Every finding on record at Regent Park Rehabilitation and Healthcare

The facility reported a census of 61 residents; the sample included 15 residents. Based on interview and record review, the facility failed to inform Resident (R) 12, R7, and R4 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:- Review of both Electronic Health Record (EHR) and paper records revealed the following: 1. R12's EHR under the Orders tab revealed orders for the following: Mirtazapine (antidepressant medication used to treat mood disorders), 15 mg to be given orally at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dated 08/15/23. Fluoxetine HCL (a medication used to treat depression), 40 mg to be given orally in the morning for depression, dated 03/12/25. Alprazolam (antianxiety medication), 0.5 mg to be given orally three times daily for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dated 10/29/24. R12's scanned documents revealed a psychotropic medication consent for R12, dated 01/18/25, signed and dated by R12 on 10/15/25. The consent did not list the psychotropic medications or the medication dosages, route, or number of times to be given daily. 2. R7's EHR Orders tab revealed orders for the following: Mirtazapine, 30 mg to be given orally at bedtime for insomnia (inability to sleep), dated 07/11/25. Fluoxetine HCL, 40 mg to be given orally in the morning for mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), dated 07/11/25. R7's scanned documents revealed a psychotropic medication consent for R7, which was signed and dated 07/11/25, and did not list the psychotropic medications or the medication dosages, route, or number of times to be given daily. 2. R4's EHR Orders tab revealed orders for the following: Sertraline HCl (antidepressant medication), 100 mg by mouth in the morning for depression, dated 11/30/23. Quetiapine Fumarate (antipsychotic medication), 12.5 mg by mouth in the evening for major depressive disorder (MDD- major mood disorder that causes persistent feelings of sadness) and behavioral disturbances (persistent, intense patterns of disruptive, impulsive, or defiant actions), dated 10/26/25. Quetiapine Fumarate 50 mg, give 0.5 tablet by mouth at bedtime for MDD and behavioral disturbances, dated 01/28/25. Mirtazapine, 30 mg to be given orally at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dated 09/12/24. Lorazepam (antianxiety medication), 0.5 mg by mouth three times a day for anxiety, dated 11/30/2023. R4's scanned documents revealed an unsigned psychotropic medication consent for R4 dated 05/11/25. It did not list the psychotropic medications or the medication dosages, route, or number of times to be given daily. On 02/10/26 at 10:59 AM, Certified Medication Aide (CMA) R stated informed consent was required before starting or making any changes to psychotropic medications. On 02/10/26 at 11:17 AM, Licensed Nurse (LN) G stated informed consents were for psychotropic medications, and they were obtained before the psychotropic medication was started and any time there was a change made to the medication. LN G also said that the informed consent was provided to the residents and/or their legal representatives. On 02/11/26 at 10:45 AM, Administrative Nurse E stated she attended an educational seminar related to informed consents, and when she returned, a PIP (performance improvement plan) was implemented to correct the informed consent process. Administrative Nurse E also stated the facility was not aware that the informed consents, which had already been completed, needed to be corrected. The facility policy Psychotropic Medication Use, dated 11/11/25, documented that every psychoactive medication, on initiation and with any dosage increase, will initiate a signed informed consent to ensure the designee has reviewed with the resident and/or resident representative the potential adverse effects of the order of any psychoactive medication.

The facility identified a resident census of 61. The sample included 15 residents, with three reviewed for beneficiary notifications. Based on interviews and record review, the facility failed to provide the Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Notice of Non-coverage (ABN) Form CMS-10055, for Resident (R) 22.Findings included: -R22's facility provided documentation noted his Medicare Part A last covered day was 01/28/26. The resident remained in the facility for long-term care. Upon request, the facility was unable to provide evidence that Form CMS-10055 was provided to R22. A Social Service Note, dated 01/30/26 at 05:02 PM, documented the social worker provided the SNF ABN. R22 would remain on private pay for approximately 30-60 days until an apartment was available. The private pay quote was provided to R22's representative. A Social Service Note, created on 02/09/26 at 10:52 AM, with an effective date of 01/30/26 at 10:52 AM, documented the resident requested staff review the SNF ABN with his representative, who was not present at that time. R22 was unsure what time she would arrive. In an email communication from the facility to R22's representative on 01/27/26 at 05:41 PM, Social Services X explained there was a form which R22 would need to sign that reviewed his appeal rights and his right to appeal if he thought Medicare should cover the long-term care stay. The email indicated the appeal could take up to four months to process but the facility would continue with therapy during that time frame. If the appeal was unfavorable, the facility would bill the room, board, and therapy costs. Review of the email communication chain lacked mention of the SNF ABN or the estimated cost to continue the therapy services should the resident wish to do so. On 02/10/26 at 02:10 PM, Social Services X stated the ABN should be provided to the resident or resident's representative prior to discharge. Social Services X said she provided the form, but the resident did not sign or return the form as he wanted to review it with his representative. Social Services X verified she was unable to show the resident was provided with the ABN Form CMS-10055; she did not have a copy. A policy dated 12/01/17 stated that for residents admitted based on Medicare reimbursement, and the Medicare coverage ends, the facility will follow regulations and policies regarding appropriate notification of discharge from Medicare services, including the right to appeal. If the residents continued to need long-term care services, the facility designee will assist in discharge planning. The appropriate notification of discharge from Medicare services was not provided.

The facility identified a census of 61 residents. The sample included 15 residents with one resident reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide care and services to prevent a reduction in ROM or contractures (abnormal fixation of a joint or tendon) for Resident (R) 49 when staff failed to follow the order for device to reduce risk or complications related to her left-hand contracture. Findings included:- R49's Electronic Medical Record (EMR) revealed the following diagnoses: hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a stroke (a sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the left nondominant side and contracture (abnormal permanent fixation of a joint or muscle) to the left hand. R49's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS recorded R49 had hemialgia and a contracture of the left hand. R49's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R49 had impaired physical functioning related to a past stroke with left sided weakness. R20's Care Plan, dated 10/03/25, directed staff to place a clean, dry, rolled washcloth between R49's fingers and palm and ensure good hygiene. R49's Physician's Orders documented an order to place a clean, dry, rolled washcloth between fingers and palm and ensure good hygiene every day and night shift, ordered on 09/26/25. R49's February 2026 Medication Administration Record (MAR) from 09/26/25 to 02/11/26 documented the rolled washcloth it was in place every day and night with no refusals noted. R49's Progress Note lacked documentation R49 refused this treatment or that it was not completed. On 02/09/26 at 10:00 AM, R49 sat at the dining room table in her wheelchair. The wheelchair had a partial padded tray attached to it. R49's left arm was not on the tray. Her hand hung down, in a loose fist, and was swollen. She had nothing in hands to address the contracture. On 02/10/26 at 02:00 PM, R49 was in bed with the head of the bed elevated. R49's left elbow was on a pillow with her hand dangling. Her hand was swollen and in a loose fist, but she did not have a rolled cloth or any device in her hands. On 02/10/26 at 03:03 PM, R49 laid in bed. R49 stated she worked with therapy, and they gave her something to wear in her hand, she said it was a pool noodle with a strap to keep it in her hand and to prevent her hand from contracting. Observation revealed it was across the room, on her dresser. When asked when she was supposed to wear it, she stated she should be wearing it at that time. On 02/10/26 at 02:48 PM, Consultant Staff GG stated he completed an evaluation on 10/02/25 for a request for therapy from the provider for a left-hand contracture. He evaluated R49 and found she did not have a contracture at that time but did have tone which indicated some resistance. He provided her with a simple resting hand splint to be worn, or they could use a rolled-up hand towel. Consultant Staff GG said R49's left arm was completely flaccid (weak and flabby) which increased the risk for contractures. On 02/11/26 at 09:38 AM, Licensed Nurse (LN) H stated the nurse was to place a clean towel or splint in R49's hand and confirmed it should be there all the time. LN H stated the nurses verified and documented its placement on the MAR. On 02/11/26 at 10:39 AM, Administrative Nurse D stated she expected the nurse to place the splint on R49's hand to prevent contractures, and to document it correctly in the MAR. The facility's REST Initiative/Restorative Nursing Documentation policy documented the goals for all elders receiving restorative nursing services will include goals to prevent contractures.

The facility identified a census of 61 residents. The sample included 15 residents with one resident reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide care and services for Resident (R) 49 when oxygen was not provided to the resident when orders were in place. Findings included:- R49's Electronic Medical Record (EMR) revealed the following diagnoses: pneumonia (an infection in the lungs), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a stroke (a sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R49's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS recorded R49 received oxygen. R49's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R49 had impaired physical functioning related to a past stroke with left sided weakness. She required staff assistance with all care. R49's Care Plan, dated 09/26/25, documented R49 was on oxygen related to ineffective gas exchange. R49 was to be on two liters of oxygen continuously. R49's Physician's Orders documented an order to monitor oxygen saturation and oxygen at two liters every day and night shift, ordered on 09/25/25. On 02/09/26 at 10:00 AM, R49 sat at the dining room table in her wheelchair with an oxygen tank attached to the back of the wheelchair in a bag. A bag was attached by the oxygen tank with the nasal cannula tubing partially in the bag. The cannula's nasal prongs were out of the bag and hanging freely. R49 was not wearing or receiving her oxygen. On 02/09/26 at 10:05 AM, Licensed Nurse (LN) I came up to R49 and placed the nasal cannula on the resident. LN I then attempted to turn on the oxygen, but the tank was empty. LN I verified that R49 was supposed to have continuous oxygen and took her back to the room to place the resident on oxygen via a concentrator. On 02/11/26 09:35 AM, Certified Medication Aide (CMA) S stated she thought R49 was supposed to have oxygen all the time. On 02/11/26 at 09:38 AM, Licensed Nurse (LN) H stated R49 required oxygen all the time. On 02/11/26 at 10:39 AM, Administrative Nurse D stated she expected the nurse to follow the orders for oxygen. The facility's Oxygen Therapy policy documented that residents would use oxygen from a portable source when they are off the main concentrator.

The facility identified a census of 73 residents, with three reviewed for elopement. Based on record review, observation, and interview, the facility failed to provide sufficient supervision for Resident (R) 1 to prevent R1 from exiting the building after an employee. This deficient practice placed R1 at risk for elopement, falls, and injury.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of nontraumatic brain dysfunction (brain damage that occurs form internal factors), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R1 required supervision or partial assistance with all of his activities of daily living (ADL) except for locomotion in his wheelchair, which he was independent. The Annual MDS, dated [DATE], lacked Care Area Assessments (CAA).R1's Care Plan documented R1 was at risk for elopement and had a wanderguard. Staff were directed to check for the placement of R1's wanderguard and the wanderguard's functioning. The care plan directed staff when R1 wandered or was exit seeking to redirect R1 (09/01/23).The Health Status Note, dated 03/22/25, documented it was around 07:00 PM when R1 was found wandering in the parking lot. This nurse explained to R1 he could not be by himself outside and wheeled him back into the building. Staff told R1 that if his friend showed up, staff would let him know. R1 agreed and was pleasant. Checked wander guard twice and read ok. Called Administrative Nurse D and the manager on-call. R1 did not get hurt or upset from bringing him back to the building. The Health Status Note, dated 03/22/25, documented the nurse reported to R1's responsible party that R1 had gotten out of the facility despite having his wanderguard on. R1's wanderguard was active. R1's responsible party was made aware R1 was outside in the parking lot for no more than five minutes. R1's responsible party was appreciative of being notified and had no concerns for R1's safety.The Facility Incident Report, dated 03/24/25, documented on 03/22/25 at 06:58:50 PM, R1 was at the front door (which is where he usually sits, and this is his norm) and informed a PRN (as needed) therapist staff X he could go outside. The therapist staff member attempted to open the door, but R1's wanderguard kept locking the door down because he was so close. At 07:00:11 PM, the PRN therapist staff X opened the door by inputting the code, and she and R1 went out the doors together. The PRN therapist staff X went to her vehicle in the parking lot and left. Approximately five minutes later, an unknown family member went to the nursing station and asked if the gentleman in the wheelchair should be outside. LN G looked at the monitor, and the screen had not turned orange, which indicated an elopement. At 07:07:20 PM, R1 was brought back inside by the charge nurse. R1 was pedaling in his wheelchair in the middle of the parking lot. LN G asked him what he was doing, and he said he was waiting for his friend. R1 was unharmed upon assessment.On 07/07/25 at 10:00 AM, observation revealed a smooth transition from the front door down into the parking lot. The parking lot is smooth and without cracks or bumps. The parking lot led out to a roundabout with one exit leading to the assisted living building and the other exit heading toward the street.On 07/07/25 at 10:30 AM, observation revealed R1 sat in his wheelchair out by the nurses' desk, moving his wheelchair back and forth with his feet. A wanderguard was in place on R1's right wrist.On 07/07/25 at 10:40 AM, Licensed Nurse (LN) H stated R1 never stayed on the unit and was always up around the front desk by the front door. R1 talked to people entering and exiting the building.On 07/07/25 at 11:00 AM, Administrative Nurse D stated all staff education was completed regarding elopement. DON stated it was a perfect storm because they did not know the call light/elopement system was not functioning until this happened. She stated nursing checked the wanderguard system quarterly, and then the actual wanderguards that were on the residents were checked every shift.On 07/07/25 at 11:15 AM, Maintenance person U stated he checked the alarm system weekly, and they got a new system to integrate with the old system, and the reader stopped functioning and talking between the two systems and had since been fixed.The facility's undated Elopement Policy documented the facility wished to ensure the safety of those residents who had been identified as being at risk for elopement. It was the policy of the facility to identify those residents at risk for elopement and take precautions to ensure their safety and well-being. Special secure living units were provided by the facility, and additional security, including a Wanderguard door locking system, was provided.The facility completed corrective actions by 03/25/25. On 03/23/25, corrections included all staff education on elopements, started teachable moments in person individually, reviewed the facility's Elopement Policy and Procedure, and completed competency checklists on elopements. On 03/24/25, signs were placed at all exits to ensure staff were notifying the correct people due to malfunctions in the call light system (elopement). On 03/25/25, a message was out to call light/alarm company to address the following malfunctions: 1. The front door did not make staff put in the elopement code as well as the normal code (new keypad ordered and installed). 2. Front door not alerting the call light monitors that there was an elopement (orange elopement sign) - fixed. 3. Front door not alerting the pagers there was an elopement, as it should - fixed. 4. Sound monitors on the 300/400 hall not working - fixed. 5. Front desk could still push the remote button to open the door even when the elopement beep sound was going off - fixed. This was all completed prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance and remained at the scope and severity of a D to represent the isolated risk to R1.

The facility identified a census of 66 residents. The facility had two kitchens. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation. This placed all residents who ate food from the facility at risk for food-borne illness. Findings included: - During the initial tour on 04/08/24 at 07:13 AM, observation revealed the following: Mixed fruit in a white container in the small refrigerator with no label or date. A small steam table pan containing fruit in the refrigerator with no label or date. A large white canister of flour had no label or date. The freezer in the kitchen area contained opened fish, sausage, potatoes, and chicken. The bags were opened to air, and unsealed, with no label or date on the bags. A storage container of mashed potatoes in the small freezer had no lid, label, or date. On 04/08/24 during lunch service, dietary staff carried multiple residents' fruit cups while touching the tops of the opened containers. On 04/09/24 at 11:08 AM, Dietary Staff CC touched the probe of the food thermometer with his bare hands without cleaning the probe before completing temperature checks on the food. On 04/10/24 at 08:30 AM Dietary Staff BB stated foods should be labeled and dated. He stated staff were expected to know how to properly take the temperatures of food items being served. The facility did not provide a policy related to food storage and preparation as requested. The facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation. This placed all residents who ate food from the facility at risk for food-borne illness.

The facility had a census of 66 residents. The sample included 17 residents with two reviewed for accidents. Based on observation, record review and interview, the facility failed to secure pressurized oxygen cylinders in a safe, locked location and out of reach of the six cognitively impaired independently mobile residents. The facility additionally failed to maintain Resident (R)11's bed at a safe height while she was unsupervised in her room. These deficient practices placed the residents at risk for preventable accidents and injuries. Findings Included: - On 04/08/24 at 07:03 AM a walkthrough of the facility was completed. Upon inspection of the facility's Clean Room in between the 100 and 200 hallways, the entry door was propped open. The room contained 37 pressurized oxygen cylinders placed in racks marked full. At 07:07 AM, Licensed Nurses (LN) I closed the door upon request. She stated the door should have been closed and should always be locked. On 04/10/24 at 11:39AM Administrative Nurse D stated the oxygen storage room should be locked and secured. She stated she expected staff to ensure the door was closed and locked after exiting the room. The facility's Oxygen Storage policy revised 12/2024 indicated oxygen cylinder tanks must be stored in a secured room with proper ventilation. The policy stated oxygen cylinders will not be left unsupervised in open rooms, hallways, corridors, or stairways. The facility failed to secure 37 pressurized oxygen cylinders in a safe, locked area, and out of reach of the six cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disorder (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (difficulty swallowing), repeated falls, and a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R11's Significant Change Minimum Data Set (MDS) completed 02/12/24 noted a Brief Interview for Mental Status (BIMS) zero indicating severe cognitive impairment. The MDS indicated she had no functional impairments to her upper and lower extremities. The MDS indicated she was dependent on staff for bed mobility, transfers, toileting, bathing, and dressing. The MDS indicated no falls since her admission. The MDS noted she received hospice care (end of life comfort care). R11's Dementia Care Area Assessment (CAA) completed 02/16/24 indicated she had severe cognitive impairment with short and long-term memory loss. The CAA noted she had impaired decision-making abilities. The CAA instructed staff to anticipate her needs. R11's Communication CAA completed 02/16/24 indicated she had severely impaired decision-making abilities. The CAA noted she could only answer yes and no to make her needs and wants known. The CAA indicated she started hospice services on 02/13/24. R11's Care Plan initiated 02/15/22 indicated she was at risk for falls related to weakness, unsteadiness, and her medical diagnoses. The plan instructed staff to ensure her call light remained within reach while unsupervised in her room, ensure the use of non-skid footwear during ambulation and transfers, encourage her to participate in exercise, physical activity for improved mobility. The plan indicated grab assist bars were installed to promote independence and stability with transfers (02/15/22). R11's plan was updated on 10/03/23 indicating she was dependent on two staff for bed mobility using her bed's grab bars. A review of R11's EMR under Progress Notes indicated her last fall was on 06/21/23. The note indicated she was found on the floor by staff next to her wheelchair. The noted indicated she was attempting to reach for her television remote that fell next to her feet. R11's Fall Risk assessment indicated she was a moderate fall risk on 02/12/24. On 04/09/24 at 07:08AM R11 slept in her bed. R11's bed was left in the high position with the back of her bed inclined upward. Her low air-loss mattress pump was set between 180 and 200 pounds (lbs.). At 07:22 staff entered her room and lowered the bed to the lowest position. On 04/10/24 at 08:00AM Certified Nurse Aid (CNA) M stated beds should never be left in the high position for residents with severe cognitive impairment. She stated staff should check the resident's positioning and beds during each encounter for safety. On 04/10/24 at 08:12AM Licensed Nurse (LN) J stated staff were expected to check R11's bed during each round or interaction. She stated the beds should be left in the low position when unsupervised. On 04/10/24 at 11:21AM Administrative Nurse D stated R11's bed should never be left in the high position while she was unsupervised or alone. She stated staff should lower the bed after performing cares or leaving the room. The facility's provided Fall revised 03/2024 indicated the facility will assess each resident for risk factors related to falls and identify interventions to prevent accidents and injuries. The policy indicated the facility elderly/frail residents were at greater risk for falls and injuries. The policy indicated the residents will be screened for risks related to physical, environmental, and medications to avoid preventable accidents and injuries. The facility failed to ensure R11's bed was maintained at a safe height while unsupervised in her room. This deficient practice placed R11 at risk for preventable falls and injuries.

The facility identified a census of 66 residents. The sample included 17 residents, four medication carts, and four medication rooms. Based on observation, record review, and interviews, the facility failed to properly label and store medications in one of four medication carts and one medication room. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - Observation on 04/08/24 at 07:06 AM Licensed Nurse (LN) I walked away from the nurse's station on the 100-hallway and left the medication cart unlocked. LN I returned and secured the cart upon request. On 04/09/24 at 07:16 AM the treatment cart contained: Three opened, undated insulin (a hormone that lowers the level of glucose in the blood) pens. On 04/09/24 at 09:36 AM the 100-hallway medication room contained: Two opened, undated vials of tuberculin vaccine serum. The medication refrigerator temperature log lacked evidence staff measured and documented a temperature for the following dates: 03/01/24, 03/02/24, 03/03/24, 03/07/24, 03/19/24, 03/20/24, 03/24/24, 03/27/24, 03/28/24, 04/02/24, 04/03/24, 04/04/24, 04/05/24, and 04/0624. On 04/09/24 at 07:16 AM, LN G stated all insulin pens should be labeled and dated at the time of opening. LN G stated the insulin pens should be stored in the refrigerator until they are opened. On 04/11/24 at 09:46 AM, LN K stated the medication refrigerator temperature was to be monitored and documented daily. LN K stated tuberculin vaccine serum and insulin pens were supposed to be labeled with the open date when opened. On 04/10/24 at 11:19 AM, Administrative Nurse D stated she expected all insulin pens and tuberculin vaccine serum vials to be labeled and dated when opened. Administrative Nurse D stated she expected the medication refrigerator temperatures to be checked and recorded. The facility's Storage of Medications policy dated April 2007 documented the facility would store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators. carts, and boxes) containing drugs and biologicals would be locked when not in use, and trays or carts used to transport such items would not be left unattended if open or otherwise potentially available to others. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. The facility failed to properly label and store medications which could potentially cause adverse consequences or ineffective treatment to the affected residents.

The facility reported a census of 66 residents. The sample included 17 residents with three reviewed for accommodation of needs. Based on observations, interviews, and record review, the facility failed to provide wheelchair foot pedals for Resident (R) 40. This deficient practice placed the resident at risk impaired care and decreased quality of life. Findings included: - R40's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (weakness and paralysis on one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (high blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), overactive bladder (urine urgency), and glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow). R40's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. R40 required staff assistance with activities of daily living (ADLs). R40's Functional Care Area Assessment (CAA) completed 01/10/24 indicated she had self-care deficits related to impaired balance due to left-sided weakness and hemiplegia after a recent hospitalization due to a stroke. The CAA indicated she required assistance from staff for her ADLs. R40's Care Plan revised 01/18/24 indicated she was at risk for falls related to impaired balance and her medical diagnoses. The plan indicated she required extensive assistance with ADL tasks due to balance impairments. The plan indicated she used a wheelchair for mobility. The plan instructed staff to assist her with mobility if needed. The plan indicated staff were instructed to provide reminders for R40's feet placement during transfers. On 04/08/24 at 07:34 AM staff propelled R40 to the dining area for breakfast without foot pedals. She was holding her feet up as staff pushed her wheelchair. On 04/08/24 at 12:43 PM staff propelled R40 down the 300 hall to her room without her foot pedals on her wheelchair. The staff member asked R40 to keep her feet up. On 04/10/24 at 07:30 AM Licensed Nurse (LN) J stated residents needed foot pedals on wheelchairs if the chair was propelled by staff. On 04/10/24 at 07:45 AM Certified Nurse's Aide (CNA) M stated all wheelchairs should have foot pedals. CNA M stated nursing provide the foot pedals on the resident's wheelchair when the chair is propelled by the staff. On 04/10/24 at 11:30 AM Administrative Nurse D stated all residents should have foot pedals on their chairs when being pushed by a staff member. The facility's Accommodation of Needs policy approved 10/01/23 documented each elder has a right to reside and receive services at this facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the elder or other elders would be endangered. Interior spaces accommodate the use of equipment and assistive devices necessary to maximize each eider's functionality of activities of daily living. The facility failed to provide wheelchair foot pedals for R40. This deficient practice placed R40 at risk of impaired care and safety.

The facility identified a census of 66 residents. The sample included 17 with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)11's pressure-reducing interventions were implemented correctly when her low air-loss mattress pump was not set to the appropriate weight setting. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (a progressive mental disorder characterized by failing memory, confusion), dysphagia (difficulty swallowing), repeated falls, and a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R11's Significant Change Minimum Data Set (MDS) completed 02/12/24 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she had no functional impairments to her upper and lower extremities. The MDS indicated she was dependent on staff for bed mobility, transfers, toileting, bathing, and dressing. The MDS indicated she was at risk for pressure ulcers and had an unstageable ulcer (the depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus). The MDS noted she had pressure-reducing devices for her bed and chair, pressure ulcer care, a repositioning program, and nutrition/hydration interventions to manage her ulcer care. The MDS noted she received hospice care (end-of-life comfort care). R11's Pressure Ulcer Care Area Assessment [CAA] completed 02/16/24 indicated she was at risk for skin breakdown and pressure related injuries. The CAA indicated staff were to turn and reposition her every two to three hours. The CAA noted she had a low air-loss mattress (LAL- air mattress designed to alternate air between surfaces of the body and prevent pressure related injuries) and pressure relieving cushion for her wheelchair. The CAA indicated she had a Braden (a scale used to assess the risk of developing pressure ulcers) score of 11 indicating a moderate risk. R11's Care Plan initiated 02/25/22 indicated she was at risk for impaired skin integrity related to her medical diagnoses. The plan indicated she had an existing pressure injury on her sacrum (triangular bone/area between the two hip bones). The plan instructed staff to ensure adequate nutrition. The plan noted she was on enhanced barrier precautions due to her existing wound. The plan indicated she had a pressure-reducing low air-loss mattress for the prevention of further wounds (02/16/24). The care plan lacked instruction of related to the monitoring and settings for the LAL mattress pump. R11's EMR under Physician's Orders noted an order for a low air-loss mattress related to her impaired skin integrity starting 01/30/24. The order lacked instructions related to monitoring and settings for the mattress pump. A review of EMR indicated no documented LAL mattress checks, preferences, or notes indicating R11 preferred her bed firmer. R11's EMR indicated she weighed 111.4 lbs. on 04/01/24. The Operator's Manual Drive 14026 documented the mattress was indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The Operating Instructions, step six, directed to determine the patient's weight and set the control knob to that weight setting on the control unit. On 04/08/24 at 07:10 AM R11 rested in her bed. Her bed was in a low position. R11's low air-loss mattress was set between 200 pounds (lbs.) to 210 lbs. On 04/09/24 at 07:08 AM R11 slept in her bed. R11's bed was left in the high position with the head of her bed inclined upward. Her low air-loss mattress pump was set at 180 lbs. At 07:22 AM staff entered her room and lowered the bed to the lowest position. The mattress pump remained set at 180 lbs. On 04/10/24 at 08:21 AM R11 slept in her bed. Her low air-loss mattress pump was set between 180 (lbs.). On 04/10/24 at 08:21 AM Licensed Nurse (LN) J stated the beds were set to the resident's weight. She stated she was not sure if the care plan covered instructions for the low air loss mattress setting. She stated nurses should be checking the bed and equipment each shift. On 04/10/24 at 08:26 AM Administrative Nurse D stated the LAL mattress were set by weight. She stated R11's Care Plan addressed the low air-loss mattress but not the setting instructions. She stated she expected staff to check the setting of the bed each shift. Administrative Nurse D stated the bed can be set up to 50 lbs. above the resident's actual weight. The facility's Low air loss mattress Policy approved 12/29/24 [sic] documented Low air loss mattresses will be used when appropriate for maintenance, and management. The patient would need to benefit from a low air loss mattress, after assessing and monitoring patients' skin integrity, guidelines for mattress setup and adjustments, protocols for cleaning and disinfecting the mattress, and instructions for staff training on proper usage. This mattress will aim to ensure the safe and effective implementation of low air loss mattresses to promote patient comfort and prevent pressure ulcers. Low air loss mattress should be adjusted no less than 50 pounds above the patients weight or to the patients preference or comfort level. The facility failed to ensure R11's pressure-reducing interventions were implemented correctly when her low air-loss mattress was set for an inaccurate weight. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers.

The facility identified a census of 66 residents. The sample included 17 residents with four residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 35's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) and oxygen tubing was stored in a sanitary manner to decrease exposure and contamination. This deficient practice placed R35 at increased risk of developing respiratory infection and complications. Findings included: - R35's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of obstructive sleep apnea (a disorder of sleep characterized by periods without respirations), respiratory failure with hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood), and hypertension (HTN-elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R35 received oxygen therapy and a non-invasive mechanical ventilator during the observation period. The MDS documented R35 received a diuretic (medication to promote the formation and excretion of urine) during the observation period. R35's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/29/24 documented R35 suffered from chronic confusion. R35's Care Plan dated 01/07/24 documented that staff would apply R35's CPAP mask at 09:00 PM every night. The care plan lacked direction to staff on cleaning and storing the CPAP mask. R35's EMR under the Orders tab revealed the following physician orders: CPAP mask every night at 09:00 PM, with setting 16 centimeters (cm) at bedtime dated 04/13/23. Oxygen therapy at two liters (L) per nasal cannula at bedtime for hypoxia dated 05/10/23. On 04/08/24 at 11:47 AM R35 sat reclined in his Broda chair (specialized wheelchair with the ability to tilt and recline) near the foot of his bed. R35's CPAP mask lay directly on the bedside table next to the head of the bed. Undated and unbagged oxygen tubing lay directly on the floor in front of the oxygen concentrator. On 04/10/24 at 09:40 AM, Certified Nurse Aide (CNA) M stated oxygen nasal cannulas and CPAP masks should always be stored in a plastic bag when not in use. On 04/10/24 at 09:48 AM, Licensed Nurse (LN) K stated oxygen nasal cannulas and CPAP masks should always be stored in a plastic bag when not in use. LN K stated the oxygen tubing should never be placed on the floor and if it touches the floor, it should be replaced. On 04/10/24 at 11:19 AM, Administrative Nurse D stated she expected the staff to follow the facility policy related to respiratory care for the storage of oxygen tubing and CPAP masks. Administrative Nurse D stated the oxygen tubing was to be changed weekly, dated, and placed in a plastic bag when not in use. The facility's CPAP/Bi-Level Respiratory Care dated 12/24/24 documented obstructive sleep apnea is a sleep disorder that occurs when the airway is obstructed or blocked and as a result, no air moves into or out of the lungs. The obstruction may be due to a variety of factors including loss of muscle control over the tongue which may cause the tongue to fall back against the airway and/or the collapse of the soft palate over the airway. Any/all use of CPAP or Bi-Level respiratory care procedures requires specific physician orders and the ordered level of air pressure to keep the airway open during sleep may not be changed without consulting the ordering physician with resultant change in settings orders. The facility failed to ensure R35's CPAP mask and oxygen tubing were stored in a sanitary manner to decrease exposure and contamination. This deficient practice placed R35, at increased risk of developing respiratory infection and related complications.

The facility identified a census of 66 residents. The sample included 17 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to administer as needed diuretic (medication to promote the formation and excretion of urine) as ordered for Resident (R) 35. The facility also failed to follow a physician's order for monitoring R40's metoprolol (beta-blocker used to lower blood pressure or pulse). This deficient practice had the potential of unnecessary medication side effects or ineffective therapeutic regimen. Findings included: - R35's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of obstructive sleep apnea (a disorder of sleep characterized by periods without respirations), respiratory failure with hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood), and hypertension (HTN-elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R35 received oxygen therapy and a non-invasive mechanical ventilator during the observation period. The MDS documented R35 received a diuretic during the observation period. R35's Dehydration Care Area Assessment (CAA) dated 03/29/24 documented R35 experienced constipation related to decreased mobility. R35's Care Plan dated 02/11/24 documented staff would administer medications as ordered. The plan of care also documented staff would ask the physician to review medication for possible dose reduction every three months. The plan of care directed staff to monitor the dose which may require a modification to achieve the desired effects to minimize the adverse consequences, especially when multiple antihypertensives medication are prescribed simultaneously. R35's EMR under the Orders tab revealed the following physician orders: Bumetanide oral tablet (diuretic medication) 1mg give one tablet by mouth in the morning for edema 04/13/23. Metolazone oral tablet (diuretic medication) 2.5mg give 1 tablet by mouth every 24 hours as needed for weight gain equal to or greater than (>) two pounds (lbs.) dated 02/09/24. Obtain weight prior to breakfast on Monday, Wednesday, and Friday, see as needed metolazone order if weight gain of two lbs. dated 03/01/24. A review of R35's EMR under the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 02/09/24 to 04/09/24 lacked evidence the as-needed metolazone was administered as ordered by the physician on the following dates when R35's weight indicated administration: 02/12/24, 022/16/24, 02/21/24, 02/26/24, and 04/01/24. On 04/08/24 at 11:47 AM R35 sat reclined in his Broda chair (specialized wheelchair with the ability to tilt and recline) near the foot of his bed. R35's CPAP mask lay directly on the bedside table next to the head of the bed. Undated and unbagged oxygen tubing laid directly on the floor in front of the oxygen concentrator. On 04/10/24 at 11:19 AM, Administrative Nurse D stated she expected the staff to follow the physician's orders. Administrative Nurse D stated she expected the nurses to administer any as-needed diuretic medications if there was a two-pound weight gain for R35. The facility's Physician Orders for Medications and Treatments policy dated 12/01/24 documented all medications would be administered as ordered by a healthcare professional authorized by the state to order medications. All physician orders would be signed and dated, including the facility standing orders. The facility failed to administer R35's as-needed diuretic as ordered. This deficient practice had the potential of unnecessary medication side effects or ineffective therapeutic regimen. 49634 - R40's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (weakness and paralysis on one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (high blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), overactive bladder (urine urgency), and glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow). R40's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated moderately impaired cognition. R40 required staff assistance with activities of daily living (ADLs). R40's Functional Care Area Assessment (CAA) completed 01/10/24 indicated she had self-care deficits related to impaired balance due to left-sided weakness and hemiplegia after a recent hospitalization due to a stroke. The CAA indicated she required assistance from staff for her ADLs. R40's Care Plan initiated 05/24/22 indicated she received medications with Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). The plan indicated she received metoprolol and instructed staff to monitor her pulse (heart rate) and blood pressure. R40's EMR under Physician's Order documented an order for metoprolol 25 milligrams (mg) by mouth daily for hypertension. The order instructed staff to hold the medication if R40's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg) or pulse (heart rate) < 55 beats per minute (bpm). Review of R40's Medication Administration Report (MAR) and clinical record lacked evidence R40's blood pressure was monitored consistently before the administration of her metoprolol. On 04/08/24 at 07:26 AM R40 slept in her recliner with her feet extended. On 04/10/24 at 07:30 AM Licensed Nurse (LN) J stated that R40's blood pressure should be monitored and documented before the metoprolol was given. She stated if the medication had parameters, nursing would not be able to document the medication given until a blood pressure was entered on the EMR. On 04/10/24 at 11:19 AM, Administrative Nurse D stated she expected the nursing staff to follow the facility policy, or the physician order related to monitoring blood pressures related to certain medications. The facility's Medication Monitoring policy reviewed 12/29/23 documented residents will be monitored for adverse drug reactions including Black Box Warnings and the resident's physician will be promptly notified if the resident becomes symptomatic. Parameters for recommended monitors will be established per facility protocol with the approval of the Medical Director on the prescribing recommendations, parameters will be maintained in the resident's clinical record per facility protocol. The facility failed to consistently monitor R40s blood pressure as ordered prior to administration of R40's beta-blocker medication. This deficient practice placed R40 at increased risk for unnecessary medication and side effects.

The facility identified a census of 66 residents. The sample included 17 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to maintain ongoing communication with hospice services related to R11's bi-weekly hospice visits. The facility additionally failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for R11. This deficient practice placed both residents at risk for delayed services and uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (a progressive mental disorder characterized by failing memory, confusion), dysphagia (difficulty swallowing), repeated falls, and a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R11's Significant Change Minimum Data Set (MDS) completed 02/12/24 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she had no functional impairments to her upper and lower extremities. The MDS indicated she was dependent on staff for bed mobility, transfers, toileting, bathing, and dressing. The MDS indicated no falls since her admission. The MDS noted she received hospice care (end-of-life comfort care). R11's Dementia Care Area Assessment (CAA) completed 02/16/24 indicated she had severe cognitive impairment with short and long-term memory loss. The CAA noted she had impaired decision-making abilities. The CAA instructed staff to anticipate her needs. R11's Communication CAA completed 02/16/24 indicated she had severely impaired decision-making abilities. The CAA noted she could only answer yes and no to make her needs and wants known. The CAA indicated she started hospice services on 02/13/24. R11's Care Plan initiated on 02/14/24 indicated she was on hospice services. The plan instructed staff to ensure comfort, dignity, and autonomy were maintained at the highest level. The plan instructed staff to keep her environment calm and quiet. The plan instructed staff to assess R11's pain and provide medication as ordered. The plan instructed staff to cooperate with the hospice team to ensure R11's spiritual, emotional, intellectual, physical, and social needs were met. The plan lacked contact information for the designated hospice service including telephone and address. The plan lacked information regarding the services provided by hospice including medications, equipment, and supplies. The plan additionally failed to identify the frequency of visits from the hospice nursing staff. R11's EMR under Miscellaneous revealed her hospice Plan of Care Order which indicated hospice provided two weekly visits from both skilled nursing and hospice aides. R11's EMR on 04/09/24 lacked the scanned hospice communications showing the bi-weekly visits were being completed and what services were provided at the time of the visits. On 04/08/24 at 07:10 AM R11 rested in her bed. Her bed was in a low position. R11's low air-loss (mattress designed to prevent and treat pressure wounds) mattress was set to 200 pounds. On 04/10/24 at 08:23 AM Licensed Nurse (LN) J stated she was not sure where the hospice documentation for R11 was located. She stated the documentation was not at the desk or in the nursing office. She stated the hospice contact information and the information regarding what was provided by hospice were not in the care plan. She stated she was not sure what services, medication, and equipment were provided by hospice. She stated hospice comes weekly but she was not sure if communication sheets were filled out. She stated hospice would just tell the nurse the orders. On 04/10/24 at 08:35 AM Administrative Nurse D stated R11 did not have a hospice book or other communication tool. She stated the facility stopped using communication books. She stated the communication forms were scanned in under miscellaneous in the EMR. She stated the facility did not put the hospice-provided medications, equipment, and staffing in the care plan. She stated staff could look in the EMR for the hospice-provided Plan of Care. On 04/10/24 at 12:01 AM Administrative Staff E stated R11's hospice documentation was delivered to the building the morning of 04/10/24 for review after it was requested for the survey. The facility's End of Life, Palliative and Hospice Care policy revised and approved 12/03/23 indicated the facility would collaborate with hospice services to provide the appropriate treatment, symptom management, prevention of complications, and meet the resident's preferences. The policy indicated the facility would collaborate with hospice to implement a comprehensive plan of care reviewed by the interdisciplinary team. The facility failed to maintain ongoing communication with hospice services related to R11's bi-weekly hospice visits. The facility additionally failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for R11. This deficient practice placed both residents at risk for delayed services and uncommunicated care needs.

The facility identified a census of 66 residents. Based on observation, record review, and interviews, the facility failed to a functional and fully operational call light system for each resident. This deficient practice placed the residents at risk for delayed care and decreased psychosocial well-being. Findings Included: - On [DATE] at 08:59 AM Resident (R)212 sat in her room for breakfast. She stated her call light had not worked since she was admitted on [DATE]. She stated nursing instructed her to yell out for help if she needed anything. She stated she did not receive a bell and was unsure if staff completed frequent checks on her. She stated she was afraid of falling with no way to alert anyone to come help her. On [DATE] at 09:05 AM a call light inspection and test revealed R212's call light did not work upon pushing the button. Certified Nurse Aide (CNA) N confirmed the call button was not functioning in R212's room. On [DATE] at 03:55 PM, R6 reported she felt her call light did not work. An inspection and test of the call light revealed the call button was not functioning. Administrative Nurse F reported the non-functioning call light to maintenance. On [DATE] at 08:48 AM Maintenance Staff U stated the facility had a new call light system and the system is checked every week. Maintenance Staff U stated the facility has a maintenance staff person on call on the weekends to take care of any issues that would come up. He said he was unaware of what the protocol would be if maintenance personnel could not get the call light to work right away. On [DATE] at 07:30 AM Licensed Nurse (LN) J stated if there was a problem with the call lights nursing would call maintenance personnel first. She stated staff would then start 15-minute checks on the resident until the issue was fixed. On [DATE] at 08:05 Certified Medication Aide (CMA) M stated direct care staff would alert maintenance on any call light not functioning. She stated the facility would provide the residents bells to utilize and nursing would complete increased frequency checks on the residents every ten to fifteen minutes. On [DATE] at 11:12 AM Administrative Nurse D stated she was aware the call lights system had some issues due to it being a new system. She stated staff were expected to notify the on-call supervisor and maintenance for any outages. She stated direct care staff were to increase the frequency of checks to ensure resident safety. She stated the facility was ordering call bells just in case. The facility's Call Light policy dated [DATE] documented the electronic call system throughout the facility will be operational so that residents may summon and receive assistance when needed. The facility provides a system that each resident may call for staff assistance from each resident's bedside and the resident's toilet and bathing room through a call light communication system that relays the call directly to a staff or a centralized staff work area. If a malfunctioning call light occurs which cannot be immediately remedied , the nursing staff will initiate 15-minute resident checks. The facility failed to ensure two of the four hallways had operational call lights for each resident to call for assistance. This deficient practice placed the residents at risk for delayed care and decreased psychosocial well-being.

The facility identified a census of 66 residents. Based on observation, record review, and interviews, the facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location for residents or visitors. Findings included: - Review of 18 months of posted nurse staffing information provided by the facility lacked evidence of the daily census on the posted staff sheet. On 04/19/24 at 10:30 AM Administrative Staff A stated the posted nursing staff information was posted on the wall outside the assistant director of nursing's office under the folder. Administrative Staff A confirmed the posted staffing was covered and stated all visitors and residents would need to do was flip the folder up to see the information. The facility was unable to provide a policy related to posted nursing information. The facility failed to include required posted nursing staffing information that included the daily census and failed to post that information in a readily accessible location for all residents and visitors to review.

The facility census totaled 53 residents (R) with fourteen in the sample. Based on interview and record review the facility failed to notify the physician of R142's low oxygen saturation, high blood pressure, and weight gains of two pounds or more as indicated. Findings included: - Review of R142's pertinent [DIAGNOSES REDACTED]. Review of the 01/06/21 Admission Minimum Data Set (MDS) revealed a status of in progress. Review of 12/31/20 Baseline Care Plan and Electronic Medical Records Care Plan revealed R142's medication regime included [MEDICATION NAME] (medication used to treat high blood pressure) for hypertension and staff monitored the resident's blood pressure. Her medication regimen included [MEDICATION NAME] (used to reduce extra fluid in the body ([MEDICAL CONDITION]) caused by conditions such as heart failure) for [MEDICAL CONDITION]. The staff monitored the resident's weight and monitored for elevated blood pressures. R142 experienced respiratory infection with COVID-19, which required staff to monitor vital signs as ordered/protocol. Oxygen use for this resident not documented on the updated electronic care plan but indicated on the paper baseline care plan as revision 01/08/21 oxygen at two liters nasal cannula continuous. Review of Physician order [REDACTED]. Review of 12/31/20 to 01/13/21 Medication Administration Record [REDACTED]. Review of 12/31/20 to 01/09/21 Progress Notes and scanned miscellaneous documents lacked documentation of physician notification for the above noted two pound or greater weight gains within specified parameters. Review of Physician order [REDACTED]. Review of 12/31/20 to 01/13/21 MAR/TAR vital signs for the above orders revealed on 01/01/21 at 08:00 AM the resident's oxygen saturation noted at 73%, and staff did not document oxygen saturation monitoring again until 01/01/21 at 09:45 PM, almost 14 hours later. Review of 12/31/20 to 01/09/21 Progress Notes and scanned miscellaneous documents lacked documentation of physician notification for the above noted low oxygen saturation of 73% on 01/01/21 at 08:00 AM. Review of Physician order [REDACTED]. [MEDICATION NAME] tablet 40 milligrams (mg) by mouth once daily [MEDICAL CONDITION] 12/31/20. [MEDICATION NAME] tablet 10mg by mouth daily [MEDICAL CONDITION] 01/01/21. [MEDICATION NAME] tablet 0.1mg by mouth every eight hours as needed for HTN, staff administered if systolic blood pressure greater than 160 since 01/01/21. Review of 12/31/20 to 01/13/21 MAR/TAR/vital signs for the above orders revealed on 12/31/20 at 05:00 PM R142 blood pressure noted as 207/81 millimeters of mercury (mm/Hg). The next blood pressure staff obtained noted on 01/01/21 at 03:36 AM of 197/86. Review of 12/31/20 to 01/09/21 Progress Notes and scanned miscellaneous documents lacked documentation of physician notification for the above noted high blood pressures on 12/31/20 at 05:00 PM and 01/01/21 at 03:36 AM. Interview on 01/14/21 at 09:24 AM with CNA D revealed staff completed vital signs, including blood pressures and oxygen saturations every shift for R142, and any vital signs out of whack for the resident would be reported immediately to the nurse. Interview on 01/14/21 at 08:56 AM with Licensed Nurse (LN) C revealed R142 received [MEDICAL CONDITION]. LN C said the staff obtained vital signs, including blood pressure, oxygen saturation, every shift and called the physician as needed. LN C then stated R142's weights were completed daily, and the nurse called the physician for weight gains of two pounds in one day or five pounds within a week. Interview on 01/19/21 at 08:30 AM with Administrative Nurse B revealed the parameters for vital signs, including blood pressure/oxygen saturations, and weights should be followed, and the nurses should use their nursing judgement/critical thinking for physician notification. Administrative Nurse B expected the nurse to call the physician every time a high blood pressure occurred and expected the nurse to document the communication appropriately for high blood pressures without an as needed medication order on the chart. Review of 09/09/20 Blood Pressure Measuring and Parameters policy revealed the purpose of the procedure was to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins and chambers of the heart. Hypertension was usually defined as a blood pressure over 140/90 mm/Hg (although the elderly often have persistent systolic readings from 140 to 160 mm/Hg), and hypertension should be reported to the physician. Review of 10/01/20 Weight Assessment and Intervention policy lacked information regarding documentation for resident's that required weight monitoring for specific [DIAGNOSES REDACTED]. Review of 11/11/20 Oxygen Administration policy revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. This policy did not address physician notifications. The facility failed to provide a policy on physician notifications as requested on 01/19/21. The facility failed to notify the physician of R142's low oxygen saturation, high blood pressures, and weight gains of two pounds or more as ordered.

The facility census totaled 53 residents with 14 residents sampled, and one reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to provide treatment and care to prevent the development of a stage 2 pressure ulcer (partial thickness loss of dermis) for Resident (R) 26. Findings included: - Review of R26's signed Physician Orders dated 12/03/20 revealed the following Diagnoses: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. She required extensive assistance of one staff for transfers, bed mobility and required extensive assistance of one staff with toileting. The MDS noted the resident as frequently incontinent, with no skin issues noted. Review of the Significant Change in Status MDS dated [DATE] revealed a BIMS score of 11, indicated moderately impaired cognition. The resident required extensive assistance of one staff for transfers, bed mobility, toilet use, and personal hygiene. The resident was frequently incontinent of bowel and bladder and noted as at risk for pressure ulcers, though no skin issues noted. Review of the Urinary Incontinence Care Area Assessment (CAA) dated 12/04/20 revealed the resident had frequent, functional urinary incontinence, and required extensive staff assistance with toileting needs. The CAA noted she was at risk for impaired skin issues. Review of the Care Plan dated 01/30/19 revealed the resident was at risk for impaired skin integrity related to impaired mobility. The resident required extensive staff assistance with bed mobility and frequent bladder incontinence. Staff were to monitor R14's skin condition while providing care and inspect for color or texture changes, redness, [MEDICAL CONDITION], incontinence associated skin damage, and report their findings to the charge nurse. On 02/13/29, the Care Plan was revised to alert staff they were to ensure adequate and proper repositioning. The Care Plan was revised on 01/05/21 alerting staff they were to offer to lay the resident down after each meal and position side to side to offload buttocks. Then on 01/11/21, the Care Plan was revised to instruct nursing staff to pain skin prep (liquid skin protectant film) to entire buttocks and allow to dry to promote skin integrity. The entire staff were to monitor continence status and minimize exposure of urine and/or bowel to the skin. Staff were to utilize a pressure reducing device in the resident's chair or wheelchair and utilize a pressure reducing mattress. Review of the 01/03/21 Health Status Note revealed a skin assessment completed with no new areas noted. Review of the 01/05/21 at 08:15 PM Health Status Note revealed staff changed the resident in bed due to incontinence of bowel and noted an open area to her left buttock, which measured 0.8-centimeter (cm) x 0.7 cm x 0.1 cm. The staff cleaned with normal saline, applied Skin Prep around area, and covered with a [MEDICATION NAME] (wound dressing) dressing. The resident voiced no complaints of pain. The staff notified the on-call nurse, family, and written communication in place for the provider. The note revealed an intervention for staff to offer to lay the resident down after meals to offload pressure to the coccyx (the tailbone). Review of the Physician Order dated 01/05/21 revealed an order to clean the wound with normal saline, apply Skin Prep around the area, and cover with a [MEDICATION NAME] dressing. The order instructed staff to change the dressing every three days and as needed (PRN), if soiled. Review of the 01/06/21 10:43 AM Skin/Wound Note (note written specifically for wounds when evaluated) revealed resident noted to have a stage three pressure wound to left buttocks measuring 0.8 cm x 0.7cm x 0.1cm. Scant drainage noted, peri (around)-wound blanchable (when a patient's skin loses redness with pressure; unblanchable skin does not) with no foul odor or sign of infection. The resident had increased incontinence noted. New wound treatment orders received to paint skin prep to peri-wound and allow to dry, mix moisture barrier (MB) cream with collagen powder (the main component of connective tissue) to create paste, and apply to the wound bed. Cover the wound with an island dressing, change every other day and PRN if soiled or saturated. The resident's Durable Power of Attorney (DPOA), charge nurse, and staff were notified of the treatment orders. All parties agree and verbalized understanding resident non-compliance with laying down may include worsening of wound. Review of the 01/11/21 01:04 PM Skin/Wound Note revealed skin/wound rounds completed. Resident's stage three buttocks wound now is resolved. Skin is intact and entire buttocks is blanchable. This nurse received new order to paint skin prep to entire buttocks daily to promote skin integrity. New orders reviewed with DPOA and charge nurse. All parties agree with treatment. Review of the 01/13/21 12:18 PM Health Status Note revealed Administrative Nurse H was notified by Licensed Nurse (LN) G to assess R26's buttocks due to possible open area. The resident had open pressure wound, stage two (shallow ulcer with a reddish base), to left buttock measuring 0.6 cm x 0.4 cm x 0.1 cm. [DIAGNOSES REDACTED] (red irritated tissue) noted, wound is blanchable, and resident reports tenderness during assessment. Provider notified and received orders to cleanse the wound with normal saline, pat dry, paint skin prep to peri-wound and mix collagen powder with MB cream, apply to wound bed, then cover the wound with an island dressing and change every other day. DPOA notified of treatment orders and in agreement. Orders reviewed with the charge nurse. Review of documentation of the Skin/Wound Rounds with specialized wound nurse practitioner completed on 01/18/21 revealed the resident had a stage two left buttocks wound measuring 0.3 cm x 0.7 cm x 0.1 cm. The wound showed improvement from last week's observation and measured smaller. New treatment order was for staff to cleanse with normal saline, pat dry, paint skin prep to left buttocks, allow to dry and cover with a silicone bordered dressing and change every Monday and Friday and PRN if soiled or saturated. Orders reviewed with charge nurse, DPOA, and staff. All parties agreed with the treatment plan and understood non-compliance with laying down may include worsening of wound. Observation on 01/13/20 at 08:38 AM revealed the resident sat in a wheelchair at the dining room table following the breakfast meal. The resident had feet up on footrests and sat on a cushion in the chair. 08:50 AM- A staff member took the resident to her room after breakfast. The resident sat in her wheelchair with over bed table beside her with a health shake given. No toileting offered by staff. She remained watching television in her wheelchair without repositioning until 09:40 AM. 09:40 AM- Administrative Nurse B was in the room with the resident. 09:45 AM- Certified Nursing Assistant (CNA) I entered the resident's room after being summoned by Nurse B. CNA I changed the resident's shirt due to the resident complaining of being hot. No change of position or incontinent check observed. 10:04 AM- LN G was in the resident's room visiting with the resident. No care was given to the resident. 10:28 AM- The resident could be heard calling out that she needs to use the bathroom. CNA E entered the resident room. Resident repeated she needed to use the bathroom. CNA E left the room to get the mechanical lift and another staff member to assist. 10:32 AM- CNA's E and F entered the room with the mechanical lift and proceeded to transfer the resident to her bed. The CNA's then pulled the resident's brief down to reveal the resident had a bowel movement and had a dressing on the left buttock with a date of 01/12/21. CNA E removed the dressing due to soiling and revealed an open area approximately 1.0 cm. by 0.5cm. The open area was noted to have [DIAGNOSES REDACTED]. CNA E cleaned the resident using wet wipes and the resident was put on the bed pan. The wound was not covered. Staff did not notify the nurse in surveyor presence. Observation on 01/14/21 at 08:50 AM revealed the resident sat up in her wheelchair and remained in her wheelchair until 09:50 AM, at which time, a staff member returned the resident to her room and placed her in front of the television with her call light accessible. There was no observed attempt to reposition or offer toileting to the resident, by the staff member. At 10:00 AM an activity staff member visited with the resident and offered an activity. Then at 10:10 AM, CNA I and CNA J entered the resident's room with the mechanical lift to lay the resident down. They transferred to her bed and turned the residnet on her right side to check her brief. CNA I removed the resident's wet brief and cleaned the resident. Noted an open wound on left buttock in which no dressing covered the area. CNA I and CNA J placed a clean brief under the resident, and CNA I put barrier cream to the perirectal area. CNA I wore the same gloves throughout putting on a clean brief and reported she did not know if the resident's wound required a dressing and she put barrier cream over the area. No hand hygiene noted by CNA I and CNA J during the change observed. During an interview on 01/13/21 at 10:50 AM CNA I reported the resident was supposed to lay down between meals but sometimes refused. The resident always needed assistance of two staff, due to using the mechanical lift During an interview on 01/14/20 at 10:20 AM CNA I reported she offered to lay the resident down when she came back from any meal. When the resident was laid down CNA I checked her brief for incontinence and changed as needed. She did not know if the resident's wound should be covered, she always puts barrier cream on when she changed the resident. During an interview on 01/14/21 at 03:00 PM CNA K reported she offered the toilet to the resident before and after meals and the resident would tell the staff when she needed the toilet. CNA K did not know when the resident developed the pressure ulcer. One day the wound was just there. The resident is total care of two for transfers and incontinent care. The resident would use the bed pan. During an interview on 01/13/21 at 10:45 AM LN G reported the resident developed the open area last week and it was reported to the wound nurse who started the treatment. Staff were to try to keep the area clean and put a patch over it every day to keep it clean. She was unaware of the treatment order being discontinued on 01/11/21 and would check with Administrative Nurse H (wound nurse) to see what needed to be done and evaluate the wound. During an interview on 01/14/21 at 10:30 AM LN G reported the wound should be covered and the dressing was not due to be changed until tomorrow. The nurse was not aware of the resident had no dressing covering wound. During an interview on 01/13/21 at 12:56 PM Administrative Nurse H reported she had done wound rounds on Monday 01/11/21 and the residents wound had resolved. She discontinued the treatment to the resident and started a treatment of [REDACTED]. Today is when she was told to look at the resident buttock as the resident had an open wound. AN H checked the resident and re-ordered the treatment order due to the wound reopening. She confirmed the dressing that was placed on 01/12/21 was placed with no order to treat the wound. During an interview on 01/19/21 at 10:40 AM Administrative Nurse B reported she was made aware of the pressure ulcer when it occurred on 01/05/21. She questioned the wound being a stage three wound by how it closed quickly and returned and stated she would review the records. Review of the facility policy Prevention of Pressure Ulcers dated 12/20/20 revealed general prevention measures included to change position at least every two hours. Place resident on a minimum of a every two-hour check and change toileting program. Ensure postural alignment, weight distribution, sitting balance and stability. The facility failed to provide treatment and care to prevent development of a stage two pressure ulcer.

The facility census totaled 53 residents. Based on observation, interview, and record review the facility failed to provide a safe, sanitary environment for residents when a Certified Nurse Aide (CNA) failed to change gloves or preform hand hygiene during incontinent care when going from a dirty brief to applying a clean brief and barrier cream to a resident. (R)26 Findings included: - Observation on 01/14/21 at 10:10 AM revealed CNA I and CNA J entered R26's room and turned the resident to her side to check her brief. The brief was wet and removed. CNA I cleaned the resident with wet wipes and an open wound was visually present on the residents left buttock. Wearing the same gloves, CNA I placed a clean brief under the resident and applied barrier cream a to the resident's perirectal area. Staff wore the same gloves throughout the observation and did not change gloves or perform hand hygiene. CNA I did not know if the residents open pressure wound required a dressing and put barrier cream over area. During an interview on 01/14/20 at 10:20 AM CNA I reported when she laid the resident down she checked her brief for incontinence and changed as needed. CNA I verified she wore the same gloves from laying the resident down throughout the incontinent care and stated she does not change gloves between changing a resident's dirty brief and applying a resident's clean brief. During an interview on 01/13/21 at 10:45 AM Licensed Nurse (LN) G reported the resident's open wound began last week and the wound nurse started the treatments. LN G said the staff try to keep the area clean and said a patch is placed over it every day to keep it clean. LN G expected the CNA's to use clean gloves and wash hands while changing a residents brief. During an interview on 01/19/21 at 10:40 AM Administrative Nurse B voiced she expected the CNA staff to know how to use gloves with incontinent care. Review of the facility policy Personal Protection Equipment- Gloves dated 12/01/20 revealed all employees must wear gloves when touching blood, body fluids, secretions, mucous membranes and/or non-intact skin. Review of the facility policy Infection Control dated 12/20 revealed hand hygiene should be performed before and after contact with a resident, immediately after touching blood, body fluids, non-intact skin, mucous membranes or contaminated items (even when gloves are worn) and when moving from contaminated body sites to clean body sites during resident care. The facility failed to provide a safe, sanitary environment when CNA staff failed to change gloves or preform hand hygiene during incontinent care when going from a dirty brief to applying a clean brief and barrier cream to a resident.

The facility had a census of 75 residents with 9 sampled for review. Based on interview and record review, the facility failed to adequately monitor and implement the facility's bowel protocol and physician orders [REDACTED]. (#8) Findings included: - Resident #8's 9/4/17 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 5, which indicated severe cognitive impairment. He/she required limited assistance of 1 person for transfers and extensive assistance of 1 person for toilet use. The 9/6/17 ADL (activities of daily living) CAA (care area assessment) stated the resident had self-care deficits related to impaired mobility secondary [MEDICAL CONDITION] of the small bowel and recent hospital stay. The 8/28/17 nursing care plan directed staff to administer medications as ordered and to monitor, document, and report side effects and effectiveness of medications. A revision to the care plan on 9/15/17 identified constipation as a problem with interventions to follow the facility bowel protocol for bowel management. The care plan also directed staff to monitor medications for side effects of constipation and to keep the physician informed of any problems. The September 2017 MAR (medication administration record) documented staff administered [MEDICATION NAME] (laxative) 17 grams daily for constipation. The MAR indicated [REDACTED]. According to the bowel record, the resident had a medium sized, putty consistency bowel movement on 9/2/17, with no further documented bowel movements from that day until the day of discharge on 9/17/17, a period of 14 days. A nurse's progress note dated 9/8/17 indicated the resident had a poor appetite, with very little consumed, and staff encouraged fluids. The note indicate the resident received MOM due to no bowel movement in more than 3 days with no results. Staff continued to monitor. A nurse's progress note dated 9/10/17 revealed staff notified the physician that the resident was not having bowel movement, even with as needed administration of medication. The resident's diet was very poor with minimal intake. The physician directed staff to continue to monitor the resident and encourage fluids and food intake. On 9/11/17, the nurse documented the resident continued with a poor appetite and consumed a few bites of tomato soup and a cracker. A nurse's note on 9/12/17 indicated the resident did not eat or drink and would only take a sip or 2 of water or juice, then refused. The physician ordered intravenous fluids for one day for dehydration. On 9/14/17, staff documented in the nurse's notes no bowel movement for over 3 days and that the MOM was ineffective. The physician ordered Magnesium [MEDICATION NAME] 1/2 bottle (5 ounces) now, and if no bowel movement in 12 hours, give the other half of the bottle. The physician also ordered to administer a [MEDICATION NAME] suppository every 8 hours as needed. A 9/14/17 fax communication to the physician indicated the resident had poor intake, no bowel movement, had [MEDICATION NAME] daily and received a dose of MOM. The note also stated the resident was without abdominal pain and had mild abdominal distention. The physician ordered to give 1/2 bottle of Magnesium [MEDICATION NAME] and if no bowel movement in 12 hours, give the other 1/2. The physician also directed staff to give a [MEDICATION NAME] suppository every 8 hours and as needed until the resident had a bowel movement. (Review of the September 2017 MAR indicated [REDACTED]. The other 1/2 of the Magnesium [MEDICATION NAME] was not given and no suppositories were administered). During an interview on 11/14/17 at 2:56 p.m., licensed nursing staff G stated he/she couldn't remember if the resident had constipation. Nurse G further stated if a resident didn't have a bowel movement in 3 days, then the nurse would look at the resident's orders and give a prn (as needed) medication, like MOM. Nurse G remembered the resident didn't eat or drink fluids well. During an interview on 11/14/17 at 3:06 p.m., administrative nurse D verified staff should follow the standing orders for constipation/bowel protocol or if the resident had other orders in place for constipation. Nurse D indicated staff printed a bowel report daily and he/she expected the charge nurses would follow-up on the report. The facility's 5/1/14 Standing Orders for skilled nursing and Long-Term Care Units included the following bowel protocol: If no bowel movement in 3 days, give MOM 30 ml by mouth. If no result within 24 hours, give [MEDICATION NAME] suppository 10 milligrams. If no result, give Fleet enema one time, and notify the physician if not result. The facility failed to follow the standing orders for constipation/bowel protocol and failed to implement specific physician orders [REDACTED].

The facility had a census of 69 residents. The sample included 23 residents with 3 reviewed for accidents. Based on observation, interview and record review the facility failed to provide adequate supervision, implement planned interventions to prevent falls, and develop appropriate interventions based on facility root cause analysis to prevent accidents for 1 of 3 residents reviewed for accidents. (#42) Resident #42 had 3 falls from his/her wheelchair. He/she fell and sustained a laceration which resulted in a staple to the back of his/her head. Findings included: - Review of resident #42's signed physician orders [REDACTED]. Resident #42 ' s quarterly MDS (minimum data set) dated 12/1/15 indicated the resident had a BIMS (brief interview for mental status) score of 1, indicating severe cognitive impairment. The resident required limited assistance of one staff for bed mobility, transfers, walking in the room and corridor, dressing, and toileting. The resident was not steady and could only stabilize with staff assistance for balance during transitions and walking; and used a walker and a wheelchair for mobility. The resident had frequent bowel and bladder incontinence. The resident did not experience any falls since the previous quarterly assessment. Review of the resident ' s annual MDS dated [DATE] revealed the resident had a BIMS score of 3, indicating severe cognitive impairment. The resident required extensive assistance of one staff for bed mobility, dressing, toileting, personal hygiene and required limited assistance of one staff for transfer, and walking in the room and corridor. The resident had no change in balance, mobility, or incontinence status from the prior assessment. The resident did not experience any falls since the previous quarterly assessment. The cognitive loss/communication CAA (care area assessment) dated 3/1/16 indicated the resident could not hear well, had chronic back pain, and received routine pain management. The 3/1/16 Falls CAA revealed the resident had no falls in the last quarter and received Celexa (an antidepressant medication) 20 mg (milligrams) every day, and Seroquel (an antipsychotic medication) 75 mg daily. The resident had chronic back pain and received routine hydrocodone 5/325 mg 1/2 tablet three times a day (TID) and received Voltaren gel (topical gel used to treat muscle and joint pain) TID routinely to his/her lower back. The 3/12/15, 6/12/15, 9/12/15, and 12/21/15 Fall Risk Assessment Evaluations placed the resident at a moderate risk of falls; and the 3/12/16 Fall Risk Assessment evaluation placed the resident at a high risk for falls. The 3/3/16 care plan revealed the resident had impaired cognitive function related to dementia and a BIMS score of 3. The resident had a risk for falls due to falls experienced prior to admission, impulsivity, impaired balance and the resident ' s unawareness of need for assistance. The care plan instructed staff to: Keep call light within reach Provide adequate low glare light (11/14/12, revised on 3/28/16) Place fall mat next to the resident ' s bed and keep his/her bed in low position at all times (3/11/14) Staff discussed a personal sitter (3/14/14) Review information on past falls, record possible root causes, remove any potential causes if possible, educate resident/family/caregivers/IDT (interdisciplinary team) as to causes; moved to a room closer to the nurse station for fall risk (3/25/14) Anti-roll back brakes placed due to observations of self-toileting and the resident did not remember to use wheelchair brakes (5/23/14) Ensure the resident wore non-skid socks at all times even when in bed (11/22/15) Ensure adequate lighting in his/her room (12/25/15) Remove walker from bedside and foldup and use with staff assistance only (4/18/16), Services were to evaluate anti-rollback brakes (4/24/16) Review of the fall investigations revealed the following: 3/18/15: the resident experienced a non-injury, unwitnessed fall which involved his/her walker. Staff educated the resident to use his/her call light and to request help. (Resident had severe cognitive impairment) 11/22/15: the resident experienced a non-injury, unwitnessed fall which identified footwear as the root cause. The resident stated he/she slid but could not recall actions immediately prior to the fall. The investigation concluded the resident slid attempting transfer from his/her bed to the wheelchair. The staff updated the care plan with the following intervention: ensure resident wore non-skid socks at all times even when in bed. 12/24/15: experienced a non-injury, unwitnessed fall; the resident stated he/she slipped out of his/her wheelchair and staff identified this as the root cause of the fall. Staff updated the care plan with the following intervention: staff would ensure adequate lighting, even though staff determined the root cause of the fall as the resident slipping out of his/her wheelchair. 4/18/16: The resident experienced a non-injury, unwitnessed fall; the resident wore regular socks and slipped. The investigation indicated the resident had a gait assist device he/she did not use at the time of the fall. Staff determined the root cause of the fall to be the resident ' s lack of shoes causing him/her to slip. Staff updated the care plan with the following intervention: remove walker from bedside, foldup, and use with staff assistance only, though it did not relate to the root cause of the fall as determined by staff. Staff also failed to follow the care plan to ensure the resident wore non-slip socks at all times. 4/24/16: The resident experienced an unwitnessed fall with an injury which involved the wheelchair; staff heard a noise and found the resident lying on the floor with a laceration to the back of the head. The wheelchair sat behind the resident with the brakes unlocked and 3 staff assisted him/her back to his/her wheelchair. Staff updated the care plan with the following interventions: environmental services to evaluate anti-rollback brakes (A safety brake used on a wheelchair, to prevent the wheelchair from rolling backward when the occupant attempted to exit or enter the wheelchair), nurse practitioner to review medications, close monitoring when the resident remained in his/her room, and fix anti-rollback brakes. Review of the 4/24/16 progress note revealed staff found the resident on the floor at 7:30 PM bleeding from the back of his/her head, with the wheelchair behind him/her. Staff applied pressure to the bleeding area for 10 minutes. The resident sustained [REDACTED]. The note further included three staff assisted the resident back to his/her wheelchair and sent the resident to the emergency room for further evaluation. Review of the progress note dated 4/25/16 revealed the resident returned to the facility with one staple to the back of his/her head laceration, and the resident hallucinated and wanted to get him/herself out of his/her room. During an observation on 5/17/16 at 3:14 PM, the resident sat in his/her wheelchair and self-propelled with his/her feet (shoes on) out of his/her room and into the hallway. No foot pedals were attached to the wheelchair and the seat cushion was under the resident as the resident sat in his/her wheelchair. During an observation on 5/18/16 at 7:29 AM, the resident sat in his/her wheelchair facing the nurse ' s station. The wheelchair had a cushion in the seat and no foot pedals. The resident was fully dressed and wore shoes. During an observation on 5/18/16 at 4:10 PM the resident sat in his/her wheelchair in his/her room with no staff in the room. The resident was dressed and wore shoes. The seat cushion sat under the resident and a towel lay on the seat cushion. During an interview on 5/18/16 at 2:29 PM, direct care staff O stated the resident had some falls and had received stiches to the back of his/her head a few weeks prior. Staff O further included staff kept the resident near them and checked on the resident about every 30 minutes. During an interview on 5/19/16 at 1:20 PM, direct care staff N stated the resident required limited assistance of one staff and had a fall risk. Staff N further revealed staff checked on the resident at specific times in the early morning, toileted him/her frequently, kept fall mats on each side of the bed and the bed low, and always non-skid socks to the resident ' s feet. During an interview on 5/19/16 at 2:44 PM, licensed nursing staff P revealed the resident fell on ce in the past 30 days. Staff P further indicated staff would ensure the bed remained in the low position and fall mats were next to the resident ' s bed. Staff P further stated staff removed the resident ' s walker to keep the resident from trying to get up by him/herself and check on the resident. Staff P stated when a resident fell the staff would fill out the fall report and give it to administrative nursing staff H, who would finish the fall investigation. During an interview on 5/19/16 at 4:12 PM, administrative nursing staff H revealed when a resident fell , the nurses filled out the incident report asking questions about what happened and what the initial cause of the fall was. The nurses then updated the care plan with an immediate intervention that he/she talked through with them. Staff H reported he/she went through the fall investigation and asked any questions he/she did not know, made sure staff completed all of the form, and kind of filled in the gaps or tried to determine anything additional that might help prevent further falls. Staff H also reported staff reviewed falls through the facility quality assurance program. Staff H reported staff tried to remove the unsafe issue related to fall investigation root cause analysis. In regards to the resident ' s fall on 4/18/16, staff H stated he/she thought the resident had his/her walker and attempted to walk, then he/she fell with the walker. Staff H confirmed the resident did not have non-slip socks on, though the care plan indicated he/she should have had them on, even while in bed. During an interview on 5/19/16 at 4:56 PM, administrative nursing staff G reported staff attempted to determine the root cause of falls to determine appropriate interventions to put in place to prevent further falls. Staff G verified his/her expectation would be for staff to follow the care plan interventions that were in place. Staff G stated he/she expected staff to apply the non-skid socks and verified the resident did not have a non-slip device in place in the resident ' s wheelchair, though the resident had a pattern of slipping out of his/her wheelchair. The December 2007 policy on falls and fall risk indicated the staff, with input of the attending physician, would identify appropriate interventions to reduce the risk of falls; if falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant; staff would identify and implement relevant interventions to try to minimize serious consequences of falling; and if underlying causes could not be readily identified or corrected staff would try various interventions, based on assessment of the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable. The facility failed to provide adequate supervision, implementation of planned interventions, and/or appropriate interventions based on root cause analysis to prevent accidents for resident #42, who experienced 5 unwitnessed falls, including 3 from his/her wheelchair during the previous year, the last resulting in a laceration to his/her head requiring a staple.

The facility census totaled 67 residents with 25 included in the sample. Based on interview, observation, and record review, the facility failed to prevent further pressure ulcers for a resident who entered the facility with pressure ulcers for 1 of 1 resident reviewed for pressure ulcers. (#25) Findings included: - Review of resident #25's physician signed history and physical dated 8/13/13 revealed the following Diagnoses: [REDACTED]. Review of the admission MDS (minimum data set) dated 8/20/13 revealed a BIMS (brief interview for mental status) score of 00, indicating severe cognitive impairment. The resident required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, extensive assistance of one staff for eating, and the resident did not walk. The resident had limited range of motion on one side for upper and lower extremities. The resident did not have any oral/dental problems, did not have any swallowing/eating problems, had a significant weight loss of 5% or more in the last month or gain of 10% or more in last 6 months, and received a mechanically altered diet. The facility determined the resident had an increased risk of pressure ulcers from the following information: the resident had a stage 1 or greater pressure ulcer, a scar over bony prominence, or a non-removable dressing/device and the facility used a formal assessment instrument/tool and clinical assessment to deter. The resident had 2 stage II and 2 unstageable pressure ulcers that were both present on admission. Review of the Pressure Ulcer CAA (care area assessment) dated 8/23/13 revealed the following analysis of findings: "(Resident) is high risk for pressure ulcers... admitted with skin concerns... a total assist with turning, transfer, (Hoyer lift), pain issues, incontinence of bowel and recently having some loose stools. See nutrition CAA as affects pressure ulcers. Proceed to care plan." Review of the resident's care plan for impaired skin integrity risk, last revised 8/14/13, revealed interventions directing staff to avoid massaging over bony prominences, encourage adequate nutrition, dietician to consult per facility protocol, ensure adequate and proper repositioning -increase to every 1 hour, ensure staff monitor continence status and minimize exposure of urine (has Foley catheter-flexible (usually latex) tubes that are passed through the urethra during urinary catheterization and into the bladder to drain urine) and/or bowel to skin, use a flat sheet and air flow paper chuck (incontinence pads) under the resident, use turning sheet until the paper chucks were ordered, heel off load boots at all times, use lotions and moisturizers to prevent skin from drying out, use [MEDICATION NAME] and alternate [MEDICATION NAME] per orders, complete the Braden assessment per facility protocol, monitor skin condition with cares for color or texture changes, redness, [MEDICAL CONDITION], or incontinence-associated skin damage and report findings to the Charge Nurse, note the resident's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing, use pressure reducing devices in the resident's chair and/or wheelchair, use a pressure reducing low air loss mattress, and use wipes for peri-care. The care plan failed to include the resident's current skin issues or skin treatments. Review of a Braden Scale for Predicting Pressure Sore Risk dated 8/13/13 revealed a score of 10, indicating the resident had a high risk for developing a pressure sore. Review of the resident's admission assessment dated [DATE] revealed the resident had the following skin issues: right upper shoulder 1 cm (centimeter) x 1 cm bruise, right upper arm 4 cm x 2 cm scab, right upper arm PICC (peripherally inserted central catheter) with bruising under the dressing, bilateral (both sides) upper extremity discoloration with dark pigmentation, left arm [MEDICAL CONDITION] (swelling), right great toe unstageable pressure area 1 cm x 1.3 cm, right second toe unstageable pressure sore 1 cm x 1.5 cm, a 0.1 cm x 0.1 cm pressure area to the front left thigh, mid-spine bruise, large left hip bruise, stage II pressure area to the coccyx 7.5 cm x 6 cm, stage II pressure area to the mid-spine 1.3 cm x 1.5 cm, bruising to fingers, rash to the chest, and bruising to the neck. The note provided no documentation of any pressure ulcers to the resident's buttocks. Review of a skin/wound note dated 8/13/13 at 4:12 p.m. reveled the following had been omitted from the resident's admission note: Upon arrival the following conditions were noted: bruise 2 cm x 2 cm to the left shoulder, bruising over pacemaker area 4 cm x 7 cm, abdominal bruising from shots, yeast infection on the scrotum and groin with denuded skin on the groin from the rash, discolored dark pigmentation on the right shin, boggy heels bilaterally, thickened yellowish toe nails, right great toe 1 cm x 1.3 cm unstageable ulcer with dark eschar (dead tissue), and a 2nd right toe 1.0 cm x 1.5 cm unstageable with dark eschar. The note provided no documentation of any pressure ulcers to the resident's buttocks. Review of a skin/wound note dated 8/15/13 at 2:50 p.m. revealed the facility admitted the resident with various skin issues. One of the nurse practitioners saw the resident that morning and assessed the following areas: "Pt (patient) also has a stage II to bottom scattered within a radius of 6 (cm) x 5 cm, new orders were received to D/C (discontinue) DuoDerm (dressing) and apply barrier cream/area open to air, wipes were ordered for pericare, groin area has a red moist rash all over the (gender specific body part) and part of ... bottom, pt. very immobile due to injured knee, an air mattress was obtained on admission and heel offloading boots are in place." Review of a Braden Scale for Predicting Pressure Sore Risk dated 8/20/13 revealed a score of 11, indicating the resident had a high risk for developing a pressure sore. Review of a skin/wound note dated 8/22/13 at 5:59 p.m. revealed staff saw the resident for his/her various wounds, the resident lay in bed at the time, and staff administered pain medication prior to the treatment/assessment. The resident had about a 6 cm x 6 cm stage II scattered wound to his/her bilateral buttock and part of this area on the resident's right buttock had deteriorated and was now unstageable measuring approximately 4 cm x 2.5 cm. A low airloss air mattress and heel offloading boots were in place. Review of a Braden Scale for Predicting Pressure Sore Risk dated 8/27/13 revealed a score of 13, indicating the resident had a moderate risk for developing a pressure sore. Review of a skin/wound note dated 8/29/13 at 11:30 a.m. revealed the sheared pressure area to the resident's bilateral buttocks improved and a left buttock DTI (deep tissue injury) measured 4 cm x 2 cm, and staff cleansed the areas gently and applied moisture barrier. Review of previous skin/wound notes revealed the DTI was a new area the resident developed. Review of a Braden Scale for Predicting Pressure Sore Risk dated 9/3/13 revealed a score of 13, indicating the resident had a moderate risk for developing a pressure sore. Review of a skin/wound note dated 9/5/13 at 10:57 a.m. revealed staff cleansed the stage II shearing ulcer to the resident's bottom and [MEDICATION NAME] (a skin cream) reapplied. The resident continued on wound treatment as ordered. Review of a physician order dated 9/12/13 revealed an order for [REDACTED]. Review of a skin/wound note dated 9/12/13 at 10:47 a.m. revealed the resident lay in bed for a skin check. The resident's entire buttocks/sacral/coccygeal/posterior L thigh had a yeast rash. The nurse practitioner was present at time of the assessment. The resident had denuded areas of skin within the rash and staff applied [MEDICATION NAME] (a medicated cream) and positioned the resident to the left side with pillows for support. The resident had a low air loss mattress to his/her bed and a pressure reduction cushion to the wheelchair. Review of a physician order dated 9/17/13 revealed an order for [REDACTED]. Review of a health status note dated 9/18/13 at 2:19 p.m. revealed the resident had a 0.8 cm x 0.8 cm stage II pressure ulcer to coccyx and the wound had yellow fibrotic (tissue present during wound healing) tissue in the wound base, covering approximately 50% of the wound bed. The wound perimeter had [MEDICATION NAME] (single layer of skin) tissue present. The entire buttock/sacral area had a yeast rash staff treated with [MEDICATION NAME]. Staff were to continue to turn the resident every hour and have pressure reducing devices in place. Observation on 9/18/13 at 8:29 a.m. revealed the resident lay in bed with pillows under the right side of the resident's back and hips. Observation on 9/18/13 at 8:41 a.m. revealed direct care staff C came in and took the resident's vitals. The resident lay in bed with pillows under the right side of the resident's back and hips. Direct care staff E removed two pillows from behind the resident's right back and hips. Staff placed a wedge cushion between his/her knees and rolled the resident to the left side. The resident had a reddened area to the left mid-back with skin intact, another reddened area along the spine to the lower mid-back skin intact, and a grapefruit sized purple brown discolored area to the right hip. The resident had a quarter sized open area to the right buttock along with a fewer small open areas to the coccyx/buttocks with a diffuse red flat rash. Licensed nursing staff I cleaned the area with a wet wipe and then put [MEDICATION NAME] cream to the coccyx/buttocks area. Staff E placed a clean draw sheet under the resident, then placed a sling under him/her. Staff C, E, and I then used a Hoyer lift to transfer the resident to his/her wheelchair. The wheelchair had a padded cushion in the wheelchair seat, padded armrests, footrests, and headrest. Observation on 9/18/13 at 9:01 a.m. revealed direct care staff C assisted the resident, who sat in the wheelchair, to brush his/her teeth. The resident remained in the same position as previous observation. Observation on 9/18/13 at 9:23 a.m. revealed direct care staff E took the resident his/her breakfast tray and fed the resident. Staff did not reposition the resident and he/she remained in the same position as before. Observation on 9/18/13 at 9:40 a.m. revealed the resident sat in a wheelchair and watched the television. The resident sat in the same position as before. Observation on 9/18/13 at 9:57 a.m. revealed the resident remained in the same position in his/her wheelchair in the his/her room. Observation on 9/18/13 at 10:14 a.m. revealed the resident sat in his/her wheelchair and watched television. The resident remained in the same position as before. Observation on 9/18/13 at 10:33 a.m. revealed administrative nursing staff D inspected the resident's right foot and toes. Staff D did not inspect any other areas of the resident's skin at that time and did not reposition the resident. Observation on 9/18/13 at 10:45 a.m. revealed the resident sat in a wheelchair in his/her room and watched television. A restorative aide went into the resident's room and assisted the resident with range of motion and stretching exercises for approximately 10 minutes but did not reposition the resident in the wheelchair. Observation on 9/18/13 at 10:58 a.m. revealed the resident sat in a wheelchair in his/her room and watched television. The resident remained in the same position as before. Observation on 9/18/13 at 11:06 a.m. revealed the resident sat in the wheelchair and asked direct care staff E to lay him/her down. Staff returned a few minutes later with the lift to lay the resident down. Observation on 9/18/13 at 1:00 p.m. revealed therapy staff F sat and attempted to feed the resident. The resident moaned several times, "Oh, it hurts so bad." Staff F pushed the resident's call light and direct care staff L came in and repositioned the resident with a pillow to be more off of his/her bottom. Staff F told staff L he/she would "see how it goes and then maybe ask the nurse for pain medication". Observation on 9/18/13 at 1:09 p.m. revealed the resident lay in bed with pillows behind his/her left back. The resident kept pulling on the positioning bed rail, moaning, and saying, "Oh, my butt, my butt," and "It hurts so bad." Direct care staff L came in again after the call light was pressed by therapy staff F and said he/she would be back to reposition the resident in bed. Staff L went out of the resident's room, came back in a few minutes with direct care staff C, and the staff repositioned the resident. Direct care staff G came in and offered the resident a pain pill and he/she refused. The resident reported he/she was more comfortable after repositioning. Observation on 9/18/13 at 3:34 p.m. revealed the resident lay in bed with pillows behind his/her right side and hip. Interview with direct care staff E on 9/18/13 at 2:12 p.m. revealed he/she would report any open areas, blisters, dry skin, reddened areas, discoloration, skin tears, smell (like for yeast) to the charge nurse. Staff E reported the resident came to the facility with some skin conditions and his/her front groin was very bad when the resident first came and that had all healed up. Staff E reported the resident received cream to his/her bottom/coccyx every two hours, staff kept him/her off of his/her back and bottom by repositioning the resident every few hours, and when the resident sat in the wheelchair, staff used pillows to kind of try to keep the resident off of his/her buttocks. Staff E reported staff asked and offered to get the resident up, but the resident complained about being up in the wheelchair because his/her bottom hurt the most when he/she sat up. Interview with direct care staff C on 9/19/13 at 3:21 p.m. revealed the resident had very thin skin and the resident's buttocks had broken down and bowel movements made it worse. Staff C reported the nurses put [MEDICATION NAME] cream on the resident's bottom and staff kept the resident turned off of his/her bottom to keep the pressure off. Interview with licensed nursing staff H on 9/19/13 at 11:23 a.m. revealed staff monitored for redness, breakdown, skin tears, bruising, and pressure areas. Staff H reported when the facility admitted a resident, two nurses went in and measured all skin areas of concern, and documented them. Staff H reported the staff looked at the areas of the concern to try to determine the cause of the skin issue. Staff H reported the areas to the resident's toes were determined to be arterial ulcers from a doppler study on 9/9/13, which determined the resident had some distal small vessel disease. Staff H reported the resident's coccyx/bottom area had been a constant battle. Per staff H report the resident had come in with an ulcer to his/her coccyx. Staff H reported the resident's current interventions were to turn the resident every hour, put cream on his/her bottom, if the resident had a bowel movement, staff tried to change him/her as soon as possible to get the stool of of the resident's skin, limit the resident's time in the chair, an airflow mattress on bed, use disposable chucks, use a flat draw sheet, and increase the resident's protein intake. Staff H reported he/she would expect the resident's skin issues to be listed on the care plan along with all of the interventions in place and confirmed the resident's current skin conditions were not listed on the care plan. Interview with licensed nursing staff I on 9/23/13 at 1:08 p.m. revealed he/she expected the nurse aides to report any redness or bruising, even if it looked old, he/she expected the aides to report it along with any changes from the resident's normal. Staff I reported the resident had some breakdown to his/her buttocks. Staff I reported he/she would expect the skin issues to be on the care plan and currently staff were repositioning the resident every 1-2 hours, using [MEDICATION NAME] and barrier cream, and getting the resident out of bed more frequently. Interview on 9/23/13 at 3:57 p.m. with administrative nursing staff A revealed he/she expected staff to reposition the resident as frequently as the care plan directs, at least every couple of hours, perform good peri-care, provide frequent toileting, and use pressure reducing pads and air mattresses. Staff A reported the care plan should be updated with any changes or new interventions added. Staff A reported the charge nurse completed the weekly skin assessments, then the quality assurance nurse followed certain wounds of significance, such as pressure or infection. Interview with nurse practitioner staff J on 9/23/13 at 2:50 p.m. revealed the resident came to the facility with horrendous skin and bad yeast [MEDICAL CONDITION] to the peri-area and buttocks. Staff J reported at one point the resident developed a deep tissue injury because the staff were not using the right stuff underneath him/her, and had used a rolled up towel to position him/her. Staff J reported the resident currently had an air mattress and lay only on a sheet with breathable blue chucks pads. Staff J did not know of the areas the resident had developed during his/her stay at the facility. Review of the facility policy for Prevention of Pressure Ulcers, last revised 10/10, revealed "The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed... The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate." The facility failed to prevent two pressure ulcers to the resident's buttocks that were not present on admission.

The facility had a census of 67 residents with 25 sampled residents. Of the 25 residents, 4 were sampled for urinary incontinence and urinary catheter usage. Based on interview, observation and record review, the facility failed to maintain the status of a continent resident and failed to provide the appropriate treatment and handling of a catheter for a resident to prevent urinary tract infections. (#18 and #180). Resident #18, assessed as continent of urine upon admission to the facility, declined and became incontinent. Findings included: - Review of the closed record for resident #18 revealed the resident admitted to the facility on [DATE]. Review of the admission MDS (minimum data set) dated 5/1/13 revealed a BIMS (brief interview for mental status) score of 5 (severe cognitive impairment). The resident required extensive assistance of one staff for transfer, toileting and personal hygiene. The MDS identified the resident was always continent of bladder (urine). Review of the quarterly MDS dated [DATE] revealed a BIMS score of 7 (moderate cognitive impairment). The resident required limited assistance of one staff for transfer, toileting and personal hygiene. The MDS identified the resident was frequently incontinent of bladder. Review of the admission CAA (care area assessment) for urinary incontinence dated 5/1/13 revealed urinary incontinence triggered with no care plan decisions indicated as the resident was continent of bowel and bladder. The resident was at slight risk for episodes of incontinence secondary to impaired mobility and cognition due to late effects [MEDICAL CONDITION](stroke), however he/she was able to recognize the need to toilet and request assistance. The resident required limited to extensive assistance with toileting and a care plan would not be developed for urinary incontinence but will include interventions of assistance with toileting in the ADL (activities of daily living) plan of care. Review of the care plan for ADLs dated 5/3/13 indicated the resident suffered from self care deficit related to impaired mobility, cognitive and communication deficit (loss) secondary to late effects [MEDICAL CONDITION] directed the staff to provide assistance of one staff for toileting, clothing management and pericare when indicated. The care plan indicated the resident was continent of bladder and directed staff to prompt the resident to toilet before and after meals and at bedtime to maintain continence. Review of the care plan for urinary incontinence initiated on 5/13/13 directed staff to assist with clothing management, encourage loose fitted clothing with stretch waistbands rather than buttoned or zippered waist and minimize buttons, snaps and multi-layered clothing. Staff were to complete a 3 day voiding diary to establish patterns, record urinary continence status each shift to determine effectiveness of prompted voiding schedule, take a history to include incontinence, fluid intake, medical, physical and functional history and contributing factors and treatment options. The care plan indicated the resident wore a disposable liner during the day and disposable brief at night to protect skin and maintain dignity. (staff did not complete a second 3 day bladder diary as directed by the initiated care plan) Review of a revision to the care plan dated 7/9/13 directed staff again to offer assistance with toileting before and after meals and at bedtime to maintain continence. (the same interventions as on the admission care plan) Review of the incontinence history assessment dated [DATE] at 1:00 PM revealed the resident had urinary incontinent accidents due to a history of leaking urine from stress incontinence and was assessed as having 1 incontinent episode per day on each shift. The contributing factors and treatment options determined the resident had mobility issues and had urge incontinence. The assessment did not list any treatment options for this resident. Review of the 3 day bladder diary, dated 4/27/13, 4/28/13, and 4/29/13 and used to assess the resident's level of continence, revealed the resident had no episodes of urinary incontinence for all three days. Review of the CNA's (Certified Nurse Aides) documentation for bladder incontinence for all three shifts dated from 4/24//13 to 5/23/13 revealed the resident was continent of urine from 4/24/13 to 5/6/13 (the first 12 days). The documentation further revealed the resident had a total of 10 incontinent episodes over the 17 remaining days of the review period. Review of the CNA's documentation for bladder incontinence for all three shifts dated 5/24/13 to 6/22/13 revealed the resident had increase of incontinent episodes with a total of 26 episodes over the 29 day review period. Review of the CNA's documentation for bladder incontinence for all three shifts dated 6/23/13 to 7/20/13 revealed the resident had a total of 29 incontinent episodes over the 27 day review period. During an interview on 9/18/13 at 11:43 AM direct care staff P stated when the resident came to the facility he/she wore pull-ups (incontinent undergarments) had difficulty with leaking of urine and could not always make it to the bathroom. Staff P stated the resident had urinary "dribbling" all the time. During an interview on 9/18/13 at 11:35 AM licensed nursing staff N stated the resident did have some issues with urinary incontinence which became worse after a non-injury fall in June, however the resident was capable of communicating with the staff and used his/her call light or came out into the hall and got staff attention if he/she needed assistance to use the bathroom. Staff N did not know why the resident had an increase in incontinence. Staff N stated he/she did not monitor the CNA's charting in the computer and expected the CNA's to tell him/her if there was a change in the resident. During an interview on 9/19/13 at 2:57 PM administrative nursing staff M reported the 3 day bladder diary obtained shortly after admission was the tool used to determine bladder incontinence issues for the MDS which would trigger the need for a CAA and care plan development. The residents would be assessed again in 14 days after admission by monitoring of the documentation done by the CNA's of incontinent episodes. If the documentation showed an increase in incontinent episodes another 3 day bladder diary would be completed and the care plan would be revised. Staff M confirmed the care plan for urinary incontinence was initiated on 5/13/13 and was not revised until 7/9/13. Staff M reviewed all the documentation of all the residents in his/her area and could not find a second bladder diary for this resident as directed by the care plan. Staff M expected the nurse on the unit to monitor the documentation charted by the CNA's, monitor the resident for increased incontinent episodes, and then report those findings back to him/her for further assessment. Staff M stated he/she had not monitored the documentation by the CNA staff, and had not monitored the nurse staff to ensure the care needs of the residents were met. Staff M stated when the resident admitted he/she had a lot of family who visited and assisted him/her to the toilet. After some time the family did not visit as much and the resident was dependent of the facility staff to accommodate his/her toileting needs. Staff M reported the decline in urinary incontinence could have been prevented if proper monitoring of the resident had been done. During an interview on 9/19/13 at 4:06 PM Administrative nursing staff A reported the expectation was for the nursing staff to communicate with the aides for any changes in the resident condition and the nurse would then report to the administrative nursing "neighborhood" coordinator. The coordinator would investigate the reason or source for the change in incontinent status and revise the care plan to maintain the level of continence and prevent further progression of incontinence. The facility failed to maintain a level of urinary continence and prevent the progression of urinary incontinence by failing to monitor and reassess the resident's care needs. As a result of the facility's failure to assess the resident's needs, he/she developed repeated episodes of incontinence and a decline in the urinary continent status for resident #18. - Review of resident #180's Admission MDS (minimum data set) dated 7/22/13 revealed the resident's BIMS (brief interview for mental status) score of 15 (cognitively intact). The resident required extensive assist of one staff member for bed mobility, transfers, locomotion off the unit, toilet use, and bathing, Review of the Urinary incontinence CAA (care area assessment) dated 7/22/13 revealed the resident was admitted to the facility for end of life care. The resident had a indwelling Foley catheter for a [DIAGNOSES REDACTED]. Review of resident #180's care plan dated 8/30/13 revealed the resident required extensive assist of staff for all ADLs (activities of daily living) including toileting. Review of the nurses progress note dated 9/9/13 at 4:12 A.M. revealed staff received a verbal order from the physician to insert a Foley catheter. On 9/18/13 at 9:04 a.m. observation revealed the resident lay in bed with the urinary collection bag on the floor next to the resident's bed. The drainage tubing was also noted on the floor next to the resident's bed. On 9/18/13 at 12:09 p.m. observation revealed the resident's urinary collection bag and tubing lay on the floor next to the resident bed. The collection bag was not in a dignity bag or in a container. The collection bag was in direct contact with the floor and the drainage port of the collection bag was noted pushed up against the trash can next to the bed. On 9/18/13 at 3:38 p.m. the resident's urinary collection bag was observed on the floor next to the resident's bed in direct contact with the floor. The drainage port of the collection bag was in direct contact with the trash can. On 9/18/13 at 3:48 p.m. interview with Administrative staff A confirmed the resident's catheter collection bag was on the floor with the drainage port touching the trash can. Staff A immediately picked up the collection bag and hung the bag on the frame of the resident's bed. On 9/18/13 at 3:40 p.m. an interview with Administrative staff A revealed Foley catheter bags are to be hung on the side of the bed or in a dignity bag while the resident's are up in a wheelchair. Staff A revealed direct care staff were to monitor the placement of the urinary collection bags with routine care. Review of the Urinary Catheter care policy last revised October 2010 revealed the catheter tubing and drainage bag were to be kept off the floor. The facility failed to secure the resident Foley catheter drainage bag and tubing off the floor to prevent contamination of the Foley catheter drainage system which had the potential to harbor infectious organisms.