Every finding on record at Pratt Health and Rehab

The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for Resident (R) 8, who had dressing changes to a pressure ulcer daily. The facility also failed to implement a complete water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, or chronic lung diseases). Findings included:-R8's Electronic Medical Record (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, cardiac murmur (abnormal sound), and hypertension (elevated blood pressure). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R8 had severe cognitive impairment. The MDS further documented that R8 had an unhealed Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) not present on admission. R8's Care Plan, dated 02/07/26, documented R8 had a pressure ulcer to the coccyx (area at the base of the spine) and directed staff to provide wound care daily. The plan further directed staff to monitor nutritional status, reminding and assisting R8 to turn/reposition at least every two hours and more often if needed, assess/record/ monitor wound healing on a weekly basis, and require the use of a therapeutic mattress. The Wound Care Consultant Progress Note dated 01/07/26, documented that R8 had developed a Stage 3 midline coccyx pressure ulcer. The wound had slough (dead tissue, usually cream or yellow in color) and was debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). The consultant ordered hydrogel (a water-based gel that donates moisture and aids autolytic debridement) and foam dressing treatment. The ulcer measured 2.5 centimeters (cm) in length and 0.7 cm in width. On 03/16/26 at 02:26 PM, R8 lay on a low air mattress, with the bed in a low position towards the floor. Licensed Nurse (LN) H assisted R8 to roll in bed to her side. LN H donned gloves but did not don a gown and provided wound care. On 03/17/26 at 11:57 AM, Administrative Nurse D reported that EBP utilization of gloves and gowns should be implemented for open wound treatment. On 03/17/26 at 09:25 AM, Maintenance Staff U verified there was no mapping of the facility water flow system, including entering, flow direction, areas of potential water collection, and the hot water system of the facility. Maintenance Staff U reported water samples were tested from the kitchen, and from each wing, though unspecific locations within the facility were sent for detection of Legionella. The report dated 02/26/26 documented that the water samples did not detect Legionella. The facility's Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP) policy, dated 04/2025, documented definition of EBP expands the use of Personal Protective Equipment (PPE) and refers to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of a gown and gloves for high-contact resident care activities is indicated. The facility's Water Management, Legionella Testing policy, dated 04, 2025, documented that the facility handles and maintains its water supply in accordance with recommendations of the Centers for Disease Control and Prevention (CDC), the Healthcare Infection Control Practices Advisory (HICPAC) Committee, and the Food and Drug Administration (FDA). The community will demonstrate its measures to minimize its risk of Legionella and other opportunistic pathogens in the building water system through a documented water management program.

The facility had a census of 38 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide Resident (R) 8, R10, and R17, or their representative, a Notice of Medicare Non-coverage (NOMNC) when skilled services ended.Findings included:-A review of R8's Electronic Medical Record (EMR) documented that her Medicare Part A episode began on 10/23/25 and ended on 01/09/26. Review of R8's clinical record and facility-provided information lacked evidence that R8 was issued a SNF NOMNC as required. A review of R10's EMR documented that his Medicare Part A episode began on 06/27/25 and ended on 08/21/25. Review of R10's clinical record and facility-provided information that lacked evidence of R10 was issued a SNF NOMNC as required. A review of R17's EMR documented that his Medicare Part A episode began on 05/03/25 and ended on 07/22/25. Review of R17's clinical record and facility-provided information that lacked evidence of R17 was issued a SNF NOMNC as required. On 03/16/26 at 02:28 PM, Administrative Nurse D provided the requested Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for R8, R10, and R17, but lacked NOMNC notices. Administrative Nurse D verified that the residents or their representatives had not received a NOMNC notice due to personnel changes in the department that handled the notices. The facility's Beneficiary Notices policy, dated 07/2025, documented that a Medicare beneficiary has the right to have Medicare make the decision to determine if skilled services will not be covered by Medicare. Two processes are available: the expedited appeals process and the standard appeals process. The standard appeals process serves a similar function to services continuing without interruption. The standard appeals process serves a similar function of enabling a beneficiary to seek Medicare payment for a Skilled Nursing Facility (SNF) stay, but it is also necessary to inform the beneficiary of possible non-coverage and, if Medicare agrees that the coverage is not appropriate, to shift the costs of care from the SNF to the beneficiary. A notice of NOMNC is prepared and given at least three days before the end of the Medicare Part A stay or when all Part B therapies are ending. Forms should be maintained in a binder with Social Services. A copy can be maintained in the Business Office as well.

The facility identified a census of 38 residents. The sample included 12 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 29 and R40 and their representative were provided with a written notification of transfer, that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable. The facility failed to ensure R40 had a discharge summary and recapitulation of stay completed upon her discharge from the facility. Findings included:1. R29's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set (MDS) dated [DATE], which documented an unplanned discharge to an acute hospital with a return anticipated.R29's Entry MDS dated 07/18/25 documented a re-entry to the facility from an acute hospital.R29's Notice of Transfer form, dated 07/10/25, documented that the form was provided to the resident's representative. The Notice of Transfer form lacked information containing a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, as well as the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.R29's EMR recorded a Discharge MDS dated 11/18/25, which documented an unplanned discharge to an acute hospital with a return anticipated.R29's EMR lacked evidence of written notification of transfer. Upon request, the facility was unable to provide evidence of notification to the state ombudsman of R29's transfer to the hospital on [DATE] and 11/18/25.2.R40's EMR recorded a Discharge MDS dated 02/11/26, which documented an unplanned discharge to an acute hospital with a return anticipated.R40's Notice of Transfer form dated 02/11/26 was provided to the residents' representative. The Notice of Transfer form lacked information containing a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, as well as the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.R40's Social Services Note dated 02/25/26 at 05:52 PM, documented that R40's guardian and five other people came to the facility and removed R40's personal belongings. The guardian decided to move the resident to another community. The guardian signed the inventory sheet and would return tomorrow to pick up R40's remaining items.R40's EMR lacked proof that a Discharge Summary and recapitulation of stay were completed by the facility that contained all required information upon her discharge on [DATE]. On 03/15/26 at 02:31 PM, Social Services X stated the ombudsman was not notified at the time of transfer and subsequent admission to the hospital. Social Services X said the facility notified the Ombudsmen at the end of the month if a resident's bed hold was released. Social Services X said that the facility completed a notice of transfer, and if the family came into the facility, staff gave a written copy. Social Services X said for the most recent transfers, staff sent electronic notices to the representative and said the facility would be updating the Notice of Transfer form with the required information. She stated a discharge summary was completed upon R40's discharge, but a full discharge summary did not include all the complete information needed or the recapitulation of the stay. The facility's Transfer and/or Discharge, Including Against Medical Advice (AMA), Discharge Notification policy dated October 2025, documented: the resident, and/or representative will be provided with the following information within the notice, in writing and language and manner they understand, prior to transfer: the reason for the transfer or discharge, and the reasons for the move in writing and in a language and manner they understand; the effective date of the transfer or discharge; the specific location (such as the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email) and telephone number of the entity which receives such requests; and information on how to obtain the appeal form and assistance in completing the form and submitting the appeal hearing request. The name, address, (mailing and email) and telephone number of the state long-term care ombudsman; The name, address, mailing and email address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmental disabled individuals (as applies); and the name, address, mailing and email address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. The above transfer or discharge information will be documented in the resident's chart. Send a copy of the notice to the State Long Term Care Ombudsman and note it in the record. The facility's Discharge Summary and Plan policy dated April 2025 documented that the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The recapitulation will include, but not be limited to, diagnoses; course of illness, treatment or therapy; pertinent lab, radiology, and consultation results; reconciliation of all pre-discharge medications with the resident's post-discharge medications, for prescribed and over-the-counter. A final summary paragraph that may be released to any provider with the consent of the resident or representative.

The facility reported a census of 41 residents with three residents sampled for safety related to transportation outside the facility. Based on observation, interview, and record review, the facility failed to ensure that staff provided a safe environment, free of accident hazards during transportation in the facility van. On 03/11/25 at approximately 09:20 AM Certified Nurse Aide (CNA) C failed to ensure Resident (R)1 was safely secured in the facility van before operating the vehicle. CNA C began to drive the van and realized R1 did not have a seatbelt on. CNA C then stopped the vehicle and R1 fell out of the wheelchair onto the floor of the facility van and injured his head, face and left arm. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) documented R1 had diagnoses which included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), long-term use of anticoagulants (a class of medications that prevent or reduce blood clotting) and difficulty walking. The 09/21/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R1 utilized a wheelchair, required partial/moderate assistance for transfers, and received an anticoagulant medication. The 09/21/24 Falls Care Area Assessment (CAA) documented R1 was at risk for falls related to impaired gait (manner or style of walking) and mobility; R1 required assistance with transfers. The 02/19/25 Quarterly MDS documented a BIMS score of 14, which indicated intact cognition. The assessment documented R1 utilized a wheelchair, was dependent on staff for transfers, and received an anticoagulant medication. R1's Care Plan documented R1 was at risk for falls related to his recent surgery and cognitive loss, revised 03/17/23. R1's Care Plan documented an intervention with an initiated date of 03/11/25 that staff were re-educated on proper safety protocol in the facility vehicle. The Nursing: Progress Note dated 03/11/25 at 09:30 AM, by Licensed Nurse (LN) D documented CNA C notified the facility that R1 fell out of his wheelchair while in the facility's van. The note documented CNA C notified the staff at the hospital for assistance and one licensed hospital staff and one unlicensed hospital staff responded to the parking lot to assist CNA C and assess R1 for injuries. The note documented the hospital staff assessed R1 and discovered a skin tear to his left elbow, bruising to his left eye area, and an abrasion (scraping or rubbing away of skin) with bruising to the left side of R1's scalp. The Communication: SBAR to Physician dated 03/11/25 at 11:04 AM documented the situation was a fall on 03/11/25. The note documented the background was R1 fell from the wheelchair while being transported to an appointment; R1's seatbelt was not properly secured before the vehicle started moving. R1 had bruising below his left eye and on the left side of his head above the left ear. R1 had a small skin tear on his left elbow. The note documented staff would be re-educated on proper transportation safety protocol. A review of the facility's investigation revealed the following: CNA C's Witness Statement dated 03/11/25 documented she forgot to put R1's seatbelt on him and R1 slid out of the wheelchair. CNA C requested assistance from the hospital and two hospital staff came to the vehicle and assessed R1. The statement noted R1 had a bump on his head, a bruise under his eye and a skin tear on his elbow; R1 stated he was fine, just sore. LN D's Witness Statement dated 03/11/25 documented CNA C called the facility at 09:35 AM and notified LN D that R1 fell from his wheelchair in the facility van while out of the facility for an appointment. LN D documented CNA C revealed she had forgotten to ensure R1's seatbelt was secure. LN D documented CNA C stated the incident occurred at approximately 09:20 AM and CNA C requested assistance from the hospital staff who assessed R1 and assisted R1 back to his wheelchair. In another Witness Statement dated 03/11/25, LN D documented a telephone interview with hospital staff who reported hospital staff found R1 on his back in the facility vehicle with CNA C supporting his head. The statement noted that the hospital staff reported assessment findings that included a skin tear to the left elbow, an abrasion to the left side of R1's head, and bruising to the left eye related to R1's glasses. The statement noted the hospital staff reported R1 was able to stand with assistance and sat in his wheelchair without any complaints of pain or discomfort. During an observation and interview on 04/03/25 at 11:33 AM, R1 sat in his recliner with no visible wounds or bruises observed. R1 stated that he remembered the incident on 03/11/25 but was unsure of how he ended up on the floor. He reported that he was seated in his chair one moment and on the floor the next moment. R1 denied any major injuries. During an interview on 04/03/25 at 12:16 PM, Administrative Staff A stated that after R1 fell on [DATE] at approximately 09:20 AM, CNA C's actions met Administrative Staff A's expectations. Administrative Staff A said CNA C followed the facility's fall procedure by immediately notifying a healthcare professional who was qualified to assess R1 for injuries and then immediately notifying the facility before returning to the facility. Administrative Staff A stated that an ad-hoc Quality Assurance Process Improvement (QAPI) meeting was held to discuss the event and CNA C was immediately re-educated related to safety protocol while transporting residents on 03/11/25. Administrative Staff A revealed red laminated cards were affixed to the facility vehicle on 03/11/25 in specific areas to remind drivers to ensure seatbelts were properly fastened before the vehicle was in motion. Administrative Staff A revealed that R1's Care Plan was reviewed and revised on 03/12/25 at an unknown time. Additionally, Administrative Staff A stated all additional staff who are qualified to drive the facility vehicle received re-education on 03/20/25 which included a skills check-off. Administrative Staff A stated that audits would be performed three times per week for 30 days. During an interview on 04/03/25 at 12:20 PM, Administrative Nurse B reported that CNA C followed the facility's fall protocol after R1's fall on 03/11/25. Administrative Nurse B stated that when CNA C and R1 returned to the facility, CNA C was immediately re-educated related to safety protocols when transporting residents in the facility vehicle; the education included a skills check-off. During an interview on 04/03/25 at 12:30 PM, CNA C revealed that on the date of the incident (03/11/25), R1 was supposed to have a doctor's appointment at the hospital, but when CNA C and R1 arrived at the hospital, the appointment had been canceled. CNA C then took R1 back out to the facility vehicle but failed to correctly secure R1 with a seatbelt in his wheelchair. CNA C said she started driving the facility vehicle and had traveled approximately 500 feet at speeds of 10-12 miles per hour (mph) when she realized R1 was not properly secured with a seatbelt. CNA C then stopped the vehicle and when she did, R1 fell from the wheelchair to the floor and was injured. CNA C stated she called the hospital for assistance and then called the facility. CNA C stated that R1 was offered treatment in the Emergency Department (ED) of the hospital by the hospital staff, but the resident declined. The facility's Transportation, Facility Van policy, dated 10/2024 documented that residents would be transported in the community vehicle in a safe manner and residents would be secured in the vehicle per the community's procedure. The facility failed to ensure R1 was safely secured in the facility van before operating the vehicle and R1 fell out of the wheelchair onto the floor of the facility van and injured his head/face and left arm. This deficient practice placed R1 in immediate jeopardy. On 04/03/25 at 02:15 PM, Administrative Staff A and Administrative Nurse B were provided a copy of the Immediate Jeopardy (IJ) Template for the failure to ensure R1 remained free of accidents. The facility's corrective measures, fully completed on 03/20/25, included the following, which were verified by the surveyor on-site during the investigation. 1. CNA C was immediately re-educated related to safety protocols while driving the facility vehicle, completed on 03/11/25. 2. Red laminated cards were placed in the vehicle at specific points to remind staff to ensure residents were properly secured before moving the vehicle, completed on 03/11/25. 3. R1's Care Plan was reviewed and revised with an updated intervention on 03/12/25 to include an intervention that staff were re-educated on proper safety protocol for appointment transports in the facility vehicle. 4. All staff authorized to drive the facility vehicle received re-education with a return demonstration related to proper securement and safety during transports in the van, completed 03/20/25. 5. The facility continued audits of transports to ensure the residents were safely secured in the van before transport. All corrections were completed before the onsite survey; therefore, the deficient practice was cited as past noncompliance at a scope and severity of J.

The facility reported a census of 41 residents with 16 residents selected for review, which included one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to maintain Resident (R)28's dignity when in bed with only his brief on, to expose himself to the residents, staff and visitors that would go by his room. Findings included: - Review of Resident (R)28's electronic medical record revealed diagnoses that included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function. The resident had impairment in functional range of motion on one side of his upper and lower extremities. The resident was dependent on staff for activities of daily living. The Cognitive Loss Care Area Assessment (CAA) dated 09/23/23, assessed the resident with risk factors that included self-care deficits, falls and injuries, decreased socialization, mood decline, weight loss, and behavioral issues. The Care Plan, reviewed 03/29/24, instructed staff to keep his blankets and sheets tucked at the foot of the bed when tucking him in at night, otherwise the resident would become tangled up in his sheets and blankets. The resident required staff assistance with bed mobility. Observation, on 04/16/24 at 07:46 AM, revealed the door to the resident's room was open, and visualization from the hallway revealed the resident positioned in bed clothed in a brief with the sheet tangled and not covering his brief or bare legs. Observation, on 04/17/24 at 07:21 AM, revealed the resident positioned in bed and visualization from the hallway revealed the resident positioned in bed clothed in a brief with his bare legs and arms moving about without the sheet covering his body. The room lacked a privacy curtain. Interview, on 04/17/24 at 07:2 1 AM, with Certified Nurse Aide (CNA) MM, revealed the resident likes to move his legs about when in bed, and staff make frequent rounds to try to keep the resident covered. CNA MM stated staff get R28 up last in the morning. Interview, on 04/17/24 at 11:45 AM, with Administrative Nurse D, revealed she would expect staff to clothe the resident with pants when in bed to prevent exposure. The facility policy Exercise of Rights, dated 09/2023, instructed staff to ensure resident privacy and dignity. The facility failed to maintain this dependent resident's dignity when positioned in bed with only his brief on, to expose himself to the residents, staff and visitors that would go by his room.

The facility reported a census of 41 residents with 16 residents sampled. Based on observation, record review, and interview, the facility failed to revise the care plan with effective interventions for Resident (R)12 related to lack of wheelchair foot pedals and R 18, related to inability to self-administer medications. Findings included: - Review of Resident (R)12's electronic medical record (EMR), revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He used a wheelchair for mobility and required substantial to maximal assistance for mobility 150 feet and partial to moderate assist for mobility of 50 feet while in the wheelchair. The Activities of Daily Living (ADL)Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/09/23, documented the resident would experience further ADL decline. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of six, indicating severe cognitive impairment. He used a wheelchair for mobility and required supervision or touching assistance of staff for wheelchair mobility of 50 feet and 150 feet. The ADL care plan, revised 03/15/24, instructed staff the resident could propel his wheelchair for long distances. The care plan lacked staff instruction regarding the use of foot pedals while propelling the resident in his wheelchair. Review of the resident's EMR from 03/18/24 through 04/15/24, revealed the resident utilized a wheelchair for mobility. On 04/16/24 at 08:43 AM, Certified Nurse Aide (CNA) M propelled the resident in his wheelchair from his room to the dining room. The resident's legs were bent at the knee with his feet underneath the wheelchair seat. The toes of his shoed feet skimmed the floor during transport. The wheelchair lacked foot pedals. On 04/16/24 at 10:48 AM, CNA N propelled the resident from his room to the dining room in his wheelchair. His shoed feet skimmed the floor during transport. The wheelchair lacked foot pedals. On 04/16/24 at 10:48 AM, CNA N stated the resident had foot pedals for his wheelchair in his room. CNA N stated the resident will at times propel himself in the wheelchair, but he gets out of breath easily, so the staff assist him with mobility. On 04/16/24 at 12:28 PM, CNA M stated the resident did not use foot pedals on his wheelchair because he would at times propel himself and the foot pedals would be in his way and could be a tripping hazard. CNA M stated the foot pedals for the wheelchair were somewhere in his room. On 04/16/24 at 12:35 PM, Licensed Nurse (LN) G stated the staff should use foot pedals while propelling residents in their wheelchairs. On 04/17/24 at 0:27 AM, Administrative Nurse D stated it was the expectation for staff to utilize foot pedals while propelling residents in their wheelchairs. The facility policy for Comprehensive Care Plans, effective 09/2023, included: The facility's Interdisciplinary Team (IDT), shall be responsible for the periodic review and updating of the care plan when there has been a change in the resident's condition and at least quarterly. The facility failed to review and revise this dependent resident's care plan to include the use of foot pedals. 28560 - Review of Resident (R)18's electronic medical record, revealed diagnoses that included chronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of the deep veins of the left lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues,) and paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) personality. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognitive status. The resident received antipsychotic medications. The Psychotropic Drug Use Care Area Assessment (CAA) assessed the resident received antipsychotic medications for psychiatric disorders. The Care Plan, reviewed 02/23/24, instructed staff the resident received Seroquel (an antipsychotic medication) which had a Black Box Warning for severe side effects. The resident had impaired cognitive function and delirium and staff advised to monitor for changes in behaviors and review medications for possible side effects. On 12/27/23, the physician instructed staff to administer Seroquel (an antipsychotic medication) 25 milligrams, every night, for adjustment disorder with disturbance of conduct/agitation. On 04/05/24 the physician instructed staff to administer Seroquel, 50 mg, every morning, for paranoid personality. The Care Plan reviewed 02/23/24, instructed staff the resident occasionally refused to follow a plan of care. Staff instructed that the resident's medications may be set up by nursing staff, placed in a pill cup and left with the resident at her bedside or with the resident in the dining room. Staff to complete a Self-Administration Medication Assessment quarterly and with changes. A Physician Order dated 05/10/23 instructed staff the resident may self-administer medications with nursing staff setup. Medications may be left with resident in dining room or at residents' bedside. Self-Administration assessment completed and to be completed quarterly and PRN. The physician instructed staff to administer the following medications: On 02/10/23 Levothyroxine (a hormone for thyroid replacement) 75 micrograms (mcg) daily, on an empty stomach. 03/30/23 Potassium, 10 milliequivalent (mEq,) daily, for supplement. On 09/07/23 Prilosec, 20 milligrams ( mg,) daily, related to acid reflux. On 11/29/23 Norco( a narcotic pain medication,) 5-325 mg, 1 tablet, by mouth, two times a day, for pain. On 11/30/23 Aspirin, 81 mg, daily. On 12/27/23 Seroquel (an antipsychotic medications used to treat psychiatric disorders,) 25 mg, at night, for adjustment disorder. On 04/05/24 Seroquel,50 mg, every morning, for paranoid personality. On 04/11/24 Cephalexin, 500 milligrams(mg), twice a day, for 10 days. Review of the April 2024 Medication Administration Record (MAR) revealed an entry with start date of 05/10/23 which instructed staff the resident may self-administer medications with nursing staff setup. Medications may be left with resident in dining room or at residents' bedside. Interview, on 04/16/24 with Licensed Nurse (LN) I, revealed the resident could no longer self-administer her medications as she requested the medications crushed in applesauce. Interview, on 04/17/24 at 11:45 AM, with Administrative Nurse D, revealed the resident did not always take her medications, and medications were found in the resident's room, so staff determined she was no longer was safe to self-administer her medications. Administrative Nurse D confirmed staff did not update the care plan and the MAR with the information The facility policy Comprehensive Care Plan revised 09/2023, instructed staff to periodically review and update the care plan when there is a change in the resident's condition. The facility failed to review and revise R 18's care plan to reflect the resident's change in condition for self-administration of medications to ensure compliance with the prescribed medications.

The facility reported a census of 41 residents with 16 selected for review with one resident reviewed for activities of daily living for dependent residents. Based on observation, interview and record review, the facility failed to ensure one Resident (R)28 received facial hair grooming opportunities. Findings included: - Review of Resident (R)28's electronic medical record revealed diagnoses that included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function. The resident had impairment in functional range of motion on one side of his upper and lower extremities. The resident was dependent on staff for activities of daily living. The Cognitive Loss Care Area Assessment (CAA) dated 09/23/23, assessed the resident with risk factors that included self-care deficits, falls and injuries, decreased socialization, mood decline, weight loss, and behavioral issues. The Care Plan dated 03/29/24, instructed staff the resident required extensive assistance of one staff for personal hygiene. Observation, on 04/15/24 at 08:45 AM, revealed the resident seated in a Broda chair (specialized chair that allows for the resident to lean back and maintain upright posturing.) The resident had several days growth of facial hair. Observation, on 04/16/24 at 07:46 AM, the resident continued with several days' growth of facial hair. Observation, on 04/16/24 at 09:30 AM, revealed the resident received a shower by hospice staff, but did not receive a shave. Observation, on 04/17/24 at 07:21 AM, revealed the resident continued with several days' growth of facial hair. Interview, on 04/17/24 at 07:21 AM, with Certified Nurse Aide (CNA) MM, revealed she shaved the resident on 04/12/24, and did not know why hospice did not provide shaving for the resident. CNA MM stated staff needed to use an electric razor as the resident tended to move about. Observation, on 04/17/24 at 09:15 AM, revealed CNA O feeding the resident oatmeal, and due to his continuous tongue thrusting outward, the cereal dripped down his chin into the stubble. Interview, on 04/17/24 at 11:45 AM, with Administrative Nurse D, revealed she would expect staff to provide shaving for the resident to aide in his facial cleanliness when eating. The facility policy Exercise of Rights, dated 09/2023, instructed staff to ensure resident privacy and dignity groomed as they wish to be groomed. The facility failed to ensure this dependent resident's received shaving opportunities to aide in clean facial hygiene when eating and maintenance of groomed appearance.

The facility reported a census of 41 residents with 16 residents selected for review which included three residents reviewed for skin issues. Based on observation, interview, and record review, the facility failed to monitor and provide sanitary dressing change for one, Resident (R)18's venous ulcer, of the three residents reviewed for skin issues. Findings included: - Review of Resident (R)18's electronic medical record, revealed diagnoses that included chronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of the deep veins of the left lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues,) and paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) personality. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognitive status. The resident had no venous ulcers. The resident had no impairment in functional range of motion in her upper or lower extremities. The Pressure Ulcer Care Area Assessment (CAA), dated 02/20/24, assessed the resident at risk for skin breakdown. The Care Plan reviewed 04/11/24, instructed staff the resident received antibiotics for cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) of the left lower extremity,and to monitor for adverse effects, but lacked instruction for wound care until 04/17/24, six days later. On 04/10/24, the physician instructed staff to administer Cephalexin (an antibiotic), 500 milligrams, twice a day, for cellulitis of the left lower extremity, for ten days. A Nurse Note, dated 04/15/24 at 12:38 AM, revealed the resident had a weeping wound on her left leg and licensed nurse changed the dressing. On 04/15/24, the physician instructed staff to cleanse the left lower extremity with wound cleanser, apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin)to the resident's peri wound (area around the wound), apply Mepilex Ag (a medicated dressing with silver to aide in wound healing), and apply an Unna boot (a type of wrapped dressing infused with zinc oxide and calamine for compression to aide in the healing of vascular ulcers,) wrap with Keflex (a type of elastic gauze wrap) and ace wrap to the left lower extremity due to two blisters and weeping drainage. Staff instructed to change the Unna boot on Monday, Wednesday, Friday, and as needed, and record the wound measurements, drainage, and signs of infection. A Nurse's note, dated 04/15/24, documented mild redness to the left lower extremity and weeping wounds and 2-3 plus pitting edema. The medical record lacked measurements/description of the blisters. Observation, on 04/17/24 at 09:02 AM, revealed Licensed Nurse (LN) H, prepared to provide wound care to the resident's left lower extremity. LN H placed a towel on the floor and instructed the resident to place her foot on the towel. LN H placed scissors, on the towel and placed an opened paper wrapped package of multiple four by four gauze sponges and a spray bottle of wound cleanser directly on the floor beside the towel. LN H removed the wraps and revealed an yellow/red colored open area on the resident's mid lateral (outer) calf area approximately two centimeters in diameter and an area approximately two centimeters of a previous blister with pink/red coloring. LN cleansed the lower extremity with wound cleanser, dried the area, and applied the Mepilex Ag dressing to the open area and began to wrap the lower extremity with the Unna boot gauze, from the below the knee toward the foot. Interview, on 04/17/24 at 09:30 AM, with LN H, revealed the dressing supplies should be placed on a barrier. LN H stated the resident had a large amount of pitting edema prior to the Unna boot application, and the resident had two blisters previously. Interview, on 04/17/24 at 11:40 AM, with Administrative Nurse D, revealed R18 had two blisters and cellulitis on her left lower extremity prior to application of the Unna boot. Administrative Nurse D stated she would expect staff to document the size and characteristics of the blisters for monitoring. Administrative Nurse D stated she would expect staff to place wound supplies on a sanitary barrier, not directly on the floor and the facility lacked a policy for application of the Unna boot. The facility policy Wound Care Guidelines, effective 03/2023, instructed staff to establish a clean field on the resident's overbed table and ensure all clean items are on a clean field. The facility lacked a policy for application of an Unna boot. The facility failed to ensure staff provided a sanitary dressing change and appropriate technique for application of Unna boot for this resident's lower extremity cellulitis with blisters/ulceration

The facility reported a census of 41 residents with 16 residents selected for review, that included one resident reviewed for vision. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)14, received vision care. Findings included: - Review of Resident (R)14's electronic medical record revealed diagnoses that included diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and major depressive disorder. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status(BIMS) score of 10, which indicated moderate cognitive impairment. The resident had adequate vision with corrective lenses. The Cognitive Loss Care Area Assessment, (CAA) dated 06/21/23, assessed the resident had risk factors of social isolation and increased anxiety. The Care Plan, reviewed 04/08/24, instructed staff the resident was at risk for potential alterations in his visual status related to use of glasses and diabetes. Staff instructed to assist the resident to keep his glasses clean and free of debris. Staff were to schedule and keep all appointments with his eye doctor. Interview , on 04/15/24 at 10:00 AM, the resident revealed his glasses were stepped on by another resident and facility staff were aware this happened but the pair of glasses he used now were not his prescription, and he could not see as well. The resident stated he needed to see an eye doctor but did not think he could see an eye doctor due to insurance issues. Interview, on 04/17/24 at 11:49 AM, with Administrative Nurse D, revealed the resident had a prescription for new glasses in July of 2022, but had not seen an eye doctor since and his prescription glasses were broken but could not recall when this occurred. Administrative Nurse D stated the resident did have insurance issues when admitted to the facility in 2022, but the issues resolved and R14 could see an eye doctor. The facility policy Exercise of Rights reviewed 09/2023, instructed staff residents have the right to a dignified existence with self-determination and communication with the access to persons and services inside and outside the facility. The facility failed to ensure R14 had access to vision care to provide enhance his sense of wellbeing.

The facility reported a census of 41 residents with 16 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to safely transport one Resident (R)12 in his wheelchair by failing to have foot pedals in place while propelling him in his wheelchair. Findings included: - Review of Resident (R)12's electronic medical record (EMR), revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He used a wheelchair for mobility and required substantial to maximal assistance for mobility 150 feet and partial to moderate assist for mobility of 50 feet while in the wheelchair. The Activities of Daily Living (ADL)Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/09/23, documented the resident would experience further ADL decline. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of six, indicating severe cognitive impairment. He used a wheelchair for mobility and required supervision or touching assistance of staff for wheelchair mobility of 50 feet and 150 feet. The ADL care plan, revised 03/15/24, instructed staff the resident could propel his wheelchair for long distances. Review of the resident's EMR from 03/18/24 through 04/15/24, revealed the resident utilized a wheelchair for mobility. On 04/16/24 at 08:43 AM, Certified Nurse Aide (CNA) M propelled the resident in his wheelchair from his room to the dining room. The resident's legs were bent at the knee with his feet underneath the wheelchair seat. The toes of his shoed feet skimmed the floor during transport. The wheelchair lacked foot pedals. On 04/16/24 at 10:48 AM, CNA N propelled the resident from his room to the dining room in his wheelchair. His shoed feet skimmed the floor during transport. The wheelchair lacked foot pedals. On 04/16/24 at 10:48 AM, CNA N stated the resident had foot pedals for his wheelchair in his room. CNA N stated the resident will at times propel himself in the wheelchair, but he gets out of breath easily, so the staff assist him with mobility. On 04/16/24 at 12:28 PM, CNA M stated the resident did not use foot pedals on his wheelchair because he would at times propel himself and the foot pedals would be in his way and could be a tripping hazard. CNA M stated the foot pedals for the wheelchair were somewhere in his room. On 04/16/24 at 12:35 PM, Licensed Nurse (LN) G stated the staff should use foot pedals while propelling residents in their wheelchairs. On 04/17/24 at 0:27 AM, Administrative Nurse D stated it was the expectation for staff to utilize foot pedals while propelling residents in their wheelchairs. The facility policy for Activities of Daily Living, revised 09/2023, included: Residents who are unable to carry out activities of daily living shall receive the necessary care and services to maintain mobility. The facility failed to safely transport this dependent resident in his wheelchair by failing to utilize foot pedals.

The facility reported a census of 41 residents with 16 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure three Residents (R)18, R34 and R35, of the five residents were monitored for adverse effects of antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications in a timely manner. Findings included: - Review of Resident (R)18's electronic medical record, revealed diagnoses that included richronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of the deep veins of the left lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues,) and paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) personality. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognitive status. The resident received antipsychotic medications. The Psychotropic Drug Use Care Area Assessment (CAA) assessed the resident received antipsychotic medications for psychiatric disorders. The Care Plan, reviewed 02/23/24, instructed staff the resident received Seroquel (an antipsychotic medication) which had a Black Box Warning for severe side effects. The resident had impaired cognitive function and delirium and staff advised to monitor for changes in behaviors and review medications for possible side effects. On 12/27/23, the physician instructed staff to administer Seroquel (an antipsychotic medication) 25 milligrams, every night, for adjustment disorder with disturbance of conduct/agitation. On 04/05/24 the physician instructed staff to administer Seroquel, 50 mg, every morning, for paranoid personality. Review of R18's medical record an Abnormal Involuntary Movement Scale (AIMS to determine severity of abnormal movements (dyskinesia) caused by antipsychotic medications) completed on 01/10/24 (14 days after the start of the medication.) Interview, on 04/17/24 at 11:45 AM, with Administrative Nurse D, confirmed lack of initial AIMS test for R18 until 14 days after therapy began. The facility Psychotropic Drug Use revised 04/2024, instructed staff to note evidence of specific side effects seen in the initial evaluation and to schedule the AIMS test to determine side effect of dyskinesia every six months. The facility failed to ensure staff obtained R 18's baseline AIMS at the start of antipsychotic drug therapy on 12/27/23 to determine adverse effects from the medication. - Review of Resident (R)35's electronic medical record revealed diagnoses that included vascular dementia (progressive mental disorder characterized by failing memory, and confusion ) with psychotic (any major mental disorder characterized by a gross impairment in reality testing) disturbance and major depressive disorder. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impairment. The resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions.) The Antipsychotic Drug Use Care Area Assessment (CAA), dated 08/16/23, assessed the resident received antipsychotic medications and staff monitored for adverse effects. The Care Plan, revised 02/02/24, instructed staff the resident was at risk for worsening impaired cognitive function due to delusions, and hallucinations and depression. The resident received psychiatric and medication therapy for treatments. On 04/25/23, the physician instructed staff to administer quetiapine fumarate (an antipsychotic medication), 50 milligrams (mg), daily, for psychosis and sleep. On 08/16/23, the physician instructed staff to administer quetiapine fumarate, 50 mg, one half tab daily, related to hallucinations. Review of the medical record revealed an Abnormal Involuntary Movement Scale (AIMS to determine severity of abnormal movements (dyskinesia) caused by antipsychotic medications) completed on 11/14/23 (seven months after the start of the medication). Interview, on 04/17/24 at 11:45 AM, with Administrative Nurse D, confirmed lack of initial AIMS test for R35 until seven months after therapy began. The facility Psychotropic Drug Use revised 04/2024, instructed staff to note evidence of specific side effects seen in the initial evaluation and to schedule the AIMS test to determine side effect of dyskinesia every six months. The facility failed to ensure staff obtained R 35's baseline AIMS at the start of antipsychotic drug therapy on 04/25/23 and in six months afterwards to determine if the resident sustained adverse effects from the medication. 34056 - Review of Resident (R)34's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. She did not receive antipsychotic medication (medication used to treat psychosis) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/10/23, documented risk factors for psychotropic medications (medications which alters mood or thought) included risk for falls, impaired balance, and the potential for adverse side effects of the medication. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 12, indicating moderately impaired cognition. She did not receive antipsychotic medication during the assessment period. The care plan for psychotropic medications, revised 03/14/24, instructed staff to monitor and report side effects from the medication. Review of the resident's EMR revealed the following physician's order: Seroquel (an antipsychotic medication), 25 milligrams (mg), by mouth (po), at bedtime (HS), for dementia and agitation, ordered 02/21/24. Review of the resident's EMR revealed an Abnormal Involuntary Movement Score (AIMS), completed on 03/14/24, with a score of zero, indicating no abnormal involuntary movement present. On 04/17/24 at 09:02 AM, Administrative Nurse D stated it was the expectation for an AIMS assessment to be completed within the first week of a new antipsychotic medication being administered. The facility lacked a policy for the completion of AIMS assessments. The facility failed to timely complete an AIMS assessment for this resident on antipsychotic medication.

The facility reported a census of 41 residents. Based on observation, interview, and record review, the facility to properly dispose of a used Fentanyl (a skin patch used to treat severe pain) after staff removed the medicated patch from Resident (R)38. Findings included: - On 04/16/24 at 10:51 AM, Licensed Nurse (LN) G removed a used Fentanyl patch (a skin patch used to treat severe pain) from the hip of Resident (R)38. After removing the patch, LN G folded the patch with the sticky side together and threw it into the trash can in the resident's room. On 04/16/24 at 10:51 AM, LN G stated she always threw the used Fentanyl patches into the trash can and was unaware the patches needed to be disposed of in a special manner. On 04/17/24 at 10:50 AM, Administrative Nurse D stated the Fentanyl patches should not be disposed of in a resident's trash can. Administrative Nurse D stated she expected the staff to dispose of the patches per facility policy. The facility policy for Receiving Pharmacy Products and Services from Pharmacy, effective 04/01/22, included: Used transdermal system should be folded so that the adhesive side of the system adheres to itself and disposed of in a trash receptacle on the medication cart in such a way to restrict access by staff, residents and visitors or staff should make the patch unusable by mixing the folded patch with an undesirable substance such as kitty litter or wet coffee grounds and place in the trash or place the folded patch in a commercially available disposal kit and disposed per package directions. The facility failed to dispose of a used Fentanyl patch in an acceptable manner.

The facility reported a census of 41 residents. Based on observation, interview, and record review, the facility failed to monitor and provide sanitary dressing change for one, Resident (R)18's venous ulcers. Findings included: - Review of Resident (R)18's electronic medical record, revealed diagnoses that included chronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) of the deep veins of the left lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues,) and paranoid (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) personality. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognitive status. The resident had no venous ulcers. The resident had no impairment in functional range of motion in her upper or lower extremities. The Pressure Ulcer Care Area Assessment (CAA), dated 02/20/24, assessed the resident at risk for skin breakdown. The Care Plan reviewed 04/11/24, instructed staff the resident received antibiotics for cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) of the left lower extremity, and to monitor for adverse effects, but lacked instruction for wound care until 04/17/24, six days later. On 04/10/24, the physician instructed staff to administer Cephalexin (an antibiotic), 500 milligrams, twice a day, for cellulitis of the left lower extremity, for ten days. A Nurse Note, dated 04/15/24 at 12:38 AM, revealed the resident had a weeping wound on her left leg and licensed nurse changed the dressing. On 04/15/24, the physician instructed staff to cleanse the left lower extremity with wound cleanser, apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin)to the resident's peri wound (area around the wound), apply Mepilex Ag (a medicated dressing with silver to aide in wound healing), and apply an Unna boot (a type of wrapped dressing infused with zinc oxide and calamine for compression to aide in the healing of vascular ulcers,) wrap with Keflex (a type of elastic gauze wrap) and ace wrap to the left lower extremity due to two blisters and weeping drainage. Staff instructed to change the Unna boot on Monday, Wednesday, Friday, and as needed, and record the wound measurements, drainage, and signs of infection. A Nurse's note, dated 04/15/24, documented mild redness to the left lower extremity and weeping wounds and 2-3 plus pitting edema. Observation, on 04/17/24 at 09:02 AM, revealed Licensed Nurse (LN) H, prepared to provide wound care to the resident's left lower extremity. LN H placed a towel on the floor and instructed the resident to place her foot on the towel. LN H placed scissors, on the towel and placed an opened paper wrapped package of multiple four by four gauze sponges and a spray bottle of wound cleanser directly on the floor beside the towel. LN H removed the wraps and revealed a yellow/red colored open area on the resident's mid lateral(outer) calf area approximately two centimeters in diameter and an area approximately two centimeters of a previous blister with pink/red coloring. LN cleansed the lower extremity with wound cleanser, dried the area, and applied the Mepilex Ag dressing to the open area and began to wrap the lower extremity with the Unna boot gauze, from the below the knee toward the foot. Interview, on 04/17/24 at 09:30 AM, with LN H, revealed the dressing supplies should be placed on a barrier. LN H stated the resident had a large amount of pitting edema prior to the Unna boot application, and the resident had two blisters previously. Interview, on 04/17/24 at 11:40 AM, with Administrative Nurse D, revealed R18 had two blisters and cellulitis on her left lower extremity prior to application of the Unna boot. Administrative Nurse D stated she would expect staff to place wound supplies on a sanitary barrier, not directly on the floor. The facility policy Wound Care Guidelines, effective 03/2023, instructed staff to establish a clean field on the resident's overbed table and ensure all clean items are on a clean field. The facility failed to ensure staff provided a sanitary dressing change to R18's lower extremity cellulitis with blisters/ulceration.

The facility reported a census of 42 residents with three residents reviewed for unnecessary medications. Based on record review and interview, the facility failed to ensure two of the three residents, Resident (R) 4 and R5 remained free of unnecessary medications when facility staff failed to provide appropriate assessment and monitoring for these residents who self-administer medications in the facility. Findings included: - R4's signed Physician Orders (PO), dated 12/29/22, documented the resident with diagnoses of gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet and episodes of acute pain), hypothyroidism (abnormally low activity of the thyroid gland resulting in metabolic changes in adults), and essential (primary) hypertension (abnormally high blood pressure that is not the result of a medical condition). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 14, or intact cognition. The resident required limited to extensive assistance of one staff member for Activities of Daily Living (ADL) and used a walker or wheelchair for mobility. The Care Plan, updated 07/21/22, advised the staff that they could leave set up medications with the resident at bedside or in the dining room. A self-administration assessment was to be performed on a quarterly basis to determine the safety of administration. The PO, dated 12/29/22, documented the following orders: 1. May leave set up medications with the resident at bedside/in dining room. Self-administration assessment to be performed on a quarterly basis to determine safety of administration. Ordered on 06/02/22. 2. Allopurinol tablet (antigout agent) 100 milligrams (mg), give 1.5 tablets by mouth one time a day related to gout, unspecified. 1.5 tabs equals 150 mg. Ordered on 04/17/22. 3. Atorvastatin Calcium (lipid-lowering agent) tablet 20 mg, give one tablet by mouth one time a day related to pure hypercholesterolemia, unspecified (too much fat in the blood). Ordered on 04/13/22. 4. Bumex tablet (diuretic) 1 mg, give 1 mg by mouth one time a day for edema (swelling caused by too much fluid trapped in the body's tissues). Ordered on 08/04/22. 5. Euthyrox tablet 1 gram (gm) (Levothyroxine Sodium) (hormone), give one tablet by mouth one time a day related to hypothyroidism, unspecified. Ordered on 04/14/22. 6. Colestipol HCI tablet (lipid [fat] lowering agent) 1 gm, give one by mouth one time a day related to essential (primary) hypertension. Ordered on 04/17/22. 7. Folate tablet 400 micrograms (mcg) (folic acid) (antianemic), give one tablet by mouth one time a day related to vitamin deficiency, unspecified. Ordered on 04/14/22. 8. Multiple vitamin tablet, give one by mouth one time a day for supplementation. Ordered on 04/14/22. 9. Omeprazole capsule delayed release 40 mg (antiulcer agent), give one capsule by mouth one time a day related to gastro-esophageal reflux (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus [the tube that connects the mouth and stomach]) disease. Ordered on 04/14/22. 10. Potassium tablet 10 milliequivalents (mEq), give one by mouth one time a day for supplement. Ordered on 10/22/22. 11. Revlimid capsule 10 mg (lenalidomide) (immune-modulator), give one capsule one time a day for 21 days on and seven days off related to multiple myeloma (cancer) not having achieved remission. Ordered on 08/17/22. 12. Magnesium Oxide tablet 400 mg, give two tablets by mouth two times a day for hypomagnesemia (lower than normal amount of magnesium in the blood). Ordered on 07/22/22. 13. Acetaminophen tablet 500 mg (non-narcotic pain reliever), give two tablets by mouth three times a day for pain. Ordered on 04/16/22. 14. Ferrous Sulfate (antianemic) tablet 325 (65-FE [iron]) mg, give one tablet by mouth for supplementation. Ordered on 04/16/22. Review of R4's electronic medical record revealed a quarterly Self-Administration Evaluation, dated 06/02/22. The record lacked a quarterly assessment for September 2022 and December 2022. Interview, on 01/05/23 at 12:51 PM, Administrative Nurse D reported that staff should complete self-administration assessments every three months with a new doctor's order put into place, but they were not being done. All residents in the facility who have been cleared for self-administration have not had an assessment since June 2022. The facility's policy for Self-Administration of Drugs F 554, effective 05/22, documented .Policy Interpretation and Implementation .13. The staff and practitioner will periodically (for example, during quarterly MDS reviews) re-evaluate a resident's ability to continue to self-administer medications . The facility failed to ensure R4 remained free of unnecessary medications when facility staff failed to provide appropriate assessment and monitoring to ensure safe administration of this resident's medications. - R5's signed Physician Orders (PO), dated 12/29/22, documented diagnoses of congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), primary pulmonary hypertension (high blood pressure in the lungs), and gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet and episodes of acute pain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status score of 15, or intact cognition. The resident required limited assistance of one staff member for Activities of Daily Living (ADL) and used a walker and wheelchair for mobility. The Care Plan, updated 06/06/22, advised the staff that they may leave set up medications with R5 at the bedside/in dining room. The PO, dated 12/29/22, documented the following orders: 1. May leave set up medications with resident at bedside/in dining room. Ordered on 10/19/20. 2. Atorvastatin Calcium (lipid [fat] lowering agent) tablet 40 milligrams (mg), give one tablet by mouth one time a day for hyperlipidemia (too much fat in the blood). Ordered on 07/13/21. 3. Bumex tablet (diuretic) 1 mg, give 1 mg by mouth one time a day for unspecified congestive heart failure. Ordered on 09/02/22. 4. Carafate tablet (Sulcrafate) (antiulcer agent), give one gram (gm) by mouth one time a day related to gastro-esophageal reflux disease. Ordered on 11/23/20. 5. Glipizide 5 mg, give 0.5 (one half) tablet by mouth one time a day for hyperglycemia (too much sugar in the blood). Administer every morning with breakfast. Ordered on 03/24/22. 6. Levothyroxine Sodium tablet 100 micrograms (mcg) (hormone), give one tablet by mouth one time a day related to hypothyroidism (abnormally low activity of the thyroid gland resulting in metabolic changes in adults), unspecified. Ordered on 04/14/22. 7. Prednisone tablet 5 mg (corticosteroid), give one tablet by mouth one time a day for arthritis. Ordered on 03/25/21. 8. Prevagen capsule (supplement for brain function), give one tablet by mouth one time a day for supplement. Ordered on 12/21/22. 9. Protonix tablet delayed release 40 mg (antiulcer agent), give one by mouth one time a day related to gastro-esophageal reflux disease. Ordered on 12/01/22. 10. Allopurinol tablet 100 mg (antigout), give one table by mouth two times a day for gout, unspecified. Ordered on 05/24/20. 11. Eliquis tablet 5 mg (blood thinner), give one tablet by mouth two times a day related to acute embolism (blood clot) and thrombosis of unspecified deep veins of the left lower extremity. Ordered on 05/24/20. 12. Sotalol HCI 80 mg (antihypertensive), give 40 mg by mouth two times a day related to essential (primary) hypertension (abnormally high blood pressure that is not the result of a medical condition). Give one-half tablet to equal 40 mg. Ordered on 05/24/20. Review of the resident's electronic medical record revealed a quarterly Self-Administration Evaluation, dated 06/02/22. The record lacked a quarterly assessment for September 2022 and December 2022. Interview, on 01/05/23 at 12:51 PM, Administrative Nurse D reported that the assessments are supposed to be performed every three months with a new doctor's order put into place, but they were not being done. All residents in the facility who have been cleared for self-administration have not had an assessment since June 2022. The facility policy Self-Administration of Drugs F 554, effective 05/22, documented .Policy Interpretation and Implementation .13. The staff and practitioner will periodically (for example, during quarterly MDS reviews) re-evaluate a resident's ability to continue to self-administer medications . The facility failed to ensure R5 remained free of unnecessary medications when facility staff failed to provide appropriate assessment and monitoring to ensure safe administration of this resident's medications.

The facility census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure staff identified and promptly responded to signs of pain expressed by cognitively impaired Resident (R)12, when the resident had two fractured ribs and staff did not offer the resident non-pharmacological pain interventions or as needed (PRN) pain medications. Findings included: - Resident (R)12's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The assessment documented the resident had no pain. The Pain Care Area Assessment (CAA) did not trigger for the 05/18/22 assessment. The Care Plan dated 11/05/21 revealed the resident was at risk for potential alteration in comfort, related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were further directed to administer two ibuprofen 200 mg tablets, every eight hours, PRN for pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician Notes dated 05/27/22 from the Behavioral Health Unit (BHU- an area of the hospital designed specifically for providing care for reasons related to mental health.) revealed the resident had a fall this afternoon resulting in fractured ribs. CT scan (computed tomography - test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) to confirm fracture. The 06/10/22 at 07:09 PM Nursing Note revealed the resident was wandering the halls. The staff attempted several times to have the resident sit down. However, he would not sit longer than a few minutes. He yelled out help from the front lobby area near the scale. The resident was found lying on his back side in the middle of the floor. The resident stated, his stomach hurt. However, when palpating his stomach area, he denied pain. The pain was near his lower rib area. This writer assessed for injury, assessed vitals, and assessed neurological status with all documented as normal for the resident. He did respond to his name. Staff assisted the resident to the chair from the floor and assisted him back to his room. The Fall Investigation dated 06/15/22 at 06:45 PM revealed staff found the resident on the floor in the dining room. On video the resident stood, leaned over and fell . The resident was encouraged to rest when tired. Resident had a small bruise on middle of his back. Physician and guardian notified. The 07/01/2022 at 05:03 PM Nursing Note revealed CNA staff on north hall heard a crash in the front TV room. The resident was found lying on his right side in front of TV stand in the front lobby area. The partition screen surrounding the scales was knocked over on floor. The resident repeated help me, help me. The resident was tearful and sobbing. Assistance of three staff transferred the resident to a chair. PRN pain medication was given. The resident sat in front of the medication cart and south break room for visual checks. No documentation of injuries. Observation on 07/25/22 at 04:20 PM revealed the resident wandering in halls alternating between yelling and weeping loudly as he walked. Another resident came into the hall and yelled at the resident to shut his mouth, she was tired of listening to him. The resident continued to walk without acknowledging the other resident. No staff responded to situation. Observation on 07/26/22 at 03:30 PM revealed the resident continuously ambulated in the halls, leaned to one side, and cried out in pain. The resident would answer if talked to with one-word responses. Observation on 07/27/22 at 07:00 AM revealed the resident wandering by the front door with only socks on his feet and no shoes. The resident leaned to the right side crying out weeping with face drawn up as if in pain as he walked. On 07/27/22 from 08:00 AM to 11:00 AM the resident continuously wandered throughout the facility. The resident talked louder as he continued to walk and would stop and scream out in pain at times. No staff intervention was noted. Interview on 07/27/22 at 11:00 AM CNA F reported the resident leaned to the side since he came back from the behavior unit. He fell while at the BHU and broke two ribs. She did not know if he leaned because they hurt, but he would cry out and hunch down when walking. Interview on 07/28/22 12:00 PM LN C regarding the assessments for residents with pain on residents that are non-verbal, like R12 they would monitor for yelling, bending over in pain, and they would use the facial scale and give the medication appropriately. Interview on 07/27/22 at 12:10 PM Administrative Nurse B verified the resident demonstrated pain in the area of his fractured ribs and further verified the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure staff identified and promptly responded to signs of pain expressed by cognitively impaired Resident (R)12, when the resident had two fractured ribs and staff did not offer the resident non-pharmacological pain interventions or as needed (PRN) pain medications.

The facility census totaled 43 residents with 12 residents included in the sample. Based on interview and record review the facility failed to provide a bed hold notification with each facility-initiated hospital transfer. (Resident (R)39) Findings included: - R39's medical record revealed a facility-initiated hospitalization transfer on 07/26/22. R39's medical record lacked evidence of a Bed Hold policy notification to the resident or resident representative. Interview with Administrative Staff L on 07/27/22 at 07:10AM revealed the facility did not give Bed Hold notification forms to the resident or resident representative upon transfer to the hospital. Review of the 05/2022 Bed Hold policy revealed the purpose of the policy was to provide residents and family members/legal representatives information upon transfer to the hospital or upon any medical/therapeutic leave. The policy noted every resident had the right to be informed of the bed hold policy. The facility failed to provide a bed hold notification at the time of R39's facility-initiated hospital transfer.

The facility reported a census of 43 residents, with 12 in the sample. Based on interview and record review the facility failed to complete a significant change comprehensive assessment for Resident (R)33. Findings included: - R33's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/27/21 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R33 had no behaviors and required limited assistance of one staff with all Activities of Daily Living (ADL). The 03/29/22 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition. R33 required limited assistance of one staff for ADL's. The 06/29/22 Quarterly MDS documented a BIMS of 00, indicating severely impaired cognition. R33 had verbal behaviors and rejection of care one to three days of the seven-day look back period. R33 required limited assistance of two staff for transfers and limited assistance of one staff for all other ADL's. R33 had impairment on one side of his body and had two or more injury falls. The record revealed no significant change MDS assessment completed between the 03/29/22 and 06/29/22 quarterly MDS assessments. Observation on 07/26/22 at 07:05 AM R33 sat in his wheelchair self-propelling out of his room, with a strong odor of urine about him. At 07:10 AM Certified Nurse Aid (CNA) H and CNA E returned R33 to his room, cleaned, and changed him. On 07/28/22 at 12:00 PM Administrative Nurse B stated she expected the assessments to be completed accurately and in a timely manner. On 08/01/22 at 01:15 PM Administrative Staff A reported that the remote MDS Coordinator had access to all medical records to complete the assessments. Before completion, the regional nurse checked the MDS assessments for accuracy. The facility used the Resident Assessment Instrument (RAI) manual to complete the assessments. The facility's 05/2022 Comprehensive Assessment policy documented that a comprehensive assessment would be completed with defined significant change. The facility failed to complete a comprehensive assessment after a significant change for R33.

The facility reported a census of 43 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to include the use of oxygen (O2) for R27. Findings included: - The 07/02/22 signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 03/20/22 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) revealed a score of 12, indicating moderate cognitive impairment. The MDS did not note the resident's oxygen therapy. The Care Plan dated 04/24/2020 revealed R27 had [CONDITION(S)] related to a history of smoking. The staff were to monitor R27 for difficulty breathing on exertion and monitor for signs and symptoms of acute respiratory insufficiency. The care plan lacked use of O2 therapy on the care plan. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/25/22 at 12:37 PM, R27 had oxygen on and running at two liters, per nasal cannula. Interview with Certified Nurse Aide (CNA) H on 07/25/22 at 01:45 PM revealed R27 always wore oxygen. On 07/27/22 at 03:00 PM revealed Licensed Nurse (LN) C did not know the care plan did not include R27's oxygen use, which ran at two liters per nasal cannula. On 07/27/22 at 01:45 PM, Administrative Nurse B verified R27 had received O2 and the care plan did not include the O2 use for R27. The Oxygen Administration policy dated 06/21 verified that oxygen therapy would be on the resident care plan. The facility failed to develop a care plan for the use of O2 for R27.

The facility reported a census of 43 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to update the care plan to include fall prevention interventions for Resident (R)12 and R33. Findings included: - R33's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/27/21 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition and documented R33 had no falls. The 03/29/22 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition and documented R33 had no falls. The 07/26/22 Care Plan documented that staff were to toilet R33 every two hours and as needed. The Fall Investigations for 06/17/22 and 07/04/22 documented an intervention for staff to toilet R33 every hour, to prevent further falls. The Care Plan lacked the updated fall prevention interventions from 06/17/22 an d07/04/22 to toilet the resident every hour. On 07/26/22 at 07:05 AM, R33 sat in his wheelchair and self-propelled out of his room, with a strong odor of urine about him. At 07:10 AM Certified Nurse Aid (CNA) H and CNA E returned R33 to his room, cleaned, and changed him. On 07/27/22 at 03:00 PM, Licensed Nurse (LN) C revealed R33 fell most frequently from his chair due to leaning forward. On 07/28/22 at 12:00 PM Administrative Nurse B stated she expected the care plans to be updated in a timely manner. The facilities 05/2022 Care Plans- Comprehensive documented each resident's comprehensive care plan was based on a thorough ongoing assessment of the resident and were revised as information about the resident, and the resident's condition, changed and would incorporate identified problem areas. The facility failed to update R33's care plan with fall interventions to prevent falls for R33. - R12's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/18/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS documented R12 had two or more non-injury falls and two or more injury falls since the prior assessment. The 06/10/22 Five Day MDS documented a BIMS of 00. R12 had one non-injury fall since readmission. The 05/27/21 Care Plan documented R12 was at risk for injuries related to multiple falls and lacked updated interventions related to the falls experienced by R12 on 06/19/22, 06/25/22, and 07/01/22. Review of the Fall Investigations and Nurse Notes dated 06/19/22, 06/25/22 at 06:45 PM, and 07/01/22 at 05:00 PM documented R12 fell with no major injuries noted. Observation on 07/27/22 at 07:00 AM revealed the resident leaned to his right side as he wandered by the front door with only socks on his feet and no shoes. On 07/27/22 at 01:30 PM Licensed Nurse C reported the resident paced all the time with little rest. He paced until he was exhausted and that led to the resident falling. Interview on 07/27/22 at 12:10 PM Administrative Nurse B revealed she expected the care plan to be updated whenever there was an incident and interventions on the care plan followed. The facilities 05/2022 Falls and Fall Prevention policy documented staff would identify interventions related to the resident's specific risks and causes of falls to try to prevent the resident from falling. The facility failed to update R12's care plan with fall interventions to prevent further falls for R12.

The facility census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure the fall prevention interventions were implemented to prevent further falls for Resident (R)12 and R33. Findings included: - R12's pertinent diagnoses from the Electronic Health Record (EHR) documented: Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), [CONDITION(S)] disorders ([CONDITION(S)] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder ), dementia with behavioral disturbance (major mood disorder), unsteadiness on feet, and tremors (involuntary movements of arms and legs). The 05/18/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. R12 had two or more falls non injury and two or more injury falls since prior assessment. The 06/10/22 Five Day MDS documented a BIMS of 00. R12 had falls since admit/ prior assessment and one non injury fall. The 05/27/21 Care Plan documented R12 was at risk for injuries related to multiple falls and lacked updated interventions related to the falls experienced by R12 on 06/19/22 06/25/22, and 07/01/22. Review of the Fall Investigations and Nurse Notes dated 06/19/22, 06/25/22 at 06:45 PM, and 07/01/22 at 05:00 PM documented R12 fell with no major injuries noted. Observation on 07/27/22 at 07:00 AM revealed the resident leaned to his right side as he wandered by the front door with only socks on his feet and no shoes. On 07/27/22 from 08:00 AM to 11:00 AM the resident wandered throughout the facility. The resident talked as he walked leaning to the right side as he walked. The resident talked louder as he continued to walk and would stop and scream at times. No staff intervention was noted. Interview on 07/27/22 at 11:00 AM Certified Nurse Aide (CNA) F reported the resident had leaned to that side since he came back from the behavior unit where he fell and broke two ribs. She did not know if he leaned while walking because they hurt or why he was leaning, but he would cry out and hunch down when walking. Interview on 07/27/22 at 12:10 PM Administrative Nurse B revealed she expected the care plan to be updated whenever there was an incident and interventions on the care plan followed. The facilities 05/2022 Falls and Fall Prevention policy documented that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling The staff will monitor and document the resident's response to interventions intended to reduce falling or the risks of falling. The facility failed to follow planned interventions and provide supervision to prevent further falls for R12. - R33's pertinent diagnoses from the Electronic Health Record (EHR) documented: repeated falls and dementia (progressive mental disorder characterized by failing memory, confusion). The 12/27/21 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident required limited assistance of one staff for all activities of daily living (ADLs) and documented R33 had no falls. The 03/29/22 Quarterly MDS documented a BIMS of 10, indicating moderately impaired cognition and documented R33 had no falls. The 04/21/21 Care Plan for R33 documented staff would place a solid seat support in R33's wheelchair anytime R33 used it. The fall investigations from 06/04/22 through 07/21/22 documented six falls for R33. Observation on 07/27/22 at 08:39 AM revealed R33 had no solid seat support in his wheelchair. Observation on 07/28/22 at 08:15 AM revealed R33 sat in his wheelchair in the dining room with no solid seat support in his wheelchair. Observation of R33's room revealed solid seat support laid on his bed and not in R33's wheelchair as care planned. On 07/26/22 at 09:00 AM Certified Nurse Aid (CNA) H revealed waiting on a special cushion for R33's chair. On 07/27/22 at 03:00 PM Licensed Nurse (LN) C revealed the staff were waiting on the wedge cushion to arrive for R33. On 07/28/22 at 12:00 PM Administrative Staff B confirmed the wedge cushion arrived and they made several attempts to place it in R33's wheelchair with no success and stated they were waiting to catch him out of his chair to place the cushion. The facilities 05/2022 Falls and Fall Prevention policy documented that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling The staff will monitor and document the resident's response to interventions intended to reduce falling or the risks of falling. The facility failed to implement care planned fall precaution interventions to prevent falls for R33.

The facility reported a census of 37, with three residents sampled for cardiopulmonary resuscitation (CPR, emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning). Based on interview and record review the facility failed to have an effective code system in place when staff failed to implement CPR on a non-responsive full code Resident (R)1 on [DATE] at 02:20 AM, which placed R1 in immediate jeopardy. Findings included: - The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The [DATE] Care Plan, revised [DATE], indicated R1 and R1's family desired a full code status for R1. The CNA Resident Care Plan Summary reviewed on [DATE] indicated R1 was a full code resident. Review of R1's medical chart lacked evidence of an Advance Directive (a written document which indicated the medical decisions for health care professionals when the person could not speak). The facility reported incident investigation #2193 submitted to the Kansas Department for Aging and Disability Services revealed on [DATE] at 02:26 AM Certified Nurse Aide (CNA) F found R1 unresponsive and contacted the charge nurse. Licensed Nurse (LN) C and LN D entered R1's room and found the resident was cold, with no pulse or heart rate, no breath sounds, and his fingernails appeared to be cyanotic (bluish/purple discoloration to the skin due to lack of oxygen in the blood). The documentation noted Administrative Nurse B informed the family of R1's unexpected death. The investigation revealed staff had not placed a green dot on R1's door to indicate R1 was a full code status resident, and nursing staff failed to follow through with R1's admission checklist, which included code status. The [DATE] signed witness statement by CNA F revealed on [DATE] at 02:00 AM CNA F found R1 not breathing and left the room immediately to get Licensed Nurse (LN) C and LN D. The nurses asked CNA F to get the vital sign machine and return to R1's room. LN C and LN D assessed R1, did not start CPR, and left the room to contact the physician. The signed witness statement by LN C dated [DATE] revealed LN C checked on R1 around 09:30 PM to 10:00 PM on the evening of [DATE] and at that time R1 did not have any complaints of pain or discomfort. LN C repositioned R1 to the right-side and noted R1's respirations were non-labored, his lungs sounded clear, and his oxygen saturation level was at 98 percent. At 02:20 AM CNA F reported R1 was not breathing and upon assessing R1, noted he was unresponsive, cold to the touch, with no respirations, no pulse, no heart sounds, and no lung sounds. The signed witness statement dated [DATE] by LN D revealed on [DATE] at approximately 02:25 AM, CNA D asked for assistance in R1's room because they thought the resident was no longer with us. LN D entered R1's room and noted the resident was pale, with no respirations, did not blink, nail beds were cyanotic, and no pulse found. LN D noted R1's face, chest, and extremities were cool to the touch and noted she thought the report sheet indicated R1 was a DNR (Do Not Resuscitate). Interview with CNA F on [DATE] at 07:30 PM indicated she saw R1 at 12:00 AM to reposition R1 and he did not complain of any issues of pain or discomfort. She said R1 did not have any issues with breathing at that time and he stated he felt fine. During her 02:00 AM rounds, CNA F walked into his room, noticed R1 was not breathing, and found he was unresponsive. She notified the nurses on duty. CNA F stated she did not know R1's code status and if she had known he was a full code, she would have started CPR. Interview on [DATE] at 06:20 PM with LN C revealed at the start of her shift on [DATE] R1 did have some difficulty with breathing. LN E placed oxygen on R1 at two liters per minute by nasal cannula and LN C repositioned the resident. At 02:25 AM CNA F told LN C that R1 was not breathing. When LN C entered his room, R1 was cold to the touch, gray in color, had no pulse or respiration. LN C stated she had no idea how long he had been gone and reported the code status for residents was located on the report sheet. Interview on [DATE] at 08:32 AM with LN D revealed upon finding R1 on [DATE] his body was cold, greyish in color, his nailbeds were purple in color, no respiration or pulse noted, indicating R1 had been gone for a while. LN D said the facility did have a system in place for full code and DNR status, prior to this incident, explaining a green dot placed on the door indicated a full code status. LN D stated the resident's code status was also posted behind the door in the nurse's station and on the report sheet. Interview on [DATE] at 03:49 PM with Administrative Nurse B regarding code status indicated she expected staff to perform CPR for a full code resident and contact emergency medical services. The facilities policy Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) dated ,d+[DATE] revealed the community staff certified in CPR would provide basic life support including CPR to residents requiring such an emergency, prior to the arrival of emergency medical personnel, and subject to related physicians' orders and the resident's advance directive. If a resident was found unresponsive and not normally breathing, a licensed staff person who was certified in CPR should initiate CPR, unless there are obvious signs of irreversible death such as rigor mortis (the stiffening of the joints and muscles of a body after death). On [DATE] at 01:52 PM Administrative Staff A and Administrative Nurse B were provided the IJ template and notified that the facility failure to have an effective system in place when staff did not initiate CPR on a non-responsive full code resident R1 on [DATE], placed the resident in immediate jeopardy. The facility implemented the following implemented the following actions on [DATE], which the surveyor verified while onsite: 1. Reeducated current licensed nurse on documentation of code status upon admission. 2. Reeducated nursing staff regarding code status per resident's request 3. Reeducated current CPR staff and nursing department on location of DNR status. 4. Reeducated nursing staff regarding finding a resident unresponsive and initiation of full code, as applicable. 5. Audited all current code status, name placard, and care plans. 6. Education to non-nursing staff on appropriate response to unresponsive resident. 7. Mock codes will be completed over the next 30 days and conducted by Administrative Staff 8. Weekly audit of all code status on current residents. 9. Current list of CPR Certified staff will be audited monthly, and a class scheduled as needed. 10. Daily audits of the green dot system conducted by Administrative Staff during the week and by nursing staff on weekends. 11. The green dot audit verified the implementation of the audit and all green dot code status stickers were correct for resident's code status. Due to the facilities corrective actions put into place on [DATE] the deficiency was deemed past non-compliance and existed at a J scope and severity.

The facility census totaled 44 residents. Based on observation, interview, and record review, staff failed to inform administration about violations regarding social media postings on 2 separate instances. The first incident involved resident #1 who direct care staff J video recorded displaying undesirable behaviors and texted it to another staff member. Other staff was present in the room and observed staff J had his/her phone in hand in the resident's room and did not report it to administration. Staff H, who received the video failed to report receiving a video of resident #1. Direct care staff J posted a picture of resident #5's hand on a social media site where at direct care staff C saw it. Staff C failed to report the photo to administration. The failure of staff to report to administration led to the failure to protect residents from further potential mental abuse or humiliation, which placed all residents in the facility in immediate jeopardy. Findings included: - Review of facility provided documents related to an incident, which occurred on 8/13/17 in which direct care staff H videotaped resident #1 while in the dining area with a dog faced filter in front of his/her face and told the resident to bark which was then uploaded to a social media site. Licensed staff K was informed of the video by his/her family and staff K immediately notified administrative nursing staff A on 8/14/17. During the investigation into the alleged abuse and violation of personal privacy by direct care staff H, staff A discovered another incident. Staff H stated he/she received a video of resident #1 from direct care staff J, he/she believed around 8/4/17, showing the resident engaging in negative behaviors by hitting direct care staff E. Direct care staff J reported during his/her interview, that yes he/she did send a video of resident #1 roaring at a stuffed animal to staff H. During the investigation into staff J, direct care staff C reported he/she had seen a picture of resident #5's hand, which he/she could identify due to the jewelry, on staff J's social media page. None of these incidents were reported to administrative personnel when they happened. Review of an undated notarized witness statement from direct care staff H revealed : approximately on August 4th (staff J) and (staff E) were in a residents room, while (staff E) provided care, (staff J) sent a video of him/her and the resident off a snapchat, that showed the resident hitting (staff E) and them laughing. Review of an undated notarized witness statement from direct care staff J revealed: on 8/11/17 I did send a video of resident to another aid but only to that aid. (Staff E) was in the video. The video was not saved or anything. Interview with direct care staff C on 8/23/17 at 3:34 PM revealed he/she saw on direct care staff J's social media page a picture of staff J holding resident #5's hand with the caption that said something about enjoying the simple things in life. Staff C reported the only reason he/she thought it was a resident's hand because of some identifiable jewelry in the picture. He/she could not recall exactly when he/she saw the picture on the social media site but knew it was staff J's social media site. He/she did not know for sure if it was against the rules because the resident's face was not visible so he/she did not report it. Staff C stated after the recent face-to-face training provided by the facility, he/she should have reported it. Interview with direct care staff E on 8/24/17 at 10:34 AM revealed he/she did not know he/she had been in a video sent to direct care staff H. Staff E reported he/she remembered placing resident #1 in bed and he/she noted staff J had his/her phone out. He/she did not know staff J video-taped or photographed him/her. He/she stated staff J always had his/her phone out texting and was the shift leader, so he/she did not say anything. Interview with administrative nurse A on 8/29/17 at 12:47 PM revealed he/she would have expected all staff to report any allegation of abuse/social media/pictures immediately to protect the residents. He/she also expected staff to not have their phones on their person in resident care areas. Staff A reported if direct care staff would have reported any of those instances, then the facility would have suspended the staff in question until their investigation had been complete. Review of the facility policy titled Reporting Abuse to Facility Management, revised 8/2016, revealed mental abuse included photographing or recording a resident in a demeaning or humiliating way regardless of consent or cognitive status. All employees were required to immediately report any suspected abuse or incidents of abuse to their direct supervisor and/or administrator. Review of the facility policy titled Abuse Investigation, revised 8/16, revealed employees of the facility accused of resident abuse were suspended pending investigation. The facility failed to ensure staff reported 3 social media incidents to administrative staff to prevent further potential abuse of residents. This deficient practice placed all 44 residents in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 8/15/17 when the facility implemented re-education of all staff, on the facility's abuse policies on screening, training, prevention, identification, protection, reporting to facility management and to the State along with the facility cell phone policy.

The facility census totaled 44 residents with 3 residents included in the sample. Based on observation, interview, and record review, the facility failed to ensure personal privacy for 2 of 3 residents (#1 and #5) when direct care staff H and J took their picture and/or videos, without consent, posted them to a social media site and electronically sent them via text message to other staff. This deficient practice placed resident #1 and #5 in immediate jeopardy. Findings included: - Review of resident #1's pertinent [DIAGNOSES REDACTED]. to process information, communicate, walk, and their senses) and [MEDICAL CONDITION] (brain disorder characterized by repeated [MEDICAL CONDITION]). Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired daily decision making. He/she required extensive two-person assist for bed mobility, transfers, dressing, and toilet use. Review of the quarterly MDS dated [DATE] revealed no change in cognition or activities of daily living (ADLs) from MDS assessment dated [DATE]. Review of the cognitive loss care area assessment (CAA) dated 1/31/17 revealed the resident had a history of [REDACTED]. Per the family, the resident's cognition had declined over the years along with the emergence of behaviors making it difficult to care for him/her at times. The resident could answer yes/no questions with much effort. The resident's mood could be unpredictable at times, especially when providing pericare and bathing. Review of the facility investigation, signed on 8/16/17, revealed that approximately 8/13/17, staff H sat by resident #1 in the dining room and started to record the resident with his/her phone. Staff H then added a dog filter to the videotape and advised the resident to bark. He/she then posted the video to a social media site, where a family member of licensed nursing staff K saw the video and alerted staff K. Staff K then alerted administrative nursing staff A, who began the investigation. During the interview, direct care staff H revealed he/she received a video via text message from direct care staff J which showed resident #1 roaring at his/her stuffed animal. Administrative staff G and A interviewed direct care staff J, who admitted to sending the video. Review of an undated notarized statement from direct care staff H revealed he/she sat with resident #1 at the dining room table and superimposed a filter with dog-ears over the resident, told the resident to bark and the resident replied with a ruff noise. Review of an undated notarized statement from direct care staff H revealed on approximately August 4th, 2017, he/she received a video text message from direct care staff J. The event revealed direct care staff E provided care to resident # 1, and direct care staff J sent a video of resident #1 hitting direct care staff E and laughing about it. Attempts to reach direct care staff H for further questions were unsuccessful on 8/24/17 at 8:43 AM, 8/24/17 at 10:48 AM, and 8/28/17 at 7:55 AM. Review of an undated notarized witness statement written by direct care staff J revealed he/she did send a video of resident #1 on 8/11/17 to another facility employee. Attempts to contact direct care staff J for further questions were unsuccessful on 8/24/17 at 8:46 AM, 8/24/17 at 10:47 am, and 8/28/17 at 7:58 AM. Observation of the resident on 8/23/17 at 1:42 PM revealed the resident laid in his/her bed with a stuffed lion lying next to him/her. The resident could not answer yes/no questions and replied with a high-pitched unidentifiable sound. Interview with direct care staff E on 8/24/17 at 10:34 AM revealed he/she did not know he/she had been in a video sent to direct care staff H. Staff E reported he/she remembered placing resident #1 in bed and staff J had his/her phone out. He/she did not know he/she was being videoed or photographed. He/she stated staff J always had his/her phone out texting and was the shift leader, so he/she did not say anything. Interview with licensed nursing staff K on 8/23/17 at 1:15 PM revealed he/she had received a message from his/her relative who recognized resident #1's face, even with the dog face filter covering the resident's face, on direct care staff H's social media site. Staff K reported the video included telling the resident to bark. The family member was concerned about it which it why he/she contacted the staff member. Staff K did not see the video, however, he/she immediately called the administrative nursing staff A and advised administration of what his/her family reported. An interview with administrative nursing staff A on 8/23/17 at 2:32 PM revealed licensed nursing staff K notified him/her of the video on 8/14/17 in the morning. He/she immediately went to the administrator and advised him/her of the situation. Administrative staff G called staff H into the facility and obtained a statement in which staff H admitted to taking the video and posting it to a social media site. During that interview, staff H revealed he/she received a text message with a video, of resident #1 hitting staff E, from staff J. Interview with administrative staff G on 8/24/17 at 3:35 PM confirmed the following sequence of events: On 8/14/17, a family member notified licensed nursing staff K of seeing resident #1's video with a dog face over the residents face, telling him/her to bark, on direct care staff H's social media page. Staff K called the facility and notified administrative nursing staff A on 8/14/17 at approximately 8:50 AM, who then notified staff G. The administrative staff G called staff H into the facility, interviewed him/her, and obtained his/her statement. During that interview, staff H revealed he/she had received a video via text from direct care staff J containing resident #1 hitting another staff member. Administrative staff G called in staff J, interviewed him/her, and obtained his/her statement. Both staff H and staff J were immediately suspended and then terminated from employment on 8/15/17. Review of the facility policy titled Use of Personal Cell/Smart Phones, Recording Devices, revised 8/2016, directed resident photographs would not be taken without the residents expressed written consent. Employees were not to keep personal communication devices on them during work times. Review of the facility policy titled Privacy, Videotaping, Photographing, and Other Imaging of Residents, revised 8/16, revealed the residents would not be subjected to the taking of unauthorized photographs or recordings. Resident photographs were considered health care records and would be retained and released in accordance with the current applicable regulations and statutes governing the release of protected health information. The facility failed to maintain resident #1's privacy after staff obtained pictures and/or video of the resident without his/her consent. This deficient practice placed residents #1 and #5 in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 8/15/17 when the facility implemented re-education of all staff, on the facility's abuse policies on screening, training, prevention, identification, protection, reporting to facility management and to the state along with the facility cell phone policy. - Review of resident #5's significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 2, which indicated severe cognitive impairment. The resident required extensive 2-person assist for bed mobility, locomotion on/off unit, dressing, eating, and personal hygiene. He/she was totally dependent on 2 staff for transfers and toilet use. Review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired daily decision making. The resident required extensive 1 person assist for bed mobility, locomotion on/off the unit, dressing, eating and personal hygiene. He/she required extensive 2-person assist for toileting and transfers. Review of the cognitive loss area assessment (CAA) dated 1/6/17 revealed the resident was cognitively impaired and hard of hearing. Staff used a white board (explain) to communicate with the resident. Review of the activities CAA dated 1/6/17 revealed the resident was alert and had cognitive impairment along with hearing difficulty. The resident was dependent on staff for activity involvement and staff set up a game of dominoes for the resident and his/her spouse nightly. Review of the facility staff interviews obtained on 8/14/17, during their investigation into a concern regarding a different resident, revealed direct care staff C reported he/she saw a resident's hand in an employee's hand posted on a social media site. Interview with direct care staff C on 8/23/17 at 3:34 PM revealed he/she saw on direct care staff J's social media page a picture of staff J holding resident #5's hand with the caption that said something about enjoying the simple things in life. Staff C reported the only reason he/she thought it was a resident's hand was because of some identifiable jewelry in the picture. He/she could not recall exactly when he/she saw the picture on the social media site but knew it was staff J's social media site. Attempts to contact direct care staff J were unsuccessful on 8/24/17 at 8:46 AM, 8/24/17 at 10:47 AM and 8/28/17 at 7:58 AM. An interview with administrative nursing staff A and administrative staff G on 8/24/17 at 8:32 AM revealed, staff H reported he/she received a text message with a video from staff J regarding resident #1. During the investigation into the allegation, administration asked all staff if they had ever seen any of the residents on social media. Direct care staff C reported thinking he/she saw resident #5's hand on staff J's social media page. He/she could not provide the time he/she saw the picture however. Staff J had already been suspended at that time with the intent of terminating his/her employment and Resident #5 passed away. Review of the facility policy titled Use of Personal Cell/Smart Phones, Recording Devices, revised 8/16, directed resident photographs would not be taken without expressed written consent. Employees were not to keep personal communication devices on them during work times. Review of the facility policy titled Privacy, Videotaping, Photographing, and Other Imaging of Residents, revised 8/16, revealed the resident would not be subjected to the taking of unauthorized photographs or recordings. Resident photographs were considered health care records and would be retained and released in accordance with the current applicable regulations and statutes governing the release of protected health information. The facility failed to maintain resident #5's privacy after staff obtained and posted on social media pictures of the resident without his/her consent. This placed residents #1 and #5 in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 8/15/17 when the facility implemented re-education of all staff, on the facility's abuse policies on screening, training, prevention, identification, protection, reporting to facility management and to the State along with the facility cell phone policy.

The facility census totaled 44 residents with 3 residents included in the sample. Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (#1 and #5) were free from potential mental abuse when direct care staff H videotaped resident #1 with a dog faced filter over his/her face and told the resident to bark and again when direct care staff J texted a video of the resident displaying behaviors to another staff member. Direct care staff J posted a picture of resident #5's hand with identifiable jewelry onto his/her personal social media page. This deficient practice placed residents #1 and #5 in immediate jeopardy. Findings included: - Review of resident #1's pertinent [DIAGNOSES REDACTED]. to process information, communicate, walk, and their senses) and [MEDICAL CONDITION] (brain disorder characterized by repeated [MEDICAL CONDITION]). Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired daily decision making. He/she required extensive two-person assist for bed mobility, transfers, dressing, and toilet use. Review of the quarterly MDS dated [DATE] revealed no change in cognition or activities of daily living (ADLs) from MDS assessment dated [DATE]. Review of the cognitive loss care area assessment (CAA) dated 1/31/17 revealed the resident had a history of [REDACTED]. Per the family, the resident's cognition had declined over the years along with the emergence of behaviors making it difficult to care for him/her at times. The resident could answer yes/no questions with much effort. The resident's mood could be unpredictable at times, especially when providing pericare and bathing. Review of the facility investigation, signed on 8/16/17, revealed that approximately 8/13/17, staff H sat by resident #1 in the dining room and started to record the resident with his/her phone. Staff H then added a dog filter to the videotape and advised the resident to bark. He/she then posted the video to a social media site, where a family member of licensed nursing staff K saw the video and alerted staff K. Staff K then alerted administrative nursing staff A, who began the investigation. During the interview, direct care staff H revealed he/she received a video via text message from direct care staff J which showed resident #1 roaring at his/her stuffed animal. Administrative staff G and A interviewed direct care staff J, who admitted to sending the video. Review of an undated notarized statement from direct care staff H revealed he/she sat with resident #1 at the dining room table and superimposed a filter with dog-ears over the resident, told the resident to bark and the resident replied with a ruff noise. Review of an undated notarized statement from direct care staff H revealed on approximately August 4th, 2017, he/she received a video text message from direct care staff J. The event revealed direct care staff E provided care to resident # 1, and direct care staff J sent a video of resident #1 hitting direct care staff E and laughing about it. Attempts to reach direct care staff H for further questions were unsuccessful on 8/24/17 at 8:43 AM, 8/24/17 at 10:48 AM, and 8/28/17 at 7:55 AM. Review of an undated notarized witness statement written by direct care staff J revealed he/she did send a video of resident #1 on 8/11/17 to another facility employee. Attempts to contact direct care staff J for further questions were unsuccessful on 8/24/17 at 8:46 AM, 8/24/17 at 10:47 am, and 8/28/17 at 7:58 AM. Observation of the resident on 8/23/17 at 1:42 PM revealed the resident lay in his/her bed with a stuffed lion lying next to him/her. The resident could not answer yes/no questions and replied with a high-pitched unidentifiable sound. During an interview with resident #6 on 8/23/17 at 1:43 PM, whom the facility had identified as alert and orientated, revealed he/she hated having his/her picture taken and would have kicked any one that would have tried. He/she stated the pictures made him/her feel bad. Interview with direct care staff D on 8/28/17 at 9:05 AM revealed he/she would find it embarrassing if someone he/she did not know or took a picture or video he/she did not give consent for with that (dog-ear) filter, and placed it on a social media site. He/she stated it would have been the same if he/she was in a resident's room and the video and/or pictures were being texted of care being provided to the resident. Interview with direct care staff I on 8/28/17 at 9:10 AM revealed, he/she would find it disturbing if someone he/she did not know posted pictures of him/her a social media site. He/she stated they would have been horrified if he/she found out his/her picture and/or a video had been obtained and texted to someone while in a resident's room. Interview with direct care staff E on 8/24/17 at 10:34 AM revealed he/she did not know he/she had been in a video sent to direct care staff H. Staff E reported he/she remembered placing resident #1 in bed and direct care staff J had his/her phone out. He/she did not know he/she was being videoed or photographed. He/she stated staff J always had his/her phone out texting and was the shift leader, so he/she did not say anything. Interview with licensed nursing staff K on 8/23/17 at 1:15 PM revealed he/she had received a message from his/her relative who recognized resident #1's face, even with the dog face filter covering the resident's face, on direct care staff H's social media site. Staff K reported the video included telling the resident to bark. The family member was concerned about it which it why he/she contacted the staff member. Staff K did not see the video, however, he/she immediately called the administrative nursing staff A and advised administration of what his/her family reported. An interview with administrative nursing staff A on 8/23/17 at 2:32 PM revealed licensed nursing staff K notified him/her of the video on 8/14/17 in the morning. He/she immediately went to the administrator G and advised him/her of the situation. Administrative staff G called direct care staff H into the facility and obtained a statement in which staff H admitted to taking the video and posting it to a social media site. During that interview, staff H revealed he/she received a text message with a video, of resident #1 hitting direct care staff E, from direct care staff J. Interview with administrative staff G on 8/24/17 at 3:35 PM confirmed the following sequence of events: On 8/14/17, a family member notified licensed nursing staff K of seeing resident #1's video with a dog face over the resident's face, telling him/her to bark, on direct care staff H's social media page. Staff K called the facility and notified administrative nursing staff A on 8/14/17 at approximately 8:50 AM, who then notified staff G. The administrative staff G called staff H into the facility, interviewed him/her, and obtained his/her statement. During that interview, staff H revealed he/she had received a video via text from direct care staff J containing resident #1 hitting another staff member. Administrative staff G called in staff J, interviewed him/her, and obtained his/her statement. Both staff H and staff J were immediately suspended and then terminated from employment on 8/15/17. Review of the facility policy titled Use of Personal Cell/Smart Phones, Recording Devices, revised 8/2016, directed resident photographs would not be taken without the residents expressed written consent. Employees were not to keep personal communication devices on them during work times. Review of the facility policy titled Privacy, Videotaping, Photographing, and Other Imaging of Residents, revised 8/2016, revealed the residents would not be subjected to the taking of unauthorized photographs or recordings. Resident photographs were considered health care records and would be retained and released in accordance with the current applicable regulations and statutes governing the release of protected health information. The facility failed to ensure resident #1 remained free from potential mental abuse after staff obtained pictures and/or video of the resident without his/her consent, placed a dogface filter on the video, and directed the resident to bark like a dog. This deficient practice placed resident #1 in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 8/15/17 when the facility implemented re-education of all staff on the facility's abuse policies on screening, training, prevention, identification, protection, reporting to facility management and to the State along with the facility cell phone policy. - Review of resident #5's significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 2, which indicated severe cognitive impairment. The resident required extensive 2-person assist for bed mobility, locomotion on/off unit, dressing, eating, and personal hygiene. He/she was totally dependent on 2 staff for transfers and toilet use. Review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired daily decision making. The resident required extensive 1 person assist for bed mobility, locomotion on/off the unit, dressing, eating and personal hygiene. He/she required extensive 2-person assist for toileting and transfers. Review of the cognitive loss area assessment (CAA) dated 1/6/17 revealed the resident was cognitively impaired and hard of hearing. Staff used a white board (explain) to communicate with the resident. Review of the activities CAA dated 1/6/17 revealed the resident was alert and had cognitive impairment along with hearing difficulty. The resident was dependent on staff for activity involvement and staff set up a game of dominoes for the resident and his/her spouse nightly. Review of the facility staff interviews obtained on 8/14/17, during their investigation into a concern regarding a different resident, revealed direct care staff C reported he/she saw a resident's hand in an employee's hand posted on a social media site. During an interview with resident #6 on 8/23/17 at 1:43 PM, whom the facility had identified as alert and orientated, revealed he/she hated having his/her picture taken and would have kicked any one that would have tried. He/she stated the pictures made him/her feel bad. Interview with direct care staff D on 8/28/17 at 9:05 AM revealed he/she would find it embarrassing if someone he/she did not know or took a picture or video he/she did not give consent for with that (dog-ear) filter, and placed it on a social media site. He/she stated it would have been the same if he/she was in a resident's room and the video and/or pictures were being texted of care being provided to him/her. Interview with direct care staff I on 8/28/17 at 9:10 AM revealed, he/she would find it disturbing if someone he/she did not know posted pictures of him/her a social media site. He/she stated they would have been horrified if he/she found out his/her picture and/or a video had been obtained and texted to someone while in a resident's room. Interview with direct care staff C on 8/23/17 at 3:34 PM revealed he/she saw on direct care staff J's social media page a picture of staff J holding resident #5's hand with the caption that said something about enjoying the simple things in life. Staff C reported the only reason he/she thought it was a resident's hand was because of some identifiable jewelry in the picture. He/she could not recall exactly when he/she saw the picture on the social media site but knew it was staff J's social media site. Attempts to contact direct care staff J were unsuccessful on 8/24/17 at 8:46 AM, 8/24/17 at 10:47 AM and 8/28/17 at 7:58 AM. An interview with administrative nursing staff A and administrative staff G on 8/24/17 at 8:32 AM revealed, staff H reported he/she received a text message with a video from staff J regarding resident #1. During the investigation into the allegation, administration asked all staff if they had ever seen any of the residents on social media. Direct care staff C reported thinking he/she saw resident #5's hand on staff J's social media page. He/she could not provide the time he/she saw the picture however. Staff J had already been suspended at that time with the intent of terminating his/her employment and Resident #5 passed away. Review of the facility policy titled Use of Personal Cell/Smart Phones, Recording Devices, revised 8/16, directed resident photographs would not be taken without expressed written consent. Employees were not to keep personal communication devices on them during work times. Review of the facility policy titled Privacy, Videotaping, Photographing, and Other Imaging of Residents, revised 8/16, revealed the resident would not be subjected to the taking of unauthorized photographs or recordings. Resident photographs were considered health care records and would be retained and released in accordance with the current applicable regulations and statutes governing the release of protected health information. The facility failed to maintain resident #5's privacy after staff obtained and posted on social media pictures of the resident without his/her consent. This placed residents #5 in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 8/15/17 when the facility implemented re-education of all staff, on the facility's abuse policies on screening, training, prevention, identification, protection, reporting to facility management and to the State along with the facility cell phone policy.

Citation Text for Tag 0323, Regulation FF09 Schiffelbein, Carol The facility had a census of 41 residents with 6 residents selected for sample. One sampled resident experienced a fracture within the previous 60 days. Based on observation, interview and record review, the facility failed to provide Resident #1 with adequate supervision and assistive devices (securing of all safety straps during transportation in the facility van/bus, ensuring transportation staff received adequate education prior to transportation of resident) to prevent accidents. Direct Care Staff C lacked evidence of adequate training in transportation procedures prior to assignment as the facility van/bus driver. On 4/7/16, Staff C failed to secure all safety straps and latches to secure resident #1's wheelchair during a transfer. When the van driver turned a corner, the wheelchair tipped over and the resident sustained [REDACTED]. Findings included: - Resident #1's clinical record included 5/24/16 signed physician's orders [REDACTED]. The 4/4/16 Admission MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 15), the need for extensive assistance of two staff for transfers, an inability to ambulate, functional limitations in range of motion on one side of the lower extremities, use of a walker and wheelchair, a history of a fall with a fracture prior to admission, no falls since admission, and participation in skilled PT (physical therapy) and OT (occupational therapy). CAAs (Care Area Assessments) dated 4/6/16 included: *ADLs (activities of daily living): Described the resident's need for extensive assistance of two staff for transfers, mobility and ADLs. *Falls: Described the resident's history of falls and potential for additional falls. The undated care plan noted resident #1's risk for falls due to gait/balance problems and included a variety of fall prevention interventions. The care plan did not include specific interventions related to fall prevention during transportation via the facility van. The care plan also described the resident's self care performance deficits related to his/her fractured right ankle. Progress notes dated 4/7/16 at 5:54 p.m. described an incident which occurred at 3:45 p.m. when resident #1 fell in the bus during transportation to a doctor's appointment. A Progress Note dated 4/7/16 at 6:59 p.m. included additional documentation of the earlier fall from the wheelchair on the facility bus, and described injuries which included a skin tear to the right zygomatic (cheek bone), and bruises to the right eye. According to the note, resident #1's physician determined no need for X-rays at the time staff notified him/her of the fall. A 4/8/16 Progress Note written at 12:22 a.m. described a purple/black bruise which extended around the right eye and down onto the cheek as well as swelling which restricted the resident's ability to open the right eye completely. A 4/8/16 Progress Note written at 1:23 p.m. described a new physician's orders [REDACTED]. Hospital ER (emergency room ) records and X-ray results dated 4/8/16 identified resident #1 with an undisplaced fracture of the right eye orbit. During an observation on 6/1/16 at 9:30 a.m., resident #1 was alert and oriented and able to verbalize his/her needs. The resident used a wheelchair to move about in his/her room. The resident lacked any evidence of injury/bruising to the right side of the face from the 4/7/16 fall from the wheelchair. During an interview on 6/1/16 at 9:30 a.m., resident #1 recalled the events of 4/7/16 prior to his/her fall from the wheelchair in the facility van/bus. According to the resident, Direct Care Staff C loaded (him/her) onto the bus and failed to fasten any of the straps intended to keep the wheelchair from moving. The resident reported he/she went flying when Staff C turned a corner and hit his/her head on something on the van/bus floor. During an interview on 6/1/16 at 12:35 p.m., Administrative Nurse B reported resident #1's wheelchair tipped over in the facility van when staff transported him/her to an appointment on 4/7/16. According to Nurse B, the incident resulted in a fracture of the bone around the resident's right eye. During a telephone interview on 6/1/16 at 12:45 p.m., Direct Care Staff C reported he/she drove the facility van/bus and provided resident transportation since December 2015, including 4/7/16, the date of the incident involving resident #1. According to Staff C, he/she loaded resident #1 into the bus in the wheelchair by use of a lift platform. With the resident seated in the wheelchair, Staff C positioned the wheelchair in the rear section of the bus and secured two floor straps to the right side of the wheelchair frame in order to prevent wheelchair movement during transport. Staff C reported he/she forgot to secure the other straps, two of which were located on the left side of the wheelchair as well as the lap belt and shoulder harness. Staff C reported they were not very far from the facility when he/she turned onto a side street. When he/she turned the bus, resident #1's wheelchair fell over and the resident fell from the chair and struck his/her face on something on the floor. According to Staff C, he/she immediately pulled over and called the facility to report the incident. Staff C denied formal training on transportation responsibilities prior to being assigned to drive the bus, and stated a former facility transportation staff member told him/her not to fasten all the straps to the wheelchair if the resident was only transported to somewhere within town. Confidential resident interviews with residents the facility identified as alert and oriented included: *On 6/1/16 at 9:10 a.m., a resident reported he/she sat on the bench seats in the facility van/bus during transportation to appointments and rarely used a seat belt. According to the resident, staff did not fasten the seat belt for him/her and didn't tell him/her to fasten it. *At 9:20 a.m., a resident reported he/she always sat in a wheelchair during transports in the facility van/bus, and staff sometimes secured the wheelchair with the floor straps to prevent wheelchair movement, and sometimes they did not. As requested, the facility provided a Transportation, Facility Van policy in effect at the time of the 4/7/16 previously described incident which involved resident #1. According to the policy, the purpose of the policy was to ensure staff transported facility residents via the community vehicle in a safe manner. The policy also included, All transportation employees will receive training for the proper use of the communities van lift and securing system and Employee driving record will be verified to have a valid driving license. Employee will not have a history of DUI (driving under the influence) .or reckless driving .Employee has no more than 2 moving violations on their current driving records . Although requested, the facility could not provide evidence Direct Care Staff C received training for proper use of the van's securing system prior to the 4/7/16 incident, and no evidence the facility verified Staff C's driving record and/or possession of a valid drivers license prior to the incident as required by facility policy. The facility failed to provide Resident #1 with adequate supervision and assistive devices (securing of all safety straps during transportation in the facility van/bus, ensuring transportation staff received adequate education prior to transportation of resident) to prevent accidents. Direct Care Staff C lacked evidence of adequate training in transportation procedures prior to assignment as the facility van/bus driver. On 4/7/16, Staff C failed to secure all safety straps and latches to secure resident #1's wheelchair during a transfer. When the van driver turned a corner, the wheelchair tipped over and the resident sustained [REDACTED].

The facility had a census of 45 residents with 3 residents selected for sample. Based on interview and record review, the facility failed to follow the advanced directive for 1 of 3 residents. Resident #1 expressed a desire for cardiopulmonary resuscitation (CPR)in the event he/she experienced lack of pulse/respirations. During provision of care, resident #1 became pulseless and without respirations. Staff failed to initiate CPR as desired by the resident's advanced directives. The resident expired. The facility failure to allow resident #1 the right to formulate an advanced directive and to honor the resident's preferences for cardiopulmonary resuscitation placed the resident in immediate jeopardy. Findings included: - Resident #1's clinical record included a face sheet which noted admission to the facility on [DATE] from the hospital. The [DATE] Admission MDS (Minimum Data Set) identified resident #1 with long and short term memory problems and no diagnoses that would result in a a life expectancy of 6 months or less. Resident #1's [DATE] care plan included, Advanced Directives full code. Follow advanced directives as set up by me (resident) and my DPOA (durable power of attorney). I am a full code. physician's orders [REDACTED]. Progress Notes dated [DATE] at 7:05 a.m. documented resident #1's gurgling respirations during a bed bath and then cessation of respirations and pulse. The clinical record included no evidence staff initiated CPR as ordered by the physician and as desired by the resident in his/her advanced directives. A notarized statement written by Licensed Nurse C on [DATE] described the events of [DATE], during which time the nurse gave resident #1 a bed bath. The statement described the resident as flaccid (weak, soft, flabby), with gurgling respirations and skin color changes during the bed bath. According to the nurses's statement, the resident took one deep breath and then stopped breathing. The resident's pulses ceased after he/she stopped breathing. The notarized statement included, I assumed res (resident) was a DNR (Do Not Resuscitate) due to health status .I did not start CPR. During an interview on [DATE] at 11:55 a.m., Administrative Nurse B reported Licensed Nurse C failed to initiate CPR for resident #1 when the resident's respirations and pulse stopped during a bed bath. Nurse B stated staff had multiple places available to check a resident's code status, including lists kept in both staff break rooms and the main nurses station, and also on the electronic clinical record. According to Administrative Nurse B, Licensed Nurse C failed to confirm resident #1's code status immediately when the resident stopped breathing and became pulseless, and then failed to initiate CPR as per the resident's wishes. During a telephone interview on [DATE] at 1:05 p.m., Licensed Nurse C reported he/she gave resident #1 a bed bath early on the morning of [DATE]. During the bathing process, Nurse C reported the resident gurgled with respirations, had skin color changes that went from normal skin color to pale, yellowish, and then took one deep breath and stopped breathing. According to Nurse C, he/she checked for a pulse after resident #1 took the last, deep breath and did not find a pulse. Nurse C reported he/she then finished bathing the resident and then summoned another nurse to confirm the lack of pulse/respirations. Nurse C admitted he/she assumed resident #1 had DNR orders and did not check to confirm the resident's code status. According to Nurse C, I did the wrong thing. I should have started CPR. According to the facility's Advance Directives policy with a revision date of [DATE], Advance directives will be respected in accordance with state law and facility policy. The facility failed to implement the advanced directives selected by resident #1 and/or his/her legal representative. The resident expressed a desire for cardiopulmonary resuscitation in the event he/she stopped breathing and did not have a pulse. When the resident became pulseless and without respirations on [DATE], facility staff failed to initate CPR. The resident expired. The facility failure to allow resident #1 the right to formulate an advanced directive and to honor the resident's preferences for cardiopulmonary resuscitation placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 2:15 p.m. by implementation of the following measures: 1) Audited the clinical records of all current residents to ensure the presence of DNR or Full Code orders in accordance with advanced directives. 2) Added additional information to the code status sheets located in the Nurses Station to reflect the code status of ALL residents (previously listed only the resident with orders for full code) 3) Enhanced system to raise awareness of resident preferences related to CPR vs. no CPR by placing green dots/stickers on resident name plates located directly outside resident rooms for all residents who chose full CPR. 4) Completed nursing education on facility policies and procedures related to Advanced Directives and CPR as well as CMS guidelines/requirements. 5) Determined a need for mock CPR drills twice annually with plans to complete the first drill within the next two weeks. After abatement, the deficient practice remained at a scope/severity of G.

The facility had a census of 45 residents, with 3 residents selected for sample. Based on interview and record review, the facility failed to provide 1 of 3 residents with the necessary care and services (thorough, timely nursing assessments following multiple changes in physical condition) to maintain the resident's highest practicable physical well-being. Resident #1 experienced changes in his/her ability to respond to verbal stimuli, muscle tone, respiratory status, and skin color. Facility staff failed to complete assessments of each significant physical change and then take appropriate action to address the resident's deteriorating condition. Resident #1 expired. Findings included: - Resident #1's clinical record included a face sheet which noted admission to the facility on [DATE] from the hospital. The [DATE] Admission MDS (Minimum Data Set) identified resident #1 with clear speech, the ability to understand others and to be understood, long and short term memory problems, and no diagnoses that resulted in a life expectancy of 6 months or less. CAAs (Care Area Assessments) dated [DATE] included: Cognitive Loss: Described the resident as unable to repeat words and recall them at a later time. According to the CAA, the resident was inattentive and unable to stay on task. ADLs (activities of daily living): Described the resident's need for extensive staff assistance with all ADLs, transfers and mobility, and use of a wheelchair propelled by staff. Communication: Described the resident's ability to make (himself/herself) understood and to understand others. According to the CAA, the resident had impaired ability to communicate and was usually understood through verbal and non-verbal expressions. The [DATE] Care Plan noted resident #1's impaired thought processes and dementia, and resistance to care. The care plan directed staff to observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. The care plan also noted the resident's advanced directives in which he/she expressed a desire for a full code (cardiopulmonary resuscitation). physician's orders [REDACTED]. Progress Notes written by Licensed Nurse C on dated [DATE] at 7:05 a.m. described resident #1's lack of verbal sounds during a bed bath, gurgling respirations, and flaccid (weak, soft, flabby) muscle tone. According to the note, Nurse C proceeded with the bed bath and the resident took one breath and then VS (vital signs) ceased. A [DATE] notarized statement written by Licensed Nurse C included, I was giving a bed bath to res (resident). Res was gurgling with clear nasal drainage, cleansed face. Res was flaccid. As I turned body, the gurgling stopped, finished bed bath. That's when res color changed. Checked for breathing. Res had one deep breath. Checked for pulse, could not find one. Res was not responding, went to go get another nurse to have (him/her) check. Unable to find VS (vital signs) During a telephone interview on [DATE] at 1:05 p.m., Licensed Nurse C reported he/she entered resident #1's room on [DATE] at approximately 7:00 a.m. to give a bed bath. Nurse C reported he/she spoke to the resident but the resident did not respond. Nurse C then started to bathe the resident who he/she described as limp. With the resident positioned on one side, Nurse C reported he/she saw clear nasal (nose) drainage and heard gurgling and snoring respirations. Nurse C continued with the bed bath. When Nurse C completed cleaning one side of the body, he/she then placed the resident on his/her back. At that time Nurse C reported the resident's facial skin color changed from a normal skin color to a pale, yellowish color and the resident stopped gurgling. Nurse C reported he/she continued with the bed bath and then the resident took one deep breath and then stopped breathing. Nurse C checked for a pulse and did not find one. According to Nurse C, he/she then finished the bed bath, and went to get another licensed nurse to come verify the lack of pulse/respirations. Upon their return to the room, Nurse C reported the other nurse confirmed resident #1 was deceased . Nurse C could not verbalize any nursing assessments he/she completed when he/she found the resident unresponsive upon entrance to the room, limp during the bathing process, with gurgling or snoring respirations, and/or with significant changes in skin color. The clinical record included no evidence of nursing assessments, including vital signs, on [DATE] prior to resident #1's death at 7:05 a.m During an interview on [DATE] at 2:10 p.m., Administrative Nurse B reported Licensed Nurse C failed to respond appropriately to resident #1's change in condition on the morning of [DATE]. According to Administrative Nurse B, resident #1's condition required nursing assessment and physician notification at several points, including when Nurse C found the resident unresponsive, when Nurse C found the resident limp, when Nurse C heard the gurgling respirations, and when Nurse C noted the change in skin color. Administrative Nurse B reported the belief resident #1's physician would have ordered transportation of the resident to the hospital for evaluation of the previously described symptoms if Nurse C had called him/her. The facility's [DATE] clinical protocol for Acute Condition Changes included: Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician . The nursing staff will contact the physician based on the urgency of the situation The facility failed to provide resident #1 with the necessary care and services (thorough, timely nursing assessments following multiple changes/declines in physical condition) to maintain the residents' highest practicable physical well-being. Resident #1 experienced changes in his/her ability to respond to verbal stimuli, muscle tone, respiratory status, and skin color. Facility staff failed to complete assessments of each significant physical change and then take appropriate action to address the resident's deteriorating condition. Resident #1 expired.

The facility had a census of 41 residents with 6 residents selected for sample. One sampled resident experienced a fracture within the previous 60 days. Based on observation, interview and record review, the facility failed to provide Resident #1 with adequate supervision and assistive devices (securing of all safety straps during transportation in the facility van/bus, ensuring transportation staff received adequate education prior to transportation of resident) to prevent accidents. Direct Care Staff C lacked evidence of adequate training in transportation procedures prior to assignment as the facility van/bus driver. On 4/7/16, Staff C failed to secure all safety straps and latches to secure resident #1's wheelchair during a transfer. When the van driver turned a corner, the wheelchair tipped over and the resident sustained [REDACTED]. Findings included: - Resident #1's clinical record included 5/24/16 signed physician's orders [REDACTED]. The 4/4/16 Admission MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 15), the need for extensive assistance of two staff for transfers, an inability to ambulate, functional limitations in range of motion on one side of the lower extremities, use of a walker and wheelchair, a history of a fall with a fracture prior to admission, no falls since admission, and participation in skilled PT (physical therapy) and OT (occupational therapy). CAAs (Care Area Assessments) dated 4/6/16 included: *ADLs (activities of daily living): Described the resident's need for extensive assistance of two staff for transfers, mobility and ADLs. *Falls: Described the resident's history of falls and potential for additional falls. The undated care plan noted resident #1's risk for falls due to gait/balance problems and included a variety of fall prevention interventions. The care plan did not include specific interventions related to fall prevention during transportation via the facility van. The care plan also described the resident's self care performance deficits related to his/her fractured right ankle. Progress notes dated 4/7/16 at 5:54 p.m. described an incident which occurred at 3:45 p.m. when resident #1 fell in the bus during transportation to a doctor's appointment. A Progress Note dated 4/7/16 at 6:59 p.m. included additional documentation of the earlier fall from the wheelchair on the facility bus, and described injuries which included a skin tear to the right zygomatic (cheek bone), and bruises to the right eye. According to the note, resident #1's physician determined no need for X-rays at the time staff notified him/her of the fall. A 4/8/16 Progress Note written at 12:22 a.m. described a purple/black bruise which extended around the right eye and down onto the cheek as well as swelling which restricted the resident's ability to open the right eye completely. A 4/8/16 Progress Note written at 1:23 p.m. described a new physician's orders [REDACTED]. Hospital ER (emergency room ) records and X-ray results dated 4/8/16 identified resident #1 with an undisplaced fracture of the right eye orbit. During an observation on 6/1/16 at 9:30 a.m., resident #1 was alert and oriented and able to verbalize his/her needs. The resident used a wheelchair to move about in his/her room. The resident lacked any evidence of injury/bruising to the right side of the face from the 4/7/16 fall from the wheelchair. During an interview on 6/1/16 at 9:30 a.m., resident #1 recalled the events of 4/7/16 prior to his/her fall from the wheelchair in the facility van/bus. According to the resident, Direct Care Staff C loaded (him/her) onto the bus and failed to fasten any of the straps intended to keep the wheelchair from moving. The resident reported he/she went flying when Staff C turned a corner and hit his/her head on something on the van/bus floor. During an interview on 6/1/16 at 12:35 p.m., Administrative Nurse B reported resident #1's wheelchair tipped over in the facility van when staff transported him/her to an appointment on 4/7/16. According to Nurse B, the incident resulted in a fracture of the bone around the resident's right eye. During a telephone interview on 6/1/16 at 12:45 p.m., Direct Care Staff C reported he/she drove the facility van/bus and provided resident transportation since December 2015, including 4/7/16, the date of the incident involving resident #1. According to Staff C, he/she loaded resident #1 into the bus in the wheelchair by use of a lift platform. With the resident seated in the wheelchair, Staff C positioned the wheelchair in the rear section of the bus and secured two floor straps to the right side of the wheelchair frame in order to prevent wheelchair movement during transport. Staff C reported he/she forgot to secure the other straps, two of which were located on the left side of the wheelchair as well as the lap belt and shoulder harness. Staff C reported they were not very far from the facility when he/she turned onto a side street. When he/she turned the bus, resident #1's wheelchair fell over and the resident fell from the chair and struck his/her face on something on the floor. According to Staff C, he/she immediately pulled over and called the facility to report the incident. Staff C denied formal training on transportation responsibilities prior to being assigned to drive the bus, and stated a former facility transportation staff member told him/her not to fasten all the straps to the wheelchair if the resident was only transported to somewhere within town. Confidential resident interviews with residents the facility identified as alert and oriented included: *On 6/1/16 at 9:10 a.m., a resident reported he/she sat on the bench seats in the facility van/bus during transportation to appointments and rarely used a seat belt. According to the resident, staff did not fasten the seat belt for him/her and didn't tell him/her to fasten it. *At 9:20 a.m., a resident reported he/she always sat in a wheelchair during transports in the facility van/bus, and staff sometimes secured the wheelchair with the floor straps to prevent wheelchair movement, and sometimes they did not. As requested, the facility provided a Transportation, Facility Van policy in effect at the time of the 4/7/16 previously described incident which involved resident #1. According to the policy, the purpose of the policy was to ensure staff transported facility residents via the community vehicle in a safe manner. The policy also included, All transportation employees will receive training for the proper use of the communities van lift and securing system and Employee driving record will be verified to have a valid driving license. Employee will not have a history of DUI (driving under the influence) .or reckless driving .Employee has no more than 2 moving violations on their current driving records . Although requested, the facility could not provide evidence Direct Care Staff C received training for proper use of the van's securing system prior to the 4/7/16 incident, and no evidence the facility verified Staff C's driving record and/or possession of a valid drivers license prior to the incident as required by facility policy. The facility failed to provide Resident #1 with adequate supervision and assistive devices (securing of all safety straps during transportation in the facility van/bus, ensuring transportation staff received adequate education prior to transportation of resident) to prevent accidents. Direct Care Staff C lacked evidence of adequate training in transportation procedures prior to assignment as the facility van/bus driver. On 4/7/16, Staff C failed to secure all safety straps and latches to secure resident #1's wheelchair during a transfer. When the van driver turned a corner, the wheelchair tipped over and the resident sustained [REDACTED].

The facility census totaled 53 residents with 3 residents included in the sample. Of those, all 3 residents were reviewed for significant medication administration errors. Based on observation, interview and record review, the facility failed to ensure each resident remained free from significant medication errors by the failure to administer narcotic pain medication as ordered by the physician for 1 of 3 sampled residents. (#1) The facility's failure to administer narcotic pain medication as ordered resulted in immediate jeopardy to the resident who experienced a decrease in blood pressure which had to be treated in the emergency room with [MEDICATION NAME] (a medication used to reverse the effects of narcotics). Findings included: - Review of resident #1's Admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). It revealed the resident received scheduled and PRN (as needed) pain medication, and also received non-pharmacological pain interventions. The assessment revealed the resident had pain or hurting frequently, limited his/her day-to-day activities because of pain, and rated the pain as severe. Review of the Activities of Daily Living (ADLs)/Functional Status CAA (Care Area Assessment) for the 2/3/14 MDS revealed the resident required some assist with some ADLs. The resident could ambulate independently but became short of breath and had chronic pain causing him/her to become unsteady. The resident could stabilize himself/herself and worked with therapy to increase strength. The resident received [MEDICATION NAME] (a pain medication) 10-325mg (milligrams) QID (four times daily) for pain, and continued to complain of pain despite the routine pain medications. Review of the resident's care plan with an effective date of 2/12/14 and a print date of 2/27/14 revealed the resident had chronic pain management for his/her back. It directed to screen for pain on admission and daily, and assess the resident to determine if he/she experienced pain. If the resident experienced pain, it directed staff to conduct and document pain assessments, obtain the resident's pain and pain management history, and discuss with the resident and his/her family any adverse effects of unrelieved pain or side effects of pain medications. Assess their knowledge of side effects and safety precautions related to use of pain medication and use of any non-pharmacological measures, assess for changes in the resident's habits, and planned for the resident to actively participate in making choices/decisions regarding pain management. It directed to monitor for signs of depression with respect to pain management, anticipate and meet needs, and the resident had his/her pain controlled by [MEDICATION NAME] 80mg twice daily related to chronic back pain. It directed staff to administer medication as ordered, monitor for side effects, review for pain medication efficacy, and assess whether pain intensity was acceptable to the resident. review of the resident's medical record revealed [REDACTED]. Another order dated 2/18/14 revealed an order for [REDACTED]. During an interview with Administrative Nursing staff B at 2:40 P.M. on 4/2/14, he/she reported he/she talked with Consultant Pharmacist D and [MEDICATION NAME] 80mg only came in an extended release version. Review of a nurse's note dated 2/21/14 at 8:55 A.M. revealed the resident notified staff he/she had blood on his/her toilet tissue. Staff assessed the resident and after noting some bleeding, the resident also reported having some light headedness. Staff assisted the resident to bed, elevated the resident's feet and applied oxygen. The resident had a blood pressure at that time of 97/61. Staff notified the physician. A second nurse's note at 9:22 A.M. that same day revealed, at 9:00 A.M. the physician provided an order to send the resident to the emergency room for evaluation. The resident left the facility by the facility's van at 9:15 A.M. Review of the Emergency Department records from the hospital revealed the resident had blood pressure readings of the following: 78/65 at 9:48 A.M., 83/47 at 10:00 A.M., 82/59 at 10:05 A.M., 66/38 at 10:10 A.M., 70/41 at 10:15 A.M., and 63/36 at 10:30 A.M. A staff member of the Emergency Department administered [MEDICATION NAME] at 10:42 A.M. and at 10:43 A.M. the resident's blood pressure increased to 101/62. Review of the [DIAGNOSES REDACTED]." Review of the facility's Controlled Substances Administration Record revealed direction for the resident to receive [MEDICATION NAME] reform 80mg tab ER (extended release), 1 tab by mouth twice daily. It revealed, on 2/20/14 the resident received the medication at 6:30 A.M., 6:00 P.M., and 8:20 P.M. (an extra dose/ error in administration) that day, then received it at 6:00 A.M. on 2/21/14. Review of the Controlled Substances Administration Record revealed, [MEDICATION NAME] ([MEDICATION NAME]) 10-325mg tablet, one tablet by mouth every 6-8 hours as needed. The resident received the medication at 4:20 A.M., and 12:30 P.M. on 2/20/14, then again at 2:10 A.M. on 2/21/14. Review of the documentation on Medication Administration Record (MAR) for February 2014 revealed the resident received a PRN dose of [MEDICATION NAME] 10-325mg at 4:20 A.M., and 12:20 P.M. on 2/20/14, and 2:03 A.M. on 2/21/14. The MAR lacked any indication staff gave the [MEDICATION NAME] 80mg ER tab at 8:20 P.M. on 2/20/14. At 5:05 P.M. on 3/27/14, Administrative Nursing staff B reported he/she felt surprised when he/she heard the hospital reported they had given [MEDICATION NAME]. Staff B reported it fortunate that the resident went to the hospital for the bleeding because he/she did not know what would have happened if the resident stayed in the facility that morning. Staff B reported he/she not know of the medication error until he/she was notified of the hospital giving the [MEDICATION NAME]. During an interview at 9:40 A.M. on 3/31/14, Licensed nursing staff C reported, after determining that a resident needed a PRN medication, he/she checked the MAR, pulled it from narcotic box and documented it on the controlled substance count sheets, then documented it on the MAR. Staff C reported he/she thought he/she might have been in a hurry, and reported, on 2/20/14 he/she grabbed the wrong card from the box. Staff C reported he/she gave the extended release medication instead of the PRN dosage. Staff C reported he/she did not know he/she made a medication error until someone called him/her the night before he/she worked again that next week. When asked why Staff C did not document the medication in the PRN section of the MAR, Staff C reported he/she did not realize that he/she did not document it until being told just then. During an interview with Consultant Pharmacist D at 8:45 A.M. on 3/31/14, he/she reported he/she had already been in the building completing his/her medication consultation review when he/she received notice of the medication error. Consultant D reported he/she felt at that time that the error might have caused harm to the resident because the resident experienced adverse reactions, and received [MEDICATION NAME]. Consultant D reported, anytime someone gives a medication other than how the physician prescribes it, it is a medication error. During an interview with Administrative Nursing staff B at 12:16 P.M. on 3/31/14, he/she reported the resident had complained of some bleeding, so the nurse called the doctor and sent him/her in to the hospital. Staff B reported the staff at the hospital called the facility to get some contact information for the resident's family member, and at that time, notified the facility that the hospital staff had to administer [MEDICATION NAME]. Staff B reported he/she went to the MAR which did not show staff gave any extra medications or errors, and then to the count sheet, which showed staff gave the wrong medication to the resident. Staff B reported the medication error occurred on 2/20/14 and it was found on 2/21/14. During an interview with Physician E at 12:30 P.M. on 4/1/14, he/she reported he/she received notification of the medication error which occurred on 2/20/14. Physician E reported [MEDICATION NAME], when given, worked very quickly. Physician E reported, one extra dose of the 80 milligram extended release medication may have just caused a little oversedation, and did not think the medication administration had anything to do with the resident bleeding, but the extended release doses plus the PRN dose could have had a cumulative effect and lowered the resident's blood pressure. Physician E reported he/she expected staff to follow his/her orders. Review of the Administering Medications policy, last revised April 2010 revealed medication must be administered in accordance with the physician's orders [REDACTED]. It also revealed the individual administering the medication needed to check the label three times to verify the right medication, right dosage, right time, and right method of administration before administering it. The facility failed to ensure a resident remained free from a significant medication error related to narcotic medication, which resulted in immediate jeopardy to the resident who experienced a decrease in blood pressure, and treatment with [MEDICATION NAME]. The facility abated the immediate jeopardy on 4-2-14 at 12:24 p.m. when all staff administering medications had received further education regarding narcotics being administered as ordered, accuracy of MAR and Narcotic Count Sheet documentation related to date, time, medication and dosing, PRN medication documentation and assuring those medications are administered. The deficient practice remains at a scope and severity of a "D".

The facility census totaled 58 residents with 23 residents sampled. Of those, 4 residents were sampled for pressure ulcers. Based on observations, interview and record review, the facility failed to provide the planned repositioning services in a timely manner for 2 sampled residents. (#9 and #63). Resident #63, with a history of pressure ulcers, developed 2 avoidable pressure ulcers. Findings Included: - Review of resident #63's signed physician orders [REDACTED]. Review of the Significant Change MDS (Minimum Data Set) dated 10/24/13 revealed a BIMS (Brief Interview of mental status) score of 5 indicating severe cognitive impairment. The resident required extensive assist of two staff for bed mobility, and dependent on 2 staff with transfers, dressing, toileting, and bathing. The MDS showed the resident at risk for developing pressure ulcers, and had two stage II pressure ulcers (a 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). The MDS revealed the resident used a pressure reducing device for chair, and staff placed the resident on a turning/repositioning program. Review of the CAA (care area assessment) dated 10/24/13 for pressure ulcers revealed the resident had stage 2 pressure areas to the coccyx and left heel. The resident complained of pain to both areas. The resident had a cushion in wheelchair and air mattress on bed. Staff were to reposition the resident every two hours or more frequently. The resident had incontinence of bladder, had pain from the pressure areas and arthritis. Review of the care plan, dated 7/1/13, revealed on 10/28/13 staff identified an actual impairment to skin integrity on the resident's coccyx and left heel. Interventions included educate the resident, family, and caregivers of causative factors and measures to prevent skin injury. The care plan directed staff to consult with the wound care clinic for wounds, place a pressure reducing mattress on the bed and a Roho cushion (specialized cushion used to treat pressure ulcers) on the wheelchair. The care plan directed staff to turn and reposition the resident every two hours and as needed, keep skin clean and dry, use lotion on resident's dry skin, do not apply on coccyx or left heel, provide incontinence care as indicated, monitor and document location, size and treatment of [REDACTED]. The care plan guided staff to conduct skin inspection on shower days and as needed. Staff were to observe for: redness, open areas, scratches, cuts, bruises and report any changes to the Nurse. On 11/5/13 at 4:05 p.m., interview with Licensed Nurse QQ identified the area to the resident's coccyx had healed, and the wound to the heel was getting smaller. The staff failed to revise the care plan to reflect the current status of the coccyx wound. Observations on 11/6/13 at 1:42 P.M., 1:57 P.M., 2:10 P.M., 2:26 P.M., 2:43 P.M. , 2:54 P.M., 3:09 P.M., 3:22 P.M., 3:38 P.M., 3:58 P.M., 4:10 P.M., and 4:13 P.M., revealed the resident in the recliner with his/her feet up, staff failed to provide a position change every 2 hours as planned. On 11/6/13 at 4:18 PM (after a total of 2 hours and 36 minutes without a position change) direct care staff M and P entered the resident's room. Licensed nurse GG came in room while direct care staff changed the incontinent resident. Licensed nurse GG looked at the resident's buttocks and reported the skin was blanchable (red skin that turns white when pressed). The resident had a small open area to left buttock, approximately dime-sized. Licensed staff GG identified the open area as newly developed and stated he/she thought the resident had a physician's orders [REDACTED]. While Licensed nurse GG was gone, Direct care staff M and P applied barrier cream to the open area on the resident's buttock. Licensed nurse GG returned and stated he/she would apply the [MEDICATION NAME] later, so staff M and P applied a clean brief and assisted the resident into the wheelchair. The staff failed to apply a protective dressing over the open area for this incontinent resident. On 11/6/13 at 4:30 PM during interview direct care staff M reported the resident had the open area last night and direct care staff M told direct care staff HH. Direct care staff M reported day shift staff had not reported to him/her about any open areas to buttocks when he/she came on duty yesterday. Direct care staff M reported he/she put barrier cream on the open area. Direct care staff M reported he/she did not report the open area to the nurse. The resident used to have an open area on his/her coccyx, direct care staff M reported staff used to reposition the resident every hour, but the area got better, so staff repositioned every 2 hours now. On 11/6/13 at 4:44 PM direct care staff M explained why the resident was not repositioned from 1:42 PM until 4:18 PM, the resident was an assist of two and direct care staff M had no other staff to assist him/her. On 11/7/13 a review of phone orders revealed on 11/6/13 a new physician's orders [REDACTED]. Apply [MEDICATION NAME] to resident's coccyx every two hours and with each brief change. On 11/7/13 at 8:01 AM observation revealed the resident sat in a wheelchair in the dining room for breakfast. Observations at 8:05, 8:08, 8:25, 8:27, 8:34, and 8:40 AM revealed the resident sat in the dining room eating breakfast. Staff did not reposition him/her. Observations at 8:57 AM revealed staff assisted the resident from the dining room to the living area, but did not reposition the resident. The resident remained in the living area without a position change at 9:00, 9:15, and 9:32 AM. Observation at 9:35 A.M. revealed administrative nurse K walked past the living area, and then direct care staff F walked past the resident. No staff offered to reposition the resident. The resident continued to sit in the living area at 9:45 and 9:58 AM without a position change. A visitor came and found the resident at 9:59 AM and assisted the resident in his/her wheelchair toward the resident's room. On 11/7/13 at 10:00 AM nursing staff member stopped and talked to visitor and resident outside of the resident's room. The staff member did not reposition the resident. On 11/7/13 at 10:08 AM the resident had 3 visitors. The visitors pushed the resident's wheelchair to the dining room from his/her room. On 11/7/13 at 10:20 AM observation revealed the resident sat in the dining room area with visitors eating and drinking snacks the visitors bought in. The resident remained in the dining room in a wheelchair with visitors through observations at 10:20 and 10:30 AM. At 10:44, the visitors helped the resident to the living area. The resident continued to sit in a wheelchair the living area at 11:00 AM. Staff had not repositioned the resident for 2 hours and 36 minutes. On 11/7/13 at 11:10 AM direct care staff F and licensed staff O assisted the resident from the living area to the resident's room, where the staff transferred the resident from his/her wheelchair to the bed. Staff removed the wet incontinent brief and licensed staff O identified two open areas to the resident's left buttock. The resident had no dressing, including a [MEDICATION NAME], in place. Licensed staff O reported staff were to leave the areas "open to air." Licensed staff O left the room, then came back in and reported that he/she had looked at the doctor's orders and identified a new order to put [MEDICATION NAME] on the open area. Licensed staff O measured the open areas and reported one as 1 cm (centimeter) x 0.2 cm and the other open area was a pinpoint. When interviewed direct care staff F did not know when the resident was to be repositioned. Direct care staff F also reported he/she gave the resident a shower this morning but wasn't able to get down to look at the resident's bottom due to trying to keep the resident in the chair and just scrubbed his/her bottom without looking and was not sure the [MEDICATION NAME] was in place. Direct care staff E on 11/7/13 12:34 PM. reported repositioning was to be done every 1-2 hours and it depended on how restless the resident was. When asked if he/she knew of any skin issues he/she replied the resident was at risk for pressure ulcers. He/she reported the resident could reposition him/herself some. The resident needed to be reminded and helped. Direct care staff E reported he/she did not know how long the pressure ulcer had been there. He/she reported the resident was last up and first down. The resident had a Roho cushion in the wheelchair for pressure relief. Licensed staff O, on 11/12/13 at 11:10 AM. reported in September the resident had an order for [REDACTED]. Direct care staff O said were to report any changes of areas or new area to the nurse immediately. Physical therapy placed the resident on Roho cushion. It is supposed to be in wheelchair. The resident consulted with physician EE; some of treatment was being done at wound care clinic. One order recommended turn every hour. He/she was asked how staff knows to follow through with that order. Licensed staff O reported nothing in nurses notes about this order, and thought that it was not really an order from the wound care doctor, but a suggestion from the nurse at the wound clinic. On 11/13/13 at 12:30 P.M. Administrative staff K said direct care staff should report to the nurse on duty right away of any skin issues. When asked about the expectations for repositioning the resident he/she reported it was every two hours. A voicemail was left for physician EE on 11/14/13 at 9:02 A.M. requesting a return call to discuss the pressure sores on the resident's buttocks. As of 3:50 P.M. on 11/18/13 the physician had not returned the call. The facility failed to provide the planned care to reposition a dependent resident every two hours. The resident developed two new, open areas on the buttocks. - Review of resident #9 ' s quarterly MDS (Minimum Data Set 3.0, a required assessment) dated 10-4-13 revealed a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). The MDS identified the resident required extensive assistance of 2 staff for bed mobility and transfers. It also indicated the resident was at risk for pressure ulcers but did not have one at that time. Review of the mini care plan the certified nurse aides used dated 3-8-13 described the resident as oriented and directed the staff to turn the resident every 2 hours with assistance of 2. During an observation on 11-7-13 at 6:46 a.m. revealed direct care staff CC assisted the resident to get dressed for the morning, then assisted the resident to the dining room table. Observations at 7:45 a.m., 7:58, a.m., 8:11 a.m., 8:27 a.m., 8:45 a.m., 9:00 a.m., 9:10 a.m., the resident remained seated at the dining room table in the same position, eating breakfast. At 9:25 a.m. the resident's spouse arrived and pushed the resident back to his/her room. Observations at 9:34 a.m. and 9:45 a.m. the resident remained in wheelchair visiting with his/her spouse. At 9:54 p.m., licensed nursing staff N was informed the resident had been sitting in the same position without staff asking to reposition him/her for almost 3 hours. At 9:59 a.m. the resident stood and staff checked the resident's skin for irritation/redness and noted the resident's buttocks were red with darker red areas to the lower buttock region. On 11-12-13 at 4:16 p.m., direct care staff Q reported the resident needed repositioned every 2 hours but was not always cooperative especially if he/she was in an activity or watching a favorite TV program. On 11-13-13 at 2:06 p.m. administrative staff K stated residents who could not reposition themselves needed to be repositioned at least every 2 hours and as needed by staff. Review of the POS [REDACTED]. The facility failed to reposition this dependent resident every 2 hours as planned.

The facility census totaled 58 residents with 23 residents included in the sample, of those 4 residents were reviewed for nutrition. Based on observation, interview, and record review the facility failed to adequately monitor weight loss and develop and implement new interventions to address weight loss for 1 of 4 sampled residents. Resident #39 lost 14.39% of weight over 3 months, a significant weight loss. Findings included: - Review of resident # 39's signed physician orders [REDACTED]. The resident also had [DIAGNOSES REDACTED].'s ([MEDICAL CONDITION], an episode of [MEDICAL CONDITION] insufficiency). Review of resident #39's significant change of condition MDS (minimum data set) dated 9/5/13 revealed a BIMS (brief interview for mental status) score of 11 (moderate cognitive impairment). The resident had a poor appetite on 7-11 days of the 14 day look back period. The MDS revealed the resident required set up help only for eating. The resident complained of difficulty swallowing. The resident's weight was 180 pounds and unknown if the resident had weight loss or weight gain. The resident had no dental problems. Review of the nutrition CAA (care area assessment) dated 9/5/13 revealed the resident had difficulty eating (cutting food, getting food to mouth), complained of difficulty swallowing, and had limited ROM (range of motion) to left upper extremity from [MEDICAL CONDITION]. The resident had increased difficulty self-propelling a wheel chair and asked for assistance when needed. The CAA identified the resident had increased difficulty cutting food, a history of cognitive loss and a history of a [MEDICAL CONDITION], with a possible [MEDICAL CONDITION] limited the resident's mobility, and refused staff assistance at meal time in the main dining room. The phyisician had ordered the staff to provide [MEDICATION NAME] (medication used for mood disorder) that could affect the resident's appetite and staff would assist with meals as allowed or as needed. The resident had a speech therapy consultation due to swallowing difficulty. Review of the care plan with a date of 2/6/13 revealed the resident received [MEDICATION NAME], monitor and report to the physician any loss of appetite. No previous or further care plan found for nutrition/weight loss until 11/5/13 that revealed the resident required staff to assist him/her to the dining room and to cut up food. The resident received nutritional supplements three times daily. Review of the weights for the resident revealed the following: On 7/24/13 188 pounds On 8/28/13 180 pounds = 8 pound loss in 30 days (weight obtained on the 27 th) The clinical record lacked evidence the facility implemented interventions to prevent further weight loss. On 9/10/13 171 pounds = 9 pound loss in 15 days On 9/24/13 168 pounds On 9/30/13 165 pounds On 10/8/13 165 pounds On 10/16/13 161 pounds On 10/22/13 161 pounds On 10/29/13 162 pounds On 11/5/13 164 pounds The resident had a 14.36% weight loss from 7/24/13 to 10/22/13 over 3 months for a total of 27 pounds. Review of the emergency room notes dated 8/26/13 revealed the resident went to the emergency roiagnom on [DATE]. Presented weak, confusion, difficulty speaking, and the resident had right side weakness. Staff notified the physician of the weight loss 8/27/13 (documented on the 28 th) and the medical record lacked any further notifications of weight loss until 10/3/13 for the supplement order. Review of the nurse's notes dated 9/3/13 revealed an order for [REDACTED]. Review of the physician progress notes [REDACTED]. Review of a Nutritional note dated 9/9/13 revealed the diet was downgraded with diet texture changed to mechanical soft with ground meat and gravy and or sauce on the meat. No order for this change was found on the chart. On 9/25/13 revealed a fax to the physician to notify the physician of weight loss. On 10/3/13, or 8 days after the notification to the physician of the weight loss, the facility received a new order for Health shakes three times daily with no specified time. The nutritional note dated 10/6/13 revealed to continue shakes with meals three times daily and encourage the resident to request foods he/she preferred to eat at meals. Review of the MAR (medication administration review) for October 2013 revealed that the resident consumed 100% of the health shakes. On 11/7/13 at 7:50 a.m., observation of the resident in the dining room at the table drinking coffee. The dietary staff served 120 ml (milliliter) of orange juice, 120 ml of milk, 240 ml of coffee and 180 ml of water. On 11/7/13 at 8:04 a.m., the resident received scrambled eggs, 2 pieces of bacon, chocolate pudding and peaches. On 11/7/13 at 8:15 a.m., the resident finished eating and consumed 100% of eggs, pudding and peaches. The resident ate one piece of bacon and left one. The resident drank approximately 1/2 (60 ml) of the orange juice, 100% of the coffee and no water. On 11/7/13 at 12:00 p.m., the resident received chicken, coleslaw, potato salad, and brownie. Staff cut the meat off the bone into small pieces. On 11/7/13 at 12:36 p.m., the resident ate few bites of chicken, half of the coleslaw and potato salad and all the brownie. On 11/12/13 at 10:36 a.m., interview with direct care staff E reported that the resident's appetite was good. The resident fed him/herself, with set up from the staff. The resident received shakes and usually drank all of them. On 11/12/13 at 11:02 a.m., interview with direct care staff F reported that it depended on the day how the resident's appetite was. Staff offered substitutes when the resident did not want the special. The resident usually drank the entire shake, I think staff give it between meals. On 11/12/13 at 3:05 p.m., interview with direct care staff R revealed the resident liked to get up for breakfast and lunch but preferred supper in his/her room. The resident had a better appetite now. The resident loves sweets. The resident got shakes between meals and drank those well. On 11/12/13 at 3:45 p.m., licensed nursing staff L reported that the resident's illness caused the resident to stay in the bed all the time and the resident was not eating. The resident lost weight but was better now. The resident received a shake three times daily between meals. Interview with dietary T on 11/13/13 at 3:00 p.m., revealed that he/she put all the weights in the computer then all the information went to administrative nursing staff K, the care plan coordinator, and the administrator. All the information was reviewed including weight loss at the weekly skin, weight and falls meeting. All weight losses were reviewed. Dietary T reported the interventions included weekly weights on weight losses greater than 5 pounds and staff obtained an order for [REDACTED]. Interview of administrative nursing staff K on 11/13/13 at 3:00 p.m. revealed that the resident was very ill-he/she had several TIA's ([MEDICAL CONDITION]). The resident was now coming back, the TIA's had stopped after getting the medication straightened out. The resident had gotten stronger. Weight loss was reviewed every week and the first step was weekly weights, if weight loss of more than 5 pounds. If the resident experienced further weight loss, staff obtained supplement orders. The physician ordered a supplement on 10/3/13. Administrative nursing staff K revealed the resident had a weight loss of greater than 5 pounds, and according to the policy, staff were to initiate weekly weights on 8/28/13. After a reweigh was done the resident still had a weight loss of 8 pounds, but staff K stated staff did not begin weekly weights until 9/24/13, almost a month later. When asked what interventions were put into place after another 9 pound weight loss on 9/24/13, Administrative staff K could not answer the question. Administrative nursing staff K reported that as of 10/3/13 the resident was on a supplement. This was 2 1/2 months after the first weight loss began. Interview with Physician EE on 11/14/13 at 8:58 a.m., revealed that the resident had a significant weight loss and that the resident had [MEDICAL CONDITION] that time. Physician EE expected notification after 2 month of continued weight loss. He/she expected a supplement be given at the beginning of the weight loss and the resident was now on a supplement. Review of the undated policy named Nursing Documentation Skin and Weight Meeting revealed: 5. All facility residents will be weighed and reviewed by the Skin and Weight Committee on a monthly basis. For those residents who remain stable and whose condition is unchanged a brief entry in the nursing or dietary progress notes indicating the assessment is satisfactory. 6. Residents who demonstrate a significant change in condition, significant weight loss/gain or gradual, consistent weight loss will be placed on weekly weights until stability is demonstrated and maintained for at least 4 weeks. Review of such residents will be documented using the weight/skin condition review form...The team however must ensure timely notification of the attending physician. 10. Residents who must be weighed weekly and reviewed by the skin and weight committee include the following; c. Residents who have a significant weight loss/gain for example: 2% in 1 week, 5% in 1 month, 7.5% in 3 months or 10% in 6 months. The care plan for each resident reviewed by the skin and weight committee would be revised and updated to reflect new approaches/interventions, during the weekly skin and weight meeting. The facility failed to monitor, plan and follow through on interventions to prevent the significant weight loss of 14.36% from 7/24/13 to 10/22/13 over 3 month period of time and total of 27 pounds in resident #39.

The facility census totaled 46 resident's with 2 resident's reviewed for pain management for end of life care. Based on observation, record review and interview, the facility failed to adequately assess, plan and manage pain for 1 of 2 sampled resident's (#27) who verbalized pain and displayed non-verbal signs of pain. - Findings include: -Review of Resident #27's physician order [REDACTED]. Review of the Hospice admission orders [REDACTED]. Review of an Admission Nursing assessment dated [DATE] identified the resident experienced pain daily but not constant. The nurse identifed the location of the pain as in the resident's arms when touched with the pain intensity marked as distressing pain. The resident's quarterly MDS 3.0 (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/12/2011 identified the resident with a BIMS score of 12/15 which indicated the resident experienced moderately impaired cognition, experienced pain frequently without a scheduled pain medication regimen and did not receive any prn (as needed) pain medications. The resident's significant change MDS with an ARD date of 7/14/2011 identified the resident with a BIMS score of 2/15 which indicated the resident's cognitive status declined from moderate to severe impairment. The MDS also identified the resident was unable to complete the resident interview regarding pain and a staff interview was conducted. The interview indicated that staff did not observe or document any signs of pain,(non-verbal sounds, vocal complaints of pain, facial expressions or protective body movements or postures) during the 5 day look back period. Review of the "Nurses Summary Seven Day Look Back Assessment" dated 7/11/11 on the 2 p.m. - 10 p.m. shift revealed the resident received non-medication pain interventions for indicators of vocal complaints of pain. On 7/14/2011 for the 6 a.m. - 2 p.m. shift revealed the resident again received non-medication pain interventions for the following indicators of pain: non-verbal sounds (crying, whining, gasping, moaning, or groaning); Vocal complaints of pain, (that hurts,ouch or stop); as well as facial expressions of pain (grimacing, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). Review of the Care Area Triggers dated 7/14/2011 revealed pain did not trigger for further assessment. The facility failed to identify the resident's pain characteristics and possible causes, contributing factors, and risk factors related to pain in order to develop an individualized plan of care regarding end of life and pain management. The facility failed to adequately assess the resident for pain. The care plan dated 11/15/2010 included a problem for ADL (Activity of Daily Living) deficit, pain with gout and OP ([MEDICAL CONDITION]); with a goal that the resident "will have relief of pain by verbalization of pain relief after medication is administered in the next 90 days." The care plan instructed staff to "report to charge nurse if resident complains of any pain, attempt non pharmalogical methods of pain control prior to medications: repositioning, sitting (gender) in (gender) recliner, quiet atmosphere, administer prn (as needed) medications for pain if non-pharmological methods are ineffective." The Nurses notes dated 7/6/2011 at 0131 (1:31 a.m.) indicated while the nurse completed a dressing change to the back of (gender) lower extremity the resident "c/o (complaints of) pain to area" with no documented evidence of intervention for pain. The nurses notes dated 7/7/2011 at 1732 (5:32 p.m.) also indicated while the nures assessed ace wraps to the resident's lower legs the resident "c/o pain upon palpation of both areas" with no documented evidence of intervention for pain. Nurses notes dated 7/8/2011 at 1500 (3:00 p.m.) again indicated that while the nurse was dressing a skin tear to the top of left foot the resident "c/o pain to area while treating area" with no documented evidence of intervention for pain. Review of resident #27's MARs (Medication Administration Record) for June 8, 2011 through August 7, 2011 revealed the resident received routine medication for their [DIAGNOSES REDACTED]. The MARs lacked any documentation that staff administered the [MEDICATION NAME] or Tylenol PRN medications from 6/16/11 through 8/7/11, including the above dates in July when the resident voiced complaints of pain. Observation on 8/3/2011 at 2:12 p.m. revealed Medication aide G and nurse aide O repositioned the resident onto (gender) left side. At that same time the resident hollered out that their legs hurt. The resident presented with facial grimacing when nurse aide G and nurse aide O repositioned the resident. On 8/4/2011 at 8:30 a.m. observation revealed nurse aide E and nurse aide D repositioned the resident in bed. Nurse aide E and nurse aide D lifted the resident up in bed by using a bed pad. The resident again yelled out, "you're hurting my legs." Nurse aide E and nurse aide D continued to reposition the resident by lifting (gender) legs and putting a pillow under them while the resident continued to voice complaints of pain in their legs. During an interview on 8/4/11 at 1:20 p.m. Nurse C reported that no staff informed (gender) that the resident voiced any pain today. Nurse C reported that the resident calls out that (gender) legs hurt whenever someone touches them. Nurse C voiced staff questioned if it was more of a behavior than pain. The facility staff failed to report voiced pain by the resident, failed to assess and administer prn pain medications as planned. Interview on 8/8/2011 at 7:50 a.m. Medication aide P reported that they believed the resident has pain. Medication aide P stated the resident will often call out when providing care that they hurt. Medication aide P reported that (gender) tells the Nurse when the resident complains of pain. Interview on 8/4/2011 12:40 p.m. regarding pain specific to resident #27, Nurse C indicated that they have tried giving the resident some of the [MEDICATION NAME] and it did not make any difference in their discomfort symptoms. Nurse C indicated that "they" question if the resident's hollering was related more to a behavior rather than pain. During this interview Nurse C reported that the facility assessed the resident's pain by completing pain assessments when the resident verbalized they were in pain and ask for something, or when they had symptoms of pain. They also addressed pain during the MDS look back period. Nurse C reported that when a resident complained of pain or when a resident showed signs of pain staff were to do a "number scale" assessment. Review of the medical record lacked any documentation of a number scale assessment for pain. The current MAR indicated [REDACTED]. The nurse documented the medications were effective. Interview on 8/8/2011 at 11:22 a.m. with Administrative Nurse A confirmed that (gender) coded the resident did not have pain on the significant change MDS dated [DATE]. Nurse A reported when the resident was assessed for this significant change MDS the resident verbalized no pain on that particular day. Nurse A determined by reviewing the MAR indicated [REDACTED]. Nurse A reported that (gender) saw the look back summary assessment but did not use them because the resident did not voice pain on the particular day and the resident had not received any pain medications. Administrative Nurse A confirmed that she should have used the summary notes for accurate completion of the MDS. The facility failed to adequately address, plan and manage resident #27's verbalized and displayed signs of pain to ensure that the resident received the care and services to support their highest practicable level of physical, mental, and psychosocial well-being regarding end of life care.