Every finding on record at Pittsburg Care and Rehab

The facility had a census of 60 residents. Based on observation, interview, and record review, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease or heavy tobacco use are most at risk of developing a pneumonia caused by legionella). Findings included:- On 03/11/26 at 10:04 AM, Maintenance Staff V reported the facility utilized a Legionella testing kit, which was conducted on 12/22/25 from the kitchen water. The final report, dated 12/30/25, did not detect Legionella. Maintenance Staff V verified the facility did not have documentation of a map from which the facility's source of incoming water, a flow diagram of the water flow of the facility, or areas of designated dead-end water areas in which the water may stagnate. The facility's Water Management, Legionella Testing policy, dated10/2022, documented approaches to controlling waterborne microorganisms (i.e., water systems decontamination) will be consistent with current Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Food and Drug Administration (FDA) recommendations or state and local health department requirements.

The facility identified a census of 60 residents. The sample included 15 residents with one resident reviewed for dignity. Based on interviews, observation, and record review the facility failed to ensure Resident (R) 9 was treated with respect, dignity, and care during mealtimes.Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods).R9's Significant Minimum Data Set (MDS) dated 12/28/25 documented a Brief Interview of Mental Status (BIMS) score of 99; a staff interview was completed which indicated the resident had severely impaired cognition. R9's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/02/26, documented she had a diagnosis of dementia and received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication daily.R9's Care Plan, documented the following interventions: 04/15/25- staff would provide set up assistance to supervision, with assistance from one staff.11/12/25-someone must sit and assist her with every meal and snacks three times a day for weight loss. R9's EMR under the Orders tab revealed the following physician orders:12/24/25 Assist the resident with meal intake every meal.On 03/10/26 at 08:37 AM, R9 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining room table. Certified Nurse Aide (CNA) M stood next to R9's chair and attempted to assist her with breakfast.On 03/11/26 at 12:44 PM, Certified Medication Aide (CMA) R stated nursing staff should be seated next to the residents they were assisting with meals. CMA R stated the nursing staff should be engaging the residents in conversation.On 03/11/26 at 12:55 PM, Licensed Nurse (LN) I stated the staff should be seated next to the residents when assisting with meals. LN I stated they should be at eye level and visit with resident during meals.

The facility identified a census of 60 residents. The sample included 15 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interviews, the facility failed to provide form CMS-10055, Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN), which included the estimated cost for continued services for skilled services to the resident or their representative for Resident (R) 36 and R44.Findings included:- Review of R36's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 01/08/26 and ended on 02/09/26. The ABN dated 02/09/26 lacked a daily rate for services. R36 remained in the facility for custodial care.Review of R44's Electronic Medical Record (EMR) documented the Medicare Part A episode that began on 08/25/25 and ended on 11/07/25. The ABN dated 11/05/25 lacked a daily rate for services. R44 remained in the facility for custodial care.On 03/11/26 at 08:11 AM, Administrative Nurse E stated she was responsible for issuing the ABN notices to the residents at the time for discharge from skilled therapy. Administrative Nurse E stated she had been instructed not to include the daily rate for services by the regional manager, related to the price fluctuation of the rate.On 03/11/26 at 12:40 PM, Administrative Staff A stated the facility did not include the rate for services on the ABN notices related to changing the rate.The facility's Beneficiary Notices policy, last approved 07/2025, documented a Medicare beneficiary had the right to have Medicare make the decision to determine if skilled services would not be covered by Medicare. Two processes are available: the expedited appeals process and the standard appeals process. The expedited appeals process was intended to keep Medicare-covered services continuing, without interruption. The standard appeals process serves a similar function of enabling a beneficiary to seek Medicare payment for a SNF stay, but it was also necessary to inform the beneficiary of possible non-coverage and, if Medicare agrees that coverage was not appropriate, to shift the costs of care from the SNF to the beneficiary.

The facility had a census of 60 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to keep the residents protected health information (PHI) private on two medication carts parked in the west hallway and the east hallway.Findings included:- On 03/11/26 at 11:31 AM, an observation revealed a medication cart parked in the east hallway with the laptop computer sitting on top. The computer screen was unlocked, and a resident's PHI was on the screen, visible to all who passed by the medication cart. The information visualized included medications, date of birth , allergy information, and code status. No nursing staff were in view of the medication cart.On 03/11/26 at 12:40 PM, an observation revealed a medication cart parked in the west hallway with the laptop computer sitting on top. The computer screen was unlocked, and a resident's PHI was on the screen, visible to all who passed by the medication cart. The information visualized included medications, date of birth , allergy information, and code status. No nursing staff were in view of the medication cart.On 03/11/26 at 12:55 PM, Licensed Nurse (LN) H stated she was always careful not to leave the computer open to a resident's PHI. LN H stated the medication cart should be locked, and the computer laptop should be cleared, or the computer should be closed when staff walk away from the medication cart.On 03/11/26 at 12:55 PM, Licensed Nurse (LN) I stated the medication cart should be locked, and the laptop computer screen lid should be closed, or the residents PHI should be cleared from the computer screen if the nursing staff walked away from the medication cart.On 03/11/26 at 02:34 PM, Administrative Nurse D stated she expected the laptop computer screen to be closed, or residents' information cleared from the computer screen when the staff would not be working at the medication cart.The facility's Confidentiality and Privacy of information policy, last approved 10/2025 documented the facility would treat all resident information confidentially. The resident had a right to personal privacy and confidentiality of his or her personal and medical records. The facility would safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information.

The facility identified a census of 60 residents. The sample included 15 residents with five residents reviewed for unnecessary medications. Based on interviews, observation, and record review the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)4 and R19, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion).Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The Quarterly Minimum Data Set (MDS) dated 01/04/26 documented a Brief Interview of Mental Status (BIMS) score of 99; a staff interview was completed which indicated the resident had severely impaired cognition. The MDS documented R4 had received antipsychotic medication, antidepressant (a class of medications used to treat mood disorders) medication, anticonvulsant (a medication that prevents or treats seizures and convulsions) medication, and opioid (a class of controlled drugs used to treat pain) medication during the observation period.R4's Psychotropic Drug Use Care Area Assessment (CAA), dated 07/05/25, documented she had a diagnosis of dementia and received an antipsychotic medication daily.R4's Care Plan documented the following interventions: 01/30/25- administer medications as ordered.R4's EMR under the Orders tab revealed the following physician orders:01/22/26 -Zyprexa (antipsychotic) oral tablet 2.5 milligram (mg) (Olanzapine) give two tablets via percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach) two times a day for combative behavior, hitting, and/or scratching. May be given by mouth if resident accepts before giving via PEG-tube.Review of R4's clinical record lacked physician documentation of risk versus benefit of administration of antipsychotic medication with a non-approved indication of use for R4, who had a diagnosis of dementia. The facility was unable to provide the physician documentation upon request. The facility did provide a Consent for use of Psychoactive Medication Therapy form, which lacked the physician documentation for the continued use with a non-approved indication.On 03/10/2026 at 07:28 AM, R4 laid on her right on her high/low bed. R4's bed was lowered to the floor, and she was covered up with the blankets pulled up to her shoulders. R4 laid on her H/L bed lowered to the floor, blankets pulled up to her shoulders.2.R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R19's Quarterly Minimum Data Set (MDS) dated 01/31/26 documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R19 received hospice services during the observation period. The MDS documented R19 had received antipsychotic medication, antidepressant (a class of medications used to treat mood disorders) medication, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) medication, and opioid (a class of controlled drugs used to treat pain) medication during the observation period. R19's Psychotropic Drug Use Care Area Assessment (CAA), dated 05/07/25, documented she had a diagnosis of dementia and had received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication daily.R19's Care Plan documented the following intervention:12/08/24 -administer medications as ordered.R19's EMR under the Orders tab revealed the following physician orders: 12/03/24 - Olanzapine (antipsychotic) tablet five milligram (mg), give one tablet by mouth at bedtime for a psychotic disorder.Review of R19's clinical record lacked physician documentation of risk versus benefit of administration of antipsychotic medication with a non-approved indication of use for R19 who had a diagnosis of dementia. The facility was unable to provide the physician documentation upon request. The facility did provide a Consent for use of Psychoactive Medication Therapy form, which lacked the physician documentation for the continued use with a non-approved indication.03/10/26 at 08:44 AM, R19 sat at the dining room table upright in her Broda chair (specialized wheelchair with the ability to tilt and recline). R19 fed herself breakfast.On 03/11/26 at 02:34 PM, Administrative Nurse D stated R4 and R19 had been followed by telehealth for psychiatric therapy for antipsychotic medication usage. R19 had been discharged from the telehealth therapy on 11/20/25, related to her being unable to participate with the therapy.The facility's Use of Psychotropic Drugs policy, effective 05/2025 documented residents would only receive psychotropic or other approved medications that have an effect on brain activity when necessary to treat specific conditions for which they are indicated and effective and would not be used for discipline or convenience of the staff. Residents and/or their representative have the right to refuse such treatment.

The facility identified a census of 60 residents. The sample included 15 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 9 with the admission to hospice services. Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods).R9's Significant Minimum Data Set (MDS) dated 12/28/25 documented a Brief Interview of Mental Status (BIMS) score of 99; a staff interview was completed which indicated the resident had severely impaired cognition. R9's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/02/26 documented she had a diagnosis of dementia and received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication daily.R9's Care Plan documented the following interventions: 014/28/26 - Hospice would provide extra bathing on Monday and Thursday.The care plan lacked other services provided by hospice.R9's EMR under the Orders tab revealed the following physician orders:01/21/26 - Hospice of family's choice to evaluate and treat.On 03/10/26 at 08:37 AM, R9 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining room table. Certified Nurse Aide (CNA) M stood next to R9's chair and attempted to assist her with breakfast.On 03/11/26 at 01:51 PM, Administrative Nurse E stated R9 had been admitted on to hospice services on 01/22/26. Administrative Nurse E stated she had completed a significant change MDS prior to R9's admission to hospice. Administrative Nurse E stated she should have completed another significant MDS after R9's admission to hospice.On 03/11/26 at 02:34 PM, Administrative Nurse D stated the significant change MDS was not completed at the time of R9's admission to hospice. Administrative Nurse D stated Administrative Nurse E had completed a significant change for R9 when she had a significant change in her health status.The facility's Electronic Transmission of the MDS policy, effective date of 10/2025, documented the MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) would be transmitted per state and federal guidelines.

The facility had a census of 60 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to ensure adequate pain management was provided to Resident (R) 41 for ongoing pain in the knees, lower back, and shoulders.Findings included:- R41 Electronic Medical Record (EMR) documented R41 had diagnoses of cardiomyopathy (heart disease), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), need assistance with personal care, and muscle weakness.R41's Quarterly Minimum Data Set (MDS), dated [DATE], documented R41 had intact cognition. The MDS further documented R41 received scheduled pain medication regimen, no as needed medication, and received a nonpharmacological intervention for pain. R41 had pain frequently at a pain level of 10 (pain scale, which 0 is no pain to 10, which is the worst pain) that occasionally affected R41's s sleep. The MDS documented R41 received scheduled pain medication regimen, nonpharmacological interventions, and no as needed medication. R41 received an antidepressant (a class of medications used to treat mood disorders), anticoagulant (a class of medications used to prevent the blood from clotting), diuretic (a medication to promote the formation and excretion of urine), opioid (medications used to treat pain), and hypoglycemic (a class of medication used to lower blood sugar levels).R41's Pain Care Area Assessment (CAA), dated 11/17/25, documented he took an opioid every six hours for low back pain, monitored every shift and as needed for any pain he may have.R41's Care Plan dated 03/26/26, noted he received opioid medication for chronic joint and lower back pain. The plan directed staff to assess pain type, location, and characteristics before and after administration of as needed medication. The plan further documented long-acting opioid use was appropriate for R41 based upon his history. The plan lacked direction to staff of nonpharmacological intervention for pain.The Physician Order dated 01/22/26, instructed staff to administer hydrocodone (opioid)-acetaminophen 10-325 milligrams (mgs) tablet by mouth every six hours for low back pain.The Physician Order dated 12/31/25 directed staff to apply diclofenac sodium external gel (topical medication used for pain relief), four grams to right knee three times a day for right knee pain.The Physician Order dated 05/28/25, instructed staff to monitor pain every shift related to use of as needed hydrocodone use.The Physician Orders lacked a prescription for as needed medication for R41's breakthrough pain or discomfort.The Physician Progress Note dated 10/23/25, documented R41 seen for pain level or 10. R41 reports pain in right leg and knee, R41 described as achy and pins/needles and increased movement. R41 currently takes hydrocodone 10 mg every six hours.On 03/09/26 at 12:05 PM, R41 lying on his bed, reported significant pain in his joints, knees, shoulders and lower back. R41 stated he received pain medication routinely but continued to experience severe pain at times.On 03/11/26 at 09:11 AM, Certified Nurse Aide (CNA) Q reported R41 did not always verbalize pain, but CNA Q stated she could tell he was having pain by 41's facial expression and his appetite would decrease. CNA Q stated when this happens, she notifies the nurse in charge.On 03/11/09:15 AM, Licensed Nurse (LN) H verified the physician orders lacked as needed medication for R41, and at times reported pain level at 10. LN H reviewed the physician order and Care Plan lacked direction to staff for nonpharmacological interventions for pain relief.On 03/11/26 at 02:33 PM, Administrative Nurse D reported R41 had been placed on routine hydrocodone, had no breakthrough pain medication or interventions in the Care Plan for nonpharmacological interventions for pain. Administrative Nurse D reported no assessment of R41's acceptable pain levels or consultation for R41's ongoing pain.The facility's Unnecessary Medication policy, dated 04/25, documented any drug used in excessive duration based on assessment of the resident's condition and therapeutic goals and after any safer treatments have been deemed clinically contraindicated.

The facility identified a census of 60 residents. The sample included 15 residents with two residents reviewed for hospice services. Based on interviews, observation, and record review, the facility failed to ensure collaboration with the hospice provider for Resident (R) 19 and R9.Findings included:- R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R19's Quarterly Minimum Data Set (MDS) dated 01/31/26 documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R19 received hospice services during the observation period. R19's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/07/25, documented she had a diagnosis of dementia and had received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication on a daily basis.R19's Care Plan documented: 04/30/25 Consult with the physician and social services to have hospice care in the facility.Staff would encourage her to express her feelings, listen with non-judgmental acceptance and compassion. Encourage a supportive system of family and friends.01/16/26 Oxygen is needed for comfort. Observe her closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain.R19's EMR under the Progress Note tab revealed a Nursing note on 04/29/25 at 09:18 PM R19 was admitted to hospice.03/10/26 at 08:44 AM, R19 sat at the dining room table upright in her Broda chair (specialized wheelchair with the ability to tilt and recline). R19 fed herself breakfast.2. R9's EMR from the Diagnosis tab documented diagnoses of dementia, major depressive disorder, anxiety, and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods).R9's Significant MDS dated 12/28/25 documented a BIMS score of 99; a staff interview was completed which indicated the resident had severely impaired cognition. R9's Cognitive Loss/Dementia CAA dated 01/02/26, documented she had a diagnosis of dementia and received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication daily.R9's Care Plan documented the following interventions:014/28/26 Hospice would provide extra bathing on Monday and Thursday.The care plan lacked other services provided by hospice. R9's EMR under the Orders tab revealed the following physician orders:On 01/21/26, hospice of family's choice to evaluate and treat.On 03/10/26 at 08:37 AM, R9 sat in her Broda chair at the dining room table. Certified Nurse Aide (CNA) M stood next to R9's chair and attempted to assist her with breakfast.On 03/11/26 at 01:51 PM, Administrative Nurse E stated R9 had been admitted on to hospice services on 01/22/26.On 03/11/26 at 12 PM, Certified Medication Aide (CMA) R stated the nurses informed the staff which residents received hospice services. CMA R stated she could find the information of what hospice provided for the residents in the book that was provided by hospice. CMA R stated the services provided by hospice should be included in the residents' care plan.On 03/11/26 at 12:55 PM, Licensed Nurse (LN) I stated the information of what services are provided by hospice could be found in the book that was provided by hospice. LN I stated it would be helpful if the residents' care plan had the services provided by hospice.On 03/11/26 at 02:34 PM, Administrative Nurse D stated the facility did include some of the services provided by hospice on the resident's care plan. Administrative Nurse D stated the facility did not include all the services provided by hospice.The facility's Hospice Program policy, approved of 12/2025 documented the facility 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. The facility may limit the hospice providers in relation to the coordination and communication of care within the facility.

The facility reported a census of 52 residents. Based on observation and interview the facility failed to ensure sanitary food storage in the therapy room refrigerator and failed to maintain the microwave in a sanitary manner. Findings included: - Observation, on 05/29/24 at 01:30 PM, with Maintenance Staff U, revealed unlabeled, undated hamburger patties in the therapy room refrigerator freezer. The freezer also contained two medical devices for cold therapy and multiple cold packs. The lower shelf of the freezer contained a purple sticky substance. The refrigerator contained the following items of concern: 1. An undated open container of almond milk with an expiration date of 12/20/23. 2. Four containers of yogurt with expiration date of 12/23/23 and a multi pack of 24 small containers of yogurt with expiration dated of 12/23/23. 3. A sack which contained various foods in undated, unmarked Styrofoam containers with a date of 04/10/24, found on a small bag of chicken strips. 4. A 32-ounce opened container of chicken broth, without an open date. Observation on 05/29/24 at 01:30 PM, of the microwave in the therapy room revealed the interior with rusted surfaces along the perimeter of the interior, and the interior upper surface with splatters of unidentified substances. Interview with Maintenance Staff U on 05/29/24 at 01:30 PM, confirmed the above items, and stated housekeeping was responsible for daily cleaning of the therapy room, and this would include the refrigerator and microwave. Interview, on 05/29/24 at 02:15 PM, with Therapy Consultant GG, confirmed the above areas of concern, and stated therapy did use the kitchen equipment for resident rehabilitation purposes. Therapy Staff GG stated he did not know who put the food in the freezer/refrigerator. The facility policy Foods Brought in by Family/Visitors dated 10/2023, instructed staff to store perishable foods in resealable containers wit tightly fitting lids in the refrigerator. Staff to label the containers with the resident's name, identification of the item and use by date. The food service staff and nursing staff are responsible for discarding perishable foods on or before the use by date. The facility lacked a policy for cleaning the microwave. The facility failed to ensure staff maintained the therapy room refrigerator, freezer and microwave in a sanitary manner and failed to ensure food items did not exceed the use by date to prevent food borne illness amongst the residents.

The facility reported a census of 52 residents with 16 residents selected for review, which included one resident reviewed for accommodation of needs. Based on observation, interview and record review, the facility failed to ensure staff assessed one Resident (R) 4, for positioning devices in a timely manner. Findings included: - Review of Resident (R) 4's medical record revealed diagnoses that included chronic back pain, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) and left wrist abscess (cavity containing pus and surrounded by inflamed tissue). The Five Day Admission Minimum Data Set (MDS) dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive function. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/12/24, assessed the resident had a diagnosis of osteoarthritis, R4 had impairment to one side of his lower extremity, and required supervision with touch assistance to total dependence with ADLs. R4 could voice his needs and wants. The Baseline Care Plan, dated 04/06/24, revealed bed rails were not indicated for the resident. The Care Plan, reviewed 05/13/24, instructed staff to know R4 had low back pain and to encourage different methods for pain relief that included positioning. The care plan instructed staff the resident required supervision of touch assistance with bed mobility. Review of a Skilled Nurse Note, dated 05/08/24 at 04:59 AM, documented staff noted the resident had increased back pain with rolling and raising and lowering the head of the bed, and the resident assisted more with turning, which helped with his back pain. Observation, on 05/22/24 at 08:30 AM, revealed R4 in bed feeding himself breakfast. The resident was alert to person, place, and time and responded to questions appropriately. The resident stated he would prefer to have positioning rails on the side of his bed to aide in movements as he had low back pain. R4 stated he mentioned this to multiple staff, and they stated the rails were available, but no one had placed them on his bed. Interview 05/28/24 at 08:45 AM with Licensed Nurse (LN) G revealed she did not know the resident requested positioning rails for his bed and would put a work order in for them. Observation, on 05/29/24 at 09:08 AM, revealed the resident positioned in bed eating breakfast. The resident stated the positioning rails were applied last evening, and he used them for positioning/turning himself in bed. Interview, on 05/29/24 at 09:10 AM, with Therapy Consultant GG revealed the use of positioning devices for R4 would be a nursing decision, and the device would assist the resident in positioning himself in bed. Interview, on 05/29/24 at 10:40 AM, with Administrative Nurse D, revealed residents were assessed by nursing staff for use of positioning rails and if a resident requested them to staff members, she would expect nursing staff to initiate the assessment for appropriateness and safety concerns. The facility policy Accidents, Bed Safety-Bed Rails, dated 09/2023, instructed staff to assess for appropriateness of positioning devices and the devices may be used at the resident's request to increase the resident's sense of security or if an assessment and consultation with the attending physician determined the need to help manage a medical symptom, help the resident reposition, move in bed and transfer. The facility failed to assess the R4's need for positioning devices to decrease pain when repositioning and to increase independence.

The facility reported a census of 52 residents with 16 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R) 25, regarding opioid medications (a powerful pain-reducing medication). Findings included: - Review of Resident (R) 25's Electronic Medical Record (EMR) revealed a diagnosis of chronic pain (pain which persists for a long period). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received scheduled and as needed (PRN) medication and reported occasional pain which affected her sleep and day to day activities. She reported the worse pain in the past five days was a four on the one to ten pain scale. The MDS inaccurately documented the resident did not receive opioid medication (a powerful pain-reducing medication). The Pain Care Area Assessment (CAA), dated 12/22/23, documented the resident received Fentanyl (an opioid medication) every (Q) 72 hours. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She received scheduled and PRN pain medications and reported occasional pain which rarely, if ever, affected her sleep or day to day activities. She reported the worse pain in the past five days was a five on the one to ten pain scale. The MDS inaccurately documented the resident did not receive opioid medication. The Care Plan for pain, revised 04/01/24, instructed staff the resident received a Fentanyl pain patch for chronic pain. Staff were to administer the patch and remove, per physician's orders. Review of the resident's EMR revealed the following physician's order: Fentanyl patch (a medication administered through a patch on the skin used in the management and treatment of chronic pain) 72 hour, 100 micrograms (mcg) per hour, transdermally (medication absorbed through the skin), every (Q) 72 hours, for pain, ordered 09/21/23. Review of the resident's Medication Administration Record (MAR) from, 12/01/23 through 05/28/24, revealed the resident received the medication, as ordered. On 05/29/24 at 06:49 AM, Administrative Nurse D confirmed the Annual MDS, dated [DATE] and the Quarterly MDS, dated [DATE], were inaccurately coded as the resident had received an opioid medication during the lookback period of the assessments. The facility utilized the Resident Assessment Instrument (RAI) for accurate completion of MDSs. The facility failed to complete two accurate MDSs for this dependent resident who received an opioid medication.

The facility reported a census of 52 residents with 16 sampled, including four residents reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure fall interventions were maintained for Resident (R)13. This placed the resident at increased risk for further falls, injury, and pain. Findings included: - Review of Resident (R)13's Electronic Medical Record revealed diagnoses that included Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The resident had two or more nonmajor injury falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 12/21/23, assessed the resident had repeated falls, weakness, lack of coordination, unsteadiness on his feet, and muscle weakness. The resident was independent for most activities of daily living and used a walker for mobility. The resident sustained two falls since the last assessment. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of four, and the resident sustained two noninjury falls, and one nonmajor injury fall since the last MDS. The Care Plan, reviewed 04/07/24, instructed staff the resident had a fall when he attempted to sit on the toilet in his bathroom. Due to the progression of the resident's Huntington's disease, the resident had increased fall incidents, did not use his walker, or call for staff assistance. The care plan instructed staff to ensure the nonskid strips in the bathroom in front of the toilet and by his recliner were in place; and ensure fall mats were in place. Observation on 05/22/24 and 05/23/24 revealed nonskid strips in front of R13's toilet. One of the strips contained a worn area approximately 10 inches in length by two inches in width. During an interview on 05/28/24 at 02:15 PM, Certified Nurse Aide (CNA) M revealed the resident often got up and ambulated without his walker or calling for staff assistance. CNA M stated the resident did have nonskid strips in front of his chair and in front of the toilet in the bathroom. During an interview and observation on 05/29/24 at 11:06 AM revealed one nonskid strip not adhered to the floor in the resident's bathroom. Housekeeping Staff V stated she cleaned the resident bathroom earlier as the resident soiled the floor. Housekeeping Staff V stated staff cleaned the bathroom frequently as the resident soiled the floor, and spits tobacco. During an observation on 05/29/24 at 01:30 PM, Maintenance Staff U confirmed the nonskid strip was not sticking to the floor, due to wetness. Maintenance Staff U stated at that time that he replaced the strip earlier and would apply a new one. During an interview on 05/29/24 at 02:15 PM, Administrative Nurse D revealed she expected staff to notify maintenance of the need for nonskid strip replacement and ensure the strips adhered to the floor. The facility lacked a policy for inspection of nonskid strips. The facility failed to ensure R13's bathroom contained nonskid strips in good working order to decrease the risk of falls as care planned.

The facility reported a census of 52 residents with 16 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure one Resident (R) 25 remained free from unnecessary medications related to the failure to administer as needed (PRN) medications for lack of bowel movements (BM) for longer than three days. Findings included: - Review of Resident (R) 25's Electronic Medical Record (EMR) revealed a diagnosis of constipation (inability to pass stool). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She was dependent on staff for toileting needs, had no behaviors, and rejected cares one to three days of the assessment period. She was occasionally incontinent of bowel and had no constipation. The Behavioral Symptoms Care Area Assessment (CAA), dated 12/22/23, documented the resident would frequently refuse bowel interventions for constipation and would hold her bowels for several days choosing not to use the bedpan to have a bowel movement (BM). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She had no behaviors and refused cares one to three days of the assessment period. She was dependent on staff for toileting needs and was always incontinent of bowel. The Care Plan for constipation, revised 04/01/24, instructed staff the resident was at risk for constipation due to decreased mobility and medication side effects. Staff were instructed to follow the facility bowel protocol for bowel management and notify the nurse if the resident had difficulty with hard stools. The nurse was to monitor the electronic documentation system daily for no BM in three days and to follow-up as needed. Staff were to record all BMs, each day. Review of the resident's electronic medical record (EMR), from 05/01/24 through 05/27/24, revealed the resident had no behaviors. Review of the resident's EMR revealed the following physician's orders: Colace (a stool softener used to soften stool and ease the passing of stool) 100 milligrams (mg), by mouth (po), twice daily (BID), for constipation, ordered 06/30/21. Lactulose oral solution (a laxative used to treat constipation) 10 grams (gr)/15 milliliters (ml), 15 ml po, every day (QD), for constipation, ordered 10/11/23. Milk of Magnesia (MOM-a laxative) 30 cubic centimeters (cc), po, QD as needed (PRN), for constipation, ordered 06/30/21. Bisacodyl suppository (a laxative), 10 mg rectally, QD PRN, for constipation, ordered 11/17/23. Fleets disposable enema (a laxative), rectally, one every (Q) 24 hours PRN, for constipation, ordered 03/08/21. Review of the resident's EMR, from 04/24/24 through 05/27/24, revealed the following concerns: The resident did not have a BM from 04/28/24 through 05/04/24, for a total of six days with staff failing to administer a PRN BM medication or enter a nurse's note documenting the resident's refusal for a bowel management intervention. The resident did not have a BM from 05/06/24 through 05/13/24, for a total of six days with staff failing to administer a PRN BM medication or enter a nurse's note documenting the resident's refusal for a bowel management intervention. The resident did not have a BM from 05/19/24 through 05/23/24, for a total of four days with staff failing to administer a PRN BM medication or enter a nurse's note documenting the resident's refusal for a bowel management intervention. On 05/28/24 at 07:51 AM, Licensed Nurse (LN) G stated the resident had constipation from time to time but would refuse the ordered PRN medications. On 05/29/24 at 12:05 PM, Administrative Nurse D communicated Administrative Nurse E would review the bowels on the electronic documentation system Monday through Fridays for any resident who may require a PRN medication for bowels. Administrative Nurse E would then communicate the findings to the staff for follow-up. Staff did not document on the Medication Administration Record (MAR) when a resident refused a PRN medication, but it was the expectation for them to complete a brief nurse's note if the intervention was offered and declined. The Facility Protocol for Bowel Management, undated, included: If a resident does not have a BM for three days, staff were to give MOM. If a resident does not have a BM for four days, staff were to give a suppository. If a resident does not have a BM for five days, staff were to give an enema, notify the PCP and make a nurses note. If the resident refuses the protocol, staff were to make a brief nurse's note stating the intervention was offered and refused. The facility failed to keep this dependent resident free from unnecessary medications by failing to administer PRN medications for the lack of BMs.

The facility reported a census of 68 residents. The sample of 22 residents included seven residents reviewed for restorative nursing services. Based on observation, interview, and record review the facility failed to ensure five of the seven sampled residents received restorative nursing services to increase range of motion, prevent further decrease in range of motion, and/or prevent decrease in mobility. Resident (R)16 received therapy services and then no restorative nursing services and declined in range of motion and walking ability; R112 who received no restorative services after therapy; R34, R30, and R12 for no restorative nursing program when they had range of motion impairments. Findings Included: - Review of the resident's (R)16's, Physician Orders, dated 08/09/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. He required limited staff assistance for bed mobility, extensive staff assistance for transfers, locomotion, dressing, walking, and toilet use. His balance during transition was not steady but he could stabilize himself without staff assistance. He had functional limitation in range of motion on one side of the upper and lower extremities. The resident received occupational therapy (OT) for 45 minutes for one day of the look back period and physical therapy (PT) for 117 minutes for three days of the look back period. The resident did not receive a restorative nursing program (RNP). The Quarterly MDS, dated [DATE] documented the following changes from the above assessment. The resident required supervision only of staff for bed mobility, transfers, locomotion, and toilet use. He required limited assistance of staff for dressing and walking did not occur. He received OT for 108 minutes and group therapy for 25 minutes over four days of the look back period. The resident received PT for 169 minutes for five days of the look back period. The resident did not receive RNP during the lookback period. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/12/22, triggered for further review due to the resident's dependence on staff for activities of daily living (ADL) secondary to having a stroke, which resulted in [CONDITION(S)] and impaired balance on one side of his body. The resident's functional limitation included limitations in the resident's ability to perform self-care. The Care Plan (CP), dated 09/11/22, indicated the resident was at risk for falls due to [CONDITION(S)], gait/balance, and [CONDITION(S)] of the right dominant side. Staff should observe and report changes or decreases in the resident's functional abilities, such as a decrease in range of motion (ROM). Staff to monitor/document mobility status and if the resident exhibits paralysis, obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Orders, dated 08/09/22, documented orders for the following: 1. Continue skilled OT services, five times a week for 44 days, which included therapeutic exercise, therapeutic activities, neuromuscular and group ADL participation, ordered on 06/16/2022. 2. Continue skilled PT services five times a week for 40 days following established plan of care, ordered on 06/16/22. 3. Discontinue (DC) PT services, effective 07/10/22. Ordered on 08/04/2022. The orders lacked a discontinuation order for the resident's OT services. The Rehabilitation Screen , dated 9/15/22, documentation revealed the resident experienced a change of condition/decline in his ADL function, which included mobility (i.e. unable to ambulate and stabilize balance) and communication for comprehension and writing has difficulty writing with his left hand. On 09/12/22 at 02:04 PM, the resident sat in a wheelchair (W/C) with his right arm propped on the arm of the w/c and his feet directly on the floor. He stated he came to the facility for therapy, but therapy stopped in July because his insurance would not pay for services. The resident reported he did not receive any restorative nursing program/services. Additionally, he had not been assisted by staff to walk since therapy stopped in July. He stated all he did was sit in his chair. The resident commented he wanted to return to the community, but would need to be able to walk to do that. On 09/13/22 at 11:02 AM, the resident self-propelled his w/c backwards down the hall by using his left hand and foot. He stated he rolled his w/c backwards to guard against his right foot catching on the floor and twisting his knee. On 09/14/22 at 01:38 PM, Certified Nurse Aide (CNA) M confirmed the resident was not on a RNP. She stated when a resident discharged from therapy services, the therapist wrote an assessment to describe their functional status and made recommendations. Then it went to the Restorative Nurse, who gave her the instructions on what restorative programs the resident should receive. CNA M stated the resident previously received therapy and she did not recall when he stopped having therapy, but he had not received a restorative plan since. On 09/15/22 at 08:53 AM, Licensed Nurse H did not know if the resident received restorative services. The resident did receive therapy and LN H reported seeing him walk with therapy, but had not seen him walk lately. LN H verified the resident currently had no RNP in the care plan. On 09/15/22 at 09:58 AM, Certified Medication Aide (CMA) T reported the resident needed help standing or to get his pants down when he went to the bathroom. CMA T said the resident was a lot better from when he first admitted . He received therapy until a few months ago, he did not walk now, but said he could stand but goes about the facility in his w/c. On 09/15/22 at 11:20AM, Administrative Nurse D stated the resident should have been put on a restorative program to maintain his functioning and to prevent decline when therapy stopped. Upon review of the resident's Electronic Medical Record (EMR), she confirmed the resident did not receive a restorative nursing service since therapy stopped. She confirmed she saw the resident walk with therapy staff a couple of times while receiving therapy, but had not seen him walking since therapy stopped. Administrative Nurse D stated therapy staff should write down how the restorative nursing should proceed with their recommendations for transition, to prevent decline and maintain functioning. Then, the restorative nurse and the aide reviews the information and set up the restorative program. Nursing staff were responsible for a RNP had difficulty getting the transition information from therapy staff in order to set up the RNP. The resident would benefit from a restorative nursing program for range of motion for lower extremities and ambulation. On 09/15/22 at 12:52 PM, Consultant therapy staff KK verified the resident received therapy and should have transitioned to a Restorative Nursing Program when he discharged from therapy services, several months ago. He stated the therapist should provide a Restorative Rehabilitation Program Recommendation, form to the Restorative Nurse for input to set up his nursing restorative program. The goal of an RNP should be to maintain the resident's functioning and prevent decline in his ADLs. Consultant KK stated he thought he had done that when the resident discharged from therapy. The resident was walking with a hemi cane ( (a cane referred to as a one arm walker) with consultant KK at the time of discharge. On 09/15/22 at 03:17 PM, Consultant therapy staff KK reported he failed to complete a Restorative Rehabilitation Program Recommendation, form when the resident discontinued from therapy as he should have done. He stated he had no explanation for the oversite. Additionally, he provided the surveyor with a Restorative Rehabilitation Program Recommendation, form dated 09/15/22 and explained he just completed this form to reflect the resident's status at the time of his discharge from therapy, on 07/10/22. Upon request Consultant therapy staff KK agreed to screen the resident to determine his current status and need for restorative services. On 09/15/22 at 04:02 PM Consultant therapy staff KK provided a Rehabilitation Screen , for the resident. The documentation revealed the resident experienced a change of condition/decline in his ADL function, which included mobility (i.e. unable to ambulate and stabilize balance) and communication for comprehension and writing has difficulty writing with his left hand. Consultant confirmed these findings and indicated the resident had declined in his functioning since he stopped receiving therapy. He reported the resident would benefit from Restorative nursing services until Therapy could be restarted to achieve his prior level of functioning. On 09/15/22 at 04:30 PM, Administrative Nurse confirmed the resident should have been transitioned to a Restorative Nursing Program to prevent decline and maintain his functioning with AROM and ambulation. The facility policy Goals and Objectives, Restorative Services, dated 09/22, documentation included specialized rehabilitation services goals and objectives shall be developed for problems identified through resident assessment. Encourage the resident to maintain his/her independence and self-esteem. The facility failed to ensure R16 received restorative nursing services to increase range of motion, to prevent further decrease in range of motion, and/or prevent decrease in mobility. - Review of Resident (R)112's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function and required limited assistance of two person for bed mobility and required limited assistance of one staff for transfers, dressing, toileting and personal hygiene. The resident required staff assistance for balance. The resident had impairment in functional range of motion on one side of her upper extremity. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/17/22, assessed the resident at risk for decline due to multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Th Return to Community Referral CAA, dated 08/17/22, assessed the resident expected to return to her home upon discharge. The Care Plan, dated 08/25/22, instructed staff the resident could take herself to the bathroom, and turn and reposition herself in bed. The resident required set up assistance for oral care and personal hygiene. The resident was able to transfer herself. Staff to encourage routine physical exercise and may need therapy consult to set up individualized program to encourage walking on a daily basis. The Care Plan lacked personalized restorative goals and treatment plan. The Hospital Discharge Summary, dated 08/16/22, documented the resident had a left shoulder arthroplasty (a surgical procedure to repair/replace damaged parts) on 08/11/22. A Physician Order, dated 08/17/22, instructed physical and occupational therapy treatment. A Physician Order, dated 08/18/22, instructed staff to apply a sling to the resident's upper left extremity. The medical record lacked a restorative program for the resident as of 09/14/22. Interview, on 09/13/22 at 09:29 AM, with the resident revealed she fractured and dislocated her left shoulder (non- dominant) from falling at home. The resident was dressed in a hospital gown and stated she did not know what clothes to wear due to shoulder pain and limited range of motion. The resident stated she did have therapy but it stopped because her insurance would not pay for it. The resident stated she did try to exercise her shoulder on her own, but direct care staff or nursing staff did not provide restorative services. The resident stated she planned to return to her home. The resident stated she did not use the sling and took herself to the bathroom and managed her own personal hygiene. Interview, on 09/13/22 at 05:06 PM, with Certified Nurse Aide (CNA) QQ, revealed the resident took herself to the bathroom and would call for staff if she needed anything. Observation, on 09/14/22 at 08:45 AM, revealed the resident transferred herself out of bed and ambulated to the bathroom without the shoulder sling. Interview, on 09/14/22 at 09:29 AM, with Consulting Therapy Staff KK, revealed the resident did receive physical therapy for muscle strengthening for ambulation and occupational therapy for her shoulder. He stated the resident's insurance company would only pay for a couple of weeks of therapy and did not know if the resident had a restorative plan. Interview, on 09/14/22 at 12:58 PM, with Consulting Therapy Staff GGG, revealed the resident did not have a restorative plan following therapy because her insurance company abruptly discontinued her therapy, and staff did not make a restorative plan for her shoulder deficits. Consulting Therapy Staff GGG stated she would expect nursing staff to ensure the resident wore her shoulder brace/sling when moving about in her room (going to the bathroom). Interview on 09/14/22 at 01:48 PM, with CNA M, revealed therapy recently notified her of the need to provide passive range of motion to the resident's left shoulder. Interview, on 09/14/22 at 04:46 PM, with Administrative Nurse E, revealed the resident discharge from skilled services around 09/05/22 and she just received a restorative plan for ambulation and shoulder passive range of motion today 09/14/22. Interview, on 09/15/22 at 10:45 AM, with administrative Nurse D, revealed she would expect communication between therapy and nursing staff to provide restorative services. The facility policy Goals and Objectives, Restorative Services reviewed 05/2022, instructed staff rehabilitative goals and objectives are developed for each resident and outlined in his/her plan of care relative to therapy services. The facility failed to provide restorative therapy for this resident with surgical repair of shoulder fracture, after discontinuation of physical and occupational therapy to maintain/increase range of motion and prevent further decrease in range of motion. - Review of Resident (R)12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function. The resident was dependent on two staff for bed mobility, transfers, toilet use and personal hygiene. The resident had impairment in functional range of motion on one side of her lower extremity. The ADL (Activity of Daily Living ) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/20/21, assessed the resident required extensive assistance of one to two staff for ADL's. The resident frequently chose not to participate in ADL functions. Staff instructed to encourage the resident to participate in activity programs that required physical mobility. Staff instructed to provide weight bearing support and non- weight bearing support. The resident required extensive assist to dependence of one to two staff when she chose to transfer and was dependent on staff to propel her in her wheelchair. The Quarterly MDS, dated [DATE], assessed the resident with normal cognitive function, and required extensive assistance of two staff for bed mobility, toileting, and personal hygiene. Transfer activity occurred once during the seven day look back period. The resident had impairment in functional range of motion on one side of her lower extremity. The Care Plan, reviewed 07/07/22, instructed staff the resident required extensive assistance of one to two staff for ADLs. The resident had behavior problem of refusing cares. The resident was not ambulatory and refused to transfer out of bed and when the resident did transfer, staff used the sit to stand mechanical lift at times. The care plan lacked restorative goals and treatment plan. The resident's records lacked a restorative plan recent updated restorative plan to include the residents' bedfast status and refusal of ambulation Observation, on 09/12/22 at 11:10 AM, revealed the resident sitting in her bariatric bed. The resident's right leg evidenced [CONDITION(S)] and her knee was in a flexed position with her right foot turned inward. The resident's left leg was slightly flexed with normal position of her foot. Interview with the resident at that time revealed she voiced concern that her right foot turned inward and did not have range of motion exercises for either leg/ankles/feet. The resident stated staff did not offer range of motion restorative therapy. The resident stated she had history of a right leg hip fracture. Interview, on 09/14/22 at 01:54 PM, with Certified Nurse Aide (CNA) M, revealed the resident did not have a current restorative plan. Interview, on 09/14/22 at 02:30 PM, with Therapy Consultant KK, revealed the resident did have a restorative program but was unaware if the resident's needs changed or if staff still provided restorative services. Interview, on 09/14/22 at 05:14 PM, with Administrative Nurse E, confirmed the resident did not have a current restorative plan. Interview, on 09/15/22 at 10:45 AM, with Administrative Nurse D, revealed she would expect communication between therapy and nursing staff in order to provide this resident restorative services. The facility policy Goals and Objectives, Restorative Services reviewed 05/2022, instructed staff rehabilitative goals and objectives are developed for each resident and outlined in his/her plan of care relative to therapy services. The facility failed to provide restorative services for this resident with limitations in functional range of motion in her right lower extremity. - Review of Resident (R)30's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status, and was totally dependent on two staff for bed mobility and transfers. The resident had bilateral (both) impairment of upper and lower extremities. The resident was at risk for pressure ulcers and had no current pressure ulcers. The resident had a pressure reducing devices to her bed and chair and was on a turning and repositioning program. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment(CAA), dated 07/24/22 did not trigger for this resident. The Pain CAA, dated 07/24/22, assessed the resident had pain due to cerebral infarction (stroke) and instructed staff to administer analgesia per orders and to administer half an hour before treatments. The Care Plan, reviewed 07/31/22, instructed staff for physical and occupational therapy to evaluate and treat. The care plan instructed staff the resident required turning and repositioning every two hours. The care plan lacked a restorative program. Review of the resident records revealed the resident lacked a restorative program. Observation, on 09/13/22 at 07:43 AM, revealed the resident positioned in her bed, alert to name displaying anxiety and pain. Observation, on 09/13/22 at 07:49 AM, revealed Licensed Nurse (LN) H, administered [MEDICATION(S)] for pain and [MEDICATION(S)] for anxiety per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had swelling in her right knee and LN H stated the physician started her on medications for gout (inflammation of the joints). The resident had heel protective boots on bilaterally (both feet). The resident moved her right and left arm and was able to grab onto objects. The resident did not move her lower extremities which were encased in pressure relieving boots to her mid-calf area. Observation, on 09/13/22 at 01:32 PM, revealed Certified Nurse Aide (CNA) O provided a bed bath to the resident. The resident moved her arms and hands. CNA O stated she did not remove the heel protective boots to wash the resident's lower extremities. Interview, on 09/14/22 at 01:42 PM, with CNA M, revealed she did discuss with the family about restorative services for the resident over the past weekend and they were in favor. The resident admitted to the facility on [DATE]. CNA M stated the resident did not have a restorative program. Interview, on 09/14/22 at 04:46 PM, with Administrative Nurse E, revealed the resident did not have a restorative program but would probably benefit from one as CNA M discussed with her on 09/14/22. Administrative Nurse E stated residents are screened by therapy and a restorative program developed based on the resident's needs. Interview, on 09/15/22 at 10:45 AM, with administrative Nurse D, revealed she would expect communication between therapy and nursing staff to provide restorative services. The facility policy Goals and Objectives, Restorative Services reviewed 05/2022, instructed staff rehabilitative goals and objectives are developed for each resident and outlined in his/her plan of care relative to therapy services. The facility failed to provide restorative services to this resident with range of motion limitations in her upper and lower extremities to prevent contractures and decline in range of motion ability. - Review of Resident (R)34's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit, constant inattention and altered level of consciousness. The resident was dependent on two staff for bed mobility and transfers. The resident had impairment in functional range of motion on one side of her upper and lower extremities. The Falls Care Area Assessment (CAA), dated 02/21/22, assessed the resident required staff assistance for stabilization. The Quarterly MD, dated 07/31/22, assessed the resident with severe cognitive deficit with constant inattention. The resident was dependent on two staff for bed mobility and transfers. The resident had impairment in functional range of motion on one side of her upper and lower extremities. The Care Plan, reviewed 08/04/22, instructed staff to ensure the resident had nonskid foot wear. when ambulating. The resident was on a functional maintenance program to maintain range of motion in her upper and lower extremities. Staff instructed to provide passive range of motion to her extremities. The resident required one to two staff assistance with transfers and two staff for bed mobility. The care plan lacked interventions for lack of weight bearing or use of splints. An untitled, undated document was provided by Certified Nurse Aide (CNA) M, that she used as a guide to provide restorative care to the resident. This document instructed staff to provide passive range of motion to the upper extremities three times per week, and passive range of motion to her lower extremities three times per week. This document instructed staff to check the resident for eating and swallowing issues and check for residual food in her mouth, notify the nurse if found, or if the resident coughed or choked during meals or snacks. This document instructed staff to cleanse her bilateral hands (both hands) with soap and water, dry and apply bilateral hand braces following breakfast (09:30 AM- 10:30 AM), following lunch (02:00 PM - 03:00 PM), and night- time. Apply bilateral hand rolls following transition to bed and remove in the morning. Observation on 09/12/22 at 10:00 AM, revealed the resident positioned in her bed with her elbows in a flexed position against her chest and her hands in a fist position. The resident did not have splint on either hand. Observation, on 09/13/22 at 02:07 PM, revealed the resident seated in her wheelchair. The resident's elbows were flexed and held close to her chest with her hands in fist positions. The resident did not have splints on either hand. Certified Nurse Aide (CNA) O and P changed the resident's shirt, then proceeded to transfer the resident to her bed. CNA O and CNA P placed their flexed elbows under the resident's axilla (armpits), and each held onto the back of the resident's pants by the waistband. The resident's legs were drawn up and her feet did not touch the floor to pivot. Staff failed to apply a gait belt for the transfer. CNA P stated at that time that the resident was care planned to transfer with a lift or one or two persons. Observation, on 09/13/22 at 04:54 PM, revealed CNA PP and QQ prepared to transfer the resident from her bed to her wheelchair. CNA PP stated staff utilized a lift for transfers, then stated the resident was a one to two-person transfer. The resident's knees and elbows were in a flexed position. Staff did not put shoes, socks or a gait belt on the resident. The resident did not follow directions. Staff lifted the resident under her axilla and held onto the back waistband of her pants. The resident's feet did not touch the floor but remained in a flexed position. Observation, on 09/14/22 at 01:57 PM, revealed the resident seated in her wheelchair. CNA M and SS placed a gait belt on the resident and lifted the resident with the gait belt to transfer into her bed. The resident did not bear weight and kept her legs in a flexed position during the transfer. CNA M confirmed the resident did not bear weight during the transfer, and staff should use a mechanical lift. CNA M stated the resident wore splints twice a day and she provided range of motion to her upper and lower extremities, three times a week. CNA M stated she would discuss with Administrative Nurse E the residents lack of weight bearing during transfer. CNA M stated the resident did bear weight at times. Interview, on 09/14/22 at 04:46 PM, with Administrative Nurse E, revealed the untitled, undated document that CNA M used for restorative services was a guide, but the splints were not noted on the care plan. Administrative Nurse E lacked the program from restorative therapy for these measures. Interview, on 09/15/22 at 10:45 AM, with administrative Nurse D, revealed she would expect communication between therapy and nursing staff to provide restorative services. The facility policy Goals and Objectives, Restorative Services reviewed 05/2022, instructed staff rehabilitative goals and objectives are developed for each resident and outlined in his/her plan of care relative to therapy services The facility failed to provide restorative services to this dependent resident with fluctuating ability to bear weight and need for hand/wrist and elbow positioning devices to prevent correct anatomical positioning of extremities.

The facility reported a census of 68 residents with 22 selected for review, including two residents reviewed for nutrition. Based on observation, interview, and record review, the facility failed to ensure adequate parameters of nutritional status for one of the two residents reviewed. The facility failed to ensure Resident (R)20 received her diet as ordered, failed to involve the Registered Dietician with R20's desire to lose weight, failed to appropriately monitor the resident's weight, and failed notify the physician of the significant weight loss. R20 experienced a 10.96 percent weight loss from 03/31/22 to 04/29/22, a 10.6 percent weight loss from 05/23/22 to 06/30/22, and a 23.55 percent weight loss from 03/31/22 to 09/03/22. Findings included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required supervision and setup for eating and drinking. R20's height was 60 inches and she weighed 263 pounds and did not/was not known if she had any weight loss greater than five percent in the last month or greater than 10 percent in the last six months. She was not on a mechanically altered diet, however, received a therapeutic diet. R20 had no natural teeth and had a stage four pressure ulcer present. R20 admitted to the facility on [DATE]. The Quarterly MDS dated [DATE] assessed R20 with the same BIMS score. She was independent with eating, with setup assistance from staff, was 60 inches tall, and weighed 219 pounds. R20 had a weight loss of five percent or more in the last month or 10 percent or more in the past six months and was not on a physician prescribed weight loss regimen. She was not on a therapeutic or mechanically altered diet. She continued to have a stage four pressure ulcer present. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 04/13/22 revealed R20 required setup and supervision for eating. The Nutritional Status CAA dated 04/13/22 revealed R20 was at risk for altered nutritional status related to a therapeutic diet and wounds. Her diet was regular texture with double protein (meat/eggs), and protein powder with her meals. The staff were to provide and serve supplements as ordered by the physician, alert the Registered Dietician (RD) to any decline in intake, and honor her food preferences. The Pressure Ulcer/Injury CAA dated 04/13/22 revealed R20 had a stage four sacral pressure ulcer and the staff were to monitor her nutritional status, serve her the diet as ordered, and monitor her intake and record the meal intake. She required supplemental protein as ordered to promote wound healing. The Care Plan dated 09/04/22 revealed R20 had oral health problems related to edentulous status (lacked natural teeth) and encouraged her to report any chewing difficulties. The staff were to provide a regular diet, double protein (meat/eggs), protein powder with meals, yogurt with breakfast, honor her food preferences, provide the diet as ordered by the physician, and provide and serve supplements as ordered by the physician. The staff were to alert the RD to any decline in her meal intake. R20 could feed herself with setup and supervision by the staff. The Weights/Vitals tab located in the EMR, revealed on 03/31/22, R20 weighed 262.8 pounds. The diet order, located in the EMR dated 03/31/22 ordered a regular diet, regular texture, double protein meat/egg, and protein powder to meals. The Nutrition: RD Admission (Initial) Assessment - V 2 dated 04/07/22, revealed R20's current meal intake was adequate and there were nutritional concerns due to a stage four pressure ulcer to her sacrum and [CONDITION(S)] due to excess calories, with a goal for her wound to heal. R20 had nutritional interventions of double meat/egg. The staff were to continue with the current plan of care, monitor her weights, and follow up with the RD as needed. The Weights/Vitals revealed on 04/29/22, R20 weighed 234.0 pounds, a total of 28.8 pounds, that was a significant loss of 10.96 percent in the past month. The Orders tab located in the EMR, revealed on 05/03/22, R20 was to receive ice cream two times a day for weight loss, scheduled at 11:30 AM and 05:30 PM. The 05/22/22 IDT: Patient at Risk (PAR) - V1 assessment located under the assessment tab in the EMR and the first PAR note since admission revealed there was no risk related to weights. The Weights/Vitals tab revealed on 05/23/22, R20 weighed 244.4 pounds, an increase of 4.4 percent since the prior month and remained a decrease since the admission weight at seven percent (18.4 pounds). The 05/22/22 IDT: Patient at Risk (PAR) - V1 assessment in the EMR revealed R20 was at risk related to her weights, she had a gain from her previous weight and intakes were 76-100 percent of meals. The goal was to maintain weight and the current interventions were effective. The Weights/Vitals tab revealed on 06/06/22 R20 weighed 238.3 pounds, a decline of 9.32 percent since admission (24.1 pounds). The IDT: Patient at Risk (PAR) - V1 located under the assessment tab in the EMR dated 06/08/22 revealed the most recent weight was 238.3 pounds which was a loss from the previous weight. R20's intakes were 76-100 percent. The goal was to maintain weight and no changes would be made, R20 would like to have weight loss. The facility failed to inform the RD and the physician of R20's weight loss desire. The 06/15/22 IDT: Patient at Risk (PAR) - V1 assessment in the EMR (seven days after the previous PAR meeting note) revealed R20 had a weight of 236 pounds on 06/13/22, a loss from her previous weight. R20's intakes were 76-100 percent and the facility started providing super cereal (a recipe that combines different ingredients and nutrients to cereal that when combined makes a high-calorie, nutritious, and fortified cereal) to help maintain, and double portions related to her wound. (This intervention of super cereal would conflict with the previous weeks note regarding weight loss desire). The Orders tab R, revealed on 06/18/22, R20 was to receive super cereal one time a day for weight loss. The Weights/Vitals tab, revealed on 06/21/22, R20 weighed 219.4 pounds, indicating an additional significant decline in weight from the last month at 10.23 percent. The IDT: Patient at Risk (PAR) - V1 dated 06/22/22, revealed a weight of 219.4 on 06/21/22, a loss from previous weight and intakes remained at 76-100 percent. Current interventions included super cereal, double portions and protein powder, and the current interventions were effective. The PAR note included R20 was losing some weight with recent start of super cereal and would continue as is for now. The Weights/Vitals tab revealed on 06/30/22, R20 weighed 218.5 pounds, a significant weight loss of 10.63 percent in the past month. The Nutrition Note located under the progress note tab in the EMR, dated 07/05/22 at 11:23 PM, revealed R20's chart reviewed by the RD related to her wound status. R20 had a stage four pressure ulcer on her sacrum and an open lesion on her left calf. R20 also had some decrease in weight and was on a regular diet plus snacks, ice cream, and super cereal. Her intakes were 75-100 percent of meals. The staff stated she could be a picky eater and would hide food she did not like under a napkin. The note included a list of preferences reviewed with R20 and for breakfast, she preferred scrambled eggs, sausage, no bacon, and biscuits and gravy. R20 did not like spinach or bread, included buns for hamburgers, preferred just the patty. The RD was to follow up as needed. The Weights/Vitals tab dated 07/06/22 revealed R20 weighed 218.5 pounds, which was the same as her weight on 06/30/22. The IDT: Patient at Risk (PAR) - V1 dated 07/06/22 revealed R20's most recent weight on 07/06/22 was 218.5 pounds, a loss from previous weights. Her intakes were 51-75 percent and she had interventions of super cereal, ice cream, double protein meat and eggs, and the interventions were effective. The Orders tab on 07/12/22 a diet order for regular texture, scrambled eggs, sausage, no bacon, biscuit, and gravy, give yogurt at breakfast, double protein meat/egg, and protein powder at meals. The Weights/Vitals tab revealed on 08/08/22 R20 weighed 206.3 pounds, a significant weight loss of 5.58 percent in the past month. The IDT: Patient at Risk (PAR) - V1 dated 08/10/22 and 08/18/22 revealed R20 not at risk related to her weights. The 08/22/22 Nutrition Note in the revealed R20's chart reviewed due to weight changes. R20 was on a regular diet with meal intakes of 75-100 percent plus an evening snack, ice cream, and super cereal. She has a 21 percent, 56-pound weight loss from March 2022 to August 2022. Although hard to understand in the interview, R20 stated her appetite was not good and it had been that way for some time. R20 had no teeth or dentures, and the staff reported she had no issues with eating and ate 100 percent of meals. The note included a recommendation of more protein for protein and to add yogurt with breakfast. (Yogurt was an intervention on 07/12/22). R20 was unsure why she was having weight changes with her good oral intake. The staff were to monitor for further weight changes and oral intake and the RD would follow up. The Weights/Vitals tab located in the EMR dated 09/03/22 revealed R20 weighed 200.9 pounds, a significant loss of 15.69 percent in three months and a significant loss of 23.55 percent since admission. The 09/07/22 IDT: Patient at Risk (PAR) - V1 revealed R20's most recent weight of 200.9 pounds on 09/03/22 was a loss from her previous weight and her intakes were 51-75 percent. The current interventions were yogurt, ice cream twice daily, and super cereal. The note included [CONDITION(S)] to lower extremities improved and there were no changes at this time. The Progress Note attached to the electronic mail, dated 09/16/22 at 02:07 PM revealed the Nutrition Note by Dietary Consultant Staff HH from 08/22/22. Physician extender Consultant Staff JJ included a handwritten note Recently started on [MEDICATION(S)] (antidepressant medication) For depression, we are continuing to monitor. Continue with Plan of Care with protein supplements. The handwritten note lacked a date signed by physician extender JJ. On 09/13/22 at 01:45 PM, CNA S stated R20 ate 50 percent of her lunch today. On 09/15/22 at 08:02 AM, R20 was in her room in bed, with juice and milk in front of her on her overbed table, and the staff had not served her breakfast yet. On 09/15/22 at 08:03 AM, R20 stated she wanted to lose weight, she did not have a goal weight in mind, did not know what her current weight was, but thought the staff weighed her recently. R20 stated sometimes she does not eat the meat served because she cannot chew it and believed she had talked to the dietician about that. On 09/15/22 at 08:26 AM, Certified Medication Aide (CMA) R confirmed R2 received pancakes, bacon, and cream of wheat for breakfast and was not served yogurt. The facility failed to serve scrambled eggs, sausage, biscuits and gravy, and yogurt. The facility served her bacon, which she preferred not to receive. On 09/15/22 at 08:29 AM, R20 told CMA R she was not going to eat; however, she drank her juice and her milk. On 09/15/22 at 08:30 AM, CMA R stated R20 was Not much of a breakfast eater. On 09/15/22 at 08:35 AM, R20 stated the staff did not serve her yogurt with breakfast, and she likes yogurt, and would eat the yogurt if they (staff) brought it to her. On 09/15/22 at 08:40 AM, Dietary Staff CC stated she did not receive the meal tray tickets for today, she did not know if they had been printed or not, and they usually got new ones every day. The Dietary Manager printed the tickets. On 09/15/22 at 08:43 AM, Dietary Staff BB stated the staff should add the protein powder to the oatmeal or cream of wheat, they try to add it to foods where it would not be recognized. Dietary Staff BB stated when R20 first admitted to the facility, her family brought her in the yogurt. The breakfast meal tray ticket dated 09/15/22 revealed the instructions lacked to serve the yogurt, double meat/eggs, or protein powder. On 09/15/22 at 11:04 AM, Licensed Nurse (LN) F stated she thought R20 had weight loss and she had a lot of [CONDITION(S)] when she first came in. LN F stated R20 had a poor appetite and was particular about what she would eat. LN F stated yogurt was a preference of R20's and sometimes the kitchen would send it out and sometimes there was some available in the fridge, she would not always accept it, and the staff were to offer it to her every morning. LN F stated R20 did not eat much for breakfast and was unaware if the resident was to receive double meat for breakfast or for all her meals. When a diet order changes, the staff should fill out a communication slip and the kitchen should get a copy of it. When the staff are passing meal trays, they should check the trays with the meal tray slip to see if they match. LN F stated R20 would occasionally voice problems chewing. She did not want her diet downgraded in the past, and she declined when offered. LN F stated her diet order included double protein for her wound and her weight loss, she should receive ice cream twice a day with lunch and supper, and super cereal, but was not sure if super cereal was oatmeal or if the kitchen made the cream of wheat as a super cereal. On 09/15/22 at 12:29 PM, R20 received her lunch tray in her room of a single serving of turkey bake, mixed vegetables, biscuit, and cake. On 09/15/22 at 12:30 PM, R20 stated sometimes staff serve her ice cream or sherbet, but was not served ice cream twice a day, every day. The meal tray ticket for the lunch dated 09/15/22, included a regular diet, however, did not include double meat, protein powder, or ice cream, and did include she was to get margarine for her biscuit. On 09/15/22 at 12:36 PM, CNA Q stated when R20 received ice cream, it was when ever it was part of the regularly scheduled meal and had not seen her served any yogurt. CNA Q stated sometimes she delivers the resident's meal trays but had not seen her get double portions of her meat. On 09/15/22 at 12:39 PM, CMA R stated the ice cream order is on the MAR (medication administration record). On 09/15/22 at 12:40 PM, R20 had her napkin over her lunch plate and had not eaten anything. CMA R questioned R2 if she would like something else, offered a peanut butter and jelly sandwich. R20 declined and stated she would like yogurt. On 09/15/22 at 12:43 PM CMA R stated R20 would occasionally refuse her ice cream, but she would usually take it. The order for the super cereal shows up on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/15/22 at 12:48 PM, Dietary Staff BB stated when he received the Diet Order and Communication slip, he would change the order in the computer and just learned on 09/09/22 how to update the tray card slips as someone else entered them before that. Dietary Staff BB confirmed R20's breakfast tray ticket lacked super cereal, double meat portions, no bacon. Dietary Staff BB stated the double meat portions were for breakfast and not the other meals, and he makes super cereal with oatmeal and cream of wheat. R20's super cereal was sent out on her tray this morning and the turkey bake had the protein powder. Dietary Staff BB stated the RD came to the facility twice a month and would generate a report of who to look at such as an annual or quarterly review and the Director of Nursing may also include someone to look at. The RD would send a report after the review and last reviewed R20 on 08/22/22, which she included to add yogurt at breakfast. Dietary Staff BB stated today was the first day the staff had asked for ice cream, however they have a freezer in the break area with ice cream in it. On 09/15/22 at 01:19 PM, Administrative Nurse D stated R20 had gradually been losing weight since she admitted and at one point said she wanted to lose weight and was happy that she was losing weight. Administrative Nurse D stated she did not know if R20 had a goal for her weight loss, did not see a note about a weight loss goal, and staff should document on the care plan if the resident had a desire to lose weight. Administrative Nurse D stated the diet order for double meat would be for every meal, not just for breakfast, and the yogurt was put into place on 07/12/22 from a dietary recommendation. RD recommendations go to her and to Dietary Staff BB. On 09/15/22 at 01:31 PM, Administrative Staff A stated she expected the diet order to be on the tray cards. On 09/15/22 at 03:46 PM, Administrative Nurse D stated she was unable to locate any physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/16/22 at 02:02 PM, Administrative Staff A documented per electronic mail Please find attached the progress note that the NP (Nurse Practitioner) had received and stated she was aware of the weight loss for R20. On 09/19/22 at 10:13 AM, Dietary Consultant HH stated she started working at the facility in June 2022, did not know R20 had a desire to lose weight, and when mentioned to R20 about why she might be losing weight, R20 did not know why and did not mention if she was trying or cutting back on portions. Dietary Consultant HH stated when a resident desired to lose weight she documents that in her notes, visits with the resident about what they typically ate and drank, what their choices were, and goals to make sure they were realistic or not, then followed up the following month. The facility staff would make any changes on the care plan. Dietary Consultant HH stated R20 needed her protein for wound healing, and the note on 08/22/22 was mis-typed and should have read she needed more protein. R20 was not open to more eggs and she did mention that she had been receiving yogurt. Consultant Staff HH stated she w yogurt was already part of her orders, and knew she was on super cereal and ice cream. Dietary Consultant HH stated the dietary orders should be on the tray tickets and the staff should follow the diet order. Dietary Consultant HH stated her understanding, as she had not observed a meal tray pass, was the staff were to check the ticket with the diet served to make sure they matched. R20 should be served biscuits and gravy every breakfast along with sausage, super cereal, scrambled eggs, and yogurt. The staff not following the dietary order could have contributed to the resident's weight loss. On 09/19/22 at 10:34 AM, the physician extender JJ stated she did not know of R20's weight loss prior to last week. She expected the facility to inform her of R20's desire to lose weight, expected the RD to be involved in a plan for weight loss, and the facility should follow the diet order. There should be a weight loss goal, or the facility should keep an eye on the weights. She recently started R20 on some medication for her mood, the facility should have contacted her sooner about the weight loss, and did not recall receiving any notes about the weight loss from a RD. Furthermore, nutrition was important for the resident due to her wound. The facility policy Weight Assessment and Intervention dated 07/2022, included the Interdisciplinary team (IDT) would strive to prevent, monitor, and intervene for undesirable weight loss or gain for residents. Any weight change of five pounds or more (pounds) since the last weight assessment would be retaken the next day for confirmation. If the staff verified the weight change, the RD would be notified per facility protocol. The threshold for significant unplanned and undesired weight change would be based on the following criteria: 1. In one month, a five percent change would be significant, greater than five percent would be severe. 2. In three months, a 7.5 percent change would be significant, greater than 7.5 percent would be severe. 3. In six months, a 10 percent weight change would be significant, greater than 10 percent would be severe. If the weight change was desirable, staff would document this and no change in the care plan would be necessary. The IDT would analyze the assessment information and conclusions would be made regarding the resident's target weight range and whether and to what extent weight stabilization or improvement could be anticipated. Approximate calories, protein, and other nutrient needs compared with intake, and relationship between current medical condition or clinical situation and recent fluctuations in weight. The IDT team would identify conditions and medications that could be causing anorexia (loss of appetite), weight gain, or increasing risk of weight loss. The care plan should address the identified cause of the weight change, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Interventions for undesirable weight change should be based on resident choices and preferences, nutrition and hydration need, chewing and swallowing abnormalities and the need for diet modifications, and the use of supplementation. If a resident declined to participate in a weight loss goal, documentation would include the resident's wishes. The facility failed to involve the Registered Dietician with R20's desire to lose weight, failed to appropriately monitor weight, and failed to ensure the physician was aware of significant weight loss, which occurred three different months for R20 who had a stage four pressure ulcer. This included a 10.96 percent loss in one month from 03/31/22 to 04/29/22, a 10.6 percent loss in one month from 05/23/22 to 06/30/22, and a 23.55 percent loss from 03/31/22 to 09/03/22.

The facility reported a census of 68 residents with 22 selected for review, which included six residents reviewed for medication use. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 24, remained free from a significant medication error when staff failed to administer antihypertensive medication (a drug used to lower blood pressure) as ordered by the physician on 117 instances between 07/05/22 through 08/21/22. This failure resulted in a hypertensive crisis (a severe increase in blood pressure that can lead to a [CONDITION(S)], stroke, or other life-threatening health problems), which required hospitalization intervention/treatment. Findings included: - Review of Resident (R) 24's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with intact cognition The Care Plan, dated 07/17/22, instructed staff to know the resident had a renal transplant and staff were to administer medications as ordered by the physician. The care plan further instructed staff to notify the charge nurse of elevated blood pressures. On 07/05/22, the resident's physician instructed staff to administer the antihypertensive medication [MEDICATION(S)] HCL ([MEDICATION(S)]) 0.1 mg (milligram), every eight hours, as needed for blood pressure readings of systolic (the first number which is the amount of pressure in the walls of the artery when the heart beats) of greater than 160 mmHg (millimeters of mercury) or a diastolic (the second number which indicates the amount of pressure in the arteries when the heart is resting) of greater than 100 mmHg. The physician instructed staff the medication should not be administered concurrently with other PRN (as needed) antihypertensive agents. On 07/05/22, the resident's physician instructed staff to administer the antihypertensive [MEDICATION(S)] HCL ([MEDICATION(S)]) 50 mg, two tabs, four times a day. Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] Between 07/05/22 and 07/31/22, the systolic blood pressure was greater than 160 mmHg on 72 occasions. Between 08/01/22 and 08/21/22, the systolic blood pressure was greater than 160 mmHg on 39 occasions, and the diastolic blood pressure was greater than 100 mmHg on six occasions. These readings corresponded to the blood pressures documented on the Blood Pressure Summary tab. Review of the blood pressure readings on 08/20/22 revealed the following: At 09:00 AM, the resident's blood pressure was 188/93 mmHg, and staff failed to administer the PRN [MEDICATION(S)]. At 01:00 PM, the resident's blood pressure was 178/89 mmHg, and staff failed to administer the PRN [MEDICATION(S)]. At 05:00 PM, the resident's blood pressure was 180/80 mmHg, and staff failed to administer the PRN [MEDICATION(S)]. At 08:00 PM, the resident's blood pressure was 180/80 mmHg, and staff failed to administer the PRN [MEDICATION(S)]. On 08/21/22 at 09:00 AM, the resident's blood pressure was 168/75 mmHg, and staff failed to administer the PRN [MEDICATION(S)]. A Nurses' Note, dated 08/21/22 at 12:00 PM, documented the resident had a severe headache with a blood pressure reading of 213/83 mmHg. Staff sent the resident to an acute care hospital. (The resident admitted to acute care on 08/21/22 at 04:11 PM and discharged to the facility on [DATE] at 12:00 PM) The Discharge Summary, dated 08/22/22, indicated the resident admitted to the acute care hospital on 08/21/22 at 04:11 PM, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged from acute care on 08/21/22 at 12:00 PM. Interview on 09/12/22 at 10:41 AM, with the resident, revealed he did not think staff administered his medications accurately. The resident stated he did not remember the details of the recent acute care hospital admission, but stated he did have a severe headache, which resolved while in acute care. Observation on 09/13/22 at 05:30 PM revealed Certified Medication Aide (CMA) S obtained the resident's blood pressure as 183/91 mmHg, prior to administering scheduled [MEDICATION(S)]. CMA S stated he would notify the nurse of the resident's blood pressures, so the nurse could administer the PRN [MEDICATION(S)]. Interview on 09/13/22 at 05:45 PM with Licensed Nurse (LN) H, revealed he would repeat the blood pressure to ensure accuracy, before administering the PRN [MEDICATION(S)] but did not administer the medication as the repeated blood pressure was 156/92 when repeated twice. Interview on 09/15/22 at 11:30 AM with Administrative Nurse D, revealed the nursing staff voiced confusion regarding the administration of the PRN [MEDICATION(S)] and did not administer the [MEDICATION(S)] for blood pressures outside of the parameters. Administrative Nurse D stated she expected staff to request clarification from the physician regarding when to administer the PRN [MEDICATION(S)], as staff took the resident's blood pressure prior to the administration of the scheduled [MEDICATION(S)], four times a day, and staff did not know if they should administer the PRN [MEDICATION(S)] with the (scheduled) [MEDICATION(S)]. Interview on 09/15/33 at 12:30 PM with Administrative Staff A, revealed the resident was kept in observation status and returned to the facility the next day, on 08/22/22. Interview on 09/15/22 at 03:30 PM with physician GG, revealed the resident required intensive care unit for intravenous drip infusion of medication to lower his blood pressure. Physician GG stated the facility did not administer the PRN [MEDICATION(S)] as ordered, which led to the resident having a hypertensive emergency. Interview, on 09/16/22 at 10:30 AM, with consulting pharmacy staff II, revealed he did not assess the resident's blood pressures for the administration of the PRN [MEDICATION(S)], but would have recommended staff to clarify the order for the PRN [MEDICATION(S)] to administer it with the scheduled [MEDICATION(S)]. The facility policy PRN Orders, revised 08/2010, instructed staff the PRN order must clarify circumstances for staff to give the medication, in as much detail to give the medication properly. The facility failed to administer and or clarify the order for the antihypertensive [MEDICATION(S)] PRN, as ordered by the physician for R24, with a kidney transplant and hypertensive heart disease, which resulted in a hypertensive emergency. R24 required hospitalization transfer, intensive care monitoring, and intravenous medication to decrease his blood pressure.

The facility reported a census of 68 residents. Based on observation, interview and record review the facility failed to handle, store, process and transport linens to prevent the spread of infection for the residents of the facility. Findings included: - On the laundry tour, on 09/15/22 at 07:58 AM, with Maintenance/Laundry Director staff U, explained that the laundry staff had not arrived for work so the laundry tour would in effect demonstrate how the laundry was left by the laundry staff the previous evening. The tour with maintenance/Housekeeping Director U revealed the following concerns: 1. The washing machine was full of clothes. 2. The vinyl floor throughout the laundry was heavily soiled. 3. The soiled laundry room had four plastic bags of soiled laundry directly on the floor. 4. The soiled laundry sorting area with three uncovered barrels of soiled laundry had linen spilling over the sides of the barrels. 5. The laundry room walls in the clean linen processing area had loose peeling sheet rock with multiple holes in the sheet rock, which created an unsanitizable surface. 6. Corroded hot water pipes extended from the wall in the clean linen processing area. 7. Multiple shelves were made of bare wood, and used to store clean linen, which could not be sanitized. 8. The dryer room with peeling paint from the ceiling. 9. Two dryers with a thick coating of lint over the filters. 10. Clothes were inside the dryer tumble cage from the night before. 11. The linen cart used to transport clean linen throughout the facility with a worn unsanitizable shredded cover. 12. Two rolling baskets/carts used to transport linen with broken unsanitizable rubber gasket around the top of the baskets, which was in direct contact with clean laundry. On 09/15/22 at 08:25 AM, Maintenance/Laundry Staff U, confirmed the above findings. He stated he did not know if the clothes had been left wet in the washing machine or was preloaded to start processing. The staff had not deep cleaned the floor in six months to a year and the laundry staff had not cleaned the floor or lint filters from the night before as they should. He stated he expected staff to clean the dryer filters every three loads and at the end of each shift. He reported the facility was undergoing renovation, but he was not aware of a scheduled renovation of the laundry area. Maintenance laundry staff U stated it was not appropriate for staff to leave laundry in the washer or dryer overnight, that all linen should be fully processed prior to staff leaving for the day. Additionally, he reported the soiled linen should be contained to prevent cross contamination and the spread of infection. The facility lacked a policy to address the processing and maintenance of the laundry to prevent cross contamination and the spread of infection. The facility failed to handle, store, process, and transport linens to prevent the spread of infection for the residents of the facility.

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. Findings included: - During the initial tour of the kitchen on [DATE] at 10:10 AM, Dietary Staff EE was cleaning the refrigerator in the kitchen using a sanitizing solution. Testing of the cleaning solution, at that time, revealed 0 ppm result when checked with a test strip. The liquid sanitizing solution the staff used to sanitize the refrigerator lacked any actual sanitizing solution in the water. On [DATE] at 10:12 AM, Dietary Staff EE stated the solution should be between ,d+[DATE] ppm and she had made the cleaning solution five to 10 minutes prior to this testing. Dietary Staff EE stated she checks the cleaning solution twice during her shift. Dietary staff EE made a new solution which tested at ,d+[DATE] ppm. On [DATE] at 11:34 AM, Dietary Staff EE was placing the pureed cake from the mixer into a bowl upon entry into the kitchen to observe pureed diet meal prep. On ,d+[DATE] 22 at 11:39 AM. four live flies noted in the kitchen, landing on serving bowls and a cake that was being cut into pieces for lunch. On [DATE] at 12:09 PM, a dead fly floated in the water of a steam table pan. On [DATE] at 03:03 PM, the kitchen tour revealed the following concerns: 1. The hall trays stacked together and stored on a metal shelf ready for use had moisture between them. 2. The three - compartment sink under the wall air conditioner had chipped floor tile below it. The air conditioner above it had dirty vents and the windowsill under it had a black powder substance covering it. 3. The metal shelf above the stove had debris and grease on it, with darkened oil -appearing runs on the front side of the shelf. 4. The knife holder on the wall had dust build-up across the top by the holes where the knives inserted to be stored. 5. The stored plates stacked together ready for use had moisture between them. 6. The trays under the stored plastic bowls contained crumbs over them. 7. The vent near the steam table had lint build-up around the edges. 8. The ceiling by the light above the microwave area had a crack approximately one-and-a-half feet long. 9. The ceiling vent by the refrigerator had lint build-up. 12. The west side unit refrigerator, near the nurse's desk had debris over the top and in the inside of it also. On [DATE] at 04:07 PM, observation of the kitchen area revealed the following areas of concern: 1. A layer of dust to the top of the refrigerator. 2 .Inside of the refrigerator had a dried yellow/brown substance at the bottom and on the three shelves of the door. 3. An opened bottle of salad dressing lacked a opened date. 4 .Under the sink of the counter in the dining room was a measuring cup uncovered which lacked a date of the white powder substance. 5. The cabinet under the sink had a dried brown liquid spill and sawdust. The cabinet contained a box of disposable straws. On [DATE] at 04:16 PM, observation of the dining/kitchen area near the east nurse's station revealed a note on the refrigerator that read Nutrition staff responsible for cleaning daily. Further observation of the area revealed the following concerns: 1. The refrigerator contained a 32-ounce container of expired plain yogurt. 2. In the door of the refrigerator there were two uncovered plastic cups, which lacked a date, of a dried white substance. 3. The door of the refrigerator had two undated, opened bottles of salad dressing and an undated opened bottle of mayonnaise. 4. There was a square container of an unknown food substance that lacked a date. 5. One undated round refillable bottle of what appeared to be salad dressing. 6. A covered plate lacked a date, which contained a dry piece of meat loaf, mashed potatoes, and green beans. 7. An undated plastic bag of what appeared to be cut up pieces of cantlope with an orange liquid at the bottom of the bag. 8. A foam container with plastic lid with a red liquid was undated. 9. A round plastic container with a red lid that was loose contained dried shredded meat and with eating utensils inside of it. 10. A small plastic undated container with a light orange colored liquid in it. 11. Three individual slices of cheese lacked a date located in the bottom left drawer. 12. The microwave on the counter had 3 areas of finish missing on the inside frame where the door rests against it exposing rust. The inside of the microwave had multiple brown splatters on the inside, the turntable had a large area of a yellow/orange substance, the top of the microwave had debris on it and the door had multiple dried smears on the inside. 13. In the drawer below the microwave was an undated, uncovered, measuring cup with a white powder substance in it. 14. The cabinet below the sink had a dried brown liquid spot and sawdust. On [DATE] at 04:31 PM, Dietary Staff BB stated he thought the white powder was thickener. Dietary Staff BB became aware of the concern issues in the area at this time and reported not being aware dietary staff were responsible for cleaning the refrigerator. The facility policy Sanitization dated ,d+[DATE] revealed all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Sanitizing of environmental surfaces must be performed with one of the following solutions: 1. ,d+[DATE] ppm chlorine solution. 2. ,d+[DATE] ppm quaternary ammonium compound (QAC). 3. 12.6 ppm iodine solution. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. The facility policy Food Safety Storage dated ,d+[DATE] revealed food will be stored and protected in a safe sanitary manner and in accordance with the Food Code. Dietary employees will maintain clean food storage areas at all times. Wrap, cover or seal all refrigerated foods and label and date per Food Code guidelines. Once opened, foods that have been stored in dry storage should either be refrigerated or sealed in airtight containers and returned to dry storage. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility.

The facility reported a census of 68 residents. Based on observation, interview and record review, the facility failed to maintain an effective quality assurance committee that identified, developed and implemented appropriate intervention plans of action in a timely manner to ensure the residents received adequate needed quality care from the facility. Findings included: - Interview, on 09/15/22 at 01:41 PM, with Administrative Staff A, revealed the facility Quality Assurance Committee met monthly and the last meeting was on 09/2021. Administrative Staff A revealed the committee identified concerns with pressure ulcers, restorative and therapy communication issues, maintenance and housekeeping issues, and food temperatures. However, these areas were not corrected with the QAA interventions as the resurvey included these areas and others as reflected below: 1.) Refer to F 561: The facility failed to provide individual choices for the one sampled dependent Resident (R)55 related to his preferences for clothing selection 2.) Refer to F F677: The facility failed to ensure three of the sampled residents, Resident (R)4, R39, and R46, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of their fingernails. 3.) Refer to F 684: The facility failed to coordinate care between hospice services and the facility to ensure the resident's advance directive for no resuscitative measures determined and carried out. 4.) Refer to F 686: The facility failed to provide treatment to Resident (R)43 in a timely manner to a pressure ulcer on the coccyx (the area below the sacrum commonly known as the tailbone), failed to ensure a dressing was in place and the air mattress settings were correct for R20 who had a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer of the sacral (area of the lower back near the spine) region, failed to ensure R11's who admitted with a stage four sacral wound and acquired an unstageable pressure area due to eschar to both heels that the air mattress was at the appropriate setting. Additionally, the facility failed to implement interventions and turn/reposition appropriately for R113 who developed an unstageable and a stage two pressure ulcer and failed to ensure R30's heels were positioned appropriately, had an air mattress in place, and failed to turn/reposition appropriately resulting in development of deep tissue injuries to bilateral heels. 5.) Refer to F688: The facility failed to ensure five of the seven sampled residents received restorative nursing services to increase range of motion, prevent further decrease in range of motion, and/or prevent decrease in mobility. Resident (R)16 received therapy services and then no restorative nursing services and declined in range of motion and walking ability; R112 who received no restorative services after therapy; R34, R30, and R12 for no restorative nursing program when they had range of motion impairments. 6.) Refer to F 689: The facility failed to ensure safe transfer techniques for one resident (R) 34 of the four residents reviewed. 7.) Refer to 690: The facility failed to ensure one of the two residents, Resident (R)20's catheter drainage bag remained below bladder level and failed to drain the catheter bag in a sanitary manner to prevent urinary tract infection. 8.) Refer to 692: The facility failed to ensure adequate parameters of nutritional status for one of the two residents reviewed. The facility failed to ensure Resident (R)20 received her diet as ordered, failed to involve the Registered Dietician with R20's desire to lose weight, failed to appropriately monitor the resident's weight, and failed notify the physician of the significant weight loss. R20 experienced a 10.96 percent weight loss from 03/31/22 to 04/29/22, a 10.6 percent weight loss from 05/23/22 to 06/30/22, and a 23.55 percent weight loss from 03/31/22 to 09/03/22. 9.) Refer to F 695: The facility failed to provide appropriate respiratory care to maintain respiratory equipment to prevent the spread of infection, for the one sampled Resident (R) 55. 10.) Refer to F 698: The facility failed to coordinate [CONDITION(S)] (a process that filters wastes and fluids from the body when the kidneys fail) care of pre and post weight assessments and details of the [CONDITION(S)] sessions with the [CONDITION(S)] provider as required for five of the five residents reviewed, 02 Resident (R)53, R41, R118, and R262. 11.) Refer to F 760: The facility failed to ensure Resident (R) 24, remained free from a significant medication error when staff failed to administer antihypertensive medication (a drug used to lower blood pressure) as ordered by the physician on 117 instances between 07/05/22 through 08/21/22. This failure resulted in a hypertensive crisis (a severe increase in blood pressure that can lead to a [CONDITION(S)], stroke, or other life-threatening health problems), which required hospitalization intervention/treatment. The facility policy Quality Assessment and Performance Improvement Plan and Program reviewed 09/2020, instructed staff the facility shall develop implement and maintain an effective comprehensive data driven Quality Assessment and Performance Improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life. The facility failed to maintain an effective quality assurance committee that identified, developed and implemented appropriate intervention plans of action in a timely manner to ensure the residents received adequate needed quality care from the facility.

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas including rooms, bathrooms and in a shower room. Findings included: - A brief tour of resident rooms and care areas beginning on 09/15/22 at 09:13 AM, revealed the following areas of concern: Five bathrooms with caulking missing/cracked/dirty around the toilets. Two rooms with gaps in the tile and debris present in the gaps. Five resident bathrooms with dirty floors. Two bathrooms with a dirty toilet. One room with an approximate 6 inch by 6 inch, hole in the wall. Five rooms with chipped paint to the doorways. One room with peeling wall paint. One room with a wash basin and bedpan stored directly on the floor. One room with a urinal dated 07/26/22, stored in a bag, with yellow liquid at the bottom of the bag. One of the shower rooms had rust-colored caulking around the toilet, a slow drip from the sink, the toilet had water running in the bowl, a darkened color between the tiles near the toilet, and the doorway had chipped paint. On 09/15/22 at 09:35 AM, Maintenance Staff U stated the facility utilized a TELS work order system. Sometimes the staff would just tell him, and he would put the work order in or just go fix the problem. On 09/15/22 at 10:07 AM, Maintenance Staff U stated he was not aware of the dripping sink or the running toilet in the shower room. He was hoping they would be getting new bathroom floors, but there was not a plan written about needed repairs. On 09/16/22 at 12:52 PM, Administrative Staff A stated a repair log was done on 08/15/22 and taken to the QAPI (quality assurance performance improvement) meeting on 08/25/22. The log was an ongoing log that they continue to update with new areas of concern or ongoing projects identified as areas that need addressed. The facility does a full repair log sweep monthly and updated the log prior to QAPI meetings. Review of the Repair Log lacked dates the staff identified the items, lacked estimated goal date, and lacked completion date. The shower room listed included a running toilet, which during tour Maintenance Staff U was not aware of the issue. The facility policy Safe, Clean, Comfortable, Homelike Environment dated 06/2022 revealed the residents have a right to a safe, clean, comfortable environment and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order. The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in these resident areas.

The facility reported a census of 58 residents. The sample included 17 residents, with four residents selected for nutritional review. Based upon observation, interview, and record review the facility, after identifying weight loss, failed to implement the registered dietitian's recommended interventions for one month, to prevent additional continued weight loss for one of the four sampled residents, Resident (R) 51. The failure to implement the recommendation resulted in further significant weight loss of 8.05% in 43 days- from 01/04/21, when R51 weighed 136.5 pounds to 02/16/21 when R51 weighed 125.5 pounds. Findings included: - A signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS), dated [DATE], documented R51 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. She received a mechanically altered therapeutic diet and required limited assistance of staff for eating. She experienced unplanned, significant weight loss and weighed 137 pounds. The Nutritional Status Care Area Assessment, dated 02/16/21, documented the Registered Dietitian recommended a Magic Cup (a frozen nutritional supplement) with meals. R51's Nutrition Care Plan dated 01/15/21 included the Registered Dietitian recommendation of a Magic Cup with meals. A Patient at Risk (PAR) Progress Note dated 01/09/21 documented R51's significant weight loss of 7.3% in one month and 10.3% weight loss in 180 days. A Registered Dietitian Nutritional assessment dated [DATE] documented R51's weight loss as 15 pounds in 90 days and provided a new recommendation for Magic Cup with each meal. A Nutrition Evaluation Progress Note dated 01/14/21 documented the resident weighed 136 pounds. Nutritional recommendations included a Magic Cup with meals three times a day. A physician order, dated 02/17/21, instructed staff to provide the resident with a Magic Cup, three times a day, with meals, for weight. The Vitals Section of the Electronic Medical Record (EMR) revealed the resident's documented weights for review. On 01/04/21, the resident weighed 136.5 pounds and on 02/16/21, he weighed 125.5 with an 11 pounds weight loss (8.05% in 43 days). On 02/23/21, (six days after the staff implemented the nutritional supplement to the resident), her weight increased to 128 pounds, and on 03/02/21, (13 days after the staff implemented the nutritional supplement) her weight increased to 131 pounds. On 03/02/21 at 07:53 AM, R51 fed herself breakfast, and ate 100% of the Magic Cup. On 03/04/21 at 08:18 AM Dietary Staff CC stated she was usually present when the Registered Dietitian saw residents, so she was aware of the recommendations made at that time and updated the residents' care plans. The Dietitian sent the recommendations to the Director of Nursing, who notified the doctors to obtain orders. Dietary staff could offer an appropriate supplement for a day to see if the resident would accept it. However, a doctor's order was required before Dietary staff could routinely provide a supplement. On 03/04/21 at 09:42 AM Registered Dietitian BB stated the Interdisciplinary Team (IDT) met weekly to review residents with significant weight loss and put interventions in place. She assessed the residents, looked at those interventions, and made additional recommendations. She sent a report containing all the recommendations to the Director of Nursing, and the recommendations were usually implemented within a few days. Normally the Director of Nursing followed through by just using the Registered Dietitian's report to notify the doctors and to obtain orders for the recommendations. However, she did not put R51's Magic Cup on the recommendations report. That was why the staff failed to implement the recommendation for the Magic Cup in January. R51 should have had the Magic Cup starting 01/14/21, or within the few days following. She further confirmed that not offering R51 the Magic Cup led to the additional weight loss. On 03/04/21 at 11:41 AM, Administrative Nurse D stated the Magic Cup was not initiated in January because it did not appear on the Dietitian's recommendations report. The Dietitian completed nutritional assessments, usually assisted by the Dietary Manager. Administrative Nurse D further explained she was not aware of the complete list of residents reviewed by the Dietitian. A resident with a ten-pound weight loss in one month would be someone she would ask the Dietitian to review. Administrative Nurse D expected to receive a recommendation for a resident she asked her to review. Administrative Nurse D stated she could go in and view progress notes. However, she did not normally do that because she used the dietician's report, which listed the dietary recommendations. She further stated she used the report as a guide to communicate with the doctor. When there was a recommendation for a supplement such as Magic Cup, the facility sent a telephone order to the doctor for them to sign. Orders would be entered in the electronic charting system, and she would then tell the Dietary Manager that it was done so the supplement could be provided to the resident. A facility policy titled Nutrition (Impaired)/ Unplanned Weight Loss Clinical Protocol, dated 02/2020, documented the threshold for significant unplanned and undesirable weight loss will be five percent weight loss in one month. Greater than five percent is severe. Dietitian will assess and recommend the appropriate diet for the resident. Strategies to increase a resident's intake may include providing nutritional supplements. Closely monitor residents who have been identified as having impaired nutrition. Such monitoring may include evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals. The facility delayed implementation of an intervention to manage significant weight loss for R51 for 15 days, which resulted in further significant weight loss of 8.05% in 43 days.

The facility had a census of 60 residents, with three residents reviewed for elopement (to leave a locked or secured psychiatric institution without notice or permission). Based on observation, record review, and interview the facility failed to provide the necessary supervision for one cognitively impaired resident who left the secured memory unit of the facility through an unlocked gate and walked unsupervised outside of the facility, approximately 20 yards of grass onto the adjoining store parking lot without staff knowledge. The facility did not know Resident (R) 1 was outside of the facility for approximately ten minutes, when the local police department returned the resident to the facility. This placed R1 in Immediate Jeopardy. Findings included: - The signed Physician order [REDACTED]. The Admission/5-day Minimum Data Set (MDS), dated [DATE], documented the resident admitted [DATE]. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score which was not obtained as the resident was rarely/never understood and indicated he had a severely impaired cognition. The MDS documented the resident wandered one to three days of the look back period. The resident's functional status documented the resident needed supervision with walking and locomotion. He did not use any mobility devices and no history of falls. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/29/20, triggered due to the resident's short term/long term memory problem, BIMS score, life decision making skills, severely impaired cognition, and wandering. The resident's Baseline Care Plan, dated 09/17/20, documented to minimize the risk of elopement and provide resident safety the resident would be on a secure unit. The resident's Care Plan, revised on 10/10/20 (after the resident wandered unsupervised from the facility), documented the resident was at risk for elopement due to his wandering. The resident did exit seek and had history of elopement at the facility and had a history of [REDACTED]. Staff were directed to try to anticipate the resident needs, validate his thoughts, and redirect him as possible. The staff were to intervene as necessary to protect the rights and safety of others, to approach and speak to him in a calm manner, divert his attention, and remove from situations and take to alternate location as needed. The resident became agitated and combative with staff when they attempted to redirect him. Staff were directed to back off, monitor for safety, and make sure the unit doors were locked/secured. Monitor him when he wandered and provide one to one to keep him safe. The resident's Wandering and Elopement Risk Evaluation dated 09/17/20, identified the resident at a low risk of elopement, with a score of nine. The residents Wandering and Elopement Risk Evaluation dated 10/09/20, identified the resident at a moderate risk of elopement with a score of 16. The resident's Admission Note in the EMR, dated 09/17/20 at 10:32 PM, documented the resident was a new admission, who had a history of [REDACTED]. The resident was alert and confused. The Progress Note dated 10/09/20 at 10:19 PM, documented the Licensed Nurse (LN) G exited the back secured unit through the dining room door at approximately 06:40 PM to go to the COVID unit for an emergency with another resident. When the LN G exited, she ensured the dining room door on the secured unit locked and noted the resident had started to wander. The note revealed that another resident (R4) was outside smoking at that time. The emergency medical services (EMS) team arrived for another resident in the COVID (coronavirus) unit at approximately 06:50 PM. At the time of the EMS arrival, documentation revealed the outside gate to the secured courtyard was locked. The RN opened the gate for the EMS team to enter the facility to transport the other resident. EMS left at 06:57 PM. The RN did not see R1 outside when she locked the gate after their departure, or when she entered the ACU (secured memory unit). At approximately 7:00 PM, the police department phoned the facility and inquired if the resident lived at the facility. The local police department transported the resident back to the facility at approximately 07:00 PM. R1 had previously wandered in the hallway and into other residents' rooms prior to the resident leaving the facility unsupervised. Observation on 10/13/20 at 11:15 AM revealed the resident in his room folding his clothing and stacking the clothing on the bed. He appeared alert and he stood and walked independently with steady balance. Observation on 10/13/20 at 12:00 PM revealed the resident went to the doorway of his room, leaned against the door frame, and watched people in the hall for a short while, then returned into his room. Observation, on 10/13/2020 at 5:15 PM, revealed the area was in business district with other facilities, a hospital, gas station and four lane road with a speed limit of 30 miles per hour. On 10/13/20 at 11:16 AM Certified Nursing Assistant (CNA) M reported the resident was able to walk independently. Staff would keep eyes on him 24/7 (24 hours/7 days a week), and check on him every two hours to make sure he used the bathroom. He packed his clothing, but, did not ever exit seek. Staff received a call from someone stating R1 was at Wal-Mart next door, and the police brought him back to the facility. He was on the back hall. The only way out was the side door, off the back-hall dining room, and out the gate by the trash cans. The door and the gate had a keypad code on the inside. The dining room door had a green push button, but management changed it when this happened. The dining room now had to be locked with a key. The only people who used the gate were the charge nurse and EMS. CNA M stated EMS came for someone on the COVID unit. The nurse was going back and forth to the COVID unit, and to get there you must go out the dining room door. All the doors are locked and alarmed and have key codes to get out and in. CNA M revealed that R1 did not know the code nor how to put it in. If R1 would have pushed on the door for a long time it would have alarmed. On 10/13/20 at 12:28 PM, CNA O reported during the day shift, on the day he eloped, R1 was anxious to get his belongings and go home. The resident became anxious and would get his belongings daily. He had dementia and did not understand he was not safe at home. He would exit seek at times, pack his belongings, and say he wanted to go home. When he went to the door, we tried to redirect him back to the community, give a drink and/or snack, take to him to his room, and try to verbally remind him where he was. CNA O verified the courtyard gate should be locked. On 10/13/20 at 01:27 PM CNA P reported around 06:10 PM, R1 was by the back-hall dining room. He was screaming and yelling and had all his stuff in his hands. He let me put his stuff in his room and R1 sat in the dining room while staff finished putting the other residents to ready for bed. CNA P revealed around 06:50 PM or 06:55 PM, she and CNA Q took the trash out, and did not see R1 leave the building. We take the trash out the front door of the secured unit. CNA P further stated she saw R1 around 06:30 PM or 06:40 PM. On 10/13/20 at 02:25 PM CNA Q reported around 06:30 PM to 06:40 PM, she observed the resident with his belongings in his tote and he stood in the hall. CNA Q revealed the nurse was on the COVID side and she did not hear a door alarm sound. On 10/13/2020 at 02:54 PM, CNA S reported she never heard any door alarms when the resident left the facility's secured area unattended. On 10/13/20 at 3:04 PM LN G reported on the night of the elopement, R1 wandered in and out of other resident's rooms and was agitated. She recalled R4 was outside around that time at 6:55 PM. Staff received a call, at approximately 7:00 PM from the police department stating the resident was with them. LN G reported staff did not hear any alarms at any time, so would have to assume R1 went out when R4 came in from smoking. LN G stated the gate did not get closed after EMS left. On 10/13/2020 at 02:39 PM, Administrative Staff A reported, staff was unable to determine how the resident left the facility. The alarms worked and the doors should have been locked. Staff speculated maybe when R4 came back inside from smoking, the resident went outside. The facility's policy titled, Elopement F689, revised 08/20, documented staff should evaluate, investigate, and report all cases of missing residents. Upon admission and quarterly, each resident should be evaluated for elopement and wandering risks. Evidence for such would be documented, interventions would be initiated, reviewed and modified, based upon the resident's risk. The facility failed to provide adequate supervision for this cognitively impaired resident, who resided in the locked memory unit, who left unattended, through an unlocked gate without staff knowledge. This deficient practice was cited as past non-compliance when the facility completed the following on 10/10/2020 at 07:30 PM 1. Education provided to all staff on elopement, call lights, door and gate being secured on 10/10/2020 at 02:00 PM. 2. The facility provided one-on-one with the resident from 10/09/2000 at 7:00 PM until 10/12/2020 at 11:00 AM. 3. The facility installed a secure lock with a code on the secured unit dining room door and removed the push button entry on the outside on 10/09/2020 at 07:30 PM, disabled the push lock and installed the lock on 10/10/2020 at 12:00 PM. 4. The facility notified the Medical Director and conducted a quality assurance/performance improvement (QAPI) plan on 10/11/2020 at 1:00 PM. 5. The facility had the resident on fifteen-minute checks starting on 10/09/2020 at 07:00 PM to 10/12/2020 at 11:00 AM. 6. The facility staff check the gate on the courtyard to ensure it was locked every fifteen minutes from 10/09/2020 at 7:00 PM to present time.

The facility reported a census of 63 residents and identified 34 residents for whom the facility managed personal funds, within the resident trust account. Based on interview and record review, the facility failed to ensure no exploitation of the personal funds of one Resident (R ) 1, of the 34 residents, when on 11/12/18, without any input from the cognitively impaired resident's family, the facility staff ordered a bed and foam mattress for the resident, in the amount of $1,166.28 and listed it as a personal need item on her resident fund account log. The new bed and mattress were identical to the other facility beds. The resident discharged from the facility on 10/30/19 and the bed remained in the facility. Findings included: - The electronic medical record evidenced the facility admitted Resident (R) 1 on 06/21/17. The physician listed [DIAGNOSES REDACTED]. The family set up a personal trust fund account for the resident on admission 06/21/17 with the facility as the payee for her Social Security checks and gave them permission to pay the resident's expenses. The annual Minimum Data Set (MDS), dated [DATE], verified the resident had severely impaired cognition and the resident could not be scored on the cognition evaluation. The resident required extensive assist for all activities of daily living except for eating. The resident received daily antipsychotic and antidepressant medications. The Care Area Assessment (CAA), dated 02/01/19 for cognition included the dementia plan would provide communication with her and/or family regarding her capabilities/needs. In 10/2018, according to R1's Trust Account Records, she received $1,564.00 monthly from social security and her care cost payment to the facility figured by Medicaid as $1,113.00 per month. Additional expenses paid from the account included a $13.00 beauty shop payment weekly and a $97.00 monthly payment for her dental plan. Interviews with two unidentified family members on 11/12/19 at 10:10 AM and 11:00 AM revealed the facility, without family approval, purchased a facility type bed and foam mattress out of the resident's funds for a total invoice amount of $1,166.28. The facility listed the bed and mattress as a personal needs item on the resident's trust account. The family questioned the facility staff and explained they were told the $1,166.28 covered the cost of new bedroom furniture and personal care items. On 11/13/19 at 1:35 PM, with questioning of why the facility bought the resident a bed/mattress on 11/12/18, Administrative Staff A explained the staff had to spend down money for R1 related to her account balance being over the Supplemental Security Income (SSI) limited money amount for Medicaid. The staff bought her clothes, a recliner, and a bed. The staff could not find anything else to spend her money on for her. On 11/13/19 at 02:30 PM, Office Manager B provided a copy of the supply invoice for the facility type bed and foam mattress which totaled $1,166.28 and delivered on 11/20/18 to the facility. On 11/13/19 at 02:45 P.M., Licensed Nurse C verified the bed utilized by the resident remained in the resident's room and was like the other residents' beds in the special care unit. The facility lacked any documented evidence, provided by the facility, that the staff notified the family of the bed/mattress purchase. The account's line item documented this expense as personal need items on the trust fund account ledger. On 11/13/19 at 04:00 P.M., Administrative Staff A verified the facility bought the bed due to the inability of finding anything else the resident needed. The facility's 11/2017, policy for Abuse, Neglect and Exploitation documented . 9.) Exploitation means taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. 10.) Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . The facility failed to ensure no exploitation of the resident's funds account, when the facility made a purchase of a $1,166.28 for a facility type bed/mattress which remained in the facility following the resident's discharge. The facility staff, without discussion with the resident's responsible party, exploited the resident's money in her trust fund account and purchased a facility type bed without consent.

The facility reported a census of 66 residents. The 8 sampled residents included 4 reviewed for accidents. Based on interview and record review the facility failed to ensure a safe transfer for 1 of the 4 residents (#8), when staff used a lift sheet to transfer the resident; the resident fell ; and received a hematoma to the head. Findings included: - Resident # 8 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 9/14/18 MDS (minimum data set) identified the resident with a BIMS (brief interview for mental status) score of 4, indicating severely impaired cognition. The resident required extensive assist with most ADLs (activities of daily living), used a walker and wheelchair for mobility, with no history of falls, and no falls since admission. The 9/14/18 fall CAA (care area assessment) documented he/she was unsteady on his/her feet, and required assistance during transfers. The 60 day MDS, dated [DATE], documented the resident used only a wheelchair with mobility. The 12/27/18 care plan instructed staff as follow: Has functional limitations related to muscle weakness and impaired gait. One to two staff assistance with transfers and use of a gait belt. I will pivot transfer to and from the wheelchair, added 9/10/2018. At risk for falls related to an unsteady gait. Resident witnessed attempting to transfer self and then will kneel down to knees on floor or will sit on the floor. If found on floor, ask him/her how he/she got there and assess for injury, added 10/24/2018. He/she frequently places self on the floor in either a sitting or lying position, dated 12/27/2018. Review of the resident's medical record, revealed the resident experienced falls as follows: 1.) On 10/4/18, no injury, and to set up a toileting plan for the resident. 2.) On 10/28/18, sent to the emergency room , no injury, and to monitor orthostatic blood pressures. (Blood pressures lying/sitting/standing, with a drop) 3.) On 1/21/19, sent to the emergency room and experienced a [MEDICAL CONDITION], and will educate the staff to have a belt or suspenders on the resident. 4.) On 2/5/19, experienced a 5 centimeter raised hematoma on the back of the head, and staff educated on transfer techniques. Nurses' notes, dated 2/5/19 at 11:45 AM, documented the resident slipped from the hands of a CNA (certified nurse aide) during transfer and hit head on the floor. The resident received hospice care and considered an active hospice patient. Licensed nursing staff F assessed the resident and Neuro Checks were initiated. The resident had a 5 centimeter raised hematoma on the back of head/scalp. The resident was to remain in bed at this time receiving end of life comfort care. On 3/4/19 at 9:30 AM, licensed nursing staff D verified being aware that the resident slipped during a transfer with staff, on 2/5/18 and added this would be considered a fall. On 3/4/19 at 10:30 AM, administrative nursing staff B, reported this resident's fall on 2/5/19, was not included on the list of falls (provided to the surveyor) because it was not entered as a fall but an event. Administrative nursing staff B reported, it was not really a fall, he/she just slipped during a transfer. On 3/4/19 at 1:30 PM, direct care staff H reported he/she was with the resident on 2/5/19, and helped with the transfer. Staff H explained that the prior shift said in report the resident's bed needed changed to the hospice bed. Direct care staff H asked direct care staff J and activity staff E to help, because the resident was tall and was dead weight (could not bear any weight to help). The resident had a draw sheet under him/her. We talked about it and activity staff E and I did not think it would work, but direct care staff J thought it would. We had the 2 beds about 3 feet apart. Direct care staff J was at the resident's head and activity staff E had the bottom, it all happened really fast. the resident started shaking and direct care staff J dropped the sheet. Activity staff E and staff H put the rest down (lower body portion). Licensed Nursing staff F was there, he/she checked the resident, and the staff members put the resident back in bed. Direct care staff H further explained the draw sheet went from the resident's shoulders to his/her waist, and when the resident hit the floor his/her eyes opened then rolled back. He/she had a goose egg on back of the head. Direct care staff H reported getting the licensed nursing staff D. Administrative nursing staff B came and asked why the staff moved the resident. Direct care staff H reported telling him/her the staff were told to change the resident's hospice bed. The resident was supposed to be a 2- person transfer with a gait belt, related to a recent [MEDICAL CONDITION]. The resident was actively dying and on pain meds and did not act differently after he/she was dropped. Hospice staff were not there at the time. Direct care staff H added staff do not use lifts on the resident's unit. Staff H further reported the resident was about 6 feet 1 inch tall and weighed about 250 lbs. On 3/4/19 at 2:15 PM, activity staff E, reported he/she went back in the resident's room later (after the fall) and checked on him/her, and the back of his/her head had a quarter sized bump on it. Staff E added no gait belt was used for the transfer and the staff were to use 2/3 people to assist him/her with transfers. On 3/4/19 at 3:50 PM, Direct care staff J reported he/she was in the room with the resident, on 2/5/19, and helped with the transfer. He/she explained the incident on a witness statement which included: Staff J was asked to help transfer the resident to a hospice bed around 11:30 AM. The 3 staff members started to transfer the resident and he/she started to shake about that time. Staff J started to lower the resident to the floor with the sheet and the resident slipped out of his/her hands and hit his/her head and upper back on the floor. The nurse (licensed nursing staff F) rushed over to check him/her and assessed the resident. After the nurse was done the staff members got him/her up and into bed and made him/her comfortable. When the staff members transferred the resident he/she had a draw sheet under the resident from his/her middle back to the legs. The facility's 5/1/11, accident and incident policy, documented the facility defined an accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome. The event may be an accident or a situation that could result in an accident. Accidents/incidents may include, but are not limited to the following: Fall/suspected falls. Injury to resident/patient during handling. The facility failed to ensure the staff provided this hospice resident with a safe transfer, when the staff used a draw sheet to transfer the resident, dropped the resident, who hit his/her head on the floor, and experienced a hematoma to the area.

The facility reported a census of 66 residents, with 3 reviewed for bowel monitoring. Based on interview, observation and record review the facility failed to ensure 2 residents (#1 and #5) received adequate monitoring for bowel function. Resident #1 went without a bowel movement and experienced a fecal (bowel) impaction which required surgical removal with hospitalization . Finding included: - Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/20/18 annual MDS (minimum data set) documented the resident with a BIMS (brief interview formatted status) score of 3, indicating severe cognitive impairment, required extensive assistance with most activities of daily living and was frequently incontinent of bowel. The 9/20/18 quarterly MDS documented the resident was always incontinent of bowel and received scheduled pain medications. The 1/21/19 care plan, revealed the following instructions to the staff with additions on 10/19/18 including: Currently took [MEDICATION NAME] (pain medication) three times a day, and Tylenol extra strength, as needed for pain control. He/she had a risk of constipation related to limited mobility and the use of pain medications daily. Currently took [MEDICATION NAME] and [MEDICATION NAME] for bowels. Staff to notify the nurse if the resident was having difficulty with hard stools, loose stools or abdominal pain. The nurse was to monitor the computer dashboard daily, for the lack of bowel movements and follow-up with the physician as needed. Addition on 10/23/18, included: Document bowel movements in the computer. Review of the resident's documented bowel movement records, from 2/2/19 through 3/4/19, revealed the following: A large loose BM (bowel movement), on 2/2/19. No BMs indicated for 2/3/19-2/5/19. Had 2 medium loose BMs on 2/6/19. Had 2 BMs (1 small/1 medium) on 2/7/19. Had 2 BMs (1 small/1 medium of putty consistency), on 2/8/19. No BMs indicated for 2/9/19-2/13/19. Had 1 small BM, (putty consistency), on 2/14/19. Had 1 small BM, (formed), on 2/15/19. No BM indicated for 2/16/19. Had 2 BMs, (1 medium loose consistency and 1 hard consistency), on 2/17/19. The resident was in the hospital, per documentation from 2/18/19-2/21/19. The nurses' notes, on 2/17/19 at 3:14 PM, documented the resident's abdomen was big and hurting per direct care staff. The nurse assessed the resident and found his/her abdomen distended at the right upper quadrants and hardened. The resident complained of pain during palpation to the area. The resident refused the morning meal and had a large hard BM earlier in the morning. The staff called the physician and received orders to send the resident to the emergency room for evaluation and treatment related to the abdominal distention and pain. The resident left the facility at 1:50 PM. The hospital discharge summary, dated 2/21/19, included: Discharge Diagnosis: [REDACTED]. The resident was sent to the emergency room where a CAT (computerized tomography scan, uses a combination of X-rays and a computer to show more details of the organs, bones, and other tissues of the body in more detail than a regular x-ray) scan of the abdomen and pelvis showed sigmoid volvulus and severe impaction. The resident's abdomen was soft on palpation with distention of the intestines. The patient had chronic constipation. Under Procedures: It documented Surgical Disimpaction. (The stool is gently broken up and pieces are removed until the rectum is empty.) On 3/6/19 at 2:15 PM, physician N reported he/she spoke with the facility almost daily and could not say what was discussed each time or give specific dates. He/she said the facility did have standing orders and it included medications to use when a resident lacked having a bowl movement. Physician N added the facility notified him/her about the resident's lack of bowel movements, and with chronic constipation. The resident received [MEDICATION NAME] for [MEDICAL CONDITION], and it was a drug that also contributed to constipation. Physician N verified the resident went to the emergency roiagnom on [DATE], with a distended abdomen and pain, and had an abdominal CAT scan, but said he/she would need to review the information to say what was found. On 3/7/19 at 9:45 AM, physician N, with further questioning related to an explaination of what a surgical disimpaction was, explained that meant the surgeon put the patient to sleep and then removed the impaction with his/her fingers and/or surgical tools. Continued review of the resident's BM records, following the hospitalization with impaction, included the resident continued to have issues with BMs as follows: Had 1 large formed, normal BM, on 2/22/19. Had 1 medium hard BM, on 2/23/19. Had 1 small soft putty BM, on 2/24/19. Had 2 BMs (1 small and 1 medium), on 2/25/19. No BM indicated for 2/26/19. Had 1 small BM (soft putty consistency), on 2/27/19. Had 1 large BM (loose consistency), on 2/28/19. No BM indicated from 3/1/19-3/3/19. Had 1 medium BM (hard consistency), on 3/4/19. The facility provided standing orders from the physician, dated 1/10/19, which documented the following: All medication orders will have an automatic stop date after 3 days of starting. Nurses must notify the physician of start of a standing order and if the condition has not resolved after three days of treatment with the standing order. The last statement on the form documented: All standing orders expire after one year. The standing orders included the following medication orders [REDACTED] 1.) Milk of Magnesia, (MOM), a laxative, 30 milliliters. every 24 hours as needed. for constipation. 2.) [MEDICATION NAME] Suppository 10 milligrams, per rectum, as needed every 24 hours, if MOM is not effective. DID THEY EVER GIVE ANY OF THE PRNS BEFORE HOSPITAL? On 2/26/19 at 10:45 AM, direct care staff I and O entered the resident's room and spoke to him/her. The staff wore gloves and checked the resident's incontinent brief which was dry. Direct care staff I asked if he/she wanted up and the resident denied and closed his/her eyes again. Direct care staff I reported staff checked the residents every 2 hours and added the resident was incontinent of bladder and bowel, all the time and at times had hard stools. Further questions of what the staff did when the resident's BM was hard, resulted in direct care staff I explaining that the resident's bowel movements were documented in the computer, and the nurse could see it there. On 2/26/18 at 11:30 AM, licensed nursing staff F reported the resident had abdominal distention, but also had active bowel sounds on 2/14/19. The staff reported he/she called the physician's office and gave an update. The computer also gave an update that the resident lacked having a bowel movement for several days, but he/she had one on the day of hospitalization . He/she was eating and drinking okay, and staff F remembered reporting this to the doctor. On 2/26/19 at 11:48 AM, licensed nursing staff D, went into the resident's room, and assisted him/her to raise up on pillows and drink all of the 4 ounces, of the physician ordered thickened juice, with a straw. Staff D explained seeing the resident's juice the staff failed to give the resident at the 10-10:30 snack/drink time. On 3/4/19 at 9:30 AM, licensed nursing staff D reported administrative nursing staff B gives the nurses a list of residents that need a laxative, after checking in the computer. He/she added the computer program would flag when a resident did not have a BM for 2 days, then 3 days, to notify the nurse something needed done. Staff D added the charge nurses monitor it on the weekends. Some doctors had standing orders for laxatives and if a nurse used a standing order he/she was to write it in as triggered, so the staff could document it as given. He/she reported the resident had a BM prior to going to the hospital. On 3/4/19 at 11:00 AM, administrative nursing staff B reported he/she reviewed the residents that need a laxative daily and gave the list to the nurses on each unit, Monday through Friday. He/she added the charge nurses were to pull the information up on the computer on the weekends. At 5:30 PM, administrative nursing staff B further verified he/she did not investigate as to the BMs consistency and amount, because that would take a long time. On 3/4/19 at 1:30 PM, administrative staff A reported the facility had no policy for the lack of having a bowel movement, but used the computer program, to notify the staff, when a resident lacked a bowel moment for 2 and then 3 days. The facility failed to monitor this resident for adequate bowel movements, which resulted in this resident having a fecal impaction that required surgical removal with hospitalization . - Resident #5 admitted the the facility on 7/31/17, with [DIAGNOSES REDACTED]. The 5/29/18 annual MDS (minimum data set) identified the resident with long/short-term memory problems and required extensive assistance with most activities of daily living. The 11/22/18 quarterly MDS documented the resident had severely impaired cognition, per staff assessment, and all ADLs required extensive assistance from staff. The 1/19/19 care plan instructed staff as follows: The resident requires extensive to total assist from staff. The resident is unable to voice the need to toilet, so staff should assist the resident to the bathroom before and after meals, at bedtime and as the resident allows. Additions on 9/13/18 included: I am at risk of constipation, related to use of [MEDICATION NAME] pain medication. I take [MEDICATION NAME] every other day for bowels. Notify the Nurse if the resident is having difficulty with hard stools, loose stools or abdominal discomfort. The nurse will review the computer dashboard daily, for no bowel movements and follow-up with the PCP (primary care physician) as needed. Addition on 10/22/18, included: The resident required 1- 2 staff for check and change if the resident is resistant to toileting. Additions on 2/26/19, included: The resident has potential fluid deficit related to nectar thickened fluids. Encourage the resident to drink fluids of choice. Provide 2-3 fluid options with meals i.e. milk-water-juice. Offer fluids between meals and when in the resident's room providing cares. The resident has a potential fluid deficit related to being on nectar thickened fluids. Review of the resident's BM (bowel movement) monitoring documentation,from 2/2/19 through 2/28/19, revealed the following: 1.) No indication of a BM, from 2/9-13/19, (for a total of 5 days). 2.) No indications of a BM on 2/24-28/19, (for a total of 5 days). On 2/26/19 at 12:30 PM, the resident sat in a wheelchair in the dining room with direct care staff H feeding the resident a pureed diet, with nectar thickened liquids. The resident ate 100% of the food and all the liquids. Activity staff E reported, on 2/26/19 at 12:40 PM, he/she assisted the resident with breakfast and he/she only drank 1/2 of the fluids. Staff E explained the resident's liquids were recently changed to the nectar thickened. Review of the (MONTH) MAR (medication administration record) revealed physician orders [REDACTED]. [MEDICATION NAME] Suppository, 10 milligrams every 24 hours, as needed for constipation, if MOM (milk of magnesia) did not work. On 2/27/19 at 10:30 AM, direct care staff H reported staff document the residents bowel movements in the computer and the resident had constipation at times. On 3/4/19 at 9:30 AM, licensed nursing staff D reported administrative nursing staff B gave the nurses a list of residents that needed a laxative, after checking in the computer. He/she added the computer program would flag when a resident did not have a bowel movement for 2 days, then 3 days, to notify the nurse something needs done. Staff D added the charge nurses monitor it on the weekends. Some doctors had standing orders for laxatives and said if a nurse used a standing order he/she was to write it in as triggered, so the staff could document it as given. Staff D verified the resident's BM record showed several days in (MONTH) this resident had no bowel movement and the standing orders were not administered. On 3/4/19 at 1:30 PM, administrative staff A reported the facility had no policy for the lack of having a bowel movement, but used the computer program, to notify the staff, when a resident lacked a bowel moment for 2 and then 3 days. The facility failed to monitor this resident's bowel movements for adequacy and failed to administer the physician ordered standing orders when needed for constipation.

The facility reported a census of 66 residents with 19 selected for review, including 3 residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure the care and services to prevent the development of an unstageable pressure ulcer for 1 (#49) of the 3 residents sampled for pressure ulcers. Findings included: - Review of resident #49's physician order [REDACTED]. The significant change MDS (minimum data set), dated 12-4-17, assessed the resident with severe cognitive deficits, total dependence on staff for activities of daily living, no impairment of upper or lower extremities, at risk for development of pressure ulcers, no current pressure ulcers identified, and a pressure relieving device for the bed. The quarterly MDS, dated [DATE], failed to document the presence of the pressure ulcer. The Braden assessment for risk of development of pressure ulcer, dated 11-22-17, assessed the resident at high risk for pressure ulcer. The CAA (care area assessment), dated 12-4-17, advised staff the resident would be care planned for risk of skin breakdown due to immobility and incontinence. Staff advised the resident need for repositioning frequently and to provide the resident with a chair cushion and a presure reducing mattress. The care plan, updated 9-11-18, advised staff the resident required staff assistance for bed positioning and the resident had potential for impairment of skin integrity. The care plan lacked interventions for pressure ulcer prevention. A physician's orders [REDACTED]. The medical record lacked documentation of physician notification of the unstageable pressure ulcer. A skin assessment, dated, 8-4-18, identified a 2.5 by 2 cm (centimeter) darkened nonblanchable (a test for blood flow to the skin to determine damage) area on the resident's medial right heel. No interventions other than skin prep (ordered on 4-28-18) in place. A skin assessment, dated 8-11-18, documented to continue with current skin prep to heels/feet, no measurements of areas. A skin assessment, dated 8-18-18, documented a 2.5 by 2.0 cm purple area to the resident's right medial heel. A wound assessment, dated 8-25-18, documented that skin prep and booties were put into place on 8-5-18. A wound assessment, dated 8-25-18, documented a deflated blister on the left heel 2 by 2.5 cm, and a 2 by 2.5 cm deflated blister, purple in color on the right heel with a date which documented staff identified the wound on 8-5-18. (Incorrect as there was never a blister on the left heel (see interview on 10-1-18 with administrative staff B, who confirmed staff referred to right heel). A skin assessment, dated 9-1-18, documented the area on left (should be right heel see interview on 10-1-18 with administrative staff B, who confirmed staff referred to right heel) heel remains, no changes, and dry stable eschar (dry, dark dead tissue). A skin assessment, dated 9-9-18, documented the area to the resident's left (should be right heel see interview on 10-1-18 with administrative staff B, who confirmed staff referred to right heel) heel as dry stable eschar and no new concerns. A skin assessment, dated 9-19-18, identified the resident's left heel (should be right heel see interview on 10-1-18 with administrative staff B, who confirmed staff referred to right heel) with approximately a 2.1 by 2.4 cm, dry stable eschar, with treatment of [REDACTED]. A skin assessment, dated 9-22-18, identified the left heel (should be right heel see interview on 10-1-18 with administrative staff B, who confirmed staff referred to right heel)with a 2.1 by 2.4 cm, dry stable eschar with a treatment of [REDACTED]. Interview, on 10-1-18 at 10:30 am, with administrative nursing staff B, confirmed the skin assessments indicating left heel, should read right heel. Staff B confirmed he/she did not identify the facility acquired unstageable pressure injury on the Matrix dated 9-24-18. The facility Matrix, dated 9-24-18, failed to identify the resident with a facility acquired pressure ulcer or worsened pressure ulcer. Observation, on 9-25-18 at 12:12 pm, revealed the resident seated in his/her Broda chair, (a reclining type of wheeled chair), in the dining room, being fed lunch by a sitter. The resident had protective booties on his/her feet . Observation, on 9-25-18 at 2:29 pm, revealed the resident returned to bed, positioned on his/her left side, with booties on bilaterally, knees bent and rubbing against each other. Observation, on 9-25-18 at 5:00 pm, revealed direct care staff P and X checked the resident for incontinence, provided pericare, noted booties on the resident's feet bilaterally, and the resident's knees were bent, and rubbed against each other. Observation of the resident's right heel revealed an area approximately 2 cm (centimeter) in diameter of black eschar. The resident's left heel was intact with normal color. Interview, at that time, with direct care staff X, revealed the resident often would not extend his/her legs or allow for positioning. Staff X stated the resident dug his/her heels on the mattress and thinks this caused the pressure area. The resident's knee areas were free of redness, however, staff failed to place and pressure relieving devices to prevent skin breakdown at that time. Observation, on 9-26-18 at 9:45 am, revealed hospice staff FF, measured the pressure area on the resident's right heel as 2 by 2.5 centimeter with black eschar. Staff FF stated the nursing staff apply skin prep every shift and use the booties for off loading. Interview, on 9-27-18 at 10:30 am, with nursing staff G, revealed the resident did have a pressure ulcer on his/her right heel but not his/her left heel. Staff applied skin prep each shift, and kept the protective booties in place. Interview, on 9-27-18 at 12:30 pm, with administrative nursing staff E, revealed he/she did not know the resident had eschar on his/her heel and so did not identify this on the MDS or develop a care plan. Staff E stated he/she did not know if nurisng staff notified the physician of the unstageable pressure ulcer. Interview, on 10-1-18 at 10:30 am, with administrative nursing staff B, confirmed the skin assessments indicating the left heel, should read the resident's right heel. Staff B confirmed he/she did not identify, the facility acquired unstageable pressure ulcer on the Matrix, dated 9-24-18. Staff B stated he/she did not know if nursing staff notified the phsycian of the unstageable pressure ulcer. The facility policy for pressure ulcers, revised (MONTH) 1, 2013, advised staff to identify the impairment and stage if indicated, notify the physician, document the order, indicate interventions on the resident's care plan, refer to the director of nursing for inclusion in the weekly meeting and recognize factors contributing to pressure, resident needs and behaviors. The facility failed to implement timely and effective interventions to prevent the development of an unstageable pressure ulcer for this cognitively impaired immobile resident who experience harm when he/she developed an unstageable pressure ulcer to his/her right heel. Furthermoe, the facility failed to moniotr effectively, asess the effectiveness of treatment and interventions, for pressure ulcers and to provide protective measures between the resident's knees when staff placed the resident in bed and his/her knees rubbed together.

The facility reported a census of 66 residents with 19 selected for review, including 3 residents reviewed for nutrition/hydration. Based on observation, interview and record review, the facility failed to ensure the registered dietician's recommendations for weight loss were acted upon for 1 resident (#6) who had a 19# pound/11.37% (percent)) significant weight loss (since last weight of 167 # on 7-10-18 and subsequent weight of 148# on 9-24-18), in 2 1/2 months. Furthermore, the facility failed to ensure resident (# 49) consistenly had thickened water available in his/her room as ordered by the physician, to ensure adequate hydration. Findings included: - Review of resident #6's physician order [REDACTED]. Pseudobulbar affect typically occurs in people with certain neurological conditions or injuries, which might affect the way the brain controls emotion), [MEDICAL CONDITION] (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with behavioral disturbance, and Diabetes type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The annual MDS (minimum data set), dated 6-27-18, assessed the resident with a BIMS (brief interview for mental status) score of 03 indicating severe cognitive impairment, physical behaviors toward others 1-3 days and verbal behaviors towards others 4-6 days. This MDS documented a 5% weight loss in 1 month or 10% weight loss in 6 months and not on a physician ordered weight loss program with a height of 74 (inches) and a weight of 161 # (pounds). The resident had no swallowing problems, on a therapeutic mechanically altered diet, and no oral issues. The quarterly MDS, dated [DATE], assessed the resident with severe cognitive impairment, no swallowing issues, a height of 74 and a weight of 176 #, on a mechanical altered diet. The CAA (care area assessment), dated 6-27-18, for nutrition, assessed the resident would be care planned for nutritional risk due to disease process. Staff would provide diet as ordered. Staff were to monitor the resident's weight. The physician will monitor labs. Registered dietician to consult as needed. Staff were to notify the physician of any changes. The care plan, updated, 8-13-18, advised staff the resident was at risk for altered nutritional and hydration status due to diabetes, swallowing and self-feeding. This care plan advised staff the resident was on a mechanical soft texture with nectar consistency fluids. Staff advised Mighty shakes (a nutritional supplement) discontinued due to the resident not drinking them. Staff advised to weigh the resident monthly, offer fluids between meals and when rendering care, provide assistance with meals, and to consult the registered dietician for inadequate intakes. Staff advised the resident would eat 50% of meals by him/herself with prompting. Review of the medical record, revealed the following weights: 3-6-18 181# 4-23-18 164# 5-1-18 164# 6-14-18 160.0# 7-10-18 167# No weight available for August 9-24-18 148# A weight meeting note, dated 4-30-18, advised staff the resident sustained [REDACTED].#). The resident weight on 2-16-18 was 181# and on 3-6-18 was 176#. This note documented the resident consumed 0-25% of meals and spit out foods. This meeting advised the resident start on mighty shakes three times a day. An interdepartmental note, dated 5-2-18, documented the resident had a 7.5% loss over the last 90 days. Current weight on 5-1-18 was 164.2 and, was 181.5 on 2/16/18. The resident was on a mechanical soft diet with nectar thickened liquids, and mighty shakes TID (three times a day) as a supplement. The resident's intakes varied from 0-100% with periodic refusals. The resident's goal weight was 165-180, and staff would refer the resident to the registered dietician for weight loss and inadequate intake. The Registered Dietician nutritional assessment, dated 6-29-18, assessed the resident with a height of 74 inches, and weight of 160#, BMI (body mass index) of 20 (normal 18.5 to 24.9), usual body weight of 160-175# and desired body weight of 165-180. This note indicated the resident had significant weight loss, and advised staff to provide a liberalized mechanical soft diet with nectar thickened liquids. The dietician recommended discontinuing the house supplement and starting 2.0 supplement (high protein liquid supplement), 180 cc (cubic centimeters), 4 times per day and super cereal in the morning. The resident lost 23# over the course of a year and meal intake decreased. The record review revealed labs drawn on, 9-20-18, with results as: [MEDICATION NAME] (a group of proteins) low at 3.5 g/dL (grams per deciliter) (normal 3.6-4.8g/dL), total Protein 6.3g/dL (norm 6-8g/dL), Hematocrit (blood count reflecting oxygen carrying ability)low at 40.7g/dL (norm 42-25), Hgb A1C ( a test for glucose level over a span of time) high at 6.5 %normal 4-6%) and average glucose high at 140mg/dL(milligram per deciliter) ( 65-115mg/dL). Review of the meal intakes from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed variable intake from 0-100% without identified patterns. The treatment administration sheet, for (MONTH) and (MONTH) (YEAR) revealed varying percentages of intake of the health shake. Dietary staff GG, weight warning note, dated 9-25-18, advised the resident often refused to be weighed and did not come to the dining room often. The note documented the resident ate 0-75% of meals, and staff would continue to monitor for further weight reduction. Interview, on 9-24-18 at 2:30 pm, with administrative staff A, confirmed lack of weights for (MONTH) (YEAR) and (MONTH) (YEAR). Staff A stated the resident may have refused to be weighed. Staff A stated staff weighed the resident via a wheelchair scale. Observation, on 9-25-18 at 1:10 pm, revealed the resident positioned in bed. Direct care staff L fed the resident ground pork cutlet with gravy, 1-2 bites, mashed potatoes with gravy approximately half of the serving and the resident declined the cheese cake. Staff L stated the resident was on a mechanical soft diet. The resident's tray did not contain a nutritional supplement. Observation, on 9-25-18 at 1:16 pm (six minutes after beginning to feed the resident) Staff L did not offer alternatives and stated the resident percentage of consumption for this meal as 25-50% and the resident drank 240 cc of thickened water. Staff L removed the tray from the resident's room and left a cup of 240 cc of thickened water on the bedside table. Staff L stated the resident often refused to get up out of bed for meals. Observation, on 09-25-18 at 5:31 pm, revealed direct care staff P and X transferred the resident from his/her bed into a wheelchair with the Hoyer lift. The resident cooperated with staff. Staff P stated the resident usually did get up for dinner, but would start yelling if staff did not feed the resident in a timely manner or return him/her to bed after the meal. Staff P transported the resident to the dining room assisted table and attempted/encouraged the resident to eat a cheeseburger and french fries of which the resident took a few bites. Staff P fed the resident a piece of cake which the resident ate 100%. Each time staff P attended to another resident at the table, the resident began to yell out. The resident did hold a handled cup in his/her hand, but did not attempt to feed him/herself. Observation, on 09/25/18 at 5:57 PM, direct care staff P offered the resident a bowl of chocolate ice cream, which the resident accepted and consumed with staff P feeding. Staff P stated the resident did like milkshakes and chocolate. Interview, on 9-27-18 at 8:30 am, with dietary staff GG, revealed the resident was on fortified cereal at breakfast, per the dietary list. Staff GG stated the resident did not receive other fortified foods. Staff GG stated the resident did have behaviors and often refused to leave his/her room. Staff GG did not know of the resident's weight loss as the resident was not weighed in (MONTH) (YEAR) or (MONTH) (YEAR) until the surveyor requested a weight. Observation, on 9-27-18 at 9:00 am, revealed direct care staff L, fed the resident breakfast in bed. The resident consumed 90% of the serving of scrambled eggs, 100% of the serving of ground sausage, but did not consume any of the supercereal. Staff L did not offer the resident more eggs or sausage. Staff L stated the resident did not always eat the supercereal and staff could offer a mighty shake if the resident refused servings. Interview, on 9-27-18 at 10:30 am with nursing staff G, revealed the resident did not have a physician's orders [REDACTED]. Staff G stated the mighty shake supplement was discontinued on 8-13-18, by a staff member for continued refusal with no other supplement ordered. Staff G stated the administrative staff should notify the physician of the resident's weight loss. Interview, on 9-27-18 at 3:06 pm, with medical staff I, revealed the facility usually does notify him/her of weight loss, and expected the facility to follow the registered dietician's recommendations. Attempt to nterview dietary consulting staff by phone occurred on 9-27-18 and 10-2-18 with no return call. The weight monitoring policy, dated 5-17-18, advised staff to weigh a resident with weight loss weekly. The Physician should be informed of a significant change in weight and may order nutritional intervention. The Registered Dietician should be consulted to assist with interventions and then actions are recorded in the nutrition progress notes. The facility policy for nutritional services, dated 3-9-15, advised staff to use fortified foods at meals to provide additional calories and protein for residents. The facility failed to weigh the resident monthly to ensure timely identification of weight loss and failed follow the registered dietician's recommendations for 2 cal, QID (on 6-29-18) after the supplemental shakes were discontinued. This dependent resident continued to experience a weight loss of 19#s since last weight on 7-10-18 of 167# and subsequent weight of 148# on 9-24-18, resulting in a significant weight loss of 11.37% weight loss in 2 and 1/2 months. - The deficient practice of failure to provide sufficient fluids to maintain proper hydration affected resident #49, a resident at risk for dehydration, related to failure to consistently provide thickened liquids in his/her room.

Based on observation, interview and record review, the facility failed to recognize the cause of pain for one of 19 sampled residents (Resident (R) 214 and failed to evaluate and treat the cause of pain which was associated with a severe excoriated skin condition. Specifically, the facility caused harm to R214 when they failed to treat the pain that occurred during incontinence care when the resident moaned, resisted and pulled away. Findings include: - Review of the Admission Record (face sheet) revealed the facility admitted R214 on 09/21/18. R214's [DIAGNOSES REDACTED]. Order Summary Report (physician's orders [REDACTED]. ([MEDICATION NAME]-[MEDICATION NAME] is used in the treatment of [REDACTED]. Weekly Skin Sheet dated 09/21/18 included, Site description .residents whole peri area is macerated and bleeding. Resident was admitted with her peri area in this condition. Admission Nursing Evaluation dated 09/21/18 page 9 included, Peri area and coccyx red. Page 10 and 11 of the Admission Nursing Evaluation regarding pain evaluation, was not completed. The areas for pain site, description, intensity, and type of pain were blank. The documentation indicated that pain was not present. On 09/24/18 at 11:00 AM R214 was observed in bed wearing a disposable brief. When Certified Nursing Assistant (CNA) K removed the disposable brief, the resident was observed to have a large loose stool covering her buttocks and perineum. The resident had severe excoriation of the labia, perineum and buttocks. Both labia were red and swollen and the perineum had open areas that were bleeding. CNA K began to wipe the resident's perineum with moist wipes as the resident yelled out each time a wipe was used. The resident pulled her buttocks away tightening her legs together to prevent further wiping while she continued to yell. CNA K continued to wipe the buttock area and stated, I know darlin, I know it hurts but it's got to get clean or it will get worse. The resident continued to yell out and resist as CNA K wiped the buttocks and perineal area. CNA K applied an anti-fungal cream to the excoriated area. R214 stopped yelling when CNA K finished wiping the excoriated areas and applying the anti-fungal cream. On 09/24/18 at 11:05 AM, the resident was asked if she had pain during incontinence care. R214 nodded her head and confirmed that she had pain. On 09/24/18 at 11:20 AM, CNA K stated, I worked Saturday night and he/she didn't have anything for his/her bottom. I told the night nurse and he/she gave me the anti-fungal cream to use. It's not a barrier cream, he/she didn't have any of that in his/her nightstand. That's what we were told to use. He/she screams every time we clean him/her up and he/she keeps having loose stools. I know it hurts him/her, but we can't leave him/her dirty. On 09/24/18 at 11:25 AM, the Director of Nursing stated, I don't know this resident very well. He/she came in late Friday night and I had to work the floor today, so I haven't had time to see him/her. I haven't seen his/her skin condition. He/she doesn't have a treatment order for his/her skin breakdown and I don't see anything on his/her admission orders [REDACTED]. He/she needs something with zinc. I haven't given him/her anything for pain this morning. Review of a Nursing Note dated 09/24/18 at 2:23 PM, included, Resident did not get out of bed today .total assist with cares .incontinent of bowel and bladder. MASD (moisture-associated skin damage) to peri area .resident very uncomfortable when peri-care is provided. On 09/26/18 at 8:45 AM, CNA K and CNA T were observed providing incontinence care to R214. CNA K stated, We have to clean you up. The resident began to moan and put his/her legs together. CNA K began to wipe the perineal area where he/she was soiled, and the resident responded in pain by yelling and tightening his/her legs and buttocks. CNA K stated, I'm sorry darlin, I know you are sore. On 09/26/18 at 4:15 PM, Registered Nurse (RN) F stated, I haven't heard him/her yelling out. He/she will do that when they are trying to clean him/her up. He/she is non-verbal and doesn't talk very much. He/she will nod his/her head or make a yaw sound when you ask him/her questions. I haven't given him/her anything for pain. On 09/26/18 at 4:30 PM, CNA M stated, He/she doesn't yell out when no one is in his/her room. He/she likes to stay in bed and he/she doesn't do anything for him/herself. He/she moans and yells when they are changing his/her brief. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documentation of the resident's pain on the MAR indicated [REDACTED]. On 09/27/18 review of page 3 of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED] The resident's admission care plan with Date initiated 09/24/18, included, I am at risk for pain related to chronic history .pain level recognized by staff by facial expression if non-verbal .administer medication as ordered. I at times will yell out or moan due to pain .reposition. Review of the admission care plan with Date initiated 09/25/18, revealed the facility had identified the residents pain experience as a behavior. The care plan included, The resident has a behavior problem such as yelling out, moaning, refusing cares, refusing to answer questions. The facility policy titled Pain Management included, The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of pain .evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status .behavioral signs and symptoms that may suggest the presence of pain include but are not limited to .resisting care .sighing, groaning .Pain assessment-asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident . Review of the resident's [DIAGNOSES REDACTED].In most cases, prescribe at least one scheduled, not as needed (PRN) [MEDICATION NAME] medication .until pain is resolved. The facility failed to evaluate and treat the cause of pain which was associated with a severe excoriated skin condition. Specifically, the facility caused harm to R214 when they failed to treat the pain that occurred during incontinence care when the resident moaned, resisted and pulled away.

The facility reported a census of 62 residents and identified 27 with full code status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops). The facility failed to maintain a system to identify the code status of 1 (#1) sampled resident, and failed to provide this resident with CPR (cardiopulmonary resuscitation, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) when his/her vital signs ceased. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's electronic medical record documented admission from the hospital on [DATE]. The admission record included [DIAGNOSES REDACTED]. system attacks your nerves). The hospital discharge summary, dated [DATE], included, the resident admitted to the hospital with [REDACTED]. The resident also admitted with severe [MEDICAL CONDITION] (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), [MEDICAL CONDITION] (systemic infection such as of the blood) and with [MEDICAL CONDITION] (high blood glucose level). The resident's, unsigned, dated [DATE], hospital information report, documented under Advanced Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under the State law, relating to the provision of health care when the individual is incapacitated), Full code. The resident's electronic and paper medical record lacked a DNR (Do Not Resuscitate order- a physician order [REDACTED]. The admission MDS (minimum data set), dated [DATE], identified the facility admitted the resident, on [DATE], with hospice services and a BIMS (brief interview for mental status) score of 14, indicating intact cognition. The resident did not walk and required extensive to total staff assistance for transfers, bed mobility and hygiene. The resident required no physical assistance of staff to eat. The CAA (care area assessment), for ADLs (activities of daily living), dated [DATE] included: the resident required extensive assistance from staff for the performance of all activities except eating. The resident did not walk. The CAA for psychosocial, noted the resident newly admitted to facility from an acute hospital with treatment for [REDACTED]. The care plan, dated [DATE] included, admitted on hospice services. Comfort care measures. Risk for weight loss related to end of life changes. Requires assistance with ADL functions. No discharge plans were in place currently. The paper medical record included a hospice/long term care agreement, dated and started on [DATE]. The plan of care failed to identify the resident's wishes regarding his/her code status. On [DATE] at 3:15 PM, interview with direct care staff F, revealed staff F worked with the resident on the evening of his/her death. Staff F explained that on [DATE], later, after the evening meal, the resident requested a snack and a drink. Staff F went to get the resident the snack and when he/she returned and entered the resident's room, he/she noted the resident lacked a pulse or respirations. Staff F immediately summoned licensed charge nurse C to the room. Then licensed nurse D entered the room and confirmed the resident's lack of vital signs at 8:25 P.M. Verification with this staff, related to his/her written statement, revealed it included, .I found (him/her) pale, unresponsive, and slightly cool. I felt for pulse, finding none and called for the nurse to come to the room . Interview on [DATE] at 1:25 P.M, with licensed nurse C, verified he/she was working at the time staff found the resident without vital signs. Staff C explained his/her failure to provide the resident with CPR at that time. He/she immediately called and notified the hospice nurse of the resident's lack of any vital signs. The hospice licensed nurse told staff C that he/she would come directly to the facility, call the time of death, and notify the family. Staff C reported that the hospice nurse, upon arrival, on [DATE] at 9:33 PM, confirmed the resident's death. Staff C further explained thinking since the resident received hospice services he/she would have a DNR advanced directive, and staff failed to check the advance directive log book at the nurses' station or in the electronic chart for the resident's code status. Earlier in the shift, the resident's POA (power of attorney) family member called to check on the resident and had told staff C that he/she just wanted the resident to be kept comfortable to the end. A notarized written statement by licensed nursing staff D, revealed the statement included his/her assessment, . I was notified on [DATE] at approximately 8:25 PM, that I was needed . I immediately followed CMA (certified medication aide) to the resident's room where I was asked to verify the resident was without vital signs with fixed pupils. At this time, I checked the resident and found this to be true . On [DATE] at 4:00 P.M., licensed nurse B verified the facility had a practice of putting the resident's code status on the front page of each resident's electronic medical record; in an advanced directive notebook at the nurse's station; and colored coded name tags outside of the resident's room. Blue name tags indicated full code and red tags indicated DNR or no code. The facility investigation revealed the resident had a blue name tag outside his/her room at the time of his/her death. On [DATE] at 11:40 A.M., social service worker E, verified it was his/her assigned responsibility to complete new resident admissions and to ensure completion of the advanced directive forms. However, on [DATE], when the facility admitted the resident, staff E was on vacation. The facility's system failed due to the back-up office staff, responsible at that time, who failed to complete the required task and failed to complete an advanced directive form on admission for the resident. Per interview on [DATE] at 10:00 A.M., administrative staff A, revealed the facility staff identified the failure, reported the incident of lack of CPR to the state agency, suspended licensed nurse C and started the investigation with corrective actions on [DATE]. The facility advance directive policy, dated ,[DATE] included: It is the policy of the facility to establish, implement and maintain written policies and procedures for advance directive. The resident has the right and the facility will assist the resident to formulate an advance directive at their option. The facility will inform and provide resident with a written description of the facility's policy to implement advance directives. It is the policy of this facility to provide basic life support, including CPR =Cardiopulmonary Resuscitation, when a resident required such emergency care, prior to the arrival of emergency medical services, subject to physician order [REDACTED]. Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association, unless a valid Do Not Resuscitate order is in place. The facility failed to ensure a completed advanced directive for this resident and the licensed nurse failed to provide CPR to the resident, when his/her vitals ceased, which placed this resident in immediate jeopardy. The deficiency was cited as past-noncompliance, as of [DATE] at 10:00 PM, when the facility implemented and completed the following: 1.) On [DATE], administrative staff A and licensed nursing staff B completed an audit of all facility residents medical records, to ensure the presence of a signed code status order. The director of nursing or designee would monitor these each month for 3 months. 2.) On [DATE] at 8:45 AM, the QAA (quality assurance and assessment) committee met, developed and approved an educational plan, which the facility implemented. 3.) On [DATE] licensed nursing staff B initiated an all nursing staff in-service, related to the policy and procedure for advanced directives and residents' code status including full and DNR. Fifty-four of the facility nursing staff completed the in-service training on [DATE] at 10:00 PM. The 17 nursing staff not completed (included several college part-time staff, and out of town staff), who staff B notified could not work on the floor until completion of their in-service with signature.

The facility had a census of 62 residents, of which 28 resided on the facility SCU (special care units (2 adjoined dementia units with shared open door, at times)). Based on observation, interview, and record review, the facility failed to ensure 8 residents on the SCU were free from physical abuse, when resident (#40) physically abused 8 other SCU residents (#37, #6, #69, #66, #32, #17, #48, and #30) on 10 occasions. This practice placed these 8 residents in immediate jeopardy. Findings included: - Resident #40's signed physician orders, dated 10/41/16, documented [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 12/26/15, included a Brief Interview for Mental Status score of 4, which indicated severely impaired cognition, with wandering as the only behavior identified. The resident received antipsychotic, antianxiety, and antidepressant medications. The quarterly Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status assessment score of 3, which indicated severely impaired cognition, with inattention, disorganized thinking, altered levels of consciousness,and with acute (sudden) onset. The assessment identified the only behavior was wandering. The resident did not receive antipsychotic medication at the time, but did receive antianxiety and antidepressant medications. The 1/16/16 Care Area Assessment for behaviors included: The resident had behaviors, usually wandering behaviors, but this resident could be physical and strike out at peers and staff. The 9/7/16 facility quarterly resident review, identified the resident had a history of [REDACTED]. (This was a facility assessment and not an MDS.) The care plan last reviewed on 9/1/16, instructed the staff to guide and attempt an intervention before the resident's behaviors escalated. Do not sit the resident around other residents that would disturb him/her. Staff were to administer medications as ordered, and place a stop sign on the neighbor's room door. Staff were to re-direct the resident to a quiet area if agitated and avoid confrontation. An update on 11/19/15, instructed to refer the resident to a psychologist/psychiatrist for medication and behavior intervention recommendations. If behavior frequency, intensity escalates, rule out physical, medical, and environmental causes, and investigate triggering events precipitating the behavior that can be eliminated or altered. An update on 2/16/16, instructed the staff to redirect the resident when wandering at the end of the hall. Review of the resident's nurse's notes, from 12/29/15 through 11/17/16, revealed the following incidents of resident (#40) being physically abusive to other residents on the SCU: 1.) On 12/29/15 at 6:19 pm, resident (#40) struck another resident (#48) on the forearm. There was no injury to the peer. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 12/29/15, the staff were instructed not to leave the agitated resident (#40) alone at the nurses station. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 12/29/15. 2.) On 1/14/16 at 1:49 pm, resident (#40) yelled out, and struck a different resident (#32) in the face. The intervention included to watch the resident when in the common area with the other resident. On 11/30/16 at 11:50 AM, administrative licensed nurse B, explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 1/14/16. 3.) On 2/6/16 at 8:30 pm, resident (#40) wandered into resident (#66's) room and hit resident (#66) in the face. The intervention was to steer the resident away from the other resident's room. On 11/30/16 at 11:50 AM, administrative licensed nurse B, explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 2/6/16. 4.) On 7/4/16 at 9:30 pm, resident (#40) walked up to resident (#6) and hit the resident in the face, which caused a swollen lip. The staff redirected resident (#40). On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 7/4/16, the staff were instructed to keep the doors between the 2 SCUs closed so the resident could not enter the other SCU side. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 7/4/16. 5.) On 8/17/16 at 11:10 am, resident (#40) was in resident (#30's) bathroom. Resident (#30) told the staff that he/she was hit in the face. Staff separated the residents and placed resident (#40) on 15 minute visual checks. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 8/17/16, the staff were instructed to leave the resident (#40) on 15 minute visual checks indefinitely. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 8/17/16, from 12:00 am through 11:00 am. 6.) On 9/20/16 at 3:31 pm, resident (#40) hit resident (#30) in the mouth while in the other resident's room. This was the second incident that involved resident (#30). On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 9/20/16, the staff placed a stop sign across the door of resident (#30) to detour resident (#40) from entering the room. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 9/20/16 from 7:15 am through 6:30 pm. 7.) On 10/15/16 at 10:40 am, resident (#69) wandered into resident (#40's) room. Resident (#40) struck resident (#69). Staff placed a stop sign at the doorway of resident (#40). On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 10/15/16. 8.) On 10/26/16 at 8:05 am, resident (#40) hit resident (#30) in the mouth when the residents were in the dining room. Resident (#30) had swelling and bleeding to the right upper lip. This was the third incident that involved resident (#30). On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 10/26/16, the staff were instructed not to sit resident (#40) next to resident (#30) in activities or the dining room and requested a medication review. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 10/26/16. On 10/27/16 at 3:05 pm, the nurse's notes revealed staff notified resident (#40's) family regarding the behaviors. The family did not want to send the resident out to a behavioral unit. 9.) On 10/28/16 at 4:11 pm, resident (#40) wandered into resident (#37's) room. Resident (#37) was on the floor crying and reported to staff that resident (#40) hit him/her. Resident (#40) refused antianxiety medication. Resident (#40) was to be on 1 to 1 if agitated. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 10/28/16, the staff stayed with the resident until he/she calmed down. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 10/28/16, from 3:30 pm through 11:00 pm. 10.) On 11/5/16 at 4:40 pm, staff heard resident (#17) crying. When the staff entered into his/her room, resident (#17) was on the floor. Resident (#40) was verbally aggressive with other residents prior to being in the room where he/she stood at the foot of resident (#17's) bed. Staff attempted to redirect the resident (#40) with food, and distraction. Staff attempted to give prn ( as needed) medication, but resident (#40) refused the medication. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 11/15/16, the staff placed resident (#40) in his/her room away from the other residents during his/her agitation after activities, smacks and medication refusal were all not effective. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs contained staff initials every 15 minutes for the visual checks on the day of the incident 11/5/16. The initials included documentation the staff checked on this resident at 4:30 pm and 4:45 pm. Resident (#40) physically abused resident (#17) at 4:40 pm., when the staff found resident (#17) on the floor with resident (#40) at the foot of the bed in the room. A physician order [REDACTED].#40) [MEDICATION NAME] and to discontinue the resident's [MEDICATION NAME]. On 11/16/16 at 8:00 am, the resident rested in the bed without signs of discomfort or behaviors. On 11/16/2016 at 1:45 pm, the resident sat in the activity room, sleeping. On 11/16/16 at 7:55 am, direct care worker J, explained resident (#40) had a history of [REDACTED]. The resident would search for the spouse. The staff tried to re-direct the resident. The resident did not focus on any one person and became agitated easily. On 11/16/16 at 12:43 pm, licensed nursing staff G reported the resident (#40) was on a 15 minute visual check because he/she would hit other residents. The resident (#40) wandered into other resident rooms, and would hit the residents. Licensed nursing staff G reported resident (#40) had not been on 1 to 1 observations, but the staff attempted to redirect the resident. The resident became agitated easily. After the resident hit another resident, then resident (#40) seemed to immediately calm down and would take a nap, or sit calmly. The facility tried to transfer the resident to a behavior unit, but the family refused to have the resident transferred. The facility's policy for behavior management, dated 3/30/16, documented staff were to develop behavior plans when appropriate to optimize the functional ability of the resident, and a determination would be made if the resident was a danger to self or others, and if so, staff would develop a plan of care to ensure safety and determine if the facility could meet the resident's needs on an ongoing basis. The facility's policy for abuse, dated 2/14/14, documented the facility had designed processes to ensure the prevention of alleged resident/patient abuse, and for the protection of the resident, the staff would move the resident to another room and provide 1 to 1 monitoring as appropriate. The facility failed to ensure these 8 residents remained free of physical abuse. These 8 residents were subjected to physical abuse, on 10 occasions, by another resident of the SCU. This deficient practice placed these 8 residents in immediate jeopardy. The facility abated the immediate jeopardy, on 11/28/16 at 3:15 PM, by initiating the following: The facility placed resident (#40) on 1 to 1, on 11/23/16 at 10:30 am, until discharge from the facility to a behavioral health unit on 11/23/16 at 11:30 am. The facility will have a weekly behavior committee that will discuss residents who have any behaviors and ensure all care plans were up to date with current effective interventions. Any resident who was the aggressor and involved in a resident to resident altercation would be placed on 1 on 1 until other effective interventions are put into place. The facility revised their Abuse, neglect, and exploitation policy. The revision included that all staff would be responsible for immediately protecting all of the residents from whoever was being abusive to them. The facility held a mandatory in-service of all staff on the facility policy and procedure for Abuse, neglect, and exploitation, including protection of residents and reporting. Furthermore, training on behaviors and abuse, neglect, exploitation will be completed during boarding and annually. The deficiency remained at a scope and severity of an H.

The facility had a census of 62 residents, of which 28 resided on the facility SCU (special care units (2 adjoined dementia units with shared open door, at times)). Based on observation, interview, and record review, the facility failed to ensure the 27 residents who resided on the SCU were adequately protected and free from physical abuse, when 1 resident (#40) physically abused 8 other SCU residents (#37, #6, #69, #66, #32, #17, #48, and #30) on 10 occasions. Furthermore, the facility failed to thoroughly investigate these 10 incidents of abuse to ensure appropriate interventions for protection of all of the residents on the SCU. This practice placed all 27 of the residents who resided on the SCU in immediate jeopardy related to physical abuse from resident (#40). Findings included: - Resident #40's signed physician orders, dated 10/41/16, documented [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 12/26/15, included a Brief Interview for Mental Status score of 4, which indicated severely impaired cognition, with wandering as the only behavior identified. The resident received antipsychotic, antianxiety, and antidepressant medications. The quarterly Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status assessment score of 3, which indicated severely impaired cognition, with inattention, disorganized thinking, altered levels of consciousness,and with acute (sudden) onset. The assessment identified the only behavior was wandering. The resident did not receive antipsychotic medication at the time, but did receive antianxiety and antidepressant medications. The 1/16/16 Care Area Assessment for behaviors included: The resident had behaviors, usually wandering behaviors, but this resident could be physical and strike out at peers and staff. The 9/7/16 facility quarterly resident review, identified the resident had a history of [REDACTED]. (This was a facility assessment and not an MDS.) The care plan last reviewed on 9/1/16, instructed the staff to guide and attempt an intervention before the resident's behaviors escalated. Do not sit the resident around other residents that would disturb him/her. Staff were to administer medications as ordered, and place a stop sign on the neighbor's room door. Staff were to re-direct the resident to a quiet area if agitated and avoid confrontation. An update on 11/19/15, instructed to refer the resident to a psychologist/psychiatrist for medication and behavior intervention recommendations. If behavior frequency, intensity escalates, rule out physical, medical, and environmental causes, and investigate triggering events precipitating the behavior that can be eliminated or altered. An update on 2/16/16, instructed the staff to redirect the resident when wandering at the end of the hall. Review of the resident's nurse's notes, from 12/29/15 through 11/17/16, revealed the following incidents of resident (#40) being physically abusive to other residents on the SCU: 1.) On 12/29/15 at 6:19 pm, resident (#40) struck another resident (#48) on the forearm. There was no injury to the peer. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 12/29/15, the staff were instructed not to leave the agitated resident (#40) alone at the nurses station. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 12/29/15. 2.) On 1/14/16 at 1:49 pm, resident (#40) yelled out, and struck a different resident (#32) in the face. The intervention included to watch the resident when in the common area with the other resident. On 11/30/16 at 11:50 AM, administrative licensed nurse B, explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 1/14/16. 3.) On 2/6/16 at 8:30 pm, resident (#40) wandered into resident (#66's) room and hit resident (#66) in the face. The intervention was to steer the resident away from the other resident's room. On 11/30/16 at 11:50 AM, administrative licensed nurse B, explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 2/6/16. 4.) On 7/4/16 at 9:30 pm, resident (#40) walked up to resident (#6) and hit the resident in the face, which caused a swollen lip. The staff redirected resident (#40). On 11/30 /16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 7/4/16, the staff were instructed to keep the doors between the 2 SCUs closed so the resident could not enter the other SCU side. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 7/4/16. 5.) On 8/17/16 at 11:10 am, resident (#40) was in resident (#30's) bathroom. Resident (#30) told the staff that he/she was hit in the face. Staff separated the residents and placed resident (#40) on 15 minute visual checks. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 8/17/16, the staff were instructed to leave the resident (#40) on 15 minute visual checks indefinitely. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 8/17/16, from 12:00 am through 11:00 am. 6.) On 9/20/16 at 3:31 pm, resident (#40) hit resident (#30) in the mouth while in the other resident's room. This was the second incident that involved resident (#30). On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 9/20/16, the staff placed a stop sign across the door of resident (#30) to detour resident (#40) from entering the room. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 9/20/16 from 7:15 am through 6:30 pm. 7.) On 10/15/16 at 10:40 am, resident (#69) wandered into resident (#40's) room. Resident (#40) struck resident (#69). Staff placed a stop sign at the doorway of resident (#40). On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 10/15/16. 8.) On 10/26/16 at 8:05 am, resident (#40) hit resident (#30) in the mouth when the residents were in the dining room. Resident (#30) had swelling and bleeding to the right upper lip. This was the third incident that involved resident (#30). On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 10/26/16, the staff were instructed not to sit resident (#40) next to resident (#30) in activities or the dining room and requested a medication review. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 10/26/16. On 10/27/16 at 3:05 pm, the nurse's notes revealed staff notified resident (#40's) family regarding the behaviors. The family did not want to send the resident out to a behavioral unit. 9.) On 10/28/16 at 4:11 pm, resident (#40) wandered into resident (#37's) room. Resident (#37) was on the floor crying and reported to staff that resident (#40) hit him/her. Resident (#40) refused antianxiety medication. Resident (#40) was to be on 1 to 1 if agitated. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 10/28/16, the staff stayed with the resident until he/she calmed down. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs lacked any 15 minute visual checks completed for the day of the incident 10/28/16, from 3:30 pm through 11:00 pm. 10.) On 11/5/16 at 4:40 pm, staff heard resident (#17) crying. When the staff entered into his/her room, resident (#17) was on the floor. Resident (#40) was verbally aggressive with other residents prior to being in the room where he/she stood at the foot of resident (#17's) bed. Staff attempted to redirect the resident (#40) with food, and distraction. Staff attempted to give prn ( as needed) medication, but resident (#40) refused the medication. On 11/30/16 at 11:50 AM, administrative licensed nurse B, reported following the incident on 11/15/16, the staff placed resident (#40) in his/her room away from the other residents during his/her agitation after activities, smacks and medication refusal were all not effective. Staff B explained the staff provided 15 minute visual checks on the resident throughout the resident's stay in the facility. Staff B provided the resident's 15 minute visual check logs. The logs contained staff initials every 15 minutes for the visual checks on the day of the incident 11/5/16. The initials included documentation the staff checked on this resident at 4:30 pm and 4:45 pm. Resident (#40) physically abused resident (#17) at 4:40 pm., when the staff found resident (#17) on the floor with resident (#40) at the foot of the bed in the room. A physician order [REDACTED].#40) [MEDICATION NAME] and to discontinue the resident's [MEDICATION NAME]. On 11/16/16 at 8:00 am, the resident rested in the bed without signs of discomfort or behaviors. On 11/16/2016 at 1:45 pm, the resident sat in the activity room, sleeping. On 11/16/16 at 7:55 am, direct care worker J, explained resident (#40) had a history of [REDACTED]. The resident would search for the spouse. The staff tried to re-direct the resident. The resident did not focus on any one person and became agitated easily. On 11/16/16 at 12:43 pm, licensed nursing staff G reported the resident (#40) was on a 15 minute visual check because he/she would hit other residents. The resident (#40) wandered into other resident rooms, and would hit the residents. Licensed nursing staff G reported resident (#40) had not been on 1 to 1 observations, but the staff attempted to redirect the resident. The resident became agitated easily. After the resident hit another resident, then resident (#40) seemed to immediately calm down and would take a nap, or sit calmly. The facility tried to transfer the resident to a behavior unit, but the family refused to have the resident transferred. The facility's policy for behavior management, dated 3/30/16, documented staff were to develop behavior plans when appropriate to optimize the functional ability of the resident, and a determination would be made if the resident was a danger to self or others, and if so, staff would develop a plan of care to ensure safety and determine if the facility could meet the resident's needs on an ongoing basis. The facility's policy for abuse, dated 2/14/14, documented the facility had designed processes to ensure the prevention of alleged resident/patient abuse, and for the protection of the resident, the staff would move the resident to another room and provide 1 to 1 monitoring as appropriate. The facility failed to thoroughly investigate these 10 incidents of abuse to ensure appropriate interventions for protection of all of the 27 residents on the SCU. This deficient practice placed these 27 residents in immediate jeopardy. The facility abated the immediate jeopardy, on 11/28/16 at 3:15 PM, by initiating the following: The facility placed resident (#40) on 1 to 1, on 11/23/16 at 10:30 am, until discharge from the facility to a behavioral health unit on 11/23/16 at 11:30 am. The facility will have a weekly behavior committee that will discuss residents who have any behaviors and ensure all care plans were up to date with current effective interventions. Any resident who was the aggressor and involved in a resident to resident altercation would be placed on 1 on 1 until other effective interventions are put into place. The facility revised their Abuse, neglect, and exploitation policy. The revision included that all staff would be responsible for immediately protecting all of the residents from whoever was being abusive to them. The facility held a mandatory in-service of all staff on the facility policy and procedure for Abuse, neglect, and exploitation, including protection of residents and reporting. Furthermore, training on behaviors and abuse, neglect, exploitation will be completed during boarding and annually. The deficiency remained at a scope and severity of an H.

The facility reported a census of 62 residents. The sample of 22 residents included 6 reviewed for accidents. Based on observation, interview, and record review, the facility failed to develop and implement interventions to ensure 3 residents (#39, #69, and #51) of the 6 sampled residents, received care and services to prevent falls. Resident #39 fell after disrobing, in the dining room, where staff reapplied the resident's clothing then left the resident, without staff supervision, in the dining room. The resident fell and sustained a fractured hip. Findings included: - Resident's #39's physician order [REDACTED]. The admission Minimum Data Set, dated dated [DATE], identified the resident with moderately impaired cognition with trouble concentrating, and needed limited assistance of staff for transfers and mobility, with extensive assistance of staff for toileting. The fall assessment lacked identification of a fall history. A fall risk assessment, dated 7/11/16, included a risk score of 11 and the 10/21/16 fall risk assessment scored the resident at 16. The assessments identified a score of 10 or greater indicated the resident was at risk for falls. A care plan, dated 7/13/16 included updates as follows: 7/20/16 -- Toilet and change the resident, if needed, every 2 hours, throughout the day. Check and change the resident at bedtime. 7/20/16 -- Footwear to prevent slipping. 7/20/16 - Keep the resident's environment well lighted and free of clutter. 7/28/16 -- Recliner placed in room for resident to rest in, due to a non injury fall. 8/2/16 -- The resident ambulates 100 feet with hand held assist, without difficulty. 8/4/16 -- Eating assistance with set-up, prompting, cueing and dependent assistance at times. Staff must be present during meals for assistance. Review of the facility investigation of a fall occurring on 10/17/16 at 1:06 PM, reported staff toileted the resident before lunch (at 12:30 PM). Following lunch the resident began disrobing and staff reapplied the resident's clothing, redirected the resident, and then went to attend to another resident who required toileting with two staff assistance. This left the dining room unattended by staff. Upon return from the other resident's room, staff noted the resident was in the dining room, on the floor, without pants or socks. Following an assessment, the staff sent the resident to the emergency room for evaluation, due to having external rotation (turning outwardly or away from the midline of the body). The documentation noted the resident admitted to the hospital with [REDACTED]. Review of the facility investigation witness statements, dated 10/19/16, identified only 2 staff were present in the memory care unit at the time of the fall and both those staff attended to another resident who required 2 person assistance for toileting. Review of the facility post fall analysis, dated 10/17/16 at 6:39 PM, included the resident exhibited impaired safety awareness/judgment and the resident was possibly attempting to toilet, at the time of the fall. Interview with direct care staff I, on 11/3/16 at 10:35 AM, reported sometimes the resident walked independently and sometimes needed assistance. The staff reported the resident needed assistance of staff for toileting every 2 hours. On 11/3/16 at 5:35 PM, direct care staff H reported the resident needed assistance with all ADL's (activities of daily living), would sometimes walk independently and staff assisted when finding the resident ambulating independently. Interview with administrative nursing staff B, on 11/3/16 at 6:00 PM, identified the resident did not require staff to walk and believed that a CMA (certified medication aide) was present in the hall of the unit at the time of the fall. The facility failed to ensure the resident received adequate supervision and/or assistive devices to prevent a fall, resulting in a hip fracture. - Resident #69's [DIAGNOSES REDACTED]. The admission 9/16/16 Minimum Data Set identified a Brief Interview for Mental Status of 3/15, indicating severely impaired cognition, with inattention, disorganized thinking, altered levels of consciousness, trouble concentrating and with physical behaviors. The assessment failed to identify the resident's history of falls, noted otherwise in the clinical record. The Care Area Assessment, dated 9/20/16, included the resident had a [DIAGNOSES REDACTED]. A Fall Risk assessment, dated 9/9/16, scored the resident with 16 points. A score of 10 or above deemed a resident at risk for falls. A care plan, implemented on a prior admission and dated 6/8/16, included the following interventions: 6/8/16 Injury Fall: Try to lead the resident to the bathroom every two hours and encourage the resident to urinate. Placing a bedside commode into the resident's room, beside the bed, might encourage the resident to recognize it as a proper place to urinate, if he getting up without assistance. Bed in low position. Gripper socks on when up. Offer toileting at 4 AM bed check. Keep environment well lighted and free of clutter. Observe for side effects of medications. Non-skid strips in front of the resident's recliner. 9/22/16 Fall with no injury. Scooting across floor. Dysem in wheelchair to prevent resident from slipping out. 10/22/16 Fall mat at bedside. Review of the nursing notes, included a fall from the bed on 10/31/16 at 10:47 PM. The staff found the resident on his/her belly on the floor beside the bed. The resident sustained [REDACTED]. The staff placed the resident in a wheelchair and monitored him/her. The staff failed to develop an intervention to keep the resident from experiencing future falls and further failed to have a fall mat in place (implemented on 10/22/16 fall), to prevent further injury. Observations on 11/3/16 at 10:00 AM, identified the resident resting in bed, eyes closed, without a fall mat present at the bedside or noted in the resident's room. At 11:05 AM, the resident sat on the edge of the bed, rubbing his/her hands together. Noted anti-skid strips on floor in front of recliner. At 11:30 AM the resident walked in the hallway of the unit. Staff noted resident up and offered to ambulate with him/her to the dining room. The resident had gripper socks to his/her feet. Direct care staff F, took the resident's hand and guided the resident to the dining room, with the resident being very cooperative. At 4:30 PM direct care staff H assisted the resident with check and changing, then assisted the resident to the dining room. The resident had skid resistant socks to his/her feet. Direct care staff I reported on 11/3/16 at 10:35 AM, the resident transferred and walked independently, however, is unsteady. The staff reported the resident had a low bed, no fall mat and sometimes became more anxious in the afternoon therefore becoming even more of a fall risk. Direct care staff H reported on 11/3/16 at 4:35 PM, the resident would sometimes toilet, but often required check and changing for toileting, due to resistance with toileting. Staff H reported the resident as a fall risk, had fallen in the past and used a low bed but no fall mat and didn't recall other interventions to prevent falls. Interview on 11/3/16 at 6:00 PM with administrative nursing staff B confirmed that placing the wheelchair for monitoring at the time of the falls, was not a long term intervention to prevent further falls. The staff further confirmed the resident needed a fall mat at the bedside. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated falls for this resident. - The POS (Physician order [REDACTED].#51 admitted to the facility with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set), dated 10-03-16, documented the resident had a BIMS (Brief Interview for Mental Status) score of 3, indicating the resident had severe cognitive impairment. The resident required extensive staff assistance of 1 for bed mobility, and extensive staff assistance of 2 for transfers, dressing, toilet use, and personal hygiene. The resident's balance was not steady, and was only able to stabilize with staff assistance. He/she had impairment on one side of their upper extremity. The CAA (Care Area Assessment) for falls, dated 10-03-16, documented the resident was at high risk for falls and had a history of [REDACTED]. The resident ambulated with the assistance of 1 staff member and used a walker. The care plan, dated 7-22-16, included the resident was at risk for falls. Interventions to prevent falls included for staff to assist the resident to the bathroom every 2 hours, a therapy referral, a fall mat next to the bed, and appropriate footwear to prevent slipping. However, this resident had severe cognitive impairment. Review of the resident's chart revealed a fall assessment, completed on 11-01-16, documenting the resident was at high risk for falls. A nurses note on 7-24-16, documented the resident had been discovered sitting on the floor in his/her room. The intervention for the fall was to encourage the resident to use the call light for assistance to the bathroom. On 11-17-16 at 3:38 p.m., the resident was resting in bed in his/her room. The call light was fastened to the sheets within reach of the resident's hand. On 11-21-16 at 9:33 a.m., the resident was sitting in his/her wheelchair in the dining room. The resident had his/her head down on their arm, propped up by the elbow on the arm of the wheelchair. The resident's eyes were closed and he/she appeared to be resting quietly. The resident was wearing gripper socks at that time. On 11-16-16 at 4:00 p.m., direct care staff AA stated, the resident was confused and did not remember to use his/her call light. On 11-21-16 at 9:46 a.m., direct care staff BB stated, the resident is confused and would not be able to remember to use his/her call light, but staff still attach it to his/her sheets while he/she was in bed. On 11-21-16 at 8:18 a.m., licensed nursing staff CC stated the resident is very confused. Staff CC explained when there is a fall, the nurse is responsible for initiating an appropriate intervention for the fall and putting it into the care plan. On 11-21-16 at 8:23 a.m., administrative staff B stated, the intervention to encourage the resident to use his/her call light was inappropriate as the resident is confused and had a BIMS of 3. The facility's policy for Fall Prevention Program, revised 5-01-11, instructs the purpose is to identify and assure the implementation of procedures which will minimize or eliminate hazards that may increase the likelihood of slips, trips and falls in and outside of the facilities. The facility failed to initiate an appropriate intervention following a fall of this dependent resident with confusion to prevent repeated falls.

The facility reported a census of 71 residents, with 26 residents selected for sample review, including 5 resident reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure 2 residents (#39 and 92), of 5 reviewed, received care and services to prevent the development of pressure ulcers. Findings included: - The facility admitted resident # 39 with [DIAGNOSES REDACTED]. The 2/27/15 admission MDS (minimum data set) identified the resident with long and short term memory problems and severely impaired of cognition and daily decision making skills. The staff identified the resident needed extensive assistance of 2 staff for ADL's including bed mobility, transfers. Furthermore, the assessment identified the resident lacked a pressure ulcer on admission, however, was at risk for the development of a pressure ulcer and had pressure relieving devices in bed and in the chair, with a turning and repositioning program with the application of ointment/medications. An 11/3/15 quarterly MDS identified the resident scored 2/15 on the BIMS, indicating severely impaired cognition, needed extensive assistance of 2 staff for eating, bed mobility and transfers, had a stage 1 or greater over a bony prominence, was at risk with unhealed pressure ulcers including one stage 2 pressure ulcer, with slough. The assessment included the previously identified pressure ulcer relieving precautions and additionally added a nutrition and hydration program. The 3/11/15 CAA (care area assessment) for pressure ulcers included the resident resided in the AACU (Advanced Alzheimer' Care Unit) and was bed and/or chair bound with dry and intact skin. The 10/23/15 care plan included the following interventions: 1. Assist with meals, as needed. 2. Serve diet of concentrated carbohydrates, with ground meat. 3. House supplement with lunch and supper. 4. Monitor meal consumption daily. 5. Offer alternate if refusing to eat. 6. Weekly weights, until stable. 7. Complete Braden scale, per policy. 8. Licensed nurse to conduct weekly skin inspection. 9. Provide pressure relieving wheel chair cushion and mattress to bed. 10. Provide thorough skin care after incontinent episodes and apply barrier cream, as needed. 11. Place resident in bed after meals, getting up just before meals. 12. Toileting plan at least every AM, upon arising, after meals and at bedtime. 13. Turn and reposition every 2 hours. 14. Needed assistance of 1-2 staff for bed mobility and toileting. Review of the residents orders, from the signed physician order [REDACTED]. The resident's Braden Scale assessment, dated 11/2/15, scored the resident at 13, with 13-14 indicating moderate risk for the development of pressure ulcer. Review of the 11/4/15 Nutrition assessment identified the resident exhibited a weight loss with poor nutritional intake, received a house supplement, and had a stage 2 pressure ulcer. Review of the residents weekly skin assessments, included the following: 9/25/15 - Skin intact. 9/30/15 - Redness; resident has reddened perineal area (gaulding). 10/4/15 - Redness; resident has reddened perineal area gaulding). 10/10/15 - Redness; resident has reddened perineal area (gaulding). 10/17/15 - Redness (area not designated) 10/24/15 - Open area noted to left buttock/coccyx. Left buttock measures 1.5 x 0.6 cm (centimeter) and right buttock measures 1.5 x 0.3 cm. No other new areas of concern. 10/31/15 - Open area. Right buttock no longer open but does have visible area of scar like tissue. Coccyx/left buttock wound still open wound bed white macerated (moisting deterioating tissue) (no measurement). 11/8/15 - Open area. Right buttock no longer open but does have visible area of scar like tissue. Coccyx/left buttock wound still open, wound bed white macerated looking (no measurement). 11/27/15 - Open area. Coccyx/left buttock (No measurements and no other narrative.) Review of nutritional intake records from 6/6/15 to 12/3/15 intake logs identified the resident had been consuming less the past month or so and frequently took 0% of the HS (bedtime) snack. Intake on 12/1/15, for the HS snack recorded 100% intake when on 12/2/15 the supplement, sat full on the bedside table, per observation, with staff present. However, overall the residents intake indicated declining intake per the documentation. Physician ordered laboratory testing included the following results: 11/5/15 Total protein 6.9 (6-8 the normal). 11/5/15 [MEDICATION NAME] 3.7 (3.5-4.8 the normal). Observation, on 12/1/15 at 2:50 PM, identified direct care staff Q and CC pushed the residents wheelchair to the residents room, to prepare to check and change the resident. Staff removed a urine wet brief, exposing a 1 inch macerated slit in the crease of the buttocks. Staff, provided perineal care to the midline only, then applied [MEDICATION NAME] cream to the macerated area, with the same gloved hand, used for cleaning the area. Staff positioned the resident on his/her back after completion of cares. Staff Q reported the area had been present for approximately 4 days and the charge nurse had instructed staff to provide the [MEDICATION NAME] (a skin barrier cream) to the area. Staff Q further reported, at that time, the charge nurse instructs staff in changes in the residents condition, that residents needed repositioning off their buttocks following meals and repositioning every 30 to 60 minutes throughout the day. The staff confirmed the resident also had a pressure relieving cushion in the wheelchair, when up. On 12/2/15 at 6:50 AM, the resident slept in the bed, on a pressure reducing mattress on his/her back. Observation at 7:05 AM identified the resident remained in the same position. At 7:13 AM, direct care staff P, assisted the resident with check and change, removed a urine wet incontinent brief, failed to provide any perineal care, then placed a dry incontinent brief onto the resident. Staff continued to dress the resident, then staff CC assisted with transferring the resident into the wheelchair, with a pressure relieving cushion in the seat of the chair. At that time, the direct care staff confirmed the presence of a full glass of supplement on the bedside table in the resident's room. Continued intermittent observations identified the resident ate very poorly, with staff assisting as the resident would allow. At 9:12 AM staff E and AA assisted the resident to lay down, checked the resident for dryness, noting dark redness to the residents coccyx and buttocks and a macerated slit to the crease of the buttocks. Staff E reported the area as almost healed and applied a barrier cream to the area. The staff repositioned the resident onto his/her left side with positioning pillows. On 12/2/15 at 1:08 PM staff served the resident chicken ala king, brussel sprouts, juice, water and a health shake supplement. Family here to assist the resident with eating, however the resident had poor intake of food and fluids. Observation of the food cart lacked identification of any alternate food choices. At 3:22 PM on 12/2/15 direct care staff DD and M assisted the resident with check and changing the resident with a loose incontinent stool present. Staff completed good perineal care to the midline and buttocks. Staff cleaned the area, however, failed to apply the barrier cream, and staff DD reported they applied the barrier cream very heavily last application. Staff positioned the resident to the opposite side as previously positioned with positioning pillows. On 12/2/15 at 6:00 PM identified staff served the resident a pureed meal of casserole, mixed vegetable and dessert. The meal lacked evidence of a health shake or milk. On 12/3/15 at 1:43 PM, dietary staff Z reported the resident is ordered to have a health shake sent with the meal of lunch and supper. On 12/3/15 at 3:30 PM direct care staff Q reported the resident had the pressure ulcer to his/her bottom for the past 2 weeks. The staff reported they were placing a dressing over the area, but that due to the location of the area and the residents frequent incontinence, the dressing became soiled and the area was not healing very well. Staff Q stated the dressing had been discontinued and the treatment was now to apply only the skin prep and [MEDICATION NAME] and the area was healing. Licensed nursing staff J reported, on 12/4/15 at 4:25 PM, the resident had an area to his/her bottom, and that the resident needed frequent repositioning and sometimes was not repositioned timely, although staff tried to stay on top of the turning/repositioning needs of all the residents. The staff indicated the resident was eating very poorly, at that time, and should get the shakes, as ordered. Staff J reported the residents treatments consisted of the CNA staff providing perineal care to the area and applying skin prep and [MEDICATION NAME] cream to the area with each check and change. The undated Skin Integrity Guideline policy instructed staff that the DNS (director of nursing services) or designee would be responsible for implementing and monitoring the skin integrity program and wound status would be monitored on a weekly basis. The interdisciplinary plan of care would address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Repositioning would be completed every 2 hours, or as needed and tolerated, taking into consideration resident tolerance and choice, tissue tolerance, current condition of skin and indicate the frequency in the individualized plan of care. The facility failed to ensure the resident received appropriate skin care and nutritional supplements as ordered to promote the healing of the pressure ulcer. - Resident #92's admission MDS (minimum data set) assessment, dated 9/2/15, identified the resident unable to complete the Brief Interview for Mental Status assessment; staff identified the resident with long and short term memory impairment and moderately impaired of decision making. The assessment identified the resident needed extensive assistance of 2 staff for ADL's including bed mobility, transfers, and toileting. The resident needed extensive assistance of 1 staff for eating and had no eating or swallowing concerns. The assessment also identified the resident at risk for the development of pressure ulcers, without identification of unhealed pressure ulcers, and the resident used pressure reducing devices for the chair and the bed and was on a turning/repositioning program. Review of the additional MDS's identified the resident discharged on [DATE] to an acute hospital setting and returned on 10/1/15. A plan of care, dated 10/23/15, revealed the following interventions for pressure ulcers: 1. Put the resident to bed after meals, get up just before meals. 2. Treatment as ordered to the right and left buttocks until clear. 3. Turn and reposition every 2 hours. 4. Orders to clean the wound (left outer foot) with normal saline and gauze prior to applying clean dressing. Do not scrub or use excessive force, apply [MEDICATION NAME] daily to wound and do not use [MEDICATION NAME]; then cover the wound with a clean white sock and clean daily. Elevate the leg as needed for [MEDICAL CONDITION]. Off load heels and turn and reposition every 2 hours as the resident will allow. The resident's care plan, dated 11/30/15, included: 1. Check and change every 2 hours, related to bowel and bladder incontinence. 2. Complete Braden Scale (a pressure ulcer risk assessment) per policy. 3. Cleanse wound with normal saline and gauze prior to applying clean dressing. Do not scrub or use excessive force, apply [MEDICATION NAME] daily to the wound; do not use [MEDICATION NAME], cover wound with a clean white sock and change daily. Elevate leg as needed for [MEDICAL CONDITION]. 4. Off load heels. 5. Provide pressure reducing wheelchair cushion. 6. Provide pressure reduction/relieving mattress. 7. Provide thorough skin care after incontinent episodes and apply barrier cream. 8. Turn and reposition every 2 hours as the resident will allow. 9. Inspect the resident's skin with care; report reddened areas, rashes, bruising, or open areas to the charge nurse. 10. Regular diet as ordered. 11. Monitor food intake daily and chart on the caretracker. 12. Monitor laboratories, as ordered, by PCP (primary care physician). 13. Monitor weekly weights and when stabilized, monthly. 14. Supplements as ordered of house supplement, TID (three times daily); prefers chocolate. 15. On 9/17/15, added [MEDICATION NAME] for an appetite stimulant. The facility wound assessments included the following: 10/12/15 -- Noted skin intact. 10/19/15 -- Identified a pre-existing rash. 10/24/15 -- Identified an open area to the left outer foot with red area measuring 2.5 diameter with 0.7 cm (centimeter) open area in the center. Wound bed pink, no drainage noted at this time. Noted as stage II. Left knee with multiple scabs (no measurements). 10/31/15 -- Open area to outer left foot remains open, approximately 1.5 cm by 0.7 cm. No mention of knee areas. 11/4/15 -- Open area to left foot remains open, approximately 1.5 cm x 0.7 cm. 11/6/15 -- Left outer foot, pressure area measured 0.8 by 0.5 by 0.1 cm, stage II, identified with purulent exudate, thin, watery, scant amount and lacked odor, 100% slough, wound white in color, with defined wound margins; treat with [MEDICATION NAME] and heel protectors. 11/18/15 -- Open area to left outer foot approximately 1.1 x 1.1 in size and resident to attend wound clinic, per family request. 11/20/15 -- Left outer foot, measured 1.1 x 1.1 cm, stage II, noted acquired in house and identified on 10/28/15, with interventions including to float heels and attend the wound clinic. The facility documentation wounds lacked an assessment with measurements past 11/20/15. Review of the wound clinic assessment identified the following: 11/19/15 -- Left lateral foot, initial exam, 0.5 by 0.3 by 0.1 cm stage 2 11/24/15 -- Left lateral foot, 6.5 by 5.4 by 0.1, stage 2 12/3/15 -- The 12/3/15 progress note detail included the foot wound is healing Review of orders included: 10/28/15-- Cleanse the left outer foot with normal saline, pat dry, apply [MEDICATION NAME] and secure the [MEDICATION NAME] with [MEDICATION NAME] tape, changing daily and PRN (as needed), until healed. On 11/5/15 the orders included a house supplement TID (three times daily) for nutrition. On 11/19/15 the orders changed to cleanse the left foot wound with normal saline and gauze; do not scrub or use excessive force. Apply [MEDICATION NAME] to wound daily and do not use [MEDICATION NAME]. Cover the wound with a clean white sock and change daily. On 11/24/15 the wound care clinic noted to continue the treatment orders. Additionally the orders noted to off-load the foot; elevate the leg, as needed for [MEDICAL CONDITION], and dangle the heel and support leg to mid thigh, and increase protein in the resident's diet. The clinical record lacked documentation staff followed up with the wound clinic's recommendation for increased protein in the diet. 12/3/15 --The wound care clinic noted to continue the above orders (11/24/15). Observation, on 11/30/15 at 12:20 PM, identified the resident received the lunch meal in the library dining area, with the resident seated in the wheelchair with foot pedals and a off-loading boot in place. The resident received chili, cornbread, dessert, water and juice. An adult child visited, at that time and inquired of the resident if they would like something else, as the resident did not like chili. The resident agreed so and family left the dining area to obtain a peanut butter sandwich from the kitchen. The staff failed to provide a health shake supplement, as ordered/planned. Intermittent observations, at 12:20 PM, 12:35 PM, 12:50 PM, 1:10 PM, 1:25 PM 1:40 PM, 1:55 PM, 2:10 PM, 2:25 PM, 2:40 PM, 2:55 PM, 3:10(2 hours and 50 minutes) identified the resident remained in the dining area in the wheelchair, without a position change provided by staff. On 11/30/15 at 3:20 PM, direct care staff M reported they had just laid the resident down, into his/her bed. On 12/2/15 at 7:46 AM, direct care staff BB and P, assisted the resident with arising cares. At that time staff noted the residents bed and clothing as saturated with urine, requiring a complete bed strip. Staff assisted the resident with changing of the brief and clothing, donning daytime clothing. The resident was noted to rest on a pressure relieving mattress, with socks to his/her feet, however, lacked heel protectors, and was resting on his/her right side. Noted a heel protector on the floor and the off-loading boot in the wheelchair at bedside. Direct care staff BB reported the resident had a sore to the left outer foot which was healing, but the direct care staff reported they do not do anything with the wound. Direct care staff DD entered the room and reported the resident needed an off-loading boot to the left foot and a heelbo (a device placed under the leg at the point the foot joins the leg to off load pressure from the bed to the heel) to the right foot when up in the chair, and the off-loading boot at all times on the left foot. At 7:55 AM, the staff transferred the resident to the wheelchair. Continued intermittent observations, on 12/2/15, of the resident up in the wheelchair at 8:00, 8:15, 8:30, 8:45, 9:00, 9:15, and 9:30 AM, identified the resident remained in the wheelchair with a pressure relieving cushion in the seat of the wheelchair. The breakfast served consisted of a waffle, oatmeal, cornflakes with milk, water and juice. The resident ate fair, independently. However, staff failed to provide a chocolate health shake, as planned. At 8:58 AM the resident continued to eat, and attempted to drink more juice, however, the glass was empty and staff in the dining area failed to offer any more fluids. On 12/2/15 at 9:36 AM, administrative nursing staff E re-made the bed then assisted the resident with laying down, checking and changing the resident for wetness, applied barrier cream and then positioned the resident onto his/her right side. Staff placed the positioning pillow between the resident's knees and the boots to bilateral feet after getting the resident positioned. On 12/2/15 at 3:10, 3:30, and 3:45 PM the resident slept in the bed, with knees flexed and laying on his/her back. At 3:51 PM, direct care staff DD and M provided check and changing for the resident then repositioned the resident onto his/her left side, with boots in place. On 12/2/15 at 10:33 AM, direct care staff BB reported the resident was mostly dependent on staff for all ADL's, except eating, with the resident feeding him/her self. The staff was not sure how long the resident had the area on his/her foot, or how it occurred. However, the staff reported the area as much improved. The staff reported the resident had the off-loading boot since admission, but not the wound. The staff reported the kitchen staff do not provide any specific snacks at bedtime, just general items, such as applesauce, pudding, etc. On 12/3/15 at 1:40 PM dietary staff Z reported the resident was a picky eater and the menu called for finger foods, with regular milk for all meals. On 12/3/15 at 3:11 PM, direct care staff Q reported the resident did not have a dressing to the wound, only a white sock. The staff were directed to keep a pillow for offloading, under the leg, but the resident moved off the pillow every time the staff positioned them. The staff reported the resident wore a boot in bed, but not when up in the chair. Additionally, the staff added, the resident is planned to be turned and repositioned about every hr, but that doesn't always happen. I'd say that realistically the resident is repositioned at meal times, when returned to bed after meals and the resident sometimes refused to go back to bed, after meals. Staff noted the resident sometimes gets a health shake at meal times, but not routinely. On 12/4/15 at 11:02 AM, licensed nursing staff J reported the resident had been attending wound care for about 3 weeks now and the wound care notes should be kept in the chart, however, staff J verified the chart lacked documentation regarding the wound clinic visits and recommended treatments. The staff confirmed the note indicating to increase the resident's protein was not noted due to staff not seeing the order. Staff noted the resident needed frequent repositioning and sometimes was not repositioned timely, although staff tried to stay on top of the turning and repositioning needs of the residents. The staff indicated the resident's intake was fair at this time and should get shakes, as ordered, but staff J was unable to verify the staff always received shakes, as ordered. The staff reported the residents treatments to the foot were conducted by the night shift and measured weekly by the wound care nurse. On 12/4/15 at 3:15 PM, administrative nursing staff B, reported the resident developed the ulcer, after being in the hospital and the facility recently began to send the resident to the wound care clinic. The undated Skin Integrity Guideline policy instructed staff that the DNS (director of nursing services) or designee would be responsible for implementing and monitoring the skin integrity program and wound status would be monitored on a weekly basis. The interdisciplinary plan of care would address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Repositioning would be completed every 2 hours, or as needed and tolerated, taking into consideration resident tolerance and choice, tissue tolerance, current condition of skin and indicate the frequency in the individualized plan of care. Positioning devices, such as pillows or foam wedges, are recommended to keep bony prominence's from direct skin to skin contact and to maintain skin moisture. The facility failed to provide timely repositioning for this dependent resident, failed to consistently provide health shakes as ordered, failed to provide off-loading boots/heel bo's as planned , and failed to follow-up recommendations for increased protein from the wound care clinic in a timely manner to promote the healing of this resident's pressure ulcers.

The facility reported a census of 76 residents, with 3 residents selected for review. Based on observation, interview and record review, the facility failed to buckle a resident in the facility van, for the residents in wheelchairs that use the facility van, when 1 of the 3 selected residents (#1) slid unbuckled from the wheelchair to the floor and sustained fractures of the tibia and fibula bones. Findings included: - Resident #1's annual MDS (Minimum Data Set), dated 8/6/15, revealed the resident as cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15 and no behaviors documented. The resident required limited assistance of 1 person for transfers, and locomotion. The Fall CAA (Care Area Assessment), dated 8/9/15, documented the resident had triggered for fall risk. He/She was bed or chair bound. The resident needed assistance with transfers, toileting, and mobility. The resident's care plan, dated 8/9/15, identified the resident at risk for falls related to a history of falls and the resident had a history of [REDACTED]. The Progress note, dated 8/19/15 at 4:45 PM, revealed the DON (Director of Nursing) was called to the transport van by the van driver. Upon entering the van, the DON noted that the resident was lying on the floor on his/her back in front of his/her wheelchair, with his/her head resting on the foot rest of his/her wheelchair. The resident's right leg was bent and crossed over his/her left leg. The resident's legs, from the knees down, were under the edge of the front seat on the right side. The resident stated his/her right leg was hurting. The resident groaned in pain with movement of his/her right lower leg. The DON noted a raised area on the resident's right leg just below the knee, and his/her right foot was rotated to the left. The resident was sent to emergency room (ER) to evaluate due to complaints of pain to his/her right leg. The facility was notified that the resident had been admitted for surgical repair to the resident's right leg. The Radiology Report, dated 8/19/15, revealed fractures of the resident's tibia and fibula bones (the two parallel bones from the knee to the ankle). On 9/3/15 at 9:00 AM, the resident rested in bed, and confirmed that he/she had an accident in the van, where the van driver came to a stop light, stopped to make a left turn, and he/she (the resident) just slid out of the wheelchair, onto the floor. The resident reported he/she yelled out in pain. The van driver (direct care staff A) drove a couple of blocks with the resident on the floor and took another resident into the facility. The head charge nurse (the Director of Nursing) came out to look at him/her and he/she was driven in the van to the hospital. The resident stated his/her wheelchair was strapped in, but the seatbelt was not used. The resident added, the seatbelt was usually used, but for some reason we (the van driver and the resident) forgot to do it. He/She must have forgotten to remind staff. The resident had surgery and had 2 rods put along the bones in his/her right lower leg. On 9/3/15 at 1:06 PM, direct care staff D reported he/she had been driving the facility van close to 1 year, and training included to secure the resident's wheelchair with 4 floor straps on the frame and the seat belt, which should always go across the resident's lap/stomach area and across the shoulder. On 9/3/15 at 2:22 PM, direct care staff A reported driving the facility van since 7/30/15. The facility van transportation training included placing the floor restraints/ straps on the the resident's wheelchair frame, and the seat belt, and to check to make sure the wheelchair was secure. Staff A's training included observation of approximately 5 transportation's which was completed by social services staff C, a video to watch about where to place the floor restraints/straps, to slip the seat belt through the wheelchair, not over the arms, and a review of the transportation policy. Staff confirmed driving the facility van on the date of the incident, on 8/19/15. Another resident was on the van and was complaining about transporting resident #1 with them. Staff A further explained, he/she restrained resident #1's wheelchair with the 4 floor restraints/straps and while listening to the other resident, it slipped staff A's mind to put resident #1's seat belt on. This was the first and only time staff A forgot to put the resident's seat belt on. Staff A reported he/she drove south on a town bi-pass road, and slowed down to stop for a red traffic light. Without warning, staff A saw the resident slip out of his/her wheelchair. Staff A put the facility van in park in the intersection, checked on the resident, and he/she calmly said his/her leg was hurting. Staff A attempted to make the resident as comfortable as possible, leaving the resident on the floor of the van, and drove the the van back to the facility, approximately a mile. Upon returning to the facility, 3 staff members, including the DON, then placed the resident into his/her wheelchair and Staff A drove the resident to the ER. On 9/3/15 at 3:10 PM, social service staff C reported a formal training was completed by him/her self and direct care staff D, on 4/30/15, from a Department of Transportation staff member, hired by the facility's corporation. The training session included defensive driving, proper placement of the resident on the van, restraining the resident's wheelchair with a total of 4 floor straps/restraints, and use of the seatbelt. At the time of the training session, staff A and D were the only employees that drove the facility van. Staff C confirmed he/she assisted with the training of direct care staff A for the safety of the van transportation. On 9/3/15 at 3:38 PM, administrative nursing staff B reported he/she was called when a resident was on the floor of the facility van. The resident layed on the floor of the van, in front of his/her wheelchair, with his/her lower extremities under the edge of the front passenger seat. The resident reported that he/she was just laying there resting, and that his/her leg was killing him/her. Staff B assessed the resident and found a knot on his/her right leg and the resident's foot was rotated. Direct care staff A's employee file contained a Resident Transportation orientation, dated 7/30/15 and another on 8/20/15, which included procedures of Loading the facility van included, All residents in wheelchairs will be secured using the (special restraint system) and all residents will be secured with the lap and shoulder restraints before movement of the van. Driving van section included, Make sure all passengers are secured with seat belts and are safe. The demonstration of tasks section included, securing the resident in a wheel chair, and the use of floor straps, and floor seat belt with initials of demonstration completed. Furthermore, observation on 3/9/15 revealed, the continued improper safety restraint use for residents being transported in the facility van. At 10:54 AM, direct care staff A and D assisted resident #4 in a wheelchair, into the facility van. Staff D propelled the resident out to the van, backed the resident onto the lift, and staff A reminded staff D to fasten the belt in front of the resident while on the lift. Staff D failed to lock the resident's wheelchair brakes on either side. Staff D kept one hand on the wheelchair as the lift raised the resident up to the van height. Staff D then got on the van and unlocked the resident's left wheel, did not touch the right wheel, and pulled the resident into the van. Staff D positioned the resident in the van and hooked the resident's wheelchair on the front right side with the floor restraint strap. Staff A unhooked the floor strap and repositioned the resident and his/her wheelchair closer to the wall of the van. Staff A and D fastened 3 of the floor latches to the frame of the wheelchair. However, staff failed to strap/secure the front right corner of the resident's wheelchair. Then, staff A threaded the seatbelt through the arm of the resident's wheelchair and staff D gave the latch (female/buckle side) to staff A. Staff A fastened the resident's seat belt where the belt only went across the resident's lap. Staff A reported the resident was secured and was ready to go to the appointment. Staff A, when questioned reported that the wheelchair was secured with 4 points of the floor straps and then confirmed that the front right side was not secured. Staff A then attached the floor strap. Staff A reported the seatbelt was correctly placed, with the belt just over the resident's lap. At 1:15 PM, direct care staff A assisted resident #2 in a wheelchair, onto the facility van's lift and raised it to the van's inner height. Direct care staff D moved the resident, in the wheelchair, into the van. Staff A positioned the resident in the van and applied the back 2 floor straps/restraints. Staff A applied the front 2 floor straps. Staff A placed the seat belt through the arm of the wheel chair, around the resident to the buckle between the arm rest and the backrest of the wheelchair. The arm rest kept the shoulder strap down at the resident's lap/ stomach region. The facility's Resident Transport Policy, dated 8/1/11, included the purpose of this policy was to promote the safety of the facility's residents/employees during transport in the company vehicles and to minimize resident/employee injury and property damage associated with vehicle accidents. All vans used to transport residents are required to be equipped with the (special restraint system). All resident wheelchairs will be secured using the (special restraint system) and all residents will be secured with the lap and shoulder restraints before movement of the van. All van drivers and assistants will be trained using the instruction material and video before transporting residents in the van. Training will include demonstration of the use of the restraint system. Initial and annual training will be documented and placed in the employee's personnel file. The facility failed to buckle the resident in the facility van correctly, resident #1 slid unbuckled from the wheelchair to the floor and sustained fractures of the tibia and fibula bones.

The facility had a census of 70 residents. The sample included 3 residents reviewed for elopement. Based on observation, record review and interview, the facility failed to provide adequate supervision and assistance devices to prevent 1 of these 3 sampled resident's (#1) from leaving the facility without staff knowledge. The resident was found 2.4 miles from the facility and was gone from the facility for at least one hour and 25 minutes. This placed the resident in immediate jeopardy. Findings included: - Resident #1's history and physical, dated on 10/08/2013, documented the [DIAGNOSES REDACTED]. The resident's Admission MDS (minimum data set), dated 10/31/2013, documented an admission date of [DATE], and a BIMS (brief interview of mental status) score of 02, indicating the resident had severely impaired cognition. The resident is usually understood and understands. He/she did not exhibit any behaviors or reject cares, but wandered daily, and the resident was independent in all ADL's (activities of daily living). The CAA (care area assessment) related to cognitive loss/dementia, dated 11/08/2013, documented the resident had a [DIAGNOSES REDACTED]. He/she was placed in the secure ACU (Alzheimer's care unit). The CAA related to behaviors, dated 11/08/2013, evidenced the resident was readily redirected, and has wandering behaviors. The care plan, dated 11/04/2013, and revised on 03/30/2014, documented the resident's safety was at risk due to decreased cognitive ability and wandering. The staff were instructed to redirect the resident when he/she wandered into other rooms or areas that were unsafe and for staff to remove him/her from potentially dangerous situations. The revision on 03/30/2014 instructed the staff to continue with the POC (plan of care). The care plan, dated 11/04/2013, and revised on 03/30/2014, documented the resident was at risk for elopement, related to attempts of trying to leave the living center, a history of elopement, and the resident statements of " I am leaving, I am going home." The staff was instructed to place the resident in the secured unit due to the resident being a risk for elopement, per facility policy, and to redirect the resident from the doors, ensure a wander guard bracelet was in place and working properly, take a picture of resident upon admission for identification and for updating the elopement book. The handwritten update, dated 02/5/2014, instructed staff to continue with current POC. The handwritten update, dated 03/30/2014, instructed staff to continue with current POC with revisions due to actual elopement. The updated revisions included checking function of wander guard bracelet every shift, 15 minute checks for 24 hours upon return to facility, request family not take the resident out on outings outside of the unit at this time, staff to supervise the resident at all times when outside, and staff will check gates in courtyard prior to outside activities and during the day time. The document entitled Risk of Elopement Assessment, dated 10/24/2013, evidenced the resident has dementia, and was oriented to person and situation only. The resident wanders aimlessly and has increased confusion in the evening, has a history of pushing on exit door handles, states he/she is going home, and asks how does he/she get out of here. The resident ambulates independently and is at risk for elopement. Staff applied the wander guard bracelet to the resident's left ankle on date 10/28/2013. The quarterly Elopement Assessment, dated 01/04/2014 and 03/30/2014, documented no changes to initial elopement assessment. The resident has a monitoring bracelet, is on visual monitoring, diversional activities are care planned, and doors are alarmed. The assessment, dated 03/30/2014, had a handwritten note stating the resident had left the facility without staff knowledge. Review of the nurses notes revealed the following: On 03/29/2014 at 4:48 PM, (the day before the elopement), resident requires redirection due to exit seeking behaviors, but compliant with occasional agitation displayed. On 03/30/2014 at 7:30 PM, (the first note documented after the elopement) 15 minute check sheet started; resident has been under constant staff supervision for the past half hour. The nursing notes lacked documentation of the incident. On 03/30/14 at 8:01 PM, SBAR (Situation/Background/Assessment/Response) documented, At approximately 5:00 PM, the resident could not be located in the facility or on the facility property. The resident was located by a facility staff member off grounds, and was taken initially to the emergency room (ER) for assessment. The resident has a history of wandering, and exit-seeking. The resident was noted to display signs and symptoms of anxiety and agitation after the spouse and son/daughter were here for a visit at 3:00 PM. Pacing, grimacing and states, " I ' m ready to go home, but I guess he/she ' s not ready for me. " A full skin assessment wad done with no injuries noted upon return from ER. Vital signs were blood pressure 146/88; pulse 92, respirations 20, and temperature 98.4 with oxygen saturation at 98% (percent) at room air. Per the facility investigation report, dated 03/30/14, the weather on 3/30/14, the day of the elopement, was 70-72 degrees Fahrenheit and the resident was dressed appropriately for the conditions, wearing long pants, long sleeve shirt, light weight jacket, tennis shoes, socks and a hat. Observation, on 04/23/2014 at 8:40 AM, revealed the doors to the facility were secure with alarms at each door. The outside doors from the locked unit all opened with pressure after 15 seconds, and alarmed immediately, the alarm will disengage with correct entry of code. The outside doors from the skilled nursing hall opened and alarmed immediately. Observation, on 04/23/2014 at 08:45 AM, of the courtyard, revealed two wooden gates approximately 8 foot tall in the courtyard. One gate exited north toward the front parking lot and one gate exited south toward the dumpster and the back parking lot. Each gate had a security keypad inside and outside the gate, and a magnetic latch on the outside of the gate. The north gate noted to also have an additional spring, mounted on the inside of the gate to assist with closing the gate. After opening the North gate, using the security code, the magnetic lock did not engage, securing the gate. This gate was opened 4-5 times, and when released, and failed to close completely to engage the magnetic locking system. The south gate noted to be out of alignment, the wood at the top of the gate near the magnetic latch binds when opening and/or shutting the gate and there is a gap of approximately 1 ? inches at the bottom between the gate and the fence framework. The south gate was opened several times and the magnetic latch did not engage unless the gate handle was pulled, physically shutting the gate to engage the magnetic latch. During the time the gate was opened, with the latch not engaged, the light on the password keypad remained green. License nursing staff F was present during testing of the gates and reported that as long as the light is green on the key pad, the gate won ' t alarm. Staff F confirmed that the gates don ' t always close and latch. Staff F reported that the codes to the gates have recently been changed and that staff is discouraged from using the gates to come and go, and that the staff used to take the trash to the dumpster through the back gate, but the trash is now taken out to the dumpster through the laundry room. Staff F confirmed while in the main portion of the courtyard, neither exit gate was visible to staff. On 04/23/14 at 11:50 am, following the path from the nursing facility to the local business where the resident was found, revealed the site where the resident was found is 2.4 miles from the facility, and the route included the resident walking and/or crossing several 2 and 4 lane busy city streets, including the main street of the city, as well as at least one railroad crossing. Maintenance staff M, interviewed on 04/23/14 at 9:27 am, reported, the only way the courtyard gates open is by using a code, one cannot physically push the gates open. There is a factory reset time on the keypads of 8 seconds when the lock will reengage after being opened. Staff M confirmed that the gates do not have alarms on them, just a security keypad to unlock the gates. Staff M confirmed that the gates are not visible from the courtyard, and there are no security cameras present. He/she also stated that the gates were not checked on a regular basis until after the incident/elopement. Administrative Staff A, interviewed on 04/23/14 at 5:25 PM, confirmed, on the evening of the elopement he/she checked the door alarms along with the Licensed Nursing Staff E and Administrative Nursing Staff B, throughout the facility prior to the return of the resident, and again after the return of the resident at approximately 9:00 PM , and the alarms, at that time, were all working properly. Staff A confirmed that it is a regular practice of the direct care staff, while doing activities on the ACU/AACU with the residents, to open up two of the exit doors from the facility into the courtyard, and prop them open while doing activities. Staff A confirmed that while staff are in the courtyard assisting residents, they are unable to visually observe resident ' s coming and going through the two opened doors and the two gates, exiting the courtyard. He/she also confirmed that while the doors are propped open, the alarms are disengaged. Administrative Nursing Staff B, interviewed at 10:14 AM and 5:38 PM, confirmed that the system failure the night of the elopement was staff supervision of the resident ' s in the courtyard and that the courtyard was not secured. Staff B reported that he/she found that the gate (back gate on north side of courtyard) appeared to be closed, but when he/she pushed on the gate, found that it was open and not latched. Staff B reported that trash had been taken out the back door of the facility through the back gate to the dumpster at around 2:30-3:30 PM on the day of the elopement. At that time, that was the route used by staff to take out trash every day. Staff B reported the staff member who found the resident had received a call to come into the facility and help with the search. On his/her drive from home he/she noticed the resident walking across a business parking lot close to him/her home. Staff confirmed that the distance from the facility to where the resident was found was 2.4 miles. Administrative nursing staff B reported that the resident has moments of clarity where he/she is able to make comprehensible conversation. Administrative nursing staff B confirmed that the resident ' s family and the physician were notified about the elopement, but the police were not notified. Furthermore staff B confirmed the gates did not consistently lock after being opened, and that there is no visual of either gate from the courtyard. Staff reported that since the elopement on 03/30/2014, staff was all in-serviced on changes in the elopement procedures. Changes include, each charge nurse is to go into the courtyard and check that each gate is secure at least once per shift, all groups that go into the courtyard must be escorted by at least two staff at all times and prior to going out with residents, the gates are checked again by the staff to be sure they are secure. There is a log of the gate checks the nurses have to sign on each shift. Also, at the time of elopement, they had a policy that CNA (certified nurses aides) staff was not to have visitors while working, and that has been reinforced through in-service as well as the CNA on shift that day was given a written warning for having visitors during that shift. On 04/23/2014 at 3:05 PM, Direct care staff I advised, when the staff hears a alarm they go towards the door and see who or why it is alarming. Staff then should try to redirect the resident. Staff I advised on the day of the elopement, it was a nice day. On nice days, we try to be active with the residents and try to take the residents outside. We had 4 of the AACU residents and about 9 residents of the ACU unit outside. When they were outside, one of the residents, who usually uses a walker, attempted to ambulate independently, and Staff I became busy assisting this resident. Direct care staff I stated he/she was the only one out there. He/she further stated he/she never saw Resident #1 outside at that time, but may have been focused on the resident, without a walker, and needing assistance. Direct care I advised the last time he/she remembers seeing Resident #1 was at approximately 4:50 PM, when Resident #1 came outside,and stayed out for only a few minutes, then stated, " I have had enough of this." Resident #1 then went inside to the dining room and sat down. Direct care staff I further stated, at approximately 5:10 PM all the residents who could walk without a walker went in, and the one resident with the walker was assisted, Direct care J and Direct care O came out to help with the others resident 's. The direct care staff noticed Resident #1 missing before supper, at approximately 5:15 PM. Direct care staff J asked Direct care staff I if he/she had seen resident #1. Direct care staff I stated he/she had not and advised staff J that staff needed check all the bedrooms, bathrooms and closets. Direct care staff I advised Resident #1 could not have been gone that long and staff started looking right away. We were looking simultaneously in the building, others outside the building, and others in cars checking the neighborhood. Direct care I advised there are usually 2 aides outside with the residents, but on the day of the elopement it the other staff's birthday, and he/she had a family visitor come to the facility, so this staff was not present in the courtyard at the time the resident left the facility. He/she stated typically the residents are always sitting in the main area, and not around the corner where the gates are. Direct care staff I advised Resident #1 does have exit seeking behaviors. When asked when the alarms were next checked after the incident, he/she responded that Administrative staff A came in and checked the alarms immediately with the nurses. Observation, on 04/23/2014 at 11:30 AM, revealed the resident at the dining room table participating with several other ACU residents playing volleyball with a balloon. The balloon would frequently fall to the floor due to no one sitting on one side of the table. Without having instruction from the staff, Resident #1 ambulated independently around to the vacant side of the table and sat down and participated in the game. Observation, on 04/23/2014 at 1:10 PM, revealed the resident walking independently down the hall at a fast, steady gait, he/she went to another resident's room and began a conversation with the other resident. Observation, on 04/23/2014 at 2:50 PM, revealed the resident sitting at dining room table with the wander guard alarm on his/her left wrist. Observation, on 04/23/2014 at 5:00 PM, revealed License nursing staff C, check the wander guard bracelet on the residents left wrist, which sounded, at this time. On 04/23/2014 at 11:09 AM, Direct care staff L advised, all doors have alarms on them and there are only 3 doors going outside. Wander guard bracelets are not used on all residents, and the CNA's (certified nursing assistants) make sure the bracelets are still on the residents and the nurses check them to see if they are working. He/she further stated, the residents are not allowed to be outside in the courtyard by themselves there has to be at least 2 aides outside with them. On 04/23/2014 at 11:22 AM, License nursing staff D advised, when the staff hears an alarm, they check to see where or why the alarm is sounding, if no one is at the site of the alarm, then they do a quick head count. We have 14 residents on the AACU (advanced Alzheimer's care unit) side of the doors. The wander guard bracelets are checked with a special tool to see if they are working, and we check placement on every shift, and document that information on the treatment record. If a resident with a wander guard bracelet gets past the ACU door, the alarm will sound by the DON (director of nursing) office. He/she further stated hen the staff take the residents outside they have to have two people at all times with the residents, we check the gates before going outside. This is a recent change where there has to be 2 staff members with more than one resident out there. On 04/23/2014 at 11:40 AM, Direct care staff G, advised the doors are all alarmed and some residents have wander guard bracelets on. He/She pointed to the residents playing volleyball with the balloon and said that is one on his/her wrist. We try to make sure the residents are wearing them and not taking them off. He/she advised when staff hear a door alarm or a wander alarm they are to go towards the alarm, because you never know if other staff are going to or not. On 04/23/2013 at 3:33 PM, Direct care staff J advised, when staff hear an alarm, they are to stop what they are doing, and answer the alarm. Staff should check to make sure a resident has not left the unit. If the resident is still at the door, staff should try to direct them away from the door, or ask the resident to help us, or give the resident a snack. Also, staff should document who and what and if they actually got off the unit. Direct care J advised the last time he/she saw Resident #1 was approximately at 4:30 PM the day of the elopement. He/she last saw the resident outside doing the activity with the other CNA, and then he/she came back inside. He/she advised she left the courtyard for approximately 10 minutes, but had thought the CNA from the dining room was going outside to assist. Upon his/her return the other direct care staff had already started bringing people in from the courtyard for supper. He/she advised he/she asked the other direct care staff and the nurse if they had seen Resident #1 and they advised no. Direct care staff I told him/her the resident left the activity and came back inside, so he/she checked in his/her room and other areas of facility resident #1 frequents, but did not find him/her. Direct care staff J advised he/she informed the nurse, at this time, and began to search the whole facility. Direct care J advised he/she thought he/she went out the back gate, as the back gate has the numbers wrote on it. I think he/she went back outside then out the back gate, as he/she is very bright. The back gates do not have any alarms, but have a security lock you have to punch in. On 04/23/2014 at 4:04 PM, License nursing staff E advised, when the alarm sounds everyone is expected to go toward the sound of the alarm. We stress the urgency of them going to the alarm. On the date of the elopement, at approximately around 4:30 PM, staff E made assignments with one staff member watching residents not attending the activity and 2 CNA's outdoors doing an activity with several residents. They were told to have 2 CNA's outside due to the number of residents. One of the two CNA's was seen in the dining area and staff E told him/her to go outside to assist with the resident's in the activity. Staff E stated he/she made sure everyone was at their assigned places and then he/she went on break. License nursing staff E stated he/she heard an alarm go off and saw staff and 2 visitors going out or off the unit toward the skilled nursing unit. He/she returned from break at approximately 4:50 PM, his/her direct care staff were getting people ready for dinner. Direct care staff J informed staff E that resident #1 was not in his/her room. I asked where they saw him/her last, and the direct care staff J said they had seen the resident last in dining room. Staff E then did a head count. We had the courtyard closed with everyone inside. Staff started going room to room and looking in closets, under beds in every room, and had the staff from the skilled unit looking for him/her also. Staff E sent another staff member to look in the courtyard. One or 2 people checked the property outside the facility. Staff worked their way from the facility, looking for resident #1 across the street at the assisted living facility. License nursing staff E stated he/she had contacted the DON (director of nursing), and other department heads, which is the protocol to follow during an elopement. He/she advised he/she did not call code Adam overhead, because everyone was already aware, and searching the facility. Licensed nursing staff E advised a short time after talking to the DON, License nursing staff N called and advised he/she found the resident on his/her way to the facility. Staff E stated he/she was about to call the police when Staff N called. Staff N then they took the resident to the emergency room for an evaluation. We just do not know what or how he/she got out. He/she had a wander guard bracelet on. Staff E stated he/she did do a check of the gates with the DON. Staff E further stated, the resident does have the cognition to use the the code and the code use to posted on the key pad, by the gate, in numbers about ? in size. Staff E also stated the code is still posted, just in a different area. The charge nurses now do a check of the court yard before an outside activity to make sure the gate locks are engaged. It appears the gate locks were loose at the time of the elopement and the gate may not have been closing properly then. The exit doors, during an activity in the courtyard, are propped open and the alarm is turned off. Per notarized statement of Administrative Nursing Staff N, the resident was found at 5:40 PM, was a little out of breath and displayed some pallor (pale color of the skin). The resident was found at a local business located at the corner of Park and Broadway Street. The facility provided policy titled Elopement Guideline, last updated 2013, documented: Door Alarms and resident protection alarms: A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents ...Only the Executive Director/or designee may authorize disabling the alarm system and is responsible for the method of monitoring for residents ' safety and resetting the alarm. Environmental Guidelines: The living center will identify any external environmental hazards as well as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. Living Center will implement interventions to minimize these risks and hazards as appropriate. The facility failed to provide adequate supervision and assistance devices to prevent this cognitively confused resident from leaving the facility without staff knowledge. The resident left the facility through a exit door which staff had propped open and turned off the alarm, then the resident went out a gate in the courtyard which had not been properly latched/locked. The resident walked at least 2 miles, crossing at least 15 residential and business streets, plus one railroad track, before being found by a staff member driving to work to assist with the search and who saw the resident in the parking lot of a local business. This placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 04/26/14 at 11:43 am by initiating the following: Policy and procedure, dated 04/01/14, for ACU/AACU: 1). Two staff members must be present during any outside activity. 2). Outside gates will be checked before taking any residents outside. 3). If a staff member is called away then another member must take their place. 4). Gates will be checked by Charge Nurse daily at the beginning of the shift. 5). No staff will exit or enter the courtyard gates except in an emergency. All staff inservice, held on 04/03/14 at 2:00 pm, which covered elopement procedures including identification of resident's at risk for elopement. Completion of maintenance to the exit gates in the courtyard, on 04/26/14 at 11:43 am, to ensure both gates closed and latched properly. The immediate jeopardy was abated, on 04/26/14 at 11:43 am, however the deficiency remained at a scope and severity of a D.

The facility identified a census of 71 residents with 26 residents sampled. Based on observation, interview and record review, the facility failed to provide necessary care and services for 5 sampled residents, that included pain management for 4 residents (#93, #56, #10, #40) and [MEDICAL TREATMENT] monitoring for 1 resident #60. Findings included: - According to the clinical record, the facility admitted resident #93, on 12/5/11, with [DIAGNOSES REDACTED]. Review of the admission 5-day-Medicare, Minimum Data Set 3.0 assessment (MDS), dated [DATE], recorded a BIMS (Brief Interview for Mental Status) score of 8, required extensive assistance of staff for bed mobility, transfers, dressing, toileting, and personal hygiene. This same Minimum Data Set recorded an interview about pain conducted by the staff and the resident revealed occasional pain present, rated at a 5 (on a scale of 0-10 with 10 the worst), that effected his/her sleep at night, and day to day activities. This same assessment recorded the resident received no scheduled pain medication and received PRN (as needed) pain medication. Review of the Care Area Assessment (CAAs), dated 12/20/11, triggered pain and documented the resident reported pain during the 7-day look back period that made it hard to sleep at night and caused him/her to limit his/her day to day activities. This CAA recorded the resident needed pain management and monitored related to wound/surgical procedure. Review of the quarterly Medicare 90-day MDS, dated [DATE], documented the resident with a BIMS score of 10, no scheduled pain medication in the last 5 days, and received PRN pain medications. This same Minimum Data Set documented the staff conducted an interview with the resident that revealed the resident had pain almost constantly in the last 5 days that made it hard to sleep at night, limited day to day activities and rated the pain a 10. Review of the resident's plan of care, dated 3/8/12, documented pain management and monitoring related to a wound and surgical procedure. This plan of care directed staff to: -Administer pain medication as ordered, -Evaluate and establish level of pain on numeric scale/evaluation tool, -Evaluate characteristics and frequency/pattern of pain, -Evaluate need for routinely scheduled medications rather than PRN pain med administration, -Evaluate need to provide medications prior to treatment or therapy, -Evaluate what makes the patient's pain worse, -Observe for potential medication side effects, -Offer spiritual support if desired, -Utilize pain-monitoring tool to evaluate effectiveness of interventions. Review of a hospital history and physical, dated 4/20/12, documented the diagnosis, [MEDICAL CONDITION] of the cecum ([MEDICAL CONDITION]) and recorded a scheduled laparoscopic right hemicolectomy (surgical excision of part or all of the colon performed to [MEDICAL CONDITION] of the colon). Review of the resident's clinical record revealed a reentry transfer form, from an acute care hospital, to the facility, dated 4/27/12, that recorded the recent surgical procedure of a laparoscopic right hemicolectomy. The resident's plan of care lacked evidence of a revision of interventions for pain management after readmission from the hospitalization for a laparoscopic hemicolectomy. Review of the nursing clinical health status re-admission assessment, dated 4/27/12, recorded the resident alert with short and long-term memory problems and required assistance with decision-making. This same assessment documented the resident with moderate intermittent aching pain rated a 5 (on a scale of 0-10), that impacted the quality of life/functioning, impacted sleeping, day to day activities, appetite, mood, and limited activity. This assessment recorded other symptoms associated with pain as nausea/anxiety with a possible causal factor of history [MEDICAL CONDITION] and the current pain treatment as Tylenol with last dose given 4/27/12 at 8:00 A.M. Review of a physician order, dated 4/28/12, documented the pain medication Tylenol 325 milligrams, 2 tablets orally, every 6 hours, as needed for pain or temperature above 100 degrees. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 5/16/12 at 1:52 P.M., the resident lay moaning in his/her bed, complained of pain, and stated, "Need something, I'm just hurting. I had bowel surgery about a month ago and still having pain." On 5/16/12 at 2:10 P.M., licensed nursing staff G reported that the resident's physician knows about the pain and ordered an increase in [MEDICATION NAME] (medication for heartburn, gastrointestinal reflux, or ulcer) for 2 weeks to see if that takes care of his/her pain. Review of the computerized clinical record, documented on 5/7/12, the resident with continued complaint of abdominal pain and decreased appetite, eating less than 50%. The documentation revealed a physician order, also dated 5/7/12, "[MEDICATION NAME], 40 milligrams, orally, 30 minutes before breakfast." Observation, on 5/17/12 at 9:32 A.M., revealed the resident seated in a wheelchair in the hallway outside his/her room, moaning, and repeating "Oh God," and moaning. Observation revealed direct care staff H stated to the resident, "You've already had something for stomach pain." (In reference to the [MEDICATION NAME].) On 5/17/12 at 9:36 A.M., when asked about his/her pain, the resident responded, "I'm hurting beyond belief." Observation at this time revealed, direct care staff JJ, applied a gait belt, and transferred the resident from a wheelchair to the bed, and the resident continually repeated, "Oh God, my stomach is hurting me." Direct care staff JJ asked the resident if he/she received the Tylenol. The resident replied, "They give me something. I do know my stomach is hurting like hell," and the resident continued to mutter "Oh, God" with every breath. On 5/17/12 at 10:49 A.M., review of the Medication Administration Record, [REDACTED]. Observation, on 5/17/12 at 1:00 P.M., revealed staff pushed the resident in his/her wheelchair down the hallway as the resident constantly softly repeated, "Oh, God." On 5/17/12 at 1:50 P.M., direct care staff H reported, no administration of the PRN (as needed) Tylenol to the resident and stated, "I worry about the Tylenol hurting his/her stomach. The nurse may have something stronger to give to him/her." On 5/17/12 at 2:45 P.M., administrative nursing staff C confirmed the resident had not received any pain medication in May. On 5/17/12 at 2:50 P.M., when asked, administrative nursing staff E, reported, "I will call the resident's physician right now, today, and get him/her something for pain." Review of the MAR, recorded on 5/17/12 staff administered the resident Tylenol as ordered at 8:00 P.M. The MAR indicated [REDACTED]. Review of the clinical record revealed a change of condition note, dated 5/17/12 timed 8:10 P.M., that documented the "Resident complained of abdominal pain (on a scale of) 10 out of 10. No PRN other than Tylenol available. Call to on-call-hospital. physician's orders [REDACTED]. Review of an untimed general nurses note, dated 5/18/12, recorded the resident returned to the facility via facility van, with new orders for [MEDICATION NAME], 5/500 milligrams, for pain. Review of the clinical record revealed a new physician's orders [REDACTED]. Review of the facility provided policy, Pain Management Guideline, dated January 2011, documented; "The guidelines provide consistent assessment, management, and documentation of pain in order to provide maximum comfort and enhanced quality of life." This same policy recorded, "Functions of appropriate pain management include, but are not limited to: recognizing and reporting pain as 5th vital sign; assessing pain and evaluating response to pain management interventions using a pain management scale based on resident self-report or objective assessment for the cognitively impaired; and recognizing that pain medications may be given around-the-clock; documenting pain assessment, intervention, and evaluation activities in a clean and concise manner per the plan of care. Resident, family and staff education regarding pain management includes staff education regarding the identification and reporting of pain as the 5th vital sign." The facility failed to assess, and provide necessary care and effective pain management for this resident with severe pain. - Review of resident #10's clinical record revealed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/29/11, the resident's physician ordered Tylenol, 500 mg (milligrams), as needed, for pain and [MEDICATION NAME] with Tylenol 5/325 mg, three times a day, as needed, for pain. The resident's admission MDS (Minimum Data Set), dated 7/8/11, recorded a BIMS (Brief Interview for Mental Status) score of 5 (a score of 0-7 indicated severe cognitive impairment), required extensive assistance of 2 staff with bed mobility, transfers, and walking in the room, used a wheelchair, on a scheduled pain medication regimen, and the resident expressed no pain when interviewed. Review of the resident's 7/26/11 CAAS (Care Area Assessment Summary) revealed pain did not trigger for further assessment. Staff recorded on the cognitive loss CAAS the resident able to make some immediate needs and wants known. Staff recorded on the activities of daily living/rehabilitation potential CAAS the resident with short and long term memory loss secondary to [DIAGNOSES REDACTED]. On 8/22/11, the resident's physician ordered a [MEDICATION NAME] 75 mcg/hr (micrograms per hour), and change every 3 days, for pain. Staff recorded on the resident's 1/8/12 quarterly resident review form, the resident rated pain at 2. Review of this form lacked any additional documentation of the location of the resident's pain and current pain treatment plan. On 2/14/12, the consultant pharmacist recorded, "Resident currently receives [MEDICATION NAME] 75 mcg/hr patch applied every 72 hours, yet requires daily dosing of prn (as needed) [MEDICATION NAME] (Frequently for back pain). Please evaluate current [MEDICATION NAME] therapy and consider whether initiation of [MEDICATION NAME] would be appropriate at this time." Review of this pharmacy recommendation form revealed the resident's physician ordered to add the [MEDICATION NAME]. Staff documented on this recommendation form noting this order on 2/23/12. Review of the resident's 3/12 MAR (Medication Administration Record) revealed staff wrote on this MAR indicated [REDACTED]. Staff recorded in the 3/26/12 nursing notes, at 5:01 PM, lacked evidence of any physician's orders [REDACTED]. Review of the resident's clinical record lacked evidence the physician had discontinued the resident's [MEDICATION NAME] for pain. The resident's quarterly MDS, dated 4/9/12, recorded a BIMS score of 12 (a score of 8-12 indicated moderate cognitive impairment), required supervision of 2 staff with bed mobility, transfers, supervision only with walking in the hall/corridor, used a wheelchair and/or walker, on a scheduled pain medication regimen, no as needed pain medications received, and the resident reported no pain during the pain interview. Staff recorded on the resident's 4/9/12 quarterly resident review, the resident had pain in the knees or back, but the pain did not radiate. Staff recorded the current pain treatment plan included a [MEDICATION NAME], every 3 days, as effective. The resident's 4/12/12 care plan directed staff to evaluate and establish the level of the resident's pain on a numeric scale/evaluation tool. The care plan recorded the resident's pain usually rated between 3-6, on a scale of 0-10. The care plan directed staff to utilize a pain monitoring tool to evaluate the effectiveness of the planned interventions. Staff recorded on the care plan, the resident stated an acceptable pain level between 2-5. The care plan had interventions for staff to evaluate the need for the as needed pain medication for break through pain, administer pain medication as ordered by the physician, evaluate characteristics and frequency/pattern of pain, evaluate what made the patient's pain worse, provide the [MEDICATION NAME] Patch as ordered to provide routine and constant pain control. and administer the [MEDICATION NAME], as ordered, for pain. On 4/18/12, the resident's physician ordered a decrease in the dosage of the [MEDICATION NAME] from 75 mcg/hr to 50 mcg/hr, change patch every 3 days. The physician ordered for staff to start the dose reduction on 4/24/12 after completion of the supply of the 75 mcg patches. Staff recorded in the 4/18/12 nursing notes, at 9:33 PM, the resident's physician saw the resident and decreased the [MEDICATION NAME] to 50 mcg when the 75 mcg supply ran out. Staff recorded the need to then remind the doctor in one month to see if staff could decrease the [MEDICATION NAME] to 25 mcg. Review of the resident's 4/12 MAR indicated [REDACTED]. Staff recorded on the resident's 4/12 pain monitoring tool the resident rated the pain at 7-8 prior to the as needed pain medications and rated the pain relief at a 4 after the administration of the pain medications. The resident received the as needed pain medications on 9 different occasions. Staff recorded the following in the nursing notes: On 4/24/12, at 11:19 PM, "The initial dose of [MEDICATION NAME] 50 mcg patch on tonight. No complaints." (Staff recorded on the 4/12 MAR, the resident received a [MEDICATION NAME] pain medication for complaints of pain on this date.) On 4/25/12 at 1:56 AM, "The resident with the [MEDICATION NAME] in place. No adverse reactions noted, and no complaints voiced." On 4/25/12 at 2:44 PM, "Monitoring the resident decrease in [MEDICATION NAME]. No adverse effect from decrease. No increase in complaints of pain, did not request as needed pain medication or complaints of breakthrough pain." On 4/25/12 at 9:11 PM, "Continuing to monitor for pain due to decrease in [MEDICATION NAME]. The resident did complain of pain all over and received [MEDICATION NAME] at 6 PM. The resident had no further complaints of pain this evening." On 4/26/12 at 8:37 PM, "The resident did complain of right right should pain and all over pain at 5:00 PM and received an as needed [MEDICATION NAME]." Review of the resident's 5/12 MAR indicated [REDACTED]. Review of the 5/12 MAR indicated [REDACTED]. On 5/21/12 at 10:11 AM, staff recorded in the nursing notes at 7:50 AM, the resident complained of pain "everywhere" and rated at a 10. Staff recorded the resident as tearful. Staff attempted to rub the resident's back and changed the position of the resident, but nothing helped the resident's pain. At 8 AM, staff documented administering the as needed [MEDICATION NAME]. At 9 AM, staff recorded the resident said the pain was "a little better", with about a rating of a 5, on a pain scale of 0-10, pain only in the neck and right shoulder. On 5/16/12 , at 8:30 AM, the resident stated the resident hurt all over. The resident stated, "I use a pain patch, but it doesn't help much." On 5/21/12 at 10:48 AM, the resident stated, "I am hurting all over. They (Staff) give me a pain pill once in a while and it helps some." On 5/21/12 at 10:51 AM, when asked the reason for the decrease in the resident's [MEDICATION NAME], licensed staff N stated, "Insurance wouldn't pay for it (the patch). The doctor decided it was not helping (the resident). Most of (the resident's) pain is in (the resident's) knees. Once in a while, (the resident) complains of back pain. I haven't been on the floor during the changes but the other nurses say (the resident) has had more break through pain since the decrease in patch strength. We have to prove (the resident) is having breakthrough (pain). The previous dose of 75 mcg was holding. Basically, we need to get back with the doctor...(The resident) is alert enough to ask for pain medication and you can look at (the resident) to tell if (the resident) is in pain. We should do a pain scale every time we give a prn pain medication." On 5/21/12 at 11:20 AM, licensed staff N and administrative staff SS verified the resident's chart lacked a physician's orders [REDACTED]. On 5/21/12 at 12:15 PM, direct care staff P stated, "(The resident) complains of pain in (the resident's) right shoulder. (The resident's) right shoulder hurts (the resident) quite a bit. We tell the nurse. (The resident) will tell you (the resident) is in pain." On 5/21/12 at 2:48 PM, licensed staff O stated, "(The resident) has a [MEDICATION NAME], we change it every 3 days. The pain patch was decreased to 50 mcg from 75 mcg. Since then (the resident) has been taking (the resident's) prn (as needed) [MEDICATION NAME] more frequently. The dose reduction was done, something with insurance. The prn [MEDICATION NAME] seems to be helping. (The resident) is able to tell us about (the resident's) pain. (The resident's) pain is in (the resident's) knees, back and shoulders...I need to call the doctor that (the resident) is having more pain since the reduction. I usually would put the [MEDICATION NAME] wherever (the resident) said (the resident) was hurting, usually (the resident's) upper back." On 5/21/12 at 4:00 PM, direct care staff Q stated, "(The resident) states (the resident's) legs hurt once in a while. I tell the nurse when (the resident) is hurting." On 5/22/12 at 7:37 AM, licensed staff N verified the resident's clinical record lacked a physician's orders [REDACTED]. Review of the facility provided policy, Pain Management Guideline, dated January, 2011, recorded, "The guidelines provide consistent assessment, management, and documentation of pain in order to provide maximum comfort and enhanced quality of life...Functions of appropriate pain management include, but are not limited to: recognizing and reporting pain as the 5th vital sign; assessing pain and evaluating response to pain management interventions using a pain management scale based on resident self-report or objective assessment for the cognitively impaired; and recognizing that pain medications may be given around-the-clock; documenting pain assessment, intervention, and evaluation activities in a clean and concise manner per the plan of care. Resident, family and staff education regarding pain management includes staff education regarding the identification and reporting of pain as the 5th vital sign." The facility failed to adequately monitor and assess this resident's pain level and as needed pain medication for effectiveness. The resident experienced more break through pain after the dose reduction of the [MEDICATION NAME], and staff failed to notify the resident's physician of the increase in the resident's break through pain. In addition, the facility failed to follow the physician's orders [REDACTED]. - According to the clinical record, the facility admitted resident #56 on 1/30/08. Review of the physician's orders [REDACTED]. Review of the Annual Minimum Data Set (MDS) 3.0 Assessment, dated 4/22/12, documented the resident with a BIMS (Brief Interview for Mental Status) score of 4 (that indicated severe cognitive impairment), required extensive assistance of staff for activities of daily living and with no scheduled or as needed (PRN) pain medication. Review of the Care Area Assessment summary (CAAs), dated 5/9/12, revealed the area for pain did not trigger for further assessment. Review of the care plan, dated 5/14/12, recorded pain management related to a potential for pain and directed staff to: - Administer pain medication as ordered, - Coordinate with patient/family/responsible party (RP) to identify patient's favorite items/activities that could serve to distract from pain, - Evaluate and establish level of pain on numeric scale/evaluation tool, - Evaluate need for routinely scheduled medications rather than PRN pain med administration, - Evaluate what makes the patient's pain worse, - Implement the patient's preferred non-pharmacological pain relief strategies, - Observe for potential medication side effects, and - Utilize pain monitoring tool to evaluate effectiveness of interventions. Review of the May 2012, POS further recorded a physician orders [REDACTED]. Review of the clinical record revealed no administration of the pain medication for the months of April or May 2012. Observation, on 5/15/12 at 1:37 P.M., revealed the resident called out and groaned as direct care staff JJ and NN transferred the resident from a wheelchair to a bed with a sit-to-stand lift. On 5/17/12 at 1:35 P.M., direct care staff KK and NN transferred the resident from a wheelchair to the bed with a sit-to-stand lift. During the transfer, the resident called out, "Owe, it's hurting me. It's hurting me all over." At this time, licensed nursing staff G inquired if the resident wanted something for pain. The resident responded, "I wish you would give me something." Licensed nursing staff G asked the resident to rate his/her pain on a scale of 1-10 and the resident replied, "10". Review of the clinical record, on 5/21/12, revealed a physician order, dated 5/17/12, for [MEDICATION NAME], 50 milligrams, 2 tablets, as needed, three times daily for pain. Review of the resident's Medication Administration Record, [REDACTED].M. and again on 5/20/12 at 8:30 A.M. The clinical record lacked evidence that the staff assessed the resident's pain prior to the administration of the medication and further lacked an evaluation of the effectiveness of the pain medications. On 5/17/12 at 1:35 P.M., direct care staff LL reported the resident would occasionally complain of pain. On 5/22/12 at 5:30 P.M., direct care staff OO revealed staff report a complaint of pain by the resident to the charge nurse. On 5/22/12 at 11:40 A.M., licensed nursing staff G revealed that after administering an oral pain medication, like Tylenol, staff reassessed the resident for the effectiveness of the medication Review of the facility provided policy, Pain Management Guideline, dated January 2011, documented, "The guidelines provide consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life." This same policy recorded, "Functions of appropriate pain management include, but are not limited to: recognizing and reporting pain as 5th vital sign; assessing pain and evaluating response to pain management interventions using a pain management scale based on resident self-report or objective assessment for the cognitively impaired; and recognizing that pain medications may be given around-the-clock; documenting pain assessment, intervention, and evaluation activities in a clean and concise manner per the plan of care. Resident, family and staff education regarding pain management includes staff education regarding the identification and reporting of pain as the 5th vital sign." The facility failed to assess, and evaluate effective pain management for this resident that complained of pain. - Review of resident #40's clinical record revealed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. On 5/25/10, the resident's physician ordered Tylenol EX (extra strength), 500 mg (milligrams), as needed, every 4 hours for pain. The resident's annual MDS (Minimum Data Set), dated 6/10/11, identified the resident with a BIMS (Brief Interview for Mental Status) score of 2 (a score of 0-7 indicated severe cognitive impairment), on a scheduled pain medication regimen, no as needed pain medications, and per the resident's pain interview, no pain expressed. Review of the resident's CAAS (Care Area Assessment Summary), dated 7/1/11, for pain management and monitoring related to chronic pain recorded to administer pain medication as ordered; evaluate and establish level of pain on numeric scale/evaluation tool, evaluate characteristics and frequency/pattern of pain, evaluate need for routinely scheduled medications rather than as needed pain medication administration, evaluate what makes the pain worse, implement the patient's preferred non-pharmological pain relief strategies, and utilize the pain monitoring tool to evaluate the effectiveness of the interventions. The resident's quarterly MDS, dated [DATE], identified the resident with a BIMS of 3, no scheduled pain medication regimen, received as needed pain medications, and per the resident's interview for pain, the resident reported rarely had pain. Staff recorded on the resident's 3/7/12 quarterly resident review, the resident with short and long term memory problems and no pain recorded. The resident's 4/5/12 care plan directed staff to administer pain medication as ordered, evaluate and establish the level of pain on a numeric scale/evaluation tool, evaluate the characteristics and frequency/pattern of pain, evaluate the need for routinely scheduled mediation rather than as needed pain medication administration, evaluate what makes the patient's pain worse, and to utilize the pain monitoring tool to evaluate the effectiveness of the interventions. Review of the resident's 4/12 MAR (Medication Administration Record) revealed staff administered the as needed Tylenol on 4/2, 5, 7, 26, 30/12. Staff only recorded on the back of the MAR, on 5/7/12 at 11 AM, Tylenol given for complaints of headache, at 12 noon, and recorded the medication as effective for relief of pain. Review of the 4/12 MAR indicated [REDACTED]. In addition, the 4/12 MAR indicated [REDACTED]. Also, the resident's clinical record lacked any type of pain monitoring tool, as directed by the care plan for monitoring the resident's pain. Review of the resident's 5/10 MAR indicated [REDACTED]. On the back of the 5/10 MAR, staff recorded on 5/8/12 at 1:30 PM, Tylenol given for complaints of back pain. Review of the MAR indicated [REDACTED]. Review of the 5/12 lacked the reason staff administered the as needed Tylenol on 5/7 and 15/12, and lacked any documentation for effectiveness of the pain medication. Also, the resident's clinical record lacked any type of pain monitoring tool, as directed by the care plan for monitoring the resident's pain. On 5/15/12 at 4:22 14 PM, the resident stated, "My head is killing me." Observation, at that time, revealed the resident holding their hand over their left eye. On 5/21/12 at 10:51 AM, licensed staff N stated, "We should do a pain scale every time we give a prn (as needed) pain medication." On 5/21/12 at 12:15 PM, direct care staff P stated, "At times, (the resident) complains of headache about 2 to 3 times a week. I tell the medication aide. (The resident) has an order for [REDACTED]. On 5/21/12 at 2:44 PM, licensed staff O stated, "(The resident) is pretty good about telling us if (the resident) has a headache. We give (the resident) prn Tylenol. (The resident) is not always able to rate a pain scale. Do follow-up for effectiveness in MAR indicated [REDACTED]. Sometimes you have to remind (the resident) that you gave (the resident) some Tylenol." On 5/21/12, at 4 PM, direct care staff Q stated, "(The resident) says (the resident's) legs hurt from walking. We tell the nurse and the nurse has us lay (the resident) down." Review of the facility provided policy, Pain Management Guideline, dated January, 2011, recorded, "The guidelines provide consistent assessment, management, and documentation of pain in order to provide maximum comfort and enhanced quality of life...Functions of appropriate pain management include, but are not limited to: recognizing and reporting pain as the 5th vital sign; assessing pain and evaluating response to pain management interventions using a pain management scale based on resident self-report or objective assessment for the cognitively impaired; and recognizing that pain medications may be given around-the-clock; documenting pain assessment, intervention, and evaluation activities in a clean and concise manner per the plan of care. Resident, family and staff education regarding pain management includes staff education regarding the identification and reporting of pain as the 5th vital sign." The facility failed to adequately assess and monitor this resident's level of pain prior to administration of the as needed Tylenol and per the facility's policy. - According to the clinical record, the facility admitted resident #60 on 5/24/08, with a readmission on 8/20/09. Review of the physician's orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) 3.0 Assessment, dated 3/09/12, documented a BIMS (Brief Interview for Mental Status) score of 9 (indicated moderate cognitive impairment), required extensive assist for activities of daily living and received [MEDICAL TREATMENT] services. Review of the physician's orders [REDACTED].<100 systolic or <60 diastolic two times a day. This same physician's orders [REDACTED]. Carvedilol, 25 milligrams, orally, twice daily for coronary [MEDICAL CONDITION] (medication for management of heart failure and hypertension), dated 6/2/11; [MEDICATION NAME], 0.1 milligrams, orally, three times daily for hypertension, dated 1/16/12; [MEDICATION NAME], 10 milligrams, orally, once daily, for hypertension on [MEDICAL TREATMENT] days prior to [MEDICAL TREATMENT], dated 1/16/12; [MEDICATION NAME] 800 milligrams, orally, one table, three times daily with meals and one with snacks, dated 4/5/12; and fish oil, 500 milligrams, orally, 2 capsules, four times daily for supplement. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. daily when the resident attended the [MEDICAL TREATMENT] center. Review of the resident's plan of care, dated 3/22/12, documented due to a history of falls,

The facility identified a census of 82 residents with 25 residents sampled. Based on observation, interview and record review, the facility failed to ensure staff implemented appropriate interventions, care, and treatment for 2 of 4 residents reviewed to prevent the development of avoidable pressure ulcers. (#43, #49) Findings included: - According to the resident's clinical record, the facility admitted resident #49 on 8/25/08, with [DIAGNOSES REDACTED]. Nursing notes, dated 5/1/11 timed 6:25 A.M., recorded the resident incontinent of bowel/bladder and staff performed incontinence care. The staff recorded the resident's buttocks cleft red and gaulded. The staff applied barrier cream and recorded the resident's skin was intact. The weekly nursing assessment dated [DATE] recorded "no skin issues noted". Nursing notes, dated 5/21/11 timed 3:31 A.M., recorded the resident up in a merry walker at this time, ambulated with a steady gait. Review of the weekly nursing skin assessments 3/1/11 through 5/27/11 recorded no skin issues noted. Skin assessment on 6/3/11 recorded two scratches on the right hand, on 6/10/11 recorded open area on coccyx, see wound sheet. Review of the annual Minimum Data Set 3.0 assessment, dated 3/5/11, identified the resident at risk for developing pressure ulcers, no pressure ulcers at this time and no pressure ulcers on the prior assessment. This same MDS recorded skin and ulcer treatments of, 1) pressure reducing device for chair, 2) pressure reducing device for bed and 3) turning/repositioning program. Review of the quarterly Minimum Data Set 3.0 assessment, dated 6/5/11, identified the resident at risk for developing pressure ulcers. This Minimum Data Set further recorded the resident without any pressure ulcers. Review of the significant change Minimum Data Set 3.0 assessment, dated 6/15/11, recorded the resident with short- and long-term memory impairment, moderately impaired decision-making skills, and required extensive assistance from staff for activities of daily living, no functional loss of range of motion, always incontinent of bowel and bladder with a scheduled toileting plan. This same Minimum Data Set documented the resident with a Stage 1 or greater pressure ulcer, and recorded staff performed a formal assessment, clinical assessment, and identified the resident at risk for pressure ulcers and no pressure reducing device for a chair. This same record documented one stage 2 pressure ulcer developed, on 6/14/11, and one unstageable pressure ulcer with measurements of 2.5 centimeters (cm) in length, 0.8 cm wide no depth. Review of the Care Area Assessment (CAA), dated 7/27/11, recorded the resident required extensive assistance with the majority of his/her activities of daily living, incontinent of bowel/ bladder, wore adult briefs at all times and ambulated the halls in a merry walker throughout the day. The CAA recorded a gluteal fold unstageable pressure ulcer that measured 2.5 cm in length x 0.8 cm in width and one stage 2 pressure area on the coccyx that measured 0.5 cm long x 0.4 cm wide x 0.1 cm deep, with a minimal amount of serous malodorous drainage. Review of the clinical record revealed a plan of care, dated 3/24/11, that identified the resident at risk for altered skin integrity. This plan of care included interventions that directed staff to: -Conduct weekly skin inspection. -Pressure relieving mattress in place on bed. -Provide thorough skin care after incontinent episodes and apply barrier cream. -Turning and repositioning throughout shift and as needed. Review of the resident's plan of care, dated 7/28/11, identified the resident incontinent of bowel and bladder with a wound infection, possible osteo[DIAGNOSES REDACTED], and Stage 4 pressure ulcer to the coccyx. The plan of care directed staff to: -Check and change me every 2 hours and as needed to provide perineal care with each incontinence episode -Administer antibiotics and treatments as ordered -Encourage proper rest. -Intravenous (IV) antibiotics x 6 weeks per physician orders. -Conduct weekly skin inspection. -Provide pressure reducing wheel chair cushion. -Provide pressure reduction/relieving mattress. -Provide thorough skin care after incontinent episodes and apply barrier cream. -Treatments as ordered. -Turning and reposition schedule per assessment. -Weekly wound assessment. -Seen by wound clinic for wound vac (vacuum). -Foley catheter, 18 French insert, leave for 10 days, if resident is compliant with Foley catheter, then continue. - If wound vac comes off, clean wound to coccyx with NS (normal saline) and then skin prep applied to periwound tissue. Dress the wound with NS soaked gauze, then 4 x 4 gauze and ABD pad, then tape to secure. Do this every 8 hours until wound vac can be replaced. -Wound clinic visit weekly. -Wound vac in place per physician's orders [REDACTED]. -Check Merry Walker every 20 minutes, release every 2 hours -Maintain toileting Review of the undated resident care sheet for direct care staff recorded: The resident was incontinent of bowel and bladder, had a urinary Foley catheter, "Merry Walker", required assistance of 1 staff, and received wound care to the buttocks and a wound vac. Review of the resident's clinical record revealed the following, untimed, physician orders: (11/2/10) Resident to ambulate with Merry Walker in facility with staff supervision. Resident to use walker for maximum of 1-2 hours with minimum 1 hour rest break between bouts of walking (1/28/11) [MEDICATION NAME] ointment as needed, applied to coccyx every 2 hours for gaulding. (2/1/11) Supplement 2-cal three times daily, document percentage taken. (2/25/11) House supplement (6/10/11) Consult with (hospital) wound care. (6/10/11) [MEDICATION NAME] CA (calcium) alginate 4 x 5 inch (wound dressings), cut piece to size of wound - external, every 72 hours on 7-3 shift, every Monday/Friday. Cleanse open area to coccyx with Normal Saline, apply [MEDICATION NAME] cut to size of wound at cover with 2 x 2 gauze, then 4 x 4 gauze, tape to secure. Change every 72 hours and as needed (PRN) soiling or displacement for the [DIAGNOSES REDACTED]. (6/28/11) Send to wound clinic for evaluation and treatment. (7/2/11) If [DEVICE] comes off, clean wound to coccyx with Normal Saline and then skin prep applied to periwound tissue, dress the wound with NS soaked gauze, then 4 x 4 gauze and ABD pad, then tap to secure. Do this every 8 hours until [DEVICE] can be replaced. -Complex. (7/25/11) Insert an 18 French catheter for 10 days. If resident compliant with Foley catheter, then continue with Foley. (7/27/11) Obtain bone scan of pelvis related to osteo[DIAGNOSES REDACTED]. (8/3/11 [MEDICATION NAME] IV 1000 milligrams (mg), x 1 dose, then pharmacy to dose and monitor, complete metabolic profile in the morning. (8/8/11) [MEDICATION NAME] 1250 mg, intravenous. (8/9/11) [MEDICATION NAME] 1250 mg, intravenous, twice daily for osteo[DIAGNOSES REDACTED]. Review of the facility provided wound evaluation flow sheets recorded assessment and treatments of the wound as follows with some exceptions. On 6/10/11, the facility recorded wound measurements of the gluteal fold of 2.5 cm x 0.5 cm, 100% black tissue, treated with [MEDICATION NAME], changed every 3-4 days. On 6/14/11, the clinic wound care note recorded an unstageable pressure ulcer at the gluteal fold of a well-nourished resident and documented previous treatment with Manuka Honey Alginate dressing changes. This report documented measurements of an unstageable pressure wound at the gluteal fold as 2.5 cm x 0.8 cm, 100% adhered, cream colored slough and Stage 2 lateral coccyx wound 0.5 cm x 0.4 cm x 0.1 cm, 100% red, non-granular tissue. The plan directed, "Dressing changes every 3-4 days and as needed with stool or urine on dressing. Cleanse the wounds with NS gauze then apply skin prep to the periwound tissue and Stage 2 pressure ulcer. Dress the wound with Manuka Honey Alginate then 4 x 4 gauze as secondary dressing and ABD pad taped to secure." The wound care directed interventions that included: "1) strict toileting schedule every 2 hours and as needed. 2) Limit time in Merry Walker 2 hours on 30 minutes off. 3) Obtain cushion for Merry Walker. 4) Obtain low air-loss mattress. 5) No recliner contraindicated with coccyx pressure). 6) Initiate pressure ulcer prevention protocols." On 6/21/11, the facility's "Wound Evaluation Flow Sheet", recorded the un-staged gluteal fold wound, 4 cm x 1.5 cm, with 50% black, 50% yellow tissue and treated with [MEDICATION NAME] 4 x 4 tape to secure. On 6/27/11, the facility's "Wound Evaluation Flow Sheet", recorded the un-staged gluteal fold wound, 6.5 x 4.5 cm x 0.0, 100% black tissue. The record lacked evidence of any treatment recorded on the evaluation. The clinical record lacked evidence of this wound care report. On 6/29/11, a clinic wound care note recorded care for a Stage 4 coccyx pressure ulcer, 5.5 cm x 2.3 cm, 85% black dry eschar, 5% red-non-granular tissue and 10% well-adhered slough with moderate, serous and slightly malodorous drainage. The plan directed, " Dressing change every 12 hours with ? strength Dakins moisten gauze. Apply [MEDICATION NAME] or petroleum barrier to the periwound tissue. Dress the wound with ? strength Dakins moistened gauze then dry gauze and ABD pad taped to secure. Prior to taping apply skin prep to protect tissue from tape adhesive. Consult the physician for surgical debridement." The wound care directed interventions that included: "1) No Merry Walker or recliner. 2) Turn every one hour and offload coccyx wound with pillows. 3) Begin toileting schedule every one-two hours as needed. 4) Obtain low air-loss mattress." The resident's clinical record lacked evidence of the current treatment and recorded the skin abraded throughout the periwound tissue. However, the facility documentation lacked evidence of the recommended change in treatment. On 7/1/11, a clinic wound service daily note, (from the wound care center), recorded the coccyx wound bed 95% black, moist eschar and 5% well adhered slough. The wound was cleaned with NS gauze and then skin prep applied to the periwound tissue. The wound was dressed with ? strength Dakins' moistened gauze then 4 x 4 gauze, and ABD pad taped to secure." The wound care documentation recorded a communication with the facility staff regarding the change in treatment from 6/29/11 and the lack of a pressure relieving cushion in the resident's wheelchair chair. The resident's clinical record lacked documentation of the change in treatment orders. Nursing notes, dated 7/7/10 timed 1:17 A.M., recorded the resident incontinent of bowel/bladder, the staff performed incontinence care and changed the resident's brief. Review of the clinical record revealed a physician progress notes [REDACTED]. On 7/8/11, a clinic wound service note recorded a coccyx Stage 4 pressure ulcer, wound bed with 100% well adhered thick green/black slough and eschar and moderate, very malodorous drainage. The periwound tissue had a moderate amount of incontinence [MEDICAL CONDITION]. The reccomended treatment included, "Turn every one hour while in bed, offload coccyx wound prop 30 degrees and prop with pillow, and continue toileting schedule." The resident's clinical record lacked evidence that facility staff had evaluated the resident's wound or the current treatment of [REDACTED]. Review of a laboratory bacterial wound culture report, dated 7/12/11, documented heavy growth of proteus mirabilis and routine fecal (bowel movement) flora. Review of a hospital surgical report, dated 7/18/11, recorded a sacral excision of 7.7 cm x 5 cm, Stage 4 pressure wound and placement of a wound vac. On 7/22/11, a clinic wound service note recorded communication with the facility that the [DEVICE] had not yet arrived. The facility reported that the resident's Dakins' dressing was changed twice daily as needed. The wound center followed up on the [DEVICE] to be delivered on 7/23/11. On 7/25/11, a wound service note recorded services for a Stage 3, coccyx pressure ulcer, 16 days post-surgical debridement with a wound bed 90% pink, non-granular tissue and 10% well adhered slough. The periwound tissue extends 1.5 cm from the periwound edge and there was a large amount of [MEDICAL CONDITION], slightly malodorous drainage. The wound measured 8.0 cm x 2.5 cm x 4.0 cm. The wound care clinic, "cleansed the wound with NS gauze and then skin prep was applied to the periwound tissue. A thin [MEDICATION NAME] was applied to the periwound edge at 6 O-clock, the wound was then window paned with drape and one piece of [MEDICATION NAME] was placed into the wound bed and draped to the left, anterior upper leg. Suction applied at 150 mmHg (milimeters of mercury/unit of pressure), continuous, high intensity". The plan directed, "Nursing to monitor dressing at coccyx every 2 hours for leaking. If wound is leaking apply drape to seal the dressing. If unable to fix leak then remove wound vac dressing and apply NS moistened gauze then 4 x 4 gauze and ABD pad taped to secure. Change NS gauze dressing every 8 hours until wound vac can be reapplied. Skin prep tissue prior to taping. Begin Foley catheter for 10 days. If patient is compliant with Foley, resume Foley. Follow physical therapy order to us (use) Merry Walker for maximum of 2 hours with a minimum of 1 hour rest. Obtain the cushion for Merry Walker. DON (director of nursing) to consult with physician at next rounds regarding medication for anxiety. Outpatient wound care to change wound vac Monday, Wednesday and Friday." On 7/29/11, a clinic wound service note recorded the pressure ulcer now a Stage 4 coccyx pressure ulcer with a bone scan scheduled for today, not completed due to facility staff brought the resident at the correct time for the scan. The re-scheduled bone scan was for 8/4/11. The wound care clinic staff instructed the facility staff on the importance of obtaining this bone scan to determine if a bone infection (osteomylitis) existed for the resident. Review of the resident's Medication Administration Record, [REDACTED]. On 8/1/11, a clinic wound service note recorded the Stage 4 coccyx pressure ulcer was minimally improved with 85% red non-granular tissue, 10% well adhered slough and 5% exposed bone. The re-scheduled bone scan was moved up to 8/2/11 and the instructions given to facility staff as to the importance of obtaining this bone scan reviewed by the wound care staff. The facility "Wound Evaluation Flow Sheet", now recorded the gleuteal fold wound as a Stage 4. Review of the clinical record revealed a 3-phase Bone Scan report dated 8/2/11, that recorded, "There may in fact be an element of bone/[MEDICAL CONDITION]/infection present in this area... There is asymmetrical uptake in the left sacroiliac region, with the patient's history of a sacral wound, this finding is worrisome for an acute [MEDICAL CONDITION]/infectious process... discussed with (PCP primary care physician." On 8/5/11, a clinic wound service note recorded the (now one area) gleuteal fold/coccyx wound minimally improved and the resident presented with a small amount of brown stool in the gluteal fold. 8/8/11, a wound service note recorded minimal improvement of the gleuteal fold/coccyx wound. The wound measured 7.9 cm x 2.3 cm x 3.6 cm. Review of the clinical record revealed a physician progress notes [REDACTED]. On 8/10/11 at 12:15 P.M., observation revealed the resident remained in a Merry Walker during dining as licensed nursing staff R feed the resident 100% of the meal. Observation on 8/11/ revealed: At 12:07 P.M. revealed the resident seated on a cotton pad (not pressure relieving) in a Merry Walker in the corner of the TV room on the 200-hall receiving intravenous (IV) [MEDICATION NAME] in an IV port on the mid-right arm wrapped with Coban, had a Foley catheter in a privacy bag attached to the Merry Walker and a wound vac hanging from the back frame on at 150 mmHg, on, plugged in and charging from an electrical outlet. The resident wore non-skid pink non-skid socks with black soles, stood up and sat down repeatedly. A recommendation was made for the faciltiy to use a pressure relieving cushion to the Merry Walker 2 months prior and observations revealed the facility staff failed to obtain the pressure relieving cushion to the resident's Merry Walker seat. On 8/11/11 at 4:15 P.M., direct care staff V and direct care staff T assisted the resident to his/her room and transferred the resident from the Merry Walker to the bed. The resident continually tried to sit up and put his/her feet over the side of the bed. Direct care staff T raised the head of the bed, however, the resident continued in his/her attempt to get out of the bed. Direct care staff V stood at the bedside and in front of the resident, then held his/her hands while the resident continually tried to get up and stand. At this time direct care staff T stated, "He/she is not going to lie down at all" and then reported the wound vac displayed the message "Therapy Not Activated" and reported the wound vac needed plugged in. 8/11/11 at 4:20 P.M., direct care staff V reported the resident received antibiotics for the wound on his/her buttocks and that staff change the resident's brief at the beginning and end of each shift. On 8/11/11 at 4:42 P.M., licensed nursing staff X directed the staff member V to take the resident to "the chapel to plug in the wound vac to charge, as he/she would not stay in bed". Licensed nursing staff X stated that the wound nurse performed all the wound care for the resident and that the resident went to the (local hospital) wound care clinic once or twice a week. On 8/11/11 at 4:45 P.M., direct care staff X emptied approximately 1000 cc urine from the resident's catheter drainage bag, assisted the resident back into the Merry Walker and back to the chapel. Direct care staff X failed to check and change the resident's brief. Observations, on 8/15/11 every 15 minutes from 11:00 A.M. to 2:00 P.M., revealed staff failed to check and change the resident's brief for fecal incontinence. Observation, on 8/16/11 every 15 minutes from 6:45 A.M., to 1:35 A.M., revealed the facility staff failed to check and change the resident's brief for fecal incontinence. On 8/16/11 at 1:35 P.M., direct care staff U and W, transferred the resident from the Merry Walker to the bed, performed catheter care and changed the resident's incontinence brief. The brief contained a four inch circular area of dark tan discoloration. The resident continually attempted to turn and get out of bed. Direct care staff worked for approximately 25 minutes to change the resident's incontinence brief. On 8/16/11 at 2:00 PM - licensed nursing staff A reported the wound care clinic replaced the wound vac pump yesterday (8/15/11) and the wound vac was working on pressure of 150. Throughout the survey, from 8/10/11 through 8/17/11, observations frequently revealed the resident ambulated, stood, sat or slept in the Merry Walker: 8/10/11 at 11:42 A.M., the resident ambulated down the 200-hall in the Merry Walker 8/11/11 at 5:30 P.M., the resident ambulated in the Merry Walker up and down the 200-hall wearing non-skid socks. 8/15/11 at 11:00 A.M., the resident sat asleep with his/her head on the padded front rail in the Merry Walker. 8/15/11 at 4:30 P.M., the resident ambulated in the Merry Walker in the chapel on the 200-hall. 8/16/11 at 6:45 A.M., the resident ambulated in the Merry Walker across from the nursing station on 200-hall. 8/16/11 at 5:50 P.M., the resident sat asleep with his/her head on the padded front rail in the Merry Walker in the chapel. Observations revealed the resident did not rest in the bed. On 8/15/11 at 11:30 A.M., licensed nursing staff A reported that wound care measured the resident's wound weekly, and staff just record the clinic's wound care notes on the facility "Wound Evaluation Flow Sheet." On 8/15/11 at 3:00 P.M., direct care staff U reported the resident "doesn't lie down". Direct care staff U reported that staff had tried to lie the resident down and he/she " just won't do it". The resident would fall asleep in the Merry Walker and the minute you put him/her down on the bed, he/she wanted back up. On 8/16/11 at 7:55 A.M., licensed nursing staff R reported the resident would not lie down, and when staff put the resident in bed, he/she would be on the floor. On 8/16/11 at 2:40 P.M., licensed nursing staff A reported that the wound care nurse reviewed the information from the resident's shower sheets for any abnormal skin issues and then called the physician for treatment orders. Licensed nursing staff A reported the floor nursing staff performed the weekly skin assessments and reported problems to the wound care nurse. Licensed nursing staff A stated the facility lacked standing orders for wound care, or a protocol for wound care, and would continue the same treatment for [REDACTED]. The facility provided a Skin Care Protocol, dated January 2011, that included interventions for all stages of reddened areas and pressure ulcers. This policy directed that the objective was to: "1) Decrease the prevalence and incidence of residents that develop pressure ulcers. 2) Provide guidelines for optimal care to promote healing to residents with all identified alterations in skin integrity i.e., surgical incisions." On 8/16/11 at 8:00 A.M., licensed nursing staff E stated he/she was unsure how the resident developed the pressure ulcer and continued that the resident stood up and sat down a lot, resisted to lay flat and would not even sleep in a recliner. Licensed nursing staff E confirmed the resident received IV antibiotics for the wound and the physician ordered a surgical procedure. On 8/16/11 at 12:50 P.M., licensed nursing staff D reported the resident constantly busy with-in the Merry Walker, walked all the time, did not sleep at night and even napped in the Merry Walker. Licensed nursing staff D identified the resident as incontinent, now with a Foley catheter and the ulcer started as a very small rectangular dark spot. On 8/16/11 at 4:00 P.M., licensed nursing staff C identified the resident as up and down, repositioned him/herself, did not stay or sleep in bed. Licensed nursing staff C reported the facility accessed wound protocol on the computer to guide staff for treatments obtained by the physician. On 8/16/11 at 5:00 P.M., licensed nursing staff O reported the resident would not stay in a chair, would not stay in the bed, and woould not stay in a recliner. Licensed nursing staff O reported he/she did not know how the resident developed the pressure ulcer. On 8/19/11 at 3:35 PM, per telephone interview with the wound clinic nurse specialist, that routinely completed the wound care for the resident, explained the resident's required needs. The nurse reported the wound clinic staff frequently informed the facility of the resident's need to stay out of the Merry Walker or recliner and to use a special pressure relieving cushion when the resident sits. The nurse explained the clinic staff felt the resident's pressure ulcer developed from 2 issues, pressure and incontinence. The nurse explained the staff finally got an indwelling urinary catheter for the resident to keep the resident dry, but the facility staff really did need to get the pressure off of the resident's bottom. Furthermore, the nurse verified that the facility's use of the cotton type cushion on the Merry Walker seat would not be adequate to relieve the pressure to heal the pressure ulcer. The nurse reported the facility needed to get the resident a special cushion such as a "Roho" type of air cushion, or a gel cushion, to relieve the pressure adequately. Review of the facility provided policy for Skin Integrity Guidelines, dated January 2011, recorded the "DNS (director of nursing service) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis." This same policy directed staff to initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin." The facility failed to ensure this cognitively impaired resident that required extensive assistance from staff, without pressure ulcers and assessed at risk for pressure ulcers, received the necessary care and services to prevent a Stage 4 pressure ulcer with osteo[DIAGNOSES REDACTED]. The clinical record lacked evidence to demonstrate the facility staff assessed and followed wound care orders and reccommended treatment interventions to promote healing. - The facility admitted resident #43 to the AACU (Advance Alzheimer's Care Unit) on 7/8/11, from the west wing. At that time, medical record documentation revealed the resident's skin had skin intact and [DIAGNOSES REDACTED]. The care plan, dated 3/11/11, at the time of the transfer to the AACU, included, :"Unable to ambulate or transfer self. W/C (wheelchair) primary mode of transport. Requires staff total assist with position changes and transfers." The clinical record failed to evidence the facility staff assessed the resident and failed to develop a plan of care for pressure ulcers and failed to update a Braden scale until after 8/1/11. An interview, on 8/11/11 at 3:10 P.M., with licensed nursing staff E revealed the pressure ulcers developed after the transfer to the AACU, during a course of treatment for [REDACTED]. The facility skin care protocol, revised 1/2011 included, "... Licensed nurse to document weekly on all wounds using the "Wound Evaluation Flow Sheet...Residents utilizing a wheelchair as a primary mode of transportation will have a pressure reducing cushion. Initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin." The facility weekly skin assessments included: "7/28/11 right heel blister, left heel soft, right foot 2 nd toe black spot. Coccyx blood blisters. 8/4/11 Old ST (skin tear) to rt.(right) elbow healing. No s/s (signs/symptoms) of infection old discoloration noted to ext.(extremity). Blister to coccyx intact, one on lt (left) buttocks open. Rt. heel open with loose skin, 4 cm in size. Message left for wound nurse." The 8/5/11 wound assessments documented by licensed nursing staff A included: "Coccyx 2.9 x 0.7 cm, (centimeters) no depth taken serous drainage. Gluteal fold 1.2 x 1.5 cm, no depth stage II , serous drainage. Rt. heel Stage III, 2.8 x 4.2 cm, no depth. 0.4 cm x 0.4 cm, no depth taken. 1st. metatarsal 0.4 x 0.4 cm,no stage no depth." On 8/5/11, an outpatient hospital wound care center evaluated and treated a sacral and right foot wound. The documented wound clinic evaluation included: 8/5/11 Outpatient wound care to evaluate and treat sacral and right foot wound. The hospital wound clinic ordered the facility to place a urinary catheter for sacral wound healing. The clinic documented a stage IV coccyx wound and a stage III right heel pressure ulcer. On 8/9/11, the resident visited the wound clinic and the clinic documented the following: "Pt. (patient) arrived in w/c (wheelchair) no cushion . Stool (bowel movement) under dressing and [MEDICATION NAME] as an absorbent dressing. Coccyx wound is 80% red, Non-granular tissue and 20 % well adhered slough. Gluteal fold wound is 80% intact tissue over slightly gray colored area. Drainage is moderate, serous and non-malodorous. The periwound edge is open and well defined. There are two areas of welts from silk tape at the periwound tissue. There is an area of blanching [DIAGNOSES REDACTED] at the left trochanter. The heel wound is 100 % red, non-granular tissue. The periwound tissue is slightly brown in color, boggy and erythemic. The periwound edge is open and well defined. Dx.(diagnosis) Stage IV coccyx pressure ulcer, right heel stage III pressure ulcer and right 1 st lateral metatarsal suspect deep tissue injury." The facility wound flow sheet completed by licensed nursing staff A remained the same on 8/12/11 as the documentation and measurements on 8/5/11. Review of the clinical record dietician notes revealed the last evaluation completed on 3/8/11. On 3/30/11, the speech therapist recommended finger foods. Following the physician's orders [REDACTED]. Staff feed the resident as care planned however, one staff member would give the resident a couple of bites and then another staff member might give the resident more bites later. In-between the resident reached for food with their fingers. The medical record documented the resident with a gradual loss of weight. On 7/19/11 the facility staff documented the resident weight as 88.8 pounds. On 8/17/11, the facility reported the resident's weight at 81.4 pounds. Observation, on 8/15/11 at 6:45 A.M., revealed the resident in a high backed w/c with foot pedals and feet dangling. The resident remained in the w/c until 9:15 A.M., (2 hours and 30 minutes later) when certified nursing staff L and S placed the resident in bed. The facility completed an 8/16/11 MDS (minimum data set), significant change in condition assessment, identified the resident with cognitive impairment, with limited range of motion and in need of extensive assistance with all activities of daily living, with a stage IV and stage III pressure ulcer, with a foley catheter and bowel incontinence. The 8/16/11 care area assessment included, " Uses w/c (wheelchair) for his/her primary mode of transportation propelled by staff. "He/she is noted to have a pressure ulcer on the coccyx that is a stage 4. with an area of eschar. Tissue surrounding the eschar is deep red and non-blanchable. The wound proceeds into the gluteal fold is non-intact, serous filled blisters. Right heel wound is noted to be a stage 3 with the wound bed 50% non intact blister, 25 % red, non granular tissue with 24% slough. Drainage is serous and nonmalodorous. The 1 st. metatarsal wound is noted to be 10 % black..." Observations, on 8/16/11 revealed the resident up in the wheelchair at 7:15 A.M. Per nursing staff L the staff transferred the resident into the w/c at 7:15 a.m. Every 15 minutes observations revealed the resident remained in the dining room, in the high backed w/c, without a position change. At 9:55 am, facility staff transported the resident out of the unit, in the wheelchair, for a music program. At 10:10 am returned to room because resident dozing during the program. At 10:15 A.M. (3 hours later). Certified nursing staff Q and R transferred the resident to bed. The resident's brief contained fecal matter and the coccyx dressing had fecal matter up under the coccyx wound dressing. The resident's coccyx dressing remained stained with fecal matter until 2:10 P.M., almost 4 hours later, at which time wound care nurse A and licensed nurse D changed the coccyx dressing. At that time, licensed nurse A commented, " the dressing is suppose to be on for 3 days but the res. has required an additional drsg. (dressing) change every day d/t (due/to) BM up in the coccyx drsg (dressing)." Observation, revealed the wound soiled with fecal matter. Licensed nursing staff A, cleaned the wound with normal saline and applied a honey alginate patch covered with an ABD dressing and meflex adhesive dressing. The nursing staff failed to measure the reddened wound. The facility failed to assess the resident at risk for and develop a plan of care to include interventions to prevent the development of pressure ulcers. Furthermore, after the development of pressure ulcers, the facility failed to provide adequate position changes and dressing changes to promote healing of this resident's pressure ulcers.

The facility reported a census of 69 residents with 32 residents in the two special care units. Based on observation, interviews and record review, the facility failed to provide adequate supervision and assistive devices to prevent injury for one sampled resident (#01), during transport in the facility van. Findings included: - The facility admitted resident #01 on 8/9/2006. Physician's admission [DIAGNOSES REDACTED]. The 9/16/10 MDS (minimum data set), assessment identified the resident with short term, long term memory loss, severely impaired decision making skills and rarely/never understands, and extensive care of staff for all ADLs (activities of daily living). Furthermore, the MDS failed to document the resident's mode of locomotion. The 5/26/10 annual MDS identified the resident as wheeled self, other person wheeled, and wheelchair primary mode of locomotion. The 6/20/10 plan of care identified the resident with poor response to others and the environment and limited ability to communicate related to aphasia and impaired cognition. The plan of care failed to instruct staff in the use of the wheelchair and the need for pedals on the wheelchair when pushed by staff. Nurses notes dated 12/17/10 at 2:00 A.M., evidenced certified nursing staff E transported the resident back from the ER (emergency room ), per facility van. Upon return from the hospital, the resident's blanket displayed bright blood. Licensed nurse D assessed the resident and documented a 3 inch open area on the end of the resident's left great toe with the toe nail missing. Following assessment, licensed nurse D sent the resident back to the emergency room for treatment of [REDACTED]. On 1/3/11 at 10:35 A.M., and 11:00 A.M., nursing staff F and G reported that the resident rarely expressed any sounds, but occasionally displayed a facial grimace. On 1/3/11 at 11:00 P.M., a phone interview with certified nursing staff E verified the resident's wheelchair failed to have foot pedals and facility staff covered the resident's bare feet covered with a blanket at the time of transport from the ER to the facility. Nursing staff E also verified that the facility van lift failed to function properly at that time. Staff E reported getting on the van lift at the hospital with the resident due to fear the lift might stop on the way up. Half way up the lift did stop and the lift beeped. Staff E kept pushing the button and finally the lift continued upward. Staff E reported making sure the resident seated securely in the van, then staff proceeded to drive back to the facility. Upon arrival at the facility, on 12/17/10 at 2:00 A.M., nursing staff E noted the left toe bleeding. Certified nurse E summoned charge nurse D. Following an assessment, licensed nurse D sent the resident back to the emergency room for treatment of [REDACTED]. On 12/17/10 at 4:11 A.M., Charge nurse D documented in nurses notes, "Revealed blood on the left great toe. Got caught in lift on van. 3 inch open area and nail missing to left great toe. Back to ER (emergency room ) said could not be stitched D/T (due to) jagged edges of wound. Keflex, (antibiotic) started 4 times a day and referral to the wound clinic." On 12/19/10 the physical therapy department documented, ..."Toenail and tip of toe missing. Laceration to inner aspect of toe. Slight bleeding area beefy red in color." On 12/23/10, the wound clinic documented, "Traumatic partial amputation left great toe. Non-verbal, pain c/o (complaint of) withdrawal foot with cleansing toe." Observation, on 1/3/11 at 9:00 A.M., revealed the resident in bed with the head and feet of the bed slightly raised. The resident held his/her mouth open and stared at the wall. The resident made no verbal replies. Observation, on 1/3/11 at 4:00 P.M., revealed the resident in bed with a blank stare and non verbal. The left great toe displayed a dry bandage. The wheelchair sat in the room with only a right foot pedal in place. The facility nursing staff failed to identify the possible hazards related to the malfunction of the van lift. The nursing staff accepted the resident from the emergency room without adequate foot covering. The residents left great toe got caught in the van lift and the resident sustained [REDACTED]. The facility failed provide a safe transfer and transport of the resident during a transport on the lift in the facility van.

The facility reported a census of 69 residents with 32 residents in the special care units. Based on observation, interviews and record review, the facility failed to provide care and timely services for one resident (#01) following a fall with an injury. Findings included: - The facility admitted resident #01 on 8/9/2006. Physician's admission [DIAGNOSES REDACTED]. The 9/16/10 MDS (minimum data set), assessment identified the resident with short term, long term memory loss, severely impaired decision making skills and rarely/never understands, need for extensive assistance with all activities of daily living. The 6/30/10, plan of care identified the resident with poor response to others and the environment and limited ability to communicate related to [MEDICAL CONDITION] and impaired cognition, in need of extensive assist with most all ADLs (activities of daily living) and at risk for injury related to history of falls and an unsteady gait. Administrative nursing staff C reported, on 11/18/10 at 9:45 P.M., certified nursing staff H found the resident on the floor, wrapped in blankets and comforter, beside the bed, in the advanced alzheimers care unit. Licensed nurse I documented in the nurses notes a small bruise to the right knee and a reddened area to the right knee, right hip and right shoulder following the fall. The nursing staff notified the primary care physician following the fall. Additional nurses notes included the following: On 11/19/10 on the evening shift, (3 P.M. to 11 P.M.)licensed nurse I documented, "Staff reported that residents right shoulder is swollen. Assessment reveals +3 [MEDICAL CONDITION] to right bicept..." On 11/20/10 on the night shift, (11 P.M. to 7 A.M.) licensed nurse D,documented, "Res. (resident) continues on fall F/U (follow up). Res. has fading bruise noted to back of right arm. Right arm is swollen from shoulder to wrist...Res. does grimace when right arm is moved..." On 11/21/10 at 6:05 A.M., "Res. continues on fall F/U (follow up). Res. has fading bruise noted to back of right arm. Right arm is swollen from shoulder to wrist...Res. does grimace when right arm in (is) moved." On 11/21/10 at 2:19 P.M., licensed nurse J documented, ..."Res. cont (continued) to have bruising to the back of right arm with the right arm having [MEDICAL CONDITION]" At 7:53 P.M., licensed nurse documented, ..."Bruising to back of right arm continues. Right arm swollen..." On 11/22/10 at 6:28 A.M., "Res. continues with fading bruise to back of right arm. Res. is protecting right arm with other arm. Right arm is swollen from shoulder to wrist. Grimaces with movement of right arm." At 3:35 P.M., "Has cont. to guard r. (right) arm @ times..." At 8:01 P.M., "Fading bruise to right arm cont. (continues). Right arm from shoulder to wrist swollen." On 11/23/10 at 5:16 A.M., ...Dependent [MEDICAL CONDITION] to Rt. upper arm. RFA (right forearm) [MEDICAL CONDITION] with 1+ pitting noted. Rt. hand swollen...Unable to extend fingers due to c/o pain/discomfort from resident..." At 2:55 P.M., "... Rt. arm continues to be swollen. (Doctor) has been notified (4 days after the initial presentation of swelling and symptoms of further injury) and resident has an appointment to see (doctor) November 24 at 9:30 A.M...." On 11/24/10 at 12:22 P.M., "Resident went to (Doctor) about right arm [MEDICAL CONDITION]. (Doctor) sent resident to emergency room to have a x-ray of right arm. emergency room called and reported that resident has a dislocated right shoulder." The x-ray assessment, on 11/24/10, documented, "Dislocation right shoulder, plan: Closed reduction, possible open reduction. Severe senility." On 11/24/120 physician's report documented, "Dislocation of right shoulder with plans for taking the patient to the operating room tomorrow for attempted closed reduction and if necessary, open reduction." On 11/29/10 the resident returned to the facility with an immobilizer to the right arm/shoulder. On 12/16/10 a physical therapist aide documented, "The pt. (patient) reports a pain level of modest facial grimace and withdrawal/increased tone for R. (right) shoulder." Observation, on 1/3/11 at 9:00 A.M., revealed the resident in bed with the head and feet of the bed slightly raised. The resident held his/her mouth open and stared at the wall. The resident made no verbal replies. On 1/3/11 at 10:25 A.M., and 10:40 A.M. nursing staff G and F reported the resident held the arm with the other arm and occasionally moaned some. Observation, on 1/3/11 at 4:00 P.M., revealed the resident in bed, on the back, with a blank stare and non verbal. The resident did not wear a sling while in bed. The facility nursing staff failed to notify the physician, in a timely manner, following increased swelling, pain and bruising of the right arm following this fall and right shoulder dislocation.