Every finding on record at Rolling Hills Health and Rehab

Based on observation and interviews, the facility failed to follow sanitary dietary standards related to food storage, unclean floors, and monitoring of dishwasher temps. Findings included:- During the initial tour on 06/22/2026 at 07:42 AM, observation revealed the following:The floors were sticky and dirty, thick dark dirt was around all standing work area legs. There was a cup of pudding with whipped topping in the single refrigerator that was undated and unlabeled. There were seven small bags of chicken in a steam table pan that were unlabeled and undated in the two-door refrigerator.The dishwasher was missing temperature recordings for 06/19/2026, 06/20/2026, 06/21/2026, and 06/22/2026.On 06/22/2026 at 08:00 AM, Dietary Staff BB stated the floors needed deep cleaning. He stated the kitchen floors were deep cleaned twice a year. Dietary Staff BB stated staff mopped the floor every night. He said the chicken was brought in by a family member, and the bags should have been dated before they were placed in the refrigerator. Dietary Staff BB stated he would dispose of the pudding that was undated and unlabeled. He stated the dishwashing temperatures were to be taken daily by the dishwasher and he would fill out the temperature log for 06/22/2206, and label the food brought in for 06/22/2026.The facility's Food Brought by Family or Visitors policy dated 10/2025 documented liberalized diets would be permitted as much as possible. Staff must be aware of and approved. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers would be labeled with the resident's name, the item and the use by date.The facility's Food Safety Requirements policy dated 10/2025 documented foods should be received and stored in a manner that complies with safe food handling practices. The community would procure food from approved sources or those considered satisfactory by federal, state, and local authorities.

Based on observation, record review, and interview, the facility failed to offer and provide or obtain informed declination for the influenza and pneumococcal vaccination for Resident (R) 1, R5, R49, and R62 or their representative. Findings included:- The Electronic Medical Record (EMR) for R1, R5, R49, and R62, lacked evidence of an informed declination for the influenza and pneumococcal vaccinations. The Immunizations tab for the above residents noted that the vaccinations had been offered but refused by the residents.Upon request, the facility was unable to provide documentation that the vaccination information, including risks verses benefits was provided to R1, R5, R49, and R62 and was unable to provide documentation of informed declination.On 06/24/2026 at 10:25, Licensed Nurse (LN) G, the facility Infection Preventionist, stated that each fall the influenza and pneumococcal vaccination was offered to residents. If the resident chose to get the vaccination, it was given. LN G stated the facility did not have residents or their representative sign a consent to decline the vaccination, but she did keep a log of who received or refused the vaccinations each year.On 06/24/2026 at 11:54 AM, Administrative Nurse D stated that a consent should be signed by the resident or their representative when the vaccinations were declined so there was a record of the declination. Administrative Nurse D stated she would make sure that consents were provided to residents moving forward when vaccinations were being offered.The facility's Vaccination of Residents, Including Influenza, Pneumococcal, RSV, and COVID-19, Reporting of dated September 2025 documented residents would be offered vaccinations per CDC and CMS guidelines. Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations. The resident or the resident's legal representative may refuse vaccinations for any reason. Residents have the right to refuse, be free of interference, coercion, discrimination, and reprisal for the community staff for refusing to take any vaccines. If vaccinations are refused, the refusal shall be documented in the resident's medical record.

Based on observation, record review, and interview, the facility failed to obtain an informed declination for the COVID-19 vaccination was provided for Resident (R)1, R5, R49, and R62 or their representative. Findings included:- Review of Electronic Medical Record (EMR) for R1 lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R1 noted that the vaccinations had been offered June 2026 but refused by the resident.R5's EMR lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R5 noted that the vaccinations had been offered June 2026 but refused by the resident.R49's EMR lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R49 noted that the vaccinations had been offered June 2026 but refused by the resident.R62's EMR lacked evidence of informed declination for the COVID-19 vaccination. The Immunizations tab for R62 noted that the vaccinations had been offered June 2026 but refused by the resident.On 06/24/2026 at 10:25 AM, Licensed Nurse (LN) G, the facility Infection Preventionist, stated that COVID vaccinations were offered to residents. If the resident chose to get the vaccination, it was given. LN G stated the facility did not have residents or their representative sign any consent or informed declination if they declined the vaccination, but she did keep a log of who received or refused the vaccinations each year.On 06/24/2026 at 11:54 AM, Administrative Nurse D stated that a consent/declination should be signed by the resident or their representative when the vaccinations were declined so there was a record of the declination. Administrative Nurse D stated she would make sure that consents were provided to residents moving forward when vaccinations were being offered.The facility's Vaccination of Residents, Including Influenza, Pneumococcal, RSV, and COVID-19, Reporting of dated September 2025 documented residents would be offered vaccinations per CDC and CMS guidelines. Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations. The resident or the resident's legal representative may refuse vaccinations for any reason. Residents have the right to refuse, be free of interference, coercion, discrimination, and reprisal for the community staff for refusing to take any vaccines. If vaccinations are refused, the refusal shall be documented in the resident's medical record.

Based on interviews and record review, the facility failed to provide the correct Center for Medicare and Medicaid (CMS) Form 10055, Advanced Beneficiary Notice (ABN), for two residents, Resident (R)34 and R55. Findings included:- The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to () receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but I can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services.The facility's Medicare ABN form staff provided to R34 (or their representative) was form CMS-R-131 for the last covered day of 02/10/2026.The facility's Medicare ABN form staff provided to R55 (or their representative) was form CMS-R-131 for the last covered day of 06/02/2026.On 06/23/2026 at 01:30 PM, Social Service X stated the form provided was what she had been told to use and did not realize that it was incorrect.On 06/24/2026 at 11:54 AM, Administrative Nurse D stated they would make sure to get the right form to use moving forward,The facility's Beneficiary Notices policy, dated July 2025, documented that a Medicare beneficiary had the right to have Medicare decide to determine if skilled services would be covered by Medicare. The Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNF ABN) CMS 10055 informed the residents of potential non-coverage and that the residents would understand they are accepting financial liability if it was determined that the services may not be covered by Medicare.

Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 62. Findings included:- R62's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses ofanxiety, major depressive disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), and need for assistance with personal care. R62's admission Minimum Data Set (MDS) dated 05/07/2026 documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R62 received antipsychotic medication and an antidepressant medication during the observation period. R62's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/07/2026 documented R62 triggered due to taking antipsychotic medications and antidepressants due to dementia, behaviors, and depression. The CAA documented R62 was recently re-admitted to the facility from a behavioral hospital. R62's Care Plan documented the following:10/20/2025-R62 had a mood problem displayed agitation, anxiety, or restlessness related to cognitive impairment and dementia, and childlike mentality. R62 had the potential and demonstrated behaviors of rejection care and constant ambulation. Staff were to assess and evaluate R62's behavior and cognition systematically and continually throughout the day and evening,05/14/2026-R62's Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) plan listed Risperdal (antipsychotic medication) increased mortality in elderly patients with dementia-related psychosis in elderly patients with dementia-related psychosis treated with antipsychotic drugs were at an increased risk of death. Risperidone was not approved for the treatment of patients with dementia-related psychosis. Encourage as much participation in activities that the resident can endure or comprehend. Give clear explanations of all care to be provided. R62's EMR under the Orders tab revealed the following physician order:Risperdal oral tablet 0.5 milligrams (mg) (risperidone). Give 1.5 mg by mouth two times a day for behaviors dated 05/04/2026. Review of R62's clinical record lacked physician documentation of risk versus benefit of administration of antipsychotic medication with a non-approved indication of use for R62 who had a diagnosis of dementia. The facility provided the physician documentation dated 06/24/26. On 06/24/2026 at 09:43 AM, Administrative Nurse E stated nurses or department heads would be the person to talk to the physician for the correct indication of medication use. Administrative Nurse E stated it was the department head's responsibility to ensure the residents had a risk versus benefit. On 06/24/2026 at 11:56 AM, Administrative Nurse D stated the nurse practitioner for the facility writes orders for psychotropic medications for the residents in the facility. Administrative Nurse D stated the nurse practitioner does understand what an approved indication for psychotropic drug use was. She stated departement heads go over what was an approved indication for psychotropic drugs with staff at each standup meeting. Administrative Nurse D stated it was the floor nurses and department heads responsibility to ensure the risk vs benefit for psychotropic medication was understood by the family's and residents and signed by the physician. The facility's Use of Psychotropic Drugs dated 05/25 documented residents would only receive psychotropic or other approved indications that influence brain activity when necessary to treat specific conditions for which that were indicated and effective and would not be used for discipline or convenience of the staff.

Based on observation, record review, and interview, the facility failed to provide Resident (R) 5, or their representative with a copy of the bed hold policy, written notification of transfer, and failed to notify the ombudsman when she was transferred to the hospital. The facility failed to ensure the Notice of Transfer to Hospital form included the required rights to appeal and the ombudsman information. Findings included:1. R5's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set (MDS) for an unplanned discharge to an acute hospital with a return anticipated on 04/30/2026.R5's Entry MDS dated 05/06/2026 recorded a reentry to the facility from an acute setting.R5's EMR lacked documentation the facility provided the bed hold, notice of transfer, and notification to the ombudsman for R5's transfer to the hospital on [DATE]. Upon request, the facility was unable to provide.R5's Entry MDS dated 05/06/26 recorded a reentry to the facility from an acute setting.2.R9's EMR recorded a Discharge MDS for an unplanned discharge on [DATE] to an acute hospital with a return anticipated.The facility provided a bed hold, notice of transfer and notice to the ombudsman of the transfer for R9's 03/06/2026 hospitalization. R9's Notice of Transfer to Hospital form dated 03/06/2026 documented when, where, and why he was transferred to the hospital. R9's responsible party was notified by phone of the transfer, and the form was not provided to the representative. The transfer form lacked information about the right to appeal and contact information. The transfer form lacked ombudsman information and contact information.On 06/23/2026 at 10:56 AM, Social Services X stated that she got verbal approval for the bed holds and notice of transfers. Social Services X stated that the transfer notice was sent with the resident to the hospital but was not sent to their representative. Social Services X stated she sent the ombudsman the transfers at the end of each month. Social Services X stated for R7 she did not complete a bed hold form, notice of transfer form, or notify the ombudsman of her transfer to the hospital since the resident's family requested that she be sent to the hospital and verbally agreed to the bed hold. Social Services X had not been aware that the notice of transfer form needed to include the right to appeal information or the ombudsman information.On 06/23/26 at 10:45 AM, Administrative Staff A stated that Social Services X completed the bed hold, notice of transfer, and notified the ombudsman of all discharges. She stated the bed hold should be completed on all transfers to the hospital and the notice would be updated to include all needed information. The facilities Bed Hold policy dated May 2026 documented upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office would provide information concerning our bed-hold policy. When emergency transfers are necessary, the facility will provide the resident and the resident representative with information concerning our bed-hold policy per state law as applicable. The bed-hold information will include any charges that the resident may incur as well as the time limit established by the State Medicaid Plan for which the facility will reserve the resident's bed space.A policy for notification of transfer and notification to the ombudsman was requested by the facility on 06/24/26 but was not received.

Based on observation, interview, and record review, the facility failed to implement effective person-centered interventions to prevent falls for two residents. Resident (R)38, who had three falls with staff, and R1, whose fall interventions were not implemented. Findings included:- R38's Electronic Health Record (EHR) revealed diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), reduced mobility, muscle weakness, and absence of the right upper limb.The Annual Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition. R38 required substantial staff assistance for oral hygiene, personal hygiene, mobility, transfers, and upper body dressing. R38 had upper body functional impairment on one side, lower body functional impairment, had no falls, and did not ambulate.The Quarterly MDS, dated 05/29/2026, documented R38 had intact cognition. R38 was dependent on staff for transfers, toileting, hygiene, and substantial assistance with mobility, upper-body dressing, and personal hygiene. R38 had upper body functional impairment on one side, lower body functional impairment, had one or more non-injury falls, and did not ambulate.The Fall Risk Assessment, dated 01/01/2026, documented R38 was a high risk for falls.The Fall Risk Assessment, dated 04/01/2026, documented R38 was a low risk for falls.R38's 06/02/2026 Care Plan had the following fall interventions:11/22/2023 Staff were to answer his call light promptly, update the care plan as needed, encourage exercise and mobility to maximize and maintain strength, balance, and coordination, and make sure appropriate shoes or non-slip socks are on when not in bed or during any transfers.08/07/2024- Staff was educated to clip the call light onto the bed instead of a bedside table for easier access.04/02/2025- Hoyer lift (total body mechanical lift) for transfer and therapy to evaluate.03/10/2026- Staff is not to place the slide board underneath him until fully ready to transfer.03/18/2026- Therapy referral and provide education to R38 on not to self-transfer.04/04/2026- Place a printed reminder to use the call light and wait for assistance.The Fall Investigation, dated 03/10/2026 at 09:00 PM, documented Certified Nurse Aide (CNA) O assisted R38 with a transfer from the wheelchair to his bed using a slide board. CNA O stated he briefly turned around to put on gloves, and during that time, R38 attempted to self-transfer to the bed and fell onto the floor. R38 was assisted up off the floor by two Certified Medication Aides (CMA) and one Licensed Nurse (LN). R38 did not sustain any injuries.The Fall Investigation, dated 03/19/2026 at 10:15 PM, documented CNA P was assisting R38 to bed. She had placed a slide board on the bed and his wheelchair. She had taken off the armrest of the wheelchair and was going to get assistance to help with the transfer when R38 attempted to self-transfer. R38 got stuck between the bed and the wheelchair, so CNA P had to lower him to the floor. R38 was assisted off the floor by three staff. CNA P was reminded never to take off the armrest from the wheelchair before there was another staff member in the room to help with the transfer. R38 sustained an abrasion (scrape) on his left elbow. The Fall Investigation, dated 04/04/2026 at 08:30 PM, documented CNA Q reported R38 attempted to transfer himself to the bed without assistance. She had to lower R38 to the floor to avoid injury. R38 was assisted off the floor by four staff. CNA Q was reminded not to wheel R38 so close to the edge of the bed without getting another staff member for assistance, as R38 had decreased safety awareness. R38 did not sustain any injury. On 06/23/2026 at 09:40 AM, CNA M and CNA N placed the Hoyer lift sling under R38 and attached the straps to the lift. CNA N used the lift remote to raise R38, CNA M positioned him over his wheelchair, and CNA N lowered him into his wheelchair. CNA M stated that R38 had not had any falls, and staff used the Hoyer lift when R38 felt weak. CNA M stated he was unsure of any fall interventions in place for R38. CNA N stated he was new to the facility and was unaware of what R38's fall prevention interventions were.On 06/24/2026 at 10:00 AM, LN H stated staff had been using the Hoyer lift for transfers as part of his fall prevention. R38 had anti-slip socks, and they had encouraged R38 to call for assistance before he tried to get up. There should always be two staff members in the room for transfers.On 06/24/2026 at 11:54 AM, Administrative Nurse D stated that the facility used a communication board for staff to look at to see if there were any changes to the residents' care plan interventions or conditions. The department heads were supposed to make sure that staff was aware of any changes, and staff could look at the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). Administrative Nurse D stated R38 used a Hoyer lift as a safety precaution due to his size and to help staff with his transfers.The facility's Falls and Fall Risk, Managing policy, dated June 2026, documented staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The interdisciplinary team would attempt to identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of the resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.- R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following 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) affecting left nondominant side, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS document R1 had an impairment of one side of his upper body. The MDS documented that R1 needed supervision or touching assistance for eating and substantial/maximal assistance with bathing and was dependent on staff for toileting. The MDS documented R1 had no falls since admission or prior admission during the observation period.The Fall Care Area assessment dated [DATE] documented R1 triggered for falls due to sustaining falls and high-risk medication, such as antidepressant (a class of medications used to treat mood disorders) due to depression; R1 had a history of cerebral infarction, generalized muscle weakness, and needed assistance with personal care.R1's Care Plan documented the following fall interventions:04/25/2025- R1 was to have a long brake extender with colored tape on the left side of his wheelchair.05/14/2025 -Maintenance was to tighten R1's brakes.05/17/2025-R1 to have a Dycem (non-slip mat used for stabilization and gripping to prevent slipping) in the wheelchair, above and below the cushion.05/27/2025-R1 was expected to have falls related to noncompliance and cognition deficit post CVA, reduced mobility, and a need for assistance with personal care.08/07/2025-R1 was to have anti-rollbacks placed on his wheelchair to prevent falls.01/14/2026-Education provided to R1 to not self-transfer, and to use the call light. On 06/22/2026 at 10:12 AM, staff transferred R1 from his wheelchair to his bed by staff. R1 did not have a Dycem under his wheelchair cushion, and R1 did not have a Dycem on top of his wheelchair cushion. R1 did not have a brake extender with colored tape on his wheelchair.On 06/23/2026 at 02:00 PM, staff laid R1 in his bed. R1 did not have a Dycem under his wheelchair cushion, and R1 did not have a Dycem on top of his wheelchair cushion. R1 did not have a brake extender with colored tape on his wheelchair.On 06/22/2026 at 10:10 AM, Certified Medication Aide (CMA) R stated she was informed of the interventions for each resident in a standup meeting, before her shift. She stated she does have access to the resident's care plan and would be able to see what interventions a resident had in place or needed. CMA R stated she did not know that R1 was to have Dycems placed in his chair or a brake extender. She stated she would get Dycem's placed and have maintenance help her with the brake extender.On 06/22/2026 at 10:40 AM, at License Nurse (LN)G stated she did not normally work R1's hall. She stated the Certified Nurses Aides (CNA) would know what interventions R1 should have in place. She stated the most important interventions for residents are discussed in a stand-up before each shift. LNG stated she was not aware of the Dycem that was to be in R1's chair; she stated the last time she worked R1's hall, he did have a brake extender in his room.On 06/22/2026 at 11:56 AM, Administrative Nurse D said nursing staff have a communication board, Kardex (a nursing tool that gives a brief overview of the care needs of each resident), care plans, and word of mouth in stand-up. As ways to communicate resident needs. She stated any intervention that was put in place was talked about, put on the communication board, and in the resident's care plan, which carried over to the Kardex. She stated it was the department head's responsibility to ensure R1 had his fall interventions in place. The facility's Falls and Fall Risk, Managing dated 06/2025, documented based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to collaborate care and services provided by the facility with the care and services provided by hospice for Resident (R)11. Findings included:- R11's Electronic Health Record (EMR) documented diagnoses of senile degeneration of the brain (the progressive deterioration of brain cells and their connections, leading to cognitive decline and behavioral changes in older adults), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), pain, and adult failure to thrive (includes not doing well, feeling poorly, wight loss, and poor self-care that could be seen in elderly individuals). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had severely impaired cognition. R11 was dependent upon staff for all activities of daily living (ADLs). The MDS documented R11 received hospice services.R11's 06/22/2026 Care Plan included the following interventions for R11:09/15/2025- administer medications for comfort before an activity, expect weight loss or gain due to terminal diagnosis, assist with supporting ADL functions, follow practitioner and Hospice orders for symptom control, keep R11 comfortable to the extent possible. The care plan lacked instruction on the services provided by hospice, including the frequency and type of support visits, supplies and medical equipment provided by hospice, and medications covered by hospice.Review of R11's clinical record revealed R11 was admitted to hospice care on 05/17/2025 with the diagnosis of senile degeneration of the brain.On 06/23/2026 at 10:30 AM, R11 laid in bed with her eyes closed.On 06/23/2026 at 01:00 PM, Administrative Nurse E verified that the visits, supplies, and medication provided by hospice were not documented in the resident's care plan. She stated she had just done an audit on all the care plans for residents on hospice and must have missed hers.The facility's Hospice Program policy, dated December 2025, documented the community may contract hospice services for residents who wish to participate in such programs, including services that will be provided and the coordination of services. The community may limit the hospice providers in terms of the coordination and communication of care within the community. The facility identifies a member of the IDT who is responsible for or working with the hospice representative. This person's responsibility provides collaboration and coordination of hospice care, communication with hospice representatives, and other health care providers participating in the hospice care. The community retained the ultimate responsibility for the care plan. Coordination of the care plan with the hospice provider, community staff, and residents' families. The care plan may be in two portions, each maintaining its own, but changes must be discussed. To promote continuity of care, collaborate with the hospice, nursing home and resident representative on the coordinated care plan noted in the medical record to include, but not limited to measurable goals and interventions based upon comprehensive and ongoing assessments. Interventions that address pertinent non-pharmacological and pharmacological interventions to manage pain and other symptoms of discomfort.

Based on observation, record review, and interview, the facility failed to implement adequate infection control practices related to sanitary storage of respiratory supplies and hand hygiene during wound care for Resident (R) 4. Findings included:- On 06/22/2026 at 07:55 AM, during the facility walk through, R20's nasal cannula laid on his bed, R20's nasal cannula (a lightweight, flexible device that delivers supplemental oxygen directly into your nose) was not stored in a sanitary container. R20's nebulizer mask (a device that changes liquid medication into a mist easily inhaled into the lungs) laid uncovered on her bedside table, R20's nebulizer was not stored in a sanitary container. R68's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask laid on the bottom of her bed, R68's feet laid on the CPAP mask. R68's CPAP mask was not stored in a sanitary container. On 06/23/2026 at 08:55 AM, Consultant GG and her assistant entered R4's room and put on a gown. Licensed Nurse (LN) G was already in the room and had prepared the top of a table with a barrier and the wound care supplies on top of the barrier. LN G performed hand hygiene with hand sanitizer from a dispenser on the wall in the room. Consultant GG applied clean gloves, and her assistant applied sanitizer to her hands and then applied clean gloves. R4 was positioned on his left side by LN G and the assistant. LN G removed her gloves, did hand hygiene, and applied clean gloves. Consultant GG was handed clean gauze that had wound cleaner on it by LN G. Consultant GG wiped R4's right leg wound with the moistened gauze pad and discarded into the trash. Consultant GG removed her dirty gloves and discarded them in the trash. Consultant GG applied clean gloves, and LN G handed her pieces of calcium alginate (a highly absorbent, non-adherent wound dressing) to wound bed, then applied the new dressing to the wound, she then removed her gloves and discarded them in the trash. Consultant GG's assistant and LN G repositioned R4 onto his left side and removed their gloves and performed hand hygiene before applying clean gloves. Consultant GG applied clean gloves (no hand hygiene performed prior). LN G handed Consultant GG a clean gauze pad that had wound cleanser gloves to begin clean wound to his left posterior leg and discarded the gauze in the trash. Without changing gloves, Consultant GG placed pieces of calcium alginate in the wound bed and then applied a new dressing. LN G handed Consultant GG another clean gauze pad and sprayed the gauze with wound cleanser. Consultant GG wiped the wound on R4's coccyx (area at the base of the spine) with the gauze pad and discarded the gauze in the trash and removed her gloves and discarded them on the trash. Consultant GG and her assistant sanitized their hands after removing their gown and gloves. Consultant GG and her assistant gathered their supplies and exited tR4's room. LN G removed her gloves and sanitized them before applying clean gloves. LN G continued wound care and applied the wound vac to the coccyx wound using appropriate gloving and hand hygiene as needed.On 06/23/2026 at 09:00 AM, Consultant GG stated yes, she should have changed her gloves and sanitized her hands after she had cleaned R4's leg wound and then applied clean gloves. Consultant GG stated she also should have taken off her gloves after she applied the new dressing to the wound and began the cleaning of his wound to his coccyx.On 06/24/2026 at 10:25 AM, LN G stated she expected any staff or consultant that was performing any cares would perform hand washing/hygiene before beginning a care, then after removing gloves, then apply clean gloves to prevent infection. LN G stated that was just standard practice. LN G stated oxygen tubing, CPAP masks and nebulizer masks should be stored in a clean storage bag when not in use.On 06/24/2026 at 12:54 PM, Administrative Nurse D stated that hand hygiene was expected to be done by anyone prior to any care being done as well as after removing dirty gloves or applying clean gloves as well after the task was completed. Administrative Nurse D stated that every Sunday night new oxygen tubing and bags for storage of the tubing were provided to residents. Residents should also have bags for the nebulizer and CPAP mask to be stored in when not in use.The facility's Administering Medications through a Small Volume Nebulizer policy dated November 2025 documented the disassembled parts should be rinsed with hot water after each use. Once daily wash the disassembled parts with warm, soapy water, then rinsethoroughly. For a deeper clean and disinfection, soak the parts in a solution of one-part white vinegar to three parts water for 30 minutes to an hour, followed by a final rinse, allow to air dry on a lint free towel. When the equipment was completely dry, store it in a plastic bag with the resident's name and the date on it.The facility's CPAP/BiPAP Support policy dated March 2026 lacked guidance on proper storage of the mask when not in use.The facility's Wound Care Guidelines policy dated June 2025 documented Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc., with alcohol before opening, as necessary. {Note: This may be performed at the treatment cart.)1. Close the door and pull the privacy curtain.2. Establish clean field on resident's overbed table (dry paper towel is adequate).3. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached.4. Wash and dry your hands thoroughly.5. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites.6. Apply disposable gloves. Loosen tape and remove dressing.7. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your handsthoroughly.8. Put on disposable gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids are likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely.9. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers.10. Pour liquid solutions directly on gauze sponges on their papers.11. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound.12. Wear disposable gloves when physically touching the wound or holding a moist surface over the wound.13. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water.14. Remove dry gauze. Apply treatments as indicated.15. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, date and apply to dressing.16. Be certain all clean items are on clean field.17. Remove the disposable cloth next to the resident and discard into the designated container.18. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard them into designated container. Wash and dry your hands thoroughly.

Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. Finding included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2025, Quarter 3 and 4, and FY 2026, Quarter 1 and 2, indicated the facility had excessively low weekend staff.Review of the facility staffing schedule revealed adequate weekend staffing for the quarters above.On 06/24/2026 at 09:45 AM, Administrative Staff B stated she compared the timesheets and the payroll forms and submitted them to the corporate office. The payroll specialist at the corporate office looked it over, and then it was submitted to CMS. Administrative Staff B further stated that she did not understand why it showed low weekend staff, as there are the same number of staff on the weekend as there were during the week.On 06/24/2026 at 01:30 PM, Administrative Staff A stated that they discovered administrative staff had accidentally been reported as hands-on staff during the week, and then on the weekend, they were not counted. She said it was fixed and would be submitted correctly.The facility's Payroll-Based Journal policy, dated October 2025, documented the community would submit payroll data in a uniform format to CMS, including staffing information for community, agency, and contract staff. The information was submitted electronically based upon specifications determined by CMS, which included the category of work for each person on direct care staff, resident census data, and information on direct care staff turnover and tenure, on the hours of care provided by each category of staff per resident per day, and hours worked.

The facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for one resident, Resident (R) 40, who received medications in error. Subsequently, R40 required rehospitalization in the intensive care unit (ICU). This also placed R40 at risk for adverse medication effects and other related complications. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of bradycardia (low heart rate, less than 60 beats per minute), cerebrovascular accident (CVA-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), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypotension (low blood pressure), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], documented R40 had moderately impaired cognition and required substantial assistance with all activities of daily living (ADL). R40 received insulin (a hormone that lowers the level of glucose in the blood), antidepressant (a medication used to treat depression), anticoagulant (a class of medications used to prevent the blood from clotting), and a diuretic (a medication used to promote the formation and excretion of urine) medication daily. R40's Medicare 5-Day MDS, dated [DATE], documented R40 had severely impaired cognition and was dependent upon staff for toileting, bathing, lower body dressing, and transfers. R40 required substantial assistance for eating, upper body dressing, and mobility. R40 received antidepressant and anticoagulation medication daily. R40's Care Plan, dated 10/21/24 and initiated on 01/26/22, documented R40 had a history of chronic kidney disease and directed staff to monitor and report changes in mental status, and any weight gain of over two pounds per day. The update, dated 11/19/23, documented R40 had a history of CVA and hypertension, and directed staff to administer hydrochlorothiazide (HCTZ- a diuretic) and lisinopril (a medication used to lower blood pressure) as ordered and monitor for weight changes; notify the physician of any abnormal readings. The update, dated 02/13/24, documented R40 was on HCTZ for diuretic therapy and directed staff to administer medication as ordered, and monitor for any adverse consequences like hypotension and fatigue. Staff were to report pertinent lab results to the physician. R40's Hospital Discharge Summary, dated 10/08/24, documented that R40 admitted to the hospital on 09/28/24 for bradycardia, acute kidney injury, and to rule out a CVA. The discharge summary directed staff to discontinue R40's HCTZ, 25 milligrams (mg), and lisinopril, 20 mg, per the physician's request. R40's Medication Administration Record, (MAR) dated 10/09/24, documented R40 received both 25 mg HCTZ and 20 mg of lisinopril at the 06:00 AM medication time. R40's EMR lacked documentation that R40's HCTZ and lisinopril had been discontinued from the MAR as ordered on 10/08/24. The Nurse's Note, dated 10/09/24 at 03:29 PM, documented that R40 was not responding verbally to questions, had minimal eye contact, and was drooling. R40's blood pressure was 68/56 millimeters of mercury (mmHg)(normal blood pressure is 120/80 mmHg). His pulse was thready at 88 beats per minute and his oxygen saturation was 96%. His blood sugar was 215 milliliters (ml) per deciliter (dl). The facility notified the physician and was directed to send R40 to the hospital. The note documented R40 admitted to the hospital to rule out a CVA; and for low heart rate and blood pressure with a second-degree atrioventricular (AV) block (a malfunction in the heart's electrical system that causes a slow heart rate). R40's EMR documented R40 returned to the facility on [DATE]. On 11/18/24 at 08:15 AM, observation revealed R40 laid in bed with his eyes closed. On 11/18/24 at 09:36 AM, Consultant GG stated R40 discharged from the hospital on 10/08/24 and readmitted to the ICU on 10/09/24 with a low heart rate. Consultant GG stated she looked at the facility paperwork that was sent with the resident to see why he was back at the hospital and saw on the MAR that he had received the HCTZ and lisinopril which should have been discontinued upon readmit to the facility. Consultant GG contacted the facility and spoke with Administrative Nurse E who verified that the medications were mistakenly given. On 11/18/24 at 10:30 AM, Administrative Nurse D stated R40 readmitted to the hospital on 10/09/24 due to kidney issues. Administrative Nurse D stated R40 did not receive the HCTZ and lisinopril that were supposed to be discontinued upon readmission to the facility. Administrative Nurse D stated she looked at the MAR and spoke with Certified Medication Aide (CMA) R, who was working the morning of 10/09/24. Administrative Nurse D said CMA R told her the resident did not receive the medications. Administrative Nurse D verified she did not actually discontinue the HCTZ or lisinopril from R40's MAR until 10/11/24. Administrative Nurse D stated she did write up the nurse who completed R40's readmission on 10/08/24 for not discontinuing the medications as ordered. On 11/18/24 at 10:40 AM, Administrative Nurse E stated she told Consultant GG that R40 had mistakenly received the medication before she found out for sure if he had received the medications. Administrative Nurse E stated she had looked at the active medication sheet and saw the medications were still on there, so she assumed R40 had received them. On 11/18/24 at 04:09 PM, CMA R stated she worked the morning of 10/09/24 and she administered R40 his morning medications that were active on the MAR. CMA R verified she had measured R40's blood pressure that morning, which was 133/76 mmHg, verified it was within normal limits, and then administered both the HCTZ and lisinopril. CMA R stated those two medications were the only medications she administered to R40 that day because he went to the hospital later that day. On 11/19/24 at 09:08 AM, Licensed Nurse (LN) G stated the float nurse was responsible for all the readmissions from the hospital and should verify the orders when the hospital called to give an update on the resident who was coming back. LN G further stated that once the resident returned to the facility, the float nurse re-verified the medications on the discharge paperwork and either added or discontinued medications. The facility's Identifying and Managing Medication Errors and Adverse Consequences policy, dated 10/24, documented that staff and practitioners should try to prevent medication errors and adverse medication consequences and should strive to manage them appropriately when they occur. The staff shall report clinically significant medication consequences and medication errors with adverse clinical consequences to the resident's attending Physician immediately. In the event of a clinically significant adverse medication consequence, nursing staff shall implement and follow any related physician orders and shall monitor closely and document the resident's condition and response to any corrective intervention for at least the next 24 hours or as otherwise directed, Nursing staff would document appropriately detailed account of any incidents on an appropriate report form. The Medical Director, Director of Nursing, and Consultant Pharmacist shall review medication errors and adverse consequences as part of the facility's Quality Assurance process. The facility failed to prevent a significant medication error for R40 when staff failed to discontinue medications as ordered by the physician and then administered the medications in error. This deficient practice resulted in R40's rehospitalization and also placed R40 at risk for adverse medication effects and other related complications.

The facility had a census of 63 residents, with 19 residents included in the sample. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for one resident, Resident (R) 105, who did not receive medications that were ordered to treat high blood pressure. This placed R105 at risk for adverse complications due to high blood pressure. Findings included: - The Electronic Medical Record (EMR) for R105 documented a diagnosis of coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dependence on dialysis (procedure where impurities or wastes were removed from the blood). The Annual Minimum Data Set (MDS) dated [DATE], documented R105 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment, she had no depression and no behaviors. The Quarterly MDS dated [DATE], documented R105 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. R105 had no depression or behaviors. She required supervision for most activities of daily living (ADL) and required moderate assistance for bathing and applying footwear. The resident's Care Plan revealed an intervention dated 03/04/24, which documented R105 took Metoprolol (is a medication that lowers your blood pressure and heart rate) for hypertension and noted the Metoprolol had a Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) to avoid abrupt cessation of therapy as chest pain and, in some cases, myocardial infarction (heart attack) have occurred. The Physicians Orders dated 12/18/24 revealed an order for Amlodipine Besylate 5 milligram (mg) tablet, give one tablet, once a day, by mouth at 12:00 PM, with parameters to hold the medication of the systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 100 beats per minute or the heart rate was less than 60 beats per minute. The Physicians Orders dated 12/20/24 revealed an order to stop R105's Metoprolol 50 mg, one tablet, by mouth, two times a day. The orders noted a new order placed in EHR for Metoprolol 75mg, give one tablet, by mouth two times a day for hypertensive heart failure. These orders were placed in EHR by the resident's provider on 12/20/24 and remained pending confirmation in the EHR until the order was clarified on 12/30/24 by Licensed Nurse (LN) J. The Medication Administration Record, (MAR) dated 12/30/24, documented the facility failed to administer R105 any Metoprolol from 12/20/24 to 12/30/24. Further review of the MAR revealed R105 did not receive her Amlodipine 5 mg at 12:00 PM on 12/28/24, and 12/29/24 as ordered, due to not being available from the pharmacy and was not available at the facility. The Nurse Vital Signs Note on 12/20/24 at 08:59 AM acknowledged a blood pressure warning of 193/71 (the normal blood pressure range for adults is typically defined as a systolic pressure (the top number) of less than 120 millimeters of mercury (mmHg) and a diastolic pressure (the bottom number) of less than 80 mmHg) for the date of 12/19/24 at 08:06 PM. The Dialysis Communication Tool dated 12/22/24 documented a blood pressure of 214/96 mmHg (high) at dialysis. The Provider Note dated 12/24/24, was a follow up visit for the increased Metoprolol. It stated that R105's Metoprolol had been increased from 50 mg to 75 mg. The Dialysis communication Tool dated 12/24/24 documented a blood pressure of 213/94 mmHg (high) at dialysis. A note was written on the tool for staff to address the resident's elevated blood pressure and red swollen legs. The resident's EHR lacked follow up by the facility. The Dialysis communication Tool dated 12/27/24 documented a blood pressure of 189/87 mmHg (high) at dialysis. The Dialysis communication Tool dated 12/30/24 documented a blood pressure of 184/91 mmHg (high) at dialysis. The Nurse Note dated 12/30/24 at 04:50 PM, revealed the facility notified the resident's provider that R105 had not received ordered Metoprolol since 12/20/24 due to the provider put the order into the EHR and staff was not aware of the order. Staff clarified the order to start R105 back on Metoprolol 50 mg two times a day. During an observation on 12/30/24 at 11:25 AM, R105 sat in her room on her bed eating popcorn and talking to staff about the medications she had in her room. During an interview on 12/30/24 at 03:20 PM, Certified Medication Aide (CMA) G acknowledged the resident's Amlodipine 5 mg was due, but not given because it was not available from the pharmacy and not available at the facility. She reported she notified the nurse and requested for the pharmacy to have it delivered immediately. CMA G reported she had not given the resident's Metoprolol 75 mg because it was on the MAR as a pending confirmation and they could not click on it. She stated the nurse would update it. She did not tell the nurse that it was pending confirmation. CMA G confirmed neither medication was in the cart. During an interview on 12/30/24 at 03:25 PM, Licensed Nurse (LN) F reported she did not know R105 had a Metoprolol pending confirmation or that the Amlodipine was not available for staff to administer. During an interview on 12/30/24 at 03:35 PM, Pharmacy Staff I stated she was unaware of any order change with the resident's Metoprolol. During an interview on 12/30/24 at 03:49 PM, LN J reported the CMA did not tell her the resident's amlodipine was out and needed to be refilled. She was not aware that it had been out as she had not been there in a few days. LN J reported she did not usually confirm orders that the doctor wrote, the Float Nurse handled new orders. During an interview on 12/30/24 at 03:54 PM, Licensed Nurse (LN) F reported the resident's provider did write orders in the EHR. The physician wrote the orders on paper and the Float Nurse would confirm the orders and write in the EHR. When she was shown the order for Metoprolol and that it had Confirmation Pending, LN F reported that meant staff needed to call the pharmacy and stated it might be a problem with the resident's insurance. During an interview on 12/30/24 at 03:58 PM, Administrative Nurse B reported the provider would come in with a list of orders they placed in EHR. Administrative Nurse B reported she asked the float nurse to check on the pending order and noted the new order was to keep the resident's Metoprolol at 50 mg two times a day. The surveyor notified Administrative Nurse B R105 had not received any Metoprolol since 12/20/24 so she stated she would notify the provider and restart it at this time. She was not aware that the resident's Amlodipine was not given. Administrative Nurse B reported her expectation that the nurse would have called the pharmacy immediately to reorder the resident's medication. If any medication was not given for three doses, the provider should have been notified. During an interview on 12/30/24 at 04:24 PM LN K acknowledged she talked to the provider about the Metoprolol order, as she was not aware of it prior to today. The provider said to restart the resident's Metoprolol 50 mg two times a day. During an interview on 12/31/24 at 10:55 AM, Nurse Consultant L revealed that the New Order Report would not show any orders that were pending confirmation. The facility's Physician Medication Order policy dated 10/2024 lack any information related to confirming pending orders in EHR. The facility failed to prevent significant medication errors for R105, who did not receive medications as ordered. This placed R105 at risk for adverse complications due to high blood pressure.

The facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 6 when staff did not use the right type of slide board for R6, who had a previous staff-assisted fall using a slide board. The facility further failed to address the risk after a staff-assisted fall. The facility failed to ensure a safe environment free from accident hazards for R10, who had large openings in the side rails presenting a risk for entrapment. Additionally, the facility failed to ensure a safe environment for R47 who had medications stored on her bookshelf, and for R52 who did not wear a smoke apron as per her plan of care while smoking. These failures placed the affected residents at risk for preventable accidents and related injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of cerebrovascular accident (CVA-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), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting the left non-dominant side, muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), and obesity (excessive body fat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition and was dependent on staff for toileting, showers, lower body dressing, and transfers. R6 required substantial assistance from staff for mobility and upper body dressing. R6 had upper and lower functional impairment on one side, had one noninjury fall, and had not received therapy. The Fall Assessments, dated 10/02/24, 07/03/24, 04/03/24, and 01/02/24, documented R6 had a high risk for falls. R6's Care Plan, dated 08/29/24 and initiated on 10/22/15 documented R6 was at risk for falls related to a history of falls, hemiplegia to his left side, and generalized muscle weakness. The update, dated 11/22/23, directed staff to encourage exercise and mobility to maximize and maintain balance, strength, and coordination. Staff were to, answer his call light promptly, use a gait belt when assisting the resident with mobility, and make sure he wore appropriate shoes or nonslip socks when not in bed and during all transfers. The care plan directed staff to monitor for any changes in his mental, emotional, or physical condition. The update dated 05/29/24, directed staff to transfer R6 with two staff and to use the Beasy transfer board (a portable slide board transfer system that has a circular seat that rotates 360 degrees to easily turn to the exact angle, allowing the smallest caregiver ability to transfer someone up to 400 pounds (lbs) using a smooth lateral glide), gait belt, and have his right leg leading. The care plan documented that if the nurse determined R6 was too weak to transfer with the Beasy board, use a Hoyer (full mechanical body lift) and two staff for transfers. The Fall Investigation, dated 10/22/24, documented R6 was on the floor beside his bed, propped up with his right arm. Certified Nurse Aide (CNA) M reported that while in the room, she performed a two-person transfer, using a gait belt and slide board. R6 became weak, so the CNA lowered him to the floor. R6 stated he became weak, his legs went out, and staff slid him down to the floor. R6 did not sustain an injury, had on proper footwear, and denied any pain. The investigation documented the care plan was followed. The investigation documented a statement from CNA M was obtained, and the Director of Nursing (DON) educated the CNA that if R6 experienced weakness, staff were to use the Hoyer lift for transfers. On 11/19/24 at 01:10 PM, observation revealed CNA M and CNA O tried to find a gait belt that fit appropriately around R6's waist. CNA M stated she had used a gait belt around his waist earlier but put it in the laundry so now they had to find one to fit him. CNA M and CNA O both tried three different gait belts on R6 but they were all too short, so CNA O left and found one that was appropriate for R6's size. CNA M lowered R6's bed, placed the wheelchair flush with the side of the bed, and removed the right armrest from the wheelchair. CNA M took the flat, wooden slide board that lacked a circular seat that rotated and attempted to place it under R6's right buttocks (the round fleshy part that forms the lower rear area of a human trunk) but it did not slide under him easily. CNA M grabbed the gait belt to assist R6 in lifting his right buttock and it took CNA O to assist CNA M with lifting. The CNA was then able to quickly slide the wooden transfer board under R6's right side. Continued observation revealed the weight of the resident on the slide board caused it to lift off of the bed on one end, and CNA O stated that staff had to use two hands on it to hold it down so the resident could slide over. CNA O held down the slide board and CNA M assisted R6 to slide over onto the bed. R6's feet were placed on the bed, and he was provided his call light. On 11/19/24 at 01:30 PM, CNA O stated she was the restorative aide who worked all over the building. CNA O said if a resident required the use of a lift or slide board, therapy would train staff on how to do it. CNA O stated she was unaware of any falls related to the slide board for R6. On 11/19/24 at 01:35 PM, CNA M stated staff follow the pocket care plan that tells them how a resident was transferred. When asked if she was aware of any falls for R6, CNA M answered by asking Are you aware of any falls? She then stated she was unaware of any falls with R6 and the slide board. On 11/19/24 at 01:40 PM, Administrative Nurse D stated she would contact therapy to see if R6 needed to be evaluated to make sure the slide board was still appropriate for him. Administrative Nurse D stated R6 was a big man and that the description of the transfer with the slide board did not sound like the transfer was done correctly. On 11/19/24 at 02:00 PM, Licensed Nurse (LN) G stated if R6 was weak, staff were to use the Hoyer lift to transfer him. LN G said there was an occurrence when R6 was weak during a transfer and staff had to lower him to the ground. On 11/19/24 at 02:15 PM, Consultant HH stated R6 was last evaluated in February of 2024 for the use of the slide board and stated staff were trained on how to use it at that time. Consultant HH further stated that any new CNAs would be trained by the other CNAs on how to use the slide board with R6. On 11/19/24 at 4:40 PM, CNA M stated she was the CNA with R6 when he was lowered to the ground. CNA M stated she had a gait belt around him, and she and another CNA started to transfer him with the slide board but he said he was weak and would not make it, so she lowered him to the ground. CNA M explained that R6 did not stand well, his legs were weak and that he was too far past the wheelchair to be placed back in the chair, so she lowered him to the floor instead. CNA M further stated she couldn't get R6 to the bed or back to the wheelchair before she had to lower him to the floor. CNA M stated she had to watch computer training on transfers and had to demonstrate a transfer to the Director of Nursing, On 10/20/24 at 10:15 AM, CNA N stated when staff transferred R6, there had to be two CNAs and a gait belt because both staff must have their hands on the gait belt to help transfer R6 with the slide board. CNA N stated that R6 was slow-moving and that if he was ever weak, there was time to let him sit for a little bit before they tried to move him. CNA N stated that R6 liked to try to put the slide board under himself, but he did not do it correctly. On 11/20/24 at 01:00 PM, Administrative Nurse D stated she did not watch CNA M transfer R6 with the slide board but had CNA M tell her how R6 was transferred; she watched CNA M do transfers with other residents. Administrative Nurse D stated she did not get a statement from the second CNA nor could she remember who the second CNA was, therefore that second CNA was not provided with reeducation on transfers with slide boards. Administrative Nurse D could not explain what the second CNA was doing while CNA M was trying to transfer R6. The facility's Safe Lifting and Movement of Residents policy, dated 10/24, documented to protect the safety and well-being of staff and residents, and to promote quality, this facility used appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care would be trained in the use of manual (gait/transfer belt, lateral boards) and mechanical lifting devices. Staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. The facility's Falls and Fall Risk, Managing policy, dated 04/24, documented that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The interdisciplinary team would attempt to identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. The facility failed to ensure a safe environment free from accident hazards for R6 when staff did not use the right type of slide board. The facility further failed to address the risk after a staff-assisted fall. This placed R6 at risk for falls and fall-related injuries. - The Electronic Medical Record (EMR) for R10 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented that R10 had severely impaired cognition and had inattention and disorganized thinking daily. R10 was dependent on staff for toileting, mobility, and transfers. R10 had lower-body impairment on one side. And the MDS documented that R10 used side rails. R10's Side Rail Assessments, dated 09/09/24, 06/06/24, 03/09/24, and 12/09/23, documented no alternative to bed rails was attempted as she used the rails to pull or push for mobility; no alternatives were attempted, and failed; negative physical outcomes were discussed with R10's representative, and the care plan was updated. The assessments noted that R10's family demanded the side rails despite the risks. R10's Care Plan, dated 08/17/24 and initiated on 02/21/24, documented R10 had a hospital bed with quarter-rails up for safety during care and to assist with bed mobility. The plan directed staff to observe for injury or entrapment (being caught in or as in a trap) related to side rail use and reposition as needed to avoid injury. The update, dated 08/19/24, documented R10 used side rails to assist in entering and exiting the bed safely, moving up and down in bed, turning side to side, and pulling herself from a lying position to a sitting position. The care plan documented that side rail precautions were discussed and consent from the family had been obtained. The Physician's Order, dated 06/06/23, ordered a hospital bed with quarter-rails per Durable Power of Attorney (DPOA) preference. The facility's Risk versus Benefits dated 09/07/23, documented the form was for two side rails on R10's bed, and the form documented that if it were signed, the responsible party assumed full responsibility for all possible risks associated with not complying with the recommendations of the skilled professionals of the facility. The form further documented there were other risks from the decision to not comply with the mentioned treatment or recommendations, up to and including death: loss of dignity, pain, serious injury, loss of movement or function, abnormal movements, hospitalization , serious skin problems, falls, broken bones, and possible entrapment of head or body in the side rails. The form indicated that the DPOA signature on the risk versus the non-compliance was clearly explained to them and that they comprehended everything. The form lacked a signature from the resident or responsible party but documented the facility had spoken to the responsible party and the physician via phone. The form was signed by Administrative Nurse D and Administrative Nurse E. On 11/19/24 at 08:00 AM, observation revealed R10's bed with quarter-rails on both sides. Both rails had an opening approximately 18 inches by 15 inches. Continued observation revealed the bed rail was attached to the bed frame. On 11/19/24 at 09:15 AM, Administrative Nurse D stated she was aware the side rail opening was large and R10 was at risk for entrapment but she was unable to change the family's mind so they thought if they assessed and had it on the care plan, that it was ok. Administrative Nurse D stated that R10 originally had the halo transfer bars but the family wanted the quarter rails. The facility's Use of Physical Restraints, Including Bedrails policy, dated 08/24, documented restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should only be used to treat the resident's symptoms and never for discipline or staff convenience, or for the prevention of falls. Examples of devices that are/may be considered physical restraints include: using bedrails that keep the resident from voluntarily getting out of bed safely due to their physical or cognitive inability to lower the bed rail independently. Before placing a resident in restraints, there should be a pre-restraint assessment and review to determine the need for restraints, The assessment should be used to determine if there are fewer restricted interventions. Restraints should only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, the order alone was not sufficient to use the restraint. The order shall include the specific reason for the restraint, how the restraint would be used to benefit the resident's medical symptoms, the type of restraint, and the period for the use of the restraint. Restrained residents should be reviewed at least quarterly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. The care plan should include the measures taken to systematically reduce or eliminate the need for restraint use, and interventions that address not only the immediate medical symptom but the underlying problems that may cause the symptoms. Bed rail use would be based on resident preference and medical symptoms. The facility failed to ensure R10 a safe environment free from entrapment risks related to unsafe openings in R10's quarter-rails used on her bed. This placed R10 at risk for entrapment and related complications. 32358 - R47's Electronic Medical Record (EMR) documented R47 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R47's Quarterly Minimum Data Assessment, (MDS) revised 10/31/24, documented R47 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. R47's Care Plan revised 10/31/24, instructed staff to cue and reorientate R47 as needed, discuss with the resident, and administer medications as ordered. On 11/18/24 at 09:48 AM, observation in R47's room revealed the resident had a 32-ounce (oz) bottle of hydrogen peroxide (a liquid chemical used to make hair very pale or to kill bacteria) a two oz bottle of Dermagel psoriasis shampoo (medicated shampoo used to help reduce the itching, scaling, swelling, and skin discoloration) and a two oz bottle of fungiCURE intensive spray (a medication used to treat fungal infection disease caused by a fungus, such as yeast or mold) on a shelf in an open wooden bookshelf, visible from her entrance door. Further observation revealed the bottle of hydrogen peroxide label read may cause fire or explosion, harmful if swallowed, causes severe skin burns and eye damage, and harmful if inhaled. The Dermagel psoriasis shampoo label read for external use only, avoid contact with eyes and keep out of reach of children. The fungiCURE intensive spray box directed it was for external use only and to keep out of reach of children. On 11/18/24 at 10:26 AM, Administrative Nurse D verified the above finding and stated the items should not be in R47's room they should be locked in the medication cart. Administrative Nurse D took the items to the medication cart and asked the medication aide to lock them up in the cart. Upon request, the facility failed to provide a policy regarding accidents. The facility failed to ensure a safe environment free from accident hazards for R47. This placed the resident at risk for injury and preventable accidents. 27168 - The Electronic Medical Record (EMR) for R52 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness and difficulty walking. The Annual Minimum Data Set (MDS), dated [DATE], documented R52 had intact cognition and required partial to moderate assistance from staff for transfers and toileting. The MDS documented the resident required a walker or wheelchair for mobility. The Smoking Evaluation, dated 11/18/24, documented R52 had no cognitive loss, could not light her cigarettes, and required staff supervision. R52's Care Plan, dated 09/19/24, documented R52 was at risk for potential injury related to smoking. The care plan documented the resident required a smoking apron while smoking and could only go outside during supervised smoking breaks. On 11/19/24 at 08:50 AM, observation revealed R52 sat in a wheelchair at the back smoking patio door. She wheeled over to the nurse's cart and received two cigarettes from the staff then wheeled herself outside and sat on the patio and smoked two cigarettes along with eight other residents. Observation revealed the resident did not wear a smoking apron. On 11/20/24 at 10:40 AM, Administrative Nurse E verified R52's Care Plan which documented the resident required a smoking apron and stated the resident would not wear it and would probably refuse. Administrative Nurse E verified the employee who entered the information in the care plan worked for the facility one day a week from home. Administrative Nurse E said R52's plan of care should not have stated the resident required a smoking apron. The facility's Smoking policy, dated October 2024, documented residents are to smoke in designated smoking areas and are not allowed to keep smoking material in their personal possession. The facility is not responsible for providing smoking materials for the residents, including but not limited to lighters. All smoking materials are to be given to facility staff. The resident would receive two cigarettes at a time and would return the lighter to the charge nurse when finished smoking. The policy documented the resident would wear a smoking apron while smoking and would put their cigarette butt in the butt can. The facility failed to provide R52 with a smoking apron per her plan of care. This placed the resident at risk for accidents and injuries.

The facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for one resident, Resident (R)40, whose hydrochlorothiazide (HCTZ-a diuretic) was discontinued. This placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of bradycardia (low heart rate, less than 60 beats per minute), cerebrovascular accident (CVA-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), chronic kidney disease ( longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypotension (low blood pressure), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], documented R40 had moderately impaired cognition and required substantial assistance with all activities of daily living (ADLs). R40 received insulin (a hormone that lowers the level of glucose in the blood), antidepressant (a medication used to treat depression), anticoagulation ( a class of medications used to prevent the blood from clotting), and a diuretic (a medication used to promote the formation and excretion of urine) daily. R40's Medicare 5-Day MDS, dated [DATE], documented R40 had severely impaired cognition and was dependent upon staff for toileting, bathing, lower body dressing, and transfers. R40 required substantial assistance for eating, upper body dressing, and mobility. R40 received antidepressant and anticoagulation medication daily. R40's Care Plan, dated 10/21/24 and initiated on 01/26/22, documented R40 had a history of chronic kidney disease and directed staff to monitor and report changes in mental status, and any weight gain of over two pounds per day. The update, dated 11/19/23, documented R40 had a history of CVA and hypertension, and directed staff to administer hydrochlorothiazide (HCTZ-a diuretic) and lisinopril (a medication used to lower blood pressure) as ordered and monitor for weight changes; notify the physician of any abnormal readings. The update, dated 02/13/24, documented R40 was on HCTZ for diuretic therapy and directed staff to administer medication as ordered, and monitor for any adverse consequences like hypotension and fatigue. Staff were to report pertinent lab results to the physician. R40's Hospital Discharge Summary, dated 10/08/24, documented that R40 was admitted to the hospital on 09/28/24 for bradycardia, acute kidney injury, and to rule out a CVA. The discharge summary directed staff to discontinue R40's HCTZ, 25 milligrams (mg), and lisinopril, 20 mg, per the physician's request. R40's Medication Administration Record, (MAR) dated 10/09/24, documented R40 received both 25 mg HCTZ and 20 mg of lisinopril at the 06:00 AM medication time. On 11/18/24 at 08:15 AM, observation revealed R40 lay in bed with his eyes closed. On 10/20/24 at 01:30 PM, Administrative Nurse D verified the interdisciplinary team worked on the care plans and verified the diuretic therapy care plan for R40's HCTZ should have been taken off the care plan when the medication was discontinued. The facility's Using the Care Plan policy, dated 10/2024, documented care plans should be used in developing the resident's daily care routines and would be available to staff personnel who have the responsibility for providing care or services to the resident. Completed care plans were available to the staff located per facility protocol and utilized to generate resident-specific information. Changes in the resident's condition would be reported to the MDS Assessment Coordinator for applicable review of the care plan, Information contained in the care plan and other documents used by the nursing staff shall be maintained confidentially by established facility policy. The facility failed to revise R40's Care Plan when R40's HCTZ medication was discontinued. This placed the resident at risk for inappropriate care due to uncommunicated care needs.

The facility had a census of 64 residents. The sample included 17 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication with the dialysis provider regarding dialysis treatments and monitoring for Resident (R)54. This placed the resident at risk for complications and health decline. Findings included: - R54's Electronic Health Record (EHR) documented R54 had a diagnosis of stage four chronic kidney disease (CKD- a critical phase when kidneys are severely damaged and can't filter waste from the blood properly). R54 Annual Minimum Data Set (MDS), dated [DATE], recorded R54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R54 required setup assistance with eating, upper and lower body dressing, putting on and taking off footwear, personal hygiene, sitting to lying, supervision with oral hygiene, toileting hygiene, showering, rolling left to right, lying to sitting on side of the bed, and sit to stand activity. R54 required supervision with oral hygiene, toileting hygiene, showering, transfers, and ambulation without a mobility device. The MDS recorded the resident received dialysis treatment. R54's Care Plan, dated 09/21/24, documented that R54 received dialysis three times a week on Monday, Wednesday, and Friday. R54's EHR revealed Dialysis Communication Form, from 09/04/24 to 11/18/24 lacked completed information from the dialysis center regarding the resident's treatment, monitoring, or orders. On 11/18/24 at 01:33 PM, observation revealed R54 sat quietly in a recliner in his room. On 11/20/24 at 12:19 PM, Administrative Nurse D stated the facility sent a communication sheet to the dialysis center but verified the facility did not receive the communication sheet information back from the dialysis center. Administrative Nurse D said if there was a change or staff needed to know anything, the dialysis center would call them. The facility's Dialysis Policy, revised 10/24, documented communication between the facility and the dialysis facility shall contain the following: Information if the medication was administered not according to orders or plan of care. New orders and results of labs. Current vital signs and weights. Advanced Directives and code status. Nutritional and fluid management, including residents' compliance with diet, during and /or after dialysis. Response to dialysis and any behaviors that may impede the treatment. Changes or declines in condition unrelated to dialysis and recommendations for monitoring. Concerns for vascular access site; and concerns and risks regarding transport to dialysis. The facility failed to ensure ongoing communication with the dialysis provider regarding R54's dialysis treatments. This placed the resident at risk for complications and health decline.

The facility had a census of 64 residents. The sample included 17 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to obtain written informed consent which included potential risks versus benefits from the resident and/or representative for the use of side rails for Resident (R)10. This placed her at risk for accident or injury due to uninformed choices regarding side rail use. Findings included: - The Electronic Medical Record (EMR) for R10 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had severely impaired cognition and had inattention and disorganized thinking daily. R10 was dependent on staff for toileting, mobility, and transfers. R10 had lower-body impairment on one side. The MDS documented that R10 used side rails. R10's Side Rail Assessments, dated 09/09/24, 06/06/24, 03/09/24, and 12/09/23, documented no alternative to bed rails was attempted as she used the rails to pull or push for mobility; no alternatives were attempted, and failed; negative physical outcomes were discussed with R10's representative, and the care plan was updated. The assessments noted that R10's family demanded the side rails despite the risks. R10's Care Plan, dated 08/17/24 and initiated on 02/21/24, documented that R10 had a hospital bed with quarter-rails up for safety during care and to assist with bed mobility. The plan directed staff to observe for injury or entrapment (being caught in or as in a trap) related to side rail use and reposition as needed to avoid injury. The update, dated 08/19/24, documented that R10 used side rails to assist in entering and exiting the bed safely, moving up and down in bed, turning side to side, and pulling herself from a lying position to a sitting position. The care plan documented that side rail precautions were discussed and consent from the family had been obtained. The Physician's Order, dated 06/06/23, ordered a hospital bed with quarter-rails per Durable Power of Attorney (DPOA) preference. The facility's Risk versus Benefits dated 09/07/23, documented the form was for two side rails on R10's bed, and the form documented that if it were signed, the responsible party assumed full responsibility for all possible risks associated with not complying with the recommendations of the skilled professionals of the facility. The form further documented there were other risks from the decision to not comply with the mentioned treatment or recommendations, up to and including death: loss of dignity, pain, serious injury, loss of movement or function, abnormal movements, hospitalization , serious skin problems, falls, broken bones, and possible entrapment of head or body in the side rails. The form indicated that the DPOA signature on the form indicated the non-compliance was clearly explained to them and that they comprehended everything. The form lacked a signature from the resident or responsible party but documented the facility spoke to the responsible party and the physician via phone. The form was signed by Administrative Nurse D and Administrative Nurse E. On 11/19/24 at 08:00 AM, observation revealed R10's bed with quarter-rails on both sides. Both rails had an opening approximately 18 inches by 15 inches. Continued observation revealed the bed rail was attached to the bed frame. On 11/19/24 at 09:15 AM, Administrative Nurse D stated the facility verbally explained the risks of the quarter-rails used on R10's bed to her family, and the family was very insistent that she have them. Administrative Nurse D stated that R10's family was very involved in her care and the bed rails were discussed in her care plan meetings. Administrative Nurse D confirmed the facility had not obtained a signed risk versus benefits from R10 or her responsible party. The facility's Use of Physical Restraints, Including Bedrails policy, dated 08/24, documented restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should only be used to treat the resident's symptoms and never for discipline or staff convenience, or for the prevention of falls. Examples of devices that are/may be considered physical restraints include: using bedrails that keep the resident from voluntarily getting out of bed safely due to their physical or cognitive inability to lower the bed rail independently. Before placing a resident in restraints, there should be a pre-restraint assessment and review to determine the need for restraints, The assessment should be used to determine if there are fewer restricted interventions. Restraints should only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, the order alone was not sufficient to use the restraint. The order shall include the specific reason for the restraint, how the restraint would be used to benefit the resident's medical symptoms, the type of restraint, and the period for the use of the restraint. Restrained residents should be reviewed at least quarterly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. The care plan should include the measures taken to systematically reduce or eliminate the need for restraint use, and interventions that address not only the immediate medical symptom but the underlying problems that may cause the symptoms. Bed rail use would be based on resident preference and medical symptoms. The facility failed to obtain written informed consent from R10 or her representative for using side rails. This placed her at risk for accident or injury due to uninformed choices associated with side rail use.

The facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Certified Nurse Aide (CNA) staff possessed adequate competency and skill for the use of a slide board for one resident, Resident (R) 6, who was lowered to the ground during a slide board transfer. This placed the resident at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of cerebrovascular accident (CVA-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), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting the left non-dominant side, muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), and obesity (excessive body fat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition and was dependent on staff for toileting, showers, lower body dressing, and transfers. R6 required substantial assistance from staff for mobility and upper body dressing. R6 had upper and lower functional impairment on one side, had one noninjury fall, and had not received therapy. The Fall Assessments, dated 10/02/24, 07/03/24, 04/03/24, and 01/02/24, documented R6 had a high risk for falls. R6's Care Plan, dated 08/29/24 and initiated on 10/22/15 documented R6 was at risk for falls related to a history of falls, hemiplegia to his left side, and generalized muscle weakness. The update, dated 11/22/23, directed staff to encourage exercise and mobility to maximize and maintain balance, strength, and coordination. Staff were to, answer his call light promptly, use a gait belt when assisting the resident with mobility, and make sure he wore appropriate shoes or nonslip socks when not in bed and during all transfers. The care plan directed staff to monitor for any changes in his mental, emotional, or physical condition. The update dated 05/29/24, directed staff to transfer R6 with two staff and to use the Beasy transfer board (a portable slide board transfer system that has a circular seat that rotates 360 degrees to easily turn the user to the exact angle, allowing the smallest caregiver ability to transfer someone up to 400 pounds (lbs.) using a smooth lateral glide), gait belt, and have his right leg leading. The care plan documented that if the nurse determined R6 was too weak to transfer with the Beasy board, use a Hoyer (full mechanical body lift) and two staff for transfers. The Fall Investigation, dated 10/22/24, documented R6 was on the floor beside his bed, propped up with his right arm. Certified Nurse Aide (CNA) M reported that while in the room, she performed a two-person transfer, using a gait belt and slide board. R6 became weak, so the CNA lowered him to the floor. R6 stated he became weak, his legs went out, and staff slid him down to the floor. R6 did not sustain an injury, had on proper footwear, and denied any pain. The investigation documented the care plan was followed. The investigation documented a statement from CNA M was obtained, and the Director of Nursing (DON) educated the CNA that if R6 experienced weakness, staff were to use the Hoyer lift for transfers. The Assisting with Transfers To/From a Bed Competency, dated 10/22/24, did not state CNA M was observed for a transfer with a slide board. It documented CNA M was observed for a Hoyer lift transfer with a different resident than the resident she had the fall with. The competencies provided did not include any training or observation for a transfer with the slide board. On 11/19/24 at 01:10 PM, observation revealed CNA M and CNA O tried to find a gait belt that fit appropriately around R6's waist. CNA M stated she had used a gait belt around his waist earlier but put it in the laundry so now they had to find one to fit him. CNA M and CNA O both tried three different gait belts on R6 but they were all too short, so CNA O left and found one that was appropriate for R6's size. CNA M lowered R6's bed, placed the wheelchair flush with the side of the bed, and removed the right armrest from the wheelchair. CNA M took the flat, wooden slide board that lacked a circular seat which rotated and attempted to place it under R6's right buttocks (the round fleshy part that forms the lower rear area of a human trunk) but it did not slide under him easily. CNA M grabbed the gait belt to assist R6 in lifting his right buttock and it took CNA O to assist CNA M with lifting. The CNA was then able to quickly slide the wooden transfer board under R6's right side. Continued observation revealed the weight of the resident on the slide board caused it to lift off of the bed on one end, and CNA O stated that staff had to use two hands on it to hold it down so the resident could slide over. CNA O held down the slide board and CNA M assisted R6 to slide over onto the bed. R6's feet were placed on the bed, and he was provided his call light. On 11/19/24 at 01:30 PM, CNA O stated she was the restorative aide who worked all over the building. CNS O said if a resident required the use of a lift or slide board, therapy would train staff on how to do it. On 11/19/24 at 01:40 PM, Administrative Nurse D stated that R6 was a big man and that the description of the transfer with the slide board did not sound like the transfer was done correctly. On 11/19/24 at 02:15 PM, Consultant HH stated R6 was last evaluated in February of 2024 for the use of the slide board and stated staff were trained on how to use it at that time. Consultant HH further stated that any new CNAs would be trained by the other CNAs on how to use the slide board with R6. On 11/19/24 at 4:40 PM, CNA M stated she was the CNA with R6 when he was lowered to the ground. CNA M stated she had a gait belt around him, and she and another CNA started to transfer him with the slide board but he said he was weak and would not make it, so she lowered him to the ground. CNA M explained that R6 did not stand well, his legs were weak and that he was too far past the wheelchair to be placed back in the chair, so she lowered him to the floor instead. CNA M further stated she couldn't get R6 to the bed or back to the wheelchair before she had to lower him to the floor. CNA M stated she had to watch computer training on transfers and had to demonstrate a transfer to the Director of Nursing, On 11/20/24 at 01:00 PM, Administrative Nurse D stated she did not watch CNA M transfer R6 with the slide board but had CNA M tell her how R6 was transferred; she watched CNA M do transfers with other residents. Administrative Nurse D stated she did not get a statement from the second CNA nor could she remember who the second CNA was, therefore that second CNA was not provided with reeducation on transfers with slide boards. Administrative Nurse D could not explain what the second CNA was doing while CNA M was trying to transfer R6. The facility's Staff Competency policy, dated 06/24, documented all nurse aide personnel shall participate in regularly scheduled in-service training classes. Nursing staff would demonstrate competency in skills and techniques necessary to care for the resident's needs, as identified through resident assessments and resulting plans of care. The facility failed to ensure CNA staff possessed adequate competency and skill for the use of a slide board for R6, who was lowered to the ground during a staff-assisted slide board transfer. This placed the resident at risk for injury.

The facility had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 37's use of an antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality)and irregularities with R38's blood pressure and pulse monitoring. This placed the resident at risk for unnecessary medications and related side effects. Findings included: - R37's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness). R37's Annual Minimum Data Set (MDS), dated [DATE] recorded R37 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS recorded R37 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic [alters mood or thought] Drug Use Care Area Assessment (CAA), dated 11/11/24, recorded R37 had a history of decreased appetite, depression, anxiety, and dementia. R37 received Seroquel, (an antipsychotic) clonazepam (an antianxiety medication), Remeron (an antidepressant), and sertraline (an antidepressant). R37's Care Plan, dated 11/07/24 recorded R37 received antipsychotic medication for the diagnosis of dementia, personality disorder, and anxiety. Staff were to monitor for side effects and effectiveness. The plan documented the facility would consult the physician to consider dose reduction when clinically appropriate. The Physician's Order, initial order date 09/09/24, directed the staff to administer Seroquel 25 milligrams (mg), twice daily for a diagnosis of unspecified dementia, moderate with other behavioral disturbances. R37's EMR lacked a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the Seroquel use. The Consultant Pharmacist Monthly Medication Review (MMR) dated 12/28/23 R37 received Seroquel with a diagnosis of anxiety and that was an inappropriate diagnosis or indication. The recommendation indicated changed but lacked what the new diagnosis was. The CP MMRs dated 01/30/24, 02/22/24, 03/28/24, 04/24/24, and 05/30/24 documented Seroquel has been associated with metabolic changes including weight gain and dyslipidemia (abnormal cholesterol levels) and recommended the facility should evaluate the continued use of Seroquel. The CP MMR dated 06/20/24, 07/24/24, 08/27/24, 09/27/24, 10/18/24, and 11/13/24 did not make any recommendations related to the continued use of Seroquel. On 11/18/24 at 04:15 PM, observation revealed the resident sat on the side of her bed. Continued observation revealed Certified Medication Aide (CMA) R administered the resident's medications which included the Seroquel. On 11/20/24 at 08:20 AM, Administrative Nurse D verified that R37 received Seroquel with a diagnosis of dementia with behavioral disturbance which she thought was an appropriate indication for the medication. Administrative Nurse D stated the pharmacist completed monthly reviews and sent them to the facility with concerns and recommendations. Administrative Nurse D said that a few months ago, R37's Seroquel had a diagnosis of anxiety. Administrative Nurse D said that was identified and the diagnosis was changed to dementia with behavioral disturbances. The facility's Pharmacist Services Overview policy, dated October 2024, recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. The facility would contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility, the Medical Director, and the Attending Physician. The facility failed to ensure the CP identified and reported the unapproved indication for the continued use of R37's antipsychotic medication, Seroquel. This placed R37 at risk for unnecessary psychotropic medication and related side effects. 32358 - R38's Electronic Medical Record (EMR) documented that R38 had a diagnosis of atherosclerosis (a buildup of fats, cholesterol, and other substances in and on the artery walls) of the coronary arteries (blood vessels of the heart). R38's Annual Minimum Data Set (MDS), dated [DATE], documented R38 had a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R38 had atherosclerosis. R38's Care Plan, revised 9/20/24, instructed staff to administer medications as the physician ordered. The plan documented that R38 received amiodarone (a medication that prevents and treats an irregular heartbeat) and instructed staff to hold the medication and call the physician if R38's heart rate was less than 60 beats per minute (BPM), or her blood pressure (BP) was less than 90 diastolic (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading). The Physician Order, dated 09/12/24 at 06:00 AM instructed staff to administer amiodarone HCl, 200 milligrams (mg) tablet, by mouth, one time a day and to notify the physician of R38's heart rate was less than 60 BPM or her DBP less than 90. R38's clinical record revealed R38's DBP was less than 90 and lacked documentation the physician was notified daily from 09/12/24 through 11/13/24. R38's clinical record revealed R38's pulse was less than 60 BPM and lacked documentation the physician was notified on the following dates: 10/06/24-58 BPM 10/25/24-58 BPM 10/30/24- 57 BPM 11/04/24-57 BPM The Consultant Pharmacist (CP) Regimen Review from 09/27/24 to 11/13/24 lacked documentation the pharmacist identified the above findings regarding R38's blood pressure and pulse monitoring being out of ordered parameters with no physician notification. On 11/18/24 at 04:25 PM, observation revealed R38 sat quietly in a wheelchair in the dining room and visited with other residents in a polite voice at her table. On 11/20/24 at 11:16 AM, Administrative Nurse D verified the CP had not alerted the facility regarding R38's irregularities for blood pressure and pulse monitoring outside of the physician-ordered parameters for the dates listed. The facility's Pharmacist Services Overview policy, dated October 2024, recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. The facility would contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility, the Medical Director, and the Attending Physician. The facility failed to ensure the CP identified and reported to the facility irregularities in R38's blood pressure and pulse monitoring. This placed the resident at risk for unnecessary medication side effects.

The facility had a census of 64 residents. The sample included 17 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician when Resident (R) 38's blood pressure and pulse were outside the physician-ordered parameters. This placed the residents at risk for ineffective medication regimens and unnecessary medication side effects. Findings included: - R38's Electronic Medical Record (EMR) documented that R38 had a diagnosis of atherosclerosis ( a buildup of fats, cholesterol, and other substances in and on the artery walls) of the coronary arteries (blood vessels of the heart). R38's Annual Minimum Data Set (MDS), dated [DATE], documented R38 had a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R38 had atherosclerosis. R38's Care Plan, revised 9/20/24, instructed staff to administer medications as the physician ordered. The plan documented that R38 received amiodarone (a medication that prevents and treats an irregular heartbeat) and instructed staff to hold the medication and call the physician if R38's heart rate was less than 60 beats per minute (BPM), or her blood pressure (BP) was less than 90 diastolic (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading). The Physician Order, dated 09/12/24 at 06:00 AM instructed staff to administer amiodarone HCl, 200 milligrams (mg) tablet, by mouth, one time a day and to notify the physician of R38's heart rate was less than 60 BPM or her DBP less than 90. R38's clinical record revealed R38's DBP was less than 90 and lacked documentation the physician was notified daily from 09/12/24 through 11/13/24. R38's clinical record revealed R38's pulse was less than 60 BPM and lacked documentation the physician was notified on the following dates: 10/06/24-58 BPM 10/25/24-58 BPM 10/30/24- 57 BPM 11/04/24-57 BPM On 11/18/24 at 04:25 PM, observation revealed R38 sat quietly in a wheelchair in the dining room and visited with other residents in a polite voice at her table. On 11/20/24 at 12:19 PM, Administrative Nurse D verified R38's above findings and stated she put the order in wrong, but staff should have been following the physician's order to call for bp and pulses out of parameters. The facility's Guidelines for Notifying Physicians of Clinical Problems Policy, revised 10/24, documented the charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management. The facility failed to ensure R38's drug regimen was free from unnecessary drugs when staff failed to notify the physician when R38 ' s BP and pulses were out of physician-ordered parameters. This placed the residents at risk for ineffective medication regimens and unnecessary medication side effects.

The facility had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)37's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R37 at risk for unintended effects related to psychotropic (alters mood or thought) medications. Findings include: - R37's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness). R37's Annual Minimum Data Set (MDS), dated [DATE] recorded R37 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS recorded R37 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/11/24, recorded R37 had a history of decreased appetite, depression, anxiety, and dementia. R37 received Seroquel (an antipsychotic), clonazepam (an antianxiety medication), Remeron (an antidepressant), and sertraline (an antidepressant). R37's Care Plan, dated 11/07/24 recorded R37 received antipsychotic medication for the diagnosis of dementia, personality disorder, and anxiety. Staff were to monitor for side effects and effectiveness. The plan documented the facility would consult the physician to consider dose reduction when clinically appropriate. The Physician's Order, initial order date 09/09/24, directed the staff to administer Seroquel 25 milligrams (mg), twice daily for a diagnosis of unspecified dementia, moderate with other behavioral disturbances. R37's EMR lacked a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the Seroquel use. On 11/18/24 at 04:15M, PM observation revealed the resident sat on the side of her bed. Continued observation revealed Certified Medication Aide (CMA) R administered the resident's medications which included the Seroquel. On 11/19/24 at 08:20 AM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of dementia with behavioral disturbances which she thought was an appropriate indication for the medication. Administrative Nurse D verified the physician had been informed of the need for another diagnosis a few months ago when the diagnosis was anxiety, and it was changed at that time to dementia with behavioral disturbance. The facility's Psychotropic Drug Use policy dated April 2024, recorded that residents would receive antipsychotics and psychotropic medications when necessary to treat conditions for which they are indicated and effective and will not be used to discipline or convenience of the staff. Residents and their representatives have the right to refuse such treatment. The facility would review the diagnoses for which the medication classes are being utilized. If they are being utilized for other than their original approved indication, then apply the psychotropic monitoring. The physician's order would include diagnosis, condition, or symptoms for what is being ordered, and monitoring. The facility would complete an evaluation of the resident prior to starting a standing order of a psychotropic. This includes goals of therapy, reason for use (indication, diagnoses); and non-pharmacological interventions attempted, but the resident's quality of life is negatively impacted by the non-use of the medications. During the comprehensive, person-centered care planning process, the resident and/or their representative should be informed of the prescribed treatment. If the resident and/or their representative refuses the treatment, the IDT member (including the physician) should inform the resident about the risks for refusal and discuss appropriate alternatives, such as offering the medication at a different time, in another dosage form, or an alternative medication or non-pharmacological approach if available and document such in the clinical record. Identify and note non-pharmacological approaches as an alternative to or an adjunct to as-needed psychotropic use, and address them in the care plan. The facility would obtain psychotropic consent for new orders, and review and document the resident's target symptoms in the clinical record of anti-depressants, anti-anxiety, and anti-psychotic medications. The nursing anti-psychotic review would be completed at the following schedule: upon admission, if the antipsychotic medication is prescribed; on the addition of any new antipsychotic medication, and at least monthly. Gradual dose reduction would be conducted per CMS guidelines. The facility failed to ensure R37 did not receive antipsychotic medication without an appropriate indication or the required physician documentation for its use. This placed R37 at risk for unintended effects related to psychotropic medications.

The facility reported a census of 69 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to maintain comfortable and safe temperature levels of 71 degrees Fahrenheit (F) or greater for ten residents, Resident (R)2, R5, R6, R7, R8, R9, R10, R11, R12, R13 when a facility furnace quit working mid-morning on 01/12/24. The furnace supplied heat to one of four wings, covering six resident rooms, with ten residents affected. Following the breakdown, a repairman came to the facility that afternoon and determined the part needed to repair the furnace required ordering. The facility placed portable infrared space heaters in the resident rooms until 01/16/24 at 02:04 PM, at which time the Fire Marshall instructed the facility to remove the space heaters. One of the ten residents, R8, moved to another room on another wing, while the nine other residents affected chose to remain in their rooms. The facility failed to monitor and document temperatures of the resident rooms until 01/17/24, after the surveyor was on site, and failed to monitor the affected resident body temperatures until 01/18/24. The outdoor temperatures from 01/12/24 through 01/17/24 per weatherunderground.com ranged from negative two degrees F to 40 degrees F with maximum wind speeds ranging from 16 miles per hour (mph) to 30 mph, with a windchill advisory in effect, due to -30 degrees F windchill factor. On 01/17/23 at 04:30 PM, four of the six resident rooms affected had temperatures below 71 degrees F. This failure to ensure the resident areas maintained a temperature of at least 71 degrees F placed the residents who remained in their rooms in immediate jeopardy and at risk of hypothermia (abnormally low body temperature). Findings included: - The high and low temperatures as recorded on weatherunderground.com, revealed the following temperatures for the area: On 01/12/24, a high of 21 degrees F and low of 19 degrees F with maximum wind speeds of 30 miles per hour (mph). On 01/13/24, a high of nine degrees Fand low of negative two degrees F, with maximum wind speeds of 24 mph. On 01/14/24, a high of six degrees F and low of negative three degrees F with maximum wind speeds of 16 mph. On 01/15/24, a high of six degrees F and low of two degrees F, with maximum wind speeds of 23 mph. On 01/16/24, a high of 24 degrees F and low of negative two degrees F, with maximum wind speeds of 16 mph. On 01/17/24, a high of 40 degrees F and low of 14 degrees F, with maximum wind speeds of 28 mph. The National Weather Service (weather.gov) recorded an Arctic air weather pattern affected the area beginning on Friday 01/12/24 through 01/16/24 and noted the recorded windchills in the -20 degrees F to -30 degrees F range. On 01/18/24 at 01:56 PM, record review of the ten residents affected by the furnace breakdown (R2, R5, R6, R7, R8, R9, R10, R11, R12, and R13) revealed the progress notes lacked any information of the resident's condition during the heater failure between 01/12/24 through 01/18/24. On 01/17/24 at 12:31 PM observed R13 lying in bed and the temperature on the wall thermostat read at 64 degrees F. R13 had short sleeves on and was covered with a sheet and fleece blanket up to chest level. On 01/17/24 at 03:05 PM, R8 observed on another wing and stated the facility would let her stay in this room until the heater could be fixed in her room. R8 stated she moved to this room yesterday because the other was too cold as there was no heat. R8 stated they had put a heater in the other room, which made it feel okay. On 01/17/24 at 04:30 PM observation revealed Administrative Staff A checked the room temperatures with an infrared laser thermometer, temperatures of the affected rooms had a temperature of 68.5 degrees F, 67.0 degrees F, 69 degrees F, and 67 degrees F. All doors to the rooms were open at the time with the exception of the room that measured 67 degrees F. On 01/18/24 at 08:07 AM, observed R13's room door open and in her bed. R13 covered with a sheet and a blanket up to her waist. The room temperature was 67.2 degrees F. On 01/18/24 at 08:08 AM, R12's room door was open, and the room temperature at 66.7 degrees F. R12 was in bed and had on long sleeves. R13 was covered in a blanket from her waist down. On 01/18/24 at 08:10 AM, R10's room door was open, and the room temperature was 67.8 degrees F. R10 stated the room was chilly. On 01/18/24 at 08:14 AM, R9's room door closed, and the room temperature was 62 degrees F. R9 stated she liked her room cool, stated she was comfortable, however did get one extra blanket. R9 had the blankets pulled up to her neck. On 01/18/24 at 08:16 AM, observed R6 and R7's room door to be open and the room temperature was 65.6 degrees F. R6 was not in the room. R7 had a blanket over him and sat in the recliner. On 01/18/24 at 08:19 AM, R2 and R5's room door was open, the room temperature was 68.1 degrees F. R2 stated the room was cold. R2 stated she usually slept with one blanket but needed three blankets now. R5 was in bed. On 01/17/24 at 12:21 PM CMA S stated R8's room had been cold, and she moved. CMA S said there was a problem down at the end of the hall she was on and she had no heat. CMA S stated it was just the back part of the hall affected by the heat. CMA S said the residents down there liked their room cold and they had not complained. CMA S stated the facility used heaters over the weekend in the affected resident rooms. On 01/17/24 at 12:32 PM, R13 stated the facility had placed a heater in her room, but the facility was told they could not use the heater, and staff removed it. R13 stated she did not know how cold her room got, she stayed in bed and could not see the thermostat, however, she did get cold. R13 stated she never used a blanket before but had done so in the past three days and usually had her fan on to help her breathe but had to turn the fan on/off every five minutes or so because of the lower temperature. On 01/17/24 at 02:44 PM, R9 stated she had no concerns with the room temperature and the facility had put a heater in the room about a week ago when the heat went out. R9 stated she preferred the room to be cooler but her roommate, R8, did not like the room cooler. R9 stated R8 moved out because of the cold, but she was always cold and R9 stated she liked to sleep with a fan. The wall thermometer read 67 degrees F. R9 had on short sleeves and covered with a comforter from the waist down. On 01/18/24 at 10:17 AM, Maintenance Staff U (one of two maintenance staff) stated the part to fix the furnace did not arrive yesterday as planned and the repair was to be completed sometime today, but unknown when. On 01/18/24 at 01:58 PM Licensed Nurse (LN) G stated she had not been checking resident body temperatures of the residents that did not want to move because of the cold, just the routine vital signs. On 01/18/24 at 02:00 PM, LN H stated she worked on 01/12/24, 01/13/24, 01/14/24, 01/15/24, and 01/17/24. Staff provided extra covers to the residents for warmth if the residents wanted additional covers. LN H stated she had not been monitoring resident body temperatures while the heat was off but would only take resident's temperatures if the Treatment Administration Record popped up as a task to obtain the temperature. On 01/17/24 at 02:53 PM, Administrative Staff A stated last week the heat went out on the [specified hallway], there were two furnaces on that hall and the one that went out covered the south side of the hall. Administrative Staff A stated all the residents were asked if they wanted to stay in their room and leave their door open, other than when getting cares, so the heat could come in from the hallway. Administrative Staff A stated when she checked on the residents this morning, they said they were doing okay. Administrative Staff A stated staff moved R8 to another hall on 01/16/24. Administrative Staff A stated infrared heaters were placed in the resident rooms on 01/12/24 and the Fire Marshall called on 01/16/24 and facility staff removed all of the infrared portable heaters. Administrative Staff A stated Maintenance Staff V might have checked the room temperatures before the portable heaters were added, however he was out until 01/22/24. Administrative Staff A stated they called a repairman who came out and said the furnace needed a part, and the part had to be ordered, it was to arrive today (01/17/24), and would be installed. The part had not been installed at this time, but the repairman was at the facility now. Administrative Staff A stated R13 did not want a portable heater, she had said no when asked, but there was one available for her. Administrative Staff A stated R8 was the only resident that wanted to move. On 01/17/24 at 04:42 PM, Administrative Staff A stated the part for the furnace was being installed now by the repair company and the repairman talked like the repair should be completed on the same day. On 01/17/24 at 04:54 PM, Administrative Staff A stated she thought Maintenance Staff V monitored the residents' room temperatures when the heat was out, however she was not sure how often and was unable to provide documentation of the room temperatures since the breakdown occurred on 01/12/24. On 01/17/24 at 05:10 PM Administrative Staff A provided a plan to address the heating outage which included: 1. The charge nurse or delegate would check temperatures in each of the rooms hourly, until the furnace was fixed. 2. If a resident gets uncomfortable, the resident will be offered to move to a different room on a different wing. 3. The residents would be offered extra blankets, as they would allow. 4. The residents and staff would be educated on keeping the doors open to allow heat to move through the rooms, except when cares were being provided. 5. The staff encouraged to dress residents appropriately for weather, as residents would allow. 6. The staff encouraged to use other exit doors to decrease drafts. The facility temperature monitoring logs revealed on 01/18/24 the lowest recorded temperature was 63 degrees F on 01/18/24 at 10:00 AM in R13's room. All the affected rooms were below 71 degrees F on 01/18/24 at 10:00 AM, 11:00 AM, and 12:00 PM, with R9's room remaining below 71 degrees F until 05:00 PM. The facility temperature monitoring logs for 01/18/24 from 10:00 AM through 01/20/24 at midnight revealed all rooms reached and maintained temperatures of 71 degrees F and above, beginning on 01/18/24 at 06:00 PM. On 01/17/24 at 05:37 PM, Administrative Staff A stated Maintenance Staff V reported to her on the morning of 01/12/24 regarding the lack of heat in the facility. The electrician came out that day and told the facility staff the heater was broke. Staff offered the residents additional blankets and checked on the residents and staff offered to move them and none of the residents wanted to move on 01/12/24. The portable heaters were provided in the afternoon on 01/12/24 when staff knew the part had to be ordered. On 01/18/24 at 07:55 AM, Administrative Staff A reported the repairman was unable to complete the repair yesterday and was to return today. Administrative Staff A stated she checked on the residents and they were all okay, one resident said it was a little cool. Administrative Staff A stated residents were offered to move but declined, and the temperature in one room was 64 degrees F. The facility policy Emergency Strategy: Utility Outage, Power Outage, including Hot and Cold Weather dated September 2023 revealed to utilize the following procedures if there is a loss of heating function (the facility temperature reaches 71 degrees Fahrenheit and remains so for four hours) to prevent hypothermia: 1. Ensure residents are dressed warmly and have enough blankets, coverings. 2. Cover the heads of the residents and protect other extremities. 3. Encourage the residents to drink fluids. 4. Monitor body temperatures. 5. Monitor environmental thermometers. 6. Evacuate residents if temperatures remain low and residents' safety and welfare are jeopardized. 7. Notify the Medical Director. The facility failed to maintain comfortable and safe temperature levels of 71 degrees F or greater, placing ten residents at risk for hypothermia, when the furnace broke down on 01/12/24. On 01/18/24 at 04:50 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facilities failure to provide comfortable and safe temperature levels of 71 degrees F or greater for ten residents when a furnace quit working on 01/12/24 through 01/17/24, placed the 10 affected resident in immediate jeopardy and at risk for hypothermia. The facility provided an acceptable plan of removal of the immediacy on 01/18/24 at 06:50 PM, which included the following corrective measures: 1. On 01/16/24 the facility notified the affected physicians and residents were offered to temporarily change rooms until the furnace was fixed. Residents who elected to remain in the affected rooms were encouraged to keep doors open to room, except during cares, so that heat from the hallway could circulate into the room. Residents were dressed warmly and offered extra blankets to provide warmth and encouraged to keep extremities and head covered for warmth and encourage to drink fluids. 2. On 01/17/24 the facility began monitoring temperatures of the six rooms affected. 3. On 01/17/24 the Regional [NAME] President of Operations re-educated facility Administrator, Director of Nursing, and Maintenance Director on the requirement to maintain comfortable and safe temperature levels of 71 degrees F or greater and the facility policy to monitor room temperatures when facility heating equipment is not working. 4. The facility will complete a facility-wide audit of room temperatures to establish room temperatures were maintained at 71 degrees F. 5. The Maintenance Director and/or designee will monitor the temperature in the affected rooms hourly, to establish the facility maintains room temperatures of 71 degrees F during the duration of the furnace being inoperable. The facility will continue to monitor the temperature every four hours, for the first 24 hours after the heater is back in working order to establish room temperatures of 71 degrees F is being maintained. 6. On 01/18/24 at 06:00 PM the facility implemented a temporary heater to maintain room temperatures of 71 degrees F. The surveyor verified the implementation of the above corrective actions while onsite, and the deficient practice remained at an E scope and severity.

The facility reported a census of 69 residents, with thirteen sampled, and three reviewed for significant medication errors. Based on observation, record review, and interview, the facility failed to prevent a significant medication error for Resident (R)1 when facility staff prepared and wrongly administered R4's medications, which included high risk medications, to R1 on 12/18/23. Certified Medication Aide (CMA) R prepared R4's medications, then asked R1 if she was ready for her medication and R1 nodded yes, so CMA R administered R4's medications to R1. CMA R thought R1 resembled the picture in the Medication Administration Record (MAR) for R4. Shortly after administration of the medications, CMA R heard Administrative Nurse E speak to R1 and realized she administered R4's medications to R1. R1 had a change in condition, her blood pressure dropped, and she required emergency medical service intervention. Staff transferred R1 to the hospital via emergency medical services and R1 admitted to observation for hypotension (low blood pressure). CMA R failed to implement the standards of practice regarding medication administration when she failed to verify the right medication was given to the right resident. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of hypotension, hypertension (HTN - elevated blood pressure), long term use of anticoagulants (medication to thin the blood and prevent blood clots), dementia (progressive mental disorder characterized by failing memory, confusion), presence of a cardiac and vascular implant and graph, 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), aphasia (condition with disordered or absent language function), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Significant Change Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS noted R1 had a diagnosis of orthostatic hypotension (blood pressure dropping with change of position), HTN, and she received anticoagulant medication for five of the seven-day review period and an antidepressant (class of medications used to treat mood disorders) medication. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/15/23 revealed R1 had dementia with poor memory and recall deficits. The Psychotropic Drug Use CAA dated 08/15/23, revealed R1 received medication to manage depression. The Quarterly Minimum Data Set, dated dated dated [DATE] revealed R1 had a BIMS score of three, indicating severe cognitive impairment, continued with the same diagnoses, and received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antidepressant, and anticoagulant medications. The Care Plan dated 12/20/23 revealed R1 received anticoagulant therapy, could be resistive to cares related to dementia, received an antidepressant and antipsychotic medication, and had communication problems related to aphasia following a stroke. The care plan instructed the staff to administer medications as ordered. The Medication Administration - Tablets, Pills, and Capsules training checklist dated 12/01/23 revealed CMA R completed requirements of the checklist, which identified the steps needed to administer tablet, pill, or capsule medications. The checklist included verifying the five rights of medication administration (right person, right medication, right route, right time, and right dose). The MAR dated December 2023 revealed R1 did not receive her ordered medications on 12/18/23, which were scheduled between 06:00 AM and 09:00 AM. The Treatment Administration Record (TAR) dated December 2023 revealed R1 received Coumadin (anticoagulant), 4.5 milligrams (mg), by mouth, the previous evening, on 12/17/23 at 05:00 PM. The Progress Notes dated 12/18/23 at 07:40 AM by Licensed Nurse (LN) G revealed R1 received another resident's medications this morning and her current blood pressure was 104/60 (normal range less than 120/80) millimeters of mercury (mmHg). R1 received the following medications in error: 2.5 mg Eliquis (anticoagulant), 10 mg Lexapro (antidepressant), 50 mg Losartan (antihypertensive - class of medication used to treat high blood pressure), 8.6 mg hydralazine (used to treat high blood pressure), Senna (laxative - used to treat constipation [difficulty passing stools]), 1 mg bumetanide (diuretic - class of medications used to treat fluid retention and high blood pressure), 30 mg isosorbide (vasodilator - class of medications which can be used to treat HTN), and 200 mg amiodarone (antiarrhythmic - class of medications used to treat heart rhythm issues and can also lower blood pressure). The MAR dated December 2023 revealed R1 received Senna on 12/17/23 at 08:00 PM and no other medications were duplicates of what was given in error. The Progress Notes dated 12/18/23 at 07:41 AM by Administrative Nurse D revealed staff notified R1's provider of the medication error and the medications received in error, which included all medications listed in the note dated 12/18/23 at 07:40 AM. The physician ordered staff to closely monitor the resident's blood pressure and call back if the blood pressure was lower than parameters. The facility Standing Orders dated 08/29/23 revealed the following blood pressure parameters: Staff were to notify the physician if a resident's blood pressure was less than 90/40 mmHg. The Vitals tab for R1 revealed on 12/18/23 at 07:45 AM her blood pressure was 110/59 mmHg, and at 08:00 AM her blood pressure was 104/60 mmHg. The Progress Note dated 12/18/23 at 08:35 AM revealed R1's blood pressure was 95/48 mmHg and staff attempted to notify the provider without success. The Progress Note dated 12/18/23 at 09:15 AM revealed R1's blood pressure was 83/40 mmHg (below parameters). R1 felt tired and was lying in bed. The Progress Note dated 12/18/23 at 09:26 AM by LN G revealed staff called 911 to send R1 out for further evaluation. The hospital's History and Physical for 12/18/23 revealed R1 received intravenous (IV-administered directly into the bloodstream via a vein) fluids for her blood pressure of 80/40 mmHg. R1 told her family she felt dizzy when she stood up to use the bathroom. The hospital placed her on telemetry (used to monitor heart rhythms) due to receiving an antiarrhythmic medication. The hospital Clinical Discharge Summary dated 12/19/23 included a diagnosis for R1 of hypotension. The Progress Notes dated 12/19/23 at 01:06 PM revealed R1 returned to the facility at 12:45 PM. On 01/17/24 at 02:27 PM CMA R stated on 12/18/23 she was assigned to the medication cart and R1 was in the dining hall, which she thought R1 was R4. CMA R stated she approached R1, thinking it was R4, and stated [resident name] I have your medication and R1 nodded her head yes and she administered R4's medications to R1. CMA R stated she was 100 percent sure it was the right person as the picture (of R4) in the electronic medical record looked similar to R1. CMA R stated not five minutes after administering the medication (to R1) she heard Administrative Nurse E saying R1's name to R1 and provided direction for R1 on how to get to her room. When CMA R saw Administrative Nurse E walking with R1, CMA R realized she gave R1 the wrong medication and informed Administrative Nurse E immediately. On 01/17/24 at 03:16 PM, R1 walked in the hallway using the handrail, with a slow and steady gait On 01/17/24 at 03:17 PM, R1 stated she had not been in the hospital recently and denied having any dizziness. At that moment an unidentified facility staff intervened to assist R1 stating she needed to use her walker. On 01/18/24 at 10:00 AM, LN G stated on 12/18/23 she was the float nurse on duty when CMA R reported the medication error. LN G stated she assessed R1 and checked her blood pressure and it was slowly dropping, and she followed up with the resident's provider. LN G stated R1's blood pressure continued to drop to 83/40 mmHg and she had to send R1 out to the hospital. R1 had complained of feeling tired and was lying in bed. On 01/18/23 at 11:37 AM, Administrative Nurse D stated she expected the staff to follow the five rights when administering medications. The facility policy, Administering Medications, dated May 2022, revealed the individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: 1. Checking photograph attached to the medical record. 2. Calling resident by name; and 3. If necessary, verifying resident identification with other facility personnel. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. Medications must be administered in accordance with the orders, including any required time frame. The facility failed to prevent significant medication error when CMA R administered R4's medications to R1, which included high risk medications, resulting in emergency medical service intervention. This deficient practice placed R1 in immediate jeopardy. On 01/18/24 at 05:15 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy template and notified of the facilities failure to prevent a significant medication error, when CMA R administered R4's medications to R1 on 12/18/23 resulting in a drop of R1's blood pressure which required emergency medical service intervention and admission to the hospital, placing R1 in immediate jeopardy. The immediate jeopardy was determined to first exist on 12/18/23. The facility identified and implemented the following corrective actions completed on 12/19/23 at 04:30 PM: 1. On 12/18/23, the facility removed CMA R from the medication cart and educated on the five rights of medication pass. 2. On 12/18/23, the facility educated all staff who pass medications on the five medication rights, before passing medications again. 3. On 12/18/23, the facility interviewed three residents, for any concerns with receiving another resident's medications, without issues. 3. On 12/19/23 the facility took a new photograph of R1 for her profile picture in the EMR. 4. On 12/19/23 at 04:30 PM Administrative Nurse D conducted an audit of all resident pictures to ensure all resident pictures were current photographs. 5. Administrative Nurse D would supervise CMA R while completing a medication pass to ensure she could give medications safely before allowed to pass medications alone. 6. Administrative Nurse D or Administrative Nurse E would conduct medication pass audits, two times a week for two months, to ensure compliance with safe medication pass following medication rights. Due to the corrective actions implemented and completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J (isolated, immediate jeopardy to resident health or safety) scope and severity.

The facility census totaled 61 residents, with four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure the safety of residents who required lift transfer, when the facility failed to ensure the competency of agency staff in lift transfers with all slings used. The agency staff failed to properly secured all six sling straps when transferring totally dependent Resident (R) 37 in the mechanical lift from the bed to his wheelchair, and the resident fell out of the lift onto his head, in a fall of approximately three feet onto the floor, and required an emergency room (ER) visit due to his injury and potential risk due to blood thinning medications he received. The ER treated the resident for a laceration above his left eyebrow, which required glue and steri-strips (medical-grade adhesive strips) to close. This failure placed the resident, and all other residents who required mechanical lift transfers, in immediate jeopardy. Findings included: - Review of R37's Physician's Orders for diagnosis in the Electronic Medical Record (EMR) dated 05/26/21 revealed [CONDITION(S)] (paralysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord). Review of the 02/14/21 Annual Minimum Data Set (MDS) revealed a staff interview for mental status, which indicated the resident had long/short term memory problems and severely impaired decision-making skills. The resident required total dependence with two staff assistance for transfers and required a wheelchair for mobility. No falls documented during the review period. Review of the 02/14/21 Falls Care Area Assessment (CAA) revealed R37 was dependent on staff for transfers due to weakness and contractures. The resident is a risk for falls and other major/minor injuries related to falls. Review of the 05/17/21 Quarterly MDS revealed a Brief Interview for Mental Status (BIMS) of two, indicating severely impaired cognition. The resident required total dependence with two staff assistance for transfers, used a wheelchair for mobility, and had one fall with minor injury during the review period. Review of 02/10/20 Fall Care Plan revealed a revision dated 04/16/20 that noted R37 was at risk for falls related to a history of [CONDITION(S)], decreased mobility, and muscle spasms. A revision dated 05/06/21 revealed R37 experienced a fall from the mechanical lift. Two staff must ensure use of the correct size of sling with all straps connected before transferring the resident in the lift. Review of the 02/10/20 ADL Care Plan revealed a revision dated 05/06/21 that instructed, R37 required a full mechanical lift with two staff assistance with a medium sling for transfers. Review of 01/04/21 and 04/06/21 Fall Risk Evaluation assessments revealed the resident was at high risk for falls. Review of 05/06/21 Fall Investigation revealed Certified Nurse Aide (CNA) E attached the medium sling straps on the lift with the resident in bed. She then asked CNA D to assist with the transfer from his bed to a wheelchair, and the resident was lifted to the wheelchair. Approximately one foot above his wheelchair, he slipped out of the end of the sling due to two straps meant to secure his legs had not been secured, and he fell forward onto his face. Staff noted a superficial cut above his left eyebrow that was two centimeters (cm) in length requiring glue and steri-strips. The immediate intervention included staff sent R37 to the emergency room for evaluation since he received [MEDICATION(S)] (blood thinner), and all diagnostics were within normal limits. The determined root cause was that CNA E had not used this particular sling with six straps; she had only used the slings with four straps. R37 had contractures, and two of the six straps were under his legs and out of view. The investigation identified the cause as operator error, and education/competency for the use of mechanical lifts/slings was completed for all staff, and lift/transfer assessments were completed for all residents. Review of 05/06/21 at 05:02 PM Nursing Note revealed staff transferred the resident back to bed by two CNA's via the mechanical lift. The resident was approximately one foot above the wheelchair when he leaned forward and fell out of the sling between the head and the foot strap. CNA D attempted to break his fall, but he landed on his left side by the right side of the mechanical lift leg. The staff provided basic first aid to R37's left eyebrow laceration and staff safely rolled him to his back with a sling under him and transferred him to bed via the mechanical lift. Review of 05/11/21 How to Safely Lift a Patient into a Patient lift revealed CNA E completed mechanical lift training on this date. The facility failed to provide documentation of mechanical lift use for this staff member prior to the incident on 05/06/21 as requested on 07/08/21. Observation of the resident on 06/30/21 at 09:27 AM revealed the resident was in bed watching TV, positioned to the left with pillows. The resident will nod yes/no to questions and displayed no signs or symptoms of distress. Interview with CNA F on 07/01/21 at 12:00 PM revealed R37 refused to get up a lot. He had never shown any fear with the lift before or after the incident. She stated on 05/06/21 she and another CNA got the resident out of bed to his wheelchair for a visit. CNA D and CNA E took R32 to lay down in bed and once the incident occurred, she went to help. CNA F stated the resident on the floor, and she noticed a few straps to the sling were not secured to the lift, so the resident slipped out. He did have a gash above his left eyebrow, and he came back from the emergency room with a band-aid on his forehead. Interview with CNA D on 07/08/21 at 08:15 AM revealed CNA E hooked R37's sling up to the lift and when CNA D came in the room, she did not check the sling straps to ensure all sling straps were secured. She then stated, there usually are not six straps on the sling; there are usually four. The staff then transferred R37 from the wheelchair to his bed, and he slipped out of the unsecured sling bottom, falling face forward approximately three feet to the floor. He landed on CNA D and one of the mechanical lift legs and she noted he had a scratch on his eyebrow. He did have to go to the hospital to get checked out and he was fine. Now she checked to ensure the sling is secured every time she assists another CNA. Interview with LN C on 07/06/21 at 11:01 AM revealed R37 sustained an injury above his left eye the day he fell . Interview with Administrative Nurse B on 07/01/21 at 10:15 AM revealed CNA E connected the upper and lower straps of the sling and she forgot to secure the third set of straps. CNA D trusted CNA E secured the sling straps appropriately. He made it approximately a foot off of the wheelchair before falling out onto the floor. He sustained a laceration to his left upper eyebrow approximately two cm long. He was sent to the hospital for evaluation due to being on a blood thinner. Interview with Administrative Nurse B on 07/08/21 at 09:56 AM by email revealed the facility did not do a skills check off with agency staff prior to the staff starting at the facility, and the agencies that the facility used did not do a skills check on the staff. The agencies staff do complete a self-assessment of their CNA knowledge base on what equipment/tasks they are competent/knowledgeable in, with most documented on a rating scale. CNA E's agency was in the process of implementing education. A review of 10/2009 Safe Lifting and Movement of Residents policy revealed to protect the safety and well-being of staff and residents and to promote quality care; this facility used appropriate techniques and devices to lift and move residents. The facility failed to ensure the safety of residents who required full lift transfers when agency staff failed to appropriately secure all six straps on the sling for R37 in the mechanical lift before transferring him from the bed to his wheelchair, resulting in a fall of approximately one to three feet onto the floor and an ER visit for a laceration above his left eyebrow requiring glue and steri-strips. This failure placed the resident in immediate jeopardy. On 07/14/21 the facility Administrator was notified of the immediate jeopardy identified and was provided a copy of the IJ template. The Administrator provided documentation of the corrective actions implemented by the facility on 05/07/21. The surveyor verified the implementation of the corrective actions while onsite at the facility on 07/07/21, which included the following: 1. All residents had a lift transfer assessment completed and those that used a Mechanical lift had care plans and task interventions updated to display transfer status as well as sling size. 2. The DON and Administrator, or designee, will monitor mechanical lift transfers during rounds that will occur weekly for 90 days. 3. Mechanical lift/sling training would take place at orientation for agency and new hires in the nursing department. The training would be completed prior to staff transferring a resident using the lift/sling. 4. The Administrator implemented a Quality Assurance and Performance Improvement (QAPI) Performance Improvement Project (PIP) to gather and process information and have findings available at the QAA meeting for a minimum of three months. The deficient practice remained at a J (isolated, with the potential to cause serious injury, harm, impairment, or death) scope and severity, at past non-compliance.

The facility reported a census of 53 residents with 31 residents positive for COVID-19 (respiratory illness that can spread from person to person). Based on observation, interview, and record review the facility failed to follow infection prevention protocols for preventing the spread of COVID-19, when Certified Nurse Aide (CNA) B worked with signs and symptoms of COVID-19 and exposed residents during her 12-hour shift. The facility further put residents and staff at risk when direct care staff did not encourage/prompt residents to wear masks during cares. These failures placed all residents in immediate jeopardy for contracting COVID-19. The facility further failed to ensure staff utilized appropriate hand hygiene before entering resident rooms. Findings included: - Review of the facility Staffing Sheets for [DATE] revealed CNA B worked the 06:00 PM to 06:00 AM shift. Review of [DATE] COVID-19 Screening for CNA B revealed she documented no symptoms of COVID-19 prior to beginning her 06:00 PM to 06:00 AM shift. Review of the [DATE] COVID-19 Screening Sheet for CNA B lacked documentation of temperatures on the screening sheet. Review of the [DATE] COVID-19 Screening Sheet for six other employees lacked documentation the screenings were validated by another staff member for accuracy and signs and symptoms. Review of the employee COVID-19 Test results dated [DATE] revealed CNA B and CNA G tested positive for COVID-19, and on [DATE] CNA H tested positive for COVID-19. Review of the facility COVID-19 Test results for all residents revealed the following: On [DATE] seven residents R1 (deceased ), R2, R3, R14, R15, R16, and R17 tested positive for COVID-19 (all residents on the hall in which CNA B worked on [DATE]). On [DATE] twelve residents (R4, R9, R11, R13, R18, R19, R20, R21, R22, R23, R24 (deceased ), and R25 tested positive for COVID-19. On [DATE] two residents (R5 and R8) tested positive for COVID-19. On [DATE] four residents (R6, R27, R28, and R29) tested positive for COVID-19. On [DATE] five residents (R7, R30 (deceased ), R31, R32, and R34) tested positive for COVID-19. On [DATE] one resident (R33) tested positive for COVID-19. On [DATE] two residents (R35 and R10) tested positive for COVID-19. On [DATE] two residents (R36 and R37) tested positive for COVID-19. On [DATE] two residents (R38 and R39) tested positive for COVID-19. Interview with R8 on [DATE] at 10:43 AM revealed CNA B worked with him back in [DATE] and he did not remember if CNA B had a cough. R8 stated CNA B wore her blue surgical mask when she cared for him, and indicated when staff cared for him, they did not encourage him to wear a mask. Interview with CNA B on [DATE] at 03:56 PM revealed she had a cough that started before she left her house for her shift at the facility on [DATE]. CNA B stated as she worked throughout the night her cough worsened. She indicated because she had just tested negative the prior week on Wednesday, she thought she could wait to tell someone about her new cough. CNA B stated when she screened herself on [DATE] she did not remember putting yes or no on the screening for cough, because she did not start really coughing until between 02:00 AM and 03:00 AM in the morning. CNA B reported Administrative Nurse A told her from now on even if she had a new little cough to let someone know. CNA B said she wore a surgical mask for her shift because there were no positive COVID-19 residents or staff, and she worked on hall two only that night. In the weeks before that night she worked on hall two and one. CNA B stated on the night of [DATE] the licensed nurses and other CNAs noticed her new cough and asked if she was ok, but none of them said she should call Administrative Nurse A or anything like that. Interview with Licensed Nurse (LN) M on [DATE] at 04:04 PM revealed he did notice CNA B had a cough on the morning of [DATE], but he was very busy and did not question it. LN M noted CNA B coughed a lot that night and he passed that on to the oncoming nurse that morning. He also stated he asked at the beginning of the shift on [DATE] if all employees present had been tested for COVID recently and CNA B did not say anything. An interview on [DATE] at 04:42 PM with Administrative Nurse A revealed the outbreak started when CNA B tested positive. The facility performed house-wide testing due to CNA B's positive COVID-19 result, and discovered three residents (R1, R2, and R3) who CNA B provided direct cares to during her shift were also positive for COVID-19. Interview with Administrative Nurse A on [DATE] at 4:43 PM revealed she was in the facility on [DATE] at 11:00 PM for CNA B's annual review when she heard CNA B cough. Administrative Nurse A stated CNA B should have been tested for COVID-19 prior to the start of her shift on [DATE] at 6:00 PM. Administrative Nurse A revealed CNA B experienced a cough during night shift on [DATE] and going into the morning of [DATE]. CNA B completed a rapid COVID-19 test on the morning of [DATE] during routine testing. CNA B assumed her cough indicated cold symptoms and called Administrative Nurse A in the morning after her shift was over. She stated CNA B should have been tested that night due to the cough and could not say why CNA B was not tested right away. She indicated the facility had missing testing supplies, but the expectation was employees needed tested prior to their shift. An interview on [DATE] at 02:23 PM with Administrative Staff J revealed she preferred to be notified about signs and symptoms for staff and expected staff with signs and symptoms to be tested and sent home until results came back. She had not informed staff about what she wanted since she began her position as administrator about one week ago. An interview on [DATE] at 02:55 PM with Administrative Staff J revealed staff only notified her about positive COVID-19 test results. Administrative Staff J stated she preferred to know if staff had symptoms but did not make those expectations clear with her staff. An interview on [DATE] at 04:28 PM with Administrative Nurse A revealed if staff had signs and symptoms of COVID-19 during their shift, they should notify her and complete a rapid test for confirmation. Interview with Administrative Nurse A on [DATE] at 04:43 PM revealed CNA B came in at 11:00 PM and noticed a CNA B had a cough. No other employees reported that CNA B had a cough. The expectation for employee testing included testing 72 hours after their prior test and before the start of shift. Administrative Nurse A stated CNA B should have been tested at beginning of her 06:00 PM shift on [DATE]. An interview on [DATE] at 02:13 PM with Physician Extender P revealed if an employee had symptoms during their shift, they should notify a superior immediately. Physician Extender P stated the staff member should be sent home after notification, rapid testing, and results. Before COVID that probably would not have been the case, but with COVID-19 it is imperative to move quickly. Review of facility policy entitled COVID-19 Testing F886, revised [DATE], revealed staff who displayed signs or symptoms of COVID-19 would be tested and expected to be restricted from the facility while awaiting the results of the testing. Review of CDC guidance provided by the facility titled, Strategies to Mitigate Healthcare Personnel Shortages, revised [DATE], revealed If HCP (Health Care Provider) develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing. The facility failed to follow infection prevention protocols for preventing the spread of COVID-19, when CNA B worked with signs and symptoms of COVID-19 and exposed residents during her 12-hour shift, which put all residents in immediate jeopardy for contracting COVID-19. - An observation on [DATE] at 11:18AM of non-COVID/non-isolation unit revealed Certified Nurse Aide (CNA) R assisted R12 with morning cares. CNA R did not ask or offer R12 to wear a face covering/mask during the interaction even though CNA R stood within one to two feet of the resident. An observation on [DATE] at 11:25AM of R13 cares on the COVID unit revealed CNA H and CNA S entered the resident's room, told the resident of the cares they would provide, and then did not offer or prompt R13 to wear a face covering/mask. An interview on [DATE] at 10:52AM with R9 revealed the staff did not encourage residents to wear masks during cares on the COVID unit. An interview on [DATE] at 11:20AM with CNA R stated she did not encourage R12 to wear a mask when she provided direct care. When asked about encouraging residents to wear a mask during cares, CNA R stated she was supposed to encourage residents to wear a mask during cares and that she would do so from now on. A phone interview on [DATE] at 04:57PM with Administrative Nurse A stated she expected staff to ask residents to put on their mask prior to staff entering the room, and expected staff to put a mask on residents who were physically unable. The facility's policy titled, Universal Source Control (Key Concepts) during a Pandemic, Including COVID-19, revised ,[DATE] instructed to protect high-risk populations such as nursing home residents, and to promote the use of everyday preventative actions which included, Residents should be in masks. The policy referred to the CDC webpage https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last updated on [DATE], which provided further guidance to include patients/residents and visitors should wear their own cloth mask (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth mask. Patients/residents should wear their cloth mask when around others or when leaving their room. The facility failed to encourage/prompt residents to wear face covering/masks during cares which put all residents in immediate jeopardy for contracting COVID-19. On [DATE] at 02:04 PM, the surveyor provided the facility with the IJ template and notified that the facility failure to follow protocols for preventing the spread of infection when staff worked with signs and symptoms of COVID-19 and exposed residents during a 12-hour shift, and put residents at further risk for COVID-19 when the facility failed to ensure residents wore masks during cares. The inability to ensure staff prevented the potential spread of infectious organisms constituted immediate jeopardy at F880, with the potential to affect all residents in the facility. The facility presented an acceptable plan for removal of the immediate jeopardy on [DATE], which included re-educate staff on the need to immediately alert charge nurse of any signs or symptoms of COVID-19 before their shift or any signs/symptoms that develop during their shift. The facility re-educated staff to encourage resident to wear a mask while staff is in room and during cares, perform audits for mask signage in each room, re-educate residents on the importance of wearing a mask when staff is in the room and during cares, and re-educate staff on the signs and symptoms of COVID-19. The DON/Designee will monitor staff during cares and symptoms of staff five times each week for four weeks, then three times each week for two weeks. Once per week during each shift report staff will be reminded of signs and symptoms of COVID-19, the policy to report any symptoms of COVID-19 to the charge nurse before and during shift, and to encourage residents to wear masks while staff are in the room and during cares. The survey team validated the immediate jeopardy removal on [DATE] approximately 12:30 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity of F. - An observation on [DATE] at 11:40 AM revealed CNA C did not perform hand hygiene when she delivered meal trays to three resident rooms. CNA C raised the head of the bed for a resident in one room room and did not perform hand hygiene when she exited the room to push the food cart back to the kitchen. An observation on [DATE] at 12:22 PM revealed CNA B carried a tablet (electronic device) in his hands when he picked up dirty meal trays from resident rooms for five different residents, and did not perform hand hygiene before going into each room. An interview on [DATE] at 12:43 PM with CNA C stated she did not perform hand hygiene between each resident or tray that she delivered. CNA C stated she washed her hands after she completed delivering meal trays to the residents. An interview on [DATE] at 04:30 PM with CNA B stated he carried his tablet in his hands as he picked up meal trays from resident rooms because he forgot to leave the tablet at the nurse's station and did not realize that he did not perform hand hygiene between entering and exiting resident rooms. CNA B stated he would try harder to remember hand hygiene in the future. An interview on [DATE] at 04:42 PM with Administrative Nurse A stated she expected staff to perform hand hygiene and sanitize electronic devices between each resident/room. The facility's policy titled, Handwashing/Hand Hygiene F 800, revised ,[DATE], instructed staff to perform proper hand hygiene when hands are not visibly soiled, with approved hand sanitizer after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. The facility failed to ensure staff performed proper hand hygiene between contact with each resident.

The facility census totaled 56 residents. The sample included 3 residents. Based on observation, interview and record review the facility failed to investigate an allegation of abuse and protect all the residents in the facility from an independent physically aggressive resident (#2) who put his/her hands around another resident's neck (resident #3) which placed all the residents in the facility in immediate jeopardy related to abuse. Findings included: - Review of resident #2's (the alleged perpetrator) physician progress notes [REDACTED]. Review of resident #2's significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of a 6 (severe cognitive impairment). The MDS indicated the resident wandered. The resident required supervision with walking on and off the unit, and required supervision of one staff member for transfers. Review of the cognitive loss and activities of daily living (ADL) care area assessment (CAA) dated 5/16/17 revealed resident #2 had a BIMS score of a 6. The resident had a significant improvement in his/her functional ability and the resident was independently mobile. The resident liked to wander the halls at times. Review of resident #2's quarterly MDS dated [DATE] revealed a BIMS score of a 6 and no behaviors. The resident required supervision with locomotion and walking on and off the unit. The resident required supervision of one staff for transfers. Review of resident #2's care plan dated 1/31/17 revealed the resident had impaired cognitive functioning/dementia. The care plan directed the staff to administer medication per physician's orders [REDACTED]. Review of resident #2's nurse's progress note dated 8/7/17 at 4:46 a.m. revealed the charge nurse heard yelling at 4:00 a.m. and upon investigation staff observed the resident having an altercation with his/her roommate (resident #3). Staff separated the residents. The staff took the aggressor (#2) outside and allowed him/her to smoke a cigarette to calm him/her down. The resident refused to tell the staff what occurred because he/she feared he/she would get arrested. The staff placed the resident on one-on-one monitoring until he/she calmed down then staff provided hourly checks. Review of resident #3's progress note dated 6/10/17 revealed the following Diagnoses: [REDACTED]. Review of resident #3's significant change MDS dated [DATE] revealed a BIMS score of 5 (severe cognitive impairment). The resident required supervision and set up help with transfers and locomotion. The resident had functional limitation to both lower legs and used a wheelchair for locomotion. The resident rejected care 1-3 day per week. Review of resident #3's cognitive CAAS dated 11/7/16 revealed the resident liked to stay in the room by him/herself and not be bothered by others. Review of resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 9 (moderate cognitive impairment) and the resident displayed verbally aggressive behavior towards others. He/she required set up help of one person for transfers and set up help and supervision with locomotion. Review of resident #3's care plan dated 7/4/16 revealed the resident had impaired cognitive functioning related to dementia. The care plan directed staff the resident preferred to stay in his/her room most of the day and refused care frequently. Review of resident #3's nurse's progress note dated 8/7/17 at 5:00 p.m. revealed the resident had an altercation with resident #2. The resident reported he/she sat in his/her wheelchair and watched television when the roommate instigated an altercation. The resident did not know why his/her roommate got upset. Review of resident #3's nurse's progress note dated 8/9/17 at 3:06 a.m. revealed the resident continued to be monitored due to the altercation with his/her roommate. The resident denied pain, no bruising or swelling to the resident's neck was observed. Interview on 8/10/17 at 1:15 p.m. with resident #3 revealed, resident #2 placed both hands around his/her neck and squeezed during the altercation. Resident #3 revealed he/she was nervous the night of the incident because his/her roommate resident #2 acted crazy and tried to harm him/her. Interview on 8/10/17 at 1:07 p.m. with social service staff C revealed he/she became aware of the issue on 8/7/17 in the morning department head meeting. Staff C revealed he/she was not informed the altercation had been violent. Staff C revealed he/she was concerned about what happened and intended to do more investigating to determine what happened and why the staff documented resident #3 had been monitored for injuries. Interview on 8/10/17 at 1:22 p.m. with social service staff C revealed he/she spoke to resident #2 and he/she admitted he/she put both hands around resident #3's neck during the altercation. Interview on 8/10/17 at 3:14 p.m. with licensed staff I revealed he/she witnessed resident #2 with his/her hands around resident #3's neck choking him/her. Staff I revealed he/she reported the altercation to administrative nurse B. He/she confirmed resident #2 and resident #3 had not been isolated from each other, the staff provided one-on-one supervision of resident #2 when he/she left the room for exit-seeking behavior because the resident feared the police would be called and he/she would get arrested. Interview on 8/10/17 at 1:00 p.m. with administrative staff A revealed he/she did not know of the altercation that involved resident #2 and resident #3 and he/she would look into it. Interview on 8/10/17 at 11:12 a.m. with administrative nurse B revealed he/she knew resident #2 and resident #3 were involved in an altercation on 8/7/17. Staff B revealed the two residents exchanged words and that was it. Staff B revealed he/she had the charge nurse complete a head-to-toe assessment on resident #3 with no injuries noted, resident #3 was not scared of resident #2, and resident #3 did not want to move to a different room. Staff B revealed resident #3 could tell the facility staff when he/she wanted something to eat or drink and when he/she wanted to go smoke and staff B felt if resident #2 harmed resident #3, he/she would have reported it by now. Staff B revealed there was no reason to report the incident to the State reporting agency because nothing happened that required a report. Interview on 8/10/17 at 1:45 p.m. with administrative staff D revealed the facility failed to complete an investigation into the altercation between resident #2 and resident #3. Staff D also confirmed the facility failed to separate resident #2 and resident #3 after the altercation. He/she confirmed resident #2 moved about freely in the building and was not under constant supervision by staff. Review of the Abuse Neglect and Exploitation (ANE) policy last revised August 2016 revealed an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source should be reported to the administrator, or his/her designee, and a member of management would investigate the alleged incident. A resident to resident altercation required staff to separate the residents, and institute measures to calm the situation, identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation, notify each resident's representative and attending physician of the incident. The facility failed to investigate the allegation of abuse, failed to protect resident #3 from resident #2 (the alleged perpetrator) and the facility failed to report the altercation between resident #2 and resident #3 which placed all the facility residents in immediate jeopardy related to abuse. The facility abated the immediate jeopardy on 8/14/17 at 5:00 p.m. by the facility re-education of the management staff, licensed nurses, certified nursing assistance, and other staff on abuse reporting and investigation. The deficient practice remained at the scope and severity of an F.

The facility census totaled 56 residents. The sample included 3 residents. Based on observation, interview and record review, the facility failed to follow the policy for protecting, investigating, and reporting abuse as directed by the facility's abuse investigation policy after an incident of resident-to-resident abuse. Findings included: - Interview on 8/10/17 at 1:15 p.m. with resident #3 revealed, resident #2 placed both hands around his/her neck and squeezed during an altercation on 8/7/17. The facility failed to follow the facility policy to protect residents and complete an investigation to ensure the safety of all the residents in the building from resident #2 (the alleged perpetrator) who was independently ambulatory and resident #3's roommate. Review of the Abuse Policy last revised August 2016 revealed the following: reports of resident abuse, neglect, and injuries of unknown source should be promptly and thoroughly investigated by facility management. Review of the Abuse, Neglect and Exploitation (ANE) policy last revised August 2016 revealed an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source should be reported to the administrator, or his/her designee, and a member of management would investigate the alleged incident. A resident-to-resident altercation required staff to separate the residents, and institute measures to calm the situation, identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation, notify each resident's representative and attending physician of the incident and report the incident to the State reporting agency. Interview on 8/10/17 at 11:12 a.m. with administrative nurse B revealed he/she knew resident #2 and resident #3 were involved in an altercation on 8/7/17. Staff B revealed the two residents exchanged words and that was it. Staff B revealed he/she had the charge nurse complete a head-to-toe assessment on resident #3 with no injuries noted, resident #3 was not scared of resident #2, and resident #3 did not want to move to a different room. Staff B revealed resident #3 could tell the facility staff when he/she wanted something to eat or drink and when he/she wanted to go smoke. Staff B felt if resident #2 harmed resident #3 he/she would have reported it by now. Staff B revealed there was no reason to report the incident to the State reporting agency because nothing happened that required a report or investigation. Interview on 8/10/17 at 1:07 p.m. with social service staff C revealed he/she became aware of the issue on 8/7/17 in the morning department head meeting. Staff C revealed he/she was not informed the altercation had been violent. Staff C revealed he/she was concerned about what happened and intended to do more investigating to determine what happened and why the staff documented resident #3 had been monitored for injuries. Interview on 8/10/17 at 1:45 p.m. with administrative staff D revealed the facility failed to complete an investigation into the altercation between resident #2 and resident #3. Staff D also confirmed the facility failed to separate resident #2 and resident #3 after the altercation. He/she confirmed resident #2 moved about freely in the building and was not under constant supervision by staff. Interview on 8/10/17 at 3:14 p.m. with licensed staff I revealed he/she witnessed resident #2 with his/her hands around resident #3's neck choking him/her. Staff I revealed he/she reported the altercation to administrative nurse B. He/she confirmed resident #2 and resident #3 had not been isolated from each other, the staff provided one-on-one supervision of resident #2 when he/she left the room for exit-seeking behavior because the resident feared the police would be call and he/she would get arrested. The facility failed to follow their abuse policies and procedures to report and investigate the altercation on 8/7/17 of resident #2 (the alleged perpetrator) placing his/her hand around resident #3's neck and protect all residents in the facility and failed to protect all residents of the facility from a potential incident with resident #2.

The facility census totaled 56 residents with 7 residents identified as at risk for elopement. The sample included 3 residents at risk for elopement. Based on observation, interview, and record review the facility failed to identify a faulty kitchen door latch. The latch prevented the door from closing properly and being locked. The faulty latch allowed cognitively impaired resident #1, identified as an elopement risk, to leave the facility without staff knowledge. Staff found the resident on a heavily traveled street 1.2 miles from the facility, which placed him/her in immediate jeopardy. Findings included: - Review of resident #1's physician progress notes [REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status score (BIMS) of a 9 (moderate cognitive impairment). The resident required supervision and set up with transfers and required set up help with locomotion on and off the unit. Review of the cognitive care area assessment (CAA) dated 7/27/17 revealed the resident admitted from a behavioral health unit. The resident had abnormalities of gait and mobility, lack of coordination, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and drug induced subacute dyskinesia (mostly irreversible neurological disorder of involuntary movements caused by long-term use of antipsychotic or neuroleptic drugs). The resident had right-side weakness noted to the upper arm. The resident did not comply with care at times. The resident had a BIMS of 9(severe cognitive impairment) and a fall risk score of 12 (high risk). Review of the wandering assessment dated [DATE] revealed the resident had moderately impaired cognition with a history of wandering at home or other setting, a history of exit-seeking and staying near exit doors. The resident had a recent psychiatric hospitalization , verbalized hallucinations and the assessment identified the resident wore a wander guard (a device that alerts staff a resident is trying to leave the facility) bracelet. Review of the care plan dated 7/20/17 revealed the resident had moderate risk for elopement/ wandering. The interventions included a wander guard to alert staff of attempts to leave the facility unattended and staff would accompany the resident when outside the facility. Review of the resident's record revealed an elopement risk assessment dated [DATE] with a score of 13 (moderate risk for elopement). Review of the facility's investigation dated 8/5/17 revealed resident #1 eloped through the kitchen staff entrance which was not wander guard alarmed. The internal kitchen door lock was a code activated slide bolt which apparently failed and remained in the open position which allowed access to the unalarmed door area. The staff reported seeing resident #1 in the hallway at 5:00 a.m. and in the dining area at approximately 5:30 a.m. drinking coffee. At 6:00 a.m. the medication assistant attempted to administer the resident's medication and was unable to locate him/her. A facility staff member located the resident about 1.2 miles from the facility and returned him/her to the facility at 6:35 a.m. Review of Wunderground.com revealed the temperature on 8/5/17 at 6:00 a.m. measured 68 degrees Fahrenheit and the weather was rainy. Interview on 8/9/17 at 2:30 p.m. with certified dietary staff E revealed the exit door in the kitchen to the outside did not latch and the door should be locked when the kitchen staff left at the end of the day. He/she revealed the only way to get to the exit doors at the back of the kitchen was to go through the front kitchen door by the dining room. Staff E revealed the front kitchen door had a key pad code but the door had play in it and did not always latch. Staff E revealed the facility determined the resident went into the kitchen through the front kitchen door because it did not latch and then exited the facility through the unalarmed back door of the kitchen. Interview on 8/9/17 at 4:15 p.m. with licensed nursing staff F revealed staff completed the elopement and wandering assessment quarterly and/or with a significant change in the resident's condition. Staff F revealed the facility used the wander guard system to alert staff a resident with a risk for elopement was near an exit door. He/she revealed the wander guard system sounded when a resident with a wander guard bracelet went within 5 feet of the door. Interview on 8/9/17 at 3:58 p.m. with social service staff C revealed licensed nurse G found the resident approximately one mile from the facility and convinced him/her to get into his/her car and return to the facility. He/she revealed the facility had video surveillance but the cameras did not record, therefore the interdisciplinary team had not determined the exact time the resident left the facility. Interview on 8/9/17 at 2:06 p.m. with administrative nurse B revealed staff picked up the resident near a busy intersection. Staff B reported the resident had delusions the devil tried to get him/her and the resident told the staff he/she wanted to go to the hospital. Interview on 8/9/17 at 4:20 p.m. with administrative nurse B revealed the resident returned to the facility at 6:30 a.m. Staff B revealed resident #1 was potentially out of the building for one hour. Interview on 8/10/17 at 8:43 a.m. with maintenance staff D revealed the dietary services staff failed to report to him/her the latch on the kitchen door did not function properly. Staff D revealed he/she checked the maintenance request logs and staff had not requested repair of the latch. Staff D revealed he/she became aware of the door latch malfunction after resident #1 eloped from the facility. Staff D revealed he/she came into the facility and changed the kitchen door lock around 8:00 a.m. on 8/5/17. Staff D revealed he/she tested the wander guard system upon the resident's return to the building and it functioned appropriately. Interview on 8/10/17 at 9:00 a.m. with certified dietary staff E revealed the door latch had stuck one or two times within the month prior to the elopement. Staff E revealed he/she had not reported the issue to the maintenance staff or filled out a work order request. Staff E revealed the kitchen staff had not arrived for work until after resident #1 eloped on 8/5/17. Staff E revealed a staff member failed to ensure the dining room entrance door shut or the latch failed and the resident eloped from the facility through the kitchen door that exited to the outside. Interview on 8/10/17 at 8:33 a.m. with administrative staff A revealed he/she did not know the door to the kitchen did not latch and only became aware of the situation after resident #1 eloped from the facility. He/she revealed the facility had not completed any repairs to the door prior to the elopement. Staff A revealed the kitchen staff had not informed anyone of the door latch issue or filled out a work order request to have the door fixed prior to elopement. Staff A revealed resident #1 had a long history of elopement attempts from other buildings and the facility identified the resident as an elopement risk upon admission to the facility. He/she revealed the resident could have only gotten out of the kitchen door because the wander guard system was tested as soon as the resident returned and the wander guard system functioned and if he/she had exited any other door the alarm would have sounded and the kitchen door was not equipped with a wander guard. Review of the facility Elopement policy last revised September 2012 revealed upon admission and quarterly, staff would evaluate each resident for elopement and wandering risk. Based upon the evaluation the resident was deemed not at risk for elopement/wandering or at risk for elopement/wandering. Staff documented evidence for such. Interventions were initiated, reviewed or modified. For residents requiring increased monitoring of wandering, the charge nurse will initiate the Elopement/Wandering form for a specific period of time identified in the care plan or physician orders. Examples of resident behavior requiring such actions were: Attempted elopement or wndering not conducive to the safety of the resident or other residents in the community. Review of the facility Work Orders, Maintenance policy last revised August 2010 revealed maintenance work orders should be completed in order to establish a priority of maintenance service. To establish a priority of maintenance services, work orders must be filled out and forwarded to the maintenance director.It should be the responsibility of the department directors to fill out and forward such work orders to the maintenance director. Emergency request would be given priority in making necessary repairs. The facility failed to identify a faulty door latch which prevented a kitchen door from shutting and locking properly. The facility's failure to identify and repair the faulty door latch allowed a resident with impaired mental and physical functioning to elope from the facility for approximately one hour and walk 1.2 miles on a heavily traveled street which placed resident #1 in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected 8/6/17 at 10:00 a.m. by changing the door latch, educating all change nurses, certified nursing staff, and all other staff. The dietary staff will provide monitoring of the door to insure it is secure and locking properly.

The facility had a census of 49 residents, with 3 residents selected for sample. The facility identified 12 residents with cognitive impairment and the ability to move about the facility independently. The sample included two of those residents plus one resident with cognitive impairment who recently left the facility without staff knowledge (Resident #1). Based on observation, interview and record review, the facility failed to have systems in place to ensure resident #1 had adequate staff supervision to prevent elopement from the facility. Resident #1 left the facility without staff knowledge in 40 degree Fahrenheit weather, ambulated south through a residential neighborhood to a heavily traveled frontage road/exit from a main 6 lane highway, headed west and crossed a bridge which spanned a creek/waterway, continued to walk west to a convenience store, entered the convenience store, and then left the convenience store and headed north on a heavily traveled street. Staff located the resident sitting on an electrical box near the heavily traveled street, 0.7 miles from the facility. The facility's failure to provide adequate supervision to prevent elopement placed resident #1 in immediate jeopardy. Findings included: - Resident #1's clinical record included signed physician's orders [REDACTED]. The 9/11/15 Admission MDS (Minimum Data Set) identified resident #1 with a BIMS (Brief Interview for Mental Status) score of 4 which indicated severe cognitive impairment, no wandering behaviors, the needs for supervision only for ambulation and transfers, impaired balance and the ability to stabilize without staff assistance, use of a cane/walker, no falls, and use of antipsychotic medication daily during the seven day observation period. CAAs (Care Area Assessments) completed on 9/16/15 included: *Cognitive Loss: resident is alert and oriented X 2 (times two) with noted confusion Resident often gets facts confused with what (he/she) thinks is correct BIMS is 4 *Falls: Resident is at risk for fall due to imbalances and ambulated with a cane The 11/20/15 Medicare 14 day MDS identified resident #1 with short term memory problems, modified independence in decision making, no wandering behaviors, the need for supervision only for transfers and ambulation, no falls since admission, and use of antipsychotic and antidepressant medication daily. The 9/20/15 care plan noted resident #1's use antipsychotic medication for dementia and mental disorders and had impaired cognitive function/dementia/impaired thought processes. Prior to 12/18/15, the care plan lacked goals/interventions related to the resident's risk of elopement and/or desire to move out of the facility. An 11/6/15 Fall Risk Assessment identified resident #1 as high risk for falls. Nurses Notes included the following: *12/18/15 at 5:01 p.m. identified as a late entry: This entry described a therapist and another resident who reported they could not find resident #1 at approximately 2:15 p.m. Staff completed a facility wide search as a result of those reports. According to the note, staff found resident #1 at 3:10 p.m. on the side of a street, sitting on an electrical box. The vital signs recorded at the time of the resident's return to the facility included a body temperature of 95 degrees Fahrenheit. Hypothermia is defined as a potentially life-threatening condition that occurs when body temperature falls below 95 degrees Fahrenheit. *12/19/15 at 9:38 a.m.: This entry described resident #1's requests for help to pack his/her bags so the resident could move from the facility that day. According to the note, staff advised resident #1 he/she could not move from the facility on that day. *12/21/15 at 9:54 a.m.: This entry described how resident #1 packed all of his/her belongings into boxes and told staff he/she planned to move to (name of assisted living apartments) that day. Staff advised the resident he/she could not move from the facility on that day. *12/21/15 at 2:41 p.m.: This entry described staff assessment of resident #1 and subsequent decision to place the resident back on 15 minute visual checks due to the resident's comments about leaving the facility. Following the 12/18/15 elopement, staff reviewed/revised resident #1's care plan as follows *12/18/15: Elopement - resident to stay safe 15 minute checks and reassess at 24 hours. *12/19/15: Reassess after elopement: 30 minute checks for 24 hours then reassess. *12/20/15: Reassess after elopement: 1 hour checks. *12/21/15: Reassess after elopement: 15 minute checks *12/21/15: Increased visual observation while out of room until seen by (physician's name) Staff completed an elopement risk assessment on 12/18/15 following resident #1's elopement from the facility. The resident scored 10 on the assessment which indicated the resident had a moderate risk for wandering. Risk factors for wandering included forgetful/short attention span, readmission within the past month, independent mobility, use of antipsychotics/antidepressants, and a history of wandering. According to Weather Underground at www.wunderground.com, the temperature in Wichita on 12/18/15 at 2:30 p.m. was 40 degrees Fahrenheit with winds of 14 miles per hour. During an observation on 12/21/15 at 3:45 p.m., resident #1 participated in an large group activity in the main dining room. The resident interacted appropriately with staff and other residents. The resident had a cane leaned against the table. During observations on 12/21/15 at 3:00 p.m. and 4:10 p.m., three of seven exit doors within the facility did not have fully functioning alarm systems as follows: *Hall 2 exit door alarm failed to sound when Maintenance Staff C held the door open for >60 seconds. *Hall 4 exit door alarm did not reset after opening and therefore residents could potentially exit the door without staff knowledge. *Hall 5 exit door had wires removed from the door alarm which disarmed the alarm that should sound when the door remained open/unlatched after a short period of time. Review of door alarm checks revealed no evidence staff checked the functionality of all door alarms after resident #1's 12/18/15 elopement. During an interview on 1/4/16 at 3:05 p.m., Maintenance Staff C reported he/she only checked the functionality of the key pad code alarm system at each exit door when he/she completed weekly door alarm checks prior to 12/22/15 and did not check to ensure an alarm sounded when the exit doors remained opened/unlatched. Staff C described the problems with the 3 nonfunctional exit door alarms noted on 12/21/15 which included one door that lacked functional magnet clips, one door with a malfunctioning switch, and one door with a delay set for a prolonged time to allow construction workers to carry supplies in/out through that door. On 12/22/15 at 7:30 a.m., survey staff drove the route used by resident #1 when he/she left the building without staff knowledge on 12/18/15. The first part of the route went through a quiet residential neighborhood. That street then came to a dead end where it connected with a heavily traveled frontage road/exit from the west bound lanes of a heavily traveled highway. As the road led west, an open field was on the right of the busy street and a short wall which separated the frontage road from the main highway was on the left. The field led to either a bridge over a creek/waterway, or down sloping terrain directly to the water. Once past the bridge, the road led to a busy convenience store located at the intersection of the frontage road and a heavily traveled north/south street. The electric box where staff located resident #1 was slightly north of the convenience store and on the right hand/east side of the busy street. During an interview on 12/21/15 at 1:30 p.m., Administrative Staff A reported Resident #1 left the facility without staff knowledge on 12/18/15 at approximately 2:30 p.m Staff A stated he/she first learned resident #1 was not in the facility when another resident reported him/her missing. After a search of the entire facility and adjacent grounds, Administrative Staff A dispersed staff to different areas of the neighborhood. According to Staff A, staff found resident #1 approximately 0.8 miles from the facility where he/she sat on an electrical box on the right side of the street. Staff A reported the resident wore a heavy coat and a scarf when staff found him/her. Although resident #1 told staff he/she planned to go home after he/she rested on the electrical box, Staff A stated, I'm not sure (he/she) would have been able to find (his/her) way home. Administrative Staff A reported the facility had a Wanderguard system (an alarm system that consisted of door alarms and personal alarm devices which sounded when at risk residents approached exit doors) but resident #1 did not utilize a Wanderguard alarm prior to the 12/18/15 elopement and staff did not place such a system on the resident after the elopement. According to Staff A, the facility placed resident #1 on every 15 minute checks following the 12/18/15 elopement, then progressed to every 30 minute checks, and then hourly checks. After the resident talked about moving out, staff placed resident #1 back on every 15 minute checks. as of 12/22/15 at 8:00 a.m., resident #1 did not have a Wanderguard device in place. During an interview on 12/22/15 at 9:32 a.m., Direct Care Staff D reported resident #1 definitely should never be outside alone. According to Staff D, resident #1 talked about moving out of the facility for approximately 2 months prior to the 12/18/15 elopement and continued to talk about moving out after the incident. Staff D also reported resident #1's cognitive status changed from day to day, and depended on his/her anxiety level. When the resident did not have anxiety, he/she functioned on a higher cognitive level than when he/she had anxiety. According to Staff D, the resident became anxious frequently and required medication for the anxiety. When that happened, nothing and no one could redirect the resident. During an interview on 12/22/15 at 10:06 a.m., Direct Care Staff E reported resident #1 could not remain outside without supervision even before the 12/18/15 elopement. According to Staff E, resident #1 expressed a desire to move out of the facility over the past several weeks and repeatedly packed up his/her room in preparation for that move. During an interview on 12/22/15 at 11:30 a.m., Administrative Staff A reported resident #1 sometimes went outside and stood in the canopy area near the front door without staff supervision. According to Staff A, that privilege was part of (his/her) freedom and the resident never attempted to leave the area prior to 12/18/15. Staff A also reported he/she opted to not utilize the Wanderguard system after resident #1's elopement on 12/18/15 because I thought it would just make things worse with (him/her). During an interview on 12/22/15 at 12:15 p.m., Direct Care Staff F reported he/she saw resident #1 outside without staff supervision at approximately 10:00 a.m. on 12/18/15. At that time, the resident walked around in the parking lot and carried an unlit cigarette. Staff F reported a theory that another resident who was also outside at the time might have let resident #1 outside either accidentally or on purpose. Staff F reported she told other staff resident #1 was outside, and by that time resident #1 came back into the building independently. According to Staff F, he/she was not at the facility when resident #1 left without staff knowledge later in the afternoon on 12/18/15. Staff F also reported resident #1 spoke frequently of leaving the facility to move to an apartment. During an interview on 12/22/15 at 2:00 p.m., Corporate Consultant B reported the facility policy required elopement assessments upon admission and at least quarterly thereafter. According to Consultant B, staff use the MDS question related to wandering behaviors in section D to assess for elopement risk, and if a resident did not exhibit wandering behaviors during the seven day observation period, the resident would not be considered at risk for elopement. Consultant B confirmed the current system did not address residents with exit seeking behaviors or those who verbalized a desire to move out of the facility. Consultant B also confirmed the current system did not factor in a resident's cognitive status and ability to move independently when determining elopement risk. During an interview on 12/22/15 at 2:30 p.m., Resident #1 recalled talking a walk a few days earlier because he/she needed to clear my head and walking helps. According to the resident, he/she left the facility and walked to the convenience store, went inside to use the restroom, and then left and headed north before he/she got tired and stopped to sit on the electrical box. Resident #1 reported he/she planned to return to the facility after the walk and knew how to get back to the facility. Resident #1 expressed surprise that everyone got upset about the walk, and stated, They let me walk around out front by the canopy all the time by myself. That's allowed here and I do it a lot. I just never took off before. During an interview on 1/5/16 at 10:40 a.m., Licensed Nurse J described resident #1 as confused most of the time. According to Nurse J, he/she worked on 12/18/15, the date of resident #1's elopement, and noticed him/her missing when it was time for the residents' 2:00 p.m. blood sugar check. When Nurse J could not locate the resident, he/she notified other staff and started a search. Licensed Nurse J reported staff often times allowed resident #1 outside without staff supervision but only when another resident with no cognitive impairment was also outside. Nurse J reported the other resident with no cognitive impairment knew resident #1 should not leave the facility/facility grounds. During an interview on 1/6/16 at 11:00 a.m., Licensed Nurse K reported he/she did not know if staff considered resident #1 an elopement risk prior to the 12/18/15 elopement, but the resident periodically told staff and other residents he/she intended to pack up and get out of here. Because of those statements, Nurse K reported he/she kept a closer eye on the resident whenever he/she started talking about packing. The facility's Elopement policy with a revision date of September 2012 included: *Upon admission and quarterly, each resident will be evaluated for elopement and wandering risk. Based upon that evaluation, the resident will be deemed not at risk for elopement/wandering or at risk for elopement/wandering. *New wandering behavior or attempted elopement will be noted on the 24 hour report, discussed in daily clinical meeting and documented in the Nurses Notes as to effect of interventions. Update Care Plan. The elopement policy did not address the increased elopement risk for residents who exhibited exit seeking behaviors or who expressed a desire to move out of the facility. The facility failed to have systems in place to ensure staff provided adequate supervision to resident #1 to prevent elopement. Resident #1 had severe cognitive impairment (based on the most recent comprehensive assessment dated [DATE]). The resident left the facility without staff knowledge in 40 degree Fahrenheit weather, ambulated south through a residential neighborhood to a heavily traveled frontage road/exit from a main 6 lane highway, headed west and crossed a bridge which spanned a creek/waterway, continued to walk west to a convenience store, entered the convenience store, and then left the convenience store and headed north on a heavily traveled street. Staff located the resident sitting on an electrical box near the heavily traveled street, 0.7 miles from the facility. After the elopement, the facility failed to check all door alarms to ensure functionality. On 12/21/15 three of seven exit doors lacked functional alarms. The facility's failure to provide adequate supervision to prevent elopement and ensure the presence of functional alarms on all exit doors placed resident #1 in immediate jeopardy. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 12-30-2015 when the facility assessed all residents of the facility for elopement risk, and revised/developed a plan of care related to elopement risks for those residents identified with such risks, reviewed the elopement policy with all staff, restricted the access of the facility door code from all residents, required all smoking residents to go to the courtyard of the facility to smoke instead of in front of the facility, implemented an enhanced check of the functioning of the door alarms and the functioning of the wander guard alarms and completed education of staff on all of these measures, with the last in-service completed on 12-30-15.

The facility had a census of 63 residents, with 7 residents selected for sample. Based on observation, interview and record review, the facility failed to provide one of 7 residents with the necessary care and services (assessment and management of pain) to maintain the resident's highest practicable physical well-being. Staff failed to pre-medicate resident #1 prior to a pressure ulcer dressing change as directed by the care plan. The resident experienced severe pain during the dressing change and staff failed to respond to and/or treat the resident's complaints of pain. Staff completed the dressing change in spite of the resident's complaints of pain. Findings included: - Resident #1's clinical record included a face sheet which noted readmission to the facility from an area hospital on [DATE]. The 7/18/14 Admission MDS (Minimum Data Set) identified resident #1 with no cognitive impairment, the need for extensive assistance of staff for bed mobility and ADLs (activities of daily living), an inability to ambulate, constant pain within the past 5 days described as severe, use of scheduled and prn (as needed) pain medication) to manage pain as well as use of non-medication interventions to decrease pain. A "Pain" CAA (Care Area Assessment) completed on 7/23/14 noted resident #1's severe pain which made it difficult for the resident to sleep at night and limited day to day activity. According to the CAA, the resident experienced severe pain "almost constantly." The care plan included 7/10/14 interventions to "Administer [MEDICATION NAME] (pain medications) prior to wound treatment as needed." physician's orders [REDACTED]. o 7/10/14 order for [MEDICATION NAME] (narcotic medication used to treat moderate to severe pain) 10 mg.(milligrams) every 4 hours as needed for generalized pain o 7/10/14 order for [MEDICATION NAME] (narcotic medication used to treat moderate to severe pain) 2 mg. as needed every 4 hours for generalized pain o 7/12/14 order for [MEDICATION NAME] 100 mcg (micrograms)/hour [MEDICATION NAME] every 72 hours for generalized pain o 7/13/14 order for treatment to the left and right buttocks every 3 days for Stage 2 pressure ulcers During an observation on 7/24/14 at 9:20 a.m., Licensed Nurse I prepared to complete a dressing change on pressure ulcers on resident #1's left and right buttocks. Direct Care Staff J and K assisted with turning the resident onto his/her side and held the resident in that position during the dressing change. During the dressing change process which consisted of wound cleaning and re-dressing the wounds, resident #1 repeatedly cried out in pain, saying things such as "Oh Lord, Oh Jesus, the pain, the pain!" and "Oh my god, the pain is killing me. I can't take it. I can't take it." Licensed Nurse I responded to the resident's complaints of pain by saying, "I know. I'm almost finished." Review of resident #1's MARS (medication administration records) immediately following the previously described observation revealed no evidence staff administered pain medication to the resident prior to the dressing change. During an interview on 7/24/14 at 1:30 p.m., Resident #1 reported he/she experienced pain rated at a 10 on a 1-10 scale during the dressing change earlier that morning. According to the resident, "The pain was so bad I couldn't stand it. It feels like my skin is splitting open." Resident #1 also reported severe pain occurs during dressing changes "almost all the time" and staff do not routinely administer pain medication prior to the dressing changes. During an interview on 7/24/14 at 3:00 p.m., Licensed Nurse I confirmed resident #1 verbalized pain during the dressing change earlier that morning. According to Nurse I, the resident complains of pain"about every time we do anything for (him/her)." Nurse I confirmed the resident has orders for "as needed" pain medication and reported he/she did not administer any pain medication prior to the dressing change described previously. During an interview on 7/28/14 at 9:00 a.m., Administrative Nurse B confirmed staff should have administered pain medication to resident #1 prior to the dressing change as directed by the care plan. Nurse B also reported staff should stop treatments that caused pain and administer pain medication prior to proceeding with the treatment. During an interview on 7/28/14 at approximately 10:00 a.m., Consultant/Mid-level practitioner J reported resident #1 had frequent complaints of pain from various sources. According to Consultant/Mid-Level practitioner J, the resident had "adequate orders to take care of (his/her) pain" and added, "Yes, I would expect staff to pre-medicate prior to a procedure that might be painful." According to the facility's undated "Pain Assessment and Management" policy, "It is the goal of the facility that all residents will be assessed for pain, interventions implemented to reduce or relieve pain, and effectiveness of interventions re-evaluated in a timely manner...." The facility failed to provide resident #1 with the necessary care and services (assessment and management of severe pain) to attain the resident's highest practicable physical well-being. Staff failed to administer pain medication prior to a pressure ulcer dressing change as directed by the care plan and the resident experienced severe pain during that dressing change.

The facility census totaled 61 with 23 residents in the sample. Based on observation, interview and record review the facility failed to provide supervision, assistance to prevent falls and failed to do thorough investigations to reveal root causes for falls for 3 of 4 residents sampled with accidents. (#64, #70, #52) Resident #70 experienced a fractured femur. Findings included: - Review of resident #70's signed history and physical dated 11-11-13 included the following Diagnoses: [REDACTED]. Review of the admission MDS (Minimum Data Set 3.0, a required assessment) dated 11-25-13 revealed a BIMS (Brief Interview for Mental Status) score of 0 indicating the resident had severe cognitive impairment. The MDS identified the resident had periods of inattention and disorganized thinking. It identified the resident required extensive assistance of 1 with toileting and transfers. It also identified the resident was not able to balance self without staff assistance. It identified the resident had a fall in the past 2-6 months and had 2 non-injury falls since admission. It also identified the resident received an antipsychotic medication and an antidepressant medication. It also identified the resident received occupational and physical therapy. Review of the cognitive CAA (Care Area Assessment) dated 11-27-13 revealed the resident does not stay focused on conversation; he/she would randomly change from subject to subject. The resident could answer simple questions regarding care, though he/she was unable to recall past history at times. He/she is slow to respond at times and may require verbal cues and prompting. The resident had been very agitated, cursing at staff, and resistive to care. The resident had a fracture from a fall prior to admission and complained of pain in left leg. It identified the resident at risk for further decline related to resisting care and confusion due to a [DIAGNOSES REDACTED]. Review of the Fall CAA dated 11-27-13 revealed the facility failed to complete the CAA to identify risk factors that could increase the resident's risk for falls. Review of the temporary care plan that was initiated on 11-19-13 revealed the resident was high risk for falls with interventions to place in fall prevention program, refer to physical and occupational therapy, keep call light within reach, and remind the resident to call for assistance before mobilizing. Review of the care plan notebook included a care plan update sheet the facility used that identified the resident had a fall on 11-20- 13 with interventions to answer call light promptly, add chair/bed alarm, assist the resident to toilet before and after meals, and place mat on the floor by the bed. It also had an update on 11-24-13 with an intervention to replace bed alarm, initiate 15 minute checks through the night, and obtain x-ray. Review of the fall risk assessment dated [DATE] revealed a score of 13 indicating high risk for falls. Review of the unusual occurrence report dated 11-20-13 revealed the resident was found on the floor by the aide sitting between the bed and w/c (wheelchair). The resident was wrapped up in bedding and was alert to self with disorientation and confusion. The report also identified no pain or injuries noted. Review of the fall investigation report dated 11-20-13 revealed the measures in place prior to the fall included brakes on, bed in low position, and call light within reach. The measures taken after the fall included to move the resident close to nurses' station in wheelchair, alarms to bed and chair and 15 minute visual checks and frequent observation. The investigation failed to identify when and where the resident was last observed, toileted. It failed to identify and evaluate potential causes of the fall. Requested documentation of the 15 minute checks on 1-15-13 and the facility failed to provide any. Review of the unusual occurrence report dated 11-24-13 revealed the medication aide found the resident on the floor during rounds. The resident was sitting on the floor against the clothing closet, wrapped in bedding. The bed alarm was pulled apart at the connection, and did not sound. The resident was alert to self, disoriented, and confused. The resident performed passive range of motion without verbalization of pain, but had slight discomfort to left ankle, no signs of joint dislocation, swelling, bruises, or bleeding at this time. Review of the 11-24-13 fall investigation report revealed the resident had brakes on bed, low position, and call light in reach, bed/chair alarm on but not sounding as intervention prior to fall. Interventions implemented after fall included moved close to nurses' station in wheelchair, frequent observation, and 15 minute visual checks. Hand written on the unusual occurrence record revealed staff reconnected the alarm and did 15 minute checks after the fall. The facility failed to implement new interventions after the fall to prevent further falls. Review of the clinical note dated 11-27-13 revealed the resident complained of left knee pain and inability to bear weight while working with therapy to his/her left leg. Physician informed and order obtained to x-ray left knee and lower leg today. A clinical note later that day revealed the resident had a fracture of left femur according to a preliminary x-ray report. The physician was informed and an order to transport resident to the hospital for evaluation and treatment. On 1-6-14 at 1:39 p.m. direct care staff A and C assisted the resident to transfer from wheelchair to bed. Staff A put a gait belt around the resident and the 2 of them assisted the resident to stand. When the resident stood, an alarm sounded. Staff then sat the resident on the bed; staff B took the alarm and put it under the resident's sheet on the bed under his/her buttock area. After the resident was comfortable on the bed staff put a brown mattress pad on the floor beside the bed and the bed was in the lowest position. On 1-8-14 at 3:28 p.m. direct care staff E stated he/she did not know anything about the resident having falls but said that he had a pressure pad alarm on in the wheelchair and bed, the bed all the way to the floor, and a mat on the floor when in bed. On 1-11-14 at 2:23 p.m. direct care staff C stated the resident had a bed alarm under the sheet and a mat on the side of the bed. Staff C stated the resident also had a pad alarm in the wheelchair. The resident required assistance of 2 with transfers and staff needed to use a gait belt. On 1-11-14 at 4:35 p.m. direct care staff C stated staff are supposed to check the alarms weekly to make sure they are working. He/she said there was a log book that was kept back in the restorative room where they were documented. On 1-12-14 at 11:59 a.m. direct care staff A stated the fall prevention program was just to let staff know the resident was at risk for falls and staff needed to keep an eye on the resident. On 1-12-14 at 12:03 p.m. direct care staff B stated the fall prevention program marked on the care plan meant the resident was a high risk for falls and had bed and chair alarms, and staff needed to keep a close eye on them. On 1-12 -14 at 12:05 p.m. licensed nursing staff D stated staff does a fall risk assessment on new admission and if the resident was a high risk for falls there is an intervention guideline tool that staff needed to use to decide what interventions to implement. Staff D stated for a resident who triggered high risk for falls all the interventions would be implemented on the guideline. Staff D stated that the guideline did not include alarms as initial interventions to put into place but if a resident had a fall then the alarm or other interventions would be discussed and implemented. On 1-11-14 at 12:22 p.m. administrative nursing staff F stated when a fall intervention program was initiated the nurse needed to initiate the appropriate interventions and that could include an alarm or any other intervention if appropriate. Staff F stated if a resident had a hip fracture, was confused and attempting to get up without staff assistance he/she would expect staff to implement an alarm and maybe a mat by the bed. On 1-12-13 at 3:08 p.m. physician G stated there should have been a care plan implemented. The facility failed to thoroughly investigate falls in order to identify hazards and implement interventions to prevent further falls. The resident experienced a fractured femur. - Review of resident #52's signed physician order [REDACTED]. Review of the Admission MDS (Minimum Data Set 3.0, a required assessment) dated 11-30-13 revealed the resident had a short and long term memory deficit and had severe impairment with decision making ability. The MDS identified the resident was dependent on 2 staff for transfers, bed mobility, and dressing. It identified the resident unable to balance when moving from seated to standing position and surface to surface transfers without assistance. It identified the resident had a fall in the 30 days prior to admission into the facility but did not have any falls since admission. Review of the FALL CAA (Care Area Assessment) dated 12-23-13 revealed the resident had disorganized thinking and did not answer questions appropriately at times. The resident had a [DIAGNOSES REDACTED]. The resident had an unsteady gait with weakness to lower extremities. The resident required extensive assistance from 2 staff with transfers, and bed mobility. It also noted the resident had a history of [REDACTED]. Review of the care plan last revised on 1-7-14 included the following updates to care plan: 12-11-13 - discontinue chair pad alarm, add pull tab alarm in chair, and use large deck of cards on bedside table for resident to keep occupied when restless. 12-28-13- and 12-29-13 had the same interventions of pad alarm discontinued, pull tab only, keep resident in sight of nurse and use Broda chair (a type of wheelchair). 1-7-14 - non injury fall. It lacked any type of update or change in current interventions. Review of the temporary care plan dated 11-15-13 it identified the resident at risk for falls. Interventions included, place in fall prevention program, refer to PT/OT, and remind to call for help before mobilizing, place call light within reach, and check resident every 1-2 hours for safety and positioning. It also directed for a mat to be at the bedside and pressure pad alarm while in bed. Review of the fall investigation dated 12-11-13 at 6:50 a.m. revealed the resident had been changed by staff just prior to fall and placed in front of the birdcage in the dining hall. Staff found the resident lying on his/her right side in front of the Broda chair. The chair/pressure pad alarm was in place but did not sound. Interventions included adding pull tab alarm and discontinue the pressure pad alarm due to Broda chair. It identified the Broda chair prevented the residents weight to be distributed over the pressure pad alarm correctly causing the alarm to not sound. The pad alarm was replaced with a pull tab alarm and moved close to nursing station and frequent observations which were already in place prior to gall. Review of the Fall trend investigation report dated 12-28-13 identified protective measure in place before the fall - included bed/chair alarm, assist with ambulation, and verbal cues reminders for safety measure take after fall included adding a pad alarm. The record identified the nurse found the resident sitting on the floor in front of his/her chair. The chair body weight alarm was in place but did not sound off at this time. According to the fall investigation on 12-11-13 the pressure pad alarm was to be replaced with a pull tab alarm. Review of the 12-29-13 witnessed fall investigation revealed the resident was in the dining room, had bed/chair alarm in place. It identified measures taken after fall included frequent observations which were already in place 2 falls prior. It noted the nurse was called to the dining room by direct care staff and the resident was on the floor, in a sitting position with adequate range of motion to all extremities. The resident had no expression of pain with range of motion and the alarm was in place and working. The investigation did not identify possible cause of fall or new interventions to be implemented to prevent further falls. Review of the fall investigation dated 1-7-14 revealed prior to the fall; the resident had a bed/chair alarm and frequent observations in place. After the fall, the resident was moved closer to nursing station and frequent observations were implemented. It identified the staff changed out the pull tab clip due to it not staying attached to the resident's clothing. Documentation included the nurse was called to the dining room and resident was seen on the floor in a sitting position. The resident had adequate range of motion to all extremities with no injury noted. The investigation did not include when the resident was last seen, what he/she was doing to adequately assess for effectiveness of interventions and possible root cause. On 1-8-14 at 3:08 p.m. the resident stood up from Broda chair which was in the dining/TV area and started to walk into the dining room. The pull tab alarm did not sound because it had come unclipped form the resident's shirt. The resident took about 5 steps before direct care staff U got to the resident and called for another staff to assist him/her. The other unidentified staff assisted the resident to sit back in his/her Broda chair. Prior to the resident actually standing up, observations from 2:00 p.m. to 3:08 p.m. revealed the resident made multiple attempts to sit up but staff would intervene and have the resident sit back down in the Broda chair. Staff made no attempt to ask the resident if he/she needed to use the toilet or needed something else. At 1-9-14 at 12:04 p.m. the resident sat in the TV area, leaned forward, the alarm sounded and, staff went and assisted the resident to lean backwards and put the tab alarm back on. At 1-9-14 at 12:27 p.m. the resident had feet on the side of the Broda chair and leaning to the right, the alarm sounded and went and put the alarm back on his/her shirt and placed the over bed table in front of the resident with some oversized cards on it. Direct care staff U asked the resident what he/she wanted and the resident wanted a pen and paper, which staff U provided. On 1-8-14 at 4:02 p.m. direct care staff E stated the resident required checking and changing every 2 hours and needed extensive assistance of staff. He/she stated the resident had a pull tab alarm and a pad alarm on the wheelchair chair and in bed. Staff E stated he/she did not think the resident had any falls but tried to get out of the wheelchair chair a lot when he/she got tired of sitting so they provide the resident with big cards and set them up like solitaire. On 1-1-14 at 4:35 p.m. direct care staff D stated the chair and tab alarms were checked every week to make sure they worked and documented on a log that was kept in a notebook in the restorative room. On 1-9-14 at 6:26 a.m. licensed nursing staff V stated the nurse made assignments and did rounds to make sure things were getting done as planned. Staff V stated the resident is kept at the nurses' station or in the dining room so he/she is close to the staff to keep an eye on him/her due to fall risk. On 1-11-14 at 4:36 p.m. administrative nursing staff F stated the restorative aide checked the alarms and the wander guards to make sure they are in good working order. He/she also stated that when an intervention is implemented that he/she expected the staff to monitor to make sure it is effective and if not to change it and put the change on the care plan. Review of the Falls - Clinical Protocol policy dated October 2010 revealed when a resident had fallen; staff was to attempt to define possible causes within 24 hours of the fall. It also revealed if the individual continued to fall; the staff and physician would re-evaluate the situation and consider other possible reasons for the resident falling and would re-evaluate the continued relevance of current interventions. The facility failed to provide adequate supervision to ensure interventions that were implemented were followed through and failed to initiate relevant interventions to prevent falls as evidenced by initiating the intervention of using the pressure pad which had already been determined to be ineffective in the Broda chair. - Review of resident #64's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 8/19/13 revealed a BIMS (brief interview for mental status) score of 6 indicating severe cognitive impairment. The resident had mild depression, rejected care 4-6 days out of 7, and wandered daily. The resident required minimum assistance of one staff with ADL'S (activities of daily living) including bed mobility, transfers, ambulation, and extensive assistance with dressing and toileting. The resident had no falls and received an antipsychotic 5 of the 7 day look-back period. Review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 5 indicating severe cognitive impairment. The resident had mild depression with no behaviors documented. The resident required extensive assistance of two with bed mobility, transferring, ambulation, mobility toilet use and personal hygiene. The resident had 2 or more falls since last assessment and received an antipsychotic, antidepressant, and a hypnotic 7 out of 7 days of the look-back period. Review of the cognitive CAA (care area assessment) dated revealed the following: the resident has cognitive loss. His/her BIMS score was 6 - severe impairment. He/she is hard of hearing which could enhance his/her confusion. The resident had difficultly expressing his/her self at times due to he/she could not find the right words that he/she wished to express. The resident had difficulty locating his/her room and the bathroom. The resident was at risk for his/her needs not met. ADL CAA- The resident required assistance of one staff to ensure completion of daily care tasks. The resident had pain, poor safety awareness, severe cognitive impairment and confusion. This all contributed to his/her inability to perform ADLs independently. Fall CAA- The resident was at risk falls and injuries. The resident had not fallen at this facility. The resident at risk for falls r/t poor safety awareness confused most of the time and had an unsteady gait. Review of the care plan with a date of 8/25/13 revealed the resident was at risk for falls due to a history of falls prior to admission. Approaches included; anticipate resident needs, be sure call light within reach and provide prompt response to all requests for assistance. Ensure that resident wears proper footwear. Provide a safe environment with clean floors, free from spills and clutter, adequate glare free light, a working and reachable call light and bed in low position, personal items within reach. Updates to the care plan revealed the following falls 9/24/13 with a femur fracture, the care plan failed to document the resident's ambulatory status at the time of the fall. No new interventions added to the care plan following readmission with a fractured femur. Fall on 10/3/13 revealed the resident slid out of the wheelchair in his/her room. Interventions included the resident brought to the nurses' station for close monitoring and an alarm placed in his/her chair and bed. 10/6/13- fall in room. Intervention included the resident moved to a room closed to the nurses' station. 11/9/13 the resident had a fall in dining room. No new intervention added to care plan. 11/17/13 fall in dining room- new interventions included obtain x-ray of R leg due to fall, obtain UA (urinalysis), CBC (complete blood count, a laboratory blood test), BMP (basic metabolic profile, a laboratory blood test) due to increased restlessness, start Klonopin (an antianxiety medication) 0.5 mg (milligrams) at bedtime for [DIAGNOSES REDACTED]. Obtain digoxin level (blood test), obtain CT (cat scan) with contrast of the head, Give Valium (antianxiety medication) 5 mg 1 hour prior to scan and obtain 2-D ECHO (a test that shows the movement of the heart). 11/24/13-fall -due to negative results of 2-D ECHO and CT and UA will start hourly checks and document on the treatment record. 12/12/13- fall with no injury- Replace battery in alarm, x-ray, start neurological checks 15 minute checks for 24 hours, 30 minute checks for 24 hours, 1 hour checks for 24 hours. 1/3/14- fall- hematoma with EMS (emergency medical service) called and broda (reclining) chair ordered. Review of the physician orders [REDACTED]. The medication discontinued on 11/21/13. Review of the physician orders [REDACTED]. Review of the physician orders [REDACTED]. Review of the fall investigation for 9/24/13 revealed the resident observed sitting in the TV area in the dining room. Approximately 3 to 5 minutes later staff found the resident on the floor in the dining room next to the chair where he/she ate meals. When the charge nurse and the administrative nurse got the resident up the resident initially had no complaints of pain. When the same nurses transferred the resident to the wheelchair the resident was unable to bear weight on the right leg and complained of pain. The investigation failed to have information regarding how the resident got to the TV area, ambulation status or how long the resident had been in the TV area. The report lacked documentation of what footwear the resident wore at the time of the fall. Review of the fall investigations for falls on 10/3/13, 10/4/13, 11/17/13 and 11/24/13 lacked witness statements or complete investigations of the falls. Review of the most recent fall investigation on 1/3/14 at 8:2 a.m. revealed: The resident was in a wheelchair the dining room for breakfast. The chair alarm in place and non-skid shoes on. Resident had been leaning against table that morning. Direct care staff had to wake the resident up to feed him/her. After breakfast a direct care staff pushed the resident away from the table then walked away for a moment to assist another resident. The resident continued to lean over. A staff yelled as the resident fell over. The resident landed head first onto the floor. A large hematoma present on left side of forehead with bleeding. At 8:35 a.m. the residents physician notified with order to send to hospital for evaluation by EMS. Family member notified at 9:15 a.m. Review of the fall risk assessment dated [DATE] revealed the residents risk score of 21. (A score of 10 on the assessment indicated high fall risk.) Review of the treatment sheets dated 11/2013, 12/2013 and 1/2014 lacked documentation of any hourly checks as care planned to be done and documented on the treatment sheets on 11/24/13. Review of the nurses progress notes dated 1/3/14 at 1:48 revealed; Resident returned from ER after fall. A 5.5cm (centimeter) x 5.5cm hematoma present on left center forehead. Continue with Neurological checks. 1) Broda chair ordered. family member made aware of the order. Review of the nurses progress notes dated 1/4/14 at 4:00 p.m. revealed; due to possible haldol toxicity, haldol has been discontinued and 2 doses of denadryl are to be given, one dose now and one dose at HS (bedtime). Observation on 1/7/13 at 1:30 p.m. revealed the resident sat by the nurses' station in a wheelchair. A chair alarm was in place in the chair. The resident had a large amount of bruising to both eyes and nasal bridge. Also a large raised area approximately 3-4 centimeters noted on the fore head with bruising and abrasion. The resident was awake, alert and interacted with staff when spoken to. Observation on 1/8/13 at 7:30 a.m. revealed the resident sat in a reclining Broda chair at the dining table. Yellow-brown bruising to face noted. The resident required total assistance with the breakfast meal by a direct care staff with the resident eyes closed throughout the meal. Observation on 1/8/14 at 4:00 p.m. revealed the resident sat in a Broda chair in the dining room and actively participating with staff assist playing Bingo. Observation on 1/9/14 at 8:10 a.m. revealed the resident sat in the TV area in a Broda chair. The resident was alert and calm. No observation of restlessness. Observation on 1/9/14 at 9:20 a.m. revealed direct care staffs Q and B transferred the resident from the Broda chair to his/her bed with the use of a gait belt and the resident bearing weight to pivot transfer. The bed was in low position and bed alarm in place. Fall mat placed in front of the bed and call light attached to the bed within reach. During an interview on 1/9/14 at 9:40 a.m. direct care staff Q reported the resident required close monitoring and spent time up around the nurses ' station or a place where there are people so the resident does not fall. The resident just got the new chair and seemed to relax while reclined in the Broda chair. The resident transferred with assist of two and a gait belt with resident able to help with the transfer. During an interview on 1/13/14 at 9:45 a.m. licensed nurse D reported he/she started employment at the facility after the time of the 9/24/13 fall but was on duty when the resident had the fall on 1/3/14. The nurse stated it was difficult to monitor the effects of the haldol due to the resident being sleepy one day from being up all night then the next day would be wide awake. On the day of the fall the resident was sleepy so it was hard to tell it was medication and what was normal for him/her. On 1/14/14 at 9:45 a.m. licensed nurse I reported nurses monitor residents for all medications. Any decline or a change in condition is recorded in the clinical notes. The resident had no abnormal behaviors leading up to the fall on 1/3/14 On 1/13/14 at 10:00 a.m. administrative nurse F reported that the resident was ambulatory with supervision when admitted and at the time of the fall. The nurse reported there was no mobility status or ambulation status on the residents care plan. On 1/13/14 at 3:45 p.m. consultant J reported he/she would have expected the staff to assist and supervise the resident with ambulation due to the resident ' s confusion and history of wandering. Review of the policy named Falls-Clinical Protocol dated 10/2010 revealed: The staff will document risk factors for falling in the resident ' s record and discuss the resident's fall risk. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where the falls happen, any observations of the events. Cause Identification For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. Monitoring and Follow-up The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. The facility failed to provide supervision, assistance to prevent falls, and failed to do thorough investigations to reveal root causes for falls for resident #64.

The facility census totaled 61 residents with 23 included in the sample. The sample included the review of 4 residents with weight loss. Based on observation, interview and record review, the facility failed to consistently implement interventions, document the amount of supplement consumed, and follow the manufacturer's recommendation on the use of protein powder to ensure the weight loss for 1 of 4 sampled residents remained unavoidable. (#64) Resident #64 lost 24 pounds, or 17.56% of his/her weight, over 5 months. Findings included: - Review of resident #64's electronic health record revealed the resident with the following Diagnoses: [REDACTED]. Review of resident #64's admission MDS (Minimum Data Set) dated 8/19/13 revealed a BIMS (Brief Interview for Mental Status) score of 6/15 (indicating severely impaired cognition), required limited assistance from one staff with eating, and a steady weight of 200 pounds, and no issues with oral/dental/gum status. Review of the resident's quarterly MDS dated [DATE] identified the resident with a BIMS score of 5/15 (indicating severely impaired cognition), required required supervision from one staff with eating, had no issues with chewing or swallowing, a steady weight of 123 pounds, and the oral/dental section was not marked. Review of the undated Nutritional Status CAA (Care Area Assessment) revealed staff had not completed the CAA. Review of the care plan dated 8/25/13, revealed the the resident was at risk for constipation and directed staff to administered medications as ordered to prevent constipation, encourage the resident to sit on the toilet, record the resident's bowel habits daily, follow the facility's bowel protocol and to keep the physician informed of any problems. The care plan did not include any interventions for nutrition/dietary in August or on admission, even though nutrition had triggered as a concern for the resident. The care plan contained the following updates: On 10/11/13, staff wrote in: Weight loss 2% x 1 week--Add protein powder to meals and have RD (Registered Dietitian) consultation. Continue weekly weights. 10/17/13: Resident has had 3.5% weight loss x 1 week and 7.7% x 1 month--no new interventions developed. 10/25/13: Weight loss of 5.5% x 1 month: Current weight 122.8 IBW (Ideal Body Weight) 97-116# (pounds), currently on med pass (a liquid dietary supplement), [MEDICATION NAME] (a medication to enhance appetite), Risk vs. Benefit obtained r/t (related to) refusal to eat or lie down. 10/31/13: Weight review. Weight loss 6.6% x 1 month. current weight 121.4 pounds - continue to monitor. No new interventions developed. 1/2/14: Weight loss--increase med pass 2.0 to 120 mL (milliliters) Review of the resident's electronic health record revealed staff documented the following weights under the "Vitals" section: 8/13/13 136.60 pounds 8/16/13 135.60 8/19/13 134.20 Review of the clinical notes (nurse's notes) revealed on 8/29/13 at 1:44 p.m. staff received a new order to add Houseshakes TID (three times a day) with meals due to poor appetite. 9/05/13 133.20 9/10/13 134.00 9/25/13 131.80 10/2/13 130.00 10/14/13 123.00 On 10/15/13 at 10:06 p.m., staff documented in the clinical notes the physician had given an order to add protein powder to meals, to be consulted by a RD, & to continue weekly weights d/t (due to) 2% weight loss x 1 week & refusing to eat meals. On 10/17/13 at 10:08 a.m., Received new order for med pass 60 ml TID for anorexia, post hip fx (fracture). On 10/17/13 at 1:41 p.m. staff received a new order for [MEDICATION NAME] ES 625 mg (milligrams) daily. 10/21/13 122.80 10/28/13 121.40 11/20/13 125.40 11/27/13 125.20 12/4/13 124.40 12/13/13 121.60 12/19/13 122.00 12/24/13 117.20 1/02/14 116.40 1/08/14 112.60 On 1/8/14, staff received an order to increase the Med Pass 2.0 to 120 mL TID with meals. The resident lost 24 pounds from 8/13/13 to 1/08/14, or a total of 17.56% in 5 months. On 1/2/14 at 4:13 p.m. a progress note written by consultant staff FF revealed the resident had lost 20 pounds in 5 months. The note identified the resident's weight remained within normal limits for his/her height, but the resident was not eating well. Staff served the resident a regular mechanical soft diet, house shakes TID and Med Pass 60 ml TID. Intake was poor but staff stated he/she did drink the Med Pass. The note identified the resident received medication to stimulate appetite, but it did not seem to be working. Since the resident drank the Med Pass, consultant FF planned to recommend increasing the amount to 120 ml TID with medications. Review of the laboratory tests in the electronic health record revealed it lacked a check of the resident's [MEDICATION NAME] level (a blood test that checks nutritional level). Review of the resident's January 2014 MAR (Medication Administration Record) revealed the order for Med Pass 2.0 listed on the MAR, with the assigned times of 8:00, 12:00, and 17:00 (5:00 p.m.). Staff signed the MAR indicated [REDACTED]. On 1/9/14 at 11:57 a.m., observation revealed staff served the resident a pureed diet goulash, green beans, and pudding. The meal lacked a healthshake. Dietary staff K sat down and started to assist the resident with eating. At 12:03 p.m., administrative staff CC brought a small container of yogurt to staff K. At 12:12 p.m., the resident finished eating and staff assisted the resident away from the table without offering or assisting the resident to drink a healthshake. The resident ate less than 50% of the meal. Staff failed to serve the healthshake with each meal as planned. On 1/13/14 at 7:55 a.m., observation revealed staff served the resident a divided plate of pureed sausage, scrambled eggs, and cream of wheat, plus 8 oz (ounces) of milk, 4 oz of orange juice, and a 4 oz healthshake. After several attempts to assist the resident to eat and the refused each time, staff took the resident out of the dining room. The resident did not eat anything, nor did he/she drink the healthshake. On 1/13/14 at 11:45 a.m., observation revealed dietary staff HH identified that the resident was one of 6 residents in the facility that received protein powder mixed in with fluids. Staff HH stated he/she mixed the protein powder in with the healthshakes that the residents received. Observation revealed staff HH emptied 6 healthshakes into 6 glasses, then opened 2 packets of protein powder and placed an unmeasured amount of the protein powder into each glass, then stirred. Review of the back of one of the empty protein powder packets revealed that recommended usage was one packet per resident, not shared among 3 residents. When asked why he/she did not place the entire packet of protein powder into one healthshake, staff HH stated "that makes the shake too thick." On 1/8/14 at 2:30 p.m., observation revealed direct care staff II, passed snacks on the same hall where the resident lived. Staff II stated he/she knew what kind of diet the resident's received on that hall because he/she helped the same residents to eat in the evenings and he/she remembered, plus there was a book that identified which diet each resident received located up at the nurse's station. Staff II said he/she did not know of any resident that had lost weight, or anyone that he/she was to pay special attention to because they were at risk for losing weight. When asked specifically about resident #64, staff II stated the resident did not get any healthshakes that he/she was aware of. On 1/13/14 at 7:15 a.m., direct care staff JJ stated the resident received a healthshake at breakfast, but staff JJ did not think the resident received one at lunch. On 1/13/14 at 7:55 a.m., direct care staff B stated staff gave the resident a shake at each meal. On 1/13/14 at 12:10 p.m., licensed nurse O stated the signature on the MAR indicated [REDACTED]. Nurse O said he/she "guessed" the nurse would document in the nurse's notes if the resident did not take it all, but he/she knew that did not happen. On 1/13/14 at 12:30 p.m., Administrative nurse H said the August admission MDS that identified the resident's weight at 200 pounds was probably inaccurate. On 1/14/13 at 3:32 p.m. dietary staff K said the staff were to give the resident a healthshake with each meal. When told there had been observations of the resident not receiving the healthshake, staff KK said the dietary staff failed to pass out all the healthshakes some times, that just that day at noon, the dietary staff had failed to pass out 2 of the healthshakes. When the concern that staff are opening two packets and sharing it among the 6 residents was shared with staff K, staff K said the staff should be giving one packet per resident. Staff K stated "I wonder why (the dietary staff member) is doing it that way?" The comment dietary staff HH had said was shared, about one protein packet per healthshake made the healthshakes too thick, and staff K said "No, (he/she) is getting that mixed up with the thickener." On 1/13/14 at 2:30 p.m., Administrative nurse F could not provide any further information as to why the care plan did not address the resident's weight loss or the plan to provide healthshakes with each meal. Nurse F did not realize the direct care staff did not know the resident was to receive a healthshake with each meal. Nurse F stated the facility's system for delivering supplements did not include documenting the amount of the supplement consumed. Nurse F stated he/she knew it was something the facility needed to work on. On 1/14/14/ at 9:05 a.m. interview with consultant FF revealed he/she had identified the resident had lost weight but stated the resident did not eat much and would often refuse whatever the staff put in front of him/her. Consultant FF reported the resident received the Med Pass and he/she recently increased the amount the staff offered the resident since the resident consistently consumed the Med Pass. He/she reported the staff also had a hard time getting the resident to take the health shakes and that could be the reason for the inconsistency in the passing of the health shakes. On 1/14/13 at 4:10 p.m., Physician Assistant I stated he/she was not surprised the resident had lost weight as the resident's [DIAGNOSES REDACTED]. Review of the facility's policy on Weight and Vital Sign Monitoring, dated 8/13, identified that when a resident had experienced a one month, three-month or six-month significant (5%, 7.5%, 10%) or severe (greater than 5%, 7.5), 10%) weight variance (loss or gain) the staff were to notify the primary physician, the dietary department (documentation of this notification should be in the nurses' notes), and then dietary were to notify the registered dietitian. The dietitian was then to review the resident's clinical condition, appropriate laboratory values, drug therapy and factors which made the maintenance of the resident's nutrition status difficult. After that, the registered dietitian would make an assessment based on his/her assessment. A point of emphasis included staff to be cautious of supplemental (nutritional/high calorie) liquids, such as specifically fortified milk shakes. Using these as the first line of attack in combating weight loss in many cases causes a vicious cycle. Sweet liquid supplements tend to "fill up" the resident, which discourages the consumption of solid foods. Additionally, such supplements should be avoided during the meal and if given it should be given no sooner than two hours prior to the meal. The policy also identified the staff were to develop a comprehensive plan of care, specifically containing what staff plan to do to address the resident's nutritional needs. The facility failed to consistently provide the healthshake with each meal as planned, failed to document the amount of supplement consumed and failed to follow the guidelines for providing sufficient protein powder to a resident that had lost a severe amount of weight, 24 pounds in 5 months, or a total of 17.56% of his/her body weight.

The facility census totaled 54 residents with 3 residents sampled for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop them unless clinically unavoidable. Resident #2 developed an avoidable stage 3 ulcer on right medial ankle and an unstageable ulcer on left hip. The facility failed to consistently implement planned interventions to promote healing and prevent new sores from developing for a resident who had a pressure ulcer. (#1) Findings included: - Review of resident #2's signed physician order [REDACTED]. Review of of the significant change MDS (Minimum Data Set 3.0, a required assessment) dated 3-28-2012 revealed the resident scored a 15 out of 15 on BIMS indicating cognitively intact. It also revealed the resident was on a toileting plan, had occasional bladder incontinence, and required limited assistance of staff with toileting. It revealed the resident did not have any pressure ulcers but was at risk for the development of pressure ulcers. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating cognitively intact. It revealed the resident required supervision with all ADL's (activities of daily living) except for limited assistance with toileting. The resident was on a toileting program and occasionally incontinent of bladder. It also revealed the resident had a stage 3 pressure ulcer measuring 0.6 cm (centimeter) x 1.0 cm. with slough present in the wound bed. It revealed the ulcer was not present on previous assessment. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 3-28-2012 revealed the resident at risk to develop pressure ulcers related to incontinence and variable diet. It revealed the resident needed supervision with daily care due to mental illness and [MEDICAL CONDITION] that impacted functioning. It also revealed the resident had a pressure relieving mattress and cushion in chair. Review of the care plan last revised on 7-15-12 revealed the resident had a potential for pressure ulcer development because of incontinence. Interventions included: following the facility policies for the prevention and treatment of [REDACTED]. It also included the dietitian to review diet routinely and make recommendations as needed and the nurse needed to observe and assess skin weekly and report changes to the doctor. The care plan also included the following revisions: On 12-11-12 revealed an intervention to right medial ankle to apply skin prep, foam dressing, and secure with foam daily due to red area. On 2-6-13 it was updated to clean right medial ankle with normal saline and cover wound bed with xeroform, cover with foam and secure with tape daily. The care plan also had a hand written update on 2-26-2013 that noted "stage 2 pressure ulcer and laboratory tests pre-[MEDICATION NAME] protein level to be drawn". The revision lacked information where the ulcer was and interventions to promote healing and prevent further ulcers. Review of the physician's initial visit regarding right medial ankle revealed on 12-11-12 a red area developed, and then on 1-23-13 a stage 3 ulcer noted by nursing and believed started secondary to tight fitting shoes and no socks. Order to apply xeroform (a type of dressing), foam, and tape every other day and continue to offload with boot. On 2-12-13 the wound progress / procedure note revealed a stage 3 ulcer measured 0.3 x 0.7 centimeters and was acquired on 1-23-13 related to shoe friction. Review of the wound progress / procedure note dated 2-19-13 noted right medial ankle ulcer healed and directed staff to continue foam on right medial ankle times 1 week and as needed. Review of the Dietitian notes dated 2-1-13 identified the resident had a healing pressure area on their right medial ankle. The resident's weight was down 12 pounds in 6 months. Recommended to help prevent further weight loss will add 2 cal med pass (a nutritional supplement) 60 millimeters three times a day with medication pass for the next 30 days and re-evaluate. Review of the shower body check program sheets for the month of February revealed the resident did not have skin assessed by aide on the 8th and 12th due to refusal of shower. The shower sheets for the 15th and 19th revealed a mark on the right inner ankle with comments on the bottom "treatment to right inner ankle in progress". On the 22nd the shower sheet showed no open or red areas noted. The sheet from February 26 noted a mark on the resident's left hip with comments written, " treatment in progress". Review of nurse's note dated 2-23-13, (one day after a skin assessment with no issues noted), revealed a stage 2 pressure area noted on left hip, nurse asked the resident to sleep on right side only. Observation on 2-27-13 at 3:21 p.m. the resident lay in bed on his/her left side with legs on top of each other, socks, and tennis shoes on with no preventative measure to prevent the recurrence of ulcer on right medial ankle. Observation on 2-28-13 at 8:06 a.m. the resident lay in bed on left side with knees drawn up into a fetal type position with no pressure reducing device between knees or feet/ankles. Observation on 2-28-13 at 9:23 a.m. licensed nurse A and another nurse went in to do dressing change and reported the nurse found the area on left hip over the weekend and got the order but it is unstageable and not a stage 2 ulcer. Observation revealed the wound bed totally covered with grayish slough, (necrotic tissue in the process of separating from viable portions of the body). Nurse A completed the treatment as ordered. When asked about the right ankle Nurse A pulled up the residents right pant leg and took off the residents shoe and pulled down the sock to expose the ankle and stated the treatment had been stopped. Observation of ankle revealed a small, dry clear scab area on ankle with slight redness noted. During an interview on 2-27-2013 at 3:20 p.m. the resident reported the staff put a dressing on the sore on his/her ankle. During an interview on 2-27-2013 at 3:34 p.m. direct care staff C reported the staff provided set up assistance for the resident and help if needed. He/she reported the resident required reminders to use the bathroom and checked for incontinence every couple of hours. Staff C also reported staff put on a moisturizing cream after showers to help maintain skin integrity, did not know of any pressure ulcers the resident had but could find out if needed. During an interview on 2-28-2013 at 5:47 a.m. direct care staff D reported staff is to walk the resident to the bathroom, the resident repositions self in the bed and either sleeps with his/her head at the head or the foot of the bed. Staff D did not know of any other interventions to promote healing or prevent pressure ulcers from developing. During an interview on 2-27-2013 at 4:28 p.m. licensed nurse E reported the aides have a bath sheet /skin assessment they fill out with each bath and then if there is a problem the nurse goes back and assesses the problem . The nurse is then to fax the physician informing them of the concern and initiation of a standing order. During an interview on 2-18-2013 at 9:34 a.m. licensed nurse A reported he/she expected staff to place a pillow between knees, and encourage the resident to be off his/her left hip. He/she reported the aides look at the skin when they do showers twice a week and when the aide gave the resident a shower over the weekend the area on the hip was found. During an interview on 2-28-2013 at 4:56 pm administrative staff F reported the aides give the shower sheet to the charge nurse who assesses the concern then they are given to the director of nursing and then to the nurse who does the skin management / medical records. When asked what they were doing to prevent ulcers for the resident, staff F reported trying to encourage the resident to turn, put head at one end of the bed, and encouraged him/her to be out of room more. Staff F also reported a low air loss mattress was not initiated because they felt it would be too much of a fall risk. He/she also reported the resident used to have foam dressing to the right inner ankle but that area resolved. The facility failed to ensure a resident who was admitted without a pressure ulcer did not develop one unless it was determined to be clinically unavoidable. The facility failed to assess the resident's skin effectively and implement measures to prevent pressure ulcers for a resident who developed a stage 3 ulcer on right medial ankle and an unstageable ulcer on left hip. - Review of resident #1's signed physician's orders [REDACTED]. Review of the quarterly MDS (Minimum Data Set 3.0, a required assessment) dated 10-14-12 revealed a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderate cognitive impairment. It also revealed the resident required extensive assistance with all ADL's (activities of daily living) except total dependence with transfers and supervision with eating. It also revealed the resident had 2 unstagable pressure ulcers. Review of the significant change MDS dated [DATE] revealed a BIMS score of 7, which indicated severe cognitive impairment. It also revealed the resident required total dependence on staff for bed mobility, transfers, and toileting. The MDS also revealed the resident had a stage 3 pressure ulcer that measured 0.5 X 0.5 centimeters with granulation tissue in wound bed. (Did not identify location) Review of the pressure ulcer CAA (Care Area Assessment) dated 1-18-13 revealed the resident continued to have a stage III pressure ulcer on "right heel" and had been treated by the facility wound doctor. The resident had healed several ulcers since last assessment. He/she wears multi podus boots (used primarily for decubitus ulcer healing, wound care and contracture management) when up and that he/she currently did not walk. It revealed the current ulcer to the "right heel" measured 0.5 x 0.9. centimeters and had decreased in size and had gone from an unstagable ulcer to a healing stage III with moderate drainage and treated with Calcium Alginate. He/she wore a multi-podus boots when up and off loaded when in bed. Review of the Braden scale for predicting pressure sore risk revealed: a score of 13 on 8-1-12, 11 on 10-2-12, 9 on 11-5-12, and 14 on 2-8-13. A score of 12 or less indicated high risk for the development of pressure ulcers. Review of the care plan last revised on 1-21-13 revealed the resident at risk for pressure ulcers related to cognitive impairment, incontinent and had a stage 3 ulcer on left heel. Interventions included: monitor wound healing weekly, check skin with each bath and alert the nurse if there are changes, follow facility policies for the prevention and treatment of [REDACTED]. It included the resident needed reminding and assistance to turn and reposition at least every 2 hours and to wear multi podus boots in and out of bed at all times. Review of the resident plan of care summary for cna's (certified nures aides) dated 11-5-12, lacked any special instructions regarding the use of multi podus boots at all times. Review of the TAR (Treatment Administration Record) revealed a treatment to the Left heel; clean with normal saline, pat dry and apply santyl (a type of [MEDICATION NAME] treatment) to wound bed, secure by wrapping foot with stretch gauze daily. Review of the clinical admission/ readmission assessment form dated 8-16-2013 revealed the resident did not have an ulcer or wound on his/her heels but did have redness to buttock. Review of physician's note dated 8-28-2012 revealed a new blister to left heel (stage 2) orders to apply skin prep daily and offload. Treatments initiated on 8-24-12 and the area measured 3.2 X 4.5 centimeters. Review of the Weekly Pressure Sore Record Documentation on 11-6-12 revealed the area was measured weekly and varied from 2.9 x 7.1 centimeters on 9-4-12 to 2.5 x 3.0 centimeters with the eschar (dead tissue that falls off (sheds) from healthy skin) beginning to separate. On 12-11-12 the ulcer measured 1.0 x 0.7 x 0.5 centimeters and the physician debrided the ulcer. The physician's note revealed, "L (left) heel has deteriorated - eschar separated and deep ulcer with necrotic tissues present - multi-podus boot in bed along with new treatment order." Further left heel wound measurements (in centimeters) included: 1-8-13 - 1.7 X 1.2 X 0.3: Stage 3 ulcer - noted slough and undermining - will require debridement next visit and a new treatment order 1-15-2013 - 0.5 X 0.9 X 0.2: Left heel with thick rubbery slough 100% -- santyl treatment -- 1-22-13 -- .8 X 1.2 X .3 -- debrided - 95% slough, new dressing treatment ordered - cont. L boot 1-29-13 - 0.8 X 1.0 X 0.2 2-5-13 - 1.2 X 0.8: slough - plan to debridement next week 2-12-13 -- 1.0 X 0.8: stage 3 - 2-19-2013 - 0.8 X 1.6: stage 2 and a new treatment for [REDACTED]. Observation on 2-27-13 at 12:28 p.m. revealed the resident had a room tray. The observation revealed the head of the bed elevated, with both knees pulled up with one in the air pointed to the ceiling and the other bent outward exposing both lower legs. The resident did not have any type of pressure reducing device on either heel. Observation on 2-27-2013 at 3:08 p.m. the resident lay in bed on his/her left side with foam wedge behind his/her back and blue multi-podus boots on both feet. Observation on 2-28-2013 at 5:46 a.m. revealed the resident lay in bed with multi-podus boots in the wheelchair and not on the resident's feet. Observation on 6:45 a.m. direct care staff B and direct care staff G assisted the resident to get up for breakfast and when they pulled the covers back revealed the resident had on blue padded protectors (bunny boots). Direct care staff B commented "they know (gender) is to have the other boots on all the time when (gender) is in bed". Direct care staff G and B proceeded to put on the multi-podus boots and finished assisting the resident with getting dressed for the morning. Observation on 2-28-13 at 9:46 a.m. licensed nurse H removed the dressing and observation revealed an open area with white in the very center and pink around it in the wound bed. During observation licensed nurse H reported the area had been debrided multiple times by the wound physician. During an interview on 2-27-13 at 1:44 p.m. direct care staff G reported the resident required total care. Staff checked and changed the resident and applied barrier cream each time, turned every couple of hours, and encourage him/her to get out of bed once in a while. During an interview on 2-27-2013 at 3:04 p.m. direct care staff I reported staff assisted the resident by changing brief in bed when incontinent and put protection cream on buttock each time. Staff repositioned him/her every 2 hours, raised the head of the bed up and he/she had a boot on when in bed. When asked if the resident needed to have the boot on all the time in bed staff I reported yes. During an interview on 2-27-2013 at 4:31 p.m. direct care staff J reported there is a shower form the aides fill out when giving baths. They fill out the form and mark any bruise, rash, sore or other concern and give it to the nurse and the nurse will check out the concern. Staff J also reported staff turned the resident every 2 hours, had boots that he/she is supposed to have on when in bed but the resident would refuse them sometimes. Staff encouraged the resident to turn and had a cream to apply to buttock every time the staff changed him/her. During an interview on 2-28-2013 at 5:47 a.m. direct care staff D reported the facilities policies for prevention and treatment of [REDACTED]. He/she reported the resident wore heel protectors and turned from side to side. Staff D also reported the resident will let staff put on the heel protectors at night with no problems but would kick them off sometimes. When asked if the heel protectors were the "bunny boots" or the bigger multi-podus boots staff D reported the resident needed to wear the "bunny boots" during the night. During an interview on 2-27-2013 at 4:28 p.m. licensed nurse E reported the aides have a bath sheet /skin assessment they fill out with each bath and then if there is a problem the nurse goes back and assesses the problem . The nurse is then to fax the physician informing them of the concern and initiation of a standing order. During an interview on 2-27-13 at 4:43 p.m. licensed nurse K reported the resident is to have boots on both feet when in bed. Staff K reported the resident will usually get out of bed for supper but the boots are to be on when in bed. During an interview on 2-28-13 at 9:46 a.m. licensed nurse H reported that the large multi-podus boots are what the resident is to have on in bed. During an interview on 2-28-13 at 4:56 p.m. administrative nurse F reported his/her expectation for the staff was to encourage the resident to reposition, let staff put the boot on her and do whatever is in the care plan. When asked if the expectation was for the resident to wear the "bunny boots" or the multi-podus boots when in bed staff F reported the multi-podus boots. The facility failed to ensure the resident consistently wore the multi-podus boots as ordered to promote healing of a stage 3 ulcer.

The facility census totaled 53 residents, with 22 included in the sample. The sample included the review of 4 residents with pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure a resident that entered the facility without pressure ulcers did not develop them unless the resident's condition demonstrated the ulcers were clinically unavoidable, and failed to provide the necessary treatment to promote healing of the ulcers once they developed for 1 of the 4 sampled residents with pressure ulcers. (#53) The resident developed 3 unstageable pressure ulcers, one on each of the heels and one on the great toe. Findings included: - Review of the physician's recapitulation of orders, signed on 9/7/12, revealed the physician identified resident #53 with the following Diagnoses: [REDACTED]. Review of a significant change MDS (Minimum Data Set-a required assessment) dated 7/9/12, identified the resident with a BIMS (Brief Interview for Mental Status) Score of 3/15 (indicated severe cognitive impairment), required extensive assistance from one staff for bed mobility and transfers, at risk for the development of pressure ulcers, did not have pressure ulcers, and staff did not provide a turning/repositioning program. Review of the re-admission MDS, dated [DATE], revealed it identified the resident with a BIMS (Brief Interview for Mental Status) score of 3/15 (indicated severely impaired cognition), required extensive assistance from one staff with bed mobility and transfer, at risk for the development of pressure ulcers, without pressure ulcers, received pressure relieving devices while in the chair and in bed, but staff did not provide a turning/repositioning program. Review of the pressure ulcer CAA (Care Area Assessment) dated 7/9/12, identified the resident at risk for skin breakdown because of his/her impaired mobility and incontinence. The staff identified the resident had a significant weight loss of greater than 5% in 30 days, that the resident had lost weight over the last 6 months and experienced and reported poor appetite. The assessment identified the resident used a pressure relieving mattress on his/her bed and a pressure relieving cushion in his/her wheelchair. The documentation revealed the resident had poor trunk support and sometimes had problems sitting upright in the wheelchair and exhibited a tendency to lean to the left. Staff documented the resident had a history of [REDACTED]. The assessment identified the resident as no longer able to walk safely with his/her walker and used the wheelchair for mobility. The assessment identified the resident at risk for skin breakdown because he/she was less mobile, incontinent, and cognitively impaired. On 8/2/12, staff completed a Braden scale (measures risk for skin integrity problems) and identified the resident at high risk for the development of pressure ulcers. Review of the care plan for pressure ulcers, dated 6/10/12 revealed the resident at risk for pressure ulcers. On 9/30/12, the staff revised the care plan to add the resident had developed 3 pressure ulcers on his/her feet, one on each heel and one on his/her right great toe. The resident needed help to reposition, experienced incontinence, cognitive impairment, had a terminal diagnosis, and finally identified "skin breakdown is an expected outcome." The care plan directed staff to check the resident's skin every time he/she bathed and report changes to the nurse, follow facility policies for the prevention and treatment of [REDACTED]. Directions for staff also included the resident needed monitoring, reminding, and assistance to turn and reposition at least every 2 hours, more often as needed or requested, to put TED hose (compression stockings to reduce [MEDICAL CONDITION]) on in the morning and take them off at bedtime. Review of a care plan revision sheet, located in the medical record at the nurse's station, revealed on 9/7/12 staff documented "Rt (right) heel and Rt great toe: Skin prep daily, monitor weekly and PRN (as needed), notify MD (physician) of complications." The care plan revision failed to address treatment to the left heel. On 9/4/12, the staff wrote a note to the physician that identified the resident had a decline in his/her mentation and health, that the staff had an inability to get the resident to comply with needed interventions to protect the resident's skin integrity. The staff identified the resident received hospice services due to the resident's decline in health status. The staff identified they provided "frequent" repositioning while in bed and while up in the wheelchair, a pressure relieving mattress, and incontinent care hourly. The documentation identified the resident exhibited extremely combative behaviors with incontinent care. The staff also identified the resident refused to allow staff to assist with eating >90 percent of the time and failed to ingest sufficient calories. The staff documented that skin integrity problems were anticipated and unavoidable related to: poor nutritional intake, combative with interventions to promote skin integrity secondary to [DIAGNOSES REDACTED]. On 9/19/12, the physician signed the note, identifying that he/she was aware of and agreed with the information contained in the note. The documentation lacked the revised interventions the facility attempted for the resident to ensure the resident consumed sufficient calories. Review of the computerized weight report revealed the following weights: 7/2/12 172.2 7/3/12 170.0 7/4/12 171.6 7/9/12 172.2 7/17/12 170.2 7/23/12 167.4 8/2/12 165.8 8/3/12 165.8 8/7/12 167.0 8/17/12 169.4 9/5/12 160.6 9/12/12 156.2 9/17/12 154.2 9/24/12 152.8 The resident lost 19.4 pounds from 7/2/12 to 9/24/12, or 11.26 percent of the resident's weight, a significant amount of weight. Review of the nurse's notes, dated 9/7/12, revealed the following documented entry: This nurse examined resident's heel and a hematoma was noticed to Rt heel and Rt great toe. NO (new order) (received from the physician to apply) skin prep daily. Monitor every week and PRN (as needed). Staff notified the physician and hospice notified. Hospice will provide boots for heels. This nurse examined the resident's buttocks. No pressure areas noted. Will continue with cream for preventive measure. The nurse's note failed to address assessment or treatment. Review of the physician's telephone orders revealed that on 9/7/12, staff received a physician order [REDACTED]. Review of the Weekly Pressure Sore Record for the right great toe revealed the pressure ulcer started on 9/7/12. Staff identified the area as a Stage II (open), measured 1.0cm (centimeter) in length and 0.7cm in width, and that staff notified the dietary department, family and physician on 9/7/12. Staff completed the next measurement on 9/17/12 and documented the following information: 9/17/12--Stage II--1.1cm in length x 1.0cm in width 9/25/12--Stage II--1.0cm in length x 1.2cm in width 10/2/12--Stage II--1.0cm in length x 1.2cm in width Notes on the back of the record revealed the following: 9/7/12: Small DTI (Deep Tissue Injury) noted to Rt great toe. Skip prep daily 9/17/12: No changes to hematoma 9/25/12: Hematoma area drying up lesion and bruised in appearance area 10/2/12: No changes noted continue skin prep Review of the Weekly Pressure Sore Record for the right heel revealed the pressure ulcer started on 9/7/12. Staff identified the area a Stage II (open) area; measured 3.5cm in length and 6.0cm in width, and staff notified the dietary department, family and physician on 9/7/12. Staff completed the next measurement on 9/17/12 and documented the following information: 9/17/12--Stage II--3.5cm in length by 5.6cm in width 9/25/12--Stage II--4.0cm in length x 5.9cm in width 10/2/12--Stage II--3.2cm in length x 5.0cm in width Notes on the back of the record revealed the following: 9/7/12: New areas noted to Rt heel- Hematoma noted to the Rt heel and soft. NO (new order) to skin prep and off load. DPOA (Durable Power of Attorney--family), PCP (Primary Care Physician) and hospice notified. 9/17/12: No changes, continue current treatment 9/25/12: No changes at this time continue current treatment. 10/2/12: Decrease in size, continue off load and skin prep. Review of the Weekly Pressure Sore Record for the left heel revealed staff documented the area started on 9/7/12 but lacked measurements. Staff documented they notified the dietary department, family and physician on 9/7/12. Staff completed the next measurement on 9/17/12 and documented the following information: 9/17/12: Stage II--4.4cm in length x 7.2cm in width 9/25/12: Stage II--4.0cm in length x 7.4cm in width 10/2/12: Stage II--4.0cm in length x 6.0cm in width Notes on the back of the record revealed the following: 9/17/12: Hematoma noticed to left heel. Treatment skin prep daily and off load 9/25/12: No changes noted, continue current treatment 10/2/12: No issues continue current treatment. The documentation on back of the record lacked a start date of 9/7/12. Review of the September treatment record revealed it included a physician's orders [REDACTED]. The treatment record lacked an order to apply skin prep to the left heel. Staff documented they followed the physician's orders [REDACTED]. On 10/3/12 at 8:07 a.m., observation revealed the resident sat in the dining room in a wheelchair, eating breakfast independently. Staff had served the resident a fried egg, a pancake, ground sausage, and an 8oz (ounce) glass of milk. On 10/3/12 at 8:52 a.m., observation revealed all of the other residents were done eating. Administrative Nurse N sat with the resident assisting him/her to finish breakfast. On 10/3/12 at 9:00 a.m., Administrative Nurse N stopped another direct care staff R and asked staff R to finish helping the resident. Staff R stood over the resident for 5 minutes, while assisting the resident to eat, and then assisted the resident from the table. Observation of the plate revealed the resident ate 50 percent of the meal, and 50 percent of the milk. Staff R took the resident to his/her room without offering a supplement to the resident. On 10/3/12 at 10:14 a.m., observation revealed direct care staff B passed a cart with snacks down the hall. The snacks were labeled with residents names. Resident #53 sat in a recliner in his/her room, sleeping. Staff B did not stop to offer the resident a snack. Observation of the snacks on the cart revealed it lacked a snack with the resident's name. On 10/3/12 at 11:39 a.m., observation revealed the resident sat in a wheelchair in the dining room at a table. Staff served the resident a plate of meatloaf, mashed potatoes and gravy, broccoli, bread and a bowl of pudding. Staff also gave the resident an 8oz glass of ice water and an 8oz glass of iced tea. The staff asked the resident if he/she wanted his/her bread buttered, but the resident said no, so staff left. The resident started to eat independently, but slowly. Five minutes later staff placed a stray in the glass of water and the resident started to drink independently. At 11:44 a.m., the resident dropped the fork onto the floor, but no staff picked it up. The resident continued to eat slowly, independently, with a spoon. On 10/3/12 at 11:52 a.m., staff R sat down with the resident and assisted the resident to eat. On 10/3/12 at 12:18 p.m., observation revealed the resident finished eating. The resident ate most of the meatloaf, all of the mashed potatoes and pudding, very little of the broccoli, half of the bread, and all of the iced water and tea. Staff R assisted the resident away from the table to his/her room. On 10/3/12 at 12:38 p.m. observation revealed direct care staff B entered the resident's room where he/she sat in a wheelchair and told the resident that he/she was going to help the resident into bed. Staff B transferred the resident into bed then removed the blue foam booties on the resident's feet and the non-skid socks to reveal the heels on both feet. Observation revealed both heels lacked a dressing. On the right heel, the resident had a dark, scab-type area that extended from the outer heel to the inner heel. The edges of the dark area were unattaching from the heel. The heel of the left foot also had a dark scab-type area on it but the edges on this heel were firmly attached to the heel. The aide changed the resident's incontinent brief, provided perineal care, reapplied the blue booties, positioned the resident for comfort and left the room. On 10/3/12 at 9:25 a.m., direct care staff B stated the resident developed two dark areas on the insides of his/her heels. Staff B thought they developed because the resident's feet were always together at night. Staff B said the blue foam booties were new and as a result of the dark areas. On 10/3/12 at 4:18 p.m., direct care staff K stated the only skin issues the resident had was a red bottom and wore blue booties to make sure the resident's heels did not break down. Staff K said that staff were to apply a barrier cream after each perineal care to prevent further breakdown of his/her bottom. On 10/4/12 at 10:40 a.m., Administrative Nurse H, responsible for wound care, stated the pressure ulcer on the left heel started after the one on the right heel and toe. Nurse H stated the areas developed because the resident's health declined and the physician wrote an order that skin problems were unavoidable in the resident's condition. Nurse H stated that it might have been the sheets or the resident's tight socks that caused the areas to develop. Nurse H confirmed the areas were healing as a result of the use of the protective booties, and the staff did not off-load the heels when the resident lay in bed until after the development of the pressure ulcers. The resident had an air mattress and the staff thought that was "good enough." Nurse H lacked knowledge that staff treated the right heel in September and not the left heel. On 10/4/12 at 4:08 p.m. Administrative Nurse A, stated he/she understood and the expectation of staff treatment of [REDACTED]. On 10/10/12 at 4:54 p.m., Consultant F stated the facility provided him/her with reports of residents with pressure ulcers. Consultant F did not remember looking at the resident for pressure ulcers. Consultant F agreed that the staff had not given the resident supplements because he/she thought the resident refused to drink them. Consultant F stated the meal intake documentation probably would not support that because the facility recently changed dietary managers, and the supervision to ensure the documentation of the meal intakes and supplement intakes had declined and staff were not making sure to document the intakes properly. As for looking at laboratory results to indicate dietary needs to promote healing, Consultant F stated that the facility did not automatically order laboratory tests when a resident developed a pressure ulcer for him/her to review during his/her visits to the facility. Review of the facility's Pressure Sore Monitoring (Assessment & Documentation) Weekly Wound Round Record directed staff on identifying a pressure ulcer a baseline nursing assessment of the ulcer as well as causative factors was completed. The Weekly Pressure Sore Record was used for the initial baseline assessment tool as well as for weekly outcome documentation. The policy also directed staff to document what interventions were in place to manage pressure (tissue load). Was pressure reduction achieved when patient was in bed and chair? Check for pressure relief between all bones and under heels. Check for effectiveness of all the pressure reduction devices used. The facility failed to provide pressure relief to the heels and feet for a resident at risk for the development of pressure ulcers, failed to monitor the dietary needs to promote healing once the areas developed and failed to provide prompt physician ordered treatment to all areas to promote healing of the pressure ulcers for this dependent and cognitively impaired resident.

The facility census totaled 53 residents, with 22 included in the sample. The sample included the review of 3 residents with weight loss. Based on observation, interview, and record review, the facility failed to ensure 2 of 3 sampled residents (#53 and #60) did not lose weight unless clinically unavoidable. The facility identified both residents lost weight and failed to develop and implement interventions to attempt to stop the weight loss. Resident #53 lost 19.4 pounds in less than 3 months, or 11.26 percent of the resident's weight, a significant amount of weight. Findings included: - Review of the physician's recapitulation of orders, signed on 9/7/12, revealed resident #53 with the following Diagnoses: [REDACTED]. Review of the significant change MDS (Minimum Data Set-a required assessment) dated 7/9/12, identified resident #53 with a BIMS (Brief Interview for Mental Status) Score of 3/15 (indicated severe cognitive impairment), dependent on one staff for eating, with a weight of 172, and a weight loss of 5 percent or more that was not physician prescribed. Review of the re-admission MDS dated [DATE], identified resident #53 with a BIMS score of 3/15, dependent one staff to eat, experienced a weight loss of 5 percent or more that was not physician-prescribed, and weighed 167 pounds. Review of the Weight Change CAA (Care Area Assessment-a further assessment) dated 7/9/12 revealed the resident experienced a significant weight loss during a hospitalization . The resident reported a poor appetite since returning from the hospital, but the assessment identified the resident's weight as stable. The resident consumed at least 50-75 percent of each meal, received a regular, mechanical soft diet. The CAA identified that because the resident weight was above the Ideal Body Weight (IBW) and the resident's Body Mass Index (BMI--ratio of body height versus weight used to determine body fat) was high, the staff identified the resident's weight loss as positive. The assessment identified the resident's weight as stable since the hospital return, so staff planned to monitor the resident's weight for 4 weeks to determine if the loss continued. The documentation identified the resident required staff assistance with ADL's (Activities of Daily Living) and the resident had declined in the ability to participate. The assessment identified the resident had a history of [REDACTED]. The assessment ended by identifying the resident experienced a significant weight loss and that placed the resident at an increased risk for impaired nutrition, poor endurance, and skin breakdown, staff planned interventions to implement to prevent further weight loss, and have the consultant dietitian review the resident's diet to make recommendations as appropriate, and for the dietary manager to monitor the resident's intake. Review of the care plan for weight loss, dated 6/10/12 identified the resident with a history of a stroke, and directed staff to monitor for pocketing (of food), choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. The care plan further directed staff to encourage the resident's socialization and interaction with table mates during meals, identified the resident's diet as regular, mechanical soft and directed staff to provide and serve the ordered diet, and monitor the resident's intake and record every meal. The care plan also identified that the dietitian would review the resident's diet and make recommendations as appropriate. On 9/30/12, staff revised the care plan to address the resident's admission to hospice services. Staff added the statement that due to the resident's terminal diagnosis, weight loss was an expected outcome, and directed staff to observe and assess for signs or symptoms of [MEDICAL CONDITION], such as emaciation, muscle wasting, or significant weight loss such as 3 pounds in less than a week, 5 percent or great in a month, 7 1/2 percent in 3 months, or over 10 percent in 6 months. The plan directed staff to notify the doctor and hospice nurse if of the previous items were noted. The care plan lacked specific interventions attempted to address the resident's weight loss. Review of the computerized weight report revealed the following weights: 7/2/12 172.2 7/3/12 170.0 7/4/12 171.6 7/9/12 172.2 7/17/12 170.2 7/23/12 167.4 8/2/12 165.8 8/3/12 165.8 8/7/12 167.0 8/17/12 169.4 9/5/12 160.6 9/12/12 156.2 9/17/12 154.2 9/24/12 152.8 The resident lost 19.4 pounds from 7/2/12 to 9/24/12, or 11.26 percent of the resident's weight, a significant amount of weight. Review of a report identified Weight/Skin Condition dated 7/30/12, completed by the dietary manager and reviewed by consultant F identified the resident's weight at 167.4 pounds and did not identify any weight trends, or any comments or recommendations. Review of the Weight/Skin Condition report dated 8/6/12 identified the resident's weight at 167 pounds and with a weight loss of 12 percent in 3 months and a 7.5 percent loss in 6 months. The dietary manager documented the resident may start eating better because the diet had been upgraded to mechanical soft from pureed on 7/5/12. The dietary staff documented the resident received a diuretic which had the potential to have the resident's weight fluctuate, also. The assessment lacked interventions to address the resident's weight loss. . Review of the Weight /Skin Condition report, dated 9/20/12, identified the resident with a significant weight change, pressure sores, and received hospice services. The report identified the resident's weight at 154.2 pounds, with a weight loss of 9.8 percent in 1 month, 10.5 percent loss in 3 months, and an 18.4 percent loss in 6 months. It also identified pressure ulcers on the resident's Rt (right) great toe, Rt heel, and Lt (left) heel. The assessment identified on 7/5/12 the physician ordered staff to provide a regular, mechanical soft diet and the resident required maximum assistance from staff to eat. The assessment identified multiple medication changes in the last month to address the resident's non-compliance with bed time medications, but lacked specific interventions to address the resident's continued weight loss. Review of the dietary progress notes, revealed an entry on 9/17/12 that identified the resident had a change of condition, and admitted to hospice services on 8/29/12 with a [DIAGNOSES REDACTED]. The note identified the resident ate in dining room independently, at times the resident required the assistance of 1 staff or cueing to complete meals. The staff documented the resident's meal intake as poor, with intakes ranging from 30-90 percent. Administrative dietary staff C documented he/she updated the resident's Nutritional Assessment and planned to the ask Consultant F to complete the assessment on the next scheduled visit. Staff C identified the resident had no issues with skin, and staff C planned to monitor the resident's weights and intake for any changes and refer to Consultant F if needed. The note lacked interventions to address the resident's weight loss and failed to address the resident's impaired skin integrity. On 10/3/12 at 8:07 a.m., observation revealed the resident sat in the dining room in a wheelchair, eating breakfast independently. Staff had served the resident a fried egg, a pancake, ground sausage, and an 8oz (ounce) glass of milk. On 10/3/12 at 8:52 a.m., observation revealed all of the other residents were done eating. Administrative Nurse N sat with the resident assisting him/her to finish breakfast. On 10/3/12 at 9:00 a.m., Administrative Nurse N stopped direct care staff R and asked staff R to finish helping the resident. Staff R stood over the resident for 5 minutes, while assisting the resident to eat, and then assisted the resident from the table. Observation of the plate revealed the resident ate 50 percent of the meal, and 50 percent of the milk. Staff R took the resident to his/her room without offering a supplement to the resident. On 10/3/12 at 10:14 a.m., observation revealed direct care staff B passed a cart with snacks down the hall. The snacks were labeled with residents names. Resident #53 sat in a recliner in his/her room, sleeping. Staff B did not stop to offer the resident a snack. Observation of the snacks on the cart revealed it lacked a snack with the resident's name. On 10/3/12 at 11:39 a.m., observation revealed the resident sat in a wheelchair in the dining room at a table. Staff served the resident a plate of meatloaf, mashed potatoes and gravy, broccoli, bread and a bowl of pudding. Staff also gave the resident an 8oz glass of ice water and an 8oz glass of iced tea. The staff asked the resident if he/she wanted his/her bread buttered, but the resident said no, so staff left. The resident started to eat independently, but slowly. Five minutes later staff placed a stray in the glass of water and the resident started to drink independently. At 11:44 a.m., the resident dropped the fork onto the floor, but no staff picked it up. The resident continued to eat slowly, independently, with a spoon. On 10/3/12 at 11:52 a.m., staff R sat down with the resident and assisted the resident to eat. On 10/3/12 at 12:18 p.m., observation revealed the resident finished eating. The resident ate most of the meatloaf, all of the mashed potatoes and pudding, very little of the broccoli, half of the bread, and all of the iced water and tea. Staff R assisted the resident away from the table to his/her room. On 10/3/12 at 9:25 a.m., direct care staff B stated that the resident usually ate well, but the resident did not like to be in large groups because the noises bothered him/her, which explained why the resident was usually last one done eating. Staff B stated the resident did not start eating until it got quiet in the dining room and things settled down. Staff B did not know if the resident had lost weight, but knew the resident did not receive supplements or snacks. On 10/3/12 at 4:18 p.m., direct care staff K stated that the resident ate pretty good and needed staff assistance to eat. Staff K did not know if the resident had lost weight, but stated that if the resident received a shake with each meal and staff were to make sure the resident drank the shake. On 10/4/12 at 3:12 p.m., Administrative Dietary staff C stated the resident did not receive any kind of supplement, nor did the dietary department change the resident's food to increase the calories or protein the resident did eat. Staff C knew the resident sat at a table where staff assisted the residents to eat. On 10/4/12 at 4:08 p.m. Administrative Nurse A confirmed the facility had not tried to prevent the resident's weight loss. On 10/10/12 at 4:54 p.m., Consultant F stated the facility provided him/her with reports of residents with pressure ulcers. Consultant F agreed that the staff had not given the resident supplements because he/she thought the resident refused to drink them. Consultant F stated the meal intake documentation probably would not support that idea because the facility recently changed dietary managers, and the supervision to ensure the documentation of the meal intakes and supplement intakes had declined and staff were not making sure to document the intakes properly. As for looking at laboratory results to indicate dietary needs to promote healing, Consultant F stated that the facility did not automatically order laboratory tests when a resident developed a pressure ulcer for him/her to review during his/her visits to the facility. Review of the facility's undated policy on Skin and Weight Meeting revealed the intent to evaluate residents with significant weight changes and impaired skin integrity and to ensure timely interventions by the facility's Interdisciplinary Team. The policy identified that the Skin and Weight meeting would be conducted by the facility on a weekly basis, and the committee would be comprised of at least Nursing, Restorative/Therapy and Dietary. The policy also directed staff that residents that demonstrated a significant change in condition, significant weight loss would be placed on weekly weights until stability had been demonstrated for at least four weeks. The committee's review of such residents would be documented using the Weight/Skin Condition Review form. The facility failed to follow the policy and conduct weekly weights for this resident, as well as failed to review the resident weekly by documenting in the Weight/Skin Condition Review form. The facility filled out 3 of the forms. The facility failed to develop and implement interventions to address a cognitively impaired, dependent resident's weight loss. The weight loss totaled 11.26 percent in less than 3 months, a significant amount of weight loss. - Review of the signed physician order [REDACTED]. Review of the admission MDS dated [DATE] revealed the resident had a BIMS score of nine indicating the resident had moderate cognitive impairment, rarely/ never understood, had depression and mood issues identified. The resident required supervision with eating and drinking. The resident had a [DIAGNOSES REDACTED]. The resident had four stage 3 ulcers present on admission. Review of the quarterly MDS dated [DATE] revealed the resident was cognitively intact with a BIMS score of 15, showed fewer signs of depression and had [MEDICAL CONDITION] with behaviors of rejecting care almost daily. The assessment identified the resident required supervision with meals, no swallowing or choking issues, and a weight gain with a weight of 104 pounds. The assessment further identified the resident had no skin breakdown present. Review of the Nutrition CAA dated 4/16/12 revealed the resident had poor nutrition due to poor oral intake. The resident had a distorted view of his/her body and did not recognize how thin and frail he/she was and that the resident had lost over 30 pounds as identified by the resident's physician. The resident had four stage 3 pressure ulcers managed by the facility wound physician. Based on the dietary manager the resident ate food without concern but could not or would not eat all the food served. The dietary manager visited with the resident regarding food choices. Review of the care plan for nutrition dated 4/16/12 identified the resident at risk for poor nutrition because his/her nutrition had been poor for a long time. It identified the resident as malnourished and underweight but nutritional status showed signs of improving. The care plan directed staff to provide health shakes with meals and at bedtime. If the resident did not drink the shakes, staff were to report to the nurse. If the resident's weight started to decline the nurses needed to contact the physician and the dietician. Review of the September and the October meal intake sheets revealed the resident took approximately 50-100% of meals in the dining room. The intake records lacked documentation that staff served or the resident consumed the health shakes with meals. Review of the laboratory tests drawn on 5/16/12 revealed an [MEDICATION NAME] (level of protein) 3.2g/dL (grams per deciliter--normal range 3.5- 5.5g/dL) Protein 6.7 g/dL (determines nutritional status--with normal range of 6.0 to 8.3), Hemoglobin- 8.7 (determines if blood is anemic or does not have enough red blood cells---normal range 12.0 to 16.0), and Hematocrit 27.5 (determines whole blood volume--normal range36.0 to 48.0). Review of the weight sheet revealed the following weights: 4/9/12- 79.9 pounds 5/18/12- 82.4 pounds 6/15/12- 107 pounds 7/17/12- 106.0 pounds 8/9/12- 105.2 pounds 9/18/12- 97.8 pounds Review of the weight record revealed a weight loss of 6.1 percent over the last 30 days, a significant amount of weight. Review of the physician orders [REDACTED]. Review of a physician order [REDACTED]. Observation on 10/3/12 at 7:50 a.m. revealed the resident sat at the dining table with a plate containing a pancake, fried egg, a single piece of bacon and a bowl of cold cereal. Drinks included 4 ounces of cranberry juice, 8 ounces of milk, and an 8 ounce glass of water and a cup of coffee. Observation on 10/3/12 at 8:25 a.m. revealed the resident ate one small pancake approximately 4 inches in diameter, the fried egg, and 1/2 bowl of cereal. The resident consumed all the juice, milk and coffee with sips out of water glass. The staff failed to provide the health shake as ordered. Observation on 10/3/12 at 11:38 a.m. revealed the resident sat eating at the dining table. The noon meal consisted of meatloaf, mashed potatoes and gravy and broccoli with buttered bread. The fluids served were ice tea, water, and a chocolate drink. The resident consumed all of the bread and few bites of potatoes and meatloaf and no vegetables. The resident consumed all fluids. The dietary person in the dining room visited with the resident though the resident would not eat more. During an interview on 10/3/12 at 10:30 a.m. direct care staff B reported that the resident needed minimal assist with daily cares. The resident fed him/her self in the dining room and did not eat very well but would drink the shakes at mealtimes. The resident needed a lot of encouragement to eat. During an interview on 10/4/12 at 3:15 p.m. dietary staff C reported that the dietician and CDM talked with the resident about his/her diet and discontinued the constant carbohydrate diet and placed the resident on a regular diet to increase the resident's intake. Dietary staff C reported that the dietary department gave the resident mighty shakes 3 times a day with meals and nursing gave the resident one in the evening. Dietary staff C reported the staff documented the shakes in the intake book. Review of the intake book with the dietary manager confirmed the staff had failed to document the shakes as given. During an interview on 10/4/12 at 10:30 a.m. licensed nurse D reported the resident took food and fluids at meal times well. The nurse stated the resident had not been eating as many sweets in his/her room as the resident had done in the past so the nurse thought his/her weight loss was from the sweets not of the food at meals. Nurse D stated staff weighed the residents once a month on bath days unless there was a concern then the resident would be weighed weekly for a couple of weeks to determine if the resident had a weight loss/gain. During an interview on 10/4/12 at 2:25 p.m. administrative nurse A reported that when a resident had a weight loss, staff weighed the resident weekly until the weight stabilized. The weight and skin committee met 1 time a week to determine what interventions to implement for that resident. Review of the facility's undated policy on Nursing Documentation on Skin and Weight Meeting revealed that residents that weight less than 100 pounds would be weighed weekly. The Skin and Weight committee would also complete the Weight/Skin Condition Review form. The policy also identified the care plans for the residents on the Skin and Weight Committee would be revised and updated to reflect the new approaches/interventions during the weekly Skin and Weight meeting. The facility failed to monitor and document the intake of nutritional supplements to determine the effectiveness of the current interventions and prevent further weight loss for resident.