Every finding on record at Saybrook Landing

Based on review of the Payroll-Based Journal (PBJ) report, review of the daily assignment sheets, review of the staffing tool, review of staff timecards, review of the facility Centers for Medicare and Medicaid Services (CMS) submission report and staff interview, the facility failed to submit complete and accurate staffing information to CMS. Additionally, the facility failed to maintain records of staffing hours for audit. This had the potential to affect all 95 residents in the facility. The facility census was 95. Findings Include: Review of the PBJ report for Fiscal Year (FY) Quarter Two 2024 (01/01/24 through 03/31/24) revealed the facility triggered an area of concern for excessively low weekend staffing. Review of the staffing tool from 03/29/24 through 03/31/24 revealed the facility did not meet the minimum daily staffing requirement of 2.50 hours on 03/31/24. Interview on 07/24/24 at 11:21 A.M. with State tested Nursing Assistant/Scheduler (STNA/Scheduler) #467, and concurrent review of the Daily Assignment Sheets (DAS), revealed STNA/Scheduler #467 stated the DAS accurately reflected the staff who were scheduled and worked on 03/31/24. STNA/Scheduler #467 confirmed on 03/31/24 the minimum daily staffing requirement of 2.50 was not met and stated she would have to follow-up with the Director of Nursing (DON) about staffing for that date. Interview on 07/24/24 at 1:16 P.M. with the DON and STNA/Scheduler #467 revealed the facility had a concern on 03/31/24 and additional staff were brought in on that day to assist. In addition to the staffing identified on the DAS, STNA/Scheduler #467 stated Activities Director (AD) #401 worked 5.6 hours, Assistant Director of Nursing (ADON) #468 worked ten hours and the facility Nurse Practitioner (NP) provided four hours of direct resident care. Review of the Time and Attendance Detail Report confirmed AD #401 worked on 03/31/24 from 7:02 A.M. through 12:37 P.M. Further review revealed no evidence ADON #468 or the NP worked on 03/31/24. Follow-up interview on 07/25/24 at 2:32 P.M. with the DON verified the facility did not accurately report staffing levels on 03/31/24 and had no evidence of ADON #468 or the NP's working hours on 03/31/24. Review of the facility document titled CMS Submission Report PBJ Final File Validation Report dated 06/24/24 confirmed the facility submitted PBJ staffing information for FY Quarter Two. However, the facility was unable to produce any other documentation regarding the PBJ for FY Quarter 2.

Based on review of Quality Assessment and Assurance (QAA) sign in sheets and staff interview, the facility failed to ensure the required members attended QAA committee meetings at least quarterly. This had the potential to affect all residents. The census was 95. Findings include: Review of the facility QAA committee agenda/minutes sign in sheets for the second quarter 2023 (April, May, June), third quarter 2023 (July, August, September), fourth quarter 2023 (October, November, December) and first quarter 2024 (January, February, March) revealed the Director of Nursing (DON), who was also the Infection Control Preventionist (ICP), was not in attendance for the third quarter 2023 and first quarter 2024 QAA committee meetings. Interview on 07/25/24 at 1:48 P.M. with the Administrator confirmed the facility's QAA committee met every three months (quarterly). The Administrator verified the DON/ICP was not in attendance for the third quarter 2023 and first quarter 2024 QAA committee meetings. The Administrator stated Assistant Director of Nursing (ADON) #468 functioned as the DON and attended the QAA meetings during the DON's leave. However, the Administrator confirmed ADON #468 was not a trained ICP. The Administrator indicated a corporate ICP covered those duties during the DON's absence, but did not attend the QAA meetings. The Administrated stated she would follow-up to determine who covered as the ICP at QAA meetings during the DON's leave. Follow-up interview on 07/25/24 at 2:30 P.M. with the Administrator verified there was no evidence of an ICP in attendance during the third quarter 2023 and first quarter 2024 QAA committee meetings.

Based on medical record review, review of pharmacy recommendations and staff interview, the facility failed to ensure a physician approved pharmacy recommendation was implemented. This affected one (#34) of five residents reviewed for unnecessary medications. The facility census was 95. Findings include: Review of the medical record for resident #34 revealed an admitted [DATE]. Diagnoses included bipolar disorder, cirrhosis of the liver, protein calorie malnutrition, anorexia, repeated falls and kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was moderately cognitively impaired. Resident #34 required supervision or touching assistance with eating and oral hygiene, partial to moderate assistance with toileting and substantial or maximum assistance with showering and personal hygiene. Review of the care plan dated 06/12/24 revealed Resident #34 was at risk for adverse effects of psychoactive medication use. Interventions included assessing for behaviors, assessing for adverse effects, giving medications as ordered and reporting negative outcomes to the physician. Review of current physician's orders revealed Resident #34 had an order for Latuda 60 milligrams (mg) by mouth (PO) once per day (QD). Review of a pharmacy recommendation/note to attending physician/prescriber, dated 03/19/24, revealed Latuda was being given upon rise and the medication had better efficacy when provided with at least 350 calories. A request was made to verify the medication was given at breakfast or with at least 350 calories. The physician agreed with the recommendation and signed the document. Interview on 07/24/24 at 1:03 P.M. with the Director of Nursing (DON) confirmed the ordered for Latuda was not updated to indicate Resident #34 should receive the medication with breakfast or with at least 350 calories. Review of the facility policy titled Physician Orders - Telephone and Verbal dated 08/16/10 revealed physician's orders would be received and confirmed in writing by the prescriber. When a new order changed an old order, the older order would be discontinued and the new order written completely.

Based on record review, interview, and facility policy review the facility failed to ensure falls were thoroughly investigated and post fall assessments were thorough and timely. This affected two residents (#79 and #92) of three residents reviewed for falls. The facility census was 91. Findings include: 1.Review of the medical record for Resident #79 revealed an admitted [DATE]. Diagnoses included difficulty walking, acute respiratory failure, scoliosis, and myocardial infarction (heart attack). Review of the physician's orders for September 2023 revealed orders for a night light, Dycem (non-skid mat) above and below her wheelchair cushion and a toilet riser. Review of the fall risk evaluation dated 08/08/23 revealed Resident #79 was at risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was moderately cognitively impaired. She required extensive assistance of two people for bed mobility and toilet use, extensive assistance of one person for transfers, limited assistance of one person for dressing, supervision and set up help for eating, she was independent with one-person physical assistance for hygiene. She had one no falls since the previous assessment. Review of the care plan dated 08/15/23 revealed Resident #79 was at risk for falls due to weakness, neurological impairment, and a history of falls. Interventions included a Dycem (non-slip mat) above and below the cushion in her wheelchair, ensuring the environment is free of clutter, night light, and encouraging use of her call light. Review of a progress note dated 09/09/23 at 12:15 A.M. revealed the State tested Nursing Assistant (STNA) was called to the resident's bathroom and observed Resident #79 sitting on her bathroom floor and an upright position with her legs extended out in front of her. Her walker was lying on the floor beside her. The resident was previously lying in bed. The resident stated she had pain at a level three (on a scale of zero to ten, ten being the worst) but refused pain medication. She requested Bengay (arthritis relief cream) to be applied to her left elbow and left knee. Resident #79 was assessed prior to moving and then assisted by three staff with the use of a gait belt to stand and sit on the toilet. The resident reported she was walking to the bathroom and her sensory system gave out and she fell to the ground. She was noted to have a two centimeter (cm) by two cm hematoma on the left back side of her head and her left elbow was red. Neurological checks were initiated, and the resident was referred to therapy. Orthostatic blood pressure checks were initiated. Review of the pain assessment dated [DATE] at 12:29 A.M. revealed Resident #79 received Bengay to her left elbow and an ice pack was applied to her head. She reported chronic pain all over. Review of the fall investigation dated 09/09/23 revealed no evidence of pain, though the resident said she had a pain level of three at the time of the fall. There was no evidence a night light was in use, or the environment was free of clutter. Interview on 11/13/23 at 10:26 A.M. with the Director of Nursing (DON) revealed the investigation listed all items which should have been in place at the time of the fall. She could provide no evidence a night light was in use, or the area was free of clutter as part of the investigation. Interview with the Administrator on 11/03/23 at 11:29 A.M. confirmed the fall investigation provided was complete and provided no evidence a night light was in use, or the area was free of clutter as part of the investigation. 2. Review of the medical record for Resident #92 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included congestive heart failure, dementia, muscle weakness, difficulty walking, and osteoporosis. Review of Resident #92's physician's orders for September 2023 revealed orders for personal alarm to the resident's bed and a low bed. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #92 was severely cognitively impaired. She required extensive assistance of two people for bed mobility, extensive assistance of one person for transfers, dressing, toileting, and hygiene and limited assistance of one person for eating. She had no history of falls. Review of the falls risk evaluation dated 09/12/23 revealed Resident #92 was at risk for falls. Review of the care plan dated 9/19/23 revealed Resident #92 was at risk for falls due to weakness, impaired cognition, history of falls, and an unsteady gait. Interventions included a bed alarm, her bed to be in the lowest position, a chair alarm, and ensuring her call light was within reach. Review of a progress note dated 9/21/23 at 4:10 P.M. revealed the STNA was called to Resident #92's room and observed the resident sitting on the floor in front of her bathroom. The resident was sitting up with her back against the wall and her legs straight out in front of her. The STNA observed the resident fall as she was responding to her chair alarm. Said she was being nosy and wanted to see what was going on in the hall when she lost her balance walking. She grabbed onto the bathroom door and fell to the floor landing on her right knee then sitting down. A head-to-toe assessment was completed, and the resident was found to have a skin tear to her left elbow. She denied pain at the time of the incident. Range of motion was within normal limits. The physician was notified with new orders to place a sign in the room to remind the resident to call for assistance, a medication review, and a clean, dry dressing every three days to the skin tear to the left elbow until healed. There was no documented evidence vital signs were assessed at the time of the fall. Review of the medical record for Resident #92 revealed the vital signs were not assessed until 09/21/23 at 10:10 P.M., six hours after the fall. Review of the pain assessment for 09/22/23 at 8:01 A.M. revealed Resident #92 complained of pain at a level three on a one to ten scale with ten being the worst. Review of the physician's orders for 09/22/23 at 8:45 A.M. revealed an order for an x-ray of the left hip and thigh as well as an order at 11:45 A.M. for an x-ray of the right femur for post fall pain. Review of the x-ray results dated 09/22/23 revealed an acute displaced fracture of the right femur. Review of the progress note dated 09/22/23 at 2:45 P.M. revealed the physician was notified of an acute right femur fracture and ordered a transfer to the Emergency Department (ED) for further evaluation and treatment. The resident left at that time. Interview on 11/03/23 at 11:00 A.M. with Registered Nurse (RN) #201 revealed residents should be assessed immediately after a fall. RN #201 confirmed there was no evidence of vital signs were assessed for Resident #92 immediately after her fall on 09/21/23. Interview on 11/13/23 at 10:36 A.M. with the DON revealed when a fall occurs, the next shift would reassess the resident. If Resident #92 fell around 4:00 P.M. the next shift would start at 6:30 P.M. and should have done another assessment. She verified a thorough follow-up post-fall assessment was not completed in timely manner. Review of the facility policy titled Fall Management, dated 10/17/16, revealed a resident would be assessed for vital signs, injury, and medical attention after a fall. The facility assesses the need for follow up measures that may reduce the risk of recurrence. The deficiency represents non-compliance investigated under Complaint Number OH00147425.

Based on interview and record review the facility failed to ensure incontinence care was provided in a timely manner. This affected five (Residents #9, #10, #11, #12, and #13) of seventeen residents residing on the Mariner unit. The facility census was 84. Findings include: Review of the personnel file for State tested Nurse Assistant (STNA) #50 revealed disciplinary action on 01/19/19 for not completing rounds every two hours. On 02/19/19 STNA #50 was again disciplined for not completing rounds every two hours. On 02/19/19 an STNA who worked with STNA #50 reported upon making rounds with STNA #50, five residents she was assigned to were found soaked in urine. On 03/14/19 at 9:34 A.M. interview with the Director of Nursing (DON) confirmed STNA #50 had been disciplined twice related to not making rounds and proving incontinence care every two hours. The DON reported other staff had been assigned to work with and oversee STNA #50. The DON verified on 02/19/19, another STNA who had been assigned to oversee STNA #50 reported upon making rounds Residents #9, #10, #11, #12, and #13, all assigned to STNA #50, had been found soaked in urine. The DON verified this occurred on the Mariner unit, and all five residents should have been checked every two hours and changed for incontinence as needed. The DON verified STNA #50 forgets to make rounds sometimes but they continued to work with her. This deficiency substantiates Complaint Number OH 945

Based on record review and interview the facility failed to ensure two staff members assisted Resident #80 during transfers with a stand lift as per the resident's Minimum Data Set (MDS) 3.0 assessment and Transfer and Lift Data Assessments. This affected one resident (Resident #80) of five residents reviewed for accidents. Findings include: Review of Resident #80's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Transfer and Lift Data assessment, dated 01/09/18 revealed Resident #80 required the assistance of two staff for transfers using a stand lift. Review of the plan of care cover sheet dated 01/09/18 indicated Resident #80 needed a stand lift transfer with assistance of one staff. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/15/18 revealed the resident required extensive assistance of two staff for transfers. The Transfer and Lift Data assessment dated [DATE] revealed Resident #80 required extensive assistance of two staff for transfers. Review of the daily task sheets documented by the facility for transfer support provided from 04/07/18 through 04/17/18 revealed one staff assist for transfers was provided on 04/07/18, 04/08/18, 04/10/18, 04/12/18, 04/14/18, 04/15/18, 04/16/18 and 04/17/18. On 04/09/18, 04/11/18 and 04/13/18 Resident #80 was provided two staff assist for transfers. Review of the nurse progress notes from 04/04/18 through 04/17/17 indicated that a two person assist was provided from 04/11/18 through 04/17/18 at 01:38 hours. The nurse notes also indicated that on 04/04/18, 04/10/18 and 04/12/18 only one staff member provided assist with transfer of Resident #80. There was conflicting information throughout the medical record regarding how many staff were required to assist Resident #80 with transfers. There were no physician orders to indicate how Resident #80 was to be transferred prior to an unusual event on 04/17/18 related to her transfers. A review of an unusual event report dated 04/17/18 (no time noted) revealed an incident involving Resident #80 and State tested nursing assistant (STNA) #31. The report explained on 04/17/18 Resident #80 was being transferred by one state tested nursing assistant, STNA #31 using a standing lift and upon standing began complaining of severe pain (rated a 10 on a scale of one to ten) in her left lower extremity. The medical record revealed an x-ray was obtained on 04/17/18 and indicated that Resident #80 had a middle shaft [MEDICAL CONDITION] and osteopenia. The resident did not fall prior to or during the transfer or have any complaints of pain prior to the transfer. Resident #80 was ordered by the house physician to be sent to the hospital emergency room and treated for [REDACTED].#80 returned less than 24 hours later with a splint cast, had surgery with splinting on 04/20/18 and returned to the facility the same day on 04/20/18 with a left leg splint cast. Resident #80 was ordered to be non-weight bearing on the left leg and to be transferred using a mechanical lift. The facility physician assessment dated [DATE] indicated that the physician believed that fracture was related to severe osteopenia and was believed to be a spontaneous fracture. An interview was conducted with STNA #31 on 05/22/18 at 2:38 P.M. STNA #31 revealed that she was very familiar with Resident #80 and that Resident #80 required the assistance of one staff with a standing lift prior to her fracture. STNA #31 explained that Resident #80 had been a stand pivot transfer with the assistance of two staff prior to 04/09/18 when she was changed to a transfer with a stand lift because her feet were no longer pivoting as the feet should to continue a stand pivot transfer. An interview was conducted with the director of nursing (DON) on 05/22/18 at 2:32 P.M. The DON revealed that Resident #80 had been transferred with a standing lift with assistance of one staff member on 04/17/18 when the resident began complaining of severe pain in her left leg. The DON verified that the plan of care indicated staff assist of one with stand lift transfer and verified that the Transfer and Lift data assessment completed by registered nurse (RN) #10 on 04/09/18 indicated that Resident #80 was to have two staff assist for standing lift transfers. The DON explained that the manufacturer's instructions for the standing lift indicated that the standing lift could be operated by one staff member and that was how her staff were trained to use the lift. The DON explained that the only reason there was two staff assist with transfers on the Transfer and Lift assessment dated [DATE] and 04/09/18 was because some staff felt more comfortable using two staff members with the standing lift. Review of the user manual for the Stand Up Patient Lift RPS350-1 model used by the facility revealed on page eight which explained how to use the lift, the manual indicated the lift may be operated by one staff member, however, each patient should be evaluated individually for their need for transfer assistance. An interview was conducted with Licensed Practical Nurse (LPN) #21 on 05/22/18 at 11:25 A.M. who verified Resident #80's MDS 3.0 assessment, dated 01/15/18 and Transfer and Lift Data assessment dated [DATE] indicated Resident #80 required the assistance of two staff with transfers using the standing lift.

Based on observation and interview, the facility failed to post accurate staffing levels that reflected the number of direct care staff. This could affect all 92 residents. Findings include: 1. An observation of the facility staffing posting on 01/25/16 at 10:00 A.M. revealed the facility census was 92 at the beginning of the day (first) shift at 6:00 A.M. The facility posting titled Staff Posting Fed. Reg showed two Registered Nurses (RNs), six Licensed Practical Nurses (LPNs) and 11 Universal Workers were providing direct care on the day shift. The total of direct care staff was listed as 19. Observed to be present in the facility on 01/25/16 at 10:00 A.M. were four LPNs, LPN#1, LPN#2, LPN#3, and LPN#4. LPN #5 was present and identified as the wound nurse. The daily assignment sheet for nursing staff on 01/25/16 listed four nurses on the first shift, which were LPN #1, LPN #2, LPN #3, and LPN #4. An interview with LPN #4 on 01/25/16 at 10:17 A.M. revealed the facility did not have designated unit managers or supervisors. She stated the facility had a wound nurse. On 01/25/16 as 10: 57 A.M. an interview with the Director of Nursing (DON) revealed that four nurses were assigned to units on day shift. She stated the staffing posting included the wound nurse, LPN#5, and the Minimum Data Set (MDS) nurse, LPN #8 . She stated the MDS nurse did not take an assignment on the floor. The two RNs listed on the staffing posting were identified as the Assistant Director of Nursing and a supervisor. An interview with the DON on 01/25/16 12:19 P.M. revealed the MDS nurse worked Monday through Friday to complete the MDS assessments and was not included on the nursing schedule because she was not part of the main nursing schedule. An interview with the DON on 01/27/16 at 11:45 A.M., revealed she said, typically we have four nurses on the floor on days and four on the night shift. 2. Review of the staffing posting for 01/19/16 revealed six LPN's, two RN's and 11 Universal Workers were providing direct care on the day shift. Review of the daily assignment sheet for nursing staff included only four nurses assigned to units on day shift. Review of the staffing posting for 01/20/16 revealed five LPN's, three RN's and 12 Universal Workers were providing direct care on day shift. Three LPNs and one RN were assigned to the units on the first shift on the daily assignment sheet for nursing . Review of the staffing posting for 01/21/16 showed six LPN's on day shift with four LPN's assigned to units according to the daily assignment sheet. Review of the staffing posting for 01/22/16 showed six LPN's on day shift. The daily assignment sheet showed three nurses assigned with one additional nurse circled as a call off with c/o written in. The wound nurse was placed on the assignment sheet in her place. An interview with the DON on 01/28/16 at 2:00 P.M. verified that four nurses were assigned to the units, one of whom was a registered nurse. She stated the two front office nurses were included in the posting. She identified the front office nurses as the wound nurse and the MDS nurse. She stated she and the Assistant Director of Nursing were included as RN's on the posting. An interview with Staffing Coordinator #10, who completed the staffing posting form, verified she had included the Director of Nursing on the posting for 01/20/16 and usually included the Assistant Director of Nursing and the MDS and wound care nurses on the form.

Based on observation, interview and docuement review, the facility failed to ensure nurse aides provided incontinence care in a manner to prevent infection. This affected one resident (Resident #16) of one resident observed for incontinence care. The facility census was 83. Findings include: Resident #16 had [DIAGNOSES REDACTED]. The resident was incontinent of bowel and had an indwelling urinary catheter. On 03/23/15 from 10:43 A.M. through 10:54 A.M. incontinence care was observed for Resident #16. Two state tested nursing assistants (STNA) #100 and STNA #101 provided the care. After STNA#100 cleansed Resident#16's perineal area and catheter tube, both STNA's turned Resident #16 onto his right side. STNA #100 used 4 washcloths to clean the bowel movement from his buttocks and anal area and had to ask STNA #101 for more washclothes to ensure the resident was clean. STNA #100 placed the soiled wash cloths and towel into a bag, and applied a barrier cream to the resident's buttocks and anal area without changing gloves or washing hands. Using the same contaminated gloves, STNA #100 placed a clean incontinent pad under resident and assisted STNA #101 to pull the resident up in bed. STNA #100 used the same gloved hands to handle the bed controller, reposition his legs put the touch call light next to his cheek. STNA #100 then turned fan back on with same gloved hands. On 03/23/15 from 10:55 A.M. to 11:00 A.M., interview with STNA #100 and STNA #101 revealed the following: When asked what she should have done after handling the soiled wash cloths, towel and incontinence pad and before handling anything else; STNA#100 replied "I guess I should have changed my gloves and washed my hands, but this is the way I was taught to do things six years ago. I need to wash when I come in the room and wash when I go out". Interview with the director of nursing (DON) on 03/23/15 at 3:00 P.M. verified STNA #100 should have washed her hands and changed her gloves after cleansing the bowel movement. Review of the facility's policy on infection control -handwashing revised April 2014, revealed employees mush perform appropriated twenty second handwashing procedures after contact with blood, body fluids, excretions, secretions, mucous membranes or nonintact skin.

Based on observation, interview and docuement review, the facility did not ensure nurse aides were competetent regarding infection control during incontinence care. This affected one resident (Resident #16) of one resident observed for incontinence care. The facility census was 83. Findings include: Resident #16 had [DIAGNOSES REDACTED]. The resident was incontinent of bowel and had an indwelling urinary catheter. On 03/23/15 from 10:43 A.M. through 10:54 A.M. incontinence care was observed for Resident #16. Two state tested nursing assistants (STNA) #100 and STNA #101 provided the care. After STNA#100 cleansed Resident#16's perineal area and catheter tube, both STNA's turned Resident #16 onto his right side. STNA #100 used 4 washcloths to clean the bowel movement from his buttocks and anal area and had to ask STNA #101 for more washclothes to ensure the resident was clean. STNA #100 placed the soiled wash cloths and towel into a bag, and applied a barrier cream to the resident's buttocks and anal area without changing gloves or washing hands. Using the same contaminated gloves, STNA #100 placed a clean incontinent pad under resident and assisted STNA #101 to pull the resident up in bed. STNA #100 used the same gloved hands to handle the bed controller, reposition his legs put the touch call light next to his cheek. STNA #100 then turned fan back on with same gloved hands. On 03/23/15 from 10:55 A.M. to 11:00 A.M., interview with STNA #100 and STNA #101 revealed the following: When asked what she should have done after handling the soiled wash cloths, towel and incontinence pad and before handling anything else; STNA#100 replied "I guess I should have changed my gloves and washed my hands, but this is the way I was taught to do things six years ago. I need to wash when I come in the room and wash when I go out". Interview with the director of nursing (DON) on 03/23/15 at 3:00 P.M. verified STNA #100 should have washed her hands and changed her gloves after cleansing the bowel movement. Review of the facility's policy on infection control -handwashing revised April 2014, revealed employees mush perform appropriated twenty second handwashing procedures after contact with blood, body fluids, excretions, secretions, mucous membranes or nonintact skin. This citation substantiates complaint OH 137.

Based on interview and medical record review, the facility failed to ensure planned interventions to prevent falls were implemented for one resident. The deficient practice resulted in harm to Resident #12 who sustained a knee fracture when he was transferred to bed with the assistance of two state tested nursing assistants (STNA) instead of with three STNAs as planned. This affected one (Resident #12) of three residents reviewed for falls. The facility census was 89. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was totally dependent on the assistance of two or more persons for transfers, bed mobility, dressing, toilet use, personal hygiene and bathing. Review of Resident #12's Care Plan Cover revealed on 10/30/14 Resident #12 required three assists with transfer. Review of an incident note dated 11/02/14 at 1:10 P.M. revealed it was a "late entry," but the time of the actual incident was not documented. The incident note indicated two STNAs transferred Resident #12 from a shower chair to his bed in the early morning. Resident #12 tightened his arms and bumped his left leg on the side of his mattress during the transfer. Resident #12 stated "Ow" but did not specify an area of pain. At around lunch time on 11/02/14, Resident #12 was found to have swelling to his knees, with his left knee more swollen than his right. Resident #12's family member was present and requested X-rays. The physician was notified and an X-ray of Resident #12's left knee was ordered. Review of a radiology report dated 11/02/14 revealed a modestly displaced impaction fracture of the distal femur of the left leg, which was presumed chronic. On 11/04/14, the physician ordered an X-ray of Resident #12's right knee and thigh due to swelling and pain. review of the radiology report dated 11/04/14 revealed an acute distal femoral shaft fracture of the right leg. Review of a facility fall investigation dated 11/12/14 revealed a past episode of a fall when Resident #12 was lowered to the floor as he was transferred from a shower chair to his bed with the assistance of one STNA (STNA #2) on 10/30/14. During the transfer, STNA #2 slipped in urine and assisted Resident #12 down her left leg to the floor. STNA #2 denied Resident #12 bumped his legs during the fall. STNA #2 informed LPN #5 that Resident #12 was on the floor. Three staff members assisted Resident #12 back to bed. On 11/18/14 at 1:05 P.M., the director of nursing (DON) confirmed Resident #12 fell on [DATE] when STNA #2 transferred him alone. The DON stated STNA #2 was terminated from employment due to performing an improper transfer for Resident #12. On 11/18/14 at 1:55 P.M., the DON confirmed Resident #12 required the assistance of three for transfers on 11/02/14, according to his plan of care which was updated after the resident had a fall on 10/30/14.

Based on interview and medical record review, the facility failed to ensure documentation in the medical record was accurate and complete. This affected one (Resident #12) of three residents reviewed for medical records. The facility census was 89. Findings include: Review of the medical record for Resident #12 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was totally dependent on the assistance of two or more persons for transfers, bed mobility, dressing, toilet use, personal hygiene and bathing. Review of a facility fall investigation dated 11/12/14 revealed Resident #12 was lowered to the floor when he was transferred from a shower chair to his bed with the assistance of one state tested nursing assistant (STNA) on 10/30/14. During the transfer, the STNA slipped in urine and assisted Resident #12 down her left leg to the floor. The STNA denied Resident #12 bumped his legs during the fall. The STNA informed the nurse Resident #2 was on the floor. Three staff assisted Resident #12 back to bed. There was no evidence in Resident #12's medical record regarding the fall that occurred on 10/30/14. This was confirmed with the director of nursing on 11/18/14 at 11:40 A.M.

Based on record review and interview, the facility failed to ensure the physician and family were notified of a significant change in resident condition and failed to notify family of a change in psychoactive medications for one resident (Resident #5). This affected one of three residents reviewed relative to notification. The facility census was 90. Findings include: 1. Resident #5 was admitted to the facility on [DATE] following hospitalization for increased confusion and debility. [DIAGNOSES REDACTED]. The face sheet of the resident's record listed both the resident's daughter and son as emergency contacts and Power of Attorneys. On 04/16/14 at 7:50 A.M., record review for Resident #5 and discussion with the Director of Nursing (DON) and Assistant Director of Nursing revealed the following. On 12/10/13 Resident #5 was admitted to the facility for rehabilitation services with the discharge plan to return home following completion of therapy. Skilled nurses notes documented the resident ' s blood pressure on 01/04/14 at 2:50 A.M. as 142/77, on 01/05/14 blood pressures were 128/74 and 136/78, on 01/06/14 at 2:58 A.M. blood pressure was 158/87, and on 01/06/14 at 2:42 P.M. blood pressure was 162/88. A nurses note, authored by Licensed Practical Nurse (LPN) #12, dated 01/07/14 at 1:24 A.M., indicated on 01/06/14 at 10:15 P.M., the resident's temperature was 101.2 degrees Fahrenheit (F) and on 01/07/14 at 12:45 A.M. it was 98.9 degrees F. The resident required assist for activities of daily living due to pneumonia and was generally alert and oriented but due to being sick was much more confused. A skilled nurses note, authored by LPN #12 and dated 01/07/14 at 1:25 A.M., indicated the resident's pulse was 94, respirations 24 and the blood pressure was 94/48. There was no notification of the attending physician of a change in condition until ten hours had passed. A nurses note dated 01/07/14 at 11:30 A.M., indicated Resident #5 complained of right sided pain which she was not able to rate or describe. Assessment revealed the temperature was 99.4 degrees F, the pulse was 80, respiratory rate was 20 and the blood pressure was 70/42. The resident was on oxygen with an oxygen saturation level of 95%. The daughter was at the bedside. The resident had just had a loose stool. The resident attempted to eat a popscicle and took a small bite then let it fall out of her mouth. The resident became lethargic. At 11:36 A.M., the nurse notified the attending physician of the vital signs, decreased appetite and current treatment with an antibiotic for pneumonia, with a complaint of feeling worse, not better. The physician was also notified the resident's daughter was concerned that the resident was feeling worse overall. An order was received to send the resident to the hospital, 911 was called and at 12:00 P.M., the resident left the facility by rescue squad and was transported to the emergency department. A nurses note on 01/08/14 at 8:49 A.M., indicated the nurse had called the hospital to check on Resident #5's status. The nurse at the hospital informed her the resident was admitted with peritonitis and remained in the intensive care unit. On 04/16/14 at 8:34 A.M., interview with Physical Therapist (PT) #13, who identified herself as director of therapy services, revealed she had seen Resident #5 regularly for physical therapy services. PT #13 verified she had authored a physical therapy progress note on 01/07/14 that indicated the resident was sent to the hospital and was in surgery when she received information of a report from the hospital that the resident had been admitted and had a bowel obstruction. On 04/16/14 at 9:45 A.M., a phone interview with LPN #12 revealed the following. LPN#12 recalled taking care of Resident #5 on the night shift just prior to the resident being sent to the hospital on [DATE] and described the course of events as follows. The resident had not been feeling well and was on an antibiotic for pneumonia. LPN #12 could not recall the exact time, but did recall the resident's temperature had been elevated, then had come down. LPN #12 also recalled the resident's blood pressure was very low compared to her usual baseline. LPN #12 said that she had not thought it was necessary to call the physician on 01/07/14 at 1:25 A.M. when the resident had an elevated temperature, increased confusion and low blood pressure. LPN #12 knew signs of a significant change in condition included an elevated temperature, confusion and a significantly low blood pressure and verified she should have completed further assessment and notified the physician of her findings immediately. Review of a facility Policy/Procedure, revised April 2003, revealed a Change of Condition was defined as follows. A deterioration in the health, mental or psychosocial status of a resident related to a) a life-threatening condition, b) a significant alteration in treatment, or c) a significant change in the resident's clinical condition. A list of life threatening conditions included cardiovascular changes which would include a significant drop in blood pressure. Procedure was to notify the resident, physician and interested family member of all changes stated in the policy. 2. Resident #5's record contained a consent for services to be provided by the facility's contracted psychiatrist that was signed by the resident's daughter and dated 12/10/13. On 01/03/14, a psychiatric evaluation was completed and the progress note revealed the Psychiatric Nurse Practioner recommended a change in medication. On 01/04/14, an order was written to discontinue [MEDICATION NAME] 10 milligrams (mg) by mouth and to start an [MEDICATION NAME], 4.6 mg to be applied to the skin daily at alternate sites. Both drugs were used for the treatment of [REDACTED]. No documentation was found in the record that the resident's daughter or son were notified that the psychiatric consult had been completed and the [MEDICATION NAME] was initiated and the [MEDICATION NAME] was discontinued for the resident. On 04/16/14 at 12:00 P.M., the DON verified the nurse should have immediately notified the attending physician and the family of a change in Resident #5's condition on 01/07/14 at 1:25 A.M. In addition, the resident's family should have been notified when the psychiatric evaluation was completed, the [MEDICATION NAME] had been discontinued and the [MEDICATION NAME] had been initiated for Resident #5. This deficiency substantiates Complaint Number OH 268

Based on interview and record review, the facility failed to arrange care plan conferences to develop an interdisciplinary plan of care for two residents (#1 and #96). This affected two of four residents whose families were interviewed. The facility census was 96. Findings include: 1. Record review revealed Resident #1 was admitted on with [DIAGNOSES REDACTED]. Interview with the resident ' s family member on 07/09/13 at 11:30 A.M. indicated she will talk to the Licensed Practical Nurse #2 and Social Service Designee to discuss concerns. She indicated she does not know about quarterly care conference meetings and that the facility does not have care plan conference meetings. She indicated she would like to go to the care conference meetings if the facility had the meetings. Interview with the Social Service Designee (SSD) #1 on 07/09/13 at 3:36 P.M. indicated Resident #1 has not had a scheduled conference in 2013. She indicated the resident ' s representative waas not notified of care plan meetings. She indicated the facility does not have scheduled care plan meetings. She indicated the family member is at the facility every day and staff communicate with her. Interview with the Director of Nursing on 07/11/13 at 1:00 P.M. indicated residents and families can asked to have a Plan of Care Meeting. Review of Saybrook Landing Health and Rehabilitation information provided by the Director of Nursing indicated initial Care Plan Meetings (Care Conferences) will be held upon admission and any subsequent readmissions from the hospital, as needed. Additional Care Plan meetings can be arranged at any time by the resident or the family by contacting on the following team members. 2. Review of Resident #96 ' s medical record revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/8/13 at 12:51 P.M., interview with Resident #96 ' s Power of Attorney (POA) revealed that she had never been invited to a care planning conference since her mother ' s admission the to the facility on [DATE]. The POA stated at this time that she would like to have a meeting with the interdisciplinary team to discuss her concerns regarding her mother although she had not been offered or invited to any meeting regarding her mother ' s care. On 7/10/13 at 3:43 P.M., interview with Social Service Designee (SSD) revealed that care planning conferences were held for residents only on admission, or if a resident had a significant change in condition. SSD # stated that Resident #96 had a care planning conference on admission to the facility, and has not had a care planning conference since that time. SSD # indicated that the interdisciplinary team meets and reviews residents regularly and stated residents and families are not invited to these meetings.

Based on observation, interview and medical record review, the facility failed to ensure that a resident received assistance with eating as planned. This affected one (Resident #34) of three residents observed during meals. The facility census was 90. Findings include: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set 3.0 (MDS 3.0) assessment dated [DATE] revealed Resident #34 required the extensive assistance of at least one other person when eating. On 11/24/12, Resident #34 was referred to the speech therapist for a swallowing evaluation due to coughing with food and/or liquids. The speech therapy evaluation dated 11/27/12 revealed that Resident #34's diet was downgraded to a pureed consistency with nectar thickened liquids. The speech therapist recommended that Resident #34 be seated at a 90 degree angle, optimally in a wheelchair, and staff were to feed the resident until she was able to safely feed herself. On 11/27/12 from 6:50 P.M. through 7:10 P.M., Resident #34 was observed sitting in a slouched position in her bed. Her over-the-bed table was positioned in front of her at the height of her shoulders. A divided dinner plate with pureed meat and vegetables and an unopened container of chocolate pudding were on a tray on the over-the-bed table. Resident #34 held a spoon in her right hand and attempted to feed herself. Her right hand shook uncontrollably and the resident had difficulty scooping food onto the spoon. During the twenty minute observation, Resident #34 successfully brought four or five bites of food to her mouth. The above observation was confirmed with the assistant director of nursing (ADON) on 11/27/12 at 7:10 P.M. The ADON then entered Resident #34's room and spoon fed the resident the remainder of her dinner. During an interview on 11/27/12 at 7:40 P.M., the ADON confirmed that Resident #34 was feeding herself alone in her room after the speech therapist had recommended that the resident be fed by staff. This deficiency is an incidental finding discovered during the investigation of Complaint Number OH 015 and Complaint Number OH 658.

Based on interview and review of a written request for medical records, the facility failed to ensure that a resident's representative received copies of medical records as requested. This affected one (Resident #82) of two residents who requested medical records in the past year. The facility census was 90. Findings include: Review of an Authorization for the Release of Health Information dated 06/16/12 revealed Resident #82's Durable Power of Attorney for Health Care (DPOAHC) requested Resident #82's Medication Administration Records (MAR) and laboratory results for urine testing that were created between May, 2012 and June, 2012. A copy of Resident #82's May, 2012 physician order [REDACTED]. When interviewed on 11/27/12 at 10:30 P.M., the administrator stated that any requests for medical records must be reviewed by the corporate office. The requested medical records would then be provided to the resident or their representative within 72 hours. On 11/28/12 at 10:30 A.M., the director of nursing (DON) indicated that a copy of Resident #82's May, 2012 physician orders [REDACTED]. She confirmed that Resident #82's DPOAHC was not provided with Resident #82's MARs that were created between , 2012 and June, 2012 as requested. This deficiency substantiates Complaint Number OH 015.

Based on interview and record review, the facility failed to clarify a resident's insulin medication orders. Multiple orders were received over several days and they were conflicting. This affected one resident, Resident #131, of 40 sampled residents. Findings include: Resident #131 was admitted to the facility on [DATE] and was discharged against medical advice on 04/06/12. The resident had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident's medication regimen included regular insulin given according to a sliding scale, based on glucose tests to be done at 7:30 A.M., 11:30 A.M., 4:30 P.M. and 10:00 P.M. A physician's orders [REDACTED].M. and 9:00 P.M. Later on 03/30/12 the order was changed to 35 units Levimer daily at 8:00 A.M. A nurses note dated 04/03/12 indicated Resident #131's blood glucose was tested at 7:00 A.M. and was low at 66. The resident's skin was cold and clammy. The resident was given oral glucose but the blood glucose was 55 when retested . The resident's glucose level came up to 90 after he received intramuscular glucagon 1 milligram (mg). A nurses note dated 04/04/12 at 4:30 A.M. indicated Resident #131 had fallen out of bed. The nurse heard the resident moaning and found him lying on the floor by his bed. The resident's blood sugar was tested and was low at 61. The resident was not able to describe what happened until he was given intramuscular glucagon one mg. The resident's physician was notified and he ordered a decrease in the resident's insulin to 30 units Levimer insulin once daily. The residents plan of care was altered to add a bedtime snack and to test his glucose at 4:00 A.M. if he did not eat the snack. A nurses note dated 04/04/12 at 6:35 P.M. indicated confusion over Resident #131's insulin needs. The note indicated the nurse practitioner (NP) was contacted and the residen'ts insulin orders were "clarified." The resident was to have an additional 10 units Levimer insulin at bedtime. The nurse practitioner's note dated 04/05/12 contradicted the nurse's note. The NP note indicated the bedtime dose of Levimer insulin was decreased to 30 units on 04/04/12 because of low glucose levels but the dose was actually being given in the morning. The note did not indicate the dose of 10 units Levimer insulin at bedtime was added. On 04/12/12 at 12:20 P.M. the nurse practitioner was interviewed. She indicated she could not recall if she was told of Resident #131's blood glucose at the time the nurse clarified the insulin orders and the NP had added the 10 units Levimer insulin at bedtime on 04/04/12. She indicated the dose might not be changed if a resident had a low glucose on one isolated morning but would require more monitoring. On 04/12/12 the director of nursing was interviewed. She indicated she wrote the clarification order on 04/04/12 that added the bedtime dose of Levimer insulin. She indicated at the time she believed the bedtime dose was already present. She verified Resident #131's record showed the bedtime dose had been discontinued on 03/31/12. This deficiency substantiates Complaint Number OH 211.

Based on observation, record review and interview, the facility failed to provide necessary supervision to prevent a fall for Resident #66. This affected one of three residents reviewed for accidents. Findings include: Resident #66 was admitted to the facility on [DATE] and readmitted on [DATE] after a left lower leg amputation. Other [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] indicated the resident was at risk for falls because of balance problems while walking and decrease in muscular coordination. The assessment indicated the resident was alert and oriented, had no history of falls and was ambulatory. The fall risk assessment dated [DATE] indicated Resident #66 was at risk for falls related to intermittent confusion, being chairbound and needing assistance with mobility, being unsteady and experiencing balance problems when walking, due to the medications she was getting and related to her medical history. The transfer and lift assessment completed on 02/29/12 by the director of nursing (DON) indicated Resident #66 required assistance of one staff and a sit-to-stand mechanical lift for transfers for safety until she progressed with therapy. The Minimum Data Set assessment dated [DATE] indicated Resident #66 required extensive assistance by two staff for transfers. A fall investigation report revealed Resident #66 sustained a fall on 03/10/12 at 11:15 A.M. Resident #66 was assisted by one state tested nurse aide to use the bedside commode. They used a pivot transfer. The investigation report indicated Resident #66 forgot about her amputation and went to put her left foot down and her right knee buckled, resulting in a fall. The nurse's progress note dated 03/10/12 indicated there was a 3 centimeter (cm) by 3 cm bloody area on the outer stump dressing. The nurse indicated the sutures were all intact. On 04/12/12 at 5:00 P.M., the DON verified Resident #66's care plan cover, which the DON indicated was used by the nurse aides to provide care, dated 02/29/12 directed caregivers to use two staff for transfers. There was no fall care plan or fall risk care plan in Resident #66's care plans. The DON verified there had been no fall care plan developed until 04/08/12, almost a month after Resident #66's first fall in March 2012. The interventions on the fall care plan initiated on 04/08/12 did not reflect current fall prevention interventions. The care plan did not include the use of a low bed, mats, and a sign on wheelchair to remember to call for help before getting up. This was verified by Registered Nurse #1 on 04/03/12 at 11:00 A.M. Resident #66 was observed in her low bed on 04/11/12 at 8:30 A.M. and 11:00 A.M. with mats by the bed and a bed alarm in place.

Based on observation, interview and clinical record review, the facility failed to adequately monitor fluid intake for Resident #87 who was identified as being non-compliant with a fluid restriction. This affected one of three residents (#87) who received [MEDICAL TREATMENT] services. Findings include: Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The social service designee documented on 12/07/11 that she was asked to speak with Resident #87 about her non-compliance with fluids and the need for an extra [MEDICAL TREATMENT] session. She indicated the resident was in complete denial and was unsure of where the extra fluid was coming from. A physician progress notes [REDACTED]. He noted the resident gained 17 pounds, required additional [MEDICAL TREATMENT] and her prognosis was poor. The communication forms from the [MEDICAL TREATMENT] center acknowledged her non-compliance with her diet and fluid restrictions. Review of the nutritional assessment dated [DATE] indicated Resident #87's current weight was 312.2 pounds and her body mass index identified her as morbidly obese. The resident had undesired weight gain of 17.6 pounds in six months. The dietitian attributed her weight gain to diet and fluid non-compliance. Her appetite remained excessive. The resident was on a calorie controlled diet to promote weight loss but it was ineffective due to her poor food and beverage choices. The dietitian indicated the resident refused psychological services for additional counsel. She did not indicate alternative interventions to educate the resident on the importance of diet compliance. Review of Resident #87's [MEDICAL TREATMENT] plan of care indicated to follow the fluid restriction as ordered. The plan of care for nutrition updated 08/24/11 identified a 1500 ml fluid restriction, encourage the resident to dine in dining room, honor food preferences as able, obtain food preferences and offer alternate fluid options. Review of the April 2012 physician's dietary orders revealed the following: no added salt, omit high sodium food, large portion entrees at meals and 1800 calorie carbohydrate controlled diet. A fluid restriction of 1000 milliliters (ml) per day had been initiated on 09/22/11. Dietary would provide 480 ml and nursing would provide 520 ml (260 ml each shift). Review of the February, March and April 2012 treatment administration records lacked consistent monitor of Resident #87's meal and fluid intake. On 04/11//12 at 2:15 P.M. Resident #87 was interviewed and observed in her room. A pitcher of water and a clear disposable bottle of water were on her over bed table. She stated she monitored her fluid intake but did not state there was a limit on how much fluid she was to have per day. Interview with Registered Nurse #20 on 04/12/12 at 12:10 P.M. confirmed the lack of consistent monitoring of Resident #87's food and fluid intakes. Interview with the dietitian on 04/12/12 at 12:35 P.M. verified Resident #87's care plan was inaccurate. The plan of care did not indicate how staff were to monitor fluid/food intake or identify alternative fluid options to help the resident be compliant with her diet.

Based on record review and interview, the facility failed to revise and update fall prevention care plans for Resident #40 and Resident #66. This affected two of 15 residents whose care plans were reviewed. Findings included: 1. Resident #40 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive assistance of one staff for transfers and bed mobility. The 2/22/12 fall assessment indicated the resident was at high risk for falls. Review of nursing notes revealed Resident #40 sustained a fall on 3/03/12 at 2:40 A.M. The resident was observed sitting on the floor on her buttocks with her back against the right side of the bed and her legs stretched out toward the door. The alarm was sounding. Review of the fall/incident investigation report revealed the plan of action was to place a floor mat beside the bed and continue a low bed and alarms. Interview with Registered Nurse (RN) #1 on 4/12/12 at 6:00 P.M. revealed it was not clear if the floor mat was a continuing intervention or newly initiated. Review of the Provider Services Fall Investigation report revealed the fall prevention plan at the time of the fall included bed and chair alarms, and a low bed and mat on the floor to the right side of the bed. RN #1 verified the fall risk care plan identified a mat to the floor and a low bed were new fall interventions initiated on 3/03/12. 2. Resident #66 was admitted to the facility on [DATE] and readmitted on [DATE] after having her left lower leg amputated. Other [DIAGNOSES REDACTED]. A fall assessment dated [DATE] indicated the resident was at risk for falls because of balance problems while walking and decrease in muscular coordination. The assessment indicated she was alert and oriented, had no history of falls and was ambulatory. The fall risk assessment dated [DATE] indicated Resident #66 was at risk for falls related to intermittent confusion, being chairbound and needing assistance with mobility, being unsteady and experiencing balance problems when walking, due to the medications she was getting and related to her medical history. The transfer and lift assessment completed on 02/29/12 by the director of nursing (DON) indicated Resident #66 required assistance of one staff and a sit-to-stand mechanical lift for transfers for safety until she progressed with therapy. The MDS assessment dated [DATE] indicated Resident #66 required extensive assistance by two staff for transfers. A fall investigation report revealed Resident #66 sustained a fall on 03/10/12 at 11:15 A.M. Resident #66 was assisted by one state tested nurse aide to use the bedside commode. They used a pivot transfer. The investigation report indicated Resident #66 forgot about her amputation and went to put her left foot down and her right knee buckled, resulting in a fall. The nurse's progress note dated 3/10/12 indicated there was a 3 centimeter (cm) by 3 cm bloody area on the outer stump dressing. The nurse indicated the sutures were all intact. Resident #66 sustained a second fall on 03/27/12 at 9:00 A.M. when she attempted to self transfer from the bed to her wheelchair. The facility intervention was to place a sign on her wheelchair to remind Resident #66 to call for assistance to get out of bed. On 04/12/12 at 5:00 P.M., the DON verified Resident #66's care plan cover, which the DON indicated was used by the nurse aides to provide care, dated 02/29/12 directed caregivers to use two staff for transfers. There was no fall care plan or fall risk care plan in Resident #66's care plans. The DON verified there had been no fall care plan developed until 04/08/12, almost a month after Resident #66's first fall in March 2012. The interventions on the fall care plan initiated on 04/08/12 was not up to date to reflect current fall prevention interventions. The care plan did not include the use of the low bed, mats, and a sign on wheelchair to remember to call for help before getting up. This was verified with Registered Nurse #1 on 04/13/12 at 11:00 A.M.

Based on observation, record review and interview the facility failed to develop comprehensive care plans to address discharge planning for Resident #5, to address falls for Resident #66 and to address [MEDICAL TREATMENT] care for Resident #87. This affected three of 15 residents reviewed for care plans. The facility census was 92. Findings include: 1. Resident #5 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED].#5 was admitted after a hospitalization and was to regain strength to return home. Resident #5 had home health services prior to being hospitalized . The social service note on 01/24/12 indicated Resident #5 met with therapy services and Social Service Designee (SSD) #3. Resident #5 asked about his options of staying at the facility under Medicaid after his therapy was completed. SSD #3 told Resident #5 they could change him from community Medicaid to nursing home Medicaid and if he wanted to do that it would be easy. The documentation indicated Resident #5 stated he would think about it. There were no other social service notes regarding Resident #5's needs, goals to reach in order to return home or follow up to the 01/24/12 social service note. Review of Resident #5 ' s plan of care in the care plan books did not reveal a care plan to address his discharge plans. Interview with Resident #5 on 04/11/12 at 9:30 A.M. revealed he had come to the nursing home for therapy and then decided to stay because his wife was at the facility for a short term stay. He indicated he would be going home the first week of May. He stated he continued his stay at the facility just because his wife was here and it was his choice to remain here a little longer. During an interview with the administrator and Registered Nurse (RN) #1 on 04/12/12 at 9:30 A.M., they indicated they were trying to get Resident #5 home but were having trouble getting care givers for his home care needs because he had fired many previously. Interview with SSD #3 on 04/12/12 at 10:05 A.M. verified there were no other social service notes documented regarding Resident #5 ' s discharge. SSD #3 indicated when a new resident was admitted and their stay was short term, she determined if and what their needs were at home related to pharmacy services, home health care, any treatments needed and whether they had a good support system so they could begin planning for the discharge. SSD #3 verified there were no follow-up social service notes documented after 01/24/12. SSD #3 reviewed Resident #5 ' s plan of care and verified there was no care plan to address discharge needs. . 2. Resident #66 was admitted to the facility on [DATE] and readmitted on [DATE] after a left lower leg amputation. Other [DIAGNOSES REDACTED]. Resident #66's fall assessment dated [DATE], determined the resident was at risk for falls due to balance problems while walking and a decrease in muscular coordination. This assessment indicated she was alert and oriented, had no history of falls and was ambulatory. The fall risk assessment completed on 02/29/12 indicated Resident #66 was at risk for falls related to intermittent confusion, being chairbound and needing assistance with mobility, being unsteady and experiencing balance problems when walking, due to the medications she was getting and related to her medical history. The transfer and lift assessment completed on 02/29/12 by the director of nursing (DON) indicated Resident #66 required assistance of one staff and a sit-to-stand mechanical lift for transfers for safety until she progressed with therapy. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 required extensive assistance by two staff for transfers. Resident #66 was identified as having sustained falls. A fall investigation report revealed Resident #66 sustained a fall on 03/10/12 at 11:15 A.M. Resident #66 was assisted by one state tested nurse aide to use the bedside commode. They used a pivot transfer. The investigation report indicated Resident #66 forgot about her amputation and went to put her left foot down and her right knee buckled, resulting in a fall. The nurse's progress note dated 03/10/12 indicated there was a 3 centimeter (cm) by 3 cm bloody area on the outer stump dressing. The nurse indicated the sutures were all intact. Resident #66 was observed in her low bed on 04/11/12 at 8:30 A.M. and 11:00 A.M. with mats by the bed and a bed alarm in place. On 04/12/12 at 5:00 P.M., the DON verified the care plan cover, which the DON indicated was used by the nurse aides to provide care, dated 02/29/12 directed caregivers to use two staff for transfers. There was no fall care plan or fall risk care plan in Resident #66's care plans. The DON verified there had been no fall care plan developed until 04/08/12, almost a month after Resident #66's first fall in March 2012. The interventions on the fall care plan initiated on 04/08/12 did not reflect current fall prevention interventions. The care plan did not include the use of the low bed, mats, and a sign on wheelchair to remember to call for help before getting up. This was verified with Registered nurse (RN) #1 on 04/13/12 at 11:00 A.M. 3. Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the April 2012 physician's dietary orders revealed the following: no added salt, omit high sodium food, large portion entrees at meals and 1800 calorie carbohydrate controlled diet. A fluid restriction of 1000 milliliters (ml) per day was initiated on 09/22/11. Dietary would provide 480 ml and nursing would provide 520 ml (260 ml each shift). A physician progress notes [REDACTED]. He noted the resident gained 17 pounds, required additional [MEDICAL TREATMENT] and her prognosis was poor. The communication forms from the [MEDICAL TREATMENT] center acknowledged her non-compliance with diet and fluid restrictions. Review of the nutritional assessment dated [DATE] indicated Resident #87's current weight was 312.2 pounds and her body mass index identified her to be morbidly obese. The resident had undesired weight gain of 17.6 pounds in six months. The dietitian attributed her weight gain to diet and fluid non-compliance. Her appetite remained excessive. The resident was on calorie controlled diet to promote weight loss but it was ineffective due to poor food/beverage choices. The dietitian indicated the resident refused psychological services for additional counsel. She did not indicate alternative interventions to educate the resident on the importance of compliance related to food and fluid needs. Review of Resident #87's [MEDICAL TREATMENT] plan of care indicated to follow the fluid restriction as ordered. The plan of care for nutrition updated 08/24/11 identified a 1500 ml fluid restriction, encourage the resident to dine in dining room, honor food preferences as able, obtain food preferences and offer alternate fluid options. This was 500 ml difference from the physician's orders [REDACTED]. On 04/11/12 at 2:15 P.M. Resident #87 was interviewed and observed in her room. A pitcher of water and a clear disposable bottle of water were on her over bed table. She stated she monitored her fluid intake but did not state there was a limit on how much fluid she was to have per day. Interview with the dietitian on 04/12/12 at 12:35 P.M. verified Resident #87's care plan was inaccurate. The plan of care lacked how staff were to monitor fluid/food intake or identify alternative fluid options to help the resident be compliant with her diet.

Based on observation, interview and record review, the facility did not ensure treatments to promote the healing of pressure ulcers were provided as ordered for Resident #78 and Resident #18. This affected two of three residents observed for wound care. The harm occured to Resident #78 when the pressure ulcer declined due to a lack of treatments to promote good healing. Findings include: 1. Resident #78 had [DIAGNOSES REDACTED]. On 01/17/12, the resident developed a pressure sore to the right buttocks documented as an "as needed" assessment on an area that was not present on admission or re-entry and not related to an Leave of Absence (LOA) or ER visit. The wound was described as a stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister), an open area to the right buttocks with surrounding tissue purple in color with a length of 4.0 centimeters (cm), a width of 3.5 cm and a depth of 0.1 cm. There was scant clear drainage with no odor, no tunneling or undermining. A physician's orders [REDACTED]. The treatment was marked as completed on the Treatment Administration Record (TAR) on 01/17/12. Wound documentation for Resident #78 dated 01/24/12 revealed the area to the right buttocks was now described as the right ischium presented with red granular tissue to base, edges evident, area of SDTI (suspected deep tissue injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to area off-center as noted, surrounding tissue to wound with maroon purple tissue character. Treatment per physician's orders [REDACTED]. Although the wound status had increased in size from 4.0 cm to 5.0 cm in length and 3.5 cm in width, and increased from a stage II to unstageable, the wound status since last assessment was marked as "unchanged" and the physician was not notified. Review of the TAR revealed the physician ordered wound treatments that should have been completed on 01/19/12, 01/21/12 and 01/23/12 were not documented as completed. On 01/30/12, the wound documentation for Resident #78 revealed the area to the right ischium presented with red granular tissue with yellow slough presenting and eschar over SDTI area, treatment continued per physician's orders [REDACTED]. The wound status since the last assessment had declined and the physician was notified of the decline on 01/30/12. Review of the TAR revealed the treatments that should have been completed on 01/27/12 and 01/29/12 were not documented as completed. On 02/03/12, Resident #78's wound to the right ischium had declined with black-brown eschar to the center of the wound with yellow slough attached to sides of connected eschar connecting with wound walls at 80% of notation. Scant visual areas of red granular tissue, periwound with dusky red, slow blanching tissue, tissue toward anus with maroon to purple notation. The area had increased in size to 9.0 cm by 6.0 cm by .1 cm. In addition, two other unstageable wounds developed (one to the right distal buttocks and one to the sacrum). On 02/08/12 between 9:12 A.M. and 10:46 A.M., wound therapy was observed for Resident #78 with the wound nurse LPN #99. The wound to the right ischium had a black and yellow wound base with red tissue surrounding the wound. Interview with LPN #99 on 02/08/12 at 5:30 P.M. confirmed treatments had not been completed by the floor nurses for Resident #78's right ischium which had declined, but she had taken corrective action on 02/03/12 with a written memo related to his pressure-reducing cushion having the proper inflation, and checking at both the beginning and end of the shift to make sure that there was a treatment in place to the buttocks areas and to apply treatments immediately if no treatment was in place. Interview with the director of nursing on 02/08/12 at 5:35 P.M. revealed the facility's system to ensure new orders were carried out was for the nurses to look at the TAR and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 2. Resident #18 had current [DIAGNOSES REDACTED]. Resident #18 had a physician's orders [REDACTED]. On 02/08/12 between 2:03 P.M. and 2:30 P.M. wound treatment was observed with LPN #99 for Resident #18. After the resident's pants were removed for the treatment to the area, there was no dressing visible anywhere on the resident's backside, in her clothing or the bed linens. The resident had been in her wheelchair prior to the initiation of the treatment. LPN #99 confirmed there was no treatment dressing on the resident. LPN #99 then measured the wound at a length of 1.2 cm and a width of 2 cm with no depth. The wound had pink tissue that was sensitive to touch. LPN #99 cleansed the wound, covered it with a padded dressing and indicated she would eliminate the calcium alginate from the wound treatment and call the physician. Interview with Resident #18 at 2:23 P.M. revealed the dressing must have fallen off during her shower. The resident indicated on Friday (02/03/12) she had received a shower. Review of the resident's TAR for February 2012 revealed LPN #99 had handwritten in the treatment record on 02/02/12 to cleanse the left medial buttock abrasion with wound cleaner/NSS, pat dry and apply calcium alginate with silver and cover with padded dressing on Monday, Wednesday and Friday. The TAR revealed the last time the wound had been treated was on 02/01/12. The treatments for 02/03/12 and 02/06/12 were not documented as completed. Interview with LPN #99 on 02/08/12 at 2:35 P.M. confirmed the treatments had not been done for Resident #18. LPN #99 indicated the floor nurses were to complete wound treatments and the LPN #99 measured the wounds once a week and did rounds with the wound physician or nurse practitioner when they were at the facility. Interview with LPN #99 at 4:00 P.M. revealed she had not measured Resident #18's wound earlier in the week as she had been on wound rounds with the nurse practitioner and this wound had not been referred. LPN #99 confirmed that the physician's orders [REDACTED]. Interview with the director of nursing on 02/08/12 at 5:35 P.M. revealed the facility's system to ensure new orders were carried out was for the nurses to look at the TAR and MAR for current orders. This deficiency substantiates Complaint Number OH 335.

Based on observation, record review, and interview, the facility failed to ensure preventative measures were in place to prevent the development of a Stage IV pressure sores to Resident #45 and a Stage II pressure sore to Resident #53. This affected two of three sampled residents reviewed for pressures sores in a total sample size of 16. The facility census was 79. Findings include: 1. Resident #45 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had both short and long term memory impairment and was totally dependent on staff to move her positioning in bed and transfer her out of bed. The resident had an indwelling urinary catheter in place and was incontinent of bowel. The resident was at high risk to develop pressure sores. The resident had been admitted with a Stage IV pressure sore to her left ischium. (A Stage IV pressure sore presents as a wound with full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present in the wound bed and undermining and tunneling are often present.) The left ischium pressure sore healed on 10/28/10. Record review of the Skin Grid/Pressure report revealed Resident #45 developed a new pressure ulcer on her upper posterior right thigh on 08/30/10. The wound measured five centimeters (cm) long by 0.6 cm. wide and 0.01 cm. The wound nurse, licensed practical nurse (LPN) #1, assessed the wound as a Stage II pressure sore (a pressure sore with partial thickness loss of the dermis and presents as an open ulcer or an intact or serum filled blister). LPN #1 also documented her findings on the August, 2010, Monthly Skin Report Form. She noted the area was related to the positioning of the resident's urinary catheter tubing. On 09/01/10 at 11:46 A.M., the wound nurse practitioner assessed the resident and documented the resident had a friction burn/blister from Foley catheter pressure. Review of the nurse practitioner documentation on 09/22/10 revealed the right upper thigh wound was downgraded to a Stage IV pressure sore. The wound had a large amount of purulent, yellow, green drainage with 75 to 100 percent black eschar. On 02/23/11 at 10:40 A.M., LPN #1 was observed completing the treatment to the resident's right upper thigh wound. The wound appeared beefy red, with serosanguinous drainage. Review of the wound measurements dated 02/18/11 revealed the wound measured 0.4 cm. long by 2.1 cm. wide and 2.0 centimeters deep with 2.0 cm. of tunneling in the 11:00 position. Review of the February, 2011, physician's orders [REDACTED]. On 02/23/11 at 3:20 P.M., interview with LPN #1, the director of nursing, (DON) and the assistant director of nursing (ADON) verified the resident had a urinary catheter in place at the time the resident developed the upper thigh pressure sore. LPN #1 stated when the pressure sore was discovered on 08/30/10, a leg strap was placed to promote proper positioning of the urinary catheter. The DON verified the facility investigation concluded the wound was caused by the catheter tubing. 2. Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment, and required extensive assistance of staff to move about in bed and transfer out of bed. The resident was assessed to be at high risk to develop pressure sores. Review of progress notes dated 01/27/10 at 5:06 P.M., revealed Resident #53 developed an open area to his right inner buttock. The wound nurse, LPN #1, assessed the area as a Stage II pressure sore that measured 0.5 centimeters (cm) long by 1.0 cm. wide and 0.1 cm. deep. The wound had a moderate amount of clear drainage. On 02/23/11 at 3:00 P.M., interview with LPN #1 and the ADON and DON revealed the resident had sustained some weight loss in January, 2011, and also had refused to sleep in his bed. Review of the dietary progress notes dated 01/13/11 revealed the resident had lost six pounds in one month, but had not sustained a significant weight loss. The resident was receiving dietary supplements and the dietitian noted the decrease in weight could be related to use of diuretic therapy. Progress note dated 01/25/11 at 3:50 A.M. revealed the resident refused to sleep in his bed after three attempts at 1:1 interventions were attempted. Resident #53 was placed on a restorative dining program on 01/27/11 after sustaining a three pound weight loss and additional supplements were ordered. Review of the physician's orders [REDACTED]. On 02/23/11 at 9:55 A.M., LPN #1 was observed completing the right buttock wound treatment. The LPN stated the resident had refused to go to bed at night and slept in the recliner chair. She stated she was not sure if a pressure reduction device had been placed in the recliner chair. During the interview on 02/23/11 with the DON, she stated the development of the pressure sore had been discussed during an interdisciplinary team meeting and there had been no evidence the staff placed the pressure reduction cushion on the recliner chair.