Every finding on record at Rock Creek of Ottawa

The facility documented a census of 69 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure an environment free from accident hazards for Resident (R) 1, who required staff assistance and a mechanical lift for safe transfers. As a result, R1 sustained a humerus (upper arm bone) fracture of her left arm. Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of morbid (severe) obesity (BMI-Body Mass Index of 40 or greater, or a BMI of 35 or greater with one or more serious health conditions), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R1 had an Annual Minimum Data Set (MDS), dated 02/10/25, which documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severe cognitive impairment. The assessment also documented R1 required a mechanical lift for transfers, and she was dependent on staff for toileting and bathing activity of daily living (ADL). R1's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/10/25, documented R1 had a BIMS score of less than 13. R1's Functional Abilities (Self-Care and Mobility) CAA, dated 02/10/25, documented R1 was dependent on staff for transfers. R1's Quarterly MDS, dated 11/13/25, documented a BIMS score of 12, which indicated moderate cognitive impairment. The assessment also documented R1 had impairment to both sides of her body, and she was dependent on staff for all transfers. The facility's untitled incident report #2710271, dated 01/07/26, documented R1 was transferred by two Certified Nurse Aide (CNA) staff members from her wheelchair to the recliner with a Hoyer lift. R1 sustained a fall to the ground when it appeared the sling came off the Hoyer hook at the left front corner. R1 had complaints of left shoulder pain and right shin pain, and there was a bruise on her right wrist. Staff notified the primary care physician and ordered R1 to be sent to the emergency room (ER) for further evaluation. The director of nursing, ER, and R1's legal representative was also notified. While at the ER, R1 was diagnosed with a fracture of the left humerus. R1 returned to the facility wearing a shoulder abduction immobilizer. CNA M's notarized Complaint Investigation Witness Statement, dated 01/07/26, documented CNA M and CNA N were transferring R1 to her recliner with the Hoyer lift. CNA M was in control of operating the Hoyer and was positioned in front of R1 and guided her to the proper position. As R1 was lowered to the recliner, the top left sling came undone, and R1 slid to the floor. R1 then complained of left shoulder pain. CNA N's notarized Complaint Investigation Witness Statement, dated 01/07/26, documented CNA N and CNA M were transferring R1 from her wheelchair to the bed and then to the recliner. CNA N documented she was responsible for guiding R1 while she was in the lift sling to the recliner, and she was positioned behind the recliner and used the lift handles to position R1 in the recliner while CNA M lowered R1 down. As R1 was lowered, the strap on the top, left side of the Hoyer came undone, and R1 slid out of the sling and onto the ground. Administrative Nurse E's notarized Complaint Investigation Witness Statement, dated 01/07/26, documented she was notified on 01/06/26 by the charge nurse and informed R1 sustained a fall while being transferred with the Hoyer lift. She then went to the unit and took CNA M and CNA N into a private room and provided transfer training. Prior to the training, Administrative Nurse E inspected the sling and lift, and both were within normal limits of function. Administrative Nurse E documented that during the training, when CNA M and CNA N placed the strap loops onto the lift, they did not ensure there was tension on the straps prior to raising the lift, which caused the lift sheet to shift off to one side and allowed the loops to come off the lift. R1's hospital After Visit Summary, dated 01/06/26, documented R1 had a left shoulder fracture which measured 3.1 centimeters (cm). On 01/27/26 at 09:15 AM, CNA O stated there were always two staff when performing lift transfers. CNA O also reported the lift training was provided for all staff a few weeks ago. On 01/27/26 at 10:30 AM, Licensed Nurse (LN) G stated there had been a resident incident regarding a Hoyer accident and she had received lift-transfer training within the last two weeks. She also stated all medical staff who provided direct resident care were provided with the remedial training. On 01/27/26 at 10:43 AM, Administrative Staff A and Administrative Nurse D reported the remedial training for lifts and transfers was provided for all direct resident care staff; there were some part-time staff who had not worked since the lift incident, but they were flagged to receive the training before their next shift to be worked. An all-staff in-service with additional training was also provided, and they implemented an administrative oversight of resident lift transfers for four weeks with a revisit that will take place. They also reported the social worker implemented resident interviews with those cognitively intact and utilized lift transfer, about how the staff were performing the transfers. On 01/27/26 at 11:43 AM, Administrative Staff A reported all full-time staff had received remedial lift and transfer training by 01/10/26, and none were allowed to begin their shift until it was completed. The facility's Rock Creek Hoyer Lift Reference 2023 documented that, prior to moving a resident, they were always to perform the transfer with two staff, and the staff were to check the sling for rips or tears and to replace the sling if there was any damage. It also documented staff to position the sling loops on the Hoyer. The facility completed corrective actions by 01/10/26, which included education to staff on safe transfers and using the necessary equipment to facilitate safe transfers with the Hoyer lift prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance and remained at the scope and severity of a G to represent the actual, but isolated harm to R1.

The facility identified a census of 72 residents. The facility had one main kitchen and one dining room. Based on observation, record review, and interview, the facility failed to ensure food was properly stored. The facility failed to ensure that the freezer was in proper working condition. The facility failed to ensure freezer temperatures remained at the required temperatures. The facility failed to ensure food temperatures were logged to ensure appropriate temperatures were reached before serving. Findings included: - Upon entry to the kitchen on 01/28/245 at 07:20 AM, it was observed and noted: In the server refrigerator, a half-gallon container of cottage cheese was over half empty and lacked an open date on the outside of the container. A gallon container of milk had been opened but lacked an open date. The bread rack had three opened loaves of bread and buns that were not in sealed, dated, or labeled bags. The dry storage room had a bag of macaroni and a bag of pasta shells that had been opened but were not in a sealed, dated, or labeled bag. The walk-in freezer had a package of opened potato patties that were not in a sealed, dated, and labeled bag. A bag of breaded chicken strips had been opened but was not in a sealed, dated, or labeled bag. A bag of breadsticks was open but was not in a sealed, dated, or labeled bag. Upon request, the facility was unable to provide daily prepared food temperature logs. A review of the November 2024 Refrigerator/Freezer Temperature Log revealed on the days of 11/24/24 to 11/28/24, it appeared that the walk-in freezer temperatures had been whited out and altered from the original temperature. A review of the Daily Food Temperatures for 12/03/24 lacked the food listing and temperature readings for the breakfast and lunch meals. A review of the Daily Food Temperatures for 12/04/24 lacked the food listing and temperature readings for the breakfast and lunch meals. An invoice dated 12/11/24 from a heating and cooling company documented a service to clean the condensate drain and thawed out the coil. Verified unit operation, and the temperature was zero degrees upon departure. Administrative Staff A provided a list of residents from the dates 12/03/24 to 12/06/24 that Resident (R) 3, R6, R16, R26, R27, R35, R44, R47, R56, R57, R58, R67, R116, R173, and R174 had complaints of nausea, vomiting, or diarrhea. On 01/30/25 at 11:01 AM, Dietary BB stated he was not aware of all the events that had taken place prior to his employment that began in December. Dietary BB stated he was not able to find the food temperature logs for the month of November 2024. Dietary BB stated he was made aware that the previous dietary manager left abruptly. Dietary BB stated that daily temperature logs of food, refrigerators, and freezers needed to be logged. All foods should be in sealed, labeled, and dated bags. On 01/30/25 at 11:22 AM, Dietary CC stated the former dietary manager was escorted out of the kitchen by Administrative Staff A. Dietary CC stated she was aware that there had been a few days in November where the food temperatures had not been logged. Dietary CC stated she was never aware that the walk-in freezer was down or not at the proper temperature. On 01/39/25 at 02:25 PM, Administrative Staff A stated that the previous dietary manager was escorted out of the building at the end after it was discovered that he had not been logging food temperatures as required. Administrative Staff A stated the prior dietary manager failed to inform her that the walk-in freezer was not retaining the proper temperature until five or six days after it had not been working properly. Administrative Staff A stated she had to call a repair company to come to fix the walk-in. Administrative Staff A stated during the first few days of December 2024, there were numerous resident complaints with symptoms of nausea, vomiting, or diarrhea. The Food, Sanitary Conditions policy revised on January 2023 documented: It was the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and or local authorities. The facility would store, prepare, distribute, and serve food under sanitary conditions. Hot food would leave the kitchen (or steam table) above 140 degrees Fahrenheit (F) and cold foods at or below 41 degrees F. Freezer temperatures should be at zero degrees F or below. Foods placed in the freezer were to be left in the original wrapping with an identifying label. If an item must be re-wrapped, a moisture-proof wrapping or closed container should be used to prevent freezer burn. All items must be labeled. Food will be covered, wrapped, or packaged to protect against contamination during food transport. The facility failed to ensure food was properly labeled and stored. The facility failed to ensure that the walk-in freezer maintained proper temperatures. The facility failed to ensure food temperature was logged to ensure the appropriate temperatures were reached before serving.

The facility identified a census of 72 residents. The sample included 19 residents, four medication carts, and two medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in two of the four medication carts. The facility also failed to label medication in one of the two medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - During the initial tour on 01/28/25 at 07:10 AM, a medication cart on the [NAME] hallway was unlocked and unattended in the hallway. On 01/28/25 at 07:19 AM, the second medication cart on the [NAME] hallway was unlocked and unattended. The medication cart contained two opened, undated insulin (a hormone that lowers the level of glucose in the blood) pens. On 01/28/25 at 07:12 AM, Certified Medication Aide (CMA) R stated she thought she had locked the medication cart when she had walked away from the cart. CMA R stated the medication cart should never be left unlocked when not in use. On 01/28/25 at 07:23 AM, Licensed Nurse (LN) G stated the medication cart should never be left unlocked when out of view. LN G stated insulin pens should be labeled with the open date and the discard date. On 01/30/25 at 01:10 PM, Administrative Nurse D stated she expected the insulin pens to be stored in the refrigerator until they were to be used. Administrative Nurse D stated once the insulin pen was removed from the refrigerator, the insulin pen should have an open date and a discard date and be stored in the locked medication cart. The facility's undated Storing and Controlling Medications policy documented the facility would store medications safely, securely, and properly following the manufacturer's recommendations or those of the supplier and in accordance with federal and state laws and regulations. The medication supply was accessible only to authorized personnel. The facility failed to properly label and store medications. This deficient practice could potentially cause adverse consequences or ineffective treatment to the affected residents.

The facility identified a census of 72 residents. The sample included 19 residents. Based on record review, observations, and interviews, the facility additionally failed to follow sanitary infection control practices related to oxygen equipment storage and Foley catheter care. These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 01/29/25 at 03:36 PM, Resident (R) 67 sat in his recliner in his room. R67's urinary catheter collection bag rested directly on the floor. Amber-colored urine was visible in his collection bag. On 01/28/25 at 10:40 AM, R28's supplemental oxygen nasal cannula was found resting on top of his bed. No plastic storage bag was observed in his room. On 01/30/25 at 12:04 PM, Certified Nurse's Aide (CNA) M stated all oxygen tubing and equipment should be stored inside clean plastic bags when not in use. She stated the tubing and cannulas should be replaced when contaminated. She stated the masks should be wiped down. She stated the urine collection bag was to be placed below the level of the bladder and never touch the floor. On 01/30/25 at 01:07 PM, Administrative Nurse D stated staff were expected to store the oxygen tubing and equipment in bags once the residents were out of the rooms. She stated the catheter collection bag and tubing were to be maintained below the level of the resident's bladder to prevent the backflow of urine. She stated no part of the urinary catheter should touch contaminated surfaces. The facility's Infection Prevention and Control Program policy revised 10/2022 indicated all staff were expected to be trained and follow safe infection prevention practices. The policy noted the facility was to ensure medical equipment was handled and stored in a manner that reduced the risk of contamination and exposure to contaminated surfaces. The policy noted oxygen therapy equipment was to be stored in a clean bag when noted in use. The policy noted the tubing or attachments must never come in contact with potentially contaminated surfaces. The policy indicated urinary catheter equipment must be maintained in a manner to prevent potential infection risks or urinary tract infections. The facility additionally failed to follow sanitary infection control practices related to oxygen equipment storage and Foley catheter care. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 72 residents. The sample included 19 residents, with Resident (R)28 reviewed for dignity. Based on observation, record review, and interview, the facility failed to ensure staff respected R28's privacy and dignity while in bed. This deficient practice placed R28 at risk of decreased self-esteem and decreased self-worth. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure (a condition where your blood does not have enough oxygen), dementia (a progressive mental disorder characterized by failing memory and confusion), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R28's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 required substantial assistance to total dependence on staff for his functional abilities and activities of daily living (ADL). R28 was frequently incontinent of bowel and bladder. R28 required supplemental oxygen. R28 required using a Bilevel positive airway pressure (BiPAP - ventilation device that helps people with breathing difficulties by providing pressurized air through a mask worn over the nose or mouth) machine. R28's Quarterly MDS, dated [DATE], documented a BIMS score of 13, which indicated intact cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 was dependent on staff for all functional abilities and ADLs. R28 was occasionally incontinent of bowel and bladder. R28 required supplemental oxygen. R28 required using a BiPAP at night. R28's Functional Abilities Care Area Assessment (CAA) dated 07/24/24 documented he was admitted after a fall and then had a hospitalization due to a change in cognition and continued functional decline. R28 continued supplemental oxygen and BiPAP. R28 was dependent on staff for self-care and mobility tasks. R28 was able to make needs known. R28 used a wheelchair for primary locomotion. R28's Care Plan, last revised on 11/14/24, directed staff he was substantial to max assist with bed mobility and dependent on staff for transfers. Staff was directed to set supplemental oxygen at two liters continuously via nasal cannula (a clear hollow tube used to deliver supplemental oxygen). Staff was directed that R28 required BiPAP at night per setting as ordered. On 01/28/25 at 10:39 AM, R28 lay on his bed. R28's room door was open. R28's right leg and brief were visible from the doorway. The curtain in the room was not drawn to protect his privacy. On 01/30/25 at 12:29 PM, Certified Nurse Aide (CNA) M stated a resident should not be exposed from their room. CNA M stated a resident should be covered with their sheet or their curtain drawn to protect their privacy. On 01/30/25 at 12:47 PM, Licensed Nurse (LN) H stated some residents did prefer to be uncovered at times. LN H stated their door should be shut or the privacy curtain drawn to protect their privacy. On 12/30/25 at 01:05 PM, Administrative Nurse D stated a resident had a right to be uncovered. Administrative Nurse D stated a resident's door should be closed or the privacy curtain should be drawn to avoid exposure from outside the room. The facility failed to provide a policy regarding dignity as requested. The facility failed to ensure staff respected R28's privacy and dignity while in bed. This deficient practice placed R28 at risk of decreased self-esteem and decreased self-worth.

The facility had a census of 72 residents. The sample included 19 residents, with five reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interview, the facility failed to utilize and ensure the appropriate use of foot pedals during wheelchair transports for Resident (R) 65 and R51. The facility additionally failed to ensure that R43, R24, and R8 call lights remained within their reach. This deficient practice placed the resident at risk for preventable accidents and injuries. Findings Included: - A review of R65's (severely cognitively impaired resident) EMR under Progress Notes revealed a Fall Committee Note completed on 07/22/24. The note indicated R65 had a minor injury fall on 07/19/24. The note revealed that R65 fell out of his wheelchair while being pushed in the hallway without foot pedals. The note revealed that R95 became fatigued while he attempted to hold his legs up. The note revealed he suffered a skin tear on his left elbow, left wrist, left hand, and below his left eye. The note revealed all staff were educated to utilize foot pedals for the wheelchairs. On 01/28/25 at 09:40 AM, R51 (severely cognitively impaired resident) was pushed down the hallway and his room. R51's wheelchair lacked foot pedals, and staff had to remind him several times to pick up his feet. On 01/29/25 at 08:40 AM, R43 (cognitively impaired resident) sat in her wheelchair to the left of her nightstand. She stated she was cold but could not get to her call light. R43's call light was on her bed across the room. On 01/29/25 at 10:02 AM, R24 (severely cognitively impaired resident) lay on her bed asleep. R24's call light was pinned to the cord on the wall at the foot of her bed. R24's pancake call light was pinned to her recliner, which also was at the foot of her bed, out of reach. On 01/29/25 at 03:35 PM, R8 (cognitively impaired resident) laid in bed. R8's call light was stuck between his mattress and the bed cane out of reach. On 01/30/25 at 12:04 PM, Certified Nurse's Aide (CNA) M stated all wheelchairs should have foot pedals for when the residents were being pushed. She stated staff should ensure each resident's call light was either clipped onto their clothing or within reach. On 01/30/25 at 12:04 PM, Licensed Nurse (LN) H stated staff should always ensure foot pedals were in place before pushing the residents and the call lights were left within reach. On 01/30/25 at 01:07 PM, Administrative Nurse D stated staff were expected to place the call lights within reach or clipped to the resident's clothing. She stated staff was expected to use foot pedals when they pushed the residents in their wheelchairs to prevent falls or injuries. The facility's Accommodation of Needs revised 01/2023 indicated the facility was to ensure the availability of and the appropriate use of assistive devices and call lights. The policy indicated the facility will evaluate each resident's individual level of functioning and care needs. The facility failed to utilize and ensure the appropriate use of foot pedals during wheelchair transports for R65 and R51. The facility additionally failed to ensure that R43, R24, and R8 call lights remained within their reach. This deficient practice placed the resident at risk for preventable accidents and injuries.

The facility identified a census of 72 residents. The sample included 19 residents, with four residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide written notification of transfer to Resident (R) 28 and his representative for his facility-initiated transfers. This deficient practice placed R28 at risk for uninformed care choices. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure (a condition where your blood does not have enough oxygen), dementia (a progressive mental disorder characterized by failing memory and confusion), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R28's Discharge Minimum Data Set (MDS) dated 03/15/24 documented an admission to the facility on [DATE]. The MDS documented an unplanned discharge to an acute hospital with a return anticipated. R28's Discharge MDS dated 03/22/24 documented an unplanned discharge to an acute hospital with a return anticipated. R28's admission Minimum Data Set (MDS) dated 03/29/24 documented he entered from a short-term hospital. R28 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 required partial assistance with upper body dressing and toilet transfers. R28 was substantial assistance for lower body dressing. R28 was frequently incontinent of bowel and bladder. R28 required supplemental oxygen. R28's Discharge MDS dated 05/30/24 documented an admission to the facility on [DATE]. The MDS documented an unplanned discharge to an acute hospital with a return anticipated. R28's Discharge MDS dated 07/15/24 documented an admission to the facility on [DATE]. The MDS documented an unplanned discharge to an acute hospital with a return anticipated. R28's admission MDS, dated 07/21/24, documented a score of 10, which indicated moderately impaired cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 required substantial assistance to total dependence on staff for his functional abilities and activities of daily living (ADL). R28 was frequently incontinent of bowel and bladder. R28 required supplemental oxygen. R28 required using a Bilevel positive airway pressure (BiPAP - ventilation device that helps people with breathing difficulties by providing pressurized air through a mask worn over the nose or mouth) machine. R28's Discharge MDS dated 08/30/24 documented an unplanned discharge to an acute hospital with a return anticipated. R28's Entry MDS dated 09/01/24 documented a re-entry to the facility from an acute hospital. R28's Quarterly MDS, dated 10/21/24, documented a BIMS score of 13, which indicated intact cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 was dependent on staff for all functional abilities and ADLs. R28 was occasionally incontinent of bowel and bladder. R28 required supplemental oxygen. R28 required using a BiPAP at night. R28's Discharge MDS dated 12/06/24 documented an unplanned discharge to an acute hospital with a return anticipated. R28's Entry MDS dated 12/08/24 documented a re-entry to the facility from an acute hospital. R28's Functional Abilities Care Area Assessment (CAA) dated 07/24/24 documented he was admitted after a fall and then had a hospitalization due to a change in cognition and continued functional decline. R28 continued supplemental oxygen and BiPAP. R28 was dependent on staff for self-care and mobility tasks. R28 was able to make needs known. R28 used a wheelchair for primary locomotion. R28's Care Plan, last revised on 11/02/24, had canceled staff direction he wanted to return to assisted living upon discharge. A canceled intervention directed staff to make arrangements with the required community resources to support his independence post-discharge. The facility provided the appropriate bed holds for R28's discharges on 03/15/24, 03/22/24, 05/30/24, 07/15/24, 08/30/24, and 12/06/24. The facility failed to provide the required written notification of transfer to R28 and his representative for his discharges on 03/15/24, 03/22/24, 05/30/24, 07/15/24, 08/30/24, and 12/06/24 that included the reason for the transfer; the effective date of transfer; the specific location of the transfer; an explanation of the right to appeal the transfer to the state; the name, address, and telephone number of the state entity which receives appeal requests; the name, address, and phone number of the representative of the office of the stated long-term care ombudsman; and the notice must be provided to the resident and resident's representative as soon as practicable. On 01/28/25 at 10:39 AM, R28 lay on his bed. R28's supplemental oxygen was not on. On 01/30/25 at 12:38 PM, Social Services X stated she completed the bed hold form when a resident was sent out to the hospital but was not aware of a form that was provided to the resident or their representative about the discharge. Social Services X stated the facility would call the representative when a resident was sent out. On 01/30/25 at 12:47 PM, Licensed Nurse (LN) H stated the nursing staff would call the family representative to notify them when a resident was sent out to the hospital. LN H stated she did not know of any written notification of transfer that was given to the resident or mailed to the resident's representative. On 01/30/25 at 01:05 PM, Administrative Nurse D stated that a bed hold was completed by social services upon each discharge. Administrative Nurse D stated she did not know of a written notification form that was required. Administrative Nurse D stated the facility had always only done the bed hold and would call the family to notify them when a resident was discharged or sent out to the hospital. The Discharge or Transfer policy, last revised in January 2023, lacked any direction regarding the Centers for Medicaid and Medicare (CMS) state operations manual (SOM) federal guideline 483.15(c)(3): Notice before transfer. The facility failed to provide written notification of transfer to R28 and his representative for his facility-initiated transfers. This deficient practice placed R28 at risk for uninformed care choices.

The facility identified a census of 72 residents. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview. The facility failed to ensure Resident (R) 8 had an adequate Centers for Medicare and Medicaid (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. This deficient practice placed the resident at risk for unnecessary medication administration and related complications. Findings included: - The Electronic Medical Record (EMR) for R8 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), and hypertension (elevated blood pressure). R8's admission Minimum Data Set (MDS) dated 01/16/25 documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated severely impaired cognition. R8 required supervision with his self-care and mobility. R8 required moderate assistance from staff with bathing. R8 ambulated with a walker. R8 was taking an antipsychotic medication. R8's Psychotropic Drug Use Care Area Assessment (CAA), dated 01/22/25, documented he was taking Seroquel (an antipsychotic medication) daily to manage moods related to Alzheimer's dementia with agitation. R8 was monitored for targeted behaviors and adverse side effects. This was not a new medication for R8. R8's Care Plan directed staff to document episodes of behavior such as agitation. The care plan directed staff that R8 took Seroquel. Staff was directed to document medication side effects and non-pharmacological interventions used. R8's Order Summary in the EMR documented an order dated 01/23/25 for Seroquel 50 milligram (mg) tablet to give one and a half tablets by mouth daily for Alzheimer's dementia with behavioral disturbance target behavior of agitation. A pharmacy review had not been conducted on R8's medication by the consultant pharmacist yet. On 01/29/25 at 03:35 PM, R8 lay on his bed. R8 stated he was tired after working with therapy earlier today. On 01/30/25 at 12:47 PM, Licensed Nurse (LN) H stated she could not say for certain what an appropriate diagnosis was for the use of Seroquel. LN H stated the pharmacy did help the facility a lot with the medications and would let the facility know if a medication did not have a correct diagnosis. LN H stated that Administrative Nurse D reviewed the medications after they had been entered into the Medication Administration Record (MAR). On 01/30/25 at 01:05 PM, Administrative Nurse D stated she reviewed each resident's medications and checked to ensure an appropriate diagnosis was used for the medication. Administrative Nurse D stated that Alzheimer's disease nor dementia were approved diagnoses for the use of an antipsychotic medication. Administrative Nurse D stated that R8 came to the facility after being on the Seroquel for some time. Administrative Nurse D stated she would ensure to get the appropriate documentation from R8's physician for the Seroquel. The facility did not provide a policy regarding psychotropic medications or physician orders as requested. The facility failed to ensure R8 had an adequate CMS-approved indication for the use of the antipsychotic medication Seroquel. This deficient practice placed the R8 at risk for unnecessary medication administration and related complications.

The facility identified a census of 72 residents. The sample included 19 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 24 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R24 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of contracture of left hand, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and 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). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented R24 had limited ROM in the upper and lower extremities on one side. The MDS documented R24 was dependent on staff assistance for activities of daily living (ADLs) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented that R24 had limited ROM in the upper and lower extremities on one side. The MDS documented R24 was dependent on staff assistance for her ADLs during the observation period. R24's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/11/24 documented she was alert and able to make her needs known. R24 was cooperative with her care and periods of confusion. R24's Care Plan dated 06/20/24 documented staff would encourage her to use the supportive devices as tolerated. The plan of care dated 11/14/24 documented staff may use a washcloth in her hand as tolerated to prevent further contracture formation. Staff may also use a weighted puppy stuffed animal on the forearm of her upper left extremity for comfort. The plan of care also documented that R24 could wear a hand splint for up to one hour at a time, up to three times a day as tolerated, to prevent further contracture formation. The plan of care dated 12/23/24 documented that therapy would screen R24 as needed for further contracture prevention and management. Review of R24's EMR from 12/01/24 to 01/29/25 lacked documentation of R24's supportive devices being applied or refused. On 01/29/25 at 10:02 AM, R24 lay asleep on her bed; her bed was in the lowest position. R24's hand rested on her chest area. R24's hands lacked any time of contracture prevention device in the palms of her hands. R24's one call light was pinned to the cord on the wall at the foot of her bed. R24's pancake call light was pinned to her recliner, which also was at the foot of her bed, out of reach. On 01/29/25 at 04:05 PM, R24 lay asleep on her bed; her bed was in the lowest position. R24's hand rested on her chest area. R24's hands lacked any time of contracture prevention device in the palms of her hands. On 01/30/25 at 11:03 AM, R24 lay asleep on her bed; her bed was in the lowest position. R24's hand rested on her chest area. R24's hands lacked any time of contracture prevention device in the palms of her hands. On 01/30/25 at 11:02 AM, Certified Medication Aide (CMA) R stated she did not believe there was anywhere to document the application of any contracture prevention supportive devices for R24. On 01/30/25 at 11:15 AM, Licensed Nurse (LN) I stated the therapy department determined what supportive devices would be utilized for contracture care. LN I stated she thought R24 had difficulty with the palm supportive device in November 2024 and was referred to therapy. On 01/30/25 at 01:10 PM, Administrative Nurse D stated the therapy department maintained contracture care. Administrative Nurse D stated she expected the care plan to be followed. The facility's Range of Motion policy, last revised 01/2023, documented it was the policy of the facility to prevent a resident's loss of range of motion (ROM). Appropriate treatment and services would be administered to increase the range of motion and/or prevent further decrease in the range of motion. Residents would be assessed to determine the level of range of motion. Preventive care would be provided so that the resident would not experience a reduction in range of motion unless clinical condition demonstrates a decline was unavoidable. The facility failed to ensure R24 received services and treatment for his contractures to prevent an avoidable reduction of ROM. This deficient practice left R24 at risk for further decline and discomfort.

The facility had a census of 72 residents. The sample included 19 residents, with two residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure an electrical furnace closet out of reach of 30 cognitively impaired/independently mobile residents. The facility additionally failed to ensure Resident (R)19's care-planned fall interventions were in place. This deficient practice placed the identified residents at risk for preventable injuries and accidents. Findings Included: - On 01/28/25 at 07:05 AM, an initial walkthrough of the facility was completed. Upon inspection of the [NAME] Hall, it revealed a furnace closet next to the resident rooms. The closet double doors were locked but easily pulled open due to damage to the door's frame. The closet contained numerous electrical boxes that contained the warning, high voltage - danger of electric shock. On 01/28/25 at 07:06 AM, Administrative Staff B verified the door would not secure and stated the room should be lockable. She stated maintenance was on the way to the facility. On 01/28/25 at 07:35 AM, The door was fixed by maintenance. On 01/30/25 at 11:07 PM, Administrative Staff A identified 30 cognitively impaired / independently mobile residents within the facility. ON 01/30/25 at 01:07 PM, Administrative Nurse D stated all hazardous materials and electrical closets should remain locked and inaccessible for the residents. The facility's Accident policy revised 01/2023 indicated the facility was expected to ensure an environment that was free from hazards and potential injuries. The policy indicated staff were expected to assess the care environment and report all potential areas of concern to prevent avoidable accidents. The facility failed to secure an electrical furnace closet out of reach of 30 cognitively impaired / independently mobile residents. This deficient practice placed the identified residents at risk for preventable injuries and accidents. 41037 - R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, lack of coordination, dementia (a progressive mental disorder characterized by failing memory and confusion), repeated falls, history of falls, and cognitive communication deficit. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R19 had a history of falls prior to her admission. The MDS documented R19 had a non-injury fall during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R19 was at risk of development of pressure ulcers. The MDS documented that R19 had one non-injury fall and two injury falls during the observation period. R19's Falls Care Area Assessment (CAA) dated 02/05/24 documented she had a history of falls related to a functional decline. R19 required supervision and assistance. R19 had one non-injury fall since her admission. R19's Care Plan dated 12/02/24 documented Dycem (non-slip mat used for stabilization and gripping to prevent slipping) was placed in R19's wheelchair to reduce her risk of sliding out of the wheelchair. R19's EMR under the Assessment tab revealed a Fall Risk Evaluation dated 12/27/24, which documented R19 was a high fall risk. On 01/29/25 at 10:17 AM, R19 sat in her recliner with her lower extremities elevated. R19's wheelchair was the foot of her recliner. The wheelchair lacked Dycem or pressure-reducing cushion. On 01/30/25 at 10:51 AM, R19 sat in her recliner and watched TV. R19's wheelchair sat next to her bed with a folded white bath towel in the seat of the wheelchair. The wheelchair lacked a pressure-reducing cushion and a Dycem. On 01/30/25 at 10:53 AM, Certified Nurse Aide (CNA) N stated R19 was at risk for falls. CNA N stated she was not sure if R19 should have a Dycem in her wheelchair. On 01/30/25 at 10:58 AM, Licensed Nurse (LN) H stated that R19 should have Dycem in her wheelchair to prevent her from sliding out of her chair. LN H stated it was everyone's responsibility to ensure all fall interventions are in place. On 01/30/25 at 01:10 PM, Administrative Nurse D stated she expected everyone to ensure fall interventions were in place for each resident. The facility's Fall Prevention policy, last revised 01/20/23, documented it was the policy of the facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize the potential for injury. The facility failed to ensure that Dycem was in the wheelchair or recliner as care planned for R19, who had multiple falls. This deficient practice placed R19 at further risk for injuries related to falls.

The facility identified a census of 72 residents. The sample included 19 residents, with two residents reviewed for bowel/bladder incontinence, a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and urinary tract infection (UTI - an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 67 with an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) when the facility failed to prevent his catheter drainage bag from resting on the floor. This deficient practice placed R67 at risk for catheter-related complications. Findings included: - R67's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate, which can lead to interference with urine flow, urinary frequency, and urinary tract infections), cognitive-communication deficit, and hypertension (HTN - elevated blood pressure). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one, which indicated severely impaired cognition. The MDS documented R67 had an indwelling catheter during the observation period. The MDS documented R67 was dependent upon staff assistance for toileting hygiene. The Quarterly MDS dated [DATE] documented a BIMS score of seven, which indicated severely impaired cognition. The MDS documented that R67 had an indwelling catheter during the observation period. The MDS documented R67 was dependent on staff assistance for toileting. R67's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 07/17/24 documented he was admitted with the indwelling catheter. R67's Care Plan dated 01/13/25 documented nursing staff would position his catheter bag and tubing below the level of his bladder. The plan of care also documented the staff position R67's catheter bag away from the entrance of the room door. R67's EMR under the Orders tab revealed the following physician orders: Catheter care every shift related to BPH dated 01/23/25. Leave catheter in place until urology appointment dated 01/23/25. On 01/29/25 at 03:36 PM, R67 sat reclined in his recliner. R67's catheter bag and tubing, which contained amber-colored urine, rested directly on the floor under his recliner. On 01/30/25 at 10:53 AM, Certified Nurse Aide (CNA) N stated that R67's catheter bag and tubing should never be on the floor. On 01/30/25 at 10:58 AM, Licensed Nurse (LN) H stated that R67's catheter bag should never be placed on the floor. On 01/30/25 at 01:10 PM, Administrative Nurse D stated R67's catheter bag or tubing should never be on the floor. Administrative Nurse D stated sometimes it was hard to find a good place to attach the catheter bag on the recliners. The facility's Indwelling Urinary Catheter Care policy, last revised 01/2023, documented it was the policy of the facility that each resident with an indwelling catheter would receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. The facility failed to ensure the standard of care was provided for R67's catheter bag, which rested directly on the floor. This. This deficient practice placed R67 at risk of catheter-related complications.

The facility identified a census of 72 residents. The sample included 19 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 28 had his physician-ordered supplemental oxygen on as ordered. The facility failed to ensure R28's nasal cannula (NC - a thin hollow tube that assists in providing supplemental oxygen) was appropriately stored when not used. This deficient practice placed R28 at risk of respiratory complications and possible infection. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure (a condition where your blood does not have enough oxygen), dementia (a progressive mental disorder characterized by failing memory and confusion), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R28's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 required substantial assistance to total dependence on staff for his functional abilities and activities of daily living (ADL). R28 was frequently incontinent of bowel and bladder. R28 required supplemental oxygen. R28 required using a Bilevel positive airway pressure (BiPAP - ventilation device that helps people with breathing difficulties by providing pressurized air through a mask worn over the nose or mouth) machine. R28's Quarterly MDS, dated [DATE], documented a BIMS score of 13, which indicated intact cognition. R28 had an impairment of his lower extremity on one side. R28 used a wheelchair to assist with mobility. R28 was dependent on staff for all functional abilities and ADLs. R28 was occasionally incontinent of bowel and bladder. R28 required supplemental oxygen. R28 required using a BiPAP at night. R28's Functional Abilities Care Area Assessment (CAA) dated 07/24/24 documented he was admitted after a fall and then had a hospitalization due to a change in cognition and continued functional decline. R28 continued supplemental oxygen and BiPAP. R28 was dependent on staff for self-care and mobility tasks. R28 was able to make needs known. R28 used a wheelchair for primary locomotion. R28's Care Plan, last revised on 11/14/24, directed staff to set supplemental oxygen at two liters continuously via nasal cannula. Staff was directed that R28 required BiPAP at night per setting as ordered. R28's Order Summary documented a physician's order dated 12/08/24 for continuous oxygen via NC at two liters. On 01/28/25 at 10:39 AM, R28 lay on his bed. R28's room door was open. R28's NC was attached to the oxygen concentrator (a machine that provides supplemental oxygen). The NC was not on R28 and was noted not to be in the provided storage bag. The oxygen concentrator was not turned on. On 01/30/25 at 12:29 PM, Certified Nurse Aide (CNA) M stated if a resident was supposed to be on continuous oxygen, that should be in the care plan. CNA M stated R28 was on oxygen and a BiPAP at night. CNA M stated the NC should be stored in a plastic bag when not in use and should be replaced if it was found on the floor. On 01/30/25 at 12:47 PM, Licensed Nurse (LN) H stated R28 should have his supplement oxygen on all the time due to his respiratory issues. LN H stated it was the responsibility of all nursing staff to ensure a resident has their oxygen on to avoid further breathing issues. On 12/30/25 at 01:05 PM, Administrative Nurse D stated all staff should be checking residents to ensure they have their oxygen on and the tubing was properly stored when not in use. R28 was supposed to be on continuous oxygen. The Oxygen Administration (Mask, Cannula) policy revised in January 2023 documented that oxygen therapy was administered as ordered by the physician or as an emergency measure until the order could be obtained. The facility failed to ensure R28 had his physician-ordered supplemental oxygen was on as ordered. The facility failed to ensure R28's NC was properly stored when not in use. This deficient practice placed R28 at risk of respiratory complications and possible infection.

The facility identified a census of 72 residents. The sample included 19, with one reviewed for competent staffing. Based on interviews and record reviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to order Resident (R) 33's physician-ordered eyedrops. This deficient practice placed R33 at risk for impaired quality of care. Findings included: - The Medical Diagnosis section within R33's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, cognitive-communication deficit, and 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). R33's Admission Minimum Data Set (MDS) completed 10/18/24 noted a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The MDS indicated she required partial to moderate assistance from staff to complete transfers, toileting, bathing, dressing, bed mobility, and personal hygiene. The MDS noted she had adequate vision and did not have corrected lenses. R33's Dementia Care Area Assessment (CAA) completed 01/24/25 noted she required supervision and moderate assistance for her activities of daily living (ADLs) related to her severe cognitive impairment. The CAA noted she was at risk for a functional decline, incontinence, skin breakdown, and nutritional impairment. The CAA noted she was able to converse with staff and make her needs known. R33's EMR under Physician Orders revealed an order (started 01/15/25) for staff to administer Refresh Plus Ophthalmic Solution (artificial tear eye drops used to treat dry eyes), one drop in her right eye four times daily for dry eyes. R33's EMR under Progress Notes revealed a Nursing note completed 01/14/25. The note revealed nursing staff received R33's prescribed eyedrop medication on 01/07/25 and instructions from her representative to contact her outside medical provider. The note indicated that R33's eyedrops were never added to her orders or administered. The note indicated staff called R33's outside medical provider on 01/07/25 but were not able to reach him. The note indicated the information was passed on to the next shift. The note revealed the facility never followed up with the provider until 01/14/25. The note indicated that R33's eyedrops had to be reordered from the pharmacy on 01/14/25 and were delivered on 01/15/25. On 01/28/25 at 09:01 AM, R33's resident representative stated the facility failed to administer prescribed R33's eyedrops ordered on 01/07/24 by her eye doctor. He stated he complained to the facility that she had not given her eye drops for over a week since they had been ordered. He stated he dropped off R33's eyedrops to the nurse on duty and explained that R33 was to receive the drops four times a day. On 01/30/25 at 08:15 AM, Licensed Nurse (LN) G stated when the resident came back to the facility with outside orders, the nurse on duty was responsible for verifying the orders and placing them in the EMR system. She stated the facility was responsible for following through with all medication orders and not delaying the resident's medication routine. On 01/30/25 at 01:07 PM, Administrative Nurse D stated nursing staff were responsible for ensuring all medication orders were received, verified, and entered accurately to ensure the continuity of care. The facility's provided Nursing Staff Competency policy revised 12/2023 indicated the facility was to ensure staff had the sufficient competencies and skill sets to provide nursing services to ensure resident safety. The facility failed to ensure staff possessed the appropriate skills and knowledge to ensure Resident (R)33's physician-ordered eyedrops were ordered and administered. This deficient practice placed R33 at risk for impaired quality of care.

The facility identified a census of 72 residents. The sample included 19 residents, with one reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion) care. Based on interviews, record review, and observations, the facility failed to provide dementia-related behavioral services for Resident (R) 65 to promote his highest practicable level of well-being, resulting in numerous non-injury falls. This deficient practice placed R65 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R65's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dysphagia (difficulty swallowing), muscle weakness, cognitive-communication disorder, and a history of falls. R65's Quarterly Minimum Data Set (MDS) completed 10/18/24 revealed a Brief Interview for Mental Status (BIMS) score of six that indicated severe cognitive impairment. The MDS revealed no wandering, rejection of care, or aggressive behaviors since his admission. The MDS noted he had lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he required substantial to maximal assistance with transfers, bed mobility, dressing, bathing, personal hygiene, and mobility in his wheelchair. The MDS revealed he had multiple non-injury falls since his admission. R65's Dementia Care Area Assessment (CAA) completed 04/20/24 indicated he was at risk for falls, nutritional impairment, incontinence, and skin breakdown related to his severe cognitive impairments and medical diagnoses. R65's Care Plan initiated 04/17/24 noted he had a functional deficit related to his dementia and limited mobility. The plan noted he required substantial assistance from staff for transfers, bathing, dressing, oral hygiene, toileting, and bed mobility. The plan noted he had numerous non-injury-related falls and was at risk. The plan instructed remind him to use his soft-touch call light and ensure it was within his reach (05/28/24). The plan noted R95's foot pedals were to be on his wheelchair while being pushed by staff (07/19/24). The plan noted occupational therapy was to evaluate him for the use of some fidget devices to use at the nurse's station to prevent falls (10/11/24). R65's EMR revealed no documentation related to the attempted use of the fidget devices or R65's refusal to use the devices. R65's EMR under Progress Notes revealed a Fall Committee Note completed on 07/22/24. The note indicated R65 had a minor injury fall on 07/19/24. The note revealed R65 fell out of his wheelchair while being pushed in the hallway without foot pedals. The note revealed R95 became fatigued while he attempted to hold his legs up. The note revealed he suffered a skin tear on his left elbow, left wrist, left hand, and below his left eye. The note revealed all staff were educated to utilize foot pedals for the wheelchairs. R65's EMR under Progress Notes revealed a Fall Committee Note completed on 09/30/24. The note revealed he had a non-injury on 09/29/24. The note revealed staff found him lying on the floor in his room. The note revealed R65 was confused and reported to staff he was working on his tractor at the time of his fall. The note revealed R65 had continued impulsiveness and lacked safety awareness. The note indicated occupational therapy was to evaluate and determine a plan to utilize some fidget devices to use at the nurse's stations to engage his interest in tractors. R65's EMR under Progress Notes revealed a Fall Committee Note completed on 10/11/24. The note revealed he had a non-injury fall on 10/10/24. The note revealed R65 fell out of his bed while he attempted to transfer himself out of bed. The note revealed R65's care-planned fall mat was not in place at the time of his fall, and he suffered a right arm skin tear. The note revealed he was assessed with no major injuries. R65's EMR under Progress Notes revealed a Fall Committee Note completed on 11/01/24. The note revealed R65 had a non-injury fall in his room when he attempted to transfer himself from his wheelchair to his bed. The note indicated he was impulsive and had poor safety awareness. R65's EMR under Progress Notes revealed a Fall Committee Note completed on 12/28/24. The note revealed R65 reported he attempted to self-transfer to his bed and slid out of his wheelchair. The note revealed staff assessed him and moved him to the nurse's station to sit. On 01/27/25 at 08:30 AM, R95 sat at the East Hall nurse's station. R65 had no activities or entertainment. R65 remained at the nurse's station until lunchtime at 11:05 AM. At 12:34 AM, R65 returned to the East Hall nursing station. R65 sat at the nurse's station desk until 02:15 PM without any activity or staff engagement. On 01/30/25 at 12:30 PM, Certified Nurse Aide (CNA) M stated R65 was impulsive and would often attempt to move himself or transfer without assistance. She stated he liked tractors and talking about farming. She stated staff would often talk to him about farming. She stated the faculty attempted using fidget devices to engage, but he would refuse. She was not sure where the refusals were documented. She stated staff were expected to ensure his fall mat and foot pedals were in place to prevent falls or injuries. On 01/30/25 at 01:07 PM, Administrative Nurse D stated sensory devices were used on him, but he would refuse to use them. She stated he would talk about farming and tractors with staff for entertainment. She stated staff were also expected to ensure his current fall interventions were in place. The facility's Care of Dementia policy revised 01/2023 indicated the facility was to provide each resident with individualized care interventions and use the last restrictive approaches to care. The policy noted each resident was evaluated and provided interventions to address each resident's needs. The facility failed to provide dementia-related behavioral services for R65 to promote his highest practicable level of well-being, resulting in numerous non-injury falls. This deficient practice placed R65 at risk for decreased quality of life, isolation, and impaired dignity.

The facility identified a census of 72 residents. The sample included 19 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure physician parameters were followed for a hypertensive medication (class of medication used to treat hypertension (high blood pressure) for Resident (R) 2. This deficient practice had the potential of unnecessary medication administration, thus leading to possible harmful side effects. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and hypertension. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. R2's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/29/24 documented she had a history of falls. R2 had periods of agitation. R2's Care Plan, dated 10/22/24, documented staff would administer her medication as ordered. R2's EMR under the Orders tab revealed the following physician orders: Carvedilol (antihypertensive) oral tablet 3.125 milligrams (mg) give one tablet by mouth two times a day for HTN. Hold if 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 diastolic blood pressure (minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) is < 60mmHg dated 01/23/25. Review of R2's Medication Administration Record (MAR) from 01/01/25 to 01/27/25 (27 days) revealed 12 (BP below-set parameter) was documented (seven times) on the following dates 01/02/25, 01/03/25, 01/11/25, 01/16/25, 01/20/25, 01/21/25, and 01/25/25. The MAR and clinical record lacked documentation of R2's BP. On 01/30/25 at 10:02 AM, R2 sat on her recliner with her feet elevated as she was using her cell phone. On 01/30/25 at 11:02 AM, Certified Medication Aide (CMA) R stated she obtained R2's BP and held Carvedilol if the BP was outside the parameter. CMA R stated there had been a place to document the BP on the MAR. On 01/30/25 at 11:15 AM, Licensed Nurse (LN) I stated CMA should report any BP that was outside the physician-ordered parameters prior to holding that medication. LN I stated yes, the BP should be recorded so the physician could review the BP outside the ordered parameters. On 01/30/25 at 01:10 PM, Administrative Nurse D stated she expected the physician orders for hold parameters to be followed and the care plan to be followed. The facility's Physician Orders policy, last revised 01/2023, documented it was the policy of the facility that drugs would be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. The facility failed to ensure staff followed the physician-ordered parameter for monitoring R2 Carvedilol. This deficient practice had the potential of unnecessary medication administration, thus leading to possible harmful side effects.

The facility identified a census of 72 residents. The sample included 19 residents, with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, because 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) 19's low air-loss mattress was set to the appropriate weight settings per her current weight. The facility additionally failed to ensure R34's Wheelchair had a pressure-reducing cushion in place per her care-planned interventions. This deficient practice placed both residents at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) noted diagnoses of muscle weakness, cognitive-communication disorder, and deep surgical incision with wound-vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal). R19's Admission Minimum Data Set (MDS) completed on 01/13/25 noted a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The MDS indicated she required substantial to maximal assistance from staff to complete transfers, toileting, bathing, dressing, bed mobility, and personal hygiene. The MDS indicated she was admitted with two stage-two (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) pressure injuries upon admission and was at risk for further pressure injury development. The MDS noted she weighed 144 pounds (lbs.) R19's Functional Abilities Care Area Assessment (CAA) was completed on 10/28/24 noted she had a recent hip replacement related to a fall before her admission. The CAA noted she required substantial assistance with her activities of daily living (ADL). The CAA noted care plan interventions were implemented to address her care risks. R19's Pressure Ulcer CAA completed 10/28/24 noted she was admitted to the facility with two pressure ulcers to her lower left extremity. The CAA noted she had a surgical incision on her left hip surgery. The CAA noted she had a pressure-reducing mat for her bed and wheelchair. R19's Care Plan, initiated on 11/08/24, indicated she had potential for further pressure ulcer development related to her immobility, incontinence, and medical diagnoses. The plan instructed staff to encourage fluid hydration and follow her diet as ordered. The plan noted she should have heel protectors on her heels while in bed. The plan noted she had a low air-loss mattress for her bed and a pressure-reducing mattress for her wheelchair. A review of the manual of low air-loss mattress manufacturers' operation (Drive Model #14029) indicated that the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range and comfort settings. The manual indicated an optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety. R19's EMR under Weights noted her current weight was 135.4 lbs. on 01/15/25. On 01/28/25 at 07:10 AM, R19 rested in her bed and waited for her breakfast to arrive. R19 had bilateral heel protectors on both her legs. R19's Wheelchair had a pressure-reducing mat in place. R19's bed had a Drive Model #14029 low air-loss mattress. The mattress pump had fixed weight settings of 50lbs, 100lbs, 150lbs, 200lbs, 250lbs, 300lbs, 350lbs. and 450lbs. R19's mattress control panel was locked at 200lbs. On 01/30/25 at 08:11 AM, R19's low air-loss mattress remained locked on 200lbs. On 01/30/25 at 08:15 AM Licensed Nurse (LN) G stated maintenance would set the beds up and program the weights settings, but nursing was responsible for ensuring the beds were functioning. She stated the beds were set by the resident's current weight but was not sure how they would reset it with the weight changes. She stated that R19 was at risk for pressure ulcers, and her mattress was set per her current weight. On 01/30/25 at 01:07 PM, Administrative Nurse D stated the low air-loss mattress was to be set per the resident's current weight. She stated nursing staff were able to change the weight settings if needed. The facility's provided Skin Management System policy revised 12/2024 indicated the facility was to implement preventative interventions to minimize the risk associated with skin breakdown and pressure injuries. The policy noted the facility will utilize pressure redistribution surfaces deemed appropriate based on the resident's risk factors and care needs. The facility failed to ensure R19's low air-loss mattress was set to the appropriate weight settings per her current weight. This deficient practice placed R19 at risk for complications related to skin breakdown and pressure ulcers. 41037 - R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, lack of coordination, dementia (a progressive mental disorder characterized by failing memory and confusion), repeated falls, history of falls, and cognitive communication deficit. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R19 was at risk of developing of pressure ulcers. The MDS documented R19 had no unhealed pressure ulcers at the time of admission. The MDS documented R19 was to have pressure-reducing devices on her bed and in her chair to prevent the development of pressure ulcers. The Quarterly MDS dated [DATE] documented a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented that R19 was at risk of development of pressure ulcers. The MDS documented R19 had no unhealed pressure ulcers during the observation period. The MDS documented R19 was to have pressure-reducing devices on her bed and in her chair to prevent the development of pressure ulcers. R19's Pressure Ulcer Care Area Assessment (CAA) dated 02/05/24 documented she was at risk of skin breakdown related to decreased mobility and bladder incontinence. Nursing staff would provide R19 with assistance with mobility and activities of daily living to help reduce her risk for development of pressure ulcers. A pressure-reducing mattress would be placed on her bed and a pressure-reducing cushion would be placed in her wheelchair. R19's Care Plan, dated 02/19/24, documented a pressure-reducing mattress was placed on her bed, and a pressure-reducing cushion was placed in her wheelchair. R19's EMR under the Orders tab revealed the following physician orders: Enhanced Barrier Precautions related to pressure ulcer every shift dated 12/03/24. Review of R19's EMR revealed a Skin Pressure Ulcer Weekly dated 01/15/25 documented a pressure ulcer with the onset date of 11/26/24 on the left buttocks. On 01/28/25 at 11:18 AM, R19 lay on her bed; her wheelchair was locked next to the bed without a pressure-reducing cushion in the wheelchair. On 01/29/25 at 10:17 AM, R19 sat in her recliner with her lower extremities elevated. R19's wheelchair was the foot of her recliner. The wheelchair lacked Dycem (non-slip mat used for stabilization and gripping to prevent slipping) or pressure-reducing cushion. On 01/30/25 at 10:51 AM, R19 sat in her recliner and watched TV. R19's wheelchair sat next to her bed with a folded white bath towel in the seat of the wheelchair. The wheelchair lacked a pressure-reducing cushion and a Dycem. On 01/30/25 at 10:53 AM, Certified Nurse Aide (CNA) N stated that R19 was at risk for skin breakdown and that R19 should have a pressure-reducing cushion in her wheelchair. CNA N stated that R19 had a pressure ulcer on her buttocks but had just recently healed. CNA N stated everyone ensured the cushion was in place in R19's wheelchair. On 01/30/25 at 10:58 AM, Licensed Nurse (LN) H stated that R19 had a recent pressure ulcer on her left buttocks. LN H stated that R19 should have a cushion in her wheelchair. LN H stated it was everyone's responsibility to ensure pressure-reducing devices were in place. On 01/30/25 at 01:10 PM, Administrative Nurse D stated R19 should have a pressure-reducing device in her wheelchair. Administrative Nurse D stated that R19 was at risk for skin breakdown. Administrative Nurse D stated she expected all staff would ensure pressure-reducing interventions were in place. The facility's Skin Management System policy, last revised 12/22/24, documented it was the policy of the facility that any resident who entered the facility without pressure ulcers would have appropriate preventive measures taken to ensure that the resident did not develop pressure ulcers, or that residents admitted with wounds would not develop signs and symptoms of infection unless the resident's clinical condition makes the development unavoidable. The facility failed to ensure a pressure-reducing heel cushion was in place for R19, who had a history of a pressure injury on her left buttocks. This deficient practice placed R19 at risk for complications related to skin breakdown and the development of further pressure ulcers.

The facility reported a census of 72 residents with three selected for review for falls. Based on observation, interview and record review, the facility failed to ensure staff provided fall intervention as care planned for one Resident (R)2, of the three residents reviewed. Findings included: - Review of Resident (R)2's medical record, revealed diagnoses included lymphedema (swelling caused by accumulation of lymph), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with neuropathy (damage of the nerves outside of the brain and spinal cord usually the hands and feet that cause weakness, numbness and pain) and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS) dated [DATE]. assessed the resident with a brief interview for mental status score (BIMS) of 15 which indicated normal cognitive function. The resident required supervision of activities of daily living (ADL) with unsteady balance and required stabilization with staff assistance. The resident had one non injury fall since the prior MDS. The Falls Care Area Assessment (CAA), dated 06/09/23 assess the resident had fall interventions in place, used her walker for ambulation, and staff assisted with ADLs as needed. The resident worked with therapy for strengthening. The Quarterly MDS, dated [DATE], assessed the resident with a BIMS score of 15, the resident had two noninjury falls and one major non injury fall since the prior MDS. The Care Plan revised 11/29/23, instructed staff the resident had functional deficits related to weakness. The resident slept in her recliner and walked independently with a four wheeled walker. A Fall intervention initiated on 10/14/23, instructed staff to add an appropriately sized piece of dycem (a non-slip material) to her recliner to keep her from sliding out. Observation on 12/20/23 at 11:00 AM, revealed the resident seated in her recliner in her room. The resident stated she preferred to sleep in her recliner and did have a fall from her recliner about a month ago. She stated she also had falls when reaching for items, but staff placed her phone charger and hearing aid charger in places that she could reach easily without falling over/out of her chair. The resident stated she should have a piece of non-slip material in the recliner seat to help her from slipping out of the recliner. The resident stated the nonskid strips on the floor in front of her recliner also help her stand. The resident stated she did wear nonskid socks. Observation, on 12/20/23 at 11:30 AM, revealed the resident ambulated to the dining room with her walker. Her gait was steady. Observation, on 12/20/23 at 12:20 PM, revealed the resident's recliner lacked the planned piece of non-slip material to prevent slipping/falls. Interview, on 12/20/23 at 12:20 PM, with Certified Nurse Aide (CNA) M, revealed she was not sure if a fall intervention for the resident included dycem in her recliner, and stated she did not have access to the care plan, but could access the resident's ADL needs. CNA M stated staff taped the resident's phone charger to her table within her reach. The resident wore nonskid socks and had nonskid tapes on the floor in front of her recliner. CNA M stated the resident spent most of her time in her recliner and could ambulate with her walker. CNA M confirmed the resident's recliner lacked the planned dycem. Interview, on 12/19/23 at 12:45 PM, with Licensed Nurse (LN)G, revealed the resident slept in her recliner and had several falls. LN G stated staff found the resident sitting at the foot of her recliner after reaching for her phone charger. LN G stated the recliner was a lift chair and the resident may have slipped out of the chair. LN G stated the resident should have dycem in her recliner and would notify therapy to obtain a piece for her recliner. Interview, on 12/20/23 at 01:30 PM, with the resident revealed she spilled pop on her recliner and on the dycem about a week ago and tried to rinse it off. She stated she did not know if it was reusable, so she set it on her sink to dry. The resident sat in her recliner on the front edge of the seat. Interview, on 12/20/23 at 04:00 PM, with Administrative Nurse D, revealed she would expect staff to place the dycem in the resident's recliner as care planned and would investigate the CNA access to the fall interventions on the Kardex (a care plan summary for CNAs) in the electronic medical record. Interview, on 12/20/23 at 04:15 PM, with Administrative Staff D, revealed the resident may have thrown the dycem away. The facility policy Fall Prevention undated, instructed staff to implement actions to reduce the incidence of additional falls and minimize the potential for injury. The facility failed to ensure staff provided the dycem to this resident's recliner to prevent slipping falls and possible injury as care planned.

The facility reported a census of 72 residents. Based on observation, interview and record review, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility, as exhibited by the failure to store and label food in the refrigerator, maintain a clean refrigerator for the resident's foods and failure to utilize pasteurized eggs (a process which kills harmful bacteria) for resident's who request soft-cooked eggs for breakfast. Findings included: - During an environmental tour on 03/28/23 at 07:36 AM, the following areas of concern were noted: 1. Dietary Staff BB failed to utilize pasteurized eggs when she cooked and served six to eight soft-cooked eggs to residents. 2. The reach in refrigerator contained an open container of Ranch salad dressing which lacked an open date. 3. The reach in refrigerator contained an open container of Mayonnaise which lacked an open date. 4. The reach in refrigerator contained a large amount of food debris on the bottom shelf. 5. The inside of the microwave in the kitchen area had a large amount of splattered, dried on food substance on the insides of the microwave oven. On 03/28/23 at 07:36 AM, Dietary Staff BB stated she cooked and served six to eight soft-cooked eggs to residents per their request. Dietary Staff BB stated she did not use pasteurized eggs for the soft-cooked eggs which had slightly runny yolks. On 03/28/23 at 07:36 AM, dietary Staff CC stated staff would be expected to utilize pasteurized eggs for any soft-cooked eggs which were served to the residents. Dietary staff CC stated any open food item in the reach in refrigerator should be dated with an open date and the inside of the refrigerator should be kept clean of any food debris. The inside of the microwave oven should be kept clean. The facility policy for Food Procurement, revised 01/2023, included: If the facility uses unpasteurized eggs, the eggs must be cooked until all parts of the egg are completely firm. The facility's PM Cooks Nightly Closing Duties, used as a guide for dietary staff, included the reach in coolers would be organized and cleaned nightly as well as the microwave oven would be cleaned inside and out at the end of each night shift. The facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility as well as failed to utilize pasteurized eggs for soft-cooked eggs served to the residents.

The facility reported a census of 72 residents with 20 selected for review including one reviewed for restorative nursing contracture management (abnormal permanent fixation of a joint). Based on observation, interview, and record review, the facility failed to provide restorative services of contracture management services for the one sampled Resident (R)31. Findings included: - The Medical Diagnosis tab for R31 included diagnosis of Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one side of the body) following cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), and contracture of the left hand. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R31 with a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. She had an upper extremity range of motion impairment to one side that interfered with daily functions or placed her at risk for injury. R31 received Occupational Therapy five days and did not receive any restorative nursing services for splint or brace assistance. The Annual MDS dated [DATE] assessed R31 with no impairment to long- and short-term memory recall, had no impairment to her upper extremity range of motion that interfered with daily functions or placed her at risk for injury. She did not require Occupational Therapy and received restorative nursing services five days for passive range of motion and two days for splint or brace assistance. The ADL [activities of daily living] Functional/Rehabilitation Potential Care Area assessment dated [DATE] for R31 revealed she required setup assist for morning and HS (hour of sleep) cares and extensive assist for dressing. The Care Plan dated 02/07/23 revealed a restorative nursing program for splint assistance. The staff were to assist with donning the left-hand splint after lunch one time per day to wear for two hours as tolerated to prevent decline with flexion of digits (fingers). R31 may wear the palmar based left digit three through five finger extension orthotic for one hour at a time three times a day to prevent further contracture formation, skin integrity compromise, and pain. The Task tab instructed the staff to assist with the splint to the left hand after lunch one time per day to wear for two hours as tolerated to prevent decline with flexion of the digits. R31 may wear the palmar based left digit three through five finger extension orthotic for one hour at a time three times a day to prevent further contracture formation, skin integrity compromise, and pain. The Occupational Discharge Summary dated 02/17/23 revealed R31 had limited use/tolerance of the current hand based finger extension splint to the left hand but tolerated two hours wear of a soft washcloth roll to facilitate finger extension until air filled finger extension orthotic was received/shipped. The Therapy to Nursing Communication binder included a daytime splint scheduled, undated, for R31 which was the daytime splint schedule posted in her room. On 03/27/23 at 04:47 PM, observed R31 with contracture to the left hand and was unable to extend digits three through five. A sign was in her room instructing staff to put a splint on her left hand at night and to take it off in the morning. The resident did not have a splint to her hand at this time. On 03/27/23 at 04:48 PM, R31 stated she was unable to open three fingers on her left hand and has a splint that she wears at night. On 03/28/23 at 10:48 AM, observed a blue splint on R31's overbed table. On 03/29/23 at 09:33 AM, observed R31 sitting in her recliner in her room, no splint or orthotic in place to her left hand. R31 had a sign in her room for Daytime Hand Splint Schedule which included times from 09:00 AM to 11:00 AM, 01:00 PM to 03:00 PM, and optional 06:00 PM to 08:00 PM. This sign was posted next to the sign for her nighttime splint. On 03/29/23 at 09:34 AM, R31 stated the splint for her hand at night was blue and the splint for her hand during the day was white and black and she had not seen it for two weeks. R31 stated she thought maybe it was in the drawer and pointed to the stand next to her recliner. R31 stated staff has not offered to assist to put the splint on today and did not think the staff knew how to do it. R31 stated she had therapy about two weeks ago. R31 stated she monitored the skin in her hand for breakdown and there was not any however stated if felt moist all of the time. On 03/29/23 at 09:44 AM, Certified Nurse Aide (CNA) P was not aware R31 was to have a splint in place at intervals during the day to R31's left hand. CNA P looked in the room for the splint and found a white rolled washrag with Coban (self-adherent elastic wrap) wrapped with a black fabric strap. The staff did find a soft fabric carrot shaped device in her drawer that the resident placed in her left hand. On 03/29/23 at 09:45 AM, R31 stated that was not the white and black splint she was referring to. On 03/29/23 at 09:49 AM, Consultant therapy staff GG stated consultant therapy staff HH made a heat molded palm protector for R31 and it had been over a month since R31 received therapy services. On 03/29/23 at 09:51 AM, Consultant therapy staff HH stated R31 had too much pain with the splint when she had returned from the hospital and another splint had been ordered that had not arrived yet that has an air bladder that was expandable. R31 had been out of the splint so long at the hospital she could not tolerate the splint she had been using before. A hand roll was made for her to use when she could not tolerate the other one, around four weeks ago, and referred to the one found in the drawer of the rolled washrag with black fabric strap and Coban wrapped around it. Consultant therapy staff HH stated the nursing staff was made aware by a written communication form placed in the communication binder for therapy to nursing. On 03/29/23 at 10:09 AM, Administrative Nurse D stated she would expect the staff to assist R31 with splint placement per therapy direction. The facility policy Contracture Documentation dated 01/2023 revealed a resident with a limited range of motion or contracture shall receive appropriate treatment and services, based on the comprehensive assessment of the resident, to increase range of motion and/or prevent further decrease. The facility failed to ensure staff assisted R31 with the left hand splint placement during the day to prevent further contracture to digits three through five of her left hand.

The facility reported a census of 72 residents. Based on observation, interview, and record review the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)64, regarding inaccurate discharge location. Findings included: - Review of Resident (R)64's medical record revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The entry Minimum Data Set (MDS), dated [DATE], documented the resident admitted from an acute hospital. The care plan, dated 02/06/23, instructed the staff the resident intended to return home following his stay at the facility. The discharge MDS, dated [DATE], documented the resident discharged from the facility to an acute hospital. On 03/29/23 at 08:51 AM, Administrative Nurse E stated the resident discharged from the facility to home on 02/13/23. The discharge MDS, dated [DATE], was inaccurate as it documented the resident discharged to the hospital. On 03/29/23 at 10:00 AM, Administrative Nurse D stated she would expect for the staff to complete the MDS correctly. The facility used the Resident Assessment Instrument (RAI) for completion of the MDSs. The facility failed to complete an accurate MDS for this resident who discharged to home from the facility.

The facility reported a census of 71 residents. The sample included three residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to timely implement appropriate interventions to prevent a pressure ulcer from reoccuring for one Resident (R) 3 of the three residents reviewed. On 07/26/19, following healing of a prior ulceration on 07/10/19, facility staff identified a hard lump in the prior wound bed of the healed ulcer. Facility staff failed to implement an intervention to reduce pressure or prevent skin breakdown until 08/01/19, after the wound reopened as an unstageable pressure ulcer. Findings included: - Resident (R) 3's signed Order Recap Report, dated 07/19/19, documented the resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (progressive dementia, resulting in loss of memory and independence), and need for assistance with personal care. Review of the R3's Minimum Data Set (MDS) assessment, dated 04/03/19, assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident required extensive assistance from one staff person with transferring, bed mobility, and her other activities of daily living (ADLs), but required supervision with eating. The resident was occasionally incontinent of urine, and was not incontinent of bowel. The resident was at risk for developing pressure ulcers, had no unhealed pressure ulcers, but did experience moisture-associated skin damage (MASD). Facility staff applied ointments or medications to areas other than the resident's feet. Review of the Pressure Ulcer Care Area Assessment (CAA), dated 04/16/19, revealed that facility staff documented the resident was at risk for pressure ulcers, due to her weakness and need for assistance with ADLs. Facility staff provided the resident with a pressure-reducing mattress and a pressure-reducing cushion for her wheelchair. The resident's care plan for pressure ulcers, updated 08/01/19, documented the resident was at risk for developing pressure ulcers due to immobility. Facility staff must administer any treatments as ordered by her physician, and monitor for effectiveness. On 04/16/19, facility staff placed a pressure-reducing cushion in the resident's wheelchair, and placed a pressure-reducing mattress on her bed. On 07/31/19, the resident developed an unstageable pressure ulcer, which required treatment per physician's orders [REDACTED]. On 08/01/19, facility staff provided a low-air-loss mattress (a type of specialized pressure-relieving mattress) to the resident. Review of Skin Assessments revealed the following: 05/29/19; 06/05/19; and 06/11/19: documented the resident was free of skin issues on her coccyx (tailbone). 06/19/19: revealed the resident developed a rash to her perineal area (area between the genitals and the coccyx), which staff cleansed with soap and water. Facility staff notified the resident's physician. 06/25/19: revealed facility staff documented the resident's buttocks appeared to be healing. 07/02/19: revealed facility staff noted blanching redness to the resident's coccyx, and applied barrier cream. 07/05/19: revealed facility staff noted a small open area to the resident's buttocks, measuring 0.5 centimeters (cm) by 0.4 cm by 0.1 cm. 07/10/19: revealed that facility staff documented in a Nursing Note at 03:54 PM that the resident's wound resolved. 07/12/19: revealed the facility wound physician assessed the wound site and noted the area to be covered with 100% [MEDICATION NAME] tissue (skin), indicating the wound resolved. Facility staff must apply protective ointment each shift. 07/17/19: revealed facility staff documented the resident's skin continued to improve. 07/19/19: revealed facility staff noted no skin issues. 07/26/19: revealed facility staff noted a hardened area when touching the resident's healed pressure ulcer site. The skin assessment failed to document implementation of an intervention to prevent skin breakdown from occurring. 07/31/19: revealed facility staff noted an unstageable pressure ulcer to the resident's prior wound site, measuring 2.5 cm by 1.4 cm by 0.2 cm. The facility wound physician observed the wound. Facility staff obtained orders to cleanse the wound with wound cleanser, apply Santyl (a chemical [MEDICATION NAME] agent) to the wound bed, cover with [MEDICATION NAME] gauze, cover with bordered gauze, change the dressing daily and as needed. Facility staff documented that the resident's physician and family were made aware of the wound. An Interdisciplinary Team (IDT) note, dated 07/31/19 at 02:06 PM, documented that a low-air-loss mattress would be provided to the resident. A Skin Assessment, dated 08/07/19, revealed facility staff measured the resident's unstageable wound, and found that it measured 4 cm by 4.2 cm by 0.1 cm. Review of a Nursing Note, dated 08/09/19 at 11:25 AM, revealed that the resident returned from an appointment with her primary care physician, who documented that she had a severe, full-thickness, necrotic pressure ulcer on her sacrum. The resident's physician ordered Bactrim (an antibiotic) DS (double strength), 1 tablet, by mouth, twice daily, for ten days; and [MEDICATION NAME] (a pain reliever), 50 milligrams (mg), by mouth, every six hours, as needed, for pain. Review of a skin assessment, dated 08/14/19, revealed the facility wound physician debrided the resident's unstageable pressure ulcer. The wound measured 4 cm by 4 cm by 3.5 cm, and had 3.5 cm of undermining surrounding the edges of the wound. The wound had foul-smelling drainage. On 08/15/19 at 09:50 AM, Licensed Nurse (LN) H and Administrative Nurse [NAME] changed the resident's dressing. The resident rested on an air mattress. The resident's wound measured approximately 4 cm by 4 cm by 3.5 cm, and undermining could be seen. A foul odor could be detected in the room during the dressing change. LN H and Administrative Nurse [NAME] repositioned the resident following the dressing change. On 08/15/19 at 11:00 AM, facility staff repositioned the resident. At 12:55 PM, facility staff repositioned the resident. At 03:00 PM, the resident rested in a different position. The resident's air mattress was in place and functioning appropriately. On 08/16/19 at 09:27 AM, Consultant GG confirmed the resident's prior pressure wound healed, and that she developed a new wound. Consultant GG stated that the resident began experiencing a recent functional decline, due to her disease processes, and earlier interventions such as the air mattress may have been beneficial for the resident. On 08/19/19 at 08:57 AM, the resident slept on her air mattress, and wore protective pillow booties on her feet. On 08/19/19 at 09:41 AM, Certified Nurse Aide (CNA) O stated the resident had a pressure ulcer on her tailbone. CNA O stated that the resident required frequent repositioning, and following the development of the ulcer, got an air mattress. On 08/19/19 at 10:30 AM, Certified Medication Aide (CMA) R stated the resident developed a pressure ulcer on her tailbone. CMA R stated that the resident had an air mattress, but that he/she was not sure when facility staff provided the air mattress to the resident. On 08/19/19 at 12:45 PM, Administrative Nurse [NAME] stated the resident had a pressure ulcer on her coccyx, that developed after a previous ulcer healed. Administrative Nurse [NAME] stated the facility placed a low-air-loss mattress as an intervention for the wound, on either 07/31/19 or 08/01/19, after the wound reopened. On 08/19/19 at 01:30 PM, Administrative Nurse D stated that facility staff provided the air mattress on 08/01/19. On 08/19/19 at 03:30 PM, Administrative Nurse D confirmed that the facility failed to timely implement an intervention following the identification of the hardness to the resident's prior wound site on 07/26/19. Review of the facility's policy titled, Pressure Ulcer Management, revised 09/2018, documented that preventative measures for pressure ulcer development included pressure reduction. The facility failed to timely implement an intervention to reduce pressure to a previously healed pressure ulcer, when facility staff identified a hardened area to the site on 07/26/19. Facility staff failed to implement an intervention to reduce pressure or prevent skin breakdown until 08/01/19, after the wound reopened as an unstageable pressure ulcer.

The facility reported a census of 58 residents with 3 selected for sample review of medications. Based on observation, interview, and record review, the facility failed to ensure 1 of the 3 sampled residents received medications, as ordered by the physician. Resident (#1) received a [MEDICATION NAME] (narcotic pain medication patch) and staff failed to remove the previous [MEDICATION NAME] from the resident at that time, therefore staff administered more of the medication than ordered. This significant medication error resulted in the resident requiring hospitalization for metabolic [MEDICAL CONDITION] (a toxic chemical reaction in the brain), secondary to narcotic overdose and with acute kidney disease secondary to dehydration. Findings included: - Resident #1's physician's orders [REDACTED]. An admission MDS (minimum data set), dated 1/30/18, included a BIMS (brief interview of mental status) of 15/15, indicating intact cognition. The resident reported feeling tired and the assessment evidenced the resident required supervised to extensive assistance for ADLs (activities of daily living) by 1 to 2 staff. The assessment of medications indicated the resident received antidepressants, anti-coagulants and diuretic medications. Review of the resident's care plan, dated 1/22/18, instructed the staff: 1.) Administer [MEDICATION NAME] as per orders. Give medication ½ hour before treatments or care. Discontinued on 2/26/18. 2.) Anticipate needs for pain relief and respond immediately to any complaint of pain. 3.) Assess for pain/discomfort per shift. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. 4.) The resident indicated an acceptable pain level of 4. Offer interventions for pain when level of pain reached or exceeded 4. Able to report pain and request something for it, added on 2/6/18. 5.) [MEDICATION NAME] [MEDICATION NAME], as ordered for pain management, added on 4/5/18 and discontinued on 4/23/18. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR), MAR (medication administration record) reflected the staff applied a [MEDICATION NAME] on 4/5/19 at 5:07 PM, removed that patch on 4/8/18 at 4:22 PM, and applied a patch on 4/8/18 at 4:23 PM. Documentation of the MAR further noted a staff removed a patch on 4/9/18 at 3:16 AM. Review of the facility investigation, dated 4/20/18, identified the resident experienced increased confusion with agitation and paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), on 4/9/18. The facility noted staff applied the initial [MEDICATION NAME] on 4/5/18 at 4:00 PM, and applied the second patch on 4/8/18 at 4:23 PM, further documenting in the removal section with a check mark at 4:22. Additionally, review of the MAR indicated [REDACTED]. Review of the nursing notes and documentation on the MAR indicated [REDACTED]. Nursing documentation at 4:58 PM, on 4/8/18, identified the resident displayed increased paranoia to the family. The facility staff notified the physician and requested laboratory testing, per the family request. Staff obtained an order for [REDACTED]. The investigation report continued with a review of hospital documentation, including a discharge summary, dated 4/14/18, which identified the resident arrived at the ER and ER staff noted the resident with 2 [MEDICATION NAME]es on the resident's right upper arm. The hospital admitted the resident with metabolic [MEDICAL CONDITION] (a toxic chemical reaction in the brain), secondary to narcotic overdose and with acute kidney disease secondary to dehydration. A witness statement from licensed nursing staff F, included with the investigation, documented nurse F administered the second patch, when an assessment of the resident failed to locate the first patch on the resident, and staff F believed the old patch must have fallen off. The facility determined that staff F failed to document/communicate the missing patch to the on-coming shift, in the MAR, or in nursing notes. A witness statement from nurse D verified the lack of communication. Observation of the resident, on 4/26/18 at 10:08 AM, identified the resident rested in bed, with oxygen at 3.5 Liters, via nasal cannula. The resident responded to communication in a normal manner, and appeared to be alert and oriented. The resident expressed being hospitalized recently, however, was not sure the reason for the hospitalization . At 4:00 PM on 4/26/18, observation identified the resident seated in a recliner in his/her room, with eyes closed and resting quietly. On 4/26/18 at 9:20 AM, licensed nursing staff D, reported the expectation included the staff member administering medications, per the physician's orders [REDACTED]. Certified medication staff E reported, on 4/26/18 at 9:28 AM, that in the past, the nurse or the CMA (certified medication aide) completed the task of removing and re-applying a new [MEDICATION NAME] without a witness. On 4/26/18 at 3:15 PM, administrative staff A reported the nurse who failed to find and remove the old patch committed a medication error when the staff failed to document in the MAR, the nursing notes, and/or report to the on-coming licensed nurse regarding the failure to locate the patch. The physician could not be reached. The facility policy, dated (MONTH) 2012 lacked instructions on the use of [MEDICATION NAME]es. The facility provided procedures utilized for instruction of medication pass, which included that two nurses should witness and document the disposal of used patches. The procedure further indicated a common error included the failure to remove the old patch. The facility failed to ensure this resident received a physician ordered significant medication, as directed, when staff failed to administer and/or ensure the placement/removal of a [MEDICATION NAME]. The resident required hospitalization for metabolic [MEDICAL CONDITION] (a toxic chemical reaction in the brain), secondary to narcotic overdose and with acute kidney disease secondary to dehydration.

The facility reported a census of 63 residents and identified 15 residents considered at risk for elopement. Based on observation, interview and record review, the facility failed to ensure 1 (#01) of the 3 sampled residents reviewed for elopement, did not exit the facility without staff knowledge. The resident exited the facility, walked 0.02 miles, and crossed a moderately busy city street, before an off-duty staff member noticed the resident, and phoned the facility. This placed the resident in immediate jeopardy. Findings included: - Resident #01's admission record, documented the facility admitted the resident on 7/13/17. The 7/13/17 social service admission note, confirmed the resident's spouse informed the facility of the resident's tendencies to wander. The Physician's admission orders [REDACTED]. Upon admission, the resident's spouse signed a wanderguard permission form and the staff placed a wanderguard monitor on the resident. On 7/13/17 at 10:00 A.M., the facility completed a wandering risk assessment for the resident, which scored a 7, indicating him/her to be at moderate risk for wandering. It included documentation of the wanderguard placed on the resident. The 7/19/17 admission MDS (minimum data set) assessment, identified the resident with a severe cognitive deficit, wandering behavior that worsened in the evenings, and the need for limited assist with activities of daily living. The 7/19/17 cognition CAA (care area assessment) included the presence of delirium (sudden severe confusion, disorientation and restlessness). The resident's medical history included, Alzhemiers disease (progressive mental deterioration characterized by confusion and memory failure) diagnosed in 2014. The family provided care for the resident at home and could no longer provide adequate care related to increased confusion, increased falls and weakness. The resident was able to verbalize some needs but was completely unaware of safety issues. The 7/13/17 care plan included, the resident may attempt to leave the facility unassisted related to dementia. Engage me in simple, structured activities that avoid overly demanding tasks. The resident mainly watched TV and napped at home. Nurses notes, on 8/22/17 at 5:20 P.M., included the facility received a phone call from off-duty direct care staff C. The employee notified the facility, he/she saw the resident on the sidewalk and joined approximately 2 blocks east, across the street from the facility. The area was mainly residential, however, included two assisted living facilities. Direct care staff transported the resident back to the facility by private vehicle. Licensed nurse D assessed the resident and the resident was found to have no injuries. The resident stated, he/she was going for a walk. The facility investigation, dated 8/24/17, revealed the staff could not account for the resident's whereabouts for approximately 13 minutes. Licensed nurse E last noted the resident at 5:07 P.M., in the front living room. The resident exited out the front door, walked without his/her walker to the front sidewalk, went east approximately 2 blocks, and crossed the paved moderately busy street, before being noticed by off duty direct care staff C. The resident wore shorts, a shirt, shoes and socks, his/her glasses and a hat. The outside temperature was 81 degrees Fahrenheit and sunny. Frequent observations, on 8/29/17 from 8:00 A.M. through 4:30 P.M., revealed the resident smiled and spoke when spoken to. The resident was self-ambulatory with his/her walker in the hallways, fed him/herself without the need for staff assistance, attended a group activity, enjoyed a family visit, watched TV and took a nap in his/her personal recliner. On 8/29/17 at 8:10 A.M., administrative staff A acknowledged the front door alarm sounded when the staff returned the resident into the facility on [DATE] at 5:20 P.M. The staff checked all 15 residents with code alerts (wanderguards) for expiration dates and found all 15 were within the expiration dates. On 8/29/17 at 9:00 A.M., maintenance staff F, reported he/she tested the wanderguard alarm system and after multiple attempts to get out the door without the alarm sounding, he/she discovered that a small triangular area, near the lower middle frame work, of the double doors, failed to sense the wanderguard and sound the alarm. Therefore the resident's ankle wanderguard failed to sense the system and failed to sound the alarm. Maintenance personal F contacted the facility's alarm company who fixed the alarm system on 8/23/17. The facility failed to ensure this confused wandering resident did not exit the facility without staff knowledge. This practice placed this cognitively impaired resident in immediately jeopardy when he/she exited the front door of the facility, walked approximately 2 blocks to the east, and crossed a moderately busy city street, before an off-duty staff member noted the resident, and notified the facility that the resident was outside and away from the facility property. The immediate jeopardy was cited as past non-compliance as of 8/28/17 at 1:00 P.M. when the facility completed the following items: 1.) Maintenance personal F contacted the facility's alarm company who fixed the alarm system on 8/23/17. 2.) The facility re-educated all employees with in-service on elopements, door alarms, and code alert system protocols from 8/25/17 through 8/28/17 at 1:00 PM. 3.) A QAPI (Quality Assessment Performance Improvement) was held on 8/25/17 and documentation revealed a plan to address and prevent any additional elopements from the facility.

The facility reported a census of 65 residents, with 3 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure 1 residents (#1) received care and services to prevent falls. Resident # 1 sustained a head injury with sutures required to close the laceration and hospitalization for monitoring of a brain bleed. Findings included: - Resident #1's significant change Minimum Data Set, dated dated [DATE], revealed the resident had severe cognitive impairment with inattention and disorganized thinking; the resident displayed little interest or pleasure in doing things, appeared down/depressed, tired, and had trouble concentrating. The staff assessed the resident without any behavioral concerns and identified the resident was totally dependent of staff for all ADL's (activities of daily living), including bed mobility, with bilateral upper and lower ROM (range of motion) impairment. The quarterly Minimum Data Set, dated dated [DATE], identified the resident without changes to above noted areas of assessment. The Care Area Assessment for falls, dated 4/17/17, identified the resident remained a high fall risk and had no recent falls. The Fall Risk Assessments, prior to the fall identified the resident scored 12 on 4/9/17 and 7/9/17, indicating the resident was a high risk for falling. The resident's care plan, dated 5/24/17, included the following instructions to staff regarding the resident's care needs: Bed mobility: the resident required 2 staff participation to reposition and turn in bed, added 7/14/15. Toileting: the resident was totally dependent on 2 staff for toileting, added 7/14/15. Transfers: the resident needed a Hoyer (mechanical) lift with 2 staff assistance, added 7/19/16. Maintain a safe environment, added 7/19/16. Monitor frequently, on rounds, added 4/18/17. Anticipate and meet the resident's needs, added 5/24/17. Review of the facility investigation, dated 7/15/17, identified the resident slipped off the side of the bed during a bed check, with 1 staff member A present. Both direct care staff entered the room, and after seeing the need for supplies, direct care staff B left the room. Direct care staff A remained with the resident. During the time staff B was absent, staff A began to provide cares to the resident, turning his/her back to the resident to obtain hygiene wipes. With staff A's back turned, the resident slipped over the edge of the bed, opposite the staff member, fell and landed on the floor. The resident sustained [REDACTED]. When staff B returned he/she obtained a cold, wet towel compress and applied it to the resident's head laceration. Staff A notified the nurse. The nurse called for an ambulance. The resident went by ambulance to the nearest hospital for treatment and sutures. Per interview with direct care staff B, the resident's bed was raised to waist height. Hospital radiology reports, dated 7/15/17 at 5:21 AM, identified the resident received a head CT (computerized tomography) without contrast, for a head injury, indicating a potential brain bleed. A follow-up CT completed at 4:52 PM, for intracranial hemorrhage (brain bleed) identified the resident continued with a laceration to the head and with left facial swelling, with the intracranial hemorrhage decreased in size from earlier in the day. A new tiny area of acute blood was noted in the prepontine cistern (an area of the brain containing cerebral spinal fluid) of the left, not present on the earlier CT. Additionally, the hospital reports documented the application of sutures to the head laceration. A 7/16/17 hospital progress note identified the resident sustained [REDACTED]. A review of the witness statements from 2 staff members, provided with the investigation, identified direct care staff A provided care for the resident while direct care staff B was out of the room, getting supplies. While staff A turned his/her back, to get a package of perineal wipes, and then turned back to the resident, the resident slid off of the bed. Staff A reported the resident landed on the floor. On 8/14/17 at 2:01 PM, direct care staff E reported the resident required total care from staff. Staff E reported, after the fall, all the staff received instruction to make sure staff followed the resident care plan instructions and to keep the beds lowered to regular heights. On 8/14/17 at 5:30 PM, direct care staff G reported the resident required total care from staff. and during the provision of cares, staff usually raised the height of the bed up to waist high, to provide cares, and then lowered the bed down to sitting on the edge of the bed height for the resident's comfort and safety. The staff reported that most staff providing cares to residents raise the beds, to facilitate protecting the staff backs, and then are responsible to lower the bed for the resident's safety. On 8/15/17 at 6:15 AM, administrative staff C and F verified the resident's care plan was not followed, when one staff attempted to provide cares, to the resident after the other staff left the room, and the resident fell to the floor, and suffered a head injury. On 8/15/17 at 4:50 AM, direct care staff B, reported he/she and the direct care staff A entered the resident's room, on the morning of the fall. The other aide (staff A) reported the resident needed more briefs, and staff B left to obtain the supplies needed. Upon returning to the room, staff A stated, The resident fell . Direct care staff B noting the blood from the resident's head, immediately went to get a cold compress, with staff A leaving to get the nurse. The policy on Repositioning, dated 10/10, included to check the care plan, assignment sheet or the communication system to determine the resident's specific positioning needs including special equipment, the resident's level of participation and the number of staff required to complete the procedure. The policy also directed to raise the bed to waist level, provide the cares and then lower the bed into the lowest position as indicated in the resident's plan of care. The facility failed to ensure this resident received adequate staff assistance, as care planned to ensure the resident remained free of accidents and injury. Resident #1 fell from his/her bed when staff A attempted to provide care without assistance from another staff person. The resident sustained [REDACTED]. and treatment for [REDACTED].

The facility reported a census of 71 residents. Based on interviews and record review the facility failed to ensure 1 (#03) of the 3 sampled residents, received 2 person assistance with transfers as planned. Upon transfer with one staff member resident #03 sustained a leg laceration which required 8 sutures to close. Findings included: - Resident #03's medical record progress note, revealed the resident admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. A physician order, dated 9/17/16, revealed the resident admitted to hospice services. The 9/15/16, significant change in condition MDS (minimum data set) assessment, identified the resident with moderate mental impairment and required the need for extensive assistance with transfers. The care area assessment, for ADLs (activities of daily living), dated 9/15/16, documented the resident required extensive assistance of 1-2 for all activities of daily living except eating. The care plan, dated 5/19/16, directed the resident required extensive assist of 2 staff to reposition and transfer. The facility incident self- investigation, dated 1/22/17 at 7:45 A.M., documented certified staff D manually transferred the resident by him/herself without assistance. The resident sustained [REDACTED]. The resident's right leg bumped into the side of the leg/foot rest of the resident's broda chair (specialized wheelchair with the ability to tilt and recline). The certified staff member immediately notified licensed nurse C who provided first aid and sent the resident to the emergency room . The emergency room documentation, dated 1/22/17, identified a large laceration on the right anterior tibial (leg) surface that measured 10 centimeters. The physician placed 8 sutures with the use of local anesthesia to the leg. The resident returned to the facility. No observations were available as the resident discharged from the facility. On 2/20/17 at 10:15 A.M., administrative licensed nursing staff B explained the resident required 2 facility staff for safe transfers and the staff failed to use 2 for this assistance. On 2/20/17 at 1:15 P.M., licensed nursing staff C described the injury and first aid provided. He/she verified the usual number of 4 aides worked on the west wing the day of the injury. On 2/20/17 at 5:10 P.M., certified staff D reported he/she knew the resident required 2 staff for transfers but provided the transfer alone, because he/she transferred the resident alone previously. The facility undated policy, related to resident transfer safety included, the clinician and patient/resident safety must never be compromised. Whenever in doubt about the level of assistance required to transfer a patient/resident safely, obtain additional assistance. The facility failed to ensure the staff transferred this dependent resident with the assistance of 2 staff members as planned. The resident sustained [REDACTED].

The facility reported a census of 60 residents with 7 residents reviewed for falls. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 6 of the 7 reviewed (#1, 2, 3, 4, 6 and 7). Resident #1 had a fall and sustained a fractured elbow when he/she fell when staff propelled his/her wheelchair without foot pedals. Findings included: - Resident #1 ' s admission MDS (minimum data set) assessment, dated 4/29/16, identified the resident scored 15/15 on the Brief Interview for Mental Status, indicating intact cognition. The MDS evidenced the resident needed extensive assistance for dressing and toileting and limited assistance for personal hygiene, locomotion, walking, transfers and bed mobility. The assessment further identified the resident used a wheelchair for mobility, lacked a fall history and was without falls since admission. A Care Area Assessment for ADL ' s (activities of daily living), dated 4/29/16, evidenced the resident required limited assist of 1 staff for all movement activities, turning, transfers, and toileting with safety reminders and repetitive education regarding utilizing the use of a call-light for assistance of staff. The Care Area Assessment for falls, dated 4/29/16, included the resident was a high fall risk related to back pain and immobility. All personal items and call-light would be kept within easy reach with repeated instruction to use the call-light for assistance. The resident ' s care plan, prior to 6/4/16 (date of fall) instructed staff to: Anticipate and meet the resident ' s needs, dated 4/29/16. Even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, and personal items within reach, dated 5/1/16. Staff added an intervention to the care plan on 6/14/16 for the use of foot pedals on the wheelchair. On 4/24/16, on admit, the fall assessment identified the resident used an ambulatory aide, lacked a history of falls, had a normal gait/balance assessment, and was continent of urine. However, the assessment lacked a conclusion, or score to identify if the resident was at risk or not. A 6/4/16 fall risk assessment, evidenced the resident had a recent fall, and lacked a history of falls. The resident had intermittent memory and recall, inadequate vision, and had occasional incontinence. The resident was unable to come to a standing position independently, had a loss of balance while standing, and decreased muscle coordination. Again the assessment lacked a score or conclusion to the residents risk for falls. Review of nursing notes, dated 6/4/16 at 7:08 PM, documented the CNA (certified nurse aide) awakened the resident for a shower. The CNA began to push the resident, seated in the wheelchair, out of the room. At that time the resident fell forward out of the wheelchair, landing face first on the floor, hitting his/her head above the right eye, and landing with his/her right arm under the resident ' s body. Licensed nursing staff K documented at 8:15 PM, continued monitoring revealed the resident, began to complain of pain and headache. Staff K notified the doctor and requested ambulance transport. A nursing note, dated 6/5/16 at 1:38 AM, documented the resident returned from the hospital with the right arm in a splint and sling. Staff K documented education to staff regarding safe transportation in the wheelchair and the proper use of foot pedals. A clarification order, dated 6/9/16, instructed staff to protect and prevent use of the resident ' s right arm due to a cortical defect, mainly soft tissue injury, chipped bone. injury. On 7/7/16 at 1:35 PM, the resident sat in his/her wheelchair in the resident ' s room. The resident reported he/she fell and fractured his/her right elbow. The resident indicated he/she did not recall anything about the fall, but noted that since the fall the staff kept foot pedals on his/her wheelchair at all times. Observation identified the resident ' s call light was out of the resident ' s reach at the back side of the recliner, and the resident indicated he/she could not reach it to call for assistance. On 7/8/16 at 8:12 AM, direct care staff H and I removed the foot pedals from the resident ' s wheelchair, and used a sit to stand lift to transfer the resident into bed. On 7/8/16 at 5:30 PM, observation revealed the resident sat in the wheelchair in his/her room, near the recliner, with his/her eyes closed. However, both call lights hung at the bedside, behind the resident, and not within reach of the resident. On 7/12/16 at 7:10 AM, the resident self-propelled towards the dining hall, with his/her feet on the foot pedals attached to the wheelchair, using his/her hands to self-propel the wheelchair. On 7/12/16 at 12:35 PM, observation revealed the resident sat in the wheelchair, in his/her room, with the wheelchair parked in front of the recliner. The call light hung over the back of the recliner, well out of the residents reach. Intermittent observations at 12:50 PM and 1:10 PM, identified the call light remained out of reach for the resident. On 7/7/16 at 2:10 PM, administrative nursing staff B, reported the staff evaluated this resident after his/her return from the hospital and determined that the resident needed foot pedals all the times. However, further noted that the resident could self propel in the wheelchair, at times. Staff reported the resident had days of more confusion than other days, and therefore decided in his/her best interest they should always have foot pedals in place. On 7/8/16 at 7:50 AM, direct care staff, J reported the resident used a sit to stand lift for all transfers. The staff was not aware of any interventions implemented after the fall, but had standard interventions, such as keeping the call light within reach, using the lift for transfers and using the foot pedals on the wheelchair, but the pedals were always in place for this resident. The facility lacked a policy and procedure on the use of foot pedals on wheelchairs of dependent residents. The facility failed to provide adequate supervision and assistive devices for this dependent resident to prevent a fall, resulting in a fracture. - The facility admitted resident #7 on 10/29/13, per the EMR (electronic medical record). [DIAGNOSES REDACTED]. The resident ' s annual MDS (minimum data set) assessment, dated 11/28/15, identified the resident scored 1/15 on the Brief Interview for Mental Status, indicating severely impaired cognition and the resident needed limited or extensive assistance of 1-2 staff for ADL ' s (activities of daily living), including transfers and mobility. Additionally, the assessment evidenced the resident had experienced falls since the prior admission, 2 or more without injury and 2 or more with injury (except major). The resident ' s quarterly MDS (minimum data set) assessment, dated 5/30/16, lacked any significant changes, however, identified the resident experienced only 1 fall without injury since the prior assessment. The Care Area Assessment for falls, dated 12/1/15, included to continue with the current plan of care, related to a high fall risk related to dementia and a history of injury falls. The resident required alarms on his/her bed and with an alarmed seat belt in the wheelchair. The resident exhibited the ability to unlatch and latch the seat belt, and evidenced very poor safety awareness. The resident should never be left alone when toileting and a gait belt should be utilized with all transfers. The resident ' s care plan, dated 6/21/16, instructed staff: 1.) Ensure the call light is within reach and encourage the resident to use it. 2.) Encourage the resident to sit in the recliner, with a seat belt, near the nurse's station, when restless or anxious. 3.) Provide a calm, quiet setting at meal times with adequate eating time. Preferred location is the dining area and encourage socialization and interaction with tablemates. 4.) Ensure appropriate footwear, non-skid socks or shoes when ambulating or mobilizing in a wheelchair. 5.) Ensure that the resident ' s hi/low bed is in the lowest position, at all times. 6.) Floor mat beside the bed. 7.) Gait belt use with any transfer. 8.) Keep the alarm box out of reach, as the resident is capable of turning off the alarm. 9.) Anti-roll back brakes on the resident ' s wheelchair. 10.) Use seat belt in chairs and a bed alarm, in bed. Ensure devices are in place and functional. The resident is able to unbuckle and buckle the seat belt. Check alarms each shift. 11.) Keep the electric bed control out of the resident ' s reach. The resident can unintentionally raise the height of the bed. 12.) Monitor closely. 13.) Monitor the motion detector is properly working every shift; the detector is on the east wall of the resident ' s room. 14.) Toilet, as soon as possible, after meals. Review of the fall risk assessments, dated 2/18/16 and 5/18/16, identified the resident with frequent incontinence, agitation, confined to chair and oriented, unable to stand independently, loss of balance, required hands on assistance to move from place to place, use of assistive device and decreased muscle coordination, as risk factors. The assessment lacked a score or conclusion as to the resident ' s risk. Review of nursing documentation on 7/11/16 at 2:56 PM, evidenced the resident transferred his/her self out of the bed. The alarm sounded, alerting staff of the resident attempting to self- transfer. The resident was found on the fall mat, sitting upright. Nursing documentation at 6:55 PM, evidenced the resident experienced a second fall, on the same date, in the dining room. The resident complained of right hip pain with subsequent transport to the hospital. Review of the witness statements included in the facility investigation, dated 7/12/16, evidenced the following concerns: Direct care staff T documented the resident previously unbuckled his/her seat belt and the staff assisted in re-buckling the belt and explained the reason for the safety feature, and then returned to dining room duties. Staff T lacked knowledge of the fall, until the licensed staff informed staff T. Licensed nursing staff V, documented he/she was called to the dining room at approximately 4:55 PM. The staff observed the resident on the floor, with his/her head against the podium. The resident ' s wheelchair was nearby, at the table where the resident sat prior to the fall. The seat belt was unbuckled, however, was not sounding. Two other aides were noted at the other end of the dining room. The resident denied knowing what occurred, and staff assisted the resident off the floor and into the wheelchair. Staff V documented they tested the seat belt, 4 times, and identified the alarm functioned, as normal. Staff further documented the staff member took vital signs and the resident complained of hip pain, after staff seated him/her in the wheelchair. Staff took the resident to his/her room for an assessment, and stood the resident to determine if any abnormality of the hip was evident. The resident continued to hold the right hip and indicated it hurt. The staff sat the resident back into the wheelchair and then took the resident to the nursing station to phone the on-call physician. The staff obtained an order to transport the resident to the emergency room . Interview on 7/12/16 at 5:15 PM, with administrative nursing staff B, verified the concern of insufficient supervision in the dining room playing a role in the resident ' s fall. The accidents and incident policy and procedure, dated 12/11, included all accidents would be investigated with corrective action taken. The facility failed to provide adequate supervision and/or proper functioning equipment to prevent repeated falls for this resident with multiple falls and then experienced a hip fracture. - The facility admitted resident #6 on 5/15/16, per the EMR (electronic medical record). [DIAGNOSES REDACTED]. The resident ' s admission MDS (minimum data set) assessment, dated 5/20/16, identified the resident scored 10/15 on the Brief Interview for Mental Status, indicating the resident as moderately impaired of cognition, needed extensive assistance of 2 staff for transfers, limited assistance of 1 staff for mobility, and used a wheelchair and walker for mobility. The assessment identified falls in the last month prior to admit/re-entry and that the resident fell in the last 2-6 months prior to admit/reentry, with a fracture related to the falls within 6 months prior to admit/reentry. The Care Area Assessment, dated 5/23/16, for falls included the resident would be care planned as a high fall risk related to multiple recent falls, the last with injuries and fractures. The resident used a walker to ambulate. The resident ' s care plan, dated 5/16/16, instructed staff to: 1.) Anticipate and meet my needs. 2.) Be sure the call light is within reach and encourage the resident to use it for assistance, as needed. The resident needed prompt response to all requests for assistance. 3.) Ensure the resident had appropriate footwear. 4.) The resident used chair and bed electronic alarms. Check the alarms, every shift, for placement and proper working order. 5.) Two person maximum assistance for transfers, due to left sided weakness and 2 fractured ribs on the left side. Support left arm due to dislocated shoulder. The resident reported, on 7/7/16 at 1:50 PM, he/she used a wheelchair for mobility and that he/she usually moved it about, independently. The resident, however, indicated that sometimes the staff pushed his/her chair, but they did not use foot pedals on the wheelchair, when they did. Review of the resident ' s room, at that time, revealed the resident ' s wheelchair present, but lacked evidence of any foot pedals present. Observation on 7/7/16 at 4:05 PM, identified direct care staff O propelled the resident to the dining room, in the resident ' s wheelchair. The wheelchair lacked pedals at that time and the residents feet were barely raised from the floor. On 7/7/16 at 2:10 PM, administrative nursing staff B, reported the staff are evaluating all residents of the facility for the use of wheelchair foot pedals. The staff identified this resident without the need for wheelchair foot pedals. On 7/12/16 at 1:58 PM, direct care staff H, reported the resident used a wheelchair for mobility and was able to self-propel the chair, without staff assisting the resident. The staff reported the resident did not use foot pedals, on the wheelchair. The facility lacked a policy and procedure on the use of foot pedals on wheelchairs of residents who are sometimes propelled by staff. The facility failed to provide adequate supervision and assistive devices for this resident who sometimes received wheelchair propelling services by the staff, without the use of foot pedals on the wheelchair. - The facility admitted resident #2 on 12/31/14, per the EMR (electronic medical record). [DIAGNOSES REDACTED]. The resident ' s annual MDS (minimum data set) assessment, dated 4/16/16, identified the staff assessed the resident with long and short term memory impairment, and severely impaired of skills for daily decision making. The assessment further identified the resident required total dependence of staff for all ADL ' s (activities of daily living) and used a wheelchair for mobility by staff. The assessment identified the resident had no falls. The Care Area Assessment for falls, dated 4/21/16, documented to continue with the current plan of care, related to fall risks. The resident had no falls. The care plan, dated 5/3/16, for falls instructed staff to: 1.) Anticipate and meet the resident ' s needs. 2.) Ensure the resident's call light is within reach and encourage me to use it for assistance as needed. 3.) Ensure that I am wearing appropriate footwear, or non-skid socks when ambulating or mobilizing in w/c. 4.) The resident needed 2 staff for transfers and bed mobility. The care plan lacked an intervention following an incident of the resident rolling in bed and becoming entrapped in the grab bar, on the side of the bed, on 5/14/16. A 4/7/16 and a 7/7/16 Fall Risk Assessment included the resident unable to independently come to a standing position, required hands on assist to move from place to place, without behaviors, confined to a chair and disoriented. The assessments lacked identification of falls in the prior 3 months. The assessments also lack a conclusion or score to determine the actual risk of the resident falling. Review of the nursing documentation, dated 5/14/16 at 2:40 AM, documented the resident was found positioned around the grab bar, on the right side of the bed, with the resident ' s head, neck and shoulders positioned above and around the side of the mattress and grab bar, his/her torso in position behind the grab bar, and the residents legs hanging off the mattress and towards the floor. The staff realigned the resident, who was last repositioned around 1:00 AM, into the center of the bed. The nurse documented the resident received the following skin discolorations: a 9 cm (centimeter) by 4 cm red area on the R upper thigh; a 12 cm by 2.5 cm red area on the L side of the stomach; a 6 cm by 2 cm bruise on the resident ' s left shin, with lots of little bruises all around this area and also towards the back of the resident ' s left lower leg; a 3.5 cm by 5 cm bruise on the right forearm.; an 11 cm by 3 cm red area from the right elbow and towards the back inner arm, and a small red area by the resident ' s right breast. Nursing documentation, on 5/17/16 at 4:20 PM, documented that staff added cushions were added to the mattress by the grab bars to prevent the resident from bumping or rolling into the grab bars, again. Review of the investigation for the resident, dated 5/14/16, identified the resident had rolled forward from the side lying position and became suspended around the grab bar. The staff noted, on 5/17/16 they placed the cushions, however, for 3 days the resident was at risk for the same type of occurence. The investigation documented the faciltiy failed to report the occurence to the state agency, as required. On 7/8/16 at 6:45 AM, the resident ' s bed, raised to a normal height, exhibited bilateral grab bars to each side of the bed, with bolsters on the mattress at each side of the grab bars. At 7:30 AM, observation identified the resident seated at the dining table, in a wheelchair, with foot pedals in place, being assisted by staff with his/her meal. On 7/8/16 at 9:05 AM, direct care staff J and H assisted with transferring the resident from the wheelchair into the bed. The staff completed a gait belt and 2 staff transfer. Staff removed the residents foot pedals, placed a gait belt to the resident ' s waist and lifted the resident who did not bear any weight, into the bed. Staff H reported the resident had not had any falls and received total care. On 7/12/16 at 12:55 PM, direct care staff M and I assisted the resident to lie down after lunch. The staff lifted the resident with a gait belt and extensive assistance, with the resident not bearing any weight, onto the bed. The staff confirmed the resident was totally dependent for all ADL ' s. Observation during cares and turning the resident side to side, revealed the resident did not use the grab bars to help in repositioning in the bed. On 7/12/16 at 3:15 PM, direct care staff N and F assisted the resident to get up for supper. Staff used a mechanical lift to transfer the resident into the wheelchair. Direct care staff N reported, at that time, the resident ' s grab bars had been removed, leaving the bolsters on the bed loose and the staff didn ' t want to leave the resident unattended in the bed. Staff F reported the resident required total care for ADL ' s. Administrative nursing staff B and C verified on 7/12/16 at 2:20 PM, the resident was unable to use the grab bars, and indicated the facility did not report the incident at the time of the occurrence, not feeling it was a reportable incident. The accidents and incident policy and procedure, dated 12/11, included all accidents would be investigated with corrective action taken. The facility failed to ensure this dependent resident received adequate supervision and care to prevent the resident from rolling and dangling off the edge of the bed for a potential 1 hour and 40 minutes. Furthermore, the facility failed to ensure all assistive devices in place to prevent repeated accidents. - The facility admitted resident #3 on 11/30/13, per the EMR (electronic medical record) and discharged on [DATE] to the hospital. [DIAGNOSES REDACTED]. The resident ' s annual MDS (minimum data set) assessment, dated 11/13/15, identified the resident scored 10/15 on the Brief Interview for Mental Status, indicating moderately impaired cognitive status, needed extensive assistance of 1 staff for transfers, limited assistance of 1 staff for locomotion, and with use of a walker and/or a wheelchair for mobility. The resident ' s quarterly MDS (minimum data set) assessment, dated 6/24/16, identified the resident scored 4/15 on the Brief Interview for Mental Status, indicating a decline with severely impaired cognition, needed limited assist of 1 staff for bed mobility, transfers and locomotion. The assessment indicated the resident needed extensive assistance for walking and the resident used a walker and/or a wheelchair for mobility. The Care Area Assessment for falls, dated 11/18/15, included to continue to care plan the resident as a high fall risk related to the resident ' s lack of safety awareness, weakness, and a history of injury falls. The resident experienced 3 non-injury falls during this last review period, and usually fell attempting to self-transfer. The resident had alarms in place, with a seat belt which the resident easily unbuckled, with staff to frequently check on the resident, and to respond promptly to lights and alarms. The resident ' s care plan, dated 5/17/16, for falls instructed staff: 1.) The resident had a history of [REDACTED]. 2.) Anticipate and meet the resident ' s needs. 3.) Ensure the call light is within reach and encourage me to use it for assistance as needed. 4.) Check on the resident frequently on rounds, answer call light and respond to alarms, promptly. 5.) Encourage the resident to toilet after meals, as soon as possible. 6.) Encourage the resident not to turn the alarms off. 7.) Encourage the resident to ask for assistance when needing to be transferred. 8.) Ensure the floor mat is beside the resident ' s bed when the resident is in the bed, at all times. 9.) Ensure the bed and wheelchair seat belt alarm are in place and functional. 10.) Ensure the alarm box is positioned out of the residents reach. 11.) Do not leave the resident in the bathroom unattended. 12.) Keep the resident at the nursing desk during the evening until bedtime. 13.) Non-skid strips on the floor in front of the bed. 14.) Provide one on one and redirection to the resident as appropriate. 15.) Resident likes to make his/her own bed, staff to provide SBA (stand by assist) for safety. Review of the resident ' s fall documentation identified the resident experienced repeated falls, with 5 in May, 2016, and 3 in June, 2016. On 7/8/16 at 6:45 AM, the resident ' s bed was made and the alarm rested on the floor at the head of the bed. The resident was not present in the room. On 7/8/16 at 9:15 AM, direct care staff J, assisted the resident to lie down on the bed. The resident grabbed hold of the grab bar and stood to self-transfer with staff J standing by and holding onto the resident ' s gait belt. The alarm on the chair sounded when the resident stood, and then the alarm on the bed chirped as the resident lay down. However, observation identified the alarm box rested in plain sight, on the top of the bedside table, within reach of the resident. The staff reported the resident is at high risk for falls, and reported interventions included the alarms, fall mat at bedside, the call light within reach and keeping the bed low, as the resident is very short. On 7/8/16 at 8:30 AM, licensed charge nurse L reported the residents identified as high fall risks should be monitored frequently and all care planned interventions should be in place. The facility accidents and incident policy and procedure, dated 12/11, included all accidents would be investigated with corrective action taken. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated falls for this resident with multiple falls. - Resident #4 ' s signed physician orders, dated 6/5/16, included: abnormal posture, abnormalities of gait and mobility, and Alzheimer ' s disease (progressive mental deterioration characterized by confusion and memory failure). The resident ' s significant change MDS (minimum data set) assessment, dated 2/23/16, identified the resident scored 0/15 on the Brief Interview for Mental Status, indicating severely impaired cognition, required total dependence of staff for all ADL ' s (activities of daily living), and identified the resident without falls. The resident ' s quarterly MDS (minimum data set) assessment, dated 5/25/16, identified the resident scored 3/15 on the Brief Interview for Mental Status, indicating severely impaired cognition, required total dependence of staff for all ADL ' s, and identified the resident with 2 or more falls, without injury, since the prior assessment. The 3/8/16 Care Area Assessment for falls included the resident continued to be a high fall risk being dependent on staff for all transfers with a mechanical lift. The resident ' s care plan, dated 5/24/16, for falls included: Ensure the call light is within reach and encourage me to use it for assistance as needed. Provide prompt response to all requests for assistance. On 11/30/15, added Dysom (a non-slip material) to the wheelchair, lift sheet, and the back of the wheelchair. The resident experienced a non-injury fall on 1/1/16; 1/12/16 staff placed a fall mat beside the bed. On 5/18/16, changed to an air mattress with cushions at the grab bar area for the resident to rest against. On 5/19/16, at 2:10 and 2:50 PM the resident fell , trying to get out of bed; changed air mattress to a less firm setting. On 6/25/16, placed a bed alarm on the bed as a fall intervention. Record review identified the staff completed fall risk assessments on 2/28/16, 3/21/16, 5/17/16, and 6/28/16, however, the assessments lacked a conclusion or score to identify the resident ' s risk of falls. Review of the residents nursing notes identified the following falls: On 2/28/16 at 5:30 AM, staff found the resident on the floor at the bedside. On 3/10/16 at 11:30 AM, found on floor at bedside. 5/9/16 at 8:20 PM, found with knees on floor. 5/15/16 2:10 PM, found on floor at bedside. 5/15/16 at 2:50 PM, found the resident sitting on the fall mat at bedside. On 6/25/16 at 12:30 AM, staff found the resident seated on the floor fall mat. Observation on 7/7/16 at 2:40 PM, identified the resident in a low bed (not included in the plan of care), with an air mattress, with bolsters at the grab bars, a bed alarm in place, dysom noted in the geri-chair, and a fall mat in place at the side of the bed. On 7/8/16 at 7:15 AM, direct care staff assisted the resident with arising cares. Direct care staff Direct care staff R reported, at that time, the resident required total care for most ADL ' s, and had numerous falls with interventions, including a bed alarm, a low bed, a fall mat and bolsters at the side, near the grab bars because the resident does move him/herself in bed as desired. On 7/7/16 at 3:20 PM, direct care staff Q reported the resident ' s fall safety interventions, included: an alarm in bed, a fall mat beside the bed, and the bed lowered to the floor. Staff Q further noted staff are made aware of new interventions after falls occur by doing rounds with the off-going shift. The facility policy for accidents and incidents, dated 12/11, included all accidents would be investigated with corrective action taken. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated falls for this resident with multiple falls. The facility failed to assess and determine the root cause and develop further appropriate interventions for falls from the bed, the resident experienced on 2/28, 3/10, 5/9, 5/15, and 6/25/16.

The facility reported a census of 77 residents, and identified 5 residents with pressure ulcers. The 15 residents sampled, included these 5 residents with pressure ulcers. Based on observations, interviews, and record review, the facility failed to provide adequate treatment and services for 6 of the 15 sampled residents, including the development of a stage 3 pressure ulcer for 1 resident #34, development of a stage 2 pressure ulcer for 2 residents # 78 & #3, and failed to promote healing of a stage 2 pressure ulcer for 1 alert and interviewable resident. Furthermore, the facility failed to provide timely position changes for 2 sampled residents (# 53 and 109), identified at risk for pressure ulcers. The staff failed to monitor the medical condition, failed to reposition in a timely fashion, failed to provide assistive pressure relieving devices, for dependent extremities, for 3 sampled cognitively impaired, dependent residents. Furthermore, the facility staff failed to provide timely pain medications prior to pressure ulcer treatments, at which time 2 sampled residents (#78 and #3) experienced pain throughout the treatments. Findings included: - The facility admitted resident #34 on 1/11/06, with [DIAGNOSES REDACTED]. The 11/16/10, dated, admission nursing assessment, recorded the resident with, "A callous and two small scabs to the right heel, without open wounds." The 11/16/10, and 12/16/10, Braden skin risk assessments, recorded a score of 19, which indicated the resident not at risk for pressure ulcers. The 11/23/10, five day MDS (minimum data set) assessment recorded the resident cognitively impaired, required limited to extensive assistance, of one person, with most ADDLE'S (activities of daily living) needs. The assessment further identified the resident as able to walk with a walker,and one staff assist, without pressure ulcers,and required pressure relieving devices for the chair and bed. The 12/9/10, physician's wound care orders instructed staff to, "Cleanse the right heel with normal saline, apply calcium alginate, and foam dressing, change every day, and as needed. Culture wounds on the right heel." ADDLE'S orders included, "Walk to dine established. Elevate the right lower extremity as much as possible." A 12/13/10, significant change MDS assessment recorded a stage two pressure ulcer and pressure relieving devices indicated for the chair and the bed. The 12/13/10, care plan recorded, "Pressure area to right heel." The care plan instructed staff to complete a weekly skin integrity report, consult the dietician for nutritional needs, inspect skin daily for signs and symptoms of infection, changes, progress, and intact dressing, keep area clean and dry, monitor labs as indicated, treat per physician order, initiate wound condition report, to document measurements, odor, color and progress." No indications of any labs obtained or the Registered Dietician saw the resident and made recommendations. A wound documentation sheet, dated 12/13/10, revealed a "Pressure ulcer to the resident's right heel, with the notation "in house acquired, stage 2, acquired on 12-9-10, with measurements of 1.4 cm (centimeter) length, 1.9 cm width, 0.1 cm depth." The 12/21/10 wound documentation sheets, recorded a "Pressure ulcer, on the right heel, stage 2, in house acquired, with measurements of 1.4 length, 1.7 width, 0.2 depth. Treatment recorded as, silver calcium alginate, foam dressing, change daily." The 12/23/10, physician's wound care orders instructed, "Change wet to dry dressing to, cleanse daily with normal saline, apply [MEDICATION NAME] and foam dressing, change daily until healed." The 1/3/11 wound documentation sheets, recorded a "Pressure wound to the right heel, stage 3, with measurements, length of 1.6 cm, width of 1.8 cm, no depth recorded, comments reflected, "covered with green slough" push score of 10, treatment of [REDACTED]. On 1/4/11, physician's wound care orders instructed, "Clean heel wound with normal saline, apply silver calcium alginate, change daily until healed." The wound assessment form dated 1/10/11, indicated a "Pressure wound to the right heel, stage 3, length of 1.6, width of 2.0, depth of 0.1, no descriptive comments, treatments, or push tool scores recorded." The wound assessment form, dated 1/17/11, indicated a "Pressure wound to the right heel, stage 3, with measurements, length of 2.0, width of 2.0, depth of 0.2." The form lacked further descriptive comments. On 1/24/11 at 8:30 am, observation revealed the resident in a wheelchair, with his/her right foot on the foot pedal, however, the resident's right heel rested directly on the floor. Continued observations at 9:15 am, 9:45 am, 10:15 am, 10:50 am, 11:20 am, 11:45 am, and 12:15 am, revealed the resident's right heel remained directly on the floor, without any pressure relieving devices. On 1/24/11, at 2:15 pm, observation of the resident's heel pressure ulcer revealed a wound of approximately 3 centimeters circumference, with an approximate depth of 0.5 centimeters, which exhibited bright, pink, moist, granulation tissue, in the wound bed, and a moderate amount of brown colored drainage observed on the dressing. The wound also contained a heavy, thick, yellow/white macerated callous formation, encircling the wound. Licensed nursing staff K, at that time, verified the wound as stage 3 and further stated, "I do the wound care. I do the assessments weekly, with measurements and then it is charted on the wound flow sheets and the sheet that tracks them. We have a consultant that comes in once a month. He/She makes recommendations and then we notify the doctor and he/she makes the final decision. This wound looks much better every week. It was bigger, and now it is pink in the center. I do treatments every day. If I can't get to them, then the nurses can do them, but I try to do as many as I can." On 1/25/11, at 6:59 am, licensed staff X stated, "I don't usually do wound care, but any of the nurses could do it if they needed to. He/She doesn't wear a boot of any kind. He/She has the sore on the right foot. I know we have had two or three different things used on it. I don't remember without looking what they were. We don't have to turn him/her or prop him/her up or anything like that. I am not sure what caused his/her sore foot. I don't know how to answer about off-loading, he/she doesn't have anything special in his/her room." On, 1/25/11 at 10:05 am, observation revealed the certified nurse aide N, offered a toileting opportunity then positioned the resident into a recliner. The staff failed to provide off-loading or positioning aides for the resident's heels with the resident's heels resting directly against the bottom edge of the footrest. On 1/25/11, at 10:30 am, licensed staff K stated, "I don't know. It originated in the facility." The staff member reported being unaware of what caused the original breakdown of the resident's heel. On 1/25/11, at 11:00 am, licensed staff Y stated, "I think that was about the time he/she went to the hospital. He/She has [MEDICAL CONDITION], and had a lot of [MEDICAL CONDITION], and went to the hospital for awhile. I think it happened at that same time. He/She used to wear those farm type boots, and with the swelling in his/her legs, the boots rubbed a hole in the heel. He/She has had some old injuries to that leg too, so I am not sure, but I think it developed because of the [MEDICAL CONDITION] and the heart failure." On 1/25/11, at 1:00 pm, observation revealed CNA staff N returned the resident to the recliner, following lunch, and failed to provide off-loading devices to the resident's chair, which allowed both heels directly contacted the bottom edge of the recliner footrest. On 1/25/11, at 1:30 pm, 2:00 pm, 2:30 pm, 2:40 pm, 3:15 pm, and at 3:45 pm, resident observations revealed the resident remained in the recliner, with the footrest elevated, and the resident's heels in direct contact with the bottom edge of the recliner's footrest. On 1/25/11 at 1:45 pm, licensed staff R stated, "I don't know how it originated. I know he/she had a wound and the nurses treated it. No, I don't know about off-loading devices for him/her. I would have to look at the treatment administration record." The facility failed to ensure assistive devices to prevent the development and worsening of this dependent resident's pressure ulcer to the heel. - The 4/6/10 care plan, developed for resident # 78, instructed staff to complete a weekly skin assessment, to assist the resident with turning and repositioning every 2 hours when in bed, to keep the resident's skin clean and dry, maintain a pressure relieving cushion to the wheel chair, and to notify the physician of any changes in the resident's skin condition. The 12/20/10 Braden Skin Risk Assessment, scored the resident at 14, with a score of 12 or less representing high risk for skin breakdown. The quarterly comprehensive assessment, dated 12/21/10, identified the resident impaired of short and long term memory, required extensive assistance of 1 staff for bed mobility, total dependency of 2 staff for transfers, and impaired range of motion to his/her upper and lower extremities, bilaterally. The assessment recorded the resident utilized a wheel chair for mobility, and identified the resident at risk for pressure ulcer development, with pressure relieving devices to the bed and chair. The assessment identified the resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A facility Wound Tracking report, dated 1/17/11, documented a stage II pressure wound to the resident's right lateral foot, acquired in-house on 1/17/11, measured 2 cm. (centimeter) by 2.5 cm. On 1/18/11, an additional physician's orders [REDACTED]. On 1/24/11 at 8:30 a.m., the resident sat in a wheel chair, without socks to his/her feet in the hallway, with a dressing intact to the lateral aspect of the right foot. Various observations of the resident from that time until 11:55 a.m., revealed the resident remained without change in position, until certified nursing staff H and N, assisted the resident onto the bed. The staff failed to reposition the resident for a period of 3 hours and 25 minutes. Observation on 1/24/11 at 3:15 p.m., revealed the resident rested in bed, with an ankle ring type cushion to the resident's left ankle area. However the ankle ring failed to elevate the resident's pressure ulcer site off of the bed. A pair of heel protectors (pressure relieving devices) remained on the bedside chair. Licensed nursing staff K, on 1/24/11 at 5:10 p.m., completed a dressing change to the resident's right lateral foot pressure ulcer site. The licensed nurse K, reported the area previously exhibited as a blister, and staff obtained an order to treat the area with skin prep. The staff member explained that the area then opened up, and, "A new treatment order, for TAO and dressing following cleansing was obtained." The area presented as approximately a 2 cm by 1.25 cm stage II area. The surrounding tissue exhibited redness and swelling, however, the wound lacked any drainage. Throughout the treatment the resident expressed pain, and licensed staff K repeatedly expressed apologies to the resident for movement of the foot that caused the resident pain during the treatment. At approximately 4:00 p.m. on 1/25/11, certified nursing staff AA and BB, transferred the resident from the bed into the wheel chair. The staff removed an ankle ring and a pair of heel protectors from the resident's feet, showed them to the surveyor, and stated, "These are what we put on him/her." Examination of the heel protectors revealed the pressure reduction devices lacked sufficient filler to provide any pressure reduction to the resident's dependent extremity. The facility policy, dated 2/1/09, for Wound Care, instructed staff, "...3. Pressure reduction surfaces should be provided on beds and chairs for at-risk residents, unless intolerance or lack of need is noted and documented. An additional policy, dated 4/21/10 for Turning and Positioning, identified, "Procedure: 1. Dependent residents should be turned every 2 hours or as identified in their care plan. The facility failed to provide timely repositioning and failed to provide pressure reduction aides to this dependent, at risk resident, who developed a pressure ulcer within the facility. During the treatment the resident experienced pain with movement of the foot. - The 8/5/10 and 1/11/11, comprehensive assessments, identified resident #3 with cognitive impairment, a pressure ulcer, used a pressure relieving device to the chair and bed, and received hospice care, and included [DIAGNOSES REDACTED]. The resident assessment protocol summary, dated 8/10/10, recorded, the resident, "Currently has a stage 4 pressure ulcer on (the) coccyx and has precautions in place; Nurses assess skin weekly and (certified nurse) aides check daily and report any sign or symptom to the nurse right away." An 8/11/10, care plan instructed staff, "Provide 2 staff assistance for transfers. Use pillows for positioning aides. Ensure adequate foot wear and clothing." A Braden Skin Assessment, dated 11/2/10, scored the resident at 13. A score of 12 or less identified high risk. Review of the Wound Tracking Report recorded the following wound measurements: On 12/27/10, 0.9 cm (centimeters) x 0.5 cm x .02 cm. On 1/3/11 1 cm x 1.2 cm x 0.1 cm. On 1/10/11 1.5 cm x 2.4 cm x 0.2 cm. On 1/17/11 1.2 cm x 2 cm x 0.2 cm. A 12/29/10 physician order [REDACTED]. On 1/24/11 at 9:50 a.m., CNA (certified nurse aides) CC and O, informed the resident of need to arise and eat breakfast. Observation, at that time, revealed the resident without off-loading or pressure relieving devices to the resident's feet, and revealed the residents foot when turned inward, rested directly onto the surface of the bed mattress. Upon dressing the resident, the staff placed socks to the feet, bilaterally, then a house slipper to the left foot. Interview at that time, with staff CC, reported the staff received instructions to not apply footwear to the foot due to the pressure ulcer. At 12:05 p.m. on 1/24/11, CNA CC propelled the resident, by wheel chair to the dining room. At that time the staff member indicated the resident remained in his/her chair all morning related to the use of catheter and ostomy and not required toileting. At 1:35 p.m. on 1/24/11, CNA CC and O assisted the resident to return to bed. The staff failed to reposition the resident for a period of 3 hours and 35 minutes. At 3:25 p.m. on 1/24/11, licensed nursing staff K, completed a dressing change for the resident, while the resident rested in bed. Again the resident presented without any off-loading/pressure relieving devices to the feet. Observation during the dressing change revealed a clean, stage II pressure ulcer to the medial aspect of the right foot. Interview at that time, with staff K, reported the area began as a result of ill-fitting shoes and the staff had received instructions to keep shoes off the right foot, until the area healed. Throughout the treatment, the resident verbalized pain, indicating, "You're hurting me, you're killing me." Immediately following the dressing change and certified nursing staff CC and O assisted the resident to transfer from the bed to the chair, the licensed nursing staff instructed a certified medication aide NN to administer pain medication for breakthrough pain. On 1/25/11 at 7:27 a.m., certified nursing staff Z and AA, assisted the resident with arising cares. The staff placed socks only to the resident's feet and one house slipper to the left foot. The facility policy, Wound and Skin Care Policy and Procedure, dated 2/1/09, instructed staff, "...3. Pressure reduction surfaces should be provided on beds and chairs for at-risk residents, unless intolerance or lack of need is noted and documented... 11. c. [MEDICATION NAME] may be given routinely before dressing changes and as needed after dressing changes..." The facility failed to promote healing and provide services including off-loading/pressure relieving devices to this dependent resident's foot, following development of a pressure ulcer, related to ill fitting shoes. Additionally, the facility failed to adequately provide breakthrough pain medication, in a timely manner, to prevent the resident from experiencing pain during treatment of [REDACTED]. - The facility admitted resident #53 on 11/25/09, with [DIAGNOSES REDACTED]. and dementia. The 11/15/10, physicians orders recorded, float heels while in bed, a barrier cream to be applied to peri area and buttocks every shift for skin protection, mechanical soft diet, with orange juice 120 cubic centimeters, by mouth three times daily. The 11/30/10, annual comprehensive minimum data set (MDS), indicated the resident at risk for pressure ulcers, without current ulcers, exhibited impaired cognition, without memory or recall ability, without decision making skills, required maximum assist of two staff for all activities of daily living (ADDLE'S). Further the assessment revealed the resident totally incontinent of bowel and bladder at all times, without swallowing or nutritional status problems, on a mechanically altered diet, without weight loss, and indicated the need for pressure reducing devices for the chair and the bed. The 11/30/10 dated Braden scale, revealed a score of 12, with 12 or less representing high risk. The 12/6/09, care plan recorded, " The resident required extensive assist with all ADDLE'S, and instructed staff to ensure call light was within reach and answered promptly, assist of one to two for transfers and utilize gait belt. Check skin during baths and cares for signs and symptoms of skin breakdown. Float heels when in bed. Use pillows to prevent skin from touching skin." On 1/24/11 at 8:45 am, observation revealed the resident in a geri chair with an egg crate pad, covered with a folded waterproof pad on top of it. At 9:40 am, certified nursing staff N and CC transferred the resident into the bed, from the geri chair. A skin check, at that time, revealed the resident's left femur joint area, (protruding) as bright red in color, circular with a pale center, approximately 5 inches across, over the top of the bony prominence. The staff positioned the resident onto his/her left side and supported the resident's back with a pillow. The staff failed to place any off-loading devices to the heels, knees, or place any protection for skin to skin contact between the legs. The mattress presented as a trough type mattress, without air or alternating pressure relief protection provided. On 1/24/11 at 9:50 am, certified nursing staff CC, indicated, "We don't do much with him/her. He/she eats in here (the resident's room), he/she can't stand the dining room, and we turn him/her and check him/her every two hours. I would report to the nurse if the resident's skin changed color or if he/she had any new open wounds." The staff member verified the eggcrate pad in the chair, and reported a lack of knowledge of any other type of cushion used in the geri chair. On 1/24/11 at 9:55 am certified nursing staff N, reported the resident, "Is 103, and doesn't ever leave his/her room. We turn (the resident) every two hours, and check (the incontinent) brief. The resident doesn't like to eat anywhere other than his/her room." The staff member indicated the use of an egg crate pad in the geri chair currently, and unaware of other types of pressure relieving devices. The staff member added, "I would report to the nurse any changes, like fever, or red spots, if the dressing came off or slipped down." On 1/24/11 at 10:05 am, observation of the resident's left femur area appeared less reddened, however, remained inflamed, but blanchable, and without open areas. On 1/24/11 at 11:48 am, an additional skin check revealed the resident's femur area with pink blanchable skin. At that time, staff N and CC transferred the resident into the geri chair with the egg crate pad to the seat. Random observations at 12:30 pm, 12:45 pm, 1:00 pm, and 1:25 pm, revealed the resident remained in the same position. At 1:52 pm, certified nursing staff CC and N, repositioned the resident into bed, onto his/her right side, with a body pillow between the legs, and a pillow behind the back. This position elevated the legs, and eliminated pressure to the left heel, and the posterior right heel, however, allowed pressure to the right outer aspect of the right heel. The staff failed to provide heel protectors or off-loading devices, at that time. On 1/24/11 at 2:09 pm, licensed nursing staff K, stated, "I do wound care. I try to do my rounds once a week, with wound assessments and tracking forms done weekly. Then we have a nurse consultant that comes in monthly. She makes recommendations and we ask the doctor and try to get him to evaluate her recommendations and then we go with what he wants. I measure and document wound assessments every week. The aides try to float the heels and the resident doesn't have any heel issues. We float with pillows, and turning. We don't use other heel things." Observations on 1/24/11 at 2:45 pm, 3:15 pm, 3:30 pm, 3:45 pm, 4:00 pm, and 4:15 pm, revealed the resident's position unchanged. At 4:35 pm, observation revealed the resident positioned in the geri chair, with his/her feet propped onto a chair opposite the geri chair, with a pillow under the legs, allowing the heels to float freely. A skin check revealed the sacrum pink and blanchable. The staff failed to provide a pressure relieving device to the chair, with a dirty, worn egg crate pad as the only attempt at off-loading. On 1/25/11, at 6:55 am, observation revealed the resident in the bed, with his/her heels in direct contact with the mattress, and the resident flat on his/her back. On 1/25/11 at 7:50 am, certified nursing staff AA dressed the resident, then certified nursing staff Z assisted in transferring the resident into the geri chair, without the egg crate pad present. Random observations at 8:30 am, 8:45 am, 9:00 am, 9:15 am, and 9:25 am, revealed the resident's position unchanged. At 9:45 am, certified nursing staff AA and Z transferred the resident into bed and positioned the resident onto his/her back. A skin check, at that time revealed a bright red, blanchable, approximate 3 inch circular area over the bony prominence of the sacrum. At 10:10 am on 1/25/11, observation revealed the above noted sacral area less reddened and remained blanchable. On 1/25/11 at 11:50 am, observation revealed the resident in the geri chair with a black cushion in the seat. The resident remained in the geri chair until 1:45 pm, when certified nursing staff AA and Z, repositioned the resident into bed, provided incontinence care, and during a skin check, revealed a very bright deep reddened area, approximately 4-5 inches in diameter to the sacral area. An additional skin check, completed 25 minutes later, at 2:15 pm, revealed the resident's skin less reddened, blanchable. When rechecked again, at 2:30 pm, the area appeared much less reddened. On 1/26/11 at 7:25 am, licensed nursing staff R, stated, "I took the eggcrate pad out of the room yesterday when I found out it was there. It is a fire hazard and we can't use it in here. (The resident) has that black cushion in his/her room, I found it for the staff to use. I don't really know. It is a cushion. It should work. I haven't seen her skin. I will have the staff show me today. I know she doesn't have any open wounds now." The facility failed to provide off-loading and pressure relieving devices, as well as sufficient turning and repositioning to prevent the development of pressure ulcers. - On 10/27/10, resident #109's Braden scale (tool used to assess for the development of pressure ulcers), staff rated the resident with a score of 12 (12 or less indicated the resident at high risk for the development of a pressure ulcer). The resident's 11/2/10 MDS (Minimum Data Set) identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of staff with all activities of daily living, and had an indwelling urinary catheter. Staff recorded on the resident's 11/8/10 CAAS (Care Area Assessment Summary) that staff provided total activities of daily living cares, including turning and repositioning no less than every 2 hours. The resident's 11/8/10 care plan directed staff to turn and reposition the resident every 2 hours while in bed. On 1/25/10, at 7:15 AM, observation revealed the resident in bed on the resident's back. At 9:30 AM and 9:50 AM, observation revealed the resident in the same position. On 1/25/10, at 9:49 AM, CNA (Certified Nurse Aide) I stated, "(The resident) is total care. I come on duty at 6:00 AM. I haven't done anything with (the resident) today yet. Maybe (the other CNA) has." On 1/25/11, at 10:02 AM, CNA H (the other CNA working on the resident's hall) stated, "I come on duty at 6 AM. I haven't done anything with (the resident) this morning yet. (The resident) is total care. We should check (the resident) every couple of hours. I haven't made it in here yet this morning. This is the first time I have been in here today. (The resident) only gets up for about 1 hour each day." On 1/25/11, at 10:05 AM, observation revealed CNAs (Certified Nurse Aides) F and H entered the resident's room to provide cares to the resident. At that time, the CNAs provided the resident a complete bed bath. The facility failed to reposition this dependent resident for at least 4 hours and 5 minutes. On 1/25/11, at 12:05 PM, licensed staff J stated staff should check the resident every 2 hours if the resident required assistance of staff with activities of daily living. The facility's turning and positioning policy, reviewed on 4/21/10, recorded, "Purpose: Provide comfort, prevent skin irritation and breakdown...Procedure: 1. Dependent residents should be turned every 2 hours or as identified in their care plan..." The facility failed to provide this dependent resident with repositioning change at least every 2 hours, as planned. - The 1/17/11 nursing admission assessment documented this alert, oriented resident with a 0.9 x 1.5 cm. (centimeter) open area on the left buttock. The 1/17/11 pressure ulcer assessment documented the resident at high risk. The 1/17/11 physician's orders [REDACTED]. Cleanse open area to coccyx with normal saline, apply TAO (triple antibiotic ointment), and Collagen cover with foam, change daily till clear." Review of further physician orders [REDACTED]. The resident admitted with a weight of 128.5 pounds. The 1/23/10 skin assessment documented, "Small open area on left buttock." The assessment failed to include the size or appearance of the pressure ulcer. Temporary care plan, dated 1/17/11, instructed the staff to provide a physical, occupational, and speech therapy evaluation for treatment, mechanical soft diet with thin liquids, health shakes BID, weekly weights, treatment of [REDACTED]. On 1/24/10 at 8:55 AM, observation revealed the resident sat in a recliner, in the room. The recliner chair lacked a pressure relieving device. At that time the resident stated she/he hoped to get stronger to return home, and feeling somewhat better, except for the sore on the buttock. At 10:00 AM, observation revealed the resident sitting in the recliner chair, watching TV. At 11:05 AM, the resident asked for assistance to the bathroom, and nurse aide HH assisted the resident to stand and ambulate to bathroom. At 12:15 PM, the resident stated she/he had to get off of their buttock, due to the pain from the sore. The surveyor asked licensed nursing staff U to assist the resident. Licensed nurse staff U assisted the resident to transfer from the chair to the side of the bed. At that time the resident stated, "It helps to sit on the air mattress for a little while." On 1/24/11 monitoring of the resident at 1:00 PM, 2:30 PM, 3:30 PM, 4:30 PM, and 5:00 PM, revealed the resident remained in the recliner chair that lacked a pressure relieving device. At 3:30 PM, the resident reported returning from physical therapy a short time earlier. The resident complained of pain, at this time, from the pressure ulcer, and needed to get off of her/his buttock. The resident stated, "I shouldn't lay down during the day, I need to stay up, so I can get stronger." On 1/24/11 at 5:00 PM, the resident requested assistance to the bathroom, and licensed nursing staff K, assisted the resident to rise from the recliner chair and ambulate to the bathroom. At this time licensed nurse staff K reported the resident needed stand-by assistance and continent of bowel and bladder. At 5:11 PM, observation revealed licensed nurse staff K removed a dressing from the residents left buttock, measured the stage 2 pressure ulcer, and applied a clean dressing according to the physician's orders [REDACTED]., Observation revealed a oval shaped, pressure ulcer, with a yellow wound bed. On 1/24/11 at 9:00 AM, nurse aide D reported the resident needed assistance to transfer, and stand-by assistance to ambulate. CNA staff D stated, "The resident usually sits up in the recliner during the day, she/he does not usually lay down in the day time." On 1/25/11 at 7:20 am, observation revealed the resident sat in the recliner, without a pressure relieving device. On 1/25/11 at 12:30 PM, licensed nursing staff K reported the therapy department screens the residents for pressure relieving devices in the wheelchairs and chairs in the rooms. On 1/25/11 at 12:40 PM, therapy staff II reported the therapist screen facility residents for need of pressure relieving devices in the wheelchairs, and occasionally for the recliners. The therapist might make a recommendation to move the cushion from the wheelchair to the recliner, if staff identified a need for the device in the recliner. Therapy staff II reported the therapy staff did not make a recommendation for this resident, to use a pressure relieving device in the recliner, and the wound nurse would be more aware of the resident's habits, and the need of a pressure relieving device in the recliner. Therapy staff II reported the therapist takes the resident to the therapy department 2 times a day, in the wheelchair, for therapy, and they did not observe the resident sat in the recliner for long periods of time. The 2/1/09 facility wound and skin care policy and protocol documented, "Pressure reduction surfaces should be provided on beds and chairs for

The facility reported a census of 77 residents, with 15 selected for review. The 15 residents sampled included 6 reviewed for nutritional status. Based on observation, interview, and record review, the facility failed to implement interventions in a timely manner for 4 dependent sampled residents (#93, #53, #3,and #32) and provide the necessary nutritional care and services to maintain acceptable weight parameters. Resident # 93 experienced harm with a significant weight loss of 15.5 pounds (10.5 %) in a 6 month period, and resident #3 experienced harm with a significant weight loss of 19.1% over a 6 month period (25.5#). Findings included: - The 12/21/10 annual MDS (minimum data set) assessment documented resident # 93 with poor memory skills, needed limited assistance from one care staff for ADDLE'S, assistance from one care staff for transfers, needed encouragement with eating, weighed 137 pounds, and without recent weight loss. The resident's [DIAGNOSES REDACTED]. The 12/27/10 care plan instructed the staff to provide a regular diet as ordered, health shake 60 cc (cubic centimeters) BID (two times a day), provide a dietary consult to determine preferred foods, dietician to evaluate quarterly, monitor weight weekly, and report weekly significant weight gains or losses to MD. The physicians orders, 7/7/10 documented, "HPS (house protein supplement), 120 cc by mouth TID (3 times daily) for weight loss. If loss continues after 1 week, change to 2 cal (supplement)120 cc. by mouth qd." The physician's orders [REDACTED]. On 10/6/10 the registered dietician's notes documented, "Oct weight 140.5 pounds, down 2.5 pounds x 1 month, 5.5 pounds in 3 months, 12.5 pounds in 6 months. No significant change but on going weight loss trend which is not desired. Regular diet continues, and continues with HPS 120 cc, TID. Remains on multiple vitamin with minerals...appetite fair per nursing. Recommend: 1) fortified foods TID with meals, 2) Increase HPS to 125 cc, 4 times a day to increase cal/protein." Review of the 12/2010 and the 1/2011, MAR (medication administration record) revealed the resident usually received 120 cc of HPS two times a day, and often refused the third supplement on the evening shift. The facility failed to follow the registered dietician's recommendations to increase the nutritional supplement for this resident with weight loss. Review of nurses notes from 9/23/10 to 1/23/10 revealed the resident received meals in room, but failed to evidence appetite, or percentage of meal intake. The resident's weight log documented the following dates and weights obtained: 7/6/10 - 147 # (pounds) 8/3/10 - 146 # 9/6/10 - 143 # 10/4/10- 140.5 # 11/1/10- 140.5 # 12/5/10- 138 # 1/3/11 - 134.5 # 1/17/11- 131.5 # The resident experienced a 10.5 % weight loss in 6 months. On 1/19/11 at 11:30 AM, administrative staff A reported 3 residents in the facility with unplanned weight loss, and reviewed by the QA (quality assurance) committee. The 3 residents failed to include resident # 93 for weight loss review. On 1/24/11 at 9:05 AM, observation revealed the resident in the room, and the breakfast tray remained on the over the bed table across the room. The resident consumed approximately 75 % of the meal, and the tray lacked evidence the resident received cereal (for fortified foods). On 1/24/11 at 11:59 AM nurse aide D placed the noon meal tray on a bed side table, and removed the lid from the plate. The resident wheeled his/her self to the bed side table, and proceeded to eat the meal. At 12:49 PM, observation revealed the resident consumed approximately 50 % of the noon meal, and staff removed the tray. On 1/24/10 at 4:25 PM, observation revealed nurse aide N placed the evening meal tray on the bed side table, across the room from the resident in the bed. Certified nursing staff N asked the resident if he/she wanted to eat supper, and the resident replied yes. Certified nursing staff N exited the room and reported they would return. Monitoring of the resident from 4:25 to 5:00 PM, revealed the resident continued to lay in the bed, with their eyes closed. At 5:00 PM, the surveyor notified licensed nursing staff K regarding the resident's meal tray placed across the room from the resident in the bed. Licensed nurse K entered the room and asked the resident if he/she wanted to get up and eat. The resident stated he/she needed assistance to get out of the bed. Licensed nurse K assisted the resident to the wheelchair, and had the meal tray returned to the kitchen, for replacement with warm food. The resident remained in the wheelchair for 20 minutes then another resident assisted the resident back to bed per the resident's request as staff had failed to deliver the tray promptly. At 5:28 PM, certified nursing staff N delivered the second meal tray. At that time social service staff EE entered the room with certified nursing staff N to assist the resident with the meal. At 6:05 PM, social service staff EE reported the resident consumed most of the meal. On 1/24/11 at 9:10 AM, nurse aide D reported the resident usually ate between 50 to 60 % of the meals, and ate all the meals in the room. On 1/24/11 at 9:18 AM nurse aide HH reported the facility no longer recorded meal intake for residents, but staff weighed every resident in the building every week. The staff reported a 3 # or more weight loss to the DON (director of nurses). On 1/24/11 at 11:15 AM, dietary staff P reported the fortified foods consisted of a special powder the cook added to the hot cereal in the mornings, which is the only meal staff added the special powder. If a resident refused the hot cereal the resident did not receive fortified foods. On 1/24/11 at 3:10 PM, registered dietary staff Q reported taking the position at the facility the last part of November 2010, and at that time noted the resident's weight was only down 2 pounds, from October, and down 5 pounds from October to December, 2010. Registered dietary staff Q reported upon reviewing the chart today the resident had a total weight loss of 13.5 pounds since October, 2011, and would make new recommendations today. On 1/24/11 at 3:19 PM, licensed nursing staff R reported the registered dietician gave new recommendations to the nursing department and the nurse notified the physician for new orders. Licensed nursing staff R stated nursing staff apparently overlooked the 10/6/10 recommendation from the previous dietitian failed to notify the physician. Licensed nursing staff R confirmed the nursing staff failed to notify the physician of the resident's gradual weight loss. On 1/25/11 at 8:15 AM, observation revealed the resident up in the wheelchair, in front of the breakfast tray, which contained biscuits and gravy, sausage, juice, coffee, water. The tray lacked a bowl of hot cereal, for fortified foods. At 9:00 AM, observation revealed the resident consumed approximately 75% of the meal. An interview on 1/25/11 at 10:00 am, ARNP (advanced registered nursing practitioner) S, reported making a recommendation in September, 2010, to start the resident on Ensure, , however the clinical record and observations lacked evidence the resident received any 2 cal as ordered by the physician, or Ensure, as ordered by the ARNP. The facility failed to implement and provide timely supplements and interventions that the physician and ARNP ordered and the Registered Dietician recommended over the span of 6 months, for this resident who had lost weight, because the interventions were not implemented in a timely manner, this resident continued to lose weight until the resident experienced a severe weight loss. - The nutritional assessment, dated 7/7/10, identified resident # 3 received hospice services, identified wounds, received HPS (high protein supplement) 120 ml (milliliters) tid (three times daily) with an equal amount of water, experienced weight loss and meal intake of fair to poor. A review of the resident's weights from July 2010 to present included: July, 2010, 133.5# August, 2010, 122.5# September, 2010, 109# October, 2010, 114# November, 2010, 110# December, 2010, 112# January, 2011, 108#, a total loss of 25.5# and a 19.1% loss in 6 months. A care plan, dated 8/11/10, instructed staff to, expect weight loss related to hospice, provide a diet of mechanical soft foods, to set-up each meal, and encourage independence with meal consumption and assist as needed; to monitor food intake with each meal, weigh weekly and report gains and losses to the physician, offer bedtime and bid (twice daily) snacks, and ice cream bid, provide HPS (High Protein Supplement) 120 ml (milliliter) TID, a scoop plate for all meals, and encourage and supervise. A hospice care plan, dated 9/23/10, identified the resident exhibited a poor appetite, and indicated to offer fruit loops when he/she, "Won't eat anything else." Dietary notes, recorded, "A significant weight loss for 3 months ( down 13.5# and 10.5%), 6 months significant loss (down 16.5# and 12.5%) and remained on hospice, weight decline unavoidable related to a disease process/terminal condition. Appetite fair, intake likely inadequate, nursing reported resident sleeping more with increased time spent in bed. Remained on a mechanical soft diet, ice cream and snacks bid (twice daily) with fruit loops at breakfast..." A review of diet orders, per the physician order [REDACTED]. The most recent comprehensive assessment, dated 1/11/11, identified the resident severely impaired of cognition and identified the resident received a mechanically altered diet, required limited assistance with meal intake, and received hospice services and included [DIAGNOSES REDACTED]. On 1/13/11 the dietician recommended and the facility faxed to the physician, a request for [MEDICATION NAME], (a high protein supplement) bid, and high caloric Carnation Instant Breakfast, 120 ml, 3 times daily, for poor appetite. A review of the record failed to identify a reply from the physician or follow-up by the facility to the physician. This recommendation, failed to be addressed by the facility for a period of 12 days, prior to this surveyor's inquiry of the recommendation. Observation, on 1/20/11 at approximately 10:20 a.m., identified staff propelled the resident, in the wheelchair, to the nursing station area, then rolled an overbed table in front of the resident, sat a dining tray on the table, uncovered the meal tray and drinks. The resident immediately began picking up fruit loop cereal from a bowl and began eating the dry cereal, picked up by individual pieces in his/her deformed arthritic hands. Certified nursing staff CC, removed the plate and warmed the plate for the resident. The resident continued eating, independently. The resident continued eating until approximately 10:50 a.m., consumed approximately 50%. On 1/20/11 at approximately 3:00 p.m., administrative staff A, provided a list of resident's currently monitored by the facility for weight loss. The facility failed to monitor this resident, #3 for weight loss, per the weight loss list/roster. Certified nursing staff MM, on 1/24/11 at 9:15 a.m., reported the staff no longer monitored the resident's meal intake. All resident's are weighed weekly and any resident having a 3# weight loss in a week, are reported to the charge nurse. On 1/24/11 at 12:55 p.m., certified nursing staff LL, reported the resident loved chocolate milk and would drink that when he/she would not take any thing else. Observation, during the noon meal, revealed the resident drank 2 glasses of chocolate milk, provided by the staff member and additionally consumed 100% of the meal provided. On 1/24/11 at 4:30 p.m. the resident sat by the nursing station, with an overbed table. A peanut butter and jelly sandwich with one bite taken, a glass of milk (untouched) and a small dish of chocolate pudding (with 2 bites taken) on the table. The staff did not assist, and the resident made little attempts to eat or drink. The resident attempted to take a bite of chocolate pudding and failed to get the plastic spoon to his/her mouth, and dropped the pudding on the front of his/her shirt. The facility staff failed to offer fruit loops or other substitutes to the resident. On 1/25/11 at 12:20 p.m., observation revealed the resident sat at the dining room table, with a plate of food and a glass of water in front of him/her. The resident stared blankly and made no movement towards picking up utensils or the glass. Approximately 15 minutes after being served certified nursing staff M sat down to assist the resident. Throughout the meal, the staff failed to offer or provide the resident with any fluid other than water and the resident received very few offers of bites of food, and no offer of sips of fluid. Interview on 1/25/11 at 4:00 p.m., with certified nursing staff BB, reviewed the snack list and reported the list failed to contain the resident's name. However, staff BB reported the staff offered the resident nightly snacks, as the resident enjoyed staying up late. Interview with certified medication aide MM, on 1/25/11 at 4:10 p.m., reported the resident received a HPS (supplement), "On my shift," however, noted the MAR (medication administration record) failed to identify the resident received the supplement. On 1/26/11 at approximately 3:00 p.m., interview with licensed nursing staff R and Y, and administrative staff A, indicated the facility lacked a thorough review system for any residents who experienced weight loss. The facility failed to identify the resident had an unplanned weight loss, failed to implement timely interventions, as recommended for reduction of weight loss, failed to provide adequate assistance, when needed at meals, and failed to offer and/or provide substitutes, of preference, when the resident did not eat, while the resident experienced a significant weight loss of 19.1% over this 6 month period (25.5#). - A 10/1/10 care plan for resident #32, instructed staff to provide the resident with a pureed diet, to monitor the resident for difficulty with swallowing, chewing and pocketing of food, provide a high protein supplement four times daily, to encourage intake and to monitor the resident's weight weekly and to offer food preferences. The 12/14/10, quarterly comprehensive assessment, identified the resident severely cognitively impaired and required extensive assistance of 1 staff for eating and included a [DIAGNOSES REDACTED]. The medical record indicated the resident weights as follows: July, 2010 = 155# August, 2010 = 154# September, 2010 = 151# October, 2010 = 148# November, 2010 = 147# December, 2010 = 140# January, 2011 = 134# The resident lost a total of 21 pounds in the past 6 months, which equaled severe weight loss. A 1/12/11, Registered Dietician Q, recommendation for the resident included offering the resident ice cream with lunch and dinner trays, provide HC CIB (high caloric Carnation Instant Breakfast), 120 ml (milliliter) three times daily, between meals, to check a pre-[MEDICATION NAME] (laboratory test). Further review of the record identified the facility faxed the physician the recommendation, however, lacked a response and furthermore, failed to follow-up with the physician, for a period of 12 days. On 1/20/11 at approximately 3:00 p.m., administrative staff A, provided a list of resident's currently monitored by the facility for weight loss. The facility failed to monitor this resident, #32 for weight loss, per the weight loss list/roster. On, 1/24/11 at 12:40 p.m., certified nursing staff (CNA) N, reported the resident received a pureed diet, however, unaware of any other special diet orders. The CNA N assisted the resident with meal intake, however, spent most of the meal time visiting with another person at the table, than encouraging the resident to eat. After a few attempts of feeding the resident, the staff member obtained a dish of ice cream and fed it to the resident. Other than the ice cream, CNA N failed to offer any other substitutes to the resident, or encourage the resident to consume more of the meal. The dining room wall posted the evening meal service, from 4:30 p.m. until 6:00 p.m. On 1/24/11 at 5:45 p.m., observation revealed the resident sat in his/her room in front of the television. At 5:54 p.m. further observation revealed the resident sat in a wheelchair in the dining room area but not pushed up to any dining room table for the meal service, which was scheduled to end at 6:00 p.m. Inquiry at that time, regarding the resident's meal intake, identified the resident not yet served the evening meal. Interview on 1/25/11 9:25 a.m., with certified nursing staff AA, reported the resident was dependent on staff for all food and fluid intake. Interview at 12:20 p.m. on 1/25/11, with certified medication aide G, indicated the resident usually only consumed 50% of the HPS (High Protein Supplement) provided on day shift, then only about 25% of the supplement on evening and bedtime pass. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the meal provided on 1/25/11 at 12:35 p.m., identified the resident received a tray of pureed food and 3 glasses of fluid, however, the meal tray failed to include any milk, dessert or ice cream, as planned. On 1/25/11 at 2:15 p.m., interview with licensed nursing staff Y, reported the recommendations from registered dietician Q on 1/12/10 required follow-up, since the Dr./ARNP(physician/advanced registered nurse practitioner) failed to address the fax, and the staff failed to follow-up in a timely manner. On 1/26/11 at approximately 3:00 p.m., interview with licensed nursing staff R and Y, and administrative staff A, indicated the facility lacked a thorough review system for any residents who experienced weight loss. This dependent resident experienced a severe weight loss, not identified by the staff for weight loss, lacked assistance at meal time, in a timely manner, and further the facility failed to implement weight loss interventions/recommendations in a timely manner, while the resident experienced a loss of 21 pounds in 6 months, which equaled a 13.5% weight loss. Findings included: - The facility admitted resident #53 on 11/25/09, from an acute care hospital, with [DIAGNOSES REDACTED]. The 12/6/09, dated care plan instructed staff, "Assist with meals. Dietary consult to determine preferred foods. Encourage intake at each meal. Monitor for difficulty with swallowing, chewing, pocketing, etc... Consult speech therapy as needed. The resident requires extensive assist with all activities of daily living (ADDLE'S). Monitor weight weekly as tolerated, report significant gains or losses to medical doctor. Offer snacks twice each day. Expected weight loss related to mechanical soft diet." The 11/30/10 dated, annual minimum data set (MDS) assessment, recorded the resident with impaired cognition, short and long term memory loss, impaired decision making skills,extensive assist of one staff for meals,no problem with swallowing, or nutritional status, on a mechanically altered diet, and without weight loss. The 12/14/10, dated care area assessment recorded, "The resident was on hospice for failure to thrive, but his/her family elected to stop hospice cares....He/She can and will at times do some of his/her own feeding but most times, staff feed him/her. ..." Review of the 11/15/10, physician's orders [REDACTED]. On 1/16/11, the physician's orders [REDACTED]." A review of the resident's weights revealed a gradual, steady weight loss monthly, from December 2009, through January 2011, including: 1/12/11 93.5# 12/14/10 95 11/11/10 94.5 10/14/10 94.5 9/15/10 97 8/31/10 94.5 The dietary progress note, dated 6/21/10, documented "Resident continued weight loss. June 96# down 2.3# x 1 month, down 5.5# x 3 months, down 22.5# x 6 months (18.9%) Remains on hospice, weight loss unavoidable related to disease process. General decline in condition per nurse report and 6/11/10 note. Order house supplement 60 cc by mouth three times each day. Mechanical soft diet continues with orange juice 120 cc three times each day. No labs. No relevant medication changes. Continue present nutritional treatment and supplements. Allow resident to consume foods and fluids of choice." The registered dietician assessment, dated 12/22/10, recorded, "Resident's height 64 inches, weight 96#, ideal body weight 120#. Assessment records that resident has own teeth, intact skin, bed/chair mobility, alert and confused, poor eating patterns, decrease in weight by 17 # since January 2010. Assessment further indicated no recent labs, below desired weight, incontinent, requires 1300-1500 calories for energy, 54 grams total for protein, 1500 cc for fluids. Recommended offering high pro juice supplement 120 cc by mouth three times per day, to continue. Mechanical soft diet to continue. Send high calorie oatmeal with breakfast. Poor by mouth intake unavoidable due to poor medical status, (cater to resident's preference as much as possible) Staff Q" Review of the supplement intake percentage record on the June, 2010, through January, 2011, medication administration records, indicated the resident consumed less than 50% of any supplements all the time in the daytime, less than 25% in the evenings. On 1/20/11, at 8:13 am, observation revealed the resident positioned in the geri chair, in the resident's room, food on a tray in front of the resident getting cold, no intake demonstrated. No staff present to assist the resident. On 1/24/11, at 8:45 am, resident observed sitting in a geriatric chair with a plate in front of him/her. The plate contained a pancake, egg, toast, 8 ounces of chocolate milk,8 ounces of water, and 8 ounces of orange juice. The food and liquids were untouched at this time. At 9:15 am, observation revealed the plate removed from the room, with approximately 60% of the pancake eaten, all other food items untouched, and approximately 50% of chocolate milk consumed. On 1/24/11, at 11:50 am, observation revealed,the lunch meal served at 11:55 am. Meal of mashed potatoes, ground salisbury steak, mixed vegetables, buttered bread, 8 ounces of water, 8 ounces of chocolate milk, 8 ounces of orange drink. Resident able to verbalize "I need a drink". Staff O provided the resident two drinks of chocolate milk. The staff handed the resident a spoon and informed the resident of the food placement. The resident stated, "I'm hungry." Staff O fed the resident one bite, replaced the spoon in the resident's right hand, set up drinking glasses on the resident's left side. Resident stated "I want a drink." Staff O gave resident one more drink then left the room. Frequent observations on 1/24/11, revealed the staff member failed to return to this resident to assist with lunch feeding. The resident failed to pick up the utensils or try to feed themselves. After one hour and forty minutes, the staff removed the resident's tray from the room. The staff failed to assist the resident or offer any alternative choices. The resident consumed one bite of mashed potatoes, and approximately one half of a 8 ounce glass of chocolate milk. On 1/24/11, at 4:55 p.m.,. observation revealed the staff served the resident a piece of cornbread, cheeseburger/macaroni casserole, cottage cheese, one 8 ounce glass of chocolate milk, one 8 ounce glass of peach flavored drink, one 8 ounce glass of water. The meal tray sat on an elevated bedside table, over the resident's lap, thus placing the plate and the food, at chest level, and hard to reach. Staff N set up the tray for the resident, attempted to encourage the resident to pick up a utensil and begin to feed themselves, however,the resident failed to attempt to eat. Staff U left the room at 4:57 pm. stating "I will be back, I have to finish passing these trays." On 1/24/11, at 5:20 pm, observation revealed staff KK, sat at the resident's bedside, and talked with him/her, trying to get the resident to eat. Staff KK stated, "He/She has had four bites of cottage cheese, three bites of this,(indicated the casserole), and four bites of ice cream. He/She isn't eating very much, but is drinking well." The resident had consumed almost half of the chocolate milk, approximately 1 ounce of the peach flavored drink, and less than one ounce of water. On 1/25/11 at 7:50 am, observation revealed the resident's breakfast delivered to the room, and set up assistance provided. Staff AA, prepared the food on the tray, offered the resident the biscuits and gravy and began to feed the resident. The resident stated, "I want a drink". Staff AA, assisted the resident to drink several swallows of the chocolate milk. However, staff provided no fortified cereal or juice. Staff AA, verified the juice was "regular juice, and un-fortified with anything". The meal provided included biscuits and gravy with meat, scrambled eggs, cranberry juice 8 ounce glass, water 8 ounce glass, chocolate milk 8 ounce glass. At 8:30 am, observation revealed the resident, consumed less than 25% of the meal. On 1/24/11, at 11:14 am staff P, stated, "We have a special powder we add to hot cereals in the morning. For those residents who don't eat hot cereal, we were going to add it to their drinks. I didn't do that." Staff verified that this resident was included on this list. However, the facility failed to provide this resident with the fortified foods/drinks as planned and as ordered by the physician. On 1/24/11, at 11:50 am, staff CC stated, "I just set him/her up, and then he/she can feed him/herself. Sometimes we have to help a little bit, but overall he/she can manage. He/She doesn't get any oatmeal or other fortified food that I know of except the orange juice. He/She doesn't drink the juice very well. I don't think he/she gets snacks since he/she doesn't eat good." On 1/24/11, at 11:55 am, staff N stated, "I would just set him/her up. He/She can feed him/herself. He/She usually does. I don't know of any fortified foods. I know he/she used to get Ensure, and now he/she gets orange juice all the time. He/She doesn't drink it much though. I don't think he/she gets snacks. He/She wouldn't eat it anyway." On 1/24/11, at 2:55 pm, staff DD stated, "I just do set up for him/her. He/She is able to feed him/herself. He/She doesn't have any fortified foods. He/She gets juice and chocolate milk with every meal. He/She doesn't get snacks. He/She won't eat them." On 1/24/11, at 3:00 pm, staff K stated, "The aides set him/her up to do meals. He/She is able to feed him/herself. I don't know about fortified foods for him/her. He/She doesn't eat much. Sometimes we help him/her, sometimes he/she does better than others. I don't believe he/she gets a snack. " On 1/24/11, at 4:38 pm, interview with staff D stated," He/She can feed him/herself. I work both shifts, and I am pretty sure nobody has to feed him/her. I don't know about any special foods or snacks for him/her." On 1/24/11 at 5:00 pm, staff U stated, "He/She feeds him/herself. He/She has some days that are better than others, but he/she does ok. He/She doesn't get any special foods. I work in the dining room some and I haven't gotten him/her anything extra. He/She won't drink much unless we help him/her. He/She doesn't take a snack anymore." On 1/24/11, at 455 pm, staff BB stated, "I don't usually work with him/her. I know we just set up him/her trays and he/she can feed him/herself. I don't know about fortified foods, I don't think he/she gets anything different. I don't know of any snacks, he/she wouldn't eat it." On 1/24/11, at 5:22 pm, interview with staff EAE revealed, "The dietician is new. He/She has only been here two weeks or a little over. He/She doesn't know every one just yet. I know the resident has lost weight, but I'm not really involved in that part of her care, and I don't know about the weights." On 1/25/11, at 7:50 am, staff AA stated, "I don't think he/she gets it (super cereal) today because he/she likes biscuits and gravy. He/She likes cream of wheat." Staff member verified that resident did not receive any fortified cereal or juice. No orange juice served to resident. The facility failed to follow the registered dietician's recommendations timely, failed to follow the physician's orders [REDACTED].