Every finding on record at Sidney Health Center Extended Care

Based on observation, interview, and record review, the facility failed to implement an effective fall prevention program; failed to follow the established fall policy and failed to identify and address the direct root causes of resident falls with and without major injury. Additionally, the facility did not ensure staff received updated fall-prevention training or education on newly implemented fall prevention interventions. These failures negatively affected 4 (#s 4, 7, 9, and 46) residents out of 5 residents sampled for falls with injuries, to include: - Resident #4 experienced a fall on 9/8/25 and sustained a rib fracture;- Resident #7 experienced multiple falls, with three individual falls on 2/13/25, 6/17/25, and 11/13/25, where she sustained injuries to include head lacerations and bruising. - Resident #9 experienced a fall on 11/23/25, sustaining an S5 sacral fracture and orbital hematoma;- Resident #46 experienced a fall on 8/30/25, sustaining a head laceration. On 12/3/2025 at 4:05 p.m., the facility Administrator and Director of Nursing were notified that an Immediate Jeopardy existed in the area of F689 - Accidents and Hazards, which was identified to be at the severity and scope of K. Upon removal of the immediacy, this was lowered to an H. The facility submitted an acceptable plan to remove the immediacy, which was verified as removed on 12/4/25 at 9:45 a.m., and it was validated that the facility did remove the immediacy as of 12/3/25 at 8:30 p.m. Findings include: 1. Resident #4: Review of resident #4's nursing progress notes, dated 9/8/25 at 4:02 p.m., showed: CNA reported to this nurse, resident was standing up from the toilet and feet slipped and she sat down hard on the toilet, striking left side of lower back on toilet rails. No bruising or swelling noted. Resident reports pain of a dull ache when ambulating or standing. During an interview on 12/3/25 at 8:42 p.m., staff member B stated there was no fall checklist packet completed for resident #4's fall in September. Staff member B stated it had not been considered a fall by staff, so no fall checklist was started. Review of resident #4's electronic medical record showed an admission date of 4/8/25. Resident #4's primary admitting diagnosis showed, Fracture of unspecified part of neck of left femur. Resident #4 had diagnoses including Long term (current use of anticoagulants) and, Chronic atrial fibrillation. Review of resident #4's Minimum Data Set (MDS) with a Quarterly assessment reference date (ARD) of 9/17/25, section J Health Conditions, showed Yes was coded for Has the resident had any fall since admission/entry or reentry or the prior assessment.? The response was marked as 1, showing a fall, and a major Injury occurred, which would include bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematoma. Review of resident #4's nursing progress notes, dated 9/5/25 at 11:09 p.m., showed: Alert medication charting: Change in Warfarin 5mg to be given Mon & Fri & 7.5 mg to be given Sun, Tue, Wed, Thurs & Sat (for the days in the week). No adverse symptoms observed with this medication change. No abnormal bleeding & or bruising. VS stable. [sic] There were no nursing progress notes to reflect any change of condition or assessments of resident #4's back or upper and lower extremities completed by nurses on 9/8/25, 9/9/25, and 9/10/25, after the 9/8/25 fall event occurred. There were no fall safety event forms completed for the 9/8/25 fall event in the bathroom. Review of resident #4's nursing progress notes, dated 9/11/25 at 2:29 p.m., showed: The resident requested an x-ray to her right ribs this morning. Walk-in clinic appt made. CT chest without contrast obtained. Impression: Acute appearing fracture of the right ninth rib posteriorly. No pneumothorax. Multiple healing left-sided rib fractures. 2. Resident #7: During an observation on 12/2/25 at 11:05 a.m., resident #7 was sitting in her recliner in her room. Resident #7 had a nasal cannula on, with tubing connected to an oxygen concentrator. Resident #7's room was dark, and she was resting with her eyes closed. No signs were posted on resident #7's door or wall to reflect that the resident was at an increased risk for falls. During an interview on 12/3/25 at 10:50 a.m., staff member A stated residents who had a history of falls had different interventions implemented and included in their care plans. Staff member A stated the facility had never considered using any kind of fall or bed alarms for residents. Staff member A stated there had been a discussion at one point to use a soft helmet for a resident as a fall safety precaution. Staff member A stated the intervention was never attempted because it was considered a dignity issue. During an interview on 12/3/25 at 11:25 a.m., staff member B stated the current fall prevention protocol meant there would be an update to the resident's care plan reflecting the resident was at increased risk for falls. Staff member B stated there would be alert charting completed on a resident after a fall. The alert charting documentation would be continued for three days after a fall occurred. The alert charting would identify fall outcomes or issues related to it. Review of resident #7's electronic medical record showed she was admitted to the facility on [DATE]. Resident #7 had a total of seven documented falls from the date of her admission through 11/13/25. Resident #7 experienced a witnessed fall and multiple unwitnessed falls. There were two fall risk assessments completed for resident #7; one on 1/2/25 and the other on 12/3/25. Review of resident #7's Minimum Data Set (MDS) with a quarterly assessment reference date of 3/26/25, section C Cognitive Patterns, showed the Staff Assessment for Mental Status reflected resident #7 had problems with short-term memory, which was for seems or appears to recall after 5 minutes, and had problems with her long-term memory, which was for seems or appears to recall long past. Section I, for the resident's Active Diagnoses, showed resident #7 had two neurological conditions: seizure disorder and Traumatic Brain Injury (TBI), which would impact her ability to remember what was instructed to her, such as remembering to use her call light for assistance. Section N, or Medications, showed the resident took high-risk drugs in the categories of anticonvulsants, diuretics, and antibiotics. These drug categories increase the risk for older adults to experience falls and or injuries, due to common side effects. Review of resident #7's fall risk assessment, dated 1/2/25, showed: - Does the resident have a history of falls in last 3 months? with the answer marked as a score of, 4 showing Three or more falls. - Fall Risk Score – Score of 10 or higher represents a high risk for falls, with a total score of 14, and a level of At Risk. Review of a facility reported incident, dated 2/13/25, showed resident #7 was found on the floor in her room with blood coming from her forehead. The report showed the resident was transferred to the ER for evaluation and treatment. A review of resident #7's Progress Notes from her medical record showed on 2/10/25 that she had been refusing to get out of bed for three days. She complained of weakness and stated she was to weak to stand to check her blood pressure checked. The nursing notes did not address her fall precautions or increased risks related to her weakness. The next progress notes occurred on 2/13/25, which is when the resident fell. Review of the facility reported incident findings, submitted to the State Survey Agency on 2/19/25, showed resident #7 was trying to transfer herself from her recliner to a wheelchair and slipped on a small rug. The findings showed that resident #7 was treated for a laceration in the ER. Resident #7's family removed the rug from the floor and agreed to gripper strips on the floor in front of the recliner, as resident #7 refused to wear gripper socks. Review of resident #7's social services progress notes, dated 2/13/25 at 12:07 p.m., showed: Stopped in to see [Resident #7], she had fallen this morning. We had just visited yesterday about waiting for help. She said that it is very hard when you are independent and she does not like having to ask for help. I talked to her about if she has a serious injury she is going to loose her independent due to a fx hip or something, so in the long run she will be more independent if she accepts help and prevents injuries. [Resident #7's] thought process was all over the place she jumped from topic to topic and at times her responses were not related to the current topics. [Resident] does admit she forgets to use call light, she refuses to have signs to remind her. She said her sons have strongly encouraged her to wait for assistance. [sic] Review of resident #7's nursing progress notes, dated 6/17/25 at 5:58 p.m., showed: During attempt to get a weight on [Resident #7]. While the CNA was helping [Resident #7] to stand she lost her grip on [Resident #7]. [Resident #7 lost her balance and fell to the floor hitting her head on the over the bed stand. When I arrived in the room [Resident #7] was laying on her left side with her head near the over the bed stand. Blood noted on the floor and [Resident #7] was asking to get up. [Resident #7] was noted to have a small laceration above her left eye that was bleeding. [Resident #7] was cleaned up since she had blood on her head and face. [Resident #7] is noted to have a small skin tear on her left forearm and an abrasion below her knee cap on her left lower extremity. Neuros started. Sent [Resident #7] to ER for further assessment . [sic] Review of resident #7's fall safety event form, dated 11/13/25, showed: CNA heard a thump and found resident laying on her left side in front of her bed. Resident states the floor was very slippery. Resident did have slipper socks on. Tube feeding running. Resident confused but able to follow direction. 2 lacerations on the forehead were cleaned and dressed. Resident incontinent of BM. She was changed. Abrasion on left knee was cleaned and dressed. DON notified. Called and gave report to ER nurse and CNA transferred resident to ER in wheelchair at 0455 (4:55 a.m.) . [sic] The fall event form showed resident #7's care plan was not reviewed, and the evaluation section marked, N/A: Event still open, failed to reflect a root cause analysis was completed for the event. A review of resident #7's comprehensive care plan showed she had a problem identified for falls. The care plan had interventions carried over from the prior year that were no longer applicable. The care plan did not address her weakness and fall prevention efforts when trying to transfer herself in/out of bed, what staff were to do related to increased monitoring if the resident was confused and could not remember to use the call light, but staff were to reinforce the use of the call light, even though the resident was noted to be confused consistently. An intervention showed staff were to make frequent rounds to establish her routines and times she liked to do things, and if there were patterns, incorporate safety interventions. It did not appear that safety interventions were developed related to this intervention. The resident had a problem of being always incontinent of bowel, but the care plan did not address interventions for staff to use to ensure the resident's incontinence needs were met as it related to fall prevention, such as a scheduled toileting plan, or increased monitoring during times when she frequently had a bowel movement. 3. Resident #9: During an observation on 12/2/25 at 10:30 a.m., there was no information in resident #9's room or on the door to alert staff that resident #9 was a fall risk. During an interview on 12/2/25 at 10:45 a.m., staff member M stated a resident's fall risk was communicated during report, and the resident's name was listed on the CNA assignment sheets. Staff member M stated there was a binder at the nursing station for reviewing the care plan changes. Staff member M stated she had received training on fall prevention, but was uncertain when it occurred. During an interview on 12/2/25 at 10:55 a.m., staff member N stated she was not aware of anything that may be posted in a resident room alerting staff to a resident's fall risk. Staff member N stated they kept track of residents who were a fall risk on the CNA assignment sheets. Staff member N stated if a resident was a fall risk, she would have them with her as much as possible, check on them a lot, and would have other staff watch the resident if staff member N was busy with another resident's care. Staff member N was unable to state specific care planned interventions for any residents she felt were a fall risk. During an interview on 12/3/25 at 10:04 a.m., staff member B stated falls had been identified as an issue and were tracked based on the fall investigation. Staff member B stated she was the staff member responsible for investigating and reviewing falls. Staff member B stated she looked at trends and staffing when the number of resident falls was high. Staff member B stated the facility was in the process of improving the review process for the falls, and she wanted to start a fall review team and implement a fall prevention program, such as a Falling Star Program. Staff member B stated these had not been implemented yet. Staff member B stated that when there was a fall, the nurse on duty completed a fall report, would send a text to staff member B, and interventions would be implemented to prevent further falls. Staff member B stated she did not keep investigation files related to falls; she would just keep her tracking sheets. Staff member B stated, I'm not always good at writing things down. During an interview on 12/3/25 at 10:50 a.m., staff member A stated the facility completed a fall checklist on all falls in the facility to ensure all fall investigation components were completed. During an interview with staff members E and F on 12/3/25 at 3:30 p.m., staff member E stated resident falls were discussed in their morning interdisciplinary meeting, and sometimes it was unclear who was responsible for updating the resident's care plan after a fall occurred. Staff member F stated the MDS department tried to update care plans when they noted it had not been completed. Staff member F reported the facility had ongoing issues with fall prevention. Staff member F stated she thought this was due to staff turnover on the management team, especially because there had been a change in the Director of Nursing position. Staff member F stated the facility planned to implement a fall review team, but this had not been implemented yet. Staff member F stated, You just came a month too early. Review of a CNA assignment sheet, updated 11/28/25, showed no documentation to reflect the fall risk for resident #9. Review of a facility reported event, dated 11/23/25 at 7:05 p.m., showed resident #9 had an unwitnessed fall with injury. The resident required treatment in the ER for a fractured S5 vertebrae, pain to the right hip and leg, pain to the left arm, a frontal hematoma, a laceration to the left forearm, one skin tear to her right arm, and one skin tear to her right elbow. The resident was released back to the facility. A review of the Emergency Department Provider Notes, dated 11/23/25, showed: . ED Provider Notes. . Assessment/Plan/Decision Making: . She (resident #9) fell down from a standing position. She (resident #9) had a large frontal hematoma on the left side. A small superficial laceration in left proximal forearm, two small skin tears in right arm. CT scan reported a fracture in Sacrum (S5). She (resident #9) had laceration in left arm repaired with glu. She (resident #9) was given Tylenol for pain. [sic] A review of resident #9's event reports for falls, between the date ranges of 11/10/25 to 11/27/25, showed resident #9 had four falls with injury within that time frame. A review of resident #9's fall care plan, with the date range from 6/2/25 to 12/2/25, showed there was no update to the resident's individualized care plan interventions in response to the falls that occurred between 11/10/25 to 11/27/25. There were no root causes identified within the event reports to be included on the care plan for future fall prevention. The last edit to the fall care plan interventions was dated 10/16/25. 4. Resident #46: Review of a facility-reported event showed resident #46 sustained an unwitnessed fall on 8/30/25, which resulted in a three cm head laceration. Resident #46 was treated in the hospital emergency department and released back to the facility. Resident #46 later passed away at the facility due to an unrelated illness and was not present for the survey. During an observation on 12/2/25 at 8:56 a.m., there were no observed fall precaution signs posted in any resident room or on the resident doors, to show the residents were at high risk for falls. During an interview on 12/3/25 at 10:50 a.m., staff member A stated the facility completed a fall checklist on all resident falls that occurred in the facility, to ensure all fall investigation components, were completed. During an interview on 12/3/25 at 11:25 a.m., staff member B stated resident #46's fall was not investigated because resident #46 passed away from an unrelated cause, before staff member B returned to work, and therefore the fall did not need to be investigated. Staff member B stated there was no root cause analysis completed for resident #46's fall with injury, and the IDT did not review the fall. Review of resident #46's nursing progress notes showed resident #46 returned to the facility on 8/30/25 at 2:02 p.m. The resident passed away on 9/1/25 at 1:49 a.m. Review of a staff education, titled Post Fall Procedures, showed: . A comprehensive post fall management plan should include, but is not limited to: . Revise plan of care and/or facility practices to reduce likelihood of another fall. [sic] Review of a facility policy titled Fall Prevention Program, revised on 12/31/24, showed: .Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: . 7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. . 9. When any resident experiences a fall, the facility will:. . e. Review the resident's care plan and update as indicated. f. document all assessments and actions. [sic] Review of the facility policy titled, Fall Risk Assessment, revised 12/31/24, showed: .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents . 1. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified. 2. The risk assessment will contain the following components: a. Identify environmental hazards and individual risks, including the need for supervision b. Evaluate and analyze hazards and risks. 4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. 5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.

Based on interview and record review, the facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement meetings, in order to meet the minimum requirements for the meeting attendees and frequency. This failure could affect any resident when or if a care system was effectively addressed or corrected for a deficient practice. Refer to F689 Accidents and Hazards, with an Immediate Jeopardy cited related to falls; F880, Infection Control; F883 Influenza Vaccines; and F887 Covid-19 vaccines, all system failures related to direct care. Findings include:During an interview on 12/3/25 at 8:31 a.m., staff member A stated that sign-in attendance sheets were not used to track attendees who participated in the QAPI meetings. Attendance was noted on the meeting minutes with the word present listed by the names of the attendees who were at each meeting. Staff member A stated the Medical Director was a member of the QAPI team but did not attend meetings regularly. Staff member A stated the medical director was provided with the meeting minutes and updated regarding significant action items being followed in QAPI.During an interview on 12/3/25 at 12:07 p.m., staff member D stated he did not physically attend QAPI meetings, but he planned to start. Staff member D stated he was provided updates from QAPI meetings via the meeting notes. Staff member D stated he was not aware whether the QAPI committee had identified resident falls as a concern, or if the facility created a performance improvement plan in an effort to decrease the number of falls residents were experiencing. During an interview on 12/3/25 at 12:07 p.m., staff member A stated she was not sure the last time staff member D attended the facility's QAPI meeting but said she thought it had been a couple of years.Review of a facility provided document titled QAPI Facility Plan dated July 31, 2025, showed, . The core members are the Medical Director or his/her designee. [sic]Review of a facility provided document, titled [Facility Name] Quality Assessment Program, which was undated, showed:. B. The Quality Assessment Committee membership includes:1. Medical Director. [sic]Review of the facility-provided documents titled Quality Assurance and Performance Improvement (QAPI) Meeting dated May 22, 2025; July 31, 2025; and October 23, 2025, showed staff member D was not marked as present for any of the meetings.

Based on interview and record review, the facility failed to maintain adequate infection surveillance and documentation within the facility over a four-month period for the early identification and monitoring of infections and safe infection control practices. This failure increased the risk for all residents in the facility and staff, related to the transmission and prevention of infectious agents. Findings include:During an interview on 12/3/25 at 10:27 a.m., staff member A stated she was unable to locate infection surveillance logs for the period of February 2025 through June 2025. Staff member A stated she only had line lists for a norovirus and a COVID outbreak that were tracked earlier in 2025. During an interview on 12/3/25 at 2:41 p.m., staff member R stated she had started in the position in July 2025. Staff member R stated in September 2025 that she had updated many of the program components to bring the facility back into compliance with the Federal regulations. Staff member R stated she did not know how the facility was tracking infections before starting her role. Staff member R stated that staff member A would have to provide information for infection surveillance logs before July 2025. Review of a facility document titled INFECTION PREVENTION AND CONTROL PROGRAM FY 2026, not dated, showed: . Surveillance, including process and outcome surveillance, will include monitoring, data analysis documentation, and communicable diseases reporting (as required by State and Federal law and regulation). Surveillance activities will be conducted to identify practice, infection trends, and early identification of new infections and potential outbreak situations. A request was made on 12/4/25 at 9:54 a.m. for the facility infection control surveillance logs for any facility infections from February through June 2025. No documentation was provided before the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure food was held at safe temperatures in the steam table1. The failure placed all residents who are served food from the steam table at risk for foodborne illness. Findings include:During an initial observation of the facility's dining room on 12/1/25 at 5:45 p.m., staff member G was observed in the dining room talking with a resident who was seated at a table. A steam table was observed, which contained trays with stuffed peppers, chicken strips, and soup. All trays were uncovered, and the lids were set off to the side of the steam table.During an observation and interview on 12/1/25 at 5:50 p.m., with staff member A, staff member G was prompted to check the holding temperatures of all foods in the steam table. Staff member G checked the temperature of one stuffed pepper on the top layer and reported the temperature at 127 degrees (Fahrenheit). Staff member G checked the chicken strips last and reported a temperature of 131 degrees (Fahrenheit). Staff member G stated that the recommended intervention if food was not held at warm enough temperatures would be to place the lids on the food trays. Staff member G did not place a lid on the trays of food in the steam table after identifying and reporting the low temperatures. During an interview on 12/2/25 at 2:40 p.m., while discussing the food service observations on 12/1/25, staff member A stated staff member G did not cover the food on the steam table after identifying the low temperatures.Two telephone interview attempts were made to staff member O regarding food service operations on 12/3/25 and 12/4/25. No return calls were received by the end of the survey period. 1Review of the State Food Safety Resource website, showed, . Anytime the temperature of TCS (Time/temperature Control for Safety) food falls between 41-135 F, the number of pathogens in the food start growing quickly. The longer food stays in the temperature danger zone, the more dangerous it becomes.Hot holding temperatures should stay above 135 FIt's an important part of your job as a food handler to keep held food out of the temperature danger zone. Check food warmers, steam tables, and hot holding units regularly to make sure hot TCS foods are being held at 135 F or hotter. The information may be located at: https://www.statefoodsafety.com/Resources/Resources/holding-time-and-temperature-log; 2025.

Based on Interview and record review, the facility failed to submit a report to the State Survey Agency within the required timeframe for reportable events for 5 (#s 9, 25, 30, 39, and 46) of 10 residents sampled for facility-reported events. Findings include: 1. Review of a facility reported event, dated 11/23/25 at 7:05 p.m., showed resident #9 had an unwitnessed fall with injury. The resident was treated in the ER and released. Resident #9 had a CT scan of her head and pelvis. The results of her CT scan showed a fracture to S5 vertebrae. The facility submitted the initial report to the State Survey Agency on 11/24/25 at 11:05 p.m. The submission was outside the maximum two-hour reporting window for incidents that result in serious bodily injury. During an interview on 12/2/25 at 3:40 p.m., staff member B stated reports to the State Survey Agency should be filed as soon as possible after an incident occurred and within two hours if there was a serious injury. Staff member B stated she did not know why any incident would be reported late. 2. Review of a facility reported event, dated 2/2/25 at 1:40 p.m., showed resident #25 was held down by staff during the administration of a medication. The event resulted in the termination of two staff members for abuse. The facility submitted the initial report to the State Survey Agency on 2/3/25 at 3:40 p.m. This was outside the maximum two-hour reporting window for incidents involving suspicion of abuse or mistreatment. Review of a facility provided document titled, Abuse Investigation-[Resident #25's Name], dated 2/2/25, showed NF4 was notified of the incident on 2/2/25 at 1:48 p.m. Staff member C was notified of the incident on 2/2/25 at 1:59 p.m. An investigation was initiated to determine if there was any abuse, and three staff members were suspended pending investigation. The report to the State Survey Agency did not occur until the following day. During an interview on 12/2/25 at 8:10 a.m., staff member A stated some incidents may have been reported late by NF4. 3. Review of a facility-reported event, dated 10/15/25, showed resident #30 sustained an unwitnessed fall. The facility's investigation included a review of the video surveillance, which showed resident #30 was attempting to move a blanket from a recliner, while holding a cup of coffee, and the resident appeared to have lost her balance and fell. The resident landed on her back. The facility's report of findings for resident #30's fall with injury was due on 10/22/25, but was not submitted until 10/24/25. During an interview on 12/3/25 at 11:35 a.m., staff member B stated the fall was determined to be accidental and not suspicious for abuse. Staff member B stated she did not know why the report of findings was not submitted on time. During an interview on 12/3/25 at 1:22 p.m., staff member A stated staff member B was responsible for the BOUNDS (Montana State Event Reporting System) reporting. Staff member A stated both she and staff member B have access to the reporting system. Staff member A stated she did not know why the investigative report findings were reported late for resident #30. 4. Review of a facility reported event, dated 9/25/25 at 6:30 p.m., showed resident #39 was involved in a resident-to-resident altercation where resident #39 was pinched by another resident. The abuse investigation findings were due on 10/2/25. Investigation findings were submitted to the State Survey Agency on 10/3/25. During an interview on 12/2/25 at 3:40 p.m., staff member B stated the facility has been working on improving the investigation processes. 5. Review of a facility-reported event, dated 8/30/25, showed resident #46 sustained an unwitnessed fall with injury. The resident was treated in the ER and released. The facility submitted the initial report to the State Survey Agency on 9/4/25; therefore, the final report to the State Survey Agency was late. During an interview on 12/2/25 at 3:40 p.m., staff member A stated reports were filed as soon as possible after an incident occurs, and staff member A stated she would be responsible for submitting a reportable incident if staff member B was unavailable or on vacation. During an interview on 12/3/25 at 11:35 a.m., staff member B stated she was not in the facility at the time of the incident and did not return to work until 9/3/25, after the resident had passed away. Staff member B stated the report and the findings were submitted on 9/4/25, after she returned to work. Staff member B stated she did not know why the report was not filed for resident #46 timely.

Based on Interview and record review, the facility failed to complete a thorough investigation and comprehensive corrective action following facility-reported events for 3 (#s 9, 39, and 46) of 10 residents sampled for facility-reported events. Findings include:During an interview on 12/2/25 at 8:10 a.m., staff member A stated the facility provided all investigation files they had for the requested incidents, which included for #s 9, 39, and 46. Staff member A stated they may not have formal investigation files on some of the incidents due to the previous Interim Director of Nursing not maintaining files for investigations. Staff member A stated that for those events, the only documentation they had was a copy of the submission of the event to the State Survey Agency. 1. Review of a facility reported event, dated 11/23/25 at 7:05 p.m., showed resident #9 had an unwitnessed fall with injury. The resident was treated in the ER and released. Resident #9 had a CT scan of her head and pelvic area. The results of her CT scan showed a fracture of the S5 vertebrae. Due to the resident's fall with significant injury, it was unwitnessed, and the resident was not a reliable reporter, the event met the reporting criteria for an injury of unknown origin. On 12/1/25 at 5:00 p.m., a request was made by the survey team for the investigation on the facility reported event for resident #9, dated 11/23/25, but the facility failed to provide an investigation file. 2. Review of a facility reported event, dated 9/25/25 at 6:30 p.m., showed resident #39 was involved in a resident-to-resident abuse altercation where resident #39 was pinched by another resident. On 12/1/25 at 5:00 p.m., a request was made by the survey team for the investigation for the abuse event involving #39, for the event dated 9/25/25, and the facility failed to provide an investigation file for this incident. 3. Review of a facility-reported event, dated 8/30/25, showed resident #46 sustained an unwitnessed fall with injury. The resident was treated in the ER and released. The facility submitted the report of findings to the State Survey Agency on 9/4/25. During an interview on 12/3/25 at 11:35 a.m., staff member B stated she was not in the facility at the time of the incident with resident #46, and she did not return to work until 9/3/25. Staff member B stated she did not investigate the incident. Review of a facility document, which was untitled and undated, showed, No investigation was conducted for the fall of [Resident #46], the fall occurred on 8/30/25. the DON was not back in the building until 09/03/2025 to do an investigation . [sic] Review of resident #46's nursing progress notes, hospital records, and death certificate validated the resident's death was not related to the fall on 8/30/25.

Based on interview and record review, the facility failed to update resident care plans based on individual resident needs for 4 (#s 4, 8, 9, and 25) of 19 sampled residents. This deficient practice placed residents at risk for injury, unmet needs, and decline in overall function and health. Findings include:1. Review of resident #4's comprehensive care plan showed an admission date of 4/8/25. The care plan showed the resident was at high risk for falls, and a care plan problem for falls was dated 4/11/25. The care plan included a long-term goal for minimizing the risk of the resident's falls and injuries. The interventions to prevent falls included: Keep call light within reach. Instruct [Resident #4] of safety measures. Fall assessment PRN. Remind [Resident #4] to change positions slowly. An additional intervention was started on 9/11/25, to show resident #4 had a recent fall when she slipped while getting up from the toilet, and the resident had a rib fracture. The staff placed gripper strips in front of the toilet. A review of resident #4's medical record showed there was no fall safety event form completed for the 9/8/25 fall event, and there were no additional interventions added to the resident's fall care plan. The resident's care plan did not include that the resident was taking a high-risk anticoagulant medication, and there was no root cause analysis completed for the fall event since there was no fall event form completed following the fall, as to ensure the interventions on the care plan addressed the direct root cause(s) and contributing factors of that fall. 2. Review of resident #8's fall safety event form, dated 11/3/25, showed resident #8 experienced an unwitnessed fall. The section for the care plan review showed the review did not occur, and there were no interventions added to the care plan following the fall. The evaluation section showed the event was still open, not closed, with no root cause analysis completed for the fall, even though the fall occurred over a month before the survey. Review of resident #8's comprehensive care plan showed an admission date of 6/8/22, and the facility added a problem related to falls on 9/22/25. The care plan's long-term goal was for resident #8 to be free from injury from falls, and for resident #8 to be able to get herself to the edge of the mattress and fall to the floor mattress. The care plan's interventions were to keep resident #8's bed in the lowest position at night, and the floor mattress would be placed beside the bed. An additional intervention on the care plan included that a Hoyer lift was to be used for all transfers. The care plan failed to include interventions for the 11/3/25 fall, either added or deleted, or that the care plan was evaluated by the IDT to show the fall interventions in place after the fall continued to be appropriate. 3. A review of resident #9's event reports, dating from 11/10/25 to 11/27/25, showed resident #9 had four falls, and the resident sustained injuries on the falls. A review of resident #9's care plan for fall prevention, dated from 6/2/25 to 12/2/25, showed no updates were made to the care plan interventions in response to the root causes of the resident's four falls, which occurred between 11/10/25 to 11/27/25. The last update made to the fall care plan interventions was dated 10/16/25. The facility failed to show that the interventions were evaluated, that the interventions continued to be appropriate, or that new interventions were identified related to the direct root causes of the four falls during that time span. 4. A review of resident #25's event reports, with the date range of 11/1/25 to 11/28/25, showed resident #25 had five falls with injury within that time frame. A review of resident #25's care plan for fall prevention, with the date range of 10/1/25 to 12/3/25, showed there were no updates made to the care plan for fall prevention efforts in response to the five falls that occurred between 11/1/25 to 11/28/25. The last update to the fall care plan interventions was dated 4/21/25. The facility failed to identify and address the direct root causes of the five falls in the fall prevention care plan. During an interview on 12/3/25 at 10:04 a.m., staff member B stated when there was a fall, the nurse on duty would complete a fall report, send a text to staff member B related to the fall, and interventions were implemented to prevent further falls. Although staff member B stated this was the process for falls, this did not occur. During an interview with staff members E and F, on 12/3/25 at 1:35 p.m., staff member E stated she, along with staff member F, split the case load of facility residents. Staff member E stated she would add updates to resident care plans after completing MDS assessments. Staff member E stated she did not know how additional updates to care plans were communicated to direct care staff who worked with the residents. Staff member E stated, right now, care plan intervention updates were, Like puddling through a mud puddle, we are going to get a process together. Staff member E stated resident falls were discussed in their morning meeting, and sometimes it was unclear who was responsible for updating the care plan after a fall. A review of a facility policy titled Fall Prevention Program last revised on 12/31/24, showed: .Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: . 9. When any resident experiences a fall, the facility will: . . e. Review the resident's care plan and update as indicated. [sic]

Based on interview and record review, the facility failed to prevent abuse for 1 (#25) of 6 residents sampled for abuse. The failure resulted in a violation of the resident's right to be free of physical restraint and placed the resident at risk for serious harm. The facility identified the abuse, addressed and corrected the deficient practice before the survey; therefore, it was past non-compliance. Findings include:Review of a facility reported event, submitted to the State Survey Agency on 2/3/25 at 3:40 p.m., showed on 2/2/25 at 1:40 p.m., facility staff held resident #25 down for the purpose of administering an intramuscular medication due to resident #25's behaviors.During an interview on 12/3/25 at 8:35 a.m., staff member A stated that due to the serious nature of the incident, the staff members involved no longer worked at the facility. Staff member A stated a Performance Improvement Project (PIP) had been added to QAPI, including monitoring for further incidents of abuse and restraints. Staff member A stated no further abuse or use of restraints was identified, and the action item had been resolved.Review of the facility's investigation for the reportable incident showed:- The facility investigation substantiated abuse.- Staff interacted with resident #25 in such a way as to have contributed to increased behaviors exhibited by resident #25.- Resident #25 exhibited behaviors that did not rise to the level of posing a risk of immediate harm to herself or others.- Resident #25 was held in a way that restricted her movement while staff administered an injectable (IM) medication.- Staff failed to follow the care plan's behavioral interventions for resident #25.- Staff documented that the medication was administered after 3 interventions failed. Interventions listed were offer food, assess pain, and music. There was no indication that assessing pain resulted in an actual intervention, such as the administration of pain medication. The interventions of offering food and music are not listed in the care plan.- There was no order in the chart to hold resident #25 down during the administration of a medication.Corrective MeasuresReview of a facility document titled, Quality Assurance and Performance Improvement (QAPI) Meeting, dated 2/27/25, showed a Performance Improvement Project (PIP) titled, Abatement Plan (PIP) for 2/2/2025 Event-Abuse by APS had been reviewed and added to the QAPI program.Review of a facility document titled Ad hoc Quality Assurance and Performance Improvement (QAPI) Meeting, dated 3/7/25, showed a QAPI meeting was conducted to review the event and outlined training, education, corrective action, monitoring, and audits put in place.Review of a facility document titled Quality Assurance and Performance Improvement (QAPI) Meeting dated 7/31/25, showed the PIP titled Abatement Plan (PIP) for 2/2/2025 Event-Abuse by APS was resolved 7/31/25.Due to the survey findings and evidence gathered, the facility identified and corrected the deficient practice before the survey.

Based on interview and record review, the facility failed to ensure adequate documentation was completed and maintained for the education provided to the resident or their responsible party, related to the risks and benefits of the seasonal influenza vaccination, for 3 (#s 6, 7, and 13) of 5 residents sampled for vaccinations. Findings include:During an interview on 12/3/25 at 2:41 p.m., staff member R stated she had administered vaccinations to facility residents for seasonal influenza and COVID vaccinations. Staff member R stated there was a section in the electronic medical record for a resident's vaccination administration information to include education on the risks and benefits provided to residents or their responsible parties. Staff member R stated she needed to go back into the resident medical records to update that section to indicate the education was provided to the resident or responsible party. Staff member R stated there were a few other nurses who administered vaccinations, but she administered most of the seasonal vaccinations. Review of a facility document, untitled and undated, included a table of residents who consented or declined to receive influenza and COVID vaccinations in October 2025. Resident #'s 6, 7, and 13 declined the influenza vaccination in October 2025. Review of resident #s 6, 7, and 13's vaccination records did not show documentation of education provided explaining the risks and benefits of the influenza vaccination to the resident or their responsible party. Review of a facility document titled Influenza and Pneumococcal Immunizations, revised 1/21, showed: . PURPOSE:To minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, and pneumococcal pneumonia. PROCEDURE: 1. Before offering the influenza immunization, and/or the pneumococcal immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of these immunizations. 2. Documentation of this education will be placed in the resident's medical record.

Based on interview and record review, the facility failed to ensure documentation was completed and maintained to show education was provided to the resident or their representative related to the risks and benefits of the COVID-19 vaccination, for 4 (#s 6, 7, 13, and 14) of 5 residents sampled for vaccinations. Findings include:During an interview on 12/3/25 at 2:41 p.m., staff member R stated she had administered Covid-19 vaccinations to facility residents. Staff member R stated there was a section in the electronic medical record for a resident's vaccination administration information to include education provided to the resident or their representative on the risks and benefits of the vaccine. Staff member R stated she needed to go back into the resident records to update that section showing the education was provided. Review of a facility document, that was untitled and undated, included a table of residents who consented or declined to receive the COVID-19 vaccination in October 2025. Resident #s 6, 7, 13, and 14 declined to receive COVID-19 vaccination in October 2025.A review of residents #6, 7, 13, and 14's vaccination records did not show documentation of the education on the risks and benefits provided prior to the COVID-19 vaccination being given or offered to the resident or responsible party. Review of a facility document titled Infection Prevention and Control Program, effective date 9/24, showed: . 8. COVID-19 Immunization:c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine. Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine.

Based on interview and record review, the facility failed to provide a resident with necessary respiratory care and services in accordance with professional standards of practice and the resident's physicians orders, which caused the residents to have insufficient oxygen saturations for 2 (#1 and #10) of 14 sampled residents. Findings include: a. During an interview on 10/8/24 at 11:35 a.m., staff member M said resident #1 had been in the tub room without her oxygen on when the resident turned blue and was not responding. Staff member M applied oxygen to resident #1, assessed the resident, and called the physician for orders. Staff member M was unable to remember the exact date this incident occurred. Staff member M said the CNA scheduled to care for resident #1 was new. Staff member M said she did was unaware if the CNA had been educated to know which residents were on oxygen. During an interview on 10/8/24 at 2:56 p.m., NF2 said someone from the facility called him and said, We made a mistake and took resident #1 to the dining room for breakfast without her oxygen. NF2 could not remember the name of the person who called him, but the staff member said resident #1's oxygen level was low, the resident had some seizure like activity, and the oxygen had to be increased to 15 liters to get her oxygen level up. NF2 said resident #1 had been using oxygen on a continuous basis for many years. NF2 said he placed a sign in the room after the incident to remind staff to always use oxygen. Review completed on 10/9/24 of the August nursing staffing schedule, staff member H and M were scheduled and assigned to work with resident #1. The schedule was verified with staff member F. During an interview on 10/9/24 at 1:46 p.m., staff member I said she did work the day shift on 8/19/24. Staff member I said resident #1 did go to the dining room for breakfast on 8/19/24. Staff member I is unaware of any incident concerning resident #1. Staff member I said residents use concentrators in their rooms and when out of their rooms, the residents use tanks on their wheelchairs. During an interview on 10/9/24 at 2:01 p.m., staff member H said she was working day shift on 8/19/24. Staff member H said she did not take care of resident #1 that day, but she said she knew resident #1 had an episode in the tub room when she did not have her oxygen on. A review of resident #1's August 2024 Physicians Order Report showed the resident had an order on 8/8/24 for oxygen at 2-4 liters per minute per nasal cannula to keep SaO2 at 90% or above. On 8/14/24, the physician's orders were .Titrate O2 as needed; Goal is to keep 88% or above. Currently at 4 liters continuous. A review of resident #1's nursing progress notes dated 8/19/21 at 3:30 p.m., showed resident #1 had a hypoxic episode in the tub room. Resident #1 did not have her oxygen on, and the nurse ran to grab some oxygen. The nurse applied the oxygen at 4 liters per minute and did a sternal rub to help rouse resident #1. An assessment was completed by the nurse, and the physician was notified. The CNA was educated on the importance of resident #1 having oxygen on continuously. A review of the physician progress notes, dated 8/19/24, showed resident #1 had severe COPD and is oxygen dependent at 4 liters per minute. The physician note showed he was called to the common area in the nursing home where resident #1 is found to be unresponsive for probably seconds likely secondary to severe hypoxia with the minor movements making her hypoxic. The physician directed the staff to send the reident tot he emergency room if her condition worsened. Review of resident #1's care plan, did not include oxygen use until the plan was revised on 8/19/24. On 8/19/24, oxygen at 4 liters per minute was added to the care plan. The care plan showed the rate could be adjusted to assist with recovery, but there were no parameters for oxygen use. The care plan was revised again on 8/20/24, showing a sign was placed above the oxygen tank to remind staff for continuous oxygen use and oxygen use was added to the CNA report sheet. b. Review of resident #10's physician orders showed an order for oxygen at 2-liters per minute per nasal cannula to be administered continuously due to hypoxia. During an interview on 10/8/24 at 11:47 a.m., staff member N said she was making rounds on the dementia unit. Staff member N found resident #10 did not have her oxygen on. She said resident #10's oxygen level was low, so she immediately applied oxygen. A review of resident #10's progress notes, written on 10/8/24, and documented as a late entry for 9/30/24, showed, resident #10 did not have oxygen on, and her oxygen saturation was 88%. The note showed the nurse educated the CNA on continuous O2 orders. Staff member N documented the oxygen level came up to baseline after oxygen was applied. A review of the facility's policy, titled Oxygen Administration, showed the following: Purpose: To treat and to prevent symptoms of hypoxia, such a tachypnea, tachycardia, shortness of breath and cyanosis (PaO2 below 60mmHg and/or saturation by pulse oximetry below 90%). Oxygen is a drug and, as such, a physician must order its use.

Based on observations and interview, the facility failed to ensure a Director of Nursing (DON) was working full-time for 35 or more hours per week, in the facility. This failure increased the risk of negative outcomes for all residents in the facility related to nursing care and services, due to the lack of onsite oversight provided by the DON to ensure completion of all necessary resident cares and treatments in the facility. During this survey, harm was identified related to respiratiry care and services, which was identified to be a system concern, and affected 2 (#1 and #10) of those who were sampled for respiratory care. Findings include: During an interview on 10/8/24 at 4:15 p.m., staff member A stated the facility had been advertising for a permanent director of nursing but had been unable to hire anyone. Staff member A said the facility had hired a director of nursing through and interim agency, and part of the contract included her ability to work on site for two weeks, and then work remotely offsite for two weeks. It was identified the facility failed to provide residents with necessary respiratory care and services in accordance with professional standards of practice and the resident's physicians orders, which caused the residents to have insufficient oxygen saturations for 2 (#1 and #10). Refer to F695, Respiratory Care and Services for more information related to the harm identified. Observations made during the survey showed the director of nursing was not present in the facility during the following time frames: - 10/7/24 at 12:15 p.m., until 5:15 p.m. - 10/8/24 from 7:15 a.m. until 5:40 p.m. - 10/9/24 from 7:15 a.m. until 5:40 p.m. - 10/10/24 from 7:15 a.m. until 9:15 a.m.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for oxygem use within 48 hours of admission, and the resident had a hypoxic event, for 1 (#1) of 3 recently admitted sampled residents. Findings include: Record review of resident #1's baseline care plan showed resident #1 was admitted on [DATE], and the baseline care plan did not include problems, goals, or interventions for oxygen use. During an observation and interview on 10/10/24 at 8:15 a.m., staff member D reviewed the comprehensive care plan which would include the baseline care plan. Staff member D said the oxygen usage was not on the baseline care plan, but there was nothing she could do about it now. Staff member D identified the oxygen was added to the care plan after the hypoxic event on 8/19/24. A review of resident #1's August 2024 Physicians Order Report showed the resident had an order on 8/8/24 (admitted ) for oxygen at 2-4 liters per minute, per nasal cannula, to keep SaO2 at 90% or above. On 8/14/24, the physician's orders were .Titrate O2 as needed; Goal is to keep 88% or above. Currently at 4 liters continuous. During an interview on 10/8/24 at 2:56 p.m., NF2 said resident #1 had been using oxygen on a continuous basis for many years prior to coming to the nursing home.

Based on interview and record review, the facility failed to adequately respond to allegations of abuse (bruises of unknown origin) and have evidence the alleged violation unknown bruising was investigated thoroughly; and the facility failed to show the allegation was reported to the required officials, for 1 (#94) of 14 sampled residents. Findings include: Review of resident #94's nurse progress note, dated 8/28/24 showed the last reported fall was 8/28/24 at 2:20 p.m., where she was noted sitting on the floor in front of her recliner. No redness or discoloration was noted after the fall. Review of resident #94's nurse progress note, dated 9/5/24 at 4:29 a.m., showed resident #94 had bruises of unknown origin on her buttocks. Staff member NF3 assessed the residents' buttock and noted dark purple and red bruising to her right upper buttocks, on her mid buttocks, and right lower buttocks to mid upper post thigh. The resident's progress note showed facility management had been notified at 5:26 a.m. Review of #94's nurse progress note, dated 9/5/24 at 5:26 p.m., showed the bruises of unknown origin were measured and described as, Dark red/purple bruising to resident's post upper/inner thigh area measures 17.5 x 11.5 cm; scattered small purple bruises present to resident's right hip; right outer hip area 9x4 cm; and upper inner buttock dark red/purple bruise measures 13 x 7 cm. This was reported to management and will be reported to day nurse. Resident does have complaints of pain in these areas. Review of the facility event report resident #94 recorded on 9/5/24 at 1:35 p.m., showed the event occurred on 9/4/24 at 8:33 p.m. The report shows the bruises to right buttock were likely from sitting down hard on the toilet. Review of resident #94's nurse progress note recorded as a late entry for 9/7/24 at 3:24 a.m., showed NF5 and the resident's family wanted to know the cause of the bruising. The nurse told NF5 she would have to talk to the director of nursing. Staff member NF3 texted the director of nursing this information. During an interview on 10/7/24 at 2:38 p.m., staff member NF3 said resident #94 had dementia, was weak and needed staff assistance to toilet, and at times even needing a complete lift transfer. Staff member NF3 said she was not aware of any time when the resident sat down hard on the toilet. Staff member NF3, who initially identified the bruises, said the bruised area was higher on the buttocks than then where the toilet seat would normally be in relation to the resident's buttocks. NF3 said staff member G said resident #94 was recently found on the floor and had put her back to bed. Staff member NF3 said staff member G worked the night shift, and NF3 said she worked quite a few shifts (scheduled eleven shifts in a row and then three days off) and was not aware of a fall occurring on her shift. During an interview on 10/8/24 at 11:55 a.m., an anonymous staff member said in the past resident #94 sits down hard onto the toilet, however, she had not sat down hard at any time recently when she had been assisting her. This staff member also said during the time this was being investigated, one of the other staff admitted to knowing the resident had fallen on the floor. This staff member would not identify the staff involved with the resident fall. During an interview on 10/9/24 at 5:30 p.m., staff member G said she was not sure what date the incident was, but it was probably about the beginning of September. Staff member G said she found resident #94 on the floor in her room laying on her back. Staff member G said she got the nurse to help get resident #94 back in bed. Staff member G said she was not asked to get any vitals or do any checks on resident #94 which is not the usual practice. Review of the abuse investigation showed the State Survey Agency had not been notified about the bruises of unknown origin on resident #94's buttocks and thighs. The investigation showed there were only four people interviewed in attempt to identify the cause of the bruising. The interviews for the four staff members were not dated to identify when the investigation was initiated. One note written by staff member G identified a fall, however this was not further investigated.

Based on observation, interview, and record review, the facility failed to ensure consistent enhanced barrier precautions were provided for 2 (#s 16 and 37) of 24 sampled residents; and the facility failed to provide documentation of infection surveillance and mandatory communicable disease reporting for six consecutive months which had an increased risk to the entire facility population. Findings include: 1. During an observation on 8/26/24 at 2:39 p.m., resident #37's door had a yellow isolation bag filled with gowns, gloves, and wipes hanging from the front of the door. There was no precaution sign on the door. During an observation and interview on 8/27/24 at 8:51 a.m., staff member M stated he did not know why resident #16 had an enhanced barrier precaution sign on his door. Staff member M said any enhanced barrier precaution supplies would be kept in resident #16's bathroom. Staff member M stated he knew where to find precautions for the residents. During an observation of resident #16's door, a sign for enhanced barrier precautions was displayed, and when observed, resident #16's bathroom and room had no equipment or PPE supplies. During an observation on 8/28/24 at 7:58 a.m., on resident #37's door, a yellow bag filled with PPE gowns, gloves, and wipes was hanging on the door. There was not an infection control precaution sign on the door. During an observation on 8/28/24 at 7:59 a.m., resident #16's door had a enhanced barrier precautions sign, but no PPE equipment or PPE supplies were found in the room or bathroom. During an interview on 8/28/24 at 1:06 p.m., staff member L stated she has been active in the infection control position for two weeks, as of 8/28/24, but she had been on medical leave for three months prior. Staff member L stated, I'm piecing infection prevention items back together since returning from medical leave. Staff member L stated she would need to check on the status of PPE supplies not being available for use in resident #16's room. Staff member L stated she would address with staff the reason the PPE supplies were not available in resident #16's room. Staff member L said she would address with staff why they didn't know resident #16 had enhanced barrier precautions, due to a MRSA infection. Staff member L stated resident #37 had enhanced barrier precautions in July (2024) however the infection was resolved prior to the survey. Staff member L stated mandatory staff training and education was provided for all staff at the end of April (2024) on enhanced barrier precautions. No further education had been provided. Review of a facility infection control document, updated 5/3/24, showed a list of nine residents on Enhanced Barrier Precautions. Review of a facility policy titled, Enhanced Barrier Precautions, effective April 17, 2024, showed: . c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. . 2. Initiation of Enhanced Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC. . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. . d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room. .8. Additional epidemiologically important MDROs may include, but are not limited to: a. Methicillin-resistant Staphylococcus aureus (MRSA) . 2. During an interview on 8/28/24 at 1:06 p.m., staff member L stated staff member F had been helping with infection monitoring . while I was gone for three months. Staff member L stated the infection control policies were reviewed on the facility intranet and documented with a timestamp. Staff member L said the older hard copy policies were not updated to show the new review date. Staff member L stated, if there were infections they have a map for outbreaks. Once infections are identified, the mapping would be updated and would allow the facility to track and monitor infections. Staff member L stated the facility surveillance tracking had been completed, but the facility was unable to find the surveillance tracking from March 2024 through August 2024. Review of a facility document, titled, Infection Control Program, with a revision date of February 2020, showed: . The Program . contains all the following required elements of a mandatory Infection Control Program as outlined below: 1. A system for prevention, identification, reporting investigation and control of infections and communicable diseases for all residents, staff, . and is based on the Facility Assessment conducted according to regulatory requirements and following nationally accepted standards; 2. Written standards, policies and procedures for elements of the Program including: a. A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility . All reportable infections are to be reported to [County Health Department] for follow up and tracking . Review of a facility policy and procedure, titled, Health Department Reports, with a revision date of February 2022, showed: . 1. Healthcare providers are mandated to report, in writing or by phone notification, confirmed or suspected cases of specific communicable and occupational diseases as designated by the state public health authorities . 1. Any time after diagnosis and before discharge, when a patient is diagnosed with one of the reportable diseases, either a written report, electronic report, faxed report, or verbal notification must be made to the local health department .

Based on interview and record review, the facility failed to review and revise the individualized resident care plans with interventions, for 2 (#s 4 and 10) of 24 sampled residents, showong. Findings include: 1. Review of resident #10's nursing progress note, dated 11/30/23, showed resident #10 was found on the floor, in the doorway, of her bathroom. Resident #10 complained of head pain which resulted from the fall. Review of resident #10's event report dated 11/30/23, showed possible contributing factors that could have increased resident #10's risk for falling. The facility failed to identify the root cause of the fall. Due to the failure to determine the cause of the fall, the care plan was not updated to reduce the risk of night time falls or toileting needs. Review of resident #10's fall prevention care plan showed no revisions or updates for fall interventions on 11/30/23. The fall care plan was not updated until 7/8/24. During an interview on 8/29/24 at 10:17 a.m., staff member F said she did not review or make changes to the care plan after the resident fall. Staff member F said the nurses taking care of the residents are to identify the root cause of the fall and update the plan of care. Staff member F said if the nurse makes a change to the care plan, it isn't reviewed, and stated, If it's in there, it is in there. Staff member F said, This is a work in progress, and with the lack of stability, there is no one checking anything. 51111 2. During an observation on 8/27/24 at 10:40 a.m., resident #4 was sitting in an electric wheelchair, and two gait belts were holding her legs together. One gait belt was strapped around her knees, and one gait belt was strapped around both her ankles. During an interview on 8/26/24 at 2:13 p.m., resident #4 stated she requested to use gait belts to hold her legs together while sitting in her wheelchair. Resident #4 stated her multiple sclerosis caused muscle weakness, and she couldn't hold her legs together comfortably, while in the wheelchair. Resident #4 stated her legs would splay outwards off the wheelchair's footrests. During an interview on 8/28/24 at 8:00 a.m., staff member I stated, in the mornings, CNAs would apply lotion to resident #4's legs and put two gait belts on resident #4's legs, per resident #4's request. Staff member I stated she did not document any application of gait belt use, and stated, I don't think the gait belts are in her [resident #4's] care plan or mentioned anywhere. Review of resident #4's comprehensive care plan, with a revision date of 7/24/24, showed: Problem Start Date: 5/17/17 - Category: Pressure Ulcer/Injury - Risk for impaired skin integrity d/t muscle weakness as evidenced by inability to control her lower extremities . 'Able to buckle and unbuckle seat belt that she uses while in her W/C . In W/C the majority of the day'. The care plan problem did not address the use of the two gait belts on her legs. Review of resident #4's comprehensive care plan did not include problems, goals, or interventions to address: - The resident's request for the gait belt usage to restrain both legs due to her disease process. - Did not show the restraint assessment was completed, and or that the belts were not used as a restraint or for convenience of staff. - Risks associated with the gait belt usage. - Necessary skin assessments due to the daily use of the gait belts and pressure on the resident's legs. - Directions for how staff were to place, remove, and check the gait belts. - Cleaning of the belts. - When gait belts were to be used, such as time of day, and if it was to be only when she was in her wheelchair. - If/when the usage of the gait belts would be re-evaluated. Review of a facility policy titled, Comprehensive Care Plans, with a revision date of January 2013, showed: . The facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetable to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. . 3. The care plan will be periodically reviewed and revised by a team or qualified persons after each assessment .

Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was created for 1 (#31) of 24 sampled residents who utilized oxygen. From admission, the resident had three MDS assessments completed, all showing oxygen therapy was provided, but the care plan was never updated, showing a repeated pattern for the failure. Findings include: Review of resident #31's electronic medical record showed on admission, the resident's pertinent diagnoses included: acute and chronic respiratory failure with hypoxia, pneumonia, and pulmonary hypertension. A review of resident #31's MDS assessments, to include the Admission assessment, dated 2/26/24, and two Quarterly assessments, dated 5/15/24 and 8/7/24, showed oxygen therapy was marked in section O0II0 for respiratory services. During an observation on 8/26/24 at 3:42 p.m., resident #31 was observed wearing a nasal cannula, connected to an oxygen concentrator, with the oxygen flow rate set at 3 liters. An oxygen tank was observed in a pack, strapped to the back of resident #31's wheelchair, and a second oxygen tank was observed on the side of the room, next to resident #31's bed. During an interview on 8/26/24 at 3:44 p.m., resident #31 stated she has lived in the facility for about six months. Resident #31 stated her reason for admission was due to difficulties with breathing. Resident #31 stated she had been using oxygen since admission and it helped with her breathing. During an observation on 8/28/24 at 11:24 a.m., resident #31 was observed wearing a nasal cannula, which was connected to an oxygen concentrator, and the oxygen flow rate was set at 3 liters. Review of resident #31's comprehensive care plan, revised on 8/20/24, failed to include a problem, goals, or interventions related to the resident's oxygen use and respiratory status, resident assessment for oxygen use/needs, oxygen saturation level to be maintained, oxygen flow rate, precautions, directions for staff, or equipment care/management for oxygen. The failure to add and address the oxygen use on the care plan was a repeated failure from the resident's admission to the date of the survey. Review of a facility policy, titled, Comprehensive Care Plans, with a revision date of January 2013, showed: . The facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetable to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . 1. Comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment . 2. The care plan will be prepared by and interdisciplinary team, that includes the attending physician, a registered nurse with the responsibility for the resident and other appropriate staff in disciplines as determined by the resident's needs . 3. The care plan will be periodically reviewed and revised by a team or qualified persons after each assessment .

Based on interview and record review, the facility failed to fully investigate and resolve a reported concern and grievance for 1 (#34) of 24 sampled residents. Findings include: During an interview on 8/26/24 at 2:46 p.m., resident #34 discussed a grievance she voiced to the facility staff, and stated she told staff member B a nurse smelled of perfume, which had a strong gagging odor. Resident #34 stated she was concerned if the smell was affecting her so strongly, she wondered how other residents with respiratory issues were handling it. Resident #34 stated this concern was voiced at a care planning meeting, where staff members F and K were present. Resident #34 stated she did not have follow-up from the grievance voiced during her care planning meeting. During an interview on 8/28/24 at 11:36 a.m., staff member K stated she was aware of a concern from resident #34 regarding her grievance on the strong perfume odor on a nursing staff member. Staff member K stated staff member B was going to follow-up on the concern with the identified nursing staff. During an interview on 8/28/24 at 4:27 p.m., staff member J stated employees were instructed at the beginning of their employment, scents were not to be used except lightly scented deodorant and laundry soap smells on clothes were allowed. Staff member J stated within the past month, she had reported to a nurse supervisor a strong smelling odor of perfume on the same staff member who was named by resident #34 in her concern. During an interview on 8/29/24 at 8:07 a.m., staff member A stated there was no written documentation found for resident #34's grievance or concerns with the the staff member's strong perfume odor. Staff member A stated staff member B addressed the concern with staff verbally. Staff member A stated she was unsure if follow-up had occurred. Review of a facility policy titled, Right to Voice Grievances, with a revision date of January 2016, showed: . 2. Verbally reported concerns/complaints can be given to any nurse, Social Services Director, Director of Nurses, Administrator . 5. The facility will investigate the concern and respond to the grievance in a prompt manner. See Attached Form used by staff to document the investigation. A facility representative will contact the person who made the grievance with the results of the investigation. The facility will state what action(s) to be taken to prevent further occurrences . 8. The facility will maintain documentation regarding the complaint for a minimum of three years .

Based on interview and record review, the facility failed to ensure the monthly drug regimen review process was used to identify and report irregularities to the attending physician, for 1 (#33) of 24 sampled residents. Findings include: Review of resident #33's physician progress note, dated 3/16/24, showed, It is not clear if she has been using her Xanax on a regular basis or only as needed. A request was made on 8/27/24 and 8/28/24 for medical provider documentation addressing the continued as needed/PRN use of Xanax. No additional information or documentation was received by the end of the survey. Review of resident #33's pharmacy progress notes, dated 5/14/24 and 7/10/24, showed psychotropic medication monitoring was completed. The document showed the as needed Xanax started in March 2024. The pharmacist's documentation showed the as needed use of Xanax beyond the 14 days was acceptable based on the pharmacist review. The pharmacist documented, Xanax is not an antipsychotic, therfore, duration beyond 14 days is acceptable [sic]. The pharmacist documented the as needed Xanax will continue. The pharmacist failed to identify a problem with the continued use of an as needed psychotropic medication beyond the 14 day recommended discontinuation. Review of the facility policy, titled Psychotropic Medication Management, dated 6/1/24, showed, . PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days) . if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their clinical rationale in the resident's medical record and indicate the duration for the PRN order . During an interview on 8/28/24 at 8:21 a.m., staff member D said he is responsible for tracking the psychotropic drug use, recommending gradual dose reductions, and notifying the facility and physicians of medication irregularities. Staff member D said resident #33 was okay to have as needed Xanax because the doctor was going to make it scheduled. Staff member D said the physician had ordered as needed Xanax to be refilled five times.

Based on interview and record review, the facility failed to ensure Provider Orders for Life-Sustaining Treatment (POLST) forms were completed for 3 (#s 2, 7, and 36) of 24 sampled residents. Findings include: 1. Review of resident #2's hard-copy and electronic copy POLST forms, showed: - In the mandatory signature and date section: the form was not dated when signed by the resident's legal decision maker. 2. Review of resident #7's hard-copy and electronic copy POLST forms, showed: - In the mandatory signature and date section, the form did not include the printed name, telephone number, or dates the form was prepared and signed. 3. Review of resident #36's hard-copy and electronic copy POLST forms, showed: - In the mandatory signature and date section: the form did not have the printed name, telephone number, and dates showing when the form was prepared and completed by the medical provider. During an interview on 8/28/24 at 8:27 a.m., staff member A stated staff member K oversaw resident POLST forms and the advance directives. Staff member A stated when a resident transferred to the facility from the hospital, POLST forms were usually started in the hospital. During an interview on 8/28/24 at 11:36 a.m., staff member K stated she didn't check on POLST forms when another staff member started filling one out, and she didn't check to see if the sections of those forms were filled out. Staff member K stated POLST forms were discussed at individual resident care plan meetings. Staff member K stated her usual practice with POLST forms is to have them filled out on admission for residents when she meets with them. Staff member K stated, There is no process for someone starting it and making sure the POLST form is completed. Review of a facility policy titled, Advance Directives and Physical Information, with a revision date of February 2020, showed: . [Facility Name], Extended Care will provide written information to residents, concerning his or her rights under State law to make decisions concerning medical care, including the right to accept or refuse medical treatment or surgical treatment and the right to formulate advance directives. 8. Facility staff will inform each resident of the name, specialty and way of contacting the physician responsible for their care. A request was made to the facility on [DATE] for a POLST policy. No additional documentation was received by the end of the survey.

Based on observation, interview, and record review, the facility failed to comprehensively re-evaluate and implement pressure ulcer prevention interventions timely, for a resident who developed bilateral pressure ulcers to the heel, which were avoidable. Both pressure ulcers's worsened and were Unstageable, for 1 (#40) of 12 sampled residents. Findings include: During an observation on 12/11/19 at 2:45 p.m., resident #40 was sitting in the recliner with the footrest elevated. The resident did not have a pillow under her legs, and she was not wearing any pressure relieving boots. During an observation on 12/11/19 at 2:46 p.m., staff member D stated, You should have a pillow under there to resident #40. Staff member D set a pillow under the resident's legs to float her heels off the footrest, for pressure relief. Staff member D removed the bilateral ace wraps from resident #40's lower legs. Resident #40's left posterior heel showed a 2 cm reddened area, with a 1 cm darker red area in the center. No broken skin was noted. Resident #40's right posterior heel showed a smaller, 1.5 cm reddened area, with a 0.5 cm darker red area in the center. No broken skin was noted. The pressure ulcer on resident #40's left heel was slightly larger, and slightly darker in color, than the one on the right heel. Neither of the areas had broken skin. Staff member D stated she would stage (assess severity) resident #40's pressure ulcer as a Stage IV, because of the eshar shadow, or as Unstageable because you cannot tell what is happening underneath the skin. During an interview on 12/11/19 at 1:34 p.m., staff member H stated resident #40's heels had little spots on them, and staff had been putting pressure relieving boots on the resident while in bed, and pillows under her legs to elevate resident #40's heels. During an interview on 12/11/19 at 1:46 p.m., staff member D stated resident #40 had a pressure ulcer on both of her heels. Staff member D stated the resident had pressure relieving boots for when she was in bed, and when she was in the recliner her heels should not be touching the footrest. Staff member D stated the physician had been notified of the wounds, and the staff was monitoring the pressure ulcers daily. Staff member D stated the pressure ulcers would have been avoidable had the resident had pressure relieving boots on before the ulcers had occurred. During an interview on 12/11/19 at 9:54 a.m., staff member F stated resident #40 had extreme [MEDICAL CONDITION], and she had been sitting in the recliner often. Staff member F stated the pressure ulcers to resident #40's heels were like a brown adhered tissue, and the staff were to still ace wrap resident #40's legs, use the pressure relieving boots, and monitor the resident's skin. Review of resident #40's Nursing Note, dated 12/6/19, showed, Fluid filled blister noted to bilat heel; . Resident heels are elevated on pillows while in bed and while in recliner; will continue to monitor for changes. Communication sent to MD. There was no documented skin monitoring in the nurse's notes regarding the pressure ulcers from 12/6/19 to 12/9/19. Review of a communication sent to resident #40's physician showed the following: -On 12/6/19 documentation showed resident #40 had fluid filled blisters to her heels bilaterally. There was no physician response, or documentation to show staff attempted to recontact the physician timely, when the physician did not respond to the initial communication. -On 12/10/19 documentation showed resident #40 had, Brown/tan spots to the back of both heels; 0.6 x 1.0 cm and 0.7 x 1.2 cm skin blanches - all is intact. Prevalon boots and daily assessments ordered. Review of resident #40's Nursing Note, dated 12/10/19, showed Tan/brown dark areas to the back of both resident's heels. Pressure injury charting begun, prevalon boots obtained and noted in Care Plan. Review of resident #40's Nursing Note, dated 12/11/19, showed, Reached out to PCP (primary care provider) in regard to communications sent to him informing him of the skin issues noted. PCP asked for communications to be resent to a different fax number. T.O. (telephone order) received to continue the prevalon boots when in bed or recliner. Daily skin assessment of the heels. Weekly skin measurements. Send weekly measurements to PCP. Review of resident #40's Skin Risk Assessment with Braden Scale showed the following: -On 11/8/19, resident #40 was at moderate risk for developing pressure ulcers and was put on a turning and repositioning program. - On 11/20/19 resident #40 was at risk for developing a pressure ulcer and a pressure relieving device for bed was implemented. Review of resident #40's Pressure Ulcer Documentation, dated 12/10/19 showed the following: -The location of the ulcer was on the left heel. It was Unstageable. The size of the ulcer was .6 x 1.0 cm. Character of the wound bed was noted to have necrotic tissue. No undermining, exudate or odor was noted. The surrounding tissue was intact. Description was noted as, Initial observation. Tan/brown area to back of left heel. Surrounding skin is reddened but blanches. - The location of the ulcer was on the right heel. It was Unstageable. The size of the ulcer was .7 x 1.2 cm. Character of the wound bed was noted to have necrotic tissue. No undermining, exudate or odor was noted. The surrounding tissue was intact. Description was noted as, Initial observation. Tan/brown area to back of left heel. Surrounding skin is reddened but blanches. Review of resident #40's Physician telephone orders showed the following; -On 12/10/19, Prevalon boots to bilateral L/E while in bed. Daily assessment. Dx-deep tissue injury. -On 12/11/19, Prevalon boots on in bed and in recliner, daily assessments of skin, weekly measurements of heels. Send measurements to PCP. Dx: Unstageable P.U. of both heels. Review of resident #40's care plan showed the following: -11/08/19 under the problem category for Pressure Ulcer it showed, resident #40 is at high risk for breakdown related to end of life condition, poor mobility, and poor nutritional intake. Under goal, the care plan showed, Minimize breakdown as her condition declines, and she becomes less mobile. Breakdown from normal physiological changes from multi system organ failure may not be preventable. Treat as soon as there is sign of pressure issues. Under approach, the plan showed, Reposition as she allows, up for meals. Clean and dry skin. Apply barrier liberally. Skin checks weekly and PRN. -12/10/19, under the situation/problem, the plan showed, Prevalon boots while in bed, Daily assessment and under comments/approaches the plan showed, to prevent pressure injury to heels. Review of the facility's Pressure Sore Policy and Procedure, with an effective date of 11/98, showed the following: - To ensure that the resident does not develop a pressure ulcer unless clinically unavoidable and that the facility provides care and services to achieve this purpose. - 1. Upon admission and periodically thereafter ( i.e. if changes in the resident's condition are identified), residents will be assessed to determine if they are at risk for developing pressure sores. - 2. Once identified and evaluated for the risk factors, individualized intervention attempts to stabilize, reduce or remove underlying risk factors, will be implemented per each resident's clinical needs. This is part of the resident's care plan, if deemed appropriate. - 3. Ongoing monitoring to identify the impact of the interventions implemented, and modifying of these interventions will be part of the resident's ongoing assessment process, as deemed clinically appropriate. - 4. Consultations with the residents primary care provider will be part of the assessment, intervention implementation and continued monitoring processes with possible consultative support from Nurse Personnel trained specifically in wound care as deemed appropriate for the resident's clinical needs.

Based on observation, interview, and record review, the facility failed to prevent the development of two pressure ulcers, with one to the coccyx worsening and becoming infected, for 1 (#11) of 13 sampled residents. Findings include: During observations on 10/30/18 at 1:30 p.m.,10/31/18 at 9:24 a.m. and 12:22 p.m., resident #11 was lying in bed on his back. Review of resident #11's Annual MDS, with the ARD of 8/21/18, showed the resident had two Stage II pressure ulcers, not present on admission, and required extensive assistance with bed mobility. Review of resident #11's Quarterly MDS's showed the pressure areas developed in (MONTH) of (YEAR), and had remained at Stage II's. During an observation and interview on 10/30/18 at 1:45 p.m., staff member D completed the dressing change for resident #11. The open area on the coccyx was approximately 3 X 2 inches with yellow slough in the center. Staff member D stated the area had become infected, had smelled bad, and became necrotic at the end of (MONTH) (YEAR). He stated the resident was placed on antibiotics, and the area had improved. Staff member D cleansed the perineal area of feces and changed gloves, but did not sanitize hands between use. Review of resident #11's Pressure Ulcer Healing Chart, showed the pressure area to the coccyx became a Stage III on 8/27/18, and a Stage IV on 9/27/18. Review of resident #11's Care Plan, initiated 6/29/15, showed high risk for impaired skin integrity. The plan did not identify the development of the pressure area to the coccyx, and did not address the decision for the resident to be bedfast. The Care Area Assessment, dated 8/21/18, showed Staff encourage resident to lay down often, instead of setting (sic) up doing puzzles. They also monitor peri area. Review of resident #11's physician visit documentation, dated 8/27/18, showed Lately there had been concern that (resident #11's) pre-sacral decubitus had been enlarging. The decubitus was reported to be 3.5 x 3.2 x 0.2 cm in (MONTH) (2018). On my examination today, the decubitus was approximately 8.3 cm with some associated smell. A wound culture was ordered, for enlarging Stage III pressure ulcer and wound infection. Review of resident #11's Annual nutrition review, dated 8/27/18, did not address the presence of a Stage III pressure ulcer to the coccyx, or the need for additional protein for healing purposes. Review of resident #11's physician fax, dated 10/15/18, showed Pressure area on coccyx area measures 7 cm x 3 cm with moderate amount of exudate, with area of black tissue in wound bed. Wound appears not improving. The physician ordered a surgery consult, which was scheduled for 11/05/18. Review of resident #11's Progress Note, dated 10/24/18, showed the order was noted by nursing, eight days after the faxed order. During an interview on 10/31/18 at 8:45 a.m., staff member C stated she did not know why the pressure area had developed into a Stage III and then Stage IV pressure wound. The facility had recently suggested resident #11 become bed rest only, which he had agreed to. (The resident) directs his own care, and there is no quality of life lying on your side. She stated the facility would order a new pressure relieving overlay mattress as the existing bed was a bariatric pressure reducing mattress. Review of resident #11's Nursing Progress note, dated 10/30/18 showed the facility was going to order a high profile ROHO cushion to assist with pressure relief, allow air to get to his seating area and to allow healing to occur faster. Staff member C did not know why these interventions had not occurred earlier.

Based on observation, staff interview and record review, the facility failed to ensure the environment remained as free of accident hazards as possible for 4 (#s 1, 6, 8, 9) of 10 sampled residents and that residents received adequate supervision and assistance to prevent accidents. Resident #1 tripped and fell on the lip of the scale and sustained a right hip fracture, skin tears, and a large hematoma to his right forehead. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, with an ARD date of 3/19/13, indicated the following: - is the resident alert? yes - is the resident oriented? no - do resident's levels of alertness or consciousness fluctuate? yes - is the resident's safety awareness intact? no - does the resident have a history of falls? yes Record review indicated the resident fell when getting off the scale on 7/29/13 at approximately 11:05 a.m. The 7/29/13 accident report completed at the same time read, "CNA was helping resident off scale, resident tripped over lip of scale and fell ." The resident was sent to the emergency room (ER) for evaluation of his hip following the fall. Record review revealed he sustained a right hip fracture, skin tears, and a large hematoma to his right forehead. The care plan for resident #1, with a date of 8/1/13, indicated that the resident had fractured his right hip, undergone surgery to repair it and was now back in the nursing home. The charting entry in nursing notes for 7/29/13 revealed the following: "CNA took resident to scale in the south tub room. Resident was stepping off of scale and tripped over lip. Resident landed on right hip on floor and left hip was on the scale. Resident was sitting in the corner between the wall and scale; right leg was bent with his feet pointing to the left side of his body, and left leg was straight in front on top of right foot. Resident's right shin and knee scraped, right elbow has a skin tear, and resident hit his head (right forehead has a hematoma). All cleaned with normal saline, skin tear has gauze placed over. Resident had complained of right hip pain, little to no range of motion in right hip without pain. No blue or black discoloration on hip but some discoloration to right mid back. Range of motion in lift leg/hip and shoulders within normal limits for resident. Resident was assisted up with three and gait belt to a chair. Resident put little to no weight on right leg. Sent to ER for evaluation of hip. Son notified and also physician notified." Staff member A, the administrator, was interviewed on 8/21/13 at 8:33 a.m. asked how resident #1 was weighed on the scale. The administrator reported: - He was ambulatory during this time and his gout was not bothering him. There were no changes in his gait or balance. -The use of a gait belt was not normally used for fully ambulatory residents because they could move more freely without it. - The normal procedure was to step onto and off the scale, over the lip. - The ramps were not normally used for ambulatory residents because they were thought to pose more of a fall risk. - The ramps were to be in the down position for residents in wheelchairs and not used for ambulatory residents. Staff members A and B, the DON and administrator, were interviewed together at 4:30 p.m. on 8/20/13; the interview revealed: Resident #1 was independent for walking at the time of the fall on 7/29/13. Staff member A indicated that resident #1 had walked independently from his room on the 300 hall to breakfast in the dining room on the morning of 7/29/13. He had also walked independently from his room to the scale to get weighed that same day. Staff member A indicated he fell while stepping off the scale after being weighed. She stated no gait belt was used on the resident. Staff member A stated the resident's power of attorney had been contacted just after the fall and that the resident was wearing his non-slip socks/slippers while he was being weighed. Interview at 5:45 p.m. on 8/20/13, with the on duty RN at the time of the fall, revealed that she did not witness the fall, but talked with the CNA who was attending to the resident when the fall occurred. She assessed the resident after the fall and sent him to the emergency room . She called the power of attorney at his work and let him know about the fall. Interview with the resident's family member on 8/21/13 at 10:35 a.m. revealed that resident #1 was a [AGE] year old man, weighing about 160 pounds and was 5' 6" tall. She indicated that the resident was very unsteady when walking and she did not understand why a gait belt was not being used when he ambulated. She stated she had seen the resident in the ER and could not believe his condition after the fall. She indicated that her biggest problem was the scale and how unsafe the use of it was due to the lip and the tripping hazard it posed. She did not want the scale being used to weigh her father or any other resident. She stated that she had indicated that to the facility Administrator and the DON following the fall. Review of resident #1's care plan before the fall indicated that he needed some cues and supervision, had short term memory loss, and impaired decision making. The approaches indicated that the resident often toileted himself, fed himself, and ambulated by himself. It indicated that he required assistance for bathing and dressing and peri-care. The care plan after he came back from the ER indicated that he required total assistance from staff for dressing, toileting, grooming, and walking. This care plan documented the presence of the right hip fracture received during the 7/29/13 fall from the scale. The care plan also indicated to only weigh resident #1 while sitting in a wheelchair and never while standing on the scale. 2. Inspection of the scale used to weigh resident #1 at 8:30 a.m. on 8/21/13, revealed that it had a 1" lip on the front of the scale which ambulatory residents had to step over when stepping up on or off the scale. There were handles to hang onto when getting weighed, and also a ramp on either side if the choice was to weigh a resident in a wheelchair. The surveyor observed residents getting weighed on the scale that had been used to weigh resident #1 on the morning of 8/21/13 with the following safety concerns noted: - At 8:45 a.m. resident #6 was weighed on the scale. The resident was ambulatory and was observed to step over the one inch lip of the scale from her wheelchair getting on and off the scale. She was assisted by one CNA. - At 9:00 a.m. resident #8 was weighed. She was in a wheelchair and was rolled up the ramp onto the scale by a CNA. The wheelchair brakes were locked after positioning the resident on the scale; she was weighed and wheeled down the ramp. The surveyor noted that the wheel chair did not fit correctly on the scale (it was too wide) and the left side of the wheelchair arm rested upon a platform lifting the left tire of the wheelchair a full two inches off the scale. The resident was listing to the right and gripped the armrests of the wheelchair while in this unbalanced position. - At 9:05 a.m. resident #9 was weighed . She was transferred by Hoyer lift from her lounge chair to her wheel chair, wheeled up the ramps upon the scale, weighed, wheeled back down the ramp and returned to her room. During the process, the right tire of the wheel chair was resting on the edge of the lip of the scale with most of the tire unsupported. Inspection of the scale as residents were getting weighed demonstrated the scale was not wide enough to weigh a resident in an averaged sized wheelchair because the wheelchair arms rode up on a platform making the wheelchair lean to one side, or the outside wheel rode up on the lip of the scale and was not fully supported. Observations of the scale use for ambulatory residents showed when the resident approached the scale from the front s/he had to step over the 1" lip when the scale was positioned in the tight area in which it was being placed. Furthermore, it was a three inch step up and over the lip of the scale to get onto the scale from the floor level.

Based on observation, staff and resident interview and record review, the facility failed to ensure a bowel management program was implemented to prevent constipation and/or fecal impaction for 5 (#s 12, 17, 18, 26, and 30) of 30 sampled and supplemented residents . On 7/18/13 at 11:15 a.m., the facility administration was notified by the surveyors that immediate jeopardy existed for one resident (#12) whose bowel movements were not adequately monitored and who did not receive adequate interventions. Resident #12 did not receive appropriate treatment for constipation resulting in an emergency room visit. The facility submitted their abatement plan to remove the immediate jeopardy on 7/18/13 at 2:38 p.m. The following is a summary of the facility's abatement plan: - Resident #12 was seen by a registered dietician and assessed with [REDACTED]. - A pharmacist completed a pharmacy review with recommendations for medications. -Resident #12 was placed on a new bowel management program based upon the hospice protocol for both pain and bowel management for residents receiving palliative care. - Resident #12's medical provider was contacted and new orders for both pain and bowel management were received. - Resident #12's care plan was updated to reflect the new treatment regime. - Bowel management for this resident as well as other residents was placed on the QA schedule to include daily, weekly, and monthly reviews. The exit conference was held with administration on 7/18/13 at 6:15 p.m. During the exit meeting, administration was informed that additional information of: a complete emergency room record for resident #12 related to his treatment for fecal impaction, the recent dietician assessment completed for this date, the bowel management plan in place for resident #12, and the pharmacy medication review completed for this date were needed in order to abate the immediate jeopardy. The survey team informed administration the above items had to be received by the state office by 8:00 a.m. on 7/19/13. The abatement plan for the immediate jeopardy was submitted and accepted on 7/19/13 with an effective date of 7/18/13 at 6:15 p.m. After the acceptance of the abatement plan, the deficient practice remained at a scope and severity level of a G. Findings include: 1. Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. In an interview during initial tour on 7/16/13 at 9:15 a.m., staff L, an RN, stated that resident #12 had dementia related to alcohol, diabetes and was receiving antibiotics. Staff L stated the resident had a urinary tract infection and that he was experiencing other health problems, like a mass on his head that was to be surgically removed. Staff L stated resident #12's weight was down the last few months due to a decrease in his appetite. Staff L stated the resident had pain in his head, a decrease in his ambulation and had a drastic change in his condition. Staff L stated the resident was not as happy as he had been previously. Staff L stated the resident also had pain in his abdomen due to an obstruction and he came back from the ER (emergency room ) with a catheter. The doctor at the ER took the resident off his pain medications on 7 /15/13. Observation of resident #12 on 7/17/13 at 2:30 p.m. revealed he was lying quietly on his right side in bed. He stated he had "eaten" lunch recently as he pointed to his juice on his bedside table. He stated he could not remember what he ate. He also stated he "ate and drank when he was hungry." Review of "Charting Entries" for resident #12 reflected: On 06/3/13 at 2:48 p.m. that, "Resident c/o (complaining of) stomach hurting and did not want to go to the DR (dining room) for breakfast. Resident has poor appetite. Did not eat much." On 6/3/13 3:58 p.m., "5/3 (physician) notified of weight loss, poor appetite, low FBS (fasting blood sugar); 5/8 decrease [MEDICATION NAME] (insulin) to 35 units q a.m. Seen by physician with several new orders. Overall had weight loss, poor appetite, decrease in amount of things he participates in related to severity of HA (headaches), still independent with ADLs (activities of daily living)." On 6/26/13 2:14 p.m., "Resident states he is not feeling well this shift. Resident has c/o of headache and pain behind the right eye. Resident received PRN (as needed) [MEDICATION NAME] 325 mg po (by mouth) at 8 a.m. and 1 p.m. with some relief. Resident was encouraged to eat as he did not eat lunch as he did not eat well for breakfast and blood sugar was 74 (70-99mg/dl per Laboratory Results reference for normal BS). Resident took a couple of small bites and drank [MEDICATION NAME] orange juice but stated he just cannot eat anymore." On 7/2/13 1900 (7:00 p/m/); "1700 (5 p.m.) resident ambulating with cane, on way to dining room for supper; was having difficulty; unsteady, weak. Wheelchair used to transport to dining room due to weakness. FSBS (Finger Stick Blood Sugar) checked 84 mg/dl, willing to drink sips of apple juice, few sips of Ensure, 2 bites of potatoes. Resident is quiet, minimal interaction with table mates." On 7/3/13 "1700 (5 p.m.) Breakfast brought to resident's room d/t (due to) feeling ill. FSBS 96." On 7/14/13 "0630 (6:30 a.m.) resident complaining of upset stomach, frequent trips to the bathroom noted this a.m. by staff, states he has upset stomach, denies nausea or emesis. Abdomen is soft. Questioned regarding stools, states he has had them more frequently today, some loose, not watery. Sips of juice and 7-Up throughout day. Has not been out of room other than shower, due to complaints of upset stomach. Refused multiple meds this a.m. Agreeable to [MEDICATION NAME] (proton pump inhibitor) and Tylenol (pain medications) for mild headache. Declined offer of [MEDICATION NAME] (antacid) for stomach. SS (sliding scale) insulin held at noon d/t no food intake, only sips of fluids." On 7/14/13, "1545 (3:45 p.m.) resident rested majority of afternoon, RN into room, continues to complain of stomach upset, "cramping." BS (bowel sounds) hyperactive x 4, resident interrupted stating, "I gotta go again right now." 1645 (4:45 p.m.) resident back in bed lying on back, BS hypoactive x 4, right upper and lower quadrant of abdomen soft, right upper and lower abdomen abnormal to palpation, resident states mild discomfort. Requested fell ow nurse RN, ----, to assess, concurred. Resident again quickly needed bathroom, noted to have small amount of dark loose stool in Attend product. TC (telephone call) to sister, ---, informed of situation, ER notified, resident prepared for transport via WC (Wheelchair)." Review of resident #12's H1/H2/IO Evaluations Report from 4/28/13 through 7/17/13 (Electronic record) reflected the following: Zeros were documented for bowel movements on: 4/28, 4/29, 4/30, 5/1, 5/2, 5/3, 5/4, 5/5, and 5/6/13; (9 days no BM) 5/25, 5/26, 5/27, 5/28, 5/29, and 5/30/13; (possibly 7 days no BM) 6/20, 6/21, 6/22, 6/23, 6/24, (no documentation for 6/25), 6/26, and 6/27/13; (7 days no BM) 7/8, 7/9, and 7/10/13. (3 days no BM) On 4/1/13 - 6/14/13, 6/18 - 6/29, 7/1-7-2, 7/4 - 7/6, 7/8 - 7/13, and 7/15 there was no information under consistency, size or color of the stool documented. During an interview on 7/18/13 at 1:40 p.m., staff F, a CNA, stated the BM List was shredded at the end of the month. After they were shredded, the computer H1/H2/IO Evaluations Report was the only record of BMs. During an interview on 7/18/13 at 1:20 p.m., staff FF, an RN, stated: "On Sunday (July 14) Resident #12 had vague complaints of not feeling well. He had gone to the bathroom. I asked him if he had passed anything and he said yes. I asked him if it was watery and he said no. I tried to assess his tummy throughout the day. He had hyperactive bowel sounds. He would go to the bathroom and then his activity would decrease. I was pushing fluids but he had minimal intake, which was not uncommon for him. He had not complained of a headache that day. I offered him pain medication for that but he said he was good, so no pain medication was given. Resident #12 is an independent toileter. We ask residents every day if they go- it just depends on the resident. Resident #12 had been documented as going. He was not triggered as constipation. I didn't think he would come back with constipation. I thought he would be coming back with something (else). His disimpaction orders received from the ER after his return to the nursing home were implemented within one hour. He was given one Fleets. He wasn't able to retain - general resistance. He was hurting and everything. It was a hard situation all around. He had some results, it wasn't clear. It was stool. We try to encourage fluid with every interaction. We do weekly percentage intakes of meal. We do fluid percentages only with the MDS. The CNAs tell the nurses when the residents are more concentrated than normal. We do a general visual on a regular basis to see how they look. CNAs chart on a BM sheet if the residents have gone. They will tell us if is a very small amount versus a regular BM. We have a standing order for MOM for him, it depends on the physician. They are marked on a regular basis for bowels on computer and BM list. CNAs are encouraged to put the BMs in the computer every day- reason we have back up." Review of Resident #12's emergency room Note dated 7/14/13 reflected: "History of Resent Illness: This is a [AGE] year old white male who was brought over to the ER for complaints of abdominal pain and the sense of a cramping pain and then also apparently frequent bowel movements this afternoon. Nursing was actually concerned about how they palpated his abdomen, meaning they thought there was some significant abnormality there. ..... Nursing notes are reviewed and note absence of really any other complaints except the issue with the bowel and apparent abdominal discomfort today. Also, apparently the patient has had some sort of decline in the last month and not eating well. A CT (computerized tomography) of the abdomen and pelvis shows profound constipation, but no other problems." Assessment and Plan: [AGE] year old compromised male with profound constipation. The patient is to be sent back to the nursing home with a disimpaction regimen that consists of the following: 1. Fleet enema q. p.m. (every evening) to begin tonight. 2. [MEDICATION NAME] 1 capful in 8 ounces of water given mid day. 3. [MEDICATION NAME] 10 mg (milligrams) q. a..m (every morning) to start tomorrow. This regimen is to run for a week. My office will follow this. We will leave the Foley in for the duration of that time because the patient's bladder was profoundly distended on the CT scan, I think secondary to the constipation. Review of the Final Radiology Report Impression reflects: Moderate colonic stool, could reflect constipation, with stool distention of the rectum up to 8.1 cm (centimeter) in caliber. Correlate regarding possible impaction. Distended urinary bladder. During a confidential interview on 07/17/13 at 9:20 p.m. the ER physician told the interviewee the resident's bowel was so packed with stool that it was pushing up on his colon, his kidneys and his ribs. Review of "Charting Entries" for resident #12 reflected : "On 7/14/13, 1955 (7:55 p.m.) resident returned from ER, Foley catheter in place draining dark amber urine. Approximately 1140 cc emptied shortly after return. Resident continued to complain of abdominal cramping, significant pain on right side, saline enema instilled. Resident complained of discomfort due to large amount of solid stool in rectum; unable to hold liquid in rectum for any significant amount of time due to increase of abdominal cramping. Small amounts of liquid brown stool expelled. Resident continues to have intermittent cramping." "On 7/15/13, 17:24 (5:25 p.m.) Resident has BS x 4 quadrants. Resident attempted to have a bowel movement throughout the day. He would go from bed side commode to the toilet in his room. Small amounts of round stool, some smearing. Resident c/o of cramps in his abdomen. Resident attempting to pull out his catheter. ..... Draining dark brown colored urine. On right side of abdomen is firm to the touch and tender. Resident slept off and on in his bed through out the day." "On 7/16/13 04;@8 (4:28 am.) Resident received Fleets enema as per order at 2000 (8 p.m.) with small results of three pea-sized pieces of BM (bowel movement). BS (bowel sounds)are present but hypoactive to all quads (quadrants). Abdomen remains firm et tender to touch in R (right) quadrant. Foley cath remains patent et draining tea-colored urine - 250 cc (cubic centimeter) out this p.m." "On 7/16/13 17:17 Resident has bowel sounds x 4. Resident stated that his stomach is cramping. Right lower abdomen is not as hard. Is more of a spongy feeling to the touch. Foley cath remains patent and draining dark brown colored urine. Resident continues to stay in his room during the day. Dr. notified of resident's problem and Dr. -------- 's orders." "On 7/16/13 22:48 (8:48 p.m.) At 1915 (7:15 p.m.) resident given Fleets enema as per order et was able to hold for approximate 15 minutes with return of dark brown watery fluid with 1 firm ball of stool approximately 2 cm (centimeters) in diameter. Rectal check revealed large quantity of hard stool in rectal vault which could not be removed digitally as resident c/o discomfort et refused further efforts. Dr. notified in ER et updated on resident condition. Dr. stated that he wanted to continue with the steps he set up in his orders of 7/14/13 when the physician saw the resident in the ER." "On 7/17/13 04:11 (4:11 a.m.) Resident rested quietly with eyes closed majority of noc (night). No further bowel output. Bowel sounds present all quads - hyperactive to lower R quadrant. Foley catheter patent et draining 300 cc dark tea-colored urine." "Observation of Resident #12 on 7/17/13 at 2:40 p.m. revealed his catheter bag was on the floor by the edge of the bed. The bag and tubing contained dark yellow fluid. The resident stated he used to go to activities but didn't want to go now because he didn't feel well." "During an interview on 7/17/13 at 3:35 p.m. resident #12 stated the facility had begun a bowel regime but that he had gone only "a little bit." He further stated he did not know how much he had drank today." "During an interview on 7/17/13 at 4:00 p.m., staff B, the DON, stated Resident #12 had a non malignant growth on his head and arrangements were being made to have to have it removed. He had seen a neurologist in June who had made the diagnosis. He is to have surgery June 29th. Staff B further said that the resident had his [MEDICATION NAME] (insulin) dosage changed recently, that he does not feel well and he has no appetite. He has had an increase in his pain medications. He is currently receiving enemas and laxatives. His [MEDICATION NAME] (pain medication) was discontinued. He is not wanting to drink fluids." When staff B was asked what changes had been made to his care, staff B stated, "he had a Foley now and Fleets (enema) and [MEDICATION NAME] (laxative) for 7 days. He had medication changes and his narcotic medication was discontinued. We are offering him food and liquids. He does not want IV (intravenous) hydration. We usually put what they normally drink and what they should drink in his care plan." When asked questions concerning his recent weight changes and constipation, staff B turned to her computer to see what was documented. Staff B found the H1/H2/IO Evaluations Report for Resident #12, however, was unable to relay to the surveyors what the abbreviations stood for and how to use the computer system to find out. Staff B was not aware of the resident's recent weight changes. The surveyor showed her his last two weights on his MDSs (Minimum (MDS) data set [DATE] and 5/28/13) revealed that the resident had lost from 202 to 182. The 30 Day Weight Change Summary showed the resident to weigh 170 pounds on 7/9/13 down from a weight of 175 in twelve days. Staff B stated, "The facility had a Norovirus in March and the resident had "got hit with that." "He had a weight loss and loose stools at that time." When asked if the physician knew of the resident's total weight loss, staff B stated, "I'm sure he is." Staff B stated "their dietician had resigned on May 30th, 2013 and a replacement dietician had not yet been hired. She stated the same dietician had been contracted and would be beginning her position here 8/2/13." Review of Resident #12's Charting Entries, dated 3/19/13 and titled: Summary Evaluation of Care Plan by the Registered Dietician revealed: "CBW (current body weight) 202 # at 126 %. Denies any GI (gastrointestinal) complaints . PO intakes fair per % notes (69%-meals; 100% snacks). Fluid intake per meal monitor, inadequate (~1817 ml/dl) but no s/sx of dehydration noted." There were no more dietician notes in the clinical record even though the resident lost over 30 pounds since the note was written. When staff B was asked what changes had been made to resident #12's care plan concerning his weight loss and constipation, staff B stated they calculated his meal percentages and that they encouraged fluids. Staff B stated they might not put his Foley in his care plan as it was temporary. Staff I, RN, stated that any nurse could update the care plans. Staff B stated "the BM program was a standing order: every 3 days we give [MEDICATION NAME] (for those without BMs), wait a day and then give MOM (Milk of Magnesia) and Fleets." Staff B was not sure if they had a policy and stated if they did it was not written down. Staff B stated Resident #12 did not have PRN MEDICATION ORDERS FOR [REDACTED]. She stated the facility would not have instituted it at that time as the pharmacist would send the medications and they would not have needed them then. On 7/17/13 Staff B handed this surveyor a yellow sticky note that read: Daily BM Logs: Resident #12 - 7/8-7/10 (no BMs) - otherwise had BM each day - at least one. No one else had more than 3 days without intervention. The sticky note did not match documentation on the electronic record regarding periods in which no BMs were documented. Review of Resident #12's physician's orders [REDACTED]. 1) [MEDICATION NAME] ([MEDICAL CONDITION]) 2) [MEDICATION NAME] (diabetes) 3) [MEDICATION NAME] (reflux) 4) [MEDICATION NAME] (chronic pain) 5) [MEDICATION NAME] (chronic pain) 6) [MEDICATION NAME] (non steroidal anti-[MEDICAL CONDITION] drug) 7) [MEDICATION NAME] (diabetes) 8) [MEDICATION NAME] (chronic pain) 9) [MEDICATION NAME] (anxiety) 10) [MEDICATION NAME] (chronic pain) 11) Multivitamin (intestinal malabsorption) Review of these drugs (1) revealed potential adverse reactions of: -[MEDICATION NAME]: nausea, constipation, anorexia, appetite decrease, abdominal pain, taste perversion -[MEDICATION NAME]: abdominal pain, nausea, constipation, taste perversion -[MEDICATION NAME]: abdominal pain, anorexia (loss of appetite), constipation, [MEDICAL CONDITION] distress, nausea -[MEDICATION NAME]: abdominal cramps, gastrointestinal pain, constipation, nausea, anorexia. (Educate resident on constipation: increase exercise, fluids, or fiber). -[MEDICATION NAME]: weight gain or loss, nausea, change in appetite -[MEDICATION NAME]: nausea, xerostomia (dry mouth), constipation, decreased appetite, weight loss, dyspepsia (indigestion). Review of Pharmacy notes given to the surveyors by the pharmacist for Resident #12 did not reflect any problems with the resident's medication regimen outside of Gradual Dose Reductions and request for [DIAGNOSES REDACTED]. Review of Resident #12's care plans did not reveal any information concerning education or an assessment of his medications to help prevent constipation/fecal impaction. The care plan did address fluid needs of 2200 ml (milliliters) as per resident estimated fluid needs or as resident desired. There were no approaches or measures of how to ensure fluid needs were met. Review of the physician's orders [REDACTED]. Under Diagnoses, constipation was not listed. Review of an undated Facility Practices (given to surveyor at 8:45 a.m. on 7/18/13) revealed a Bowel Protocol as follows: "BMs are monitored daily. CNA (certified nurse aide) will check on the BM log sheet kept at the Nurse's station when a resident has a BM. Night nurse will check the log and fill out the 'BM' list for the next day. This list is for the residents who have not had a BM for 3 days. Day nurse will check the physician orders [REDACTED]. If the resident does not go that day, they are added to the BM list once again. If a suppository of fleets is ordered, they will be given. Resident's condition is monitored for any distress due to not having a bowel movement. If distress is occurring, healthcare provider will be contacted or ER visit if indicated. If bowel issues are chronic, regularly scheduled laxatives will be considered. These interventions were not implemented during the time frames when the resident was documented without bowel movements. During an interview on 7/18/13 at 1:40 p.m., staff F stated the BM List was shredded at the end of the month. After they were shredded, the computer H1/H2/IO Evaluations Report was the only record. During an interview on 7/18/13 at 8:25 a.m. resident #12 stated he was still having abdominal cramping, pain, and a little loose stools. He was eating an container of applesauce that his family had brought him. Observation revealed the resident's breakfast uneaten on the bedside table (one piece of french toast and one sausage link). Observation and interview with Resident #12 on 7/18/13 at 10:30 a.m. reflected the resident was in pain. The resident stated he had just had another enema and he was hurting a lot in his rectum. He looked exhausted and his facial expressions and body movement reflected his discomfort. 2. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17's medications included: - [MEDICATION NAME] (antianxiety) 0.5 mg at hs; - [MEDICATION NAME] (antibiotic)100 mg q am; - [MEDICATION NAME] ([MEDICATION NAME]) 5 mg, 1 -2 tablets every 4 hrs prn; - [MEDICATION NAME] ([MEDICATION NAME])10 mg daily; - [MEDICATION NAME] ([MEDICAL CONDITION])100 mcg every day; - aspirin ([MEDICATION NAME]) 81 mg every day; - [MEDICATION NAME] ( antidepressant) 30 mg every day; - [MEDICATION NAME] (antipsychotic) 300 mg every a.m.; - vitamin b12 (vitamin) 1mg every month; - multivitamin with minerals (vitamin) every day; - extra strength tylenol ([MEDICATION NAME]) 1000 mg twice a day; - [MEDICATION NAME] (stool softner) 100 mg every day; - [MEDICATION NAME] xl (beta blocker) 50 mg every evening; - [MEDICATION NAME] (antilipemic)40 mg every evening; and - phillips milk of magnesia (constipation) 15 - 45 ml as needed. The licensed staff documented resident #17 had been given [MEDICATION NAME] 5 mg on 6/3, 6/6 two times, 6/7, 6/11, 6/28, 6/29, 7/1 two times, 7/2 three times, 7/3, 7/10 two times, 7/12, 7/13, 7/14, and 7/18/13. These medications may cause constipation. The facility staff did not implement standing orders for constipation. The surveyor reviewed the facility medication administration records for April, May, and June 2013 for resident #17. The licensed staff documented resident #17 had milk of magnesia on 4/1/13, 4/30/13, and 5/31/13. There was no other documentation the licensed staff gave milk of magnesia to resident #17 in June or July 2013. There was no documentation of the effectiveness of the milk of magnesia that was given. The surveyor reviewed the facility H1/H2/IO Evalutaions Report for May, June, and July 2013. There was no documentation that resident #17 had bowel movements from 5/16/13 to 6/2/13 (16 days), 6/4/13 - 6/22/13 (20 days), 6/23/13 - 7/2/13 (10 days), and 7/10/13 to 7/18/13 (6 days). There was no documentation the facility staff had notified the physician about resident #17 not having bowel movements for so many days. The care plan for resident #17 was reviewed. The care plan had a goal date of 7/14/13 and did not address constipation. 3. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #18 had physician orders [REDACTED]. - [MEDICATION NAME] (antihypertensive combination) 50 mg/75 mg half tab every a.m.; - [MEDICATION NAME] (benzodiazepine) 0.5 mg every a.m.; - [MEDICATION NAME] extra strength liquid (antacid) 7.5 ml every a.m.; - [MEDICATION NAME] (stool softner)1 scoop every a.m.; - aspirin ([MEDICATION NAME]) child chewable 81 mg every a.m.; - [MEDICATION NAME] [MEDICATION NAME] (antihypertensive) 40 mg twice a day; - tylenol extra strength ([MEDICATION NAME]) 500 mg three times a day; - [MEDICATION NAME] (antipsyhotic) 0.5 mg every p.m.; - [MEDICATION NAME] laxative (stool softner)10 mg twice a day as needed; and - milk of magnesia (stool softner) 15- 45 ml as needed. The surveyor reviewed the facility H1/H2/IO Evaluations Report for May, June, and July 2013. There was no documentation that resident #18 had bowel movements from 4/23- 4/27 (5 days), 4/29 - 5/4 (6 days), 5/5-5/12 (8 days), 5/13- 5/18 (5 days), and 5/22 - 5/27 (6 days). The surveyor reviewed the facility medication administration records for April, May, and June 2013 for resident #18. The licensed staff documented resident #18 had milk of magnesia on 4/25/13 and 4/26/13. There was no other documentation the licensed staff gave milk of magnesia to resident #18 in May or June 2013. There was no documentation of the effectiveness of the milk of magnesia that was given. The facility staff did not implement standing orders for constipation. There was no documentation the facility staff had notified the physician about resident #18 not having bowel movements for so many days. The surveyor requested the care plan for resident #18 and did not received a copy of the care plan from the facility staff. 4. Resident # 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #26's medications were documented as follows; -[MEDICATION NAME] 75 mcg every day ([MEDICAL CONDITION]). -Tylenol 325 mg one every am ([MEDICAL CONDITION] arthritis). -[MEDICATION NAME] 15 mg/ml bid (gastritis/duodenitis). -[MEDICATION NAME] 50 mg every HS ([MEDICAL CONDITION]). -Ambien 5 mg 1/2 tab prn (other [MEDICAL CONDITION]). -Tylenol 325 mg 2-3 tabs every 4-6 hours prn ([MEDICAL CONDITION] arthritis). -Milk of Magnesia 15-45 ml po prn (constipation). The facility staff did not implement standing orders for constipation. Review of resident #26's H1/H2/IO Evaluations report from 4/1/13 through 7/17/13 reflected the following: Zeros were documented on: 4/4 - 4/7 (4 days), 4/17 - 4/21(5 days), 6/20 - 6/26 (7 days), 7/2 - 7/5(4days) and 7/13 - 7/17/13 (5 days). The surveyor reviewed the facility medication administration records for April, May, June and July 2013 for resident #26. The licensed staff documented resident #26 had milk of magnesia on 4/10/13, 4/16/13, 4/27/13, 6/3/13, 6/8/13, 6/16/13, 6/20/13, 6/26/13, 7/6/13 and 7/18/13. There was no documentation of the effectiveness of the milk of magnesia that was given. There was no further bowel protocol for resident #26 identified on the MAR. During review of the Care Plan constipation was not addressed as a problem. 5. Resident #30 had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's medications included: -[MEDICATION NAME] (depression) 10 mg daily -[MEDICATION NAME] (antipsychotic) 25 mg every AM -[MEDICATION NAME] (anti-[MEDICAL CONDITION]) 500 mg with food twice daily -Tylenol (pain) 325 mg 2 tabs twice daily -[MEDICATION NAME] (pain) 650 mg every 4-6 hours PRN -[MEDICATION NAME] (antipsychotic) .5 mg HS PRN Review of the MARS for July, June, May and April 2013 did not indicate evidence of any stool softner/laxative being given. There was nothing on the MARS indicating a bowel protocol had been implemented. Review of the facility's H1/H2/IO indicated the resident did not have a bowel movement between: -6/26/13 to 7/1/2013 (4 days) -6/13/13 to 6/17/13 (3 days) -6/5/13 to 6/9/13 (3 days) -6/1/13 to 6/5/13 (3 days) -5/25/13 to 5/29/13 (3 days) -5/21/13 to 5/25/13 (3 days) -5/2/13 to 5/6/13 (3 days).

Based on observation, record review and resident and staff interview, the facility failed to ensure 2 (#s 3, 12) of 15 sampled residents maintained acceptable parameters of nutritional status. Resident #3 and #12 experienced significant weight losses that the facility failed to adequately assess, develop interventions for, and implement interventions to address. Findings include: 1. Resident #3 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review on 7/18/13 at 11:20 a.m., of the resident's Care Plan with the goal date of 9/1/13 indicated there was "Potential for nutritional/dehydration problems." The goal was "Nutrition to maintain within 90-110% of IBW 99-121#." The approaches included "Sprinkle sugar packets on food...Feeding ability: self at female supervised table. Provide cues and encouragement; assist with feeding as needed & allowed by resident....Monitor wt and intake at POC intervals... Record % taken at meals at L/S (lunch/supper) on wed, thurs, fri...Use scoop plate at all meals for easy utensil loading." During an interview on 7/17/13 at 8:45 a.m., staff member JJ, dietary aid, stated, "We only document intake on Wednesdays, Thursdays and Fridays for lunch and supper." Review of meal intake documentation revealed this was accurate. For all residents, meal intake was monitored for 6 meals out of a total of 21 meals per week. Intakes for the breakfast meals and weekend meals were never recorded. Documented weights on the facility weights and heights report were: -114.7 pounds on 1/4/13, -114 pounds on 1/18/13, -113 pounds on 4/6/13, -112.7 pounds on 5/3/13 -90.4 pounds on 5/7/13. -96.8 pounds on 5/17/13 -106.6 pounds on 7/17/13. The report indicated there was a (negative) 19.9 % weight change from April to May. During an interview on 7/17/13 at 9 a.m., staff member Y, an RN, stated, She (resident #3) can feed self at times but is messy." During an interview on 7/17/13 at 2:44 p.m., the DON, staff member B, stated,"They should be helping her if she is not eating." During the supper observation of 7/16/13 from 5:15 p.m. to 6:20 p.m., resident #3 was in the dining room for supper. The resident had a pureed fruit cup, pureed broccoli, pureed sweet potatoes, and pureed ham. All of this was on a flat clear glass plate and not the scoop plate per the care plan. After the resident was served her tray of food by staff the resident consumed all the juice out of the juice box. An empty gurgling sound emanated as the resident continued to attempt to get more from the box. Staff came over and took the juice box, setting it aside and placing the fruit cup in front of the resident with a spoon. The resident fed herself the fruit. Staff did not stay. At 6:20 p.m. the resident was observed to have gone back to sucking the straw in the empty juice box. The fruit cup was empty. Staff had not come back to prompt the resident further. The pureed broccoli, pureed sweet potatoes, and pureed ham remained on the resident's plate in front of her without having been eaten. During the breakfast observation of 7/18/13 at 8:08 a.m., resident #3 was served eggs, pureed waffle on a flat clear glass plate. The resident did not have a scoop plate. Staff member G, a CNA sat next to her prompting her to eat, offering her more cereal after finishing the first bowl and attempting to feed her which the resident responded to by letting the bite of waffle fall from her lips. At 8:55 a.m., there was a trail of food spilled down the front of her clothing protector and a bit of food on the table next to her plate. There was no more egg on her plate. During an interview on 7/18/13 at 8:45 a.m., staff member G, indicated he was not aware the plan called for sprinkling sugar on food but indicated that with the syrup on the resident's waffle had gotten on the eggs as well. During an interview on 7/17/13 at 2:55 p.m. the DON, staff member B, indicated, the change in the plan when the resident lost weight was to sprinkle sugar on the food. The DON indicated the plans were done quarterly so the goal date of 9/1/13 was developed in 6/13. The plan with the goal date of 6/12/13 was developed in 3/13. Review of the most recent Care Plan with the goal date of 9/1/13 included sprinkling sugar on the food. Review of the Care Plan prior to this one with the goal date of 6/12/13 also included sprinkling sugar on the food. Review of the Care Plans did not indicate evidence of a revision following the resident's weight loss. Review on 7/18/13 at 9 a.m., of the resident's record indicated a dietary charting entry dated 1/29/13. This entry indicated "spoke to ST regarding bedside swallow eval conducted last fall (Oct?). ST reports resident's unique eating tendencies (e.g. aversions to certain textures, spitting) likely r/t cognitive decline in resident. ST recommended scoop plate at meals for easier utensil loading. Approach will be added to resident's Nutrition POC in addition to ST's swallow precaution recommendations." There was no evidence of the dietician responding to the resident's 19.9% weight loss between April and May. During an interview on 7/18/13 at 9:07 a.m., staff member F, CNA, indicated this was the only dietary charting entry for 2013. 2. Resident #12 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident #12's Minimum Data Set ((MDS) dated [DATE] reflected the resident weighed 202 pounds. Review of resident's #12's MDS dated [DATE] reflected the resident weighed 182 pounds, showing a 20 pound weight loss. Review of a 30 Day Weight Change Summary reflected the resident weighed 170 pounds on 7/9/13, showing a 12 pound weight loss in approximately 6 weeks. The resident experienced a significant (greater than 10 % in 6 months) 15.8% weight loss from 3/12/13 to 7/9/13; the resident was not on a physician-prescribed weight-loss regimen. In resident #12's care plan with a goal date of 8/28/13, under the title, "potential for nutritional/dehydration problems" the goals listed were, "Nutrition to maintain within 90-110% of IBW 155-189#. Foster optimal glycemic control. Foster optimal lab levels." Under the section labeled, "Approaches" were listed, "Monitor wt and intake at POC intervals. Weight every bath day or as resident desires/allows." a. Observation on 7/17/13 at 2:30 p.m. revealed resident #12 was resting in bed. He stated he just had lunch and pointed at his half filled [MEDICATION NAME] orange juice glass sitting on his bedside table. He stated he could not remember what he had eaten. b. Documentation between April 2013 and the survey ending on 7/18/13 showed the resident's progression as follows: -Review of Physician's Progress Notes dated 4/22/13 reflected the resident had lost a little weight and was continuing to have low blood sugars. Under "Plan" there were no recommendations for the identified weight loss. -Review of the Physician Telephone Orders for 5/3/13 reflected a change in the resident's insulin orders. Review of resident #12's 6/3/13 Charting Entries reflected on 5/3/13 the physician had been notified of the resident's weight loss, poor appetite, low fasting blood sugar. -Review of Physician's Telephone Orders for 5/8/13 reflected the decrease of the dosage of the resident's insulin. -Review of resident #12's 6/3/13 Charting Entries reflected on 5/8/13 there had been a decrease in the resident's insulin. The resident had been seen by the physician with several new orders prescribed. The resident overall had weight loss, a poor appetite, and a decrease in the amount of things he participated in related to the severity of his headaches. The resident was documented as being independent with his activities of daily living. -Review of Resident #12's Physician order [REDACTED]. -On 7/2/13 there was documentation of the resident having difficulty ambulating, being unsteady, and weak. The resident used the wheelchair to transport himself to the dining room. The resident was willing to drink sips of apple juice, a few sips of Ensure, and eat 2 bites of potatoes. Multiple Charting Entries dated 5/2/13, 5/3/13, 5/12/13,5/1/13, 5/20/13, 5/03/13, 6/4/13, 7/1/13, 7/2/13, and 7/14/13 reflected repeated documentation of poor appetite, minimal intake, weight loss, low blood sugars, needing encouragement to eat, FSBS (finger stick blood sugar) maintaining as resident sipped on Ensure and juice. c. Review of the Dietary Charting Entries showed the last documented dietary note was written on 3/19/13. That assessment revealed the resident was at 126% of his current body weight of 202 pounds. The resident had not been assessed following the 15.8% unplanned significant weight loss of 32 pounds, from 202 pounds to 170 pounds, he experienced between 3/13 and 7/19/13. d. During an interview on 07/17/13 at 4:00 PM, staff B stated the facility dietitian had resigned on 5/30/13 and would not be returning until August 2nd, 2013.