Every finding on record at Newton Presbyterian Manor

The facility had a census of 53 residents and the sample included 14 residents. Based on observations, record review and interview, the facility failed to ensure an environment free of accident hazards for Resident R 53 who obtained ahip fracture during a fall and R23 when a Certified Nurse Aide transferred her without a gait belt causing a fall.Findings included:- R53's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) intertrochanteric (the area of the hip/thigh bone located between the greater and lesser trochanters left femur (thigh bone), and muscle weakness. R53's 04/15/25 Quarterly Minimum Data Set(MDS) documented a Brief Interview for Mental Status (BIMS) of four, which indicated severely impaired cognition. No behavior. R53's MDS documented that she was independent with transfers and ambulation and had one noninjury fall. R53's 07/15/25 Significant Change MDS documented a BIMS of four, which indicated severely impaired cognition. R53's MDS documented she had behaviors, wandered, resident rejected care, verbal behavioral symptoms directed towards others, and physical behavioral symptoms directed towards others for 1-3 days in the lookback period. R53's MDS documented that she required moderate assistance with activities of daily living (ADL), including transfers. R53 required maximal assistance with toileting hygiene, and she was independent with bed and wheelchair mobility. R53's MDS documented ambulation was not attempted due to medical conditions or safety concerns. R53's MDS documented one major fall with injury. R53's 07/21/25 Falls Care Area Assessment (CAA) documented CAA triggered related reported falls during the look-back period. Contributing factors include decreased safety awareness. Risk factors include falls and injuries from falls. The care plan would be reviewed to ensure proper interventions are in place to reduce the risk of falls. R53's 10/31/24 Care Plan revealed that education was provided to the resident/family/caregivers about safety reminders and what to do if a fall occurred. Staff were directed to ensure R53 were wearing non-skid footwear when ambulating or mobilizing in a wheelchair. Staff were instructed to follow facility fall protocol. Staff were instructed to provide R53 with a soft-touch call light and keep close to R53 when she was alone. R53's 06/04/25 Care Plan revealed that the staff were to provide non-slip strips on the floor in front of R53's recliner. R53's 07/02/25 Care Plan revealed staff instructed to ensure R53's bags she carried were lightweight to aid in resident balance. R53's 07/24/25 Care Plan revealed that R53 ambulated very short distances. Staff were instructed to offer R53 a wheelchair. R53's 07/24/25 Care Plan revealed that staff were to provide assistance for R53's transfers. R53's EMR Fall Risk Evaluation reviewed from 04/10/25 through 10/11/25 documented that R53 was a high risk for falls. R53's Progress Note, dated 07/02/25 at 05:02 AM, documented at about 03:55 AM, staff found the resident lying on her left side at the beginning of the hallway. Next to the resident were two full purses and a book she was carrying. R53 was unable to give a description of what happened. The resident voiced that she was hurting once she was turned to her back and observed a massive purple bump on her left forehead near her left eye. R53's hand had a hematoma (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) the size of her hand on the back side, which was growing. Provider and durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) were notified, and R53 was transferred to the hospital. R53's Progress Note, dated 07/02/25 at 12:09 PM, documented R53 returned from the hospital with a left wrist fracture (broken bone). R53's Progress Note, dated 07/08/25 at 12:44 PM, R53 returned from orthopedic appointment to always wear brace except for bathing for six weeks. R53's Progress Note, dated 08/14/25 AM at 12:06 PM, documented R53 required one staff member's limited assistance with ADLs, transfers, and ambulation. R53 continued carrying both heavy purses while ambulating and got upset at the staff when they tried to carry them for the resident. R53's Progress Note, dated 08/21/25 AM at 01:48 PM, documented R53 required one staff member's limited assistance with ADLs, transfers, and ambulation. R53 continued carrying both heavy purses while ambulating and got upset at the staff when they tried to carry them for the resident. R53's Progress Note, dated 09/02/2025 at 11:23 AM, documented that R53 had fallen in the living room at approximately 09:57 AM. R53 was lying on her back, looking up to the ceiling with her legs facing the center of the living room, with pillows under her head. R53 was grimacing with pain and had rapid respirations. Staff reported that R53 had lost her balance and fallen on her left side and was in a left lateral position. Staff reported they assisted R53 to her back. There were no visual injuries to the resident at that time. R53's Progress Note, dated 09/02/2025 at 11:35 AM, documented orders received to send R53 to the hospital for an evaluation. DPOA notified and transferred R53 at 10:45 AM. R53's Progress Note, dated 09/02/2025 at 09:29 PM, documented that R53 was admitted to the hospital with a left hip fracture. Review of the facility's Post Fall Root Cause Analysis, dated 07/07/25, documented that R53 was carrying extremely heavy bags, which caused her to lose her balance and fall. Review of the facility's Post Fall Root Cause Analysis, dated 09/03/25, documented that staff reported to charge nurse R53 fell in the [NAME] living room, and as reported, R53 lost her balance and fell to her left side. The resident was unable to report how she fell. Immediate intervention when R53 was walking in a highly congested area, the staff were to walk with the resident. Review of the facility's Facility Reportable Incident 2606988 dated 09/09/25 documented R53 had tripped on another resident's foot while coming back into the living room, walking between furniture and other residents. Certified Nurse Aide (CNA)/(Life Enrichment Staff) FF assisted R53 to her back. The statements lacked that a staff member witnessed the fall. The facility investigation lacked the video from the camera was reviewed. Review of Complaint Investigation Witness Statement of Facts dated 09/02/25 documented Licensed Nurse (LN) EE stated at approximately 09:55 AM LN EE entered the [NAME] Hall and observed R53 ambulating in the living room area. R53 wore her tennis shoes and carried her pick bag, which appeared to have only a jacket in it. LN EE stated she was standing behind the chair, speaking to CNA FF, and stated she heard R53 hit the ground; however, she stated she did not see the actual fall. Review of Complaint Investigation Witness Statement of Facts, dated 09/02/25, documented that CNA FF stated she was talking to someone, and she looked to her right at that time, R53 fell and landed on her left side. CNA FF stated R53 fell hard. On 02/24/26 at 04:32 PM, CNA Q reported that R53 was very unsteady when she walked, and staff were instructed to give her a wheelchair if she was up ambulating. CNA Q reported that R53 continued to carry her heavy pink bag and would not let the staff carry it for her. CNA Q reported that sometimes R53 did not want to use the wheelchair, so staff would walk with her. CNA Q reported that R53's room was room nine and that it was approximately 100 feet from the lounge. CNA Q reported that R53 did not ambulate after she fractured her left hip. On 02/25/2026 at 10:06 AM, LN K reported that R53 would ambulate with staff assistance. LN K reported that R53 was sleepy, and the staff would assist her into a wheelchair. On 02/25/26 at 01:00 PM, CNA Z reported that R53 required a staff member to walk with her and reported that R53 was unsteady and could not walk long distances. CNA Z reported that staff would offer R53 a wheelchair and R53 could propel herself in the wheelchair. CNA Z reported that R53 carried heavy bags and would not allow the staff to carry the bags for her. On 02/25/25 at 02:30 PM, Administrative Staff A reported that she determined that R53 had tripped over another resident's foot as she watched the video. Administrative Staff A reported that she failed to document that she reviewed the video in the facility report, and she did not request a download to save the video when R53 fell on [DATE]. Administrative Staff A reported that the fall was witnessed by CNA FF and requested that she be called for a statement. Administrative Staff A reported that CNA FF had already completed a statement on 09/02/25 that did not have documentation that the fall was witnessed. The facility's policy Falls, dated 11/01/24, documented that residents would be identified for risk of falls and interventions implemented to reduce risk. - R23's Electronic Medical Record (EMR), dated 2/2/26, revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion) and abnormal gait and mobility. R23's Significant Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating moderately impaired cognition. She had rejected care for one to three days during the seven-day look-back period. R23 had two or more falls since admission with no injuries. R23's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating intact cognition. She had verbal and behavioral symptoms directed toward others for one to three days during the look-back period. R23's Care Plan, dated 08/27/24, noted R23 was at moderate risk for falls related to safety awareness with the diagnosis of dementia. The plan lacked direction to staff related to transfer until 02/18/26, when an intervention was added to the care plan to transfer the resident with a two-person assist and a gait belt. R23's Nurse's Notes, dated 2/18/26 at 06:20 PM, documented at 04:50 PM during a one-person transfer from the recliner to the wheelchair, R23's knees buckled, which caused her to fall to the floor, landing on her right knee and left cheek. Staff transferred R23 from the floor to the wheelchair with the assistance of two people. A Nurses Notes, dated 02/24/26 at 04:11 PM, reviewing the fall on 02/18/26 documented R23 was being assisted using a pivot transfer; her knees buckled, and the resident fell to the floor. The staff member was not using the gait belt. Immediate interventions, including one-to-one education with staff to use a gait belt for transfers, were completed. Observation on 02/24/26 at 09:09 AM, R23 was up in her recliner, drinking her coffee. During an interview on 02/24/26 at 10:29 AM, Certified Nurse Aide (CNA) KK revealed R23 now required a two-person transfer. During an interview on 02/25/26 at 11:35 AM, Administrative Nurse D stated that a staff member had transferred R23 without a gait belt, which caused her to fall. Administrative Nurse D said the facility did a teachable moment with the staff member, and she expected the staff to use a gait belt with proper technique on transfer. The facilities policy Falls, revised 11/1/24, documents that residents will be identified for risk of falls and interventions implemented to reduce risk. The resident's high-risk status will be documented on the comprehensive plan of care or service plan.

The facility identified a census of 53 residents, with 14 residents sampled, including two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to identify and implement pressure ulcer preventative measures, consistent with professional standards of practice, to prevent the development of a facility acquired stage three pressure ulcer to Resident (R)53's left heel after R53 returned from the hospital, due to surgical repair of her left hip fracture.Findings included:- R53's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) intertrochanteric (the area of the hip/thigh bone located between the greater and lesser trochanters) left femur (thigh bone), and muscle weakness. R53's 07/15/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of four, which indicated severely impaired cognition. R53's MDS documented that she had behaviors, wandered, rejected cares, had verbal behavioral symptoms directed towards others, and physical behavioral symptoms directed towards others for 1-3 days in the lookback period. R53's MDS documented that she required moderate assistance with activities of daily living (ADL), including transfers. R53 required maximal assistance with toileting hygiene, and was independent with bed and wheelchair mobility. R53's MDS documented ambulation was not attempted due to medical conditions or safety concerns. The MDS documented she was at risk of developing pressure ulcers, had no skin issues, no pressure-reducing device in her wheelchair, and was not on a turning and repositioning program.R53's 09/16/25 Medicare 5-day MDS documented a BIMS score of four, which indicated severely impaired cognition. R53's MDS documented that she required total assistance with ADLs, bed mobility, toileting hygiene, and transfers. The MDS documented she was at risk of developing pressure ulcers, had an open lesion on her foot, no pressure-reducing device on her bed, and was not on a turning and repositioning program.R53's EMR lacked evidence of a significant change in condition MDS.R53's 10/21/25 Quarterly MDS documented the resident had one unhealed and unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer, not present on admission. The MDS documented R53 had no pressure-reducing device on her bed, and she was not on a turning and repositioning program. R53's Pressure Ulcer/Injury Care Area Assessment (CAA) triggered related to her potential for pressure injuries. The contributing factors included incontinence and impaired mobility, and the risk factors included skin breakdown and pressure injuries. The CAA noted the care plan was reviewed to reduce the risk of pressure injuries, and a weekly skin assessment would be completed by a licensed nurse.R53's Care Plan, dated 09/25/24, revealed R53 required total assistance of two staff with a mechanical lift for transfers. The staff were instructed to cleanse the left heel with wound cleanser, pat dry with gauze, apply Skin-prep (liquid skin protectant) to peri-wound (skin surrounding the wound), cut the calcium alginate (highly absorbent dressing) to the size of the wound bed, and apply to the wound bed, cover dressing with Aquacel (a soft, sterile dressing).R53's Care Plan, dated 09/26/25, revealed staff were to provide a pressure-reducing mattress and float both of the resident's heels while in bed, to prevent pressure at the bony prominences.R53's Braden Scale (scale used to predict pressure ulcer risk), dated 07/09/25 at 08:08 AM, documented a score of 18, which indicated at risk.R53's Progress Note, dated 09/02/25 at 09:29 PM, revealed that R53 was admitted to the hospital for a fracture of her left hip.R53's Skin/Wound Note, dated 09/11/25 at 03:17 PM, documented that staff completed an admission skin and wound assessment after returning from the hospital. The note documented that the resident had no wounds to her back, bottom, and/or feet/heels.R53's Braden Scale, dated 09/11/25 at 04:55 PM, documented a score of 13, which indicated moderate risk.R53's Dietary Note, dated 09/15/25 at 01:18 PM, documented no open skin issues.R53's Skin/Wound Note, dated 09/16/25 at 12:09 PM, documented that staff changed the bandage on R53's left heel and noted the wound was from a blister that opened. The wound bed was pink with a dark center area, with minimal drainage. The edges were present from where the skin was removed. Skin prep was applied to the peri wound, and staff placed a bordered heel dressing. A picture of the wound was taken and sent to the Director of Nursing and the provider.R53's Skin/Wound Note, dated 09/16/25 at 03:00 PM, documented that the facility received verbal consent from the resident's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) for evaluation and treatment from the wound clinic. R53's first visit to the clinic would be 09/19/25. The note indicated current interventions that were in place and that they were reviewed with the DPOA.R53's Health Status Note, dated 09/18/25 at 12:16 PM, documented R53 had an open wound on the left heel, required heels to be floated, and the wound to be covered with Aquacel foam dressing. The wound clinic would be in the next day to evaluate.R53's 09/18/25 Physician's Orders included for staff to apply skin prep to R53's right heel, every shift, for the prevention of skin breakdown. The order instructed staff to float both of the resident's heels while in bed to prevent pressure of bony prominences, every shift.R53's Progress Note, dated 09/19/25 at 06:45 AM, documented that staff pulled the sheets back to reposition the resident and saw dry red streaks of blood embedded in the fitted sheet. The staff checked R53's skin and located an open blister on the left heel and assumed R53 rubbed the left heel open against the bed/sheet, exposing the blister. The staff found a flap of skin hanging (from the blister) and noted the blister was not present/noticed prior to this day.R53's Health Status Note, dated 09/24/25 at 01:39 PM, documented that R53 was discussed in weekly risk management with the interdisciplinary team present for dates 09/17/25 - 09/24/25. The note revealed the resident continued with an open wound to the left heel that was followed by wound clinic. The next visit was scheduled for 09/26/25. Current treatment was to cleanse the area with wound cleanser, apply skin prep to the peri wound, apply calcium alginate, and cover with Aquacel foam dressing. The resident's heels were floated with protective booties while in bed.R53's Order Note, dated 09/26/25 at 11:12 AM, documented an order received from the wound care clinic provider for the left heel. Staff would cleanse the area with wound cleanser and pat dry with gauze. Apply skin prep to the peri-wound area. Apply a thin layer of Santyl (prescription ointment is used to remove damaged tissue from skin ulcers) ointment to the wound bed. Cut calcium alginate to fit the size of the wound bed and apply it, then cut an additional piece of calcium alginate to cover the remaining open area of the heel. Cover the wound with an Aquacel Foam dressing. Change daily and as needed.R53's 09/29/25 Physician's Orders documented the resident had a low air loss mattress and the staff were to check to ensure the mattress was plugged in and inflated to manufacturer settings, every shift.R53's Nutritional Note dated 10/01/25 at 11:47 AM documented that R53 received wound care treatment to an open area noted on her left heel. The note further revealed:On 09/19/25, the resident had a new open area to the left heel, which measured 9.73 centimeters (cm) by 4.02 cm by 3.31 cm.On 09/26/25, the resident's left heel open area measured 9.07 cm by 4.00 cm by 3.2 cm.R53's 10/03/25 Physician's Orders included providing R53 with ProSource (nutritional supplement to promote wound healing), give 30 milliliters (ml), by mouth two times a day for wound healing.R53's Order Note, dated 10/10/25 at 08:00 PM, documented that staff were to cleanse the resident's left heel with hypochlorous acid (a natural, weak acid produced by human white blood cells to fight infections and inflammation) and pat dry with gauze. Then, apply skin prep to the peri-wound area, apply a thin layer of Santyl ointment to the wound bed, cut calcium alginate to fit the size of the wound bed and fill the deepest part, cut an additional piece of calcium alginate to cover the remaining opened area, avoiding contact of the peri wound, and cover the wound with an Aquacel foam dressing. The staff were to change the dressing daily and as needed.R53's Nutritional Note dated 10/13/25 at 11:02 AM documented the following:On 10/03/25, the left heel open area measured 6.33 cm by 3.38 cm by 2.45 cm.On 10/10/25, the left heel open area measured 2.75 cm by 2.15 cm by 1.78 cm.R53's Skin Issue Note, dated 11/14/25 at 02:49 PM, documented that the wound characteristics had improved and documented the wound as a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer wound, acquired in-house. The wound was noted as greater than three months and staged by the wound clinic. The left heel wound measured 1.7 cm by 1.2 cm by 0.2 cm with 1.5 cm undermining (a serious complication where tissue destruction occurs under the skin edges, creating a hidden pocket or shelf beneath intact skin, often making the wound much larger than appears on the surface).R53's 01/05/26 Physician's Orders included that the resident had a wound to her left heel, and staff were to cleanse with hypochlorous acid, apply a collagen pad, and cover with bordered foam dressing. Change every three days and as needed for wound healing.R53's EMR lacked documentation of wound clinic notes.On 02/24/26 at 04:32 PM, Certified Nurse Aide (CNA) Q reported that when R53 readmitted from the hospital on [DATE], R53 did not have an air mattress on her bed or heel booties. CNA Q reported R53 was not on a turn and reposition schedule and reported she had told the nurse that R53's heels were red. CNA Q reported that R53 received an air mattress and a float for heels after her left heel had a wound.On 02/25/26 at 11:53 AM, Administrative Nurse D and Consultant Nurse GG (Regional RN) reported they expected preventative skin interventions to be in place to avoid a pressure ulcer. Consultant Nurse GG reviewed R53's care plan in EMR and revealed that R53's preventative skin interventions were not provided until after R53 had a pressure ulcer.The facility policy Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment, dated 10/14/24, documented that all residents are considered to have a potential risk for the development of pressure ulcers. Nursing staff would evaluate skin integrity, implement preventative measures as indicated and treat skin breakdown. Implement pressure ulcer/ injury preventative measures to maintain intact skin.

The facility reported a census of 53 residents with 14 residents included in the sample. Based on observation, interview, and record review the facility failed to effectively utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high care) and failed to follow established infection control practices related to hand hygiene, peri-care, medication administration, and cleaning of resident nebulizers. The facility further failed to cover resident clean clothing while transporting it through the hallway.Findings included:- On 02/23/26 at 11:22 AM, Certified Medication Aide (CMA) T and Certified Nurse Aide (CNA) M brought Resident (R) 43 to her room in her wheelchair. The entrance door to the resident's room had signage placed directing staff that the resident required enhanced barrier precautions (EBP) when providing direct care, which included catheter care, wound care, transfers, and toileting. R43 required PPE, which included gowns and gloves. The PPE set-up was at the entrance to the resident's room, and CMA T and CNA M applied gloves and positioned a gait belt around R43. The aides reported that R43 needed to lie down to receive wound care on her feet and coccyx (tailbone). CNA N joined CNA M and CMA T to assist with the transfer of the resident. CNA N sanitized his hands and applied gloves, but none of the three staff present put on a gown. One of the aides emptied the resident's urinary catheter without a gown in place. After they transferred R43 from the wheelchair to the bed, they rolled the resident to her right side, placed a turn sheet beneath her, positioned her in the bed, and CNA N then placed his gloved hands in his pockets. CNA M removed her gloves, did not perform hand hygiene, and picked up a sheet and blanket to fold them without performing hand hygiene after removing her gloves. CNA M exited the resident's room without performing hand hygiene. CNA M reported it was her understanding that staff were to use gloves and gowns with EBP when providing direct contact and catheter care. After reading the sign on the resident's door, CNA N, CNA M, and CMA T agreed they should have used a gown as well as gloves when providing direct care to the resident due to wounds and/or a urinary catheter.On 02/23/26 at 12:03 PM, Consultant HH, Consultant II, Consultant JJ, and Administrative Nurse FF provided wound care for R43 without wearing a gown. They confirmed the resident had open wounds on her coccyx, right ankle, and right lateral foot toward the heel. They obtained measurements, pictures, and provided wound care without wearing gowns. On inquiry, Consultant HH stated she did not realize the resident had a catheter, but confirmed she was aware she had wounds. Consultant HH stated the staff should probably wear a gown when providing direct care to R43.On 02/24/26 at 08:32 AM, Licensed Nurse (LN) J positioned R1's feet on her foot pedals prior to moving her from the dining room table. LN J then applied gloves without sanitizing her hands, checked R1's blood sugar, administered the resident's insulin, and assisted R1 back to the table. LN J then went back to the lounge, moved her cart with R1's supplies, took her gloves off, removed the medication cart keys from her pocket, and placed the box back into the cart without sanitizing her hands.On 02/24/26 at 08:39 AM, LN J confirmed she should have washed/sanitized her hands when her gloves came off and did not.On 02/24/26 at 09:22 AM, LN J removed R57's breathing treatment medication from the box and confirmed the medication. She then went to R57's room and knocked on his door. R57's nebulizer (machine used to deliver breathing treatment) mask laid directly on the nightstand, with an unidentified liquid still in the medication chamber. The mask and medication delivery chamber were not taken apart, and/or placed on a barrier, air drying from the prior administration. LN J added the new medication in the nebulizer chamber (with the existing unidentified liquid), placed the mask standing upright on the machine, and told R57 she would be back. LN J then removed the gloves she had worn since she entered the room and performed hand hygiene. LN J reported that R57 was recently admitted to the facility, and he was able to complete his own breathing treatment. She reported that the nebulizer should have been rinsed out and stored in its own box that was kept in the medication room.On 02/24/26 at 03:47 PM, Administrative Nurse E stated she expected staff to rinse out and air dry the nebulizer after each use.On 02/24/26 at 10:57 AM, CMA S and CNA P propelled R4 into her room. After getting the resident to bed, CMA S and CNA P pulled R4's pants down and opened her wet brief. CMA S cleaned R4's peri-area, removed her glove from her left hand, and kept her right one on. She rolled the resident towards the wall, and CNA P cleansed her buttocks. While continuing to wear the gloves she used during peri-care, CNA P opened the drawer again and removed a bottle of powder, which she applied to R 4's front groin area. They then applied a clean brief, pulled up her pants, removed their gloves, and transferred R4 back to her wheelchair without performing hand hygiene after removing their gloves.On 02/24/26 at 11:08 AM, Housekeeping Staff V carried a resident's clean personal clothing on hangers, uncovered, in the hallway. Housekeeping Staff V reported she did not cover the resident's personal clothing when she delivered it.On 02/24/26 at 01:01 PM, LN G entered R15's room, washed her hands, put on gloves, put on a gown, and tied her gown. She used her gloved hands to touch the resident's wheelchair handles to move the wheelchair away from the bed. LN G touched the resident's feet, repositioned him in the bed, opened the wound dressing packages, placed a date on the bandage, removed the soiled dressing from his right foot, picked up the wound cleanser, placed Santyl (debriding ointment) directly on the open wound, and applied dressing with the same gloves. LN G proceeded to provide the same care to the resident's left foot. She did not remove her gloves or perform hand hygiene throughout the observation.On 02/24/26 at 01:32 PM, LN G stated she should have placed a barrier before setting up the resident's wound dressing supplies, changed her gloves between dirty and clean tasks, as well as performed hand hygiene when removing her gloves and prior to reapplying gloves to prevent cross-contamination and/or the spread of infection.On 02/25/26 at 11:33 AM, Administrative Nurse D stated she expected staff to follow EBP protocol, which included personal protective equipment (PPE) as outlined on the signage on the resident's door. She stated gowns and gloves should be worn when providing direct care to residents with catheters, wounds, and anyone with an artificial opening into their body. Hand hygiene should be performed upon entering a resident's room, prior to applying gloves, in between glove changes, after removing gloves, and anytime going from a dirty task to a clean task to prevent cross-contamination and prevent the spread of infection.The facility policy titled Enhanced Barrier Precautions, dated 02/03/25, included Enhanced Barrier Precautions (EBP), which are an effective infection control intervention used to reduce the transmission of multidrug-resistant organisms in skilled and long-term care nursing facilities. EBP involves the use of PPE, specifically gowns and gloves, during high-contact resident care activities.The facility policy titled Hand Hygiene, dated 02/03/25, included that all staff members will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare. Indications for hand washing include:Before and after removing glovesBefore and after medication administrationBefore and after having direct contact with residents.Before and after contact with residents' intact skin, such as assisting residents with activities of daily living, transfers, and repositioning.Moving from a contaminated body site to a clean body site during resident care.Gloves reduce hand contamination by 70-80%, prevent contamination, and protect elders and healthcare personnel from infection. However, the use of gloves does not eliminate the need for hand hygiene. Change gloves during elder care if moving from a contaminated body site to a clean body site during resident care.The policy titled Nebulizer Cleaning Instructions, dated 02/03/25, documented that after each treatment, staff would rinse the resident's nebulizer and mouthpiece/mask with tap water, allow it to air dry, and store it in an open Ziploc bag or container after the nebulizer components dried. Staff would wipe down the outside of the machine, using a damp cloth. After the last treatment of the day, staff would completely disassemble the nebulizer, including the mouthpiece/mask.

The facility reported a census of 53 residents with 14 included in the sample. Based on interview and record review the facility failed to ensure staff adhered to the principles of antibiotic stewardship through the lack of monitoring for the appropriate use of prescribed antibiotics to prevent antibiotic resistance and the spread of multidrug resistant organisms within the facility. Findings included:1. Upon request, the facility failed to provide antibiotic and infection surveillance logs for 02/01/26 through 02/24/26, which demonstrated the facility did not track infections/antibiotic use within the facility for this month. The facility further failed to identify any commonalities, patterns, or trends related to infections/antibiotic usage to ensure residents were not administered ineffective antibiotics to prevent antibiotic resistance and the spread of multidrug-resistant organisms.On 02/24/2026 at 02:37 PM, Administrative Nurse E stated the facility used McGreer's Criteria (standardized guidelines used to identify and count infections in long-term care settings) for determining the appropriateness of antibiotic use. Administrative Nurse E verified the facility lacked evidence of antibiotic tracking and trending and/or documentation regarding how a determination of the appropriate use of antibiotics was made when antibiotics were prescribed by a physician.2. Review of R 9's Incident Note dated 02/20/26 at 03:30 PM revealed the resident's physician ordered a urinalysis (UA) with culture and sensitivity.The 02/21/26 at 12:23 PM Progress Note included preliminary positive UA results with culture and sensitivity results pending.The 02/23/26 at 09:41 AM Progress Note included the UA results and noted orders were received to start Nitrofurantoin (antibiotic), 100 milligrams (mg), by mouth two times a day for five days for urinary tract infection.On 02/25/26 at 09:27 AM, Licensed Nurse (LN) G reported that the provider generally would not start an antibiotic without a culture and sensitivity report. The LN reported the facility used McGeer's Criteria and opened an Antibiotic Stewardship Assessment. The lab did not always send the results back to the facility, and they would have to call the lab to obtain the findings. LN G then called the lab for R9's culture and sensitivity results and obtained the final report. The LN then reported the results were negative for UTI (although the resident was placed on an antibiotic for UTI, two days prior). LN G stated no further testing was indicated.On 02/25/2026 at 04:22 PM, Administrative Nurse D confirmed the above findings and stated R9 should not have received antibiotics for a UTI when her final culture report was negative for UTI. Administrative Nurse D confirmed that antibiotic stewardship should be tracked and monitored for trends and patterns, as well as for the appropriate use to prevent the overuse of antibiotics and the risk to residents of developing multidrug-resistant organisms.The facility's policy Antibiotic Stewardship, dated 02/04/25, documented that antibiotic stewardship refers to a set of commitments and actions to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improved antibiotic prescribing and management practices to reduce inappropriate use and to ensure that residents receive the right antibiotic for the right indication, dose, and duration.

The facility reported a census of 53 residents. The sample included 14 residents. Based on interview and record review, the facility failed to provide Resident (R)1 who had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition, care in a dignified manner during administration of medication.Findings included: - On 02/24/2026 at 08:32 AM, Licensed Nurse (LN) J moved R1 from the dining room table while she ate her breakfast. LN J propelled R1 approximately 10 feet away from the table toward the lounge that was still visible for residents in dining room. LN J applied gloves completed R1's fingerstick in the lounge. LN J lifted up R1's shirt and exposed her abdomen and administered an injection of insulin to R1's abdomen in the lounge. On 02/24/2026 at 08:39 AM LN J reported that she would always complete R1's fingerstick and administer insulin in the lounge area and reported that the residents that sat in the dining room could observe that. On 02/25/26 at 11:53 AM Administrative Nurse D revealed she expected the staff to provide care in privacy and expected the staff to complete blood sugars and insulin in the resident's room or an area that was not visible for others to observe. The facility's policy Dignity, dated 02/2015, documented the Community would promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

The facility identified a census of 53 residents, with 14 residents sampled. Based on observation, interview, and record review the facility failed to identify a significant change and complete an assessment for one resident reviewed for significant change assessments. Resident (R) 53 had a decline with ambulation, toileting hygiene, transfers, and bed mobility.Findings included:- R53's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) intertrochanteric (the area of the hip/thigh bone located between the greater and lesser trochanters left femur (thigh bone), and muscle weakness. R53's 07/15/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of four, which indicated severely impaired cognition. R53's MDS documented that she required moderate assistance with activities of daily living (ADL) including transfers. R53 required maximal assistance with toileting hygiene, and she was independent with bed and wheelchair mobility. R53's MDS documented ambulation was not attempted due to medical conditions or safety concerns.R53's 07/21/25 Cognitive Loss/Dementia Care Area Assessment (CAA) revealed R53 had impaired judgment and safety. R53 required 24-hour nursing care in a secure residence. R53's 07/21/25 ADL Functional/Rehabilitation Potential CAA did not trigger.R53's 09/16/25 Medicare 5-day MDS documented a BIMS score of four. R53's MDS documented she required total assistance with ADLs bed mobility, toileting hygiene, and transfers. Ambulation was not attempted due to medical condition or safety concernsR53's 10/21/25 Quarterly MDS documented a BIMS score of three. R53's MDS documented she required total assistance with ADLs bed mobility, toileting hygiene, and transfers. Ambulation was not attempted due to medical condition or safety concerns.R53's EMR lacked evidence of a significant change in condition MDS.R53's 01/30/25 Care Plan revealed R53 was able to make major positions changes in bed; R53's care plan was revised on 09/25/25 and R53 staff were to provide one to two maximal assistances to reposition in bed.R53's 10/31/24 Care Plan revealed staff were to provide maximal assistance of one for toileting. R53's care plan was revised on 09/25/25 and revealed R53 staff were to provide total assistances for toileting.R53's 07/24/25 Care Plan revealed staff were to provide moderate assistance of one for transfers. R53's care plan was revised on 09/25/25 and revealed R53 staff were to provide total assistances with two staff members and mechanical lift for transfers.R53's 07/24/25 Care Plan revealed staff instructed R53 ambulated very short distances. Staff were instructed to offer R53 a wheelchair. R53's care plan was revised on 09/25/25 and revealed R53 staff were to provide total assistances with two staff members and mechanical lift for transfers.R53's Discharge GG Evaluation on 09/04/2025 at 04:05 PM documented R53 toileting hygiene discharge performance R53 required supervision or touching assistance. R53's bed mobility discharge performance rolls left, and right was independent. R53's transfer discharge performance R53 required supervision or touching assistance. R53 walk 10 feet discharge performance she was independent and required supervision or touching when R53 ambulated 150 feet.R53's Restorative Nursing Screener / GG Evaluation on 09/17/2025 at 08:39 AM documented R53 toileting hygiene admission performance R53 required total assistance. R53's bed mobility admission performance rolls left, and right she required total assistance. R53's transfer admission performance R53 required total assistance. R53 walk 10 feet -150 feet admission performance not attempted due to medical condition or safety concerns.R53's Health Status Note, dated 09/25/2025 at 12:33 PM, documented R53 was a mechanical lift with assistance of two staff members due to left hip fracture. Resident wears incontinence products and is occasionally incontinent of both bowel and bladder and has been using bed pan to promote continence. R53 was dependent on wheelchair for locomotion.On 02/24/26 at 04:32 PM, Certified Nurse Aide (CNA) Q reported R53 requires total assistance with her ADLs after she fractured her left hip. CMA T reported that R53 required verbal cues to complete her ADLs before she fractured her hip.On 02/25/26 at 11:53 AM, Administrative Nurse D and Consultant Nurse GG (Regional RN) the facility currently had no MDS coordinator. Consultant Nurse GG reviewed R53's documented MDSs in R53's EMR and reported that R53 should have had a significant change MDS after she fractured her left hip 09/02/25.On 02/25/26 at 01:00 PM CNA Z reported that R53 requires total assistance with her ADLs after she fractured her left hip.The facility did not provide a policy,

The facility reported a census of 53 residents; there were 14 residents in the sample. Based on observation, record review and interview, the facility failed to update Resident (R) 36's Care Plan with interventions for R36's right hand positioning device to prevent contractions (abnormal fixations of a joint or muscle) indwelling urinary catheter (a device inserted into the bladder that drains urine into a collection bag). Findings included:- R36's Electronic Health Record (EMR) recorded the following diagnoses: hemiplegia/hemiplegia affecting the right side (muscular weakness of one half of the body) benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate).R36's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition with no changes in the ADLs.R36's Annual MDS, dated [DATE], documented a BIMS score of 13, indicating intact cognition. The MDS also documented R36 had right side impairment to upper and lower extremities and was dependent on staff for all Activities of Daily ADL's.R36's Care plan, dated 09/06/24, revealed R36 has an ADL self-care deficit associated with cerebral infarction, R36 is totally dependent on a staff member for personal hygiene and oral care. The care plan lacked information regarding an indwelling foley catheter or a device for position of the right hand.R36's Physician Orders, dated 2/19/26, directed to change the indwelling catheter every four weeks or as needed.Observation on 02/14/26 at 08:12 AM, R36 sat in his recliner in his room. A carrot positioning device laid on the bedside table.During an interview on 02/25/26 at 08:30 AM, Licensed Nurse (LN) G stated any of the staff can update the care plans with interventions such as the carrot positioning device and the indwelling catheter. She said she was unaware R36's Care Plan lacked the information.During an interview on 02/25/26 at 11:33 AM, Administrative Nurse D stated she expected all nursing staff to update the care plans.The facilities policy Care Plan, revised 2/3/25, the person-centered plan of care is developed in conjunction with the resident and or legal representative. To identify the individual's needs, strength, preferences, health status, life history and establish obtainable goals. An appropriate plan of care with services and items the resident is to receive is developed to ensure the highest level of functioning the resident may be expected to obtain.

The facility identified a census of 53 residents, with 14 residents sampled, including two residents reviewed for quality of care. Based on observation, interview, and record review, the facility failed to provide a mechanical lift transfer for Resident (R) 53 which resulted in an injury.Findings included:- R53's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) intertrochanteric (the area of the hip/thigh bone located between the greater and lesser trochanters) left femur (thigh bone), and muscle weakness. R53's 07/15/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R53's MDS documented she had behaviors, wandered, rejected care, had verbal behavioral symptoms directed towards others, and physical behavioral symptoms directed towards others for 1-3 days in the lookback period. R53's MDS documented she required moderate assistance with activities of daily living (ADL) including transfers.R53's Pressure Ulcer/Injury Care Area Assessment (CAA) triggered related to potential for pressure injuries. The contributing factors included incontinence and impaired mobility, and the risk factors included skin breakdown and pressure injuries. The CAA noted the care plan was reviewed to reduce the risk of pressure injuries and weekly skin assessment would be completed by a licensed nurse. R53's 10/21/25 Quarterly MDS documented a BIMS score of three and documented the resident required total assistance with ADL, bed mobility, toileting hygiene, and transfers. R53's MDS documented she was at risk of developing pressure ulcers, and she had one unhealed, unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure injury that was not present on admission. R53's MDS documented no pressure reducing device on her bed and she was not on a turn and repositioning program.R53's Care Plan, dated 09/25/24, revealed R53 required total assistance of two staff with a mechanical lift for transfers.R53's Incident Progress Note, dated 11/04/25 at 09:25 AM, documented staff reported R53 had a large bruise to the left side of her chest, under her left arm. The note documented R53 said she did not know how she received the bruise. The note included the area was assessed and measured 22.5 centimeters (cm) by 9.5 cm, was purple in color with hints of red scattered throughout, and R53 complained of pain when the area was touched.Review of facility's risk management documentation, dated 11/17/25, revealed the facilty found staff transferring R53 with two staff assistance and a gait belt. The documentation noted R53 was care-planned for two staff assistance and a mechanical lift (for transfers). The documentation included the facility provided education, instructed staff to follow the care plan, and provided instructions on how to locate the care plan and Kardex.On 02/24/2026 at 03:12 PM, Certified Medication Aide (CMA) T reported the staff looked in the EMR in the Kardex to know what skin interventions a resident required.On 02/25/2026 at 09:27 AM, Licensed Nurse (LN) G reported the Certified Nurse Aides (CNA) and CMAs were educated to update the nurse when a resident had a skin concern. LN G stated when a resident had a bruise or skin tear and could not say how that happened or it was not witnessed, the staff completed an incident report. LN G said Administrative Nurse D would complete an investigation. LN G said the CNAs should follow the residents care plan interventions for resident safety.On 02/25/26 at 11:53 AM, Administrative Nurse D said she expected all the staff to follow the care plan to keep residents safe and prevent injuries. The facility's policy Care Management, dated 02/03/25, documented management of resident care is conducted systematically and comprehensively by interdisciplinary team knowledgeable in current concepts of geriatric care. Resident care is designed to meet a resident's individual needs. Coordination of the plan of care is the responsibility of nursing; however, planning, implementation and evaluation require joint participation by each discipline rendering service.

The facility identified a census of 53 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1's hypoglycemic (medication used to lower blood glucose levels) medication levels were monitored to determine the effectiveness of her ordered hypoglycemic medication. Findings included:- The Electronic Medical Record (EMR) for R1 documented a diagnosis of diabetes mellitus.R1's 07/29/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated intact moderately impaired cognition. R1's MDS revealed she received seven days of insulin injections and also received hypoglycemic medications.R1's 08/05/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented that R1 had impaired judgment and had memory deficits noted. Needed staff support.R1's Care Plan, 08/26/2024, revealed an altered endocrine status related to hyperglycemia (greater than normal amount of glucose in the blood) and hypoglycemia (less than normal amount of sugar in the blood) due to the diagnosis of diabetes mellitus.R1's 02/23/26 Care Plan lacked monitoring of laboratory for diabetes mellitus.R1's 09/04/24 Physician Orders documented Jardiance (medicine used to lower blood sugar), give 25 milligrams (mg), by mouth one time a day for diabetes.R1's 09/04/24 Physician Orders documented glargine (long-acting insulin), give 10 units subcutaneously (beneath the skin) at bedtime for diabetes.R1's 09/08/24 Physician Orders documented Januvia (used to improve blood sugar control), give 100 mg, by mouth one time a day for diabetes.R1's 10/03/24 Physician Orders documented Humalog (rapid-acting insulin), give 10 units subcutaneously (beneath the skin) once a day for hyperglycemia.R1's 10/04/24 Physician Orders documented Humalog insulin, give 8 units subcutaneously once a day for hyperglycemia.R1's 07/01/25 Physician Orders documented a complete blood count (CBC- laboratory blood test), complete metabolic panel (CMP-laboratory blood test), and hemoglobin A1c (HbA1c-blood test used to evaluate the level of glucose control over the past 90 days) every six months for an old myocardial infarction (heart attack).R1's EMR revealed HbA1c was completed on 07/01/25.R1's EMR revealed that a CBC was completed on 08/01/25.R1's EMR revealed a CMP completed on 01/02/26.R1's EMR lacked evidence that a CBC and HbA1c were completed on 01/02/26.On 02/24/26 at 03:00 PM, R1 lay in bed with eyes closed.On 02/25/2026 at 08:03 AM, Administrative Nurse E reported that R1's CBC and HbA1c were not completed. Administrative Nurse E reported R1's January medication administration record had the CBC, CMP, and HbA1c, but there was no note documenting why they were not completed or rescheduled. Administrative Nurse E reported she expected the physician orders to be followed.On 02/25/2026 10:20 AM, Administrative Nurse E reported that the routine laboratory blood drawings would be completed every Tuesday by the outside laboratory staff on the day shift, and the charge nurse was responsible for having blood drawings completed. The facility's Drug Regimen Review, dated 08/2024, documented that a resident's medication regimen would be reviewed monthly and as needed by a licensed pharmacist to monitor current or potential impact as indicated by laboratory values. The community would ensure that the pharmacist had access to residents' laboratory tests.

The facility reported a census of 53 residents. Based on observation, interview and record review the facility failed to ensure the posted daily nurse staffing sheets were posted daily as required. Findings included:- An observation on 02/24/26 at 1:38 PM revealed the three houses [NAME], [NAME], and Ute did not have an accurate staffing sheet posted. The last date noted was 01/13/26.On 02/25/26 at 12:30 PM, Administrative Staff A stated the staffing sheets should be posted daily with each shift's information completed.The facilities policy Daily Nurse Staffing Report, reviewed 08/18/25, documented that nursing service is to provide each resident admitted to health care center with the appropriate level of care to attain his/her optimum level of functioning. Daily at the beginning of each shift identify the [NAME] number of staff and actual hours worked for the following licensed and unlicensed staff directly responsible for resident care.

The facility reported a census of 53 residents. Based on observation and interview, the facility failed to maintain and or dispose of kitchen garbage refuse properly.Findings included:- During the initial tour of the kitchen on 02/23/26 at 08:50 AM, observation of the outside garbage bins with Certified Dietary Manager (CDM) BB revealed one trash bin with trash on top of the bin.During an observation on 02/24/26 at 6:00 PM, the facility has a garbage bin across the street from the facility with a bag of trash on top of the bin.During an observation on 2/25/26 at 7:55 AM, the facility's garbage bin across the street from the facility the lids to the bins were not closed.During an interview on 02/25 at 10:20 AM, CDM BB stated he expected the trash to be inside the bins, not on top, and the lids should be closed. The facility policy Dumpster and Trash Compactor, undated, documents to ensure lids are correctly closed after use.

The facility reported a census of 49 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent an injury to dependent Resident (R) 1 when staff failed to transfer the resident according to the resident's plan of care with two staff present. This failure resulted in R1 obtaining a 2-to-3-centimeter (cm) laceration (a cut in body skin) on her left lower extremity, which required transport to the Emergency Department and 10 sutures to treat the wound. Findings included: - R1's Physician Order Sheet (POS), dated 08/16/24, documented the resident had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), hallucination (sensing things while awake that appear to be real, but the mind created), and osteoarthrosis (chronic arthritis without inflammation). The 08/13/24 Admission Minimum Data Set (MDS), documented the resident had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 07. R1 required a manual wheelchair, propelled by staff for mobility. R1 required total assistance from staff with bed mobility and maximum assistance from staff with transfers. She required total assist with oral hygiene, toileting, dressing, and personal hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated, 08/19/24, documented the resident had a BIMS score of 07, which indicated severely impaired cognition. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated, 08/19/24, documented the resident required extensive assistance with Activities of Daily Living (ADL). The Fall Care Area Assessment (CAA), dated, 08/19/24, documented the resident was care planned for staff assistance with transfers due to decline in mobility, increased level of assistance, and decreased safety awareness. The 11/12/24 Quarterly MDS, dated [DATE], documented the resident had moderately impaired cognition, with a BIMS score of 8. The resident required maximum assistance by staff with her manual wheelchair. The resident did not have upper or lower functional impairment in Range of Motion. The resident meals were independent. She required partial assist with bathing. She required maximum assistance with bed mobility. and transfers, R1's Care Plan, dated 08/24/24 instructed staff to know R1 was severely cognitively impaired related to dementia. R1 required substantial/maximum assistance to total dependence by two nursing staff for ADLs. The Witness Statement dated 10/23/24, at approximately 07:45 AM revealed Certified Nurse Aide (CNA) M documented she assisted the resident to stand with a gait belt. When the resident stood up, the resident complained of pain in her leg. CNA M immediately sat her down in wheelchair and observed bleeding from the left lower extremity. She reported to the Licensed Nurse (LN) H, that she did not know how the injury happened. On 10/23/24 at 07:45 AM the Health Status Note documented by LN G revealed he was alerted on 10/23/24 at 07:45 AM that the resident had a skin tear to her shin. LN G cleansed the laceration and applied pressure because the laceration was bleeding profusely. The laceration was located on her left lower extremity and measured 2 to 3 centimeters (cm). At 09:00 AM, the resident's health care provider gave an order to transport the resident to the emergency department (ED) and she left for emergency department (ED) at 09:35 AM. On 10/23/24 at 01:41 PM the Health Status Note documented by LN G revealed the facility received report from the ED notifying them the resident received 10 sutures and that she would be discharged on Keflex (antibiotic medication) four times a day for seven days. The resident's sutures would need to be removed in seven days. R1's Skin/Wound Note, dated 11/04/24 (after the sutures were removed) revealed R1 had an open area, which measured 3.0 cm by 2.4 cm, which were reinforced with steri-strips and covered with a foam dressing. On 12/17/24 at 11:18 AM Certified Medication Aide (CMA) R and CNA O transferred R1 from her recliner in her room to her wheelchair, utilizing a gait belt. The resident wore non-slip black shoes. The nursing staff placed foot pedals on the resident's wheelchair and propelled her to the dining room for lunch. On 12/17/24 at 12:10 PM CMA R reported resident care plans could be found in the Kardex for each of the residents, which included transfer status and for any changes in transfer status. CMA R reported R1 required two nursing staff for transfers. On 12/17/24 at 01:15 PM LN G reported R1 required two staff assistance for transfer before the incident on 10/23/24 and further reported the resident continued to require two nursing staff for transfers on 12/17/24. LN G stated on 10/23/24 the facility provided education on the Lifting & Transferring Residents Policy and resident Care Plan. On 12/17/24 at 02:00 PM, Administrative Staff A reported CNA M did not follow R1's care plan by transferring the resident by herself. Administrative Staff A stated the resident's care plan clearly documented the resident required two staff members for transfers. On 10/23/24, the facility provided education on the Lifting & Transferring Residents Policy and resident Care Plan. Each can and CMA completed a Transferring the Resident to a Chair or Wheelchair competency check off. The facility Lifting & Transferring Residents Policy and Care Plans, dated 10/01/21, documented the facility will provide a safe work environment for resident care area by providing and requiring the use of safety materials, equipment, and training designed to prevent injury. The facility failed to prevent an injury to dependent R1 when staff failed to transfer the resident according to the resident's plan of care with two staff present. This failure resulted in R1 obtaining a 2-to-3-centimeter laceration on her left lower extremity, which required transport to the Emergency Department and 10 sutures to treat the wound.

The facility had a census of 55 residents. The sample included 14 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to establish the physician-ordered fluid restriction for one resident, Resident (R) 40. This placed the resident at risk for dehydration (a harmful reduction in the amount of water in the body) or fluid overload (too much fluid in the body). Findings included: - The Electronic Medical Record (EMR) documented R40 had diagnoses of heart failure (the heart does not pump blood as well as it should), hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and anxiety (metal or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R40's Admission Minimum Data Assessment (MDS), dated [DATE], documented R40 had intact cognition. R40 required extensive assistance from two staff for bed mobility, transfers, ambulation, dressing, and toileting. R40 required set-up assistance for eating. The Quarterly MDS, dated [DATE], documented R40 had intact cognition. R40 required substantial assistance with toileting, dressing, and transfers and supervision with mobility. R40 required set-up assistance for eating. R40's Care Plan, dated 01/29/24 and initiated on 08/15/23 documented R40 was on a regular diet with an 1800 milliliter (ml) fluid restriction. R40 would receive 75 percent (%) of his fluid from nutrition (1350 ml), and 25% from nursing (450 ml). The care plan further directed staff to provide R40 with his choice of fluids at each meal and place them at his bedside. The Physician's Order, dated 12/07/23, directed staff to implement a fluid restriction for R40 of 1800 ml every 24 hours. R40's Treatment Administration Record (TAR) for December 2023 lacked documentation the resident was on a fluid restriction. R40's TAR for January, February, March, and April 2024 lacked documentation the resident was on a fluid restriction. On 04/10/24 at 11:55 AM, observation revealed two 24-ounce (oz) mugs and a 20 oz disposable cup with coffee in it on R40's bedside table. On 04/10/24 at 12:35 PM, Certified Medication Aide (CMA) M stated she had not known R40 was on a fluid restriction even though the fluid restriction was displayed on the face sheet of the EMR in bold letters. CMA M further stated she also worked the floor as a Certified Nurse Aide (CNA) and was unaware of the restriction. On 04/10/24 at 12:45 PM, Licensed Nurse (LN) G stated she worked a couple of days a week and was unsure if R40 was on a fluid restriction or where staff would document fluid intakes. On 04/10/24 at 12:55 PM, Dietary BB stated she would be notified by her supervisor if a resident was on a fluid restriction and the supervisor would inform her how much fluid would be given at meals. Dietary BB stated she was unaware of R40's fluid restriction. On 04/15/24 at 02:14 PM, Administrative Nurse D verified R40's fluid restriction was never implemented by staff and said staff should have been monitoring R40's fluid intake. The facility's Fluid Restrictions and Additions policy, dated 09/22, documented that fluid restrictions were ordered by the physician, and dining services would adjust the resident's menu and nourishments accordingly. The amount of fluid for each item would be indicated on the resident's menu or tray ticket and nursing personnel were responsible for recording and monitoring the fluid intake. Dining services would provide 75% of the fluid restriction and nursing would provide 25% of the fluid restriction. The facility failed to establish a fluid restriction as ordered for R40. This placed the resident at risk for dehydration or fluid overload.

The facility had a census of 55 residents. The sample included 14 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 40 remained free from avoidable falls when staff failed to provide R40 with the necessary equipment to ensure safety, including a call light and mobility devices, on two separate occasions which resulted in falls on both occasions. This placed the resident at risk for avoidable injury. Findings included: - R40's Electronic Medical Record (EMR) documented diagnoses of heart failure, hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R40's Admission Minimum Data Assessment (MDS), dated [DATE], documented R40 had intact cognition, and required extensive assistance from two staff for bed mobility, transfers, ambulation, dressing, and toileting; R40 required extensive assistance from one staff for personal hygiene. The MDS further documented R40 had unsteady balance and no falls since admission. The Quarterly MDS, dated [DATE], documented R40 had intact cognition, required substantial assistance with toileting, dressing, and transfers, and required supervision with mobility. R40 did not ambulate. The MDS further documented R40 had a functional impairment in both lower limbs. R40 had two falls since the last assessment. The Fall Risk Assessments, dated 08/2/23, and 01/09/23 documented a moderate risk for falls. R40's Care Plan, dated 01/29/24 and initiated on 08/03/23, directed staff to ensure his walker and wheelchair are within his reach and easy access. The update, dated 08/22/23, directed staff to check on R40 frequently and ensure safety and call light placement. The update, dated 11/14/23, directed staff to place a call light box above the resident's bed and a clip to the call button to prevent any tripping hazard. The update, dated 01/09/24, directed staff the ensure R40's wheelchair was within reach before exiting the room. The Root Cause Analysis Investigation, dated 11/11/23 at 01:35 AM, documented R40 was found lying on the carpeted floor next to his bed, face down with his legs extended. His call light was next to him. R40 stated his call light was on the floor and he leaned over to retrieve it which caused him to roll out of bed. The investigation further documented R40 sustained a laceration to the top of his head, which required first aid. R40 was taken to the local hospital and the laceration was cleansed and glued. The staff were educated to ensure R40's call light was within reach before exiting the room. The Root Cause Analysis Investigation, dated 01/09/24 at 12:21 PM, documented R40 hollered for assistance and was found on the floor in his room. R40 stated he tried to get out of the recliner to use his walker to go to the bathroom, but both the walker and wheelchair were not within reach, and he stated he could not call for assistance because his call light was not within reach either. The staff was educated to ensure his call light and wheelchair were within reach before exiting his room. On 04/15/25 at 08:29 AM, observation revealed R40 in the bathroom. Licensed Nurse (LN) H told R40 to use the grab bar beside the toilet to assist him in standing up. R40 stood up, LN H performed personal care then assisted R40 into his wheelchair. LN H pushed R40 by his recliner, gave him his call light, and told him to call if he needed assistance. On 04/10/24 at 12:15 PM, Certified Nurse Aide (CNA) R stated R40 did not have any falls when she worked and said she always made sure R40 had his call light before she left the room and stated they are trained regarding abuse and neglect yearly. On 04/15/24 at 08:40 AM, LN H stated R40 called when he required assistance. LN H said R40 had not had any falls on her shift, and stated they have ongoing training regarding falls and abuse and neglect. On 04/15/24 at 02:14 PM, Administrative Nurse D stated, R40 should not have been left without access to his call light, staff were educated and another call light was placed where it would be accessible. The facility's policy Falls revised 10/12/22 documented that residents would be identified for risk of falls and interventions would be implemented to reduce the risk The facility failed to ensure R40 remained free from avoidable falls. This placed the resident at risk for injury.

The facility had a census of 55 residents. The sample included 14 residents, with seven reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment and failed to develop a comprehensive trauma-informed care plan for Resident (R) 35, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). This placed R35 at risk for unmet behavioral and mental health needs and retraumatization. Findings included: - The Electronic Medical Record (EMR) for R35 documented diagnoses of PTSD, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], documented R35 had intact cognition and required supervision with toileting, transfers, and bathing. R35 required set-up assistance with personal hygiene; R35 was independent with mobility. The assessment documented R35 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication and had no behaviors. R35's Care Plan, dated 01/08/24 and initiated 01/05/24, documented R35 received psychotropic (medication used to treat mental illnesses) medication with the potential for drug-related complications from anxiety and depression. The plan directed staff to educate the family on potential risks, benefits, and alternatives, administer medication as ordered, and monitor for adverse side effects. The care plan lacked direction to staff on R35's trauma triggers and coping strategies. R35's EMR lacked evidence a trauma-informed assessment was completed for R35 after admission. The Physician's Order, dated 12/27/23, directed staff to administer buspirone (an antianxiety medication), 5 milligrams (mg) by mouth twice per day for depression. The Physician's Order, dated 12/27/23, directed staff to administer Trazadone (an antidepressant medication), 50 mg by mouth at bedtime for depression. The Physician's Order, dated 01/08/24, directed staff to administer Lexapro (an antidepressant), 10 mg by mouth daily for depression. On 04/10/24 at 09:38 AM, observation revealed R35 at a group activity actively participating. On 04/10/24 at 12:20 PM, Certified Nurse Aide (CNA) R stated she had not been aware of R35's PTSD diagnosis and she was not informed of any triggers R35 would have or of her history. On 04/11/24 at 09:46 AM, Licensed Nurse (LN) G stated she had not been aware of R35's diagnosis of PTSD and did not know what her triggers were. LN G stated R35 was quiet and did not have any type of behavior. On 04/11/24 at 01:00 PM Social Services X stated she had completed a life stressor assessment on R35 when the resident was previously in the facility back in June 2023 but said she had not completed a trauma-informed care assessment for the most recent admission. Social Services X further stated she had not spoken with staff regarding R35's PTSD triggers due to R35's intact cognition and R35 was a very private person. Social Services X verified that she had not completed any care plan for R35 related to her mood and PTSD diagnosis. On 04/15/24 at 02:15 PM, Administrative Nurse D stated she had provided the staff with education related to R35's PTSD and stated a care plan was just completed to assist staff in recognizing what triggered R35's PTSD and anxiety. Administrative Nurse D said she was not aware R35 needed to have a trauma-informed care assessment. The facility's Trauma Informed Care policy, dated 10/12/21, documented the organization was committed to implementing trauma-informed approaches to the care provided and the organizational culture created for the residents of the community. The policy further documented a trauma-informed assessment would be completed within 72 hours of admission for initial screening of a history of trauma and it would determine if the resident had trauma-related symptoms. The assessment would be completed by Social Services, designee, or other licensed staff. The interdisciplinary team would discuss the findings to determine the resident's treatment plan including interventions to avoid re-traumatization and assist in identifying and managing trauma-related triggers. Staff would be trained and competency-tested on trauma-informed care during orientation, annually, and at any time deemed necessary by the supervisor. The facility failed to complete a trauma-informed care assessment and failed to develop a care plan for R35, who had a diagnosis of PTSD. This placed R35 at risk for unmet behavioral and mental health needs and retraumatization.

The facility reported a census of 55 residents with 22 selected for review which included 12 residents reviewed for medications. Based on observation, interview and record review, staff failed to follow physician orders for ten of the 12 residents(R)4, R10, R11, R18, R20, R29, R35, R31, R38, and R 50 reviewed for medications. Findings included: - Review of R 10's Physician Order Sheet undated, revealed diagnoses included [CONDITION(S)] (rapid, irregular heartbeat), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Care Plan, reviewed 07/20/22, instructed staff the resident received [MEDICATION(S)]. The care plan instructed staff if the drug must be discontinued in patients, without adequate continuous anticoagulation, it increased the risk of clotting events such as stroke. A Physician's Order, dated 12/24/21, instructed staff to administer [MEDICATION(S)] (a medication to prevent clot formation) 5 milligrams (mg), twice a day for [CONDITION(S)] (BID). Review of the Hospital and Surgery Reservation from the vascular surgeon, revealed the resident was scheduled for a vascular procedure on 06/28/22, and it instructed the staff to hold the resident's [MEDICATION(S)] 5 mg, for three days prior to the procedure (06/25, 06/26, 06/27 and 06/28). A Physician's Order, dated 06/28/22, instructed staff to restart the [MEDICATION(S)] 5 mg BID on 06/29/22 in the PM. The MAR contained an entry to hold the [MEDICATION(S)] 5 mg BID on Friday 06/25/22 and to restart the medication pending instructions after the procedure on 06/28/22. Review of the June 2022 Medication Administration Record (MAR) revealed staff did not administer the [MEDICATION(S)] 5 mg BID on 06/24/22 (two doses prior to the ordered stop date of 06/25/22) . Staff did not resume the [MEDICATION(S)] 5 mg for the PM dose on 06/29/22 but administered a PM dose on 06/30/22, (with two more missed doses). Review of the July 2022 MAR, revealed staff did not administer the [MEDICATION(S)] 5 mg on 07/01/22, 07/02/22, 07/03/22, 07/04/22, 07/05/22 and the 07/06/22 AM dose, (with 10 doses missed). Interview, on 08/24/22 at 08:07 AM, with Licensed Nurse (LN) G, revealed staff entered the [MEDICATION(S)] order for this resident wrong into the system. Interview, on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed she would expect the charge to run a report at the end of their shift to see what meds were not signed for and then to investigate why. Administrative Nurse F stated staff entered the [MEDICATION(S)] 5 mg BID hold date and resumption date into the electronic system incorrectly, and confirmed the resident missed 12 doses of the physician ordered medication. The facility policy Physician Order Flow Sheet undated, instructed staff to enter the order in Physician's Orders, Fax the order to pharmacy, scan the order into the Matrix system, under the correct tab, place a copy of the order in the Medical Records box for follow through, document in note in the Matrix all order details including name of medication dose, diagnosis and pull up the EMAR/TAR and ensure the order displays correctly. The facility failed to ensure staff administered this medication as ordered by the physician to hold and then to restart this resident's [MEDICATION(S)]. - Review of resident (R)11's Physician Order Sheet, undated, revealed diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). Review of the Physician's Orders, revealed the following: On 12/02/20, original order date, [MEDICATION(S)] (a medication used for Alzheimer's disease) staff to administer 10 milligrams (mg) twice a day (BID). On 03/17/22, original order date, [MEDICATION(S)] (an antidepressant), 100 mg, daily for major depressive disorder. Review of the July 2022, Medication Administration Record (MAR) revealed staff did not administer [MEDICATION(S)] 100 mg for the morning doses as ordered by the physician, on 07/13/22 through 07/18/22, (for a total of six missed doses of the medication). Review of the July 2022, MAR revealed staff did not administer [MEDICATION(S)] 10 mg, for the morning dose on 07/13, 14,16,17, and 07/18/22. (a total of five missed doses.) Staff did administer the AM dose on 07/15/22. Interview, on 08/24/22 at 11:30 AM, with Certified Medication Aide (CMA)R, revealed CMAs should check in the medication room for over flow medications to replace medications that were out. CMAs were responsible to order medications in a timely manner. Interview, on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed she would expect the charge nurse to run a report at the end of their shift to see what meds were not signed for and then to investigate why. She would expect the CMAs to check the medication room for the medications and if they were not available, to follow up with the charge nurse/pharmacy. The facility policy Teachable Moment, dated 06/23/21, instructed staff to not wait until the medication is gone before reordering. If electronic reorders have not arrived, call the pharmacy to see why and/or reorder. The facility failed to ensure staff ensured timely reordering of medications and investigate medications not administered at the end of each shift to ensure this resident received the medications as ordered by the physician. - Review of resident (R)18's Physician Order Sheet, undated, revealed diagnoses included dementia progressive mental disorder characterized by failing memory, confusion) and major mood disorder (major mood disorder). A Physician's Order, dated 05/19/22, instructed staff to administer [MEDICATION(S)] (an antipsychotic) 25 milligrams (mg) every hour of sleep for hallucinations. Review of the May 2022 Medication Administration Record, (MAR) revealed staff administered [MEDICATION(S)] 25 mg every hour of sleep beginning 05/24/22 (five days after the facility received the order). Review of the June 2022 MAR, revealed two missed doses of [MEDICATION(S)] on 06/18/22 and 06/19/22. Interview, on 08/24/22 at 11:30 AM, with Certified Medication Aide (CMA) R, revealed CMAs should check for medications in the medication room. If the medication was not available staff would need to notify the charge nurse and reorder the medication from the pharmacy. Interview on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed she expected the charge nurse to run a report at the end of their shift to see what meds were not signed for and then investigate why. She would expect the CMAs to check the medication room for the medications and if they were not available, to follow up with the charge nurse/pharmacy. Administrative Nurse F stated staff ordered the medication for [MEDICATION(S)] on 05/19/22, with the wrong code and it did not transfer correctly onto the MAR. The Physician Order Flow Sheet, undated, instructed staff to pull up the e MAR/TAR and ensure the order displays correctly. The facility failed to ensure this resident received [MEDICATION(S)] as ordered by the physician. - Review of resident (R)29's Physician Order Sheet, undated revealed diagnoses included cerebral vascular infarction (stroke), major depressive disorder (major mood disorder), and [CONDITION(S)] disorder (major mental illness that caused people to have episodes of severe high and low moods). A Physician's Order, dated 06/17/22, instructed staff to discontinue [MEDICATION(S)] SR (an antidepressant sustained release) 100 milligrams (mg) twice a day, and to then start [MEDICATION(S)] XL (extended release) 300 mg, every morning for major depressive disorder. Review of the June 2022 Medication Administration Record (MAR) revealed an entry for [MEDICATION(S)] SR (not the ordered XL type of medication) 300 mg daily for [CONDITION(S)] disorder. Staff administered this incorrect medication on 06/18/22, 06/21/22 and 06/22/22 through 06/30/22, (with incorrect administration for a total of 13 doses). Staff failed to discontinue the [MEDICATION(S)] SR as ordered on 06/17/22. Review of the July 2022 MAR revealed an entry for [MEDICATION(S)] SR (not the ordered XL type of medication), 300 mg once a day for major depressive disorder. Staff administered this incorrect ordered medication from 07/01 through 07/25/22, for a total of 25 doses. Interview, on 08/24/22 at 11:30 AM, with Certified Medication Aide (CMA) R, revealed CMAs should check for medications in the medication room. If the medication were not available staff would need to notify the charge nurse and reorder the medication from the pharmacy. Interview on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed staff entered [MEDICATION(S)] SR 300 mg daily instead of [MEDICATION(S)] XL 300 mg daily into the electronic medical record which caused the incorrect MAR entry for [MEDICATION(S)] SR 300 mg. The error was caught when another provider instructed staff to discontinue [MEDICATION(S)] SR 300 mg and start [MEDICATION(S)] XL 300 mg on 07/21/22. Administrative Nurse F stated the facility was aware of the medication errors. The facility policy Physician Order Flow Sheet, undated, instructed staff to pull up the e MAR/TAR and ensure the order displayed correctly. The facility administered this resident's [MEDICATION(S)] SR 300 mg daily instead of [MEDICATION(S)] XL 300 mg daily as ordered by the physician, for a total of 38 doses. - Review of Resident (R)4's electronic medical record EMR, under the Diagnoses tab, included a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The revised care plan, dated 03/25/22, instructed staff the resident had an alteration in her thought process due to dementia (progressive mental disorder characterized by failing memory, confusion) and took [MEDICATION(S)] (medication used to treat dementia of the Alzheimer's type). Review of a physician's order for R 4, provided by the facility, revealed a new order for [MEDICATION(S)] (used to treat moderate to severe dementia of the Alzheimer's type), 5 milligrams (mg), by mouth (po), ordered on 06/05/22. However, review of the resident's Medication Administration Record (MAR), for August 2022, revealed the resident first received the medication on 08/17/22 (over 2 months after the physician ordered it). On 08/24/22 at 11:38 AM, Licensed Nurse (LN) GG stated when a new order comes through, the nurse was to fill out a fax form and send it to the pharmacy for the medication to be delivered. The nurse would then add the new medication to the MAR. On 08/25/22 at 09:41 AM, Administrative Nurse F stated, the charge nurse was responsible for checking for new orders throughout the shift. The facility identified not all new orders were being initiated in a timely manner. On 08/25/22 at 11:10 AM, Administrative Nurse D stated, the facility identified not all new orders were being processed correctly. Administrative Nurse D stated it was the expectation that residents get the medications ordered by their physicians in a timely manner. Review of the facility policy for, process for new orders, undated, included: When receiving a new order, staff were to enter the order into the Physician's Orders in the resident's EMR and fax the new medication order to the pharmacy. Staff were then place a copy of the order into the Medical Records box for follow through. The facility failed to follow physician's orders for over two months, for this dependent resident with Alzheimer's disease. - Review of Resident (R)50's electronic medical record (EMR), under the Diagnoses tab, included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The revised care plan, dated 05/02/22, instructed staff the resident had exit seeking and wandering behaviors. Review of the resident's EMR, under the Orders tab, revealed an order for [MEDICATION(S)] 0.5 mg, po, with dinner, ordered 07/07/22. Review of a physician's order, provided by the facility, revealed a physician's order, dated 07/17/22, for [MEDICATION(S)] (used to treat a certain mental/mood disorders), 0.25 milligrams (mg) with breakfast, by mouth (po), to start on 07/18/22. Review of the resident's Medication Administration Record (MAR), located in the resident's EMR, revealed staff failed to administer the [MEDICATION(S)] 0.25 mg with breakfast, ordered 07/17/22, until the morning of 07/29/22. The resident went 11 days without the ordered medication. On 08/24/22 at 11:38 AM, Licensed Nurse (LN) GG stated when a new order comes through, the nurse was to fill out a fax form and send to the pharmacy for the medication to be delivered. The nurse would then add the new medication to the MAR. On 08/25/22 at 09:41 AM, Administrative Nurse F stated, the charge nurse was responsible for checking for new orders throughout the shift. The facility identified not all new orders were being initiated in a timely manner. On 08/25/22 at 11:10 AM, Administrative Nurse D stated, the facility identified not all new orders were being processed correctly. Administrative Nurse D stated it was the expectation that resident's get the medications ordered by their physician in a timely manner. Review of the facility policy for, process for new orders, undated, included: When receiving a new order, staff were to enter the order into the Physician's Orders in the resident's EMR and fax the new medication order to the pharmacy. Staff were then place a copy of the order into the Medical Records box for follow through. The facility failed to follow physician's orders for change in this dependent resident with behaviors, [MEDICATION(S)] medication. - Review of Resident (R)35's electronic medical record (EMR), under the Diagnoses tab, revealed a diagnosis of constipation (the inability to pass stool). The care plan, revised 05/04/22, instructed staff the resident required limited assistance of one staff for toileting. Review of a physician's order, dated 07/07/22, revealed an order for a KUB (A radiographic scan of the kidney, ureter, bladder and the surrounding structures), due to left lower abdominal pain. Review of an ID Note, in the resident's EMR, dated 08/16/22 (over a month later), revealed the KUB had not been completed. On 08/24/22 at 11:38 AM, Licensed Nurse (LN) GG stated when a new order comes through, the nurse was to note the order and schedule the test with the radiographic company. Staff failed to get the KUB ordered for this resident. On 08/25/22 at 09:41 AM, Administrative Nurse F stated, the charge nurse was responsible for checking for new orders throughout the shift. The facility identified not all new orders were being initiated in a timely manner. On 08/25/22 at 11:10 AM, Administrative Nurse D stated, the facility identified not all new orders were being processed correctly. The facility has done one to one training with nurses and completing training with agency nurses. Administrative Nurse D stated it was the expectation that residents get radiographic examinations ordered by their physicians in a timely manner. Review of the facility policy for, process for new orders, undated, included: When receiving a new order, staff were to enter the order into the Physician's Orders in the resident's EMR and fax the new medication order to the pharmacy. Staff were then place a copy of the order into the Medical Records box for follow through. The facility failed to follow physician's orders for this dependent resident with a history of constipation to timely obtain the KUB for testing. - The diagnosis tab, located at the dashboard in the electronic medical record (EMR), for Resident (R)20, included diagnoses of hypertension (elevated blood pressure), [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and chronic pain. The Medication Record for 08/2022, included these physician orders: 1. On 01/19/22, [MEDICATION(S)] (medication used to relieve pain) pain relief, four percent topical patch, once daily, for low back pain. 2. On 03/07/22, [MEDICATION(S)] (medication used to treat hypertension), 50 milligrams (mg), by mouth, twice daily for hypertension. 3. On 06/28/22, [MEDICATION(S)]-acetaminophen (medication used to treat pain), 7.5 mg/325 mg, by mouth, three times daily, for pain. The Progress Note for the physician visit dated 07/07/22, revealed under the assessment section hypertension-overmedicated. The progress note included an order to decrease [MEDICATION(S)] to 25 mg, by mouth, twice daily. The note included a fax date of 07/08/22. Additional orders included: 1. Peri-cream, to rectal area, as needed. 2. Biofreeze (medication used to treat pain), to right hand/elbow/forearm, twice daily as needed. 3. Chest x-ray. 4. Consider CBC (completed blood count-blood test that provides information about the cells in a person's blood), BMP (basic metabolic profile-blood test that measures eight different substances in the blood), and BNP (brain natriuretic peptide-blood test measures levels of a protein in the blood to provide information on how the heart is working). 5. [MEDICATION(S)] (medication used to treat irritation/itch/swelling of hemorrhoids) cream, to the rectal area, twice daily. The physician order tab, located under the attachment link in the EMR, revealed the staff scanned in the physician visit progress note dated 07/07/22, on 07/22/22 (15 days after the physician order). The Interdisciplinary Note (ID) dated 08/05/22, for R20 revealed a Certified Medication Aide (CMA) reported to the charge nurse R20's blood pressure was low this evening, reading 98/54. The charge nurse reviewed the record and found the [MEDICATION(S)] had parameters for a pulse of less than 50 but no parameters for the blood pressure. Upon reviewing the EMR the nurse located an order dated 07/07/22 (over a month prior), on a progress note to decrease the [MEDICATION(S)] to 25 mg, by mouth, twice daily and the ID notes lacked any physician order changes. The staff notified the physician on call, which gave orders to: 1. Start [MEDICATION(S)], 25 mg, by mouth, twice daily. 2. Obtain labs: CBC, BMP, and BNP. 3. Discontinue the [MEDICATION(S)] cream. 4. Discontinue the chest x-ray. 5. Start Biofreeze, to right hand/elbow/forearm, twice daily, as needed. The Medication Record dated 08/2022, for the [MEDICATION(S)] patch, revealed the staff did not administer the medication due to med not available. The ID note dated 08/10/22 at 03:17 PM\, revealed R20 was to have a [MEDICATION(S)] patch placed every morning and removed every evening. It was discovered during medication pass on 08/09/22, that R20 did not have a [MEDICATION(S)] patch placed. The facility investigation notes, for 08/09/22, revealed the evening CMA went to remove the patch per the Medication Record and R20 lacked a patch. The Medication Record dated 08/14/22, included that on 08/14/22, the staff administered [MEDICATION(S)]-acetaminophen for the scheduled time of 07:00 PM through 10:00 PM. The Individual Residents Controlled Substance Record for R20 for the [MEDICATION(S)]-acetaminophen, for the bedtime dose, lacked an entry for 08/14/22. The count was correct indicating the staff did not administer the medication. The ID note dated 08/18/22 at 11:16 AM, revealed the staff notified R20's responsible party of a medication error with the [MEDICATION(S)]/acetaminophen at bedtime on 08/14/22. On 08/25/22 at 08:41 AM, Licensed Nurse (LN) J stated R20's physician faxes her progress notes, which will include order changes, two to three days after her visit to the facility. The faxes are received through the electronic fax system, which required a staff to have an email address to access the fax system. When a new progress note comes through an email arrives to the nursing staff, director of nursing, quality assurance nurse, medical records, and assistant director of nursing, and a nurse from the assisted living side. We then have a Physician Order Flow Sheet that was to be filled out with new physician orders and then attach the printed order to the flowsheet and place in the file box for medical records. The orders were to be noted when processed. LN J stated the flow sheet had been in place for one to two months. On 08/25/22 at 09:41 AM, interview with Administrative Nurse E and Administrative Nurse F revealed the Physician Order Flow Sheet had been in place for years. The physician progress notes which can include orders comes to the electronic fax system, and they arrive all together from all three halls, any nurse can see the notes. An agency nurse may not have an email to be able to get into the system and there was not always a facility nurse on duty each shift to access the system. When an order comes through, the nurse should print work the order following the Physician Order Flow Sheet, make a note in the ID notes of the EMR, place the order with the flow sheet in the medical records box, then medical records checks to see if the nurse entered the order correctly into the EMR. The orders scanned in the EMR on 07/22/22, were not entered into the EMR system for the staff to follow. The CMA working on 08/14/22, signed she gave the medication in the EMR, but not on the controlled substance record. The staff were unable to find the [MEDICATION(S)] patch due to it being removed on 08/08/22. On 08/25/22 at 11:40 AM, Administrative Nurse D stated the orders received on 07/08/22 and scanned in on 07/22/22 were not processed and should have been. Some of the agency nurses did not have access to the system as that company did not want them to have access and we had to ask for special permission for them to get access for the frequently working agency nurses. The staff failed to check in the overflow for the [MEDICATION(S)] patch, which was in stock, when they did not apply it on 08/08/22. The facility policy Medication Administration dated 03/15/22, included if the medication ordered was not present to notify the charge nurse, check pharmacy delivery sheet for listing, notify pharmacy to request emergency dose, notify the physician, and retrieve the dose immediately. Prior to administering medication, the staff were to check the medication and dosage schedule on the electronic medication administration record and compare with the medication label. The Physician Order Flow Sheet undated, included for all orders to enter the order in the Physician Orders and document the details of the order (name of medication, dose, diagnosis, treatment location, notification of DPOA (Durable Power of Attorney) and the order sent to the pharmacy. The staff were to pull up the medication record/treatment record to ensure the order displayed correctly. The facility failed to process accurate physician orders in a timely manner and failed to administer these medications as ordered by the physician for R20. - The diagnosis tab, located under the attachment link of the dashboard in the electronic medical record (EMR) for Resident (R)31, included a diagnosis of hypertension (high blood pressure). The physician orders tab in the EMR included an order, dated 01/19/22, for [MEDICATION(S)] (medication used to treat hypertension), 20 milligrams (mg), every day, for hypertension. The Interdisciplinary Notes located in the EMR, dated 08/05/22 at 12:31 PM, revealed Certified Medication Aide (CMA) OO stated R20 received two doses of [MEDICATION(S)] on 08/04/22 in the morning. The AM slot in the medication cart for R31 had a medication card of [MEDICATION(S)] that was in current use for the month with a tablet popped out of the packet for 08/04/22 and another full month card for [MEDICATION(S)] behind the current month card with one tablet popped out for 08/04/22 also. The facility investigation notes revealed both cards of [MEDICATION(S)] in the AM spot had the tablet for 08/04/22 Popped out. R20 was most likely given two doses of [MEDICATION(S)] on the morning of 08/04/22. On 08/23/22 at 10:46 AM, CMA S stated she thought she was working when the medication error happened. At the time of the error, overflow medications were kept in an overflow area of the medication cart in the bottom drawer. On 08/25/22 at 10:30 AM, Administrative Nurse F stated before the staff administer a medication, the staff should check to make sure they have the right resident, right medication, right dose, right route, and the right time. On 08/25/22 at 11:42 AM, Administrative Nurse D stated before the staff administer a medication, they should follow the five rights. The facility policy Medication Administration dated 03/15/22, revealed before administering medication, the staff should check the medication and dosage schedule on the electronic medication administration record (eMAR) and compare with the medication label. The label should be read three times when removing the medication from the drawer, before and after pouring, and document on the eMAR after the staff poured the medication. If there was any discrepancy between the EMAR and the label, staff were to check the physician orders before administering the medication. The facility failed to compare the medication to the EMAR for R31 resulting failure to follow the physician order for the resident's [MEDICATION(S)] with administration of two doses of the medication instead of the ordered one. - The diagnosis tab on the dashboard, located in the electronic medical record (EMR) included diagnoses, for Resident (R) 38 of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), [CONDITION(S)] (swelling resulting from an excessive accumulation of fluid in the body tissues), [CONDITION(S)] (rapid, irregular heart beat), and [CONDITION(S)] heart disease (thickening of the walls of the arteries that supply blood and oxygen to the heart). The Interdisciplinary Note (ID) note dated 08/22/22 at 01:56 PM, for R38 revealed the staff failed to administer medications to the resident as ordered by the physician, when they administered this resident another resident's medications this morning. The facility investigation notes, for 08/22/22 revealed a Certified Medication Aide (CMA) administered R38 another resident's medications during the morning medication pass. The staff administered Aspirin (nonsteroidal anti-[CONDITION(S)] medication), Vitamin D3, magnesium, and [MEDICATION(S)] (antidepressant medication). The facility educated the CMA that the resident MAR (medication administration record) has the resident's picture on the top left corner and after the medications are popped out of the card they should immediately be taken to the resident. On 08/23/22 at 10:46 AM, CMA S stated that on 08/22/22 she wrote the name, date, and room number on the medication cups on her medication cart. She had popped the medications for R24 and administered them to R38. CMA S stated she realized she had done that when she returned to the cart to get [MEDICATION(S)] (medication used to treat constipation) and saw the medication cup with the room number of R38's. She then reported the mistake immediately to the charge nurse and the director of nursing. On 08/25/22 at 10:30 AM, Administrative Nurse F stated before the staff administer a medication, the staff should check to make sure they have the right resident, right medication, right dose, right route, and the right time. On 08/25/22 at 11:42 AM, Administrative Nurse D stated before the staff administer a medication, they should follow the five rights. The facility policy Medication Administration dated 03/15/22, instructed the staff to identify the resident, and if necessary, verify resident identification with other facility personnel. The facility failed to identify the correct resident before administering medications resulting in the failure to administer R38 the correct medications as ordered by the physician, when R38 received another resident's medications.

The facility reported a census of 55 residents with 22 selected for review. Based on observation, interview and record review, the facility failed to review and revise the plan of care for one resident (R)2's with a pressure ulcer. Findings included: - Review of resident (R)2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS, dated [DATE], assessed the resident with moderate cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities, with no current pressure ulcers and was at risk for pressure ulcers development with no interventions in place. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities. The resident was assessed as at risk for pressure ulcer development and had no unhealed pressure ulcers. The resident had a pressure reducing devise on her bed. The Pressure Ulcer Care Area Assessment (CAA), dated 05/16/22, assessed the resident at risk for pressure ulcer and other related skin complications due to decreased mobility incontinence, self-care limitations and dementia. The resident had no current pressure related skin alterations. A Braden score (an assessment for pressure ulcer risk) of 18 indicated a risk for skin integrity concerns. The Quarterly MDS, dated [DATE], assessed the resident with severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfer and ambulation. The resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer. The resident had a pressure reducing device for her bed and pressure ulcer care and application of dressings to her feet. The Care Plan, reviewed 07/11/22, instructed staff the resident was at risk for pressure ulcers and not able to make major position changes independently. The resident required extensive assistance with transfers and bed mobility. Staff to encourage adequate intake at meals and offer snacks. The resident took a diuretic (medication to remove excess fluid) for hypertension (high blood pressure). This care plan lacked interventions for the blood blister and subsequent pressure ulcer/wound on her left foot. A Wound Treatment Order dated 06/08/22, revealed the resident had an ulcer (described as other) on her left heel with measurements of 1.25 centimeters (cm) by 1 cm, by 0.25 in depth. The wound had no drainage. Staff requested wound cleanser with an autolytic (an agent that breaks down damaged tissue) agent for debridement (removal of damaged tissue) and to change the dressing every 3-5 days. The physician signed the request, and the treatment began on 06/11/22, per review of the June 2022 treatment administration record (TAR). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An e-mail, dated 08/19/22, Licensed Nursing staff (LN) H, described the resident's left foot ulcer as 0.5 by 0.5 by 0.3 with 0.4 cm tunneling, and requested an order to apply calcium alginate (a type of material that minimize infection and form a moist gel) to the wound bed. Per the August 2022 TAR this treatment started 08/20/22. A Nursing Progress Note, dated 03/21/22, assessed the resident with 2-3 plus pitting [CONDITION(S)] in her lower extremities. Staff identified a scabbed area to her left elbow and pink discoloration to her coccyx region. A Nursing Progress Note, dated 04/14/22, indicated the resident had intermittent confusion and forgetfulness but was alert and oriented and worked with therapy. The resident had bilateral dependent [CONDITION(S)] and had [CONDITION(S)] wraps applied by therapy to her bilateral lower legs. A Nursing Progress Note, dated 05/05/22, indicated the resident was admitted to hospice care. The Braden scores for pressure ulcer development documented as follows: On 03/24/22, score of 17 (19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 6-9 very high risk). On 04/07/22, score of 16 mild risk. On 06/23/22, score of 18 mild risk. The Skin Evaluation Record General Skin Check dated 05/11/22 at 07:20 AM, indicated the resident had no new issues. The Skin Evaluation Record General Skin Check, dated 05/11/22 at 09:19 AM, indicated the resident had a blood blister on her left heel, approximately 2 centimeters (CM) by 1 centimeter with undefined edges and without pain. Review of the May 2022, treatment administration record, lacked documentation of daily monitoring of the blood blister. The medical record lacked documentation of daily monitoring or resolution of this blood blister. The Skin Evaluation Record General Skin Check, dated 05/18/22 at 06:54 AM, revealed the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 05/25/22 at 02:21 PM, indicated the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 06/01/22 at 08:57 AM, indicated the resident had no new issues. The Skin Evaluation Record Left Heel dated 06/18/22, indicated the resident had a partial thickness wound on her left heel, measuring 1.5 cm by 1.5 cm with a depth of 0.1 cm with origin date of 06/11/22. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record General Skin Check, dated 06/22/22 indicated no new issues. The Skin Evaluation Record Left Heel dated 06/28/22, indicated the resident had a partial thickness wound to her left heel measured 0.9 by 0.8 by 0.1 cm with irregular edges with dry yellow scab in place surrounded by new epithelial tissue. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record Left Heel, dated 07/03/22, indicated the resident had a small circular lesion, painful to touch, with 60% clean non-granulating tissue, and 40 % slough with an increase in the wound from the prior week with measurements of 1.5 cm by 1 cm by 0.2 cm with scant serous (yellow clear fluid) drainage. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/11/22, reveals a circular lesion with 100% slough. A soft debridement used but painful to fully remove the slough layer. The area measured 0.8 by 0.6 by 0.1 cm. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/16/22, revealed a circular lesion with 100% slough with measurements of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound and revealed granulating tissue with pink epithelial tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/29/22, revealed 100% slough with measurement of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound, and revealed granulating tissue and pink epithelial tissue surrounding the wound edge. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/05/22, revealed the wound measurement of 0.5 by 0.7 by 0.2 with macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/09/22, revealed the 0.7 by 0/9 by 0.2 cm with macerated surrounding tissue and a pink tissue surrounding the wound. The Skin Evaluation Record Left Heel, dated 08/18/22, revealed the wound measured 0.5 by 0.5 by 0.3 cm with undermining of 0.4 cm at 2:00 o'clock, macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/24/22, revealed staff applied calcium alginate to the wound bed and covered it with a foam dressing. The wound had a scant amount of purulent drainage on the dressing with slough noted to the wound bed. Staff measured the wound as 0.2 by 0.3 cm with no depth and discoloration noted in the surrounding skin. Observation, on 08/23/22 at 09:15 AM, revealed the resident seated in her recliner with footrest elevated. The resident had her shoes on, and her feet were hanging off the end of the footrest beginning at her lower ankle area and continued in this manner until 10:00 AM. Observation on 08/23/22 at 10:00 AM, with Licensed Nurse (LN) G, revealed she did notice a blood blister in the area in May, but it did not currently require treatment and the staff performs weekly skin assessments. LN G stated she did not know how this ulcer developed, but since she was on hospice services, wound care was not consulted. LN G stated nursing staff check the dressing daily, and change the dressing as needed but at least every 3 days. LN G removed the resident's shoe and the dressing to her left heel was intact. LN G then replaced the resident's shoe after asking the resident if she wanted her shoe on. The resident sat in her recliner with the footrest in the elevated position and her heel positioned off the end of the footrest. LN G stated the resident preferred to keep her shoes on when in her recliner, but the heel was off the edge of the footrest for pressure relief. Interview, on 08/23/22 at 02:45 PM, with Certified Nurse Aide (CNA) O, revealed the resident sits in her recliner with the footrest elevated but prefers to keep her shoes on. CNA O stated the resident ambulates with her walker with stand by assistance of staff. Observation on 08/24/22 at 08:44 AM, with LN H, revealed she does wound care once a week and measures the area. At that time LN H removed the resident's shoe and sock and observed the wound on the left lateral heel area. LN H measured the wound as 0.2 cm by 0.3 cm with no depth. The wound was yellow brown in color. LN H stated the wound had tunneling last week but greatly improved. LN O did not know if staff float her heels but thought they did when she lay in bed LN H did not know if staff removed her shoes when she sat in the recliner. LN H stated the resident no longer received wraps for [CONDITION(S)] (accumulation of fluid) but did not know when therapy stopped the wraps. Interview, on 08/24/22 at 03:30 PM, with LN I, revealed the resident sits in her recliner with her shoes on per her preference. She stated staff float her heels at night in bed with pillows. Interview, on 08/24/22 at 10:57 AM, with Administrative Nurse DD, confirmed the care plan lacked interventions for the resident's left foot pressure ulcer and would expect nursing staff to add interventions as needed to heal and prevent further decline. Interview, on 08/24/22 at 04:30 PM, with Administrative Nurse D, revealed she would expect staff to update the care plan to include interventions for the blood blister and subsequent pressure ulcer on the resident's left foot. Administrative Nurse D stated she would expect nursing staff to identify risk factors and revise the care plan as indicated. The facility policy Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment, revised 10/21/21, instructed staff to provide daily documentation of heel pressure ulcer/injury. Risk factors should be reviewed along with possible causes and a determination made to what extents if any, the factors can be modified. Modifiable risk factors should be addressed in the plan of care. The facility failed to review and revise this resident's care plan for specific interventions and risk factors for her left heel pressure ulcer to heal and prevent further decline.

The facility reported a census of 55 residents with 22 selected for review which included two residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure staff provided care and interventions to prevent pressure ulcers for one of two sampled at risk residents (R)2 in which staff identified a blood blister on her foot and subsequently developed an unstageable pressure ulcer (coverage of a wound by slough and/or eschar) on the same area of the foot. Findings included: - Review of resident (R)2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS, dated [DATE], assessed the resident with moderate cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities, with no current pressure ulcers and was at risk for pressure ulcers development with no interventions in place. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities. The resident was assessed as at risk for pressure ulcer development and had no unhealed pressure ulcers. The resident had a pressure reducing devise on her bed. The Pressure Ulcer Care Area Assessment (CAA), dated 05/16/22, assessed the resident at risk for pressure ulcer and other related skin complications due to decreased mobility incontinence, self-care limitations and dementia. The resident had no current pressure related skin alterations. A Braden score (an assessment for pressure ulcer risk) of 18 indicated a risk for skin integrity concerns. The Quarterly MDS, dated [DATE], assessed the resident with severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfer and ambulation. The resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer. The resident had a pressure reducing device for her bed and pressure ulcer care and application of dressings to her feet. The Care Plan, reviewed 07/11/22, instructed staff the resident was at risk for pressure ulcers and not able to make major position changes independently. The resident required extensive assistance with transfers and bed mobility. Staff to encourage adequate intake at meals and offer snacks. The resident took a diuretic (medication to remove excess fluid) for hypertension (high blood pressure). A Wound Treatment Order dated 06/08/22, revealed the resident had an ulcer (described as other) on her left heel with measurements of 1.25 centimeters (cm) by 1 cm, by 0.25 in depth. The wound had no drainage. Staff requested wound cleanser with an autolytic (an agent that breaks down damaged tissue) agent for debridement (removal of damaged tissue) and to change the dressing every 3-5 days. The physician signed the request, and the treatment began on 06/11/22, per review of the June 2022 treatment administration record (TAR). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An e-mail, dated 08/19/22, Licensed Nursing staff (LN) H, described the resident's left foot ulcer as 0.5 by 0.5 by 0.3 with 0.4 cm tunneling, and requested an order to apply calcium alginate (a type of material that minimize infection and form a moist gel) to the wound bed. Per the August 2022 TAR this treatment started 08/20/22. A Nursing Progress Note, dated 03/21/22, assessed the resident with 2-3 plus pitting [CONDITION(S)] in her lower extremities. Staff identified a scabbed area to her left elbow and pink discoloration to her coccyx region. A Nursing Progress Note, dated 04/14/22, indicated the resident had intermittent confusion and forgetfulness but was alert and oriented and worked with therapy. The resident had bilateral dependent [CONDITION(S)] and had [CONDITION(S)] wraps applied by therapy to her bilateral lower legs. A Nursing Progress Note, dated 05/05/22, indicated the resident was admitted to hospice care. The Braden scores for pressure ulcer development documented as follows: On 03/24/22, score of 17 (19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 6-9 very high risk). On 04/07/22, score of 16 mild risk. On 06/23/22, score of 18 mild risk. The Skin Evaluation Record General Skin Check dated 05/11/22 at 07:20 AM, indicated the resident had no new issues. The Skin Evaluation Record General Skin Check, dated 05/11/22 at 09:19 AM, indicated the resident had a blood blister on her left heel, approximately 2 centimeters (CM) by 1 centimeter with undefined edges and without pain. Review of the May 2022, treatment administration record, lacked documentation of daily monitoring of the blood blister. The medical record lacked documentation of daily monitoring or resolution of this blood blister. The Skin Evaluation Record General Skin Check, dated 05/18/22 at 06:54 AM, revealed the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 05/25/22 at 02:21 PM, indicated the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 06/01/22 at 08:57 AM, indicated the resident had no new issues. The Skin Evaluation Record Left Heel dated 06/18/22, indicated the resident had a partial thickness wound on her left heel, measuring 1.5 cm by 1.5 cm with a depth of 0.1 cm with origin date of 06/11/22. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record General Skin Check, dated 06/22/22 indicated no new issues. The Skin Evaluation Record Left Heel dated 06/28/22, indicated the resident had a partial thickness wound to her left heel measured 0.9 by 0.8 by 0.1 cm with irregular edges with dry yellow scab in place surrounded by new epithelial tissue. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record Left Heel, dated 07/03/22, indicated the resident had a small circular lesion, painful to touch, with 60% clean non-granulating tissue, and 40 % slough with an increase in the wound from the prior week with measurements of 1.5 cm by 1 cm by 0.2 cm with scant serous (yellow clear fluid) drainage. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/11/22, reveals a circular lesion with 100% slough. A soft debridement used but painful to fully remove the slough layer. The area measured 0.8 by 0.6 by 0.1 cm. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/16/22, revealed a circular lesion with 100% slough with measurements of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound and revealed granulating tissue with pink epithelial tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/29/22, revealed 100% slough with measurement of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound, and revealed granulating tissue and pink epithelial tissue surrounding the wound edge. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/05/22, revealed the wound measurement of 0.5 by 0.7 by 0.2 with macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/09/22, revealed the 0.7 by 0/9 by 0.2 cm with macerated surrounding tissue and a pink tissue surrounding the wound. The Skin Evaluation Record Left Heel, dated 08/18/22, revealed the wound measured 0.5 by 0.5 by 0.3 cm with undermining of 0.4 cm at 2:00 o'clock, macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/24/22, revealed staff applied calcium alginate to the wound bed and covered it with a foam dressing. The wound had a scant amount of purulent drainage on the dressing with slough noted to the wound bed. Staff measured the wound as 0.2 by 0.3 cm with no depth and discoloration noted in the surrounding skin. Observation, on 08/23/22 at 09:15 AM, revealed the resident seated in her recliner with footrest elevated. The resident had her shoes on, and her feet were hanging off the end of the footrest beginning at her lower ankle area and continued in this manner until 10:00 AM. Observation on 08/23/22 at 10:00 AM, with Licensed Nurse (LN) G, revealed she did notice a blood blister in the area in May, but it did not currently require treatment and the staff performs weekly skin assessments. LN G stated she did not know how this ulcer developed, but since she was on hospice services, wound care was not consulted. LN G stated nursing staff check the dressing daily, and change the dressing as needed but at least every 3 days. LN G removed the resident's shoe and the dressing to her left heel was intact. LN G then replaced the resident's shoe after asking the resident if she wanted her shoe on. The resident sat in her recliner with the footrest in the elevated position and her heel positioned off the end of the footrest. LN G stated the resident preferred to keep her shoes on when in her recliner, but the heel was off the edge of the footrest for pressure relief. Observation, on 08/23/22 at 11:30 AM, revealed staff ambulated with the resident and her walker to the dining room. Interview, on 08/23/22 at 02:45 PM, with Certified Nurse Aide (CNA) O, revealed the resident sits in her recliner with the footrest elevated but prefers to keep her shoes on. CNA O stated the resident ambulates with her walker with stand by assistance of staff. Observation on 08/24/22 at 08:44 AM, with LN H, revealed she does wound care once a week and measures the area. At that time LN H removed the resident's shoe and sock and observed the wound on the left lateral heel area. LN H measured the wound as 0.2 cm by 0.3 cm with no depth. The wound was yellow brown in color. LN H stated the wound had tunneling last week but greatly improved. LN O did not know if staff float her heels but thought they did when she lay in bed LN H did not know if staff removed her shoes when she sat in the recliner. LN H stated the resident no longer received wraps for [CONDITION(S)] (accumulation of fluid) but did not know when therapy stopped the wraps. Interview, on 08/24/22 at 03:30 PM, with LN I, revealed the resident sits in her recliner with her shoes on per her preference. She stated staff float her heels at night in bed with pillows. Interview, on 08/24/22 at 04:30 PM, with Administrative Nurse D, revealed she would expect staff to follow the wound protocol and monitor the blood blister when identified on 05/11/22. Administrative Nurse D stated she would expect nursing staff to identify risk factors and revise the care plan as indicated. The facility policy Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment, revised 10/21/21, instructed staff to provide daily documentation of heel pressure ulcer/injury. The licensed nurse will complete a skin evaluation and if new alterations are noted the licensed nurse will initiate treatment per guidelines and document as indicated. The support surface is on aspect of the comprehensive treatment plan. Utilizing a therapeutic support surface does not lessen the need to turn the resident, utilize clinically proven treatment regimes, provide nutritional support or routinely assess the wound. Staff instructed to use site specific support surfaces on the resident's extremities. Risk factors should be reviewed along with possible causes and a determination made to what extents if any, the factors can be modified. Modifiable risk factors should be addressed in the plan of care. The facility failed to monitor daily for resolution of this resident's blood blister identified on 05/11/22, failed to identify causative factors of the development of the blister and failed to timely determine interventions for the prevention of pressure ulcer injury which resulted in an unstageable pressure injury to the resident's heel.

The facility reported a census of 55 residents with 22 selected for review including six residents reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to follow and implement care plan interventions following a fall for Resident (R)7 and failed to ensure the oxygen tubing for R14 was off the floor to reduce a tripping hazard. Findings included: - The Physician Orders for 08/22/22, for Resident (R)7 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and history of falling. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R7 with a short-term and a long-term memory problem and moderately impaired decision making. He required extensive assistance of one staff for transfers and limited assistance of one for walking. His balance during transitions were not steady and required staff to support him, however he could balance himself when walking. R7 used a walker for mobility and had not had any falls since the prior assessment. The Significant Change MDS dated [DATE] did not reveal any changes to his cognition, transfers, or walking. His balance during transitions and walking were not steady and required staff support. He continued to use a walker for mobility and since the last assessment he had one non-injury fall and had one fall with injury that was not a major injury (break in a bone, head injury). The Falls Care Area assessment dated [DATE] revealed R7's fall risk score was 18, indicating a high risk for falls, and he has had several falls due to his poor balance and unsteady gait. The Care Plan dated 05/08/22 for R7 revealed he was at risk for falls due to his confusion, multiple medications, history of falls and general weakness. Interventions included for the staff to ensure his bed was in the position easiest for him to access/exit, assist with ambulation when he was feeling weak or having poor balance, and to remind him to use the walker as sometimes he forgot. R7 required a walker and limited to extensive assist of staff with walking. The care plan had these added interventions: 1. On 08/01/22, the staff were to keep his walker within his reach but not directly in front of him when he was in his room. 2. On 08/22/22, the staff were to increase visual checks to approximately every hour when he was in his room, and to maximize his independence and quality of life by adding an easy touch call light. The Interdisciplinary Notes (ID) located in the electronic medical record (EMR) revealed R7 fell on [DATE], 04/29/22, 05/08/22, and 08/21/22. The ID note located in the EMR, dated 08/22/22 at 12:41 AM, revealed the staff found R7 sitting on the floor in the middle of the room on 08/21/22 at 11:30 PM. R7 stated he was walking across the room and going back to bed. The fall resulted in an abrasion (scraping or rubbing away of a surface, such as skin, by friction) to the left buttocks 14.4 centimeters (cm) by 3.7 cm and an abrasion to the right side of his back measuring 17.1 cm by 1.4 cm. The intervention was to increase visual checks to approximately every hour when he was in his room. The facility Investigation Report for the fall on 08/21/22 included additional interventions of an easy touch call light pad placed in R7's room on 08/22/22 and to keep his walker within reach but not directly in front of him when he was in his room. On 08/23/22 01:34 PM, R7 was in his room sitting in the recliner and his walker was across the room at the foot of the bed out of his reach. The staff failed to ensure the walker was in reach while in his room as planned to prevent further falls. On 08/23/22 at 02:55 PM, R7 continued to sit in his room in the recliner with the walker out of reach. The staff failed to ensure the walker was in reach while he was in his room. On 08/24/22 at 08:51 AM, Certified Medication Aide (CMA) LL, who was providing direct care, stated R7 was a fall risk and there was a touch pad call light that the staff placed beside him. CMA LL stated when he was in his room the walker was to be in his reach in front of him and she had not been told what the new fall intervention was for his fall on 08/21/22. CMA LL stated there was not a place to look and see what the intervention was, the charge nurse would let her know. On 08/24/22 at 08:58 AM, CMA T, who was providing direct care, stated R7 was a fall risk and was told on 08/22/22 that he fell but she did not know what the new intervention was put in place to prevent further falls. CMA T stated he did have a touch pad call light that was beside him and the staff check on him about every 15 minutes and the new intervention was probably in the care plan book. On 08/24/22 at 03:25 PM, observed R7 in his room sitting in his recliner and the touch pad call light was draped across the top of a folding tray table next to the recliner, rather than placed next to him. On 08/24/22 at 03:29 PM, CNA MM stated when she comes in for her shift, report was done and that was when any new fall interventions were communicated. CNA MM stated typically a new intervention was not put in place after a fall unless it keeps happening then they would come up with a new intervention to prevent a fall from happening again. CNA MM was not sure if R7 was a fall risk as it was her second time working that unit and did not know if R7 had fell recently, however stated the touch pad call light should be placed on his chair. CNA MM was not aware of any other interventions other than lowering the bed to the floor. On 08/24/22 at 03:47 PM, Licensed Nurse (LN) I stated when a resident falls the staff attempt to determine the cause of the fall, come up with a new intervention to prevent further falls, and document the intervention on the care plan and in the ID notes. The staff were made aware of the intervention by passing it on in report and the intervention was in the care plan. The care plan included an intervention on 08/22/22 for an easy touch call light and to keep the walker in his reach but not directly in front of him when in his room. LN I stated she would expect the staff to follow the care plan. On 08/25/22 at 11:45 AM, Administrative Nurse D stated she expected the staff to communicate fall interventions during shift-to-shift report, place the intervention on the care plan which all staff had access to, and staff should follow the care plan interventions. The facility policy Falls dated 10/11/21 included interventions after a fall should be documented on the care plan, however lacked direction how to communicate if a fall occurred and the post fall interventions to the staff. The facility failed to follow the implemented interventions following R7's fall, failed to communicate the interventions to the staff, for R7 with a history of falls, to prevent further falls. Review of resident (R)14's Physician Order Sheet, undated, revealed diagnoses included cerebral infarction (stroke sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), [CONDITION(S)] ([CONDITION(S)] progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (progressive mental disorder) characterized by failing memory, confusion, and [CONDITION(S)] (chronic [CONDITION(S)] disease that affected joints and other organ systems). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with moderate cognitive impairment, required limited assistance of one person for bed mobility, transfer toilet use, dressing and personal hygiene. The resident required supervision with ambulation and had unsteady balance with stabilization with staff assistance. The resident had no impairment in the upper or lower extremities. The resident was not on a toileting plan and had occasionally urinary incontinence and frequent bowel incontinence. The Fall Care Area Assessment (CAA,) dated 06/14/22, assessed the resident had impaired balance with contributing factors of weakness and physical performance limitations affecting balance and history of falls. The 'Urinary Incontinence CAA dated 06/14/22, assessed the resident required assistance with toileting and had occasional urinary incontinence. The Care Plan, reviewed 08/18/22, instructed staff the resident sometimes moved too fast with a walker and staff were to remind her to slow down. Staff instructed to remind the resident to sit farther back in her chair and bed to help prevent falls. Staff instructed to offer to walk with the resident when she was having balance problems. Staff to remind the resident to check the wheels on her walker before she starts ambulating. Staff instructed to check on her often and offer to take her to the bathroom. Staff to provide the resident with the shortest length of oxygen tubing appropriate for her needs so she does not trip on it. Staff to make sure her walker is within her reach. Review of the Fall Investigation Report, dated 07/17/22 at 08:00 PM, revealed staff found the resident on the floor in her room and the resident stated she tripped over her oxygen tubing. The immediate intervention was to remind the resident to manage her oxygen tubing and to change her concentrator to her portable unit which was attached to her walker. Observation, on 08/22/22 at 03:02 PM, revealed the resident in bed without her oxygen on. The resident's oxygen concentrator was on and the tubing was in a disorganized pile on the floor beside the oxygen concentrator which was positioned beside the resident's bed. The resident's portable oxygen concentrator was on her walker near her chair, with the tubing also on the floor. Interview, on 08/22/22 at 03:15 PM, with Certified Nurse Aide (CNA) P, revealed the resident will often put herself in bed and forget to wear the oxygen. CNA P stated the portable oxygen concentrator needs to be recharged when not in use. CNA P stated the resident's tubing was extra long so she could go the bathroom with it. Observation, on 08/23/22 at 12:46 PM, revealed CNA Q, assisted the resident to her room with the rolling walker and portable oxygen. CNA Q did not offer the resident a toileting opportunity and positioned the resident in her bed and placed the nasal cannula from the room oxygen concentrator on the resident. The tubing was in a disorganized pile on the floor beside the oxygen concentrator beside her bed. Observation, on 08/23/22 at 12:51 PM, revealed the resident got herself up out of bed and ambulated to the bathroom in her room. CNA Q stated the resident does get up by herself and confirmed the resident could trip over the oxygen tubing that was laying on the floor. Interview, on 08/24/22 at 12:11 PM, with Licensed Nurse (LN) I, revealed she would expect staff to keep the oxygen tubing off the floor and in a plastic bag attached to the oxygen concentrator. LN I stated the resident often took herself to the bathroom, so her tubing was longer than average to enable her to keep it on when in the bathroom. LN I confirmed the tubing could be a trip hazard and staff needed to keep it in a neat coil. Staff should toilet the resident upon return to her room and before/after meals. Interview, on 08/24/22 at 04:30 PM, with Administrative Nurse D, revealed she expected staff to keep the oxygen tubing in a manner to prevent falls. Administrative Nurse D stated the oxygen tubing was exceptionally long and the facility needed to find ways to limit the trip hazard. The facility policy Falls, revised 10/11/21, instructed staff to identify residents for risk of falls and implement interventions to reduce the resident of falls. The facility failed to implement measures to reduce the risk of further falls for this resident with extra long oxygen tubing.

The facility reported a census of 55 residents with 22 selected for review including 12 residents reviewed for unnecessary medications. Based on record review and interview, the facility failed to act upon the pharmacy recommendation for one of the residents, Resident (R)20. Findings included: - The diagnosis tab, located at the dashboard in the electronic medical record (EMR), for Resident (R)20, included a diagnosis of hypertension (elevated blood pressure). The Medication Record for 08/2022, included a physician order with a start date of 03/07/22, for instructions to administer the resident [MEDICATION(S)] (medication used to treat hypertension), 50 milligrams (mg), by mouth, twice daily for hypertension. The Interdisciplinary Note (ID) note, dated 05/31/22, revealed the consultant pharmacist reviewed the resident's available chart data and instructed the staff to refer to the recommendation. The Note to Attending Physician/Prescriber with a print date of 05/31/22, revealed R20 was [AGE] years old and has had several low blood pressures and variable pulses. Please take a moment to review blood pressure and pulse data and consider if medication reduction(s) were appropriate currently, or, provide a statement below acknowledging review and desire to continue present therapy. The form included a physician signature, lacked a date when the physician signed, and lacked a response to agree, disagree, or statement acknowledging review and desire to continue the present therapy. Handwritten on the form included noted 06/03/22 by Licensed Nurse (LN) I. The facility failed to act upon the pharmacist recommendation to ensure the physician responded to address if a medication reduction was appropriate. The Progress Note for the physician visit dated 07/07/22, revealed under the assessment section hypertension-overmedicated. The progress note included an order to decrease [MEDICATION(S)] to 25 mg, by mouth, twice daily. On 08/25/22 at 08:41 AM, LN J stated when there are recommendations from the pharmacy reviews, the staff fax the recommendation to the doctor. If the physician declines the recommendation, we document that in an ID note, and if they agree with the recommendation, we document that in an ID note and what the new order was, then the order would be added to the EMR. LN J stated if the physician signs the recommendation, but does not include a response, she would then call the physician and add the clarification or refax the note and place it in the report book until the response received. On 08/25/22 at 09:41 AM, Administrative Nurse F stated she sends the pharmacy recommendations to the physician, and they are returned via the electronic fax system program to her fax number. Administrative Nurse F stated if the physician signs the pharmacy recommendation form but does not answer a response, the recommendation form should be sent back to the physician. The recommendation printed on 05/31/22 regarding R20's low blood pressures should have been sent back to the physician for a response. The facility did not provide a policy for processing pharmacy reviews. The facility failed to act upon the pharmacist recommendation to ensure the physician responded to the pharmacy consultant recommendation for R20 on 05/31/22 timely. R20 continued with low blood pressures and the physician addressed the low blood pressures on a visit on 07/07/22, with new orders to decrease the medication for hypertension, 37 days after the pharmacy recommendation.

The facility reported a census of 55 residents and identified 25 residents as elopement risks. The sample included four residents reviewed for accidents/elopement (exit of facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure two of the four sampled residents remained safe including Resident (R) 2 for staff failure to secure an oxygen tank during the resident's shower. When Certified Medication Aide (CMA) R removed the oxygen tank from the secured back of the resident's wheelchair and set it unsecured on the floor, she knocked the oxygen tank over onto the resident's left foot, causing a fracture of the left great toe. The facility also failed to provide adequate supervision for R1, who was a fall and elopement risk, when Licensed Nurse (LN) G left the resident alone outside the facility in an unsecured area. Findings included: - R2's Physician Order Sheet (POS), dated 02/09/22, documented the resident with a diagnosis of [CONDITION(S)] ([CONDITION(S)], a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe). The Comprehensive Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 14, or intact cognition. The resident required extensive assistance of two staff members for transfer and bathing. The resident also used oxygen during the lookback period. The Activities of Daily Living Care Area Assessment (CAA), dated 02/27/22, documented the resident with a diagnosis of [CONDITION(S)] which caused her to experience shortness of air during exertion and she received continuous oxygen via nasal cannula. She required limited assistance from staff with bathing. The Care Plan updated 05/19/22, documented the resident with a self-care deficit related to progressive weakness and jerking movements. The staff were to provide appropriate assistance with activities of daily living (ADLs) to ensure all needs and cares were met over the next 90 days. The staff assisted the resident with bathing and the resident received oxygen therapy. The oxygen tank should always be kept in a bag or rolling tank canister. A Licensed Practical Nurse (LPN) note, dated 05/18/22 at 08:46 AM, by Licensed Nurse (LN) K revealed R2 reported an oxygen tank fell on her left great toe after her shower in the spa room. There was a dark purple bruise on R2's entire toe. A U shaped blood blister noted on the left side of the toe. Staff to monitor daily until resolved. A Registered Nurse (RN) note, dated 05/19/22 at 08:15 AM, by LN I revealed an x-ray report dated 05/18/22 of R2's left great toe which documented the resident received a comminuted (bone that is broken in at least two places) fracture of the distal phalanx (tubular bone of the toe) of the first toe with minimal displacement. Staff notified consultant Staff GG of the x-ray results. Consultant Staff GG was in the facility on 05/18/22, assessed R2's toe, and advised staff to continue to provide symptom management for R2's fracture with no orthopedic referral. An LPN note, dated 05/24/22 at 09:46 AM, by LN H revealed a late entry from 05/18/22. At approximately 08:46 AM, a CMA reported to LN H that the resident stated an oxygen tank fell on her left great toe in the spa room after her shower. LN H assessed R2's toe and noted a small u shaped blood blister to the inside of the toe. The entire toe was reddish purple in color with no swelling at that time. Observation on 05/25/22 at 10:08 AM, revealed the resident lying on her bed asleep with no signs of pain or distress. She had a bandage on her left foot which remained wrapped and elevated on a pillow. Interview on 05/24/22 at 01:58 PM, CMA R revealed the morning of 05/18/22, she assisted the resident in the spa room to get ready for a shower. There was an oxygen tank in a bag on the back of the resident's wheelchair. CMA R removed the tank from the bag and set it on the floor, unsecured, next to the resident, who was sitting in the shower chair. When CMA R moved R2 in the shower chair towards the shower, the oxygen tank fell over and onto R2's foot. R2 told CMA R that the tank fell on her toe. CMA R assisted the resident to finish her shower and after it was over, she looked at her foot. The resident was unable to tell her which toe the tank hit. CMA R found no injury, so she helped the resident finish getting ready and back to her room. CMA R did not report the incident immediately to the charge nurse. Interview on 05/25/22 at 09:27 AM, LN H revealed a couple of hours after R2's shower, Certified Nurse Aide (CNA) M reported R2 told her that an oxygen tank fell on her toe during her shower. CMA R provided the shower, but failed to immediately report the incident to LN H. LN H assessed the resident's toe and noted it to be reddish in color with no swelling. There was a blood blister between the first and 2nd toes of R2's left foot. LN H provided pain medication to the resident and thought no more about it until the resident complained of elevated pain in her foot later that day. LN H contacted the physician for an order for stronger pain medication which she received and administered to the resident. She reported the incident to the next shift. The next day LN H found out the physician ordered an x-ray which showed a toe fracture. CMA R should have reported the incident to her when it happened, and the oxygen should have been placed in a caddy to secure it in an upright position. The facility policy for Oxygen Therapy, revised 10/08/21, documented .Oxygen Tanks .1. To use oxygen tanks .a. Store all O2 cylinders in an upright position in a storage device/wheeled tank cart .3. Place delivery device comfortably on resident . The facility failed to ensure R2's oxygen tank remained secured. During a shower, the tank fell over onto the resident's foot and she experienced a fractured toe from the accident. - R1's Physician Order Sheet (POS), dated 03/30/22, documented the resident with a diagnosis of dementia with behavioral disturbance (a chronic or persistent disorder of the mental processes caused by brain disease marked by memory disorders, personality changes, and impaired reasoning). The Comprehensive Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 9 or moderately impaired cognition. The resident required extensive assistance of two staff members for transfer and walking. He used a walker and a wheelchair for mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/08/22, documented the resident was at risk for continued cognitive loss due to the diagnosis of dementia and had short term memory deficits. The Activities of Daily Living CAA, dated 04/08/22, documented the resident required limited to extensive assistance with activities of daily living (ADLs). The staff reported that he can be sneaky and would sometimes take himself (with his walker) to the bathroom from his bed in his room. He often walked with staff with his walker but used a wheelchair for longer distances when he was tired. The Care Plan, updated 05/16/22, advised the staff that the resident had a safety alarm bracelet on his left ankle due to exit seeking behaviors and used a walker for ambulation. R1 was at risk for elopement related to his wander risk assessment. His frequency for wandering was rare, but he did get confused and turned around at times in the unit. An Elopement Risk Screen, dated 03/05/22, documented the resident with a score of 12 or at risk for elopement. The resident wore a safety alarm bracelet and resided in a secured unit. A Licensed Practical Nurse (LPN) note, dated 05/05/22 at 09:26 PM, by Licensed Nurse (LN) J revealed the resident had been exit seeking all evening. R1 became agitated and cursed at staff because they would not open the door. Attempts at redirection were unsuccessful. R1 sat in a chair in the dining room and watched the door to see if it would open. A sign was put on the outside of the entrance door directing staff to use a different door to get into the unit. The resident finally got up and went to bed. A Registered Nurse (RN) note, dated 05/08/22 at 01:41 PM, LN I, revealed the resident was exit seeking at approximately 12:45 PM. LN I administered as needed (PRN) anti-anxiety medication and the resident was resting in the recliner in the living room of the unit. Review of the facility's video footage, dated 05/08/22, with Administrative Staff A, revealed at approximately 04:14 PM, Certified Medication Aide (CMA) S and the resident approached the front entrance of the facility and CMA S punched the code on the door to open it and the resident went outside. CMA S stayed in the foyer and visited with Certified Nurse Aide (CNA) N. The CMA had her back turned to the entrance door. R1 walked down the sidewalk towards the parking lot turned around and walked back and sat down on a bench within a few feet of the entrance door. It was 04:16 PM. At that time, CMA S left and LN G went outside and sat down to visit with the resident. LN G sat with the resident until approximately 04:26 PM when she got up and went back into the facility. The resident sat on the bench alone until approximately 04:29 PM when he stood up and went to the entrance door to get back into the facility. The door would not open. Visitors approached the door and went to get assistance to let the resident back into the facility. The resident was let back in without incident. Interview, on 05/16/22 at 12:01 PM, Administrative Nurse D stated residents who wore safety alarm bracelets required staff supervision when outside the facility and should not be left alone. The staff involved knew the resident wore a safety alarm bracelet and was an elopement risk. The staff should have remained outdoors with him to ensure his safety. Interview, on 05/24/22 at 12:42 PM, Consultant Staff HH stated all agency staff are required to have an orientation checklist completed starting with their first shift in the facility. The checklist covered elopement and residents who were elopement risks. All staff should be aware of residents who are elopement risks in the facility. The facility's policy Hazardous Wandering and Elopement (Unwitnessed Exit), updated 05/09/22, documented .Policy .the community will exercise reasonable care to prevent injuries and ensure a secure environment for residents .Procedure .3. Staff, especially primary caregivers, will be notified of residents who are likely to attempt to leave or to get lost within the community. Staff will be instructed on the use of effective interventions to prevent unwitnessed/exits . The facility failed to ensure adequate supervision continued for R1, who was a fall and elopement risk, when a staff member left the resident alone outside the facility in an unsecured area.

The facility reported a census of 48 residents with one resident reviewed for physical restraints. Based on record review and interview, the facility failed to ensure that Resident (R) 1 remained free from physical restraints on 11/03/21, when the resident had escalating behaviors in the memory care unit during medication administration. Licensed Nurse (LN) G failed to appropriately respond to the agitated state of R1, which resulted in a physical altercation. LN G called for help from additional staff and the response from multiple staff members caused a higher escalation in the resident's behaviors which resulted in five staff members holding the resident down on the floor. Administrative Nurse D attempted medication administration with a spoon as the resident was being restrained on the floor by LN G and other staff members. The resident yelled and screamed NO! and shook her head back and forth. This placed R1 at risk for serious physical injury and the physical restraining of R1 by five staff members placed the resident at risk for psychosocial and physical harm. This deficient practice placed the resident in immediate jeopardy. Findings included: - R1's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition and fluctuating disorganized thinking. R1 had physical and verbal behavioral symptoms which were directed at others one to three days during the seven-day lookback period. She rejected care from the staff one to three days and wandered daily. The resident did not use a mobility device and required setup assistance of two staff members for transfers and walking. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/05/21, documented R1 with a BIMS score of four indicating severe cognitive impairment. The resident had physical and verbal aggression towards the staff during the assessment period. The resident resided in the memory care unit due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Behavioral Symptoms CAA, dated 10/05/21, documented R1 rejected care from the staff and wandered the unit. The Psychosocial Well-being CAA, dated 10/05/21, documented the resident was upset at the time of admission and lashed out at the staff with both physical and verbal aggression. Since admission, R1 settled down and interacted with the staff and other residents in an appropriate manner. The Care Plan, revised 11/03/21, advised the staff that the resident had an activities of daily living (ADL) self-care deficit due to dementia and [CONDITION(S)]. The resident required set-up assistance with ADLs such as toileting, transferring, and ambulation. The resident required prompting by the staff to complete her ADLs. On 11/03/21, the care plan advised the staff not to touch R1 without her permission. A Registered Nurse's Note, dated 11/03/21 by LN G, revealed she was in R1's room packing up her belongings. Certified Medication Aide (CMA) R came down the hall with the resident stating that the resident had her medications in her hand. LN G stated well hello there, shall we get dressed? Let's take your medications first. R1 threw the pills on the hallway floor and started stepping on them. R1 went right up to LN G and stated, you need to get out of here. LN G started picking up the pills and R1 attempted to kick at her and was swinging to hit her. LN G stated, let's not do that. The resident started kicking and hitting. Additional staff were summoned to assist LN G. R1 was kicking, attempting to bite, cussing, and name calling. R1 received medication from LN G but spit it out and continued to try to hit and kick at staff. A Witness Statement, dated 11/03/21, by LN G revealed she got called to the memory care unit because R1 was having behaviors. The resident was being aggressive with staff at the medication cart. LN G redirected the resident and took her back to the dining room to eat. The resident sat down and started eating breakfast. LN G went to the resident's room to pack her things to leave the facility. CMA R radioed LN G and stated the resident had her meds but wouldn't take them. LN G left R1's room and went to the resident and told her to take her medication and then they would get her ready to leave the facility. The resident threw the pills on the floor in the hallway and started stepping on them. LN G told her not to do that and the resident started swinging at her. LN G said No! to the resident and raised the resident's hands and wrists up away from her. R1 was also trying to kick and bite at LN G. They ended up on the floor in the hallway. They had a hold of each other's wrists and arms. R1 continued to attempt to kick and bite at LN G while they were lying on the floor. LN G hollered for help. Two CMAs, one CNA, and the maintenance man came to assist and were able to get the resident to let go of her wrists. Administrative Nurse D finally arrived and asked if the resident only had [MEDICATION(S)] (antianxiety agent). CMA R got the medication and it was given to R1 by Administrative Nurse D. R1 spit the medication out of her mouth and into the face of CNA M. All staff remained calm and the resident was told that they wanted her to stop biting, kicking, and hitting. The resident wanted up off the floor. LN G told her they would let her get up if she stopped hitting, biting, and kicking the staff. LN G removed herself from the resident and went to get another dose of [MEDICATION(S)]. When she returned, R1 was up off the floor and talking to Social Services Staff (SS) X and Activity Staff Z at the end of the hall. A Witness Statement, dated 11/04/21, by Certified Nurse Aide (CNA) M, revealed R1 was in a bad mood and calling staff vulgar names. She saw the resident walk down the hallway to the dining room. The next thing CNA M knew, she heard people hollering for help down the hall. LN G asked CNA M to hold the resident's arm so they could give her a pill, so she did. The resident spit the pill into her face. Afterwards, they let R1 up off the floor to walk down the hall and CNA M went back to the dining room. A Witness Statement, dated 11/04/21, by Administrative Nurse D, revealed staff reported to her that R1 was being combative. When she arrived, the resident was on the floor with CMA R, CNA N, LN G, and Maintenance Staff U. They were holding the resident's arms and legs as they were lying on the floor. R1 hollered out that she wanted out of there and was going to call the police. LN G reported to Administrative Nurse D that R1 was having combative behaviors and physically attempting to harm staff. Administrative Nurse D attempted to talk to the resident through reassurance and bargaining but R1 continued to be verbally aggressive and threatening physical harm to the staff. Administrative Nurse D offered to give the resident medication and the resident agreed but bit the spoon and spit it out. SS X and Activity Staff Z arrived on the scene and asked the staff to let R1 go and leave her be. They let her go. Administrative Nurse D explained the situation to SS X and Activity Staff Z and suggested the resident be redirected to her room if possible. SS X and Activity Staff Z walked away with the resident towards the end of hall and Administrative Nurse D asked if they were ok with R1. They responded yes and Administrative Nurse D left the unit. A Witness Statement, dated 11/03/21, by Activity Staff Z, revealed that it was reported to her by SS X, that staff had R1 restrained in the memory care unit on the floor. Transportation Staff GG asked Maintenance Staff U to help restrain the resident and they needed clarification if that was appropriate. Activity Staff Z went to the unit to find six staff (five restraining R1) and the resident on her back on the floor. R1 was yelling, screaming, and trying to get up. Activity Staff Z observed Administrative Nurse D trying to put medication in R1's mouth while she was being held down to the floor by the five staff members. R1 was hollering No! Call the police! She moved her head side to side trying to avoid Administrative Nurse D putting medication in her mouth. The resident was on the floor with CMA R, CNA N, LN G, and Maintenance Staff U. Activity Staff Z told everyone to let her go, release her, let her go. The staff were hesitant. CMA R let go of R1's legs and the staff helped R1 get up. SS X talked with Administrative Nurse D and she left upset. Activity Staff Z wasn't sure what was said between the two staff members. Activity Staff Z got R1's attention. R1 swung at her head and missed. She asked the resident to look at her and asked if she would walk down the hall with her. R1 stated she wanted to go home. Activity Staff Z and SS X talked with her and calmed her down, offering emotional support. LN G came to them with something in a syringe. SS X told LN G that R1 didn't need the medication, the resident was calm now. LN G turned and left. They took the resident to her room to help her get ready to leave the facility. They helped get all her things together and visited with R1. The resident was calm and in a good mood at the time she left the facility. A Witness Statement, dated 11/03/21, by SS X, revealed she was contacted by Activity Staff AA at 08:23 AM that there was an incident taking place with R1 in the memory care unit. Transportation Staff GG was running to get Maintenance Staff U to help restrain R1. SS X educated Activity Staff AA that the facility was not authorized to provide any physical restraints to residents and stated that she would go to the memory care unit as soon as possible. SS X reported the situation to Activity Staff Z and both walked to the memory care unit. Upon entering, they observed R1 lying on her back on the floor in the middle of the residential hallway with six staff members standing over her, five of which were physically holding R1 to the ground. The resident was screaming and yelling and trying to get up. SS X also observed Administrative Nurse D trying to put medication in the resident's mouth as R1 was being held down to the floor by the five staff members. The resident repeatedly yelled no and tried to move her head side to side and back and forth to avoid the medication that Administrative Nurse D continued to attempt to put in her mouth. They approached the staff members and advised them to leave the area and that SS X and Activity Staff Z would handle the situation. Staff allowed the resident to get up and SS X and Activity Staff Z walked with R1 down to the end of the hallway. LN G approached with medication to give to the resident which SS X told her they did not need. LN G left. They helped the resident get ready to leave the facility without incident and the resident was fine before getting in the van for transport. SS X notified Administrative Staff A at 09:10 AM that the incident was likely a state reportable occurrence. Interview, on 02/10/22 at 02:30 PM, Administrative Staff A revealed it was reported to her by SS X the day it happened. The investigation revealed there were five people holding R1 down and Administrative Nurse D attempting to give the resident medication. The resident became agitated and Administrative Staff A thought the staff panicked because they weren't sure what to do. LN G and R1 were on the floor and R1 was kicking and hitting at her. LN G hollered for help and the staff came out of the woodwork. LN G held the resident down while Administrative Nurse D was trying to give the medication. It should not have taken five people to hold R1 down. They should have backed off. The staff showing up only escalated the resident's agitation and the situation. The staff reported to Administrative Nurse D more than once what was happening with R1 and asked her to come and help. At first Administrative Staff D was not going to do anything about it, but finally decided to go to the unit. Due to the fact that she didn't want to handle the situation and trying to force the medication into the resident's mouth when R1 was refusing, it was determined that Administrative Nurse D's position here at the facility be terminated. LN G received dementia education, verbal counseling, and allowed to continue her duties here at the facility. The other staff were also provided education about dementia and handling escalating behaviors. Maintenance Staff U should not have been involved in that situation. LN G no longer worked for the facility. Interview on 02/11/22 at 4:18 PM with SS X revealed during the incident she assisted in asking all the staff members to leave the immediate area around R1 and assisted in de-escalating the resident's behaviors after everyone left. Activity Staff Z and SS X worked together during the incident. They calmed the resident down and assisted R1 to pack and leave the facility to admit to a geriatric psych unit. All memory care staff received training on managing escalating behaviors. The facility was not authorized to physically restrain the residents. Interview on 02/14/22 at 09:45 AM with Activity Staff Z revealed during the incident she told the staff to let go of R1 and leave the area. SS X helped her to de-escalate the situation and R1's behaviors towards the staff. Afterwards, they were able to get R1 to the end of the hallway, talk with her, and calm her down. They all went to R1's room to gather her belongings and prepare to leave the facility. There were prior arrangements for R1 to admit to a geriatric psych unit that morning. They assisted the resident into the van and transported her to the unit. Staff Z stated the facility was not authorized to physically restrain residents. The facility policy, Restraint Use, reviewed 10/11/21, documented .Residents will attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints .Emergency Use .2. If a resident's unanticipated violent behavior or aggressive behavior places him/her or others in imminent danger, the resident does not have the right to refuse the use of restraints .the use of restraints is a measure of last resort . The facility failed to ensure that Resident (R) 1 remained free from physical restraint on 11/03/21, when the resident had escalating behaviors in the memory care unit during medication administration. Licensed Nurse (LN) G failed to appropriately respond to the agitated state of R1, which resulted in a physical altercation. LN G called for help from additional staff and the response from multiple staff members caused a higher escalation in the resident's behaviors which resulted in five staff members holding the resident down on the floor. Administrative Nurse D attempted medication administration with a spoon as the resident was being restrained on the floor by LN G and other staff members. The resident yelled and screamed NO! and shook her head back and forth. This placed R1 at risk for serious physical injury and the physical restraining of R1 by five staff members placed the resident at risk for psychosocial and physical harm. This deficient practice placed the resident in immediate jeopardy. This deficiency was cited as past non-compliance as the facility completed the following as of 11/30/21: 1. At 08:00 AM on 11/04/21, Administrative Staff A began investigation interviews with facility staff involved in the incident. Along with the interviews, dementia and behavior care education was provided verbally to the staff. 2. At 06:46 PM on 11/30/21, the final facility staff member completed mandatory education as follows: a.) Caring for the Person with Dementia: Behaviors and Communication b.) Recognizing, Reporting, and Preventing Abuse

The facility reported a census of 39 residents with four residents sampled, including one resident reviewed for accidents. Based on observation, interview, and record review the facility failed to provide safe bathing opportunities when staff left Resident (R)1unattended in the shower, which resulted in a fall that caused a fracture to the resident's left hip. Findings included: - The Physician order [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He required limited assistance of one staff for transfers and walking in his room. His balance was not steady, and he was only able to stabilize with staff assistance. He had no limitation in his functional range of motion (ROM) and used a walker as a mobility device. He did not have any falls documented since admission to the facility The Care Area Assessment (CAAs) for Falls, dated 10/14/20, documented the resident had a history of [REDACTED]. He had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Activities of Daily Living (ADL) Functional/Rehabilitation Potential, dated 10/14/20, documented the resident had a [DIAGNOSES REDACTED]. He had functional decline which could put him at a high risk for falls. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He required supervision with set up help for ADLs and bathing and had no functional impairment in ROM. He had one fall with injury (except major) since his prior assessment. The Cognition Care Plan dated 02/09/21 instructed staff the resident had an alteration in his thought processes due to a [DIAGNOSES REDACTED]. The ADL Care Plan dated 02/09/21 instructed staff the resident required limited to extensive assistance of one to two staff with ADLs and he preferred showers. The Falls Care Plan dated 02/09/21 instructed staff the resident was at risk for falls due to a [DIAGNOSES REDACTED]. Review of the resident's Electronic Medical Record (EMR), revealed fall assessments, dated 01/09/20 and 10/22/20, which placed the resident at a moderate risk for falls. Review of the resident's EMR, under the ID Notes dated 01/27/21 revealed the resident experienced a fall while he was in the shower. Staff summoned Licensed Nurse (LN) G to the shower room. When LN G entered the shower room, she observed the resident on the floor. The resident laid naked on his left side propped on his left elbow with his right hand holding onto the handrail on the back wall of the shower area. The shower area floor was wet. When LN G asked the resident what happened, the resident responded that he did not know. LN G noted a hematoma (a solid swelling of clotted blood within the tissues) and abrasion (an area damaged by scraping or wearing away) to the resident's forehead and sheared skin on the back of his head. Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) M assisted the resident to a standing position after drying the wet shower area floor. The resident gasped in pain and informed LN G that his left hip hurt. LN G noted an abrasion to the resident's left hip. Staff assisted the resident to the shower chair, dried him, and dressed him. Staff then transferred the resident to the wheelchair and transported the resident to his room. LN G contacted the resident's physician and received an order to send him to the emergency room (ER) for an evaluation. Review of the resident's EMR, dated 01/27/21 revealed the resident admitted to the hospital with [REDACTED]. Review of the resident's x-ray report dated 01/27/21 included: Probable left femoral neck fracture ([MEDICAL CONDITION] hip). Review of the hospital discharge papers dated 02/05/21 included a discharge [DIAGNOSES REDACTED]. On 02/09/21 at 04:03 PM CNAs O and N transferred the resident from his bed to the recliner with the use of the sit to stand lift (a mechanical lift). Staff attached the lift sling to the resident and raised him in the lift to a standing position. The resident was able to bear weight on both legs and was able to hold on firmly to the handles of the lift. On 02/09/21 at 04:03 PM CNA N stated before the resident fell in the shower room, he had been able to walk independently with the use of a cane or a walker. On 02/10/20 at 10:13 AM CNA M stated she had been giving the resident his shower at the time of the fall. CNA M stated she told the resident to stay seated in the shower chair as she got some towels. CNA M turned her back to obtain the towels from around the corner. CNA M stated she only turned her back for a second to get the towels, but when she turned back around she saw the resident falling to the floor and she was unable to get to the resident in time to break his fall. On 02/10/21 at 10:51 AM CMA S stated CNA M called for help when the resident fell , and CMA S responded to the shower room with the vitals machine. CMA S stated, when she got to the shower room, the resident was on the floor, naked. The shower mats were on the floor next to the resident's feet and the shower chair had been pulled out. CNA M knelt down next to the resident. The resident complained of pain in the left hip area. When LN G came into the shower room, staff sat the resident up and he continued to complain of a lot of pain. The nurse assessed the resident and staff transferred him from the floor to the shower chair, where they dried and dressed him. Staff then transferred him from the shower chair to his wheelchair. He could barely bear weight, which was unusual for him. Staff then transported the resident to his room in the wheelchair and the nurse called the Emergency Medical Services (EMS). On 02/10/21 at 10:57 AM LN G stated a staff member told her the resident had fallen in the shower room. The resident was on the floor on his left side, holding onto the handrail with his right hand and propped on his left elbow. The floor around the resident was wet. Staff set the resident up to a sitting position on the floor and he complained of left hip pain. LN G stated the resident had a hematoma and/or abrasion to the left hip at that time. Staff transferred the resident to the shower chair where he was dried and dressed and then transferred to his wheelchair and taken back to his room. The resident continued to complain of pain, so LN G stated she got an order to send the resident to the hospital for an evaluation. The hospital called back later and said the resident was being admitted for a left [MEDICAL CONDITION]. On 02/10/21 at 01:22 PM Administrative Nurse D stated the fall occurred when the CNA turned to get more towels to dry the resident following his shower. Staff are discouraged from turning their backs on a resident while they are in a shower chair. The facility policy for Bathing, undated, included: Staff should collect needed items before starting the procedure. The facility failed to keep R1 safe from harm when the CNA turned her back to him to obtain more towels following his shower. This resulted in the resident attempting to stand on his own on the wet shower floor and falling, which resulted in a fracture to his left hip.

The facility had a census of 49 with 3 reviewed for accidents Based on observation, interview and record review, the facility failed to provide supervision and assistive devices to ensure one of the three residents, Resident (R) 1 remained free of accidents related to failure to ensure the planned gripper socks remained on the resident. R1 fell without the gripper socks on and sustained a [MEDICAL CONDITION]. Findings included: - The unsigned Physician order [REDACTED]. The significant change of condition Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score as 9, indicating moderately impaired cognition. The resident's functional status documented the resident required extensive assist of 2 staff for transfer and toileting, total dependence for locomotion, and ambulation only occurred once or twice during the look back period with the assist of 2 staff. The 08/22/19 Cognitive Loss/Dementia Care Area Assessment CAA, documented the resident was alert and oriented to person, time and place (x 3) with intermittent confusion. At times she had difficulty with word find, delayed speech, and word salad. The 08/22/19 Fall CAA, documented her impaired cognition, mood/behavior symptoms, impaired mobility, and incontinence could impact her ability to maintain balance and understand cueing. Her risk for falls could impact her ADL function and mobility. Her care plan will direct staff to provide the safest environment to prevent falls and injuries. The fall care plan, dated 08/11/19, included to ensure the resident wore hard-soled shoes with backs during awake times and gripper socks at night. The revision, following the fall, dated 10/08/19, directed when the resident went to bed staff were to make sure the resident had the gripper socks on and not fuzzy socks. On 08/11/19, the Fall Risk Assessment, documented a score of 16, and identified anything over 13 as high risk for falls. The Physicians Order Sheet, dated 10/14/19, following return from the hospital documented the following orders: Start date 10/14/19: Tylenol 325 mg; Take 2 tablets by mouth four times a day due to left hip pain. Start date 10/14/19: [MEDICATION NAME] 5 mg: Take 1 tablet by mouth every 3 hours as needed for pain. Start date 10/14/19: [MEDICATION NAME] 2 mg/mL: Take 0.5mg/0.25mL by mouth every 3 hours as needed for restlessness and agitation. On 10/8/19, the Fall Investigation Report evidenced the Certified Nurse Aide, (CNA) M, reported to the Licensed Nurse (LN) G at approximately 8:00 AM she heard R1 holler and found R1 sitting on the floor in her bathroom with her legs straight out in front of her. Resident stated that she did hit her head. She complained of pain in her head and leg. Resident's right leg was turned out. DPOA (Durable Power of Attorney) notified and requested the resident be evaluated at the hospital for evaluation. The facility staff called 911 and EMS transported resident to hospital. The resident was wearing fuzzy socks. She was not wearing the non-skid per her care plan. Review of clinical documentation on 10/14/19 recorded the resident returned from the hospital in wheelchair. She had a urinary catheter (a tube placed in the body to drain and collect urine from the bladder) and transfered with mechanical lift. She had three incisions on her right hip due to right [MEDICAL CONDITION] surgical repair from the fall on 10/8/19. Resident returned to facility with skilled services. On 10/29/19 at 10:20 AM, Certified Nurse Aide (CNA)M, reported that she was working at time of R1's fall. CNA M was in another resident's room and found R1 in her bathroom. She had a soft call light by her legs and attached to the arm rest of her chair. When she stood up, her call light was lit and did alert staff that she was in the bathroom. She would take herself to the bathroom frequently without asking staff for assistance. CNA M stated she did not know of a specific toileting plan for the resident. I know the resident had on fuzzy socks at the time of the fall, but I did not know that she should have had non-skid socks on per the care plan. I am aware that she does wear non-skid socks now, but not aware that she can't wear the fuzzy socks or that she does change into the fuzzy socks herself. I could see her changing her socks because she was very independent. She doesn't wait for staff to assist her with dressing, toileting or transferring most of the time. On 10/29/19 at 9:10 AM and on 10/30/19 at 7:37 AM, Licensed Nurse G stated that the resident required stand by assist prior to the fall on 10/8/19. Staff tried to be there for all ADL's but was not always possible due to resident's independence. She did not use her call light each time that she needed assistance. She was care planned for gripper socks, however, at the time of the fall, she was wearing one fuzzy sock and the other fuzzy sock was off. The fuzzy socks were not part of the care plan. She would change her own socks after staff put on the gripper socks. She was not on a toileting plan. The staff checked on her every time they walked by about every 15-30. I don't remember the last time she was last toileted LN G reported the resident had began declining prior to the fall, with increased confusion, decreased alertness, and increased weakness. The resident returned on skilled services, however was unable to participate in the skilled therapy. The resident passed away on 10/23/19. On 10/30/19 at 10:08 am, Administrative Nurse D, stated that fall investigation report indicated that the resident did have blue fuzzy socks on and the care plan intervention was for the resident to wear non-skid socks. I have been told the resident was independent, but I have not personally seen the resident change her non-skid socks to the fuzzy socks. I agree that the staff and the facility should have been making sure that the resident wore non-skid socks at all times or hard-soled shoes per the resident's care plan. We need to complete more staff teaching and awareness to ensure each resident intervention are implemented and reviewed at the beginning of each shift to assure that a resident's interventions have not changed, or new interventions have been put in place. Staff do not appear to be ensuring residents interventions are implemented. On 10/30/19 at 8:24 am: Consultant GG, stated that the resident had been declining rapidly due to cardiac health concerns and late stages of dementia. She stated that the resident was declining nutrition, fluid intake and becoming increasing physically weaker. The facility's dated, 3/26/19, policy, Falls read: Residents were identified for risk of falls and interventions implemented to reduce risk of falls. The facility failed to ensure staff consistently implemented planned interventions for this cognitively impaired dependent resident, at risk for falls. Facility staff failed to ensure R1's gripper socks remained on. R1 fell without the gripper socks on and sustained a [MEDICAL CONDITION] . Furthermore, the facility failed to determine the root cause analysis of what the resident was attempting to do at the time of the fall, to prevent further falls.

The facility reported a census of 58 residents with 22 residents sampled, including 1 resident reviewed for pain. Based on observation, interview and record review, the facility failed to notify the physician of increased severe pain for further treatment insturction and failed to develop and implement effective non-pharmacological pain management for the 1 (#13) sampled resident with severe pain, indicated by yelling out, moaning and groaning, and facial grimacing during cares. Findings included: - The POS (Physician order [REDACTED].#13 had [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set), dated 5-22-18, documented the staff assessment for cognition revealed the resident to have severely impaired cognition. The resident required total assistance of 2 for bed mobility, transfers, toilet use and personal hygiene. He/she received scheduled and PRN (as needed) pain medications, and denied pain in the previous 5 days. The CAA (Care Area Assessment) for pain, dated 5-22-18, did not trigger. The quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident to have severely impaired cognition. He/she required extensive assessment of 2 for bed mobility, transfers, dressing and toilet use. He/she received scheduled and PRN pain medications and the resident reported pain in the previous 5 days (a change since the previous MDS, 5-22-18), but was unable to rate the intensity or frequency of the pain. The staff interview for pain revealed the resident had pain indicators which included, non-verbal sounds, vocal complaints, and facial expressions, daily. The care plan for pain, dated 5-23-18, instructed staff to encourage the resident to request pain medications prior to the pain becoming too intense. The resident had PRN and scheduled pain medications available, and had pain when he/she sat in one place for long periods of time. The resident complained of pain during transfers. The plan lacked any non-pharmological interventions to address the resident's pain. review of the resident's medical record revealed [REDACTED]. *Tylenol 650 mg po every 4 hours, PRN for pain, ordered 5-15-18. *[MEDICATION NAME] (a pain reliever), 7.5 mg po at bedtime for pain, ordered 5-15-18. *Tylenol Extra Strength 500 mg (milligrams) 2 tabs, po (by mouth) every 8 hours PRN, for pain, ordered 7-01-18. *[MEDICATION NAME] (treats certain types of nerve pain), 100 mg po twice daily, for chronic pain, ordered 10-03-18. Review of the resident's October, (YEAR) MAR (Medication Administration Record) revealed the resident was given PRN Tylenol 22 times for complaints of pain with movement or transfers. On 10-29-18 at 10:43 a.m., direct care staff B and H, entered the resident's room to transfer him/her from the bed to the wheelchair. The resident had vocal complaints of pain during cares and transfer. The resident repeated, Oh, God, Oh, God during the cares and transfer, had facial grimacing and audible moaning and groaning while being moved and transferred. The complaints of pain stopped once staff settled the resident in his/her wheelchair. On 10-31-18 at 8:41 a.m., A sign above the resident's bed read, Must keep pillow between legs while rolling. Do not roll the resident to the left side. Roll to the right side only. Stabilize the left leg and do not allow the leg to adduct (move toward midline) or abduct (move away from midline). On 10-31-18 at 8:41 a.m., direct care staff H and Q entered the resident's room to give cares. Staff rolled the resident to the left and right, without a pillow placed between his/her legs, while removing the soiled brief, cleaning the resident and applying a clean brief. The resident stated, Oh, God, had facial grimacing, yelling out and audible moaning and groaning during the cares when moved in the slightest. On 10-31-18 at 9:10 a.m., administrative staff A asked the resident if he/she had pain in his/her leg. The resident replied he/she had pain only when staff moved his/her leg. The resident cried out when staff A slightly moved the resident's left leg. On 10-30-18 at 9:40 a.m., direct care staff H stated, the resident had a lot of pain. He/she would cry out in pain and tear up with any type of movement. The resident received Tylenol for pain, but it was ineffective. Staff H stated the nurse would be notified when the resident had pain. On 10-30-18 at 2:20 p.m., direct care staff L stated, the resident had a lot of pain in his/her hips. Staff L was aware of the pain due to the resident crying out and facial grimacing whenever staff moved the resident. On 10-30-18 at 12:21 p.m., licensed staff B stated the resident would resist cares where he/she needed to be moved as he/she had pain whenever staff moved or repositioned the resident. The resident used quite a bit of PRN Tylenol for the pain. Staff B was unsure if the resident's physician was aware of the level of the resident's pain. On 10-30-18 at 2:35 p.m., licensed staff N stated, the resident would yell out and curse at staff at night time when staff lay him/her down in bed. He/she had pain in his/her hip and would have pain during transfers. Staff N stated he/she lacked notification of the physician of the resident's pain and was unsure if the physician was aware of the resident's level of pain. On 10-30-18 at 10:51 a.m., physician O stated, he/she did not recall staff reporting the resident's pain. He/she would expect to be updated on a resident's uncontrolled pain. There are different things that could have been done to help in controlling the resident's pain. On 10-31-18 at 8:23 a.m., administrative staff A stated he/she would expect staff to notify the resident's physician of uncontrolled pain. Staff A stated the resident only had pain when staff moved him/her. The facility policy for Pain Management, revised 3/2017, included: Residents experiencing pain will have a plan of care established and monitored to effectively treat the pain. The facility failed to develop and implement effective pain management for this dependent resident with severe pain, including the use of the pillow between the resident's legs upon staff movement, notification of the physician for further instruction when the resident's level of pain increased, and the use of other non-pharmological interventions to address the resident's pain. The resident experienced harm related to experiencing pain to the degree that he/she yelled out, made moaning and groaning sounds, and displayed facial grimacing during cares.

The facility reported a census of 51 residents. The 12 residents sampled included 4 residents reviewed for accidents. Based on observations, interviews, and record review, the facility failed to ensure assistive devices to prevent accidents during use of the whirlpool lift chair, for 1 (#19) of the 4 residents reviewed for falls. Resident #19 fell and experienced a hip fracture from the whirlpool lift chair. Findings included: - Resident #19's admission MDS (minimum data set) assessment, dated 12/23/13, documented the resident with a BIMS (brief interview for mental status) score of 13/15, indicating cognition intact, and independent with most ADLs (activities of daily living), with the use of a walker and did not use a wheelchair. The assessment further documented the resident without pain. The 12/23/13 cognitive CAA (care area assessment) dated 12/23/13. The resident has a [DIAGNOSES REDACTED]. The current BIMS was 13/15, as his/her disease progressed we expect to see declines in his/her cognitive status. The 6/23/14 care plan, documented the resident used a walker with ambulation, needed cueing at times, independent with most ADLs, and staff provided assistance with baths. The 8/5/14 care plan, following the resident's hip fracture (on 7/12/14), documented the resident required extensive assistance of one staff with all activities of daily living. The resident had a history of [REDACTED]. The nurses' notes, dated 7/12/14 at 9:15 PM, documented the resident experienced a witnessed fall in the bathroom while being assisted with the bath by a staff member. The resident reported slipped on the towel, with pain in the right elbow and right knee rated at 7 out of 10 scale. The completely naked resident had just finished in the bath. The staff provided Tylenol 500 mg. (milligrams) and an ice pack to the resident's right knee for pain. Nurses' notes on 7/14/14 at 7:53 AM, documented the resident was completely unable to walk or bear weight on the right leg, used a wheelchair to the bathroom, identified as very unusual for the resident as the resident was normally independent with ambulation using a front wheeled walker. Direct care staff reported to the nurse, this has been going on since the witnessed fall on Saturday, and the resident had not walked since that time. Nurses' notes on 7/14/14 at 11:53 AM, documented the resident admitted to the hospital for a right hip fracture. Observation on 8/13/14 at 8:32 AM, revealed direct care staff N pushed the resident's wheelchair from the dining room to the bathroom. The staff put a gait belt on the resident and assisted the resident to transfer onto the toilet. The resident assisted the staff during the transfer by holding onto the grab bar by the toilet. On 8/13/14 at 3:30 PM, licensed nursing staff E, reported working on 7/12/14 when the resident fell in the whirlpool room. The direct care staff reported the fall and staff E went to the whirlpool room to assess the resident. Direct care staff O was with the resident, and reported the resident fell from the whirlpool lift chair. Staff E added the resident did not complain of any hip pain during the assessment, just pain in the right knee. Staff E had asked licensed staff D, to assist with the assessment. At that time, the two licensed staff completed further assessment with range of motion, by moving the resident's legs and arms, and the resident failed to complain of hip pain, when the extremities were being moved about. Licensed staff E explained the resident reported his/her right knee and elbow hurt, and said it was not bad. Direct care staff O, reported to staff E, the resident did not have the safety belt on in the whirlpool lift chair, but staff E could not remember if the belt was on the lift chair at the time of the assessment. On 8/13/14 at 3:50 PM, direct care staff O reported he/she assisted the resident with a whirlpool bath on 7/12/14 between 8:00-9:00 PM. Staff O explained the incident. The resident was in the whirlpool lift seat, coming down when he/she became anxious and began scooting in the seat. The staff asked the resident to sit still, but the resident continued to scoot in the seat. The whirlpool seat was still coming down and was about waist high when the resident fell forward from the seat and, fell on to the right elbow and the right leg. Staff O pulled the call light and put a towel over the resident. Licensed nursing staff E came in and assessed the resident. Staff E had the resident move his/her arms, hands, legs and feet. The resident complained of pain with the right leg at that time. Direct care staff O reported the resident did put weight on his/her legs when transferred by the two staff from the floor to the wheelchair. Direct care staff O worked the next day on the 2-10 shift. On that day, when Staff O assisted the resident to the bathroom he/she would stand on both feet during the transfers, but said it hurt when doing it. The resident did not use the walker for mobility, but sat in the wheelchair, and used the call light for help. On that day, Staff O reported to Licensed nurse E, also on the evening shift, the resident reported the right leg hurt with transfers. Licensed nurse E explained giving the resident Tylenol for the pain. Direct care staff O, verified at the time of the fall, the resident did not have a safety belt around him/her in the whirlpool lift chair and then the resident fell . On 8/13/14 at 4:15 PM, direct care staff P reported staff was to use a support belt (safety belt attached to the whirlpool lift chair), with all residents in the whirlpool. Staff P explained the whirlpool tubs either have a safety belt on the lift chair, or it was available there to put on. On 8/13/14 at 4:30 P.M. licensed nursing staff F, reported they worked dayshift on 7/14/14, and sent the resident to the hospital. The direct care staff reported to Staff F the resident was unable to walk as usual with the front wheel walker, and reported pain, since the fall on Saturday evening (7/12/14). Staff F reported the staff should put the safety belt on the resident when they were in the whirlpool. On 8/14/14 at 8:11 AM, administrative staff B reported the facility did a teachable moment with all staff on 7/28/14, related to use of the lift transfer chair with the spa tub for the residents. Administrative staff B, also provided the manufacture's recommendations for the use of the Penner/Cascade system, which documented, Only personnel who were thoroughly trained in the operation of the Penner Transfer Lift System should operate this equipment. Operation of this equipment by untrained personnel could result in injury to the operator or patient. The information also documented as follows: Failure to secure the resident properly with the seat belt could result in injury to the resident or the operator. On 8/14/14 at 8:49 AM, licensed nursing staff G reported the whirlpool had a safety belt that the staff were supposed to use for the residents. The facility did a staff in-service/ teachable sheet after resident #19 fell , to remind the staff to use the safety belt. At that time, observation of the whirlpool room revealed the safety belt through the back of the lift chair. Licensed nursing staff G, reported as far as he/she knew, it had always been there. On 8/14/14 at 9:05 AM., administrative nursing staff B reported the investigation revealed other staff also were not using the safety belt, and the lift chair lacked the safety belt on it when the resident fell . Staff B added the facility lacked a policy about the use of the lift in the whirlpool and stated the facility used the manufacturer's recommendations. On 8/14/14 at 9:30 AM, direct care staff I reported the resident went to the doctor on 7/14/14, and admitted to the hospital from there. The whirlpools all had a safety belt and they were on the chair 95% of the time, and if not they are usually hanging there. We are supposed to use the safety belt with all of the residents in the whirlpool for safety. That is how I was trained. The facility failed to ensure adequate safety devices while using the whirlpool chair lift for this resident, who fell while raised in the lift and sustained a fractured right hip.

The facility census totaled 57 residents with 15 residents included in the sample. Of those, 3 residents were reviewed for weight loss. Based on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents (#41) maintained acceptable parameters of nutrition by the failure to identify and address severe weight loss, and follow through with interventions and treatment. The resident experienced a 10.7% weight loss in less than 180 days, a severe amount of weight loss. Findings included: - Review of resident #41's Significant Change MDS (Minimum Data Set) assessment dated [DATE] revealed it identified the resident with a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). It identified the resident needed extensive assistance of one person for bed mobility, needed limited assistance of one for transfers, walking in room, and personal hygiene, and needed supervision and set up assistance for eating. It identified the resident with no swallowing issues, had a height of 67 inches and weight of 144 pounds, experienced no or unknown weight loss or gain and had no dental concerns. Review of the CATs (Care Area Triggers) for the Significant Change MDS dated [DATE] revealed Nutritional Status did not trigger for further assessment. Review of the physician's orders [REDACTED]. Review of the resident's care plan with the last care plan conference date of 4/10/13 identified the resident at risk for alterations in nutrition related to missing teeth. It revealed the resident received a regular diet with FEP (Fortified [MEDICATION NAME] Powerfoods) 1 meal per day, directed staff to weigh the resident monthly and PRN (as needed), give choice of fluids at each meal and place at bedside. It identified the resident liked coffee at meals and water between, directed staff to complete the [MEDICAL CONDITION] screen quarterly and PRN, and identified favorite foods as chocolate in any form, oatmeal and toast, bananas, cottage cheese, cinnamon rolls, applesauce, and desserts. It identified the resident liked snacks such as anything chocolate and kept snacks in his/her room for whenever he/she wanted something. The care plan also identified the resident used selective menus to allow the resident to choose what he/she wanted to eat for lunch and supper, liked juice and coffee with meals, including 1 creamer added to the coffee. Review of the Conference Summary dated 4/10/13 revealed the resident liked cottage cheese and sweets, and directed dietary to make sure the household had cottage cheese, the resident did not feel like coming to dining room at times, and his/her weight continued to decrease slowly. It also identified, "Give 2 desserts." Review of the 10/23/2012 Nutritional Progress note revealed the resident had a slow weight loss related to inadequate energy intake. It identified a current weight of 153 pounds, with a weight one year prior of 159. The note identified a gradual decrease, and planned to monitor and consider interventions if weight loss became severe. Review of a 12/11/12 Nutritional Progress note revealed the resident experienced unplanned weight loss related to inadequate intake. It identified the resident with a current weight of 152 pounds, and identified the weight as appropriate for the resident to maintain. The resident moved seats in the dining room, went to a private room, and staff planned to monitor to see if this improved weight over time. It directed to monitor and intervene as needed. Review of a QA (Quality Assurance) note from 2/26/13 at 12:57 P.M. revealed the weight loss had slowed since December, and staff planned to continue with current interventions and intervene if the weight loss did not stabilize. The note did not include any new interventions implemented. When asked about interventions during this time period at 11:45 A.M. on 4/29/13, Consultant L reported on 2/26/13, he/she recommended offering alternates if the resident took in less than 50% at meals. The care plan did not include this intervention. Review of a QA interdisciplinary note dated 3/21/13 at 10:44 A.M. revealed the team reviewed the resident's weight and identified the weight at 147 pounds, an insidious loss of 5% in 6 months. The note identified implementing the FEP program, which Consultant L recommended, and planned to monitor weights weekly. Review of the Quarterly Dietary note dated 4/8/13 completed by dietary staff O revealed it identified no significant weight loss, and a current weight of 144 pounds. Review of a QA interdisciplinary noted dated 4/22/13 revealed it identified Consultant L reviewed the resident's weights and recommended increasing FEP to twice daily and trying an appetite stimulant and increasing fiber in the resident's diet. It identified notifying the physician of needing the appetite stimulant, but did not indicate staff notified the physician of any significant or severe weight loss. Review of a fax dated 4/22/13 revealed it identified a downward weight trend and suggested to try an appetite stimulant to help increase the resident's intake. On 4/25/13, the physician replied to proceed with the appetite stimulant. A fax date dated 4/25/13 to the physician revealed the staff needed clarification of which appetite stimulant to use and on 4/26/13 received a reply from the physician for [MEDICATION NAME] 7.5 milligrams every evening at bedtime. Observation at 12:27 P.M. on 4/24/13 revealed the resident received meatloaf, mashed potatoes, peas and a regular sized bowl of chocolate pudding. Observation revealed the resident ate 1/2 of the peas, 1/4 of meatloaf, a couple bites of mashed potatoes and set it to the side. The resident then ate his/her chocolate pudding, and drank from his/her coffee, juice and water. Observation at 12:54 P.M. on 4/24/13 revealed, Direct Care Staff G asked the resident if that plate belonged to the resident that meal. The resident nodded and confirmed, then Staff G replied, "You didn't want nothing?" The resident shook his/her head no, and Staff G walked away. Observation revealed the resident ate the whole bowl of chocolate pudding. The resident then placed his/her coffee mug into the empty bowl and pushed it over to the edge of the table, and finished drinking his/her fluids. The resident ate less than 50% of the meal, but staff failed to offer alternatives or encourage the resident to eat more. Review of the Meal Intake Chart for that noon meal on 4/24/13 revealed staff documented the resident consumed 75% of the meal. Observation at 5:36 P.M. on 4/24/13 revealed the resident with water, apple juice and coffee at the table. At 5:58 P.M. the resident received a large pancake, scrambled eggs, and 2 round sausage patties. At 6:23 P.M.. Direct Care Staff H asked the resident if he/she wanted apricots and the resident nodded. Staff H provided the resident with one small bowl of apricots. Observation again at 6:34 P.M. revealed the resident ate all apricots, and all other food except 1/2 of the sausage. Observation at 10:12 A.M. on 4/25/13 revealed the resident sat in the dining room to eat breakfast. The resident reported he/she liked chocolate and tapioca pudding and would eat more than one bowl of those if staff gave them to him/her, but reported he/she did not not remember ever getting two desserts at a meal, and did not think he/she even got one dessert at every meal. The resident also reported he/she liked apricots, but thought only one serving of fruit to be enough. Review of the facility's weight records revealed the following: Review of the Weekly Weight Chart report from the electronic record revealed: Week of 10/31/12 - 157 pounds Week of 11/28/12 - 152 pounds Week of 1/2/13 - 152 pounds Week of 1/30/13 - 149 pounds Week of 2/20/13 - 146 pounds Week of 2/27/13 - 147 pounds Week of 3/20/13 - 144 pounds Week of 3/27/13 - 144 pounds Week of 4/3/13 - 143 pounds Week of 4/10/13 - 142 pounds Week of 4/17/13 - 140 pounds Review of the Written Weight Record from the notebook at the Utz nurses station revealed: 2/18/13 146.8 pounds 2/25/13 146.2 pounds 3/25/13 144.2 pounds 4/15/13 142.4 pounds 4/22/13 140.4 pounds Observation at 2:17 P.M. on 4/25/13 revealed staff assisted the resident to stand on a portable scale. Observation revealed the resident now had a weight of 139.6 pounds. During an interview with Dietary staff K at 6:42 P.M. on 4/24/13, he/she reported he/she knew what to provide each resident by the meal cards. Review of the card for the resident at that time revealed coffee, oatmeal, toast, juice and 2 bananas for breakfast, identified cottage cheese and applesauce as things the resident liked, and included, "Ask (gender) if (gender) needs anything" and "2 desserts at each meal". The card identified the resident received FEP (Fortified [MEDICATION NAME] Powerfoods). At that time Staff K reported FEP meant dietary staff added sour cream to mashed potatoes, put cheese in eggs, and did other things to increase the calories in the foods for the resident. Staff K reported he/she had cottage cheese available, and if the resident asked for it, then staff provided it to the resident. The resident chose if he/she wanted 2 desserts, but didn't really eat too many desserts, especially fruits. Staff K reported the resident asked if he/she wanted ice cream, would ask if wanting a second dessert, and staff needed to ask if the resident needed anything. During an interview with Direct Care staff J at 1:17 P.M. on 4/25/13, Staff J reported the kitchen had cards available with the residents' current diets, including if the resident had double desserts, and the care plan also addressed diets. Staff J reported he/she did not think the resident had anything special about his/her diet. Staff J reported he/she thought the resident had a little weight loss but had not experienced a whole lot. Staff J reported he/she felt the resident did not eat as well as others at times, and did complain at times about not liking some foods. Staff J confirmed the resident really started to like applesauce and cottage cheese in the last couple months, but today picked cottage cheese over applesauce. Staff J reported the resident never asked for cottage cheese, and staff had to offer or suggest it to the resident and then the resident would take it. Staff J reported the resident never asked for it, and staff had to encourage the resident to get it. During an interview with Direct Care staff G at 1:55 P.M. on 4/25/13, when asked about if the resident should have gotten 2 servings of pudding at the meal the day prior, Staff G reported the resident did not like pudding, and so did not think the resident ate pudding at all. Staff G reported he/she did not think the resident had any weight loss lately, because "we" would have put the resident on health shakes or another type of supplement. Staff G reviewed the care plan and reported he/she did not know the resident received the FEP diet. During an interview with Nursing staff I at 2:00 P.M. on 4/25/13 reported staff knew what type of diet and foods to provide the resident by looking at the cards in the kitchen or by looking at the care plan. When asked what type of diet the resident received or if the resident had lost any weight, staff I reported unsure about either, and needed to review the resident's record. When asked what FEP meant, staff I reported he/she thought it meant adding extra protein to the food when staff made it in the kitchen. Staff I reported he/she thought dietary staff added protein powder and other things. When asked about the cheese and sour cream added during meal service, staff I reported he/she did not think those additions were effective to slow weight loss. Staff I confirmed staff needed to encourage the resident to eat at meals, the resident knew he/she could ask for anything he/she wanted, but staff needed to offer food items and snacks as well. Staff I reported he/she did not have concern regarding weight loss unless the resident lost 3% of his/her weight in a week. At that time, Staff I reviewed the book of weights and identified the weight loss as "not alarming." When asked about pudding, Staff I reported pudding did not help the resident gain weight, the resident just liked desserts, had the preference of two at a meal, but did not use that as an intervention to help with weight loss. Staff I confirmed staff needed to follow the care plan because that is the plan the family, resident, and staff identified as the best way to care for the resident. During an interview with Licensed Nurse M at 12:50 P.M. on 4/29/13, he/she reported he/she did not know for sure if the resident had experienced any weight loss and would have to check in the record. During an interview with Dietary staff O at 9:37 A.M. on 4/29/13, he/she reported the risk meeting met each week and looked at resident weights to see who triggered for significant weight loss, or anyone that was close to significant loss. Staff O reported significant weight loss as 5% in 30 days and 10% in 180 days, and used the MDS report to identify those losses. Staff O reported he/she also pulled that report for the dietician. Staff O reported they looked at intake averages to help determine which meal the resident ate best, and possibly which meal to start the resident on the FEP program. Staff O reported he/she did not think the resident had experienced significant loss, then reviewed the Section K for MDS report he/she looked at to determine whether resident #41 had significant weight loss and confirmed it did not identify the resident with significant loss. Staff O then reviewed the actual weights and confirmed the resident actually had experienced significant loss. When asked the reason for 2 desserts at meals, staff O reported the resident really liked sweets and dessert, so staff added to help with weight. Staff O also reported he/she expected staff to encourage the resident to eat and to offer alternates like the cottage cheese and his/her other likes to see if the resident would eat that. Staff O reported he/she added, "ask (gender) if (gender) needs anything" to the diet card because the resident made a comment one day that staff did not ask the resident if he/she wanted any other food items or assistance. During an interview with Consultant staff L at 11:37 A.M. on 4/29/13, Staff L reported he/she identified insidious weight as a trend of losing weight, but not triggering for significant loss. Staff may monitor the weight loss, start interventions and monitor effectiveness. Staff L reported, if the resident then triggered for significant loss, Staff L reported he/she might be more aggressive with interventions, possibly initiating more than one intervention at a time. Staff L reported he/she received a list of everyone in the facility, and reviewed the weight percentages provided to see how much loss each resident experienced. Staff L reported he/she did spot checks of the report to ensure it calculated the right percentage and never found any concern. When asked if he/she reviewed the actual weights in another computer program, Staff L reported he/she did not have access to that program. Again, at that time, Dietary staff O pulled up the report Staff O used to identify signficiant or severe weight loss, (the resident has now experienced severe weight loss) and confirmed it did not identify the loss. Consultant L reviewed the highest and lowest weight and confirmed a 10.7% weight loss. Review of the K0200 Height and Weight report (the report used by Dietary staff O to identify significant weight loss) on 4/29/13 revealed it identified the resident with a weight of 140 lbs. It identified the resident with a percentage change of -2.63% in last 30 days and -8.35% in last 180 days. Under the weight loss question, the report coded the resident with no or unknown weight loss. During an interview with Physician N at 2:01 P.M. on 4/29/13, Physician N reported he/she found out about any weight loss from the facility identifying it and reporting to Physician N. Physician N confirmed he/she may treat a resident with significant or severe weight loss more aggressively or with different interventions than a resident with gradual/minimal loss. For resident #41, he/she ordered [MEDICATION NAME] because it stimulated the resident's appetite and helped with depression when this resident did have the potential for depression. Physician N reported he/she could not remember everything off the top of his/her head, but did not believe the resident had experienced any significant weight loss. Review of a Fax Form to they physician identified on 5/1/13 the facility notified the physician the resident lost 10.71% of his/her body weight (significant change) in 175 days. Review of the facility's Nutritional Status/Risk for [MEDICAL CONDITION] policy, last revised February 2008 revealed it included, "1. Parameters of nutritional status which need to be addressed include unplanned weight loss..." It also revealed under section 3.c, standard parameters for evaluating unplanned and undesired weight loss were identified as in 30 days (1 month) a weight loss of 5% (significant loss) or >5% (severe), in 90 day (3 month), a weight loss of 7.5% (significant loss) or >7.5% (severe loss), and in 180 days (6 month) a weight loss of 10% (significant loss) or >10% (severe loss). Section 3.e revealed, if monthly weight supported significant unplanned weight loss, it directed staff to notify dietary, primary care provider and family of the weight loss. The facility failed to identify and address severe weight loss, and follow through with interventions and treatment. The resident experienced a 10.7% weight loss in less than 180 days, a severe amount of weight loss.