Every finding on record at Sharon Lane Health and Rehabilitation

The facility had a census of 47 residents. The sample included 12 residents, with two residents reviewed for accidents and/or hazards. Based on observation, interview, and record review, the facility failed to ensure rooms containing hazardous materials were kept locked and kept them out of reach of the eight cognitively impaired /independently mobile residents. Findings Included: - On 09/29/25 at 07:04 AM, an initial walkthrough of the facility was completed. An inspection of the 200 Hall revealed an unsecured Telephone room with empty boxes and a wire panel that was unlocked.An inspection of the R14's room revealed an uncontained oxygen cylinder sitting directly on the floor. On 09/29/25 at 07:17 AM, Housekeeper Staff U stated the room should be locked. He stated there had been folks at the facility working on the phone lines. Housekeeping Staff U locked the Telephone room. On 09/30/25 at 02:06 PM, Licensed Nurse (LN) I stated the telephone had wires in it and should always be locked. She stated the oxygen cylinders should never be left in a room without a stroller, or the cylinder should be placed on the back of a wheelchair. She stated the cylinders should always be contained. On 09/30/25 at 02:34 PM, Administrative Nurse D stated oxygen cylinders should never be left directly on the floor in a resident's room. She stated the Telephone room should always be locked. The facility's Accidents and Supervision policy, revised 02/15/25, documented the resident's environment would remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. The facility would establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. - R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, need for assistance with personal care, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), displaced fracture sixth cervical vertebra (the seven bones that make up the neck region of the spine), fracture of scrum (the large, triangular-shaped bone at the very bottom of the spine, located between the two hip bones), displaced intertrochanteric (part of the proximal (upper) end of the left femur (thigh bone), and repeated falls. The Quarterly Minimum Data Set (MDS) for R6, dated 06/30/25, recorded a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R6 had an impairment to one side of her lower body. The MDS documented R6 needed setup or cleanup for oral hygiene and eating. The MDS documented R6 was dependent on staff for toileting, bathing, and dressing. The MDS documented R6 was at risk for falls and had a fall with fracture before admission or entry. R6's Fall Care Area Assessment (CAA), dated 01/31/25, documented R6 triggered for falls related to a history of falls. The CAA documented R6 was in the facility for a fall at home and a urinary tract infection. The CAA documented R6 had a fall risk of eight, which indicated a moderate risk for falls, and requires a Hoyer (total body mechanical lift) for transfers due to cognition. The CAA documented R6 had no falls since admission. R6's Care Plan dated 02/10/25 documented that R6 was at risk for falls due to confusion, knee pain, and a recent fall with a fracture. The plan of care for R6 documented staff would place a bright yellow tape on R6's brake handle to help remind her to lock her brakes before transferring. The plan of care for R6 documented that the staff were to ensure R6's call light was in reach and orient her to her call light. R6's plan of care documented staff were to ensure R6 wore nonskid socks or shoes with each transfer. The plan of care for R6 documented staff would arrange R6's room to accommodate physical limitations. R6's care plan, dated 04/28/25, documented that staff would assist with wheelchair locomotion on and off the facility unit. On 09/29/25 at 07:14 AM, R6 laid in her bed on her right side. R6's call light was clipped to her privacy curtain. R6's call light was out of her reach. On 09/29/25 at 11:35 AM, R6's call light was at the top of her bed. R6's was by the bottom of her bed in her wheelchair. R6's call light was out of her reach. On 09/30/25 at 02:06 PM, Licensed Nurse (LN) I stated call lights should always be within the resident's reach. She stated all of the nursing staff were responsible for ensuring the residents had their call light within reach. On 09/30/25 at 02:19 PM, Certified Nursing Aide (CNA) M stated call lights should either be clipped to the resident or put in the resident's hand. CNA M stated the nursing staff should always let the resident know where the call light is placed. On 09/30/25 at 02:34 PM, Administrative Nurse D stated call lights should always be placed within the resident's reach. She stated the staff should orient the resident to the call light before leaving the resident's room. The facility's Accidents and Supervision policy, revised 02/15/25, documented the resident's environment would remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. The facility would establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.

The facility identified a census of 47 residents. The facility had three medication rooms. Based on observation, interview, and record review, the facility failed to, in accordance with state and federal guidelines, ensure that a vial of tuberculin (a substance used in the tuberculin skin test to detect an immune system response to the bacteria that causes tuberculosis) was labeled properly after being opened. Findings included: - On 09/30/25 at 07:32 AM, upon inspection of the rehabilitation unit medication room an open and undated multi-use vial of tuberculin was located in the medication refrigerator. The vial cap was removed. The prescription tag on the box documented an order date of 08/29/25.On 09/30/25 at 07:35 AM, Licensed Nurse (LN) G stated that the vial should have been dated when opened. LN G stated he would discard the vial and obtain a new vial to have available.On 09/30/25 at 02:35 PM, Administrative Nurse D stated that LN G had reported to her that he had not dated the tuberculin vial when he opened it for use. Administrative Nurse D stated the tuberculin vial should be dated upon being opened and then discarded after 28 days.The facility's Multidose Medication Storage and Labeling policy dated 04/06/25 documented each multidose medication must be labeled with the date opened and the beyond-use in accordance with manufacturer instructions or facility policy (e.g., not to exceed 28 days if not otherwise specified).

The facility identified a census of 47 residents. The facility identified 14 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 19's ventilator mask was stored in a sanitary manner, failed to implement adequate hand hygiene, and further failed to ensure R59's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) was not on the floor. Findings included:- On 09/29/25 at 07:15 AM, R59 sat in a recliner in her room. R59's catheter bag rested on the floor, and no dignity bag was noted to cover the bag. Urine was visible in the urine collection bag.On 09/29/25 at 08:36 AM, R19 sat in his wheelchair. R19's CPAP mask laid on his bedside table. R19's CPAP mask was not stored in a sanitary manner. On 09/30/25 at 07:12 AM, Certified Medication Aide (CMA) R served R6's Carnation milk and Miralax (bowel medication) in disposable cups. CMA R touched the rims of each cup when handing the cups to R6.On 09/30/25 at 07:26 AM, Licensed Nurse (LN) H prepared R25, R41, and R52's Voltaren (topical pain reliever medication) gel and placed the medication into a plastic cup with each resident's name. LN H placed three plastic medication cups into a white plastic tray. LN H exited the medication room, entered R25's room, failed to perform hand hygiene, and applied a pair of clean gloves. LN H placed the white tray with the resident's medication onto R25's bedside table. LN H assisted R25 with her blankets, placing R25's pajama pant legs above her knees. LN H applied the Voltaren gel to R25's knees. LN H removed her gloves without performing hand hygiene upon removal. She removed the white tray with R41 and R52's medication. LN H entered R41's room, failed to perform hand hygiene, applied a pair of clean gloves, and set the white tray onto R41's bedside table. LN H applied the Voltaren gel onto R41's neck and shoulders. LN H removed her gloves, failed to perform hand hygiene after the removal of her gloves, and removed the white tray from the bedside table. LN H failed to perform hand hygiene. LN H entered R52's room, failed to perform hand hygiene, applied a pair of clean gloves, and set the white tray with R52's Voltaren gel onto the bedside table. LN H applied the gel onto R52's knees, removed her gloves, and failed to perform hand hygiene upon removal of her gloves. LN H returned to the medication room with the white tray. On 09/30/25 at 07:45 AM, LN H prepared R33's medication for gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) administration. LN H placed the plastic medication cups into a white tray. LN H exited the medication room with the white tray and entered R33's room with the white medications. LN H applied clean gloves but failed to perform hand hygiene. LN H placed the white tray with R33's medication onto her roommate's bedside table. LN H retrieved an undated clear syringe from an empty water pitcher from R33's bedside table. LN H inserted the clear syringe into R33's G-tube and attempted to administer a water flush without success. LN H removed the syringe with water from the G-tube and placed the syringe into the white tray, with the open tip directly onto the bottom of the white tray. LN H removed the syringe from the white tray and flushed R33's G-Tube. On 09/30/25 at 02:06 PM, LN I stated urinary catheter bags should never be on the floor. LN I stated all respiratory equipment should be placed in a bag; the bag should have the last changed date. She stated that all nursing staff were responsible for ensuring respiratory equipment was stored in a sanitary manner. LN I stated hand hygiene should be performed after each glove change or when gloves were dirty or soiled, and between residents. She stated that staff should never touch the rim of a cup before handing the cup to anyone. LN I stated the syringe for the peg tube feeding should be stored in a sanitary manner, dated, and covered.On 09/30/25 at 02:17 PM, Certified Nurse Aide (CNA) M stated that urinary catheter bags should never touch the floor. CNA M stated she was unsure how to store a CPAP. CNA M stated staff should wash hands between residents, and from clean to dirty. On 09/30/25 at 04:31 PM, Administrative Nurse D stated the catheter bag should never touch the floor at any time. She stated respiratory equipment not in use should be in a dated bag. Administrative D stated hand hygiene should be performed between residents, and between dirty and clean. She stated staff should never hand a resident a cup with the rim or touch the rim of a cup. She was unsure if the syringe for the peg tube should be dated. She stated the syringe for a peg tube was changed daily and placed in a graduate cylinder (a collection cylinder). The Infection Prevention and Control policy dated 02/15/25 documented the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The Hand Hygiene policy dated 02/15/25 documented all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The facility's Storage and Maintenance of Respiratory and Medical Equipment policy, revised 03/25/25, documented to ensure respiratory and medical equipment was stored in a manner that minimizes the risk of contamination and maintains compliance with infection prevention and control standards. All respiratory therapy equipment and other reusable medical devices must be stored properly when in active use to protect against contamination, ensure resident safety, and maintain readiness for use.The facility's Medication Administration via Enteral Tube policy, revised 04/09/25, documented it was the policy of the facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing safe practice guidelines.

The facility identified a census of 47 residents. The sample included 12 residents, with one sampled resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to preserve Resident (R) 59's dignity when staff failed to ensure that R59's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bag was covered with a catheter dignity bag (a bag that conceals urinary drainage bags from public view). Findings included:- R59's Electronic Medical Record (EMR) documented diagnoses of urinary retention (the inability to empty the bladder completely), hypertension (HTN- elevated blood pressure), and radiculopathy (a condition where a nerve root in the spine becomes compressed or irritated).R59 was admitted to the facility on [DATE], the admission Minimum Data Set MDS was not due for completion.R59's Care Plan dated 09/25/25, directed staff that she was dependent on staff for toileting. The care plan directed staff that R59 was incontinent of bladder and had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) due to urinary retention. The care plan directed staff to ensure the drainage bag was below the level of the bladder. The care plan directed staff to empty the catheter drainage bag every shift and as necessary. On 09/29/25 at 07:15 AM, R59 sat in a recliner in her room. R59's catheter bag rested on the floor, and no dignity bag covered the bag. Urine was visible in the urine collection bag.On 09/30/25 at 02:06 PM, Licensed Nurse (LN) I stated that the catheter bag should never be on the floor. LN I stated the catheter bag should be below the level of the bladder but secured off the floor with a dignity bag covering the collection bag.On 09/30/25 at 02:19 PM, Certified Nurse Aide (CNA) M stated the catheter bag should never be on the floor and should always have a dignity bag to cover the collection bag, so the urine was not visible from outside the room.On 09/30/25 at 02:35 PM, Administrative Nurse D stated that the catheter bag should be placed below the level of the bladder and have a dignity bag covering the collection bag. Administrative Nurse D stated the catheter bag should never touch the floor at any time.The facility's Promoting/Maintaining Resident Dignity policy dated 10/21/24 documented it was the practice of the facility to protect and promote resident rights, treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment that maintains or enhances the resident's quality of life by recognizing each resident's individuality. The facility was to maintain resident privacy.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for self-administration of medication. Based on observation, interviews, and record review, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 43. Findings included:- R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dysphagia (swallowing difficulty), seizure (violent involuntary series of contractions of a group of muscles), major depressive disorder (major mood disorder that causes persistent feelings of sadness), dementia (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated 07/02/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R43 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) on bilateral lower extremities. The MDS documented R43 was dependent on staff assistance for toileting, bathing, bed mobility, and transfers. The MDS documented R43 had received anticonvulsant (a medication that prevents or treats seizures and convulsions) medication during the observation period. R43's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/02/25 documented he had some confusion and required assistance with his activities of daily living. R43's Care Plan dated 07/08/25 documented staff would administer his medication as ordered. The plan of care lacked documentation of self-administration of medication. Review of R43's EMR under the Assessment tab lacked an assessment for self-administration of medication. On 09/29/25 at 10:31 AM, R43 laid flat on his bed. R43's a plastic medication cup of unidentified pills sat on the bedside table, an arm's length away from his bed.On 09/30/25 at 02:05 PM, Licensed Nurse (LN) I stated the facility did not have any residents that she was aware of who were assessed to self-administer their own medications. LN I stated the facility would complete an assessment to ensure the resident was safe to administer their own medications, and that assessment would be found under the Assessment tab in the resident's EMR.On 09/30/25 at 02:36 PM, Administrative Nurse D stated a resident would have an assessment to ensure they were safe to self-administer their own medication. Administrative Nurse D stated the nurse should never leave a resident's medication unattended on their bedside table. Administrative Nurse D stated R43 did not have an assessment to administer his own medication. The facility's Resident Self-Administration of Medication policy, revised 04/09/25, documents it is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for tube feeding complications. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 33's water for tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) bag was marked with the date, time, and the facility further failed to ensure R33's syringe was marked with a date.Findings Included:- R33's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), traumatic brain injury (a disruption in the normal function of the brain caused by an external force, such as a blow, bump, jolt, or penetrating injury to the head), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), muscle spasms, need for personal care, and hemiplegia (paralysis of one side of the body) effecting right and left sides of the body.The Quarterly Minimum Data Set (MDS) for R33, dated 07/14/25, recorded a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented eating was not applicable and was dependent on staff for all activities of daily living (ADL). R33's Tube Feeding Care Area Assessment (CAA) dated 07/14/25 documented R33 triggered for tubing feeding secondary to the presence of a percutaneous endoscope gastrostomy tube (PEG- a tube inserted through the wall of the abdomen directly into the stomach) while a resident in the facility. The CAA documented R33 was nothing by mouth (NPO), and the estimated nutrition needs from the dietitian included calories and protein to promote a healthy weight. R33's Care Plan dated 02/15/22 documented R33 was at risk for altered nutrition and hydration related to the use of a feeding tube. R33's plan of care documented staff were to use personal protective equipment (PPE) when performing peg tube care. The plan of care for R33 documented nursing staff would check tube placement per protocol before administering feedings or medications. R33's plan of care dated 09/18/22 documented she was NPO and received her nutrition through a peg tube. The EMR under the Orders tab documented the following physicians' orders:Per feeding pump, flush 100 milliliters (ml) of water every four hours. May use water flush for medication administration every four hours for hydration/nutrition, dated 12/11/24. Enteral Feed Order every shift. Administer Osmolyte (feeding formula) at 1.2 mL per hour (hr) continuously via a feeding pump. May turn off two hours a day for showers/personal care. May administer G side of GJ tube, dated 08/07/25.GJ Tube- left lower abdomen. Cleanse with wound cleanser, apply a drain sponge, every day shift for skin integrity, dated 08/23/25. R33's EMR lacked direction for staff as to when to change out the syringe for R33's water flush.On 09/29/25 at 07:50 AM, R33 laid in his bed, with his head elevated. R33 was receiving internal feeding and water. R33's internal water bag was not marked with a date, and the syringe placed in a graduated cylinder (a container for measuring) was not dated. On 09/30/25 at 08:11 AM, R33 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline). R33 was receiving internal feeding and water. R33's internal water bag was not marked with a date, and the syringe placed in a graduated cylinder was not dated. On 09/30/25 at 02:06 PM, Licensed Nurse (LN) I stated that a tube feeding bag and water bag should be labeled with the date, the resident's name, and the time. She stated the syringe should be dated. LN I stated she thought the syringe was changed out weekly. On 09/30/25 at 03:34 PM, Administrative Nurse D stated she did not believe the facility required the syringe and water bag to be dated. She stated the syringe and water bags were changed daily.The facility's Medication Administration via Enteral Tube policy, revised 04/09/25, documented it was the policy of the facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing safe practice guidelines.

The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 19's continuous positive airway pressure (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored in a sanitary manner. Findings included:- R19's Electronic Medical Record (EMR) from the Diagnosis tab 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), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), fluid overload (occurs when there is an excessive amount of fluid in the body), pneumococcal (type of bacterial infection), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), cellulitis (a common bacterial infection of the skin and underlying tissues) of left limb, and hemiparesis/hemiplegia (weakness and paralysis on one side of the body). The admission Minimum Data Set (MDS) dated [DATE] was in progress. R19's Base Line Care Plan dated 09/22/25 lacked direction for staff to care for R19's respiratory equipment, including his CPAP. R19's EMR under the Orders tab revealed the following physician orders: CPAP with home settings at night, at bedtime for sleep apnea (a disorder of sleep characterized by periods without respirations), dated 09/18/25.On 09/28/25 at 08:36 AM, R19 sat in his wheelchair, R19's CPAP mask laid on his bedside table. R19's CPAP mask was not stored in a sanitary manner. On 09/29/25 at 02:06 PM, Licensed Nurse (LN) I stated all respiratory equipment should be placed in a bag; the bag should have the last changed date. She stated that all nursing staff were responsible for ensuring respiratory equipment was stored in a sanitary manner. On 09/29/25 at 02:19 PM, Certified Nurse's Aide (CNA) M stated she was unsure how to store a CPAP. On 09/29/25 at 02:34 PM, Administrative Nurse D stated all respiratory equipment should be contained in a bag when not in use. The facility's Storage and Maintenance of Respiratory and Medical Equipment policy, reviewed 03/25/25, documented to ensure respiratory and medical equipment was stored in a manner that minimizes the risk of contamination and maintains compliance with infection prevention and control standards. All respiratory therapy equipment and other reusable medical devices must be stored properly when in active use to protect against contamination, ensure resident safety, and maintain readiness for use.

The facility identified a census of 47 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure dosing instructions for Voltaren (an anti-inflammatory class of medication used to reduce inflammation and treat pain) gel for Resident (R) 31. Findings included:- R31's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic pain, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), contracture (abnormal permanent fixation of a joint or muscle), and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Significant Change Minimum Data Set (MDS) dated 07/24/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R31 had frequent pain during the observation period. R31's Pain Care Area Assessment (CAA) dated 08/05/25 documented nursing staff would monitor her pain. R31's Care Plan dated 04/13/22 documented nursing staff would address her complaints of pain promptly with pain medications as ordered. R31's EMR under the Orders tab revealed the following physician orders: Diclofenac sodium external gel one percent (%) (Diclofenac Sodium (Topical)) apply to the right hip topically every six hours as needed for pain, dated 09/17/25. The order lacked a dose. On 09/30/25 at 01:05 PM, R31 sat upright in her wheelchair at the front desk as she waited for transportation for a doctor's appointment to have her pain medication refilled.On 09/30/25 at 02:05 PM, Licensed Nurse (LN) I stated all medication should have dosage ordered by the physician to be administered.On 09/30/25 at 02:36 PM, Administrative Nurse D stated she would expect every medication should have an indication for administration.The facility's Unnecessary Drugs policy, last reviewed 02/25/25, documented it was the facility's policy that each resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident' s highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. Adequate Indications for use refers to the identified, documented clinical rationale for administering a medication that was based upon an assessment of the resident' s condition and therapeutic goals and after any safer treatments have been deemed clinically contraindicated. Also, adequate indication for use means that the medication administered was consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals.

The facility had a census of 54 residents. The sample included 14 residents with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure 33 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. The facility additionally failed to appropriately transfer Resident (R)4 with two staff resulting in a non-injury fall. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 01/29/24 at 07:15 AM a walkthrough of the facility's Wizard's Way hallway revealed an unlocked oxygen storage closet. The closet contained 15 fully pressurized supplemental oxygen tanks stored in a floor rack and one cylindrical container on a portable stand. At 07:20 AM Certified Nurses Aid (CNA) O walked down the hall and stated she was not sure if the door was supposed to be locked but secured the door. At 07:25 AM a walkthrough of the facility's [NAME] Lane hallway revealed an unsecured oxygen storage room with a broken door. The room contained 18 fully pressurized oxygen tanks. At 07:33 AM the door hinges were fixed by maintenance and secured. On 01/30/24 at 07:20 AM the Wizard's Way oxygen storage room was again unsecured with 15 full oxygen tanks stored in it. ON 01/31/24 at 0130PM Administrative Nurse D stated the Wizard's Way room door remained unlocked in case of emergencies. She confirmed the nurses had keys to lock and unlock the storage rooms. On 01/31/24 at 02:15 PM Administrative Staff A stated the facility started leaving the Wizard's Way oxygen storage room unlocked in case emergency oxygen was needed. She confirmed staff were not stationed to continuously monitor the unlocked oxygen storage closet. The facility's Administration of Oxygen policy revised 10/2021 noted that all oxygen cylinders will be stored in dry, securely fastened, and well-ventilated areas away from sources of combustion. The facility failed to secure 33 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. 41037 - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), history of embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and thrombosis (clot that developed within a blood vessel). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R4 required extensive assistance of two staff members for transfers. The MDS documented R4 had no falls during the observation period. The MDS documented R4 received anticoagulant medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented R4 was dependent on staff for all effort during a sit-to-stand transfer. The MDS documented R4 received anticoagulant medications during the observation period. R4's Fall Care Area Assessment (CAA) dated 04/07/23 documented R4 had difficulty with balance and required assistance with ADLs. R4 required a stand-up lift for transfers. R4's Care Plan dated 06/08/17 documented the transfer technique changed for R4 to extensive assistance of one or two staff members. The plan of care dated 10/01/23 documented R4 was dependent on two staff members, or the stand-up lift was to be used. A review of R4's EMR under the Progress Notes tab revealed an Incident Note dated 01/30/24 at 08:01 AM which documented a Certified Nurse Aide (CNA) lowered R4 to the floor during a transfer from her bed to the wheelchair. A review of the Fall Investigation dated 01/30/24 documented that at 07:30 AM CNA M transferred R4 from her bed and during the transfer R4's legs became weak. CNA M had to lower R4 to the floor. Observation on 01/30/24 at 09:40 AM R4 slept in a recliner at the foot of her bed. Her bilateral lower extremities were elevated, and her call light was within reach. On 01/30/24 at 12:07 PM, CNA M stated R4 was transferred with two staff members and the sit-to-stand lift. On 01/31/24 at 11:56 AM, CNA P stated the staff would find the information for each resident's individualized care from the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) which comes from the resident's care plan. CNA P stated R4 was to be transferred with the assistance of two staff members or by the sit-to-stand lift. CNA P stated the decision for which method of transfer for R4 would be determined by therapy. On 01/31/24 at 12:27 PM, Licensed Nurse (LN) G stated the staff would find the information for each resident's care from the Kardex. LN G stated she was not sure how many staff were had assisted with R4's transfer on 01/20/24 when she was lowered to the floor. LN G stated after she reviewed the incident report from R4's fall on 01/30/24, she stated CNA M had transferred R4 alone. LN G stated R4 had recently returned from the hospital and had needed more assistance. On 01/31/24 at 01:02 PM Administrative Nurse D stated everyone had access to the Kardex with the resident's information could be found. Administrative Nurse D stated CNA N had lowered R4 to the floor during a transfer. Administrative Nurse D stated R4's functional abilities would fluctuate during the day and staff assistance would change. Administrative Nurse D stated R4 would decide the mode of level of assistance needed for transfers. Administrative Nurse D stated the staff would always provide a safe transfer. The facility's Accident/Fall Prevention policy last revised on 10/16/23 documented the facility would provide an environment as free from accident hazards as possible and provide adequate supervision and assistance to prevent accidents. The care plan team would investigate and determine the root cause of the fall and implement appropriate fall interventions to prevent further falls. Discussion would focus on interventions that have been implemented and other intentions that may be required to prevent/reduce falls and meet the resident's needs. Any new interventions would be updated on the resident care plan. The facility failed to ensure staff followed R4's plan of care which included she was dependent on two staff members' assistance with a sit-to-stand lift for transfers. This deficient practice placed R4 at risk of further falls and related injuries.

The facility identified a census of 54 residents. The sample included 14 residents with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 34's bilateral lower extremities to prevent pressure ulcers and further failed to monitor refusals to evaluate the ongoing necessity and effectiveness of interventions. This placed R34 at increased risk for pressure ulcer development. Findings included: - R34's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion). The Quarterly Review Minimum Data Set (MDS) dated [DATE], documented R34 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. The MDS further documented R34 was at risk for pressure ulcers and was dependent on staff assistance for toileting, bathing, personal hygiene, and mobility/transfers. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 01/20/23, documented R34 required extensive assistance with bed mobility and positioning. The CAA further documented R34 was at risk for pressure ulcer development. R34's Care Plan listed an intervention initiated on 11/24/23 which directed staff to place Zero G boots (pressure reducing boot that floats heels and eliminates pressure and friction to the skin) on his bilateral (both sides) lower extremities when in bed as resident would allow. R34's EMR lacked documentation of any refusal to wear the Zero G boots while in bed for all of January 2024 including 01/29/24 and 01/30/24. On 01/29/24 at 08:09 AM R34 slept in his room in bed. R34's Zero G boots were on the floor at the foot of his bed. On 01/30/24 at 07:29 AM R34 slept in his bed. R34's Zero G boots were on a shelf across from the foot of his bed. R34's feet/heels rested on his mattress. On 01/31/24 at 09:06 AM Licensed Nurse (LN) G stated R34 refused care a lot and that the nursing aides should have let nurses know when he did. LN G stated the nurses assessed R34's heels for skin breakdown, but nurses should have entered a note if R34 refused to wear the Zero G boots. On 01/31/24 at 12:27 PM LN G stated residents with foam boots were care planned to wear them as the residents allowed. LN G stated staff offered and tried to place the Zero G boots, but R34 did not always allow staff to put the boots on him. LN G stated the facility did not have a policy that stated staff should document applying pressure reduction boots or resident refusals. LN G stated the only way staff were able to track if the boots were a necessary intervention was to know how much time a resident spent in bed. On 01/31/24 at 01:01 PM Administrative Nurse D stated she expected staff to encourage R34 to wear the Zero G boots while he was in bed. Administrative Nurse D stated R34 may let staff put the Zero G boots on him and ask for them to be removed when staff were ready to leave the room. Administrative Nurse D stated R34 was uncooperative with care and was care planned to have the boots on if he allowed staff to put them on. Administrative Nurse D further stated she did not believe staff documented refusals or when the boots were applied, and staff would know if the boots were effective if R34's heels/feet did not have skin breakdown. The facility's Skin Assessment policy with a revised date of 11/23/22, documented that a full body or head-to-toe skin assessment would be conducted by a licensed or registered upon admission/re-admission and weekly thereafter. The facility failed to ensure pressure-reducing measures were placed on R34's bilateral lower extremities to prevent pressure ulcers and further failed to monitor refusals to evaluate the ongoing necessity and effectiveness of interventions. This placed R34 at increased risk for pressure ulcer development.

The facility identified a census of 54 residents. The sample included 14 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently monitor and document Resident (R) 48's central venous catheter (central line- a catheter placed in a large vein) for signs of infection, bleeding, and other complications. This deficient practice placed R48 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R48's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R48's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R48 needed assistance with activities of daily living (ADLS). R48 received dialysis during the observation period. R48's Nutritional Care Area Assessment (CAA) documented R48 received a regular diet with diabetic condiments and thin liquids. R48 received dietary supplements and could make her food preferences known. R48's Care Plan dated 07/26/22 directed staff to monitor the dialysis catheter site every shift, before and upon return from dialysis for dislodgement. The plan directed staff to monitor the site every shift for signs and symptoms of infection and report symptoms to the physician. R48's EMR under the Orders tab revealed a physician order revised 01/10/24 for R48 to attend dialysis three times a week on Monday, Wednesday, and Friday with a chair time of 03:00 PM. A review of R48's Dialysis Communication sheets revealed staff documented the dialysis access site was monitored before and after R48 had dialysis on Mondays, Wednesdays, and Fridays. A review of R48's clinical record lacked documentation staff monitored the catheter site for bleeding, infection, or complications on non-dialysis days. Observation on 01/29/24 at 07:25 AM R48 sat on the side of her bed. Licensed Nurse (LN) K assessed the catheter site. Interview on 01/30/24 at 02:42 PM LN K stated R48's catheter site was only monitored before and after dialysis, and when R48 bathed. LN K stated the catheter site was not typically monitored and documented at any other time. On 01/31/24 at 01:00 PM Administrative Nurse D stated R48's catheter site was monitored and documented before and after dialysis. Administrative Nurse D stated the site was monitored daily as staff saw and spoke to R48 each day. Administrative Nurse D stated she did not think nursing would document an assessment, except on the dialysis sheet sent with R48 to dialysis and returned with R48 after dialysis. The facility's Resident with Dialysis policy Revised 11/10/219 documented it is the policy of the facility to ensure residents receive continuity of care when receiving dialysis services. The facility failed to consistently monitor and document R48's dialysis access site for signs of infection, bleeding, and other complications on non-dialysis days. This deficient practice placed R48 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 54 residents. The sample included 14 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to follow Resident (R)2's physician's orders to notify the medical provider of weight gain related to his diuretic medication (promotes the formation and excretion of urine). These deficient practices placed the resident at risk for unnecessary medications and side effects. Findings Included: - The Medical Diagnosis section within R2's Electronic Medical Records (EMR) included diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and atrial fibrillation (rapid, irregular heartbeat). R2's Quarterly Minimum Data Set (MDS) completed 11/20/23 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated he weighed 182 pounds (lbs.) with no significant weight loss. The MDS noted he took diuretic medication. R2's Urinary Incontinence Care Area Assessment (CAA) completed 06/23/23 indicated he was at risk for skin breakdown and falls. The CAA noted he required extensive assistance with his activities of daily living (ADLs). R2's Care Plan initiated on 07/20/23 indicated he required substantial assistance with bathing, dressing, personal hygiene, and toileting. The plan indicated he took Lasix (a diuretic) and required monitoring for side effects related to low blood pressure, dizziness, headache, and weight loss. The plan instructed staff to weigh him daily related to his diuretic use and report weight gain of two pounds within one day or five pounds within one week to his medical provider (12/08/23). R2's EMR under Physician's Orders revealed an order dated 08/03/23 for staff to administer 20 milligrams (mg) of Lasix once daily by mouth for edema. On 11/20/23 weight parameters were added to the order that instructed staff to monitor R2's weight daily and report weight gain of two pounds in one day or five pounds in one week to the medical provider related to edema. A review of R2's EMR under Weights from 11/20/23 through 01/31/24 revealed he had weight gain outside the provided parameters on five occasions. The review revealed weight gains on 12/4/23 (2.6 lbs.), 12/9/23 (2.2 lbs.), 12/26/23 (3.4 lbs.), 01/05/24 (4.3 lbs.), and 1/15/24 (two pounds). The EMR noted the physician was only notified of the 12/26/23 weight gain. On 01/30/24 at 07:15 AM R2 was weighed via wheelchair scale by staff. R2 weighed 174.8 lbs. R2 received his Lasix medication at 07:45 AM. On 01/31/2024 at 12:30 PM, Licensed Nurse (LN) G stated that any time a medication or treatment order indicated physician notification a progress note would have been completed noting the loss and communication with instructions of the provider. She stated the nurse would note the weight change and enter a progress note into the EMR. On 01/31/2024 at 01:20 PM Administrative Nurse stated staff were expected to notify the physician based on the resident's ordered parameters and document the weight change in the EMR and staff could enter a comment indicating the communication in a progress note. The facility's Physician's Orders for Medication and Treatment policy 10/2023 indicated the facility would ensure each resident's orders would be implemented per the medical provider's instructions. The policy indicates the facility will ensure the medical provider is notified of changes within the resident's medical status or care needs related to medications held or outside of given parameters. The facility failed to follow R2's physician's orders to notify the medical provider of weight gain related to his diuretic medications. This deficient practice placed R2 at risk for unnecessary medications and side effects.

The facility identified a census of 54 residents. The sample included 14 residents with three residents reviewed for hospitalization . Based on observation, record review, and interviews, the facility failed to prevent a significant medication error when Resident (R) 4 continued to receive an anticoagulant (class of medications used to prevent the formation of blood clots) and mood stabilizer after the medications were discontinued. This deficient practice placed R4 at risk for increased complications and adverse side effects related to medication interaction. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), history of embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and thrombosis (clot that developed within a blood vessel). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R4 required extensive assistance of two staff members for transfers. The MDS documented R4 had no falls during the observation period. The MDS documented R4 received anticoagulant medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented R4 was dependent on staff for all effort during a sit-to-stand transfer. The MDS documented R4 received anticoagulant medications during the observation period. R4's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/07/23 documented R4 had difficulty with balance and required assistance with ADLs. R4 required a stand-up lift for transfers. R4's Care Plan dated 03/06/20 documented staff would administer medications as ordered by the physician. R4's EMR, under the Orders tab, revealed the following physician orders: Eliquis tablet (anticoagulant)) five milligrams (mg), give one tablet by mouth two times a day related to cardiac arrhythmia (pounding racing heart rate) dated 04/22/20. Depakote (mood stabilizer) oral tablet delayed release 250mg, give 250 mg by mouth two times a day related to mood disorder with major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest dated 08/08/23. R4's EMR, under the Misc. tab, revealed Hospital Discharge Orders provided to the facility on R4's readmitted d 01/19/24 documented the following medications were discontinued: apixaban (Eliquis) 5 mg tablet divalproex (Depakote) 250 mg tablet, delayed release A review of R4's EMR under the Progress Note tab revealed an Admission Note dated 01/19/24 at 11:31 PM which documented R4 arrived back at the facility at 03:45 PM from the hospital. The physician was notified of R4's return to the facility, and the current orders were verified with the physician and the discharge orders were faxed to the pharmacy. Review of R4's January 2024 Medication Administration Record (MAR) revealed the Depakote order, started 08/08/23 and on hold from 01/1524 through 01/19/24 was administered from 01/19/24 through current. R4's MAR revealed the Eliquis order, started on 04/04/2 and on hold from 01/15/24 through 01/19/24 was administered from 01/19/24 through current. The clinical record lacked documentation, including the clinical rationale, from the physician to reorder Eliquis or Depakote for R4. Observation on 01/30/24 at 09:40 AM R4 slept in a recliner at the foot of her bed. Her bilateral lower extremities were elevated, and her call light was within reach. On 01/29/24 at 04:05 PM Administrative Nurse D and Administrative Nurse E stated the physician wanted R4 to continue to take the Eliquis and Depakote. Administrative Nurse D stated that the documentation in R4's medical record which stated that the physician reviewed the orders upon readmission did not clearly reflect or indicate that the physician ordered the Eliquis and Depakote to continue despite the fact the hospital physician ordered to discontinue. On 01/29/24 at 04:35 PM Consultant Pharmacist HH stated he reviewed current physician orders for R4 and confirmed the Eliquis and Depakote had been discontinued on 01/19/24. Consultant Pharmacist HH stated he was unable to find a current physician order for R4 to restart Eliquis or Depakote. The facility's Physician Orders for Medication and Treatment policy last revised on 10/16/23 documented all medications would be administered as ordered by a health care professional authorized by the state to order medications. All physician orders would be signed and dated, including the facility standing orders. All orders for medications and treatments would be written, dated, and signed by the health professional with the authority to write medication and treatment orders. The facility failed to ensure R4 was free from medication errors when staff administered Eliquis and Depakote despite orders to discontinue the medications. This placed R4 at risk for potential adverse side effects related to medication interactions.

The facility identified a census of 53 residents. The sample included 15 residents with 10 residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure that bathing was provided for one resident who required partial or complete assistance from staff for bathing. This deficient practice placed resident (R)50 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices and impaired psychosocial well-being. Findings included: - The electronic medical record (EMR) for R50 documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R50 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. R50 required extensive to total dependence of one to two staff for ADLs. R50 required the use of a wheelchair for mobility. The Quarterly MDS dated [DATE] documented R50 had a BIMS score of 11 which indicated a moderately impaired cognition. R50 required extensive to total dependence on one to two staff for ADLs. R50 required the use of a wheelchair for mobility. R50 was total dependent on staff of one for bathing. The ADL Care Area Assessment (CAA) dated 10/22/21 documented R50 needed assistance with ADLs due to impaired function and mobility. R50 transferred with a Hoyer lift (total body mechanical lift used to transfer residents) and assist of two. He needed limited to extensive assist of one to two with bed mobility, toileting, dressing and hygiene. He used a wheelchair for locomotion. He was incontinent of bowel and bladder and wore a disposable brief and staff assisted with peri-care. The Life Preferences Care Plan initiated 11/03/20 documented that R50's bathing would be done based on personal preferences to include type of bathing and frequency. Staff were to continue bathing practices based on R50's individual preferences/choices through the next review period. R50 preferred to have a bath in the evening on Tuesdays and Fridays. The ADL Care Plan dated 11/10/20 documented R50 required limited to extensive assistance of one for bathing. Review of the Documentation Survey Report between 02/01/22 and 02/28/22 revealed R50 preferred to take a shower in the evening on Tuesday and Friday. The report revealed that R50 received a shower on three occasions (02/04/22, 02/08/22, 02/22/22). R50 refused a shower on 02/15/22. The report lacked any documentation on scheduled shower days on four occasions (02/01/22, 02/11/22, 02/18/22, and 02/25/22). Review of the Documentation Survey Report between 04/01/22 and 04/30/22 documented that R50 preferred a shower in the evening on Tuesday and Friday. The report revealed that R50 received a shower on four occasions (04/01/22, 04/05/22, 04/15/22, and 04/29/22). The report lacked documentation on scheduled shower days on five occasions (04/08/22, 04/12/22, 04/19/22, 04/22/22, 04/26/22). The Progress Notes tab of R50's EMR lacked documentation why a bath or shower was not given or was refused on the dates documented above. On 05/04/22 at 01:40 PM Certified Medication Aide (CMA) R stated there was a binder at the nurse's station that had bathing/shower schedules for residents in it. The shower schedule was updated regularly for residents that wanted to change their shower days or frequency. Residents who refused a shower/bath were asked the resident later in the day and if the resident still refused the aide would let the charge nurse know. Staff would then chart the bath/shower or the refusal under Tasks in the resident's chart. On 05/04/22 at 01:55PM Licensed Nurse G stated that a resident's shower schedule was in the shower book as well as in their care plan. The aide would let her know if a resident had refused a bath, the she would go in and talk to the resident and try to get them to take a shower, if the resident still refused she would then document a progress note stating that the resident refused. Showers/baths are documented under the Tasks tab and there should be something documented on each day that a resident was scheduled for a shower saying what type of shower/bath was given or if the bath was refused. There would not be any reason blank space on bath days other than if it was simply not given or offered. On 05/04/22 at 02:15 PM Administrative Nurse D stated R50 was often non-compliant and resistant of cares. He would often refuse initially and later take a shower. Most days R50 would not even allow staff to lay him down. Administrative Nurse D stated that ideally there should be no reason why a scheduled shower day would not have something documented on that day. Staff could chart that the shower/bath was given, if it was refused, or resident was not available. The facility Routine Procedures Personal Hygiene-Bathing-Shower policy dated 04/01/18 documented: It is the policy of this facility to promote skin integrity and dignity for each resident. Each resident will be given a choice for their preference of type of bathing and frequency of bathing. The facility failed to ensure a shower/bath was provided for R50, who required extensive assistance with bathing, which had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial well-being.

The facility identified a census of 56 residents. The sample included 15 residents, with two residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure staff implemented interventions per the plan of care for Resident (R) 52. This deficient practice placed R52 at risk for major injuries related to falls. Findings included: - R52's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and hypertension (elevated blood pressure). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented that R52 required extensive assistance of one staff member for transfers and toileting, limited assistance of one staff member for bed mobility, ambulation in room and dressing. The MDS documented R52 required supervision of one staff member for ambulation in hallway, locomotion on the unit, and personal hygiene and was independent with eating after setting up assistance. The MDS documented R52 had one fall with injury during look back period. The Quarterly MDS dated [DATE] documented a BIMS score of nine which indicated moderately impaired cognition. The MDS documented that R52 required extensive assistance of one staff member for locomotion on and off the unit, limited assistance of one staff member transfers, bed mobility, ambulation in room, dressing, toileting, and personal hygiene and was independent with eating after setting up assistance. The MDS documented R52 had one non-injury fall during the look back period. R52's Fall Care Area Assessment (CAA) dated 12/06/21 documented she was at risk for further falls related the need of assistance with activities of daily living (ADL's) and use of antipsychotic (class of medications used to treat [CONDITION(S)] (any major mental disorder characterized by a gross impairment testing) and other mental emotional conditions). R52's Care Plan dated 11/23/21 documented R52 required a call light within reach and directed staff to ensure her room and environment was clutter-free. Review of the EMR under Progress Notes tab revealed R52 had an unwitnessed fall in the bathroom on 11/25/21 which she received a skin tear to right forearm and an x-ray of left hip was ordered related to pain, which was negative for a fracture. On 01/15/22 an unwitnessed non-injury fall was documented which occurred in R52's room. On 03/28/22 an unwitnessed non-injury fall occurred in the bathroom. On 05/02/22 at 01:38 PM R52 laid on her bed with her eyes closed. The bedside table was outside of her reach and the call light hung across bedside table, also out of reach. Papers and clothing were observed on the floor next her bed. On 05/03/22 at 08:26 AM R52 laid on bed asleep. The bedside table was out of reach and the call light was on the floor next to the bed, also out of reach. On 05/03/22 at 02:42 PM R52 sat in her wheelchair. She propelled herself out of the room, and down the hallway. R52 asked facility staff where her bathroom was located. Facility staff directed R52 to a bathroom location. R52 propelled herself into the bathroom and transferred herself onto the toilet. On 05/04/22 at 07:10 AM R52 laid on bed. The bedside table was out of reach., Paperclothing were onserved on the floor next to the bed and the call light was also noted on the floor next to bed, out of reach. On 05/04/22 at 01:46 PM in an interview, Certified Medication Aide (CMA) R stated the fall interventions were on each of the resident's Kardex (a medical information system used by nursing staff to communicate important information on their patients. It was a quick summary of individual patient needs that was updated at every shift change) and everyone had access to the Kardex. On 05/04/22 at 02:00 PM in an interview, Licensed Nurse (LN) G stated the staff should review the care plan daily. LN G stated the nurses can make changes to the resident's care plan when needed such as falls. LN G stated nurses start the fall investigation after a fall occurred and then sent to be review by administration. LN G stated R52 required minimal contact assist with transfers and reminders to use her call light. On 05/04/22 at 02:14 PM in an interview, Administrative Nurse D stated charge nurses add an intervention to the resident's care plan directly after each fall. Administrative Nurse D stated the nurse starts the fall investigation after each fall and all staff can review the resident's care plan. Administrative Nurse D stated any changes or new intervention come across the resident's Kardex as an alert. Review of the facility Accident/Fall Prevention policy last revised on March 2020 documented the charge nurse would review the resident's care plan and make any additions to the care plan that are needed. The care plan team will investigate and determine the root cause of the fall and implement appropriate fall interventions to prevent further falls. The facility failed to implement the fall interventions for R52, which placed her at risk for further falls.

The facility identified a census of 56 residents. The sample included 15 residents with four reviewed for incontinence care. Based on observation, record review, and interviews, the facility failed to implement incontinence care interventions for Residents (R) 37 and R204. This deficient practice placed the residents at risk for complications related to and increased incontinence. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R37's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated that she had frequent bowel and bladder incontinence with a toileting program in place. Her MDS stated that she required extensive assistance with bed mobility, transfers, personal hygiene, locomotion, and toileting. R37's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 09/10/21 stated that she required limited to extensive assistance with all ADL's related to her medical diagnosis. The CAA stated that she was occasionally incontinent of bladder but continent of bowel. R37's Urinary Incontinence CAA dated 09/10/21 stated the she was a risk for skin breakdown and urinary tract infections related to her occasional incontinence. The CAA indicated that she had a Braden (scale for predicting pressure ulcer risk) score of 18 and required to have a pressure relieving mattress and wheelchair cushion. A review of R37's Care Plan dated 09/20/21 indicated that she required limited to extensive assistance from one staff member for bathing, bed mobility, dressing, personal grooming, and toileting. The care plan indicated that she usually had to use the bathroom once per night but lacked documentation of an individualized toileting program and lacked person centered interventions related to the management of bowel and bladder incontinence including timeframes for night time toileting. A review of R37's Bowel and Bladder assessment completed 09/05/21 indicated that she was incontinent three times or less each week and continent of bowel upon her admission. The assessment indicated that she had mixed urge and stress incontinence. The assessment recorded a voiding dairy and a toileting plan were completed. The assessment indicated that R204 should be wearing incontinence briefs. R37's ADL Function and Restorative Assessment completed 03/10/22 indicated that she required limited assistance toileting. The assessment indicated that she was bowel continent and bladder continent with dribbles. A review of R37's Bladder Incontinence Lookback report from 01/01/22 through 05/03/22 (123 days reviewed) revealed that she had 79 bladder incontinence occurrences reported. On 05/02/22 at 08:00 AM R37 was observed in her room watching television. R37's wheelchair had protective cushioning per her care plan for skin prevention. R37 reported that she did require some assistance from staff but does not know of a toileting program. An interview on 05/04/22 at 01:48 PM with Certified Medication Aid (CMA) R, she stated that the direct care staff use a Kardex (condensed form containing information pulled directly from resident's care plan) to identify a resident's toileting status and if any special precautions were needed. She reported that R37 was incontinent but unable to verify if the resident was on a toileting program. She reported that the direct care staff can let the charge nurse know if information is missing from the Kardex or needed to update information. An interview on 05/04/22 at 02:00 PM with Licensed Nurse (LN) G, she stated that toileting plans should be in the care plan utilized by direct care staff. She reported that R37 was started on a toileting program after the voiding dairy was completed. She reported that R37 was incontinent and does require cares and assistance with toileting. She stated the nursing staff can view both the care plans and the Kardex information. She noted that the nursing staff can reported missing information to the MDS coordinator or the Director of Nursing to update a resident's care plan. An interview on 05/04/22 at 02:13 PM with Administrative Nurse D, she stated that toileting programs should be in the care plans. She stated each resident will have a bowel and bladder assessment to assess if an individual program was needed. The resident would have a three-day voiding assessment completed and then a plan for toileting completed. A review of the facility's Urinary and Bowel Incontinence policy revised 2019 stated that the facility will complete a three-day voiding and bowel pattern upon admission to assess residents continency and frequency of incontinent episodes. The policy stated that facility will develop an appropriate toileting plan for each resident and repeat the assessment if the resident had a change in patterns. The policy stated that resident's that are incontinent of bowel and bladder will receive appropriate treatment and services to prevent urinary tract infections and restore as much normal function as possible. The facility failed to implement a toileting program for R37. This deficient practice placed the residents at risk for complications related to incontinence. -The electronic medical record (EMR) indicated the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R204's Entry Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she had an indwelling urinary catheter (tube inserted into the bladder to drain urine into a collection bag). The MDS noted that her bowel incontinence was not rated and had no bowel program initiated. The MDS indicated that R204 required extensive assistance with mobility, transfers, locomotion, toileting, and bathing. A review of R204's MDS revealed no Care Area Assessment (CAA) available to view in the resident's EMR due to resident's admission to facility on 04/14/22. A review of R204's Care Plan revised 05/03/22 stated that she required catheter care every shift, monitor for symptoms of infections, provide privacy, and check the catheter bags position for comfort. The care plan lacked resident-centered interventions related to the management and/or prevention of her bowel incontinence. A review of R204's Bowel and Bladder assessment completed 04/25/22 indicated that she was bowel incontinent three times or less weekly and had an indwelling urinary catheter. The assessment decision stated to review for continued use of the indwelling catheter but did not mention developing a toileting plan for bowel maintenence. The assessment indicated that R204 should be wearing incontinence briefs. A review of R204's Incontinence Lookback report from her admission on 04/14/22 through 05/03/22 (21 days reviewed) revealed that she had 22 bowel incontinence occurrences reported. On 05/04/22 at AM R204 sat in her room watching television. She denied any concerns or complaints. An interview on 05/04/22 at 01:48 PM with Certified medication Aid (CMA) R, she stated that the direct care staff use a Kardex (condensed form containing information pulled directly from resident's care plan) to identify a resident's toileting status and if any special precautions were needed. She reported that she knows of R204 but has not directly worked with her. She reported that the direct care staff can let the charge nurse know if information is missing from the Kardex or needed to update information. An interview on 05/04/22 at 02:00 PM with Licensed Nurse (LN) G, she stated that toileting plans should be in the care plan. She reported that R204 had a bowel and bladder assessment completed but not sure if a toileting planned had been added to the care plan. She stated the nursing staff can view both the care plans and the Kardex information. She noted that the nursing staff can reported missing information to the MDS coordinator or the Director of Nursing to update a resident's care plan. An interview on 05/04/22 at 02:13 PM with Administrative Nurse D, she stated that toileting programs should be in the care plans. She stated each resident will have a bowel and bladder assessment to assess if a individual program is needed. The resident will have a three-day voiding assessment completed and then a plan to for toileting completed. A review of the facility's Urinary and Bowel Incontinence policy revised 01/2019 stated that the facility will complete a three-day voiding and bowel pattern upon admission to assess residents continency and frequency of incontinent episodes. The policy stated that facility will develop an appropriate toileting plan for each resident and repeat the assessment if the resident had a change in patterns. The policy stated that resident's that are incontinent of bowel and bladder will receive appropriate treatment and services to prevent urinary tract infections and restore as much normal function as possible. The facility failed to implement bowel incontinence interventions for R204 resulting in frequent bowel incontinence. This deficient practice placed the residents at risk for complications related to incontinence.

The facility identified a census of 54 residents. The sample included five residents reviewed for bathing. Based on record review and interviews, the facility failed to provide consistent bathing for Resident (R) 5. This deficient practice placed R5 at increased risk for skin breakdown and decreased self-esteem and dignity. Findings included: - R5 admitted to facility on 08/20/21 and discharged on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE], documented R5 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R5 required extensive physical assistance with one staff for bathing; limited physical assistance with one staff for bed mobility, transfers, dressing, and toileting. The MDS recorded R5 was at risk for pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). The Quarterly MDS dated [DATE], documented R5's BIMS score was not assessed due to rarely/never understood. R5 required extensive physical assistance with one staff for bed mobility, dressing, toileting, and personal hygiene; extensive physical assistance with two staff for transfers; and total physical dependence with one staff for bathing. R5 was at risk for pressure injuries and had skin tears. The Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 08/24/21, documented R5 needed supervision to limited assistance of one with mobility, transfers, dressing, personal hygiene, toileting, and bathing. The ADL/Mobility Care Plan dated 08/31/21, documented R5 required assistance with personal cares and mobility and directed R5 required limited to extensive assistance with one staff for bathing. On 11/16/21 at 11:17 AM an anonymous reporter verbalized to the state agency R5 had previously resided in a different room on the other side of the facility. When R5 moved to the other side, she was not added to the shower list. The reporter voiced concern R5 had not received a shower for well over a month. The Documentation Survey Report documented R5 was scheduled for bathing after breakfast on Tuesdays and Fridays. Review of the report for 09/01/21 to 11/25/21 (85 days) revealed R5 received two baths: 10/22/21 and 11/16/21. Not Applicable (NA) was documented on 09/03/21, 09/10/21, 09/14/21, 10/08/21, 10/12/21, 10/19/21, and 11/09/21. The following dates lacked bathing documentation: 09/07/21, 09/17/21, 09/21/21, 09/24/21, 09/28/21, 10/05/21, 10/15/21, 10/26/21, 11/02/21, 11/05/21, 11/12/21, 11/19/21, and 11/23/21. The report lacked indication R5 refused bathing. On 12/08/21 at 01:49 PM, Certified Nurse Aide (CNA) M stated the aides were responsible for bathing and bathing was documented in Point of Care (POC- EMR system for CNA documentation) and on assignment sheets. CNA M stated blanks or missing documentation meant the bathing did not get done or it did not get documented. CNA M stated NA might have been used if a resident was out of facility. Staff knew who required assistance by looking at the Kardex (communication tool used by nursing staff by providing current patient information across shifts). On 12/08/21 at 01:57 PM, Administrative Nurse D stated the aides were responsible for bathing and bathing was documented in POC and on assignment sheets. She stated blanks or missing documentation meant bathing did not get documented, if an aide was unable to complete bathing then they notified the nurse so the nurse could have re-approached the resident. Administrative Nurse D stated bathing was scheduled and completed based on resident preference. If a resident transferred to a different unit, staff were able to see when bathing was scheduled in the EMR. The facility's Resident Routine Daily Preferences policy, last revised 11/15/20, directed the facility honored resident preferences for daily routines including bathing. The policy directed all preferences were added/revised on the resident's baseline/comprehensive individualized care plan and direct care staff were instructed to follow the preferences of each resident at all times. The facility failed to provide consistent bathing for R5. This deficient practice placed R5 at increased risk for skin breakdown and decreased self-esteem and dignity.

The facility identified a census of 57 residents. The sample included 25 residents. Based on observations, record reviews, and interviews the facility failed to ensure the consultant pharmacist identified and reported the lack of documentation for physician ordered weights and notification to the physician for weights outside of the ordered parameters for 1 (#30) resident, the lack of bowel monitoring for 2 (#39, #10) residents, and the notification to the physician for blood sugar results outside of the physician ordered parameters for 1 (#26) of 5 residents sampled for unnecessary medication use. Findings included: - The Electronic Medical Record (EMR) for resident #30 documented a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated a moderately impaired cognitive status. The resident required supervision to extensive facility staff assistance with his/her Activities of Daily Living (ADLs). The resident received a diuretic (medication to promote the formation and excretion of urine) 7 of 7 days in the look back period. The resident had no weight gain or loss and consumed a therapeutic diet. The quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident required set up to extensive facility staff assistance with his/her ADLs. The resident received a diuretic 7 of 7 days in the look back period. The resident had no weight gain or loss and consumed a therapeutic diet. The ADL Care Area assessment dated [DATE] documented the resident required facility staff assistance with his/her ADLs. The nutrition/hydration care plan dated 10/31/17 documented the facility staff weighed the resident daily and followed weight parameters ordered by the physician. The physician's orders [REDACTED]. The daily weight monitoring reviewed (MONTH) (YEAR) through (MONTH) 2019 lacked weight documentation for 4 of 31 days in (MONTH) (YEAR), 3 of 30 days in (MONTH) (YEAR), 3 of 31 days in (MONTH) (YEAR), 3 of 31 days in (MONTH) (YEAR), 7 of 31 days in (MONTH) 2019, 1 of 28 days in (MONTH) 2019, 5 of 31 days in (MONTH) 2019, and 1 of 30 days in (MONTH) 2019. The monitoring also documented weight gains without notification to the resident's physician for a 4 pound weight increase from (MONTH) 4th to the 5th, (YEAR); a 5.3 pound increase between (MONTH) 9th and 12th (YEAR); a 7.9 pound increase between (MONTH) 4th and 5th (YEAR); a 5.5 pound increase between (MONTH) 15th and 16th, (YEAR); a 4.9 pound increase between (MONTH) 12th and 13th; a 29 pound increase between (MONTH) 30th and 31st, 2019; and a 6 pound increase between (MONTH) 4th and 5th, 2019. The monthly pharmacy Medication Regimen Review (MRR) reviewed (MONTH) (YEAR) through (MONTH) 2019 lacked documentation for weight monitoring reviews. On 5/2/19 at 12:19 PM the resident sat at the dining table eating lunch and talking to his/her table mates. The resident did not show signs of [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). On 5/6/19 at 12:11 PM licensed staff G stated weights outside of physician ordered parameters are called to the physician and documented in the resident's progress notes. On 5/6/19 at 12:25 PM administrative staff E verified the resident's weight monitoring lacked documentation for weights obtained and physician notification for weights outside of parameters as ordered. On 5/6/19 at 1:05 PM administrative staff D stated he/she expected the facility nursing staff to obtain and document weights and document physician notification for weights outside of parameters as ordered by the physician. On 5/07/19 08:50 AM pharmacy consultant GG stated he/she reviews daily weights for residents receiving diuretics, when ordered. The facility's Consultant Pharmacist Services Provider Requirements policy dated (YEAR) documented the consultant pharmacist reviews medication and treatment administration records and physician orders [REDACTED]. The facility failed to ensure the consultant pharmacist identified and reported multiple occurrences of the facility staff failure obtain physician ordered weights and notify the physician for weights outside of the ordered parameters for this resident with [MEDICAL CONDITION]. - Review of the EMR for resident #10 documented [DIAGNOSES REDACTED]., and urethra). Review of the Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognitive function. The resident required supervision with the assistance of one staff member for activities of daily living (ADL's), and was always continent of bowel and bladder. Review of the Quarterly MDS dated [DATE], documented a BIMS score of 15, which indicated intact cognition. required supervision with no physical help from staff for activities of daily living (ADL's). Resident #10 was occasionally incontinent of bladder and always continent of bowel. Review of the Care Area Assessment (CAA) dated 04/29/18 triggered for ADL Function due to the resident's cognitive status and his/her need for supervision to limited assistance with ADL's. The care plan dated 03/17/19 alerted staff to monitor medications the resident received for constipation. It further directed the resident required assistance with personal cares and mobility. Review of medication orders revealed the following medications: [REDACTED] [MEDICATION NAME] Suppository 10 milligrams (MG) ([MEDICATION NAME]) (medication for constipation) - Insert 1 suppository rectally as needed for constipation Insert 10mg suppository daily as needed (PRN); ordered on [DATE] Senna S Tablet 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) (medication for constipation) - Give 1 tablet by mouth as needed for constipation Give 1 tab daily as needed; ordered on [DATE] [MEDICATION NAME] HCl (medication for pain that has a side effect of constipation) Tablet 50 MG - Give 50 mg by mouth every 8 hours for pain; ordered on [DATE] [MEDICATION NAME] Solution 20 MG/5 milliliter (ML) (medication for pain and air hunger or shortness of air that has a side effect of constipation) - Give 0.25 ml by mouth every 2 hours as needed for pain, SOA (shortness of air); ordered on [DATE] Senna Plus Tablet 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) (medication for constipation)- Give 2 tablet by mouth two times a day for constipation; ordered on [DATE] [MEDICATION NAME] Powder (Polyethylene [MEDICATION NAME] 3350) (medication for constipation) - Give 17 gram by mouth one time a day for bowel management; ordered on [DATE] Review of the documentation for bowel movements from 07/10/18 - 05/02/19 revealed a combination of documented lack of bowel movement and missing documentation from nursing staff for several days in which no prn medication was documented as given. The medical record lacked documentation of implementation of interventions related to constipation. The EMR revealed missing documentation for bowel movements or no bowel movements for more than three days when prn medication was not administered for constipation during the following range of dates: (MONTH) 10-13, (YEAR) (4 days); (MONTH) 22-25, (YEAR) (4 days), (MONTH) 10-16, (YEAR) (7 days); (MONTH) 19, (YEAR) - (MONTH) 05, (YEAR) (17 days); (MONTH) 13-18, (YEAR) (6 days); (MONTH) 23, (YEAR) - (MONTH) 01, 2019 (10 days); (MONTH) 03-06, 2019 (4 days); (MONTH) 11-19, 2019 (9 days); (MONTH) 21-24 (4 days); (MONTH) 01-07, 2019 (7 days); (MONTH) 09-13, 2019 (5 days); (MONTH) 15-19, 2019 (5 days); (MONTH) 01-05, 2019 (5 days); and (MONTH) 12-18 (7 days). The pharmacy's monthly medication reviews between (MONTH) (YEAR) and (MONTH) 2019 lacked recommendations regarding the lack of documentation for bowel movements. An observation on 05/06/19 at 11:15 AM resident #10 ambulated in the hall with a walker towards the dining room. An interview on 05/06/19 at 10:33 AM with direct care staff N stated he/she documented in PCC (Point Click Care) resident bowel movements as they occurred or by the end of the shift, and the documentation included the method, size, and texture of the bowel movements. Direct care staff N stated that he/she had no problems getting residents who are independent to report bowel movements to staff. Direct care staff N stated that PCC will alert direct care staff and nurses when a resident went 2 or more days without a documented bowel movement and that direct care staff notified nurses of the alerts. An interview on 05/06/19 at 10:40 AM with direct care staff M stated that he/she documented bowel movements on the computer and when residents self-toileted, they were able to report bowel movements to direct care staff. An interview on 05/06/19 at 10:44 AM with licensed nursing staff H stated that bowel movements were documented every shift and residents who were independent were asked if they had a bowel movement at the end of each shift. Licensed nursing staff H stated that he/she checked the computer every morning and afternoon for alerts because alerts would be displayed for residents who did not have a bowel movement for two or more days. Licensed nursing staff H stated that he/she would perform a bowel assessment and chart it in the computer and administer prn medications for constipation if needed but stated he/she had not noticed a lack of documentation for bowel movements or that bowel movements were not charted. An interview on 05/06/19 at 1:05 PM with administrative nursing staff D stated that administration routinely checked for missing documentation as often as several times each week. Administrative nursing staff D stated that he/she expected direct care staff to document all bowel movements on every shift, nurses would follow up with prn medication and chart in the notes, and that a lack of bowel movement documentation was unacceptable. An interview on 05/07/19 at 08:50 AM with consultant GG stated he/she would look to see if prn medications for constipation were effective. The facility's Consultant Pharmacist Services Provider Requirements policy dated (YEAR) documented the consultant pharmacist reviews medication and treatment administration records and physician orders [REDACTED]. The facility failed to ensure the pharmacist idenitfied and reported irregularities in regards to the documentation of bowel movements for resident #10 who was at risk for complications of constipation. Findings included: - The electronic medical record (EMR) documented [DIAGNOSES REDACTED]. condition in which small, bulging pouches develop in the digestive tract). The significant change Minimum Data Set ((MDS) dated [DATE], documented staff assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS recorded the resident required extensive assistance of 2 people for bed mobility, transfers, and toilet use. The quarterly MDS dated [DATE] documented staff assessed the resident with a BIMS score of 11, which indicated moderately impaired cognition. The MDS recorded that he/she required extensive assistance of 2 staff people for transfers and toileting. The activities of daily living (ADL) Care Area Assessment (CAA) dated 12/11/18 documented that the resident needed supervision to extensive assistance with 1-2 persons for transfers and toileting. The Urinary CAA documented the resident was occasionally incontinent of bowel and was on a bowel management program. The quarterly care plan dated on 3/16/18 for Medication monitoring care plan documented the resident was on laxative for constipation. Bowel movement records in the EMR for 04/2019, 03/2019, 02/2019, and 12/2018, documented that the resident did not have a bowel movement from 12/4/18 until 12/8/2018 (4 days), from 12/19/2018 until 12/22/2018 (4 days), from 12/24/18 from 12/31/2018 (8 days), from 2/11/19 until 2/15/2019 (5 days), from 3/17/2019 until 3/23/2019 (7 days), 3/13/2019 until 3/16/2019 (4 days). No documentation was noted from the point of care chart from 4/19/19 until 4/24/2019 (6 days). The EMR lacked evidence a bowel and bladder assessment was performed during the intervals of no bowel movement documented. The electronic Medication Administration Record [REDACTED]. The EMAR documented the resident refused [MEDICATION NAME] (medication used to treat constipation) in (MONTH) 2019, 16 out of 30 days. Review of the pharmacist's medication review regimen for the months for (MONTH) and (MONTH) 2019 documented no recommendations. The (MONTH) 2019 review recommended to separate [MEDICATION NAME] ( medication used to treat constipation) dose by two hours from other medications. Observation on 5/1/2019, at 10:30 A.M. the resident sat at the dining table and stated he/she had no concerns. On 5/6/19 at 12:04 P.M. direct care staff M stated he/she knew how to take of a resident by referring to the jot sheet and Kardex (brief outline of care for the residents). He/she stated that if a resident has not had a bowel movement in 2 days, it was reported to the nurse. He/she stated that bowel movements are charted in the point of care. On 5/6/19 at 11:31 A.M. licensed nursing staff G stated bowel movements are charted by the certified nursing assistants (CNA). He/she stated that point click care alerts them if a resident has not had a bowel movement in 2 days., or the resident also notified him/her. He/she stated that if a resident has not had a bowel movement he/she would offer prune juice, prn order, or if he/she does not have one the doctor is notified. On 5/6/19 01:05 P.M. administrative nursing staff D stated the CNA charts bowel movements. It comes up on the dash board if the resident has not had a bowel movement in 48 to 72 hours. He/she expected certified nursing staff to document bowel movement in the chart. He/she would expect his/her nurses to do a bowel assessment if that resident has not had a bowel movement. Administrative nursing staff D verified lack of bowel movement charting in the EHR. During a telephone interview on 5/7/2019 at 8:50 AM, pharmacy consultant GG stated he would look to see if as needed medication for constipation were effective and he/she would review the bowel documentation. The facility pharmacy services (consultant pharmacist services provider requirements) revised (YEAR), documented that reviewed Medication Administration Record [REDACTED]. The pharmacist failed to identify and report missing documentation of bowel movements and missed opportunities for administration of prn medication for resident # 39. This placed the resident at risk for complications from constipation. - The electronic medical record (EMR) for resident #26 listed [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The MDS noted the resident fed him/herself after setup and required extensive assistance of 1 staff member with most activities of daily living (ADLs) such as bed mobility, transfers and dressing. The resident received insulin injections on 7 of 7 days in the look back period. The Care Area Assessments (CAAs) dated 02/25/19 documented the resident received both long acting and short acting insulin (used to treat diabetes mellitus), staff continued to monitor as ordered. The care plan for medication monitoring initiated 03/03/18 documented that he/she received insulin, both long acting and short acting, for management for diabetes and was at risk for complications from side effects of medications. Review of the physician's medication orders recorded: Accu checks (checking of blood glucose level) before meals and before bedtime for DM, notify physician if blood sugar below 70 or greater than 350, start date 02/14/18; Humalog (short acting insulin), inject 21 units before meals and per correction scale, hold if blood glucose is less than 80 and call the physician. If blood glucose is greater than 350 give 5 units and notify the physician, start date 02/26/19; [MEDICATION NAME] (long acting insulin), inject 55 units every night at bedtime for DM, hold if blood glucose level is below 90 and if blood glucose is greater than 400, notify physician, start date 10/23/18. Review of the electronic Medication Administration Record [REDACTED]. On 05/02/19 at 12:09 pm resident #26 was observed in the dining room sitting in his/her wheelchair, eating lunch. On 05/06/19 at 12:11 pm interview with licensed practical nurse G revealed that the MAR indicated [REDACTED]. Staff then chart in the point click care system when blood glucose level is out of parameter, he/she should notify the physician and note it in the resident's chart and any further orders given. On 05/06/19 at 1:01 pm interview with administrative staff D stated the nurse should chart blood glucose reading in the point click care system and if any action was taken. Staff D stated the physician should be notified whenever the blood glucose level is out of parameter and an entry should be made in the point click care chart of any action taken by the nurse or orders given by the physician. Charts are checked nightly by night shift nurse for errors and the day shift nurse the next day puts in any orders that might have been received the night before. On 05/07/19 at 8:50 am pharmacy consultant GG stated that he/she did review the blood sugar logs when doing the medication review. The facility's Consultant Pharmacist Services Provider Requirements policy dated (YEAR) documented the consultant pharmacist reviews medication and treatment administration records and physician orders [REDACTED]. The facility failed to ensure the consultant pharmacist identified and reported blood sugars outside of the physician ordered parameters for resident #26 who was at risk for complications related to insulin use.

The facility identified a census of 57 residents. The sample included 25 residents. Based on observations, record reviews, and interviews the facility failed to obtain physician ordered weights and notify the physician for weights outside of the ordered parameters for 1 (#30) resident, monitor bowel movements for 2 (#39, #10) residents, and notify the physician for blood sugar results outside of the physician ordered parameters for 1 (#26) of 5 residents sampled for unnecessary medication use. Findings included: - The Electronic Medical Record for resident #30 documented a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated a moderately impaired cognitive status. The resident required supervision to extensive facility staff assistance with his/her Activities of Daily Living (ADLs). The resident received a diuretic (medication to promote the formation and excretion of urine) 7 of 7 days in the look back period. The resident had no weight gain or loss and consumed a therapeutic diet. The quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident required set up to extensive facility staff assistance with his/her ADLs. The resident received a diuretic 7 of 7 days in the look back period. The resident had no weight gain or loss and consumed a therapeutic diet. The ADL Care Area assessment dated [DATE] documented the resident required facility staff assistance with his/her ADLs. The nutrition/hydration care plan dated 10/31/17 documented the facility staff weighed the resident daily and followed weight parameters ordered by the physician. A physician's orders [REDACTED]. The daily weight monitoring reviewed (MONTH) (YEAR) through (MONTH) 2019 lacked weight documentation for 4 of 31 days in (MONTH) (YEAR), 3 of 30 days in (MONTH) (YEAR), 3 of 31 days in (MONTH) (YEAR), 3 of 31 days in (MONTH) (YEAR), 7 of 31 days in (MONTH) 2019, 1 of 28 days in (MONTH) 2019, 5 of 31 days in (MONTH) 2019, and 1 of 30 days in (MONTH) 2019. The monitoring also documented weight gains without notification to the resident's physician for a 4 pound weight increase from (MONTH) 4th to the 5th, (YEAR); a 5.3 pound increase between (MONTH) 9th and 12th (YEAR); a 7.9 pound increase between (MONTH) 4th and 5th (YEAR); a 5.5 pound increase between (MONTH) 15th and 16th, (YEAR); a 4.9 pound increase between (MONTH) 12th and 13th; a 29 pound increase between (MONTH) 30th and 31st, 2019; and a 6 pound increase between (MONTH) 4th and 5th, 2019. On 5/2/19 at 12:19 PM the resident sat at the dining table eating lunch and talking to his/her table mates. The resident did not have trouble with chewing or swallowing. The resident did not show signs of [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). On 5/6/19 at 12:11 PM licensed staff G stated weights outside of physician ordered parameters are called to the physician and documented in the resident's progress notes. On 5/6/19 at 12:25 PM administrative staff E verified the resident's weight monitoring lacked documentation for weights obtained and physician notification for weights outside of parameters as ordered. On 5/6/19 at 1:05 PM administrative staff D stated he/she expected the facility nursing staff to obtain and document weights and document physician notification for weights outside of parameters as ordered by the physician. The facility's Documentation Charting and Guidelines policy dated (MONTH) (YEAR) documented the nursing staff follow physician's orders [REDACTED]. The facility failed to obtain physician ordered weights and notify the physician for weights outside of the ordered parameters for this resident with [MEDICAL CONDITION]. - Review of the EMR for resident #10 documented [DIAGNOSES REDACTED]., and urethra). Review of the Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognitive function. The resident required supervision with the assistance of one staff member for activities of daily living (ADL's), and was always continent of bowel and bladder. Review of the Quarterly MDS dated [DATE], documented a BIMS score of 15, which indicated intact cognition. required supervision with no physical help from staff for activities of daily living (ADL's). Resident #10 was occasionally incontinent of bladder and always continent of bowel. Review of the Care Area Assessment (CAA) dated 04/29/18 triggered for ADL Function due to the resident's cognitive status and his/her need for supervision to limited assistance with ADL's. The care plan dated 03/17/19 alerted staff to monitor medications the resident received for constipation. It further directed the resident required assistance with personal cares and mobility. Review of medication orders revealed the following medications: [REDACTED] [MEDICATION NAME] Suppository 10 milligrams (MG) ([MEDICATION NAME]) (medication for constipation) - Insert 1 suppository rectally as needed for constipation Insert 10mg suppository daily as needed (PRN); ordered on [DATE] Senna S Tablet 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) (medication for constipation) - Give 1 tablet by mouth as needed for constipation Give 1 tab daily as needed; ordered on [DATE] [MEDICATION NAME] HCl (medication for pain that has a side effect of constipation) Tablet 50 MG - Give 50 mg by mouth every 8 hours for pain; ordered on [DATE] [MEDICATION NAME] Solution 20 MG/5 milliliter (ML) (medication for pain and air hunger or shortness of air that has a side effect of constipation) - Give 0.25 ml by mouth every 2 hours as needed for pain, SOA (shortness of air); ordered on [DATE] Senna Plus Tablet 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) (medication for constipation)- Give 2 tablet by mouth two times a day for constipation; ordered on [DATE] [MEDICATION NAME] Powder (Polyethylene [MEDICATION NAME] 3350) (medication for constipation) - Give 17 gram by mouth one time a day for bowel management; ordered on [DATE] Review of the documentation for bowel movements from 07/10/18 - 05/02/19 revealed a combination of documented lack of bowel movement and missing documentation from nursing staff for several days in which no prn medication was documented as given. The medical record lacked documentation of implementation of interventions related to constipation. The EMR revealed missing documentation for bowel movements or no bowel movements for more than three days when prn medication was not administered for constipating during the following range of dates: (MONTH) 10-13, (YEAR) (4 days); (MONTH) 22-25, (YEAR) (4 days), (MONTH) 10-16, (YEAR) (7 days); (MONTH) 19, (YEAR) - (MONTH) 05, (YEAR) (17 days); (MONTH) 13-18, (YEAR) (6 days); (MONTH) 23, (YEAR) - (MONTH) 01, 2019 (10 days); (MONTH) 03-06, 2019 (4 days); (MONTH) 11-19, 2019 (9 days); (MONTH) 21-24 (4 days); (MONTH) 01-07, 2019 (7 days); (MONTH) 09-13, 2019 (5 days); (MONTH) 15-19, 2019 (5 days); (MONTH) 01-05, 2019 (5 days); and (MONTH) 12-18 (7 days). The pharmacy's monthly medication reviews between (MONTH) (YEAR) and (MONTH) 2019 lacked recommendations regarding the lack of documentation for bowel movements. An observation on 05/06/19 at 11:15 AM resident #10 ambulated in the hall with a walker towards the dining room. An interview on 05/06/19 at 10:33 AM with direct care staff N stated he/she documented in PCC (Point Click Care) resident bowel movements as they occurred or by the end of the shift, and the documentation included the method, size, and texture of the bowel movements. Direct care staff N stated that he/she had no problems getting residents who are independent to report bowel movements to staff. Direct care staff N stated that PCC will alert direct care staff and nurses when a resident went 2 or more days without a documented bowel movement and that direct care staff notified nurses of the alerts. An interview on 05/06/19 at 10:40 AM with direct care staff M stated that he/she documented bowel movements on the computer and when residents self-toileted, they were able to report bowel movements to direct care staff. An interview on 05/06/19 at 10:44 AM with licensed nursing staff H stated that bowel movements were documented every shift and residents who were independent were asked if they had a bowel movement at the end of each shift. Licensed nursing staff H stated that he/she checked the computer every morning and afternoon for alerts because alerts would be displayed for residents who did not have a bowel movement for two or more days. Licensed nursing staff H stated that he/she would perform a bowel assessment and chart it in the computer and administer prn medications for constipation if needed but stated he/she had not noticed a lack of documentation for bowel movements or that bowel movements were not charted. An interview on 05/06/19 at 1:05 PM with administrative nursing staff D stated that administration routinely checked for missing documentation as often as several times each week. Administrative nursing staff D stated that he/she expected direct care staff to document all bowel movements on every shift, nurses would follow up with prn medication and chart in the notes, and that a lack of bowel movement documentation was unacceptable. The facility's Documentation Charting and Guidelines policy dated (MONTH) (YEAR) documented the nursing staff follow physician's orders [REDACTED]. The facility failed to ensure the documentation and monitoring of bowel movements for resident #10 who was at risk for constipation. - The electronic medical record (EMR) documented [DIAGNOSES REDACTED]. condition in which small, bulging pouches develop in the digestive tract). The Significant change Minimum Data Set ((MDS) dated [DATE], documented staff assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS noted that resident required extensive assistance of 2 people for bed mobility, transfers, and toilet use. The quarterly MDS dated [DATE] documented staff assessed the resident with a BIMS score of 11, which indicated moderately impaired cognition. The MDS noted that he/she required extensive assistance of 2 staff people for transfers and toileting. The functional Care Area Assessment (CAA) dated 12/11/18 documented that the resident needed supervision to extensive assistance with 1-2 persons for transfers and toileting. The Urinary CAA documented the resident was alert and oriented with some forgetfulness at times. It further documented that resident was occasionally incontinent of bowel and was on a bowel management program. The quarterly care plan dated on 3/16/18 for Medication monitoring care plan documented the resident was on laxative for constipation. Bowel movement records for 04/2019, 03/2019, 02/2019, and 12/2018, documented that the resident did not have a bowel movement from 12/4/18 until 12/8/2018 (4 days), from 12/19/2018 until 12/22/2018 (4 days), from 12/24/18 from 12/31/2018 (8 days), from 2/11/19 until 2/15/2019 (5 days), from 3/17/2019 until 3/23/2019 (7 days), 3/13/2019 until 3/16/2019 (4 days). No documentation was noted from the point of care chart from 4/19/19 until 4/24/2019 (6 days). The EMR lacked evidence a bowel and bladder assessment was performed during the intervals of no bowel movement documented. The electronic Medication Administration Record [REDACTED]. The EMAR documented the resident refused [MEDICATION NAME] (medication used to treat constipation) in (MONTH) 2019, 16 out of 30 days. Observation on 5/1/2019, at 10:30 A.M. The resident sat at the table and he/she stated he/she had no concerns. On 5/6/19 at 12:04 P.M. direct care staff M stated he/she knew how to take of a resident by referring to the jot sheet and Kardex (brief outline of care for the residents). He/she stated that if a resident has not had a bowel movement in 2 days, it was reported to the nurse. He/she stated that bowel movements are charted in the point of care. On 5/6/19 at 11:31 A.M. licensed nursing staff G stated bowel movements are charted by the certified nursing assistants (CNA). He/she stated that point click care alerts them if a resident has not had a bowel movement in 2 days., or the resident also notified him/her. He/she stated that if a resident has not had a bowel movement he/she would offer prune juice, prn order, or if he/she does not have one the doctor is notified. On 5/6/19 01:05 P.M. administrative nursing staff D stated the CNA charts bowel movements. It comes up on the dash board if the resident has not had a bowel movement in 48 to 72 hours. He/she expected certified nursing staff to document bowel movement in the chart. He/she would expect his/her nurses to do a bowel assessment if that resident has not had a bowel movement. Administrative nursing staff D verified lack of bowel movement charting in the EMR. The facility bowel monitoring policy dated (MONTH) 1, (YEAR) documented that CNA's will document bowel function in the clinical record at the time of notification. The policy also stated that the licensed nurse will document an assessment of bowel function which include: auscultation of bowel sounds in all quadrants, palpation of abdomen for tenderness, resident report of discomfort of feeling full and may perform digital exam of rectal vault, if necessary. The facility failed to monitor bowel movement and administer prn medication for resident # 39. This placed the resident at risk for complications from constipation. - The electronic medical record (EMR) for resident #26 listed [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The MDS noted the resident fed him/herself after setup and required extensive assistance of 1 staff member with most activities of daily living (ADLs) such as bed mobility, transfers and dressing. The resident received insulin injections on 7 of 7 days in the look back period. The Care Area Assessments (CAAs) dated 02/25/19 documented the resident received both long acting and short acting insulin (used to treat diabetes mellitus), staff continued to monitor as ordered. The care plan for medication monitoring initiated 03/03/18 documented that he/she received insulin both long acting and short acting for management for diabetes and was at risk for complications from side effects of medications including palpitations. (rapid, irregular heartbeat), [MEDICAL CONDITION] (accumulation of fluids in extremities), fatigue, headache, confusion, [DIAGNOSES REDACTED] (low blood sugar), weakness, and blurred vision. Review of the physician's medication orders recorded: Accu checks (checking of blood glucose level) before meals and before bedtime for DM, notify physician if blood sugar below 70 or greater than 350, start date 02/14/18; Humalog (short acting insulin), inject 21 units before meals and per correction scale, hold if blood glucose is less than 80 and call the physician. If blood glucose is greater than 350 give 5 units and notify the physician, start date 02/26/19; [MEDICATION NAME] (long acting insulin), inject 55 units every night at bedtime for DM, hold if blood glucose level is below 90 and if blood glucose is greater than 400, notify physician, start date 10/23/18. Review of the Electronic Medication Administration Record [REDACTED]. On 05/02/19 at 12:09 PM resident #26 was observed in the dining room sitting in his/her wheelchair, eating lunch. On 05/06/19 at 12:11 PM interview with licensed practical nurse G revealed that the MAR indicated [REDACTED]. Staff then chart in the point click care system when blood glucose level is out of parameter, he/she should notify the physician and note it in the resident's chart and any further orders given. On 05/06/19 at 1:01 PM interview with administrative staff D stated the nurse should chart blood glucose reading in the point click care system and if any action was taken. Sometimes, nursing staff get busy and might not get it charted right away, but the physician should still be notified whenever the blood glucose level is out of parameter and an entry should be made in the point click care chart of any action taken by nurse or orders given by the physician. Charts are checked nightly by night shift nurse for errors and the day shift nurse the next day puts in any orders that might have been received the night before. The facility's Documentation Charting and Guidelines policy dated (MONTH) (YEAR) documented the nursing staff follow physician's orders [REDACTED]. The facility failed to ensure nursing staff reported to the physician blood sugars outside of the physician ordered parameters for resident #26 who was at risk for complications related to insulin use.

The facility had a census of 63 residents. Based on record review and interview, the facility failed to provide the resident (or their representative) the completed (SNFABN) Skilled Nursing Facility Advanced Beneficiary Notices, (CMS) Centers for Medicare and Medicare Services. Findings included: - The Medicare ABN informed the beneficiary that Medicare may not pay for future skilled therapy services. and failed to provide a cost estimate for continued services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility lacked documentation Resident #42, or his/her representative, was provided the estimated cost documentation for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The noticed should have documented the amount so the resident and/or his/her representative could make a decision about his/her options, then would document the amount of the services/items. The resident's skilled nursing services ended on 12/21/2017. The facility lacked documentation Resident #18, or his/her representative, was provided the estimated cost documentation for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The noticed should have documented the amount so the resident and/or his/her representative could make a decision about his/her options, then would document the amout of the services/items. The resident's skilled nursing services ended on 3/02/2018. The facility lacked documentation Resident #48, or his/her representative, was provided the estimated cost documentation for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The noticed should have documented the amount so the resident and/or his/her representative could make a decision about his/her options, then would document the amount of the services/items. The resident's skilled nursing services ended on 3/29/2018. The facility lacked documentation Resident #26, or his/her representative, was provided the estimated cost documentation for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The noticed should have documented the amount so the resident and/or his/her representative could make a decision about his/her options, then would document the amount of the services/items. The resident's skilled nursing services ended on 5/07/2018. The facility lacked documentation Resident #35, or his/her representative, was provided the estimated cost documentation for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The noticed should have documented the amount so the resident and/or his/her representative could make a decision about his/her options, then would document the amount of the services/items. The resident's skilled nursing services ended on 5/27/2018. On 6/21/2018 at 1:30 PM, Social Service Staff X. stated he/she provided the resident and/or their representative the CMS form and , however lacked completion of the form indicating the resident/DPOA responsibility if he/she chose to continue the service. On 6/25/2018 10:45 AM, Administrative Staff A, stated he/she was aware of the CMS and CMS form , but he/she was unaware the staff lacked completion of the form, so the resident or the DPOA could make a decision to continue services or not. Upon request a policy for ABN notices was not provided by the facility. The facility failed to provide the resident or their representatives the ABN completed form when discharged from skilled care, which placed them at risk to make uninformed decisions about their skilled care.

The facility had a census of 80 residents. The sample included 5 residents. Based upon observation, record review and interviews the facility failed to provide effective interventions to prevent falls for 2 (#1, #2) of 3 residents sampled for falls. Findings included: - Resident #1's computerized medical [DIAGNOSES REDACTED]. The resident's significant change Minimum Data Set (MDS) 3.0 dated 12/20/12 included the resident had severely impaired cognition, short and long term memory problems, required extensive staff assistance with bed mobility and transfers, and did not walk in the room/corridor. The MDS included the resident required staff supervision with locomotion on the unit, totally dependent upon staff for dressing, toilet use, personal hygiene and limited staff assistance with eating. The MDS recorded the resident was not steady and only able to stabilize with human assistance when moved from seated to standing position, moved on/off the toilet, surface to surface transfers and the activity of walking and turning around facing the opposite direction did not occur. The MDS included the resident utilized a wheelchair, had 2 or more non injury falls and 2 or more non major injury falls. The resident's activity of daily living Care Area Assessment (CAA) dated 12/21/12 included the resident was alert, confused, had a [DIAGNOSES REDACTED]. The CAA included the resident needed extensive to total staff assistance for most activities of daily living including mobility, the resident propelled his/her wheelchair on the unit and needed more assistance with locomotion off the unit. The CAA included the resident refused care often, became physically aggressive with staff during cares, staff re-approached the resident at a later time and provided the resident space. The resident's fall CAA dated 12/21/12 triggered; however there was no evidence to support the facility assessed the causative factors why the fall CAA triggered. The resident's fall risk assessment dated [DATE] and 12/11/12 identified the resident scored 11 (high risk for falls). The resident's care plan dated 12/20/12 addressed the resident was at risk for falls related to a history of falls, cerebrovascular accident (the sudden death of brain cells due to lack of oxygen when the blood flow to the brain was impaired by blockage or rupture of an artery to the brain ) with right sided hemiparesis (weakness), abnormal gait and the resident was unaware of his/her limitations when he/she attempted to self transfer. The resident's fall interventions included: 3/15/11 the facility educated staff regarding encouraging the resident to be out in the common areas when he/she was out of bed for increased staff observation and provided the resident non-skid socks, 3/19/11 the staff provided the resident with a urinal at night and educated the resident how to use the urinal, 3/27/11 the staff placed the bed with one side against the wall, placed yellow tape on the assistive device to identify the resident as a fall risk, and keep the door to the room open for observation. 4/5/11 the facility educated staff to attach the resident's call light cord to the resident's clothing when the resident was in bed, 4/23/11 staff ensured the resident's bed was in the lowest position at bedtime, 2/25/12 the facility re-educated the staff to ensure staff locked the resident's wheelchair and it was next to the resident's bed when he/she was in bed, 3/18/12 the facility re-educated staff to leave the resident's door open for increased observation, 3/29/12 the facility placed a fall mat beside the resident's bed when the resident was in bed at night, 3/31/12 staff placed a transfer bar to the left side of the resident's bed to assist the resident with bed mobility and transfers, 4/24/12 the facility re-educated the staff to ensure the resident's wheelchair was locked and placed next to the his/her bed and placed a sign on the resident's wall to cue/remind staff, 5/15/12 staff provide the resident a pancake call light, and staff re-educated regarding placing the fall mat beside the resident's bed when the resident was in bed, 6/10/12 the facility re-educated the resident on the use of the urinal in his/her room, staff placed the urinal at the resident's bedside for easy access and staff educated to encourage the resident to use the urinal often, 6/28/12 staff toilet the resident every 4 hours during the day, 6/30/12 staff applied anti-roll back device to the resident's wheelchair, and 7/10/12 the facility placed non-skid strips on the resident's fall mat to decrease his/her fall risk when he/she was incontinent. A nurse's note dated 8/2/12 and timed 10:48 P.M. documented at 10:20 P.M., the resident sat on his/her bottom on the floor beside his/her bed, the wheelchair bedside the resident, the wheelchair was locked, the resident did not activate the call light and staff educated this cognitively impaired resident on the use of the call light for staff assistance. A nurse's note dated 8/13/12 and timed 7:57 A.M. documented staff found the resident sitting on the floor next to his/her bed at 7:15 A.M. No new interventions attempted. A nurse's note dated 8/23/12 and timed 4:04 P.M. documented staff found the resident on the floor beside his/her bed with the wheelchair directly in front of the resident. The facility attempted no new interventions. A nurse's note dated 8/28/12 and timed 11:10 A.M. documented at 10:50 A.M. staff observed the resident sitting upright on the floor at the head of his/her bed, the resident's back leaned against the bed frame and the resident's wheelchair noted on the resident's right side facing the nightstand. The note included the resident attempted to transfer himself/herself from the wheelchair to the bed without staff assistance and staff encouraged this cognitively impaired resident to call and wait for staff before he/she transferred. The care plan documented the interventions dated 8/28/12 to educate staff on importance of making bed prior to resident returning to bed. A nurse's note dated 9/2/12 and timed 6:55 A.M. documented the resident slipped and fell due to urine on the floor by the resident's bedside, staff found the resident in a sitting position and the resident's back was up against the nightstand. The note included staff re-educated the resident to use the call light or ask for assistance with all transfer. No new interventions documented. A nurse's note dated 9/12/12 and timed 6:49 P.M. documented at 5:25 P.M. staff found the resident on the floor in his/her room by his/her bed and the resident independently transferred him/herself. No new interventions documented. A nurse's note dated 9/13/12 and timed 6:40 P.M. documented at 6:25 P.M. staff observed the resident on the floor in his/her room, the resident was in a supine position, horizontal to the bed, the resident's head toward the head of the bed, the resident incontinent of urine, and the resident confused. The resident had a [DIAGNOSES REDACTED]. A nurse's note dated 9/23/13 and timed 6:48 P.M. documented that at 5:00 P.M. staff observed the resident on the floor perpendicular to his/her bed, the resident laid on his/her left side with his/her feet under the bed, and the resident's wheelchair nearby and unlocked. The note included the top of the resident's scalp had a 1.5 centimeter (cm) laceration (wound to the skin) and the facility transferred the resident to a local hospital. A nurse note dated 9/23/12 and timed 9:51 P.M. documented the resident returned to the facility at approximately 7:15 P.M. with 5 staples (used to close the wound) to his/her scalp. A nurse's note dated 10/4/12 and timed 2:18 P.M. documented the resident sat on the floor on the side of his/her bed, the resident's back to the side of his/her bed, the resident's wheelchair to the right of the resident and the resident had a skin tear re-opened from a previous fall, and staff applied Steri strips. A nurse's note dated 10/5/12 and timed 6:43 P.M. documented at 5:15 P.M. staff found the resident sitting on his/her buttocks, the resident's knees slightly flexed, and the resident's back up against the side of his/her bed. The note included the resident attempted to transfer from his/her wheelchair to the low bed when the fall occurred, this was the resident's second fall within the last 2 days, and staff re-educated this cognitively impaired resident to use the call light to ask for staff assistance prior to transfers. The care plan included staff offered to assist the resident to bed following the evening meal. A nurse's note dated 10/23/12 and timed 3:58 P.M. documented staff found the resident on the floor next to his/her bed at approximately 1:15 P.M. and the resident's wheelchair was directly in back of the resident. The care plan documented maintenance repaired the anti-roll back device on the wheelchair. A nurse's note dated 11/1/12 and timed 5:53 P.M. documented at 5:25 P.M. staff found the resident on the floor in his/her room, the resident's wheelchair was behind him/her and the resident was incontinent of urine. The note included staff explained to the resident to use the call light to ask for staff assistance when getting in and out of bed. The care plan listed the intervention dated 11/2/12 that staff placed a stop sign in the resident's room to remind this severely cognitively impaired resident to stop and ask for assistance. A nurse's note dated 11/5/12 and timed 6:15 A.M. documented the intervention for the severely cognitively impaired resident was to use the call light to ask for staff assistance for all transfers. The care plan documented the intervention dated 11/5/12 - to place the pancake light on the resident's left side while in bed. A nurse's note dated 11/17/12 and timed 6:47 P.M. documented the resident laid on the floor on his/her right side, the resident's head rested on the bottom corner of the night stand, the resident had a reddened knot on the the right side of the temporal area and a bump on his/her right second finger. The care plan documented physical therapy would assist for the continued appropriateness of the transfer pole. A nurse's note dated 11/26/12 and timed 3:24 P.M. documented the resident laid on his/her back, the resident was directly in front of his/her bed and the resident's wheelchair was in back of the resident. The care plan documented physical therapy would assess for the continued appropriateness of the low bed. A nurse's note dated 12/6/12 and timed 6:30 P.M. documented a direct care staff walked by the resident's room, observed the resident sitting on the floor next to his/her bed, and the resident's wheelchair was next to the resident. The note included this was the second fall for the resident this evening. The record lacked documentation regarding the previous fall that day. The staff should re-educate the resident to ask for assistance when transferring, the resident did not appear to understand, and the resident's bed was in the low position. The facility's intervention included the facility monitored the resident's blood pressure three times a day, attached a call light to the resident's clothing (was in effect since 4/5/11) when the resident was in bed and provided a night light if the resident attempted to transfer himself/herself at night. A nurse's note dated 12/16/12 and timed 1:22 P.M. documented staff found the resident in an upright position on the floor, the resident's left side next to his/her bed and the resident's wheelchair directly in back of the resident. The facility's intervention included staff educated to ensure the resident's wheelchair was locked at the resident's bedside for attempted self-transfers (intervention in place since 2/25/12), and provided maintenance to the anti-roll back device on the resident's wheelchair. A nurse's note dated 12/19/12 and timed 2:39 P.M. documented staff found the resident on the floor with his/her back against the bed and the resident's wheelchair directly to his/her right side. The facility's intervention included the pharmacist to review the resident's medications that may cause urinary urgency or retention. A nurse's note dated 12/28/12 and timed 11:27 P.M. documented that at approximately 10:15 P.M. staff found the resident on his/her buttocks on the floor of his/her room at his/her bedside, staff assisted the resident to the wheelchair and the resident immediately started to wheel himself/herself out of his/her room to the dining room. Intervention included staff encouraged the resident to spend time in the nurses' view as much as possible for increased observation (in place since 3/15/11). A nurse's note dated 12/29/12 and timed 3:16 P.M. documented at approximately 1:00 P.M. staff found the resident on the floor in his/her room with his/her back against the bed and the resident's wheelchair directly to his/her right side. Interventions included staff placed non-skid strips to the fall mat by the resident's bedside (in place since 7/10/12). A nurse's note dated 1/2/13 and timed 2:59 P.M. documented staff found the resident on the floor, the resident's left side next to the bed, and the resident's back against the front of the wheelchair. Intervention included staff transferred the resident to a comfortable sitting chair at meals when the resident allowed. A nurse's note dated 1/17/13 and timed 4:34 A.M. documented staff observed the resident on the floor next to his/her bed on the fall mat, the resident's call light within reach but not activated. Intervention included maintenance fixed the bed lock and the right arm rest on the resident's wheelchair. A nurse's note dated 1/24/13 and timed 3:02 P.M. documented staff found the resident on the floor in front of his/her bed with the wheelchair directly to his/her right side at approximately 1:00 P.M. Intervention included dietary staff assisted in notifying nursing staff when the resident left the table at meal times. A nurse's note dated 1/27/13 and timed 7:46 A.M. documented that on 1/26/13 at 11:40 P.M., staff observed the resident on the floor mat next to his/her bed. Intervention included staff placed the resident's snack at his/her bedside for safe transfer. A nurse's note dated 2/3/12 and timed 8:57 A.M. documented another resident summoned staff to the resident's room, and the resident laid on his/her back in between the wheelchair and his/her bed. Intervention included staff re-educated on the need to assist the resident to bed upon the resident leaving the dining room. A nurse's note dated 2/8/13 and timed 2:27 P.M. documented that at 8:30 A.M., the resident sat on his/her buttocks on the floor mat next to his/her bed in front of the locked wheelchair, the resident stated he/she was trying to get into bed, the resident's call light within reach, not activated and staff informed this cognitively impaired resident to activate the call light to request staff assistance when transferring to and from bed and wheelchair. Additionally, the 2/8/13 nurse's note timed 2:27 P.M. documented after lunch, staff observed the resident transferring himself/herself to bed without staff assistance. Observation on 2/7/13 at 1:40 P.M. revealed the resident sat in his/her wheelchair at a dining room table and staff present in the dining room. Observation on 2/7/13 at 1:50 P.M. revealed the resident sat in his/her wheelchair at a dining room table and with no staff present. Observation on 2/7/13 at 2:44 P.M. and 3:40 P.M. revealed the resident laid in bed, the bed approximately 5 inches from the floor, a fall mat with non-skid strips beside the resident's bed and the resident's wheelchair beside the resident's bed. On 2/7/13 at 3:56 P.M. staff propelled the resident to a dining room table and observation revealed the staff did not offer to sit the resident in a chair at the table. Observation on 2/8/13 at 7:50 A.M. revealed the resident sat in his/her wheelchair at the dining room table, finished eating breakfast and no staff in the dining room. Further observation at that time revealed a yellow piece of tape on the wheel chair. Observation on 2/8/13 at 8:15 A.M. revealed the resident sat in the wheelchair at a dining room table. On 2/8/13 at 10:07 A.M. direct care staff G and a hospice staff transferred the resident from the bed to the wheelchair. Observation revealed the resident as non-interviewable. During interview with direct staff G at that time, he/she stated the resident required staff assistance of 1 to 2 for transfers. On 2/8/13 at 1:00 P.M. licensed nurse D entered the resident's room. Further observation revealed the resident with his/her back against the wall, the resident's legs in the wheelchair, the resident transferring self from the wheelchair to the bed by placing his/her leg over the arm of the wheelchair. Licensed nurse D assisted the resident to bed. Licensed nurse D stated sometimes the resident wheeled himself from the dining room and placed himself/herself in bed and other times staff assisted the resident from the dining room and placed the resident in bed. On 2/8/13 at 3:30 P.M. licensed nurse C stated the resident required staff assistance with transfers and staff should assist the resident from the dining room and assist the resident to bed. On 2/8/13 at 3:10 P.M. administrative nursing staff B stated the facility implemented interventions such as the fall mat with strips, activities, and ensured the resident's bed in lowest position. Administrative nursing staff B stated the facility repeatedly explained to the resident that he/she should wait for staff assistance prior to transfers, the resident was non-compliant, and did not seem to grasp the concept. Nursing administrative staff B confirmed the resident had severely impaired cognition. On 2/8/13 at 3:30 P.M. licensed nurse C stated the resident required staff assistance with transfers and staff should assist the resident from the dining room and assist the resident to bed. The facility failed to assist the resident to bed after meals, failed to offer the resident a chair when in the dining room and failed to provide effective interventions for this severely cognitively impaired resident with multiple falls and a laceration that required staples. - Review of resident #2's computerized medical [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) 3.0 dated 11/10/12 identified the resident scored 7 (severely impaired cognition) on the Brief Interview for Mental Status, required limited staff assistance with bed mobility, locomotion off the unit, dressing, and personal hygiene, staff supervision with locomotion on the unit, extensive staff assistance with toileting and did not walk in the room/corridor. The MDS coded the resident was unsteady but able to stabilize without human assistance when moved from seated to standing position and not able to stabilize without human assistance when moved on/off the toilet and surface to surface transfers. The MDS identified the resident utilized a wheelchair and fell 2 or more times since admission/readmission or the prior assessment. The resident's fall Care Area Assessment (CAA) dated 2/8/12 included the resident was alert, confused, self transferred during the day and required limited staff assistance during the late evening and at night. The CAA documented the resident at risk for falls related to impaired balance, confusion and incontinence. The resident's 5/10/12 fall assessment identified the resident scored 8 (the assessment did not identify if the score represented the resident at risk for falls). The resident's 2/6/13 fall assessment identified the resident scored 13 (at high risk for falls). The resident's care plan dated 11/3/12 addressed the resident at risk for falls. Interventions included: 2/20/11 - staff positioned one side of the resident's bed against the wall, staff ensured the resident's call light was within reach, the staff would assist with wheel chair locomotion on and off the unit, and staff placed a piece of yellow tape on the resident's assistive device to identify the resident was at risk for falls, 3/24/11: Staff educated the resident to lock his/her wheelchair before standing, 4/20/11: staff attached a a reminder card to the resident's call light cord to remind the resident to call for assistance, 4/30/11: the facility placed an anti roll back device on the resident's wheelchair, 9/15/11: the facility placed a transfer bar on the resident's bed to assist the resident with bed mobility and transfers, 5/18/12: the facility placed a non-skid material to the seat of the resident's wheelchair, 8/22/12: staff educated the resident to put his/her shoes on prior to transferring out of bed, 9/17/12: maintenance assessed the anti-roll back device for proper functioning. The care plan included the resident was cognitively impaired and the resident's family encouraged positive behaviors and educate as tolerated. A nurse's note dated 5/18/12 and timed 11:22 P.M. documented at 7:20 P.M. the resident called for help, the resident sat on the floor in the doorway of his/her room, the resident's wheelchair was right behind him/her. The note included the resident stated he/she wanted to go to the dining room and slipped out of his/her wheelchair. Per the resident's care plan, the intervention included the facility placed a non- slip material in the resident's wheelchair. A nurse's note dated 8/22/12 and timed 10:10 P.M. documented staff found this cognitively impaired resident on the floor in his/her room between the bed and wheelchair. The note included staff encouraged the resident to call for assistance with all transfers from bed to wheelchair, the resident was in regular socks and no shoes, and staff encouraged the resident to wear proper foot wear with all transfers. A nurse's note dated 9/17/12 and timed 5:22 A.M. documented at 5:00 A.M. the resident was on the floor and called for help. The note included the resident stated he/she tried to get out of bed and into his/her wheelchair and fell to the floor. The note included the wheels of the resident's wheelchair were not locked and staff educated this severely cognitively impaired resident on using the call light to ask for staff assistance and the importance of locking the wheels on the wheelchair prior to transferring. A nurse's note dated 2/4/13 and timed 4:42 A.M. documented at approximately 3:00 A.M. the resident called out for help, staff observed the resident's torso hanging off the side of the bed, staff attempted to assist the resident back into the bed and the resident started to slide. Review of the facility's fall log revealed the new fall intervention included: staff provided a winged mattress to the resident's bed to define bed parameters. During the initial tour of the facility on 2/7/13 at approximately 12:45 P.M. the resident called out for help. Observation revealed the resident in bed and stated he/she was wet. Direct care staff H entered the resident's room, the resident was incontinent of urine and staff performed incontinent care. Further observation revealed the resident's bed had a pressure relieving mattress but the mattress was not a winged mattress. Further observation revealed the seat of the resident's wheelchair without a device and there was a red colored device (not properly placed) between the seat and the back of the wheelchair. On 2/7/13 at 1:50 P.M. the resident propelled his/her wheelchair toward the dining room. On 2/7/13 at 2:44 P.M. the resident laid in bed, the bed approximately 5 inches from the ground and no winged mattress in place. Further observation revealed the resident's wheelchair next to the resident's bed and the seat of the wheelchair with a device and a red colored device stuck between the seat and the back of the wheelchair. On 2/8/13 at 7:50 A.M. the resident laid in bed, and no winged mattress on his/her bed, no device in the seat of the resident's wheelchair and a red colored device between the seat and the back of the wheelchair. On 2/8/13 at 10:07 A.M. direct care staff G stated the resident did not have a winged mattress. On 2/8/13 at approximately 10:30 A.M. the resident laid in bed, licensed nurse D observed the resident's wheelchair, stated he/she did not think the resident's wheelchair had a non-slip device and licensed nurse D pulled the red-colored device from between the seat and the back of the wheelchair. Observation revealed the red-colored device, when positioned properly supported the resident's back. During interview with therapy consultant O on 2/8/13 at approximately 10:40 A.M., the therapy consultant stated the resident did not have a non-slip surface in his/her wheelchair and the red colored device provided comfort to the resident's back when the resident sat in the wheelchair. On 2/8/13 at 1:00 P.M., licensed nurse D confirmed the resident did not have a wing mattress on his/her bed. On 2/8/13 at 3:10 P.M. administrative nursing staff B stated he/she did not know why the resident did not have the wing mattress (intervention after the 2/4/13 fall). At that time, administrative nursing staff B contacted another staff via telephone, stated the resident refused the wing mattress, staff documented on the incident report the resident's refusal and he/she would provide the incident report regarding the resident's refusal. Administrative nursing staff B stated the resident refused any device placed in his/her wheelchair. Administrative nursing staff B provided a copy of the incident report on 2/8/13 at approximately 4:00 P.M. Review of the post-fall assessment/investigation dated 2/5/13 listed the new intervention: facility to provide a winged mattress to define parameters. Documentation also included the resident refused to change mattresses and the resident stated he/she would ask for staff assistance prior to transfer. Review of the resident's clinical record lacked evidence the facility attempted to place the mattress at any other time or spoke with the resident's family regarding educating the resident to the placement of the mattress. The facility failed to provide the non-skid device in the resident's wheelchair as care planned, failed to attempt placement of the the winged mattress at another time and failed to ask the resident's family to educate the resident regarding the mattress as care planned for this cognitively impaired resident with a history of falls.