Every finding on record at Sandpiper Healthcare & Rehabilitation Center

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness. Findings included: - On 11/05/24 at 08:15 AM, observation in the kitchen's walk-in freezer revealed the following: Fourteen uncovered, unlabeled, and undated styrofoam bowls of chocolate ice cream on a tray. A three-gallon container of chocolate ice cream with the lid opened and lifted approximately one-half inch. An uncovered, unlabeled, opened, and unsealed plastic bag of shredded carrots. An unlabeled, undated opened, and unsealed plastic bag of breaded fish. On 11/06/24 at 11:00 AM, observation in the kitchen revealed the following: The flour and sugar containers had numerous different-sized blackish-gray areas around the outside and the lids had a greasy gray substance with white particles. Fourteen fluorescent light fixtures, approximately 18 inches by 3 feet, had bugs and debris inside the cover. On 11/05/24 at 08:17 AM, the Dietary Manager (DM) BB verified the above findings in the kitchen's walk-in freezer and stated the bowls of ice cream were old. DM BB said staff should label, date, and make sure the items were in a sealed container before placing them in the freezer. On 11/06/24 at 02:46 PM, DM BB verified the findings in the facility kitchen. DM BB stated he was unsure if maintenance cleaned the ceiling lights but said he would find out. The Kitchen Cleaning Rotation Sheet, had items listed for dietary to clean daily, weekly, monthly, and annually. The facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, undated, documented all food items would be labeled. The label must include the name of the food and the date by which it should be consumed or discarded. The policy documented that leftover contents of cans and prepared food would be stored in covered, labeled, and dated containers in refrigerators and/ or freezers. The facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for all residents who received their meals from the facility's kitchen. This placed 73 residents at risk for foodborne illness.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to provide a sanitary environment in one of three dining rooms. This placed the residents who ate in the main dining room at risk for impaired health and well-being. Findings included: - On 11/5/24 at 8:20 AM, observation in the main dining room revealed the wall to the right of the kitchen entrance door had numerous different-sized reddish-brown dried liquid-stained areas, approximately eight feet long and three feet high. On 11/06/24 at 08:40 AM, Administrative Nurse D verified the above observation and stated housekeeping and dietary were both responsible for cleaning the main dining room wall. Administrative Nurse D stated dietary staff had recently moved the serving table to the kitchen and the area was where it used to be. The Environmental Services Checklist: Daily Cleaning of Patient Rooms, documented daily cleaning tasks for the environmental services to provide daily. The facility failed to provide a sanitary environment in the main dining room when staff failed to clean the wall by the entrance door to the kitchen. This placed the residents who ate in the main dining room at risk for impaired health and well-being.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to store and label biologicals adequately when staff failed to date four insulin (medications used to treat high blood glucose levels) pens when opened and failed to remove or dispose of four expired bottles of stock medications. This deficient practice placed Residents (R)9, R27, R71, and R228 at risk of receiving expired, ineffective insulin and other residents at risk of receiving expired ineffective stock medications. Findings included: - On [DATE] at 08:28 AM, observation of the 300-hall medication cart revealed the following: R9's glargine (long-acting insulin) pen without an open date or the discard date. R27's glargine pen without an open date or the discard date. R71's glargine pen without an open date or the discard date. R228's glargine pen without an open date or the discard date. Four expired stock medication bottles: Senna Plus (laxative) expired ,d+[DATE] Thiamin/vitamin B (vitamin supplement) expired ,d+[DATE] Bisacodyl (laxative) expired ,d+[DATE] Allergy relief expired ,d+[DATE] On [DATE] at 08:28 AM, Licensed Nurse (LN) I verified the expiration dates and undated insulin pens. She stated staff were to date the insulin pens when opened. The facility's Medication Storage policy, dated [DATE], stated the facility would ensure all medication on the premises would be stored according to the manufacturer's recommendations. The medication rooms would be routinely inspected by the consultant pharmacist for discontinued and outdated drugs and those medications would be destroyed in accordance with policy. The facility failed to date insulin pens when opened and/or add a discard date for four residents and failed to remove or dispose of expired stock medications, placing the residents at risk of receiving expired or ineffective medications.

The facility had a census of 74 residents. The sample included 18 residents with two residents reviewed for transfers. Based on record review and interviews, the facility failed to provide written notification within a practicable timeframe of a facility-initiated transfer to Resident (R) 25 and R6. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for R25 and R6. This deficient practice placed the residents at risk of uninformed care choices and impaired rights. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), osteomyelitis (local or generalized infection of the bone and bone marrow), metabolic encephalopathy (ME-neurological disorder that occurs when a chemical imbalance in the blood affects the brain), and discitis (a rare but serious infection and inflammation of the intervertebral disc in the spine.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received a diuretic (a medication to promote the formation and excretion of urine) and opioid (a class of controlled drugs used to treat pain) medication during the observation period. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 05/21/24, recorded R25 required assistance with ADLs due to impaired balance during transfers, and functional impairment in activity due to weakness and obesity. The CAA recorded the resident had chronic pain. R25's Care Plan, dated 09/10/24 recorded that R25 exhibited an alteration in comfort due to demobilization from a recent hospital stay due to metabolic encephalopathy, discitis, and osteomyelitis. The staff would monitor for pain and try nonpharmacological attempts first and if unsuccessful administer pharmacologic interventions. The care plan documented the resident required chronic use of antibiotics and staff would monitor for ongoing signs of infection and notify the physician as needed. The care plan recorded the resident had a diagnosis of MRSA in her spine wound and staff would wear personal protective equipment (PPE) when providing care. A Nurse's Note dated 09/25/24 at 07:40 AM documented R25 called 911 and reported pain. Emergency Medical Services arrived at 06:59 AM and transported the resident to the hospital. The 10/04/24 hospital transfer notes documented that R25 had worsening discitis and an abscess (cavity containing pus and surrounded by inflamed tissue). The resident's hospital stay included a laminectomy (a surgical procedure that removes part or all of the vertebra) of thoracic (mid-spine) level 7-9 and a spinal fusion at thoracic level 5-11. R25's clinical record lacked evidence a written notice of transfer was provided to the resident. The facility was unable to provide evidence the facility notified the LTCO of the resident's transfer/discharge from the facility. On 11/05/24 at 03:45 PM, observation revealed R25 lying in bed on her back. Licensed Nurse (LN) K administered Vancomycin (antibiotic) 2.25 grams per intravenous (IV-administered directly into the bloodstream via a vein) solution per a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) line for spinal osteomyelitis. On 11/05/24 at 01:00 PM, Administrative Staff B stated the facility sent a report monthly to the LTCO that included the residents who were discharged home but stated she did not include residents who were discharged to the hospital. The facility's Transfer and Discharge policy, dated 01/09/24, documented it was the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or the other residents are endangered. For emergency transfers, the resident would be provided a notice of bed hold policy as well as the representative at the time of transfer, but no later than 24 hours of the transfer the social service director, or designee would provide the notice of transfer to a representative of the state long term care ombudsman by way of a monthly list. The facility failed to provide a written notification of transfer to R25 as soon as practicable. The facility further failed to notify the State LTCO of transfers/discharges for R25. This deficient practice placed R25 at risk for uninformed care choices and impaired rights. 32360 - The Electronic Medical Record (EMR) for R6 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and legal blindness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition. R6 required substantial assistance with showers, dressing, mobility, and transfers. R6 received insulin (a hormone that lowers the level of glucose in the blood) daily. R6's Care Plan, dated 09/10/24 and initiated on 05/13/24, documented R6 exhibited an alteration in generalized discomfort due to decreased mobility and was able to voice pain as necessary. The update dated 06/13/24 documented R6 was dependent upon staff for transfers and did not ambulate. The update, dated 08/02/24, directed staff to use a two-person assist and a walker for transfers. The Progress Note dated 10/05/24 at 02:08 PM, documented R6 was admitted to the hospital for pain. R6's clinical record lacked evidence the resident was provided a written notice when she was transferred to the hospital. The facility was unable to provide evidence the facility notified the LTCO of the transfer. On 11/06/24 at 08:15 AM, observation revealed R6 sat in her wheelchair and listened to a podcast on her phone. R6 stated she had been at the hospital due to pain in her back and had not received any type of written notice when she had been sent to the hospital. On 11/06/24 at 09:46 AM, Administrative Staff E verified she did not have verification that any written notice was provided to R6 when she went to the hospital. Administrative Staff E further stated she did not send a notice of R6's transfer to the LTCO and was unaware she was supposed to for hospital transfers. On 11/06/24 at 12:50 PM, Administrative Nurse D stated she was unaware if a written notice of transfer was provided to R6 when she went to the hospital. The facility's Transfer and Discharge policy, dated 01/09/24, documented that each resident was permitted to remain in the facility and not transfer or discharge the resident except in limited situations when the health and safety of the individual or other residents were endangered. The policy further documented that for emergency transfers, the resident was provided, as well as the representative a notice of transfer. The Social Service Director or designee shall provide notice of transfer to a representative of the state long-term care ombudsman via a monthly list. The facility failed to provide R6 written notice as soon as practicable for R6's facility-initiated transfer to the hospital and also failed to notify the LTCO. This placed R6 at risk of uninformed care choices and impaired rights.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)26 and R6 with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility and in the same room. Findings included: - R25's Electronic Medical Record (EMR) recorded diagnoses congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), osteomyelitis (local or generalized infection of the bone and bone marrow), metabolic encephalopathy (ME-neurological disorder that occurs when a chemical imbalance in the blood affects the brain), and discitis (a rare but serious infection and inflammation of the intervertebral disc in the spine.) R25's Quarterly Minimum Data Set (MDS), dated [DATE] recorded R25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADLs). The MDS recorded the resident received a diuretic (a medication to promote the formation and excretion of urine) and opioid (a class of controlled drugs used to treat pain) medication during the observation period. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 05/21/24, recorded R25 required assistance with ADLs due to impaired balance during transfers, and functional impairment in activity due to weakness and obesity. The CAA recorded the resident had chronic pain. R25's Care Plan, dated 09/10/24 recorded that R25 exhibited an alteration in comfort due to demobilization from a recent hospital stay due to metabolic encephalopathy, discitis, and osteomyelitis. The staff would monitor for pain and try nonpharmacological attempts first and if unsuccessful administer pharmacologic interventions. The care plan documented the resident required chronic use of antibiotics and staff would monitor for ongoing signs of infection and notify the physician as needed. The care plan recorded the resident had a diagnosis of MRSA in her spine wound and staff would wear personal protective equipment (PPE) when providing care. A Nurse's Note dated 09/25/24 at 07:40 AM documented R25 called 911 and reported pain. Emergency Medical Services arrived at 06:59 AM and transported the resident to the hospital. The 10/04/24 hospital transfer notes documented that R25 had worsening discitis and an abscess (cavity containing pus and surrounded by inflamed tissue). The resident's hospital stay included a laminectomy (a surgical procedure that removes part or all of the vertebra) of thoracic (mid-spine) level 7-9 and a spinal fusion at thoracic level 5-11. R25's clinical record lacked evidence a copy of the bed hold policy was provided to the resident and the facility was unable to provide evidence upon request. On 11/05/24 at 03:45 PM, observation revealed R25 lying in bed on her back. Licensed Nurse (LN) K administered Vancomycin (antibiotic) 2.25 grams per intravenous (IV-administered directly into the bloodstream via a vein) solution per a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) line for spinal osteomyelitis. On 11/05/24 at 08:30 AM, Administrative Staff B verified the facility had not provided the resident the bed hold notice when she was discharged /transferred to the hospital. The facility's Bed Hold Notice Upon Transfer policy, dated February 2023, documented at the time of transfer for hospitalization or therapeutic leave, the facility would provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. In the event of an emergency transfer of a resident, the facility would provide within 24 hours written notice of the facility's bed hold policies, as stipulated in the State's plan. The facility would keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the resident's file. The facility failed to provide R25 with a copy of the facility bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility and in the same room. 32360 - The Electronic Medical Record (EMR) for R6 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and legal blindness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had intact cognition. R6 required substantial assistance with showers, dressing, mobility, and transfers. R6 received insulin (a hormone that lowers the level of glucose in the blood) daily. R6's Care Plan, dated 09/10/24 and initiated on 05/13/24, documented R6 exhibited an alteration in generalized discomfort due to decreased mobility and was able to voice pain as necessary. The update dated 06/13/24 documented R6 was dependent upon staff for transfers and did not ambulate. The update, dated 08/02/24, directed staff to use a two-person assist and a walker for transfers. The Progress Note dated 10/05/24 at 02:08 PM, documented R6 was admitted to the hospital for pain. R6's clinical record lacked evidence the resident was provided a bedhold policy when she was transferred to the hospital and the facility was unable to provide evidence upon request. On 11/06/24 at 08:15 AM, observation revealed R6 sat in her wheelchair and listened to a podcast on her phone. R6 stated she had been at the hospital due to pain in her back and had not received a bedhold policy when she was sent to the hospital. On 11/06/24 at 07:45 AM, Licensed nurse (LN) G stated she did not know what the bed hold policy was and did not know if one was sent with R6 when she went to the hospital. On 11/06/24 at 09:46 AM, Administrative Staff E stated that if she was working and a resident was sent to the hospital, she would send a bed hold agreement with them. Administrative Staff E stated she did not keep any verification or documentation if the agreement was sent with R6 when she went to the hospital. On 11/06/24 at 12:50 PM, Administrative Nurse D stated she was unaware if the bed hold policy was provided to the R6 at the time of transfer. The facility's Bed Hold Notice Upon Transfer updated policy, documented at the time of transfer for hospitalization s or therapeutic leave, the facility would provide to the resident and/or the resident representative written notice which specifies the duration of the bed hold policy and addresses information explaining the return of the resident the next available bed. The facility failed to provide R6 with the bed hold notice which specifies the duration of the bed hold when she was transferred to the hospital. This placed R6 at risk of not being permitted to return and resume residence in the facility and in the same room.

The facility had a census of 74 residents. The sample included 18 residents with two residents reviewed for pressure ulcers (PU-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, interview, and record review the facility failed to initiate interventions to mitigate risks for the development of pressure ulcers for Resident (R) 128, who developed two facility-aquired pressure injuries. This deficient practice placed R128 at risk for further pressure-related injury and related complications. Findings included: - R128's Electronic Medical Record (EMR) documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), hypertension (elevated blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), pneumonia (a lung infection) and history of a hip fracture. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented that R128 required moderate staff assistance for toileting, dressing, standing, and transfers. The MDS documented R128 was at risk for PU but did not currently have one. Interventions included pressure relief to the chair and bed and surgical wound care. The Pressure Ulcer Care Area Assessment (CAA), dated 07/23/24, triggered secondary to R128's potential for pressure ulcers. Contributing factors included functional mobility impairment and incontinence. Risk factors include pain, development of PU, skin condition, and fluid deficit risk. A licensed nurse assessed the resident's skin each week and put proper interventions in place to prevent skin breakdown. Skin was also assessed by caregivers with each bath and each time the resident was dressed. The physician was to be notified of any abnormal findings and treatment orders obtained. The dietitian was monitoring food and fluid intake and implementing dietary interventions as necessary. Caregivers assisted with repositioning at least every two hours and as needed for comfort. A care plan would be initiated to improve R128's current activities of daily living (ADL) status and functional ability, maintain his continence status, prevent pain, and decrease pressure ulcer risk. The CAA documented that no pressure injuries were noted upon admission. The Five Day MDS, dated [DATE], documented that R128 had a BIMS score of seven; R128 required moderate staff assistance for toileting, dressing, standing, and transfers. The MDS documented that R128 was at risk for PU and had one PU, not present on admission. The MDS documented a pressure relief device for R128's chair and bed as well as nutritional interventions and PU care. R128's Braden Scale (a tool used to assess risk for pressure-related injuries), dated 07/20/24, indicated R128 was at mild risk for pressure injuries with a score of 18. R128's Care Plan documented R128 had an actual impairment to the skin integrity of both heels related to pressure (initiated 09/23/24 and revised on 10/22/024). The plan recorded an intervention dated 08/09/24 that directed staff to encourage R128 to offload his heels as he allowed. The plan documented an intervention initiated on 09/23/24 (and revised 10/22/24)that directed staff to provide R128 heel protectors or a pillow to protect his heels and a blue overlay mattress for his skin while in bed. An intervention dated 10/22/24 recorded that weekly treatment documentation would include measurement of each area of skin breakdown's width, length, depth, the type of tissue and exudate, and any other notable changes or observations. R128's ADL Care Plan initiated on 09/23/24, directed staff to provide substantial or maximal assistance for bed-to-chair transfers, lower body dressing, putting on or taking off footwear, sitting to standing, and toilet transfers. R128's Care Plan lacked interventions to prevent the development of PU prior to 08/08/24. The Skilled Nursing Note, dated 08/08/24 at 06:17 PM, documented no noted skin concerns. The Skilled Nursing Note, dated 08/09/24 at 10:46 AM, documented that staff found a wound on the resident's left heel and notified the wound nurse. The Wound Care Note, dated 08/09/24, documented an initial visit. R128 had a pressure ulcer on his left heel. Orders included a multivitamin in the morning for wound healing, zinc sulfate for wound healing, Arginaid oral packet (protein supplement) two times a day for wound care, and vitamin C two times a day for wound healing for 30 Days. The note recorded that the left heel wound measured 4.1 centimeters (cm) x 3.2 cm x 0.1 cm, and the wound bed was 100 percent (%) eschar (dead tissue). The wound had light serous (thin, clear) drainage, no odor, and the surrounding skin was normal. The note documented the left heel wound was new and gave orders for wound care including to offload (take pressure off) the resident's heels. The Interdisciplinary Team -IDT note, dated 08/12/24, documented that R128 was not wearing heel protectors while in bed with a left hip injury and pressure sustained to the left heel resulted in a wound. The note recorded interventions that included a wound assessment and vascular studies. The note indicated that offloading was obtained. Routine wound care was implemented for optimal healing and the wound specialists would follow routinely. R128's Discharge Assessment, dated 09/17/24 documented the resident was admitted to the facility after a left hip fracture surgery. He received therapy during his stay and had a healing unstageable PU to his left heel that was facility-acquired. He required supervision with ADLs due to weakness and confusion. He ambulated with a walker and standby assistance. The Progress Note, 09/19/24 at 10:03 AM, documented R128 discharged home at 09:55 AM. The Progress Note, 09/20/24 at 03:25 PM, documented that R128's representative brought him back to the facility after being discharged for 24 hours. R128's Braden Scale, dated 09/20/24, documented he had no sensory impairment, was occasionally moist and was chair fast but also noted no mobility limitations and noted R128's nutrition was adequate. The score of 18 indicated R128 was at mild risk for pressure-related injuries. The Wound Care Note, dated 10/04/24, documented R128 had a pressure ulcer to his left heel that was improving. The Wound Care Note, dated 10/11/24 documented R128 had a PU to the right heel that was new, a deep tissue injury to his left plantar (sole or bottom) foot, and an unstageable pressure ulcer to his left heel that was improving. R128 reported that his feet hit the footboard. The footboard was removed from the bed. The right heel wound measured 3.4 cm x 2.2 cm x 0.1 cm. with 90% eschar, 10% granulation, and heavy serous drainage. The left heel wound measured 4.0 cm x 2.6 cm x 0.2 cm, with 40% eschar, 40% slough (dead tissue, usually cream or yellow in color), and 20% granulation. The new deep tissue pressure injury to the left foot, a dry intact blister, measured 3.8 cm x 2.9 cm x 0 cm. The Wound Care Note, dated 10/20/24, documented that the right heel wound measured 3.5cm x 2.6cm x 0.1 cm with 30% slough and 70% granulation. The left heel wound measured 3.7cm x 2.3cm x 0.1cm with 40% eschar, 40% slough, and 20% granulation. The left plantar wound measured 4.6cm x 3.6cm x 0.1cm with a dry, absorbed blister. The Physician Order, dated 10/23/24, directed staff to administer Vitamin C 250 mg in the morning for wound care. The Wound Care Note, dated 10/25/24, documented R129 had an unstageable pressure ulcer to his left heel that was improving. He also had an unstageable PU to the right heel that was improving and a deep tissue injury to his left plantar foot that had resolved. The footboard had been removed from R128's bed and he wore heel protectors. He had acquired pneumonia (infection of the lungs) and had declined since then. A Physician Order, dated 11/05/24, directed staff to administer Prostat (liquid protein supplement) 30 cubic centimeters (cc) daily for 30 days in the morning for protein supplement. On 11/05/24 at 03:25 PM, observation revealed Licensed Nurse (LN) H donned personal protective equipment (PPE) and changed the wound dressings on R128's heels. LN H removed the dressing on R128's left heel which had a small amount of drainage on the old dressing. LN H changed gloves and disinfected her hands between soiled and clean items. The left heel wound appeared to have slough and granulation mixed, with no drainage noted. LN H applied wound dressings as ordered then wrapped the foot with gauze and ace wrap. LN H removed the right heel PU dressing and cleaned the wound. R128 jumped and stated that it hurt when LN H was cleaning it. The right heel PU and lateral foot wound had moderate drainage. LN H changed gloves and disinfected her hands between soiled and clean items. The lateral foot wound was very dark in the center with slight redness surrounding the wound. Observation revealed an air mattress on the bed, and large pressure relief boots on R128's dresser. LN H talked R128 into wearing the boots while he was in the wheelchair and applied them. LN H then removed her PPE. On 11/06/24 at 11:46 AM, LN J stated R128 was in another unit at first and when he came to the current unit, he already had the pressure ulcer. LN J stated staff were to apply the pressure relief boots at all times when R128 was up and elevate his feet and legs, or place pillows when he doesn't want to wear the boots. LN J stated that R128 already had an air mattress when he moved to the unit. On 11/06/24 at 12:30 PM, LN I stated staff offloaded R128's heels and applied pressure relief boots before the PU developed. LN I stated upon admission R128 required assistance from one staff for transfers due to a hip fracture and surgery. She stated the left PU developed prior to his transfer to another unit. LN I stated the facility started zinc, vitamin C, and Arginaid after the wounds developed. On 11/07/24 at 10:14 AM, Administrative Nurse E stated upon admission R128 had a Braden scale of 18 and did not qualify for additional pressure relief; he was moving well and was ambulatory. Administrative Nurse E verified that on 08/03/24 R128 had intact skin. She said staff notified her on 08/08/24 of R128's new skin issue and she notified risk management to ascertain the root cause and develop interventions to prevent another PU. Administrative Nurse E stated on 08/09/24 she notified the physician and received orders for a Doppler study (a test to measure the flow of blood through your blood vessels) and the results indicated no issues with blood flow. Administrative Nurse E stated she notified the Wound Advanced Practice Registered Nurse (APRN) to assess and treat the wound. Administrative Nurse E stated R128 was discharged on [DATE], then readmitted on [DATE], and was ambulatory at that time. She stated interventions in place at that time were heel protectors on both feet and a blue overlay air mattress for pressure relief. She stated R128 had pneumonia with hypoxia (inadequate supply of oxygen), cancer, very low hemoglobin (Hgb-measure of blood that carried oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs), and received blood transfusions. Administrative Nurse E stated the right heel PU was found on 10/09/24. The facility's Pressure Injury Prevention and Management policy, dated 01/01/2020, stated after a thorough assessment the interdisciplinary team would develop a relevant care plan to include measurable goals for prevention and management of pressure injuries with appropriate interventions. The policy stated interventions would be documented in the care plan and communicated to all relevant staff. Any changes to the facility's pressure injury prevention and management processes would be communicated to staff in a timely manner and the resident's care plan would be modified as needed. The facility failed to respond to R128's risk factors for pressure injuries with interventions to prevent the development of PU for R128. This placed R128 at risk for further pressure-related injury and related complications.

The facility had a census of 74 residents. The sample included 18 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to provide an environment free from accident hazards when staff failed to use the Hoyer lift (full body mechanical lift) to facilitate a safe transfer for Resident (R) 130 whose admission note indicated she required a Hoyer lift for transfers. This deficient practice placed R130 at risk for falls and potential injury. Findings included: - R130 was admitted to the facility on [DATE]. R130's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), atrial fibrillation (rapid, irregular heartbeat), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), COVID-19 (highly contagious respiratory virus) with acute and chronic respiratory failure, sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), and neuromuscular dysfunction of bladder. The Admission Minimum Data Set (MDS) was in process. R130's baseline activities of daily living (ADL) care plan, dated 11/01/24 documented R130 required assistance with ADLs related to weakness from recent hospitalization , initiated 11/01/24. The plan noted the resident had safety concerns related to a history of falls or risk for falls (initiated on 11/01/24 and revised on 11/05/24). The plan documented R130's transfer status changed to a mechanical lift, created on 11/05/24 with an initiated date of 11/02/24. The plan documented interventions dated 11/05/24 which directed to be sure R130's call light was within reach and encourage its use, and educate family, caregivers, and the resident on safety reminders and what to do if a fall occurred. R130's baseline care plan also documented the following: Sit to Stand - (6 Independent, 5 Setup or clean-up assistance, 4 Supervision or touching assistance, 3 Partial-Moderate assistance, 2 Substantial/maximal assistance, 1 Dependent, 7 Resident Refused, 9 Not Applicable, 10 Not Attempted due to environmental limitations, 88 Not attempted due to medical condition or safety concerns.) Initiated: 11/05/24 Toilet Transfer - (6 Independent, 5 Setup or clean-up assistance, 4 Supervision or touching assistance, 3 Partial-Moderate assistance, 2 Substantial/maximal assistance, 1 Dependent, 7 Resident Refused, 9 Not Applicable, 10 Not Attempted due to environmental limitations, 88 Not attempted due to medical condition or safety concerns.) Initiated: 11/05/24. The Fall Risk Scale, dated 10/31/24, recorded a score of 40 which indicated a moderate risk for falling. The assessment noted that R130 had no fall history. R130 required a cane or walker for ambulation. She exhibited a weak gait and was aware of her own safety limits. The Progress Note, dated 10/31/24 at 03:39 PM, documented R130 arrived at 11:30 AM, via outside transportation. The note documented that R130 required a Hoyer lift for transfers. The Progress Note, dated 11/02/24 at 05:29 PM, documented a witnessed fall that happened when staff, a nurse, and a Certified Nurse Aide (CNA), were transferring the resident from her wheelchair to her recliner. The note documented the resident's legs buckled, and she had to be lowered to the floor. The note documented that R130 had non-skid shoes on, a gait belt was in use, and the floor was clear and dry. The note documented that R130 was unable to stand or participate fully in transfers. On 11/06/24 at 08:30 AM, observation revealed R130 lying in a low bed with her eyes closed. On 11/06/24 at 10:50 AM, CMA S stated he was unsure how R130 was transferred. On 11/06/24 at 02:35 PM, Administrative Nurse D stated the nameplate with a yellow dot on R130's door indicated the resident required a Hoyer lift. Administrative Nurse D said that with a new admission, the facility placed the transfer status on the door (dot). Administrative Nurse D verified that R130's Care Plan had not included that staff were to use a Hoyer lift and verified the facility was still working on a baseline care plan. The facility's Fall Prevention Program dated 01/02/20 stated 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. Upon admission, the nurse would indicate on the 24-hour report the resident's fall risk and initiate interventions on the baseline care plan. The facility failed to provide an environment free from accident hazards when staff failed to use the Hoyer lift to facilitate a safe transfer for R130 whose admission note indicated she required a Hoyer for transfers. This deficient practice placed R130 at risk for falls and potential injury.

The facility had a census of 74 residents. The sample included 18 residents with one reviewed for urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review the facility failed to provide adequate catheter care and services within the standards of care for Resident (R) 130. This deficient practice placed R130 at risk for urinary tract infection and other catheter-related complications. Findings included: - R130 was admitted to the facility on [DATE]. R130's Electronic Medical record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), atrial fibrillation (rapid, irregular heartbeat), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), COVID-19 (highly contagious respiratory virus) with acute and chronic respiratory failure, sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), and neuromuscular dysfunction of bladder. The Admission Minimum Data Set (MDS) was in process. R130's baseline urinary care plan, dated 11/01/24, documented a Foley catheter. Check and change to maintain dignity. Initiated: 11/05/24 Provide good peri-care after incontinent episodes and use a barrier cream to keep her skin healthy. Initiated: 11/05/24 On 11/06/24 at 08:30 AM, observation revealed R130 lying in bed with her eyes closed. Observation revealed a urinary catheter collection bag in a privacy bag hung on the side of the bed to dependent drainage. There was no EBP signage or gowns observed in the room or closet. On 11/06/24 at 02:46 PM, Certified Medication Aide (CMA) R washed her hands and applied gloves but did not don a gown. She used an alcohol wipe on R130's catheter port before and after emptying the bag, then removed her gloves and washed her hands. On 11/07/24 at 07:58 AM, observation revealed R130 lying in bed with the urinary catheter bag on the bare floor by her bed. Certified Nurse Aide (CNA) O verified the catheter bag should not be touching the floor. At that time, without wearing gloves or gown, CNA O moved the catheter bag and touched the tubing on R130's thigh to see if it was kinked. She verified there was no tubing securement device in place. CNA O also verified there were no EBP signs in the room or closet. On 11/07/24 at 08:40 AM, Administrative Nurse F verified there was no EBP signage in R130's room. Administrative Nurse F verified staff should have initiated EBP for the resident with a catheter, and the catheter bag should not touch the floor. Administrative Nurse F also said staff should have placed a tubing securement device on the catheter tubing. On 11/07/24 at 08:47 AM, Administrative Nurse D verified staff should have worn a gown and gloves while touching the catheter bag and tubing. Administrative Nurse D stated the catheter tubing should have been secured with a Stat-lock (tubing securement device to prevent dislodgement or pain from pulling). The facility's Catheter Care policy stated the facility would ensure that residents with indwelling catheters received appropriate catheter care and maintain their dignity and privacy. Catheter care would be performed every shift, drainage bags would be covered at all times, and staff were to document care and report any concerns to the nurse on duty. The facility failed to provide adequate catheter care and services within the standards of care for R130. This deficient practice placed R130 at risk for urinary tract infection and other catheter-related complications.

The facility had a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to adhere to infection control for Enhanced Barrier Precautions (EBP -an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and gloves used during high contact resident care activities) for Resident (R)26, who had a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart)line in her right upper arm, and R130 who had a urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). This placed the residents at increased risk for infection. Findings included: - On 11/05/24 at 03:45 PM observation revealed License Nurse (LN) K entered the room of R26, who was on EBP. Observation revealed a sign posted on the cabinet of the resident's room giving instructions on personal protection equipment (PPE-gown and gloves). The PPE equipment and supplies were located in a cabinet in the resident's room. Continued observation revealed LN K entered the resident's room and donned only gloves. LN K cleansed the resident's PICC port to administer the antibiotic. LN K stated the medication had to run for 2.5 hours then she would return and disconnect it at that time. On 11/06/24 at 08:30 AM, observation revealed R130 lying in bed with her eyes closed. Observation revealed a urinary catheter collection bag in a privacy bag hung on the side of the bed to dependent drainage. There was no EBP signage or gowns observed in the room or closet. On 11/06/24 at 02:46 PM, Certified Medication Aide (CMA) R washed her hands and applied gloves but did not don a gown. She used an alcohol wipe on R130's catheter port before and after emptying the bag, then removed her gloves and washed her hands. On 11/07/24 at 07:58 AM, observation revealed R130 lying in bed with the urinary catheter bag on the bare floor by her bed. Certified Nurse Aide (CNA) O verified the catheter bag should not be touching the floor. At that time, without wearing gloves or gown, CNA O moved the catheter bag and touched the tubing on R130's thigh to see if it was kinked. CNA O also verified there were no EBP signs in the room or closet. On 11/07/24 at 08:40 AM, Administrative Nurse F verified there was no EBP signage in R130's room. Administrative Nurse F verified staff should have initiated EBP for the resident with a catheter upon admission. On 11/05/24 at 4:30 PM interview with LN K verified that R26's cabinet door had an Enhanced Barrier Isolation sign with the initials EBP posted on the door frame and instructions for wearing appropriate PPE. LN K verified she should wear the appropriate PPE, a gown, and gloves when providing care for the resident. On 11/06/24 at 08:00 AM interview with Administrative Nurse D verified the staff should wear PPE when providing care for R26. Administrative Nurse D said the facility would do some education with the staff in regard to EBP and wearing PPE for resident care. On 11/07/24 at 08:40 AM, Administrative Nurse F verified there was no EBP signage in R130's room. Administrative Nurse F verified staff should have initiated EBP for the resident with a catheter upon admission. On 11/07/24 at 08:47 AM, Administrative Nurse D verified staff should have worn a gown and gloves while touching the catheter bag and tubing. The facility's Enhanced Barrier Precautions policy, dated 08/03/2024, documented the facility would fully implement EBP for the prevention of transmission of multidrug-resistant organisms. EBP refers to the use of gowns and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition such as residents with wounds or indwelling medical devices. EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical devices are removed. The facility failed to ensure staff used EBP as required R26 and R130. This placed the resident at increased risk for infection.

The facility reported a census of 84 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility. Findings included: - Observation of the kitchen area, on 04/11/24 at 09:49 AM revealed the following concerns: 1. Dietary Staff CC lacked a beard cover and had a hat in place which did not cover all of his hair. 2. Observation of the Dish Machine Log - High Temp dated April 2024, which hung on a bulletin board on a wall next to the dish machine, lacked documentation the staff checked the wash and rinse temperature at breakfast, lunch, and supper since 04/02/24. 3. The walk-in refrigerator contained a bag of deli meat which lacked a date, a pan of Au Gratin potatoes dated 04/04/24, a plastic container of sour cream dated 04/07/24, and some containers without lids, plastic containers of ketchup and mayonnaise which lacked a date and ten containers lacked a lid, two large bowls of salad, undated, a bowl with two hardboiled eggs, undated, a large tray of 29 raw breaded chicken, undated and lacked a cover and Dietary Staff DD was preparing to place another tray of breaded raw chicken breasts without a cover in the refrigerator. 4. Six trays of muffins uncovered in the kitchen area. 5. The reach in refrigerator by the ice machine contained a carton of thickened cranberry juice and thickened lemon-flavored water with an open date of 03/24/24. The carton revealed the juice may be kept in refrigerator for seven days after opening (11 days past the timeframe). A carton of tomato juice with an open date of 03/26/24 and the carton lacked instructions on when to discard. Additionally, there was a pitcher of orange juice dated 04/01/24, cranberry juice dated 04/01/24, lemonade dated 04/05/24, and grape juice dated 04/01/24. A pitcher lacked a lid and had a blue colored liquid in it and lacked a date, a pitcher labeled tea lacked a date, and a pitcher of lemonade. Additional pitchers in the refrigerator included apple juice dated 04/07/24 and cranberry dated 04/06/24. On 04/11/24 at 09:32 AM, Dietary Staff CC revealed he arrived at 06:00 AM and had not had a chance to test the dishwasher machine temperatures and it should be done at breakfast, lunch, and supper. Dietary Staff CC stated the log lacked temperatures since 04/02/24. On 04/11/24 at 09:40 AM, Dietary Staff BB stated items past expiration should be exposed of, he checks those on Friday and items should be dated. Dietary Staff BB stated the pitchers of juices should be changed out daily and the staff do not always get the labels changed, he monitors that but had not got to it today. He stated the pitcher with the blue liquid was Kool-aide for activities and should have a lid and a date. Additional trips to the kitchen revealed the following concerns: On 04/11/24 at 10:18 AM, Dietary Staff DD was preparing raw chicken with a hat in place which exposed a ponytail in the back and hair extending from the side of the hat next to her ears. On 04/11/24 at 10:19 AM Dietary Staff DD stated she had worked there three years and has always worn a ball cap. On 04/11/24 at 10:33 AM Administrative Staff A stated the dietary staff should be checking the dishwasher temperatures three times a day. On 04/11/24 at 11:17 AM, Dietary Staff DD prepared pureed chicken parmesan, buttered peas, and buttered noodles without using recipes for instructions on how to prepare or measurements to use. Dietary Staff DD failed to add butter when preparing the peas and the chicken parmesan was not prepared per recipe prior to making the pureed chicken parmesan. On 04/11/24 at 11:20 AM, Dietary Staff DD stated she did not use a recipe when preparing the pureed diets, she did not have any recipes, however Dietary Staff BB did and she had not ever seen any recipes. Dietary Staff DD stated she did not add butter to the peas or pasta when pureeing them because she added butter to them when she prepared them prior. On 04/11/24 at 11:45 AM, observed Dietary Staff check temperatures of food items on the steam table: chicken 135 degrees Fahrenheit (F), buttered pasta 157 degrees F, peas 171 degrees F, marinara sauce 148 degrees F, roast beef 147.5 degrees F, and mechanical soft chicken 123 degrees F. Dietary Staff DD removed the mechanical soft chicken so it could be heated up to 145 degrees F. Dietary Staff failed to document the measured temperatures of the food. On 04/11/24 at 11:50 AM, Dietary Staff DD began preparing plates to serve, placing the chicken on top of the noodles, then added sauce and then parmesan cheese. Dietary Staff DD failed to prepare and serve the chicken parmesan according to the recipe. The recipe for Chicken Parmesan dated 2024, revealed to ladle hot marinara sauce evenly over cooked chicken, top with mozzarella cheese, return to oven for two to three minutes to melt the cheese. On 04/11/24 at 11:52 AM, Dietary Staff DD observed opening the door to the kitchen with gloved hands and came back through the door using her gloved hands and holding a bag of potato chips. Dietary Staff DD then opened the bag with the same gloved hands and removed chips from the bag to place on a plate. After surveyor intervened, Dietary Staff DD removed the gloves, washed hands, applied a new pair and removed a bun from a package and placed on a plate. On 04/11/24 at 11:54 AM, Dietary Staff DD stated she should have removed gloves, washed her hands, and applied a new pair before touching the potato chips. On 04/11/24 at 12:12 PM Dietary Staff BB stated the staff should follow the recipes. There is a book in the kitchen near the microwave with the recipes. Dietary Staff BB stated the staff should remove gloves, wash hands, and apply new gloves after having contact with surfaces prior to touching food. On 04/11/24 at 01:33 PM, review of the Food Temperature Log dated 04/07/24 through 04/11/24 lacked documentation of the measured food temperatures from the lunch meal. On 04/11/24 at 01:34 PM, Dietary Staff DD stated she had not recorded the food temperatures from lunch and thought she could remember all of them. On 04/11/24 at 01:35 PM, Dietary Staff BB stated the staff should record the food temperatures at the time they were measured. On 04/11/24 at 01:39 PM, observed Dietary Staff EE place trays of brownies in the walk-in refrigerator on a cart uncovered where multiple other trays of food items uncovered were stored. On 04/11/24 at 02:52 PM, observed Dietary Staff FF with a hat on and hair extended past the hat while peeling potatoes with bare hands. On 04/11/24 at 02:53 PM Dietary Staff FF stated a hair net was not required in the kitchen if hair was short and a hat was in place. Dietary Staff FF stated he wears gloves when handling food, however, the potatoes were going to be rinsed off. The facility policy General Food Preparation and Handling dated 2021 revealed food will be covered for storage, food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food. Leftovers must be dated, labeled, covered, cooled, and stored in a refrigerator and used within seven days per Food Code or discard. The facility policy Food Safety and Sanitation, dated 2021 revealed hair restraints required and should cover all hair on the head. Beard nets required when facial hair visible. Leftovers are used within 72 hours or discarded. Perishable foods with expiration dates should be used prior to the use by date on the package. The facility policy Cleaning Dishes/Dish Machine dated 2021 revealed prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. The facility policy Dish Machine Temperature Log dated 2021 revealed staff were to record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff are correctly monitoring dish machine temperatures. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility.

The facility reported a census of 84 residents with one resident reviewed for therapeutic diet. Based on observation, interview, and record review, the facility failed to follow the menu for Resident (R)3 to provide the physician ordered gluten free diet. Findings included: - The Medical Diagnosis tab in the electronic medical record (EMR) for R3 included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] assessed R3 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition and R3 did not receive a therapeutic diet. The MDS did not trigger the Nutritional Status Care Area Assessment. The Quarterly MDS dated [DATE] assessed R3 with a BIMS score of nine, indicating moderate cognitive impairment and did not receive a therapeutic diet. The Care Plan dated 01/10/24 for R3 instructed the staff to serve the diet as ordered. The dashboard of the EMR for R3 revealed an allergy to gluten. The Dietician Recommendations dated 08/27/21, revealed R3 previously followed a gluten free diet, he avoided breads, pasta, etc. The Registered Dietician recommended a gluten free diet per resident preference. The physician agreed and requested a new order be written on 08/31/21. The Diet Type Report dated 04/11/24 revealed a Regular type, Regular texture, Regular fluid, gluten free diet. The Gluten Free Menu for week one, dated 2024 and lacked month and day, revealed on Thursday for lunch, menu items included gluten free chicken parmesan, gluten free noodles, buttered peas, and a gluten free dessert or fruit. The facility recipe for Chicken Parmesan revealed instructions to dredge the chicken breast in flour, then coat with egg, and dredge in breadcrumb mixture. The recipe included allergies to gluten. On 04/11/24 at 12:12 PM (Thursday), observation revealed Dietary Staff DD prepared R3's meal which included the parmesan chicken and buttered noodles. When Dietary Staff DD sat the plate down next to R3's meal ticket, she stated Oh, that's our gluten free guy and took the plate away. Dietary Staff DD then prepared a new plate and placed the parmesan chicken, buttered peas and was going to serve when surveyor intervened about the breaded chicken. Dietary Staff DD stated the chicken was not gluten free, had been prepared with flour. Dietary Staff DD removed the chicken and placed roast beef on the plate and said she would add some gravy to it. Surveyor intervened and questioned if the gravy was gluten free and Dietary Staff DD responded, probably not and did not place the gravy over the meat. The staff served R3 roast beef, buttered peas, and potato chips. On 04/11/24 at 12:21 PM, Dietary Staff BB stated the staff should follow the recipes and menus and the book was in the kitchen located near the microwave. On 04/11/24 at 12:30 PM observed R3 at the table, there was no food left on his plate and he had an orange and two bananas next to his plate. R3 stated he was not aware of any allergies, and when asked about gluten, he responded like bread? R3 stated he tries not to eat bread, as it slows his energy down and he learned that when he was a trained medic in the services. The facility policy Standardized Recipes dated 2017 revealed cooks/chefs were expected to use and follow the recipes provided. The facility policy Therapeutic Diets dated 2017, revealed the facility will provide a therapeutic diet that was individualized to meet the clinical needs and desires of a patient/resident to achieve outcomes/goals of care.

The facility reported a census of 99 residents with four residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to perform proper hand hygiene between resident contacts while delivering meal trays and failure to don appropriate personal protective equipment (PPE - equipment worn by personnel to minimize exposure hazards that can lead to injuries or illnesses) when delivering meals to a resident under isolation precautions (a combination of appropriate PPE and hand hygiene practices to prevent the spread of infectious agents between individuals). This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility. Findings include: - Review of the Electronic Health Record (EHR) for Resident (R)1 revealed the following pertinent medical diagnoses: sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock), zoster (a highly contagious virus that causes shingles [a viral inflammation of nerve pathways characterized by a painful burning rash with or without weeping blisters]) and intraspinal (inside the spine) abscess (a cavity containing infectious drainage and surrounded by inflamed tissue), and granuloma (a tumor of a mass of tissue resulted from an infection or injury). The Admission Minimum Data Set (MDS), dated [DATE] was incomplete as the required seven-day look-back period had not transpired. The Care Area Assessments (CAA), dated 11/17/23 were incomplete as the required seven-day look-back period had not transpired. The Care Plan, dated 11/20/23 revealed the following: 1. On 11/20/23, instructed staff that R1 was under contact isolation precautions for shingles. 2. On 11/20/23, instructed staff to wear PPE of gloves and gown when in R1's room and providing cares. The physician's orders, dated 11/20/23 at 09:59 AM, documented that resident was under isolation (contact) precautions due to shingles. On 11/20/23 at 12:00 PM, the door to the resident room had a sign for visitors to see the nurse prior to entry. Interview with Licensed Nurse D stated that the resident required contact precautions for shingles and MRSA (Methicillin-resistant Staphylococcus Aureus - a type of bacteria resistant to many antibiotics) and that gown/gloves are required for entry. On 11/20/23 at 12:10 PM, Dietary Staff C entered R1's room and carried a tray with two meal tray setups. Dietary C failed to apply PPE and placed R1's food on the over-the-bed table at the same time, carried another resident's tray inside the isolation room. Dietary staff then exited R1's room without performing hand hygiene and walked into an unidentified resident's room and delivered the unidentified resident's food tray, then left that room and failed to perform hand hygiene. On 11/20/23 at 12:12 PM, Dietary Staff C confirmed that he had walked into R1's room without donning PPE while carrying two resident's meal trays, then walked into the second resident's room and delivered foods without performing hand hygiene. Dietary Staff C stated that this was normal practice and that he was unaware of any need to don PPE or perform hand hygiene between resident contacts. On 11/20/23 at 12:20 PM, Dietary Staff E observed entering one resident room carrying two resident meal trays, exited the first room without performing hand hygiene and then delivered the second meal tray to second resident's room and exited without performing hand hygiene. On 11/20/23 at 12:20 PM, Dietary Staff E confirmed that she had walked into one resident's room carrying two meal trays, exited the first room without performing hand hygiene and delivered the second meal tray to the second resident's room and exited that room without performing hand hygiene. She stated that this was normal practice for her and that she was unaware of any need to perform hand hygiene between resident contacts. On 11/20/23 at 12:20 PM, Licensed Nurse D stated that all staff who enter R1's room should don PPE and perform hand hygiene upon exiting R1's room. Failure to do this presented an infection control concern for cross contamination between residents and that dietary staff should be delivering one meal to one resident at a time and performing hand hygiene between resident contacts. On 11/20/23 at 04:45 PM, Dietary Staff G revealed that staff should not take two resident's meal trays into one room then deliver the food to a second resident as the expectation is for staff to only deliver one meal tray to one resident at a time. Staff were expected to don PPE as appropriate if residents were under isolation precautions. Staff were expected to perform hand hygiene between every resident contact when delivering meal trays. On 11/20/23 at 05:05 PM, Administrative Nurse F and Administrative Nurse B stated that the expectation for all staff to don PPE as appropriate when residents were under isolation precautions. Further stated that staff delivering meal trays should deliver one meal to one resident, perform hand hygiene, collect an additional meal tray from the meal cart then deliver the second meal to the second resident while performing hand hygiene between resident contacts. Additionally stated that all staff had been trained in proper donning and doffing of PPE. The facility's undated Transmission-Based (Isolation) Precautions policy, documented that personnel carrying for residents on contact precautions would wear a gown and gloves in the environment of residents on isolation precautions for all interactions that may involve contact with the resident and would don PPE upon room entry and discarding before exiting, lacked instructions for hand hygiene upon entering or exiting a resident's room on isolation (contact) precautions. The facility failed to maintain an effective infection control program with the failure of staff to perform proper hand hygiene between resident contacts while delivering meal trays and failure to don appropriate PPE when delivering meals to a resident under isolation (contact) precautions. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility.

The facility reported a census of 94 residents with 4 residents in the sample. Based on observations, interviews, and record reviews the facility failed to provide staff with competencies and skills sets to meet the behavioral health needs of one of the four residents, R1 during a period of agitation by the resident. Findings include: - The Physician Orders dated 09/12/22 revealed diagnoses of delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (a progressive mental disorder characterized by failing memory, confusion), and paranoid schizophrenia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking). The annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severely impaired cognition. Behaviors identified included delusion with no behaviors noted. R1 required extensive assistance one-person assist with all Activities of Daily Living ADL's. Review of the Care Area Assessment (CAA) for behavioral symptoms, dated 07/03/22, triggered due to physical/verbal abuse towards staff/other residents. R1 was resistant to cares, wandered, yelled out, and cursed. Risk factors included injuring self or others, decrease socialization, social isolation and increase anxiety. Review of the Care Plan dated 07/08/20 revealed R1 had the tendency to exhibit behavior issues such as being resistive to care and with the potential to be aggressive towards other. Instructions to the staff included that when R1 became agitated to intervene before the agitation escalated, to guide him away from the source of the distress, to engage calmly in conversation and if his response was aggressive staff were to walk calmly away and approach later. R1 received a psychotropic medication related to his behaviors, mood fluctuation and increased agitation. Review of the Progress Note dated 01/16/23 at 09:30 AM, revealed that R1 had been throwing things in his room, refused his morning medications, when staff attempted to give R1 a beer, R1 threw the beer at the nurses' station. The staff notified the resident's daughter regarding R1's behaviors. The nurse attempted to have R1 speak with his daughter, but the resident threw the phone at the nurse. The resident attempted to hit another resident in the commons area who sat on the couch. The staff moved the other resident out of the common's area for their safety. A Progress Note, dated 01/16/23 at 01:00 PM, documented the resident's daughter and granddaughter arrived at the facility with a recorded video (from inside of the resident's room). The facility staff reviewed the video with Administrative Nurse D regarding R1's care from Licensed Nurse (LN) E in the video. It revealed that LN E had the walker in her hands and appeared to be taunting R1 by slamming the walker in front of and towards him. Administrative staff then placed LN E on suspension until an investigation could be completed. Review of this video provided by a family member, revealed two staff standing just inside his closed doorway and most of the time they stand with arms closed over chest. Another staff member goes on into the room around the resident in the wheelchair and moving about the room. The resident goes to a drawer and opens it. You can see the staff member reaching in/around the open drawer and shuts it. The staff gets the walker from across the room and places it near the bedside. The resident is in the wheelchair and the staff tells him to go ahead and stand-up multiple times (walker is still behind the resident), then she gets the walker and puts it out in front of the resident in the wheelchair. The staff tells him repeated go ahead and stand up. He grabs it and tries to go forward in the wheelchair while moving the walker. At one point the staff member picks up the walker and lifts it off the floor poking it towards the resident and then down on the floor several times such as taunting. As the video continues the resident becomes more and more agitated. The same staff member stays in the room saying things to him, until another staff member comes in and gives the resident a piece of chocolate and calmly talks to him. Observation, on 01/23/23 at 12:40 PM, observation revealed R1 in the common areas sitting in his wheelchair with his eyes closed. The resident's uncovered skin areas revealed no visible bruising noted. Observation, on 01/24/23 at 09:50 AM, revealed R1 in the common's room. Per request Certified Nurse Aide (CNA) R and Certified Medication Aide (CMA) R removed R1's sweater to view his upper bilateral arms without any bruising noted. Interview with Administrative Nurse E, on 01/24/23 at 09:25 AM, explained the incident in the video that the resident had been more combative than usual. R1 attempted to lunge the walker towards the LN G she than took the walker away from R1. Administrative Nurse E requested the staff leave the residents room gave R1 a piece of chocolate which R1 behaviors started to decline LN G did not want to leave R1 in his room by himself due to fear he would hurt himself. Interview with Licensed Nurse G, on 01/24/23 at 11:05 AM, about the incident on 01/16/23 at 09:30 AM, revealed R1 became agitated and he had attempted to kick out the window in the common's area. Staff and LN G placed couches in front of the windows to protect them. R1 had thrown a beer and the phone at LN G and then attempt to hit one of the other residents. Staff returned R1 to his room when he started breaking things and LN G asked a staff member to go and get help. LN G stated that she did have the walker but only to try and have R1 stand. LN G had not been aware that she could leave the R1 in the room and walk away. Interview with Administrative Nurse D, on 01/24/23 at 11:20 PM, stated the expectation was for the staff to try and decrease the situation or call for help. LN G was not aware she could leave the resident in the room by himself while he was agitated. The facility's Behavior Management Plan dated 2017 revealed residents who exhibit behavioral concerns may require a behavior management plan to ensure they are receiving appropriate services and intervention to meet their needs. The facility failed provide staff with competencies and skills sets to meet the behavioral health needs of one of the four residents, R1 during a period of agitation by the resident.

The facility reported a census of 100 residents. Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week by not having a registered nurse scheduled as required. Findings included: - Review of the nursing schedule and day sheets from 12/01/2021 to 12/01/2022 revealed no RN coverage for 12/05/21, 12/19/21, 01/01/22, 01/02/22, 01/15/22, 01/16/22, 01/29/22, 01/30/22, 02/12/22, 02/13/22, 02/26/22, 02/27/22, 12/10/22, and 12/11/22. On 01/05/23 at 01:56 PM, Administrative Staff S reported that that the nurse managers (some of whom are LPNs) cover weekend call time and was unaware that RN coverage must include an eight consecutive hour tour of duty in the building every 24 hours. Review of the facility's undated policy Nursing Staffing Posting Information lacked information about staffing number requirements for RN coverage. The facility failed to ensure the use of a RN for at least eight consecutive hours per day, seven days a week by not having a RN scheduled to work on 14 days during the look-back period. This had the potential to affect all residents.

The facility reported a census of 100 residents. The facility reported all residents received meals prepared in the kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and in sanitary conditions due to the staff's failure to date and cover cooked food items, failure to perform hand hygiene, and the failure to handle ready-to-eat sandwich foods including ham, turkey cheese and bread. under sanitary conditions, to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - An initial tour of the kitchen on 01/03/22 at 10:00 AM, revealed the following concerns: 1.) A walk-in refrigerator revealed six uncovered, undated pumpkin pies on a tray. On 01/04/23 at 11:00 AM observed dietary staff DD as she made ham and cheese sandwiches and turkey and cheese sandwiches for the noon meal. With gloved hands, staff removed the bread of the bread bag and placed the bread directly on the counter. She then opened the wrapping on the cheese. Dietary staff DD then went to another counter to get the meat that was in pans. She then proceeded to make 6 ham and cheese and six turkey and cheese sandwiches. Staff laid the sandwiches directly on the counter and she picked up a knife laying by the sandwiches and proceeded to cut them all in half and placed them in a large pan. Throughout the entire process, dietary staff DD failed to change her gloves and failed to perform hand hygiene. Interview on 01/04/23 Dietary Staff CC reported she should know when to wear gloves. He then asked surveyor if she had talked to the dietary staff about the right way to do things. The surveyor responded that was CC's responsibility to teach his staff. He agreed and would talk to her. The undated facility's policy for General Food Preparation and Handling revealed foods were to be covered for storage. Hand hygiene with ready to eat foods was not addressed in the policy. The facility failed to store foods safely and in sanitary conditions due to the staff's failure to date and cover cooked food items, failure to perform hand hygiene, and the failure to handle ready-to-eat foods under sanitary conditions, to prevent the spread of food borne illnesses to the residents of the facility.

The facility reported a census of 100 residents with 20 residents selected for review that included three residents sampled for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based on observation, interview, and record review, the facility failed to provide sanitary placement of Resident (R)15 and R47's urinary catheter collection bags. This had the potential to cause urinary tract infections (UTI) and injury from accidental removal of the catheter. Findings included: - Review of R15's diagnoses from the 06/08/22 Physicians Orders in the Electronic Health Record (EHR), revealed the following diagnoses: neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (damage to brain cells due to a lack of oxygen and/or blood flow). The quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive one-person assistance with personal hygiene and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The annual MDS dated [DATE], revealed the resident had a BIMS of 15, indicating intact cognition. The resident required extensive one-person assistance with personal hygiene and had an indwelling urinary catheter. Review of the 06/14/22 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), revealed risk of recurrent UTIs and injury from use of catheter. The care plan, dated 06/08/22, guided staff to provide catheter care as needed. Review of EHR Physician Orders (related to the urinary catheter bag) revealed an order, dated 06/09/22, for a privacy bag to be placed on the side of the bed. On 01/03/23 at 01:18 PM, revealed the resident's catheter drainage bag sat directly on the floor. The urinary collection bag lacked a covering over it approximately one-third full. On 01/03/23 at 01:18 PM, a family member reported it was normal for the drainage bag to sit on the floor. On 01/04/23 at 01:30 PM, certified nurse's aide (CNA) L reported that if a urinary collection bag dropped or came in contact with the floor, the charge nurse should be notified so the bag could be changed. On 01/04/23 at 01:49 PM, CNA M revealed that staff should hang the urinary collection bags from the resident's wheelchair frame or bed frame, and if the bag fell on the ground, the nurse would be notified so the bag could be changed. On 01/04/23 at 01:53 PM, Licensed Nurse (LN) D revealed that collection bags should not have contact with anything except dignity bags and should be hooked onto the resident's bed frame or wheelchair frame. If a bag came in direct contact with the floor, the bag should be changed. On 01/05/23 at 10:15 AM, Administrative Nurse B, revealed that after collection bags are emptied, they were replaced to the edge of the bed or the wheelchair and never on the floor. Furthermore, if any part of the collection bag had contact with the floor, then the bag should be changed. The facility's policy Appropriate Use of Indwelling Catheters, dated 09/09/20, revealed staff should utilize catheters in accordance with current standards of practice. The facility's policy Catheter Care Policy, dated 10/01/19, lacked documentation on bag positioning. The facility failed to provide appropriate care of R15's catheter drainage bag, increasing her risk for developing UTIs and injury from accidental removal of the catheter. - Review of R47's diagnoses from the 05/08/20 Physicians Orders in the Electronic Health Record (EHR) revealed the following diagnoses: neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and urinary tract infection (UTI). The quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident required extensive one-person assistance with personal hygiene and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The annual MDS dated [DATE], revealed a BIMS of 11, indicating moderately impaired cognition. The resident required extensive two-person assistance with personal hygiene and had an indwelling urinary catheter. Review of the 05/06/22 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), revealed risk of recurrent UTIs and injury from use of catheter, including maintenance to decrease risk for recurrent UTIs. The care plan, dated 06/08/22, guided staff to provide catheter care as needed. Review of EHR Physician Orders revealed an order, dated 05/08/20 for privacy bag to be placed on the side of the bed. On 01/03/23 at 12:44 PM, revealed the resident's catheter drainage bag sat directly on the floor, approximately three-quarters full. The collection bag lacked a privacy bag. On 01/04/23 at 09:31 AM, revealed the resident's catheter drainage bag directly on the floor, approximately one-half full, with the drain port in direct contact with the floor. On 01/04/23 at 12:50 PM, revealed the resident's catheter drainage bag stored directly on the floor. On 01/04/23 at 01:30 PM, certified nurse's aide (CNA) L reported if a collection bag is dropped or came in contact with the floor, the nurse should be notified so the bag could be changed. On 01/04/23 at 01:49 PM, CNA M revealed that staff should hang collection bags from the resident's wheelchair frame or bed frame, and if the bag fell on the ground, the nurse should be notified so the bag could be changed. On 01/04/23 at 01:53 PM, Licensed Nurse (LN) D revealed that urinary collection bags should not have contact with anything except dignity bags, and staff should hook the bag onto the resident's bed frame or wheelchair frame. If a bag came in direct contact with the floor, the bag should be changed. On 01/05/23 at 10:15 AM, Administrative Nurse B, revealed that after staff empties the urinary collection bags, they were to be replaced to the edge of the bed or the wheelchair and never on the floor. Further, if any part of the collection bag had contact with the floor, then the bag should be changed. The facility's policy Appropriate Use of Indwelling Catheters, dated 09/09/20, revealed staff should utilize catheters in accordance with current standards of practice. The facility's policy Catheter Care Policy, dated 10/01/19, lacked documentation on bag positioning. The facility failed to provide appropriate care of R47's catheter drainage bag, increasing her risk for developing UTIs and injury from accidental removal of the catheter.

The facility reported a census of 100 residents, with 20 included in the sample, including one resident sampled for respiratory services. Based on observation, interview and record review, the facility failed to provide necessary respiratory care and services on one Resident (R) 41's, who required physician ordered oxygen. Findings included: - Resident (R) 41's signed physician orders, dated 12/27/22 revealed the following diagnoses: acute respiratory failure (difficulty to breathe) and end stage renal failure dependent on dialysis (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required supervision with his daily cares. The resident would get short of air when lying flat or exertion and required oxygen (O2). The Quarterly MDS dated [DATE],revealed no changes in the resident's daily cares. The resident required O2 therapy. The Care Area Assessment (CAA) dated 06/13/22, did not address the resident's use of oxygen therapy. The Care Plan dated 06/22/2022 revealed the resident required use of supplemental oxygen (O2) and the resident was at risk for complications. Staff should change the O2 tubing and rinse the filter weekly. The resident required continuous use of the O2. Provide O2 as ordered. The physician orders included continuous oxygen at 2 Liters per minute/ nasal cannula, dated 06/16/22 On 06/27/22, the physician's order revealed nurses to change the O2 tubing, and rinse the filter, every week on Monday nights. Date the tubing when changed. Observation on 01/04/23 at 09:40 AM, revealed the resident ambulated in the hall returning to his room following breakfast. The resident ambulated with a walker and had a slow steady gait. The resident was slightly short of air as he ambulated. He voiced he was going to put his O2 on when he got back to his room. Observation on 01/04/23 at 02:30 PM, revealed the resident sat in his room watching TV. The resident had his O2 concentrator on. The O2 tubing lacked a date. In addition, the tubing attached to his portable O2 bottle, attached to the resident's wheelchair, also lacked a date. On 01/07/23 at 11:30 AM, the resident complained of shortness of breath. The resident did not have his O2 on. On 01/04/23 at 02:30 PM, Certified Nursing Assistant (CNA) K reported the resident had O2 but did not know who was responsible to care for it. On 01/05/23 at 07:20 AM, Licensed Nurse (LN) C reported the resident was on O2 therapy. She was not sure but thought the night nurse should change the O2 tubing and date it. LN C just never noticed if there were any dates on the resident's oxygen tubing. Interview on 01/07/22 at 01:30 PM, Administrative Nurse B reported staff should check the tubing for dates and ensure the tubing's dated when staff change the tubing's. Review of the facility's policy named Oxygen Administration dated 01/01/20, revealed Nursing was to change the tubing/mask/cannula weekly and as needed if it becomes soiled or contaminated. The facility failed to provide necessary respiratory care and services on this resident, who required physician ordered oxygen.

The facility reported a census of 100 residents with 20 residents sampled. Based on observations, interview and record review, the facility failed to follow physicians' orders for one Resident (R)81, of the six residents reviewed for unnecessary medications. Findings included: - The Physician Orders dated 10/31/22, for R81, indicated the following diagnoses included chronic atrial fibrillation (rapid, irregular heartbeat) and lymphoma (cancer of the lymphatic system that helps to fight infection). The significant change Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, that revealed intact cognition. The resident Th received four days of diuretics (medication to promote the formation and excretion of urine). The significant (MDS) dated [DATE], revealed the resident had no changes on the (BIMS) score. The resident received seven days of a diuretic. R81 was on hospice care. The Care Plan, dated 11/11/22, revealed a black box warning for Lasix (medication used to decrease fluid in the body). Review of the Electronic Medical Record, revealed the following physician orders: 1.) the following physician orders Lasix, 40 milligrams (mg), one tab by mouth, two times daily for edema (swelling resulting from excessive accumulation of fluid in the body tissues), dated 12/15/22. 2.) Potassium bicarb-citric acid tab effervescent, 20 milliequivalents per liter (meq) give one tab orally, two times a day, for supplement with meals, dated 08/10/22. Review of the Progress Notes from 12/28/22 to 01/05/22, revealed staff failed to administer the potassium bicarb-citric acid twice a day. The documentation indicated the facility was waiting to receive the medication from the pharmacy. The progress notes lacked documentation that the facility contacted the pharmacy regarding the missing medication. Observation on 01/03//22 at 10:50 AM R81 had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) to both feet. The resident's had wrappings and Prevalon boots (an open, floated-heel designs medical boot designed to float the heel(s) on both feet. Observation on 01/05/22, revealed R81 remained in bed with both Prevalon boots and wraps on. Interview on 01/05/22 at 08:00 AM with Consultant staff GG , reported the resident had the Lasix increased in the last two weeks, from 20 meq to 40 meq ,and was not aware the resident had not receive the potassium biarb-citric acid tab as ordered. Interview on 01/05/22 at 08:10 AM with Certified Medication Aide (CMA) J, reported the medication aide should notify the charge nurse on duty if a medication was unavailable to administer. Interview, on 01/05/22 at 08:20 AM, 'Licensed Nurse LN C reported staff did not contact the pharmacy regarding the medication unavailable to give, and verified staff failed to contact a the physician when R81 had not received her medication potassium bicarb-citric acid as ordered. Interview on 01/05/22 at 08:48 AM with Administrative Nurse B, revealed her expectation was staff should reorder the medication and contact the pharmacy if the medication was not received in a timely manner. The facility's policy for Physician/Practitioner Orders dated 01/01/2020, revealed the facility shall use uniform guidelines for the ordering of medication. Physician orders may be received by telephone, by a licensed nurse or registered health care specialist in their own area of specialty, follow through with orders by making appropriate contact or notification of pharmacy. The facility failed to follow the physician's orders for this resident in regard to her Potassium medication.

The facility reported a census of 100, with 20 residents in the sample, that included six residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to ensure the consultant pharmacist identified the use of a as needed (PRN) Ativan (antianxiety) medication with a stop date for Resident (R) 8, one of the six residents reviewed. Finding included: - Review of R8's Physician's Orders dated 09/12/22, revealed a diagnosis of delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (progressive mental disorder characterized by failing memory, confusion), and paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbance of language and communication and fragmentation of thought). Review of the modification of the annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The resident had delusion, but no behaviors indicated during the 7 day look back period. R8 required extensive assistance with one- person physical assistance with all Activities of Daily Living (ADL). Medication administration during the 7 day look back period indicated R8 received antipsychotic (medication capable of affecting the mind, emotions, and behavior) medication for seven days on a routine basis only. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/03/22, revealed staff were to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition. Staff were to approach the resident in a calm and non-threatening manner as to help the resident feel calmed and unhurried. Review of the Behavioral Symptoms (CAA) dated 07/03/22, triggered due to physical/verbal abusive to staff/other residents, resistant to care, wanders, yells out, and cursing. The care plan to be developed/reviewed, to monitor the resident's behavior patterns, decrease agitation and monitor the effectiveness of psychotropic medication. Review of the Psychotropic Drug Use (CAA) dated 07/03/22 psychotropic medications will be addressed in the resident's care plan. Staff to monitor for any adverse side effects of medication usage to help prevent or minimize the risk of current medication regimen, staff to administer medication as ordered to help prevent any side complications. The physician is to review regularly if a gradual drug reduction (GDR) is clinically appropriate or clinically indicated. Review of the Care Plan dated 10/30/19, revealed psychotropic medication prescribed at risk for complication related to behavioral management, paranoid schizophrenia, increase agitation with staff and increased paranoia. Administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Monitor/document as needed (PRN) medication for any adverse reaction of psychotropic (medication). Review of the Physician Orders dated 03/03/22 revealed an order for lorazepam 0.5 milligrams (mg)/ 0.1 milliliters (ml). staff to apply 0.1 ml topically, every eight hours PRN, for anxiety. Review of the Electronic Medication Record from 03/03/22 to 01/05/22, revealed the PRN lorazepam 0.5 mg/0.1 ml remained on R8's record with no end date listed on the medication. Interview on 01/05/22 at 10:25 AM with Licensed Nurse C, reported was unaware the PRN cream required a stop date and that it needed to be stopped by day 14. The cream really does not help the resident. LN C reported this was applied to the resident about two weeks ago due to his behaviors, but staff had to distract him instead. Interview on 01/05/22 at 11: 53 AM with Administrative Nurse B, reported she was responsible to place the stop dates on all PRN psychotropic medication. Interview on 01/05/22 at 11:53 AM with Consultant Pharmacist FF revealed he did not make any recommendations regarding this R8's (PRN) Ativan. The facility's policy for Medication Regimen Review dated 01/01/2020 indicated the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The review of the medical record in order to prevent, identify, report, resolve medication-related problems, medication error or other irregularities The facility failed to ensure the consultant pharmacist identified the use of a as needed (PRN) Ativan (antianxiety) medication with a stop date for Resident (R) 8, one of the six residents reviewed.

The facility reported a census of 100, with 20 residents in the sample, that included six residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to obtain an end date for the use of as needed (PRN) Ativan (antianxiety) medication for one Resident (R) 8, of the six residents reviewed. Finding included: - Review of R8's Physician's Orders dated 09/12/22, revealed a diagnoses of delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), dementia (progressive mental disorder characterized by failing memory, confusion), and paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbance of language and communication and fragmentation of thought). Review of the modification of the annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The resident had delusion, but no behaviors indicated during the seven day look back period. R8 required extensive assistance with one-staff physical assistance with all Activities of Daily Living (ADL). Medication administration during the seven day look back period indicated R8 received antipsychotic (medication capable of affecting the mind, emotions, and behavior) medication for seven days on a routine basis only. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/03/22, revealed staff were to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition. Staff were to approach the resident in a calm and non-threatening manner as to help the resident feel calmed and unhurried. Review of the Behavioral Symptoms (CAA) dated 07/03/22, triggered due to physical/verbal abusive to staff/other residents, resistant to care, wanders, yells out, and cursing. The care plan to be developed/reviewed, to monitor the resident's behavior patterns, decrease agitation and monitor the effectiveness of psychotropic medication. Review of the Psychotropic Drug Use (CAA) dated 07/03/22 psychotropic medications will be addressed in the resident's care plan. Staff to monitor for any adverse side effects of medication usage to help prevent or minimize the risk of current medication regimen, staff to administer medication as ordered to help prevent any side complications. The physician is to review regularly if a gradual drug reduction (GDR) is clinically appropriate or clinically indicated. Review of the Care Plan dated 10/30/19, revealed psychotropic medication prescribed at risk for complication related to behavioral management, paranoid schizophrenia, increase agitation with staff and increased paranoia. Administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Monitor/document as needed (PRN) medication for any adverse reaction of psychotropic (medication). Review of the Physician Orders dated 03/03/22 revealed an order for lorazepam 0.5 milligrams (mg)/ 0.1 milliliters (ml). staff to apply 0.1 ml topically, every eight hours PRN, for anxiety. Review of the Electronic Medication Record from 03/03/22 to 01/05/22, revealed the PRN lorazepam 0.5 mg/0.1 ml remained on R8's record with no end date listed on the medication. Interview on 01/05/22 at 10:25 AM with Licensed Nurse C, reported was unaware the PRN cream required a stop date and that it needed to be stopped by day 14. The cream really does not help the resident. LN C reported this was applied to the resident about two weeks ago due to his behaviors, but staff had to distract him instead. Interview on 01/05/22 at 11: 53 AM with Administrative Nurse B, reported she was responsible to place the stop dates on all PRN psychotropic medication. The facility's policy for Use of Psychotropic Drugs, dated 10/01/19, revealed PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and for a limited duration. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of that medication. The facility failed to obtain an end date for the use of as needed (PRN) Ativan (antianxiety) medication for R8 to prevent possible adverse reactions.

The facility census totaled 90 residents, with 13 included in the sample. Based on observation, interview, and record review the facility failed to prevent the neglect of 13 residents when Licensed Nurse (LN) C failed to provide competent nursing care during his shift from 07:00 PM on [DATE] through 07:00 AM on [DATE]. LN C reported consuming an unknown amount of Resident (R)1's [MEDICATION NAME] (an addictive narcotic pain medication) at an unknown time during his shift. Certified Nurse Aide (CNA) I found LN C sleeping at the nurse's station on [DATE] at approximately 06:15 AM, and then LN D found LN C asleep in R3's room at approximately 07:00 AM. The Electronic Medical Record (EMR) lacked documentation of provision of resident cares (including medication/treatment administration, resident assessments, and nursing notes) during his shift for Resident (R)1, R3, R4, R5, R6, R7, R8, R9, and R11.These cumulative failures led to the neglect of all 13 residents in his care (including one who died on his shift) and placed all 13 residents in immediate jeopardy . (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13) Findings included: - Interview on [DATE] at 01:23 PM with LN C revealed he began his shift on [DATE] at 07:00 PM with 13 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13) assigned under his care. When LN C began his shift, he received report from LN D, who informed him R1 readmitted to the facility on palliative care (end of life care). His assignment also included other residents that required varying assistance, medications, and treatments. Record review revealed nine residents assigned to LN C required the following care: 1. R1 required palliative care per Physician's Orders dated [DATE]. Review of R1's Care Plan dated [DATE] revealed no revision on return to facility on [DATE]. Review of an E-mail (electronic mail) from Physician Extender K to Administrative staff A dated [DATE] revealed LN C notified Physician Extender K on [DATE] at 10:06 PM that end of life care began for R1, oxygen saturation (oxygen in the blood) was in the 70th percentile (normal range ,[DATE]%), and the resident needed [MEDICATION NAME] for comfort. On [DATE] at 10:15 PM (3 hours and 15 minutes into LN C's shift) the physician's office responded with the order for [MEDICATION NAME] sulfate solution 20 milligrams (mg) per milliliter (ml), to administer 0.25 ml by mouth every one hour as needed (PRN) for comfort. Review of the [MEDICATION NAME] Narcotic Count Sheet for R1 dated [DATE] revealed the following documentation: 1. LN C signed out 0.25 ml of [MEDICATION NAME] at 10:00 PM (6 minutes before LN C called for an order) 2. LN C signed out 0.25 ml of [MEDICATION NAME] at 11:00 PM 3. LN C signed an entry on the [MEDICATION NAME] narcotic sheet which was illegible. Review of R1's [DATE] Medication Administration Record (MAR) lacked documentation of any PRN [MEDICATION NAME] administration from 10:00 PM on [DATE] to 07:00AM on [DATE]. Review of the EMR from [DATE] at 07:00 PM through [DATE] at 07:00 AM revealed lack of charting regarding R1 expiring until after LN C's shift ended and LN D charted a medication administration note entry noting R1 as deceased on [DATE] at 08:41 AM. Review of R1's EMR for blood pressure, pulse, oxygen saturations, and respirations revealed no documentation after return to the facility on [DATE] at 07:00 PM through [DATE] at 07:00 AM on LN C's shift. Interview with Certified Nurse Aide (CNA) E on [DATE] at 02:05 PM revealed on [DATE] when she and LN D came in to work at the facility, they heard a beeping sound and noticed the narcotic drawer was open on the medication cart in Express Recovery. When CNA E and the night shift CNA I were about to do rounds, CNA I said that someone died , and CNA E asked if anyone notified the family. CNA I said that was not her job. When CNA E and CNA I walked into R1's room the resident was in bed and covered in urine from head to toe. CNA I reported that she cleaned him up, but stated he clearly had urine all over. CNA I said R1 was in the same position as when the LN C positioned him the night before he died . CNA E and LN D notified Administrative Nurse F and Administrative Nurse F came back to the unit. CNA E observed LN C trying to call the family that morning, but he could not form words and his eyes were closing, so CNA E took the phone and talked to R1's family member. Interview with LN C on [DATE] at 01:23 PM revealed R1 had air hunger (struggling to breath) at 07:00 PM on [DATE] when he came on shift and the day shift nurse reported the resident did not have much longer to live. He said he called the doctor's office at 07:00 PM after he assessed R1 because he was alert to mild painful stimuli, not obeying commands, had his mouth wide open with dry oral secretions, concerning lung sounds, and was pale. LN C did not remember what R1's vital signs were, but it was evident that he was at the end of his life. LN C reported that he had 13 residents he was caring for that night and had written the doses of R1 administered [MEDICATION NAME] doses on a notepad and was not sure why he did not document those doses or sign them out. He stated at 04:00 AM on [DATE], he noticed R1 passed away and attempted to call the family but did not document it in the resident's chart. At 04:30 AM, he took a little sip of R1's [MEDICATION NAME] and stated he then passed his residents' their morning medications. He did not remember being asleep at the nurse's desk that morning or when the morning nurse found him leaning on the side of R3's bed with the feeding tube pole teetering between himself and the wall. The LN D woke him up, he tried to give report on all residents and count narcotics, and reported he left the facility after that. He stated he administered eight doses of the [MEDICATION NAME] to R1 and reported that he called the doctor's office for the [MEDICATION NAME] at 08:00 PM on [DATE]. LN C said he administered a dose of [MEDICATION NAME] to R1 at 08:00 PM on [DATE] and every hour until 03:00 AM on [DATE]. 2. Review of R3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two indicating severely impaired cognition. The assessment noted R3 had a feeding tube (tube into the stomach for nourishment) providing 51% or more nutrition and 501 cubic centimeters (cc) or more of fluids. R3 required extensive assistance of two staff for all activities of daily living (ADLs). Review of the Care Plan dated [DATE] revealed R3 had a risk for respiratory complications due to a [MEDICAL CONDITION] (a tube into the windpipe to assist with breathing) as evidenced by hypoxic episodes (low levels of oxygen). R3 required continuous oxygen. Nursing staff were to monitor oxygen saturation levels and report, as indicated. Staff were to provide [MEDICAL CONDITION] care as necessary and ensure [MEDICAL CONDITION] ties were secured, with suctioning as needed. R3 required tube feedings related to a swallowing problem and the resident was dependent with tube feeding and water flushes. R3 had a Low Air Loss (LAL) Mattress to prevent pressure areas. Review of Physician Orders dated [DATE] revealed R3 with a feeding tube site. Staff were to cleanse the site with wound cleanser/normal saline (NS), pat dry, apply T-sponge (gauze pad with a slot cut out for the tube), and secure with tape. Staff were to change nightly and PRN every night shift. Review of the MAR for [DATE] revealed lack of peg tube site documentation on [DATE] at bedtime. Notarized Witness Statement by LN D on [DATE] revealed she found LN C on R3's bed asleep with R3 also in the bed. LN D noted the feeding tube knocked over and the bed air mattress deflated. LN C was sweating profusely, flustered, and tried to assemble the feeding tube. LN D observed the narcotic drawer open and a [MEDICATION NAME] bottle on the floor under the medication cart located in Express Recovery. Observation of R3 on [DATE] at 04:30 PM revealed the resident laid on his back with the head of his bed elevated. The resident had a feeding tube running on a pump with the container full. The resident had a [MEDICAL CONDITION] with oxygen running via [MEDICAL CONDITION]. The resident appeared clean with no odors of incontinence present. The resident had a functioning air mattress on his bed. Interview with CNA E on [DATE] at 02:05 PM revealed on the morning of [DATE] CNA E noted R3's bed completely saturated with urine, R3 had a bowel movement, and it was evident the resident had not been cared for during the night shift. Interview with LN D on [DATE] at 12:54 PM revealed she got to work [DATE] at 07:00 AM and found LN C in R3's room and woke him. LN C told her that he came into R3's room because he heard the beeping and the feeding tube was undone, so he tried to fix it. LN D recalled R3's air mattress was deflated, so LN D plugged the air mattress back in and placed R3's oxygen back on his [MEDICAL CONDITION]. Once that was done, LN D assessed R3's oxygen level, which was 90%, and assessed for pain to which he did not look in distress or uncomfortable. 3. The [DATE] Admission MDS revealed R4 had a BIMS score of 10, indicating moderate cognitive impairment. R4 required extensive assistance of two staff with ADLs. R4 rarely complained of pain, had very poor vision, and did not wear glasses. The resident was dependent on [MEDICAL TREATMENT] (a blood purifying treatment given when kidney function is not optimum). Review of [DATE] Care Plan revealed: Revision [DATE]- Resident requirement for transfer: Extensive assistance of one to two staff. Revision [DATE]- Staff were to check and change to maintain dignity for R4. Revision [DATE]- R4 had very poor vision and he did not wear glasses. Revision [DATE]- Due to poor vision, the resident was unable to see button on call light in order to request staff assist with transfers. Resident given a push pad call light, was able to demonstrate effective use several times, and properly used call light twice throughout remainder of shift. Revision dated [DATE] revealed R4 received [MEDICAL TREATMENT] related to [MEDICAL CONDITION] (kidney disease). Review of R4's [DATE] MAR lacked documentation of the ordered finger stick blood glucose (BG) checks at 06:00 AM on [DATE] and lacked documentation of R4's hours of sleep on the night shift [DATE] to [DATE]. Observation of R4 on [DATE] at 04:23 PM revealed the resident sat in a recliner with legs elevated. R4's walker was beside the recliner and the call light was on the chair. Interview with CNA E on [DATE] at 02:05PM revealed on [DATE] when she walked into R4's room there were two unidentified pills in a medication cup sitting on his side table. CNA E told R4 not to touch them and CNA E got LN D and LN D disposed of the pills. During an interview on [DATE] at 01:57 PM, LN D reported when she came on shift the morning of [DATE] CNA E reported a cup with two unidentified pills on the nightstand of R4's room. The nurse picked them up and destroyed them. 4. Review of R5's [DATE] Admission MDS revealed R5 had no speech, was rarely/never understood, and rarely/never understood others. The MDS noted the resident had severely impaired cognitive skills for daily decision making. R5 required total assistance of two or more staff for all ADLs. R5 had an indwelling urinary catheter, required oxygen, oral suctioning, and [MEDICAL CONDITION] care. Review of [DATE] Care Plan revealed R5 required total assistance for ADLs. Staff were to monitor lung sounds as needed. Staff were to provide [MEDICAL CONDITION] care as necessary and [MEDICAL CONDITION] (strings to anchor the [MEDICAL CONDITION]) were secured, suction as needed, and noted the resident had an indwelling catheter (a tube placed into the bladder to drain urine). R5 required tube feedings related to dysphagia (difficulty swallowing). Review of oxygen saturations in the EMR revealed no oxygen level recorded for the night shift of [DATE] to [DATE]. Review of R5's MAR for [DATE] revealed staff did not administer his 06:00 AM dose of [MEDICATION NAME] 0.5 mg on [DATE], to be given by feeding tube every 8 hours for anxiety/agitation (started on [DATE] per physician order). R5 did not receive his 06:00 AM dose of [MEDICATION NAME] tablet 10 mg on [DATE], to be given via feeding tube three times a day for muscle spasms (started on [DATE]). R5's midnight dose of [MEDICATION NAME]-[MEDICATION NAME] solution 0XXX,[DATE].5 (3) mg/3ml, 3 ml by [MEDICAL CONDITION] every 6 hours, for shortness of breath/wheezing was marked as a y and signed as given by LN C, however no minutes were recorded and the 06:00 AM on [DATE] treatment was not administered per the MAR as ordered per physician orders on [DATE]. The resident's [DATE] at 11:00 PM enteral feeding order for every four hours for nutrition via bolus: [MEDICATION NAME] (liquid nutrition) 1.5 can every four hours by feeding tube was not administered and neither was the [DATE] 03:00 AM administration. The associated [DATE] at 11:00 PM and [DATE] at 03:00 AM enteral feed flush of water before and after feedings of 75 ml were not administered as ordered on physician orders dated [DATE]. R5 did not receive his physician ordered (dated [DATE]) flushes to his [MEDICAL CONDITION] with saline and suction every 4 hours for prevention of mucus plug on [DATE] at 12:00 AM or 04:00 AM. Observation of R5 on [DATE] at 04:33 PM revealed the resident laid on his back with head and feet elevated. The resident had a [MEDICAL CONDITION] with oxygen running at 5 liters per [MEDICAL CONDITION]. 5. Review of R6's [DATE] Care Plan revealed R6 required extensive assistance of two staff for transferring and toilet use. Review of R 6's Physician Orders included: [DATE] [MEDICATION NAME] (narcotic pain medication) ,[DATE] milligrams (mg), give two tablets by mouth every four hours as needed for severe pain. [DATE] [MEDICATION NAME] ,[DATE] mg, give one tablet by mouth every four hours as needed for moderate pain. [DATE] pain monitoring- every shift; Review of [DATE] MAR and Treatment Administration Record (TAR) lacked documentation for the night shift of [DATE]. [DATE] [MEDICATION NAME] ([MEDICAL CONDITION] replacement hormone) 112 micrograms (mcg), give 112 mcg by mouth one time a day for [MEDICAL CONDITION]. Review of [DATE] MAR lacked documentation of administration on [DATE] at 06:00 AM. Observation of R6 on [DATE] at 04:16 PM revealed the resident rested in bed with the head of bed elevated. The resident had his walker beside the bed. 6. Review of R7's [DATE] Care Plan revealed R7 required supervision with toileting and transfer. Review of the [DATE] Admission MDS revealed a BIMS score of 14, indicating intact cognition. The resident required extensive two-person assistance for transfers and toilet use, unsteady balance, impaired range of motion on one side of the lower extremities and used a walker and wheelchair for mobility. The resident required PRN pain medications and nonpharmacological interventions for frequent pain that limited day-to-day activities and sleep. The resident rated the pain as a 7 on a scale of 0 to 10, with 10 being the worst pain. Physicians Orders dated [DATE] revealed R7 required pain monitoring every shift, however the [DATE] MAR lacked evidence of pain documentation on night shift for [DATE]-[DATE]. Physicians Orders dated [DATE] directed staff to monitor hours of sleep each shift for evaluation of medications used to treat [MEDICAL CONDITION]. Review of [DATE] MAR lacked documentation of sleep on the night shift on [DATE] to [DATE]. Physicians Orders dated [DATE] for behavior monitoring stated, if behaviors were present, a progress note had to be completed every shift. Review of [DATE] MAR lacked documentation of behaviors on night shift [DATE] to [DATE], related to the one-time dose of [MEDICATION NAME] (antianxiety medication) noted below. Physicians Orders dated [DATE] at 08:30 PM revealed [MEDICATION NAME] (antianxiety medication) 1 mg, give 1 mg by mouth one time only for anxiety. Review of [DATE] MAR revealed LN C administered this one-time order at 08:43 PM. Physicians Orders dated [DATE] for [MEDICATION NAME] ([MEDICATION NAME] with calming effects) 25 mg, give 25 mg by mouth every 6 hours for anxiety. Review of [DATE] MAR revealed missed documentation of 06:00 AM scheduled dose on [DATE]. Physicians Orders dated [DATE] at 06:00 AM revealed [MEDICATION NAME] 0.5 mg ordered on [DATE], give 0.5 mg by mouth four times a day for anxiety. Review of [DATE] MAR revealed missed documentation of 06:00 AM scheduled dose on [DATE]. Review of Pain Scale Assessments for [DATE] lacked evidence of documentation from [DATE] to [DATE] on the night shift. Observation of R7 on [DATE] at 04:18 PM revealed an alert resident watching TV in her room. 7. Review of R8's [DATE] Care Plan revealed the resident had a tendency to exhibit behavior issues such as resistive to care and potential to be aggressive towards others. The care plan instructed staff to administer medications as ordered. R8 required limited assistance of one staff with ADLs. Revision dated [DATE] revealed the resident wore Continuous Positive Airway Pressure ([MEDICAL CONDITION], apparatus worn with a mask to keep airways open during sleep) for sleep apnea (disorder of sleep characterized by periods without respirations). Review of Physician Orders dated [DATE] regarding pain monitoring, instructed staff to code pain interventions and address pain for R8 every shift. Review of the [DATE] MAR and TAR lacked evidence of documentation for pain assessments on [DATE] to [DATE] on the night shift. Review of Physician Orders dated [DATE] revealed [MEDICATION NAME] (medication used to treat low blood pressure) 5 mg, administer by mouth three times a day for [MEDICAL CONDITION] (low blood pressure). Review of the [DATE] MAR revealed missing documentation for [DATE] at 06:00 AM. Review of Physician Orders dated [DATE] revealed an order for [REDACTED]. Review of [DATE] MAR and TAR revealed no documentation for behavior monitoring on the [DATE] to [DATE] night shift. 8. Review of R9's Admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The resident required assistance of one person with ADLs and toileting. Review of the Physician Orders dated [DATE] and corresponding MAR revealed on [DATE] the 06:00 AM blood sugars were not recorded as done as ordered, and the resident did not receive insulin or oral antidiabetic medications. 9. Review of R11's Admission MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Review of R11's Care Plan dated [DATE] revealed [MEDICAL CONDITION] (kidney disease) requiring [MEDICAL TREATMENT]. Staff were to monitor during ADLs for sign/symptoms of shortness of breath. Staff were to monitor/document/report any signs or symptoms of bleeding, swelling, redness, warmth at access site upon returning from [MEDICAL TREATMENT]. Staff were to provide relief of discomfort from side effects of disease and treatment and take medications as ordered. Revision dated [DATE] directed staff to encourage and educate R11 to follow a fluid restriction. Review of the MAR for [DATE] revealed on [DATE] an order for [REDACTED]. Review of the MAR dated [DATE] indicated the resident received Basaglar (long acting insulin) eight units at 08:00 PM. Review of the MAR for [DATE] revealed the resident always wore a life vest (external defibrillator - treatment for [REDACTED]. The clinical record lacked evidence of documentation staff changed the battery on [DATE] from 07:00 PM through [DATE] at 07:00 AM, as ordered. Review of the MAR for [DATE]-[DATE] revealed an order for [REDACTED]. The MAR lacked documentation of completion of the order on the [DATE] 07:00 PM through [DATE] at 07:00 AM shift. Review of the MAR for [DATE] included an order to monitor sleep at night. There was no documentation of completion on the [DATE] 07:00 PM to [DATE] 07:00 AM shift. Observation on [DATE] at 04:40 PM revealed the resident laid in his bed on his back with the head of bed elevated. The resident rested quietly with a wheelchair beside his bed. The resident wore his life vest. Interview with CNA E on [DATE] at 02:05PM revealed on [DATE] when she and LN D arrived for the shift on [DATE], they heard a beeping sound and the medication cart was unlocked and the narcotic drawer was open on the Express Recovery. When they went towards the beeping in R3's room, LN C was in R3's room. LN D awakened LN C, who then tried to pick up the feeding tube and put it back together. While LN C was doing so, LN D placed the supplemental oxygen back on R3's [MEDICAL CONDITION]. When CNA E and the night shift CNA I were about to do rounds, she mentioned that a resident died . CNA E asked if anyone notified the family and CNA I said that was not her job. When the CNAs walked into R1's room, the resident was in bed and saturated in urine from head to toe. CNA I reported that she cleaned him up, but he clearly had urine all over. CNA E and LN D notified Nurse F because no one had been notified, and LN F came back to the Express Recovery unit. CNA E observed LN C attempt to call the family that morning, but he could not form words and his eyes were closing. CNA E stated Administrative Nurse F walked LN C out of the building at approximately 08:,[DATE]:45AM on [DATE]. R2 complained of pain to CNA E, saying his call light had not been answered all night, he said Thank God, the night shift nurse had not been in to help him with pain. There were two other residents, R3 and R5, that had beds that were completely wet with urine, and R3 had a bowel movement. During an interview on [DATE] at 12:54 PM LN D revealed she arrived to work at 07:00 AM on [DATE] and found LN C in R3's room sleeping. When she arrived on the unit, the feeding tube pump in R3's room was beeping because it was empty. The feeding was to run from 03:00 PM on [DATE] to 11:00 AM on [DATE]. She also noticed the narcotic drawer was left open in the medication cart on the Express Recovery. She then went towards the beeping, found LN C leaning, sleeping on R3's bed, and woke him. LN C told her that he came into R3's room because he heard the beeping and the feeding tube was undone, so he tried to fix it. R3's oxygen was off R3's [MEDICAL CONDITION] and the air mattress deflated, so LN D plugged the air mattress back in and placed R3's oxygen back on his [MEDICAL CONDITION]. LN D assessed R3's oxygen levels, which was 90% and assessed pain, but he did not have signs or symptoms of distress or discomfort. LN C's glasses were on the floor, so LN D picked them up and she noticed R1's [MEDICATION NAME] bottle under the medication cart, then placed it on top of the medication cart. LN D reported that during that time, LN C walked into multiple resident rooms and tried to walk to the bathroom. LN D then went to get Administrative Nurse F and told her about LN C's behavior, reporting LN D was off the unit about five minutes. LN D then returned to Express Recovery and attempted to count narcotics with LN C, and LN D reported LN C could not see or write. LN C then went to the bathroom again. LN D looked over the narcotic count (detailed audit of the quantity of the current stock of a drug on hand compared with the amount dispensed to determine any losses or overages) and noted that the [MEDICATION NAME] for R1 was wrong. The [MEDICATION NAME] bottle for R1 had 24cc left when she found the bottle with 6 cc missing (120 mg). Administrative Nurse F verified R1's [MEDICATION NAME] sulfate count. LN C reported to LN D that he tried to call R1's family about his death. LN D did not suspect impairment with LN C until LN D noticed the [MEDICATION NAME] balance was wrong. Interview on [DATE] at 05:05 PM with Administrative Nurse F revealed she became involved with the incident when LN D told her the narcotic count was wrong. Administrative Nurse F approached the medication cart while LN C and LN D counted the narcotics. Everything was okay until they counted the liquid [MEDICATION NAME] for R1, and it did not measure right. Administrative Nurse F looked at the [MEDICATION NAME] bottle and compared it to the count sheet. LN C attempted to document doses given on the narcotic sheet. Administrative Nurse F took the count sheet and asked LN C how often he gave it throughout the night. He told her he gave 0.25 ml every hour. When asked when the last dose was given, he could not answer. Administrative Nurse F asked him where the rest of the [MEDICATION NAME] was, and he could not account for the missing [MEDICATION NAME]. She asked LN C if he gave his drug keys to anyone during the shift and he reported he did not. Administrative Nurse F reported she wrote out what the [MEDICATION NAME] should have been if LN C gave it like he said and there was still missing [MEDICATION NAME]. That conversation took ,[DATE] minutes due to LN C not understanding, falling asleep, and slurred speech. LN C became very agitated with questions and denied taking the medication. He became very disruptive and argumentative with Administrative Nurse F, so she told him to gather his belongings and leave. LN C could not walk straight and kept getting in front of Administrative Nurse F asking her not to call Administrative Nurse B repeating this over and over, and insisted he was not impaired. He clocked out and exited the building. Administrative Nurse F stepped out and saw LN C walking at the edge of the parking lot and at that point she called Administrative Nurse B. Administrative Nurse B took over from there while LN C was still in parking lot. Interview with Administrative Nurse B on [DATE] at 04:45 PM revealed she did not know there was no documentation for the extra [MEDICATION NAME] for R7's behaviors. When asked when she was notified of the situation, she reported Administrative Nurse F called her and she was at the facility in 20 minutes. Administrative Nurse B stated, she would have expected documentation for pain, any assessments and cares from nurses, CNAs, or any other employee that had information on residents and observations of staff. Review of the facility policy Provision of Care dated 2019 revealed each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. All employees are responsible for following established policies and procedures. Review of the Documentation in Medical Record policy dated ,[DATE] revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Licensed staff and interdisciplinary team members shall document assessments, observations, and services provided in the residents' medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Review of the facility policy Providing End of Life Care dated [DATE] revealed assessment and evaluation may be documented by multiple members of the interdisciplinary team (e.g. nurses, practitioner, social worker, dietician, etc.). The facility failed to prevent the neglect of 13 residents when Licensed Nurse (LN) C failed to provide necessary nursing care during his shift from 07:00 PM on [DATE] through 07:00 AM on [DATE] which constituted immediate jeopardy at F600. The immediate jeopardy at F600 also constituted Substandard Quality of Care at 42 CFR 483.12. The immediate jeopardy was determined to first exist on [DATE], when LNC received report and assumed responsibility for multiple residents which required complex nursing care. LN C consumed R1's [MEDICATION NAME] at an undetermined time and cared for his assigned residents while impaired. The deficient practice was cited as past non-compliance when LN C left the building [DATE], the facility reconciled all medication carts, reassessed pain for all residents under the care of LN C, and provided education on [DATE] to anyone starting there shift on Reporting of erratic behavior of other employees. The deficient practice remained at a scope and severity of K.

The facility census totaled 90 residents, with 13 residents in the Express Recovery. Based on interview and record review the facility failed to prevent the missappropriation of Resident (R)1's [MEDICATION NAME] (an addictive opioid medication used to treat moderate to severe pain) when Licensed Nurse (LN) C consumed an unknown quantity of R1's [MEDICATION NAME] during an unspecified time during his shift between 05/01/20 at 07:00 PM until 05/02/20 at 07:00 AM. The misappropriation of R1's [MEDICATION NAME] by LN C placed the 13 residents under his care in immediate jeopardy. Findings included: - Review of R1's Electronic Medical Records (EMR) included a diagnosis, dated 05/01/20, of cerebral infarction (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). Review of 01/29/20 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of two indicating severely impaired cognition. The resident had scheduled pain medications for mild, occasional pain that limited day-to-day activities when present and daily opioid (narcotic pain medication) used in the seven-day review period. Review of the Care Plan revised on 04/08/19 directed staff to monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Review of Physician order [REDACTED].>05/01/20- Admit R1 for end of life care. 05/01/20 at 10:15 PM revealed an order for [REDACTED]. Review of May 2020 Medication Administration Record [REDACTED]. Review of the Narcotic Count Sheet for R1, dated 05/01/20, revealed one documentation of 0.25ml given at 10:00 PM and 0.25ml dose given at 11:00 PM. The third documentation was not legible. Review of LN C's Witness Statement dated 05/01/20 reported that he administered a total of eight doses of the [MEDICATION NAME]. There was no documentation that R1 received the remaining five doses of [MEDICATION NAME]. Review of an E-mail (electronic mail) from LN D to Administrative staff A dated 05/04/20 revealed LN D completed the end of shift report with LN C with the following information: R1 transferred to the behavioral unit for evaluation, and then transported from there to the hospital with a [DIAGNOSES REDACTED]. R1 was in a stuporous (lacked critical mental function and level of conciousness) state, not responding to verbal or tactile stimuli, and no facial grimacing. LN C asked LN D if R1 had orders for [MEDICATION NAME] or [MEDICATION NAME] (medication used to treat anxiety). R1 had orders for [MEDICATION NAME] and [MEDICATION NAME] (a narcotic pain medication), but not for [MEDICATION NAME]. LN D relayed to LN C that R1 had no indicators of pain since he arrived back at the facility. LN D told oncoming LN C to check R1 frequently due to his condition. Review of R1's EMR for the tweleve hour 7 PM - 7 AM shift on 05/01/20 to 05/02/20 lacked evidence of nursing notes, nursing assessments of the resident, or completion of pain assessments. Review of an E-mail from Physician Extender K to Adminitstrative staff A dated 05/04/20 revealed LN C notified physician extender K on 05/01/20 at 10:06 PM that end of life care began, and oxygen saturation (oxygen in the blood) was in the 70th percentile (normal range 92-100%) and the resident needed [MEDICATION NAME] for comfort. Review of the 05/02/20 Facility Investigation revealed the witness statement completed by LN C stated, R1 received approximately eight doses and passed away. That was when I, (LN C), took some oral ([MEDICATION NAME]) by mouth and do not remember much after that. The facility reported incident identified 6 ml of [MEDICATION NAME] sulfate unaccounted for, which equaled to 120 mg of [MEDICATION NAME]. Interview with Certified Nurse Aide (CNA) E on 05/13/20 at 02:05 PM revealed on 05/02/20 when she and LN D came on shift, they heard a beeping sound and noticed the narcotic drawer was open on the medication cart. When they went to the beeping in R3's room, LN C attempted to pick up the feeding tube and put it back together and hook oxygen to the resident. Interview with CNA G on 05/14/20 at 07:13 PM revealed on 05/02/20 at approximately 07:10 AM when he got to the Express Recovery Unit was that LN C was sweating a lot and he looked tired. Interview with LN C on 05/13/20 at 01:23 PM revealed R1 had air hunger at 07:00 PM on 05/01/20 when he had come on shift and the day shift nurse reported he did not have much longer to live. He reported that he called the on call physician on 05/01/20 at 07:00 PM after he assessed R1 because he was alert to mild painful stimuli, not obeying commands, had his mouth wide open with dry oral secretions, concerning lung sounds, and was pale. LN C did not remember what R1's vital signs were, but said it was evident that he was at the end of his life. He then stated maybe he called the doctor's office for the [MEDICATION NAME] at 08:00 PM on 05/01/20, but he did give eight doses of the [MEDICATION NAME] to R1. LN C said he administered to R1 a dose of [MEDICATION NAME] at 08:00 PM on 05/01/20 and every hour until 03:00 AM on 05/02/20. He stated at 04:00 AM on 05/02/20, he noticed R1 had passed away. At 04:30 AM, he took a little sip of R1's [MEDICATION NAME]. LN C reported this was the first time he had slipped up in two years and eight months. He had no idea why he drank R1's [MEDICATION NAME]. He stated he had not ever stolen from a resident at the facility. During an interview with LN D on 5/11/2020 at 07:25 AM revealed she came on duty for the day shift on 05/02/2019 to work the unit. When she arrived, LN C was acting like he was really out of it. Both tried to count narcotics, but he was sweating, could not focus on counting, and there was a problem with missing [MEDICATION NAME]. During an interview with LN D on 05/13/20 at 12:54 PM revealed she got to work at 07:00 AM and found LN C sleeping in R3's room. LN D woke LN C and noticed he was slurring his words and confused. LN D noticed that LN C glasses were on the floor, and when she picked them up, she noticed R1's [MEDICATION NAME] bottle under the medication cart and placed the [MEDICATION NAME] bottle on top of the medication cart. She reported during that time, LN C walked in and out of multiple resident rooms and tried to walk to the bathroom. When she attempted to count narcotics with LN C, he could not see or write. He then went to the bathroom again, and while he was gone, LN D looked over the narcotic count and noted the [MEDICATION NAME] for R1 was off from count sheet. The [MEDICATION NAME] bottle for R1 had 24 ml left out of 30 ml when she found the bottle. Interview with Administrative Nurse F on 05/13/20 at 05:05 PM revealed she got involved with the incident when LN D told her the narcotic count was off. She approached the medication cart while LN C and LN D were counting the narcotics. Everything was okay until they counted the liquid [MEDICATION NAME] for a resident, and it did not measure right. When she got there, she looked at the bottle and compared it to the count sheet. LN C then attempted to document doses given on the narcotic sheet. Nurse F then asked LN C how often he administered the [MEDICATION NAME] to R1 throughout the night and LN C told her he had given 0.25 ml every hour. When Nurse F asked LN C when he administered the last dose of [MEDICATION NAME] to R1 and why there was missing [MEDICATION NAME], LN C could not answer or account for the missing [MEDICATION NAME]. Nurse F then asked LN C if he had given his drug keys to anyone during the shift and he reported he did not. Nurse F reported she wrote out what the [MEDICATION NAME] should have been if LN C gave it like he said, but stated there was still missing [MEDICATION NAME]. Nurse F said the conversation took 20-30 minutes due to LN C not understanding questions, slurring his speech, and not able to keep his eyes open. LN C was very disruptive, argumentative, agitated with questions, and denied consuming the medication. Nurse F instructed LN C to gather his belongings, but LN C could not walk straight and kept standing in front of Nurse F asking her not to call Administrative Nurse B, repeating the sentence over and over. Interview with Administrative Nurse B on 05/11/20 at 05:20 AM revealed on 05/02/20 LN D and Administrative Nurse F attempted to stop LN C from leaving the facility, but he walked outside to the parking lot between two cars and fell . He continued to fall while attempting to ambulate. Administrative Nurse B called Emergency Medical Services (EMS), and two doses of [MEDICATION NAME] (medication that reverses narcotics) were administered to LN C. After the two doses he became more alert but still had signs of impairment. During a follow-up interview with Adminstrative Nurse B on 05/14/20 at 04:45 PM revealed after identification of the missing [MEDICATION NAME], Nurse F held onto the [MEDICATION NAME] until placement in the secured lockbox by 10:00 AM on 05/02/20. Nurse B questioned LN C about the signs and symptoms of R1, and it was evident from LN C assessment of R1 that the resident needed the [MEDICATION NAME] for comfort. She did not know if R1 got all the doses that LN C said he gave. She hoped he did get those doses. Review of 2017 Resident Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure policy revealed Recover Care explicitly and expressly prohibits, and will take steps to prevent, any Associates from engaging in any behavior or actions that may result in the abuse, neglect, and exploitation of residents and misappropriation of resident property. Review of revised 10/2017 The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure policy revealed exploitation was defined as the fraudulent or otherwise illegal, unauthorized, or improper act or process of an individual, including a caregiver or fiduciary, that uses the resources of an elder for personal benefit or gain. The facility failed to ensure R1's [MEDICATION NAME] was not misappropriated by LN C when the facility discovered LN C consumed R1's [MEDICATION NAME] at an unknown time during his shift. LN C was responsible for 13 residents and cared for these residents while impaired.which placed the 13 residents under his care in immediate jeopardy. The deficient practice was cited as past non-compliance when LN C left the building, the facility reconciled all medication carts, reassessed pain for all residents under the care of LN C, and provided education on 05/02/20 to anyone starting there shift on Reporting of erratic behavior of other employees. The deficient practice remained at a scope and severity of J.

The facility had a census of 109 residents, with 6 residents selected for sample. Based on interview and record review, the facility failed to ensure 1 of 6 residents remained free from neglect when staff failed to adequately assess and treat a deterioration in the resident's physical condition over an approximate 2 hour time period, failed to notify Hospice of the changes, and failed to notify the resident's physician. The resident expired approximately 2 hours after staff first noted the resident's deterioration. (Resident #1) Facility failure to ensure the resident remained free of neglect placed the resident in immediate jeopardy. Findings included: - Resident #1's clinical record included a [DIAGNOSES REDACTED].) [MEDICAL CONDITION] (inadequate exchange of gases within the respiratory system) with [MEDICAL CONDITION] (inadequate supply of oxygen), [MEDICAL CONDITION] (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dependence on supplemental oxygen. The [DATE] Significant Change MDS (Minimum Data Set) identified the resident with long and short-term memory problems, independent decision making abilities, dependence on staff for extensive assistance with bed mobility and transfers, shortness of breath (difficulty breathing) with exertion, no shortness of breath when sitting at rest, life expectancy of 6 months or less, use of supplemental oxygen and enrollment in hospice care. The [DATE] Care Plan directed staff to check oxygen saturation levels as ordered and Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Review of the [DATE] physician's orders [REDACTED].'s terminal [DIAGNOSES REDACTED]. Review of oxygen saturation level documentation since the [DATE] order for saturation levels twice daily revealed the staff failed to obtain/record oxygen saturation levels twice daily as ordered on (MONTH) 24, 26 and 29 of 2019. The staff failed to obtain/record oxygen saturation levels twice daily as ordered on (MONTH) 3, 5, 9, 16, 22, and 25 of 2019. According to the documentation, the resident had an oxygen saturation level of 91% on [DATE] at 9:57 p.m Review of the clinical record lacked evidence staff completed a thorough nursing assessment after obtaining the 91% oxygen saturation reading. The documentation lacked evidence staff monitored oxygen saturation levels at all on [DATE]. Documentation of the resident's vital signs lacked evidence staff assessed resident #1's vital signs in the 72-hour time period prior to his/her death on [DATE]. Progress notes lacked any entries related to resident #1's medical/respiratory condition and/or the presence of increased secretions/respiratory issues on [DATE]. The progress notes also lacked any entries related to the resident's death in the evening hours of [DATE]. The facility provided an investigation into an allegation of neglect which involved resident #1 and an incident which occurred on [DATE]. According to that investigation, resident #1 developed increased oral secretions after the evening meal on [DATE]. Direct care staff D noticed the increased secretions/mucous coming from the resident's mouth and immediately notified licensed nurse/charge nurse C. Nurse C directed direct care staff D to clean the resident's mouth with a swab and mouthwash. Staff D attempted to do as the nurse asked, and when the attempts were unsuccessful, Staff D went back to the nurse to advise him/her of a continued problem with secretions/mucous coming from the resident's mouth. Licensed nurse C failed to immediately assess/treat the resident's condition. At approximately 7:00 p.m., direct care staff told licensed nurse E, the oncoming charge nurse, of resident #1's respiratory condition and nurse E immediately assessed the resident, determined he/she was in respiratory distress with blue tinged lips and fingers, and went to get suction equipment. The resident expired before licensed nurse E could use the suction equipment. As part of the facility's previously referred to investigation, administrative nurse B and administrative nurse F interviewed licensed nurse C who was the charge nurse at the time resident #1 began to experience respiratory issues on [DATE]. According to investigation documents, nurse C reported resident #1 had copious amounts of mucous and the resident's lungs were full. Nurse C went on to say the resident was on hospice and a DNR (do not resuscitate) and there was nothing that could be done. Nurse C also confirmed he/she failed to notify hospice or the resident's physician about the deterioration in the resident's medical condition. The facility also provided a document entitled Incident Facts related to the [DATE] incident. On that document, the facility identified the Root Cause Analysis as: Licensed nurse C identified that the resident possibly aspirated and did not provide immediate emergency care. Licensed nurse C was terminated on [DATE] for failure to provide emergency care. Original information provided by the facility to the Survey and Certification Agency Complaint Hotline included recent implementation of an improvement plan for licensed nurse C related to a direct care staff complaint in (MONTH) 2019 in which Nurse C allegedly failed to respond in a timely manner to assess a resident following a fall. The facility's investigation included a PIP (Performance Improvement Plan)/Action Plan for licensed nurse C dated [DATE]. One expected standard of performance included on the plan was, Nurse will respond immediately to resident concerns communicated by other staff. The desired outcome for that area was Immediate attention to injuries/decline. A transcribed note dated [DATE] from resident #1's primary care physician noted the resident's death on [DATE] was from complications of [MEDICAL CONDITIONS]. During a telephone interview on [DATE] at 10:22 a.m., licensed nurse C reported he/she noticed resident #1 had increased secretions prior to the evening meal on [DATE]. According to nurse C, he/she cleaned the secretions from the resident's mouth by using his/her fingers and then sent the resident to the dining room. Nurse C described the secretions as tenacious (thick, colorless). Nurse C confirmed he/she failed to take vital signs, oxygen saturation levels or complete other nursing assessments of the resident's respiratory/medical condition at that time. After the evening meal, licensed nurse C reported one of the direct care staff advised him/her that the resident vomited. Nurse C recalled he/she went to the resident and cleaned his/her mouth and again there seemed to be a lot of mucous in the mouth, but the resident did not seem to be in respiratory distress. Nurse C confirmed he/she again failed to monitor vital signs, oxygen saturation levels or complete other assessments related to the resident's change in respiratory status. Licensed nurse C reported he/she got busy with other things and then suddenly, the oncoming nurse was there and thought resident #1 should be suctioned. Resident #1 expired shortly thereafter, prior to suctioning. According to licensed nurse C, he/she never considered using suction to manage the resident's secretions, and never considered calling hospice or the resident's physician. Nurse C also described the hours preceding the incident with resident #1 as hectic because his/her assignment included a different nursing unit than usual and I basically had 50 residents to take care of that I didn't know. During an interview on [DATE] at 9:06 a.m., direct care staff D reported he/she first saw a change in resident #1 after the evening meal on [DATE]. At that time, staff D saw resident #1 sitting in his/her wheelchair down by the water fountain. The resident had white stuff coming out of his/her mouth. Staff D recalled he/she instructed resident #1 to cough and spit, but the resident repeatedly said, I can't, I can't. Staff D then wheeled the resident to the nurses' station and showed licensed nurse C the resident's condition. According to direct care staff D, licensed nurse C instructed him/her to take the resident to his/her room and swab out the resident's mouth with swabs and mouthwash. Staff D reported he/she tried to do as the nurse directed, but thick white stuff kind of like soap bubbles continued to come out of the resident's mouth. Staff D reported he/she then went back to licensed nurse C to advise him/her of the continuing problem and nurse C told staff D he/she would go check on the resident in a second. Since direct care staff D believed Licensed Nurse C was on his/her way to assess the resident, Staff D went to provide care to another resident. Approximately 30 minutes later, after providing care to the other resident, Staff D returned to the hallway and noticed other staff around resident #1 and the resident looked bad. According to staff D, licensed nurse C was not one of the staff near the resident. As other staff members, including oncoming licensed nurse E ran to get suction equipment, licensed nurse C entered the room, but did not assist in any way. Direct care staff D reported resident #1 expired before nurse E had a chance to suction him/her. During an interview on [DATE] at 3:20 p.m., administrative staff A reported the facility investigated the [DATE] incident involving resident #1 and concluded the facility's systems for dealing with declines in resident condition worked except for licensed nurse C's response to the emergency situation. According to administrative staff A, the facility terminated licensed nurse C after the incident. During an interview on [DATE] at 9:05 a.m., administrative nurse B reported he/she can't understand why the nurse didn't go assess the resident. Nurse B verbalized a belief licensed nurse C failed to take action on resident #1's behalf because the resident was a DNR and on hospice. During an interview on [DATE] at 7:00 a.m., administrative nurse B reported he/she worked with licensed nurse C to improve his/her response time and listening to what other staff told him/her about the residents. Administrative nurse B recalled a fall on the Memory Unit in which a direct care staff member reported licensed nurse C failed to respond in a timely manner and according to Administrative Nurse B, that issue was written into Nurse C's action plan/performance improvement plan. The facility's Abuse Prohibition policy with a revision date of [DATE] defined neglect as failure of the Center, it's employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The [DATE] Change in Condition: Notification Of policy included, A Center must immediately inform the patient, consult with the patient's physician and notify, consistent with his/her authority, the patient's Health Care Decision Maker when there is .a significant change in the patient's physical, mental or psychosocial status (that is, deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). The facility failed to ensure resident #1 remained free of neglect when staff failed to adequately assess and treat a deterioration in the resident's physical condition over an approximate 2 hour time period, failed to notify Hospice of the changes, and failed to notify the resident's physician. The resident expired approximately 2 hours after staff first noted the resident's deterioration. Facility failure to ensure the resident remained free of neglect placed the resident in immediate jeopardy. The facility implemented corrective action beginning on [DATE] as follows: o Immediately suspended licensed nurse C for failure to provide emergency care to resident #1 o Completed licensed nurse education face to face on [DATE] to 22 of 24 nurses employed by the facility. The facility had a written plan for education of the remaining two nurses prior to the start of their next shifts. Topics for the nursing education were emergency care for hospice residents and emergency care for residents who have elected the DNR option. o Terminated licensed nurse C on [DATE] for failure to provide emergency care to resident #1. o Reported licensed nurse C to the Kansas State Board of Nursing on [DATE] for substantiated neglect The J level finding was corrected on [DATE] and was considered past noncompliance.

The facility identified a census of 103 residents and three residents sampled for falls. Based on observation, record review and interview the facility failed to provide supervision and assistance devices to each resident to prevent avoidable accidents. The facility assessed, and care planned for Resident #1 to be transferred with an assistance device (Hoyer Lift) and a facility staff failed to follow the care plan and transferred the resident with a gait belt, resulting in fractures to both of Resident #1's legs. Findings included: - The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1's annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderately impaired cognition. The resident required extensive assistance of one staff for bed mobility and eating, total dependence of two staff for transfers and toilet use and total dependence of one staff with locomotion on and off the unit, dressing and personal hygiene. The MDS further indicated the resident had no falls since the previous MDS assessment. Review of the Quarterly MDS, dated [DATE], revealed a BIMS score of 8 which indicated moderately impaired cognition. Resident #1 required extensive assistance of one staff with bed mobility and eating, total dependence of two staff with transfers and toilet use, total dependence of one staff for locomotion on and off the unit, dressing and personal hygiene and no falls since previous MDS assessment. Review of the facility Morse Fall Assessments (simple method of assessing a patient's likelihood of falling) for Resident #1 on 6/2/2018 and 9/2/2018 identified the resident at high risk for falling. Resident #1's care plan, dated 7/17/2018, identified the resident at risk for falls related to weakness, history of falls, balance deficit, medication regimen and incontinence. The care plan further instructed staff of the resident's decreased ability to perform activity of daily living (ADL) task and needed assist of one staff for personal hygiene and two staff assist with bathing, bed mobility, check and change, dressing and transfers with Hoyer lift, assist of two updated on 9/21/2018. Resident #1's care plan was updated on 10/4/2018 identified and addressed the resident had fractures of the Bilateral Lower Extremities (BLE) (left and right femurs - the femur or thigh bone is the bone in upper leg from knee to hip joint.), required braces to bilateral lower extremities to immobilize BLE. The care plan directed staff to monitor pain, monitor the color of toes, exposed skin and check for pedal pulses (feeling of blood flow to feet) every shift and remove splints and ace wraps and check skin integrity daily. Review of the facility documented progress notes dated 9/27/2018 at 7:35 A.M. revealed the CNA (certified nurse aide)/ Restorative aide reported a large dark bruise on the resident's left inner thigh to the charge nurse. The CNA stated that resident did not have this bruise yesterday on day shift. The CNA was not sure how the resident got the bruised area but thinks it may have happened during evening or night shift on Wednesday 9/26/2018. The resident was unable to tell staff when or how the bruise happened. The resident was asked if he/she was hurt while being transferred or when being repositioned in bed and resident stated, I don't know. The resident indicated the bruised area on the leg was a little sore but not hurting too bad. The bruise was large, oblong shaped, very dark purple on the left inner thigh. No open areas, swelling or visible signs of injury at this time. Two staff members assisted the resident up in wheelchair without incident using the Hoyer lift. The Director of Nursing (DON) was notified of the injury due to unknown cause at this time. All staff members working on Wednesday 9/26/18 will be questioned on how or when bruise may have occurred. The physician and spouse were notified of the bruised left thigh. Review of the facility documented progress note dated 9/27/2018 at 9:00 A.M. It was reported to this nurse that resident had large bruise to L(left) thigh. Origin of injury is unknown however; resident's transfer status was recently changed from a 2 person assist to a Hoyer lift. Upon investigating, the conclusion was made that the injury was caused by resident newly being transferred via Hoyer lift with a criss cross sling which crosses between the resident's legs. Intervention: Res to use full body sling and not criss cross sling at all times. Staff made aware and full body sling placed in resident's room. Review of the facility documented progress note dated 9/28/2018 at 7:45A.M. revealed an assessment of the bruise to the resident's left inner thigh was dark purple in color and the resident asked staff not to press on his/her leg due to pain. Review of the facility documented progress note dated 9/29/2018 at 7:45 A.M. revealed the bruise to left thigh remained purple in color with not much change from yesterday's assessment and the resident stated it hurts. Review of the facility documented progress note dated 9/30/2018 at 7:45 A.M. revealed the resident was up in the wheelchair with no sign or symptoms of pain or discomfort from his/her left leg bruise. The assessment of the bruise revealed it remained dark purple in color and the resident had no complaint of pain with palpitation. Review of the facility documented progress note dated 10/1/2018 at 10:15 A.M. revealed the night nurse reported the resident had swelling to the left upper leg, in addition to bruising noted earlier this week (9/27/18). The resident was now having swelling and redness of the left leg to the knee area and the left knee was rotated inward. When asked if the leg hurts the resident stated yes but only when his/her leg was palpated or examined by staff or with repositioning. The resident states no pain to left leg while laying still in bed. The resident was unable to state what happened to his/her leg. He/she answered basic questions appropriately only at times. The resident was staying in bed to prevent having to move his/her leg as much as possible. Resident seen by nurse practitioner and new orders received for X- rays of femur, left hip, pelvis and left knee. Verbal order also given from nurse practitioner that resident may be sent to emergency room (ER) if X-ray reports show that resident has fracture to left leg. Mobile x-ray services called and x-rays to left leg ordered. Family notified of new orders. Review of the facility documented progress note dated 10/1/2018 at 17:30 (5:30 P.M.) revealed the report received from Mobile X-ray services revealed the resident had a fracture to his/her left femur. Family notified of the resident transfer to the emergency room for fractured left leg. A call placed to Emergency dispatch and Emergency Medical Services (EMS/Ambulance) arrived at 1710 (5:10 P.M.). The resident placed on sling carefully and slid onto board with several staff members assisting. Resident transferred out of facility to local hospital per EMS without difficulty. Review of the facility documented progress note dated 10/1/2018 at 23:10 (11:10 P.M.) reveaeled the resident returned per EMS with splint and ace bandage covering splint, knee immobilizer placed to help with keeping leg from moving, and an appointment to be made with orthopedic physician with- in 1 week. Assessment of the resident revealed a splint in place with immobilizer on left leg, circulation to lower part of splint has toes pink no swelling and good cap refill, above splint no swelling or discoloration except the bruising that was already there, family decided it would be too much for the resident to have any surgery. Radiology Results Report dated 10/1/2018 indicated an acute spiral left femur fracture involving distal femur with displacement. (A spiral fracture is a bone fracture occurring when torque is applied along the axis of a bone. Spiral fractures often occur when the body is in motion while one extremity is planted.) Review of the facility documented progress note dated 10/5/2018 at 13:16 (1:16 P.M.) Resident out of the facility less than 24 hours, resident alert and oriented to self and situation. Transferred to bed with 4 assist, non-verbal but smiles at staff. Denies pain at this time and given pain medication prior to discharge from hospital. Immobilizers/ace wraps on bilateral legs. No swelling or tightness around ankles and groin area. Right groin with purple bruise. Toes warm with good capillary refill. On air mattress and repositioned for comfort. Resting in bed at this time. Review of the facility documented progress note dated 10/8/2018 at 13:05 (1:05 P.M.) Incident Note Text: On 10/4/18, staff noticed a deformity to the resident's right thigh area. MD notified, stat x-ray showed an acute comminuted fracture (A comminuted fracture is a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma such as in vehicular accidents.) of the distal (lower) right femur. Resident was sent to ER for evaluation and returned after decision was made to not proceed with surgery and elected hospice services. Review of the facility Self-Reported investigation dated 10/8/18, indicated a large purple bruise on Resident #1's left thigh was reported to the Director of Nursing on 9/27/2018. The resident did not know the origin of the bruise, but the bruise lined up with the cross-body sling being used for transfers. On 10/1/2018 the resident complained of pain in left leg and the nurse assessment noted a deformity to the left thigh area. MD notified and gave orders to do stat x-ray. X-ray showed an acute spiral [MEDICAL CONDITION] distal femur. The resident was sent to the emergency room for evaluation and treatment and returned the same day with an ace bandage and knee immobilizer. The resident's spouse does not wish for the resident to have surgery. On 10/4/2018 staff observed the resident to have right knee swelling. MD in facility and assessed the resident. X-ray ordered and showed a comminuted [MEDICAL CONDITION] femur with moderate displacement and impaction. Resident again sent to the emergency room for evaluation and treatment and returned in less than 24 hours with ace bandage and knee immobilizer. After the 10/1/2018 swelling and increased redness and pain in the left thigh, and the subsequent [DIAGNOSES REDACTED]. Staff members who worked with Resident #1 from 9/27/2018 to 10/1/2018 were interviewed related to cares and transfers for Resident #1. Staff C was suspended on 10/5/2018 after review of witness statements for allegation of failure to follow care plan. Staff C did admit to not following the plan of care on the date prior to the initial injury to Resident #1. Review of the Notarized statement given by direct care staff C indicated care was provided to Resident #1 on 9/27-28/2018. Staff C did not notice bruise on Resident #1's leg on 9/27/2018 but did notice it on 9/28/2018. When asked how Resident #1 was transferred Staff C answered a two person transfer with gait belt. On 10/15/2018 at 11:35 A.M. an observation revealed direct care staff D and E transferred Resident #4 with Hoyer lift. Staff placed the Hoyer lift transfer sling under the resident, connected to the lift so that the resident head was always higher than the feet, resident lifted and one staff operating the lift while the second staff stood behind the resident to stabilize the resident and the resident guided and lowered into the wheelchair. On 10/15/2018 at 11:45 A.M. observation revealed the resident in bed asleep with bilateral leg splints on. On 10/15/2018 at 4:40 P.M. observation revealed the resident in bed with bilateral leg splints on and TV on. On 10/16/2018 at 11:10 A.M. observation revealed asleep in bed with bilateral leg splints on. On 10/16/2018 at 11:15 A.M. an observation revealed direct care staff F and direct care staff E transferred resident #5 with use of Hoyer lift. Staff E and Staff F used proper technique. On 10/17/2018 at 12:15 P.M. observation revealed the resident's husband in the room waiting on noon meal to arrive, so he could feed the resident. The resident had on bilateral leg splints in bed. On 10/22/2018 at 7:40 A.M. observation revealed the resident slept in bed with bilateral leg splints on. On 10/17/2018 at 11:45 A.M. an interview with administrative staff A indicated the facility notified the state agency on 10/2/18 at 1:15 P.M. Review of the facility investigation revealed witness statements from staff interviews dated 10/1/18 through 10/8/18. One staff member was terminated on 10/5/18 for indicating they transferred resident #1 with a gait belt and not he Hoyer lift per the 9/27/18 care plan. On 10/17/2018 at 12:00 P.M. an interview with administrative nursing staff B indicated once the facility noticed the bruising and swelling on Resident #1's leg the facility notified the MD and ordered an x-ray. When the results came back the facility started and investigation and reported to the state survey agency. The facility interviewed all staff that had worked on the hall with the resident and obtained notarized statements from all the staff. One staff member (Staff C) did admit to transferring the resident with two assist and gait belt (not the care planned two assists with Hoyer lift). None of the staff working during that period with Staff C verified they assisted Staff C with a gait belt transfer on 9/27/2018. Staff C was terminated for not following the resident's care plan for transfers. Review of the facility's Safe Resident Handling/Transfer Equipment Reviewed 3/1/2016 revealed: Staff may use Safe Resident Handling Equipment, such as lifts or repositioning equipment, for patients when needed. Patients will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment. Slide boards are an approved method of transfer. The Total Lift will be used as the primary intervention to manual lifting, transferring, and repositioning and requires a minimum of two persons to perform the lift. The Total Lift is used for those patients who are dependent non-weight bearing or have inconsistent weight bearing. In addition, the total lift will be used to lift patients off the floor, unless contraindicated. The divided leg sling is used with the total lift for the majority of patients. The full body sling is used only when the divided sling in not appropriate. Examples include: History of [MEDICAL CONDITION], hip surgery, or hip replacement with the last 12 months; Inability of patient to lean forward independently or with minimal assistance while sitting in a sling placement. The facility failed to ensure direct care staff followed the residents care plan for safe transfers for this cognitively impaired dependent resident which resulted in a fractured left leg identified on 10/1/18 and a fractured right leg on 10/4/18.

The facility identified a census of 102 residents, with 15 residents who resided in the memory care unit. Two residents were sampled for resident to resident abuse. Based on observations, record review, and interview the facility failed to implement appropriate measures for two residents on the Memory Care Unit to prevent an opposite gender sexual contact. The Resident #1 had behaviors of wandering and inappropriate undressing on the unit and Resident #2 (opposite gender) had behaviors of undressing, wandering the unit without any pants on, wandering into other resident rooms, making sexual comments to staff and inappropriate touching of self. The facility failed to monitor and protect all opposite gender residents on the Memory Lane Unit. Resident #2's behaviors resulted in an Immediate Jeopardy. Findings included: - The facility admitted Resident #1 to the Memory Lane (Dementia unit, a secured unit for residents with progressive disorder characterized by failing memory and confusion) with [DIAGNOSES REDACTED]. Resident #1's Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition, behaviors of wandering and resisting care. He/she required extensive assistance of one staff for bed mobility and transfers and limited assistance of one staff for ambulation in his/her room and corridor, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. A Quarterly MDS assessment, dated 7/19/2018, revealed a BIMS score of 12 which indicated moderately impaired cognition, physical and verbal behaviors directed towards others, rejected care and wandered. He/she required extensive assistance of one staff with transfers and toilet use, limited assistance of one staff of bed mobility, ambulation in room and corridor, dressing, eating and personal hygiene. Resident #1's care plan, dated 6/19/2018, instructed staff to assist the resident with bathing, grooming, toilet use and transfers due to resident behaviors. The care plan indicated the resident had tendencies to exhibit behavior of resisting care, potential to be aggressive towards others, fabricate stories and make false allegations. The care plan instructed staff to redirect the resident when he/she chose to lie down on the floor instead of the bed. He/she also showed poor impulse control and refused care. He/she would take his/her clothes off, spend time in his/her room, and would walk into the hallway. Resident #1 often undressed after being assisted with dressing. The care plan also stated the resident would often hit, kick and curse at staff. Resident #2hadh admission [DIAGNOSES REDACTED]. Short term memory loss, change in behavior and reduction in concentration) and other Impulse Disorders (psychiatric disorders characterized by impulsivity - failure to resist a temptation, urge or impulse that may harm oneself or others). The Quarterly MDS assessment, dated 7/2/2018, assessed Resident #2 with a BIMS score of 8 which indicated moderately impaired cognition and he/she exhibited physical and verbal behaviors directed towards others. Resident #1's care plan revised on 7/31/2018 indicated he/she enjoyed touching his/her genitals and did not care if other residents were near. The resident exhibited sexual inappropriateness toward staff and other residents. Interventions directed staff to administer medications as ordered and monitor for side effects and effectiveness. Staff should anticipate and meet the resident's needs. Intervene as necessary to protect the rights a safety of others, divert attention and remove from situations, and take to him/her to an alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes. On 8/21/2018, staff placed the resident on 1:1 observation until he/she transferred to a behavioral unit due to increased sexual behavior. Review of the facility progress notes dated 7/30/2018 at 2:56 P.M. documented, (Resident #2) made inappropriate comments to staff about wanting to have sex with them and asking to touch their buttocks. When resident was asked not to talk like that he/she stated, I can't help it I'm just horny. Resident also continued to take pants off throughout the shift. Progress notes dated 7/31/2018 at 8:37 P.M. revealed the following documentation, staff entered resident # 1's room to find opposite gender resident (Resident #2) sitting next to Resident #1 while he/she was lying in bed. Opposite gender resident was touching Resident #1 inappropriately. Resident #1 was not yelling out or trying to get opposite gender resident to stop. Resident #2 stopped touching Resident #1 once staff entered the room. Resident #2 was taken back to his/her room and placed on 1:1 pending investigation. Both residents were unable to explain the situation. During interview both residents denied feeling unsafe or violated. Progress note dated 7/31/2018 9:00 P.M. documented, 1on 1 aides with the resident related to behaviors. Resident made multiple sexually inappropriate statements to the aide. Behaviors continued to be monitored throughout the night with no additional statements made by the resident. The resident remained a 1on1 at this time. Orders received on 8/1/18 for Depo-[MEDICATION NAME] Suspension ([MEDICATION NAME] Acetate) (hormone used to reduce testosterone levels) 100 milligram (mg) one time a day every 3 month. Review of the facilities Self-Reported Investigation indicated on 7/31/2018 at approximately 6:45 P.M. direct care staff D entered Resident #1's room and found him/her lying naked on his/her bed and Resident #2 sat on the side of his/her bed touching his/her genitals. Both residents were engaged in the act, there were no signs of distress and the act appeared to be consensual. The report further indicated that Resident #2 had a history of [REDACTED]. Resident #1 had a history of [REDACTED]. On 9/4/2018 at 11:20 A.M. staff D reviewed his/her notarized witness statement per telephone interview. The witness statement was read as written and staff D verified it was accurate as it was read to him/her. Staff D was asked upon entering Resident #1's room were both Resident #1 and Resident #2 naked. Staff D indicated Resident #2 had on a hospital gown only and Resident #1 was lying in bed with a gown and brief on and neither of them were naked. Staff D indicated that Resident #1 was not fully awake, half awake and half asleep was how he/she described Resident #1. The facilities Elder Justice Act and Reporting Suspected crimes against Residents Policy and Procedure revealed the facility would facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. The policy's procedure of Duty to Report, stated all associates have a duty to report any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. The facility had a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, as well as the results of all investigations of alleged violations. The policy indicated the following must be reported: Instances of abuse of all residents, irrespective of any mental or physical condition, that cause physical harm, pain or mental anguish. This includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. On 8/27/2018 at 4:45 P.M. an interview with Staff A and Staff B indicated after the 7/31/2018 incident Resident #1's family member met with the facility. Resident #1's family member wanted to discuss why the police were not notified. Staff A and Staff B discussed the situation with Resident#1's family member and asked what they would tell the police? Who initiated the contact? . Review of a facility Self-Reported Investigation indicated on 8/21/2018 at approximately 7:30 P.M. a CNA D found Resident #2 once again in Resident #1's room. Resident #1 was asleep, and Resident #2 was touching his/her breast and had his/her hand down the front of his/her brief. The facility again failed to protect Resident #1 from Resident #2's sexual behaviors. This incident was called to the police and again reported to the state agency. The facility failed to protect Resident #1 from Resident #2 from resident to resident sexual abuse by allowing Resident #2 to stay on Memory Lane unsupervised with other vulnerable residents. This deficient practice placed 14 residents of the memory care unit in immeidate jeopardy. The facility abated the immediate jeopardy on 8/30/18 at 8:00 P.M. when the facility implemented education plan for staff. Resident #2 was sent to a behavioral health unit on 8/23/18 following the second incident. The deficient practice remained at the scope and severity of a G.

The facility reported a census of 98 residents with 5 residents included in the sample. Based on observation, interview and record review the facility failed to provide treatment and services necessary to prevent the development of facility acquired 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) for 4 of 4 residents sampled for pressure ulcer development in the facility. Resident #1 developed 2 facility acquired deep tissue injuries (DTI) on his/her right heel and side of the foot by his/her small toe. Resident #2 developed a stage 2 pressure ulcer to his/her left ischial (back lower portion of the hip) area, which was a recurring ulcer acquired in the facility. Resident #3 developed 2 unstageable (known wound, but not stageable due to coverage of the wound bed by dead tissue) pressure ulcers to his/her heels (one on the back of each heel) while in the facility and the facility failed to evaluate the wounds at least weekly and failed to order any treatment for [REDACTED]. Resident #4 developed a sore on his/her sacral area on 8/27/17 the facility identified the area as moisture associated skin damage (MASD- skin damage caused by moisture rather than pressure) and shearing (the separation of skin layers caused by friction or trauma) on 9/7/17, did not assess the wound from 9/28/17-10/22/17 (25 days) in which the wound more than doubled in size. On 11/21/17 the facility continued to categorize the wound as MASD that had purulent (discharging pus) drainage and a hole in it. On 11/25/17 the local hospital assessed the resident wound as a sacral decubitus ulcer (pressure ulcer) which required surgical debridement (surgical procedure to cut away dead or infected tissue from a wound) on 11/30/17, a [DEVICE] (negative pressure system applied to a wound to promote healing), 6 weeks of intravenous (IV-introduced into the veins) antibiotics with a peripherally inserted central catheter (PICC line - a form of intravenous access that can be used for a prolonged period of time) since the sacral wound revealed a large amount of [MEDICATION NAME] avium (rare type of bacteria) and a moderate amount of [MEDICAL CONDITION] (MRSA- a type of bacteria resistant to many antibiotics), and the surgical specialist categorized the wound as a stage 3 (Full thickness tissue loss - subcutaneous fat may be visible but bone, tendon or muscle is not exposed) sacral ulcer, and upon discharge from the hospital the wound was a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Dead tissue may be present on some parts of the wound bed-often includes undermining and tunneling) pressure ulcer. The facility's failure to monitor as planned, accurately identify and prevent the development of resident #4's facility acquired pressure ulcer placed the resident in immediate jeopardy. Findings included: - Resident #4's [DIAGNOSES REDACTED]. Severe cases [MEDICAL CONDITION] can lead to the medical emergency, septic shock), [MEDICAL CONDITION] (MS- progressive disease of the nerve fibers of the brain and spinal cord), contracture (abnormal permanent fixation of a joint), [MEDICAL CONDITION] (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), [MEDICAL CONDITION] (condition characterized by decreased activity of the [MEDICAL CONDITION]), constipation, ulcerative [MEDICAL CONDITION] (chronic inflammation of the large intestine), muscle weakness, and pain. Review of quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating normal cognition. The resident required extensive assist of two staff with bed mobility, toileting and personal hygiene. The resident had an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag) and was always incontinent of bowel. The resident had a risk 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), but no skin breakdown. Review of the annual MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognition. The resident required total assistance of two staff for bed mobility, transfers, personal hygiene and bathing. The resident required extensive assist of 1 staff for locomotion in corridors with the use of a wheelchair. The resident had impairment in range of motion in both lower extremities, had a Foley catheter and was always incontinent of bowel. The resident had a risk for pressure ulcers, but had no skin breakdown. Review of the care area assessments (CAAs) dated 9/1/17 revealed: Activities of daily living (ADL) CAA- the resident lived in the facility for the last three years. The resident was alert and oriented to name and place, was able to make his/her needs known, required total assistance with ADLs, had impaired mobility related to his/her [DIAGNOSES REDACTED]. Pressure ulcer CAA dated 9/1/17 recorded the resident had a suprapubic catheter (tube inserted into the bladder through the lower abdomen to drain urine into a collection bag) in place related to [MEDICAL CONDITION] bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) secondary to MS. The resident was also incontinent of bowel, and wore a brief for his/her dignity and to wick moisture from the skin. The resident required total assistance with catheter care and hygiene needs and was recently treated with antibiotics for a urinary tract infection [MEDICAL CONDITION]. Review of the Braden Skin (scale used to predict pressure ulcer risk) assessment dated [DATE] revealed the resident had a score of 17, indicating he/she was at risk for skin breakdown. The preventative interventions included the use of a pressure redistribution surface if the resident was bed or chair bound, use of a commercial moisture barrier, use of a lift sheet to move the resident for prevention of friction and shear, good hydration maintenance and avoid drying his/her skin. Review of the Braden Skin assessment dated [DATE] revealed a score of 13, indicating moderate risk for development of pressure sores. The preventative interventions included the use of a pressure redistribution surface if the resident was bed or chair bound, observe and assess regularly, monitory closely for sensory impairment, use of a commercial moisture barrier, use of absorbent pads or briefs that wick and held moisture, use of a lift sheet to move the resident for prevention of friction and shear, good hydration maintenance, and avoid drying his/her skin. Review of the 4/12/17 care plan revised 12/2/17 revealed the following interventions related to skin management: 4/12/17: Monitor for signs/symptoms of increased pressure/redness before, during, and after placement of Bucks traction (Skin traction applied by strapping the resident's affected lower limbs and attaching weights) and report as indicated. 4/12/17, revised 5/1/17: the resident was not able to remove the Bucks traction without assistance, but when in place, it did not prevent him/her from doing anything he/she would be physically able to do if it were not in place related to his/her [DIAGNOSES REDACTED]. 4/12/17, revised 6/13/17: Reposition every 2 hours while in bed 4/25/17: Low air loss (LAL- mattress used for pressure redistribution) Mattress 4/25/17: Monitor closely for sensory impairment 4/25/17: Observe and assess regularly 4/12/17: Observe skin condition daily with ADL care and report abnormalities 4/12/17, revised 5/3/17: Pat (do not rub) skin when drying 4/25/17: Pressure redistribution for bed and wheel chair 4/25/17: Prevalon (soft, comfortable boot designed to lift the heel off of the mattress, minimizing pressure on the heel) boots to bilateral feet every evening shift 4/25/17: Use barrier cream (provides a protective covering to skin) every shift as needed 4/25/17, revised 5/3/17: Use lift/draw sheet to move the resident in bed 5/3/17: Prevalon boots while up in wheelchair for dinner 11/22/17: encourage the resident to lay on his/her right or left side as often as possible 11/22/17: obtain culture of the wound, send to lab 11/22/17: weekly wound assessments, performed by a licensed nurse Review of the physician progress notes [REDACTED]. The physician noted the resident had a history of [REDACTED]. The physical exam revealed warm, soft and normal texture skin, without rash or [MEDICAL CONDITION] upon skin assessment. The physician progress notes [REDACTED].e. physician or nurse practitioner) to properly obtain a history, perform a physical exam, review his/her past history and chart material in order to assess if he/she was stable or in need of further evaluation and /or change in his/her care plan and orders. This could not be accomplished by a non-clinician such as a licensed practical nurse (LPN) or a registered nurse (RN). Due to this patient's multiple co-morbid conditions, frequent and close follow-ups visits were required to monitor and change treatments quickly to prevent worsening of the conditions and attempt to prevent hospitalization s. Review of the progress notes from physician extender staff K's visit on 7/24/17 revealed on physical dermatologic exam the resident had pallor (pale color of the skin) with multiple scabbing to bilateral (both sides) shins, ankles and toes, no redness, swelling or drainage noted. Review of the progress notes from physician extender staff K's visit on 7/31/17 revealed no change in dermatological exam since the 7/24/17 exam. Review of the 8/21/17 change in condition evaluation (re-admission) revealed the resident had a skin wound or ulcer that started on 8/21/17 in the morning. The resident received long-term care and had a scratch on his/her right buttock. Review of the weekly skin assessments (performed by the licensed nursing staff but do not comment on the wound since the facility utilized the Wound Rounds to track wounds) revealed the following: 8/18/17 revealed no skin concerns though previously reported skin concerns existed 8/21/17 revealed the resident had a scratch to his/her right buttock 8/25/17 revealed no skin concerns identified, skin was intact. Review of the wound skin progress notes (form of nurses progress note not tied to the Wound Rounds program) dated 8/27/17 revealed the direct care staff reported the resident had an open area to his/her right buttocks. Staff noted an area approximately 5-6 centimeters (cm) in length by 0.4 cm wide and appeared to be a blood blister type wound to the outer part of his/her right buttock and another area between that area and the buttocks crack that was approximately 2-3 cm in length x 0.5 cm in width that was open, stage 1 ( An observable, pressure- related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues) to stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister). Staff cleaned the area and placed comfort foam border over the site. The third shift (10:00 p.m. to 6:00 a.m.) direct care staff stated it had been reported to the nurse. The tissue around the area was red and blanched (skin loses redness with pressure and upon release of pressure the skin returns to normal color, an indicator of normal circulation), but slowly. Review of the Wound Rounds (electronic wound charting/tracking system the facility utilized to track wounds and contained an image of the wound) on the resident revealed the following wounds the facility identified as bilateral buttocks (since the wound spanned across the top of the residents buttocks, lower sacral area), MASD which were facility acquired and identified on 9/7/17 at 3:04 p.m. On 9/7/17: MASD: Partial thickness wound to bilateral buttocks with 100% bright pink or red tissue type. The wound had a light amount of bloody exudate (fluid that leaks out of body vessels and tissues) with indistinct wound edges, no odor, no signs of infection, no antibiotics for the resident, and no dressing present. The wound measured 7 cm in length by 12 cm in width by 0.1 cm in depth, without undermining or tunneling. Comment by licensed nursing staff U revealed the resident presented with multiple small open areas to his/her bilateral buttocks with many different characteristics of the wound beds. The staff held the measuring tape in the image vertical and to the left of the resident's wound. The resident was incontinent of bowel and the nurse noted many of the resident's bowel movements were loose and watery. The resident had been on an air mattress and he/she was known to slide down while the head of the bed (HOB) was elevated. Staff U noted a new treatment plan was implemented at that time (the comment did not specify of what the treatment plan consisted and no treatment orders documented until 9/15/16). The charting sheet lacked evidence staff notified the physician or family. Review of the weekly skin assessments dated 9/1/17, 9/8/17, 9/13/17, 9/23/17, 9/29/17, 10/6/17, 10/13/17, 10/27/17, 11/3/17, 11/10/17, and 11/17/17 revealed no skin concerns, though previously reported skin concerns existed (but the assessment did not mention the specific skin concern). Review of the nutritional progress notes dated 9/13/17 the resident was bed-bound, was able to make his/her choices known and feed him/herself. Skin review indicated the resident had MASD to bilateral buttocks, and no pressure wounds. No recommendation for nutrition intervention at this review. Review of the progress notes from physician extender staff K's visit on 9/14/17 revealed no change in skin assessment since the 7/24/17 exam. Review of the Wound Rounds on 9/15/17 revealed the resident had MASD: partial thickness wound to his/her bilateral buttocks with 100% bright pink or red tissue type. The wound had a light amount of bloody exudate (fluid that leaks out of body vessels and tissues) with distinct and attached wound edges no odor, no signs of infection present, no antibiotics for the resident, and no dressing present. The wound measured 6.5 cm in length by 7.8 cm in width by 0.1 cm in depth, without undermining or tunneling. The staff held the measuring tape in the image vertical and to the left of the resident's wound. Comment by licensed nursing staff U revealed the area to the resident's bilateral buttocks had more defined wounds within it this week with 2 smaller wounds (did not specify location of each of the two smaller wounds) which measured 3.5 cm in length by 1.9 cm in width by 0.1 cm in depth and 1.7 cm in length by 1.5 cm in width by 0.1 cm in depth. Staff U noted the treatment plan was adjusted at that time (did not specify of what the treatment plan consisted, or of how it was adjusted). No notification to the physician or family noted on the sheet. Review of the nurse's note dated 9/15/17 revealed a new order from the wound nurse to cleanse the open areas to the resident's bilateral buttocks with cleanser, skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to periwound, cover with border foam dressing, and to change daily and as needed (PRN). The clinical record lacked Wound Rounds documentation for the 9/21/17 assessment and only revealed a nurse's progress note regarding a wound assessment. Review of the wound/skin progress notes dated 9/21/17 revealed the staff completed a wound assessment of the resident's bilateral buttocks. The wound to the resident's left gluteus (buttocks) presented as a full thickness wound at the time, which measured 5 cm (length) by 4 cm (width) by 0.1 cm (depth) and staff noted yellowish/grey slough (dead tissue, usually cream or yellow in color) to approximately 15% of the wound bed with 85% granulation (tissue formed during wound healing). The wounds to the resident's right buttocks measured 1.3 cm (length) by 1 cm (width) with 100% granulation and 2.6 cm (length) by 1.4 cm (width) with 100% granulation. The staff encouraged the resident to lay side-to-side throughout the day. The resident's air mattress remained in place and staff adjusted the resident's treatment plan, at that time per the progress note (did not stated what the treatment plan was or of how it was adjusted). Review of the 9/21/17 physician's orders [REDACTED]. The ordered stated to change the dressing daily and PRN in the evening with a start date of 9/22/17. Review of the Wound Rounds on 9/27/17 (12 days after prior wound rounds assessment) revealed MASD: full thickness wound with 30% bright pink or red, 40% slough, loosely adhered, and 30% necrotic (pertaining to the death of tissue in response to disease or injury) soft, adhered tissue type. The wound had a moderate amount of bloody exudate with distinct and attached wound edges with no odor, no signs/symptoms of infection, no antibiotics for the resident, and no dressing present. The wound measured 6.5 cm in length by 4 cm in width by an unknown depth, without undermining or tunneling. The staff held the measuring tape in the image vertical and to the left of the resident's wound. Comment by Licensed nursing staff U revealed 2 additional wounds located on the residents right buttocks with the following measurements: 0.9 cm in length by 0.8 cm in width with 100% granulation and 2 cm in length by 0.9 cm in width with 100% granulation. Staff U noted the treatment was updated accordingly last week as stated in the progress note (but did not list the treatment plan). No notification to the physician or family noted on the sheet. Review of the progress notes from physician extender staff K's visit on 10/11/17 revealed no change in dermatological exam since the 7/24/17 exam (which did not identify any skin issues with the resident's buttocks area). Review of the physician's orders [REDACTED]. Review of the treatment administration record (TAR) lacked evidence staff changed the dressings on 10/21/17, 10/24/17, and 11/5/17. Review of the Wound Rounds on 10/23/17 (26 days after prior assessment) revealed MASD: full thickness wound with non-blanchable, 55% [DIAGNOSES REDACTED], 5% bright pink or red, 10% slough, loosely adhered, and 30%, necrotic soft, adhered. The wound had a moderate amount of serosanguineous (semi-thick reddish drainage) exudate with distinct and attached wound edges, no odor, no signs/symptoms of infection, no antibiotics for the resident, and no dressing present. The wound measured 17.9 cm in length by 11 cm in width by unknown depth, without undermining or tunneling. The staff held the measuring tape in the image horizontal and above the resident's wound. Comment by licensed nursing staff C noted new treatment orders were in place (referencing the order from 10/20/17). No notification to the physician or family noted on the sheet. Review of the Wound Rounds on 11/3/17 (11 days after prior assessment) revealed MASD: full thickness wound with non-blanchable 55% [DIAGNOSES REDACTED], 5% bright pink or red, 10% slough, loosely adhered, and 30%, necrotic soft, adhered. The wound had a moderate amount of serosanguineous exudate with distinct and attached edges, no odor, no signs/symptoms of infection, no antibiotics for the resident, a dated and initialed dressing was present. The wound measured 14.7 cm (length) by 11 cm (width) by unknown depth, without undermining or tunneling. The staff held the measuring tape in the image vertical and to the right of the resident's wound. Comments by licensed nursing staff C noted honey alginate (alginate absorbed exudate while the honey promoted a moist healing environment for wounds). No notification to the physician or family noted on the sheet. Review of the progress notes from physician extender staff K's visit on 11/8/17 and 11/10/17 revealed no change in dermatological exam since the 7/24/17 exam. Review of the Wound Rounds on 11/12/17 (9 days after prior assessment) revealed MASD: full thickness wound revealed no change since prior assessment, with the same measurements and descriptions as the prior assessment. The staff held the measuring tape in the image horizontal and below of the resident's wound. Comment by administrative nursing staff B revealed no new orders and the continued current plan of care. No notification to the physician or family noted on the sheet. Review of the 11/15/17 quarterly nursing assessment revealed the resident had a wound to his/her coccyx and buttocks. (No measurements or size approximation included in the assessment) Review of the Wound Rounds on 11/21/17 (9 days after prior assessment) revealed MASD: full thickness wound non-blanchable 55% [DIAGNOSES REDACTED], 5% bright pink or red, 10% slough, loosely adhered, and 30%, necrotic soft, adhered. The wound had heavy purulent exudate with distinct and attached edges with no odor, but signs and symptoms of infection were present and the resident was not on antibiotics. The wound had a dated and initialed dressing present. The wound measured 5.4 cm (length) by 3.6 cm (width) by unknown depth without undermining or tunneling. The staff held the measuring tape in the image vertical and in the middle of the residents wound (vertically in alignment with the gluteal crease and unable to see the coccyx). Comments by licensed nursing staff C revealed a new wound culture and new treatment. No notification to the physician or family noted on the sheet. Review of the (MONTH) (YEAR) TAR revealed a one-time wound culture for wound drainage, completed on 11/22/17. The lab results returned on 11/23/17 revealed a moderate amount of Escherichia coli (bacteria commonly found in the lower intestine). On 11/24/17 the staff noted new orders for 1 gram (gm) [MEDICATION NAME] (antibiotic), intramuscular (IM- administered into a muscle) injection, to be administered to the resident every day for 7 days. Review of the 11/24/17 nurses note revealed the resident continued on antibiotics for his/her wound with drainage. Review of the 11/25/17 infection note revealed the resident continued on an antibiotic for his/her wound infection. Review of the nurse's note dated 11/25/17 at 11:23 p.m. revealed Emergency Medical Services (EMS) arrived at the facility at 8:30 p.m. and transported the resident to a local hospital due to resident vomiting feces and EMS noted the resident had a sore on his/her buttocks area. Review of the hospital records from the resident's transfer on 11/25/17 revealed a specialty consultation note for infectious disease on 11/28/17 which noted the resident had a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) sacral decubitus (pressure ulcer) which was necrotic (pertaining to the death of tissue in response to disease or injury). The specialist consult noted he/she would advise on antibiotic duration after the depth and extent of the decubitus sacral wound was known following surgical debridement. On 11/30/17 the resident underwent [REDACTED]. The sacral tissue culture collected on 11/30/17 returned on 12/3/17 revealed a large amount of [MEDICATION NAME] avium (rare type of bacteria) and a moderate amount of [MEDICAL CONDITION] (MRSA- a type of bacteria resistant to many antibiotics). The hospital discharge summary dated 12/4/17 revealed the resident had a sacral decubitus (pressure) ulcer on admission. The resident received an evaluation from surgery regarding his/her sacral decubitus (pressure) ulcer. The resident underwent [REDACTED]. The surgical tissue culture showed [MEDICATION NAME] avium [MEDICAL CONDITION]. The hospital consulted another infectious specialty physician to assist with the antibiotics for the resident's sacral wound. The resident received and continued on IV meropenem (antibiotic used to treat severe infections) and IV [MEDICATION NAME] (antibiotic used to treat bacterial infections in the bowels) with stop date of 1/11/18 (6 weeks). The resident had a peripherally inserted central catheter (PICC line - a form of intravenous access that can be used for a prolonged period of time) in place and tolerated the antibiotics. The discharge summary included the following discharge [DIAGNOSES REDACTED]. The hospital discharged the resident to a specialty care hospital on [DATE]. Interview with direct care staff F on 12/12/17 at 9:50 a.m. revealed the resident required total assistance by 2 staff for most of his/her ADLs. Staff F stated the resident would scoot him/herself down in bed and staff had to do frequent checks on his/her positioning. Staff F reported the staff floated the resident's heels and applied foot booties and positioned the resident on his/her side every 2 hours. Staff F stated the resident was not compliant with the turning because he/she wanted to watch television. Staff F said the resident complained about his/her bottom hurting, and staff F reported this to the nurse immediately. Interview with direct care staff H on 12/13/17 at 10:14 a.m. revealed on 11/25/17 the resident reported not feeling well around 1:45 p.m. and staff H reported this to licensed nursing staff Y. Staff H said the resident vomited a gritty brown substance and had very liquid stools. Staff H said he/she changed the resident 3 times between 1:45 p.m. and 2:00 p.m. (shift change). Staff H reported the resident's stool contaminated the bandage on the resident's bottom and he/she had to remove it. Staff H stated the sore on the resident's bottom was very concerning to him/her because it was very large, red and had a blackish center to it. Staff H stated the sore was more concerning to him/her than the resident's vomiting of a brown gritty substance. Staff H informed the licensed nursing staff Z the bandage had been removed and needed replaced and staff Z said he/she would take care of it and to just put a brief back on the resident. Staff H left shift around 2:00 p.m. and did not see either staff Y or staff Z address the needs of the resident before he/she left off shift. Interview with licensed nursing staff D on 12/12/17 at 8:02 a.m. revealed resident #4 developed a coccyx wound at the facility. Staff D said the resident had been in traction for 6 hours straight a day and stated the traction was required to help prevent an ileus (obstruction of the intestines, caused by immobility of the bowel) due to the resident's severe contractures (legs drawn up). Staff D said the facility got the traction broken up into smaller segments of time and once that happened the wound started to improve. Staff D said the resident would push back while he/she provided wound care because the resident wanted to watch television. Staff D stated on 11/25/17 the resident was sent out because the resident had vomited what looked like coffee grounds, but he/she had not seen it. Staff D stated the wound was the only change in the resident's status and stated the wound improved. Interview with administrative nursing staff B on 12/12/17 at 7:55 a.m. stated the family member of resident #4 was donating a specialty bed to the facility to help take care of the resident to help prevent skin issues. Staff member B stated the resident had been in Buck's traction (Skin traction applied by strapping the person's affected lower limb and attaching weights for tension) for 6 straight hours a day previously, and staff B talked to therapy and broke up the Buck's traction into 2 hour increments to help with the wound healing. Interview with administrative nursing staff B on 12/12/17 at 10:34 a.m. revealed he/she did not have any documentation for the resident wound measurements between 9/28/17-10/22/17. Staff B reported a wound nurse left employment with the facility and staff B attempted to keep up on wound measurements on his/her own. Staff B stated licensed nursing staff looked at the wounds during that time frame and if the nurses saw anything they would have let staff B know, but he/she did not have any documentation to support that claim. Interview with administrative nursing staff B on 12/12/17 at 5:11 p.m. revealed he/she expected weekly wound rounds to be completed, per policy. Staff B stated the wound on resident #4's bottom reoccurred and stated he/she expected nursing staff to have spoken to staff B of any wound concerns. Staff B stated he/she could visually see the enlargement of the wound from 9/27/17-10/23/17 (pictures on the wound round sheets and measurements). Interview with administrative nursing staff B on 12/19/17 at 10:50 a.m. revealed staff B was not wound certified, and said he/she would have to agree with the wound nurse assessment calling the wound on resident #4's sacral area MASD. Staff B reported on 11/21/17 there was a small hole in the wound which would drain and sometimes if the staff squeezed the hole they would get drainage out of the hole. Staff B reported the measurements were recorded on the wound round sheets only. Interview with physician extender staff K on 12/12/17 at 8:30 a.m. revealed the wound on the resident's bottom was a pressure wound. Staff K expected to be contacted if the facility had problems getting the wound healed, or if a particular treatment was not working. Staff K expected the staff to use their nursing judgment and communicate with staff K accordingly. Interview with physician extender staff K on 12/12/17 at 1:21 p.m. revealed the facility staff should call the physician's office and have any new wounds put on the schedule for new skin issues, so staff K was aware the resident had a wound. Staff K said he/she expected weekly wound assessments to be done and to be notified if there were issues. Staff K stated he/she did not get involved in the wounds unless there were issues and stated he/she had seen the resident's wound on his/her bottom, but not recently. Interview with physician extender staff K on 12/19/17 at 11:24 a.m. revealed he/she did not follow the wounds real closely and he/she did not spend a lot of time on them. Staff K reported the wounds were the facility's deal and the facility should call Staff K office if they ha

The census included 98 residents with 5 residents included in the sample. Based on observation, interview and record review the facility failed to ensure staff assessed and identified the immediate medical needs of resident #4 with a history of small bowel obstruction and a noted change in condition after the resident began vomiting brown emesis on 11/25/17 around 1:30 p.m. and was not assessed until he/she was sent out for emergency medical services (EMS) at 8:45 p.m. (7 hours later) with no mention of the urinary output or that the vomit contained feces. The resident was septic (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead.) with a urinary tract infection [MEDICAL CONDITION] upon admission at the hospital. These failures placed the resident in immediate jeopardy related to neglect of the resident's change in condition and lack of nursing assessment. Findings included: - Resident #4's [DIAGNOSES REDACTED]. Review of quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating normal cognition. The resident required extensive assist of two staff with bed mobility, toileting and personal hygiene. The resident had an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag) and was always incontinent of bowel. Review of the annual MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognition. The resident required total assistance of two staff for bed mobility, transfers, personal hygiene and bathing. The resident required extensive assist of 1 staff for locomotion in corridors with the use of a wheelchair. The resident had impairment in range of motion in both lower extremities, a urinary catheter, and was always incontinent of bowel. Review of the activities of daily living (ADL) care area assessment (CAA) dated 9/1/17 revealed the resident lived in the facility for the last three years. The resident was alert and oriented to name and place, able to make his/her needs known, required total assistance with ADLs, had impaired mobility related to his/her [DIAGNOSES REDACTED]. Urinary incontinence and indwelling catheter CAA dated 9/1/17 documented the resident had a suprapubic catheter (tube inserted into the bladder through the lower abdomen to drain urine into a collection bag) in place related to his/her [DIAGNOSES REDACTED]. The resident wore adult briefs for his/her dignity and to wick moisture from the skin. The resident required total assistance with catheter care and hygiene needs, and was recently treated with antibiotics for a urinary tract infection [MEDICAL CONDITION]. Review of the nutritional assessment dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The resident was bedridden, made choices and fed him/herself. Review of the Braden Skin (scale used to predict pressure ulcer risk) assessment dated [DATE] revealed the resident used absorbent pads or briefs to wick and hold moisture away from the skin. Review of the 4/12/17 care plan revised 12/2/17 revealed the following interventions related to the resident's urinary catheter: Catheter care every shift and as needed (PRN) Monitor output for odor, color, consistency, and amount Keep the catheter off the floor Monitor urine for sediment, cloudy, odor, blood and amount The care plan did not address the resident's history of bowel impaction (mass of dry, hard stool that will not pass out of the colon or rectum), incontinence of bowel, constipation, and history of small bowel obstruction. Review of the nurse's note dated 8/1/17 at 10:14 a.m. revealed the resident complained of nausea/vomiting and his/her abdomen was hard and distended (enlarged). The staff called the physician office and obtained a new order for a KUB (kidneys, ureters, and bladder x-ray). Review of the nurse's notes dated 8/1/17 at 4:00 p.m. revealed the resident had a KUB in the morning and noted the resident had nausea/vomiting, abdominal distended, and brown emesis and a temperature of 99.2 degrees Fahrenheit (F). Upon notification of the results to the physician he/she ordered to send the resident out to the local hospital emergency room via emergency medical services (EMS) due to a positive KUB (abdominal x-ray indicative of an issue involving the bowels for the resident). Review of the nurse's note 8/8/17, revealed the staff completed a bowel and bladder assessment on resident #4. The resident was not incontinent of urine and had a catheter. The current bowel history showed the resident had a bowel movement every other day, had a history of [REDACTED]. Review of the nurse's note dated 8/28/2017 revealed the staff completed the resident's bowel and bladder assessment. The resident was not incontinent of urine, had a catheter. The current bowel history showed the resident a daily bowel movement, a history of constipation, a history of impaction, a history of bowel obstruction, and a history of bowel incontinence. Review of the bowel charting from 11/25/17 revealed the resident had a large bowel movement at 12:15 a.m. recorded as putty like and another at 8:33 p.m. charted as loose/diarrhea. Review of the electronic Medication Administration Record [REDACTED] [MEDICATION NAME] Clear and Natural Powder (1 tablespoon by mouth (PO) one time a day) Polyethylene [MEDICATION NAME] Powder 17 grams (GM) PO two times a day (BID) Senna Capsule, 2 tablets PO BID [MEDICATION NAME] Solution 20 milligrams/milliliters (mg/mL), give 30 mL PO three times a day (TID) Review of the electronic treatment administration record (eTAR) revealed the staff changed the suprapubic catheter on 11/21/17. Further review of the eTAR lacked evidence staff performed the suprapubic catheter care as ordered (every shift and monitor output every shift and failed to monitor urinary output every shift) on 10/9/17, 10/11/17, 10/21/17, 10/23/17, 10/25/17, 10/26/17, 11/2/17, 11/4/17, 11/8/17, 11/9/17, 11/16/17, 11/17/17, 11/23/17 (5 days out of (MONTH) (YEAR), 7 out of 25 days in November). Review of the TAR regarding urinary output for the resident revealed on 11/25/17 the resident had 200 mL urinary output for day shift (6:00 a.m. -2:00 p.m.) and had 200 mL urinary output for evening shift (2:00 p.m. - 10:00 p.m.). A decrease of 600 -700 mL per shift compared day and evening shift on 11/24/17. Review of the nurse's note dated 11/25/17 at 11:23 p.m. revealed the resident continued with dark brown vomiting, complained of stomach pain rated a 6 out of 10 (with 0 equaling no pain and 10 as the worst pain), with stomach overly distended. The nurse noted the resident stated he/she had not eaten meals since 11/24/17. The nurse noted the resident's heart rate was abnormally elevated with a heart rate of 114-117 beats per minute (bpm) (normal 60-100 bpm). Licensed nursing staff M notified the on-call physician at approximately 8:15 p.m. and on-call physician gave new orders to send the resident out to the emergency room (ER). EMS arrived at the facility at 8:30 p.m. and transported the resident to a local hospital at 8:45 p.m. (This was the only nurses note from 11/25/17 which noted the resident's condition and vomiting. The note lacked an assessment of bowel sounds.) Review of the hospital records from the resident's transfer on 11/25/17 revealed the EMS unit responded to the facility and found resident #4 sitting in bed with emesis containing stool on his/her face, chest, and around his/her neck. The staff reported to EMS the resident had been vomiting feces for at least 12 hours and complained of abdominal pain. The facility staff stated they called 911 only after the resident requested to be transported to the hospital and asked the EMS unit if the resident really needed to be transported. Upon physical assessment at the emergency room the resident was found to have abdominal pain and vomiting with severe distention and rigidity noted to his/her abdomen with stool noted in emesis. The staff documented no actual vomiting noted but instead a consistent stream of stool emesis noted and documented the resident had brown urine containing large amounts of sediment noted from his/her suprapubic catheter. The record noted on 11/25/17 at 9:17 p.m. the resident continued to complain of vomiting the last 12 hours and currently vomited feces, his/her abdomen was distended and rigid and his/her catheter had brown output. The hospital noted the resident had a history of [REDACTED]. The resident experienced constipation and subsequently developed abdominal distention and vomiting. The hospital record revealed the resident admitted for similar presentations, found to be constipated, and resolved with bowel regimen as well as nasogastric (NG- placement of a tube through the nose into the stomach) suction. The hospital record revealed the impression for the resident included small bowl obstruction, leukocytosis (elevated white blood cells in the blood), and vomiting with a plan to admit to the hospital. Review of the hospital urinalysis (examination of urine) from 11/26/17 at 12:20 a.m. (less than 4 hours after the resident left the facility) revealed the resident had dark yellow, cloudy urine, with the following out of range (normal range): Elevated pH of 8.5 (normal range: 5.0-8.0) 1+ positive for leukocyte esterase (a product of white blood cells and a sign of infection) (normal range: negative) 3+ positive for protein (elevated number may indicate kidney problems) (normal range: negative) Positive blood (sign of infection or other kidney/bladder damage) (normal range: negative) Positive [MEDICATION NAME] (sign of infection) (normal range: negative) Trace glucose (normal range: negative) White Blood Cells (WBC- elevated number indicative of infection) > 50 /HPF (high power field- number of cells counted in the microscopic slide) (normal range: 0-4) Red Blood Cells (RBC) > 50/HPF (normal range: 0-2) with moderate bacteria (indicative of infection) noted. The hospital discharge summary dated 12/4/17 revealed the hospital significant findings included the resident had a small bowel obstruction (SBO) on admission in which surgery was consulted, but not needed. The resident had an NG tube at one point and his/her SBO resolved. The resident had a urine culture which returned positive for highly resistant (bacteria resistant to the anti-microbial effect of antibiotics) Morganella Morganni (bacteria found in the intestines) and [MEDICAL CONDITION] (MRSA- a type of bacteria resistant to many antibiotics) and the hospital changed his/her suprapubic catheter. The hospital consulted with an infectious disease specialist to assist in ordering antibiotics for the complicated UTI. The resident had 6 weeks of intravenous (IV-introduced into the veins) meropenem and [MEDICATION NAME] (antibiotics) with a peripherally inserted central catheter (PICC line- a form of intravenous access that can be used for a prolonged period of time) with a stop date of 1/11/18 (6 weeks post). The hospital discharged the resident to a specialty care hospital on [DATE] with the following discharge Diagnoses: [REDACTED]. Interview with direct care staff F on 12/12/17 at 9:50 a.m. revealed the resident required total assistance by 2 staff for most of his/her ADLs. Staff F stated the resident had a catheter and had good output of over 1000 milliliters per day per shift and drank a lot of water. The staff stated the resident had issues with his/her bowels and received medications for his/her bowels. Staff F reported the resident had good bowel movements and knew the resident had been sent out to the hospital previously for bowels being backed up. Staff F reported the resident did not seem like him/herself prior to going to the hospital (refusing to get up, not acting him/herself) and staff F could tell something was off with the resident. Staff F stated prior to going to the hospital the resident said he/she was not feeling very good, his/her stomach was distended and staff F reported that to the nurse. Interview with direct care staff H on 12/13/17 at 10:41 a.m. revealed on 11/25/17 the resident reported not feeling well around 1:45 p.m. and staff H reported this to licensed nursing staff Y. Staff H stated the resident was not him/herself that day and the resident had brown grainy texture vomit typical of when he/she was not feeling well. Staff H said the resident had been vomiting a gritty brown substance and had very liquid stools. Staff H said he/she changed the resident 3 times between 1:45 p.m. and shift change around 2:00 p.m. Interview with administrative nursing staff D on 12/12/17 at 8:02 a.m. revealed the resident had a history of [REDACTED]. Staff D stated the MS created a slowing of his/her gastrointestinal tract and the contractures caused an ileus (obstruction of the intestines, caused by immobility of the bowel). Staff D stated on 11/25/17 the resident was sent out because the resident vomited what looked like coffee grounds, but he/she had not seen it. Staff D stated the resident had a suprapubic catheter that would get clogged and had a lot of sediment and required frequent changes and flushing's. Staff D said the resident had a lot of output normally and if it decreased or changed the direct care staff reported the output every shift. Interview with licensed nursing staff L on 12/12/17 at 4:39 p.m. revealed the resident was fragile due to his/her MS. Staff L stated he/she did not know if the resident had vomited feces before, but stated the resident did have bowel conditions and occasionally had bowel problems in which the resident received numerous bowel medications to ensure the resident had good bowel movements. Staff L stated the resident had no issues with his/her catheter. Interview with licensed nursing staff M on 12/19/17 at 3:51 p.m. revealed he/she was the nurse for resident #4 on 11/25/17 from 2:00 p.m. Staff M stated the direct care staff reported to him/her resident #4 vomited brown stuff and when staff M looked in the room, the resident continued to vomit brown stuff. Staff M said he/she heard the resident had always been sent out for that reason (vomiting brown substance). Staff M stated he/she sent the resident out because the resident's stomach was full and hard and the resident had constipation for a few days. Staff M stated the vomiting started maybe at the beginning of his/her shift (2:00 p.m.). Staff M reported the vomit was brown and runny and did not have a smell that he/she could remember. Staff M reported he/she asked the resident if the resident wanted to go to the hospital and the resident stated yes and staff M said then he/she sent the resident out to the hospital. Staff M reported the EMS staff arrived and stated the resident was vomiting feces. Staff M stated he/she had not dealt with a resident vomiting feces before and did not know the vomit was feces. Staff M did not remember what the resident's urine looked like or how the resident's catheter looked. Staff M said the progress note on 11/25/17 was his/her complete assessment of the resident. Interview with administrative staff A on 12/19/17 at 9:33 a.m. revealed the resident experienced the same symptoms before and it was typical for his/her disease state. Staff A stated the facility suspended staff Y for not checking on the resident and the facility investigated the incident as a possibility of neglect on the part of the first shift nurse. Staff A verified on 11/25/17 everything the first shift nurse (licensed nursing staff Y) saw, the second shift nurse also saw (licensed nursing staff M and Z). Staff A did not know why the second shift nurse did not send the resident out before 8:30 p.m. Interview with the licensed nursing staff EE from the specialty care hospital on [DATE] at 11:50 a.m. revealed the resident was on two IV antibiotics (one 12 hour and one for 6 hours) every day until 1/11/18. Staff EE stated the resident's care was complicated due to his/her [DIAGNOSES REDACTED]. Interview with administrative nursing staff B on 12/19/17 at 3:11 p.m. revealed he/she expected a nursing assessment to be completed by the second shift nurse for the resident before sending the resident to the hospital. Staff B stated the resident had periods where he/she vomited a lot and required staff positioning the resident in a certain position, and then the resident would be fine. Staff B stated the facility staff did not call him/her regarding resident #4. Staff B said the facility staff reported to him/her the resident vomited coffee ground emesis and did not know about stool in the resident's vomit. When asked if the staff should have sent the resident out sooner as coffee ground emesis is a sign of upper [MEDICAL CONDITION], staff B responded he/she was not working so he/she guessed it would be based on the nurse's assessment. Staff B stated if he/she thought it was stool emesis, he/she would have sent the resident out for emergent medical treatment. Review of the facility policy titled Abuse prohibition, revised 4/7/17, revealed neglect was defined as the failure of the center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility failed to provide a policy on nursing assessment after a change in condition but provided a policy on notifications after a change in condition, which was not applicable. The facility failed to ensure the licensed nursing staff assessed and identified the immediate medical needs of a resident related to his/her history of bowel obstruction and was not sent out for emergency medical assistance until after 7 hours of vomiting feces and upon admission to the local hospital the resident was diagnosed with [REDACTED]. These failures placed the resident in immediate jeopardy related to neglect. On 12/30/17 at 6:30 p.m. the facility abated the immediate jeopardy when: The facility educated the staff on escalating concerns of neglect or failure to assess if staff failed to take action after the initial concern was presented. The facility responded immediately to the allegation of neglect upon reporting on 11/28/17 and suspended licensed nursing staff Y pending the investigation of neglect. Staff Y currently remained on medical leave. The facility notified the state agency on 11/28/17 of the allegation of neglect and initiated an internal investigation. The resident #4 was sent out on 11/25/17 for evaluation and treatment. The facility provided education to the inter-disciplinary team (IDT) on 12/29/17 by the Regional Nurse Consultant related to Abuse, Neglect, and Exploitation (ANE). Staff A and Staff B provided education to active staff members and staff not in attendance would receive an educational session prior to working. The licensed staff nurses received an additional element to the education focused on timely and thorough assessments of residents. The facility will conduct weekly interviews with residents by the IDT to begin 1/2/17 as part of the IDT/Ambassador rounds to ensure the residents have no concerns related to cares and services in the facility. The interviews would be reviewed for any negative findings by administration and address concerns. Findings will be taken to monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months to review resident responses and identify and address any trends. Five staff members were interviewed weekly by the IDT (started 1/2/17) for 4 weeks, then 3 staff members weekly for 4 weeks, then 1 staff member for 4 weeks and then indiscriminately thereafter, regarding any observations of ANE and who to contact regarding ANE. The facility conducted re-education for any staff member whose answers indicated a need for further education. The deficient practice remained at the scope and severity of a G.

The facility reported a census of 105 residents which included a sample of 3 residents. Based on observation, interview and record review the facility failed to ensure 1 of 3 residents remained as accident free as possible when a direct care staff member transferred the resident by him/herself and not with 2 staff as the care plan directed. The resident sustained [REDACTED]. (#4) Findings included: - Review of resident #4's signed physician order dated 11/30/16 revealed the resident had the following Diagnoses: [REDACTED]. Review of the 11/11/16 admission MDS (minimum data set) revealed a BIMS (brief interview for mental status) score of 11, indicating moderate cognitive impairment. The resident required extensive assistance of 2 or more staff with bed mobility, transfers, and toilet use. The resident was not steady and only able to stabilize with staff assistance for balance during transitions of moving from seated to standing position, moving on and off toilet, and surface-to-surface transfers (between bed and chair or wheelchair). The resident had functional limitation to both sides of upper extremities in range of motion and used a wheelchair for mobility. The resident and staff believed the resident was capable of increased independence in at least some ADLs (activities of daily living). The resident had a fall in the last month and in the last 2-6 months. The resident had a fall with a fracture related to fall in the 6 months prior to admission/entry or reentry. The resident had 1 fall since admission/entry or reentry or the prior assessment that resulted in a major injury. Review of the ADL/Functional rehabilitation potential CAA (care area assessment) dated 11/17/16 revealed the resident required extensive assistance of 2 persons and after the left humerus (bone of the upper arm) fracture, both extremities had restricted movement. Review of the Falls CAA dated 11/17/16 revealed the resident had an increased risk for falls related to medication regimen, limited mobility, and history of falling. The facility had fall precautions in place and the staff were to use a gait belt to transfer the resident. Review of the 11/10/16 fall risk assessment, as part of the admission assessment, identified the resident at a high risk for falls. Review of the resident's care plan, initiated 11/4/16, revealed the resident was at risk for falls related to impaired mobility as evidenced by a history of falls and included the following interventions: *educate staff/resident to ensure brakes on wheelchair were locked prior to transferring (11/10/16) *assist resident to transfer with 2 person assist (11/4/16) *place call light within reach while in bed or close proximity to the bed. (11/15/16) *remind resident to use call light when attempting to ambulate or transfer (11/5/16) *provide resident/patient with 2 person assist for transfers using gait belt and stand and pivot(11/4/16) Review of the facility fall incident investigation dated 11/15/16 revealed the following: On 11/10/16 at approximately 6:30 a.m. resident #4 pressed his/her call light to be assisted off of the toilet. Direct care staff G asked orientating direct care staff I to assist the resident. The orientating direct care staff I entered the room, placed a gait belt on the resident and began to assist the resident to the wheelchair. The right side of the wheelchair was not locked and the wheelchair rolled back. The orientee direct care staff I assisted the resident to the ground. The resident complained of left arm pain. An x-ray done at facility showed a left humeral head and neck fracture. The facility sent the resident to the emergency room . The facility interviewed the resident and the resident stated the wheelchair rolled back and staff I assisted him/her to the floor. The mentor direct care staff G stated he/she asked orientee direct care staff I to assist resident #4 off the toilet and did not know the resident required 2 person assistance at that time. Orientee direct care staff I stated he/she assisted the resident to the wheelchair and the wheelchair started to roll back since it was unlocked on one side. Direct care staff I stated he/she assisted the resident to the floor and noted the resident kept ahold of the grab bar with his/her left hand. Direct care staff I did not know if the resident hit his/her left arm on the toilet riser. After completion of the investigation, the facility determined direct care staff G mentor failed to check the level of assistance needed for the resident prior to sending orientee direct care staff I to assist the resident. The facility disciplined the direct care staff G for the failure and provided education to all staff on the unit regarding locking the wheelchairs before transfers, and orientating direct care staff were not to provide care to the residents alone until completion of orientation. Review of the radiology report dated 11/10/16 revealed the resident had an acute (sudden onset) mildly impacted humeral head and neck fracture (a break in the top of the upper arm bone) of the left arm. Observation on 12/12/16 at 3:10 p.m. revealed resident #4's family in his/her room visiting with the resident. The resident sat in his/her wheelchair watching television, left arm in a sling, with a call light next to the resident and non-slip shoes on his/her feet. During an interview on 12/14/16 at 9:30 AM, direct care staff G reported he/she worked the day resident #4 fell . Staff G reported he/she sent direct care staff I to assist resident #4 off of the toilet. Staff G stated he/she finished with the resident he/she was working with and then left to help Staff I. Upon arrival staff G found resident #4 on the floor lying on his/her right side and direct care staff I at the resident's side. Staff G stated one side of the wheelchair brake was not engaged and the resident had on a gait belt. Staff G got the nurse and three staff assisted the resident to the wheelchair using a gait belt. During an interview on 12/13/16 at 3:54 PM, licensed nursing staff F stated the resident had a high risk for falls. Staff F stated he/she helped resident #4 the morning the resident fell . Staff F reported that direct care staff I assisted the resident alone and the resident fell to the resident's right from the toilet. The resident complained of left arm pain and the facility did an in house x-ray of his/her left arm around lunchtime. The resident left to the emergency room to see an orthopedic doctor. During an interview on 12/14/16 at 8:40 a.m., administrative nursing staff A revealed direct care staff I did not lock the wheelchair and independently assisted resident #4, while still on orientation, as instructed by direct care staff G. Review of the facility policy titled Safe Resident Handling/Transfer Equipment reviewed 3/1/16 revealed staff used a gait belt on patients who could safely ambulate with assistance and/or perform greater than or equal to 50% of lift/transfer with stand pivot assistance with one staff member. Use of two staff members may be care planned for monitoring and/or safety as indicated. The facility failed to transfer this cognitively impaired dependent resident in a safe manner as care planned. The resident's care plan directed two staff to assist the resident with transfers. The resident sustained [REDACTED].

The facility census totaled 110 residents with 25 residents included in the sample. Three residents were reviewed for accidents related to falls. Based on observation, interview and record review the facility failed to thoroughly investigate all falls and implement appropriate fall interventions to prevent accidents for 2 of 3 residents (#160 and #57), resulting in fracture injuries for resident #57. Findings included: - Review of resident #57's signed physician order [REDACTED]. Review of the annual MDS (minimum data set) dated 11/2/15 revealed the resident had long and short term memory problems and severely impaired decision making abilities. The resident did not have any behaviors. The resident required extensive assistance of 1-2 staff for all ADLs (activities of daily living) and used a wheelchair for mobility. The resident was always incontinent of urine and frequently incontinent of bowel. The resident received scheduled and as needed pain medications for non-verbal sounds and facial expressions of pain 1-2 days during the 5 days of the observation period. The resident had 1 non injury fall and 2 minor injury falls since the prior MDS assessment. The resident received an antipsychotic daily for 7 days of the observation period. Review of the significant change MDS dated [DATE] revealed no change in cognition, behaviors, or ADLs. The resident continued to receive pain medications for non-verbal sounds of pain 1-2 days of the 5 days of observation. The resident had no falls since prior assessment. Review of the falls CAA (care area assessment) dated 11/14/15 revealed the resident had frequent falls recently, continued to be at risk for falls with injury related to urinary incontinence, impaired mobility, anxiety, dementia, behaviors, and medication regimen. Staff had implemented fall prevention measures that included: medication reviews, assistance with ADLs, visual checks, and physical therapy services. Review of the cognitive loss/dementia CAA 11/14/15 revealed the resident required extensive assistance with ADLs. The resident was alert and oriented to name only, he/she had a [DIAGNOSES REDACTED]. Review of the care plan dated 11/13/14 identified the resident at risk for falls and included the following interventions and revision dates: 7/28/15 - during times of agitation allow the resident personal space away from others; the pharmacy consultant to review medications; the resident enjoyed standing up at the railing in the hallway, staff to assist the resident to face the railing at times of restlessness as he/she desired. 11/13/14 - staff needed to anticipate the resident's ADL needs, evaluate medications, assure toileting needs are met, fall assessment to be completed quarterly, annually and as needed, offer cueing and reminder for safety awareness throughout the day -- used a wheelchair with foot pedals for mobility - required assistance with transfers and wheelchair propulsion, staff to offer diversional activities. 12/1/14 - med review by ARNP 12/2/14 - pharmacy review chart -- resolved 3/1/15 12/18/14 - staff to offer recliner at nurse's desk for comfort when restless -resolved 3/1/15 1/28/15 - antiroll back device placed to the back of the resident's wheelchair. 6/27/15 PT/OT to evaluate and treat the resident - resolved 8/1/15 7/5/15 - staff to offer a hot pack to place behind the resident's back to help with pain during restless periods - resolved 8/1/15 7/26 /15 - medication/lab review by APRN - resolved 8/1/15 10/3/15 - staff to assist in keeping frequent used items within his/her reach. 10/27/15 - PT/OT to evaluate and treat for strengthening/pain management/transfer safety Review of the fall investigations for resident #57 revealed the following: On 6/19/15 at 7:00 PM the resident had a witnessed fall while standing at the railing by the nurse's station. The resident received a skin tear to his/her right hand which facility staff treated. The investigation identified the resident had 3 falls in the past 2-6 months and none in the past 30 days. The initial intervention included staff education, resident education, evaluation of equipment, staff to do observations and monitoring of the resident. The investigation did not identify any contributing factors and the determination revealed the resident stood up and sat back down and missed the wheelchair. It included an intervention for physical and occupational therapy to evaluate. On 6/27/15 at 7:30 AM the resident had a witnessed fall at the nurse's station again facing the wall where the resident stood up and as he/she sat down the resident stepped away from the wheelchair and fell . The resident received a skin tear to his/her right hand which facility staff treated. The initial interventions again included staff education, observation and monitoring. It also included staff to provide 1:1 (1 staff to the resident) activity of the resident's choice and staff identified the contributing factor to be the wheelchair. The determination revealed the resident had increased yelling/anxiety and also had a recent decrease of Risperdal (an antipsychotic medication). The intervention was for the nurse practitioner (ARNP) to complete a medication review. The staff failed to identify causal factors of the fall. On 7/5/15 at 10:35 AM the resident had another witnessed fall while sitting in the wheelchair by the nurse's station. The resident leaned too far to the right and fell to the floor. The investigation identified action taken for staff to complete frequent monitoring every 30 minutes. The determination revealed the resident leaned too far to the right and fell but failed to identify why the resident leaned to the right. It did identify the resident had his/her Risperdal increased back to the previous dosage but continued to yell out and have behaviors. The staff had additional intervention to offer the resident a hot pack from restorative to place behind the resident's back during restless periods. On 7/12/15 at 12:41 PM the resident had an unwitnessed fall in the assisted dining room. The investigation revealed staff had taken the resident to the assisted dining room a few minutes prior and the nurse found the resident on the floor in the dining room. The resident had a skin tear to his/her left middle finger and pain to his/her left shoulder. The facility provided staff education but did not identify what education was provided. Determination revealed there was no staff in the dining room at the time of the fall and planned interventions included for staff to stay in the dining room until all residents were out and to assist any resident at risk for falls to the nurse's station. On 7/24/15 at 6:30 PM the resident had an unwitnessed fall where staff found the resident on the floor in the hallway. The resident had no injuries. It revealed the resident faced the wall and stood and sat down in the wheelchair prior to the fall. The initial interventions again included staff education, resident education and observation and monitoring. The determination revealed the resident fell doing hallway rail standups. The additional intervention was for the ARNP to again complete a medication review. On 10/3/15 at 8:50 AM the resident had an unwitnessed fall in the assisted dining room. There were staff in the dining room but no one saw what happened. The nurse aide heard the resident hit the floor and looked up and saw the resident on the floor. The resident had a laceration above his/her left eyebrow and other complaints of pain and was sent to the emergency department for evaluation. Determination revealed the resident had increased restless and anxiousness prior to the fall. It also noted the resident had reached for a glass at the time of the fall per witness statements. Review of the hospital discharge instructions revealed the resident had a closed head injury, left shoulder strain and scalp laceration. Review of the chest x-ray revealed the resident had a subtle unhealed fracture of the right seventh rib laterally but was unable to determine its precise acuity and presumed to be recent. On 10/17/15 at 6:00 PM the resident had another unwitnessed fall in the hallway while sitting in the wheelchair facing the hand rail. The investigation had no determination of investigation as to the root cause of the fall. On 10/26/15 at 6:00 PM the resident had another fall that was unwitnessed in the assisted dining area. Staff called the nurse to the dining room and observed the resident face first on the floor. The resident had been sitting in his/her wheelchair at the table prior to the fall. Again the intervention was for staff to provide observations and monitoring. The resident received a laceration to the left eyebrow and was sent to the emergency department. The resident returned with a [DIAGNOSES REDACTED]. The investigation revealed that the resident's Risperdal had been decreased to 0.25 mg at bed time and the resident had increased tearfulness, was combative with staff at times, and increased yelling out noted. Additional interventions included a new order for physical and occupational therapy for strengthening, pain management and transfers. During an interview on 5/31/16 at 5:51 PM direct care staff H reported he/she looked at the Kardex in the computer or used the dots (color coded according to amount of assistance needed) on the door. He/she thought the resident had a chair alarm and staff needed to remind the resident that when he/she stood up at the rail to hold onto it and make sure the wheelchair was locked. During an interview on 6/1/16 at 2:43 PM administrative nursing staff F reported therapy evaluated the resident and he/she could practice standing up and sitting back down at the hand rail. Staff F stated the resident was up and down a lot, fidgety, and sometimes it would help if the staff would take the resident to the bathroom. Staff F stated as far as he/she could remember staff did not provide 1:1 care for the resident. Staff stated he/she had been in the dining room serving before and by the time he/she turned to get a plate out of the cart, the resident had stood up and fallen. Staff F stated that with each fall the nurse needed to evaluate the cause of the fall, the interventions and implement an appropriate intervention to prevent more falls. During an interview on 6/2/16 at 7:41 AM licensed nursing staff K reported when a resident fell the nurse needed to complete a physical assessment, an investigation report and needed to determine the cause of the fall, how to prevent further falls, and then update the care plan. Staff K reported after all of that was done then the ADON (assistant director of nursing) would review the report and determine if the interventions were appropriate or not. Staff K reported the resident was anxious and when he/she faced the railing and could stand up and sit down he/she fell less than he/she did with his/her back to the rail. Staff stated they gave the resident trinkets and other things to hold onto but that didn ' t really help. During an interview on 6/1/16 at 3:12 PM administrative nursing staff B reported the nurses on the floor had to do a head to toe assessment, it the fall was unwitnessed the nurse needed to complete neurological monitoring, fill out the event and the investigation on the computer. The fall team then would look at the interventions to see if they were appropriate. Staff B stated he/she expected the nurse to identify what might have caused the fall and implement an intervention, and reevaluate current interventions for effectiveness. During an interview on 6/02/16 at 11:21 AM Nurse Practitioner staff P reported he/she did not primarily care for the resident but knew that the resident standing/sitting at the hand rail was partially entertainment for the resident to do because he/she liked to stand up. He/she also felt that the facility kept a close eye on the resident. Review of the facility's falls management policy dated 3/15/16 revealed residents at risk for falls would receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall would receive appropriate care and investigation of the cause of the fall. The facility failed to investigate the root cause of the falls, implement appropriate fall interventions to prevent further falls for a resident who had multiple falls including one with fractured ribs and a closed head injury that required an emergency room visit and another fall that also required an emergency room visit. - Review of resident #160's signed physician order [REDACTED]. Review of the annual MDS (minimum data set) dated 8/28/15 revealed a BIMS (brief interview for mental status) score of 15 indicating no cognitive impairment. The resident had no signs of delirium, any hallucinations, delusions, or inappropriate behaviors. The resident required extensive assistance of 1 person for ADLs (activities of daily living) and was unsteady but could stabilize self without staff assistance. The resident used a walker and wheelchair as assistive devices. The resident had two or more non injury falls since admission and received an antipsychotic, antianxiety, antidepressant medication daily for 7 days of the observation period. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. The resident had improved in ADL status and required limited assistance to supervision to complete ADLs. The resident had no other changes as compared to the information above from the 8/28/15 MDS. Review of the ADL Functional/rehabilitation CAA (care area assessment) dated 9/18/15 revealed the resident required 1 person assistance with ADLs and could feed him/herself with set up assistance. The resident had debility, unsteady gait, incontinence, hard of hearing, dementia, and poor safety awareness. The resident used a wheelchair for mobility, and could ambulate short distances with a front wheeled walker. Review of the Falls CAA dated 9/10/15 revealed the resident fell on [DATE] and on 7/19/15 in his/her room. The resident had generalized muscle weakness, unsteady gait and was at risk for falls. The resident had a history of [REDACTED]. Review of the care plan last reviewed on 9/11/15 included the following interventions related to fall prevention: 9/11/15 - Assist the resident with ADLs as needed encouraging independence within his/her functional limitation Assist x1 with bed mobility, transfers, dressing, ambulation, wheelchair propulsion, bathing and hygiene. The resident can ambulate short distances with front wheeled walker and stand by assistance. He/she needed a wheelchair for long distances. Provide a safe environment by monitoring positioning, assist with ADLs provide nap time and fall prevention. Redirect resident when security system sounds and/or resident attempts to leave the building. Physical therapy evaluation/screen as needed for any decline or possibly therapy to increase mobility Assess for changes in medical status, pain status, and mental status and report to physician as indicated. Bed and chair alarm to be on as directed. Fall assessment completed upon admission, quarterly, annually and as needed. The resident has been moved to a room that is closer to the dining/activity room. Offer choices of activities outside of his/her room as he/she will allow. Staff educated to offer 1:1 care to the resident when upset as he/she will allow. Provide verbal cues for safety and sequencing when needed. The resident was educated to have proper footwear on when ambulating/transfers Remind the resident to use call light when attempting to ambulate or transfer. Maintain a clutter free environment in the resident's room and consistent furniture arrangement. When the resident is in bed, place all necessary personal items within reach. Monitor for and assist with toileting needs. Therapy/Rehabilitation PT evaluation as needed The resident needed assistance with toileting, assist him/her to the toilet upon rising, before and after each meal, and before he/she went to bed and as needed. Review of the fall investigations revealed the following: On 6/22/15 at 3:30 PM revealed the staff found the resident sitting on the floor at the foot of his/her bed. The resident stated he/she tried to sit in the wheelchair and fell on the floor. The resident had no injuries. The investigation revealed staff failed to identify the root cause of the fall and implement interventions to prevent further falls. On 7/19/15 at 2:15 AM revealed the nurse found resident sitting in the recliner in his/her room crying. The resident stated he/she fell and twisted his/her back and shoulders. The resident also reported he/she got him/herself up off the floor. Interventions included placing the call light and other items in reach. On 9/2/15 at 11:30 AM resident found sitting in the wheelchair in the doorway of his/her room crying. The resident stated he/she fell and hurt his/her left arm and reported pain at a 10, being the worst pain ever. The nurse assessed the resident and no obvious injury noted, the resident reported he/she could hardly move his/her left arm. The facility notified the APRN and went to assess the resident, and observation revealed the resident using his/her left arm in the bathroom without any problems. The fall investigation lacked root cause analysis to identify probable cause and interventions to prevent further falls. On 12/29/15 at 6:00 PM staff found the resident in his/her room and the resident stated he/she stumbled walking back to his/her chair from the bathroom. The investigation lacked root cause analysis and interventions to prevent further falls. On 3/14/16 at 8:15 PM staff found the resident on the floor in his/her room outside of the bathroom. The resident stated he/she took him/herself to the bathroom. The investigation revealed 2 staff assisted the resident back to the wheelchair and then into the bed. The investigation lacked root cause analysis and interventions to prevent further falls. Observation on 5/31/16 at 7:51 AM revealed the resident sat in the bathroom on the toilet without staff present. When finished the resident grabbed a hold of the grab bar and stood up, pulled up his/her pants and then plopped down into the wheelchair that was locked. The resident then propelled him/herself over to the sink, washed his/her hands and brushed his/her teeth. On 5/31/16 at 4:00 PM the resident came out of the bathroom sitting in wheelchair. The resident then propelled the wheelchair over to the end of his/her bed and got out of the wheelchair, put his/her hands on the bed and overbed table and walked over to his/her recliner and sat down without calling for staff assistance. During an interview on 5/31/16 at 7:51 AM the resident reported he/she did not need any assistance from the staff to get in and out of bed or on and off the toilet. The resident reported he/she could also get dressed without staff assistance. The resident reported he/she had fallen before but did not have any serious injuries, just some scrapes and bruises. During an interview on 5/31/16 at 9:27 AM direct care staff I reported he/she knew how much assistance and how to care for the residents from the cheat sheet in the assignment book and the color coded dots on the name plate by the door as well. Staff I stated the resident mostly needed stand by assistance and did most everything him/herself. Stated every once in a while the resident will fall but it is not a common occurrence. Staff stated he/she did not see the resident as a fall risk and did not do anything particular for him/her to prevent falls. During an interview on 5/31/16 at 5:51 PM direct care staff H reported the resident had fallen but was doing well. Staff H stated he/she walked the resident to try and maintain the resident's strength and ability to do things. Staff H reported that sometimes the resident got confused or agitated and that was when they needed to keep an eye on him/her. During an interview on 6/1/16 at 3:03 PM licensed nursing staff V reported if a resident fell the staff had to complete an assessment, notify the physician and family, and complete an investigation report and document in the record. Staff V reported the nurse needed to determine what might have caused the fall and implement an intervention at that time. During an interview on 6/1/16 at 3:12 PM administrative nursing staff B reported the nurses on the floor had to do a head to toe assessment, it the fall was unwitnessed the nurse needed to complete neurological monitoring, fill out the event and the investigation on the computer. The fall team then would look at the interventions to see if they were appropriate. Staff B stated he/she expected the nurse to identify what might have caused the fall and implement an intervention, and reevaluate current interventions for effectiveness. Review of the facility's falls management policy dated 3/15/16 revealed residents at risk for falls would receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall would receive appropriate care and investigation of the cause of the fall. The facility failed to thoroughly investigate the causal factors of multiple falls and failed to implement appropriate interventions to prevent further falls.

The facility had a census of 120 residents. The facility identified 13 residents at risk for elopement. Based on observation, interview and record review, the facility failed to provide 1 of 1 residents sampled (#1)with adequate supervision to prevent accidents (elopement). Resident #1 had wandering behaviors and left the facility without staff knowledge on 12/6/15. The facility failed to review/revise the plan of care following the 12/6/15 elopement to include adequate interventions to prevent future elopements. On 3/27/16, resident #1 left the facility (4:25 p.m. per review of the video) without staff knowledge again when he/she left via an alarmed door. Another resident who knew the code to the alarm turned the alarm off, and staff failed to check why the exit door alarm sounded and then stopped. Resident #1 walked approximately 1/2 mile down a side street. Staff found the resident near a main east/west roadway, with a speed limit of 40 miles per hour, in a heavily traveled business/residential area. The resident returned to the facility at 4:55 p.m. according to staff review of the facility video. According to Weather Underground (www.wunderground.com), the temperature on 3/27/16 at 3:53 p.m. was 52 degrees Fahrenheit with winds out of the west at 9.2 miles per hour. Facility failure to provide adequate supervision to prevent elopement placed the resident in immediate jeopardy. Findings included: - Resident #1's clinical record included signed physician's orders [REDACTED]. The 9/10/15 Admission MDS (Minimum Data Set) identified the resident with long and short term memory problems, no wandering behaviors, the need for extensive assistance of one staff person for ambulation, unsteady balance when walking and only able to stabilize with staff assistance, use of a walker and wheelchair, and daily use of antipsychotic medication. The 3/11/16 Quarterly MDS indicated an inability to complete the BIMS (Brief Interview for Mental Status) assessment and no assessment of long/short term memory loss. According to the MDS, the resident required supervision of one staff person for ambulation, no use of assistive devices such as a walker or wheelchair, and the presence of daily wandering behaviors. CAAs (Care Area Assessments) completed on 9/10/15 included: Cognitive Loss/Dementia: Described the resident's cognitive decline within the past 6-7 months prior to admission and noted pre-admission problems which included erratic driving and walking from one town to another in search of a vehicle. According to the CAA, the resident had an admission to a behavioral unit prior to admission as well. Falls: Identified the resident as at risk for falls due to confusion. Resident #1's 9/14/15 care plan noted impaired communication, risk for falls and recent start of antipsychotic medication (Seroquel). The care plan included no evidence of review/revision following the resident's 12/6/15 elopement from the facility. The current care plan dated 3/27/16 (after the resident's second elopement) identified resident #1 as at risk for elopement related to attempts to leave with family after visiting with them. Interventions to prevent elopement included: 1) All staff within hearing range of alarms would respond to open door alarms 2) Education to DPOA (Durable Power of Attorney) and staff of elopement potential triggers and prevention measures. 3) Staff to encourage independence while inside the building but ensure supervision while outside. 4) If staff were unable to redirect the resident, staff were to stay with the resident to provide support and supervision until able to redirect. 5) 15 minute checks at all times to include while in his/her room 6) Provide picture ID (identification) and description of resident to offices/staff located near exits. 7) Redirect resident when security system sounds and/or resident attempts to leave. 8) Utilize sign in/sign out records when the resident leaves the facility with escort. A 8/31/15 History and Physical from the hospital described resident demonstrated progressive confusion and was declared incompetent and assigned a legal guardian during the hospitalization . Treatment in the hospital included initiation of antipsychotic medication and use of physical restraints. Elopement Risk Monitoring forms completed on 9/30/15 at the facility did not identify the resident as an elopement risk. The 12/7/15 Elopement Assessment noted resident #1's impulsiveness, restlessness, agitation and with a [DIAGNOSES REDACTED]. Nurses Notes included: 12/6/15 - Described an incident where staff found resident #1 out in the parking lot and returned the resident to the building. According to the note, the facility placed the resident on 15 minute elopement checks following the incident. According to facility review of a video the resident exited the facility at 4:25 p.m. and returned at 4:55 p.m., for a total of 30 minutes out of the facility. The facility reported resident #1's elopement from the facility on 3/27/16 at 4:23 p.m. Nurses Notes from 3/27/16 lacked documentation specifically about the elopement (when the resident left, weather conditions, type of clothing worn by the resident, location where staff found the resident, resident's condition upon return) other than an entry at 11:41 p.m., more than 7 hours later, that described the resident's refusal of post - elopement assessments. Nurses Notes after the elopement included: 3/28/16 at 5:41 a.m.: Described the resident's pacing during the shift 3/28/16 at 12:59 p.m.: Described contact with the family via telephone and noted continued 15 minute visual checks. According to Weather Underground (www.wunderground.com), the temperature on 3/27/16 at 3:53 p.m. was 52 degrees Fahrenheit with winds out of the west at 9.2 miles per hour. Review of documentation of the 15 minute elopement checks implemented for resident #1 included: 3/31/16 log sheet failed to document every 15 minute checks in the 73 minute time period from 10:15 a.m. to 11:28 a.m Additionally, as of 5:43 p.m. on 3/31/16, the log sheet lacked evidence of completion of the 15 minute checks since 3:45 p.m., a total of nearly two hours. During an observation on 3/31/16 at 1:39 p.m., resident #1 ambulated in the hallway without staff assistance. On 3/31/16 at 12:38 p.m., survey staff drove the assumed route resident #1 took on 3/27/16, as described by facility staff, when he/she left the facility without staff knowledge. The immediate terrain accessible to the resident once outside included a private lake approximately 200 feet north of the facility, a four lane Interstate Highway with a 65 mile per hour speed limit approximately 1 block east of the facility, and an Interstate exchange/exit from the Interstate Highway onto a smaller street. The residential neighborhood where the facility is located transitioned into a business neighborhood within a few blocks of heading south. The distance from the facility to the location where staff found the resident measured 1/2 mile. The parking lot where staff located the resident was in a business area, adjacent to a heavily traveled 4 lane east/west street. During an interview on 3/31/16 at 10:54 a.m., Administrative Nurse A reported staff notified him/her of resident #1's absence from the building on 3/27/16 at approximately 4:44 p.m. At that time, staff advised him/her the resident left at approximately 4:25 p.m. According to Nurse A video footage confirmed resident #1 left the facility at 4:25 p.m. and resident #2 alerted Direct Care Staff B of the elopement at 4:29 p.m Administrative Nurse A reported staff should have called a Code Pink first and then started a search for the resident, rather than searching his/her room and the dining room prior to calling the Code Pink. Nurse A also reported staff located resident #1 at a strip mall right before a main street. During an interview on 3/31/16 at 3:38 p.m., Resident #2 reported he/she sat in the lobby on the afternoon of 3/27/16 and noticed resident #1 pushing buttons at the exit door. Resident #2 stated an alarm started to sound and resident #1 went out the door. Resident #2 then went over to the alarm box, entered the correct code in, and silenced the alarm because he/she thought resident #1 had family out in the parking lot that he/she went out to see. According to Resident #2, staff did not respond to the door alarm prior to him/her silencing it, and after about 5 minutes he/she went to get staff to alert them to the fact that resident #1 went outside alone. At that point, staff started to search for resident #1. During an interview on 3/31/16 at 2:05 p.m., Direct Care Staff B reported he/she worked on the afternoon of 3/27/16. On that afternoon, Staff B reported a resident in the front lobby told him/her that another resident with a brown coat on entered the code into the exit door and then went outside alone. In response to that report, Staff B recalled resident #1 wore a brown coat that day so he/she went to the resident's room to look for him/her. After he/she also searched in the dining room. Staff B told the charge nurse about resident #1's possible elopement from the facility and the nurse initiated a Code Pink. During an interview on 3/31/16 at 2:43 p.m., Social Services Staff C stated a receptionist usually manned the front desk daily, but on 3/27/16, the person scheduled for that job called in and staff then made alternate arrangements for someone else to man the desk. Staff C reported the substitute who manned the front desk did not stay until 6 p.m. that afternoon as planned, and therefore no one was at the desk when resident #1 left the facility without staff knowledge. During an interview on 3/31/16 at 5:15 p.m., Administrative Staff D confirmed the person scheduled to work at the receptionist desk on 3/27/16 called in and the person who covered those responsibilities that day clocked out at 4:30 p.m The Elopement of Patient policy with a revision date of 5-15-14 noted Patients 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 provide resident #1 with adequate supervision to prevent elopement. The resident left the facility without staff knowledge on 12/6/15. Following that elopement, the facility failed to review/revise the plan of care to include adequate interventions to prevent future elopements. On 3/27/16, resident #1 left the facility without staff knowledge again when he/she left via an alarmed door, another resident who knew the code to the alarm turned the alarm off, and staff failed to check why the exit door alarm sounded and then stopped. Resident #1 walked approximately 1/2 mile down a side street. Staff found the resident near a main east/west roadway in a heavily traveled business/residential area. Facility failure to provide adequate supervision to prevent elopement placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 4-1-16 at 2:00 PM by implementing the following: Initiation of 15 minute checks upon return to the facility at 4:55 p.m. on 3/27/16. Completion of re-education of all staff on the Elopement Management Plan Completion of missing resident drills, one for each shift Completion of 15 minute checks on the resident beginning immediately on the return of the resident to the facility. After abatement, the deficient practice remained at a scope/severity of D.

The facility had a census of 110 residents with 29 sampled for review and 6 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure 3 of 6 residents reviewed for accidents received adequate supervision to prevent accidents related to transfers and falls. Facility staff transferred resident #78 with a mechanical lift with 1 person assisting the resident instead of 2 persons as care planned and as directed in the facility's mechanical lift policy. The facility also failed to implement fall prevention strategies for resident #191 after a fall and failed to transfer resident #57 with the mechanical lift as care planned. (#78, #191, #57) Findings included: - Resident #78's 8/28/14 admission MDS (minimum data set) assessment revealed the resident had severely impaired cognition and was dependent on 2 persons for transfers. The resident required extensive assistance of 2 persons for bed mobility and toileting. According to the assessment, walking did not occur during the assessment period. The resident had functional limitations in range of motion on one side of both upper and lower extremities and used a wheelchair for mobility. Resident #78's 9/2/14 fall CAA (care area assessment) identified the resident as at risk for falls, non-ambulatory (unable to walk), and dependent on staff for all transfers. According to the resident's 11/27/14 quarterly MDS assessment, he/she remained dependent on 2 staff for transfers, walking did not occur, and no falls occurred since the prior assessment. Resident #78's 8/28/14 nursing care plan directed staff to transfer the resident using a mechanical lift with 2 person assistance. A revision to the care plan dated 11/29/14 instructed staff to ensure placement of the sling before transferring with the mechanical lift with 2 staff assisting. The facility's 11/29/14 investigation revealed direct care staff I transferred resident #78 from the bed to his/her wheelchair with the mechanical lift and the resident slid from the lift to the floor. The resident complained of pain to the left leg and according to the assessment the resident's left leg appeared shorter than the right leg. Emergency medical personnel transported the resident to a local hospital for treatment. The 11/29/14 hospital history and physical stated the resident's chief complaint at the time of admission was a left thigh deformity following a fall from a transfer lift. According to the document, the resident was being transferred when he/she fell approximately 4 feet from the lift. Radiographs (X-rays) identified a distal subtrochanteric femur fracture (broken leg). Resident #78 no longer resided at the facility and was unavailable for observations. During an interview on 1/13/15 at 1:26 p.m., direct care staff J stated that resident #78 required 2 persons for transfers with a mechanical lift. Staff J further stated that direct care staff I transferred resident #78 on 11/29/14 alone, without assistance from other staff. An interview on 1/13/15 at 5:42 p.m. with direct care staff P revealed that resident #78 was dependent on 2 staff for transfers with the mechanical lift. Staff P further confirmed the resident's care plan directed staff to transfer the resident with 2 persons using the mechanical lift. During an interview on 1/13/15 at 5:49 p.m., licensed staff Q confirmed staff should always transfer residents with the mechanical lift with 2 staff present. Staff Q confirmed resident #78 sustained a fractured leg after the fall from the lift on 11/29/14. An interview on 1/13/15 at 7:13 p.m. with administrative nurse B verified resident #78 sustained a fracture after the resident fell from a lift when direct care staff I transferred the resident without adequate assistance. Nurse B stated he/she was unaware that staff transferred residents in this manner prior to the incident with resident #78. Administrative nurse B indicated the facility's policy stated that lift transfers should be done with 2 staff. During an interview on 1/14/15 at 4:45 p.m. physician EE verified resident #78 sustained a fracture on 11/29/14 as a result of the fall from the lift that occurred at the facility. The facility's undated Mechanical Lift policy stated at least 2 people should be present for transfers with the mechanical lift. The facility failed to ensure staff safely transferred resident #78 from the bed to the wheelchair with a mechanical lift with 2 staff assistance. Resident #78 sustained a fall with a fractured leg when he/she fell from the lift with only 1 staff person performing the transfer. - Review of resident #57's annual MDS (minimum data set) dated 10/10/2014 revealed a BIMS (brief interview for mental status) score of 15, which indicated no cognitive impairment. The resident required extensive assist of 2 with bed mobility. He/she was dependent on assist of 2 staff for transfers and toileting and he/she required extensive assist of 1 with personal hygiene, dressing and locomotion on and off the unit. The resident used a wheelchair for mobility. Review of resident #57's quarterly MDS (minimum data set) dated 7/10/2014 revealed a BIMS (brief interview for mental status) score of 15, which indicated no cognition impairment. The resident required extensive assist of 1 with bed mobility, locomotion on and off the unit, dressing and personal hygiene. The resident was dependent on assist of 2 staff for transfers and bathing and required extensive assist of 2 staff with toileting. He/she use a wheelchair for mobility. Review of the ADL (Activities of Daily Living) (CAA (care area assessment) dated 10/23/2014 revealed the resident had weakness with a [DIAGNOSES REDACTED]. Review of the resident's ADL care plan, initiated on 10/23/2014 revealed the resident required the use of a Hoyer mechanical lift with transfers using 2 staff. Review of a nursing order dated 1/12/2015 revealed the resident complained of pain below his/her left knee that occurred during a transfer. He/she had rated pain a 9 out of 10 with a 10 being most severe. The resident displayed facial grimacing. There was no visible bruising or injury noted at the time of the assessment. A phone call was placed to the physician and a new order was received for Norco 5/325 (pain medication) mg (milligrams) one to two tablets by mouth every 4 hours as needed for pain. The resident rated his/her pain a 5 out of 10 after an hour of administration and the resident was noted as falling asleep. The APRN (Advance Practical Registered Nurse) had been notified via a written note to follow up in the morning. The nurse would continue to intervene as needed. Review of a radiology report dated 1/13/2015 revealed results of a left knee x-ray, which indicated no fracture, dislocation or joint effusion. The conclusion of the x-ray was mild osteoarthritis of the left knee. During an observation on 01/12/2015 at 3:27 p.m. direct care staff GG and direct care staff JJ transferred the resident using a Hoyer lift. The resident informed direct care staff GG and JJ that his/her left leg hurt from a transfer that morning. The resident was attached to the sling and the hoyer lift was used to transfer the resident from the wheelchair to the bed. During an observation on 01/13/2015 at 7:21 a.m. direct care staff QQ assisted the resident with dressing. The resident complained of his/her leg hurting when direct care staff QQ was dressing his/her lower body. Direct care staff QQ left the room and stated his/her intent to notify the nurse of the resident's complaints of left leg pain. Direct care staff RR returned with direct care staff QQ to assist with bed mobility and transfer. The direct care staff QQ and RR attached the sling to the Hoyer lift and the resident was transferred from his/her bed to the wheelchair. The sling was detached from the lift. Direct care staff QQ placed foot pedals on the resident's wheelchair. The resident complained of pain when direct care staff QQ attempted to place his/her left leg on the foot pedal. Direct care staff QQ placed a pillow under the resident's left leg for comfort. The resident asked for the pillow to be removed due to increased discomfort and the pillow was removed by direct care staff QQ. During an interview on 01/12/2015 at 3:23 p.m. the resident reported staff manually transferred him/her with 2-3 people assist from the wheelchair to the shower chair. The resident reported staff had always manually transferred him/her to and from the shower and he/she was not aware of the reason. The resident stated his/her left leg had hurt from the knee down since the transfer this morning at approximately 11:00 a.m. He/she stated his/her left leg twisted during the transfer. The resident rated his/her pain at a 9 on a scale of 0-10 with 10 being the most severe. The resident described the pain as a sharp twist, which was constant in nature. During an interview on 01/12/2015 at 3:00 p.m. direct care staff GG revealed the resident transferred using a Hoyer lift with assist of 2 staff. He/she reported the policy was to always transfer 2 staff present. During an interview on 01/13/2015 at 7:30 a.m. direct care staff QQ revealed staff, including him/herself had manually lifted the resident for shower transfers. He/she reported 2-3 staff usually assisted when manually lifted. He/she was unable to provide a rationale for manually lifting the resident versus a mechanical lift. He/she reported staff are trained to use the mechanical lift and the care plan directed staff to use a mechanical lift with 2 person assist. During an interview on 01/13/2015 at 8:13 a.m. administrative nursing staff D revealed he/she was made aware of the resident's left leg pain on 1/12/2015. Administrative nursing staff D reported staff should be transferring the resident according to his/her care plan, which was a Hoyer lift with assist of 2 staff, not manually. The facility failed to transfer resisdent #57 with a mechanical lift as care planned. - Review of resident #191's admission MDS (Minimum Data Set) dated 1/2/2015 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident's cognition was intact. The resident required supervision and assist of one with bed mobility, transfers, ambulation, toileting, dressing and personal hygiene. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) for admission date of [DATE] revealed the CAAs had not been completed by the due date of 1/8/2015. Review of the fall risk assessment dated [DATE] revealed the resident had no history of falling, was incontinent, had an acute infection, needed an assistive device to ambulate, had a memory deficit, received medications which increased fall risk, had a hearing deficit, was diagnosed with [REDACTED]. Review of a fall risk assessment dated [DATE] revealed the resident had experienced a fall in the last 30 days, had a [DIAGNOSES REDACTED]. Review of resident #191's temporary care plan dated 12/26/2014 revealed the resident had been oriented to the call light, bathroom and to staff. He/she required the assistance of 1 staff with bed and chair mobility, transfers, ambulation, dressing, personal hygiene, bathing and locomotion. The resident was occasionally incontinent of urine and was continent of bowel. He/she needed assistance of 1 staff with continence management He/she used a walker for mobility. There was no intervention indicated on the care plan for a fall which occurred on 1/5/2015. Review of a nursing note dated 1/5/2015 revealed the resident fell at 6:30 p.m. No injuries were noted. The resident was instructed to ask for assistance while ambulating for the remainder of the evening. Review of an incident report dated 1/5/2015 revealed the resident was found sitting on the floor at bedside on his/her bottom at 6:30 p.m. He/she was alert and able to tell the nurse he/she had fallen. The resident reported he/she hit his/her head and neurological checks were initiated. Increased confusion had been noted prior to the fall. Prior to the incident the resident had just eaten supper and was back in his/her room. Immediate intervention by the nurse was he/she requested the resident to ask for assistance while ambulating that evening due to increased confusion and he/she planned to monitor more frequently until the resident's urinary tract infection subsided. It was determined the resident was trying to take him/herself to the restroom and lost his/her balance. The resident was provided education regarding the need to accept assistance from staff. During an interview on 01/13/2015 at 12:32 p.m. direct care staff DD revealed the resident was not a fall risk. He/she reported the resident was a stand by assist for transfers. He/she is not aware if the resident had experienced falls since admission and was not aware if the resident had any fall interventions in place. Direct care staff DD reported the care plan was located in a blue book at the nurses ' station. He/she stated she does not really look at the book. Direct care staff DD reported he/she had access to a basic care plan in the electronic aide documentation system. He/she revealed the system did not identify the resident as a fall risk. During an interview on 01/13/2015 at 9:49 a.m. Licensed nursing staff O revealed the resident had experienced one fall on 1/5/2015, since admission. He/she reported the resident was being treated for [REDACTED]. He/she reported the fall interventions currently in place were to increase monitoring every 30 minutes, which he/she does not document. During an interview on 01/13/2015 at 5:49 p.m. Administrative nursing staff B revealed the care plan should be updated within 24 hours with a new intervention after a fall has occurred. Review of the facility's policy for Fall Management dated 12/16/2013 revealed the licensed nurse would communicate the incident and new interventions through the 24 hour report. The facility failed to communicate and implement appropriate interventions following a fall on 1/5/2015 for resient #191.

The facility had a census of 110 residents with 29 sampled for review and 5 reviewed for weight loss. Based on observation, interview, and record review, the facility failed to ensure 2 of 5 residents sampled for nutrition maintained acceptable parameters of nutritional status. The facility failed to follow-up on dietician recommendations, failed to notify the physician, dietician, and the resident's family of a significant weight loss, and failed to implement interventions to prevent future weight loss for resident #24 who experienced a 7.41% weight loss in 73 days. The facility also failed to provide assistance with eating for resident #121. Findings included: - Resident #24's 0/17/14 admission MDS (minimum data set) assessment revealed the resident had moderately impaired cognition and required extensive assistance of 1 person for all activities of daily living, including eating. The resident's weight was 108 pounds and he/she received a therapeutic diet. Resident #24's 10/22/14 ADL (activities of daily living) CAA indicated the resident required extensive assistance with eating and had left-sided weakness. The nutrition CAA stated he/she was at risk for nutritional compromise. The CAA further indicated the resident ate in the assisted dining room and the registered dietician would evaluate his/her nutritional status. The nutrition nursing care plan dated 10/22/14 directed staff to provide the ordered diet and to offer substitutes if he/she disliked the food served. The care plan directed staff to weigh the resident weekly for 4 weeks, then monthly if his/her weight was stable. A revision to the care plan on 10/30/14 stated the resident received meals in the assisted dining room and indicated the resident's family member often assisted him/her with meals. The care plan also stated the resident enjoyed fried eggs and sliced tomatoes for breakfast and ate tomatoes at any meal. An admission nutrition assessment completed on 10/22/14 by Dietician G revealed resident #24 received a regular diet and required assistance with meals due to his/her left-sided weakness. The assessment indicated the resident initially took 25% of meals and was improving. The resident's admission weight was 108 pounds and he/she appeared nourished. Review of the resident's laboratory studies indicated mild [MEDICAL CONDITION] and mild protein depletion. Dietician G recommended weekly weights for 4 weeks, sugar-free house shakes for a protein supplement, and a multi-vitamin with iron daily. Review of resident #24's 12/31/14 physician orders [REDACTED]. The order sheet included an order to weigh the resident weekly for 4 weeks, then monthly. Review of resident #24's weights documented in the electronic record revealed the following: 10/17/14 108 pounds 10/31/14 108 pounds 11/07/14 105 pounds 11/28/14 105 pounds 12/29/14 100 pounds Review of the electronic weight record revealed resident #24 sustained a significant weight loss of 7.41% in 73 days. Review of the clinical record lacked documentation that the resident's physician, the registered dietician, or family received notification of resident #24's significant weight loss from 10/17/14 to 12/29/14. During an observation on 1/12/15 at 8:06 a.m., resident #24 sat in his/her wheelchair in an assisted dining room. The resident attempted to feed him/herself with a family member assisting him/her. The resident ate oatmeal, eggs, and bacon and consumed approximately 50% of the meal. The meal did not include any dietary supplements or sliced tomatoes. On 1/13/15 at 12:03 p.m. resident #24 sat in the assisted dining room with a family member seated by him/her. The resident fed him/herself a lunch of ground chicken, peas, rice, bread with butter, and apple cobbler. The resident consumed approximately 40% of the meal. The meal did not include any dietary supplements or sliced tomatoes. During an interview on 1/7/15 at 9:24 a.m., resident #24's family member stated he/she had concerns about the resident's weight and could tell to look at him/her that he/she lost weight since coming to the facility. The resident's family member further indicated facility staff failed to notify him/her of any weight loss. An interview on 1/13/15 at 1:26 p.m. with direct care staff J stated staff assisted resident #24 with meals and that his/her family frequently assisted the resident with meals. Staff J was unaware of any weight loss or use of supplements for resident #24. During an interview on 1/13/15 at 5:11 p.m., direct care staff CC revealed the resident's family usually helped feed the resident and he/she was unaware of any weight loss. An interview on 1/13/15 at 5:49 p.m. with licensed nurse Q indicated he/she did not think the resident had any weight loss and was unaware of the 7.41% weight loss since the resident's admission to the facility. During an interview on 1/13/15 at 4:20 p.m., dietary staff F reported the facility had a weekly assessment meeting that identified residents with weight loss. He/she further stated that administrative nurse H tracked the residents' weights and provided this information to the registered dietician when he/she came to the facility. On 1/13/15 at 4:30 p.m. Administrative nurse H reviewed the weight log for resident #24 and reported he/she had a 7% weight loss in 73 days. Nurse H was not aware of Dietician G's recommendations on the admission nutrition assessment. Nurse H verified the facility did not notify the resident's physician, the dietician, or family of the weight loss. During an interview on 1/13/15 at 7:13 p.m., administrative nurse B lacked knowledge of resident #24's 7.41% weight loss and was unaware of the dietician's recommendations on the resident's admission assessment for a dietary supplement and vitamin. Nurse B verified the facility failed to follow-up on the recommendations from the dietician made in October at the time of admission. During an interview on 1/14/15 at 4:25 p.m., Dietician G stated that he/she usually gives his/her recommendations to the dietary manager to relay to nursing staff. Dietician G further stated facility staff provided a list of residents' weights. Facility staff highlight the residents on the list with weight loss. Dietician G could not remember if this resident was on the list for weight loss on his/her last visit. An interview with physician EE on 1/13/15 at 4:45 p.m. revealed he/she was aware of the resident's weight of 108 pounds on admission to the facility and the weight of 105 pounds on 11/7/14. Physician EE was not aware of the resident's weight of 100 pounds on 12/29/14. According to physician EE, he/she could not recall if the facility relayed the dietician's recommendations. The facility failed to follow-up on recommendations from the dietician for resident #24 at the time of admission for a sugar-free house shake and a multi-vitamin with iron. The facility also failed to notify the physician, dietician, and resident's family of the weight loss and failed to implement interventions to prevent further weight loss for resident #24 who had 7.41% weight loss in 73 days. - Review of resident #121's signed physician orders [REDACTED]. Review of resident #121's annual MDS (minimum data set) dated 8/19/14 revealed the resident was unable to complete a BIMS (brief interview for mental status). The resident had short and long term memory deficit and required extensive assistance with transfers, bed mobility, and toileting. The resident required minimal assistance with eating. Review of the significant change in status MDS dated [DATE] revealed the resident was unable to complete the BIMS and had poor memory and decision making ability. The resident required extensive assistance of two staff for bed mobility, transfers, and assistance of one for eating. The resident had a significant weight change. Review of the nutritional CAA (care area assessment) dated 10/28/14 revealed the resident was at risk for nutritional impairment. Resident #121 had baseline dementia and was readmitted to the facility after hospitalization for a TIA. The resident had a weight loss. He/she had an increase in behaviors of refusing to be cooperative with care. He/she was able to consume a regular diet and was offered choices of foods to eat. The resident could feed himself/herself. Review of the clinical record revealed an initial/temporary care plan dated 10/21/14 that indicated the resident was independent with meals. No comprehensive care plan had been developed for the resident. Review of the meal intake sheets dated 9/14 through 1/12/15 revealed the resident usually ate 75% of his/her meals until the beginning of December. Then a decline in percent consumed occurred. In January 2015 the resident began refusing meals and when he/she ate it was usually 0-25%. Review of the clinical record revealed weights of: 09/26/14- 157 pounds 10/26/14- 145 pounds 11/20/14- 148 pounds 11/28/14- 148 pounds 12/29/14- 144 pounds Review of the nutritional assessment by the registered dietician dated 10/22/14 revealed a weight loss from 157 to 145 on readmission from the hospital due to a TIA. The plan was to review the resident's weight in November. Observation on 1/8/15 at 12:20 p.m. revealed direct care staff T took a room tray in and placed it on the bedside table directly in front of the resident. Staff T removed the covers from the plate and drinks, cut up the meat, raised the head of bed and left the resident to eat by himself/herself. The resident lay in bed with his/her eyes closed and did not attempt to eat. Observation on 1/8/15 at 12:38 p.m. revealed a staff member entered the resident room and sat the resident up further in bed and asked the resident if he/she was going to eat. The staff member then left the room without assisting the resident to eat. Observation on 1/8/15 at 12:43 p.m. revealed licensed nursing staff U brought the resident's roommate into the room but never talked to resident #121 and left the room. The lunch tray lay untouched on the table. Observation on 1/9/15 at 8:00 a.m. revealed the resident sat in the assisted dining room in a wheelchair. Direct care staff T sat beside the resident assisting and encouraging the resident to eat. The resident picked up the milk carton and drank from a straw and took small bites of scrambled eggs and sausage when staff offered. Further observation revealed the resident ate approximately 1/2 eggs and 1/2 sausage patty. Observation on 1/9/15 at 12:15 p.m. revealed the resident sat at a table in the assisted dining room for the noon meal. The resident had chicken strips, potatoes and vegetables. The resident had a cup of juice and a glass of water. Further observation at 12:40 p.m. revealed the resident ate approximately 25% of the meal and drank all fluids. The resident required total assistance with the meal. Observation on 1/12/15 at 7:50 a.m. revealed the resident sat in the assisted dining room with a breakfast plate of eggs, bacon and a jelly biscuit. The resident also had a glass of milk, juice, and water. The resident had his/her head down and eyes closed. A direct care staff called the resident's name and reminded the resident to eat but the resident refused the meal. The resident sipped milk, juice, and a vanilla health shake with staff coaxing. Observation on 1/12/15 at 9:00 a.m. revealed the resident was taken from the dining room by a direct care staff. Observation of the resident's breakfast revealed the resident did not eat food or drink from the meal. No staff were observed assisting the resident to eat during the meal. The staff would tell the resident to eat but no physical assistance had been given. During an interview on 1/12/15 at 2:30 p.m. with the resident's family member, he/she stated that until recently the resident sat in the main dining room with him/her. He/she would coax the resident to eat and the resident fed him/herself. The family member revealed he/she did not know what the change was but now the resident required help and had moved to an assisted dining room. During an interview on 1/12/15 at 12:15 p.m. direct care staff V reported the resident would eat on some days but had a very poor appetite and needed assistance and much coaxing. Staff V reported on other days the resident would eat on his/her own. During an interview on 1/12/15 at 4:45 p.m. licensed nurse W reported staff knew to offer the resident liquids. Staff W also reported at meal times the resident may refuse most of the meal though would usually drink his/her fluids. During an interview on 1/13/15 at 6:00 p.m. administrative nurse B reported the staff should give the resident assistance with eating and if the resident would not eat they should ask again in a few minutes. Nurse B reported the staff should keep asking until the resident did eat. Staff B had no explanation of why the staff did not give the resident more assistance with meals. Review of the facility's ADL/Mobility Management policy dated 12/18/10 revealed the initial assessment provided the resident's baseline function. Staff should utilize the referral process to skilled therapy when a decline in ADLs was identified. The facility failed to adequately assist resident #121 with feeding. Resident #121 required assistance with eating and had weight loss.