Every finding on record at Parkway Operator LLC

Based on observation and interview, the facility failed to maintain a sanitary kitchen to prepare food for the residents who received meals from the kitchen. Findings included:- On 07/28/2026 at 11:52 AM, during observation of the kitchen, three Hydrion PH sanitizer paper testing strips, stored above the three-compartment sink, were found outdated, with two that had expiration dates of 09/30/2018 and one with an expiration date of 07/15/2025.On 07/27/2026 at 11:52 AM, Dietary Staff BB stated he was unaware the testing strips had an expiration date.Upon request, the facility failed to provide a policy on kitchen sanitation.

Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ- an electronic record mandated by the Centers for Medicare and Medicaid Services (CMS) that details direct care staffing hours worked in long-term care settings) as required, resulting in a trigger for excessively low weekend staffing.Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2026 Quarter (Q) 1 and Q2 indicated excessively low weekend staffing.Review of the facility's Nursing staffing schedules for the above quarters revealed adequate staffing on duty was provided.On 07/29/2026 at 12:15 PM, Administrative Nurse D stated Administrator A submitted the nursing information for the PBJ report and stated they were always staffed well on the weekends, as they do have agency staff assisting when needed.The facility's Payroll Based Journal policy, dated 10/2025, documented the community would submit payroll data in a uniform format to CMS, including staffing information for community, agency, and contract staff. The facility distinguished employees from agency and contract staff and reported information about direct care staff, and they specified whether the individual is an employee of the facility or is engaged by the facility under contract or through an agency.

Based on interview and record review, the facility failed to follow the latest guidelines from the Centers for Disease Control and Prevention (CDC) to administer the COVID-19 vaccine following written consent or obtain informed declination documentation for Resident (R) 2, R1, R8, and R23.Findings included:1. R2's Electronic Medical Record (EMR) documented a declination for the COVID-19 booster vaccine on 06/14/2024, but lacked a current declination for the latest COVID-19 booster.2. R1's EMR documented a COVID booster received on 06/14/2023. The facility had a consent for a COVID-19 booster vaccine to be administered but lacked a signature date or record that R1 had received the most current vaccine.3. R8 EMR documented a consent for a COVID-19 booster dated 07/20/2026 but lacked documentation that R8 had been administered the current COVID-19 booster vaccine.4. R23 documented the declination of a COVID-19 booster on 12/18/2024. The facility failed to document a current COVID-19 booster vaccine offer.On 07/29/2026 at 11:29 AM, Administrative Nurse D verified the lack of documentation related to the COVID-19 vaccine. Administrative Nurse D reported the facility utilizes the month of October to update the immunization status for the residents. The facility works with the local health department for the administration of vaccines. Administrative Nurse D verified the residents should receive information and the most current vaccination recommendations from the CDC.The facility's Vaccination of Residents, including influenza, Pneumococcal, RSV and COVID-19 dated 09/2025 documented the community will offer the COVID-19 vaccination when available to the community. The vaccine may be offered and provided directly by the community or through a third-party arrangement with a pharmacy partner, local health department, or other appropriate health entity. The residents or their representatives will receive education on the benefits and risks of receiving the COVID-19 vaccine. Document refusals in the medical record.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high-contact care) for Resident (R) 5 and R35's wound care and R4's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) and tracheostomy care (opening through the neck into the trachea through which an indwelling tube may be inserted).Findings included:- On 07/29/2026 at 10:33 AM, Licensed Nurse (LN) I provided wound care for R5's buttock pressure ulcer (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). LN I donned gloves, removed the soiled dressing, then proceeded to clean the wound and apply ordered treatment and dressing to the wound. LN I failed to utilize a gown barrier, which was available at the resident's door, during any part of the procedure. On 07/29/2026 at 11:00 AM, LB I provided wound care for R35's ulcer to the plantar (bottom) area of the right foot. LN I donned gloves to remove the dressing. LN I then donned a barrier gown to complete the treatment and dressing. LN I stated that she had forgotten to place a barrier gown on to provide wound care, due to being nervous during the observation of the care for wounds on both R5 and R35. On 07/29/2026 at 11:33 AM, Administrative Nurse D verified that staff should have donned a gown and gloves during the treatment of wounds. The facility's Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP) policy, dated 05/2026, documented that EBP expanded the use of PPE and referred to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact activities. Nursing Home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. - On 07/28/2026 at 08:15 AM, R4's room door had an Enhanced Barrier Precautions (EBP -infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) sign and a door caddy with gowns and gloves in it. Licensed Nurse (LN) G went into R4's room to administer morning medications via R4's gastrostomy tube (G-tube: a tube surgically placed through an artificial opening in the stomach) and to perform tracheostomy (opening through the neck into the trachea, through which an indwelling tube may be inserted) care. LN G washed his hands and donned clean gloves and used a 60-milliliter (mL) syringe to check for residual (the amount of fluid remaining in the stomach before a feeding or at regular intervals) before administering his medications. LN G removed his soiled gloves, washed his hands, and donned a new pair of gloves. LN G flushed his G-tube with 60 mL of water, administered the medications, and flushed his G-tube with another 60 mL of water. Further observation revealed LN G removed his soiled gloves, washed his hands, donned clean gloves, and prepared R4 for tracheostomy care. LN G removed the 4 x 4 gauze pad (medical dressings used to clean, cover, and absorb drainage from wounds) from under the tracheostomy tube. LN G changed his gloves and stated his right hand was his sterile hand, and then he cleansed the area with a mixture of sterile saline and hydrogen peroxide. LN G removed the inner cannula (a removable tube that slides inside the main tracheostomy tube) and put in a new one. LN G changed his gloves, removed the tracheostomy tie (a securement strap that holds a tracheostomy tube firmly in place against the neck), and replaced it with a clean one. LN G then took R4's oxygen saturation (percentage of oxygen in the blood). On 07/28/2026 at 08:40 AM, LN G stated both the residents in the room were on EBP precautions and staff were supposed to wear a gown and gloves while providing care to R4. On 07/29/2026 at 12:18 PM, Administrative Nurse D stated staff are to wear a gown and gloves with cares for any resident on EBP. The facility's Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP policy, dated 05/2026, documented enhanced barrier precautions are used during high -contact resident care activities. For residents with indwelling medical devices such as feeding tubes and tracheostomies, staff are to wear personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves).

Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for one resident, Resident (R) 4.Findings included:- R4's Electronic Medical Record (EMR) documented diagnoses 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), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), tracheostomy (opening through the neck into the trachea which an indwelling tube may be inserted), and dysphagia (swallowing difficulty).R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R4's cognition was not assessed. R4 was dependent upon staff for all activities of daily living (ADL). The MDS documented the resident received tracheostomy care, had a gastrostomy tube (G-tube: a tube surgically placed through an artificial opening into the stomach, and received hospice services.R4's 06/02/2026 Care Plan documented the following interventions for R4:09/09/2025- The care plan directed staff to administer medication as ordered, monitor for verbal and nonverbal cues of pain, and intervene accordingly. The care plan directed staff to notify Hospice of any changes in condition and had a DNR (do not resuscitate). The care plan lacked the frequency and type of support visits, supplies, and medical equipment provided by hospice.Review of R4's clinical record revealed the resident was admitted to hospice care on 09/06/2025. The facility had a plan of care provided by hospice in a communication book dated 06/04/2026.On 08/27/2026 at 08:30 AM, R4 was in bed with his eyes closed.On 07/29/2026 at 1:18 AM, Administrative Nurse F stated she was new to the position and had training on the care plan process. Administrative Nurse F further stated she would update the care plan with the information required related to his Hospice care.On 07/29/2026 at 12:10 PM, Administrative Nurse D stated the care plan should reflect the care provided by both the staff and Hospice.The facility's Hospice Program policy, dated 12/2025, documented the community may contract for hospice services for residents who wish to participate in such programs, including services that would be provided and the coordination of services. To promote continuity of care, collaborate with the hospice, nursing home, and resident/representative on a coordinated care plan noted in the medical record to include, but not limited to, resident choices regarding care, all services needed, interventions based on assessments, and the provider responsible for performing specific services.

Based on observation, interview, and record review, the facility failed to adequately store drugs and biologicals for Resident (R) 35, R15, and R38 when staff failed to date insulin upon opening. Findings included:- On 07/27/2026 at 08:40 AM, during the initial tour of the facility, Licensed Nurse (LN) H was preparing medications. Upon inspection of the medication cart, R35's Novolog (short-acting insulin) pen, R15's Glargine (long-acting insulin) pen, and the R38 Novolog vial lacked an open date. LN H verified the facility's policy was to date insulin when opened for use, and insulin should have been dated with the open date.On 07/29/2026 at 11:54 AM, Administrative Nurse D verified that the insulin should be dated when opened and put into use.The facility's Storage of Medications policy, dated 10/2024, documented that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed, per state regulation.

Based on observation, interview, and record review, the facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) for Resident (R) 48, upon the resident's discharge from the facility.Findings included: - R48's Electronic Medical Record (EMR) documented diagnoses of dementia without behavioral disturbances (a progressive mental disorder characterized by failing memory and confusion), heart failure, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two.The admission Minimum Data Set (MDS), dated [DATE], documented R48 had moderately impaired cognition. R48 required supervision with toileting hygiene, showers, transfers, and set-up assistance with personal hygiene. R48 had lower functional impairment on both sides, did not ambulate, and wanted to be discharged back to the community.R48's 05/20/2026 Care Plan documented the following interventions for R48:05/21/2026- Talk to his family member to make sure she was on board with him living with her. The care plan directed staff to work with the KCVA (Kansas City Veterans Administration) to obtain assistance with transferring R48 to the Veterans Administration (VA) in Illinois and to address the financial issues associated with moving out of state. The care plan further directed staff to educate R48 on good self-care behavior, and Social Services (SS) would provide visits to assist R48 with the adjustment and to help with discharge planning.The Nurse's Note, dated 06/02/2026 at 08:53 AM, documented R48 went to Social Services X and stated he was discharging home with his family today. R48 stated his family member was in Kansas City and planned to pick him up. The note further documented that nursing staff were notified and would get their discharge paperwork ready.The Nurse's Note, dated 06/02/2026 at 10:01 AM, documented R48 was discharged from the facility to home and picked up by family; the Nurse Practitioner (NP) was notified and ordered to have R48 discharged from the facility.R48's EMR lacked a recapitulation of his stay in the facility.On 07/28/2026 at 11:09 AM, Administrative Nurse D verified there was no recapitulation for R48's stay. Administrative Nurse D stated that normally the discharge paperwork was started at admission, but R48 was originally supposed to be long-term; one day he came and stated his ride was coming and he was going home.The facility's Discharge Summary and Plan policy, dated 03/2026, documented that when a resident's discharge was anticipated, a discharge summary and post-discharge plan would be developed to assist the resident to adjust to his/her new living environment, that was safe and able to provide the care they required post-transfer. The discharge summary would include a recapitulation of the resident's stay at the facility, and a final summary of the resident's status at the time of the discharge and as permitted by the resident.

Based on record review, interview, and observation, the facility failed to provide cardiopulmonary resuscitation (CPR-an emergency lifesaving procedure performed when the heart stops beating) for Resident (R) 1 who had a documented desire for full resuscitative measures. On [DATE] at approximately 01:25 PM, Certified Nurse Aide (CNA) M was called to R1's room where R1 was leaned back against the toilet and mumbling. CNA M and CNA N called for Licensed Nurse (LN) G and placed R1 into her wheelchair because she asked to be laid down. During this time, LN G came in, assessed R1, and gave her some lorazepam (an antianxiety medication - a class of medications that calm and relax people) to help calm her down. The three staff then moved R1 towards her bed, and during that time, R1 became unresponsive. R1 was limp and did not respond to verbal or tactile stimuli but staff did not initiate CPR and placed R1 in bed. LN G ignored the green sticker on the door, which indicated the resident's desire for full resuscitative measures, and returned to the nurse's station, where he reviewed the resident's Electronic Medical Record (EMR) and identified the resident's Full Code status, but LN G did not implement CPR. The facility's failure to ensure staff provided CPR for cardiac arrest, per R1's documented wishes, placed R1 in immediate jeopardy.Finding included:- R1's EMR documented diagnoses of encephalopathy (a broad term for any brain disease that alters brain function or structure), altered mental status, chronic systolic heart failure (a condition in which the left ventricle of your heart, which pumps most of the blood, has become weak), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) type two, muscle weakness, and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. R1's MDS assessment recorded R1 elected hospice services (specialized medical care for persons suffering from life-threatening illness, providing comfort and quality of life measures). R1's Care Plan initiated [DATE] included R1 elected a Full Code Status and CPR measures to be performed. Staff were directed to respect R1's wishes and rights regarding her decision to have CPR performed. R1's plan of care further instructed communication of her choice to all appropriate staff members and to initiate CPR if R1 was found pulseless or breathless and continue CPR until paramedics arrived to take over. R1's Orders tab documented a physician's order dated [DATE] for Full Code, all measures. R1's Orders tab documented a physician's order dated [DATE] for lorazepam intensol oral concentrate two milligrams (mg)/milliliter (ml) administer 0.5 ml by mouth every one hour as needed for anxiety. LN G's Nurses Progress Note dated [DATE] at 02:47 PM documented R1 called out to staff requesting assistance to the bathroom. Staff assisted R1 to the bathroom and noted difficulty with posture while R1 sat on the toilet. When staff attempted to assist R1 back to her wheelchair, R1 repeatedly stated she wanted to lie down. R1, who was normally a one staff assist with transfers, required two staff assistance with a stand and pivot transfer, due to increased weakness. R1 began yelling, Hey, Hey, and became increasingly restless. LN G administered R1's lorazepam as ordered to assist with restlessness. LN G documented that during the follow-up assessment to evaluate the effectiveness of the medication, LN G noted R1's posture became limp. R1 was unresponsive to touch and verbal stimuli, no pulse or respirations were observed, and R1's color changed. The facility's report dated [DATE] documented that R1 received hospice services, and LN G incorrectly assumed R1 had a Do Not Resuscitate (DNR) code status. R1's code status was reviewed and identified it should have remained listed as a Full Code. The event was reported due to the failure to verify R1's code status prior to determining interventions for an unresponsive resident. The facility report further documented the root cause analysis identified a failure to verify code status for an unresponsive resident due to an assumption of staff based upon the resident's hospice status. The facility report documented corrective actions were initiated, including immediate re-education with staff regarding mandatory verification of code status for all unresponsive residents, regardless of hospice enrollment status; a facility-wide audit of current resident code statuses was completed and verified for accuracy; a mock code drill was conducted to validate staff competency and understanding of emergency response expectations. LN G's unnotarized Witness Statement dated [DATE] documented CNA staff assisted R1 in the restroom, and one staff member called out to LN G for assistance. LN G observed R1 leaning back on the toilet while staff tried to assist her. LN G documented two staff members assisted R1 into her wheelchair due to her increased weakness. While transferring R1, the resident repeatedly yelled out that she wanted to lie down and then started yelling out, Hey, Hey, Hey, and became more restless. LN G administered R1's prescribed lorazepam for anxiety and agitation to help with her restlessness. LN G then assessed R1 for medication effectiveness during which time R1 became limp, and unresponsive to touch and verbal stimuli. LN G noted R1 had no pulse, respirations, and R1's color had changed and she became pale. CNA N's unnotarized Witness Statement dated [DATE] documented she answered R1's bathroom call light and assisted R1. CNA N noted R1 was mumbling and leaning back. As R1 leaned back, CNA N called for help. CNA N and CNA M then called for LN G due to R1 seeming off. R1 was able to stand for peri care and to transfer to her wheelchair. CNA N documented R1 was repeating, Help me, and I'll lay down. CNA N documented that as staff were about to transfer R1 to bed, R1 started leaning, LN G gave R1 some medicine, R1's eyes rolled back, and then that was it. CNA M's unnotarized Witness Statement dated [DATE] documented she was called to assist with R1. CNA M documented upon arrival to assist with R1, R1 laid back on the toilet mumbling. CNA M asked R1 what was wrong, and R1 continued to mumble. CNA M documented that was when LN G was called to assist with R1's care and assess R1. CNA M documented that CNA N, LN G and herself proceeded to clean up R1 and assist R1 off of the toilet and into her wheelchair. R1 began yelling and stated she wanted to lie down, repeatedly. CNA M further documented when all three staff members went to try and get R1 into bed, they noticed R1 went unresponsive, her eyes rolled back, and she started to slide out of her wheelchair. On [DATE] at 09:08 AM, CNA M stated she was assisting another resident when she was called to the room to assist the CNA in the room with R1. R1 leaned back against the toilet and was mumbling. CNA M asked R1 if she was ok, and R1 just continued to mumble. CNA M and CNA N got R1 into her wheelchair, and she asked to be laid down. She kept repeating that she wanted to lay down. During this time, her nurse came in and assessed her and gave her some medication to help calm R1 down. Afterwards, the staff moved R1 towards her bed because she wanted to lie down. CNA M noted R1 became unresponsive, and staff moved her onto the bed. R1 was limp and not responding to anything. CNA M stated she knew R1 was a Full Code prior to going on to hospice but also knew that after R1 went on to hospice, there was talk about her code status. CNA M said she thought the nurse would know, so she left it to the nurse. CNA M said the color under the name tags on the door revealed the code status of the resident, and that the color codes were there when this occurred with R1. CNA M stated the code status was also listed in the Plan of Care (POC), the Treatment Administration Record (TAR), and staff could check the door. CNA M stated that [NAME] meant the resident was a Full Code, and red meant the resident was a DNR. On [DATE] at 12:47 PM, LN G stated staff alerted him that R1 kept screaming. LN G assisted with getting R1 cleaned up and transferred into her wheelchair. LN G stated he gave R1 her lorazepam to help calm her down, but about two to three minutes later, R1 kept yelling Hey. LN G stated he observed R1 go unresponsive and die right there. LN G stated he made a mistake because he thought R1 was a DNR, and then, when LN G was looking at R1's chart, he noticed that she was a Full Code. LN G stated he knew it sounded bad, but R1 died in that moment, and LN G did not feel that he would have been able to get R1 back. LN G revealed that about ten minutes had passed from when R1 stopped breathing to when LN G knew her actual code status. LN G stated the code status was listed outside of the door; green for Full Code and red for DNR. LN G said when he left R1's room that day he did not think to look at the door to see R1's code status. LN G further stated that if he had looked, he did not think the end results would have been different. LN G stated he would have done CPR and then called 911 to make that final call. On [DATE] at 11:35 PM, Administrative Nurse D stated she expected staff to start CPR if the resident was a Full Code. She further stated that if a resident was a DNR, she expected the staff to assess the resident and notify the appropriate people. Administrative Nurse D stated there was some confusion because the resident was on hospice. Administrative Nurse D stated that ultimately, LN G was terminated because he should have checked the code status, and the green name tag (indicating Full Code) was outside of R1's room. The facility's Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) policy, last approved in March of 2026, directed that staff must maintain current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. The policy further directed that staff were to verify the presence of advanced directives regarding CPR upon admission per policy. On [DATE] at 02:30 PM, Administrative Nurse D and Administrative Nurse E received a copy of the Immediate Jeopardy [IJ] Template and were notified that beginning on [DATE], the facility's failure to perform CPR on R1, placed R1 in IJ. The facility identified, immediately implemented, and completed corrective actions as follows:1. The nurse involved was immediately suspended on [DATE]. LN G was terminated on [DATE].2. The Director of Nursing (DON) or designee completed all staff training on advanced directives and how to identify the code status in the medical record, face sheet, physician orders, or other approved facility documentation, and nursing staff were reminded of the importance of accurate communication during shift report and ensuring code status documentation remained current and easily accessible was completed ([DATE]).3. Facility-wide code status audit was completed ([DATE]).4. A mock drill was completed to verify facility staff responded appropriately to an unresponsive resident ([DATE]).5. The concerns and corrective actions would be reviewed through the facility's Quality Assurance Performance Improvement (QAPI) program. Trends, audit results, and compliance would be monitored, and additional interventions would be implemented as needed to ensure sustained compliance. Due to the correction actions completed prior to the onsite survey, the deficient practice was deemed past non-compliance at a scope and severity of J (isolated with actual harm).

The facility had a census of 36 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 3, FY 2024 Quarter 1, and FY 2024 Quarter 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (20) dates. A review of the facility licensed nurse timeclock data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 08/07/24 at 01:26 PM, an observation revealed a licensed nurse on duty in the facility. On 08/07/24 at 01:10 PM Administrative Staff B stated they verify hours through their clock-in system and then upload the hours to the PBJ, and corporate then sends the final report. Administrative Staff B stated they had to enter agency staffing hours manually based on the invoice information. Administrative Staff B stated if there were any discrepancies then it would likely be due to agency staffing hours as they were manually entered. The facility did not provide a policy related to PBJ reporting upon request. The facility failed to submit complete and accurate staffing information through PBJ as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

The facility identified a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff crushed and mixed Resident (R) 37's medications without a physician's order to administer via a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This resulted in a medication error rate of 23.08%. Findings included: - On 08/06/24 at 09:43 Licensed Nurse (LN) H prepared R37's medications for administration via G-tube. LN H had R37's Medication Administration Record (MAR) pulled up on her laptop for R37. LN H crushed six medications including citalopram hydrobromide (a medication used to treat depression), prednisone (a steroid medication used to decrease inflammation), a probiotic (a supplement used for digestive disorders), vitamin D3, senna (medications used to treat constipation), and sotalol (a beta-blocker sued to treat hypertension) and emptied the crushed medications into a medication cup and added water. LN H went to R37's bathroom and returned with two 60-milliliter (ml) syringes filled with the medications. LN H stopped R37's enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) that infused via a Kangaroo pump (an enteral feeding pump used to deliver continuous or intermittent feeding). LN H disconnected the enteral tubing port from R37's G-tube hub and placed the tubing end on a barrier towel. LN H then opened an alcohol wipe and cleaned the G-tube hub and the tip of each 60 ml syringe with the medications in them. LN H connected one of the 60 ml syringes to the G-tube hub and administered the medications into the G-tube. LN H repeated with the second syringe with medication. LN H disconnected the syringe from R37's G-tube, wiped the end of the enteral feeding tubing with an alcohol wipe, reconnected the tubing to the G-tube, and restarted the enteral feeding. LN H did not flush the G-tube before the administration of the medications as well as after administration. A review of R37's physician's orders revealed that R37 lacked a physician's order to crush and mix medications for administration. R37's MAR documented an order dated 05/24/24 to crush medications as appropriate. On 08/07/24 at 10:36 AM LN G stated that it was the policy of the company that enteral medications could be mixed when administered unless contraindicated. LN G stated that R37's MAR should have the order to mix the medications when being administered via G-tube as well as the amount of water to flush the G-tube with before and after the medication administration. On 08/07/24 at 01:37 PM Administrative Nurse D stated that each resident who received medications via G-tube should have a physician's order to indicate that medications could be administered mixed as well as the amount of water to flush the tube with before and after mediation administration. The facility failed to provide a policy for Medication Administration or Medication Errors. The facility failed to ensure the medication error rate did not exceed five percent when staff failed to ensure R37 had a physician's order to administer medications mixed via a G-tube. This resulted in a medication error rate of 23.08%.

The facility identified a census of 36 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. These deficient practices placed the residents at risk for infectious diseases. Findings Included: -An initial walkthrough of the facility was completed on 08/05/24 at 07:10 AM. An inspection of Resident (R)35's room revealed an over-the-door storage bin for personal protective equipment (PPE). The bin contained gloves, gowns, masks, and foot covers. An inspection of R35's room revealed no signage or indicator of precautions she was on. R35 had a tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) and a percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach). An inspection of R17's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R17 had a tracheostomy, PEG-tube, and Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). An inspection of R2's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R2 had a PEG-tube. An inspection of R12's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R12 had a Foley catheter. An inspection of R22's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R22 had a Foley catheter. An inspection of R24's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R24 had a Foley catheter. An inspection of R37's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R37 had a tracheostomy, PEG-tube, and Foley catheter. An inspection of R27's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R27 had a fistula (abnormal passage from an internal organ to the body surface or between two internal organs) for her dialysis (a procedure where impurities or wastes were removed from the blood). An inspection of R18's room revealed an over-the-door storage bin for PPE but lacked signage or precaution indicators. R18 had a fistula for his dialysis treatment. On 08/07/24 at 10:15 AM Licensed Nurse (LN) G stated the EBP rooms did not contain signage or indicators related to what precautions were needed. She stated the nursing team passed down which residents were on EBP and what PPE was required. She stated the electronic medical records (EMR) indicated if a resident was on EBP. She stated agency, visitors, and outside vendors could ask the nurse what PPE was required upon arrival. On 08/07/24 at 01:31 PM Administrative Nurse D stated the EMR had a stop sign logo on the resident's online chart to signify they were on EBP precautions. She stated no signage or indicators were posted in or outside the rooms. She stated visitors would need to ask staff before entering the rooms. She stated the proper PPE was supplied outside the rooms and signage would be posted if the resident was on contact precautions. The facility's Enhanced Barrier Precautions (EBP) policy revised 03/2024 indicated the facility will identify and assess individuals at risk for infections related to open wounds or bacterial colonization. The policy stated the facility would provide the appropriate PPE including gowns and gloves to use during high-contact care. The policy noted the facility will utilize High Contact Care signage for residents on EBP. The facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 36 residents. The sample included 13 residents with 13 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)6's Care Plan to reflect his bowel incontinence needs. The facility additionally failed to revise R22's plan to include preventative offloading of his heels and ankles. This deficient practice placed both residents at risk for complications related to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R6's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid)), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). A review of R6's Quarterly Minimum Data Set (MDS) completed 05/09/24 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDs indicated he had functional impairments to both lower extremities and used a wheelchair. The MDS indicated he was dependent on staff for bathing, toileting, and transfer. The MDS indicated he had frequent incontinence of bowel and bladder. The MDS indicated he was not on a toileting program. R6's Urinary Incontinence Care Area Assessment (CAA) completed 09/14/23 indicated he was frequently incontinent and required assistance with toileting. The CAA noted he was at risk for skin breakdown and urinary tract infections related to his incontinence. The CAA noted a care plan was developed to provide goals and to minimize the risks associated with incontinence. R6's Functional Abilities CAA completed 09/14/23 indicated he required assistance with his activities of daily living (ADLs) related to his physical and cognitive impairments. The CAA noted a care plan was developed to provide goals and to minimize the risks associated with an ADL decline. R6's Care Plan initiated 08/30/22 indicated he was at risk for functional limitations and an ADL deficit related to his medical diagnoses. The plan noted he required extensive assistance from one staff for bathing, bed mobility, dressing, transfers, and toileting. The plan noted R6 had stress incontinence of his bladder and instructed staff to encourage fluids to promote voiding and monitor for signs of infections. The plan lacked documentation related to his assessed bowel incontinence and his need for disposable incontinence products. R6's EMR revealed a Nursing: Bowel Incontinence evaluation completed on 05/09/24. The evaluation indicated he had impaired cognitive function and mobility. The evaluation noted he had bowel incontinence, and his care plan would be updated. R6's EMR revealed a Nursing: Bladder Incontinence evaluation completed 02/21/23. The evaluation indicated he had urgency bladder incontinence. The evaluation indicated he was required to wear adult incontinence briefs at all times. On 08/05/24 at 10:55 AM R6 sat on his bed in his room. A portable urinal was placed next to his bedside table. R6 reported he needed assistance with toileting and wore incontinent briefs. On 08/06/24 at 10:32 AM Certified Nurse Aide (CNA) M stated the care plan should include detailed interventions related to R6's incontinence needs. She stated he required an incontinence brief to be worn at all times. She stated staff were required to provide frequent checks for incontinent residents. On 08/07/24 at 10:15 AM Licensed Nurse (LN) G stated the care plan should include the daily care needs for each resident. She stated the plans were updated quarterly by the interdisciplinary team. She stated all staff had access to view the care plan information. On 08/07/24 at 01:31 PM Administrative Nurse D stated the care plans should include what products and services are required for daily ADLs. She stated the bowel and bladder assessment results should be used to provide interventions to the residents. She stated the evaluations should be used for the care plans. The facility's Care plan policy revised 08/2022 stated each resident will have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated the care plans will be reviewed and updated to reflect changes that may occur with the resident's goals and care needs. The facility failed to revise R6's Care Plan to reflect his bowel incontinence needs. This deficient practice placed R6 at risk for incontinence complications and uncommunicated care needs. 47834 - The Diagnoses tab of R22's Electronic Medical Record (EMR) revealed diagnoses for muscle weakness, a need for assistance with personal care, lack of coordination, abnormal posture, transient cerebral ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), and venous insufficiency (poor circulation). The Annual Minimum Data Set (MDS) dated [DATE], documented R22 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R22 had functional limitation in range of motion (ROM) to both upper and lower extremities with impairment to both sides. The MDS documented R22 was dependent on staff for bathing, toileting, and mobility. The MDS documented R22 had no unhealed pressure ulcers at stage one (pressure wound which appears reddened, does not blanche, and may be painful but is not open) or higher. The Quarterly MDS dated [DATE], documented R22 had a BIMS score of 14 which indicated intact cognition. The MDS documented R22 was dependent on staff for his Activities of Daily Living (ADL) and mobility. The MDS further documented R22 was at risk for pressure ulcers and had one or more unhealed pressure ulcers at stage one or higher. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 12/22/23, documented R22 was dependent on two or more staff for bed mobility and was at risk for pressure ulcers or other skin integrity issues. The CAA further documented R22 had a low air loss mattress (a mattress used to help prevent skin breakdown by distributing the patient's body weight over a broad surface area). R22'sCare Plan with an initiated date of 01/20/22, documented R22 was at risk for skin breakdown due to impaired mobility and a history of skin breakdown with the right knee documented under the focus section. R22's Care Plan with an initiated date of 10/21/21, documented R22 had chronic pain due to physical disability, emotional distress, a history of hip fracture, back pain, and contractures (abnormal permanent fixation of a joint or muscle). R22's Care Plan lacked evidence of any pressure-reducing measures for R22's bilateral lower extremities to prevent pressure ulcers. A Nursing: Weekly Skin Condition Report dated 06/18/24, documented R22 had a pressure wound to his right knee with a first observed date of 06/16/24. A Nursing Weekly Skin Evaluation dated 07/25/24 documented R22 had redness and non-skin tear open areas to the right knee and right inner ankle. On 08/06/24 at 11:44 AM an observation revealed R22 rested in his room in bed. R22 lay on his back, with the head of the bed elevated. R22's torso leaned to the left side and his hips were rotated to the left with his knees bent. His right leg rested on top of his left leg. He was covered in a blanket and had a pillow between his thighs. On 08/07/24 at 07:56 AM R22 rested in bed. R2's torso leaned to the left, his hips were rotated to the left and his right leg rested on top of his left leg with his knees bent. R22 had one pillow between his thighs and one between his lower extremities. On 08/07/24 at 11:43 AM Consultant HH stated R22 was receiving therapy services weekly for ROM. Consultant HH stated therapy was working with R22 to help improve his positioning. Consultant HH stated they had begun using a brace on R22 to help straighten his legs as R22's contractures (abnormal fixation of a muscle or joint) limited his movement; however, he further stated due to R22's knee wound they had to stop using the braces until his wound healed. Consultant HH stated they attempted to use a wedge to help offload some of the pressure on R22's knees and ankle; however, R22 was resistive to their interventions at times. Consultant HH stated R22 was agreeable to using a pillow between his thighs and lower legs to reduce pressure. On 08/07/24 at 12:17 AM Consultant GG stated their department had worked with R22 to help improve his positioning and ROM for two years now. Consultant GG stated they had attempted offloading measures, such as wedges or pillows before R22's wounds formed; however, R22 would decline placement of the devices at times, and they would have to reintroduce them or try new interventions as R22 would allow. Consultant GG stated after R22's knee wound was discovered, they attempted to reintroduce pressure-reducing measures for his bilateral extremities, and R22 was agreeable to using pillows between his legs. On 08/07/24 at 01:26 PM, Licensed Nurse (LN) G stated the plans were updated quarterly by the interdisciplinary team. She stated all staff had access to view the care plan information. LN G stated R22's Care Plan should have had information related to his refusals of care and interventions. LN G further stated staff had tried many things for R22's pressure-related issues in a short amount of time and wasn't sure if all the interventions had been entered into his care plan; however, LN G stated pressure-reducing measures should have been on R22's Care Plan. On 08/07/24 at 01:31 PM Administrative Nurse D stated R22's Care Plan should have the information required for staff to provide care for him. Administrative Nurse D stated the pressure-reducing measures used by staff for R22, along with his refusals, should have been updated on his care plan. The facility's Care plan policy revised 08/2022 stated each resident will have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated the care plans will be reviewed and updated to reflect changes that may occur with the resident's goals and care needs. The facility failed to revise the care plan with an intervention for pressure-reducing measures for R22's bilateral lower extremities to prevent the development of further pressure ulcers. This deficient practice placed R22 at risk for increased risk for pressure ulcer development due to uncommunicated care needs.

The facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R)43 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R43. Findings included: - R43 admitted to the facility on [DATE] and discharged to hospital on 05/20/24. The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure, heart failure, muscle weakness, and type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R43's Discharge Minimum Data Set (MDS) completed 05/20/24 noted a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. R43's EMR indicated a comprehensive MDS assessment was not completed due to his recent admission. No Care Area Assessment (CAA) was completed at the time of his discharge. R43's EMR under Progress Note indicated he experienced right lower quarter abdominal pain during a therapy session and was sent out to an acute medical facility for treatment. R43's EMR lacked documentation showing a bed hold was provided to R43 or his representative. On 08/07/24 at 08:45 AM Social Service Staff X stated a written notification of transfer or bed hold was not issued to R43 or his representative because the facility believed he was coming back. She stated the facility would hold the bed for residents transferring out to the hospital. On 08/07/24 at 09:20 AM Administrative Nurse D stated the facility called family members for hospital transfers. She stated the facility believed R43 was returning and didn't need to provide the form. The facility did not provide a policy related to written notification and bed hold for discharges and transfers as requested on 08/07/24. The facility failed to provide a bed hold policy notice to R43 or his representative when he transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R43.

The facility identified a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37's comprehensive care plan addressed his functional abilities and how much assistance was needed from staff. The facility failed to ensure R37's comprehensive care plan included a care area and interventions for Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) care. This placed R37 at risk of impaired care due to uncommunicated care needs. Findings included: - R37's Electronic Medical Record (EMR) documented diagnoses of respiratory failure, urinary tract infection (UTI-an infection in any part of the urinary system), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R37's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. R37 required partial to moderate assistance with tub and shower transfers and substantial to maximal assistance with his functional abilities. R37 had an indwelling catheter. R37's Functional Abilities Care Area Assessment (CAA) dated 06/29/24 documented R37 was a new admission and required assistance with activities of daily living (ADLs) and had a BIMS of 12. R37 was at risk for self-care deficits. R37's Urinary Catheter CAA dated 06/29/24 documented R37 required assistance with toileting hygiene and had an indwelling catheter. R37 was at risk for UTI. R37's Care Plan revised on 07/17/24 directed staff he had a tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) and staff was to ensure the ties were secured at all times. Staff was directed to reassure the resident to decrease his anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R37's Care Plan revised on 06/26/24 lacked a care area and interventions to direct staff on the amount of assistance R37 required with his ADLs. R37's Care Plan revised on 06/26/24 lacked a care area and interventions to address R37's Foley catheter. On 08/06/24 at 08:40 AM R37 laid on his back in his bed. R37's head of the bed was elevated at about 45 degrees, his enteral feeding (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) was infusing, and the tracheostomy tube was intact and secured. R37's catheter was below the bladder level and secured to the bed rail in a dignity bag. On 08/07/24 at 01:26 PM, Licensed Nurse (LN) G stated that care plans were a group effort, but she completed the comprehensive care plans. LN G stated R37 had gone to the hospital shortly after his admission so his care plan had not been completely updated. LN G stated R37's Care Plan had been overlooked and she had not realized that his care plan lacked staff direction for his ADLs and catheter care. On 08/07/24 at 01:37 PM Administrative Nurse D stated R37 had gone out to the hospital before the completion of his comprehensive assessment and had not noticed that his care plan had not been updated with interventions for his ADLs and catheter. The Comprehensive Care Plans policy last revised in August 2022 documented: The comprehensive care plan was based on a thorough assessment that included, but was not limited to, the MDS and physician's orders. Assessments of residents were ongoing and care plans were revised as information about the resident and resident's condition changed. The care plan should describe the resident's nursing, medical, physical, mental, and psychosocial preferences. The care plan should include person-specific, measurable objectives and time frames with a goal to measure progress towards meeting such. The facility failed to ensure R37's comprehensive care plan addressed his functional abilities and how much assistance was needed from staff for ADL care and his Foley catheter. This placed R37 at risk of impaired care due to uncommunicated care needs.

The facility reported a census of 36 residents. The sample included 13 residents with two 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 observations, interviews, and record review, the facility failed to ensure Resident (R)17's low air-loss mattress pump was appropriately set to his recommended weight range. This deficient practice placed R17 at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), 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), neuromuscular bladder dysfunction (dysfunction of the urinary bladder caused by a lesion of the nervous system), dysphagia (difficulty swallowing), muscle weakness, and paralytic ileus (function paralysis of the nerve around the digestive tract). R17's Quarterly Minimum Data Set (MDS) completed 05/04/24 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated he was dependent on staff assistance for bed mobility, toileting, transfers, bathing, and dressing. The MDS indicated he had impairments to both sides of his upper and lower extremities. The MDS indicated he was at risk for pressure ulcers. The MDS indicated he had no active pressure injuries. The MDS noted he had pressure-reducing devices for his bed and wheelchair, a repositioning program, and non-surgical dressings in place. The MDS indicated he received enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). The MDS indicated he weighed 155 pounds (lbs.). R17's Pressure Ulcer Care Area Assessment (CAA) completed 02/04/24 revealed he was at risk related to his incontinence and need for assistance with bed mobility. The CAA indicated he needed a special mattress or seat cushion to reduce or relieve pressure. R17's Care Plan initiated 04/12/19 indicated he was at risk for skin breakdown and pressure ulcers related to his medical diagnoses and limited mobility. The plan indicated he was dependent on staff assistance for bed mobility, transfers, toileting, personal hygiene, dressing, and bathing. The plan instructed staff to reposition and monitor for skin breakdown. The plan instructed staff to provide preventative skin treatment and peri-care. The plan lacked indication related to the low air-loss mattress weight setting and monitoring requirements. R17's EMR under Physician's Order revealed an order for a pressure reduction (low air-loss) mattress. The order indicated his bed weight was 430 pounds (lbs.) A review of the low air-loss mattress's manufacturer operation manual (New Source Medical's Air Force One Model) indicated the alternating air mattress system was designed for patients who were at risk or had pressure ulcers. The manual indicated the bed's weight capacity weight was from 80 to 1000lbs. The manual indicated the mattress's internal pressure should be adjusted according to the patient's weight. The manual indicated the bed's weight setting could be adjusted for comfort one increment at a time until comfort is achieved. On 08/05/24 at 08:15 AM R17 slept in his bed. His bed was in the medium position. The head of his bed was elevated above 30 degrees. R17 had a low air-loss mattress system (Air Force 1000 model). The mattress control panel's weight was set to 300 lbs. On 08/07/24 at 10:12 AM R17 slept in his bed. His low air-loss mattress was set to 180 lbs. On 08/07/24 at 10:15 AM Licensed Nurse (LN) G stated the low air-loss mattress bed was set based on the weight of the residents. She stated some of the residents had preset weight orders recommended by the manufacturer and should have been set based on the order. She stated staff were expected to check the low air-loss mattresses each shift for functionality and safety. On 08/07/24 at 01:43 PM Administrative Nurse D stated an outside company came in to install the low air-loss mattresses and set the weight settings. She stated staff don't not adjust the weight setting of the bed. She stated the mattress weight setting should be set by weight but was not sure why R17's air mattress was recommended for 430 lbs. The facility's Prevention of Pressure Injuries policy revised 08/2022 indicated the facility will assess and identify residents at risk for developing pressure-related injuries. The policy indicated the facility will implement interventions to prevent injuries as well as promote healing for existing injuries. The policies noted the facility will utilize preventative skin treatments, techniques, and pressure-reducing equipment to ensure appropriate healing and prevention. The policy indicated the facility will implement pressure redistributing devices, wedges, and repositioning. The facility failed to ensure R17's low air-loss mattress pump was appropriately set to his weight range. This deficient practice placed R17 at risk for complications related to skin breakdown and pressure ulcers.

The facility identified a census of 36 residents. The sample included 13 residents with one resident reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to provide written notification of transfer to Resident (R)43 and/or their representative, with a written notice specifying the location and reason for R43's facility-initiated transfer. This deficient practice placed R43 at risk for miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services. Findings included: - R43 admitted to the facility on [DATE] and discharged to hospital on 05/20/24. The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of acute kidney failure, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure, heart failure, muscle weakness, and type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R43's Discharge Minimum Data Set (MDS) completed 05/20/24 noted a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. R43's EMR indicated a comprehensive MDS assessment was not completed due to his recent admission. No Care Area Assessment (CAA) was completed at the time of his discharge. R43's EMR under Progress Note indicated he experienced right lower quarter abdominal pain during a therapy session and was sent out to an acute medical facility for treatment. The EMR lacked documentation showing written notification of transfer was provided to R43 or his representative. On 08/07/24 at 08:45 AM Social Service, Staff X stated a written notification of transfer was not issued to R43 or his representative because the facility believed he was coming back. She stated the facility would usually just call the family to inform them of the transfer rather than provide written notification. On 08/07/24 at 09:20 AM Administrative Nurse D stated the facility called family members for transfer notification and did not provide a written form or documentation. The facility did not provide a policy related to written notification and bed hold for discharges and transfers as requested on 08/07/24. The facility failed to provide a written notification of transfer for R43. This deficient practice placed R43 at risk for miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services.

The facility identified a census of 39 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to ensure an adequate number of staff to provide assistance during a mechanical lift transfer to prevent accidents for Resident (R)1. As a result, R1 sustained a mid to lower coccyx (area at the base of the spine) fracture. This deficient practice also placed R1 at risk for increased pain and further impaired mobility. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of restless legs syndrome, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) with dyskinesia (inability to execute voluntary movements), lack of coordination, reduced mobility, muscle weakness, and chronic pain syndrome. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required substantial to maximum assistance from staff with sit-to-stand activity and chair/bed to chair transfers. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 08/24/23 documented R1 had an unsteady gait and needed assistance with ADLs. R1 worked with therapy services. The Falls CAA dated 08/24/23 documented R1 had an unsteady gait and required staff assistance with transfers. R1 was at increased risk for falls. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. R1 required substantial to maximum assistance from staff with sit-to-stand activity and chair/bed to chair transfers. R1's Care Plan initiated on 09/17/23 and revised on 10/19/23 documented R1 utilized a sit-to-stand mechanical lift to get from the chair to the commode and/or commode to chair and required a Hoyer (full body mechanical lift) lift for getting in and out of bed. R1's Care Plan lacked direction regarding the number of staff to assist with R1's sit-to-stand or Hoyer transfers. R1's Nursing: Lift and Transfer Evaluation dated 09/08/23 documented R1 followed instructions, transferred with the assistance of one or two staff, and was not weight bearing. The evaluation further documented R1 used the sit-to-stand lift with one person's assistance with a medium sling. R1's Physical Therapy: PT Discharge Summary dated 11/15/23 documented R1 was able to transfer with the maximum assistance of two staff members with the sit-to-stand lift. The skilled interventions documented that R1 participated in techniques to improve safety with the sit-to-stand including transfer training and strengthening. The summary documented that facility staff received training. The Nursing Change of Condition Note dated 12/24/23 at 08:20 PM documented at 07:45 PM Certified Nurse's Aide (CNA) M called out for assistance to R1's room. R1 sat on her buttocks and reported that CNA M went fast with the transfer. The note documented R1 reported her legs weakened and gave out, and her hands could not hold her up any longer resulting in a fall. R1 complained of pain in her back and her upper posterior (backside) thigh. R1 requested to be checked out at the emergency room . R1's Physical Therapy: PT Evaluation dated 12/27/23 documented R1 was referred for therapy services related to a recent fall from the sit-to-stand lift resulting in a coccyx fracture. R1's Physicians Progress Notes dated 12/28/23 documented R1 was seen for a mild nondisplaced fracture of the mid to lower coccyx. The Facility Investigation dated 01/02/24 documented R1 requested to transfer into her bed and was assisted by CNA M. CNA M utilized the sit-to-stand lift for the transfer. During the transfer, R1 fell to the ground. R1 reported she informed CNA M that she was falling, but CNA M failed to slow down. CNA M's undated Witness Statement documented in December 2023, CNA M used the sit-to-stand lift for R1 while she tried to put R1 into bed. CNA M further documented that due to frustration and being overwhelmed, R1 started to slide out of the sling. CNA M stated she went behind R1 and guided R1 to the floor, and called for Licensed Nurse (LN) G. LN G's undated Witness Statement documented on 12/24/23 LN G went to R1's room and noted R1 on the floor. R1 reported to LN G that CNA M went too fast with the transfer and R1's legs failed to support her and R1 could not hold herself up. The statement recorded R1 informed LN G that she fell . On 01/10/24 at 01:43 PM, R1 sat in her wheelchair. R1 had one leg rest on the left side of her wheelchair. R1 had hand tremors while she spoke. R1 stated when she was being transferred with the sit-to-stand lift, she started to slip. R1 said she told CNA M she was slipping but CNA M she said she was not slipping. R1 stated the next thing she knew; she fell on the floor. R1 stated CNA M said she tried to catch R1, but R1 said she fell too fast and there was no way CNA M could get around behind R1. On 01/10/24 at 12:10 PM Administrative Nurse D stated when this event occurred, she looked for the manual for the sit-to-stand lift and was unable to locate it. Administrative Nurse D further stated she located a manual online, printed it off, and noted that it strongly recommended two staff members with the sit-to-stand lift. Administrative Nurse D revealed on the Nursing: Lift and Transfer Evaluation the only choice for the number of staff needed for the sit-to-stand lift indicated one staff member and it was not until the manual was found online that she learned it was strongly recommended for two staff members. Administrative Nurse D stated she had been educating staff to use two staff members with the sit-to-stand lift since the event. On 01/10/24 at 02:16 PM, Consultant GG stated the sit-to-stand lift was to have two staff members present to do the transfer. Consultant GG stated R1 used a sit-to-stand lift and when someone came off of therapy, staff received training regarding the therapy recommendations. Consultant GG revealed that staff would have received training instructing them two staff members should use the sit-to-stand lift for R1. On 01/10/23 at 02:23 PM Certified Medication Aide (CMA) R stated to use the sit-to-stand lift it required two staff members. CMA R revealed she always used two staff members. On 01/10/23 at 02:29 PM, LN H stated all mechanical lifts required two staff members to transfer residents. The LF2020 Easy Lift Sit to Stand Manual dated 2014 documented under warnings that two caregivers were strongly recommended to take part in the lifting process. The facility's Safe Lifting and Movement of Residents policy revised on 10/09 documented staff responsible for direct resident care would be trained in the use of manual and mechanical lifting devices. The facility failed to implement safe transferring with a mechanical sit-to-stand lift for R1, which resulted in a fall. R1 sustained a mid to lower coccyx fracture. This deficient practice also placed R1 at risk for increased pain and further impaired mobility.

The facility had a census of 40 residents. The sample included 12 residents with one reviewed for dignity. Based on observation, interviews, and record review, the facility failed to treat Resident (R) 31 with respect and dignity and care for him in a manner that promoted quality of life. This placed the resident at risk for impaired dignity. Findings included: - R31's Electronic Medical Record (EMR) revealed a diagnosis of chronic kidney disease (inability to filter waste from the body), and urinary retention (difficulty urinating and completely emptying the bladder). R31's quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition. The MDS recorded the resident required an indwelling urinary catheter (a tube inserted into the bladder to drain urine). The Urinary Catheter care plan dated 09/28/22, directed the staff to position the urinary catheter bag and tubing below the level of the bladder and away from the door entrance. On 11/17/22 at 09:20AM, observation revealed R31 laid in bed on his back. Further observation revealed a urinary catheter bag hanging on the side of the bed uncovered with urine visible from hall/doorway. On 11/21/22 at 09:45AM, observation revealed R31 laid in bed on his back. Further observation revealed an uncovered urinary catheter bag with urine in it hanging on the side of the bed visible from the doorway. On 11/21/22 at 10:15AM, Administrative Nurse D verified the uncovered urinary catheter bag. Administrative Nurse D stated the urinary catheter bag should be stored in a covered bag. The facility's Resident Rights policy, dated May 2022, stated the facility staff are to provide care for each resident to promote and maintain resident dignity and respect. The facility failed to provide dignity for R31, placing the resident at risk for impaired dignity.

The facility had a census of 40 residents. The sample included 12 residents with two reviewed for pressure ulcers (localized injury to skin and/or underlying tissue as a result of pressure, or pressure in combination with shear and/or friction). Based on record review and interview, the facility failed to complete a significant change assessment after the development of an unstageable pressure ulcer for one of two sampled residents, Resident (R) 40. This placed the resident at risk to have an inaccurate assessment of his health status. Findings included: - The Physician Order Sheet, dated 11/02/22, recorded R40 had diagnoses of cerebrovascular accident (CVA) (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), diabetes mellitus (when the body cannot use glucose, not enough insulin made, or body cannot respond to insulin) and hemiplegia (paralysis of one side of the body) The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R40 had a Brief Interview for Mental Status (BIMS) score of zero (severely impaired cognition) with physical behaviors and rejection of cares. The MDS recorded R40 required total staff assistance with bed mobility, transfers, had an unstageable pressure ulcer (wound bed obscured slough [dead tissue usually cream or yellow in color] or eschar (dead tissue) and Moisture Associated Skin Damage (MASD). The Pressure Ulcer Care Plan, dated 11/08/22, recorded R40 at risk for skin issues due to limited mobility, diabetic disease process, non-compliance with cares and a history of skin breakdown. The Pressure Ulcer Care Plan directed staff to provide R40 treatments and preventive interventions for wounds as ordered by the physician and to monitor for wound changes weekly. The Physician Progress Note, dated 10/26/22, recorded R40 had an unstageable pressure ulcer on the right buttocks. The Physician Progress Note, recorded the wound clinic continued to provide cares and treatment. The Wound Care Center Progress Note, dated 10/31/22, recorded R40 had right buttock unstageable pressure ulcer with odorous serosanguinous drainage (semi-thick reddish drainage). On 11/22/22 at 10:17 AM, Administrative Nurse D stated staff should have completed a significant change assessment for R40, who developed an unstageable pressure ulcer. The Comprehensive Assessment Policy, dated August 2022, recorded a significant change was defined as a condition that will not resolve itself without physician and staff intervention, and requires interdisciplinary review and care plan revisions. The Comprehensive Assessment Policy directed staff to complete a significant change MDS assessment within 14 days of a significant change in the resident's condition. The facility failed to complete a significant change assessment after R40 developed of an unstageable pressure ulcer, placing the resident at risk to have an inaccurate assessment of his health status

The facility had a census of 40 residents. The sample included 12 residents with two reviewed for diabetic ulcers (open wound caused by neuropathy (weakness, numbness, and pain from nerve damage) and/or poor blood circulation). Based on record review and interview, the facility failed to provide heel protectors (medical device used to offload pressure from the heel and foot to wounds and pressure ulcers) as ordered by the wound clinic for one of two sampled residents, Resident (R) 40. This placed the resident at risk to worsen his current diabetic ulcer or develop more skin issues. Findings included: - The Physician Order Sheet, dated 11/02/22, recorded R40 had diagnoses of cerebrovascular accident (CVA - (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), diabetes mellitus (when the body cannot use glucose, not enough insulin made, or body cannot respond to insulin) and hemiplegia (paralysis of one side of the body) The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R40 had a Brief Interview for Mental Status (BIMS) score of zero (severely impaired cognition) with physical behaviors and rejection of cares. The MDS recorded R40 required total staff assistance with bed mobility, transfers, had an unstageable pressure ulcer (wound bed obscured slough (dead tissue usually cream or yellow in color) or eschar (dead tissue) and Moisture Associated Skin Damage (MASD). The Pressure Ulcer Care Plan, dated 11/08/22, recorded R40 at risk for skin issues due to limited mobility, diabetic disease process, non-compliance with cares and a history of skin breakdown. The Pressure Ulcer Care Plan directed staff to provide R40 treatments and preventive interventions for wounds as ordered by the physician. The Pressure Ulcer Care Plan lacked documentation staff provided R40 heel protectors at all times as recommended by the wound clinic. The Physician Order, dated 10/31/22, directed staff to apply Betadine (topical medication that provide infection protection) and a foam dressing to R40's left heal every Monday, Wednesday, and Friday. The Wound Care Center Progress Note, dated 11/14/22, recorded R40's left posterior heel diabetic ulcer was debrided and directed staff to ensure R40 had heel protectors on all times. The Physician Progress Note, dated 11/16/22, directed staff to send R40 to the hospital for a coccyx wound infection related to possible osteomyelitis (local or generalized infection of the bone or bone marrow). Review of R40's medical record lacked documentation of R40's wound clinic ordered heel protectors on 11/22/22 (8 days after the wound clinic order). On 11/22/22 at 10:17 AM, Administrative Nurse D stated staff should have documented and followed the wound clinic recommendation for R40 to wear heel protectors at all times. The Skin/Wound Care policy, dated 07/14/22, directed staff to implement preventative measures to help protect and heal existing wounds, and this included heel protectors/pressure relief boots. The facility failed to provide heel protectors as ordered by the wound clinic for R40, placing the resident at risk to worsen his current diabetic ulcer or develop more skin issues.

The facility reported a census of 43 residents. the sample included 17 residents. Based on observation record review, and interview the facility failed to provide adequate supervision to prevent falls with injury for resident #1 and failed to adequately assess for side rail use for resident #26 of 3 residents reviewed for falls/accidents. Findings included: - Resident #1's 5 day Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15 which indicated the residents cognition was intact. The MDS recorded the resident required limited assistance with most activities of daily living (ADLs), was occasional incontinent, had a history of [REDACTED]. The 2/12/14 fall Care Area Assessment (CAA ) recorded the resident had 1 non injury fall and 2 minor injury falls since the previous assessment. The resident had a history of [REDACTED]. The resident was previously on one-on- one, had a bed alarm but turned it off and continued to ambulate on his/her own. The 2/2714 quarterly fall risk assessment recorded a value of 16 which placed the resident at risk for falls (a score of 10 or greater indicated at risk status). Review of the clinical record and fall investigation reports revealed the resident experienced falls on 12/17/2012, 1/3/2013, 1/17/2013, 3/12/13, 3/25/13, 4/3/13,4/18/13, 5/24/13, 6/15/13, 8/22/13, 8/26/13, 9/1/13, 9/2/13, 9/7/13, 11/18/13, 12/03/13,1/1/2014, 1/9/2014, 1/28/14, 2/22/14, and 2/27/14. The resident experienced 21 falls since 12/17/12. Review of the electronic nurses progress notes revealed: - On 4/3/13 at 3:36 P.M. the resident at 7:30 A.M. wanted to brush teeth and comb his/her hair without help. At 7:45 A.M. another direct care staff member informed staff the resident was found on the floor. The nurses note stated the resident wanted to change his/her shoes and fell forward in the wheelchair, and denied hitting his/her head, staff re-educated the resdient on call light use. -On 4/18/13 at 3:10 P.M. the resident was up in his/her room and walked in front of his/her roommate and fell on the floor on his/her bottom. Staff notified the physician who orded staff to allow the resident to walk with his/her walker and 1 person assistance. - On 4/18/13 at 12:13 P.M. therapy addressed resident refusals, the resident stated he/she did not feel therapy was helping. - On 5/24/13 at 2:55 P.M. resident had a non-injury fall. - On 6/15/13 at 9:55 P.M. residents roommate reported the resident was on the floor. Resident #1 found sitting on the floor between the bed and the wheelchair, wheelchair was locked and the call light was in place. The resident was unsure if he/she hit his/her head, staff re-educated to use the call light. -On 8/22/13 at 6:27 P.M. the resident had an unwitnessed fall in his/her room, staff re-educated to call light use. -On 8/26/13 witnessed resident fall in dining room near where the resident was seated, he/she attempted to stand, fell to his/her bottom then to elbows, a call was placed to the phsyician and family, no injuries noted, no new orders. -On 9/2/14 at 2:40 P.M. the resident was found on the floor on his/her back, blood surrounded the resdient's head, abrasion to his/her nose, "and an abrasion that possibly came from his/her tooth hitting his/her lip," the resdient stated he she was on the way to the bathroom, staff assisted the resident to the bathroom, and back to his/her bed. The physician was notified and no new orders at this time. -The next nurses progress notation dated 9/4/13 at 12:08 A.M. indicated Facial x rays were positive for nasal and right maxillary bone fractures, the physician was notified ordered the resident sent to the hospital. -On 9/7/13 at 4:45 P.M. the resident was found on the floor on his/her back with his/her brief half off and feces on the floor. A call was placed to the physician for a bed/wheelchair alarm, the physician noted it was attempted before and the resident does not want. The note indicated the resident declined need for personal alarms and the resident needs to be reminded to use call light, have frequent checks and directed staff to keep the door to his/her room open. -On 11/18/14 at 1:18 staff found the resident on floor with his/her back to the door, the resident stated he/she was getting clothes from his/her closet, the resdient's left shoulder was noted out of alignment and swollen, pain 10 out of 10 and the physician ordered hospital evaluation. -On 11/27/13 at 6:30 the resident returned from hospital left arm in sling. -On 1/1/14 at 8:50 A.M. the residnet fell in the bathroom, staff found the resident seated on the floor with his/her head against wall, the resdient stated he/she was going to get a clean brief from his/her closet, slid on his/her socks and fell to the floor. -On 1/7/14 at 6:45 P.M. the resident was found on the floor on his/her side lying position, with his/her head between the dressers and the wheelchair, wheelchair upright and unlocked, staff assited the resident assisted with a lift and whellchair assessment revealed the anti-lock brake was not working properly, no injury noted, Physician and family notified. -On 2/22/14 at 2:30 P.M. staff heard a noise and noise and found the resdient on the floor seated behind door. The resident had a 6 cm (centimeter) laceration with 0.5 cm gap at middle bleeding on the right forehead. The physician ordered emergency room evaluation and treatment and the resident exited the facility at 3:25 P.M. The E.R. nurses progress noted recorded the residents return to the facility on [DATE] at 12:31 P.M. The facility hard chart psychiatric consult dated 1/29/14, documented the resident attempted to outtalk the interviewer and and recorded likely anxiety due to two much stimulation. He/she was able to be made aware of dangers he/she faces. The residents care plan (revised 2/28/14) directed staff to: allow {resident} to choose his/her clothes, to avoid attempts of the resident getting his/her own clothes, offer him/her assistance with toileting needs, offer toileting upon awakening and before and after meals, bed in low position, call light or personal items in within reach, offered reminders it was unsafe to transfer alone, and to call for assistance, provide non-skid footwear, keep environment clutter free, offer therapy as needed, and assist with ADL care. This same care plan documented some of the the residents fall's, resulted in visits to the emergency room , listed suture removal dates and resident's visit with his/her physician. The E.R. and residents care plan lacked documentation of the psychiatric notes of 1/29/14 and/or any new individualized interventions attempted after each of the resident's falls. On 3/25/14 at 1:02 P.M. observation revealed the resident stood near his/her closet going through his/her clothes, wearing a red sweatshirt. The residnet did not wear any shoes, socks, or pants. On 3/25/14 at 1:02 P.M. direct care staff U stated the resident "tries" this all the time, staff acknowledged the unsafe situation and responded. On 3/26/14 at 3:35 P.M. the resident stated he/she called for (named the direct care giver,) and he/she helped me, and added "he/she had a bad heart and he/she did not want to fall anymore." On 3/27/14 at 3:00 P.M. administrative licensed nurse D acknowledged the resident's falls and stated we have tried a lot of different approaches, but the resident wants to maintain his/her independence. The facility's Post Fall Investigation Summary policy revised 2013 recorded: "The interdisciplinary Care Plan team will complete a review of the Post fall investigation. This will be completed within 72 hours. Recommendations implemented shall be recorded on the report and plan of care revised as necessary. The facility failed to provide adequate supervision to prevent falls and failed to develop interventions after each fall to assist the resident with independent mobility. - Resident # 26 ' s significant change Minimum Data Set (MDS) 3.0 dated 2/6/14 identified the resident scored 5 (severely impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required extensive staff assistance with bed mobility, dressing, toilet use, eating and personal hygiene. The resident was totally dependent upon staff for transfers, the activity of walking did not occur in the room/corridor, required staff supervision with locomotion on the hall, and the resident was unsteady and was able to stabilize without human assistance with surface to surface transfers. The MDS coded the resident had a functional impairment on both sides of his/her lower extremity, utilized a wheelchair, and did not fall since the last assessment. The resident ' s Cognitive Loss Care Area Assessment (CAA) dated 2/20/14 documented the resident had impaired short and long term memory impairment, and a gradual decline regarding his/her cognition. The resident ' s Activity of Daily Living CAA dated 2/20/14 documented the resident required extensive staff assistance with transfers, bed mobility, dressing and personal hygiene. Staff transferred the resident via a mechanical lift and the resident ambulated via his/her wheelchair. The CAA included the resident ' s bilateral lower extremities had functional limitations and the resident had a left below the knee amputation. The resident ' s Fall CAA dated 2/20/14 identified the resident was at risk for falls and did not fall since the previous assessment. The resident ' s Fall Risk assessment dated [DATE] identified the resident scored 12 (a score of 10 to 12 indicated the resident was at high risk for falls). Review of the resident ' s care plan did not support the facility developed a care plan to address ways to minimize the resident ' s fall until 3/12/14. The resident ' s Side Rail Assessment Screen dated 1/14/14 included the resident was not ambulatory, was not able to get into bed unassisted, was not able to turn from side to side unassisted while in bed and did not attempt to get in/out of the bed unassisted. The Side Rail Assessment Screen included the resident activated his/her light to request assistance with transfers, the side rail did not restrict the resident ' s freedom of movement or normal access to his/her body, the resident was not able to get out of bed unassisted, was unable to turn from side to side with the side rails, and was unable to lower the side rail. The resident currently used the side rail for positioning and support, and was not receiving medications that required increase safety precautions. The facility did not measure the gaps between the rails and the gaps between the side rail and the mattress to determine if the side rails were conducive to the resident ' s safety. The resident ' s care plan with a print date of 3/26/14 included the following interventions in place since 3/12/14: the resident was at risk for falls related to the resident fell in the past 30 days, staff assessed the resident for bed, staff maintained the resident ' s bed in a low position, ensured the resident ' s call light or personal items were available and in easy reach of the resident or staff provided the resident with a gripper (device used to reach items), and staff ensured the resident ' s environment was well lit and free of clutter. The resident ' s care plan did not include the resident utilized one-half length (?) side rails on both sides of his/her bed. A nurse ' s note dated 3/11/2014 and timed 7:34 A.M. documented the resident had a non-injury witnessed fall in his/her room. The resident pulled and got himself/herself to the end of bed and fell to the floor. The note included the resident stated he/she thought he/she could get up and walk and fell to floor to his/her bottom. On 3/25/14 at 2:00 P.M. the resident laid in bed. Observation revealed the resident ' s left leg amputated below the knee, half- length side rails in place and raised bilaterally, and the resident ' s bed was in the highest position. On 3/26/14 at 8:30 A.M. the resident laid in bed. Observation revealed raised half-length side rails in place and the resident ' s bed was in a high position. On 3/26/14 at 3:00 P.M. the resident laid in bed. Observation revealed raised half-length side rails in placed bilaterally and the resident ' s bed was in the highest position. On 3/26/14 at 2:50 P.M. direct care staff P stated the resident liked to have his/her bed in the high position and staff maintained the resident ' s bed was in the highest position so the resident could watch television. On 3/26/14 at 3:45 P.M. licensed nurse I stated the resident liked to look outside and raised his/her bed to the highest position so he/she could see outside. On 3/26/14 at 3:50 P.M. the resident ' s family member stated the resident attempted on several occasions to exit the bed from the foot of the bed but he/she was always present on the other occasions and was able to catch the resident before he/she exited the foot of the bed. The resident ' s family member stated he/she was present on the day the resident fell from the foot of the bed but he/she could not reach the resident in time to prevent the fall. The resident ' s family member stated the resident ' s bed was in a high position depending upon whether a tall or short direct care staff assisted the resident. The resident ' s family member stated if a taller staff member assisted the resident, the direct care staff raised the height of the resident ' s bed and after performing care did not lower the height of the resident ' s bed. The resident ' s family member stated he/she was not sure why the resident had the side rails. On 3/27/14 at 1:43 P.M. direct care staff Q stated the resident did not have a history of falls and the resident liked his/her bed in a high position. Direct care staff Q stated the resident held onto the side rail when staff repositioned the resident in bed. Direct care staff Q stated the facility communicated resident ' s needs and care via the care plan book located at the nursing station. On 3/27/14 at 2:37 P.M. administrative nursing staff D stated the resident liked his/her bed in the high position and it was the resident ' s preference as to whether the bed was in a low or high position. Administrative nursing staff D confirmed the resident fell from the foot of the bed on 3/11/14 and the side rails were raised at that time. The facility failed to ensure the resident ' s bed was in a low position and failed to reassess the safety of the side rails after the resident fell from the foot of the bed on 3/11/14. The facility also failed to develop a care plan for this resident at risk for falls prior to the resident ' s fall on 3/11/14.

The facility identified a census of 41 residents and the sample included 20 residents. Based on record review and interview, the facility failed to identify a 9 pound weight loss within 14 days for one of three residents sampled for nutrition. (#54) Findings included: - Resident #54 admitted to the facility on [DATE] and discharged on [DATE]. The August 2011 physician's orders [REDACTED]. The admission Minimum Data Set (MDS) 3.0 dated 8-10-11 recorded the resident with a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS recorded the resident did not have a poor appetite and did not overeat. The MDS recorded the resident required supervision with eating. The MDS recorded no dietary or dental concerns. The MDS recorded the resident at 17 inches tall and 178 pounds. The MDS recorded the resident did not receive a diuretic medication. The nutritional status Care Area Assessment (CAA) dated 8-10-11 recorded the resident was 68 inches tall (a discrepancy from the MDS), weighed about 178 pounds and fed him/herself in the dining room. The CAA continued that the resident had his/her own teeth remaining and denied pain or discomfort in his/her mouth. His/her appetite was good and he/she was able to feed him/herself, the resident received a regular diet and came to the dining room for meals, appeared to enjoy what staff served him/her, and staff would monitor his/her weight weekly for the first 4 weeks, but this was "about normal" for this resident. The 14-day MDS 3.0 dated 8-13-11 recorded the resident with a BIMS score of 14 which indicated the resident with intact cognition. The MDS recorded the resident required supervision with eating. The MDS recorded the resident without swallowing difficulties or dental concerns, with a height of 68 inches (a discrepancy from the previous MDS) and weighed 175 pounds, without weight loss of 5 percent (%) or more in the last month or 10% or more in the last 6 months. The initial plan of care for nutritional risk dated 8-4-11 recorded the resident left 25% or more food uneaten at most meals and included interventions to interview and provide food/beverage preferences, evaluate need of nursing rehabilitation programs, monitor daily dietary intake and interview the resident for special meal and snack requests. The comprehensive Care Plan dated 8-11-11 did not address the resident's nutritional risk or concerns. The weight flow sheet recorded the resident was 68 inches tall. The resident's weekly weights were: 8-4-11 178.2 8-11-11 175.2 8-18-11 169.2 (9 pounds; 5.1 percent weight loss in 14 days) The clinical record lacked documentation of a weekly weight on 8-25-11. Nurse's notes dated 8-3-11 at 10:34 P.M. recorded the resident was a new admit. Nurse's notes dated 8-4-11 at 2:43 A.M. recorded the resident fed him/herself. Nurse's notes dated 8-7-11 at 2:22 P.M. recorded the resident was up for the morning meal, but refused lunch related to having pizza in an activity program prior to lunch. Nurse's notes dated 8-26-11 and timed at 2:07 P.M. recorded at 10:00 A.M., the resident discharged to home with his/her family member. The dietary order dated 8-3-11 and untimed recorded the resident received a cardiac diet. The Nutrition fax consult dated 8-10-11 and untimed recorded the resident received a regular/cardiac diet; 81% average consumption since admission height 68 inches, weight 178.2 pounds and recorded the resident's nutrition needs were met with intake of meals and snacks. The progress note dated 8-10-11 at 12:22 P.M. recorded the staff met with the resident, who had no real dietary issues, weight was 178.2, resident was very pleasant, had company daily, and recorded staff would observe for concerns The Nutritional screening and assessment dated [DATE] and not timed recorded pizza was not his/her favorite, and staff obtained the resident's food preferences, however they were not listed on the form. The clinical record lacked documentation of any further dietician consultations/communication. On 9-12-11 at 9:53 A.M. interview with direct care staff stated the resident was pretty independent, ate in the main dining room independently and took snacks when passed. On 9-12-11 at 10:32 A.M., direct care staff B stated the resident ate in the independent dining room, ate 100% pretty much every time and that restorative did the residents' weights and then dietary checked the weights and adjusted accordingly with mighty shakes, etcetera. On 9-12-11 at 10:54 A.M., licensed nursing staff B stated the restorative aide obtained residents' weights, then the weights went to nursing then dietary, and all evaluated the weights. If necessary, staff took another weight, just to make sure the weight was accurate. Staff would refer to dietary, and/or doctor if necessary if much of a discrepancy. During an interview on 9-12-11 at 12:23 P.M., licensed nursing staff A stated the resident ate in the independent dining room and that restorative weighed residents upon admission and every week for 4 weeks then monthly unless there was a problem. Staff reviewed weights in the morning stand up meeting when social services, dietary, director of nursing and MDS staff were present. If there was a weight loss, the dietician came in and did an evaluation, recommended drinks and monitored closely what the resident ate. Licensed nursing staff A stated the resident's 9 pound weight loss in 14 days would certainly be a concern and that he/she would expect staff to refer the resident to the dietician. During an interview on 9-12-11 at 12:46 P.M., licensed nursing staff D acknowledged the resident's comprehensive care plan did not address nutrition. During an interview on 9-12-11 at 1:17 P.M., administrative staff B stated that upon admission, staff obtained an initial weight and then restorative obtained the weights. Administrative staff B stated he/she was in the weight book almost every day, looked at the weekly weights, reviewed them and took them to the start up meeting and talked about any concerns. He/she continued that a concern was a 5 pound weight gain or loss. Administrative staff B continued that he/she would talk to the resident if they were interviewable, to see if they were wanting to lose weight. He/she stated that they asked general questions and generally went in and wrote a progress note. That would be the determination of starting with the dietician. He/she continued that something like that(referring to the resident's weight loss) we should have caught sooner. Typically residents drop a couple of pounds getting in to a new facility. Staff should have alerted and consulted the dietician. With a weight loss like that its an automatic re-weigh to see why the discrepancy and check the scales, etc. Administrative staff B acknowledged the lack of re-weigh or supporting documentation in the clinical record. On 9-12-11 at 2:30 P.M., administrative staff B stated there was no concern with the resident's initial weight, and as for documenting each conversation he/she had with the resident, they did not have, the resident ate an average of 85 percent for the month he/she was here and was not on [MEDICATION NAME] (a diuretic). Normally if we do have a weight discrepancy, the first thing we do is reweigh the residents to make sure the scales were accurate and the second thing was to talk to the resident. Administrative staff B stated he/she did not have any other weights for the resident. The facility-provided policy entitled Weight Monitoring dated 2002 instructed staff to monitor nutrition over time and that all resident weights must be reviewed by the dietary service Manager for any significant change. Suggested parameters for evaluating significance of unplanned and undesired weight loss included a severe loss of greater than 5% in one month. The policy continued that when a weight change was significant or severe, the licensed nurse would notify the resident's physician and obtain and carry out treatment orders if given. The licensed nurse would also notify the resident's family member or legal representative. If a significant loss or trend is identified, an assessment of nutritional status would be completed to identify the cause of change and nutritional interventions to be implemented. The resident's medical record lacked documentation of physician notification regarding the resident's weight loss. The facility failed to adequately monitor and assess this newly admitted resident's nutritional status, which resulted in a weight loss of 9 pounds (5.1 %) in 14 days.