Every finding on record at Prairie Sunset Home Inc

The facility reported a census of 38 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - On 03/03/25 at 08:03 AM during an initial tour of the main kitchen, refrigerator, freezer, and dry food storage areas, the following areas of concern were observed: Observation of the storage room revealed: One undated bag of tortilla chips left open to air and laying on the counter. One undated bag of coconut flakes loosely rolled shut on a shelf. One undated, open box of baking soda box with discoloration and water damage to the box. One undated, open box of baking soda. Observation of the refrigerator revealed open and undated items including a bottle of soy sauce, large jug of barbeque sauce, [NAME] jug of ketchup, large jug of salad dressing, large jug of picante sauce, large tub of beef base, and a large tub of chicken base. Observation of the freezer revealed an undated box of chicken fried steak with the bag inside left open to air. Observation of the walk-in refrigerator revealed: Individual portions of deserts, which included various cakes and pies left uncovered and undated. A large bag of shredded mild cheddar cheese left open and undated. A large bag of cubed Monterey [NAME] cheese, and a large bag of [NAME] cheeses were opened and not dated. In the kitchen serving area there were bags of open cereal that were undated. During an interview on 03/06/25 at 08:03 AM, Dietary Manager BB revealed she expected staff to label, and date opened food items. Dietary Manager BB stated that the above concerns identified with dry storage and freezer storage, which included undated and unsealed items were unacceptable and she stated she would throw out the appropriate items. Dietary Manager BB verified that if food was not labeled with a date there was no way for staff to know how long it had been opened and when to throw it out. The facility's undated policy Food Safety- Use and storage of food and beverage brought in for residents, food procurement revealed that education on safe food handling would be provided to all staff who may provide foods or fluids to residents of the facility. The education would include the requirement for covered containers or secure wrapping for foods, proper labeling and dating of each item, and leftover foods to be used within three days or discard. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 38 residents. Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for the residents of the facility, in two of four resident halls. Findings included: - During an initial tour of the facility on 03/04/25 at 01:25 PM, revealed the following areas of concern on hall 400: 1. One hall had three resident private bathrooms with incontinent products resting directly on the bathroom floor and lacking a barrier. 2. One hall had a trash can for disposal of Enhanced Barrier Precautions (EBP) outside of a resident room with disposed personal protective equipment (PPE) coming out of the partially covered trash can. 3. One resident room had multiple items on the closet floor. 4. The medication room had one box, which contained approximately 75 cards of assorted medications to be returned to the pharmacy resting directly on the floor and lacking a barrier. The facility policy for Infection Control, revised 06/22, included: The facility shall have an infection control program to provide a safe, sanitary, and comfortable environment for the residents.

The facility reported a census of 38 residents with 15 residents included in the sample. Based on observation, record review and interview, the facility failed to complete a resident centered comprehensive care plan for one Resident (R) 14, regarding non-pharmacologic interventions for pain. Findings included: - Review of Resident (R)14's electronic medical record (EMR) revealed a diagnosis of chronic pain (physical suffering or discomfort caused by illness or injury). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She received as needed (PRN) pain medication and non-pharmacological interventions (interventions not based on medication) for pain. She rated the worse pain in the past five days to be five out of 10 on the one to10 pain scale (scale used to rate pain with zero being no pain and 10 being the worse pain possible). She received opioid medication (a class of drugs healthcare providers prescribe to manage moderate to severe pain) during the assessment period. The Pain Care Area Assessment (CAA), dated 12/25/24, did not trigger for further development. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 13, indicating intact cognition. She received PRN pain medication and non-pharmacological interventions for pain and received opioid medication during the assessment period. The care plan for pain, revised 01/02/25, lacked staff instruction on non-pharmracologic interventions for pain. Review of the resident's EMR revealed the following physician orders: Gabapentin (prescription medication used to treat neuropathic pain), 100 milligrams (mg), by mouth (po), at bedtime (HS), for a diagnosis of restless leg syndrome (RLS-a brain, nerve and sleep condition that causes a strong, nearly irresistible urge to move your legs that ' s at least partially relieved by movement), ordered 08/12/24. Review of the resident's Medication Administration Record (MAR) revealed the resident received the Gabapentin in February and March, as ordered. Norco (an opioid medication combination of hydrocodone (an opioid medication) and acetaminophen (a non-opioid pain reliever) which works in the brain to change how a person's body feels and responds to pain), 5-325 mg, po every (Q) six hours, PRN, for pain, ordered 08/12/24. Review of the resident's MAR revealed the resident received the Norco seven times from 02/01/25 through 02/28/25, for pain rated between five and nine on the one to 10 pain scale and four times from 03/01/25 through 03/05/25 for pain rated six to nine on the one to 10 pain scale, with effective results. Tylenol (acetaminophen) extra strength (ES), 500 mg, po, Q 6 hours, PRN, for pain, ordered 08/12/24. Review of the resident's MAR revealed the resident received the tylenol medication 15 times from 02/01/25 through 02/28/25, for pain rated one to seven on the one to 10 pain scale and seven times from 03/01/25 through 03/05/25 for pain rated five to eight on the one to 10 pain scale, with effective results. During an observation on 03/03/25 at 10:44 AM, the resident sat a recliner in her room with her feet elevated on the footrest. The resident had facial grimacing, indicating pain. On 03/03/25 at 10:44 AM, the resident stated she always had back pain, which did not affect her sleep or day to day activities. She stated she was unaware of any pain interventions other than the pain medications available to help ease her pain. On 03/05/25 at 08:47 AM, Certified Nurse Aide (CNA) N stated the resident had back pain. When the resident has pain, she will let the nurse know the resident needs pain medication. On 03/05/25 at 08:57 AM, Administrative Nurse D confirmed the resident lacked non-pharmacologic pain interventions on her care plan to help ease her back pain. The facility policy for Baseline Care Plans, revised 11/15/17, included: The facility will implement interventions to assist the resident to achieve their goals. The facility failed to complete a comprehensive resident-centered care plan to include non-pharmacologic pain interventions.

The facility reported a census of 38 residents with 15 residents sampled, including one resident reviewed for pain. Based on observation, interview and record review, the facility failed to offer non-pharmaceutical interventions for pain for one Resident (R)17, who has chronic pain. Findings included: - Review of Resident (R)14's electronic medical record (EMR) revealed a diagnosis of chronic pain (physical suffering or discomfort caused by illness or injury). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She received as needed (PRN) pain medication and non-pharmacological interventions (interventions not based on medication) for pain. She rated the worse pain in the past five days to be five out of 10 on the one to 10 pain scale (scale used to rate pain with zero being no pain and 10 being the worse pain possible). She received opioid medication (a class of drugs healthcare providers prescribe to manage moderate to severe pain) during the assessment period. The Pain Care Area Assessment (CAA), dated 12/25/24, did not trigger. The Quarterly MDS, dated ,d+[DATE], documented the resident had a BIMS score of 13, including intact cognition. She received PRN pain medication and non-pharmacological interventions for pain and received opioid medication during the assessment period. The Care Plan for pain, revised 01/02/25, instructed staff to know the resident was able to call for assistance when she was in pain and was able to request pain medication. Review of the resident's EMR revealed the following physician orders: Gabapentin (prescription medication used to treat neuropathic pain), 100 milligrams (mg), by mouth (po), at bedtime (HS), for a diagnosis of restless leg syndrome (RLS-a brain, nerve and sleep condition that causes a strong, nearly irresistible urge to move your legs that's at least partially relieved by movement), ordered 08/12/24. Review of the resident's Review of the resident's Medication Administration Record (MAR) revealed the resident received the medication in February and March, as ordered. Norco (an opioid medication combination of hydrocodone (an opioid medication) and acetaminophen (a non-opioid pain reliever) which works in the brain to change how a person's body feels and responds to pain), 5-325 mg, po every (Q) six hours, PRN, for pain, ordered 08/12/24. Review of the resident's MAR revealed the resident received the medication seven times from 02/01/25 through 02/28/25, for pain rated five to nine on the one to 10 pain scale and four times from 03/01/25 through 03/05/25 for pain rated six to nine on the one to 10 pain scale, with effective results. Tylenol (acetaminophen) extra strength (ES), 500 mg, po, Q 6 hours, PRN, for pain, ordered 08/12/24. Review of the resident's MAR revealed the resident received the medication 15 times from 02/01/25 through 02/28/25, for pain rated one to seven on the one to 10 pain scale and seven times from 03/01/25 through 03/05/25 for pain rated five to eight on the one to 10 pain scale, with effective results. On 03/03/25 at 10:44 AM, the resident sat in the recliner in her room with her feet elevated on the footrest. The resident had facial grimacing, indicating pain. On 03/03/25 at 10:44 AM, the resident stated she had back pain, which did not affect her sleep or day to day activities. She stated she was unaware of any pain interventions other than the pain medications available to help ease her pain. On 03/05/25 at 08:47 AM, Certified Nurse Aide (CNA) N stated the resident had back pain. When the resident had pain, she would let the nurse know the resident needed pain medication. On 03/05/25 at 08:57 AM, Administrative Nurse D confirmed the resident lacked non-pharmacologic pain interventions to help ease her back pain. The facility policy for Pain Care, effective 05/10/17, included non-pharmacological measures should be used along with pharmacological measures for maximum pain relief. The facility failed to initiate non-pharmacologic pain interventions to help this resident with chronic pain.

The facility reported a census of 38 residents with 15 residents sampled including five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor five Residents (R) 26, and R 34, regarding failure to monitor the side effects of psychotropic (drugs that affect the brain and central nervous system, altering mood, thoughts, emotions, and behavior) and antipsychotic (drugs that treat psychotic symptoms like hallucinations and delusions) medications and the failure to obtain a stop date for R 18's antianxiety (drugs that treat anxiety disorders) medication, Ativan. Findings included: - Review of Resident (R)26's electronic medical record (EMR) revealed a diagnosis of major depressive disorder (major mood disorder which causes persistent feelings pf sadness). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He received antipsychotic (drugs that treat psychotic symptoms like hallucinations and delusions) and antidepressant (a type of psychotropic drugs that affects the brain and central nervous system, altering mood, thoughts, emotions, and behavior) medication during the assessment period. The Psychotropic Drug Care Area Assessment (CAA), dated 11/13/24, documented staff would administer his medications and monitor for adverse side effects and to report any concerns to his physician. The Quarterly MDS, dated 02/12/25, documented the resident had a BIMS score of zero, indicating severe cognitive impairment. He received antipsychotic and antidepressant medications during the assessment period. The Care Plan, revised 02/12/25, instructed staff to monitor for adverse side effects and report any concerns to the physician. Review of the resident's EMR revealed the following physician orders: Mirtazapine (an antidepressant medication), 15 milligrams (mg), by mouth (po), at bedtime (HS), for a diagnosis of MDD, ordered 02/27/25. Sertraline (an antidepressant medication), 2.5 milliliters (ml), po, every day (QD), for a diagnosis of MDD, ordered 02/27/25. Olanzapine (an antipsychotic medication), 5 mg, po, at HS, for a diagnosis of MDD, ordered 02/27/25. Review of the resident's EMR lacked monitoring of any side effects for the resident's antipsychotic and/or antidepressant medications. On 03/05/25 at 08:57 AM, Administrative Nurse D stated staff did not monitor for side effects of antipsychotic and antidepressant medications for more than 72 hours after the medication was started. The facility policy for Antipsychotic Medications, effective 09/21/21, included: The charge nurse will monitor for resident behaviors and signs and symptoms of adverse consequences of antipsychotic medication every shift, and document in the resident's record. The facility failed to monitor for adverse side effects for this dependent resident who received antidepressant and antipsychotic medications. - Review of Resident (R)34's electronic medical record (EMR) revealed a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She did not receive antidepressant (a type of psychotropic drugs that affects the brain and central nervous system, altering mood, thoughts, emotions, and behavior) medication during the assessment period. The Mood State Care Area Assessment (CAA), dated 09/09/24, documented staff would observe for changes in the resident's mood and to report any concerns to the physician. The Quarterly MDS, dated 12/10/24, documented the resident had a BIMS score of 15, indicating intact cognition. She received antidepressant medication during the assessment period. The Care Plan, revised 12/11/24, instructed staff to monitor for and report any adverse side effects from the antidepressant medication to the physician. Sertraline (an antidepressant medication), 50 milligrams, by mouth (po), every morning (QAM), for a diagnosis of depression, ordered, 09/28/24. Review of the resident's Medication Administration Record (MAR), revealed the resident received the antidepressant medication, as ordered. On 03/05/25 at 08:57 AM, Administrative Nurse D stated staff did not monitor for side effects of antidepressant medication for more than 72 hours after the medication was started. The facility policy for Antipsychotic Medications, effective 09/21/21, included the charge nurse will monitor for resident behaviors and signs and symptoms of adverse consequences of antipsychotic medication every shift, and document in the resident's record. The facility failed to monitor for adverse side effects for this dependent resident who received antidepressant and antipsychotic medications.

The facility reported a census of 38 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, on a daily, for the 38 residents who reside in the facility. Findings included: - Review of the facility's Daily Staffing Sheets, from 02/01/25 through 03/03/25, revealed the total hours and actual hours worked by staff was not completed on the daily staffing sheets. On 03/05/25 at 02:00 PM, Administrative Nurse D stated she was unaware the daily staffing sheets needed to include the total hours and actual hours worked. The facility policy for Posting Direct Care Daily Staffing Numbers, undated, included information for the shift staffing for each staff shall include the total number of nursing staff working for the posted shift and the actual time worked during the shift for each category. The facility failed to properly complete the daily staffing sheets for the residents of the facility.

The facility census totaled 31 residents with 12 residents in the sample, including two residents sampled for accident hazards. Based on observation, interview, and record review, the facility failed to provide timely and appropriate interventions to prevent further falls for Resident (R) 28. The resident had a history of multiple falls and fell while attempting to self-toilet and sustained a fractured humerus (bone of the upper arm). Findings included: - R28's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate impairment in cognition. The resident required extensive assistance of two staff for daily cares and was frequently incontinent of bladder and bowel. The resident received pain medications on a scheduled and as needed basis. The resident had a recent fall with a fracture. The Fall Risk assessment dated [DATE] indicated the resident was high risk for falls. Review of the Quarterly MDS dated [DATE], revealed a BIMS score of six, indicating severe cognitive impairment. The resident required assistance of one staff for supervision and physical assistance with transfers, ambulation, and toileting. The resident was a fall risk and had one non-injury and one minor injury fall since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/20/22 revealed the resident could make herself understood, usually understood others but was unable to retain information, and staff were to anticipate her needs. The Falls CAA dated 11/20/22 documented staff were to observe and assess for increased fall risks and eliminate them when able, and report concerns to the physician as needed/warranted. Staff were to observe and assess for interventions that decrease fall risks and implement as needed. Review of the Care Plan dated 03/16/22, revealed the resident was a fall risk due to actual falls and deconditioning (weakness) and included the following interventions: On 03/16/22, staff to encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. On 03/16/22, staff were to ensure the resident wore appropriate footwear (non-skid socks or shoes) when ambulating or mobilizing in her wheelchair. On 03/16/22, staff were to ensure the resident's walker was on the side of her bed, near the bathroom, at night to cue the resident to use the walker when she would get herself up to toilet. The Care Plan included the resident was incontinent of bladder (dated 07/04/22) and included the following interventions: On 07/04/22, activity staff were to notify nursing staff if R28 was incontinent during activities. On 07/04/22, staff were to establish voiding patterns for R28. On 07/04/22, Certified Nurse Aide (CNA) to monitor/document for signs of urinary tract infection (UTI) such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On 07/04/22, staff were to ensure the call light was within the residents reach and encourage her to use the call light for assistance. On 06/13/23, anti-roll breaks were placed on the resident's wheelchair. On 09/19/23, staff were to provide visual checks during the night hours to ensure the resident's walker was in reach. The resident fell on [DATE] and staff placed a silent electronic motion alarm on the resident to alert staff when the resident attempted get up without staff knowledge as the resident would not call for assistance. The care plan lacked fall prevention interventions after the falls that occurred on 05/10/22, 11/14/22, 12/24/22, 02/03/23, and 05/20/23. The Fall Investigation dated 05/10/22 at 07:40 AM revealed the resident reported she fell in her bathroom. She had diarrhea and weakness, and felt it was from Metformin (medication for control of the blood glucose). The medication was discontinued, and staff failed to implement an intervention to keep the resident free from possible further falls. The Fall Investigation dated 09/13/22 at 01:08 AM revealed the resident was found lying on the floor of her bathroom with her head between the toilet and the wall, and her legs extended straight out towards the door. R28 had one sock on, no undergarments, and had a shirt and a sweater in place. She hit her head and had visible bruising starting on her upper left back. Two staff got her up and walked her to bed. The staff noted she was wobbly and unsure what to do. Staff sat her on the side of the bed and R28 could not stay sitting up without holding onto the grab rail or the frame of the bed. She stated she got up to go to bathroom, and the next thing she knew, she was on the floor in the bathroom. The resident was incontinent, ambulated without proper footwear, and slipped and fell using her walker to ambulate herself to the toilet. A witness statement from CNA E documented she had not gone in to check the resident yet on her shift. (Her shift began at 10:00 PM and she had not checked on R28 three hours into her shift). The Fall Investigation dated 11/02/22 at 08:10 AM revealed an unnamed Certified Medication Aide (CMA) heard the resident yelling for help and found the resident lying on the floor in her bathroom. The CMA notified the nurse, and the nurse found the resident lying on the floor with her head against the wall near the bathroom door. She was lying on her right side facing the doorway. The resident was alert and oriented to person only and could not tell the nurse what happened. The nurse observed bluish bruising with a small amount of swelling above R28's left eyebrow. The resident could not lift her left arm and cried out in pain when the nurse touched her arm. There was visible bruising on the resident's upper left arm near her shoulder. Three staff assisted the resident to her bed. At 08:30 AM (20 minutes after the fall), the staff notified the resident's Durable Power of Attorney (DPOA) of the fall and resident transfer to hospital for evaluation. At 08:32 AM, staff received an order to send the resident to emergency room (ER). At 08:50 AM, the resident left the facility in an ambulance (40 minutes after the resident's fall). Review of the investigation documented the resident had no injuries post fall, however, the update from the hospital revealed the resident had a fractured humerus. The care plan documented staff placed a silent electronic motion alarm on the resident to alert staff when the resident attempted mobility as the resident would not call for assistance. The Fall Investigation dated 11/14/22 at 05:24 PM revealed the resident was found seated next to her recliner, leaned against the raised footrest. The call light had been clipped to the arm rest of her chair, her wheelchair was across the room, and the staff noted no injuries found and assisted the resident to the side of the bed. The investigation lacked an intervention to prevent further falls. The Fall Investigation dated 12/24/22 at 02:45 PM revealed the resident was on the floor, sitting on her buttocks in front of her recliner. The resident reported she just slid out of her recliner. The investigation lacked an intervention to prevent further falls. The Fall Investigation dated 02/03/23 at 06:54 AM revealed the resident was found sitting on the floor in her bathroom doorway facing her bed with her legs in front of her. Resident stated she had attempted to get back to her bed after using her bathroom. The resident sustained a small skin tear to her right ankle and her right elbow. The investigation lacked an intervention to prevent further falls. The Fall Investigation dated 05/20/23 at 09:00 AM revealed a housekeeper reported the resident was on the floor. The resident was observed against the bedframe at the head of the bed with her walker was up against the wall in the unlocked position. The bathroom was observed to have feces (bowel movement) on the floor. Two staff assisted the resident to her wheelchair. Staff observed the resident leaned backwards while in the standing position, and staff placed the resident in the wheelchair to take her to breakfast. The resident was unable to state how the fall occurred. The resident received a scrape to her left great toe as well as redness to her upper back. The investigation lacked an intervention to prevent further falls and the care plan indicated the resident should have a silent alarm on. The Fall Investigation dated 06/09/23 revealed the resident was found seated on the floor in front of her easy chair when her son came for a visit. The investigation lacked an intervention to prevent further falls. The care plan indicated staff should have had the silent electronic alarm on. Review of a Voiding Diary dated 03/17/22, revealed it was not used due to inaccurate data. The staff did not do the voiding diary during the night or anytime the resident slept and only took the resident to the bathroom at approximately three-to-four-hour intervals instead of the required intervals on the voiding diary. Review of the Bowel and Bladder Assessment completed on 02/15/23, revealed the resident was incontinent, needed assistance with toileting, was sometimes aware of need to void and a timed, scheduled toileting plan recommended. However, the facility lacked an individualized toileting plan. Review of the Bowel and Bladder Assessment completed on 05/17/23, revealed no changes from the previous assessment. Continued with no toileting plan. Observation on 06/12/23 at 10:30 AM, revealed the resident slept while seated in her recliner. A wheelchair was approximately two feet in front of the resident and a wheeled walker parked against the wall by the door of the room approximately 20 feet away from the resident. A call light was clipped to the arm of the chair and no sensor monitor observed in the room. Observation on 06/13/23 at 09:00 AM revealed CNA H assisted the resident from her recliner to her wheelchair. The resident wore skid free socks. CNA H lacked a gait belt and the staff failed to ask the resident if she needed to use the toilet. CNA H propelled the resident down the hall to the dining room and no motion sensor observed in the room. Observation on 06/14/23 at 11:00 AM CNA I could not locate the electronic silent monitoring system at first, and then located the silent alarm, crawled under the resident's bed, and obtained the alarm system. CNA I confirmed the alarm was not used and was in the off position. During an interview on 06/12/23 at 12:23 PM, a family member reported he came in last week and R28 was on the floor in her room. He thought maybe she was trying to get in her wheelchair from her recliner. He reported R28 could not remember to use the call light for assistance, and one of her falls resulted in a broken arm. On 06/13/23 at 04:00 PM, CNA G reported the resident needed many reminders and was not that mobile since she broke her arm. CNA G stated R28 attempted to take herself to the bathroom has and had a lot of falls. CNA G did not know of the silent motion sensor in the resident's room and had not ever seen it. On 06/14/23 at 09:40 AM CNA H reported she got the resident up for breakfast. The resident liked to sleep in, required extensive assistance of one staff, and walked in her room with her walker. CNA H stated R28 was not safe to ambulate by herself, and there was no toileting plan for the resident, and she was more incontinent. CNA H stated they put antiroll locks on her chair and CNA H did not know the resident had a silent alarm. On 06/14/23 at 10:00 AM, CNA I reported the resident was very inconsistent and required assistance with her activities of daily living (ADL). She reported the resident did not have a toileting plan but thought that would be good for her. She did not know if the resident had a silent alarm and if she did, the staff were not using it. On 06/13/23 at 11:10 AM, Licensed Nurse (LN) J reported she did not add new interventions to the resident's care plan following her falls. LN J said she reviewed care plans before all care plan meetings and would update any problems/concerns then. On 06/14/23 at 10:30 AM, Administrative Nurse B stated after reviewing the resident fall history she felt a toileting plan would have benefitted the resident to prevent some of her falls. She also reported she expected staff to review the care plan and revised with falls, and if no revision was warranted there should still be documentation. The facility's policy for Fall Protocol, dated 12/31/21, revealed the charge nurse would assess severity of fall/injury for need of emergency care, complete risk management assessment in the EMR including fall risk assessment, and the charge nurse would update interventions on the fall care plan with any new occurrence of falls. The facility failed to identify causal factors for the resident's falls and failed to provide timely and appropriate interventions to prevent further falls. The resident had a history of multiple falls and fell while attempting to self-toilet and broke her arm.

The facility reported a census of 31 residents. The facility had one main kitchen. The kitchen served food to one main dining area. Based on observation, interview, and record review, the facility failed to properly store food in the main kitchen refrigerators due to foods left uncovered, boxes placed directly on the floor in the freezer and dry storage area, and staff failed to discard expired foods in accordance with professional standards for food service safety, to prevent food borne illness to the residents. Findings included: - During the brief initial tour of the kitchen, on [DATE] at 07:40 AM, observation revealed the following concerns: 1. The walk-in refrigerator had one undated, large sheet pan of yellow cake. One undated, large tub of salad mixes with cheese, five 32 ounce (oz.) tubs of yogurt with a use by date of [DATE]. There was one three-pound (lb.) tub of ricotta cheese with a use by date of [DATE], six four-ounce yogurt cups with a use by date of [DATE], and a one five lb. tub of cottage cheese with a use by date of [DATE]. Furthermore, a rolling cart with 15 uncovered, undated, serving cups of chocolate pudding/pie and three plates of sliced pie. 2. The walk-in freezer had four boxes and seven tubs of various ice cream flavors stored directly on the floor. 3. The reach in refrigerator had an opened, not resealed, undated 32 oz. package of lunch meat, an opened, not resealed, undated 2.3 lb. bag of lettuce, and an undated package of 16 sliced cheese. Furthermore, a large pan of prepared mashed potatoes with a use by date of [DATE]. 4. The kitchen had two refrigerators and two freezers with temperature logs that were missing several days of readings, to include no dates on [DATE] and [DATE], no PM dates for the month of [DATE], no AM dates on [DATE] through [DATE] as well as other dates. 5. The kitchen dry storage area had three boxes stored directly on the floor with five boxes on top of them blocking the entrance into the area. 6. The kitchen had four large storage bins, one with flour, one with sugar, one with powdered sugar, and one with brown sugar. The lids of all four storage bins had dried light and dark areas, and debris on them. On [DATE] at 08:00 AM, Dietary staff D stated the dietary staff were all supposed to know to rotate the stock and check expiration dates. Dietary staff D stated the truck had just delivered and that was why the boxes and tubs were on the floor in the freezer and in the dry storage area. On [DATE] at 08:08 AM, Dietary staff C confirmed staff should not store boxes directly on the floor, and that she knew the truck had just delivered. Dietary staff C confirmed staff should discard expired foods, and that it was all dietary staff's responsibility to check that everything should be covered and dated once opened. The facility's ,d+[DATE] policy for Food and Nutrition documented all staff would store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to store food in accordance with professional standards for food service safety. This failure placed the 31 residents, who resided at the facility, at risk for food borne illness.

The facility census totaled 31 residents with 12 included in the sample. Based on interview and record review, the facility failed to revise care plans for Resident (R) 28, related to falls. Findings included: - R28's electronic Medical Record (EMR) revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate impairment in cognition. The resident required extensive assistance of two staff for daily cares and was frequently incontinent of bladder and bowel. The resident received pain medications on a scheduled and as needed basis. The resident had a recent fall with a fracture. The Fall Risk assessment dated [DATE] indicated the resident was high risk for falls. Review of the Quarterly MDS dated [DATE], revealed a BIMS score of six, indicating severe cognitive impairment. The resident required assistance of one staff for supervision and physical assistance with transfers, ambulation, and toileting. The resident was a fall risk and had one non-injury and one minor injury fall since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/20/22 revealed the resident could make herself understood, usually understood others but was unable to retain information, and staff were to anticipate her needs. The Falls CAA dated 11/20/22 documented staff were to observe and assess for increased fall risks and eliminate them when able, and report concerns to the physician as needed/warranted. Staff were to observe and assess for interventions that decrease fall risks and implement as needed. Review of the Care Plan dated 03/16/22, revealed the resident was a fall risk due to actual falls and deconditioning (weakness) and included the following interventions: On 03/16/22, staff were to encourage the resident to participate in activities that would promote exercise and physical activity for strengthening and improved mobility. On 03/16/22, staff were to ensure the resident wore appropriate footwear (non-skid socks or shoes) when ambulating or mobilizing in her wheelchair. On 03/16/22, staff were to ensure the resident's walker was on the side of her bed, near the bathroom, at night to cue the resident to use the walker when she would get herself up to toilet. On 07/04/22, staff were to ensure the call light was within the residents reach and encourage her to use the call light for assistance. On 06/13/23, staff placed anti-roll breaks on the resident's wheelchair. On 09/19/23, staff were to provide visual checks during the night hours to ensure the resident's walker was in reach. The care plan lacked revisions on the fall that occurred on 05/10/22, 11/14/22, 12/24/22, 02/03/23, and 05/20/23 to provide guidance to staff to possibly prevent the resident from further falls. The Fall Investigation dated 05/10/22 at 07:40 AM revealed the resident reported she fell in her bathroom. She had diarrhea and weakness, and felt it was from Metformin (medication for control of the blood glucose). The medication was discontinued, and staff failed to review and revise the care plan for this fall. The Fall Investigation dated 11/14/22 at 05:24 PM revealed the resident was found seated next to her recliner, leaned against the raised footrest. The call light had been clipped to the arm rest of her chair, her wheelchair was across the room, and the staff noted no injuries found and assisted the resident to the side of the bed. Staff failed to review and revise the care plan for this fall. The Fall Investigation dated 12/24/22 at 02:45 PM revealed the resident was on the floor, sitting on her buttocks in front of her recliner. The resident reported she just slid out of her recliner. Staff failed to review and revise the care plan for this fall. The Fall Investigation dated 02/03/23 at 06:54 AM revealed the resident was found sitting on the floor in her bathroom doorway facing her bed with her legs in front of her. The resident stated she had attempted to get back to her bed after using her bathroom. The resident sustained a small skin tear to her right ankle and her right elbow. Staff failed to review and revise the care plan for this fall. The Fall Investigation dated 05/20/23 at 09:00 AM revealed a housekeeper reported the resident was on the floor. The resident observed against the bedframe at the head of the bed with her walker was up against the wall in the unlocked position. The bathroom had feces (bowel movement) on the floor. Two staff assisted the resident to her wheelchair. Staff observed the resident leaned backwards while in the standing position, and staff placed the resident in the wheelchair to take her to breakfast. The resident was unable to state how the fall occurred. The resident received a scrape to her left great toe as well as redness to her upper back. Staff failed to review and revise the care plan for this fall. On 06/13/23 at 11:10 AM, Licensed Nurse (LN) J reported she did not add new interventions to the resident's care plan following her falls. LN J said she reviewed care plans before all care plan meetings and would update any problems/concerns then. On 06/14/23 at 10:30 AM, Administrative Nurse B reported she expected staff to review the care plan and revise the care plan with falls, and if no revision was warranted, there should still be documentation. Review of the facility policy named Care Plan Development and Revisions dated 01/10/20 revealed revisions can be made any time changes are noted. These can be made by the Director of Nurses (DON), MDS coordinator, charge nurse, Dietary manager, or Social Services director. The facility failed to revise care plans for Resident (R) 28 related to falls.

The facility reported a census of 31 residents, with 12 sampled, including one resident sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide care consistent with standard of practice for the one sampled Resident (R) 30 to maintain good grooming and personal hygiene related to showers, nail care, and facial hair removal. Findings included: - The 06/12/23 Electronic Health Record (EHR) documented R30 had the following diagnoses of presence of artificial hips right and left (surgery to replace hip joints with artificial parts) and emphysema (long-term, progressive disease of the lungs characterized by shortness of breath). The 05/27/23 Significant Change Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 14, indicating intact cognition. R30 required physical help of one staff for bathing/showering. The 05/27/23 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R30 would require continued assistance from staff. The 04/12/23 Significant Change MDS documented R30 required physical help in part of bathing/showering by one staff. The 05/02/23 Care Plan documented staff were to check nail length, trim, and clean nails on bath days and as needed. R30 required one staff assistance with bathing. The Progress Notes from March 2023 through June 2023, lacked documentation of the resident's refusals of showers/baths. The Tasks in the EHR documented in the last 30 days, the resident received four (05/24/23, 05/31/23, 06/06/23, and 06/12/23) out of eight bathing opportunities. On 06/12/23 at 10:45 AM, R30 observed sitting in his room in his recliner with long facial hair growth, greasy/oily appearing hair, and long jagged nails on both hands. On 06/13/23 at 04:19 PM, R30 stated he does need assistance with showering and shaving, because he cannot see out of his right eye, and did not want to cut up his face. R30 stated he had to ask when he wanted assistance with nail care or shaving and most of the time they would assist, he confirmed he did need them trimmed. On 06/14/23 at 09:31 AM, R30 observed sitting in his room in his recliner with long jagged nails on both hands, R30 is clean shaven and had clean hair. On 06/14/23 at 09:11 AM, certified nurse's aide (CNA) K, revealed she was the shower aide assigned to showers for the day. She stated if the residents refused, she would get the charge nurse. CNA K stated she offered nail care with each shower given. She stated showers were to be documented in the electronic record. CNA K stated she had not given R30 a shower recently. On 06/14/23 at 09:39 AM, Licensed Nurse (LN) L revealed staff should document showers in the electronic record. LN L confirmed R30 required staff assistance with bathing. On 06/14/23 at 01:26 PM, Administrative Nurse B revealed she expected her staff to provide bathing at least twice weekly, to document it in the electronic record, and to provide shaving and nail care with each encounter. The facility 06/14/23 Activity of Daily Living (ADL) policy documented a resident who is unable to carry ADL will be receive the necessary services to maintain good nutrition, grooming, and oral and personal hygiene. The facility failed to provide care consistent with professional standard of practice, for this resident that required assistance with bathing and facial hair removal, nail care, to maintain good grooming, and personal hygiene.

The facility reported a census of 91 residents. The sample included 12 residents, with one resident sampled for bowel/ bladder incontinence. Based on observation, interview, and record review, the facility failed to provide an individualized toileting plan for Resident (R) 28, to ensure the resident remained as continent as possible. Findings included: - R28's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate impairment in cognition. The resident required extensive assistance of two staff for daily cares and was frequently incontinent of bladder and bowel. The resident received pain medications on a scheduled and as needed basis. The resident had a recent fall with a fracture. The Fall Risk assessment dated [DATE] indicated the resident was high risk for falls. Review of the Quarterly MDS dated [DATE], revealed a BIMS score of six, indicating severe cognitive impairment. The resident required assistance of one staff for supervision and physical assistance with transfers, ambulation, and toileting. The resident was a fall risk and had one non-injury and one minor injury fall since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/20/22 revealed the resident could make herself understood, usually understood others but was unable to retain information, and staff were to anticipate her needs. The Urinary Incontinence and Indwelling catheter CAA dated 11/20/22, revealed the resident required staff assistance to toilet and would require continued assistance. Staff were to observe/assess for changes in continence and report concerns to her physician as needed. Staff were to observe/assess for interventions that promote a decrease in incontinence and implement. Staff were to observe/assess for complications including urinary tract infection (UTI) and skin breakdown and report those concerns to the physician for further treatment. The Care Plan revealed the resident was incontinent of bladder (dated 07/04/22) and included the following interventions: On 07/04/22, activity staff were to notify nursing staff if R28 was incontinent during activities. On 07/04/22, staff were to establish voiding patterns for R28. On 07/04/2022, Certified Nurse Aides (CNA's) were to monitor/document for signs of UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or changes in eating patterns. On 07/04/22, staff were to ensure the call light was within the residents reach and encourage her to use the call light for assistance. On 06/13/23, anti-roll breaks were placed on the resident's wheelchair. On 09/19/23, staff were to provide visual checks during the night hours to ensure the resident's walker was in reach. The Fall Investigation dated 05/10/22 at 07:40 AM revealed the resident reported she fell in her bathroom. She had diarrhea and weakness, and felt it was from Metformin (medication for control of the blood glucose). The medication was discontinued, and staff failed to implement an intervention to keep the resident free from possible further falls. The Fall Investigation dated 09/13/22 at 01:08 AM revealed the resident was found lying on the floor of her bathroom with her head between the toilet and the wall and legs extended straight out towards the door. R28 had one sock on, no undergarments and had a shirt and a sweater in place. She hit her head and had visible bruising starting on her upper left back. No other injuries noted. The resident denied pain. Two staff got her up and walked her to bed. She was wobbly and unsure what to do. She was sat on the side of the bed and could not stay sitting up without holding onto the grab rail or the frame of the bed. She stated she got up to go to bathroom, and the next thing she knew, she was on the floor in the bathroom. Review of the incident reported the resident was incontinent and walking without proper footwear and slipped and fell using walker to ambulate to BR. A witness statement from (CNA) E stated she had not gone in to check the resident yet on her shift. Her shift began at 10:00 PM, three hours into her shift. The Fall Investigation dated 11/02/22 at 08:10 AM revealed an unnamed Certified Medication Aide (CMA) heard the resident yelling for help and found the resident lying on the floor in her bathroom. The CMA notified the nurse, and the nurse found the resident lying on the floor with her head against the wall near the bathroom door. She was lying on her right side facing the doorway. The resident was alert and oriented to person only and could not tell the nurse what happened. The nurse observed bluish bruising with a small amount of swelling above R28's left eyebrow. The resident could not lift her left arm and cried out in pain when the nurse touched her arm. There was visible bruising on the resident's upper left arm near her shoulder. Three staff assisted the resident to her bed. At 08:30 AM (20 minutes after the fall), the staff notified the resident's Durable Power of Attorney (DPOA) of the fall and resident transfer to hospital for evaluation. At 08:32 AM, staff received an order to send the resident to emergency room (ER). At 08:50 AM, the resident left the facility in an ambulance (40 minutes after the resident's fall). Review of the investigation documented the resident had no injuries post fall, however, the update from the hospital revealed the resident had a fractured humerus. The Fall Investigation dated 02/03/23 at 06:54 AM revealed the resident was found sitting on the floor in her bathroom doorway facing her bed with her legs in front of her. Resident stated she was attempting to get back to bed after using her bathroom. The Fall Investigation dated 05/20/23 at 09:00 AM revealed a housekeeper reported the resident was on the floor. Upon arrival R28 was observed against the bedframe at the head of the bed. Her walker was up against the wall in the unlocked position. Feces (bowel movement) was on the bathroom floor. Review of a Voiding Diary dated 03/17/22, revealed it was not used due to inaccurate data. The staff did not do the voiding diary during the night or anytime the resident slept and only took the resident to the bathroom at approximately three-to-four-hour intervals instead of the required intervals on the voiding diary. Review of the Bowel and Bladder Assessment completed on 02/15/23, revealed the resident was incontinent, needed assistance with toileting, was sometimes aware of the need to void and a timed, scheduled toileting plan recommended. However, the facility lacked an individualized toileting plan for R28. Review of the Bowel and Bladder Assessment completed on 05/17/23, revealed no changes from the previous assessment. Continued with no toileting plan. Observation on 06/13/23 at 9:00 AM revealed CNA H assisted the resident with a transfer to her wheelchair from her recliner. CNA H failed to offer the resident a toileting opportunity. Staff propelled the resident to the dining room for a meal. On 06/13/23 at 4:00 PM CNA G reported is not that mobile since she broke her arm but still attempted to take herself to the bathroom by herself. She has had a lot of falls. On 06/14/23 at 09:40 AM CNA H reported the resident was not safe to ambulate by herself. There is no toileting plan for the resident, and she is more incontinent. On 06/14/23 at 10:00 AM CNA/RA I reported the resident is very inconsistent and needs assistance with her activities of daily living (ADLs). She reported the resident did not have a toileting plan but thought that would be good for her. On 06/14/23 at 10:30 AM, Administrative Nurse B stated after reviewing the resident fall history she felt a toileting plan would have benefitted the resident to prevent some of her falls. The undated facility policy called Bladder Schedule Voiding Protocol revealed a voiding schedule based on a three-day voiding pattern assessment, comprehensive assessments including causal factors of the resident's incontinence, and progress and consultant notes would be placed in the resident's care plan. The facility failed to provide an individualized toileting plan for Resident (R) 28, to ensure the resident remained as continent as possible.

The facility reported a census of 31 residents with 12 residents included in the sample which included five residents selected for review of influenza, pneumococcal, and COVID vaccines. Based on interview and record review, the facility failed to ensure the resident/resident representative received information/education regarding the benefits, risks, or medical contraindications of pneumococcal for three Residents (R), including R26, R23 and R35. Findings included: - Review of the Electronic health record (EHR) for Resident (R) 26, lacked documentation of any pneumococcal vaccine or declination of the vaccine provided to the resident and/or their representative to demonstrate the benefits verses risk of receiving the vaccine. The record lacked documentation the resident had been offered or provided an opportunity to receive the vaccine. Review of the EHR for R 23 lacked documentation of any pneumococcal vaccine or declination of the vaccine provided to the resident and/or their representative to demonstrate the benefits verses risk of receiving the vaccine. The record lacked documentation the resident had been offered or provided an opportunity to receive the vaccine. Review of the EHR for R 35 lacked documentation of any pneumococcal vaccine or declination of the vaccine provided to the resident and/or their representative to demonstrate the benefits verses risk of receiving the vaccine. The record lacked documentation the resident had been offered or provided an opportunity to receive the vaccine. On 06/13/23 at 09:00 AM, administrative Nurse B reported the residents did not get the vaccine as she could find no record of them. She reported she was not aware the residents should be offered the vaccine when they admitted to the facility. On 06/13/23 at 01:00 PM, administrative Nurse B reported she located a consent form for the pneumococcal but verified staff had not been offering the vaccination. and identified 14 residents lacked pneumococcal vaccinations Review of the facility policy named Flu and Pneumonia Immunization dated 01/17 revealed before offering the pneumococcal immunization, each resident or the resident representative would receive education regarding the benefits and potential side effects of the immunization. Each resident would be offered a pneumococcal vaccine, unless the immunization is medically contraindicated, or the resident has already been immunized. The resident or the resident representative can refuse immunization and the residents medical record includes documentation that indicates, at a minimum, the following: The resident or resident representative provided education regarding the benefits and potential side effects of pneumococcal immunization; and the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contradictions or refusal. The facility failed to provide proof of vaccination or declination of vaccines for pneumococcal for these three residents reviewed.

The facility reported a census of 35 residents. The facility had one main kitchen where food was stored and prepared for one dining room. Based on observation, interview, and record review the facility failed to store and prepare food under sanitary conditions when the facility failed to properly store food items, clean kitchen equipment, ensure refrigerator and freezer temperature were documented and dietary staff did not properly restrained hair. These failures affected all the residents of the facility. Findings included: - During the initial kitchen tour on 11/02/21 at 07:27 AM, the following concerns were identified: 1. The temperature log for the Arctic Air double door refrigerator lacked 19 entries for the month of October 2021 and lacked temperature documentation for 11/01/21. 2. Walk-in refrigerator had a large covered plastic container with a fruit dessert that was not dated. 3. A crate with four, gallon jugs of milk stored on the floor of the walk-in refrigerator. 4. Four large cylindrical cartons of ice cream stored on the floor of the walk-in freezer. 5. Five large bags of ice stacked on top of each other stored on the floor of the walk-in freezer. 6. Seven boxes of various food items stored on the floor of the walk-in freezer. 7. A large manual can opener had brown/black grime inside the base holder, and near the puncture mechanism. 8. Dining room refrigerator located under the juice dispensers did not have a temperature log completed. During the follow-up kitchen tour on 11/04/21 at 11:08 AM revealed the following concerns: 1. An observation on 11/04/21 at 11:36 AM, revealed Dietary Staff (DS) R wore a baseball cap with hair not fully restrained and failed to wear a beard guard. 2. An observation on 11/04/21 at 11:36 AM, revealed Dietary Staff (DS) T wore a baseball cap with hair not fully restrained. 3. One opened bag of shredded cheddar cheese with no opened date or use by date. 4. One package of sliced Swiss Cheese with an expiration date of 11/01/21. 5. An observation on 11/04/21 at 11:42 AM, revealed DS R wore black disposable gloves and prepared sandwiches for the lunch meal. DS R removed slices of bread from bags and placed them on a cookie sheet. DS R touched his clothing when adjusting his pants and proceeded to use the same gloves to place meat slices, bacon, lettuce, tomatoes and the final layer of bread on to sandwiches. In an interview on 11/04/21 at 03:18 PM, Dietary Staff (DS) S stated the facility provided hairnets for dietary staff and stated if staff wore a hat that still allowed hair to be exposed the staff should wear a hairnet. DS S stated beard guards should also be worn. The Hair covering in Kitchen policy date 11/04/21 revealed, Hair is to be covered at all times . The Glove Usage-To Ensure Cross Contamination is Prevented policy dated 11/04/21 revealed, During food prep single use gloves to be used when handling raw animal food or when working with ready to eat food .Discard gloves when damaged, soiled, or when interruptions occur during tasks. The undated Food & Nutrition- Safety-Sanitization policy revealed, .Containers of food are stored on clean surfaces, off the floor, and in a manner to protect them from contamination .Effective procedures are established for the cleaning of all equipment .Document the temperature of external and internal refrigerator gauges. The facility failed to properly store food items, clean kitchen equipment, ensure refrigerator and freezer temperature were documented and dietary staff properly restrained hair.

The facility census totaled 35 residents, with 12 included in the sample. Based on interview and record review the facility failed to develop a comprehensive care plan to include the use of oxygen (O2) for Resident (R)23. Findings included: - R23's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition and received oxygen. Review of R23's Care Plan lacked any interventions concerning the use of O2. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The September to November 2021 Electronic Treatment Administration Record (ETAR) and Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 11/03/21 at 01:04 PM revealed R23 used O2 via an oxygen concentrator and also had a portable O2 tank for use when she was not in her room. In an interview on 11/03/21 at 12:03 PM, Certified Nurse Aide (CNA) F stated R23 used O2 continuously and when not in use, staff rolled up the O2 tubing and placed it in the handle of the oxygen concentrator. CNA F stated the nightshift nurse was the one to change out the O2 tubing and stated that she believed the tubing should be dated. In an interview on 11/04/21 at 08:54 AM, Certified Medication Aide (CMA) H stated the O2 tubing was replaced once a month by the medication aide and documentation of O2 tubing changed was documented on the EMAR. CMA H stated when O2 tubing was not in use they rolled up the O2 tubing and stuck it in the handle of the O2 concentrator in order to keep the O2 tubing off the floor. In an interview on 11/04/21 at 12:30 PM, Licensed Nurse (LN) I stated R23 used O2 and the night shift usually changed O2 tubing on a monthly basis. LN I stated this should be documented on the nurses ETAR/EMAR. In an interview on 11/04/21 at 03:21 PM, Administrative Nurse B stated she expected the care plan to include the use of R23's oxygen. The facility did not provide a policy regarding Care Plans as requested. The facility failed to ensure the care plan included information about the use of oxygen for R23.

The facility reported a census of 35 resident, with 12 included in the sample, and one resident reviewed for discharge. Based on interview and record review the facility failed to document a recapitulation of the resident's stay upon discharge for the Resident (R) 41. Findings included: - The 08/20/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Date Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. R41 required extensive assistance with Activities of Daily Living (ADL). The Activities of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA) dated 08/20/21 revealed R41 required continued assistance from staff, and the staff were to assist the resident only to the degree needed while allowing/encouraging R41 to remain as independent as possible. The Care Plan dated 08/24/21 indicated R41 wished to discharge to her home after completing a skilled stay and noted R41's family members would be available to assist with any needs and transportation to appointments, if needed after discharge, and considered home health services with the options for physical therapy and occupation therapy. The Care Plan documented the staff were to establish a pre-discharge plan with R41 or R41's family and or care givers. The Nurses Notes dated 10/07/21 at 10:10 AM documented the discharge of R41 from the facility with her medication list (faxed to the pharmacy) and two cards of controlled medication. Interview with Licensed Nurse (LN) I on 11/04/21 at 08:41 AM revealed LN I had never done a recapitulation of a residents visit. LN I stated the nurses go over the medication(s) call the pharmacy for medications at home, but the Social Service staff or the Assisted Director of Nursing do the recapitulation of the residents stay. Interview with Social Service Designee SSD P on 11/04/21 at 08:33 AM revealed during the discharge of R41, SSD P was out of the facility. Interview with Administrative Nurse J on 11/04/21 at 08:33 AM indicated at the time of R41's discharge from the facility Administrative Nurse J was too busy to do the discharge that day and said we usually do the recap of the visit. Interview with Administrative Nurse B on 11/04/21 at 02:21 PM indicated Administrative Nurse J took care of the discharges, but she was doing the SSD job since she was out of the facility. Administrative Nurse B stated both the SSD staff and the Administrative Nurse J completed the recapitulation together and she did not expect the LN to complete this task. The facility policy Prairie Sunset Home Dischage Care Plan Policy undated indicated residents will be assessed for their discharge goals, preferences and care needs to meet their goals. The resident will be periodically reassessed to identify changes that require modification of the discharge plans and update the plans as needed. A discharge summary will be completed upon discharge to include: a recapitulation of the resident's stay in the facility ( diagnoses, course of illness/treatment,therapy,lab,radiology and consultation reports). A final summary of residents status medication reconcilitation and post discharge plan of care developed with the resident and resident representative. The facility failed to document a discharge summary including a recapitulation of R41's stay at the facility upon discharge as required.

The facility census totaled 35 residents, with 12 included in the sample, and five residents reviewed for oxygen (O2) use. Based on observation, interview, and record review the facility failed to provide necessary respiratory care and/or services consistent with professional standards of practice when they failed to change disposable O2 equipment for Resident (R)23 and R27. Findings included: - R23's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition and received oxygen. Review of R23's Care Plan lacked any interventions concerning the use of O2. A Physician Order dated 09/10/21 revealed R23 was to have O2 at 2-4 Liters (L) per minute per nasal canula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) as needed (PRN) for dyspnea (difficulty breathing) to keep O2 saturation at 90% or greater. The September to November 2021 Electronic Treatment Administration Record (ETAR) and Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 11/03/21 at 01:04 PM revealed R23 used O2 via an oxygen concentrator and also had a portable O2 tank for use when she was not in her room. In an interview on 11/03/21 at 12:03 PM, Certified Nurse Aide (CNA) F stated R23 used O2 continuously and when not in use, staff rolled up the O2 tubing and placed it in the handle of the oxygen concentrator. CNA F stated the nightshift nurse was the one to change out the O2 tubing and stated that she believed the tubing should be dated. In an interview on 11/04/21 at 08:54 AM, Certified Medication Aide (CMA) H stated the O2 tubing was replaced once a month by the medication aide and documentation of O2 tubing changed was documented on the EMAR. CMA H stated when O2 tubing was not in use they rolled up the O2 tubing and stuck it in the handle of the O2 concentrator in order to keep the O2 tubing off the floor. In an interview on 11/04/21 at 12:30 PM, Licensed Nurse (LN) I stated R23 used O2 and the night shift usually changed O2 tubing on a monthly basis. LN I stated this should be documented on the nurses' ETAR/EMAR. In an interview on 11/04/21 at 03:21 PM, Administrative Nurse B stated R23 used oxygen and stated oxygen tubing should be changed out monthly or as needed and should be documented on the standard EMAR. The Oxygen policy dated 03/06/20 revealed, The Unit Nurse or CMA must document in the resident's chart: .Weekly and PRN tubing changes on TAR. The facility failed to ensure staff changed out oxygen tubing for R23 consistent with professional standards of practice and according to facility policy. - Review of the R27's signed Physician Orders dated 09/14/21 indicated the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score 15, indicating intact cognition. R27 required extensive assistance of one staff with all Activities of Daily Living (ADL) except eating no respiratory treatment noted. The Care Plan dated 09/02/20 lacked use of nebulizer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The Electronic Medical Record EMR indicated R27 received [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 milligram(mg) in three milliliters (ml) one dose inhale orally three times a day related to chronic obstructive pulmonary disease, with an order date of 06/26/21. Observation on 11/02/21 at 08:19 AM revealed the nebulizer mask laying on the bedside table with a date of 09/22/21, (over a month ago) indicating the last time the mask had been changed out. Interview with Certified Medication Aide (CMA) K on 11/04/21 at 08:11 AM indicated the nebulizer mask should be changed out monthly. Interview with Licensed Nurse I on 11/04/21 at 08:53 AM indicated the nebulizer mask were to be changed out by the CMA staff, since they administered the breathing treatments. Interview with the Administrative Staff B on 11/04/21 at 02:25 PM indicated she expected the staff to change out the nebulizer mask on a monthly basis and as needed. Review of the facility policy Handheld Nebulizer dated 07/01/2018 revealed the instructions for staff to change the nebulizer mask/pipe and tubing on a monthly schedule. The facility failed to change the nebulizer mask and tubing on a monthly schedule for R27.

The facility census totaled 35 residents with five residents reviewed for unnecessary medications. Based on interview and record review the facility failed to ensure the pharmacist identified and reported missing documentation concerning physician notifications for blood pressures that exceeded parameters for Resident (R)35 and R36. Findings included: - R35's Medication Review Report dated 03/25/21 revealed a diagnosis of hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and received a diuretic (medication to promote the formation and excretion of urine) six days during the seven-day lookback period. The Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition and received a diuretic medication daily. The Care Plan dated 02/02/18 revealed R35 received medications that had the potential for adverse effects to include [MEDICATION(S)] (antihypertensive medication) for hypertension. A review of the Physician Orders included the following: Order dated 06/30/20 for [MEDICATION(S)] (antihypertensive medication) 25 mg, one tablet, by mouth, daily for hypertension. Order dated 03/17/20 for [MEDICATION(S)] (antihypertensive medication) 50 mg, one tablet, by mouth, daily for hypertension. Order dated 03/17/20 for [MEDICATION(S)] (antihypertensive medication) 40 mg, one tablet, by mouth, daily for hypertension. Order dated 03/17/20 for [MEDICATION(S)] (antihypertensive medication) 10 mg, one tablet, by mouth, daily for hypertension. Order dated 10/05/21 to notify practitioner if blood pressure was less than 90/40 millimeter of mercury (mmHg) or greater than 180/115 mmHg. Order dated 10/05/21 for [MEDICATION(S)] (antihypertensive medication) 0.1 milligrams (mg), by mouth two times a day for hypertension. The August 2021 Electronic Medication Administration Record (EMAR) lacked evidence the facility staff notified the physician for R35's blood pressure of 194/85 mmHg on 08/12/21. The September 2021 EMAR lacked evidence the facility staff notified the physician for R35's blood pressure of 184/84 mmHg on 09/24/21. The October 2021 EMAR lacked evidence the facility staff notified the physician for R35's blood pressures of 193/79 mmHg on 10/21/21 and 193/79 mmHg on 10/28/21. The Progress Notes and documents scanned under the Miscellaneous tab of the Electronic Health Record lacked evidence of physician notifications regarding the blood pressures greater than 180/115 mmHg. The Pharmacy Reviews from 11/24/20 through 10/27/21 failed to identify lack of physician notifications for blood pressures that exceeded parameters. In an interview on 11/03/21 at 04:30 PM, Certified Medication Aide (CMA) D stated R35 received medications for hypertension which had parameters. CMA D stated staff took R35's blood pressure before giving her blood pressure medications. CMA D stated staff held blood pressure medications and notified the nurse if R35's blood pressure exceeded the parameters. In an interview on 11/04/21 at 12:35 PM, Licensed Nurse (LN) I stated R35 received medications for hypertension with parameters of less than 90/40 or greater than 180/115 and nursing staff were to contact the primary care physician when blood pressures exceeded parameters. LN I stated notifications to the physician should be documented in a progress note. In an interview on 11/04/21 at 02:52 PM, Consultant Pharmacist Q stated she expected the facility to follow through with calling the physician with notifications for blood pressures that were outside of parameters. Consultant Pharmacist Q stated she made multiple notes concerning the facility not doing this, she had talked to the Director of Nurses (DON) about this concern, as the physician has made the parameters very clear, and the nurses have been told about following through with this expectation. In an interview on 11/04/21 at 04:45 PM, Administrative Nurse B stated the consultant pharmacist did not make her aware of blood pressures outside of parameters. The Consultant Pharmacist Reports policy dated 01/20/21 revealed, The consultant pharmacist documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for prescriber and/or nursing review. The facility failed to ensure the consultant pharmacist identified and reported missing documentation concerning blood pressures that exceeded physician ordered parameters for R35. - R36's Medication Review Report signed 03/22/21 revealed a diagnosis of hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition and received a diuretic (medication to promote the formation and excretion of urine) daily. The Care Plan dated 10/15/19 revealed R36 took medications that had the potential for adverse effects to include [MEDICATION(S)] (diuretic medication.) A review of the Physician Orders included the following: Order for 10/11/19 [MEDICATION(S)] (antihypertensive medication) 4 mg, one tablet by mouth daily for hypertension. Order for 10/12/19 [MEDICATION(S)] (antihypertensive medication) 240 mg, give one capsule by mouth, daily for hypertension. Order dated 03/05/20 to notify practitioner or office if blood pressure was less than 90/40 or greater than 180/115. Order dated 07/28/21 for [MEDICATION(S)] (antihypertensive medication) 25 mg, give one tablet by mouth, two times a day for hypertension. Order dated 05/06/21 for [MEDICATION(S)] 40 mg, give one tablet by mouth two times a day for heart failure. Order dated 09/28/21 for [MEDICATION(S)] (antihypertensive medication) 0.2 milligrams (mg), give 0.2 mg by mouth, two times a day for hypertension. Review of the August 2021 Electronic Medication Administration Record (EMAR) lacked evidence the facility staff notified the physician for R36's elevated blood pressure of 195/75 mmHg on 08/04/21 and 182/81 mmHg on 08/13/21. Review of the October 2021 EMAR lacked evidence the facility staff notified the physician of R36s elevated blood pressure of 190/73 mmHg on 10/31/21. Review of the Progress Notes and documents scanned under the Miscellaneous tab of the Electronic Health Record did not reveal any physician notification about blood pressures greater than 180/115 mmHg. The Pharmacy Reviews from 11/24/20 through 10/27/21 failed to identify lack of physician notifications for blood pressures that exceeded parameters. In an interview on 11/03/21 at 04:03 PM, Certified Medication Aide (CMA) E stated R36 received medications that came with parameters. CMA E stated she notified the nurse if any blood pressures were out of parameter and the nurse would notify the physician as required. In an interview on 11/04/21 at 12:35 PM, Licensed Nurse (LN) I stated R36 received medications for hypertension with parameters of less than 90/40 or greater than 180/115 and nursing staff were to contact the primary care physician when blood pressures exceeded parameters. LN I stated notifications to the physician should be documented in a progress note. In an interview on 11/04/21 at 03:24 PM, Administrative Nurse B stated she expected the nurse to reassess blood pressures out of parameters and notify the physician if blood pressures were still out of parameter. Administrative Nurse B stated physician notifications should be documented in a progress note. In an interview on 11/04/21 at 02:52 PM, Consultant Pharmacist Q stated she expected the facility to follow through with calling the physician with notifications for blood pressures that were outside of parameters. Consultant Pharmacist Q stated she has made multiple notes concerning the facility not doing this, she has talked to the Director of Nurses (DON) about this concern, as the physician has made the parameters very clear, and the nurses have been told about following through with this expectation. In an interview on 11/04/21 at 04:45 PM, Administrative Nurse B stated she the consultant pharmacist did not make her aware of blood pressures outside of parameters. The Consultant Pharmacist Reports policy dated 01/20/21 revealed, The consultant pharmacist documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for prescriber and/or nursing review. The facility failed to ensure the consultant pharmacist identified and reported missing documentation concerning blood pressures that exceeded physician ordered parameters for R36.

The facility census totaled 35 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of blood pressure medication for Resident (R)35, and R36. The facility License Nurse (LN) staff did not notify the physician of elevated blood pressures which exceeded the physician ordered parameters for R35 and R36. Findings included: - R35's Medication Review Report dated 03/25/21 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and received a diuretic (medication to promote the formation and excretion of urine) six days during the seven-day lookback period. The Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition and received a diuretic medication daily. The Care Plan dated 02/02/18 revealed R35 received medications that had the potential for adverse effects to include [MEDICATION(S)] (antihypertensive medication) for hypertension. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Order dated 06/30/20 for [MEDICATION(S)] (antihypertensive medication) 25 mg, one tablet, by mouth, daily for hypertension. Order dated 03/17/20 for [MEDICATION(S)] (antihypertensive medication) 50 mg, one tablet, by mouth, daily for hypertension. Order dated 03/17/20 for [MEDICATION(S)] (antihypertensive medication) 40 mg, one tablet, by mouth, daily for hypertension. Order dated 03/17/20 for [MEDICATION(S)] (antihypertensive medication) 10 mg, one tablet, by mouth, daily for hypertension. Order dated 10/05/21 to notify practitioner if blood pressure was less than 90/40 millimeter of mercury (mmHg) or greater than 180/115 mmHg. Order dated 10/05/21 for [MEDICATION(S)] (antihypertensive medication) 0.1 milligrams (mg), by mouth two times a day for hypertension. The August 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2021 EMAR lacked evidence the facility staff notified the physician for R35's blood pressure of 184/84 mmHg on 09/24/21. The October 2021 EMAR lacked evidence the facility staff notified the physician for R35's blood pressures of 193/79 mmHg on 10/21/21 and 193/79 mmHg on 10/28/21. The Progress Notes and documents scanned under the Miscellaneous tab of the Electronic Health Record lacked evidence of physician notifications regarding the blood pressures greater than 180/115 mmHg. Observation on 11/03/21 at 10:50 AM revealed R35 sat in her recliner reading a newspaper. R35 was calm, did not show any signs of depression, anxiety or sedation. In an interview on 11/03/21 at 04:30 PM, Certified Medication Aide (CMA) D stated R35 received medications for hypertension which had parameters. CMA D stated staff took R35's blood pressure before giving her blood pressure medications. CMA D stated staff held blood pressure medications and notified the nurse if R35's blood pressure exceeded the parameters. In an interview on 11/04/21 at 12:35 PM, Licensed Nurse (LN) I stated R35 received medications for hypertension with parameters of less than 90/40 or greater than 180/115 and nursing staff were to contact the primary care physician when blood pressures exceeded parameters. LN I stated notifications to the physician should be documented in a progress note. In an interview on 11/04/21 at 03:24 PM, Administrative Nurse B stated she expected the nurse to reassess blood pressures out of parameters and notify the physician if blood pressures were still out of parameter. Administrative Nurse B stated physician notifications should be documented in a progress note. A Nursing Home Standing Order/Protocols signed 06/06/19 included Notify practitioner or office if blood pressure (BP) is less than 90/40 or greater than 180/115. The facility failed to ensure the adequate monitoring of antihypertensives medications when facility staff did not notify the physician as ordered for blood pressures greater than 180/115 mmHg for R35. - R36's Medication Review Report signed 03/22/21 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition and received a diuretic (medication to promote the formation and excretion of urine) daily. The Care Plan dated 10/15/19 revealed R36 took medications that had the potential for adverse effects to include [MEDICATION(S)] (diuretic medication.) A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Order for 10/11/19 [MEDICATION(S)] (antihypertensive medication) 4 mg, one tablet by mouth daily for hypertension. Order for 10/12/19 [MEDICATION(S)] (antihypertensive medication) 240 mg, give one capsule by mouth, daily for hypertension. Order dated 03/05/20 to notify practitioner or office if blood pressure was less than 90/40 mmHg or greater than 180/115 mmHg. Order dated 07/28/21 for [MEDICATION(S)] (antihypertensive medication) 25 mg, give one tablet by mouth, two times a day for hypertension. Order dated 05/06/21 for [MEDICATION(S)] 40 mg, give one tablet by mouth two times a day for heart failure. Order dated 09/28/21 for [MEDICATION(S)] (antihypertensive medication) 0.2 milligrams (mg), give 0.2 mg by mouth, two times a day for hypertension. Review of the August 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the October 2021 EMAR lacked evidence the facility staff notified the physician of R36s elevated blood pressure of 190/73 mmHg on 10/31/21. Review of the Progress Notes and documents scanned under the Miscellaneous tab of the Electronic Health Record did not reveal any physician notification about blood pressures greater than 180/115 mmHg. Observation on 11/03/21 at 10:30 AM, revealed R36 was in a good mood, chatted with other residents, and took part in a resident meeting and did not exhibit any negative behaviors, depression, anxiety or sedation. In an interview on 11/03/21 at 04:03 PM, Certified Medication Aide (CMA) E stated R36 received medications that came with parameters. CMA E stated she notified the nurse if any blood pressures were out of parameter and the nurse would notify the physician as required. In an interview on 11/04/21 at 12:35 PM, Licensed Nurse (LN) I stated R36 received medications for hypertension with parameters of less than 90/40 or greater than 180/115 and nursing staff were to contact the primary care physician when blood pressures exceeded parameters. LN I stated notifications to the physician should be documented in a progress note. In an interview on 11/04/21 at 03:24 PM, Administrative Nurse B stated she expected the nurse to reassess blood pressures out of parameters and notify the physician if blood pressures were still out of parameter. Administrative Nurse B stated physician notifications should be documented in a progress note. A Nursing Home Standing Order/Protocols signed 06/06/19 included, Notify practitioner or office if blood pressure (BP) is less than 90/40 or greater than 180/115. The facility failed to ensure the adequate monitoring of antihypertensives medications when facility staff did not notify the physician as ordered for blood pressures greater than 180/115 mmHg for R36.

The facility reported a census of 36 residents with 13 in the sample. Based on observation, interview, and record review the facility failed to notify the physician, as ordered, when Resident (R) 24's blood sugars were higher than 450 milligrams per deciliter (mg/dl). Findings included: - Review of R24's 01/06/20 signed Physician order [REDACTED]. Review of the Care Plan dated 04/05/2012 revealed the staff were to obtain blood sugars as ordered by the physician, and monitor/document for side effects and effectiveness. Review of the 01/06/20 physician's orders [REDACTED]. Review of the record revealed blood sugar levels from 06/01/19 to 01/08/20 with no physician notification when R24's blood sugar was higher than 450 mg/dl on the following dates: 06/06/19 at 07:47 PM revealed a blood sugar of 476 mg/dl 06/17/19 at 11:56 AM revealed a blood sugar of 489 mg/dl 06/18/2019 at 03:00 PM revealed a blood sugar of 452 mg/dl 12/26/19 at 11:51 AM revealed a blood sugar of 58 mg/dl 12/26/19 at 10:05 AM revealed a blood sugar of 483 mg/dl Interview on 01/08/2020 at 08:35AM with Certified Mediation Aide (CMA) B revealed the blood sugars were completed by the nurses on the floor. Interview on 01/08/2020 at 02:02 PM with Licensed Nurse (LN) A revealed if the blood sugars were above 450 mg/dl, the nurses were to notify the physician. and if the blood sugar was low the nurses contacted the physician. Interview on 01/09/2020 at 10:19 AM with Administrative Nurse C revealed any time the residents blood sugar were over 400 mg/dl the blood sugars were rechecked after administration of insulin as ordered and if still above 400 mg/dl staff notified the physician. Review of the policy regarding Diabetic Management/Insulin with an effective date of 06/28/17 revealed each resident should have physician orderd parameter for blood glucose levels requiring physician notification. The facility failed to notify the physician of blood sugars above 450 mg/dl as per physician orders [REDACTED].

The facility census totaled 36 residents with 13 included in the sample. Based on observation, interview, and record review the facility failed to revise the care plan to include monitoring and use of insulin for one of 13 sampled residents as related to the [DIAGNOSES REDACTED]. Findings included: - Signed physician's orders [REDACTED]. Review of the significant change in status Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The resident received insulin injections. The Care Area Assessment (CAA) for Nutrition dated 12/11/19 noted R30's [DIAGNOSES REDACTED]. The 10/31/18 Care Plan noted the presence of a potential for a nutritional problem related to the [DIAGNOSES REDACTED]. The care plan lacked interventions related to blood glucose monitoring and/or use of insulin. A Physician order [REDACTED]. A 12/03/19 Physician order [REDACTED]. A 12/13/19 Physician order [REDACTED]. During an observation on 01/07/20 at 11:44 AM, Licensed Nurse (LN) A performed blood glucose monitoring for R30 and obtained a result of 409 mg/dl (normal blood glucose levels range from 70-125 mg/dl). LN A then administered insulin via an injection into R30's lower right abdomen. During an interview on 01/7/20 at 11:30 AM, LN A confirmed R30 often experienced high blood glucose levels which required as needed (PRN) does of insulin. During an interview on 01/08/20 at 01:25 PM Administrative Nurse F acknowledged the current care plan lacked interventions related to blood glucose monitoring and use of insulin. The facility did not provide a policy for Care Plans as requested on 01/13/20 at 07:50 AM. The facility failed to review/revise the care plan to include blood glucose monitoring and use of insulin for R30.

The facility had a census of 36 residents with 4 residents selected for sample. The facility identified 3 of the 4 sampled residents with current or recently healed pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction.) Based on observation, interview and record review, the facility failed to ensure 3 residents with current or recently healed pressure ulcers received appropriate care (completion of weekly skin assessments as per facility policy to monitor for alterations in skin integrity, consistent/thorough assessments of existing pressure ulcers to include wound measurements and staging information) to prevent the development of pressure ulcers and promote healing of existing ulcers. Resident #2 developed two facility acquired pressure ulcers to the left foot in (MONTH) 2019. Resident #3 developed two facility acquired pressure ulcers to the buttocks in (MONTH) 2019. Those wounds resolved/healed and then reopened in late (MONTH) 2019. Resident #4 developed two facility acquired pressure ulcers to the buttocks in (MONTH) 2019. The staff failed to complete skin assessments per facility policy in the time period prior to the development of each resident's pressure ulcers. After development of the pressure ulcers, the facility staff failed to routinely/consistently assess the wounds to include measurements and staging information. Findings included: - Resident #2's clinical record included a comprehensive [DIAGNOSES REDACTED]. becomes congested with fluid). The 2/20/19 significant change MDS (Minimum Data Set) identified the resident with no cognitive impairment (brief interview for mental status score of 13) and the need for extensive assistance of two staff for bed mobility and transfers. According to the assessment, the resident had a current unstageable pressure ulcer that was not present on admission. The resident also experienced frequent bowel and bladder incontinence. The 2/13/19 care plan noted the resident's potential for development of pressure ulcers and/or skin breakdown. The care plan described education provided to the resident on the importance of repositioning every two hours and as needed and keeping the heels offloaded to prevent pressure. The care plan also directed staff to provide assistance of one for transfers and bed repositioning. On 5/15/19, care plan revisions included a change to a treatment to the pressure ulcer on the left foot. A 12/1/18 Braden skin assessment (a standardized assessment tool used to identify risk for development of skin breakdown/pressure ulcers) identified the residents as no risk for skin breakdown. The clinical record lacked evidence of completion of additional assessments of skin breakdown risk since 12/1/18, a time period of more than 5 months. Review of weekly skin assessments and/or wound assessment documentation found in the progress notes in the clinical record revealed the facility failure to complete weekly skin assessments as follows: No evidence of skin assessments in the 18-day time-period from 1/7/19 to 1/25/19. No evidence of skin assessments in the 16-day time-period from 2/8/19 to 2/24/19. A 3/5/19 progress note written at 10:59 AM described a new area of skin breakdown to the left great toe along a bony prominence which appeared red, non-blanchable with a dark purple center which measured 2.6 centimeters (cm) by 2.0 cm. The documentation lacked assessment information related to staging of the wound. A 3/10/19 progress note written at 3:12 PM described a new area of skin breakdown to the left inner aspect of the foot which measured 0.5 cm by 1 cm. The documentation lacked assessment information related to staging of the wound. No evidence of skin assessments in the 15-day time-period from 3/10/19 to 3/25/19. No evidence of skin assessments in the 23-day time-period from 4/1/19 to 4/24/19. No evidence of skin assessments in the 16-day time-period from 4/30/19 to 5/16/19. A 5/16/19 progress note written at 11:20 AM described a continued area of skin breakdown/pressure ulcer to the left heel which measured 1 cm by 1.2 cm. The documentation lacked assessment information related to staging of the wound. During an observation on 5/28/19 at 10:30 AM, resident #2's left heel had a scabbed over area that was without drainage. The resident reported he/she experienced pain in the left heel which was throbbing in nature. The resident required staff assistance with transfer from the bed to the chair and with positioning him/herself comfortably in the recliner. During an interview on 5/28/19 at 1:20 PM, administrative nurse B reported licensed nurses should complete skin assessments for all residents on a weekly basis. Upon review of resident #2's clinical record, Nurse B confirmed staff failed to complete and/or document weekly skin assessments repeatedly from 1/1/19 - 5/16/19. Administrative Nurse B also confirmed resident #2 developed pressure ulcers to the foot after admission/readmission to the facility. During an interview on 5/29/19 at 3:55 PM., Medical Director F denied knowledge facility staff failed to complete weekly skin assessments for residents as per facility policy. Medical Director F also lacked knowledge licensed nursing staff failed to consistently measure and stage existing pressure ulcers with each assessment. According to Medical Director F, the facility needed to develop a more proactive approach to pressure ulcer prevention. The facility's (MONTH) 29, 2008 policy for Wound Measurements included, A complete skin assessment is to be completed upon admission, with a weekly assessment thereafter. Skin assessments are to be documented in the resident chart on all intermediate care residents Wounds are to be measured weekly and documented in resident's chart Site, stage, size (specific measurements) depth, color, drainage and odor The facility failed to provide resident #2 with appropriate care (completion of weekly skin assessments as per facility policy to monitor for alterations in skin integrity, consistent/thorough assessments of existing pressure ulcers to include wound measurements and staging information) to prevent development of facility acquired pressure ulcers and promote healing of existing ulcers. The staff failed to complete skin assessments per facility policy in the time-period prior to the development of the pressure ulcers, and after development of the pressure ulcers, the staff failed to routinely/consistently assess the wounds to include measurements and staging information. - Resident #3's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 4/10/19 quarterly minimum data set (MDS) identified the resident with moderate cognitive impairment (brief interview for mental status score of 8), dependence on extensive assistance of one staff for bed mobility and transfers, and functional limitations in range of motion on one side of the lower extremities. According to the MDS, the resident did not have any current pressure ulcers. The 5/8/19 significant change MDS identified the resident with severe cognitive impairment (brief interview for mental status score of 7) and the need for extensive assistance of two staff for bed mobility/transfers/ambulation. According to the MDS, the resident had a current Stage 2 (partial-thickness skin loss with exposed dermis) pressure ulcer that was not present on admission. The 5/13/19 pressure ulcer care area assessment (CAA) noted the presence of a Stage 2 pressure ulcer to the left inner buttock. The 5/14/19 care plan identified the resident's potential for pressure ulcer development and noted the history of opening and closing wounds on the right buttock. According to the care plan, the resident required monitoring/reminding/assistance to turn and/or reposition at least every 2 hours and more often as needed or requested. The Braden skin assessments (a standardized assessment tool used to identify risk for development of skin breakdown/pressure ulcers) completed on 1/29/19 and 4/22/19 identified the resident as low risk for skin breakdown. Review of the weekly skin assessments and/or wound assessment documentation found in the progress notes in the clinical record revealed the facility failure to complete weekly skin assessments as follows: No evidence of skin assessments in the 37-day time period from 1/21/19 to 2/27/19. A progress note written on 3/10/19 noted the presence of two new open areas on the right buttock which measured 0.8 centimeters (cm) by 0.6 cm (upper buttock wound) and 0.4 cm by 0.6 cm. (lower buttock wound). The documentation lacked assessment information related to the staging of the wounds. A progress note written on 3/13/19 described the buttock pressure ulcers as resolved. A progress note written on 4/2/19 referred to an open area on buttocks. The note lacked information related to wound measurements or staging. A progress note written on 4/11/19 referred to two open areas on the right and left buttocks with measurements of each wound recorded at 2 cm by 1.5 cm. The documentation lacked assessment information related to staging of the wounds. No evidence of skin assessments in the 13-day time-period from 4/11/19 to 4/24/19. A progress note written on 4/24/19 described the presence of one pressure ulcer to the left inner buttock which measured 0.9 cm by 0.2 cm with a red wound base. The documentation lacked assessment information related to staging of the wounds. A progress noted dated 4/30/19 described no open areas to the buttocks. No evidence of skin assessments in the 15-day time-period from 4/30/19 to 5/15/19. During an observation on 5/28/19 at 12:20 PM, resident #3 lacked the ability to respond to simple verbal commands. The resident required the assistance of one staff to stand up from the wheelchair and ambulate to the toilet. At the time of the observation, the resident had no areas of skin breakdown on the buttocks or other pressure areas. During an interview on 5/28/19 at 1:20 p.m., administrative nurse B reported licensed nurses should complete skin assessments for all residents on a weekly basis. Upon review of resident #3's clinical record, Nurse B confirmed staff failed to complete and/or document weekly skin assessments repeatedly in the time-period from 1/1/19 - 5/16/19. Administrative Nurse B also confirmed resident #3 developed pressure ulcers to the buttocks after admission to the facility. During an interview on 5/29/19 at 3:55 p.m., Medical Director F denied knowledge facility staff failed to complete weekly skin assessments for residents as per facility policy. Medical Director F also lacked knowledge licensed nursing staff failed to consistently measure and stage existing pressure ulcers with each assessment. According to Medical Director F, the facility needed to develop a more proactive approach to pressure ulcer prevention. The facility's (MONTH) 29, 2008 policy for Wound Measurements included, A complete skin assessment is to be completed upon admission, with a weekly assessment thereafter. Skin assessments are to be documented in the resident chart on all intermediate care residents Wounds are to be measured weekly and documented in resident's chart Site, stage, size (specific measurements) depth, color, drainage and odor The facility failed to provide resident #3 with appropriate care (completion of weekly skin assessments as per facility policy to monitor for alterations in skin integrity, consistent/thorough assessments of existing pressure ulcers to include wound measurements and staging information) to prevent development of facility acquired pressure ulcers and promote healing of existing ulcers. The staff failed to complete skin assessments per facility policy in the time-period prior to the development of the pressure ulcers, and after development of the pressure ulcers, the staff failed to routinely/consistently assess the wounds to include measurements and staging information. - Resident #4's clinical record included a comprehensive [DIAGNOSES REDACTED]. by failing memory/confusion), muscle weakness [MEDICAL CONDITION] of the lung. The 3/27/19 significant change minimum data set (MDS) identified the resident with no cognitive impairment (brief interview for mental status score of 15), the need for extensive assistance of one staff for bed mobility and transfers and the presence of functional limitations in range of motion on both sides of the upper and lower extremities. According to the MDS, the resident was always incontinent of bladder and experienced occasional bowel incontinence. The assessment also identified the presence of a current Stage 3 pressure ulcer which was not present on admission. The 4/2/19 care plan identified the resident with limited physical mobility due to general weakness. The care plan also noted the resident's potential for pressure ulcer development and skin breakdown related to incontinence and decreased mobility. The care plan directed staff to provide encouragement and reminders to turn and reposition at least every two hours and more often as needed or requested. The care plan described the resident as frequently incontinent. The Braden skin assessments (a standardized assessment tool used to identify risk for development of skin breakdown/pressure ulcers) completed on 1/1/19 and 3/31/19 identified the resident as low risk for skin breakdown. A Braden assessment completed on 4/1/9 identified the resident as moderate risk for skin breakdown. The physician's orders [REDACTED]. Review of weekly skin assessments and/or wound assessment documentation found in the progress notes in the clinical record revealed facility failure to complete weekly skin assessments as follows: No evidence of skin assessments in the 22-day time-period from 1/1/19 - 1/23/19. A progress note written on 1/23/19 at 12:24 p.m. described a purple discoloration to the resident's inner buttocks. No evidence of skin assessments in the 21-day time-period from 1/30/19 - 2/20/19. A progress note written on 1/30/19 at 11:26 AM described a purple discoloration to the inner buttocks and the resident's refusal of the application of cream to those areas. A progress note written on 2/27/19 at 11:34 AM described a purple discoloration to the resident's buttocks. No evidence of skin assessments in the 17-day time-period from 3/6/19 - 3/23/19. A progress note written on 3/6/19 at 11:28 AM described a purple discoloration to the resident's inner buttock cheeks. A progress note written on 3/23/19 at 8:39 AM described the presence of an open area on the right inner buttock which included a white colored wound base, surrounded by dark red granulation tissue (tissue formed during wound healing). The wound measurements recorded were 1.3 centimeters (cm) by 3 cm. The documentation lacked assessment information related to staging of the wound. A progress note written on 3/27/19 at 9:40 p.m. described the presence of two open areas on the resident's buttocks. The documentation lacked wound measurements or information related to staging of the wounds. No evidence of skin assessments in the 23-day time-period from 3/31/19 - 4/23/19. A progress note written on 3/31/19 at 9:02 AM described the presence of one wound to the right buttock which measured 2 cm by 3.5 cm. The documentation lacked information related to staging of the wound. According to the note, the wound base was covered with white slough (dead tissue) surrounded by dark red granulation tissue. The documentation lacked information related to staging of the wound. A progress note written on 4/23/19 at 12:06 PM described the presence of an open wound on the right buttock which measured 0.4 cm by 0.3 cm with a small amount of dry yellow slough tissue present. The documentation lacked information related to staging of the wound. No evidence of skin assessments in the 26-day time-period from 4/24/19 - 5/20/19. A progress note written on 5/20/19 at 7:07 AM described no open areas/skin breakdown on the resident's body. During an observation on 5/28/19 at 11:00 AM, resident #4 required staff assistance of one to stand from a sitting position next to his/her recliner. At the time of the observation, the resident had no areas of skin breakdown on the buttocks or other pressure areas. During an interview on 5/28/19 at 1:20 PM, administrative nurse B reported licensed nurses should complete skin assessments for all residents on a weekly basis. Upon review of resident #4's clinical record, Nurse B confirmed staff failed to complete and/or document weekly skin assessments repeatedly in the time-period from 1/1/19 - 5/16/19. Administrative Nurse B also confirmed resident #4 developed pressure ulcers to the buttocks after admission to the facility. During an interview on 5/29/19 at 3:55 p.m., Medical Director F denied knowledge facility staff failed to complete weekly skin assessments for residents as per facility policy. Medical Director F also lacked knowledge licensed nursing staff failed to consistently measure and stage existing pressure ulcers with each assessment. According to Medical Director F, the facility needed to develop a more proactive approach to pressure ulcer prevention. The facility's (MONTH) 29, 2008 policy for Wound Measurements included, A complete skin assessment is to be completed upon admission, with a weekly assessment thereafter. Skin assessments are to be documented in the resident chart on all intermediate care residents Wounds are to be measured weekly and documented in resident's chart Site, stage, size (specific measurements) depth, color, drainage and odor The facility failed to provide resident #4 with appropriate care (completion of weekly skin assessments as per facility policy to monitor for alterations in skin integrity, consistent/thorough assessments of existing pressure ulcers to include wound measurements and staging information) to prevent development of facility acquired pressure ulcers and promote healing of existing ulcers. The staff failed to complete skin assessments per facility policy in the time-period prior to the development of the pressure ulcers, and after development of the pressure ulcers, the staff failed to routinely/consistently assess the wounds to include measurements and staging information.

The facility census totaled 35 residents with 19 included in the sample. Based on observation, interview, and record review, the facility failed to ensure the 2 of 3 residents sampled for nutrition received interventions to prevent severe weight loss for resident #34 over a 31 day period and weight loss for resident #41. Findings included: - Review of resident #34's [DIAGNOSES REDACTED]. (low level of sodium in the blood). Review of the resident's admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 02 indicating severe cognitive impairment. The resident stated it was somewhat important to have snacks available between meals. The resident required supervision of one person for eating. The resident had no swallowing disorders. The resident weighed 122 pounds (lbs.) and was 60 inches tall. The resident had no dental issues. Review of the resident's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 01 indicating severe cognitive impairment. The resident required supervision of set up help only for eating. The resident had no swallowing disorders. The resident weighed 115 lbs. and was 59 inches tall. Care area assessment (CAA) dated 1/18/17 for behaviors triggered due to confusion, the resident did not always remember to complete his/her activities of daily living (ADLs) thoroughly. The staff assisted with care but the resident would not allow assistance at times because he/she did not comprehend. The staff utilized staff segmentation to help the resident better understand and explain what they were doing to help. The CAA for nutrition and ADLs did not trigger. Review of the resident's care plan dated 1/13/17 directed staff to give the resident adequate time to eat and give him/her foods of choice. The staff were to notify the physician if the resident refused to eat, experienced significant weight loss of 3 pounds (lbs.) in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, or greater than 10% in 6 months. The resident was on a regular diet. The registered dietician was to evaluate and make diet change recommendations as needed. The staff weighed the resident weekly and as needed per facility protocol. For eating, the resident required set up supervision and encouragement with meals. Staff assistance of one was to help as needed. Review of weight record revealed the resident weighed 122 pounds (lbs.) on 1/14/17. Record review of progress notes dated 2/27/17 revealed hospitalization of the resident from 2/23/17 to 2/27/17, and the resident returned to the facility on [DATE] with a recorded weight at the facility of 115 lbs. Record review of lab work completed on 3/1/17 for basic metabolic panel, magnesium, and phosphorous levels revealed all levels within normal limits. Record review of progress note dated 3/9/17 at 2:41 PM revealed the resident continued on skilled services post hospitalization for low back pain. The nursing staff offered the resident [MEDICATION NAME] (medication used to relieve moderate to severe pain) for pain and discomfort. The resident was able to self-propel with lower extremities. The resident required cueing with toileting and assistance with eating. Per weight record review, the resident weighed 104 lbs. on 3/31/17; no other weights documented for March 2017. The resident lost 11 pounds in 33 days, a 9.56% weight loss. According to the medical record, the facility initiated meal intake recordings for resident #34 on 4/5/17. Review of the care conference record dated 4/4/17 included the dietary narrative that stated the resident continued on a regular diet and, made food choices known. The resident weighed 107.6 lbs., a weight loss of 14.4 lbs. since last care plan, dated 1/20/17 (a 6.43% weight loss in 74 days). The staff noted the resident had not eaten as well since readmission from the hospital on [DATE]. Record review of written dietary log dated 4/7/17 from dietary staff MM recommended diet order clarification to regular. Observation on 6/5/17 at 7:47 AM revealed for the breakfast meal the resident ate one banana, drank one cup of coffee, and only a small amount from a bowl of cheerios. The resident consumed approximately 25% of the breakfast meal with staff cueing. Observation on 6/5/17 at 12:44 PM revealed for lunch the resident ate 1 1/2 chicken legs, most of the serving of green beans, approximately ½ of fruit salad, a small amount of potatoes, and drank one cup of coffee. The resident consumed approximately 50% of the lunch meal with staff cueing. Interview on 6/5/17 at 10:39 AM with direct care staff Z revealed the resident would usually eat 25-40% of meals and that the resident had no trouble eating but required cueing. Interview on 6/12/17 at 4:40 PM with direct care staff KK revealed the direct care staff obtained resident weights and recorded the weights in medical records. Staff KK stated he/she reported resident weights to the nurse but did not know if all direct care staff reported weights to the nurse. If staff KK was aware of a resident weight loss, he/she would offer a snack between meals. If resident #34's family was here, the resident would usually eat most of the meal. If resident #34's family was not present, staff took turns sitting with the resident or cueing the resident during meals. Some days resident #34 required more encouragement to eat than on other days. If resident #34 did not eat well in the dining room, staff KK offered an alternative or took a small supper to the resident in his/her room. Staff KK stated upon the resident #34's return from the hospital at the end of February, the resident was not very hungry due to back pain, but with the pain now more controlled the resident's dietary intake had improved. Interview on 6/5/17 at 4:30 PM with dietary staff M revealed if a resident lost 5% of his/her body weight in 30 days the nurse should notify the physician. The dietary manager looked at weights on a weekly basis and if noted anything out of the ordinary would ask for a re-weigh. If a question remained as to why the resident continued weight loss, staff M would ask the nurse to notify the doctor. Interview on 6/12/17 at 4:09 PM with dietary staff M revealed the resident returned from the hospital on [DATE] and weighed 115 lbs. The next weight obtained on 3/31/17 was 104 lbs. Staff M asked for a re-weigh completed on 4/5/17 at 108 lbs. Staff M did not recall why the re-weigh was not done on 3/31/17. Staff M stated he/she would normally notify the nurse but confirmed there was no documentation of nurse notification of the weight loss. Staff M did not recall why the nurse was not notified. Interview on 6/5/17 at 5:26 PM with licensed nursing staff Q revealed the resident had a 7% weight loss in 3 months and the facility had not intervened to prevent weight loss. Interview on 6/12/17 at 5:01 PM, licensed nursing staff LL stated identified weight loss would either come from dietary staff M's notification or staff LL looking up a resident's weight if a resident had a change in eating habits. If there was weight loss, staff LL would check with dietary for a recommended supplement. Staff LL would then notify the physician of the weight loss of the resident and the recommended dietary supplement. Regarding resident #34, Staff LL thought staff notified the physician of his/her March 2017 weight loss but stated the dietary note did not reflect this nor did any subsequent documentation. Interview on 6/5/17 at 6:38 PM, administrative staff G stated it would be his/her expectation the facility monitored resident #34's weight loss and notify the physician. Interview on 6/13/17 at 8:13 AM, dietary staff MM stated he/she did not notify the physician of the resident #34's weight loss, as the nursing staff was to notify the physician of weight changes. Staff MM stated he/she did notify the nursing staff and administrative staff G and made notation on a paper report given to administrative staff B and dietary staff M. Staff MM also inquired with dietary staff M about the resident being re-weighed and dietary staff M then spoke to nursing. For noted weight loss, staff MM stated he/she would initially recommend fortified foods. If no improvement with fortified foods, staff MM would start a supplement the resident would agree to. Staff MM stated he/she had no idea why interventions were not implemented for this resident and was not aware of any interventions attempted to prevent weight loss. Staff MM stated he/she did speak to dietary staff M about possible supplements. Interview on 6/13/17 at 8:57 AM administrative staff G stated prior to May 2017 the nursing staff identified weight changes by going into the medical record for a look at weights or dietary staff M would notify nursing of weight loss and it would be the nurse's responsibility to notify the physician. Since May 2017, administrative staff G and dietary staff M monitor weights for weight loss and notify the nurse of significant changes. Staff G stated the resident's change in weight was brought to his/her attention in early April when the resident's weight was 108 lbs. and does not recall dietary staff MM notifying him/her of the resident's weight change from 2/27/17 to 3/31/17. Interview on 6/13/17 at 10:53 AM physician NN stated he/she received no notification of the resident's weight changes from 2/27/17 to 3/31/17. Physician NN stated he/she expected notification of the weight change. If notified of this weight difference, he/she would have the resident come in for an office visit and a possible work up for failure to thrive and possible lab work. Supplements would be on hold until he/she determined the cause of the weight loss. Review of the facility policy, Weight Management Program dated 4/27/17 revealed residents with significant weight loss would be brought to Care Conference team for re-evaluation of the care plan and the resident's physician and consulting dietician contacted for recommendations. The facility failed to follow the care plan and notify the physician of resident #34's weight loss of 11 lbs. (or 9.6%) from 2/27/17 to 3/31/17. Findings included: - Review of Resident #41's signed physician history and physical dated 12/9/16 reveled the resident recently had a cardiac bypass surgery graft (a type of surgery that improves blood flow to the heart) required due to a [MEDICAL CONDITION] infarction(a [MEDICAL CONDITION]) and diabetes (a disease where the body is affected on how it uses blood sugars). Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment. Resident #41 required supervision of one staff member for eating and complained of difficulty and/or pain when swallowing. He/she weighed 193 pounds (lbs.) and weight loss/gain was unknown. Review of the nutritional status care area assessment (CAA) dated 1/16/17 revealed the resident received a regular diet with regular texture. He/she stated he/she had choked on some food and had been avoiding mashed potatoes and bread due to it sticking in his/her throat. The physician had ordered speech therapy for consultation that identified the resident at risk for nutritional problems. The facility staff needed to assess/monitor the resident's weight and report concerns to the physician. The residents care plan, initiated 1/9/17 and revised 1/10/17, advised staff: The resident preferred to eat in his/her room; Monitor/record/report to the physician as needed with emaciation (abnormally thin or weak), muscle wasting, and significant weight loss (3 lbs. in 1 week, 5% in 1 month, 7.5% in 3 months, or greater than 10% in 6 months), and refusing to eat; The registered dietician needed to evaluate the resident and make dietary change recommendations as needed (PRN); The resident required set up, supervision and encouragement with meals; Staff were to weight weekly and as needed per facility policy; The resident had difficulty swallowing softer foods; Ordered and ate food of his/her choice from the menu; Monitor for choking and notify charge nurse and/or the physician if swallowing difficulty occurred. The care plan lacked any interventions implemented after the resident started losing weight to prevent further weight loss. Review of resident #41's medical record revealed the resident's initial weight at the facility measured 193 lbs. on 1/9/17. The dietary profile completed on 1/10/17 revealed the resident reported his/her normal weight at home was greater than 200 lbs. but had reported a slow loss since his/her hospitalization (prior to residents admission). The resident reported he/she preferred smaller portions and he/she had a fair appetite with breakfast being his/her favorite meal. Review of a health status note dated 1/14/17 revealed the resident had swelling to both his/her lower extremities. The licensed staff contacted the physician regarding the swelling and ordered [MEDICATION NAME] (a medication used to rid excess fluid from body tissues) 20 milligrams (mg) to be given daily for the swelling on 1/16/17. On 1/24/17, staff documented the resident's weight as 185 lbs. A dietary note dated 1/24/17 revealed the resident continued on a regular diet and he/she had a 7.6 lbs. weight loss since admission. Review of speech therapist progress notes, signed 1/27/17, revealed improvement with functional performance. On 2/2/17, staff documented the resident's weight as 178 lbs. Review of a dietary note dated 2/3/17 revealed the registered dietician (RD) saw the resident and noted the resident currently weighed 178 lbs. and previously weighed 186 lbs. He/she documented the wheelchair might not have been subtracted and continued to recommend a regular diet with the resident's preferred foods. Review of a health status note dated 2/20/17 revealed staff no longer observed swelling in the resident's lower legs. On 2/23/17, the facility documented the resident's weight as 179 lbs. Review of a dietary note dated 3/3/17 revealed the RD saw the resident and stated the resident was at risk for involuntary weight loss related to [MEDICAL CONDITION] (swelling in the body's tissues) [MEDICAL CONDITION] reflux disease (a digestive disorder ) [MEDICAL CONDITION] (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) laxative use (substances used to loosen or increase bowel movements) diuretic use (water pill) and antihyperglycemic agent (medication to lower blood sugar) and continued to recommend a regular diet. Upon the resident's discharge from the facility, 3/19/17, the resident weighed 179 lbs. as documented on 3/16/17. This was a 7.25% weight loss during the residents stay in the facility. Review of the resident's medical record from 1/9/17 to discharge on 3/19/17 revealed no notification to the resident's physician of his/her weight loss. Interview with direct care staff V on 6/5/17 at 3:26 PM revealed he/she remembered the resident and their preference for smaller meals. He/she stated the resident usually ate everything given to him/her, but could not remember if the facility monitored his/her intake. During an interview on 6/05/17 at 4:30 PM dietary staff M reported the licensed staff were to notify the physician if weight loss occurred and obtain intervention orders if indicated. Interview with licensed nursing staff Q on 6/5/17 at 3:41 PM revealed he/she did not recall the resident specifically, but licensed staff are to monitor the residents diet and weights and ask for orders as indicated. Interview with administrative nursing staff G on 6/5/17 at 6:38 PM revealed he/she would expect the weight loss to be monitored and called to the physician. Review of the policy/procedure entitled weight management program, revised 4/27/17, revealed the resident's physician and consulting dietician would be contacted for recommendations. The facility failed to implement interventions to prevent further weight loss and notify the physician of weight loss for resident #41.

The facility had a census of 40 residents with 3 included in the sample. Based on observation, interview, and record review, the facility failed to ensure 3 of 3 residents (#1, #2, and #3) received adequate supervision and assistance to prevent accidents, resulting in a fractured tibia/fibula (lower leg bones) for resident #2. The facility also failed to investigate to determine causal factors to prevent further falls for 3 of 3 residents. The facility also failed to ensure staff utilized gait belt assistive devices resulting in falls for 2 of 3 residents (#1 and #3). Findings included: - Review of resident #2's hospital signed physician history and physical dated 11/24/14 revealed the following Diagnoses: [REDACTED]. Review of resident #2's admission MDS (minimum data set) dated 12/9/14 revealed a BIMS (brief interview for mental status) score of 15, indicating no cognitive impairment. Resident #2 required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene, and did not walk. For balance with transitions during walking, resident #2 was not stable and only able to stabilize with staff assistance for moving from a seated to a standing position, turning and facing the opposite direction, moving on and off the toilet, and surface-to-surface transfers. Resident #2 had functional limitation in range of motion for one lower extremity and used a wheelchair for mobility. The resident did not participate in a toileting plan, was occasionally incontinent of urine and always continent of bowel. The resident fell in the month prior to admission, fell in the 2-6 months prior to admission, and sustained a fracture from a fall prior to admission. Resident #2 did not experience falls since admission. Review of resident #2's Falls CAA (care area assessment) dated 12/9/14 revealed the resident was at moderate risk for falls. The resident could maintain his/her sitting balance without difficulties, but did have difficulties during transitions. The resident had a [DIAGNOSES REDACTED]. The resident's pain and incontinence could contribute to his/her potential for falls. He/she had a moderate risk for falls. The resident had difficulties with balance. Review of resident #2's ADL (activities of daily living) Functional/Rehabilitation Potential CAA dated 12/9/14 revealed resident #2 had difficulties completing his/her own ADLs and required staff assistance to have his/her daily needs met. The resident admitted [DATE] from the hospital. The resident used 1/4 bed rails to assist with his/her bed mobility. The resident had a [DIAGNOSES REDACTED]. The resident had difficulties reaching/dressing his/her lower half and required staff assistance. The resident required staff assistance with pulling up/down his/her clothing due to balance and weakness difficulties. The resident required staff assistance with transferring on/off the toilet. The resident used a wheelchair for mobility. Review of resident #2's medical record revealed the following fall risk assessments: 11/26/14: score of 14, indicating moderate risk 1/12/15: score of 16, with a score of 15 or greater indicating high risk 1/18/15: score of 16 1/25/15: score of 12, indicating moderate risk 2/4/15: score of 18 2/10/15: score of 13, indicating moderate risk 2/12/15: score of 17 2/19/15: score of 20 3/2/15: score of 21 Review of resident #2's care plan, reviewed 12/18/14, revealed the resident was at risk for falls and experienced falls. The resident also had a hip fracture (added 2/20/15). Interventions directed staff to: * Anticipate and meet the resident's needs. * Be sure the resident's call light was within reach and encourage him/her to use it for assistance as needed. He/she needed prompt responses to all requests for assistance. * Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred. * Encourage the resident to participate in activities that promoted exercise, physical activity for strengthening, and improved mobility such as: exercise class. * Provide a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light and personal items within reach. * PT/OT (physical therapy/occupational therapy) to evaluate and treat as ordered or PRN (as needed). * Review information on past falls and attempt to determine the cause of falls. Record possible root causes. Alter or remove any potential causes of falls if possible. Educate resident/family/caregivers/interdisciplinary team as to the causes of falls. * Establish voiding patterns. * Check the resident for incontinence with each toileting episode and PRN for incontinence. * Follow MD (medical doctor) orders for the resident's weight-bearing status. See MD orders and/or PT treatment plan. * Monitor/document/report to MD PRN signs or symptoms of hip fracture complications. Staff updated the care plan with the following interventions: * 1/18/15- Identify the reason resident got up (Was it a pattern at that particular time of day?). * 2/5/15- Use a motion alarm at all times to alert staff when the resident entered his/her room. Test the alarm every shift. * 2/13/15- The resident needed assistance back to his/her room after meals, cares provided, and motion monitor set up. * 2/20/15- Monitor for and report complications related to osteoporosis. Review of a nurse's note dated 1/12/15 at 7:44 PM revealed the resident had a non-injury fall. The resident had a history of [REDACTED]." Per an investigative nursing summary by administrative nursing staff C written on 3/5/15 for the resident's fall on 1/12/15 revealed staff found the resident on the floor in another resident's room. The contributing factor was the wheelchair brakes were not locked. Review of a nurse's note dated 1/18/15 at 7:10 AM revealed the resident fell without injury. The resident had a history of [REDACTED]. The resident fell while ambulating to bathroom without staff assistance. An investigative nursing summary of the resident's fall on 1/18/15, written by administrative nursing staff C on 3/5/15, revealed he/she found the resident in a kneeling position by the bed. The resident stated he/she went to the bathroom and fell on his/her way back to the bed and crawled from the bathroom to his/her bed. The resident did not use the call light prior to taking him/herself to the bathroom. The summary did not include when staff toileted the resident prior to the fall or if the planned interventions were in place. Review of a nurse's note dated 1/18/15 at 8:37 PM revealed the resident stated his/her right foot hurt when he/she attempted to stand on it. The resident's right great toe and second toe of the right foot were swollen and bruised. The bruising on the great toe was noted from the top of the toe below the nail around the outer side of the foot to the underside of the toe. Review of a nurse's note dated 1/22/15 at 3:34 PM revealed the resident fell on [DATE] when he/she got up without assistance. The resident had pain, swelling, and bruising to his/her right foot. The resident had an order for [REDACTED]. Review of a nurse's note dated 1/23/15 at 2:57 PM revealed the nurse received a call from the resident's physician informing him/her the resident had broken his/her great toe and the toe next to it on the right foot. The physician indicated the resident needed to wear a hard, flat-bottomed shoe. Review of a nurse's note dated 1/24/15 at 11:14 PM revealed the resident fell without injury. Staff found the resident on the floor at 8:15 PM lying on his/her back in front of his/her heater facing the doorway. The wheelchair was in a locked position in front of his/her recliner facing the heater. The resident stated, "I got myself out of the wheelchair and used the heater to stabilize me then got on the floor to do my exercises!" An investigative nursing summary, written by administrative nursing staff C on 3/5/15, revealed for the resident's fall on 1/24/15, the resident did not use his/her call light and transferred without assistance. Review of the PT plan of care dated 1/27/15 revealed resident #2 used a front wheeled walker with a total 100% assist and his/her balance caused him/her to be a high risk for falls. The resident had a recent fall and sustained a right ankle sprain with swelling noted. Review of a nurse's note dated 2/4/15 at 10:46 PM revealed the resident fell without injury. The resident had gait imbalance. The resident transferred him/herself without assistance, causing the fall. Per an investigative nursing summary by administrative nursing staff C written on 3/5/15 for the resident's fall on 2/4/15, staff found the resident sitting on his/her bottom in the bathroom between his/her wheelchair and toilet. The resident stated he/she tried to transfer him/herself to the toilet. Review of a nurse's note dated 2/5/15 at 1:56 PM revealed the resident fell without injury after lunch. Per an investigative nursing summary by administrative nursing staff C written on 3/5/15 for the resident's fall on 2/5/15, staff found the resident on the floor in his/her room, sitting in front of the heater. The resident stated he/she tried to get into his/her recliner. Staff identified a contributing factor of the fall as the resident's failure to call for assistance. Review of a nurse's note dated 2/10/15 at 7 PM revealed staff found the resident on the floor sitting in front of the recliner with his/her legs out in front of him/her and his/her back against the recliner. The resident's personal care item was on the floor and spilled on the carpet. The resident stated he/she dropped the item and tried to pick it up causing him/her to slide out of the wheelchair. The resident did not have any injury. According to the note, the resident recently had several neurological-type events and the resident had slurred speech. An investigative nursing summary written by administrative nursing staff C on 3/5/15 revealed for the resident's fall on 2/10/15, the resident fell un-witnessed in his/her room. Staff identified the resident attempted to transfer without assistance. Review of a nurse's note dated 2/13/15 at 12:34 AM revealed staff went in to administer medication to the resident and found the resident on the floor. The resident stated he/she attempted to transfer to his/her recliner from the wheelchair. The resident had one tennis shoe on the left foot and a stocking on the right foot. When staff checked the resident for injury, the resident voiced pain in his/her left lower leg just below the knee rotating around to the back of his/her leg. Staff observation of the left lower leg later revealed it was swollen and deformed. Review of a nurse's note dated 2/13/14 at 1:14 AM revealed an emergency room (ER) nurse reported to the facility staff nurse the resident had a non-displaced fracture of the tibia and fibula. Review of the hospital ER (emergency room ) discharge instructions dated 2/13/15 revealed resident #2 had a tibia/fibula fracture. Review of a physician progress notes [REDACTED].#2 sustained a fracture of the left tibia, then returned to the hospital on [DATE] for surgery. Observation on 3/4/15 at 9:56 AM revealed resident #2 had a silent motion alarm in place that activated the call light when the surveyor approached the bed. The resident lay in his/her bed. Several staff walked by during the time the call light was activated. At 10:09 AM (13 minutes after the call light was initiated), a staff member answered the call light and reset the alarm. Observation on 3/4/15 at 4:09 PM revealed resident #2 lay in bed without any blankets on. The resident wore a leg immobilizer and an una boot (foot brace) on his/her left leg. The resident's motion sensor alarm was not in the on position and did not sound upon approach to the bed. Interview with activities staff A at that time revealed the resident's motion alarm connected to the call light was not on or operational. Interview with resident #2 on 3/4/15 at 10:03 AM revealed he/she hurt his/her leg when he/she fell out of the wheelchair. Interview with direct care staff D on 3/4/15 at 2:46 PM revealed resident #2 broke his/her toes from a fall. The resident required the assistance of 1 person for walking and transfers prior to breaking his/her toes. Staff D reported the resident recently fell out of bed and broke his/her tibia and fibula in his/her left leg. Staff D reported resident #2 was a fall risk because his/her cognitive level was very poor and the resident was impulsive. Staff D reported staff used a motion alarm that initiated the call light when the resident moved through the sensor, lowered the bed, used another motion sensor alarm on the other side of the bed that sounded, and staff kept a close eye on him/her. Staff D reported the resident could use his/her call light and did sometimes. Interview with direct care staff E on 3/5/15 at 10:13 PM revealed resident #2 seemed to have increased confusion the past several months and had more falls trying to be independent. Staff E reported staff told the resident and reminded him/her not to do things by him/herself, but recently the resident did not seem to remember the reminders of not to get up on his/her own. The resident required a one person assist with transfers and walking. Staff E reported the resident stopped PT because he/she did not do very well. Staff E reported the resident broke his/her leg from a fall. Interview with licensed nursing staff F on 3/5/15 at 6:58 AM revealed resident #2 did not call for assistance when in his/her room. Staff F reported the resident could use his/her call light and his/her cognition varied. Staff F reported the resident had motion alarms that were to be on even when the resident was not in the room to alert staff when the resident went into his/her room independently. Interview with administrative nursing staff C on 3/5/15 at 10:55 AM revealed he/she did not have any investigations into causal factors for falls. Staff C reported resident #2 had a medium or high fall risk and fell fairly frequently. The resident had a motion alarm that sounded a call light, a motion alarm that sounded, and staff provided a lot of encouragement for the resident not to transfer him/herself, but that did not seem to help. Staff C reported he/she had looked at medical incidents to try and determine if there were contributing medical factors. Staff C reported he/she expected staff to make sure the alarms were on because when the resident fell and sustained the leg fracture, the alarm was not on. Review of the undated facility policy for Fall Reporting and Investigating, revealed all falls were to be documented, investigated, and reported to the physician within a timely manner. A fall log would be kept by the director of nursing or designee and reviewed during Quality Assurance meetings for evaluation and possible recommendations for further actions. Interview with physician extender G on 3/5/15 at 11:47 AM revealed resident #2 fell and the fall caused the tibia/fibula fracture. Physician extender G reported resident #2's bone quality from x-ray was pretty poor and the resident's fracture could be attributed to the fall and poor bone quality. Physician extender G reported if the resident did not experience the fall, he/she would not have sustained the fracture. The facility failed to utilize the planned intervention for a motion alarm, resulting in a fall with a fracture for resident #2. The facility also failed to investigate falls for causal factors. The facility had a census of 40 residents with 3 included in the sample. Based on observation, interview, and record review, the facility failed to ensure 3 of 3 residents (#1, #2, and #3) received adequate supervision and assistance to prevent accidents, resulting in a fractured tibia/fibula (lower leg bones) for resident #2. The facility also failed to investigate to determine causal factors to prevent further falls for 3 of 3 residents. (#1, #2, #3) The facility also failed to ensure staff utilized a gait belt assistive device during transfers resulting in falls for 2 of 3 residents (#1 and #3). Findings included: - Review of resident #2's hospital signed physician history and physical dated 11/24/14 revealed the following Diagnoses: [REDACTED]. Review of resident #2's admission MDS (minimum data set) dated 12/9/14 revealed a BIMS (brief interview for mental status) score of 15, indicating no cognitive impairment. Resident #2 required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene, and did not walk. For balance with transitions during walking, resident #2 was not stable and only able to stabilize with staff assistance for moving from a seated to a standing position, turning and facing the opposite direction, moving on and off the toilet, and surface-to-surface transfers. Resident #2 had functional limitation in range of motion for one lower extremity and used a wheelchair for mobility. The resident did not participate in a toileting plan, was occasionally incontinent of urine and always continent of bowel. The resident fell in the month prior to admission, fell in the 2-6 months prior to admission, and sustained a fracture from a fall prior to admission. Resident #2 did not experience falls since admission. Review of resident #2's Falls CAA (care area assessment) dated 12/9/14 revealed the resident was at moderate risk for falls. The resident could maintain his/her sitting balance without difficulties, but did have difficulties during transitions. The resident had a [DIAGNOSES REDACTED]. The resident's pain and incontinence could contribute to his/her potential for falls. He/she had a moderate risk for falls and had difficulties with balance. Review of resident #2's ADL (activities of daily living) Functional/Rehabilitation Potential CAA dated 12/9/14 revealed resident #2 had difficulties completing his/her own ADLs and required staff assistance to have his/her daily needs met. The resident admitted [DATE] from the hospital. The resident had a [DIAGNOSES REDACTED]. The resident had difficulties reaching/dressing his/her lower half and required staff assistance. The resident required staff assistance with pulling up/down his/her clothing due to balance and weakness difficulties. The resident required staff assistance with transferring on/off the toilet and used a wheelchair for mobility. Review of resident #2's medical record revealed the facility completed 9 fall risk assessments from 11/26/14-3/2/15, each time indicating the resident had a moderate to high risk of falls. Review of resident #2's care plan, reviewed 12/18/14, revealed the resident was at risk for falls and experienced falls. The resident also had a hip fracture (added 2/20/15). Interventions directed staff to: * Anticipate and meet the resident's needs. * Be sure the resident's call light was within reach and encourage him/her to use it for assistance as needed. He/she needed prompt responses to all requests for assistance. * Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred. * Encourage the resident to participate in activities that promoted exercise, physical activity for strengthening, and improved mobility such as: exercise class. * Provide a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light and personal items within reach. * PT/OT (physical therapy/occupational therapy) to evaluate and treat as ordered or PRN (as needed). * Review information on past falls and attempt to determine the cause of falls. Record possible root causes. Alter or remove any potential causes of falls if possible. Educate resident/family/caregivers/interdisciplinary team as to the causes of falls. * Establish voiding patterns. * Check the resident for incontinence with each toileting episode and PRN for incontinence. * Follow MD (medical doctor) orders for the resident's weight-bearing status. See MD orders and/or PT treatment plan. * Monitor/document/report to MD PRN signs or symptoms of hip fracture complications. Staff updated the care plan with the following interventions: * 1/18/15- Identify the reason resident got up (Was it a pattern at that particular time of day?). * 2/5/15- Use a motion alarm at all times to alert staff when the resident entered his/her room. Test the alarm every shift. * 2/13/15- The resident needed assistance back to his/her room after meals, cares provided, and motion monitor set up. * 2/20/15- Monitor for and report complications related to osteoporosis. Review of a nurse's note dated 1/12/15 at 7:44 PM revealed the resident had a non-injury fall. The resident had a history of [REDACTED]." Per an investigative nursing summary by administrative nursing staff C written on 3/5/15 for the resident's fall on 1/12/15 revealed staff found the resident on the floor in another resident's room. The contributing factor was the wheelchair brakes were not locked. Review of a nurse's note dated 1/18/15 at 7:10 AM revealed the resident fell without injury. The resident had a history of [REDACTED]. The resident fell while ambulating to the bathroom without staff assistance. An investigative nursing summary of the resident's fall on 1/18/15, written by administrative nursing staff C on 3/5/15, revealed he/she found the resident in a kneeling position by the bed. The resident stated he/she went to the bathroom and fell on his/her way back to the bed and crawled from the bathroom to his/her bed. The resident did not use the call light prior to taking him/herself to the bathroom. The summary did not include when staff toileted the resident prior to the fall or if the planned interventions were in place. Review of a nurse's note dated 1/18/15 at 8:37 PM revealed the resident stated his/her right foot hurt when he/she attempted to stand on it. The resident's right great toe and second toe of the right foot were swollen and bruised. The bruising was from the top of the great toe below the nail around the outer side of the foot to the underside of the toe. Review of a nurse's note dated 1/22/15 at 3:34 PM revealed the resident fell on [DATE] when he/she got up without assistance. The resident had pain, swelling, and bruising to his/her right foot. The resident had an order for [REDACTED]. Review of a nurse's note dated 1/23/15 at 2:57 PM revealed the nurse received a call from the resident's physician informing him/her the resident had broken his/her great toe and the toe next to it on the right foot. The physician indicated the resident needed to wear a hard, flat-bottomed shoe. Review of a nurse's note dated 1/24/15 at 11:14 PM revealed the resident fell without injury. Staff found the resident on the floor at 8:15 PM lying on his/her back in front of his/her heater facing the doorway. The wheelchair was in a locked position in front of his/her recliner facing the heater. The resident stated, "I got myself out of the wheelchair and used the heater to stabilize me then got on the floor to do my exercises!" An investigative nursing summary, written by administrative nursing staff C on 3/5/15, revealed for the resident's fall on 1/24/15, the resident did not use his/her call light and transferred without assistance. Review of the PT plan of care dated 1/27/15 revealed resident #2 used a front wheeled walker with a total 100% assist and his/her balance caused him/her to be a high risk for falls. The resident had a recent fall and sustained a right ankle sprain with swelling noted. Review of a nurse's note dated 2/4/15 at 10:46 PM revealed the resident fell without injury. The resident had gait imbalance. The resident transferred him/herself without assistance, causing the fall. Per an investigative nursing summary by administrative nursing staff C written on 3/5/15 for the resident's fall on 2/4/15, staff found the resident sitting on his/her bottom in the bathroom between his/her wheelchair and toilet. The resident stated he/she tried to transfer him/herself to the toilet. Review of a nurse's note dated 2/5/15 at 1:56 PM revealed the resident fell without injury after lunch. Per an investigative nursing summary by administrative nursing staff C written on 3/5/15 for the resident's fall on 2/5/15, staff found the resident on the floor in his/her room, sitting in front of the heater. The resident stated he/she tried to get into his/her recliner. Staff identified a contributing factor of the fall as the resident's failure to call for assistance. Review of a nurse's note dated 2/10/15 at 7 PM revealed staff found the resident on the floor sitting in front of the recliner with his/her legs out in front of him/her and his/her back against the recliner. The resident's personal care item was on the floor and spilled on the carpet. The resident stated he/she dropped the item and tried to pick it up causing him/her to slide out of the wheelchair. The resident did not have any injury. According to the note, the resident recently had several neurological-type events and the resident had slurred speech. An investigative nursing summary written by administrative nursing staff C on 3/5/15 revealed for the resident's fall on 2/10/15, the resident fell un-witnessed in his/her room. Staff identified the resident attempted to transfer without assistance. Review of a nurse's note dated 2/13/15 at 12:34 AM revealed staff went in to administer medication to the resident and found the resident on the floor. The resident stated he/she attempted to transfer to his/her recliner from the wheelchair. The resident had one tennis shoe on the left foot and a stocking on the right foot. When staff checked the resident for injury, the resident voiced pain in his/her left lower leg just below the knee rotating around to the back of his/her leg. Staff observation of the left lower leg later revealed it was swollen and deformed. Review of a physician order [REDACTED]. Review of the hospital ER (emergency room ) discharge instructions dated 2/13/15 revealed resident #2 had a tibia/fibula fracture. Review of a physician progress notes [REDACTED].#2 sustained a fracture of the left tibia, then returned to the hospital on [DATE] for surgery. Observation on 3/4/15 at 9:56 AM revealed resident #2 had a silent motion alarm in place that activated the call light when the surveyor approached the bed. The resident lay in his/her bed. Several staff walked by during the time the call light was activated. At 10:09 AM (13 minutes after the call light initiated), a staff member answered the call light and reset the alarm. Observation on 3/4/15 at 4:09 PM revealed resident #2 lay in bed without any blankets on. The resident wore a leg immobilizer and an una boot (foot brace) on his/her left leg. The resident's motion sensor alarm was not in the on position and did not sound upon approach to the bed. Interview with activities staff A at that time revealed the resident's motion alarm connected to the call light was not on or working at the time. Interview with resident #2 on 3/4/15 at 10:03 AM revealed he/she fell out of the wheelchair and hurt his/her leg. Interview with direct care staff D on 3/4/15 at 2:46 PM revealed resident #2 broke his/her toes from a fall. The resident required the assistance of 1 person for walking and transfers prior to breaking his/her toes. Staff D reported the resident recently fell out of bed and broke his/her left tibia and fibula. Staff D reported resident #2 was a fall risk because his/her cognitive level was very poor and the resident was impulsive. Staff D reported staff used a motion alarm that initiated the call light when the resident moved through the sensor, lowered the bed, used another motion sensor alarm on the other side of the bed that sounded, and staff kept a close eye on him/her. Staff D reported the resident could use his/her call light and did sometimes. Interview with direct care staff E on 3/5/15 at 10:13 PM revealed resident #2 seemed to have increased confusion the past several months and had more falls trying to be independent. Staff E reported staff told the resident and reminded him/her not to do things by him/herself, but recently the resident did not seem to remember the reminders of not to get up on his/her own. The resident required a one person assist with transfers and walking. Staff E reported the resident stopped PT because he/she did not do very well. Staff E reported the resident broke his/her leg from a fall. Interview with licensed nursing staff F on 3/5/15 at 6:58 AM revealed resident #2 did not call for assistance when in his/her room. Staff F reported the resident could use his/her call light and his/her cognition varied. Staff F reported the resident had motion alarms that were to be on even when the resident was not in the room to alert staff when the resident went into his/her room independently. Interview with administrative nursing staff C on 3/5/15 at 10:55 AM revealed he/she did not have any investigations into causal factors for falls. Staff C reported resident #2 had a medium or high fall risk and fell fairly frequently. The resident had a motion alarm that sounded a call light, a motion alarm that sounded, and staff provided a lot of encouragement for the resident not to transfer him/herself, but that did not seem to help. Staff C reported he/she had looked at medical incidents to try and determine if there were contributing medical factors. Staff C reported he/she expected staff to make sure the alarms were on because when the resident fell and sustained the leg fracture, the alarm was not on. Review of the undated facility policy for Fall Reporting and Investigating, revealed all falls were to be documented, investigated, and reported to the physician within a timely manner. A fall log would be kept by the director of nursing or designee and reviewed during Quality Assurance meetings for evaluation and possible recommendations for further actions. Interview with physician extender G on 3/5/15 at 11:47 AM revealed resident #2 fell and the fall caused the tibia/fibula fracture. Physician extender G reported resident #2's bone quality from x-ray was pretty poor and the resident's fracture could be attributed to the fall and poor bone quality. Physician extender G reported if the resident did not experience the fall, he/she would not have sustained the fracture. The facility failed to utilize the planned intervention for a motion alarm, resulting in a fall with a fracture for resident #2. The facility also failed to investigate falls for causal factors. - Review of resident #1's closed record revealed a significant change MDS (minimum data set) dated 4/4/14 indicating resident #1 had short and long-term memory problems and modified independence for daily decision making. The resident required extensive assistance of two or more st

The facility census totaled 24 residents, with 24 residents included in the sample. Of those, 5 residents were reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure 2 of 5 residents' (#36) and (#14) environments remained as free of accident hazards as possible and received supervision and assistive devices to prevent accidents by the failure to implement interventions or needed supervision after a reported fall to prevent further fall for resident #14, and provide the planned interventions and adequate supervision to address exit seeking behavior for resident #36. By the failure to provide supervision or implement interventions for resident #14, the resident fell in his/her room and acquired a C2 fracture in the resident's neck. Findings included: - Review of an Inter-Agency Transfer dated 10/7/11 identified resident #14 with the following Diagnoses: [REDACTED]. Review of a hospital History and Physical, dated 7/31/11, identified the resident lived at home, fell on his/her right arm and received a distal radial fracture. Review of the resident's admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 8/10/11 identified the resident admitted to the facility on [DATE], and had a BIMS (Brief Interview of Mental Status) of 14 (13-15 indicated cognitively intact). It identified the resident needed limited assistance of one staff member for transfers and walking in his/her room, and extensive assist of one staff for locomotion on the unit, and the resident needed limited assist of one for toilet use. It noted the resident had a fall in the last month prior to admission, had a fall in the last 2-6 months, and had a fracture related to a fall in the last 6 months prior to admission. It identified the resident had no falls since admission to the facility. Review of the Falls Care Area assessment dated [DATE] revealed, "Triggered due to fall at home which resulted in this admission for PT (Physical Therapy) and OT (Occupational Therapy). Used walker at home, independent with ADL's at home, living by (gender's self). Unable to use walker now due to cast on arm, which has also affected her balance somewhat." Review of an admission Fall Risk assessment dated [DATE] revealed the resident with a fall risk score of 11 (score of 10 or more indicated high risk). At 9:24 A.M. on 12/6/11, Therapy staff D reported the resident worked with PT on several occasions. Staff D reported the resident started to get stronger, and family and the resident wanted the resident to do a trial at home. Staff D also reported, after the resident was home, he/she "fell that weekend sustaining a T7 (thoracic vertebrae) fracture. Review of a Therapy Discharge note dated 9/16/11 revealed, "Feel pt (patient) is not safe to be by (gender's self)." Review of an Admission/Discharge/Reentry Skin assessment dated [DATE] identified the resident, "Reports (gender) may have fallen while at home. ROM (range of motion) intact, LOC (level of consciousness) as previously." At 10:46 A.M. on 12/6/11 Administrative nursing staff B reported staff did not reassess the resident's fall risk when the resident reported having a fall while at home on therapeutic leave. Review of an Occupational Therapy Evaluation dated 9/23/11 identified the resident as alert, oriented with mild confusion, had poor safety awareness, and was independent with wheelchair mobility/management inside his/her room, Cognitive status, orientation was alert, oriented with mild confusion, and safety awareness poor. It also identified the resident as a fall risk, and the referral reason for the evaluation was due to decline in activities of daily living and mobility, recent falls, and weakness. During an interview at 9:39 A.M. on 12/6/11, Therapy staff D reported the resident started on therapy again after having the fall when he/she went on the therapeutic leave. Staff D reported therapy evaluated the resident on 9/21/11, and planned goals for the resident to resume to his/her prior level of functioning. Staff D reported he/she did not recommend for the resident to transfer and ambulate independently. Staff D also reported, on the 21st through 27th of September, the resident progressed physically, but was not retaining the education. Staff D confirmed, on 9/30/11 the resident should have had staff assistance in his/her room, and also confirmed the resident was not at an independent level in his/her room, needing staff for safety. Review of the Physical Therapy Daily Treatment note next to Therapeutic Activities/Transfers on 9/29/11 revealed "SBA (stand by assist) all transfers" and on 9/30/11 "SBA all transfers" Review of the Medicare Daily Skilled Charting check sheet, dated 9/28/11 and 9/29/11, revealed staff identified the resident with abnormal gait and impaired balance on all 3 shifts for both days. Review of a 9/28/11 2200 (10:00 P.M.) nurse's note revealed staff identified the resident as alert and oriented to person, place and time, requested assist with activities of daily living if needed, mobile in the resident's room with a walker at times, self-propelled in the wheelchair at others. Review of a 9/29/11 2200 (10:00 P.M.) nurses note revealed it identified the resident as alert and oriented to person, place and time, active per the resident's norm, independent with activities of daily living as able, made needs known and was mobile per self propelled wheelchair. The note also revealed the resident as independent in the bathroom and continent. Review of a 9/30/11 1330 (1:30 P.M.) nurses note revealed, "Res (resident) continues on skilled. A and O x 3 (alert and oriented to person place and time). ADLs (activities of daily living) per self. Transfer without assist and mobility per w/c (wheelchair)..." Review of the 9/30// 2235 (10:35 P.M.) nurses note revealed, "Res was in room and stood up to shut (gender's) door and tripped on (gender's) w/c. (Gender) stated (gender) hit (gender's) head and then heard (gender's) neck pop. (Gender) then sat up and knocked on (gender) door to get help. Res was found sitting on the floor. (Gender) was helped to a lying position and head and neck stabelized (sic). Dr (doctor) and DPOA (Durable Power of Attorney) notified. EMS (Emergency Medical Services) called and transported (gender) to (Hospital)." Review of a 10/1/11 0030 (12:30 A.M.) nurses note revealed, "Resident returned to facility - called (Hospital) and received report. Sustained no fx (fracture) d/t (due to) fall. Neuro checks done - WNL (within normal limits). conts (continues) to c/o (complain of) pain, level 8-10 in neck. Ice applied" Nurses notes on 10/2/11 at 1415 (2:15 P.M.) identified the resident complained of severe pain to the left side of the neck and ear, and staff provided treatment. A 10/3/11, 1045 (10:45 A.M.) nurses note identified the physician ordered a C (cervical) collar to help stabilize the resident's head and neck. On 10/3/11 at 2300 (11:00 P.M.), the resident continued to complain of pain to his/her neck, "It's pretty bad." and staff provided treatment. At 0500 (5:00 A.M.) on 10/4/11, a nurses note identified the resident had neck pain of 7 (on 1-10 pain scale) and staff provided treatment. A 10/4/11, 1328 (1:28 P.M.) nurses note revealed, "Call received from (Physician) - CT (computed tomography) scan shows Fx (fracture) of C2 (cervical vertebra #2)." It identified the physician ordered to transport the resident to the hospital for evaluation. Observation at 11:45 A.M. on 11/29/11 revealed the resident rested in bed with eyes closed, and wore a neck brace. During an interview at 2:29 P.M. on 12/5/11, Direct Care staff E reported he/she did not help out after the fall occurred, but reported the resident did everything on his/her own before that point, and reported the resident was completely independent in his/her room at that time. Staff E reported the resident had difficulty at times, and reported staff kept an eye on the resident. On 12/5/11 at 2:42 P.M., Licensed nursing staff J reported the resident was not confused prior to the fall, but did need one person assist with transfers in his/her room. At 4:44 P.M. on 12/5/11, Direct Care staff F reported he/she worked the evening the resident fell . Staff F stated, "At that point (gender) was independent. (Gender) was doing things by (gender's self). Staff F confirmed the resident could go from his/her wheelchair to the bathroom by his/herself and did all transfers independently. Staff F also reported he/she did not remember where the resident had sat prior to the fall, but reported he/she knew the resident did not like the recliner, and was not sitting in it. On 12/5/11 at 4:29 P.M. Direct Care staff G reported he/she did not work often, and did not see the fall. Staff G reported he/she did not remember what care the resident needed, but reported he/she would look at the care plans and talk with nurses to know how to care for the resident when he/she came on shift. Review of an Interim Plan of Care dated 8/16/11, in place at the time of the fall, identified the resident needed assist of one to toilet by staff and wore briefs, used a wheelchair with staff assistance (independent in room (crossed out and dated 10/10/11-indicating the resident no longer was independent in his/her room as of 10/10/11) needed assist of one person, and ambulated short distances holding onto staff. During an interview at 10:19 A.M. on 12/6/11, Administrative nursing staff B reported he/she did not find out about the fall until 3 days after it occurred. Staff B reported the resident had been very independent in his/her room with bathroom privileges. Staff B confirmed the resident admitted to the facility due to a wrist fracture from a fall, and had another fall resulting in a T7 vertebrae fracture 2 weeks prior to the fall on 9/30/11. Staff B also confirmed after the resident came back to the facility after the therapeutic leave, staff failed to investigate the cause of the fall at home to make changes in interventions to prevent the resident from further falls. Staff B also confirmed the nurses notes had conflicting and contradicting information regarding the resident's assistance needs and independent status. Staff B viewed the interim care plan, confirmed the resident still did not have a comprehensive care plan at the time of the fall on 9/30/11 (57 days late), and reported he/she thought staff determined the resident to still be independent in his/her room and needed assistance in the hall, but reported he/she did not know how staff made that determination. Staff B confirmed staff did not complete a fall assessment after the fall on 9/30/11 and a Fall Risk assessment did not get completed until 10/28/11, showing an increased fall risk score of 18. Staff B reported, when he/she looked at the care plan, it was unclear if the care plan was updated after the fall or what staff were directed to do at the time of the fall. The facility failed to implement interventions or needed supervision, after a reported fall to prevent further falls for resident #14. The resident fell and sustained a fracture to the resident's C2 vertebrae. - The facility's admission data sheet for resident #36 identified an admission date of [DATE]. The signed admission orders [REDACTED]. A telephone order dated 11/11/11 included [DIAGNOSES REDACTED]. The Interim Plan of Care dated 9/29/11 included a behavior of wandering while at home and displayed exit seeking (attempting to leave the premises) behaviors. The plan directed staff to "follow facility protocol for elopement (absent without staffs' knowledge) risk and procedure for missing persons. The plan directed staff to ensure that the resident carries identification or wears an identification bracelet and to instruct visitors to inform staff members when their visit has ended. The plan further directed staff to do the following; determine whether wandering is aimless or goal directed, and respond accordingly. Provide an outlet: a walk, an activity, a distracting activity for restlessness. Engage in creative activity programs as wanderers are often bored and lonely." Review of the nurses' notes revealed an entry on 10/9/11 at 6:20 p.m. "resident has had increased behavior or confusion and trying to elope, resident walked most of the shift trying to get out the doors." On 10/9/11 at 7:15 p.m. the resident went out the door into the courtyard and was walking towards the gate, he/she stated that he/she was going to wait outside for his/her spouse. The admission MDS (Minimum Data Set 3.0, a required assessment) with an assessment reference date of 10/11/11 identified the resident with moderately impaired cognition based on the staff assessment for cognitive patterns. The MDS section for delirium indicated the resident experienced inattention and disorganized thinking, had trouble concentrating on things and episodes of being short-tempered or easily annoyed. The MDS identified the resident with daily wandering behavior that placed the resident at significant risk of getting to a potentially dangerous place and intrude on the privacy or activities of others. The MDS identified the resident as independent with ADLs except supervision with toilet and personal hygiene, with no balance issues and no fall history for the resident. The CAA (Care Area Assessment) narrative report for cognitive loss/dementia included the following "triggered due to BIMS (Brief Interview for Mental Status) score, resident unable to follow questions, does not recall after 5 minutes, but does seem to recall long past. Has [DIAGNOSES REDACTED]. The ADL CAA included "resident is independent in ambulation, but requires assistance and guidance for all ADLs due to dementia. The behavioral symptom CAA included "resident is independent in ambulation. (He/she) is disoriented at all times but can appear cognizant at times, is able to converse about his/her life in the long past. (He/she) occasionally states 'I'm ready to go home now'. Staff include "him/her" in activities throughout the day, which (he/she) appears to enjoy. (He/She) is friendly and cooperative with others." The CAA failed to include information about the resident's wandering and exit seeking behavior. The CAA for falls included the following; "resident has poor safety awareness due to dementia. Wandering care plan in place. Fall risk assessment scores at high risk due to disorientation, incontinence and anti-anxiety medication." The CAA failed to include the risk factors associated with wandering and exit seeking behavior. The Interim Care Plan was still in affect with the wandering behavior plan which did not direct staff to provide increased supervision during exit seeking behavior. Review of the nurse's notes dated 10/12/11 and timed 6:30 p.m. revealed "skin assessment WNL (within normal limits) without variance, alert, smiling. Vital signs after exercise/walking blood pressure 119/72, temperature 97.8, pulse 79, respirations 22 and pulse oximetry 97% on room air. Decreased wandering behavior states 'I'm tired and kinda cold' assisted with pajamas and robe. sitting quietly, looking at a book, no new orders, family has visited via phone." On 10/13/11 at 10:17 a.m. the facility reported to the State Agency that the resident had gotten outside without staffs' knowledge on 10/12/11. The facility reported the resident was last seen at 2:15 p.m. by certified medication aide N and then discovered outside a few blocks away at 2:40 p.m. by certified medication aide N. The facility's investigation signed 10/17/11 identified factors of shift change, several deliveries and visitors entering/exiting the facility and the function of the magnetic locks of all exit doors was last checked on 10/7/11. The investigation lacked information regarding interview with residents, visitors, family or staff concerning the incident. The facility's investigation indicated the family agreed to obtain a bracelet with the resident's name on it for him/her to wear. On 11/30/11 at 4:38 p.m. administrative nurse B reported he/she had talked with all the staff to try and find out how the resident got out. He/she confirmed the only witness statement obtained was from the staff who found the resident outside. Administrative nurse B reported he/she had no written evidence to support that interviewing of staff, residents, visitors or families was conducted regarding the incident to determine causal factors as a way to prevent future episodes. Administrative nurse B also confirmed the resident lacked the identification bracelet as directed in the Interim Plan of Care. Interview with social services designee K on 12/1/11 at 3:25 p.m. revealed that on 10/12/11 administrative nursing staff B and C, social service designee K, activity director O were all in care plan meetings that began at 2:00 p.m. Social service designee K reported the resident was very anxious when he/she first came and wanted to go home especially after the spouse visited but he/she seems to have adjusted now. Interview with nurse aide P on 12/1/11 at 2:00 p.m. revealed he/she was in the therapy room on 10/12/11 around 2:00 p.m. working with another resident. Interview with nurse aide Q on 11/30/11 at 4:50 p.m. confirmed the resident had wandering behavior when he/she was admitted which has improved now. Nurse aide Q reported most of the staff were involved with a another resident who had fallen at the time resident #36 went outside. Nurse aide Q (from the 2pm-10pm shift) reported that when he/she reported at 1:45 p.m. he/she entered a room with a closed door to obtain report from the day shift nurse and the day shift aides remained on the floor. Then after report the 1st shift aides and 2nd shift aides do a walking round checking on the residents for whereabouts or toileting needs. Following the above episode of the resident going outside without staff's knowledge while staff were all busy in other areas of the facility the facility updated the Interim Care Plan with "intensify activities at shift changes and busy times of day." The comprehensive care plan developed on 10/19/11 and reviewed/revised on 11/18/11 included a problem of independent with ambulation and has a history of wandering while at home related to dementia and voices desires to go home which increases the resident's risk for elopement. The goal included the resident will be safe, and exit seeking attempts to leave premises will be eliminated with the resident being at ease in the environment and cease aimless wandering. The plan directed staff to follow the facility's protocol for elopement risk and facility procedure on missing persons. The plan indicated staff posted a note on the exit doors to remind visitors to make sure that the door closes behind them and no residents follow them out...encourage the resident to take rest periods throughout the day to decrease inappropriate reactions related to over tiredness. The plan identified the resident frequently leaves activities early, even when encouraged to stay. He/She looks persistently for things to do or how to get home all of which increases his/her risk of falling or other injury related to wandering. The goal included resident will engage in facility daily activities even if for a short time and will be easily re-directed to participate in a different activity when he/she is up wandering in the halls over the next 90 days. The plan directed staff to evaluate for boredom, thirst, hunger, need to toilet, exercise, or companionship as contributing to wandering and attempt to resolve need at that time. Staff to gently attempt to re-direct attention as necessary to encourage the resident to participate in an activity or to come to the TV area... Increase supervision (read, chat, walk, music, etc.) at shift-change and periods of increased in/out traffic at doors due to the resident waits at doors looking to go home. Provide distraction or redirection. The plan directed staff to use a motion alarm at night that triggers the resident's call light so that staff are aware of him/her getting up so that they can assist as needed. The Interdisciplinary Care plan review notes dated 11/18/11 included care plan reviewed and updated. The resident continues to walk throughout facility, will come to some activities but stays for short periods of time. Record review completed on 11/30/11 revealed the nurse aide flow sheets for November 2011 failed to include any information about the resident's elopement risk or exit seeking behaviors. The behavior sheets for November 2011 listed multiple standardized behaviors and 2 areas the facility could customize with resident specific behaviors that were blank. The facility failed to identified the resident's wandering and exit seeking behavior as behaviors of this resident which staff should monitor. On 11/29/11 at 7:30 a.m. observation revealed the resident asleep in bed. At 8:25 a.m. observation revealed the resident remained in bed asleep with a sensor alarm located on the floor which did not activate when tested . Further inspection of the device found the switch in the off position. At 8:52 a.m. the resident continued to sleep and the alarm remained in the off position. At 9:04 a.m. staff member entered the room and visualized the resident but failed to turn the alarm to the on position. At 9:05 a.m. certified medication aide R entered the room and turned on the alarm. Interview on 11/29/11 at 9:08 a.m. with certified medication aide R confirmed the sensor alarm was to be on at all times and that he/she had just turned it on. The facility's "Elopement/Wandering/Missing Resident" Policy and Procedure with a revision date of 8/22/11 directed staff to assess each resident prior to and/or at the time of admission for potential elopement. Interventions in the plan of care for residents who wander should address the specific behavioral patterns of the resident...Residents identified at risk for elopement will be assessed by the care plan team during care plan conferences. Individualized measures will be implemented and addressed on the comprehensive care plan. Will have picture taken and information needed for Missing Person Profile (police requested information) obtained. A picture book of high risk wanderers is provided a the nurses' desk. Will be considered for Identification bracelet with name of resident, PSH (name of facility), and phone number, to be placed on resident's wrist or ankle. The policy included a section titled, "Resident's at Risk for Elopement" which included provide resident with an identification bracelet and a bracelet alert, check the door alarms daily to ensure it is in working order and staff education-Mock Elopement drills will be completed at least annually to reinforce the elopement procedure. The facility failed to provide adequate supervision for this resident with wandering and exit seeking behavior to prevent the resident from eloping on 10/12/11. The facility failed to adequately assess, plan or implement parts of the plan for this resident identified with wandering and exit seeking behaviors.