/15 at 5:30 p.m.: Noted the presence of the left upper shoulder wound that had a "minimal amount" of tan drainage. According to the note, the wound bed contained pink tissues as well as yellow slough (dead tissue, usually cream or yellow in color). o 3/15/15 at 3:27 p.m.: Described the wound to the left upper shoulder as "...yellow slough noted to approximately 50% of wound. There is a small amount of black colored area on top of the slough." February 2015 Treatment records included: o "Provide a bed buddy every two hours every 20 minutes as needed for pain to affected area." Staff signed off the treatment on 2/20/15 and 2/21/15. The treatment record included no documentation of placement of a Bed Buddy on 2/24/15. During an observation on 3/16/15 at 1:55 p.m., Licensed Nurse C removed a dressing from resident #1's upper left scapula area. The wound beneath the dressing was approximately the size of a half dollar, with pinkish-red tissue noted in the lower 1/3 of the wound and yellow slough in the upper 2/3. During the observation and examination of the wound,. resident #1 reported it hurt "a little." The facility investigation into the burn to resident #1's shoulder included a notarized statement from Administrative Nurse B which summarized the events leading up to the injury . According to that statement, resident #1 requested a bed buddy on the afternoon of 2/24/15. Direct Care Staff D heated the bed buddy in the microwave for 2 minutes and then, when it didn't feel hot enough, heated it for an additional minute. Staff D failed to put a bowl of water in the microwave during the warming process as per the manufacturer's recommendations. Staff D reported the bed buddy smelled like "burned rice" and he/she thought it felt too warm to use. Direct Care Staff E was also in the room and also thought the bag smelled like burned rice, but did not think it was too warm. At resident #1's request, Staff D and E assisted the resident to lean forward in the bed and they placed the bed buddy between the resident's upper left scapula area and the mattress and then eased the resident back to a position where he/she compressed the bed buddy behind him/her. Staff D and E denied resident complaints about the temperature of the bed buddy at the time of placement. During their investigation, staff interviewed resident #1 and included a summary of that interview in their documentation. Resident#1 reported he/she asked staff for the bed buddy and asked that they place it behind him/her. As part of their investigation, the facility also assessed resident#1's skin sensitivity to the left shoulder area, and noted inconsistencies in ability to detect touch to the left shoulder and arm. A notarized statement provided by Direct Care Staff D described resident #1's request for a bed buddy on 2/24/15. According to the statement, Staff D heated the bed buddy in the microwave for two minutes, turned it over and then heated it for an additional one minute. Staff D then assisted with placement of the bed buddy on resident #1's left shoulder. A notarized statement provided by Direct Care Staff E described resident #1's request for a bed buddy on 2/24/15. According to the statement, Staff D heated the bed buddy in the microwave in another room, and when she brought the hot pack into resident #1's room, it smelled like "burnt rice." Staff E then applied the bed buddy to resident #1's shoulder. During an interview on 3/16/15 at 11:30 a.m., resident #1 reported he/she received burns from a "bed buddy" staff applied to "my back and shoulder" on 2/24/15. According to the resident, he/she asked staff for the hot pack because it helped with pain in the left arm and shoulder. Staff got the hot pack and "sandwiched it" between the mattress and the upper shoulder per his/her request. Staff then left the room. Resident #1 reported he/she didn't have much feeling on the left side, but the hot back became uncomfortable quickly so he/she removed it. Resident #1 denied knowledge of an injury to the left shoulder until staff noticed the blister early the next morning. During an interview on 3/16/15 at 1:30 p.m., Direct Care Staff E reported resident #1 received a burn from a hot pack that staff applied on 3/24/15. According to Staff E, prior to that incident, CNAs (certified nurse aides) could warm up the bed buddies and put them on residents without any involvement of the licensed nurses. Staff E could not recall training on how to use Bed Buddies or other hot packs safely. Staff E also reported staff sometimes covered the hot packs before applying them, but "not always." Additionally, Staff E denied knowledge of the time period staff should leave the hot packs in place, stating, "We usually just took them out when they felt cold." Since resident #1 received the burn as the result of hot pack application, Staff E reported only licensed nurses can apply hot packs. Staff E described the application of resident #1's hot pack on 2/24/15, and stated Direct Care Staff D heated the bed buddy in the microwave for more than 2 minutes without any water in the microwave. When Staff D brought it into the room, it smelled like burned rice "but we didn't think anything about it" and they then placed the hot pack between the mattress and resident #1's upper left shoulder blade area. During an interview on 3/16/15 at 1:15 p.m., Licensed Nurse C reported he/she learned of resident #1's burn from a bed buddy a few days after the injury. Nurse C confirmed the resident received "a pretty nasty burn" from the hot pack. Nurse C denied knowledge of the facility policy for application of hot packs/bed buddies prior to resident #1's injury, but described the current revised policy that required only licensed nurses or licensed therapy staff to provide such treatment. During an interview on 3/17/15 at 9:30 a.m., Administrative Nurse B reported he/she thought "everyone" could apply hot packs/bed buddies prior to resident #1's burn. Since the burn, the facility revised the policy and now only allows nurses to apply the hotpacks which also require assessment of skin before and after the treatment. Attempts to interview resident #1's physician were unsuccessful on 3/17/15 at 9:00 a.m.. On 3/17/15 at 11:10 a.m., Physician F's nurse reported the physician wanted him/her to pass on information that resident #1 received 2nd degree burns as a result of the hot pack. As requested, the facility provided the policy for use of hot backs/bed buddies prior to resident #1's burn on 2/24/15. According to that "Warm Moist Packs #8003" policy dated 08/03, the facility would provide "therapeutic warm, moist packs for residents, according to doctor's orders, in a safe and effective manner." Additional policy contents related to specific requirement for warm moist packs and Bed Buddy packs included: o Charge nurse (RN (registered nurse), LPN (licensed practical nurse), CMA (certified medication aides)) is responsible for administering other warm moist packs and assessing skin condition of resident before, during and after treatment. o Continuous low heat in one area can burn. Continually shift the position of the Bed Buddy when in use. o Do not sleep on the Bed Buddy. o Should not be used in areas of poor circulation or insensitive skin. The facility failed to provide resident #1 with adequate supervision to prevent accidents when non-licensed staff applied an overheated Bed Buddy rice pack to resident #1's left upper scapula area. Staff did not monitor/reposition the hot pack after placement. Resident #1 received 2nd degree burns as a result of hot pack placement.

The facility reported a census of 98 residents with 8 included in the sample. Based on interview and record review, the facility failed to develop and implement interventions to prevent the development of a facility acquired avoidable stage III pressure ulcer (a localized full thickness skin loss where fat tissue may be visible as a result of pressure or pressure in combination with shear) for 1 of 3 residents reviewed for pressure ulcers. (#3 a closed record) Findings included: - Review of resident #3's annual MDS (Minimum Data Set) dated 6/24/13 revealed he/she had short and long-term memory problems and his/her cognitive skills for daily decision making were severely impaired. The resident did not exhibit rejection of care. He/she required extensive assistance of 2 or more staff for bed mobility, transfers, and locomotion on/off the unit. The resident used a walker and a wheelchair. The assessment indicated the resident had a therapeutic, mechanically altered diet and no weight loss. He/she was always incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and did not have any unhealed or healed pressure ulcers at the time of the assessment. Review of resident #3's Skin CAA (Care Area Assessment) dated 6/28/13 revealed the resident was at risk for pressure ulcers due to his/her incontinence and bed mobility. The resident often slept in the recliner in the lobby due to his/her attempts to get out of bed often becoming a safety issue. The resident wore incontinence briefs. The staff assisted resident #3 with peri-care and application of moisture barrier after each incontinent episode to prevent skin breakdown. Review of resident #3's quarterly MDS dated [DATE] revealed the resident had memory problems and severe impaired cognitive skill for daily decision making. He/she did not reject care. The resident required extensive physical assistance of 2 or more staff for bed mobility, transfers, and locomotion on/off the unit. The resident was always incontinent of bowel and bladder. He/she did not have any weight loss. The assessment reported the resident did not have any unhealed pressure ulcers. Review of resident #3's Pressure Ulcer Care Plan, last updated 4/16/14, revealed on 3/29/14 the resident had a Braden (scale for pressure ulcer risk) score of 16, indicating the resident was at risk for developing a pressure ulcer. The resident required the assistance of staff with toileting and peri-care. The staff monitored the resident's skin with routine care and bathing, paid special attention to areas located over bony prominences. Interventions directed the staff to report any red/open areas to the charge nurse for further assessment/treatment, provide a pressure redistribution cushion in the resident's wheelchair and pressure redistribution mattress on the resident's bed, and assist the resident with frequent position changes. Additional interventions direct the staff to assist the resident to the bathroom as he/she alerted the staff when needed, the resident required 1-2 staff assistance with toileting, peri-care and adjustment of clothing, and apply facility provided barrier cream to perineal area after toileting/incontinence to protect skin. An undated revision alerted the staff of a stage II (partial thickness loss of skin presenting as a shallow, open ulcer with a red pink wound bed without slough (soft, moist tissue that may be white, yellow, tan, or green and it may be loose or firmly adherent)) and a stage III (full thickness tissue loss, subcutaneous (beneath the skin) fat may be visible, but bone, tendon, or muscle are not exposed) pressure ulcer to the right and left mid-coccyx (small triangular bone at the base of the spine )and the staff were to provide a dressing as determined by the physician and wound nurse and major repositioning while up every 1.5 hours and in bed when the resident slept if tolerated. Review of a nurse's note dated 6/24/14 revealed resident #3 returned to the facility from behavioral health. The note reported the resident's skin to be warm and dry. The assessment did not indicate any [MEDICAL CONDITION]. Review of resident #3's comprehensive skin assessment dated [DATE] revealed a Braden score of 16, indicating the resident was at risk for developing a pressure ulcer. The resident's skin was in normal limits. The resident's skin integrity was intact with no [MEDICAL CONDITION], no moisture, no ulcers, and no pain. Review of a nurse's note dated 6/30/14 revealed during morning cares the staff noted skin erosion to bilateral (both sides) of the gluteal crease (pertaining to the buttocks) at resident #3's coccyx. The staff cleansed the area and covered with a Duoderm (a moisture-retentive wound bandage) dressing. The note indicated the resident had been in bed a lot of time on 6/30/14. The staff measured the areas: the lesion on the left was 2.3 cm x 1.3 cm (centimeters) and on the right 1 cm x 1.2 cm. The note stated the areas were reddened with no signs of infection. Review of resident #3's skin assessment dated [DATE] revealed the resident had a Braden score of 17, indicating the resident was at risk for developing a pressure ulcer. The assessment reported the resident had poor skin color, his/her skin temperature was warm, his/her skin turgor was within normal limits, he/she had dry or rough skin, and his/her skin integrity was intact. The assessment noted the resident had incontinence of bowel and bladder, wore briefs, and did not have excessive moisture. The assessment reported the resident did not have any ulcers. Review of a Braden scale score dated 7/2/14 revealed a score of 17, indicating the resident was at moderate risk for developing pressure ulcers. Review of a nurse's note dated 7/3/14 revealed the area of concern on resident #3's coccyx was assessed. The note reported the resident had a stage III pressure ulcer on his/her right side and midline coccyx measuring 3 cm x 1 cm with yellow slough in the wound bed to midline and mixed slough/granulation (the pink/red, moist, shiny tissue that glistens and fills a wound bed when it begins to heal) to the right side. The note reported a stage II pressure ulcer to the left side of the coccyx measuring 1.5 cm x 1.5 cm with a pink wound bed. The staff applied a dressing after cleansing the area per pressure ulcer protocol. The staff notified the physician via fax that he/she implemented standing orders for wound care. An interview on 7/15/14 at 8:45 a.m. with a family member of resident #3 revealed the resident was in the hospital with a Stage III sore on his/her bottom. He/she reported resident #3 developed the pressure ulcers while at the facility. During an interview on 7/17/14 at 5:08 p.m. direct care staff N revealed the staff repositioned and toileted resident #3 every 2 hours. Staff N reported the resident had a cushion pad in his/her wheelchair to relieve pressure. Staff N reported the resident was not allowed to stay in the recliner or bed for very long to help prevent pressure. During an interview on 7/17/14 at 1:12 p.m. licensed nursing staff P revealed skin assessments were done on admission and then weekly for the next 4 weeks. Staff P reported resident #3 had no skin issues upon departure to the behavioral health and no skin issues upon return to the facility. Staff P confirmed the resident's pressure ulcers developed in the facility. During an interview on 7/17/14 at 2:19 p.m. licensed nursing staff Q revealed when he/she was notified of skin issues, he/she assessed it. Staff Q reported he/she assessed resident #3 on 7/3/14 and staged his/her pressure ulcers. At 3:42 p.m. staff Q confirmed the wound measurements in the note dated 7/3/14 were accurate. During an interview on 7/17/14 at 2:33 p.m. licensed nursing staff R revealed he/she assessed resident #3 ' s coccyx when the resident was readmitted to the facility and reported the resident did not have any skin integrity issues. Staff R reported following the nursing assessment done on 6/30, the physician was notified and protocol initiated. Staff R reported the wound nurse assessed resident #3 several days later. At 3:38 p.m. staff R confirmed the wound measurements in the nursing note dated 6/30/14 were accurate. During an interview on 7/17/14 at 4:02 p.m. administrative nursing staff D revealed he/she expected the staff to reposition resident #3 every 2 hours. Staff D reported he/she expected the staff to report any skin issues including redness. During an interview on 7/21/14 at 10:20 a.m. with licensed nursing staff Q he/she reported he/she added the undated revision to the care plan on 7/3/14 when he/she did his/her assessment. During an interview on 7/21/14 at 1:17 p.m. physician U revealed he/she expected to be notified if problems with a resident develop, or if the resident had a medical change. Physician U reported he/she last saw resident #3 on 5/27/14 and had not received any notes from the physician caring for the resident in the behavioral health facility. Review of the facility's policy for Pressure Ulcer Prevention, last revised 4/14, revealed the staff implemented interventions to relieve/reduce pressure based on a resident's Braden score and assessment. The facility failed to develop and implement interventions to prevent the development of facility acquired pressure ulcers resulting in a stage II and stage III pressure ulcers on the coccyx of resident #3.

The facility census totaled 98 residents with 8 included in the sample. Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for nutrition received snacks as planned to prevent weight loss. (#1) Findings included: - Review of resident #1's signed physician history and physical dated 3/25/12 revealed the resident had [DIAGNOSES REDACTED]. Review of resident #1's annual MDS (minimum data set) dated 4/5/14 revealed the resident had a BIMS (brief interview for mental status) score of 11, indicating moderate cognitive impairment. The resident required only supervision help from staff for transfers, walking in the room, and locomotion on and off the unit. The resident required supervision and setup help from staff for eating. The resident did not have any dental or swallowing concerns and received a therapeutic diet. The resident had not lost more than 5% of his/her weight in a month or 10% in 6 months. Review of resident #1's nutrition CAA (care area assessment) dated 4/8/14 revealed the resident enjoyed eating meals in his/her room and in the dining room but needed reminders to come out for meals. The resident could make his/her food preferences known. The resident consumed 100% of a regular diet most of the time. The resident fed him/herself and did not have any chewing or swallowing difficulties. The resident's BMI (Body Mass Index) was 24 which indicated normal weight status. The resident was unsteady but could ambulate to the dining room. The resident walked frequently and appeared to meet his/her energy requirements with large portions as his/her weight had been stable throughout the year. Review of resident #1's care plan for altered nutritional status, dated 7/8/14, revealed interventions directed staff to provide a regular diet, serve large portions, offer fortified foods at meals, offer afternoon and bedtime snacks, observe intake at meals, meet food preferences, offer a substitute when the resident did not eat food provided, provide Medication Pass 2.0 60 ml (milliliters) (a nutritional supplement) four times a day, monitor weight through the variance committee, and monitor labs when available. Review of a nutritional assessment dated [DATE] revealed resident #1 received a regular diet with regular beverages and portion sizes. The resident did not have any food allergies and had [DIAGNOSES REDACTED]. The resident did not have any oral problems and did not require any equipment adaptations for eating. The resident's average meal intake was 100%. The resident needed 1600 total calories and 64 grams of protein. The resident's ideal body weight was 130 lbs. (pounds). Review of resident #1's weights revealed: On 4/17/14 the resident weighed 141 lbs. On 5/15/14 the resident weighed 139 lbs. On 6/17/14 the resident weighed 128 lbs. On 7/15/14 the resident weighed 130 lbs., indicating an 11 pound weight loss in 3 months (7.8%). Review of a progress note dated 6/25/14 revealed resident #1 ate only 2 ice cream cups and corn salad at supper. Review of a fax to the physician from the dietician dated 6/25/14 revealed resident #1 had a significant weight loss of 7.9% in one month. The resident's current weight was 127 lbs. and the resident consumed less than 25% of his/her meals. The dietician noted the weight loss seemed unavoidable related to the resident's change in condition. Staff requested to add Medication Pass 2.0, 60 milliliters (ml) four times a day to add 480 calories and 20 grams of protein to the resident's diet. The fax also indicated the staff planned to offer snacks throughout the day. The physician returned the fax and agreed. Review of resident #1's June 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The entry for snacks lacked any documentation. Review of resident #1's July 2014 MAR (medication administration record) revealed the resident received Medication Pass 2.0, 60 ml four times a day. The MAR indicated [REDACTED]. The entry for snacks lacked any documentation from 7/1/14-7/17/14. Review of a dietician progress note dated 7/3/14 revealed resident #1 received a regular consistency diet, large portions, and ate 31% on average. The resident received assistance from staff for eating. The resident received fortified foods at meals for extra calories due to a recent significant weight loss. The resident was to have snacks in the afternoon and at bedtime. The resident received Medication Pass 60 ml four times a day, and there was a physician order for [REDACTED]. Review of the dietician's note dated 7/9/14 revealed resident #1 had a 2 lb. weight gain for the week and seemed to be doing better with his/her eating. The resident accepted the Medication Pass which added 480 calories each day. Review of the clip board documentation on 7/17/14 at 1:20 p.m. revealed the most recent documentation on the north snack cart was dated 7/5/14. Observation on 7/16/14 at 12:14 p.m. revealed resident #1 sat at the dining room table and received milk, grape juice, ground chicken with gravy, broccoli, dinner roll, lettuce and tomato slices, half a baked potato, and pudding. The resident ate approximately 50% of his/her meal. Interview with direct care staff C on 7/16/14 at 3:43 p.m. revealed resident #1 usually ate pretty well and he/she liked ice cream a lot. Staff C reported the staff kept some ice cream in the freezer on the hall for the resident and gave it to him/her whenever he/she wanted it or to keep him/her busy. Interview with direct care staff L on 7/17/14 at 1:22 p.m. revealed resident #1 liked to snack throughout the day, usually twice a day. Staff L reported staff offered all resident's a snack and documented it on the clipboard on the snack cart. Interview with direct care staff M on 7/17/14 at 3:32 p.m. revealed staff offered snacks to everyone and documented it on the form on snack cart clipboards and then the completed forms went to administrative nursing staff F. Interview with licensed nursing staff E on 7/17/14 at 1:08 p.m. revealed the direct care staff had a snack sheet that told them who needed snacks, staff passed snacks to those people and then documented in the computer system after they passed the snacks. Staff E reported staff did offer resident #1 a snack. Staff E reported the resident had some weight loss because he/she had been very sick for a while and it had completely altered the resident's health status. Staff E reported for a while staff thought the resident would not live very long. Staff E reported that he/she could not get the resident to eat very well during that time. Staff E reported the resident had improved and gained some of the lost weight back, but he/she still required assistance with eating. Interview with administrative nursing staff F on 7/17/14 at 1:30 p.m. revealed the staff did not have a specific list of residents who needed snacks but were expected to offer snacks to everyone and document it three times a day. Staff should document whether the resident refused or accepted the snacks on a paper on a clipboard on the snack cart. Staff F reported the resident received snacks frequently throughout the day as a means to keep the resident busy and for entertainment. Staff F reported after aides documented the snack passes, they gave him/her the completed documentation and he/she kept it. Review of the documentation with staff F revealed the most recent completed documentation sheet he/she had in his/her office was dated 6/9/14. Staff F reported he/she did not know how staff monitored to ensure resident's received snacks. Interview with administrative nursing staff D 7/17/14 at 2:17 p.m. revealed the facility had a snack pass scheduled on the MAR indicated [REDACTED]. Staff D reported the dietary manager or dietician sometimes recommended snacks or the nurse might suggest snacks for residents at risk for weight loss. Staff D reported the direct care staff were to offer snacks three times a day to everyone and document on a snack pass chart on the cart whether each resident got a snack or refused it. Staff D reported administrative nursing staff F reviewed the sheets and monitored resident snack intake. Staff D confirmed the snack charts were the only way to ensure resident #1 received his/her snacks as planned. Staff D reported the facility had put the charting system for snacks in place since the last survey to ensure the documentation was completed. Interview with administrative nursing staff G on 7/17/14 at 1:50 p.m. confirmed there was not any documentation in resident #1's chart regarding when staff were offering the resident snacks. Interview with consultant staff B on 7/17/14 at 2:39 p.m. revealed when resident #1 started losing weight, staff moved the resident to a different dining table in the dining room so he/she could receive assistance with eating. Staff B reported when the resident consumed less than 50% of a meal, staff were to give him/her snacks. Staff B reported the resident's family member was not concerned about the resident's weight loss, and wanted minimal interventions, so staff interventions concentrated on assistance with eating. Staff B reported staff used a check mark to document when a resident consumed a snack. Staff B reported all residents were offered snacks and staff D and staff F monitored the documentation of snacks. Staff B reported initially when the snack cart documentation was put in place, staff used a checkmark on the form to indicate the resident got a snack and had found that documentation then needed to be put in the computer charting system, so now staff B had told staff to give everyone a snack and only document if they were told not to give a resident a snack. Interview with physician T on 7/21/14 on 12:20 p.m. revealed resident #1's weight loss was not unexpected and he/she felt it was a result of the resident's progressive [MEDICAL CONDITION]. Physician T reported it would be okay for staff to try giving snacks or supplements to prevent further weight loss. Review of the facility policy for Hydration/Snacks, revised 2/6/14, revealed it lacked direction for staff regarding documentation of snacks. The facility failed to offer resident #1 snacks as care planned, contributing to a 7.8% weight loss in 3 months.

The facility census totaled 114 residents with 22 included in the sample. The sample included the review of 1 resident for pressure ulcers. Based on observation, interview, and record review, the facility failed to consistently implement interventions to heal a current pressure ulcer and prevent further pressure ulcers from developing for 1 of 1 sampled resident with a history of pressure ulcers. (#71) Findings included: - Review of resident #71's history and physical dated 6/20/13 revealed the following Diagnoses: [REDACTED]. Review of the admission MDS (minimum data set) dated 6/28/13 revealed a BIMS (brief interview for mental status) score of 15, indicating no cognitive impairment. The resident required extensive assistance of two or more staff for bed mobility, transfers, and personal hygiene. The resident had occasional bladder incontinence, was at risk for pressure ulcers and did not have pressure ulcers. The resident had a pressure reducing device for the chair, and applications of ointments/medications other than to feet. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment. The resident required supervision with setup help only for personal hygiene, and extensive assistance of two or more staff for bed mobility and transfers. There were no other changes in the resident's assessment from the admission assessment regarding risk of pressure ulcers, presence of a pressure ulcer, or treatments to prevent the development of a pressure ulcer. Review of the Pressure Ulcer CAA (care area assessment) dated 6/28/13 revealed the resident had a risk for pressure ulcers due to weakness and required extensive staff assist with toileting. The resident had a Braden risk score of 22 indicating at risk for the development of pressure ulcers. The resident needed extensive assistance with bed mobility and transferred with two staff assistance. The resident had two bilateral open areas to the buttocks that were moisture-associated skin damage. The resident had dribbling bladder incontinence. Review of the resident's care plan for Pressure Ulcers, initiated on 10/12/13, revealed on 10/22/13 the resident had multiple superficial pressure sores to buttocks, and directed staff to apply barrier cream and initiated a 2 hour turning schedule. Other interventions directed staff to have the resident on a pressure reducing mattress, monitor for positioning in the bed and recliner, assist with repositioning every 2 hours and PRN (as needed) for comfort, keep skin clean and dry. Apply moisture barrier after incontinent occurrence, when in bed monitor skin with bathing and cares, notify nurse of concerns. On 1/13/14, staff added the following information to the care plan: shearing to buttocks due to poor positioning in chair. The care plan lacked interventions to address the shearing and to encourage healing and prevent reoccurence. On 1/24/14 staff added the following information to the care plan: an unstageable pressure ulcer to the resident's left lateral foot, and directed staff to apply soft blue booties, monitor daily and report changes to the physician, blue boots at night when in bed. On 2/21/14, staff updated the care plan to include the new treatment of [REDACTED]. Review of a Wound note dated 1/24/14 revealed during a shower, an aide identified a skin issue on the outside of the resident's left foot and the the nurse assessed the area as 1 cm (centimeter) x 1 cm dark brown, dried area over a bony prominence. The nurse documented the area as an unstageable pressure ulcer and identified staff gave the resident blue heel boots. Review of a Wound note dated 2/20/14 revealed the pressure ulcer on the left foot measured 1.0 cm x 1.0 cm and had a dried scab to the area. Staff removed the scabbed area with cleansing of [MEDICATION NAME] (antiseptic agent used to clean wounds). After removing the scab, the staff identified the area as stage II (open) and measured 0.3 cm x 0.3 cm x 0.1 cm with a pink base. Later that same day, staff received a fax from the physician to discontinue cleaning the open area with [MEDICATION NAME] and to use a dressing of hydrogel and gauze. Review of a physician visit record dated 1/28/14 revealed the resident had a ulcer to his/her right buttock. The record lack documentation as to when this ulcer healed, or what interventions were developed and implemented to ensure healing and prevent a redevelopment. Review of a Resident Screen form dated 2/17/14 revealed "per report from wound care nursing, shearing occurring from resident sliding down in recliner chair. Resident reports increased pain in buttocks." "Do feel that OT (Occupational Therapy) services for positioning are indicated at this time." Review of a Occupational Therapy Plan of Care dated 2/21/14 revealed the resident presented to therapy presenting positioning deficits, including sliding forward in his/her chair as a result of inadequate cushioning. The resident declined physically as he/she was previously better able to position self in chair, impacting skin integrity. The documentation lacked interventions on how staff were to manage the resident's sliding and prevent further shearing of the resident's skin. Observation on 2/26/14 at 10:02 a.m. revealed direct care staff K and direct care staff M used the sit-to-stand lift to get the resident off the toilet. Observation of the resident's bottom at that time revealed the resident's skin on the perineal area was intact, pink and had an oblong area to the right buttock of a darker shade of skin. Staff K and M lay the resident down in his/her bed. Staff M and K did not take off the resident's shoes or offer to put on the blue cushioned boots. The cushioned boots sat in the resident's wheelchair. Observation on 2/26/14 at 2:15 p.m. revealed the resident sat in a recliner in his/her room. Observations at 2:30 p.m., 2:50 p.m., 3:06 p.m., 3:23 p.m., 3:38 p.m. 3:55 p.m., 4:07 p.m., 4:18 p.m., 4:30 p.m., 4:45 p.m., 4:57 p.m. revealed the resident sat in his/her recliner in the same position. At 4:57 p.m., the surveyor requested a skin check. At this time, the resident sat in the same position for 2 hours and 42 minutes. Direct care staff J and direct care staff L used the sit-to-stand lift to assist the resident to stand. Observation of the resident's bottom at that time revealed the resident's bottom was pink with darker oblong areas near the crease of the resident's buttocks, with some skin slough on the right buttock. Interview with the resident on 2/26/14 at 2:15 p.m. revealed the resident reported staff had him/her wear the blue padded boots at night because he/she had a sore on the bottom of his/her foot and staff had put a dressing on it earlier in the day. Interview with the resident on 2/26/14 at 2:51 p.m. revealed he/she could reposition "a little bit" in the chair and staff helped him/her to reposition. The resident reported staff told him/her he/she was getting a sore on his/her bottom from sitting. Interview with direct care staff J on 2/26/14 at 3:40 p.m. revealed the resident had forgetfulness and required repositioning and toileting assistance every 2 hours. Staff J reported the resident had an area of breakdown on his/her bottom and to prevent further breakdown, staff repositioned the resident every 2 hours, rotated the resident completely in bed every 2 hours, and put on padded boots on the resident's feet at night when he/she lay in bed. Interview with licensed nursing staff H on 2/27/14 at 3:22 p.m. confirmed an inconsistency in the care plan regarding the use of the resident's cushioned boots. Staff H reported the soft blue booties and blue boots were actually the same thing, and since the resident had a pressure ulcer to his/her foot, it made sense for staff to use the cushioned boots whenever the resident lay in bed. At 3:28 p.m., staff H removed the dressing to the resident's left foot and reported the wound unstageable as it was covered with eschar. Observation at that time confirmed the appearance of the wound as covered in dark eschar and revealed staff H measured the wound and reported it measured 13 mm (millimeters) x 10 mm. (Or 1.3 cm x 1.0 cm). The area had been debrided and the scab removed on 2/20/14, and 7 days later on 2/27/14 the area was again covered in eschar, as well as larger in size. Interview with administrative nursing staff B on 2/27/14 at 3:53 p.m. revealed he/she expected staff to reposition a resident with a history of pressure ulcers every 2 hours, put a cushion in chair, add a specialty mattress, assess the resident's skin daily, and make sure the resident's skin stayed hydrated. Staff B stated a group of staff called the skin group looked over wounds, those at risk for wound infections, and developed and initiated interventions to prevent open areas if at risk. Review of the facility's policy on Pressure Ulcer Treatment, dated 4/11, revealed guidance to staff for residents at risk for pressure ulcer development staff were to ensure frequent turning, maximal remobilization, protect heels, manage moisture, nutrition, friction and shear and pressure reduction support surface is bed or chair bound. The facility failed to manage shear and consistently implement the planned timely repositioning services and offloading devices of boots while in bed for a resident with a pressure ulcer on the foot and a history of pressure ulcers on the buttocks.

The facility identified a census of 114 residents with 11 residents sampled. Based on observation, record review and interview, the facility failed to adequately address pain for 3 sampled residents (#203, #59 and #114) and failed to monitor 1 sampled resident's bruising (#185). - Resident #203's admission face sheet recorded the resident admitted to the facility on [DATE] and with Diagnoses: [REDACTED]. The temporary care plan without a date noted for this resident the following for pain: Pain: the goal is no pain, however, there were not any interventions listed for staff to use to achieve this goal. The PRN Medication policy dated 4/28/11 noted under Procedure: ... 4. Follow up assessment will be performed by the Licensed RN or LPN 30 minutes to one hour after medication administration. The Pain Policy dated 6/11 recorded under "Identifying and Managing Untreated Pain: ...5. Consult with MD regarding pain medication needs, unrelieved pain and management of medication side effects.... 7. Utilize the pain log to record and monitor pain management issues." The July 2011, physician's orders [REDACTED]. This POS lacked evidence the resident received a scheduled pain medication. The pain assessment dated [DATE] noted a 5 on scale of 1-10 with 10 the worst. The resident received PT (Physical Therapy) 5 times a week since 7/5/11 for the total right knee replacement. The notes reviewed recorded the resident participated in PT, but did not note if the resident experienced pain during the sessions. The MAR (Medication Administration Record) dated July 2011, recorded the resident received the prn [MEDICATION NAME] 44 times from 7/2/11 through 7/13/11. The staff noted the reason the resident received prn medication and generally noted the effectiveness of the medication as resting, relief, sleeping, no 10 pain, or no complaint of pain about 30 minutes 1 hour after the resident received the medication. The staff continued to give the [MEDICATION NAME] 5/500 mg po to the resident as requested with an increase on the MAR indicated [REDACTED] On 7/2/11 Pain right knee = 1 time the resident requested the prn pain medication. No time effectiveness = "no pain". On 7/311 pain right knee = 3 times the resident requested the prn pain medication. No times noted for effectiveness and all note "No pain." On 7/4/11 pain right knee = 3 times the resident requested the prn pain medication. No times noted for effectiveness and 1 = no pain and the rest note pain decrescendo from 10 to 3 or 4. On 7/5/11 pain right knee = 4 times the resident requested the prn pain medication. No times for effectiveness and note helpful 2 times, no pain 1 time and resting 1 time. On 7/6/11 pain right knee = 5 times the resident requested the prn pain medication. No times for effectiveness and note better 2 times, no better 1 time, letting up 1 time and resting 1 time. On 7/7/11 pain right knee = 5 times the resident requested the prn pain medication. No times for effectiveness and note some better 3 times, and resting 2 times. On 7/8/11 pain right knee = 4 times the resident requested the prn pain medication. No times for effectiveness and note some better 2 times, continued pain 1 time and resting 1 time. On 7/9/11 pain right knee = 4 times the resident requested the prn pain medication. No times for effectiveness and note helpful 4 times. On 7/10/11 pain right knee = 4 times the resident requested the prn pain medication. No times for effectiveness and note helpful 1 times, continued pain 1 time, resting 1 time, no notation 1 time. On 7/11/11 pain right knee = 5 times the resident requested the prn pain medication. No times for effectiveness and note helpful 3 times, continued pain 1 time and no entry 1 time. On 7/12/11 pain right knee= 5 times the resident requested the prn pain medication. No times for effectiveness and note helpful 3 times, no pain 1 time and no entry 1 time. On 7/13/11 pain right knee = 5 times the resident requested the prn pain medication. No times for effectiveness and note slightly helpful 2 times, sleeping 1 time, and no entry 1 time. The pain log noted on 7/10/11 the resident received [MEDICATION NAME] 5/500 mg po for last 1-2 days q (every) 4-6 hours and would continue to monitor. Observation on 7/13/11 at 7:45 A.M. revealed the resident laid on his/her right side with the head of the bed increased to approximately 30 degrees and the resident's eyes are closed. Observation on 7/13/11 at 8:30 A.M. revealed the resident sat at the dining room table and requested his/her breakfast. The resident at this time had a grimace on his/her face, clenched hands and teeth and he/she requested pain medications and voiced his/her pain was a 10 on a scale of 1-10 with 10 being the worst. Observation on 7/13/11 at 9:15 AM revealed the resident sat in a chair in his/her room, and the staff gave the resident his/her inhaler and instructed on how to wait for 1 minute between puffs. The resident was noted to still have a pained expression on his/her face, and voiced his/her right leg still hurt even after the pain medication he/she received at 8:30 A.M. Observation on 7/13/11 at 12:20 P.M. revealed the staff served the resident lunch at the dining room table. He/She continued to voice his/her right knee was "killing him/her with pain." Observation on 7/13/11 at 1:50 P.M. the resident sat in a chair in his/her room and again had facial grimacing, clenched teeth and clenched hands. The resident in an interview at this same time stated that at 8:30 AM when they received the pain medication he/she experienced pain on a scale of 1-10 at 10 (worst), he/she stated that after they received the pain medication the pain improved to only an 8. The resident voiced that the pain this morning was so bad he/she was nearly in tears. He/She voiced he/she requested and received pain medication again around 1:10 P.M. The resident stated that he/she was really worried how he/she would be able to do therapy (PT) at 2:00 P.M., because his/her pain had not really subsided. He/She stated lately he/she had trouble sleeping because the prn pain medication was not effective for his/her pain. He/She voiced he/she was not aware that he/she only had prn pain medication and thought he/she had regularly scheduled pain medication, and stated he/she would take the medication if the physician ordered him/her any scheduled pain medication. Interview on 7/13/11 at 1:30 P.M. with licensed staff G confirmed the physician's orders [REDACTED]. This same staff stated that when he/she checked back with the resident this morning about the effectiveness of the pain medication, the resident voiced the medication helped him/her. Interview on 7/13/11 at 1:50 P.M. with resident stated that at 8:30 AM when he/she got the pain medication he/she had pain on a scale of 1-10 at 10 (worst), she stated that after he/she received the pain medication, the pain improved to only an 7. He/She stated that the pain in the morning was so bad that he/she was nearly in tears. He/She voiced he/she had requested and received pain medication again around 1:10 P.M. and was worried how he/she would be able to do physical therapy at 2:00 P.M., because his/her pain had not really subsided. He/She stated lately he/she also had trouble sleeping due to the pain medication was not effective to decrease his/her pain. He/She stated he/she was not aware that he/she only had prn pain medication available to him/her and thought he/she had regularly scheduled pain medication, and stated that he/she would take the pain medication on a regular basis if the physician would order scheduled pain medication for the resident. Observation and interview on 7/14/11 at 10:05 A.M. with the resident, who sat in a chair in his/her room and had his/her right knee elevated. He/She stated he/she took medication earlier today (at 9:15 A.M.) according to the MAR, the resident received [MEDICATION NAME] 5/500 mg (2 tabs) po prn. At this time (50 minutes later) the resident stated he/she continued to have pain in the right knee. The resident rated his/her continued pain at a 7 and stated the pain when he/she got the medication was at 10. The resident voiced that he/she had an appointment later today with the physician at his/her office and he/she planned to talk to the physician regarding the increased pain level he/she had experienced and how it was difficult to do the physical therapy due to the increased level of pain he/she experienced. Interview on 7/14/11 at 10:20 A.M. with licensed nursing staff H, stated he/she just faxed the current MAR indicated [REDACTED]. Interview on 7/14/11 at 10:30 A.M. with licensed nursing staff I stated that when he/she gave the resident his/her pain medication today the resident voiced his/her pain at a 7. He/She stated that the resident voiced his/her pain was better after about 45 minutes when he/she checked back with him/her, but that he/she did still have pain. He/She stated the resident was going to a physician's appointment today and the staff sent the MAR indicated [REDACTED]'s prn requests as noted for about a week now. Interview on 7/14/11 at 11:30 A.M. with licensed nursing staff F stated that the pharmacist's and physician's around this area did not tend to order the elderly residents any scheduled pain medications and if the physician did order scheduled pain medication then the pharmacist recommended changing it to a prn medication. This same staff stated that if a resident generally had increasing pain and used a prn pain medication, the nursing staff after 2-3 days would contact the physician and try to get a scheduled pain medication for the resident. The resident's clinical record through 7/14/11 at 12:00 P.M. did not record any scheduled pain medications ordered or that the facility notified the physician that the resident reported the prn pain medication did not provide effective relief of the resident's pain. The facility failed to recognize this dependent resident had experienced increasing pain and a lack of effectiveness from the prn pain medication to the point of tears and difficulty sleeping. The facility also failed to contact the physician regarding the increased pain the resident experienced to allow the physician to evaluate whether the resident required scheduled pain medication or a more effective prn medication for pain. - Review of resident #59's Significant Change Minimum Data Set (MDS) 3.0, a required comprehensive assessment, dated 2/22/11, revealed resident #59 received limited assistance for moving on and off the toilet and moving from sitting to standing. The MDS documented the resident had a toileting program that managed the resident incontinence. The MDS identified Resident #59 had a memory impairment, one fall with a major injury, daily pain and received as needed pain medication. The Care Area Assessments, a further assessment of triggered concerns, dated 3/9/11, documented the resident had pain from a [MEDICAL CONDITION] sustained on 2/10/11. Review of resident #59's most recent MDS Quarterly assessment, dated 5/31/11, revealed the resident needed extensive assistance with toilet use, bed mobility and transfers and used a walker and a wheelchair. The MDS documented [DIAGNOSES REDACTED]. The resident's MDS pain assessment documented no pain with use of as needed pain medication. Review of Resident #59's nursing care plan (NCP), dated 3/7/11, revealed a potential for pain from a [MEDICAL CONDITION] sustained on 2/10/11. The facility identified a goal to achieve a consistent level of comfort while maintaining as much function as possible. The documented approaches included pain medication as ordered, assess, record and notify the physician of distress or unrelieved pain. The NCP directed staff to premedicate the resident with an as needed pain medication for activities, meals and therapy. The NCP documented alternative (other than medication) comfort measures included massage, reposition and relaxation techniques. Observation on 7/13/11 from 2:33 - 3:05 P.M., revealed Direct Care Staff (DCS) F and G toileted resident #59 using a sit to stand lift. DCS F and G used the lift to transfer Resident #59 to the toilet and waited in the room for the resident to finish. DCS F and G asked Resident #59 if he/she had finished and if he/she wanted to lie down as he/she seemed tired. Resident #59 did not respond and DCS G stated the resident seemed to be leaning to the side. As DCS F and G started to raise the resident from the toilet with the lift, the resident stated "Don't do that". DCS F and G used the lift to lower the resident to the toilet. DCS F and G stated at this time that they had just started using this lift to transfer the resident (between bed, wheelchair and toilet) and the resident was not sure about it. DCS F and G talked kindly to resident #59 for a few minutes but the resident would not stand with the lift. DCS F left the room and returned with Licensed Nurse F who encouraged the resident as DCS F and G used the sit to stand lift and raised the resident from the toilet and moved him/her to the wheelchair then to the resident's bed to lie down. Observation at this time revealed Resident #59 moaned while in the lift and saying "Oh, oh". DCS F and G positioned Resident #59 in his/her bed and covered him/her with a blanket and the resident stopped moaning and saying "Oh, oh". Interview of DCS G at this time revealed resident #59 was a one or two person transfer before a fall last week. DCS G stated resident had been able to stand with assistance and hold onto the grab bar in the bathroom until he/she fell and hit his/her back. Further, the resident did not transfer well now. Review of the Nurse's Notes, dated 7/6/11 at 2215 (10:15 P.M.), revealed the staff found the resident on the floor on his/her back stating he/she had mild pain at the mid back. Review of Resident #59's lumbar and cervical spine x-rays, dated 7/7/11, revealed no fractures with some compression and [MEDICAL CONDITION] changes. Review of Resident #59's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED].M. for back pain with an assessed result of "helpful". Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED] Interview, on 7/14/11 at 9:30 A.M. of Direct Care Staff H revealed staff let him/her know when the resident was hurting and he/she told the nurse but does not give the resident pain medication without the nurse directing him/her to do so. Interview, on 7/14/11 at 9:32 A.M., with Licensed Nurse D revealed the resident had more pain since his/her fall last week. Further, staff watches the resident's facial expression or the resident would moan. It depended on what type of pain the resident was having. Licensed Nurse D further stated at this time that the resident received [MEDICATION NAME] (pain medication) yesterday (7/13/11) at 1:30 PM and received [MEDICATION NAME] the day before one time but the [MEDICATION NAME] seemed more effective for the resident. The facility failed to assess, monitor and provide adequate intervention to relieve the resident's pain so he/she could fully participate in activities of daily living. - Review of Resident #114's most recent Minimum Data Set (MDS) 3.0 Admission, dated 5/30/11, revealed the resident needed extensive assistance with activities of daily living, used an electric wheelchair and had [DIAGNOSES REDACTED]. The MDS documented the resident received scheduled pain medication, and had frequent pain the resident rated a 5 on a scale of 0-10 with 10 being the worst possible pain. Review of Resident #114's Care Area Assessment, a further assessment of pain as a triggered concern, revealed the resident had a history of [REDACTED]. The CAA documented the resident took scheduled pain medication and took as needed pain medication. The CAA identified a plan to monitor for pain and effectiveness of pain medication. Review of resident #114's care plan dated 6/2/11, revealed a potential for pain to his/her joints due to [MEDICAL CONDITION] arthritis. The facility identified a goal of pain level of 4 or less with resident input. Planned approaches included pain medications as ordered, monitor effectiveness of scheduled medications, provide as needed pain medications and if no relief report to physician. Observation on 7/13/11 at 7:38 A.M., revealed direct care staff G and I toileted resident #114 using a sit to stand lift to move the resident between the wheelchair and toilet. After transferring resident #114 to his/her wheelchair, DCS G attempted to place resident #114's feet on the foot rest. Resident #114 stated "can't, it hurts too much". Observation at this time revealed the resident's heels rested on the edge of the foot rest. Observation of the resident in the dining room for breakfast on 7/13/11 revealed the resident's left foot no longer rested on the foot rest. During interview at this time, the resident stated he/she had pain all the time and his/her left hip and knee hurt more when his/her left foot was on the foot rest. Observation on 7/14/11 from 9:45-10:15 A.M., revealed the resident in his/her room watching an exercise program. Resident #114 sat in his/her recliner with his/her legs up and used a neck pillow. Interview of resident #114 at this time revealed this position helped decrease the pain. Interview on 7/13/11, at 10:09 A.M., resident #114 stated a few days ago he/she experienced pain at a rating of 7 and staff gave him/her pain medication which helped. Further, resident #114 stated staff usually said they had given him/her all they could but the medication they give me was like Aspirin or something. I can't get up and do the things I would like to do because of the pain. It is in different places like my hip and knee and different places at different times. Review of Resident #114's Treatment Administration Record for May, June and July 2011 indicated the staff should complete the pain log to be completed weekly. Review of Resident #114's pain log revealed staff had completed the log five times between 5/7/11 and 7/5/11. The pain log documented the resident received scheduled pain medications of [MEDICATION NAME] 10 milligrams two times a day and [MEDICATION NAME] 10/500 mg two times a day. The pain log identified the resident's pain level goal to be 0-1 on a 0-10 scale with 10 being the worst possible pain. The pain log documented the following about Resident #114's pain assessment: ? On 5/7/11, rated at 6-8, generalized, received as needed [MEDICATION NAME] two times with a plan to observe. ? On 5/14/11, rated an 8 in hips, knees and left shoulder, received as needed [MEDICATION NAME] two times and a plan to observe. ? On 6/11/11 a pain rating of 7-9 in knees, hips and shoulders, and a plan to observe. ? On 6/21/11 a pain rating of 5-9 in hips, knees, shoulders and ankles with a plan to observe. ? On 7/5/11 a pain rating of 9 with a plan to observe. Review of Resident #114's Physician order [REDACTED]. ? [MEDICATION NAME] 10-325 mg by mouth at noon and bedtime and every 4 hours as needed since 5/23/11. ? [MEDICATION NAME] 10 mg by mouth between 6 and 8 AM and again between 4 and 6 PM since 3/15/11. Review of Resident # 114's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on 7/14/11 at 3:15 P.M., of Licensed Nurse E revealed staff complete the resident ' s pain log weekly and assessed pain when as needed pain medication given. The facility failed to monitor effectiveness of the resident's medication for pain and provide as needed pain medication as ordered. - Resident #185's physician's orders [REDACTED]. The admission Minimum Data Set 3.0 dated 5/18/11 recorded the resident was cognitively intact. The resident required 1 staff extensive assistance with transfers, limited assistance of 1 with toilet use and extensive assistance of 2 staff with bed mobility. The resident had a fall within the month prior to admission, but no falls since admission. The Care Area Assessment (CAA) for falls with no date recorded the resident was at risk for falls related to dizziness and balance issues related to [DIAGNOSES REDACTED]. He/She required assistance with transfers and mobility. The CAA did not address bruising. The care plan for hypertension dated 5/31/11 with interventions dated 6/14/11 directed staff to observe for side effects of aspirin use such as tinnitus, hearing loss, bleeding, rash and bruising. Review of the nursing notes from 6/13/11 through 7/13/11 revealed nursing staff failed to document the resident's bruises. Observation on 7/11/11 at 5:19 P.M. revealed the resident with numerous bruises of different colors on bilateral arms. During interview on 7/13/11 at 8:10 A.M. the resident reported he/she would like to know why they bruised so easily. They reported taking a low dose aspirin daily. During interview on 7/14/11 at 12:17 P.M. licensed nursing staff A reported nursing staff should fill out a skin injury investigation report for a resident with bruises, make a nurses note and monitor the bruises for 72 hours. He/She acknowledged staff failed to document assessment or monitoring or follow up for this resident's bruises. The facility failed to assess, document or monitor this resident's bruises.