Every finding on record at Rossville Healthcare and Rehabilitation Center

Based on record review, interview, and observation, the facility failed to maintain infection control designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for Residents (R)1, R2, R3, R4, and R5. Findings included: - 1. R1's Electronic Medical Record (EMR) documented R1 had diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle wasting, cognitive impairment, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness) pneumonia (an infection in the lungs), respiratory failure (when the lungs cannot send enough oxygen to the blood) with hypercapnia (a condition that occurs when there is too much carbon dioxide in the blood) and hypoxia (inadequate supply of oxygen), and traumatic brain injury (TBI-an injury to the brain caused by external forces). The Annual Minimum Data Set (MDS), dated 07/10/2026, documented R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R1 had difficulty communicating some words or finishing thoughts and missed some part or intent of a message but could understand most of a conversation. The MDS documented R1 had impairment of both sides of his upper and lower extremities. The MDS documented R1 was dependent on staff for all activities of daily living (ADLs). The MDS documented R1 received oxygen therapy and required a non-invasive mechanical ventilator (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/10/2026, documented R1 had diagnoses of TBI, communication deficit, and cognitive impairment. The CAA documented R1 had poor short-term memory and poor decision-making skills. The CAA documented activities were provided to keep R1 engaged. The Functional Abilities CAA, dated 07/10/2026, documented R1 was dependent on staff for all care, had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). R1 had difficulty swallowing and had a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) for nutrition. R1's Care Plan, initiated on 04/30/2017, documented R1 was on supplemental oxygen. The care plan directed staff to change R1's oxygen tubing and rinse the oxygen concentrator filter weekly. The care plan lacked any direction regarding keeping oxygen tubing off the floor (09/28/2023). The care plan documented R1 was dependent on staff for completion of all ADLs (12/27/2023). The care plan directed staff R1 enjoyed watching television, going outside when the weather was nice, watching various types of movies, listening to music, and reading about guitars. The Health Status Note, dated 07/16/2026, documented a chest X-ray had been performed on R1, and the results were bilateral poorly defined infiltrates (pneumonia), and an antibiotic, Levaquin 500 milligrams, was ordered daily via g-tube. The Infection Note, dated 07/16/2023, documented an infection control assessment had been completed because R1 had a lower respiratory infection. On 07/23/2026 at 09:45 AM, observation revealed R1 lay in his bed on his right side. The room was dark, with no lights on, and the curtains were shut. R1's mouth was full of thick grey mucus. R1 had oxygen on via a nasal cannula. The oxygen tubing lay on the floor of the room. The oxygen concentrator was dirty, with dried nutritional formula on its exterior. The oxygen concentrator humidifier bottle contained no distilled water and had a date of 07/02/2026. The tubing which connected the humidifier to the oxygen concentrator was dated 07/02/2026. The oxygen concentrator filter was filthy with thick grey dust and dirt. On 07/23/2026 at 11:45 AM, Licensed Nurse (LN) G and Administrative Nurse D demonstrated the correct way to perform a G-tube feeding with R1. The surveyor pointed out the tubing on the floor, the empty oxygen humidifier, the unclean condition of the oxygen concentrator, and the dates on the oxygen supplies. 2. R2's EMR documented R2 had diagnoses of asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), respiratory failure, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and pneumonia. The Annual MDS, dated 06/17/2026, documented R2 had a BIMS of 15, which indicated intact cognition. The MDS documented R2 required substantial staff assistance to dependence on staff for most of her ADLs. The MDS lacked documentation of oxygen use. The Functional Abilities CAA, dated 06/17/2026, documented R2 received skilled services because of a right hip dislocation with removal of the right hip. The CAA documented R2 required maximum assistance up to dependent care for ADLs. R2's Care Plan, dated 04/21/2025, documented R2 required continuous oxygen and directed staff to change oxygen tubing and rinse the filter weekly. The care plan lacked any direction regarding keeping the oxygen tubing off the floor. The Infection Note, dated 07/07/2026, documented an infection control assessment was completed on R2 because of a lower respiratory infection (pneumonia). R2's Medication Administration Record (MAR), dated July 2026, documented R2 was prescribed Levaquin 500 milligrams by mouth daily for a lower respiratory infection. On 07/23/2026 at 12:30 PM, observation revealed R2 being wheeled in a wheelchair to her room. R2's oxygen was on a portable oxygen canister. In R2's room, the oxygen concentrator R2 used for continuous oxygen revealed there was no filter in R2's oxygen concentrator. Grey dust could be seen in the holes that should have been covered by a filter. The oxygen concentrator humidifier and the tubing from the humidifier to the oxygen concentrator had a date of 07/02/2026. 3. R3's EMR documented R3 had diagnoses of COPD and respiratory failure with hypoxia and hypercapnia. The End of Skilled Care MDS, dated 07/17/2026, documented R3 had a BIMS score of 15, which indicated intact cognition. The MDS documented R3 was dependent with all her ADLs. The MDS documented R3 was on continuous oxygen. The Functional Abilities CAA, dated 04/05/2026, documented R3 had been readmitted to the facility for acute on chronic COPD with respiratory failure. The CAA documented R3 was dependent on staff for all cares but could feed herself. The CAA documented R3 was a full lift due to immobility and deconditioning. R3's Care Plan, dated 05/10/2021, documented R3 used supplemental oxygen. The care plan directed staff to change the oxygen tubing and rinse the concentrator filter weekly on Wednesdays. The care plan lacked direction regarding keeping oxygen tubing off the floor. The Health Status Note, dated 07/08/2026, documented R3 had returned from the emergency room with a diagnosis of exacerbation of COPD and pneumonia. New orders were received for doxycycline (antibiotic)100 milligrams for seven days and cefdinir (antibiotic) 300 milligrams for 7 days. The Skilled Note, dated 0713/2026, documented R3 had labored breathing with shortness of breath. Head of the bed elevated to 90 degrees. R3 currently on antibiotics for pneumonia. On 07/23/2026 at 11:30 AM, observation revealed R3 sat in a wheelchair out in the common area. R3's oxygen concentrator had been brought with her and was plugged into the wall. Observation revealed R3's oxygen tubing lay on the floor, and the oxygen concentrator filter had thick grey dust and dirt covering it. The oxygen concentrator humidifier and the tubing from the humidifier to the oxygen concentrator had a date of 07/02/2026. 4. R4's EMR documented R4 had diagnoses of COPD, unsteadiness on feet, muscle weakness, and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Quarterly MDS, dated 07/22/2026, documented R4 had a BIMS of 13, which indicated R4 had intact cognition. The MDS documented R4 was dependent on staff for all ADLs. The MDS documented R4 required oxygen therapy. The Functional Abilities CAA, dated 04/24/2026, documented R4 was on hospice and received medication for discomfort and air hunger. The CAA documented R4 was dependent on staff for care due to weakness and COPD. R4's Care Plan, dated 12/02/2025, documented R4 required supplemental oxygen and directed staff to change oxygen tubing and rinse filter weekly. The care plan lacked direction regarding keeping oxygen tubing off the floor. On 07/23/2026 at 11:15 AM, observation revealed R4 sat in a geri-chair at the lunch table and fed herself. R4 sat at the assisted table. R4's oxygen concentrator had been brought out to the dining room and was plugged into the wall. R4's oxygen tubing lay on the floor, and the oxygen concentrator filter had thick grey dust and dirt covering it. The oxygen concentrator humidifier and the tubing from the humidifier to the oxygen concentrator had a date of 07/02/2026. 5. R5's EMR documented diagnoses of respiratory failure with hypoxia, pneumonia, muscle wasting, weakness, and failure to thrive. The Annual MDS, dated 07/06/2026, documented R5 had a BIMS of 0, which indicated severely impaired cognition. The MDS documented R5 was dependent on staff for all ADLs. The MDS documented R5 required supplemental oxygen. The Functional Abilities CAA, dated 07/06/26, documented R5 was dependent on staff for ADLs, was on a pureed diet with nectar thickened liquids, had poor safety awareness, and was at risk for falls. R5's Care Plan, dated 12/15/25, documented R5 required supplemental oxygen and directed staff to change oxygen tubing and rinse filter weekly. The care plan lacked direction regarding keeping oxygen tubing off the floor. On 07/23/26 at 11:15 AM, observation revealed R5 sat at the assisted table, and a Certified Nurse Aide (CNA) fed R5. R5's oxygen concentrator had been brought to the dining area and was plugged into the wall. R5's oxygen tubing was on the floor, and the oxygen concentrator filter had thick grey dust and dirt covering it. R5's oxygen tubing did not have any date on any of the tubing or oxygen humidifier. On 07/23/26 at 11:15 AM, CNA M verified both R4 and R5's oxygen filters were dirty. On 07/23/26 at 11:45 AM, LN G and Administrative Nurse D verified R1's oxygen concentrator was dirty with dried nutrition formula, R1's oxygen tubing was on the floor, R1's oxygen humidifier did not have any distilled water in it, and the date on the oxygen humidifier and the tubing from the oxygen humidifier to the concentrator was dated 07/02/26. On 07/23/26 at 12:30 PM, CNA N verified R2's oxygen concentrator did not have a filter, and there was dust in the holes where the concentrator filter should be. CNA M stated she did not know anything about the oxygen concentrator filter. On 07/23/26 at 02:00 PM, Administrative Nurse D stated none of the residents' oxygen tubing should have been on the floor. Administrative Nurse D explained the facility had run out of the shorter oxygen tubing and had to use longer tubing, and that was why the oxygen tubing was on the floor. Administrative Nurse D stated oxygen concentrator filters should be cleaned weekly. Administrative Nurse D stated the oxygen concentrator humidifier and the tubing from the humidifier to the concentrator were only changed monthly. On 07/23/26 at 02:00 PM, Administrative Staff A stated the facility followed the manufacturer's guidelines regarding the oxygen humidifier and the tubing from the oxygen humidifier to the oxygen concentrator, and the guidelines instructed those elements to be changed monthly. Administrative Staff A was asked to present the manufacturer's guidelines but did not do so. The facility's undated Oxygen Concentrator Policy documented the purpose of the policy was to establish responsibilities for the care and use of oxygen concentrators. The documented nursing would change oxygen tubing and mask/cannula weekly and as needed as it became soiled or contaminated, and nursing would change the humidifier bottle when empty, every seventy-two hours, or as recommended by the manufacturer. The facility's undated Infection Control Policy documented the facility would provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The policy documented all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with the facility's current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Single-use disposable equipment must be discarded after use.

Based on record review, observation, and interview, the facility failed to ensure residents received the required assistance with activities of daily living (ADL) when staff failed to provide Resident (R) 1 with the necessary oral care to keep R1's mouth free from mucus. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle wasting, cognitive impairment, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness) pneumonia (an infection in the lungs), respiratory failure (when the lungs cannot send enough oxygen to the blood) with hypercapnia (a condition that occurs when there is too much carbon dioxide in the blood) and hypoxia (inadequate supply of oxygen), and traumatic brain injury (TBI-an injury to the brain caused by external forces). R1's Annual Minimum Data Set (MDS), dated 07/10/26, documented R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R1 had difficulty communicating some words or finishing thoughts and missed some part or intent of a message but could understand most of a conversation. The MDS documented R1 had impairment of both sides of his upper and lower extremities. The MDS documented R1 was dependent on staff for all ADLs. The MDS documented R1 received oxygen therapy and required a non-invasive mechanical ventilator (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/10/26, documented R1 had diagnoses of TBI, communication deficit, and cognitive impairment. The CAA documented R1 had poor short-term memory and poor decision-making skills. The CAA documented activities were provided to keep R1 engaged. The Functional Abilities CAA, dated 07/10/26, documented R1 was dependent on staff for all care, had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). R1 had difficulty swallowing and had a gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) for nutrition. R1's Care Plan, initiated on 04/30/2017, documented R1 was dependent on staff for oral care and R1 would be free from infection, pain, or bleeding. The care plan directed staff to assist R1 with oral care twice daily and as needed. The Health Status Note, dated 07/16/2026, documented a chest X-ray had been performed on R1, and the results were bilateral poorly defined infiltrates (pneumonia), and an antibiotic, Levaquin 500 milligrams, was ordered daily via g-tube. The Infection Note, dated 07/16/2023, documented an infection control assessment had been completed because R1 had a lower respiratory infection. On 07/23/2026 at 09:45 AM, observation revealed R1 lay in his bed on his right side. The room was dark, with no lights on, and the curtains were shut. R1's mouth was full of thick grey mucus. On 07/23/2026 at 11:45 AM, Licensed Nurse (LN) G and Administrative Nurse D demonstrated the correct way to perform a G-tube feeding with R1. Neither LN G nor Administrative Nurse D provided R1 with oral care at this time. R1 continued to have thick mucus in his mouth. On 07/23/2026 at 01:00 PM, observation revealed R1 sat in his geri-chair in the common area and watched TV. Blood could be seen in R1's mouth and around his lips. There was no mucus in R1's mouth. R1 said, Ya, when asked if his mouth hurt. On 07/23/2026 at 02:00 PM, Administrative Nurse D verified oral care should have been completed for R1 that morning. The facility's undated Oral Care Policy documented it was the practice of the facility to provide oral care to residents to prevent and control plaque-associated oral disease.

- R69's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle wasting and atrophy multiple sites (wasting or decrease in size of a part of the body), communication deficit, repeated falls, and muscle weakness. The Significant Change Minimum Data Set (MDS) dated 03/10/25 documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R69 was dependent on staff assistance for lower extremity dressing and bathing. She required partial to moderate staff assistance with transfers. The MDS documented R69 had two non-injury falls since the last MDS. R69's Falls Care Area Assessment (CAA) dated 03/14/25 documented she had recent falls and continued to be at risk for further falls related to her confusion and poor safety awareness. R69's Care Plan, dated 07/17/24, documented staff would anticipate and meet her needs. The plan of care documented staff would ensure her call light was within reach, also encourage her to call for assistance as needed, and respond promptly to all requests. The plan of care documented staff would monitor trends in falls or the increased number of falls to rule out acute illness or mental changes. The plan of care initiated on 09/09/24 and revised 02/24/25 documented staff provided a sign in her room to remind R6 to wear appropriate footwear or non-skid socks when walking. The plan of care initiated on 10/15/24 and last revised on 02/24/25 documented staff placed a sign in R69 room to remind her to call for assistance. The plan of care dated 12/23/24 documented a Dycem (non-slip mat used for stabilization and gripping to prevent slipping) would be applied to her recliner, and grip strips were applied to the floor in front of her recliner. The plan of care dated 01/02/25 documented on12/31/24, grip strips were applied in front of R69's bed. The plan of care initiated on 01/08/25, last revised on 03/06/25 documented on 01/05/25 staff removed the riser from her recliner and discussed with her family about purchasing a new recliner that was safer for R69. The plan of care dated 01/16/25 documented on 01/14/25 the family was going to look into purchasing a smaller recliner to promote safety for R69. The plan of care initiated on 02/04/25, last revised on 03/06/25 documented on 02/03/25. Dietary staff would serve R69 first at mealtime. The plan of care dated 02/24/25 documented on 02/21/25 the staff would provide cups with lids for R69. The plan of care dated 02/28/25 documented on 02/27/25, a medication review would be completed. The plan of care dated 03/12/25, documented on 03/09/25, bright tape was applied to R69's brakes as a visual cue. The plan of care dated 03/27/25, documented on 03/26/25, staff would obtain orthostatic (measurements of blood pressure and pulse taken with the patient in the supine, sitting, and standing positions to assess low blood pressure and possible blood pooling in the lower extremities resulting in dizziness) blood pressures x 72 hours. The plan of care dated 04/01/25 documented on 03/28/25 a request for labs and a medication review was placed by the physician. Review of R69's EMR under Progress Notes tab revealed a General Note dated 02/22/25 at 05:12 AM, documented R69 had a non-injury fall. The facility was unable to provide an investigation with a root cause analysis of the fall upon request. On 02/28/2025 at 06:30 AM, a General Note documented R69 had a non-injury fall. The facility was unable to provide an investigation with a root cause analysis of the fall upon request. On 04/02/25 at 07:40 PM, an interact Situation, Background, Assessment, and Recommendation (SBAR) was documented for a fall evaluation was completed. The facility was unable to provide an investigation with a root cause analysis of the fall upon request. The facility was unable to provide evidence a medication review was completed for the fall intervention on 02/27/25 and 03/28/25 upon request. R69's EMR under the Assessment tab revealed the following: Morse Fall Scale was completed on 12/18/24, post fall documented R69 was a high fall risk for falling. On 12/23/24, a Morse Fall Scale was completed post fall documented R69 was a high fall risk for falling. On 12/31/24, a Morse Fall Scale was completed post fall documented R69 was a high fall risk for falling. On 01/08/25, a Morse Fall Scale was completed post fall documented R69 was a high fall risk for falling. On 01/15/25, a Morse Fall Scale was completed on admission, documenting R69 was a high fall risk for falling. On 02/03/25, a Morse Fall Scale was completed post Post-fall documented R69 was a high fall risk for falling. On 02/22/25, a Morse Fall Scale was completed on admission, documenting R69 was a high fall risk for falling. On 02/28/25, a Morse Fall Scale was completed post fall documented R69 was a high fall risk for falling. On 03/06/25, a Morse Fall Scale was completed for a significant change documented R69 was a high fall risk for falling. On 03/10/25, a Morse Fall Scale was completed post fall documented R69 was a high fall risk for falling. On 04/02/25, a Morse Fall Scale was completed post fall documented R69 was a high fall risk for falling. On 04/22/25 at 07:07 AM, R69 was asleep on her bed. R69's room lacked a sign that reminded her to use her call light for assistance. R69's room also lacked a sign to remind her to wear appropriate footwear. On 04/22/25 at 07:55 AM, R69 was pushed in her wheelchair as her feet drug along the floor from the common area into the dining room by Certified Nurse Aide (CNA) OO. R69's wheelchair lacked bright tape on her wheelchair brakes. On 04/23/25 at 12:20 PM, CNA MM stated the staff would communicate in the report of any new changes made for any of the residents. CNA MM stated the fall interventions could be found on the resident's care plan or on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA MM stated she was not usually responsible for ensuring a resident's fall interventions were in place on a regular basis. On 04/23/25 at 12:35 PM, Licensed Nurse (LN) G stated that nursing usually double-checks to ensure all of a resident's fall interventions were in place. LN G stated that new fall interventions were communicated during report and could be found on the resident's care plan or on the Kardex. On 04/23/25 at 01:01 PM, Administrative Nurse D stated that the MDS coordinator tracks the fall interventions for each resident to ensure they have the interventions in place. Administrative Nurse D stated that each fall was reviewed by the interdisciplinary team (IDT) would review each fall and determine the root cause analysis. Administrative Nurse D stated that the IDT would review the interventions that the resident had in place. Administrative Nurse D stated she was not sure if the falls on 02/22/25, 02/28/25, and 04/02/25 were not investigated. The facility's Fall Risk Assessment policy, dated 02/01/20, documented it was the policy of the facility to ensure the facility provides an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. Monitor the effectiveness of the care plan interventions and modify the interventions as necessary, in accordance with current standards of practice. The facility's Fall Prevention Program policy, dated 02/01/20, documented each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility would: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify the physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. The facility reported a census of 74 residents, with 19 residents sampled. Based on observation, interview, and record review, the facility failed to ensure a safe care environment related to environmental hazards. On 04/21/25 at 07:15 AM, an inspection of the facility's open kitchenette area off the main entry revealed the kitchenette's oven/stove top power shut-off was not activated. An inspection of the electric oven/stove top revealed working stove top burners and oven, and the counter to the left of the oven revealed a working bread toaster. On 04/21/25 at 07:30 AM, an inspection of the 200-hallway revealed an unlocked maintenance closet which contained 15 bottles of disinfectant cleaner. On 04/21/25, an inspection of the secured memory care unit revealed cognitively impaired Resident (R) 24 going through an unlocked cabinet next to the television area, which contained a half-gallon jug of bleach and disinfectant spray. The facility failed to secure potentially hazardous materials and equipment, which placed 11 cognitively impaired/independently mobile residents on the main unit and four cognitively impaired/independently mobile residents on the memory care unit in immediate jeopardy. The facility additionally failed to implement effective fall interventions for R69. This deficient practice placed R69 at risk for falls and accidents. Findings Included: - On 04/21/25 at 07:15 AM, an inspection of the facility's open kitchenette area off the main entry revealed the kitchenette's oven/stove top power shut-off was not activated. Further inspection of the electric oven/stove top revealed working stove top burners and oven. An inspection of the counter to the left of the oven revealed a working bread toaster. On 04/21/25 at 07:30 AM, a walkthrough of the facility revealed the entry door to the maintenance office on the 200 hallway was unlocked. An inspection of the office revealed 15 bottles of assorted disinfectant cleaners, which contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. On 04/21/25 at 07:20 AM, Administrator A verified the oven was functioning and stated the oven had a shut-off switch. She stated she did not know where the switch was and needed to call maintenance. At 07:23 AM, she received a text from maintenance noting the switch was in the cabinet above the oven. At 07:25 AM, the switch was located and shut off. She stated she was not sure how long the switch was turned on, but said residents were not supposed to have access to the oven or burners. She also unplugged the toaster and relocated it to a cabinet. She stated the residents should not have access to the potentially hazardous material or equipment. On 04/21/25 at 10:00 AM, Certified Nurse Aide (CNA) O stated cleaning products were to be stored in locked cabinets out of residents' reach. On 04/21/25 at 10:05 AM, Licensed Nurse (LN) H stated hazardous materials and cleaning products were to be locked up and out of residents' reach. She stated the residents were not allowed to use the stove, but were not sure if the stove had an electrical shut-off switch to prevent the residents from accidentally turning the burner or oven on. She stated that only the activities and maintenance staff used the oven. She stated that direct care staff had no training or in-service on how to shut the power off. On 04/21/25 at 10:30 AM, Activity Staff Z stated that only activities and maintenance staff had keys to the power shut-off cabinet. She stated that she was not sure the last time the stove was used. She stated that direct care staff were not trained on how to shut off the power to the oven/stovetop. On 04/21/25 at 10:40 AM, Maintenance Staff U stated the last time he remembered the stove being used was on Friday (04/18/25). He stated he was not sure how or why the power was left on to the oven/stovetop. The facility's Accidents and Supervision policy (undated) indicated the facility would ensure a safe care environment for all residents. The policy indicated the facility would identify all potential hazards and risks. The policy indicated the facility would provide preventative interventions and supervision to minimize the risks. - The Medical Diagnosis section within R24's Electronic Medical Records (EMR) noted diagnoses of autism spectrum disorder (ASD - a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication), dysphagia (difficulty swallowing), major depressive disorder (major mood disorder), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R24's Quarterly Minimum Data Set (MDS) completed 03/28/25 revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted he required substantial to maximal staff assistance with bathing, toileting, transfers, dressing, and personal hygiene. The MDS noted he had verbal and physically aggressive behaviors. The MDS noted he had no upper or lower extremity impairments. The MDS noted he could ambulate without the use of assistive devices. R24's Functional Abilities Care Area Assessment (CAA) completed 09/08/24 indicated he required moderate to substantial assistance with his activities of daily living (ADL). The CAA noted he had poor safety awareness and was at risk for falls. R24's Cognitive Loss CAA completed 09/08/24 indicated he had both cognitive loss and dementia. The CAA noted staff were to monitor for acute mental status changes and communicate in short, simple sentences to allow him to understand. R24's Care Plan initiated on 04/19/23 indicated he resided in the memory care unit due to his autism diagnosis. The plan noted he wandered on the secure unit regularly. The plan instructed staff to provide him with structured activities to keep him engaged. The plan noted he required staff assistance with bathing, toileting, oral hygiene, dressing, and personal hygiene. The plan noted he could independently transfer and ambulate. The plan noted he had impaired cognition and thought processes. The plan noted he had a history of rummaging through closets and needed staff supervision. On 04/21/25 at 07:12 AM, a walkthrough of the Memory Care Unit was completed. An inspection of the television area revealed R24 standing next to the wall cabinet to the right of the televisions. R24 opened the far-right cabinet and rummaged around the shelves. R24 closed the closet door and moved to the far-right side closet. He continued rummaging through the closet, pulled out a fan, then closed the door. Staff were across the room at the nurse's carts but provided no supervision during this incident. Inspection of the closet revealed a one-gallon jug of bleach and Lysol disinfectant stored on the shelves he was rummaging in. The products contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. On 04/21/25 at 07:25 AM, Administrative Staff A stated that the staff were expected to secure areas and equipment that contained potentially hazardous materials to prevent exposure to the residents. On 04/21/25 at 10:00 AM, Certified Nurse's Aide (CNA) O stated cleaning products were to be stored in locked cabinets out of residents' reach. On 04/21/25 at 10:35 AM, Licensed Nurse (LN) G stated that the storage closets were to be always locked. LN G stated that cleaning products should never be stored in the residents' common areas. The facility's Accidents and Supervision policy (undated) indicated the facility would ensure a safe care environment for all residents. The policy indicated the facility would identify all potential hazards and risks. The policy indicated the facility would provide preventative interventions and supervision to minimize the risks. On 04/21/25 at 01:04 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ. On 04/21/25 at 03:45 PM, the facility provided an acceptable immediacy removal plan, which included the following: On 04/21/25 at 07:25 AM, the power shutoff switch was activated, and the cabinet was locked. On 04/21/25 at 07:25 AM, the maintenance office was locked. The keypad was reprogrammed to the entry door for the maintenance office. On 04/21/25 at 07:25 AM, the pop-up toaster was unplugged and moved to a cabinet. On 04/21/25 at 07:25 AM, the chemicals were removed from the closet in the Memory Care Unit. On 04/21/25 at 07:30 AM, maintenance completed full facility safety rounds. On 04/21/25, education was provided to staff about safe chemical use and storage. Implementation of the corrective actions were verified onsite on 04/21/25 at 03:50 PM. The deficient practice remained at the scope and severity of E (pattern, potential harm) after the removal of the immediacy.

The facility identified a census of 74 residents. The sample included 19 residents, and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure that five of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA M was hired on 02/02/18 and had no yearly performance evaluation upon request. CNA N was hired on 04/25/22 and had no yearly performance evaluation upon request. CNA O was hired on 01/16/23 and had no yearly performance evaluation upon request. CNA P was hired on 04/07/22 and had no yearly performance evaluation upon request. CNA Q was hired on 01/19/24 and had no yearly performance evaluation upon request. On 04/23/25 at 09:08 AM, Administrative Nurse D stated that Administrative Staff A would provide the list of employees due for their yearly performance review. Administrative Nurse D stated that the department directors were responsible for completing their staff's yearly performance reviews. The facility's Evaluation Process policy, dated 12/01/19, documented it was the policy of the facility to review the work performance of employees with a formal written evaluation annually.

The facility identified a census of 74 residents with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food and equipment storage. This deficient practice placed the residents at risk related to foodborne illnesses and food safety concerns. Findings Included: - On 04/21/25 at 07:00 AM, a walkthrough of the facility's kitchen was completed: An inspection of the kitchen's reach-in freezer unit revealed 13 uncovered cups of chocolate ice cream open to the air in the freezer. The cups were unlabeled and undated. An inspection of the plate and utensil storage area revealed stacked bowls in a plastic bin facing upward. An inspection of the kitchen's reach-in refrigerator located in the dry food storage office revealed an opened, but unlabeled/undated chocolate pie. On 04/21/25 at 07:20 AM, an inspection of the open kitchenette in the main entry area revealed stains and old food debris covering the inside of the refrigerator and microwave. The kitchenette freezer contained open, but unlabeled/undated food items. On 04/22/24 at 12:18 PM, the food cart was transported to the memory care unit. Clean plates were stored on the second shelf of the cart facing upwards. On 04/21/24 at 12:15 PM, the food cart was transported to the memory care unit. Clean plates were stored on the second shelf of the cart facing upwards. On 04/23/25 at 11:34 AM, Dietary Staff BB stated staff were expected to store all the food utensils and plates downward to prevent cross-contamination. She stated all open food items were to be dated and labelled before being stored in the kitchen or kitchenettes. The facility's Food Preparation and Service revised 12/2024 stated the facility was to ensure food service employees handle kitchen food and equipment in a manner that complies with safe handling practices. The policy noted all food was to be labeled and dated. The policy noted cooking equipment would be maintained in a sanitary environment and stored in a manner to prevent contamination or soiling.

The facility identified a census of 74 residents. The sample included 19 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 74 residents residing in the facility. Findings Included: - On 04/21/25, Administrative Staff A provided a Facility Assessment updated 12/19/24. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs by shifts for the weekends and staffing needed for the specialized Memory Care Unit. On 04/21/25, a review of the facility's Payroll Based Journal (PBJ - a staffing data report) from 04/01/24 to 03/31/25 revealed excessively low weekend staffing triggered for all four quarters. On 04/24/25 at 01:30 PM, Administrative Staff A stated the facility assessment was recently updated to reflect the recent Centers for Medicare and Medicaid Services (CMS) staffing assessment requirements. She stated the facility assessment reflected the required staff hours per day, but may not have broken down the hours to reflect weekends and specialty units. She stated the reported PBJ hours were pulled from the completed facility assessment data. The facility's Facility Assessment policy, revised 06/18/24, indicated the facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents during day-to-day operations, including evenings, nights, and weekends.

The facility had a census of 74 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). This placed the residents at risk for impaired care due to unidentified staffing issues. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year 2024, all four quarters indicated the facility triggered for low weekend staffing. On 04/23/25 at 01:01 PM, Administrative Nurse D stated that the weekend staffing was not low. Administrative Nurse D stated there was a call-in on the weekends at times, but staffing was not low. On 04/22/25 at 01:22 PM, Administrative Staff A stated that the information submitted was based on the payroll hours. Administrative Staff A stated the facility was not staffed lower than during the week for the direct care staff. The facility's Payroll Based Journal policy dated 12/01/19 documented it was the policy of the facility to electronically submit to Centers for Medicare & Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

The facility identified a census of 45 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to address quality deficiencies prior to the survey. This deficient practice placed the residents at risk for ineffective care. Findings Included: - The facility identified a census of 74 residents. The sample included 19 residents, with three reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R) 59 during meals. This deficient practice placed the residents at risk for impaired dignity and quality of life. (Refer to F550) The facility identified a census of 74 residents. The sample included 19 residents, with four reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 23, R65, R10, and R281 had a way to communicate their needs due to their call lights being left out of reach. The facility additionally failed to ensure safe transport for R44, R71, and R76 due to them being pushed in their wheelchairs without foot pedals. This deficient practice placed the residents at risk for preventable accidents and injuries. (refer to F558) The facility identified a census of 74 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 2's medical record. This placed this resident at risk for impaired right to confidentiality. (Refer to F583) The facility identified a census of 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food. (Refer to F657) The facility identified a census of 74 residents. The sample included 19 residents, with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure R10's footrest was down on her wheelchair, her feet had appropriate footwear, and further failed to ensure R6 was provided with assistance while eating. This defiant practice placed R10 and R6 at risk of impaired activities of daily living (ADL) and unmet care needs. (refer to F677) The facility identified a census of 74 residents. The sample included 19 residents, with five residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing devices were in place for Resident (R) 6 and R10, who were at risk for the development of pressure ulcers. This deficient practice placed R6 and R10 at risk for complications related to skin breakdown. (Refer to F686) The facility identified a census of 74 residents. The sample included 19 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10's resting splint and R41's cockup splint were applied for contractures (abnormal permanent fixation of a joint or muscle), and dysphagia (swallowing difficulty). This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). (Refer to F688) The facility reported a census of 74 residents, with 19 residents sampled. Based on observation, interview, and record review, the facility failed to ensure a safe care environment related to environmental hazards. On 04/21/25 at 07:15 AM, an inspection of the facility's open kitchenette area off the main entry revealed the kitchenette's oven/stove top power shut-off was not activated. An inspection of the electric oven/stove top revealed working stove top burners and oven, and the counter to the left of the oven revealed a working bread toaster. On 04/21/25 at 07:30 AM, an inspection of the 200-hallway revealed an unlocked maintenance closet which contained 15 bottles of disinfectant cleaner. On 04/21/25, an inspection of the secured memory care unit revealed cognitively impaired Resident (R) 24 going through an unlocked cabinet next to the television area, which contained a half-gallon jug of bleach and disinfectant spray. The facility failed to secure potentially hazardous materials and equipment, which placed 11 cognitively impaired/independently mobile residents on the main unit and four cognitively impaired/independently mobile residents on the memory care unit in immediate jeopardy. The facility additionally failed to implement effective fall interventions for R69. This deficient practice placed R69 at risk for falls and accidents. (refer to F689) The facility identified a census of 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food. (Refer to F692) The facility identified a census of 74 residents. The sample included 18 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 13's continuous positive airway pressure (CPAP - a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored in a sanitary manner. This placed R13 at an increased risk for respiratory infection and complications. (Refer to F695) The facility identified a census of 74 residents. The sample included 19 residents, and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure that five of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. (Refer to F730) The facility identified a census of 74 residents. Based on record review and interviews, the facility failed to maintain the posted daily nurse staffing data for the required 18 months. (Refer to F732) The facility identified a census of 74 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure staff provided the necessary person-centered activities and interventions to address Resident (R) 37's dementia (a progressive mental disorder characterized by failing memory, confusion) diagnosis. This deficient practice placed R37 at risk of ineffective treatment and decreased quality of care. (Refer to F744) The facility identified a census of 74. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 2, R37, and R67 antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication lacked a Centers for Medicare and Medicaid (CMS) approved indication for use. These deficient practices placed R2, R37, and R67 at risk of unnecessary medication administration and related complications. (Refer to F756) The facility identified a census of 74. The sample included 19 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the physician provided an appropriate Centers for Medicare and Medicaid Services (CMS) indication for use of Resident (R) 2 and R67's prescribed antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The facility failed to ensure the physician provided the risk versus benefit for the continued use of antipsychotic medications. These deficient practices placed R2 and R67 at risk of unnecessary medication administration and related complications. (Refer to F758) The facility identified a census of 74 residents with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food and equipment storage. This deficient practice placed the residents at risk related to foodborne illnesses and food safety concerns. (Refer to F812) The facility identified a census of 74 residents. The sample included 19 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 74 residents residing in the facility. (Refer to F838) The facility had a census of 74 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). This placed the residents at risk for impaired care due to unidentified staffing issues. (Refer to F851) The facility identified a census of 74 residents. The facility identified 14 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure that trash was not left on the floor, and linens, dishes, trash bags, and gloves were not left on the radiator or handrail. The facility failed to ensure Resident (R) 22's, and R39's nasal cannula oxygen tubing was stored in a sanitary manner and failed to ensure R13'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 was stored in a sanitary manner, and further failed to ensure the Hoyer (total body mechanical lift) was sanitized after resident use. These deficient practices placed the residents at risk for infectious diseases. (Refer to F880) The facility had a census of 74 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on the record review and interview, the facility failed to ensure that five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care. (refer to F947). The faciity Quality Assurance and Performance Improvement (QAPI) policy dated October 2022 documented it was the policy of this facility to develop, implement, and maintain an effecive, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provided. The QualityAssessment and Assurance (QAA) Committee shall be interdisciplinary and shall develop and implement appropriate plans of action to correct identified quality deficiencies; regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements; policies and procedures for feedback, data collection systems, and monitoring. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: tracking and measuring performance, establishing goals and thresholds for performance improvements, identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed; a prioritization of program activities that focus on resident safety, health outcomes, autonomy, choice and quality of care, as well as, high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves. The facility must also consider the incidence, prevalence, and severity of problems or potential problems identified. A commitment to quality assessment and performance improvement by the governing body and/or executive leaders. Process to ensure care and services delivered meet accepted standards of quality. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: the written QAPI plan; systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; data collection and analysis at regular intervals; documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The plan and supporting documentation will be presented to the State Survey Agency or Federal surveyor at each annual recertification survey and upon request. The plan and supporting documentation will be presented to the Centers for Medicare & Medicaid Services (CMS) upon request.

The facility had a census of 74 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure that five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - Review of the information facility's in-service records revealed the following CNAs were employed with the facility for more than 12 months: CNA M was hired on 02/02/18 and had not completed the required in-services in the past 12 months. CNA N was hired on 04/25/22 and had not completed the required in-services in the past 12 months. CNA P was hired on 04/07/22 and had not completed the required in-services in the past 12 months. CNA O was hired on 01/16/23 and had not completed the required in-services in the past 12 months. CNA Q was hired on 01/19/24 and had not completed the required in-services in the past 12 months. On 04/23/25 at 09:08 AM, Administrative Nurse D stated it was a team effort to ensure the direct care staff received their 12-hour required in-service education. Administrative Nurse D stated that the facility had hired a clinical nursing educator to help with in-services and education. The facility failed to provide a policy related to required yearly in-services.

The facility identified a census of 74 residents. The sample included 19 residents, with four reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Residents (R) 23, R65, R10, and R281 had a way to communicate their needs due to their call lights being left out of reach. The facility additionally failed to ensure safe transport for R44, R71, and R76 due to them being pushed in their wheelchairs without foot pedals. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 04/21/25 at 07:04 AM, an inspection of R23's bed revealed no call light within her reach. She attempted to locate the light but was unable to find it. R23's bed was pushed against the wall and her call light was on the floor underneath her bed. On 04/21/25 at 07:06 AM, R65 slept in her bed. R65's call light was on the floor underneath her bed and out of reach. On 04/21/25 at 07:07 AM, R10 rested in her bed. R10 was unable to locate her call light. R10's call light was found behind her bed. On 04/21/25 at 07:09 AM, R281 lay in his bed. He was unable to locate his call light. His call light was found on the floor at the foot of his bed. On 04/21/25 at 07:10 AM, staff pushed R44 in his wheelchair up the 200 Hall to the front commons area. R44's wheelchair lacked foot pedals, and his feet touched the ground multiple times while being pushed. On 04/22/25 at 11:36 AM, staff pushed R71 (a severely cognitively impaired resident) in his wheelchair from the 100 Hall to the dining room in the memory care unit. R71's wheelchair had no foot pedals and his feet slid on the ground during transport. On 04/22/25 at 12:05 PM, R76 (a severely cognitively impaired resident) was pushed by staff in his wheelchair from the 100 Hall to the weight scale in the television area. R76's wheelchair had no foot pedals, and his feet slid on the ground during transport. On 04/22/25 at 12:07 PM, staff pushed R71 in his wheelchair from the dining area to the main hall. R71's feet slid on the ground while being pushed. On 04/22/25 at 12:14 PM, staff pushed R71 back to the dining room in his wheelchair. R71's feet slid on the ground while being pushed. On 04/23/25 at 12:19 PM, Certified Nurse's Aide (CNA) MM stated the call lights were to be placed within reach of the residents. She stated staff were expected to ensure the residents could always use their call lights. She stated all residents had foot pedals for their wheelchairs and were to be used while being pushed. She stated the resident's feet should never drag or touch the ground while being pushed. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated call lights were to be placed next to the residents, and staff were expected to ensure they were always within reach. She stated that foot pedals were to be used each time staff pushed the residents. On 04/23/25 at 01:06 PM, Administrative Nurse D stated staff were expected to use foot pedals or encourage the resident to propel themselves. She stated the resident's feet should never drag while being pushed. She stated staff were expected to ensure the call lights were always within reach of the residents. The facility's Accommodation of Needs policy revised 12/2024, indicated the facility will make reasonable accommodations for each resident to include preferences, choices, and requirements in relation to each resident's physical limitations and ability to maintain independence.

The facility identified a census of 74 residents. The facility identified 14 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure trash was not left on the floor, and linens, dishes, trash bags, and gloves were not left on the radiator or handrail, failed to ensure Resident (R) 22's, and R39's nasal cannula oxygen tubing was stored in a sanitary manner and failed to ensure R13'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 was stored in a sanitary manner, and further failed to ensure the Hoyer (total body mechanical lift) was sanitized after resident use. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 04/21/25 at 07:01 AM during the initial walk-through: On hall 300 a cup, gloves, and trash bags were on the handrail. A clear trash bag filled with briefs, and wipes and laid on the floor at the top of hall 200, close to the commons area. A white towel a plate with a plastic spoon and a cup were laid on the register at the end of hall 400. R22's and R39's nasal oxygen tubing was wrapped around the stationary canisters in their rooms. R22's and R39's nasal cannulas were not stored in a sanitary manner. On 04/21/25 at 08:10 AM, R13 laid in her bed. R13's CPAP mask and tubing laid on the floor between her bed and the wall. R13's CPAP was not stored in a sanitary manner. On 04/22/25 11:46 AM, R11 was transferred from her bed into her wheelchair with the assistance of the Hoyer. Certified Medication Aide (CMA) R pushed the Hoyer lift from R11's room to R6's room without cleaning the lift. On 04/23/25 at 12:09 PM, Certified Nurse's Aide (CNA) MM stated all respiratory equipment should be in a bag with a date. CNA MM stated some of the residents have their bags for their CPAPs, and the mask and tubing should be in their bags. CNA MM stated trash should not be left on the rails or the floor. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated residents' CPAP should be stored in a bag with a date and stored in the bag when not in use. LN G stated all respiratory equipment should be stored in a bag when not in use. She stated the facility had barrels for trash, and trash should not be left on the floor or handrails. LN G stated the CNAs can get purple top-lid sanitary wipes to wipe down equipment between residents from nursing. On 04/23/25 at 01:01 PM, Administrative Nurse D stated the bags for respiratory equipment should be changed weekly. She stated all residents should have a bag for respiratory equipment when not in use. Administrative Nurse D stated all nursing staff were responsible for ensuring respiratory equipment was stored in a sanitary manner. She stated there should never be trash bags on the floor or trash on the radiator. Administrative Nurse D stated shared equipment should be sanitized between residents, and staff know the purple top wipes could be found in the nurse's cart. The facility's Infection Prevention and Control Program undated policy documented the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, comfortable environment, The facility would help prevent the development and transmission of communicable diseases and infections as per acceded by national standards and guidelines.

The facility identified a census of 74 residents. The sample included 19 residents, with three reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R) 59 during meals. This deficient practice placed the resident at risk for impaired dignity and quality of life. Findings Included: - The Medical Diagnosis section within R59's Electronic Medical Records (EMR) included diagnoses of aphasia (difficulty speaking), dementia (a progressive mental disorder characterized by failing memory and confusion), and hypertension (high blood pressure). R59's admission Minimum Data Set (MDS) noted a Brief Interview for Mental Status (BIMS) score of seven indicating severe cognitive impairment. The MDS noted she was dependent on staff assistance for transfers, toileting, oral hygiene, bathing, dressing, and bed mobility. The MDS noted she required set-up assistance with her meals. The MDS noted no recent weight loss or swallowing disorders. R59's Functional Abilities Care Area Assessment (CAA) completed 03/20/25 indicated she was totally dependent on staff assistance for all care due to her cognitive impairment and weakness. R59's Nutritional Status CAA completed 03/20/25 indicated she was at risk for nutritional impairment related to her medical diagnoses. The CAA noted she was on a regular diet and required set-up assistance from staff. R59's Care Plan initiated 03/15/25 indicated she was dependent on staff assistance for all her activities of daily living (ADL). The plan noted she had cognitive impairment and memory loss. The plan instructed staff to provide supervision, cueing (verbal guidance), and reorientation. The plan noted she preferred a quiet environment during mealtimes. The plan noted she required maximum assistance at times during meals and instructed staff to ensure she was not pocketing her food. On 04/22/25 at 07:30 AM, staff attempted several times to feed R59 while standing over her during breakfast. On 04/22/25 at 12:27 PM, staff attempted to assist R59 with eating her meals while standing over her. R59 ate a small portion of her meal during lunch. On 04/23/25 at 12:19 PM, Certified Nurse's Aide (CNA) MM stated staff were to sit next to the resident during mealtimes to provide assistance. She stated staff were not to stand over the residents while providing meal assistance. On 04/23/25 at 01:06 PM, Administrative Nurse D stated staff were expected to sit next to the residents during meal assistance and should never stand over them while feeding them. The facility's Dementia Care policy revised 12/2024 indicated the facility was to ensure a safe, supportive, and dignified care environment for residents to attain the highest level of practicable well-being.

The facility identified a census of 74 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 2's medical record. This placed this resident at risk for impaired right to confidentiality. Findings included: - An observation on 04/22/25 at 01:50 PM revealed that facility staff left R2's point of care (POC) information of the Electronic Medical Record (EMR) open and visible on the nurse aide's wall kiosk monitor. On 04/23/25 at 11:45 AM, Certified Nurse Aide (CNA) NN stated that the aides should never leave a resident's POC information open and visible on the wall monitor screen. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated the aides should not be leaving resident information pulled up and visible on the wall screen monitor. On 04:23/25 at 01:02 PM, Administrative Nurse D stated she would expect any nursing staff to lock any screen, either on the laptop or on the wall kiosk, after they had completed charting. The facility policy Promoting/Maintaining Resident Dignity dated 01/2020 documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintained or enhanced a resident's quality of life by recognizing each resident's individuality. Staff were expected to maintain resident privacy.

The facility identified a census of 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food. Findings included: - R37's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction (stroke), and respiratory failure (the inability of the lungs to adequately exchange gases). R37's admission Minimum Data Set (MDS) dated 01/21/25 documented a Brief Interview for Mental Status (BIMS) was unable to be completed due to his rarely or never being understood. R37 had severely impaired cognitive skills for daily decision making. R37 was dependent on staff for activities of daily living (ADL) and used a wheelchair for mobility. R37 showed signs or symptoms of coughing or choking during meals or when swallowing medications. R37 required a feeding tube (administration of nutritionally balanced liquefied foods or nutrients through a tube) to aid in nutritional intake. R37's Nutritional Status and Tube Feeding Care Area Assessment (CAA) dated 01/23/25 documented R37 was receiving skilled services. R37 was dependent with cares, he was incontinent of bowel and bladder, and at risk for falls due to weakness. R37 received nothing by mouth (NPO) and was dependent on tube feeding for nutrition and was at risk for dehydration due to infection and dependent on bolus for hydration. R37 was at risk for impaired skin and had wounds on hands and at the peg site. R37's Care Plan revised on 03/11/25, directed staff he was dependent on tube feeding and water flushes. See MD orders for current feeding orders. Staff were directed he was on an NPO diet. Staff was directed that R37 received percutaneous endoscope gastrostomy tube (PEG - a tube inserted through the wall of the abdomen directly into the stomach) feedings of TwoCal HN (a nutritionally complete, high-calorie formula designed to meet the increased protein and calorie needs of metabolically stressed residents) 220 milliliters (ml.) bolus with 125 ml water before and after each bolus feeding. Staff were directed R37 needed the head of the bed elevated 45 degrees during and thirty minutes after tube feeding. Staff were directed to increase the head of the bed during feedings. R37's care plan had an intervention revised on 04/21/25 that directed staff he was on a regular general diet, with mechanical soft textures-ground meats, thin liquids consistency, nosey cups, and he needed max assistance. Staff were directed he receive peg tube feedings of TwoCal HN 220 ml. bolus with 125 ml. water before and after each bolus feeding. R37's care plan lacked revised interventions that included direction for his current nutrition/eating order that included a mechanical soft diet with max assistance, and for the resident to be in an upright position in the wheelchair. R37's Order Summary Report documented a physician's diet order dated 01/15/25 for enteral feed order every shift, and check placement every shift. Check for residual (checking and managing the amount of fluid remaining in the stomach after a period of enteral feeding, often through a feeding tube) every shift. Contact the physician if residual exceeds 50 ml. R37's Order Summary Report documented a physician's diet order dated 03/03/25 for a regular type of diet, with a mechanical soft texture, and regular consistency. Max assist, upright in wheelchair. Mechanical soft/ground meats; a slow rate of intake; thin liquids; small sips, with nose cups; remain upright 30 minutes post intake; continue tube feeding as the primary nutrition/hydration. R37's Order Summary Report documented a physician's diet order dated 04/12/25 for enteral feed order four times daily, Nutren 2.0 (a ready-to-use, calorically dense liquid nutrition supplement used for complete or supplemental nutrition support, especially for individuals with high caloric requirements or severe fluid restriction) 250 ml. If the resident eats 50 percent (%) or less of meals. Water flush with 30 ml before and 30 ml after bolus. This order lacked route directions. On 04/22/25 at 08:35 AM, R37 was observed reclined back in his Broda chair while being assisted to eat breakfast by Activities Z, who was also a certified nurse aide (CNA). On 04/23/25 at 08:25 AM, R37 was observed reclined back at a degree of about 45 degrees in his Broda chair while being assisted with eating. The unidentified staff member repositioned R37's Broda chair after she realized R37 was not in an appropriate position. On 04/23/25 at 09:15 AM, CNA NN stated R37's diet had recently changed to being able to eat regular ground food with assistance. CNA NN stated she could not say for certain if R37's care plan had an intervention for R37's new diet. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated R37 had been on enteral tube feeding for some time and had recently been advanced to a mechanical soft diet and an enteral feeding bolus. LN G stated R37 should be seated in an upright position when he was being assisted with eating his meals. On 04/23/25 at 01:05 PM, Administrative Nurse D stated that the nurses or the MDS coordinator were responsible for ensuring that care plans got updated to reflect any new interventions that should be placed to direct staff on R37's change in his diet from NPO to a regular mechanical soft diet. The facility policy Care Plan Revisions Upon Status Change, dated 01/02/20, documented that the comprehensive care plan would be reviewed and revised as necessary when a resident experienced a status change. Upon identification of a change in status, the nurse would notify the MDS Coordinator. The MDS Coordinator and the interdisciplinary team would discuss the resident's condition and collaborate on intervention options. The care plan would be updated with the new or modified interventions. Staff involved in the care of the resident would report the resident's response to new or modified interventions. Care plans would be modified as needed by the MDS Coordinator or other designated staff member.

- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), dysphagia (swallowing difficulty), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R6 required substantial to maximum staff assistance for bed mobility. The MDS documented R6 was dependent on staff assistance for transfers and with his activities of daily living (ADL). The MDS documented R6 was at risk for the development of pressure ulcers. The MDS documented staff placed pressure-reducing devices on his bed and in his chair. The Quarterly MDS dated 02/19/25 documented a BIMS score of zero, which indicated severely impaired cognition. The MDS documented that R6 was dependent on staff assistance with eating, bathing, transfers, personal hygiene, and mobility. The MDS documented R6 was at risk of developing pressure ulcers. R6's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 08/05/24 documented he was dependent on staff assistance with ADLs. R6's Care Plan, dated 12/28/23, documented he was dependent on staff assistance with eating. On 04/21/25 at 08:04 AM, R6 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room. R6 sat with his breakfast on a bedside table across his lap, and no staff sat and offered assistance or encouraged him during breakfast. On 04/22/25 at 8:10 AM, R6 sat in the dining room in his Broda chair with his breakfast on the bedside table across his lap. R6 had difficulty scooping his pureed diet (modified diet which food is blended into a pudding-like consistency for individuals with chewing or swallowing difficulty) onto his spoon. Certified Nurse Aide (CNA) M sat next to R6 and offered no assistance during breakfast. On 04/23/25 at 08:49 AM, R6 sat in his Broda chair in the dining room without staff, with his breakfast on the bedside table across his lab, as he attempted to eat his breakfast. On 04/23/25 at 12:20 PM, CNA MM stated the level of assistance required for their ADLs would be listed on their care plan or on the Kardex (nursing tool that gives a brief overview of the care needs of each resident). CNA MM stated that staff could also ask the nurse or another staff member. On 04/23/25 at 12:35 PM, Licensed Nurse (LN) G stated staff were able to review the care plan or Kardex to find the level of assistance required to provide care. LN G stated that the nurses could make changes in the care plan if needed. On 04/23/25 at 01:01 PM, Administrative Nurse D stated she expected staff to review the resident's care plan or the Kardex to know what level of assistance was needed during meals. Administrative Nurse D stated she would expect staff to assist a resident with meals if needed. The facility's undated policy Activities of Daily Living (ADL) documented that the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration was unavoidable. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility would identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline, or lack of improvement. The facility identified a census of 74 residents. The sample included 19 residents, with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10's footrest was down on her wheelchair and her feet had appropriate footwear, and further failed to ensure R6 was provided with assistance while eating. This defiant practice placed R10 and R6 at risk of impaired activities of daily living (ADL) and unmet care needs. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), muscle weakness, major depressive disorder (major mood disorder that causes persistent feelings of sadness), pain, contracture (abnormal permanent fixation of a joint or muscle), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented that R10 was rarely or never understood. The MDS documented R10 was impaired on both sides of her body. The MDS documented R10 required supervising or touching for eating and was dependent on staff for dressing, toileting, and oral hygiene. R10's Functional Abilities (Self-Care) Mobility Care Area Assessment (CAA) dated 09/19/24 documented R10 resides in long-term care due to her diagnosis of Alzheimer's, CHF, and depression. The documented R10 requires substantial to maximal assistance for care, R10 was incontinent of bowel and bladder, and has a history of physical outbursts, but no occurrences this quarter. The CAA documented R10 was at risk of falls due to weakness. R10's Care Plan dated 01/26/2025 documented R10 had a recliner back wheelchair with head support and bilateral lower extremities (BLE) foot support with leg rests and saddle cushion when she was out of bed to assist with positioning and ADL functions. R10's plan of care documented she was dependent on the assistance of staff with ADLs related to impaired cognition, mobility, putting on and taking off footwear. R10's plan of care documented staff were to ensure R10 was wearing appropriate footwear. On 04/21/25 at 07:23 AM, R10 was pushed to the Common Area by staff. R10 was in her wheelchair, she had no socks on, and the footrest was not pulled down on her chair. R10's legs and feet were dangling off the chair, uncovered. On 04/23/25 at 12:09 PM, Certified Medication Aide (CNA) MM stated she had access to the resident's care plan through the Kardex (nursing tool that gives a brief overview of the care needs of each resident). CNA stated all residents should have footwear on unless the resident could tell you they did not want to wear footwear. On 04/23/25 at 12:33 PM, Licensed Nurse (LN)G stated it was the CNA's duty to ensure each resident was fully dressed and had the devices they needed before coming out to the dining area. On 04/23/25 at 01:01 PM, Administrative Nurse D stated it was the resident's preference if they would like to wear socks or shoes. She stated that if a resident kicked when staff were applying socks, the staff may not put the socks on the resident. Administrative Nurse D stated if the resident needed something specific, the nurses and aides would find the information in the resident's care plan. The facility's undated policy Activities of Daily Living (ADLs) documented that the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility would identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline, or lack of improvement.

The facility identified a census of 74 residents. The sample included 19 residents, with five residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing devices were in place for Resident (R) 6 and R10, who were at risk for the development of pressure ulcers. This deficient practice placed R6 and R10 at risk for complications related to skin breakdown. Findings included: - R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), dysphagia (swallowing difficulty), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated 08/01/24 documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R6 required substantial to maximum staff assistance for bed mobility. The MDS documented R6 was dependent on staff assistance for transfers and with his activities of daily living (ADL). The MDS documented R6 was at risk for the development of pressure ulcers. The MDS documented staff had placed pressure-reducing devices on his bed and in his chair. The Quarterly MDS dated 02/19/25 documented a BIMS score of zero, which indicated severely impaired cognition. The MDS documented that R6 was dependent on staff assistance with eating, bathing, transfers, personal hygiene, and mobility. The MDS documented R6 was at risk of developing pressure ulcers. R6's Pressure Ulcers Care Area Assessment (CAA) dated 08/05/24 documented he was at risk for skin impairment related to incontinence and diagnoses. R6's Care Plan, last revised on 01/31/25, documented staff would encourage him to offload his bilateral lower extremities (BLE) while in bed. R6's EMR under the Orders tab revealed the following physician orders: Ensure pressure ankle foot orthotic boot (PRAFO - special boot which keeps the ankle and foot aligned to treat muscle weakness and imbalance) boots are in place on bilateral lower extremities every shift for wound care dated 08/26/23. On 04/21/25 at 08:04 AM, R6 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room. R6 sat with his breakfast on a bedside table across his lap, and no staff sat and offered assistance or encouraged him during breakfast. No PRAFO boots were in place on R6 BLE. On 04/22/25 at 8:10 AM, R6 sat in the dining room in his Broda chair with his breakfast on the bedside table across his lap. R6 had difficulty scooping his pureed diet (modified diet which food is blended into pudding-like consistency for individuals with chewing or swallowing difficulty) onto his spoon. Certified Nurse Aide (CNA) M sat next to R6 and offered no assistance during breakfast. No PRAFO boots were in place on R6 BLE. On 04/22/25 at 02:55 PM, R6 laid asleep on his right side on his bed in the lowest position with his BLE resting directly on the mattress. On 04/23/25 at 08:49 AM, R6 sat in his Broda chair in the dining room without staff with his breakfast on the bedside table across his lab, as he attempted to eat his breakfast. No PRAFO boots were in place on R6 BLE. On 04/23/24 at 09:08 AM, Administrative Nurse D stated she was unable to find the evidence that R6's PRAFO boots had been applied to his BLE. Administrative Nurse D stated the order had been entered into R6's EMR, stating no documentation was required. On 04/23/25 at 12:09 PM, Certified Nurse's Aide (CNA) MM stated that all nursing staff have access to the care plan. CNA MM stated that if a resident's heels were to be floated or the resident was to have boots, the nurse would let staff know, or she would find that information in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated if a resident required their heels floated or should have on foam boots, this information would either be on the Kardex for the CNAs to apply or the Treatment Assessment Record (TAR), and nursing would follow up to ensure the boots were placed before signing the task was done. On 04/23/24 at 01:01 PM, Administrative Nurse D stated the care plan should reflect that a resident needed heels floated or boots. She stated staff were expected to ensure all treatments were in place. The facility's Pressure Injury Prevention and Management policy, dated 01/01/20, documented the facility was committed to the prevention of avoidable pressure injuries and promoting the healing of existing pressure injuries. - R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), muscle weakness, major depressive disorder (major mood disorder that causes persistent feelings of sadness), pain, contracture (abnormal permanent fixation of a joint or muscle), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented that R10 was rarely or never understood. The MDS documented R10 was impaired on both sides of her body. The MDS documented R10 required supervising or touching for eating and was dependent on staff for dressing, toileting, and oral hygiene. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 09/19/24 documented R10 resided in long-term care due to a diagnosis of Alzheimer's, CHF, DM, and Depression. The CAA documented R10 required Substantial to maximal assistance for care, she was incontinent of bowel and bladder. The CAA documented R10 was at risk for impaired skin due to incontinence and immobility. R10's Care Plan dated 04/11/25 documented R10 was at risk for alteration in skin integrity related to incontinence and impaired mobility. R10's plan of care documented R10 used a foam mattress, heels would be floated in bed as tolerated, and the staff were to follow facility protocols for the treatment of injury. R10's plan of care documented treatment to the left heel, nursing was to see the Treatment Assessment Record TAR. R10's Braden Scale for Prediction Pressure Sore Risk dated 03/16/25 documented a score of 13, indicating a moderate risk for pressure ulcers. R10's EMR under Assessments under the Skin, Wound Evaluation tab dated 04/08/25 documented a blister (fluid-filled sack), pink or red, intact, unbroken skin, appears healed. A note in the assessment documented a verbal reminder provided to nursing staff to assist the resident in wearing pressure relief ankle foot orthosis (PRAFO) boots. R10's physician's orders under the Orders tab revealed the following orders: Left Heel: cleanse with wound cleanser, apply skin prep, and allow to dry completely. Leave open to air every shift for wound care dated 04/09/25. On 04/22/25 at 12:21 PM, R10 laid on her bed, R10's heels were not floated. R10's boots were laid under the hand sink; the boots were not on R10's feet. On 04/23/25 at 12:09 PM, Certified Nurse's Aide (CNA) MM stated that all nursing staff have access to the care plan. CNA MM stated that if a resident's heels were to be floated or the resident was to have boots, the nurse would let staff know, or she would find that information in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated if a resident required their heels floated or should have on foam boots, this information would either be on the Kardex for the CNAs to apply or the Treatment Assessment Record (TAR), and nursing would follow up to ensure the boots were placed before signing the task was done. On 04/23/24 at 01:01 PM, Administrative Nurse D stated the care plan should reflect that a resident needed heels floated or boots. She stated staff were expected to ensure all treatments were in place. The facility's Pressure Injury Prevention and Management policy, dated 01/01/20, documented the facility was committed to the prevention of avoidable pressure injuries and promoting the healing of existing pressure injuries.

The facility identified a census of 74 residents. The sample included 19 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10's resting splint and R41's cockup splint were applied for contractures (abnormal permanent fixation of a joint or muscle) and dysphagia (swallowing difficulty). This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), muscle weakness, major depressive disorder (major mood disorder that causes persistent feelings of sadness), pain, and contracture. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented that R10 was rarely or never understood. The MDS documented R10 was impaired on both sides of her body. The MDS documented R10 required supervising or touching for eating and was dependent on staff for dressing, toileting, and oral hygiene. R10's Functional Abilities (Self-Care) Mobility Care Area Assessment (CAA) dated 09/19/24 documented R10 resided in long-term care due to her diagnoses of Alzheimer's, CHF, and depression. The CAA documented R10 required substantial to maximal assistance for care, R10 was incontinent of bowel and bladder, and has a history of physical outbursts, but no occurrences that quarter. The CAA documented R10 was at risk of falls due to weakness. R10's Care Plan dated 08/29/24 documented Occupational Therapy (OT) recommended R10 use a right upper extremity (RUE) resting hand splint and left-hand glove for up to six hours in the daytime. Staff were to take off the splint at night and were to check R10's skin during self-care daily. R10's plan of care on 01/24/23 documented R10 had an alteration in musculoskeletal status related to contracture of the right hand and fingers. R10's plan of care documented her mobility would be maintained without worsening of contractures with the use of palm protectors by the review date. R10's plan of care documented her mobility would be maintained without worsening of contractures with the use of palm protectors. R10's medical record under Task documented Restorative Nursing Program (RNP): BUE modified resting hand splints for 4-6 hours as tolerated daily; rolls as an alternative as needed. Dates from 04/17/25-04/29/25 were marked with an X. R10's medical record under Restorative Monthly Progress Note documented the last progress note dated 11/19/24. R10's physician's orders under the Orders tab revealed the following orders: OT recommends for the patient to use a recliner back wheelchair with head support and bilateral lower extremity (BLE) foot support with leg rests; saddle cushion when out of bed to assist with positioning /ADL functional ability dated 03/14/25. OT recommends for patient use BUE-modified resting hand splints to both hands 4-6 hrs a day as tolerated; off for skin checks, with passive range of motion during application of splints during self-care tasks, may use bilateral hand rolls as an alternative when orthotics were not being used, dated 03/14/25. Ensure bilateral resting hand splints were in place every shift for contractures dated 02/05/25. Monitor skin integrity under bilateral resting hand splints every shift, dated 01/31/25. On 04/21/25 at 07:23 AM, R10 sat in her room in her wheelchair in the commons area. R10's right hand was closed and held next to her chest. R10's left hand was closed and laid on her leg. R10 did not have resting splints on her hands or bilateral hand rolls. On 04/22/25 at 01:19 PM, R10 sat in her wheelchair in the commons area. R10 was moving her right and left wrists in a waving motion. R10's right and left hands were closed. R10 did not have resting splints on hands or bilateral hand rolls. On 04/23/25 at 09:55 AM, R10 sat in the commons area elevated back in her wheelchair. R10's arms were curled to her chest. R10's left and right hands were closed. R10 did not have resting splints to the hands or bilateral hand rolls. On 04/23/25 at 12:09 PM, Certified Nurse's Aide (CNA) MM stated that if a resident needed a splint or hand rolls, therapy would apply the splints. CNA MM was unsure when restorative therapy was done. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated therapy would let nursing know what splints or devices a resident would need, and how often the splint should be used. LN G stated she did not know if nursing or the CNAs applied splints. On 04/23/25 at 01:01 PM, Administrative Nurse D stated the facility was revamping the restorative program. Administrative Nurse D stated that what staff or restorative aides were to do to help with residents' contractures would be found in the care plan. She stated the restorative charts under the task tab. The facility's Restorative Nursing Programs policy, dated 10/14/24, documented the facility would provide maintenance and restorative services designed to maintain and improve a resident's abilities to the highest practicable level. - R41's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, contracture (abnormal permanent fixation of a joint or muscle), hypercholesterolemia (greater than normal amounts of cholesterol in the blood), cognitive function and awareness weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), protein-calorie malnutrition (not enough protein or food to support the body), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) for R41, dated 10/17/24, recorded a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R41 had an impairment on one side of her body. The MDS documented R41 was impaired on both sides of her body. The MDS documented R41 required substantial to maximum assistance from staff for eating, and was dependent on staff for toileting, dressing, and bathing. R41's Functional Abilities (Self-Care) Care Area Assessment (CAA) dated 12/23/24 documented R41 was admitted to hospice for malnutrition. The CAA documented R41 had contractures, dysphasia, and dementia. The CAA documented R41 was dependent with care, incontinent of bowel and bladder, and was at risk for falls related to weakness and poor safety awareness. The CAA documented R41 received pain medication for general pain and contractures. R41's Care Plan dated 01/30/23 documented R41 had an alteration in musculoskeletal status related to contracture left wrist, left knee, and left ankle. The plan of care for R41 documented staff were to encourage, supervise, and assist with her supportive device of a cockup splint (supportive splint) for wrist. The plan of care documented staff were to anticipate and meet R41's needs and ensure her call light was within her reach. R41 EMR revealed a restorative progress note dated 09/10/24, documented staff were to encourage R10 to complete self-feeding and drinking tasks with setup and verbal cues for techniques and encouragement. On 04/21/25 at 08:35 AM, R41 sat in the dining room in her Broda chair (specialized wheelchair with the ability to tilt and recline) upright. R41's hands were closed. R41 was picking up drinks with her fingers. R41's left hand and wrist were curled to her chest, and her hand was closed. R41 did not have her cockup splint on her hand. On 04/22/25 at 07:17 AM, R41 sat in her Broda chair in the commons area. R41's left hand and wrist were curled, and her left hand and wrist were curled up toward her chest, and her hand was closed. On 04/23/25 at 12:09 PM, Certified Nurse's Aide (CNA) MM stated that if a resident needed a splint or hand rolls, therapy would apply the splints. CNA MM was unsure when restorative therapy was done. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated therapy would let nursing know what splints or devices a resident would need, and how often the splint should be used. LN G stated she did not know if nursing or the CNAs applied splints. On 04/23/25 at 01:01 PM, Administrative Nurse D stated the facility was revamping the restorative program. Administrative Nurse D stated that what staff or restorative aides were to do to help with residents' contractures would be found in the care plan. She stated restorative charts under the task tab. The facility's Restorative Nursing Programs policy, dated 10/14/24, documented the facility would provide maintenance and restorative services designed to maintain and improve a resident's abilities to the highest practicable level.

The facility identified a census of 74 residents. The sample included 19 residents, with three sampled residents reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 was positioned appropriately in his Broda chair (specialized wheelchair with the ability to tilt and recline) while being assisted by staff with eating at meals. This placed R37 at risk of swallowing complications and possible aspiration (inhaling liquid or food into the lungs) of food. Findings included: - R37's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction (stroke), and respiratory failure (the inability of the lungs to adequately exchange gases). R37's admission Minimum Data Set (MDS) dated 01/21/25 documented a Brief Interview for Mental Status (BIMS) was unable to be completed due to his rarely or never being understood. R37 had severely impaired cognitive skills for daily decision making. R37 was dependent on staff for activities of daily living (ADL) and used a wheelchair for mobility. R37 showed signs or symptoms of coughing or choking during meals or when swallowing medications. R37 required a feeding tube (administration of nutritionally balanced liquefied foods or nutrients through a tube) to aid in nutritional intake. R37's Nutritional Status and Tube Feeding Care Area Assessment (CAA) dated 01/23/25 documented R37 was receiving skilled services. R37 was dependent on cares, he was incontinent of bowel and bladder, and at risk for falls due to weakness. R37 received nothing by mouth (NPO) and was dependent on tube feeding for nutrition and was at risk for dehydration due to infection and dependent on bolus for hydration. R37 was risk for impaired skin and has wounds on hands and at peg site. R37's Care Plan revised on 03/11/25, directed staff he was dependent on tube feeding and water flushes. See MD orders for current feeding orders. Staff were directed he was on an NPO diet. Staff was directed that R37 received percutaneous endoscope gastrostomy tube (PEG - a tube inserted through the wall of the abdomen directly into the stomach) feedings of TwoCal HN (a nutritionally complete, high-calorie formula designed to meet the increased protein and calorie needs of metabolically stressed residents) 220 milliliters (ml.) bolus with 125 ml water before and after each bolus feeding. Staff were directed R37 needed the head of the bed elevated 45 degrees during and thirty minutes after tube feeding. Staff were directed to increase head of bed during feedings. R37's care plan had an intervention revised on 04/21/25 that directed staff he was on a regular general diet, with mechanical soft textures-ground meats, thin liquids consistency, nosey cups, and he needed max assistance. Staff were directed he received peg tube feedings of TwoCal HN 220 ml. bolus with 125 ml. water before and after each bolus feeding. R37's Order Summary Report documented a physician's diet order dated 01/15/25 for an enteral feed order, every shift, check placement every shift. Check for residual (checking and managing the amount of fluid remaining in the stomach after a period of enteral feeding, often through a feeding tube) every shift. Contact the physician if residual exceeds 50 ml. R37's Order Summary Report documented a physician's diet order dated 03/03/25 for a regular diet, with a mechanical soft texture, and regular consistency. Max assistance, upright in wheelchair. Mechanical soft/ground meats; a slow rate of intake; thin liquids; small sips, with nose cups; remain upright 30 minutes post intake; continue tube feeding as the primary nutrition/hydration. R37's Order Summary Report documented a physician's diet order dated 04/12/25 for enteral feed order four times daily, Nutren 2.0 (a ready-to-use, calorically dense liquid nutrition supplement used for complete or supplemental nutrition support, especially for individuals with high caloric requirements or severe fluid restriction) 250 ml. If the resident eats 50 percent (%) or less of meals. Water flush with 30 ml before and 30 ml after bolus. This order lacked route directions. On 04/22/25 at 08:35 AM, R37 was observed reclined back in his Broda chair while being assisted to eat breakfast by Activities Z, who was also a certified nurse aide (CNA). On 04/23/25 at 08:25 AM, R37 was observed reclined back at a degree of about 45 degrees in his Broda chair while being assisted with eating. The unidentified staff member repositioned R37's Broda chair after she realized R37 was not in an appropriate position. On 04/23/25 at 09:15 AM, CNA NN stated R37's diet had recently changed to being able to eat regular ground food with assistance. CNA NN stated R37 should be positioned in a straight up position in his Broda chair while being assisted to eat a meal to reduce the risk of choking or aspirating (inhaling liquid or food into the lungs) his food. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated R37 had been on enteral tube feeding for some time and had recently been advanced to a mechanical soft diet and an enteral feeding bolus. LN G stated R37 should be seated in an upright position when he was being assisted with eating his meals. On 04/23/25 at 01:05 PM, Administrative Nurse D stated she expected staff to have R37 positioned in an upright position in his Broda chair while assisted with eating. Administrative Nurse D stated he could be reclined slightly but should still be more upright to avoid aspirating or choking on the food. The facility policy The Dining Experience: Staff Role dated 2020, documented staff members would strive to enhance the residents' quality of life while serving meals that meet nutritional needs, offer choices, be served with dignity, and consider the person-centered care plan. Staff would offer personal attention to each resident and monitor the resident's satisfaction and food intake. Staff would be sure the resident was positioned appropriately at the table.

The facility identified a census of 74 residents. The sample included 18 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 13's continuous positive airway pressure (CPAP - a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored in a sanitary manner. This placed R13 at an increased risk for respiratory infection and complications. Findings included: - R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of personal history of nicotine dependence, major depressive disorder (major mood disorder that causes persistent feelings of sadness), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), kidney failure, hypertension (high blood pressure), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), difficulty walking, lack of coordination, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), falls, overactive bladder, schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, weakness), and respiratory failure (a condition where the lungs struggle to transfer enough oxygen into the blood or remove enough carbon dioxide, leading to low oxygen levels or high carbon dioxide levels in the body). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R13 required set up and clean up for eating, and was dependent on staff for oral hygiene, toileting, bathing, and dressing. The MDS documented R13 required oxygen therapy and a non-evasive mechanical ventilator during the observation. R13's Functional Abilities (Self-Care) Mobility Care Area Assessment (CAA) dated 02/19/25 documented R13 resided in a long-term care facility. Her diagnoses were respiratory failure, COPD, Parkinson's, DM, Schizophrenia, dysphagia, anxiety, and depression. The CAA documented R13 needed maximum to dependent assistance with care and used a wheelchair for her primary mode of transportation. The CAA documented R13 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) due to urinary retention and incontinence of bowel. The CAA documented R13 had a history of falls due to Parkinson's disease. R13's Care Plan dated 06/22/23 documented staff were to encourage R13 to wear her CPAP as ordered. Staff were to monitor for changes in oxygenation status and keep the physician informed. R13 was to utilize cushioned padding on tubing as indicated. R13's plan of care dated 04/06/23, documented R13 required oxygen therapy. The plan of care dated 03/02/23 documented staff were to change the 0xygen (02) tubing and rinse the filter weekly. R13's EMR under the Orders tab documented the following physician orders: Auto CPAP every night shift dated 06/27/23. Clean CPAP mask and tubing on Saturdays, every day shift dated 08/06/23. Check CPAP water level nightly, every night shift related to COPD dated 08/06/23. On 04/21/25 at 08:10 AM, R13 laid in her bed. R13's CPAP mask and tubing laid on the floor between her bed and the wall. R13's CPAP was not stored in a sanitary manner. On 04/23/25 at 12:09 PM, Certified Nurse's Aide (CNA) MM stated that all respiratory equipment should be in a bag with a date. CNA MM stated that some of the residents have their own bags for their CPAPs, and the mask and tubing should be in their bags. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated that a resident's CPAP should be stored in a bag with a date. LN G stated that the CPC should be stored in the bag when not in use. On 04/23/25 at 01:01 PM, Administrative Nurse D stated that the bags for respiratory equipment should be changed weekly. She stated that all residents should have a bag for respiratory equipment when not in use. Administrative Nurse D stated that all nursing staff were responsible for ensuring that respiratory equipment was stored in a sanitary manner. The facility's CPAP/BiPAP Cleaning policy, dated 05/24, documented the facility was to clean the CPAP equipment in accordance with the current guidelines and manufacturer recommendations to prevent the occurrence or spread of infection.

The facility identified a census of 74 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure staff provided the necessary person-centered activities and interventions to address Resident (R) 37's dementia (a progressive mental disorder characterized by failing memory, confusion) diagnosis. This deficient practice placed R37 at risk of ineffective treatment and decreased quality of care. Findings included: - R37's Electronic Medical Record (EMR) documented diagnoses of dementia, major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R37's admission Minimum Data Set (MDS) dated 01/21/25 documented a Brief Interview for Mental Status (BIMS) was unable to be completed due to his rarely or never being understood. R37 had severely impaired cognitive skills for daily decision making. R37 was dependent on staff for activities of daily living (ADL) and used a wheelchair for mobility. R37 required a feeding tube (administration of nutritionally balanced liquefied foods or nutrients through a tube) to aid in nutritional intake. R37 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) on a routine basis. R37's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/23/25 documented he had an actual cognitive deficit related to the dementia process. R37 resided on the memory care unit. Staff were to monitor him for signs and symptoms of acute mental status changes to help treat the underlying condition. Staff were to communicate using short and simple sentences to allow adequate time for R37 to understand others and for him to communicate his needs. Staff were to approach him in a calm and non-threatening manner to help the resident feel calm and unhurried. BIMS were to be completed quarterly and as needed to help monitor for trends in cognition. R37's Care Plan, revised on 03/11/25, directed staff to use his preferred name. Staff were directed to identify themselves at each interaction and face the resident when speaking, and make eye contact. Staff were directed to reduce any distractions (turn off the TV, radio, and close his door). Staff were directed R37 understood consistent, simple, directive sentences. Staff were directed to provide the resident with necessary cues and stop and return if he was agitated. R37's care plan lacked person-centered activities and services to direct staff for his dementia care needs. On 04/22/25 at 02:31 PM, R37 laid in his bed. R37's bed was in a low position, and he was hollering inaudible words in his native Cantonese language. No staff were present in R37's room. On 04/23/25 at 08:51 AM, Certified Nurse Aide (C NA) NN stated she did have access to the care plan and [NAME] (nursing tool that gives a brief overview of the care needs of each resident). CNA NN stated she would expect R37 to have a dementia care area on the care plan to help direct staff with care needed specifically for dementia. CNA NN stated staff would try to do activities with R37 one-on-one, but he was not able to participate. On 04/23/25 at 12:33 PM, Licensed Nurse (LN) G stated she would expect any resident with a diagnosis of dementia to have person-centered care to direct staff with the needed interventions specific to that resident. LN G could not state a reason why R37 did not have a dementia care plan since he was on the memory unit. On 04/23/25 at 01:02 PM, Administrative Nurse D stated all residents with dementia should have person-centered dementia care plans and interventions. Administrative Nurse D stated that residents, especially a resident like R37, who was on the memory unit, should have very specific interventions to assist staff with his care when he had behaviors or activities specific to him. Administrative Nurse D could not state why R37 did not have person-centered dementia interventions in place. The facility's Dementia Care policy, dated 12/11/24, documented it was the policy of this facility to provide the appropriate treatment and services to every resident who displayed signs of or was diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The facility would assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that included the resident, their family, and representative, to the extent possible. The care plan interventions would be related to each resident's individual symptomology and rate of dementia progression, with the result being noted improvement or maintenance of the expected stable rate of decline associated with dementia and dementia-like illnesses. Care and services would be person-centered and reflect everyone's goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care would be utilized, to include meaningful activities aimed at enhancing the resident's well-being.

The facility identified a census of 72. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from preventable accidents. On 12/05/23 R1 fell forward from her wheelchair while being lowered on the facility bus lift, after staff failed to ensure the brakes were fully engaged and no staff were present on the ground monitoring the lift. This deficient practice resulted in an emergent transfer of R1 to the hospital where she was diagnosed with a subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). This deficient practice also placed R1 at further risk for injury and pain. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented R1 had diagnoses of traumatic subdural hemorrhage (bleeding) with loss of consciousness, fall from non-moving wheelchair, and unsteadiness on feet. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance with one staff for bed mobility, locomotion, dressing, and personal hygiene and extensive assistance with two staff for transfers and toileting. R1 had no falls since the last assessment. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 15, which indicated intact cognition. R1 used a manual wheelchair and required supervision or touching assistance to wheel 50 feet with two turns and required substantial/maximal assistance to wheel 150 feet. R1 had no falls since last assessment. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 05/08/23, documented R1 required extensive assistance for care and used a wheelchair for her primary mode of transportation. The Falls CAA dated 05/08/23, documented R1 had a history of falls, had no falls that quarter, but remained at risk. R1's Care Plan dated 07/11/17, documented R1 had an ADL self-care performance deficit related to impaired mobility. The care plan directed staff provided supervision using manual wheelchair. The facility's investigative report, dated 12/11/23, documented on 12/05/23 around 01:00 PM, R1 returned to the facility from a shopping trip via the facility transport bus. Transportation W assisted residents from the bus. Once it was R1's turn, Transportation W assisted R1 onto the lift platform and began lowering the lift. When the lift platform reached the pavement, the platform gate stop lowered and R1's wheelchair began rolling off the platform onto the pavement. R1's wheelchair continued rolling until she put her feet down, causing her to fall out of her wheelchair onto the ground where she hit her left forehead. Transportation W assisted with the transfer from inside the bus using the remote and thought another staff member was standing below to assist with lowering residents on the lift. R1 was alert and oriented to person, place, time, and situation per baseline and a hematoma (a very bad bruise) was noted to her left forehead. Staff contacted Emergency medical services (EMS) and EMS transported R1 to the emergency room (ER) for evaluation and treatment. R1's representative and physician were notified. R1 admitted to the hospital and returned to the facility on [DATE] with orders for physical therapy and occupational therapy. The report documented the suspected cause of the incident was the resident unlocked her wheelchair as the lift reached the ground. In Administrative Staff B's unnotarized, undated, witness statement, Administrative Staff B stated on 12/05/23, she stood outside the front door of the facility and witnessed Transportation W lowering R1 on the lift. At that time, R1 started to roll forward, her legs got caught underneath her wheelchair, and then she fell face first onto the ground. Administrative Staff B stated she ran inside to get help and asked Activities Z to go back outside to help, but she stated she was waiting to use the restroom and that was why she came back inside. Administrative Staff B stated Transportation W said she thought someone was at the bottom of the lift to assist. In Transportation W's notarized witness statement, dated 12/05/23, Transportation W stated on 12/05/23, she loaded R1 onto the lift and told her to put her brakes on since she could not reach around R1. Transportation W stated she thought there was another person on the ground area as the lift got closer to the ground. She stated R1's wheelchair started moving and she stopped the lift, but the momentum of the wheelchair did not stop. R1 fell forward to the ground and Transportation W ran out of the bus to check on her as soon as it happened. The Trauma Services History and Physical dated 12/05/23, documented R1's computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan of the head on 12/05/23 revealed a left extra-axial (outside the brain) hemorrhage. R1's CT scan of the head on 12/06/23 revealed an acute left subdural hemorrhage. On 12/13/23 at 12:57 PM, R1 sat in her wheelchair in her room. She had purple bruising on the left side of her face and a bump/hematoma on her left forehead. She stated she did not remember anything from her fall on 12/05/23, but stated she usually put her wheelchair brakes on, if asked. On 12/13/23 at 12:42 PM, Transportation W stated on 12/05/23, they returned from shopping with a van full of residents and R1 was at the back of the bus. She stated she thought there was a spotter at the bottom of the lift, and she told R1 to put her wheelchair brakes on since she could not reach around her because of her size to put the brakes on. Transportation W stated she placed R1 onto the lift and as the lift was going down, her wheelchair started moving forward. She stopped the lift but because of R1's momentum, she went through the lift gate and fell . Transportation W stated the spotter ran off to the restroom and she could not see if R1 put her wheelchair brakes on because of her size, but usually put her brakes on when told to. On 12/13/23 at 02:31 PM, Activities Z stated on 12/05/23, they returned from shopping and R1 was the third resident to come off the bus. She stated she needed to go to the restroom and told Transportation W she would be back. Activities Z stated R1 was still on the bus at that time. When she came out of the restroom, she was told to go help with R1 outside. Activities Z stated normally when unloading the bus, Transportation W was inside the bus unhooking residents and loading them onto the lift while Activities Z stood outside of the bus. She stated while unloading residents from the bus, she waited for Transportation W to put a resident on the lift then she made sure their brakes were on while they were lowered to the ground. On 12/13/23 at 02:40 PM, Maintenance U stated the proper procedure for unloading residents from the bus was unfolding the lift from the bus, unfastening the tiedowns inside on the residents, rolling the wheelchair onto the lift while making sure they were in the center of the lift, making sure the wheelchair brakes were locked, have the resident hold onto the grab bars if able, lock the safety strap across the front, then lower the lift down. He stated he always trained the bus driver to lower from the ground, not from inside the bus because if a resident accidently unlocks their brakes, then the staff could visualize that. On 12/13/23 at 02:56 PM, Administrative Nurse D stated when unloading residents from the bus, staff were expected to make sure brakes were locked and were outside the bus to visualize the whole thing. She stated Maintenance U did training with Transportation W about following manufacturer's guidelines on operating the bus lift. On 12/13/23 at 03:10 PM, Administrative Staff A stated when unloading residents from the bus, staff were to make sure the brakes were on even if the resident was able to put on their own brakes. Upon request, the facility provided the manufacturer's instructions for the Public Use Lift. The instructions direct unfold the platform, stand clear and press the unfold switch until the platform stops. The instructions directed to unload a passenger, load passenger onto the platform and lock the wheelchair brakes with the outer barrier up, then press the down switch until the entire platform reaches ground level and the outer barrier unfolds fully. The facility's Staff Vehicle Safety Policy and Procedure, revised May 2022, directed all facility passenger vehicles were used only for facility purposes and were operated only by authorized persons who meet the driver criteria in the vehicle safety program. The facility's Accidents and Supervision policy, not dated, directed the facility established and utilized a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. The facility failed to ensure R1 remained free from accidents, when on 12/05/23, she fell forward from her wheelchair while being lowered on the facility bus lift. This deficient practice resulted in R1 being transferred to the hospital where she was found to have a subdural hematoma. The facility completed the following corrective actions by 12/12/23: Staff were educated on driver safety along with completed competencies. An AdHoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/11/23. The facility bus was taken in for an inspection and servicing with replacement of lift occupant belt and outer barrier screw completed on 12/12/23. This deficient practice was cited at past non-compliance. The scope and severity remain at a G.

The facility had a census of 70 residents. The sample included 21 residents of which five were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review and interview, the facility failed to implement interventions to prevent the development of pressure injuries and promote healing for existing pressure injuries for Resident (R)22 and R38 who developed facility acquired pressure ulcers. Findings included: - R22 's Electronic Medical Record (EMR) recorded diagnoses which included diabetes mellitus (when the body cannot use glucose), morbid obesity (being 100 pounds or more above ideal body weight), and wedge compression fracture of second lumbar vertebra (spinal bone). R22's Admission Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS recorded R22 required extensive assistance of two staff for bed mobility and transfers. The MDS recorded a formal assessment tool was used to predict pressure ulcer risk and R22 was at risk for pressure injuries. The MDS documented R22 had no pressure ulcers and had a pressure reducing device to her bed. The Pressure Ulcer Care Area Assessment (CAA), dated 03/13/23, documented the resident had a compression fracture of the spine and required extensive assistance, which placed her at risk for impaired skin. She had incontinence with weakness and deconditioning. The CAA documented the resident had no skin issues or pressure ulcers. R22's Quarterly MDS, dated [DATE], recorded the resident had a BIMS score of 13. The MDS documented R22 required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had one unstageable (unable to determine depth of wound due to wound bed obscured) pressure ulcer. The Braden Scale Assessment for predicting pressure ulcer risk recorded the following risk assessments: 03/03/23 documented a score of 19.0 no risk; 03/10/23 Braden score of 15.0 mild risk; 03/25/23 Braden score of 19.0 no risk, and 06/26/23 Braden score of 19.0 no risk. The ADL Care Plan, dated 03/07/23, documented the resident had limited physical mobility due to compression fractures and required extensive assist of one to two staff for bed mobility. The plan directed R22 was totally dependent of two staff for transfers with a sit to stand lift. The Skin Integrity Care Plan, dated 03/04/23, documented the resident was at risk for alterations in skin integrity related to immobility. A revision was created on 08/16/23 which recorded the resident had a venous wound (wound caused by poor circulation) and a skin tear to her left medial (inner) calf. An intervention dated 03/04/23 directed staff to educate the resident and caregiver as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. The care plan documented staff would provide and monitor nutrition (03/04/23), encourage the resident to report pain which may have prevented repositioning (03/04/23) and provide skin assessments weekly by a licensed nurse (04/27/23). The Physician Order, dated 03/03/23 directed the staff to apply a pressure redistribution mattress to bed. The Wound Evaluation, dated 05/18/23, documented R22 had one open area on her left heel, which measured 2.9 centimeters (cm) by 3.7 cm with no tunneling. The evaluation recorded the area was a pressure related deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear), facility acquired. R22's Care Plan was updated on 05/24/23 and noted R22 had a stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcer to her left heel. Interventions implemented at that time included follow the treatment plan as ordered (05/24/23), licensed nurse to perform weekly skin assessments (05/24/23), and wound nurse to assess and treat (05/24/23). The Wound Evaluation, dated 06/15/23, documented R22 had one open area on the left heel, measuring 6.4 cm by 3.0 cm2.9 cm. The evaluation documented the area was an unstageable pressure ulcer, facility acquired. R22's Care Plan was updated on 06/12/23 (revised on 08/20/23) which directed R22 had a foam or gel cushion in use. R22 would receive treatments as ordered (06/12/23) and staff were to encourage offloading of heels and repositioning, dated 06/12/23 (revised on 08/20/23). The Physician Order, dated 06/18/23, documented to cleanse the open area on the left heel with wound cleanser, pat dry, apply collagen (protein to aid wound healing) to wound bed, apply Derma Blue (highly absorbent vertically-wicking foam primary dressing embedded with three proven antimicrobials) cut to fit wound bed, cover with ABD (highly absorbent dressing that provides padding and protection for large wounds) pad, kerlix (woven gauze) and secure with tape. Change dressing daily until healed. Ensure resident is wearing Circaid wraps (adjustable compression wraps) after wound treatment is complete. The Wound Evaluation, dated 07/13/23, documented R22 had one open area on the left heel, measuring 5.1 cm by 2.1 cm by 3.0 cm. The evaluation documented the wound as a stage 3 pressure ulcer facility acquired. On 08/22/23 at 07:50 AM, observation revealed R22 sat in a wheelchair at the dining room table with a gauze dressing only to her left foot, and a non-slip sock partially over the foot and dressing. Continued observation revealed the resident did not have a protective boot on the foot/heel and did not have any pressure relieving cushion on the metal foot pedal. On 08/22/23 at 08:55 AM, observation revealed R22 sat in wheelchair in her room. Licensed Nurse (LN) I removed the non-slip sock and gauze dressing from R22's left foot. Continued observation revealed LN I performed the dressing change as ordered. LN I then applied a Circaid wrap to the residents lower left leg from the knee to ankle area. On 08/23/23 at 10:00 AM, Administrative Nurse D verified the resident developed the facility acquired stage three pressure ulcer on her left heel on or around 05/18/23 and verified the resident did not have pressure relieving boots or any offloading measures in place prior to the development of the ulcer. Administrative Nurse D confirmed there was a delay in implemented offloading measures after the wound was identified. The The Pressure Injury Prevention and Management, policy dated 01/01/2020, documented the facility was committed to the provision of avoidable pressure injuries and promotion of healing of existing pressure injuries. Licensed nurses would conduct a full body skin assessment on residents upon admission/re-admission and weekly for four weeks then quarterly. Findings would be documented in the medical record. Nursing assistants would inspect skin during bath and repost concerns to the nurse. Interventions would be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. Evidenced based interventions for prevention would be implemented for all residents who are assessed at risk or who have a pressure injury present. The facility failed to initiate interventions to prevent the development of pressure injuries for R22, who was at risk. The facility further failed to initiate standard interventions related to relieving pressure from heel immediately when a facility quired pressure ulcer was noted. The pressure ulcer evolved from a DTI to a Stage 3 facility acquired left heel pressure ulcer for R22, placing the resident at risk for further skin breakdown. 32358 - R38's Electronic Medical Record (EMR) documented R38 had diagnoses of absence of left leg below knee, anemia (deficiency of healthy red blood cells in blood), and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R38's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score 15, which indicated intact cognition. The MDS documented R38 required extensive staff assistance with bed mobility, transfers, toilet use, dressing, and personal hygiene, limited staff assistance with locomotion on and off unit, and was independent with eating. The MDS documented R38 was at risk for pressure ulcers, had a pressure reducing device for bed, and had no pressure ulcers. R38's Pressure Ulcer Care Area Assessment (CAA), dated 07/18/23, documented R38 required extensive assistance with cares, was incontinent of bowel and bladder, had weakness, and an amputation (surgical removal of a body part). The Braden Scale (assessment tool for predicting the risk of pressure ulcers), documented a score of 14, indicating moderate risk for pressure ulcer development on both 07/14/23 and 07/27/23. R38's Skin Integrity Care Plan, dated 07/14/23, documented R38 was at risk for alterations in skin integrity related to immobility and instructed staff to educate the resident and her family and caregivers to causes of skin breakdown, including transfer/positioning requirements and the importance of taking care during ambulation, mobility, good nutrition, and frequent repositioning. The care plan instructed staff to encourage R38 to report pain that may prevent repositioning. R38's Pressure Ulcer Care Plan, initiated 08/09/23, documented R38 had a stage two (partial thickness extending past the top layer of skin to tissue underneath) pressure ulcer to her right heel. The plan instructed staff to follow the treatment plan as physician ordered; licensed nurse to perform weekly skin assessments, and wound nurse to assess R38's skin concerns weekly. The care plan lacked further interventions to prevent R38 from acquiring a right inner heel pressure ulcer such as offloading or pressure reduction boots. The Skin Assessment, dated 07/17/23, documented the resident had no pressure ulcers. The Skin Assessment, dated 07/24/23, documented the resident refused skin assessment three times that shift. Review of the clinical record lacked evidence staff completed or attempted a skin assessment after 07/24/23 until 08/06/23. The Nurse's Note, dated 08/06/2023 at 06:47 AM documented during the weekly skin assessment, the nurse noted a blistered area to R38's right inner heel approximately the size of a quarter. The skin around the area was peeling off and started to bleed when the nurse tried to measure/assess area. R38 stated that she noted the area a few days ago. The area on R38's heel was where she rested it on her wheelchair foot pedal. The note documented the nurse cleansed the area, applied an ABD (large pad to absorb drainage) pad and wrapped it with Kerlix (gauze dressing). Staff would continue this treatment daily until otherwise ordered by her physician or the wound nurse. The note documented R38 was able to put her foot on the foot pedal flat as well and the nurse educated R38 on doing this instead of placing the heel on the foot pedal. R38 verbalized understanding. The note documented the nurse floated R38's heel over a pillow in bed that night, left a physician communication form for the physician and would have wound nurse assess on next wound rounds. The note documented R38 denied pain. The Physician Order, dated 08/06/23, instructed staff to cleanse R38's right inner heel with wound cleanser, apply ABD pad and wrap with kerlix daily; check every shift for placement. The Skin/Wound Assessment, dated 08/07/23 documented the resident had an area 3.16 centimeters squared (cm2) with a stage two pressure ulcer which measured 2.41 centimeter (cm) long (L) by 1.78 cm wide (w) on R38's right medial (inner) heel. The assessment documented the pressure ulcer was acquired in the facility. The treatment directed to cleanse with wound cleanser, apply abdominal dressing (ABD) pad, wrap with kerlix and tape to secure. The assessment noted interventions implemented included cushion foam mattress, nutrition/dietary supplement, and repositioning device. On 08/21/23 at 03:15 PM, observation revealed Licensed Nurse (LN) H prepared for R38's dressing change on her right inner heel. R38's inner heel had skin peeling approximately six cm x three cm, with an open area in the middle approximately three cm by three cm, without drainage or odor. On 08/21/23 at 03:15 PM, LN H verified R38's right inner heel pressure ulcer was facility acquired and stated it was due to R38 placed her right inner heel on the foot plate of her wheelchair. On 08/22/23 at 10:12 AM, Administrative Nurse D verified R38's right inner heel was facility acquired and there should have been interventions in place to prevent the development of the pressure ulcer. Administrative Nurse D stated R38 acquired the right inner heel pressure ulcer by placing the area on her wheelchair foot plate. The facility's Pressure Injury Prevention and Management Policy, revised 01/01/20, documented the facility would establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. The facility failed to implement interventions to prevent the development of a facility acquired stage two pressure ulcer for R38, who was admitted with moderate risk for developing a pressure ulcer. The facility failed to implement measures to promote healing which addressed the root cause of the facility-acquired ulcer placing the resident at risk for continued breakdown.

The facility had a census of 70 residents. The sample included 21 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24 had the appropriate fall interventions when an unwitnessed fall occurred. The facility failed to collect staff statements regarding the event, failed to investigate to rule out abuse and neglect, and failed to ensure all interventions were in place. The facility failed to identify causative factors for a fall, which resulted in a subdural hematoma (serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain) for R24. Findings included: - R24's Electronic Medical Record (EMR) documented the resident had diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), fracture right femur (thigh bone), and fracture left humerus (bone of the upper arm). R24's Quarterly Minimum Data Set (MDS) dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) of 8, indicating moderately impaired cognition. The MDS recorded the resident required extensive assistance of two staff for bed mobility, transfer, walking in room and corridor, locomotion on and off the unit, toileting, and personal hygiene. The MDS recorded the resident was not able to stabilize without staff assistance. The Morse Fall Risk Assessment, dated 04/04/23, recorded a score of 60, which indicated R24 was at high risk for falls. The Activities of Daily Living [ADL] Care Plan, dated 03/30/23, directed two staff to assist the resident with transfers using a Hoyer (full body mechanical lift). R24 required assistance of two staff for bed mobility and assistance of one staff for grooming and hygiene. The Fall Care Plan, dated 03/30/23, directed staff to anticipate the residents needs and respond quickly to the resident's call light; provide a safe environment, with a working and reachable call light. The plan directed staff to keep R24's personal items within reach and keep his bed in the low position at night, with fall mats by the bedside when the resident was in bed. A Physician Order dated 04/10/23 directed to administer Coumadin (anticoagulant) six milligrams (mg) by mouth at bedtime for atrial fibrillation (rapid, irregular heartbeat). A Physician Order dated 04/10/23 directed to administer Coumadin 0.5 mg at bedtime for treating/preventing clots. The Nurses Note, dated 04/29/23 at 10:38 AM, documented staff found R24 prone (face down) on the floor, next to the bed at approximately 08:00 AM. R24 had not activated his call light and all personal items were within reach. The note recorded the resident rolled over the raised border of a perimeter mattress and landed with his right hand under his body. R24 had a skin tear on his right hand (fourth finger), and a nosebleed. The nurse assessed the resident and obtained vital signs, and performed a neurological assessment, and a head-to-toe assessment. According to the note, R24 was alert and oriented with no departure from his neurological baseline. His speech was clear. The note documented the resident was transferred by paramedics from the floor to a stretcher and transported to the hospital at 08:47AM. Staff notified R24's representative, the facility administrator, and R24's primary physician. R24's clinical record lacked notation regarding placement of the fall mats, and height position of R24's bed. The facility was unable to provide any investigation related to R24's fall. The facility was unable to provide staff statements or evidence abuse and/or neglect was investigated and ruled out. The facility was unable to provide evidence the incident was reported to the State Agency. The Patient Discharge referral scanned into R24's EMR documented the resident admitted to the hospital on 04/29/23 and discharged from the hospital to the long-term care facility on 05/04/23. R24's principal diagnosis was subdural hematoma with onset date 04/29/23. The Nurses Note, dated 05/04/23 at 04:57 PM documented the resident returned to the facility via stretcher. The note documented the resident was admitted to the facility for rehabilitation. On 08/21/23 at 12:10 PM, observation revealed the resident sat at the dining room table in a Broda (specialty chair with ability to tilt and recline) chair and ate lunch. On 08/22/23 at 03:35 PM, Administrative Nurse D stated R24's medical record documented the resident had a fall on 04/29/23 and rolled out of bed. R24 admitted to the hospital for a few days with a diagnosis of a subdural hematoma. Administrative Nurse D stated she did not work at the facility at the time and verified the facility discovered the event was not investigated or reported when the incident occurred. On 08/23/23 at 11:36 AM Consultant HH stated the facility recently discovered staff previously employed by the facility were not following the facility protocol and policy regarding investigation and/or reporting of incidents. Consultant HH verified the facility began auditing charts once the discovery was made but had not yet audited back to April therefore had not discovered the incident with R24. The facility's Fall Prevention Program policy, dated 02/01/20, documented each resident would be assessed for the risk of falling and would receive care and services in accordance with the level of risk to minimize the likely hood of falls. Upon admission, the nurse would complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse would indicate on the 24 hours report the resident's fall risk and initiate interventions of the resident's baseline care plan, in accordance with the resident's level of care. The nurse would refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. When any resident experiences a fall, the facility would assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan, and update as indicated, document tall assessments and actions. And obtain witness statements in the case of injury. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure,' undated, documented it was the facility's policy to provide for the safety and dignity of all resident's by implementing proper procedures for enforcing the resident's right to be free from abuse, neglect, misappropriation of residents' right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility shall report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, within 5 working days of the incident. If the alleged violation is verified, appropriate corrective action must be taken. The facility failed to ensure R24 had the appropriate fall interventions when an unwitnessed fall occurred. The facility failed to collect staff statements regarding the event, failed to investigate to rule out abuse and neglect and ensure all interventions were in place. The facility failed to identify causative factors for a fall, which resulted in a subdural hematoma for R24.

The facility had a census of 70 residents. The sample included 21 residents with six reviewed for nutrition. Based on observation, record review, and interview, the facility failed to follow up and implement the nutritional interventions to prevent further weight loss and promote weight gain for Resident (R)6, who had a significant weight loss despite having enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food). The facility further failed to monitor weights as ordered and failed to identify and implement interventions to address refusals and complications related to the tube feeding for R6, who had a significant weight loss of 10.9 percent in three months, and/or 7.77 percent in one month. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of traumatic brain injury (TBI-sudden injury that causes injury to the brain,) hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), epilepsy (brain disorder characterized by repeated seizure), 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), abnormal posture, and muscle weakness. R6's Quarterly Minimum Data Set, dated dated dated [DATE], documented R6 had severely impaired cognition and required extensive assistance with two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS documented R6 was 70 inches tall, weighed 147.0 pounds (lbs.) and had no significant weight loss in the last 30 days or six months. R6 received 51 percent (%) or more nutrition through parenteral or feeding tube. The Nutrition Care Area Assessment (CAA), dated 10/21/22, documented R6 was on a mechanical diet due to swallowing difficulty and required extensive assistance with eating due to weakness and due to his diagnoses of TBI, epilepsy, CVA, hemiparesis, hemiplegia, and weakness. R6's Care Plan dated 03/23/23 documented R6 required tube feeding due to a swallowing problem and nutrition deficit. The plan, revised on 03/27/23 recorded R6 was at risk related to the required tube feedings, The plan directed staff would obtain weekly weights and provide tube feeding of: Isosource 1.5 calorie (a nutritionally complete, calorically dense tube feeding formula contains fiber to help support digestive health and bowel function) 250 milliliters (ml) via J-tube five times a day with 100 ml of water pre and post medication administration as physician ordered. The plan documented R6's ideal body weight was 166 lbs., plus or minus 10 percent. R6's Care Plan dated 04/26/23, documented R6 had weight loss. On 05/24/23 the plan documented R6 as at risk for current weight loss due to nutritional status and tube feeding, Interventions dated 05/24/23 directed staff to follow jejunostomy (J-tube: tube placed through the skin of the abdomen into the midsection of the small intestine) tube feeding as ordered and the registered dietician (RD) would follow weight loss and make recommendations as needed. R6's care plan lacked interventions related to R6's grabbing at the tube or R6's behaviors to prevent staff from administering the enteral nutrition. R6's Vital Signs - Weights documented the following weights: 03/28/23 154.0 lbs. 04/24/23 148.6 lbs. 05/22/23 150.6 lbs. 06/19/23 149.0 lbs. 07/24/23 146.8 lbs. 08/07/23 141.6 lbs. 08/23/23 135.4 lbs. This indicated a total weight loss of 10.09 percent in three months from 05/22/23 to 08/23/23 and/or a significant loss of 7.77 percent in one month, from 07/24/23 to 08/23/23. The Physician Order, dated 03/24/23, directed staff to administer Isosource 1.5 calorie oral liquid nutritional supplement, 390 ml via J-tube every four hours due to severe protein-calorie malnutrition, which was discontinued on 04/14/23. The Registered Dietitian (RD) Assessment, dated 03/28/23, documented the resident currently weighed 150.4 lbs., and noted the resident had a usual body weight of 172.0 lbs. The assessment documented the resident returned from the hospital with eternal feeding orders via J-tube, orders for continuous feedings, however those were discontinued, and bolus feedings were in place. Staff were to administer Isosource 1.5 calorie and bolus 390 ml every four hours via J-tube. For a total of 2340 ml of formula, a day. RD would continue to monitor for diet and education needs. A Physicians Order dated 04/12/23 directed staff to obtain R6's weight twice weekly on Mondays and Thursday. On 04/14/23 a Weight Change Warning note by the RD documented the resident had a five percent change. The note recorded wight loss was not indicated at that time. The RD completed a consult with the director of nursing (DON) that day. The note recorded the residnet continued to choose to lay prone on floor-mat during nursing attempts to administer some bolus-feeds and nursing reported they were unable to administer some bolus-feeds due to safety-risks and/or aspiration precautions. The warning also noted, nursing reported the resident tampered with his tube and the contents of some bolus-feeds were spilled out onto the resident's stomach. The RD suspected all of those factors contributed, in part to R6's recent significant weight loss. The noted recommended if R6's behaviors were not hindering bolus-feed administrations as ordered, it would provide a total of 2340 ml/day in formula, providing 3510 calories a day and 159 grams (GM) of protein a day thereby promoting weight gain. RD suspected R6 may benefit from continuous-feeds, versus bolus-feeds to support full administrations of formula & to promote weight stabilization. The note recommended to consult to R6's physician for consideration to discontinue orders for bolus-feeds and recommend continuous-feed orders instead. The Physician Order, dated 04/18/23, directed staff to administer Isosource 1.5 calorie oral liquid nutritional supplement 100 ml via J-tube continuous nutritional supplement. Discontinued on 07/17/23. The RD Assessment, dated 07/11/23, documented the resident currently weighed 142.2 lbs. and usual body weight was 172 lbs. The assessment documented the resident went to the hospital after pulling out his J-tube and returned with a catheter tubing connected to the J-tube. Resident was then sent to another hospital and returned on 07/08/23 with a gastrostomy tube (G-tube: a tube inserted into through the belly that brings nutrition directly to the stomach.) Staff were to administer Isosource 1.5 calorie and continuous feeding via G-tube at 100 ml an hour for 20 hours for a total of 2000 ml of formula. The resident had a significant weight loss on 07/05/23 of 5.3 lbs. in one month as documented weight on 06/05/23 was 150.0 lbs. The Physician Order, dated 07/17/23, directed staff to administer Isosource 1.5 calorie oral liquid nutritional supplement, 250 ml via J-Tube five times a day for nutritional supplement. The RD recommendations dated 08/07/23 documented the resident had a significant weight loss trend established while nothing by mouth (NPO) status and enteral orders for Isosource 1.5 continued. The RD recommended changing the formula for increased calories and proteins and recommended Two-Cal (high calorie enteral feeding formula) and bolus feeding at 250 ml five times a day (same flowrate), for total of 1250 ml/formula a day and providing 2500 calories, 104 grams of proteins and 875 ml of free water from formula per day, to promote stabilization on weights as some weight gain may be desirable. RD to continue to follow. The RD Assessment, dated 08/18/23, documented the resident currently weighed 141.6 lbs. and had a usual body weight of172.0 lbs. The assessment documented NPO status continued, and weight was documented last on 08/07/23. Nursing progress notes dated 08/14/23 charted some vomiting and noted the tube feeding was being held with Zofran (anti-nausea and vomiting medication) ordered as needed. RD suggested to see her recommendation on 08/07/23. R6's clinical record lacked evidence the facility followed up on the RD's recommendations from 08/07/23 to address R6's significant weight loss. The clinical record lacked evidence the staff weighed the resident twice weekly as ordered between 08/07/23 and 08/23/23. On 08/22/23 at 10:15 AM, observation revealed the resident laid in bed with his eyes closed. License Nurse (LN) I explained to the resident she was in the room to administer his feedings and elevated the head of the bed approximately 30 degrees. Continuous observation revealed LN I administered the resident's morning medications per tube followed by a 40 ml water flush, then administered the Isosource 1.5 calorie 250 ml carton of nutritional supplement followed by 100 ml of free water. Observation of the resident throughout the medication administration revealed three times he attempted to grab at the tubing, and LN I had to redirect his hand from the tubing. On 08/24/3 at 10:00 AM, Administrative Nurse D verified the resident had a significant weight loss and had lost 18.6 lbs. in four months. Administrative Nurse D verified the RD made recommendation to change the nutritional feeds to increase the calories the resident received on 08/07/23, and said the recommendation was sent to the physician, but the facility had not received any acknowledgement or order form the physician to change the resident's nutritional supplemental feedings the RD had recommended. Administrative Nurse D verified staff should follow up and stated she would contact the doctor and get a change of nutritional supplement. The Nutrition and Hydration, policy, dated 09/09/20, documented the residents within the facility would maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident was able to maintain the highest practicable level of well-being. The use of enteral feeding will not be used unless there is a valid clinical rationale, and the resident/resident representative has consent to its use. The resident his/her representative would be informed of the process and its risk and benefits prior to consent. The facility would provide nutritional and hydration services to each resident, consistent with the resident's comprehensive assessment. Recognize, evaluate, and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration. Provide therapeutic diet considering the resident's clinical condition and preferences. The resident fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers. The documentation for nutrition and hydration services to include consent and risk vs benefits would be found in the resident's chart. The Appropriate Use of Feeding Tubes, policy dated 09/09/20, documented the facility would ensure that a resident maintains acceptable parameters of nutritional, and hydration status. A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding. The plan of care would address the use of feeding tube, including strategies to prevent complications. The facility failed to follow up and implement the nutritional interventions to prevent further loss and promote weight gain for R6, who received complete enteral nutrition. The facility further failed to monitor weights as ordered and failed to identify and implement interventions to address refusals and complications related to the tube feeding for R6, who had a significant weight loss of 10.9 percent in three months, and/or 7.77 percent in one month.

The facility identified a census of 57 residents. The sample included three residents with three residents reviewed for wound care. Based on observations, record review, and interviews, the facility failed to implement orders and provide the necessary care and services for a facility-acquired pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 1. This deficient practice resulted in worsening wound status and a transfer to the hospital for evaluation and treatment. Findings included: - R1 admitted to the facility on [DATE], was transferred to the hospital on 09/12/22, and readmitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented R1's Brief Interview for Mental Status (BIMS) was not conducted due to R1 rarely/never being understood. R1 required extensive physical assistance with two staff for bed mobility, transfers, dressing, and toileting; extensive physical assistance with one staff with locomotion; and supervision with one staff for eating. R1 was always incontinent of bowel and bladder. R1 did not have any pressure wounds at time of assessment, but was at risk for pressure wounds, and had a pressure relieving device for his bed and chair. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of four which indicated severe cognitive impairment. R1 required extensive physical assistance with two staff for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene; limited physical assistance with one staff for eating. R1 was always incontinent of bowel and bladder. R1 did not have any pressure wounds at time of assessment, but was at risk for pressure wounds. R1 had a pressure relieving device for bed and chair, was on a turning/repositioning program, and received nutrition or hydration intervention to manage skin problems. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/27/21, documented R1 had a BIMS score of three with cognitive loss and dementia noted. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 09/27/21, documented R1 required extensive assistance for all mobilities. The Pressure Ulcer/Injury CAA dated 09/27/21, documented R1 was at risk for pressure ulcer/injury related to extensive assistance required for mobility. The Rehabilitation/Mobility Care Plan dated 09/24/20, documented R1 had an ADL self-care performance deficit and required assistance with his cares. The Care Plan directed R1 required extensive assistance of one staff as needed for bed mobility, transfers, and toileting; total assistance as needed for mobility. The Skin Integrity Care Plan last revised 12/07/21, directed R1 was at risk for alterations in skin integrity related to impaired mobility and he had a diabetic ulcer to his left heel. The Care Plan directed staff administered medications as ordered; R1 had a low air-loss mattress, a wheelchair cushion, and pressure relief ankle foot orthosis (PRAFO, worn on the calf and foot similar to a boot, used for patients who spend a significant amount of time in bed to prevent pressure ulcers from developing on the back of the heel) boots to relieve pressure; staff performed weekly skin assessments; staff reviewed Treatment Administration Record (TAR) for current treatment orders; and R1's wounds were followed weekly on wound rounds with pictures and measurements. The Care Plan did not address a turning/repositioning program or R1's current pressure wounds. R1's clinical record revealed the following: A Skin and Wound Evaluation on 09/08/22 documented R1 had a new in-house acquired, stage three (full-thickness skin loss potentially extending into the subcutaneous [innermost layer of skin in your body] tissue layer) pressure ulcer on his coccyx (small triangular bone at the base of the spine). The pressure ulcer measured at 5.1 centimeters (cm) length by 1.5 cm width. The treatment included generic wound cleanser with primary dressing documented as other. The Assessment did not include the treatment order. A Nurse's Note on 09/08/22 at 05:51 PM documented R1 had open area to his coccyx, and the wound was red and bleeding slightly. A Nurse's Note on 09/12/22 at 12:16 PM documented Consultant GG evaluated R1 and ordered to send R1 to the hospital for further evaluation and treatment, due to a change in R1's condition, new open area, temperature elevation over the weekend, and high blood glucose level. R1's EMR did not reveal any wound care orders for the coccyx wound from 09/08/22 to 09/12/22. Consultant GG's Progress Note on 09/12/22 documented staff were concerned with R1's fever for the last two days and a new wound present to coccyx, which was discovered on 09/07/22. The Progress Note documented an intact blister stage two (partial-thickness skin loss into but not deeper than the dermis, this included intact or ruptured blisters) pressure ulcer of right heel and a large unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow/white material in the wound bed] and/or eschar [dry, dead tissue within a wound]) decubitus ulcer (pressure ulcer) of the coccyx which measured at 8.0 cm length by 4.0 cm width by 0.1 cm depth. The Progress Note documented unstageable pressure ulcer was newly discovered on 09/07/22 and Consultant GG was not notified of new wound until 09/12/22. R1 was being sent to emergency room (ER) for evaluation due to decreased level of consciousness and fever. New order for R1 to be repositioned every two hours scheduled. A Nurse's Note on 09/12/22 at 12:57 PM documented R1 left facility at 01:05 PM to hospital. A General Note on 09/13/22 at 01:45 AM documented R1 was admitted to the hospital for altered mental status and [CONDITION(S)] (high blood sugar). The Discharge Summary from the hospital on 09/15/22 documented disposition orders for wound dressing to left and right buttocks of skin-prep (liquid skin protectant) to periwound (around wound) skin, cover with [MEDICATION(S)] (moisture-retentive dressings, which contain gel-forming agents) dressing, and change every five days; and right heel wound of hydrogel (water based gel) with ABD pad (thick absorbent pad) and kerlix (gauze for wound wrapping), change daily. An Admission Summary on 09/15/22 at 05:08 PM documented R1 readmitted to facility. R1 had wounds on his sacrum (large triangular bone between the two hip bones) and right heel. A Skin and Wound Evaluation on 09/15/22 documented R1 had a stage four (full-thickness skin and tissue loss- these sores extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) pressure ulcer on his coccyx acquired on 09/08/22. The pressure ulcer measured at 8.0 cm in length by 10.4 cm in width. The Assessment did not include the treatment order. A Skin and Wound Evaluation on 09/15/22 documented R1 had a stage three pressure ulcer to right heel present on admission. The pressure wound measured at 4.8 cm in length by 5.2 cm in width. The Assessment documented a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Consultant GG's Progress Note on 09/16/22 documented R1 was sent to theER on [DATE] for further evaluation after Consultant GG noted decreased level of consciousness, fever, and new sacral and heel wound. The Progress Note documented new wound care order to apply hospital ordered [MEDICATION(S)] dressing to coccyx, change every five days and as needed; apply hydrogel to right heel wound bed, cover with ABD pad and kerlix, change daily. A Weekly Skin Check on 09/17/22 at 01:17 AM documented R1's coccyx area had a wound, treatment was done. R1's EMR recorded an order with a start date of 09/18/22 for coccyx wound, which directed staff to clean with wound cleanser, pat dry, cover with [MEDICATION(S)] dressing in the morning every five days for wound care and as needed if soiled or missing. R1's EMR from 09/15/22 to 09/18/22 did not reveal any wound care orders for the resident's coccyx wound, discovered on 09/08/22. R1's EMR did not reveal any wound care orders for the right heel wound from 09/15/22 to 09/19/22. R1's EMR recorded an order with a start date of 09/19/22 for right heel wound, which directed staff to clean with wound cleanser, pat dry, apply hydrogel to wound bed, cover with ABD pad and kerlix every day shift for wound care. On 09/19/22 at 01:22 PM, R1 laid in bed with his head of the bed elevated at 45 degrees. He leaned to his right side and ate lunch with the assistance of staff. On 09/19/22 at 01:42 PM, R1 laid in bed with his eyes closed, he appeared to be resting comfortably. He was repositioned to his left side from last observation. On 09/19/22 at 02:17 PM, Certified Nurse Aide (CNA) M stated the aides checked residents' skin during cares and bathing then alerted the nurse if there were new skin concerns. He stated the Kardex (CNA plan of care) documented if a resident was on a turning/repositioning program. CNA M stated interventions to prevent pressure ulcer development were repositioning, frequent incontinence care, and lotioning the skin. He stated R1 used to be on 400 hall and had recently moved to 200 hall, but he knew R1 was to be repositioned every two hours. On 09/19/22 at 03:30 PM, Licensed Nurse (LN) G stated the nurses assessed residents' skin weekly, if there was a new skin concern, then there were standing orders for wounds. He stated the physician was notified of new skin concerns and the standing orders were used until the physician ordered a treatment. LN G stated standing orders were placed in the EMR. He stated the care plan or Kardex documented if a resident was on a turning/repositioning schedule, and he was not sure who updated the care plan. He stated interventions to prevent pressure ulcer development were good nutrition, turning, encouraging fluids, and monitoring. LN G stated R1 had a pressure wound on his coccyx and right heel and he was turned/repositioned every two hours. He stated when a resident readmitted from the hospital, medical records used to go over the orders to make sure the orders were placed in the computer. LN G stated when a resident readmitted , he looked over the discharge paperwork to see if there were any order changes, then confirmed any new orders with the resident's physician. If there were new orders, he placed them in the EMR and faxed the orders to the pharmacy. He stated when he worked on 09/18/22, he received dressing change orders for R1 and placed them in the computer, he stated R1 had readmitted to the facility on [DATE]. On 09/19/22 at 03:55 PM, Administrative Nurse E stated if a new wound was found, a picture and measurements were taken. She stated medical records usually completed the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse E stated all nursing staff had access to the care plan and if a nurse found a new skin concern or a resident started on a new antibiotic, the care plan should have been updated. She stated the Interdisciplinary Team (IDT) met weekly and the care plan was updated at that time if needed. Administrative Nurse E was unable to locate in R1's care plan or Tasks tab of the EMR that he was on a turning/repositioning program. On 09/19/22 at 03:55 PM, Administrative Nurse D stated nurses assessed residents' skin weekly and if there were new skin concerns, the nurse notified the family and physician. She stated CNAs had access to the care plan and the care plan should include if a resident was on a turning/repositioning schedule along with in the Tasks tab of the EMR. Administrative Nurse D stated R1 had a wound to his coccyx and right heel; she was notified of the coccyx wound on 09/08/22. She stated there were standing orders for wound care until the physician directed what treatment to do and standing orders were placed in the EMR. Administrative Nurse D stated when the wound was discovered, the standing orders should have been placed in the EMR that day, she was not sure if the physician was notified of the new wound. She stated the admitting nurse checked the discharge orders from the hospital for new orders. Administrative Nurse D was unable to locate any treatment orders for R1's coccyx wound from discovery on 09/08/22 to 09/12/22 and 09/15/22 to 09/18/22. She stated the lack of wound care could have contributed to worsening R1's coccyx wound. On 09/20/22 at 03:15 PM, Consultant GG stated she was not notified of the coccyx wound until 09/12/22 when she was in the facility to see R1. She stated the facility usually called her to notify of new wounds and to get treatment orders. Consultant GG stated from the wound picture taken on 09/08/22 to her assessment done on 09/12/22, there was a significant worsening of the wound. She ordered staff to send R1 to the hospital for evaluation. Consultant GG stated she visited R1 on 09/16/22 after he returned from the hospital and continued the hospital treatment orders. She stated the facility should have followed the hospital discharge orders when he readmitted . When she saw a resident, she returned to her office to write her progress note, type up any new orders, then faxed it to the facility and called to ensure the facility received the new orders. She expected the new orders to be implemented the day they were written. Consultant GG stated the facility's lack of treatment orders and notification to the physician contributed to the worsening of R1's coccyx wound and hospitalization . The facility's 01/01/20 Pressure Injury Prevention and Management policy directed after completing a thorough assessment, the IDT developed a relevant care plan that included measurable goals for prevention and management of pressure injuries with appropriate interventions. The interventions were based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment including moisture management, impaired mobility, nutritional deficit, staging, and wound characteristics. Evidence-based interventions for prevention were implemented for all residents who were assessed at risk or who had a pressure injury present, and basic or routine care interventions could include redistributing pressure such as repositioning. The policy directed staff to notify the attending physician of the presence of new pressure injury upon identification. Interventions on a resident's plan of care were modified as needed and considerations for needed modifications included: changes in resident's degree of risk for developing a pressure injury, new onset or recurrent pressure ulcer development, lack of progression towards healing, resident non-compliance, and changes in the resident's goals and preferences. The facility's Wound Treatment Management policy, dated 01/01/20, directed wound treatments were provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The policy directed in the absence of treatment orders, the LN notified the physician to obtain treatment orders and treatments were documented in the TAR. The facility's Documentation of Wound Treatments policy, dated 01/01/20, directed wound treatments were documented at the time of each treatment and additional documentation included, but not limited to: date and time of wound management treatments, weekly progress towards healing and effectiveness of current interventions, any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Consulting Physician/Practitioner Orders policy, dated 01/01/20, directed consulting physician/practitioner orders were those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who was acting on behalf of the attending physician. A consulting physician/practitioner may include, but was not limited to, a resident's: surgeon, wound clinic physician, specialist, and nurse practitioner or physician assistant to any of the above physicians. The facility failed to implement orders and provide the necessary care and services for a facility acquired pressure ulcer for R1. This deficient practice resulted in worsening wound status and a transfer to the hospital for evaluation and treatment.

The facility identified a census of 60 residents. The sample included three residents reviewed for weight loss. Based on observations, record review, and interviews, the facility failed to implement recommendations and interventions made by the dietitian for a significant weight loss of 9.6% in less than three months for Resident (R) 1 and failed to implement interventions to address a significant weight loss of 11.7% in six months for R2. This deficient practice resulted in physical complications including unintended weight loss and decreased nutritional status. Findings included: - R1 admitted to the facility on [DATE], transferred to the hospital on [DATE], readmitted to the facility on [DATE], and died in the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four which indicated severe cognitive impairment. R1 required extensive physical assistance with two staff for bed mobility, transfers, dressing, and toileting; and extensive physical assistance with one staff for eating, locomotion, and personal hygiene. R1 had no or unknown weight loss of 5% or more in the last month or 10% in the last six months. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated [DATE], documented R1 had a recent BIMS score of three, cognitive loss and dementia noted. R1 had confusion and a decreased ability to make self-understood. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated [DATE], documented R1 required extensive assistance for cares and required staff to assist with oral care. The Nutritional Status CAA dated [DATE], documented R1 required extensive assistance for cares, was on a low concentrated sweet (LCS) diet and required staff to assist with oral care. The Rehabilitation/Mobility Care Plan dated [DATE], documented R1 had an ADL self-care performance deficit and required assistance with his care needs. The care plan directed staff provided supervision and physical assistance as needed for dining. The Nutrition Care Plan dated [DATE], documented R1 was at risk for nutritional problems or potential for nutritional problem related to his need of a therapeutic diet. The Care Plan directed staff monitored/record/reported to medical doctor as needed, signs and symptoms of malnutrition including significant weight loss of greater than (>) 5% in one month, > 7.5% in three months, and > 10% in six months and the registered dietitian (RD) evaluated and made diet change recommendations as needed. The Care Plan documented an intervention on [DATE] for staff to provide and serve Glucerna (supplemental shake) twice daily as ordered. The Care Plan did not address the significant weight loss or new interventions put into place for the significant weight loss in [DATE]. The Orders tab of R1's EMR documented an order with a start date of [DATE] for [MEDICATION(S)] (vitamin C) 500 mg one time a day for supplement due to wounds and an order with a start date of [DATE] and discontinued date of [DATE] for lactobacillus (probiotic) 200 mg one time a day for prophylactic for three weeks. R1's EMR revealed on [DATE], R1 weighed 228.0 pounds (lbs) and on [DATE], R1 weighed 206.2 lbs. This was a significant weight loss of 9.6% in less than three months. R1's EMR revealed the following notes: A Nutrition/Dietary Note on [DATE] at 09:12 PM documented R1 had a significant weight loss of 21.8 lbs in two months. Consultant GG recommended considering providing sugar-free ProStat (liquid protein supplement) 30 milliliters (mL) twice daily (BID) to support wound healing processes, Juven (nutritional supplement) 1 packet twice daily for multiple skin impairments, vitamin C 500 milligrams (mg) daily for further wound healing support, probiotic once daily starting on or after [DATE] and to continue for 21 days after initiation to promote gastrointestinal health and recovery on completion of multiple antibiotics (medication used to treat infections). A Interdisciplinary Team (IDT) Note on [DATE] at 01:11 PM documented IDT met to discuss R1's high risk areas. R1 was on antibiotics for coccyx (small triangular bone at the base of the spine) wound. Reached out to Consultant GG for recommendations. Sugar-free Prostat 30 mL BID, Juven BID, vitamin C 500 mg daily, and probiotic one-time daily recommendations were approved. Primary care provider (PCP) and care plan were up-to-date. A Progress Note from Consultant II on [DATE] documented R1 was down 21 lbs in the past two months and Consultant GG started R1 on Glucerna, Juven, and vitamin C supplement. Continue oral intake as tolerated. A Progress Note from Consultant II on [DATE] documented R1 had 21 lbs of weight loss in the past two months and supplements included Glucerna, Juven, and vitamin C to assist with wound healing. Continue oral intake as R1 tolerated and continue to monitor. A General Note on [DATE] at 07:25 PM documented hospice was going to the facility to meet R1's durable power of attorney (DPOA- legal document that names a person to make healthcare decisions when the resident was no longer able to) to sign papers. R1's EMR lacked evidence an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 03:48 PM, Certified Nurse Aide (CNA) G stated the CNAs obtained the weights and wrote the weights on the paper for the nurse to chart in the computer. She stated the nurse looked into any weight changes. On [DATE] at 04:24 PM, Licensed Nurse (LN) G stated the CNAs were responsible for obtaining weights and if there was a discrepancy then she reweighed them herself, documented it in the EMR, and notified Administrative Nurse D. She stated Consultant G made recommendations and the doctor reviewed the recommendations. If the doctor signed off on the recommendations or made new orders, the nurse put the orders into the EMR. She stated the doctor usually followed Consultant GG recommendations. On [DATE] at 05:01 PM, Administrative Nurse D stated the CNAs obtained weights and the charge nurse documented the weights on the Treatment Administration Record (TAR). She stated Consultant GG consulted weekly usually, sometimes she reviewed residents remotely. Administrative Nurse D stated the physician looked at Consultant GG's recommendations and the charge nurse put any new orders in the EMR. She stated the recommendations made by Consultant GG for R1 for ProStat and Juven should have been started but she was unable to see that they were started. On [DATE] at 10:31 AM, Consultant GG stated she reviewed the client at risk (CAR) list when she consulted for the facility weekly. She stated if she made a recommendation for weight loss, they were emailed to Director of Nursing (DON), Assistant DON (ADON), Administrator, and/or Certified Dietary Manager (CDM). Consultant GG was not sure what the facility process was after she emailed the recommendations, but the physician had to sign off on any recommendations. She stated she used to follow up with previous recommendations but would be told by staff that the recommendations were in process with the physician to review and sign. She stated she did get concerned and had voiced concerns because her recommendations were not showing up as orders. Consultant GG stated she hoped that an intervention was put into place if the physician did not keep her recommendation and she had noticed that it was a struggle to get recommendations approved. She stated she expected recommendations to take maybe a week to get put into place. The facility's Weight Monitoring policy, not dated, directed the facility ensured that all residents maintained acceptable parameters of nutritional status. The care plan directed interventions were identified, implemented, monitored, and modified consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. The policy directed the physician was encouraged to document the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement recommendations and interventions made by the dietitian for a significant weight loss of 9.6% in less than three months for R1. This deficient practice resulted in physical complications including unintended weight loss and decreased nutritional status. - R2 admitted to facility on [DATE]. R2's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not conducted due to R2 rarely/never understood. R2 required extensive physical assistance with two staff for bed mobility and dressing; extensive physical assistance with one for eating and personal hygiene; total physical dependence with two staff for transfers and toileting. R2 had a loss of liquids/solids from his mouth when eating, had no or unknown weight loss of 5% or more in the last month or 10% in the last six months, and received a mechanically altered diet. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated [DATE], documented R2 had impaired cognitive function/dementia or impaired thought processes due to his traumatic brain injury. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated [DATE], documented R2 required maximum assistance for cares and was at risk for dehydration due to requiring assistance with hydration. He was missing teeth and required assistance with oral care. The Nutritional Status CAA dated [DATE], documented R2 was at risk for nutritional complications related to being prescribed a mechanically-altered diet. He was able to take in food and fluids with supervision from staff, staff assisted at times. The Rehabilitation/Mobility Care Plan, last revised [DATE], directed R2 had an ADL self-care performance deficit related to traumatic brain injury. The Care Plan documented an intervention, last revised [DATE], that R2 need assistance of two for all ADLs and staff provided additional assistance. The Nutrition Care Plan, last revised [DATE], directed R2 was at risk for nutritional problems related to R2 requiring a mechanically altered diet. The Care Plan documented an intervention, last revised [DATE], directed R2 needed full feeding assistance; and an intervention, last revised [DATE], directed staff provided and served chocolate milk and protein cookie at bedtime and high protein twice a day. The Care Plan did not address R2's current significant weight loss status. R2's EMR revealed on [DATE], R2 weighed 190.0 pounds (lbs); on [DATE], R2 weighed 175.0 lbs; on [DATE], R2 weighed 169.3 lbs, and on [DATE], R2 weighed 167.7 lbs. This was an 11.7% significant weight loss in six months from [DATE] to [DATE], and a 7.9% significant weight loss in three months from [DATE] to [DATE]. The Orders tab of R2's EMR documented an order with a start date of [DATE] and discontinued date of [DATE] for Juven (nutritional supplement) one packet two times a day for wound healing; an order with a start date of [DATE] for a high protein snack two times a day for supplement; and an order with a start date of [DATE] for Juven one packet two times a day for wound healing. R2's EMR revealed the following notes: A Nutrition/Dietary Note on [DATE] at 05:21 PM documented R2 had a significant weight loss of 5.9% in one month. Order continued for Juven to support wound-healing processes. Registered Dietitian (RD) recommended providing a protein cookie, providing a high-protein snack twice a day between meals, and continuing to encourage increased oral intakes. A Weight Change Note on [DATE] at 06:43 PM documented a 7.5% weight loss and R2 previously had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An Interdisciplinary Team (IDT) Note on [DATE] at 01:49 PM documented IDT met to review resident high-risk areas. RD recommended high protein and the care plan was updated. An IDT Note on [DATE] at 01:41 PM documented IDT met to review resident high-risk areas. RD recommended high protein and the care plan was updated. A Weight Change Note on [DATE] at 06:28 PM documented R2 had a 10.0% weight loss over 180 days. R2 previously had orders for Juven, however, the orders were discontinued or may have ended. RD recommended consider providing Juven one packed twice daily to support wound-healing processes. The Miscellaneous tab of R2's EMR revealed Dietitian Recommendations dated [DATE] for L-[MEDICATION(S)] 1000 mg/day to support wound healing and omega-3 fish oils one gram to further promote wound healing process. The scanned document had a slash through the recommendations with Consultant HH's signature and date of [DATE]. R2's medical record lacked documentation Consultant HH addressed R2's significant weight loss. On [DATE] at 04:48 PM, R2 laid in bed and watched television. On [DATE] at 03:48 PM, Certified Nurse Aide (CNA) G stated the CNAs obtained the weights and wrote the weights on the paper for the nurse to chart in the computer. She stated the nurse looked into any weight changes. On [DATE] at 04:24 PM, Licensed Nurse (LN) G stated the CNAs were responsible for obtaining weights and if there was a discrepancy then she reweighed them herself, documented it in the EMR, and notified Administrative Nurse D. She stated Consultant G made recommendations and the doctor reviewed the recommendations. If the doctor signed off on the recommendations or made new orders, the nurse put the orders into the EMR. She stated the doctor usually followed Consultant GG recommendations. On [DATE] at 05:01 PM, Administrative Nurse D stated the CNAs obtained weights and the charge nurse documented the weights on the Treatment Administration Record (TAR). She stated Consultant GG consulted weekly usually, sometimes she reviewed residents remotely. She stated R2 had a significant weight loss and Consultant GG was following him. Administrative Nurse D stated the physician looked at Consultant GG's recommendations and the charge nurse put any new orders in the EMR. Administrative Nurse D stated if Consultant HH did not agree with Consultant GG's recommendations, she put a slash through the recommendations. On [DATE] at 10:31 AM, Consultant GG stated she reviewed the client at risk (CAR) list when she consulted for the facility weekly. She stated if she made a recommendation for weight loss, they were emailed to Director of Nursing (DON), Assistant DON (ADON), Administrator, and/or Certified Dietary Manager (CDM). Consultant GG was not sure what the facility process was after she emailed the recommendations, but the physician had to sign off on any recommendations. She stated she used to follow up with previous recommendations but would be told by staff that the recommendations were in process with the physician to review and sign. She stated she did get concerned and had voiced concerns because her recommendations were not showing up as orders. Consultant GG stated she hoped that an intervention was put into place if the physician did not keep her recommendation and she had noticed that it was a struggle to get recommendations approved. She stated she expected recommendations to take maybe a week to get put into place. Consultant GG stated after she made recommendations for R2's weight loss, she did not think any other recommendations get put into place after they were denied by the physician. The facility's Weight Monitoring policy, not dated, directed the facility ensured that all residents maintained acceptable parameters of nutritional status. The care plan directed interventions were identified, implemented, monitored, and modified consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. The policy directed the physician was encouraged to document the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement interventions to address a significant weight loss of 11.7% in six months for R2. This deficient practice resulted in physical complications including unintended weight loss and decreased nutritional status.

The facility had a census of 70 residents. The sample included 19 residents with two reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to provide interventions to prevent the development of two facility acquired pressure ulcers for one of two sampled residents, Resident (R) 50. One unstageable (severity that cannot be determined with a visual exam) pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction) to R50's left heel and a deep tissue injury (non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) to R50's right heel. Findings included: - R50's Physician order [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS documented the resident had a pressure reducing device for the bed and chair, received pressure injury care, and had one Stage 2 (partial thickness loss of the dermis, presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer (buttocks) present upon admission. The Pressure Ulcer Care Area Assessment (CAA), dated 01/03/2020, documented the resident had as Stage 2 pressure injury (buttocks) present on admission. The Skin Integrity Care Plan, dated 12/27/19 documented the resident had both potential and actual impairment to skin integrity, pressure ulcer on his buttocks present upon admission, pressure relief boots bilaterally when in bed, or a pillow under the resident's calves to offload the heels. The care plan update, 01/22/2020, documented staff applied Prafo boots (a boot to prevent bedsores or ulcers from developing on the back of the heel) the resident's feet. The care plan update, 01/27/2020, directed staff to administer the resident double protein portions at lunch and supper. The Braden Scale Assessment, dated 12/27/19, documented a score of 16 indicating at risk to develop pressure ulcers. The assessment, dated 01/13/2020, documented a score of 12 indicating high risk to develop pressure ulcers. The Nutritional Assessment, dated 01/02/2020, documented the resident had no supplement orders and required assistance with meals. The Nurse's Note, dated 01/18/2020 at 07:15 AM, documented the resident had two wounds on his bilateral (affecting both) heels. The note documented staff assessed the heels, the areas measured approximately 4 cm (centimeters) x 4 cm, and oozed blood. Nursing staff cleansed the areas, applied dressings, and notified the dayshift nurse. The Wound Rounds Assessment, dated 01/18/2020, documented the resident's left heel wound classified as unstageable, with serous exudate (a clear, thin, watery fluid with relatively low protein content, usually observed in acute or mild inflammation), and measured 2.10 cm x 2.0 cm. The assessment documented the resident's right heel classified as a deep tissue injury, bright beefy red color, with serosanguineous drainage (sticky and bloody fluid), and measured 2.5 cm x 2.5 cm. R50's Physician Orders, dated, 01/22/2020, directed staff to clean the resident's right heel with iodine (a mild antiseptic), apply collagen (promotes healing and new tissue growth), Vaseline gauze (a sterile, absorbent dressing), and cover with a foam dressing. The order further directed staff to clean the left heel with iodine, apply [MEDICATION NAME] (absorbs wound drainage) to the calcium alginate sheet (helps the wound heal by limiting secretions in the wound and minimizing bacterial contamination), and cover with foam dressing. The Wound Protocol Standing Orders, dated 01/22/2020, directed staff to administer Prostat (a supplement to increase protein needs) 30 ml (milliliters) by mouth, twice daily for 30 days, Multivitamin one by mouth, daily for 30 days, Vitamin C (an essential nutrient found mainly in fruits and vegetables) 500 mg (milliigrams), one by mouth twice daily for 30 days, and Zinc (a supplement used for fighting off infections and producing cells) 220 mg, one by mouth daily for 30 days. The Nurse's Note, dated 01/30/2020 at 11:28 AM, documented staff contacted the physician and reported the resident's heels drug on the ground when propelled in the wheelchair despite foot pedals, the resident's feet slid between the foot pedals, and therapy would place a foot bolster (a long pillow) on the wheelchair. The note documented the physician changed the wound type to trauma (physical injury) from friction instead of pressure ulcers. The Wound Rounds Assessment, dated 02/05/2020, documented the resident's left heel classified as trauma, light serous drainage, measured 2.0 cm x 1.50 cm with 50% slough (dead skin tissue that may have a yellow or white appearance), and 50% bright pink or red tissue. The assessment documented the resident's right heel classified as trauma, moderate amount of serosanguinous drainage, measured 4.50 cm x 3.50 cm with 20% bright beefy red tissue, and 80% necrotic (dead) soft tissue. On 02/05/2020 at 01:20 PM, observation revealed the resident's right heel with a 4.50 cm x 3.50 cm necrotic area, an approximately 2.0 cm x 2.0 cm opened red, beefy area in front of the necrotic area, and slough present surrounding the entire wounds. Observation further revealed the resident's left heel with 2.0 cm x 1.50 cm opened area with slough in the center of the wound. The surrounding skin around the wound light pink/red in color and inflamed. On 02/05/2020 at 01:20 PM, Licensed Nurse (LN) I stated the wounds were not from pressure but friction from the resident dragging his heels between the foot pedal. This surveyor asked LN I why staff did not stop and place the resident's feet on the pedals to prevent injury, LN I stated, then the staff would have to stop 30 times and place his feet on the pedals. LN I stated therapy placed a bolster on the wheelchair pedals so the resident's heels would not drag. On 02/05/2020 at 1:40 PM, Physician HH stated the wounds were not from friction and felt the areas were from pressure. Physician HH further stated staff should have had interventions put into place to prevent the resident from getting the areas on his heels. On 02/10/2020 at 1:28 PM, Certified Nurse Aide (CNA) MM stated staff repositioned the resident every two hours and the boots were placed on the resident's after he obtained the sores on his heels. On 02/10/2020 at 1:45 PM, LN K stated he noticed the resident's heels had bandages and were broke down. LN K further stated the boots were placed on the resident after his heels broke down and staff did not float the resident's heels. On 02/10/2020 at 5:00 PM, Administrative Nurse D stated the resident kept removing his feet from the foot pedals and the therapy department placed a foot bolster on the wheelchair to keep his feet from falling between the foot pedals. The facility's Pressure Injury Prevention Guidelines, dated 01/01/2020, documented to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence based interventions for all residents who are assessed at risk or who have a pressure injury present. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment. The facility failed to implement timely effective interventions to prevent two facility acquired pressure ulcers for cognitively impaired dependent R50, identified at risk for pressure ulcers.

The facility identified a census of 71 residents. The sample included 6 residents reviewed for elopement risk (when a resident leaves the facility without staff knowledge). Based on record review, observation, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent elopement after he/she was identified at risk for elopement. On 3/14/18 at 3:50 P.M., resident #1 exited a major department store (while on a supervised activity outing) at a hazardous location and was found by local police approximately 1.5 miles away at 5:25 P.M., approximately 1 hour and 35 minutes after he/she exited the store. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The (MONTH) (YEAR) electronic medical record (EMR) for resident #1 included [DIAGNOSES REDACTED]. (a progressive disease that destroys memory and other important mental functions), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and dyspnea (shortness of breath). The annual Minimum Data Set (MDS), dated [DATE], documented staff assessed the resident with a Brief Interview for Mental Status score of 8, which indicated severely impaired cognition. The MDS documented the resident had short and long-term memory problems, inattention, disorganized thinking, and could walk without the use of assistive devices. The resident received anti-psychotic medications (medication used for mental illness) and anti-depressant medications (medication used to relieve feelings of sadness). The care area assessment for cognition, dated 1/26/18, documented the resident's [DIAGNOSES REDACTED]. Staff would monitor his/her cognitive status, approach him/her in a calm and non-threatening manner, allow adequate time for him/her to comprehend what was going on, and allow him/her to communicate his/her needs. The elopement risk assessment, dated 1/26/18, documented a score of 12, which placed the resident at moderate risk for elopement. The elopement risk assessment, dated 3/15/18, documented a score of 10, which placed the resident at lower risk for elopement. The resident's care plan, dated 12/26/17, recorded the resident was at high risk for elopement and directed staff to encourage his/her independence while in the building, but ensure supervision while outside, and to encourage participation in positive meaningful activity programs or choice. In the event of an elopement, staff should follow search and reporting protocols. The care plan further directed staff to keep the resident's routine consistent to alleviate confusion, redirect when wandering around doors/exits, social work visits routinely, and to frequently visualize the resident's whereabouts. The revised care plan, dated 3/14/18, directed staff to educate healthcare decision makers and staff of the resident's elopement potential, history, triggers, and preventative measures. The resident enjoyed going on walks, both around facility, and out in the community. His/her family must sign him/her out of the facility with the time, date, and destination prior to exiting the facility and provide a picture and description of the resident in the elopement book. The facility investigation notes, dated 3/14/18 at 6:00 P.M., documented direct care staff O and P and the activity assistant S accompanied eight residents on a shopping trip. Direct care staff P was tasked with managing residents 1& 2. Resident #1 had a BIMS score of 8 and was an elopement risk. Resident #2 had a BIMS Score of 15, but needed assistance walking. While assisting resident #2 in one aisle, staff P failed to notice resident #1 move from his/her location into another aisle. Resident #1 exited the shopping center, and was found 1.5 hours later at another shopping center approximately 1.5 miles away. At approximately 3:50 P.M., while staff P observed both residents from the end of the two aisles, staff P looked from resident #1 to resident #2 one time, and resident #1 wandered out of sight. Staff P then began searching for resident #1 inside the store, after assisting resident #2 to the front of the store with other staff and residents. Staff was unable to locate resident inside the store, employees stationed at the doors were notified of a missing resident, and staff P checked all the bathrooms. Staff notified the director of nursing and administrator at approximately 4:30 P.M. they were unable to locate the resident. The administrator and social service designee immediately provided a color picture, face sheet, and current description of resident #1's clothing to local law enforcement. Law enforcement found resident #1 at 5:30 P.M. and returned him/her to the facility at 6:15 P.M., dressed in khaki pants, a polo shirt, a jacket, and a baseball cap, as well as footwear that was appropriate for the time of day and temperature outside. According to www.Wunderground.com, on 3/14/18 between 3:53 P.M. and 5:53 P.M., the outside temperature averaged 65.0 degrees Fahrenheit, south-west winds were 15 to 20 miles per hour (mph), and clear skies. On 3/21/18 at a 9:00 A.M., the resident sat in a recliner in a central area in the facility, unagitated, confused, and responsive to cueing and direction from staff. On 3/22/18 at 2:00 P.M., review of the area traveled by the resident revealed an area with many potential hazards including, but not limited to, changing 4 lane roads, entrance and exit ramps to a major interstate with varying speeds from 65 to 40 mph, slopes, irregular traffic patterns, curbed concrete sidewalks, trees, ravines, construction zones, irregular traffic patterns, and four lane main roads at 35 to 40 mph. The resident traveled approximately 1.5 miles. The undated and unnotarized witness statement by direct care staff O documented he/she assisted other residents to shop, check out, and return to the bus. Staff O stated staff P (the driver) pulled the bus up to the store front, staff loaded the other residents into the bus, and staff P went in to the store to search for the resident. Staff notified facility administration of the missing resident. The undated and unnotarized witness statement by direct care staff P documented he/she assisted residents #1 and #2 to shop. Resident #1 wandered one aisle over (in the candy aisle) from resident #2 (in the chip aisle). Staff P stood at the end of the two aisles to monitor both residents. Staff P stated resident #1 went missing while he/she observed resident #2 in the chip aisle. He/she thought the resident had rejoined the group at the front of the store. Staff P assisted resident #2 quickly through the checkout and began loading residents on the bus. At that time, staff P noticed resident #1 was missing, notified other staff, and began to search for resident #1. The undated and unnotarized witness statement by activity staff S documented he/she assisted other residents to shop, check out, and they had returned to the bus when staff P notified them of the missing resident. Staff S documented his/her last visual contact with resident was at the beginning of the outing when the resident used the restroom. The undated and unnotarized witness statement by administrative licensed nurse D documented the facility was notified on 3/14/18 at approximately 4:30 P.M. of the missing resident. Staff notified local police of the missing resident at 4:47 P.M. and provided a physical description of the resident, his/her clothing, and his/her diagnoses. Staff D notified the resident's family at 4:53 P.M., and notified the physician at 5:01 P.M. Law enforcement found the resident at 5:30 P.M. and returned him/her to the facility at 6:15 P.M. The resident immediately went to the dining room for dinner upon return to facility, and staff obtained his/her vital signs, which were within normal limits. The resident denied pain upon return to facility. The undated and unnotarized witness statement by direct care staff Q documented on 3/14/18, he/she was notified at 4:30 P.M. resident # 1 had walked away from the group shopping trip. Staff Q drove to the location of the group outing to assist in searching for resident. He/she arrived on scene at approximately 5:15 P.M. and was updated by staff members and store personnel. Staff Q updated local police with resident #1's description. At approximately 5:30 P.M., law enforcement notified staff the resident had been found. The resident and staff returned to the facility at approximately 6:20 P.M. The undated and unnotarized witness statement by administrative staff A documented he/she spoke with resident #1 after the elopement occurred. Staff A asked the resident why he/she went for a walk and the resident stated he/she just needed to get away. Staff A asked the resident how he/she walked down the street and crossed the road and the resident stated he/she walked on the sidewalk, and he/she went to the crosswalk and pushed the button. On 3/21/18 at 1:49 P.M., administrative licensed nurse D stated staff could not have anticipated this incident would happen. He/she did not think any system failed, but stated the facility immediately put interventions in place to ensure this could not happen again. The facility's Elopement of Patient policy, revised 5/15/14, documented residents would be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the nursing assessment process. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. The facility failed to ensure this cognitively impaired resident received adequate supervision and appropriate interventions to prevent an elopement on 3/14/17 while on a supervised outing from the facility. This deficient practice placed resident #1 in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 3/16/18 at 5:00 P.M., when the facility completed the following actions: A resident wandered away during a facility outing. The staff member that assisted the resident who eloped was assisting another resident and lost sight of resident #1. Staff supervision of the resident on the outing was not continuous. Immediately, the facility suspended facility recreational outings pending investigation and implementation of interventions. The facility created a form to utilize prior to facility outings to ensure full assessment of residents attending the outings. The form documents residents planning to attend outings, BIMS score, fall risk, elopement risk, ADL assistance needed, mobility status, and devices needed. Nursing management would complete final assessment of residents, including if they were cleared to attend the outing and any special needs (1:1 staff assistance, certified nurse aide needed for transfers, etc.) that they may require. The facility also added elopement/wandering history to the initial referral assessment to ensure the facility had an accurate history of residents prior to admission. Immediately upon return to facility, resident #1, who eloped, was assessed with [REDACTED]. His/her BIMS score and elopement risk were re-assessed and his/her care plan was reviewed and updated. Staff placed the resident on 30-minute visual checks upon return to facility for 24 hours and he/she showed no exit-seeking behaviors, as was his/her pattern prior to the outing. The facility continued with locked/coded exit doors that sound when opened without the code entered. The resident did not show any changes in his/her physical or psychosocial status following the incident. Staff re-education was provided to the departments involved in facility outings on 3/15/18 beginning 3:00 P.M. and all day on 3/16/18 beginning at 9:00 A.M. The facility would ensure that prior to any future outings, staff involved in the outing received the education. Education included re-education on the outings policy and procedure and education on the new forms that the facility implemented to ensure adequate assessment of residents' histories, as well as adequate assessment of residents' needs on outings. Referrals to the facility would have the updated referral form with elopement/wandering history beginning 3/16/18, which would be monitored by the administrator or designated admissions personnel. Nursing management would review the outings list and residents' assessment prior to facility recreational outings beginning 3/15/18 with no end date, which would be monitored by the director of nursing or designee with no end date.

The facility had a census of 78 residents. The sample included 17 residents. Based upon observation, record review and interview the facility failed to provide adequate supervision to prevent falls for 2 (#51, #14) of 3 residents sampled for falls. The facility identified 6 independently mobile residents with cognitive impairment that did not reside in the Special Care Unit. The facility failed to ensure that chemicals were not accessible to residents. Findings included: - Review of resident #14's electronic health record identified the resident had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident had severely impaired cognition, no behaviors, was totally dependent upon staff for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, personal hygiene and bathing. The MDS identified the resident was not steady and was only able to stabilize with human assistance when moving from a seated to a standing position and surface to surface transfer and the activity of walking, turning around and facing the opposite direction while walking and moving on and off the toilet did not occur. The MDS recorded the resident utilized a wheelchair and had 1 injury fall since the prior assessment. The resident's Cognitive Loss Dementia Care Area assessment dated [DATE] included the resident had a [DIAGNOSES REDACTED]. The resident's Fall CAA dated 7/25/15 included the resident was at risk for falls due to medication usage, dementia, and poor safety judgement. The resident required supervision of 1 staff with all activity of daily living (ADL) tasks and transfers. Staff ensured the resident's call light was within reach when the resident was in his/her room, staff ensured the resident's needs were met and the resident's room was free from clutter. Staff frequently visualized the resident frequently throughout the day and kept the resident involved in facility events to help with fall interventions. The resident utilized a cradle mattress (mattress used to define the parameters of the bed), a low bed, and a fall mat beside his /her bed and was on 30 minute visual checks. The wheelchair was the resident's primary mode of locomotion which was propelled by staff. The resident's wheelchair had a right lateral support in place to enhance the resident's positioning and a thin gel cushion with dycem (non-slid material) under it to prevent the cushion from sliding out of chair. The resident's quarterly Fall Risk Review dated 5/12/15 recorded yes responses to the resident had a history of [REDACTED]. According to the legend a yes response represented the resident was at high risk for falls. The resident's Fall Risk assessment dated [DATE] identified the resident scored 21. According to the legend a score of 12 or above represented the resident was at high risk for falls. The resident's care plan dated 12/3/15 addressed the resident had an alteration in his/her thought process; was confused due to the [DIAGNOSES REDACTED]. Staff assisted the resident with ADLs as needed. The resident had impaired vision related to the aging process. The resident had impaired mobility and at risk for falls related to hypertension (elevated blood pressure), pain, psychosis, anxiety, depression, and mood disorder. Staff monitored the resident's vital signs as needed, observed the resident for changes in the resident's gait, balance and mobility and reported the changes to the resident's physician. Staff anticipated the resident's ADL needs, kept the resident's routine as consistent as possible, and reminded the resident to use the call light for assistance and to not get up independently without assistance if the resident was unable to transfer or ambulate by himself/herself. Staff assured the resident's toileting needs were met, kept the resident's room and hallways free of clutter. The resident utilized a cradle mattress, a fall mat, a low bed and staff ensured the bed control was positioned so the resident would not hit the control if he/she rolled out of bed. Staff provided frequent visual checks when walking by the resident's room and encouraged the resident to be involved in facility activity/events. The resident's wheelchair had a right lateral support, a thin gel cushion with dycem under it, body pillows for positioning when in bed, staff performed 30 minute visual checks and assisted the resident to a recliner when the resident was restless. An entry dated 11/27/15 included staff placed foot pedals on the resident's wheelchair when the resident was up in the wheelchair. The resident's CNA (Certified Nurse Aide) Pocket Care Plan (an aide that informs staff of the resident's care needs) dated 12/15/15 and 12/21/15 included the resident required staff assistance of 1 staff with toileting, 1 to 2 staff assistance with the sit to stand lift only, foot pedals on the resident's wheelchair at all times, protective devices/alarms included the resident utilized a cradle mattress, mat at bedside, a low bed, body pillows and was a high fall risk. The 12/15/15 Pocket Care Plan did not include staff should not leave the resident unattended when in the shower/bath room. The resident's clinical record revealed the resident fell 12 times from 10/8/14 to 12/18/15. A nurse's note (NN) dated 11/5/14 and timed 3:40 P.M. or 6:40 P.M. included at 2:45 P.M. the resident hollered, the resident sat on the floor in his/her room with the personal alarm intact and not sounding. The resident had a laceration to his/her left eyebrow. Staff cleaned and applied pressure to the laceration, the laceration was too large for steri-strips and staff received a physician's orders [REDACTED]. A NN dated 11/5/14 and timed 10:00 P.M. documented the resident returned from the ED with sutures and a laceration (cut) to his/her left eyebrow. The hospital's ED reports with a visit date of 11/5/14 included the resident's discharge [DIAGNOSES REDACTED]. A SBAR (Situation, Background, Assessment and Request) form dated 11/11/14 documented at 6:00 P.M. the resident's pull-alarm sounded and the resident sat upright next to his/her bed with his/her back against the bed. The resident's left hip had an abrasion and was bruised and staff applied an ice pack to the resident's left hip area. A NN dated 12/10/14 and timed 11:50 P.M. documented the resident was on the floor in his/her room, The resident's alarm was still attached and in the resident's hand. The resident had a small scratch just above his/her left lip. Staff assisted the resident to his/her wheelchair, propelled the resident to the dining room for monitoring, initiated 30 minute checks and followed the facility's fall protocol. An SBAR form dated 5/21/15 included the resident laid on the floor on his/her right side next to his/her bed on the fall mat. The resident hit his/her head on the bed control and the resident's right forehead was bruised. Time? An SBAR form dated 8/11/15 and timed 10:00 A.M. documented the resident leaned forward, fell out of the wheelchair, landed on his/her forehead and the right side of the resident's forehead had a reddened area. An SBAR form dated 11/30/15 and timed 10:15 A.M. documented the resident fell out of his/her wheelchair. The resident had a laceration that measured 2 millimeters (mm) above his/her left eye, bruising above his/her left eye and an abrasion above his/her left temple. Staff cleaned the areas and applied an ice pack to the resident's forehead above his/her left eye. An SBAR form dated 12/18/15 documented the resident fell at 6:40 A.M. and received a forehead laceration. The form included the resident was positioned in the shower chair prior to the fall. Staff left the resident unattended in the bathroom on the shower chair, the resident fell on to the bathroom floor. Staff received a physician's orders [REDACTED]. A hospital ED's report with a visit date of 12/18/15 included the resident's [DIAGNOSES REDACTED]. Review of the facility's investigation regarding the resident's 12/18/15 fall included video surveillance of the incident revealed at 6:16 A.M. a staff propelled the resident from his/her room to the shower room via a shower chair. The stand up lift was parked in the hall across from the shower room. At 6:34 A.M. staff exited the shower room and went in the hall and the stand up lift had been removed. The staff tried to reenter the shower room but had a hard time getting the key to work. The staff reentered the shower room, leaned out of the door and yelled for the nurse. The facility educated the staff member to not walk away when a resident was in the shower room. On 12/21/15 at 9:48 A.M. observation revealed the resident sat in a recliner and the foot rest of the recliner in a raised position. Further observation revealed the resident had approximately 15 to 20 sutures from his/her mid-forehead to almost the bridge of his/her nose, and reddish colored bruises under both eyes and a dark colored bruise on his/her right hand. On 12/22/15 at 7:25 A.M. direct care staff U was in the resident's room. Staff U transferred the resident from his/her bed to the wheelchair via a gait belt. Observation revealed the resident's wheelchair had a gel cushion, no dycem under the cushion and no right lateral support in place. Observation revealed the resident required extensive staff assistance during the transfer. Staff U completed the resident's ADL task after placing the resident in the wheelchair. Observation revealed the gel cushion curled up on the sides and was centered in the seat of the wheelchair. After staff U completed the task, he/she propelled the resident from his/her room to the dining room. Further observation revealed staff did not place foot pedals on the resident's wheelchair prior to propelling the resident to the dining room. On 12/22/15 at 9:45 A.M. direct care staff U and V toileted the resident in the shower room. After toileting the resident direct care staff U and V transferred the resident from to the toilet to his/her wheelchair via the sit to stand lift. Further observation revealed no foot pedals or right lateral support on the resident's wheelchair and no dycem under the cushion in the resident's wheelchair. Staff U confirmed no dycem was under the cushion and he/she stated all resident's with gel cushions should have dycem in place. Direct care staff V reviewed the pocket care plan dated 12/21/15 and observation revealed the pocket care plan did not include the dycem. Direct care staff U stated the resident was at risk for falls and should not be left unattended in the shower/bath room. On 12/22/15 at 1:50 P.M. direct care staff U confirmed the resident's foot pedals were not in place when he/she propelled the resident earlier in the day and also stated staff only transferred the resident with the sit to stand lift when toileting the resident. On 12/22/15 at 2:15 P.M. licensed nurse L stated the resident was at risk for falls, did not have a right lateral support on his/her wheelchair, no dycem under the cushion in his/her wheelchair, and should have wheelchair pedals in place when staff propelled the resident's wheelchair. He/she stated the dycem was not included on the pocket care plan. Licensed nurse L stated the pocket care plan was a form of communication that ensured staff knew what care and services the resident received. He/she stated the resident utilized a cradle mattress, a low bed, and body pillows for positioning when in bed and a fall mat in place when the resident was in bed. The surveyor and licensed nurse L entered the resident's room and observation revealed the resident laid in bed without body pillows, the bed was in a low position and the fall mat was in place. Licensed nurse L confirmed the body pillows were not in place. On 12/22/15 at 4:00 P.M. administrative nursing staff D stated the resident's fall interventions were on the resident's care plan, staff should follow the interventions and the pocket care plan the resident's electronic/hard copy should mirror each other. Administrative nursing staff E present during the interview stated dycem should be under the resident's wheelchair gel and he/she confirmed it was not in place. On 12/22/15 at 4:08 P.M. administrative nursing staff E stated staff should transfer the resident at all times with the sit and stand lift. The facility's Fall Management Policy and Procedure dated October 2014 included it was the policy of the facility to assess residents for risk of falls. The facility identified and analyzed fall risk, implemented investigations, monitored plans for effectiveness and modified interventions as necessary. The facility did not included a Policy and Procedure that included not include leaving residents unattended when in the shower/bath rooms. The facility failed to ensure this severely cognitively impaired resident with a history of falls was not left unattended in the shower. The resident fell and sustained a laceration that required transfer to a local hospital for sutures. The facility also failed to transfer the resident at all times via the sit to stand lift, and failed to ensure the dycem, wheelchair foot pedals and body pillows were in place as planned. - On initial tour of the facility on 12/15/15 at approximately 9:30 AM, observation of the beauty shop revealed an unlocked cabinet with Clorox Disinfecting Wipes with a warning liquid may cause eye and skin irritation and a bottle of Betco PH7Q with a warning to keep out of reach of children. During an interview with administrative staff A on 12/15/15 at 11:18 AM, staff stated the beauty shop was unlocked because the construction workers needed access but that it is expected to remain locked at all times except on Thursdays when the beautician is present. Administrative staff A locked the door and provided education to the construction workers. The facility provided policy on chemical storage dated 11/1/07 stated storage areas are locked when not in operation to prevent unauthorized access. The facility failed to ensure that the resident environment remained free of accident hazards. - During the initial tour of the facility on 12/15/2015 at 9:30 A.M., observation revealed a cabinet over stove in the Café dining area was unlocked, and contained 2 bottles of chemicals: one bottle of cooktop cream cleanser, and one bottle of glass cleaner. In interview on 12/15/2015 at 10:44 A.M., Administrative Staff F stated the facility policy is to keep chemicals locked in a cabinet, so residents cannot access them. During this interview, he/she locked the cabinet. Review of document provided by facility, titled Environmental Services Policies and Procedures dated 9/1/99 and revised 11/1/07, showed the policy is products stored in dry storage areas are maintained in a safe and sanitary manner. This includes chemicals to be stored away from other products, and storage areas to be locked when not in use to prevent unauthorized access. The facility failed to provide a safe environment free from accident hazards for 6 cognitively impaired and independently mobile residents. - Resident #14 had [DIAGNOSES REDACTED]. The resident's 12/4/2015 Quarterly MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 99, which indicated the resident was unable to complete the interview. The resident's cognitive skills for daily decision making were severely impaired. Delirium was present and fluctuating, but there were no signs of altered levels of consciousness. The resident required extensive assistance of 2 or more persons for bed mobility, transfers and toilet use. Walking in room and walking in corridor did not occur. The resident's balance was not steady, and he/she was only able to stabilize with staff assistance. The resident had no impairment in range of motion for upper or lower extremities, but used a wheelchair for mobility. The patient received antipsychotic and antidepressant medications for 7 days of the sample period, and antianxiety medications for 1 day of the sample period. The resident ' s care area assessment dated [DATE] included care area assessments (CAAS) for Falls. The CAAS for Falls said Resident #14 is at risk for falls due to history of falls, decreased mobility, seizures, difficulty in walking, impaired safety judgment, and muscle weakness. He/she requires 1-2 assistance with activities of daily living (ADLs) and transfers. Staff ensures needs and wants are fulfilled, so Resident #14 does not attempt self-cares. Resident #14 uses a PA when in bed and wears non-skid socks when not wearing shoes. The 7/23/15 care plan for Resident #14 stated falls are likely to occur with this resident, and instructed staff to remind resident to not get up independently without assistance, use a personal alarm when resident in bed, assure resident ' s toileting needs are met, and ensure non-skid footwear on while in bed. On 12/23/2015 at 9:30 A.M., the facility provided an updated pocket care plan, with information about Resident #14. This pocket care plan included instructions for Resident #14 to wear non-skid footwear when shoes are not worn. In an observation on 12/21/2015 at 1:30 P.M., Resident #14 was in his/her room in wheelchair. Direct Care Staff members Q and T used a sit-to-stand lift to move Resident #14 from his/her wheelchair to his/her bed. Using this apparatus required Resident #14 to place his/her feet on a platform and partially support his/her weight. Direct Care Staff members Q and T secured the resident to the machine by a harness around his/her waist, and straps behind his/her knees to prevent falling. While transferring, Resident #14 was wearing TED hose (compression stockings) covered by white athletic socks. The transfer occurred without complications and Resident #14 was cooperative. The resident was then left in bed to nap, but when Direct Care Staff members Q and T left the room, no non-skid footwear had been placed on Resident #14 ' s feet. In an observation on 12/22/2015 at 7:15 A.M., Resident #14 was sitting in his/her wheelchair, in the common room. Resident was not wearing non-skid foot wear; only TED hose and white athletic socks. In an interview on 12/22/2015 at 9:20 A.M., Direct Care Staff LL produced an updated pocket care plan, which nursing staff members receive at the beginning of each shift. This pocket care plan includes notes about each resident's care. On Resident #14, there were no notes about orders for non-skid footwear. Asked if he/she has ever seen orders for Resident #14 to wear non-skid footwear when not wearing shoes, and Resident #14 said he/she had not. When asked how they would know if a resident had orders for non-skid footwear, Direct Care Staff LL said he/she would be told by licensed nursing staff, but had never been given instructions about non-skid footwear for this resident. When asked why Resident #14 had socks over his/her TED hose, Direct Care Staff LL residents do not like wearing shoes with just TED hose, because it feels uncomfortable. In an interview on 12/22/2015 at 7:28 A.M. Licensed Staff M said he/she does not personally attend to Resident #14 and was not familiar with resident's orders for non-skid footwear. But he/she said she believes the facility has a policy for residents to wear non-skid footwear even if they cannot stand, because it will help prevent slips if residents try to stand up. In an interview on 12/22/2015 at 7:34 A.M., Licensed Staff K said he/she was aware that Resident #14 has orders for non-skid footwear to be worn whenever shoes are not on. Licensed Staff K left this interview and checked Resident #14, and noticed the resident was not wearing non-skid footwear or shoes. Licensed Staff K walked to supply closet to get non-skid socks, and then put them on Resident #14 ' s feet. In interview on 12/22/2015 at 4:08 P.M., Administrative Nursing Staff D said the order for each resident ' s footwear should be on the pocket care plan. There is no facility-wide policy on non-skid footwear. It is an individual policy for each resident's safety. Administrative Nursing Staff D also said the facility ' s licensed staff, who read charts, are trained to instruct direct care staff members about the elements of a resident ' s care plan, and ensure those elements are implemented. The facility failed to provide assistance devices to prevent accidents to this resident.

The facility had a census of 66 residents. Based upon record review, observations and interviews the facility failed to provide supervision to prevent accidents for 2 (#1, #3) of the 3 residents sampled for falls. Findings included: - Review of resident #1's quarterly Minimum Data Set 3.0 (MDS) with an assessment reference date of 5/23/12 identified the resident scored 9 (moderately impaired cognition) on the Brief Interview for Mental Status, had severely impaired vision, did not exhibit any behaviors, was totally dependent upon staff for bed mobility, transfers, toilet use and personal hygiene; required extensive staff assistance with dressing, locomotion on the unit and did not walk in the room or corridor. The MDS identified the resident was not steady and only able to stabilize with staff assistance when moving from seated to standing and surface to surface transfers, and did not walk or turn around while walking. The MDS identified the resident had (1) non major injury fall since admission/reentry or the prior assessment. The resident's fall care area assessment (CAA) dated 9/2/11 included the resident was at risk for falls due to medications he/she received, muscle weakness, abnormal posture and impaired judgement. The CAA documented the resident wore non-skid shoes or socks with an ankle brace during transfers, staff ensured the resident's call light was within reach when the resident was in his/her room, the resident needed reminders at times to use the call light and occupational therapy evaluated the resident for the use of a reacher. The resident's activity of daily living (ADLs) CAA dated 9/2/11 included the resident required staff assistance of 1-2 with ADLs and 2 staff transferred the resident via a mechanical lift. The resident's visual CAA dated 9/2/11 included the resident had visual changes due to a [DIAGNOSES REDACTED]. The resident's fall risk assessment dated [DATE] and 7/25/12 identified the resident scored 20 (according to the legend a score of 10 or higher indicated the resident was at risk for falls). The resident's lift chair safety assessment dated [DATE] and last reviewed on 11/11/11 included the resident could not safely operate the control to raise the chair to the up position and the resident could not come from the up position in the chair to a fully upright standing position without assistance. The assessment included the resident could not stand upright without manual assistance, was not able to safely and independently move about and the resident did not have the cognition to understand and remember to use safety precautions such as use of assistive devices. A handwritten entry included the resident's family member signed a waiver to allow the resident to keep the control within his/her reach although it was unsafe. Review of the resident's safety protocol and waiver for use of assistive devices dated 9/9/11 included the resident was not competent to make his/her own heath care decisions and a family member was the resident's durable power of attorney. The waiver included the resident's [DIAGNOSES REDACTED]. The waiver included the resident demonstrated poor safety awareness and impairment in what he/she could safely do and the resident continued to use the reacher and motorized lift chair without staff present which placed the resident at high risk for falls. The waiver documented the resident's agent expressed the resident continued to use the recliner chair with lift and his/her reacher device against the recommendations of the facility staff. The wavier included the staff monitored the resident for unsafe behaviors and falls and the facility reviewed the agreement with the resident's agent at least quarterly and with a significant change in the resident's condition. The clinical record lacked evidence to support the facility reviewed the agreement with the resident's agent at least quarterly. During interview with nursing administrative staff D on 9/4/12 at approximately 1:30 P.M. stated the facility reviewed lift chair assessments and waivers every quarter. Nursing administrative staff D stated the facility had not reviewed the resident's lift chair assessment since November of 2011 and had not reviewed the resident's lift chair assessment with the resident's agent since August of 2011. Nursing administrative staff D stated the facility had not reviewed the lift chair assessment and waiver every quarter because the resident's family was adamant the resident had access to the lift chair control. The resident's care plan dated 5/23/12 included the resident was confused, had dementia with associated behaviors and was visually impaired related to the [DIAGNOSES REDACTED]. The care plan included the staff transferred the resident via a mechanical lift, the resident wore non-slip shoes, staff reminded the resident to use the call light to ask for staff assistance and staff reminded the resident not to transfer independently without staff assistance if he/she was unable to transfer or ambulate by himself/herself. The care plan included occupational therapy evaluated the resident for a reacher when he/she was in his/her room and staff checked the resident every 30 minutes because the resident and the resident's family refused to sign to let staff have the lift chair control and refused to allow the facility to use a personal safety alarm knowing the consequences. A nurse's note (daily and every shift charting note) dated 5/9/12 and not timed documented the resident's call light was on, the resident's personal alarm sounded and the resident laid on his/her stomach in front of his/her recliner. The note include the resident had bruising on both of his/her knees and on his/her lower left shin. The facility's investigation (date unknown) included on 5/9/12 the resident raised the electric lift chair to get closer to his/her bedside table to eat, the resident had raised the lift chair too high and slid out of the chair. The recommendation to prevent falls in the future included staff would ensure the resident's meals were placed within the resident's reach to prevent the resident from raising the lift chair. A nurse's note dated 8/5/12 and timed 5:45 P.M. documented staff found the resident face down on the floor in front of his/her recliner and the recliner was fully extended. The note included the resident had the recliner control in his/her hand, staff repositioned the resident on his/her back, staff observed the resident's nose was bruising, the resident's right forehead had a bump, the resident's left knee was swollen and the resident complained of pain when staff moved the resident's left knee. The note included the resident stated he/she pushed the lift chair up, the lift chair became stuck in the upright position which caused him/her to fall out of the chair onto the floor. The note included the facility transferred the resident to a local emergency room . Review of the resident's history and physical (from a local hospital) with an admission date of [DATE] documented the resident fell forward from his/her chair tonight, hit his/her nose and injured his/her knee. The history and physical (H&P)included the resident has had several falls and injuries but tonight when he/she fell forward it was not determined if the resident fainted or the chair pushed the resident forward and in the resident's weakened condition he/she went down on his/her knees and forward on his/her nose. The history and physical documented the resident had a nasal fracture and a small tibia anterior fracture (bone lower leg) of the left leg/knee. The H&P included the resident had progressive degenerative arthritis (joint disease), severe osteoporosis (thinning of bone tissue), had been doing fairly well but had complications with standing and it was impossible for the resident to transfer without assistance. The H&P documented the resident could not see because of macular degeneration and per the resident's family had shown some signs of dementia. The assessment included the resident had a concussion and fracture of nose with epistasis (nose bleed), severe, with turbinate hypertrophy (swelling of structures in the nose) and deviation, a tibia anterior plateau fracture of the left leg, macular degeneration with blindness, hypoxemia (low oxygen) on room air because of the nasal fracture and edema which had worsened the resident's ability to breathe. On 9/4/12 at 8:15 A.M. the resident laid in bed on his/her back. Observation at that time revealed the lift chair control on the floor next to the chair and the chair plugged in. On 9/4/12 at 9:50 A.M. direct care staff I and J transferred the resident from the bed to the lift chair via the mechanical lift. After staff positioned the resident in the lift chair, the staff pinned the lift chair control to the upper right corner of the chair. Observation also revealed the resident had a light colored bluish bruise over his/her left forehead. During interview with direct care I at that time, the staff stated the control was no longer to be within the resident's reach; therefore staff pinned the control to the chair to ensure it was not within the resident's reach. Direct care staff I stated the bruise was a result of the resident's fall on 8/5/12. During interview with nursing administrative staff A on 9/4/12 at approximately 1:15 P.M. the staff stated the resident fell from the lift chair during the month of August 2012 and fractured his/her left leg and nose. The staff stated the resident had fallen from the lift chair several times prior to 8/5/12, the facility assessed it was unsafe for the resident to operate the control but the resident's family wanted the resident to have access to the control and the resident's agent signed a waiver which allowed the resident to have access to the control. The facility allowed this cognitively impaired resident with a history of falls to have access to a lift chair control although the facility had assessed the resident was at high risk for falls if the resident continued to have access to the lift chair control. This resident fell from the lift chair and sustained a nasal fracture and a tibia fracture on 8/5/12. - Review of resident #3's September 2012 physician order [REDACTED]. The resident's quarterly Minimum Data Set (MDS) 3.0 with an assessment reference date of 7/13/12 identified the resident scored 10 (moderately impaired cognition) on the Brief Interview for Mental Status, had impaired vision and hallucinations and delusions. The resident's MDS identified the resident required extensive staff assistance with bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, toilet use and did not walk in room or corridor. The resident's MDS recorded the resident was not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off the toilet and surface to surface transfers, did not walk or turn around while walking and had a non-major injury fall since admission/reentry or prior assessment. The resident's fall care area assessment (CAA) dated 2/17/12 documented the resident was at risk for falls due to medications he/she received, impaired safety judgement , short term memory impairment and muscle weakness. The CAA included the resident required 1-2 staff assistance with all activities of daily living, and 1-2 staff transferred the resident with a gait belt. The CAA included the resident slept in a low bed for safety and had chair to bed alarms to alert staff when the resident moved about. The resident's fall risk assessment dated [DATE] identified the resident scored a 14 (a score of 10 or higher represented the resident was at risk for falls). The resident's fall risk assessment dated [DATE] identified the resident scored a 10. The resident's care plan dated 7/25/12 included the resident was confused, had an alteration in thought process related to dementia with behaviors and required 1-2 staff assistance for transfers. The care plan addressed the resident was at risk for falls due to poor safety judgement, short term memory deficit and muscle weakness. The care plan included the resident utilized a chair to bed alarm at all times, staff was not to leave the resident unattended when the resident was in the wheelchair and the facility placed Dycem (non-slip material) under and on top of the resident's wheelchair cushion to prevent the resident from sliding. An entry dated 8/15/12 included the facility educated staff to not leave the resident unattended in the bathroom. The certified nurse aide's pocket care plan for resident #3 included the resident was at risk for falls, staff would not leave the resident unsupervised when the resident was in his/her wheelchair and staff placed Dycem on top and under the resident's wheelchair cushion. The pocket care plan did not include staff should not leave the resident unattended while in the bathroom. A daily and every shift charting note dated 3/2/12 and timed 6 A.M. to 6 P.M. documented the resident slipped out of his/her wheelchair, landed on his/her bottom on the floor with his/her right arm still holding onto the arm of the wheelchair. A daily and every shift charting note dated 6/19/12 and timed 7:00 P.M. documented staff found the resident lying on the floor in the living room entry way, the resident stated he/she fell from the standing position to the sitting position like a sleigh ride, stated he/she fell on his/her tail bone, expressed pain with range of motion and the facility transferred the resident to a local emergency room . The note included the resident returned to the facility at 1:45 A.M. with a [DIAGNOSES REDACTED]. The facility's investigation for the resident's 6/19/12 fall revealed the facility educated staff to ensure the resident's alarms were in place. A daily and every shift charting note dated 8/15/12 timed 5:45 A.M. documented staff found the resident on the floor in his/her bathroom, the resident reported he/she hit his/her head on floor and staff observed a knot on the occipital region of the resident's head. The note included the resident denied dizziness but vomited 3 times. The facility's investigation for the resident's 8/15/12 fall included the resident attempted to try to transfer himself/herself from the toilet. Recommendations to prevent falls in the future included the facility educated staff to not leave the resident unattended in the bathroom. On 9/4/12 at 12:30 P.M. the resident sat at the dining room table, a personal alarm in place and the resident leaned to the right. On 9/4/12 at 2:30 P.M. the resident laid in bed, the bed in a low position and a personal alarm in place. During interview with licensed nurse G on 9/4/12 at 4:30 P.M. the staff stated the resident was at risk for falls and should not be left unattended in the bathroom. Licensed nurse G stated the direct care staff had access to the pocket care plan that included the resident's special needs. During interview with administrative nursing staff C on 9/4/12 at approximately 4:55 P.M. the staff stated the resident should not be left unattended in the bathroom. Nursing administrative staff C stated a new certified nurse aide left the resident unattended in the bathroom on 8/15/12 and the resident fell . Nursing administrative staff C stated he/she was not sure if the pocket care plan included the resident was not to be left unattended in the bathroom. During interview with direct care staff K on 9/4/12 at 5:01 P.M. the staff stated he/she had worked at the facility approximately 4-5 weeks. Direct care staff K stated the morning of 8/15/12 he/she assisted the resident the bathroom, he/she exited the resident's room to place soiled clothes in the utility room and when he/she reentered the resident's room the resident was on the floor. Direct care staff K stated on 8/15/12 he/she was not aware staff should not leave the resident unattended in the bathroom. On 9/4/12 at 5:10 P.M. the resident sat in his/her wheelchair, nursing administrative staff C stood the resident up, the resident's alarm sounded and no Dycem was on or under the resident's wheelchair cushion. Administrative staff C confirmed the Dycem was not on or under the resident's wheelchair cushion and stated the Dycem should be in the resident's wheelchair as care planned. The facility's fall prevention policy and procedures revised 11/05 included the facility assessed residents for risk of falls, followed up and evaluated falls of residents, identified the reason for the fall and prepared a plan of care to reduce the potential for future falls. The facility failed to ensure staff did not leave this cognitively impaired, dependent resident with a history of falls unattended in the bathroom, failed to ensure the Dycem was in place as care planned and failed to ensure the personal alarm was in place at all times.

The facility had a census of 69 residents. Based upon observation, record review and interviews the facility failed to provide adequate supervision to prevent falls for 1 (#2) of 3 residents sampled for falls resulting in injuries. Findings included: - Review of resident #2's October 2012 Physician order [REDACTED]. The resident's annual Minimum Data Set (MDS) 3.0 dated 6/10/12 identified the resident had short and long term memory impairment and severely impaired cognitive skills for daily decision making. The MDS coded the resident required limited staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit and toilet use. The MDS recorded the resident required extensive staff assistance with dressing and personal hygiene, was not steady but able to stabilize without staff assistance when moved from seated to standing position, walking, turning around while walking, moving on and off the toilet and surface to surface transfers. The MDS identified the resident was on a current toileting program, was always incontinent of urine and had not fallen since the prior assessment. The resident's fall care area assessment (CAA) dated 6/14/12 included the resident was at risk for falls due to [DIAGNOSES REDACTED]. The CAA included the resident had a history of [REDACTED]. The CAA documented the resident required assistance of 1 with activities of daily living and mobility and the resident's call light was in reach when the resident was in his/her room. The resident's quarterly MDS dated [DATE] identified the resident had short and long term memory problems, severely impaired cognitive skills for daily decision making skills, delirium and no behaviors. The MDS coded the resident required limited staff assistance with bed mobility, transfers, extensive staff assistance when walking in the room and corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. The MDS recorded the resident not steady, and only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around while walking, moving on and off the toilet and surface to surface transfers. The MDS identified the resident was on a toileting program, was always incontinent of urine and had not fallen since the last assessment. From 6/9/12 to 9/6/12 the resident went from requiring limited staff assistance to requiring extensive assistance with locomotion and walking. According to the MDS 3.0 manual (page 2-23) a significant change assessment is appropriate when a resident declined in 2 or more areas and any decline in an activity of daily living physical function area where the resident was newly coded as extensive assistance. The resident's fall risk assessment dated [DATE] and 9/25/12 identified the resident scored 12 ( a score of 10 or above deemed the resident was at risk for falls). The resident's care plan meeting minutes dated 9/12/12 and timed 8:30 A.M. documented the resident as alert, confused and unable to voice his/her needs. The care plan meeting minutes included the resident ambulated with 1 staff and had not fallen for greater than 3 months. The resident's care plan dated 9/12/12 included the resident had alteration in thought process related to dementia with behaviors. The care plan included the resident required stand by assist of 1 for cueing so the resident did not get distracted from destination. The care plan included the resident at risk for falls related to dementia with behaviors, [DIAGNOSES REDACTED], obesity, confusion, and poor safety judgement. The care plan included staff anticipated the resident's needs, reminded the resident to use the call light to ask for assistance and reminded the resident to not get up independently without assistance if the resident was unable to transfer or ambulate by himself/herself. A hand written entry dated 10/7/12 included staff were not to leave the resident on the toilet unattended. Review of the resident's pocket care plan (brief version of the resident's care plan that direct care staff carried in his/her pocket that included the resident's special needs) in place on 10/7/12 included the resident required 1 staff assistance with activities of daily living and ambulation. A daily and every shift charting note dated 10/7/12 and timed 9:45 P.M. documented staff found the resident face down on the floor in front of the toilet in the resident's bathroom and a moderate amount of blood was under the resident's face. The note included the resident had a 1.5 centimeter (cm) laceration above his/her lip, the bridge of the resident's nose was slightly swollen, the resident had a 2 cm diameter abrasion on the left side of his/her forehead, small reddened areas on his/her left elbow and chin, the resident's left eye was reactive to light but the resident's right eye was negative. The note included the facility received a physician's orders [REDACTED]. A daily and every shift charting note dated 10/8/12 and timed 5:45 A.M. documented the resident returned to the facility with new orders. Review of the resident's hospital's discharge summary dated 10/8/12 included the resident fell on his/her face while in the bathroom and sustained a left nose fracture and facial laceration secondary to the fall and a closed head injury. physician's orders [REDACTED]. On 10/8/12 at 10:00 A.M. the resident sat in a recliner in the special care unit with his/her feet elevated. The observation revealed the resident had a laceration with 2 sutures under his/her nose, a laceration above his/her left forehead, and the resident's nose reddened. On 10/8/12 at 12:40 P.M. the resident sat in a chair at the dining room table and ate his/her lunch meal. On 10/8/12 at 12:55 P.M. direct care staff H assisted the resident from the chair, direct care staff H walked in front of the resident and physically guided the resident holding both of the resident's hands. Observation revealed the residents gait was wobbly and direct care staff I assisted direct care staff H in ambulating the resident from the dining room to the resident's room. During interview with direct care staff H at that time, direct care staff H stated prior to 10/7/12 he/she never left the resident unattended in the bathroom due to the resident's cognition and unsteady gait. On 10/8/12 at 11:25 A.M. direct care staff H stated the resident could ambulate independently but staff walked with the resident because the resident had wandering tendencies. Direct care staff H stated the resident did not toilet himself/herself and staff took the resident to the bathroom. Direct care staff H stated the resident required staff assistance of 1 when ambulating and with activities of daily living. Direct care staff H stated the resident was not to be left unattended on the toilet prior to 10/7/12 even though the intervention was not included on the resident's pocket care plan until after the resident fell on [DATE]. On 10/8/12 at approximately 11:30 A.M. licensed nurse E stated the resident required staff assistance of 1 for all cares and standby staff assistance when ambulating due to wandering. Licensed nurse E stated the resident's care plan prior to 10/7/12 did not include the resident was not to be left unattended when on the toilet. Licensed nurse E stated the resident required cueing and due to the resident's cognition the resident could not activate his/her call light to inform staff he/she needed assistance. On 10/8/12 at approximately 11:45 A.M. nursing administrative staff C stated during the month of 6/2012 the resident ambulated without staff assistance. Nursing administrative staff C stated due to the resident's [DIAGNOSES REDACTED]. Nursing administrative staff C stated he/she thought the resident's pocket care plan prior to 10/7/12 included staff were not to leave the resident unattended when on the toilet. Nursing administrative staff F present during the interview with nursing administrative staff C stated it was his/her understanding the resident's pocket care plan prior to 10/7/12 included for staff not to leave the resident on the toilet unattended. During interview with nursing administrative staff D on 10/8/12 at approximately 11:50 A.M. staff stated the resident's pocket care plan did not include staff was not to leave the resident unattended on the toilet until 10/8/12. On 10/8/12 at approximately 11:55 A.M. nursing administrative staff B stated the resident had [DIAGNOSES REDACTED] which caused the resident to rock back and forth, he/she thought the resident got momentum from the rocking which caused the resident to fall from the toilet. Administrative staff B stated the resident did not require stand by assistance when ambulating and the resident had not fallen since at least January of 2012. On 10/8/12 at 12:20 P.M. administrative staff A stated the resident had not fallen this year and was not a safety risk when left unattended on the toilet. On 10/8/12 at approximately 12:25 P.M. licensed nurse E stated it was reported to him/her during shift change on 10/8/12 that staff placed the resident on the toilet, left the resident unattended on the toilet and the resident fell . On 10/8/12 at 12:55 P.M. direct care staff I stated prior to 10/7/12 he/she never left the resident unattended because the resident had a tendency to rock back and forward when he/she was on the toilet. During interview with direct care staff J on 10/9/12 at 10:00 A.M. staff stated he/she placed the resident on the toilet the night of 10/7/12 and left the resident unattended on the toilet. Direct care care J stated the resident's roommate came into the hallway and told him/her the resident was on the floor. Direct care staff J stated he/she was the only staff on duty at the time of the resident's fall. Direct care staff J stated when he/she was on duty, he/she placed the resident on the toilet prior to the resident going to bed, it took the resident approximately 15 minutes to use the toilet, after he/she placed the resident on the toilet he/she exited the resident's room to complete other task and returned to the resident's bathroom approximately 15 minutes later. Direct care staff J stated the resident had never attempted to get off of the toilet independently. The facility's fall prevention policy and procedure revised 11/05 included the facility assessed residents for risk of falls and prepared a plan of care to reduce the potential for future falls. The facility failed to ensure staff did not leave this severely cognitively impaired resident with an unsteady gait, a history of falls, and that required extensive staff assistance with locomotion and walking, on the toilet unattended, the resident fell and sustained a head injury and a fractured nose.

The facility identified a census of 75 residents. The sample included 18 residents with 5 residents reviewed for weight loss. Based on observation, record review, staff and resident interview, the facility failed to implement effective interventions to prevent weight loss for 3 of 5 residents (#35, #83, and #25). Findings included: - Review of resident #35's Physician order [REDACTED]. The POS included the resident received a regular mechanical soft diet, power pudding every day (order received on 12/1/11), fortified food plan (order received 11/23/11), ice cream twice a day, 1 can of 1.5 [MEDICATION NAME] via percutaneous endoscopic gastrostomy tube (PEG tube) after meals if the resident consumed less than 50 percent (%) (order received 11/17/11). The resident's significant change MDS 3.0 with an ARD of 10/27/11 identified the resident weighed 158 pounds, had not experienced a weight loss, received a mechanically altered therapeutic diet, and did not have any pressure ulcers. The resident's quarterly Minimum Data (MDS) Set MDS 3.0 with an assessment reference date (ARD) of 1/23/12 identified the resident had short and long term memory problem, severely impaired cognition, and did not exhibit any behaviors. The MDS coded the resident was totally dependent upon staff for bed mobility, eating, toilet use, personal hygiene, required extensive staff assist with transfers, walking in the room, and locomotion on and off the unit. The MDS identified the resident weighed 149 pounds, had experienced a weight loss, and was not on a physician prescribed weight loss program. The MDS coded the resident received 25% of his/her total calories via a [MEDICATION NAME]/tube feed, and 501 cubic centimeters a day or more intravenously or by tube. The MDS identified the resident was at risk for pressure ulcers, had a stage one or higher pressure ulcer, the date of the oldest Stage 2 was 1/11/12, and the pressure ulcer had necrotic tissue. The resident's nutritional Care Area Assessment (CAA) dated 11/2/11 documented the resident was at risk for weight loss due to dysphagia and pre-senile depression, received a regular mechanical soft diet, required staff assistance during meals and consumed 75-100% of meals. The CAA documented the resident received fortified cereal every A.M., staff encouraged adequate nutrition and hydration, and the resident received fluids via a PEG tube. The resident's care plan dated 1/18/12 addressed the resident's current weight 149 pounds, was on the fortified food plan, no diet concerns at this time, had a potential for weight loss related to dysphagia, and was totally dependent upon staff for eating. The care plan included the facility would provide diet as ordered, offered substitutes if the resident did not like the meal served or ate 50% or less of the meal. A entry dated 11/10/11 documented the resident received 1 can of Ensure due to weight loss, and fortified cereal every morning. An entry dated 11/17/11 included the resident received 1 can of [MEDICATION NAME] 1.5 if he/she consumed less than 50% of the meal. An entry dated 12/1/11 included the resident received power pudding daily. An entry dated 11/23/11 included the facility added fortified foods to the resident's diet due to weight loss. The resident's weight log recorded the following weights: 11/13/11: 154 pounds 11/16/11: 156 pounds 11/27/11: 152 pounds 12/11/11: 151 pounds 12/18/11: 147 pounds 01/15/12: 149 pounds 02/5/12: 147 pounds consisting of a 9 pound or 5.76% weight loss in approximately 3 months. The November 2011 ADL Flow sheet revealed the facility did not record the resident's lunch or dinner intake on 11/20/11, dinner intake on 11/24/11 or 11/25/11. The flow sheet recorded the resident consumed 25% of the lunch meal on 11/20/11 and 11/29/11. The resident's November 2011 Treatment Administration Record (TAR) did not support that the facility gave the resident the can of [MEDICATION NAME] when the resident consumed less than 50% of his/her meal on the above dates as physician ordered. The December 2011 ADL flow sheet did not record the resident's meal intake on 12/3/11. The flow sheet recorded the resident consumed 5% of the lunch meal on 12/3/12, 20% of dinner on 12/4/11, 25% of dinner on 12/7/11, 30% of dinner on 12/12/11 and 15% of the dinner meal on 12/17/11. The December 2011 TAR recorded the facility did not provide the resident with the can of [MEDICATION NAME] when the resident consumed less than 50% of his/her meal on the above dates as physician ordered. The January 2012 ADL flow sheet recorded the resident ate 25% of the dinner meal on 1/4/12, ate 30% of the lunch meal on 1/9/12 and the meal intake for the 1/20/12 meal was not recorded. The January 2012 TAR recorded the facility did not provide the resident with the can of [MEDICATION NAME] when the resident consumed less than 50% of his/her meal on the above dates as physician ordered. A Medical Nutritional Therapy Progress Note completed on 10/27/11 by a Registered Dietician (not timed) documented the resident readmitted to the facility, current weight was 163 pounds, gradual weight loss in the past 90 days, and the resident had a PEG placed that was used for water flushes only. A Registered Dietician note dated 11/22/11 (no time) documented the resident had a 6% significant weight loss from 10/25/11. The note included the dietician recommended to add fortified foods to the resident's diet, and if the resident continued to loss weight, consider enteral feedings per the resident's plan of care. A registered dietician note dated 12/23/11 documented the resident's current weight was 147 pounds, and had a 5.5% significant weight loss in the past 30 days. The note documented the resident weighed 156 pounds on 11/6/11. The note included the resident currently received 1 can [MEDICATION NAME] 1.5 after meals if intake was less than 50%, and the resident also received 1 can Ensure twice a day. The resident's January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 1/23/12, 1/24/12, 1/25/12 and did not receive the Ensure at 8:00 A.M. on 1/24/12, 1/25/12, 1/26/12 or 1/27/12 . The resident's laboratory report dated 10/21/11 recorded the resident's [MEDICATION NAME] at 3.4 grams/deciliter (g/DL) with a normal reference range of 3.5-5.5 g/dl; the resident's total protein was 6.4 g/dL with a normal reference range of 6-8.3 g/dl. During interview with dietary staff I on 2/20/12 at 7:46 A.M. stated staff provided the fortified food plan (FFP) to residents with weight loss or decreased intake of calories and residents who received the plan received 8 ounces of hot chocolate and milk during the lunch meal. He/she reported that they had options to provide for the fortified food plan (FFP) and that on this date fortification for the breakfast meal was cheesy egg and 8 ounces of milk. On 2/16/12 at 8:03 A.M. the resident received the breakfast meal which consisted of oatmeal with brown sugar, scrambled egg, slice of toast, milk, water and juice. At 8:15 A.M. staff assisted the resident with the breakfast meal. At 8:35 A.M. the resident had finished the meal and had consumed 100% of all foods except the toast. During interview with dietary staff CC at approximately 8:15 A.M. the staff stated the milk, water and juice were all served in 4 ounce (oz.) glasses. On 2/16/12 at 12:15 P.M. the resident received the lunch meal which included a roll, ground meat, stuffing, green beans, jello, 4 ounces of lemonade, juice, and water. The resident did not receive milk or hot chocolate as part of the fortified food plan with this meal. At 12:45 P.M. on 2/16/12 staff assisted the resident and the resident had consumed all of all foods and liquids served. Observation revealed staff did not offer the resident additional food and did not receive cheesy potatoes and hot chocolate as part of the fortified food plan. Staff did not offer the resident more food when he/she ate 100% of the meal. On 2/16/12 at 5:20 P.M. the resident received the dinner meal which included ground meat, mixed vegetables, and mashed potatoes. The observation revealed the resident did not receive the ordered power pudding. On 2/20/12 at 7:20 A.M. staff placed the resident's breakfast meal in front of him/her. The meal consisted of ground ham, cheese and egg, and a biscuit. At 7:28 A.M. the resident sat at the table, food in front of him/her, and no staff assistance. At 7:30 A.M. (10 minutes after staff served the resident's food) administrative nursing staff W assisted the resident with the breakfast meal. At 8:01 A.M., observation revealed a bowl of hot cereal added to the resident's breakfast meal. At 8:30 A.M. the resident had consumed 100% of the meal. On 2/20/12 at 12:10 P.M. the resident received his/her lunch meal which consisted of ground meat with gravy, rice pilaf, mashed potatoes and gravy, desert, 8 oz of milk, and water. The observation revealed the resident did not receive hot chocolate as part of the fortified food plan. On 2/20/12 at 7:46 A.M. Dietary staff l stated residents received the power pudding at the dinner meal and confirmed none of the residents received the power pudding during the dinner meal on 2/16/12. During interview with administrative staff W on 2/20/12 at 11:30 A.M. the staff stated if the Ensure was circled it meant the facility was out of the supplement and the resident did not receive the Ensure on those days. Administrative staff W confirmed the resident did not always receive the can of [MEDICATION NAME] as physician ordered if the resident's meal consumption was less than 50%. During the interview consultant staff H (who was present) confirmed the nutritional supplements were started in November of 2011 (after the weight loss). During interview with dietary staff I on 1/20/12 at 1:07 P.M. the staff stated the resident received the ice cream at the end of the meal. During interview with direct care staff D on 1/20/12 at 1:09 P.M. (the staff who assisted the resident with the lunch on 2/16/12 and 2/20/12) stated the resident did not receive ice cream at the end of the lunch meal today and also stated the resident usually did not get ice cream after meals. During interview with licensed nursing staff G on 2/20/12 at approximately 5:15 P.M. the staff stated the resident received 1 can of [MEDICATION NAME] via the PEG if the resident's meal consumption was less than 50%. Licensed nurse G stated the resident only received ice cream as a desert and not on a scheduled basis. During interview with administrative staff W on on 2/20/12 at approximately 5:40 P.M. the staff stated he/she was aware that the resident had experienced a weight loss, the resident received Ensure twice a day, 1 can of [MEDICATION NAME] via PEG if he/she did not consume 50% of the meal, and he/she was unsure about the ice cream. The facility Nutrition Protocols for Weight Loss, dated 4/2004, included that a dietician would assess the resident by calculating weight loss based on 30 day, 90 day and 180 day parameters and complete a weight loss review form that was to be included with report. Interventions in increments may include the following: Review meal intake, medications, [DIAGNOSES REDACTED]. Check for swallow or needed assistance at meals. Recommend Occupation Therapy or Speech Therapy intervention. Add vitamin/mineral, if needed. Fortify meals with fortified meal plan foods. If additional calories are needed, add center supplement of choice. If above interventions are not adequate, add 2 cal/cubic centimeter med pass product in 4 oz. increments. The facility failed to timely implement nutritional interventions, and failed to administer nutritional supplements per physician's orders [REDACTED]. - The Physicians Order Sheet (POS) for resident #83, dated 2/12, listed [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an assessment reference date of 11/4/11 reported a Brief Interview for Mental Status (BIMS) of 6 indicating severe cognitive impairment. The resident displayed behaviors of [MEDICAL CONDITION], hallucinations and [MEDICAL CONDITION], physical verbal behavioral symptoms directed toward others, behavior symptoms interfered with resident care, and rejection of care. The resident required one person physical assist with eating. The resident had no swallowing disorder, and no or unknown weight loss, weight was 144 pounds, and height was 65 inches. The quarterly MDS dated [DATE] reported a BIMS of 4 which indicated severe cognitive impairment. The resident required 2 plus persons physical assist with eating and had no swallowing disorder. The resident weighed 132 pounds and had no weight loss. The quarterly Resident (MDS) data set [DATE] recorded the resident at risk for altered nutritional status, weight loss, inability to cut meats, and had increased confusion. The residents decision making was severely impaired, and had poor appetite, usually understands and understood, and rejected care. The 11/11 care plan for nutritional status reported a potential for weight loss related to mood, [MEDICAL CONDITION] reflux disease, depression, and pain. The care plan directed staff to observe for signs and symptoms of acute illness which may cause weight loss, provide diet as ordered, offer substitutes as needed if resident does not like meal served or if 50 percent or less of meal consumed, dietary manager to visit resident routinely to determine likes/dislikes, weigh weekly, notify physician if 5 percent weight loss in one month, 7.5 percent in 3 months, or 10 percent in 6 months, dietician consult as needed for weight loss, assure consistency of food was appropriate for resident to chew and swallow, and observe for signs and symptoms of dysphagia, consult speech therapy as needed, and resident requires set up help. The care plan for nutrition updated 1/19/12 reported the resident to receive fortified food plan (FFP) to diet, mighty shakes twice a day between meals. Review of the weekly weights reported 11/27/11 147 pounds, 12/4/11 146 pounds, 12/11/11 143 pounds, 12/18/11 144 pounds, 12/25/11 143 pounds, 1/1/12 135 pounds, 1/8/12 137 pounds, 1/15/12 134 pounds, 1/22/12 132 pounds, 1/29/12 134 pounds, 2/5/12 133 pounds, and 2/12/12 130 pounds consisting of 13 pounds or 11.5 percent. Record review of dietary progress notes revealed: On 12/6/11 weight 146 pounds. Down 5 pounds in 30 days or 3 percent. Registered Dietician to monitor. On 1/19/12 Weight 133.5 pounds revealed a 8.6 percent significant weight loss past 30 days , 10 percent weight loss in 100 days from admission. Staff reported fair oral intake but improving and drinking mighty shakes when offered. Recommend adding FFP to diet and Mighty Shakes twice daily between meals to prevent further weight loss. Record review of the January and February 2012 treatment records reported bedtime snack given, and mighty shakes given at 10:00 A.M. and 2:00 P.M. Review of physician progress notes [REDACTED]. Observation on 2/16/12 at 8:00 A.M. revealed the resident ate breakfast without assist, the resident ate portions of milk, bacon, eggs, oatmeal and part of toast approximately 25 percent of the meal. Staff provided the resident with a container of Glucerna. On 2/16/12 at 5:30 P.M. observation revealed the eating dinner of meatballs, potato, vegetable and milk, without assistance. Staff provided the resident with a container of Glucerna. On 2/20/1 at 8:05 A.M. resident observed eating breakfast consisting of milk, sausage eggs, bacon, and a container of Glucerna without assistance. Resident consumed approximately 50 percent of the meal. Interview of direct care staff C on 2/20/12 at 8:00 A.M. indicated that the resident did not like health shakes and instead received Glucerna with extra chocolate at meals. Interview of licensed Staff F on 2/20/12 at 7:10 A.M. reported that the resident receives Glucerna with meals and medications but that the Glucerna was not documented. Interview of dietary staff I on 2/20/11 at approximately 7:45 A.M. reported that the fortification for the fortified meal plan provided by dietary for residents with weight loss or decreased intake of calories. He/she reported that they had options to provide for the fortified food plan (FFP) and that on this date fortification for the breakfast meal was cheesy egg and 8 ounces of milk. Interview of administrative staff A on 2/20/12 at 4:30 P.M. reported that when physicians came to see residents, staff provided them with a list of all vital signs and weight, etcetera. He/she further reported there was a weight variance committee which met regularly, usually monthly. The facility Nutrition Protocols for Weight Loss , dated 4/4 included that a dietician would assess the resident by calculating weight loss based on 30 day, 90 day and 180 day parameters and complete a weight loss review form that was to be included with report. Interventions in increments may include the following: Review meal intake, medications, [DIAGNOSES REDACTED]. Check for swallow or needed assistance at meals. Recommend Occupation Therapy or Speech Therapy intervention. Add vitamin/mineral, if needed. Fortify meals with fortified meal plan foods. If additional calories were needed, add center supplement of choice. If above interventions were not adequate, add 2 calories per cubic centimeter med pass product in 4 ounce increments. If there is continued weight loss or if weight falls below the ideal body weight parameters, review with the center for do not resuscitate status and family and physician wishes regarding tube feeding. The facility failed to reassess and implement timely interventions for this cognitively impaired resident which resulted in weight loss. - Resident # 25's physician's orders [REDACTED]. The Significant Change Minimum Data Set (MDS) 3.0 dated with assessment reference date 12/07/11 recorded the resident with a Brief Interview for Mental Status score of 5 which indicated the resident with severe impaired cognition. The resident required total assist for bed mobility, transfers and toileting and extensive assistance with locomotion, dressing and hygiene and limited assistance with eating. The resident's height was 61 inches and he/she weighed 119 pounds and had no weight loss. The Care Area assessment dated [DATE] for nutrition recorded the resident was at risk for weight loss. He/She received a regular diet of pureed or mechanical soft consistency as desired. He/She received a health shake twice daily, power pudding at the 5 P.M. meal and Ensure three times daily. Staff provided supervision during meals. The resident usually consumed 50-75 percent of meals. The resident's weight was stable. The Care Plan for nutrition with last care plan review date 2/15/12 directed staff to provide good oral care, observe for acute illness which may cause weight loss, provide a regular diet with mechanical soft or pureed food as the resident desired and weigh the resident weekly. The care plan directed staff to offer health shakes twice daily. The care plan listed the intervention with the start date of 10/20/11 directed staff to give power pudding at 5:00 P.M. with the meal. Staff added a new intervention dated 10/28/11 which directed staff to give the resident Ensure three times a day during meals. The physician's orders [REDACTED].M. meal. On 10/28/11 the physician ordered staff to give the resident Ensure with each meal due to the resident was not eating. On 1/30/12 the physician added a new order for staff to give the resident health shakes twice daily. Review of the physician's orders [REDACTED]. On 1/30/12 the resident admitted to hospice services following a hospital stay. The Annual Nutritional assessment dated [DATE] recorded the resident with a weight of 115.5 pounds indicating gradual weight loss for the past year. The resident had [DIAGNOSES REDACTED]. He/She had an [MEDICATION NAME] level on 1/28/11 of 4.0. Caloric needs were calculated as 30 kilocalories per kilogram = required 1560 calories and 52 grams of protein daily. The Weight Change History Sheet documented on 6/05/11 the resident weighed 119.0 pounds, 9/25/11 he/she weighed 117.5 pounds and 12/25/11 staff recorded a weight of 112.0 pounds. On 1/22/12 the resident weighed 115 pounds. This indicated the resident had a 4.6 percent weight loss in three months. Review of the January 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The February 2012 MAR indicated [REDACTED]. Observation on 2/16/12 at 8:12 A.M. revealed staff served the resident his/her meal and the resident ate 100% of cereal, 25% of 1 piece of toast and 75% of scrambled eggs. Staff served the resident a chocolate health shake which the resident refused to drink. Staff failed to offer the resident Ensure with the meal. Observation on 2/16/12 at 12:08 P.M. revealed staff served the resident ground turkey, dressing, gravy, roll, green beans and jello with approximately 240 cubic centimeters of juice and water. The resident ate 100% of the jello, 25% of the beans and drank 25% of the fluids. The resident then pushed himself/herself away from the table and wheeled away from the dining room. Staff failed to provide the resident Ensure with the meal. Observation on 2/16/12 at 5:45 P.M. revealed staff served the resident mechanical soft meat, potatoes, bread, mixed vegetables, apple cake and approximately 240cc's each of juice and water. The resident fed himself/herself independently and drank independently. Staff did not provide the ordered power pudding or Ensure. Observation on 2/20/12 at 8:15 A.M. revealed staff served cereal with syrup, ground ham, eggs and a biscuit to the resident. He/She had juice, milk and water to drink. The resident consumed 100% of the eggs. Direct care staff D served the resident a chocolate health shake and assisted the resident to drink. Staff did not serve the resident the Ensure with the meal as ordered. Following the meal staff assisted the resident to bed. On 2/20/12 at 9:10 A.M. the resident laid in bed on his/her back asleep. During interview on 02/16/12 at 12:35 P.M. direct care staff D reported the resident received supplements and staff offered him/her a health shake for breakfast and had a pop [MEDICAL CONDITION] for snack between breakfast and lunch. He/She would offer a health shake again after lunch. He/She did not report any knowledge of staff offering Ensure three times a day with meals. During interview on 2/20/12 9:01 A.M. direct care staff E reported he/she should give the resident Ensure which came in a can in the dining room with the resident's meal. He/She acknowledged he/she did not give the resident Ensure today with the meal. He/She said, "I must have spaced it off" and then reported he/she would then go to the resident's room and offer the Ensure. During interview on 2/20/12 at 11:30 A.M. administrative nursing staff A reported the Ensure circled on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During interview on 2/20/12 at 4:40 P.M. licensed nursing staff G reported direct care staff E or staff passing medications should give Ensure to the resident with his/her meal. It was the responsibility of the staff passing the medication to document in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The licensed nurse did not monitor routinely in the dining room to make sure staff gave the appropriate supplements as ordered. It was not acceptable to give the supplement later in the day after the meal. During interview on 2/20/12 at 5:25 P.M. consultant H reported knowledge that staff failed to provide power pudding to residents on 2/16/12 and also acknowledged staff should have given Ensure with the meal as ordered. The facility provided a policy entitled Nutrition Protocols For Weight Loss dated 04/04 which directed staff to provide additional calories if needed and add center supplement of choice. The facility failed to provide this resident with weight loss physician ordered supplements.