Every finding on record at Sunporch of Dodge City

The facility identified a census of 40 residents with four residents included in the sample. Based on observation, interview and record review, the facility failed to ensure one resident, Resident (R) 1 was assessed for safety related to bed rail use. Additionally, the facility failed to obtain or provide evidence of informed consent from R1 or his representative prior to the use of bed rails. Findings included:R1's Electronic Health Record (EHR) documented diagnoses that included vascular dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), delirium (sudden severe confusion, disorientation, and restlessness) and major depressive disorder (MDD - a major mood disorder that causes persistent feelings of sadness). R1's 12/30/25 Annual Minimum Data Set (MDS) documented that a Brief Interview of Mental Status (BIMS) interview could not be completed because the R1 is never or rarely understood. The staff assessment documented memory problems and severely impaired cognition. R1's 12/30/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented severe cognitive impairment and memory problems. R1's Care Plan, reviewed 03/17/26, documented R1 had an alteration in musculoskeletal status related to broken bones in the left wrist/forearm, and on 02/09/26, the facility replaced R1's bed to be one without bed rails, initiated on 02/13/26. R1's EHR under the Assessments tab revealed no risk assessment for bed rail use since his admission to the facility on [DATE]. On 03/17/26 at 10:20 AM, R1 rested in a Geri-chair (a recliner on wheels that can be pushed around like a wheelchair, usually with a removable tray) in his room in a reclined position and eyes closed. R1's left wrist was in a splint with the forearm supported by a pillow. R1's bed did not have bed rails attached. On 03/17/26 at 11:00 AM, Administrative Nurse D provided a list of residents in the facility and identified that 25 residents' beds had at least one bed rail attached. Administrative Nurse D stated that prior to the incident on 02/08/26, which involved R1, no nursing bed rail safety assessments had been conducted since she was hired by the facility. On 03/17/26 at 11:17 AM, Maintenance U stated he did not have inspection logs specific to bed rails, but he performed a monthly facility assessment that included all safety-related items, such as ensuring bed rails were securely fastened to the bed frame of all applicable beds. Maintenance U stated that if nursing personnel identified a bed rail that needed to be removed, he would have it removed the same day as it was requested. On 03/17/26 at 11:34 AM, Maintenance U provided inspection logs for weekly checks from 09/06/25 to 03/07/26 except for the week of 10/11/25. Maintenance U highlighted the inspection instruction to check the full facility for safety and fall risks and rooms for extension cords, rolling chairs, floor mats, and any trip hazards. The inspection logs did not specify inspection of bed rails. On 03/17/26 at 11:45 AM, Administrative Nurse D stated that the facility had no nursing safety assessment for the bed rails on R1's bed. Administrative Nurse D also confirmed that the facility had not obtained informed consent from R1 or his representative prior to R1 being in a bed with bed rails. On 03/17/26 at 01:10 PM, Administrative Nurse D stated her expectation was for a nursing bed rail assessment to be performed on admission, quarterly, annually, and as needed if a significant change occurred. Additionally, Administrative Nurse D stated the facility should obtain informed consent from the resident or the resident's representative prior to use of bed rails, and the consent should be reviewed at least annually. Administrative Nurse D stated that bedrails should only be used when absolutely necessary and only to assist the resident in increasing their independence by assisting the resident with bed mobility or transfers into or out of the bed. On 03/17/26 at 01:15 PM, Administrative Staff A stated maintenance personnel should ensure the good working order of bed rails. Additionally, Administrative Staff A stated that prior to the incident with R1 on 02/08/26, the facility did not have a nursing safety assessment process related to bed rails. Administrative Staff A stated her expectation was for Administrative Nurse D or her designee to perform a bed rail safety assessment on admission, quarterly, and as needed if any changes occurred. The facility's Bed Safety and Bed Rails policy, dated 08/2022 documented the use of bed rails or side rails was prohibited unless the criteria for use have been met that included attempts to use alternatives, interdisciplinary team (IDT - a team of facility staff consisting of members of various departments including but not limited to; dietary, nursing, maintenance, therapy, etc.) evaluation, resident assessment and informed consent. The assessment would determine potential risks to the resident that included accident hazards, restricted mobility, and psychosocial outcomes.

The facility reported a census of 32 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. The facility identified 12 CNAs employed over 12 the month period. Findings included: - Review of employee files on 01/27/25 at 05:08 PM revealed a lack of performance evaluations or skills check-off for two Certified Nurse Aides (CNAs), CNA S and CNA T. CNA S had a date of hire of 09/09/23 and CNA T had a date of hire of 03/11/23. On 01/27/24 at 05:20 PM, Administrative Staff A revealed all CNA staff were required to complete a skills check-off in lieu of a performance evaluation annually. If the CNA was unable to perform the required tasks satisfactorily, then remediation was performed until the CNA could perform the required tasks. Administrative Staff A further reported CNA S and CNA T were absent during the most recent skills check-off and were supposed to have made up the check off with Administrative Nurse B and confirmed that it had not happened yet. The facility did not provide a policy related to annual performance evaluations or skills check-off evaluations for CNA staff as requested on 01/27/25. The facility failed to complete an annual performance review at least once every 12 months for two CNAs reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. This deficient practice had the potential to negatively affect the physical and psychosocial well-being of all the residents in the facility.

The facility reported a census of 32 residents with 12 residents sampled and five reviewed for unnecessary medications. Based on observations, interviews and record review, the facility failed to ensure the physician responded in a timely manner to monthly medication regimen reviews (MRR) for Resident (R)15, 19 and R25 related to psychotropic (any class of medications that alters mood or thought) medications and for R3 when the physician failed to provide appropriate rational when they declined a pharmacy recommended gradual dose reduction (GDR) for psychotropic medications. These deficient practices had the potential to lead to the residents receiving medications unnecessarily. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R)15 included diagnoses of generalized dependence on wheelchair, dementia (a progressive mental disorder characterized by failing memory, confusion), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), hypertensive (high blood pressure) chronic kidney disease (CKD - a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluids from the blood), diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (MDD - major mood disorder which causes persistent feelings of sadness) with psychotic (any major mental disorder characterized by a gross impairment in reality perception) symptoms and hypothyroidism (condition characterized by hyperactivity of the thyroid gland). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The assessment documented R15 had a PHQ-9 (a scale used to determine the presence of depression) score of zero which indicated no depression and had no behavioral symptoms related to psychosis. R15 utilized a walker and/or wheelchair for locomotion and documented one fall with injury since the previous assessment. R15 required partial/moderate assistance for toileting and personal hygiene, supervision/touching assistance for upper body dressing, setup/cleanup assistance for oral hygiene and was independent with eating. Additionally, the assessment documented R15 received antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 05/13/24 documented R15 had moderate cognitive impairment. The ADL Functional / Rehabilitation Potential (CAA) dated 05/13/24, documented R15 had limited range of motion to both lower extremities and required partial assistance for transfers and supervision for ambulation (walking). The Falls CAA dated 05/13/24 documented R15 had balance problems with walking and had decreased muscular coordination and used assistive devices. The Psychotropic Drug Use CAA dated 05/13/24 documented R15 took Seroquel (quetiapine - an antipsychotic medication) and Paxil (paroxetine - an antidepressant) and had no recent gradual dose reduction (GDR) attempt. The Quarterly MDS dated [DATE], documented a BIMS score of 15, which indicated intact cognition. The assessment documented R15 had a PHQ-9 score of zero, which indicated no depression and utilized a walker and/or wheelchair for locomotion and documented two or more non-injury falls and one fall with minor injury since the previous assessment. R15 required setup/cleanup assistance with bathing but was otherwise independent with cares. Additionally, the assessment documented R15 received antipsychotic and antidepressant medications. The Care Plan , documented R15 took antipsychotic and antidepressant medications and instructed staff to monitor for possible side effects (unintended effects caused by medication use) and notify the charge nurse, initiated on 01/17/22 Review of the Physician Orders revealed the following: Seroquel (quetiapine fumarate - an antipsychotic medication), 25milligram (mg) tablet, give 0.5 tablet by mouth (PO) two times daily (BID) for behaviors related to MDD with psychotic symptoms and give one tablet PO in the evening (HS) related to MDD with psychotic symptoms, dated 07/27/22 at 08:00 PM. Paxil (paroxetine - an antidepressant medication), 20 mg, give one tablet po one time a day related to MDD with psychotic symptoms, dated 02/29/20 at 07:00 AM. Review of the pharmacy MRR reports revealed that on 12/16/24 the pharmacist recommended a GDR for Paxil (paroxetine) and Seroquel (quetiapine). The facility faxed the physician on 12/19/24 and 01/23/25 without a response from the physician. Observation on 01/22/25 at 10:41 AM, R15 was seated in the recliner in his room and appeared calm and relaxed. Observation on 01/27/25 at 06:00 AM, R15 self-propelled his motorized wheelchair down the hallway into the dining area and retrieved a cup of coffee, then returned to his room. R15 appeared calm and relaxed with a pleasant/cheerful demeanor During an interview 01/23/25 at 03:23 PM, Administrative Nurse B confirmed the above information related to the timeliness of the MRR and GDR request stated that her expectation is that the physician would respond within a week, and then a second request would be made. Additionally, Administrative Nurse B revealed that she does not expect a timely response from R15's physician. Administrative Nurse B stated that the facility does have a medical director that is not R15's physician and was unsure of what policy and/or procedures were in place to ensure timely follow-up from a physician who refuses to respond timely or appropriately to MRR or GDR requests. The facility's undated Medication Regimen Reviews policy documented that a consultant pharmacist would conduct a MRR of each resident who received medication in the facility at least monthly and as needed, if indicated. If the physician does not provide a timely or adequate response to the report or if no action has been taken, the consultant pharmacist would contact the medical director or administrator. The facility's undated Designation of a Personal Physician policy documented that residents in the facility had the right to choose a personal attending physician and exercise that right based on the physician's ability and willingness to meet pertinent responsibilities which included the physician must follow the facility's established guidelines governing the responsibilities of the physician to the resident and to the facility. Additionally documented should the resident's attending physician fail or refuse to fulfill their responsibilities to the resident in a timely manner, the facility may contact the medical director for order fulfillment and/or to assume resident care. The facility did not provide a policy specific to a GDR process as requested on 01/27/25. The facility failed to ensure that R15's medication remained free of unnecessary medications when the facility failed to ensure that R15's physician responded in a timely manner to a GDR request from the consultant pharmacist. 50659 - The Electronic Health Records (EHR) documented R19 had the following diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 012/23/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R19 had no behaviors or depression. R19 required Set up for showers and was independent with all other activities of daily living (ADLs). R19 had no falls, and she was administered anti-psychotic (class of medications used to treat major mental conditions which cause a break from reality) medication, and anti-depressant (class of medications used to treat mood disorders) medication. The 01/03/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R19 had Alzheimer's and had severely impaired cognition. She was at risk for ADL declines, behaviors and communication deficiencies. Goal is to avoid declines or complications due to her cognitive impairment. The 10/01/24 Quarterly MDS documented a BIMS score of five, indicating severely impaired cognition. R19 no depression and had behaviors one to three days with wandering. R19 was independent in all ADLs, she received anti-psychotic, and anti-depressant medications. She wore a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). The Care Plan documented the following: Staff instructed took antipsychotic and antidepressant medications and instructed staff to monitor for possible side effects (unintended effects caused by medication use) and notify the charge nurse, initiated on 08/17/21. Review of the Physician Orders revealed the following: Remeron (Mirtazapine - an anti-depressant medication), 15 milligram (mg) tablet, give one tablet by mouth, one time a day for major depressive disorder (MDD - major mood disorder which causes persistent feelings of sadness) with severe psychotic (any major mental disorder characterized by a gross impairment in reality perception), date ordered 10/23/22. Citalopram Hydrobromide Oral Tablet (an anti-depressant medication), 20 mg tablet, give one tablet one time a day for MDD, with severe psychotic features, date ordered 02/26/23. Seroquel (quetiapine fumarate - an antipsychotic medication), 50 mg tablet, give one tablet by mouth, every evening for behavior, date ordered 04/04/24. Seroquel 50 mg tablet, give one tablet by mouth, in the morning for anti-psychotic related to dementia in other diseases without behavioral disturbances, psychotic disturbances, mood disturbances ad anxiety, date ordered 11/04/24. Review of the pharmacy medication regimen reviews (MRR) reports revealed that on 07/23/24 MRR R19 was currently on Citalopram 20 mg, Mirtazapine 15 mg and Quetiapine 25 mg in am and 50 mg at pm. The facility must attempt gradual dose reduction of psychotropic medications to find the lowest effective dose. The facility lacked a physician response for the MRR. During an observation on 01/22/25 at 10:00 AM, R19 had been wandering up and down the 300 hallway several times. R19 was well groomed, was wearing an outdoor vest, carried her black handbag and her walking cane under her arm. During an observation on 01/22/25 at 02:30 PM R19 wandered in hallway 300, she wore a burgundy coat and carried her black handbag. During an observation on 01/23/25 at 01:40 PM, R19 was seated in front lobby chair approximately 12 feet from the exit/entrance door. R19 watched the oxygen vendor man punch the code on the exit panel. During an interview 01/23/25 at 03:23 PM, Administrative Nurse B confirmed the above information related to the timeliness of the MRR and GDR request stated that her expectation is that the physician would respond within a week, and then a second request would be made. Additionally, Administrative Nurse B revealed that she does not expect a timely response from R15's physician. Administrative Nurse B stated that the facility does have a medical director that is not R15's physician and was unsure of what policy and/or procedures were in place to ensure timely follow-up from a physician who refuses to respond timely or appropriately to MRR or GDR requests. During an interview on 01/27/25 at 11:10 AM Administrative Nurse B reported she could not locate the MRR or R19 for 07/23/24. The facility's undated Medication Regimen Reviews policy documented that a consultant pharmacist would conduct a MRR of each resident who received medication in the facility at least monthly and as needed, if indicated. If the physician does not provide a timely or adequate response to the report or if no action has been taken, the consultant pharmacist would contact the medical director or administrator. The facility's undated Designation of a Personal Physician policy documented that residents in the facility had the right to choose a personal attending physician and exercise that right based on the physician's ability and willingness to meet pertinent responsibilities which included the physician must follow the facility's established guidelines governing the responsibilities of the physician to the resident and to the facility. Additionally documented should the resident's attending physician fail or refuse to fulfill their responsibilities to the resident in a timely manner, the facility may contact the medical director for order fulfillment and/or to assume resident care. The facility did not provide a policy specific to a GDR process as requested on 01/27/24. The facility failed to ensure that R19's medication remained free of unnecessary medications when the facility failed to ensure that R19's physician responded in a timely manner to a GDR request from the consultant pharmacist. - The Electronic Health Records (EHR) documented Resident (R)3 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), pain and anxiety. The 02/28/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. R3 had a total mood severity score of zero, which indicated no depression, and she had one wandering behavior noted. R3 required moderate assistance with activities of daily living (ADL) such as toileting hygiene, showering, personal hygiene, and dressing. R3 required supervision for ambulation and transfer and set-up for eating. R3 was occasionally incontinent of bladder, and she had no falls. R3 received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antidepressants (class of medications used to treat mood disorders), and anti-anxiety (class of medications that calm and relax people) medications during the lookback period. The 03/11/24 Psychotropic Drug Use Care Area Assessment (CAA) R3 was administered Quetiapine (an anti-psychotic medication) for dementia with behavioral disturbance, Clonazepam (an anti-anxiety medication) for anxiety, and Mirtazapine (an anti-depressant medication) for depressive episodes. R3 was at risk for adverse consequences due to medication use, goal was to avoid adverse consequences of medication use and to have improvement in her behavior and depressive symptoms. The 11/12/24 Quarterly MDS lacked a BIMS and total mood severity score. R3 required total assistance with all ADLs. R3 was non ambulatory, she had no behaviors or falls. R3 received anti-psychotic, anti-depressant, and anti-anxiety medications during lookback period. The Care Plan documented the following: R3's medications would be reviewed by the pharmacist consultant monthly, and by a physician every 60 days, and by both as needed, date initiated 06/18/21. Staff instructed to look at Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for all listed drugs could be located in the physician orders and the EHR on medication administration record, date initiated 06/18/21. Review of the Physician Orders revealed the following: Remeron (Mirtazapine - an anti-depressant medication), 7.5 milligram (mg) tablet, give one tablet by mouth, one time a day for depression, date ordered 10/18/22. Seroquel (quetiapine fumarate - an antipsychotic medication), 50 mg tablet, give one tablet by mouth, tow times a day dementia with unspecified severity, with other behavioral disturbances, date ordered 04/18/23. Clonazepam (an anti-anxiety medication), 0.5 mg tablet, give one tablet, by mouth, two times a day, for anxiety/restlessness, date ordered 06/23/24. Clonazepam 0.5 mg tablet, give one tablet, by mouth, every four hours as needed for anxiety, date ordered 06/24/25. Review of the pharmacy medication regimen reviews (MRR) reports revealed that on 09/24/24 MRR R3 had received, Clonazepam 0.5 mg twice a day, and Clonazepam 0.5 mg tab every four hours as needed. Mirtazapine 15 mg po at bedtime, and Seroquel 50 mg twice a day. The facility must attempt a gradual dose reduction (GDR stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic medications to find the lowest effective dose. The facility lacked an appropriate physician response for the GDR with his only statement was disagree, dated 10/22/24. During an observation of 01/23/25 at 07:21 AM, R3 was seated in her wheelchair in the lobby with her eyes closed. During an observation of 01/27/25 at 06:48 AM, R3 received care from Certified Nurse Aide (CNA) F and Certified Medication Aide (CMA) P. R3 had no behaviors, followed requests and showed understanding to what staff were asking her to do. R3 kept her eyes closed most of the time During an interview 01/23/25 at 03:23 PM, Administrative Nurse B confirmed the above information related to the timeliness of the MRR and GDR request stated that her expectation is that the physician would respond within a week, and then a second request would be made and was unsure of what policy and/or procedures were in place to ensure timely follow-up from a physician who refuses to respond timely or appropriately to MRR or GDR requests. The facility's undated Medication Regimen Reviews policy documented that a consultant pharmacist would conduct a MRR of each resident who received medication in the facility at least monthly and as needed, if indicated. If the physician does not provide a timely or adequate response to the report or if no action has been taken, the consultant pharmacist would contact the medical director or administrator. The facility did not provide a policy specific to a GDR process as requested on 01/27/24. The facility failed to ensure that R3s medication remained free of unnecessary medications when the facility failed to ensure that R3's physician responded in a timely manner to a GDR request from the consultant pharmacist. 51332 - The Electronic Health Records (EHR) documented Resident (R)25 had the following diagnoses that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), Alzheimer's disease, (progressive mental disorder characterized by failing memory, confusion),anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), insomnia (inability to sleep), hypertension (elevated blood pressure) depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (progressive mental disorder characterized by failing memory, confusion). The 06/04/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition, and a PHQ-9 (an assessment scale to determine the presence of depression) totaled 0. R25 had no behaviors to indicate psychosis (any major mental disorder characterized by a gross impairment in reality perception). R25 received an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), hypnotic (a class of medications used to induce sleep and treat insomnia) medication, opioid (class of drug used to treat moderate to severe pain) medication, antiplatelet (class medications that prevent platelets from clumping together and forming clots) medications and antidepressant (class of medications used to treat mood disorders) medications . The 06/14/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R25 is on Restoril (temazepam- a sedative/hypnotic medication), Geodon (ziprasidone- an antipsychotic medication), Seroquel (quetiapine - an antipsychotic medication), Pristiq (desvenlafaxine- antidepressant medication) and Lorazepam (Ativan- an antianxiety medication.) The 11/12/24 Quarterly MDS documented Brief Interview for Mental Status BIMS score of 99 staff unable to complete and lacked a PHQ-9th. R25 had behaviors of yelling and hitting. R25 received an antipsychotic, antianxiety, hypnotic, opioid, antiplatelet and antidepressant. On 11/25/24 the Care Plan documented Medical Doctor responded to gradual dose recommendations (GDR) request noting this is a chronic long-term issue and no changes would be made unless R25 had a significant change. Initiated 07/07/23. The 11/25/24 Care Plan documented R25 utilized the following medications: Pristiq (desvenlafaxine ER), Seroquel (quetiapine), Geodon (ziprasidone), Plavix (clopidogrel - a blood thinner medication), Restoril (temazepam), Lorazepam (Ativan), and Ultram (Tramadol - an opioid medication). Initiated on 07/01/22, staff would monitor and report adverse reactions (unintended effects caused by medication use) to medication to nurse if R25 exhibited signs and symptoms: falls, weight loss, fatigue, agitation, depression, lethargy, unsteadiness, confusion, poor appetite, constipation, diarrhea, bruising, and red eyes. The 11/25/24 Care Plan documented R25 utilized the following psychotropic medications (Geodon and Quetiapine) r/t dementia with psychotic disturbance. Initiated on 07/14/22, staff would monitor and report adverse reactions of psychotropic medications such as unsteady gait, tardive dyskinesia(abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting and any behavior symptoms not usual to the person. On 01/23/25, review of the Physician Orders revealed the following: Restoril (Temazepam), oral capsule 30 milligram (mg), give one tablet, by mouth (PO), at bedtime (HS), every day, for sleep and restlessness, ordered 01/02/25, end date indefinite. Restoril (Temazepam), oral capsule 15 milligram (mg), give one tablet, by mouth (PO), at bedtime (HS), every day, for insomnia, ordered 09/24/24, end date indefinite. Revised 09/30/24, discontinued 01/02/25. Restoril (Temazepam), oral capsule 30 milligram (mg), give one tablet, by mouth (PO), as needed, at bedtime (HS) milligram, for sleep, ordered 09/03/24, end date indefinite. Review of the pharmacy monthly medication review (MRR) reports revealed that on 09/24/24 the pharmacist recommended a GDR for Geodon (ziprasidone- an antipsychotic medication). The facility faxed the physician on 10/14/24 and the physician disagreed without a date or a rationale which and was documented as noted by the facility on 10/22/24. On 10/22/24, Consultant Pharmacist recommended discontinuing the order for Restoril (Temazepam), scheduled for Once a day at bedtime (qHS) since there were two active orders with different dosages scheduled at this time. One order was for Restoril (Temazepam), 30mg qHS and the other was for Restoril (Temazepam) 15 mg qHS. Provider responded to discontinue the order for Restoril (Temazepam) 30 mg and keep the order of Restoril (Temazepam) 15 mg QHS on 10/22/24. Facility this on 11/4/24. On 12/16/24 Consultant Pharmacist recommended, reviewing and updating the missing side effects for Pristiq (desvenlafaxine) to residents chart. The facility was unable to provide documentation of a physician response. Observation on 01/22/25 at 09:05 AM R25 shirt appeared to have stains from uneaten food present. R25 had not been shaved and appeared unkept with hair unbrushed and face unwashed. Observation on 01/23/25 at 09:31 AM, R25 was administered his morning medications while seated on his couch and R25 appeared calm and relaxed with a pleasant/joking demeanor. R25 allowed staff to administer medications without difficulty and to aid with cares without difficulty. During an interview 01/23/25 at 03:23 PM, Administrative Nurse B confirmed the above information related to the timeliness of the MRR and GDR request stated that her expectation is that the physician would respond within a week, and then a second request would be made. Additionally, Administrative Nurse B revealed that she does not expect a timely response from R25's physician. Administrative Nurse B stated that the facility does have a medical director that is not R25's physician and was unsure of what policy and/or procedures were in place to ensure timely follow-up from a physician who refuses to respond timely or appropriately to MRR or GDR requests. The facility's undated Medication Regimen Reviews policy documented that a consultant pharmacist would conduct a MRR of each resident who received medication in the facility at least monthly and as needed, if indicated. If the physician does not provide a timely or adequate response to the report or if no action has been taken, the consultant pharmacist would contact the medical director or administrator. The facility's undated Designation of a Personal Physician policy documented that residents in the facility had the right to choose a personal attending physician and exercise that right based on the physician's ability and willingness to meet pertinent responsibilities which included the physician must follow the facility's established guidelines governing the responsibilities of the physician to the resident and to the facility. Additionally documented should the resident's attending physician fail or refuse to fulfill their responsibilities to the resident in a timely manner, the facility may contact the medical director for order fulfillment and/or to assume resident care. The facility did not provide a policy specific to a GDR process as requested on 01/27/25. The facility failed to ensure that R25's medication remained free of unnecessary medications when the facility failed to ensure that R25's physician responded in a timely manner to a GDR request from the consultant pharmacist.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to follow sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses. Findings included: - Observation of the kitchen and food storage areas on 01/22/25 at 08:19 AM, revealed the following areas of concern: Two bread bags were opened without a date. The freezers had items that were not labeled with an open date, which included: bread, rolls, spinach, french fries, onion rings, beef tips, and chicken tenders. Items in walk in cooler were not labeled with an open date, which included: a gallon of milk, a container of half and half, one container of grape jelly, a bottle of ketchup, a half of an onion, and a tray of blueberry muffins. During an interview on 01/22/25 at 08:40 AM, Dietary Manager U, confirmed the food items in the refrigerator and the undated, opened, bread was unacceptable. She reported she was unaware the items in the freezer were required to be labeled and dated when opened. The facility's policy Refrigerators and Freezers dated 12/2014 documented this facility will ensure safe food expiration guidelines. All food shall be appropiately dated to ensure proper rotation by expiration dates. The policy lacked when food is opened to label and date items in refrigerator and freezer. The facility did not provide a dry food storage policy. The facility failed to follow sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses.

The facility reported a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to the lack of hand hygiene when incontinent care was provided to R3 and improper removal of personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) after care provided to R3. The facility staff failed to wear proper PPE when emptying a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bag and when changing the leg bag (a small bag that collects urine from a Foley catheter and is worn on the leg during the day) to the gravity drainage bag. The facility failed to provide respiratory care consistent with professional standards of care for R3 and R134, regarding the cleaning of the nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) equipment after each use when medication was administered. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: During an observation on 01/22/25 at 09:34 AM, Licensed Nurse (LN) G removed the nebulizer equipment off from R3 after breathing treatment was completed. LN G placed the nebulizer equipment into a bag. LN G washed her hands, and she reported she would not rinse the nebulizer equipment after she administered a breathing treatment as the nebulizer equipment was cleaned once a day on the night shift. During an observation on 01/22/25 at 02:35 PM, R134's nebulizer was intact with a clear liquid residue noted in chamber, that was placed in a bag. During an interview on 01/27/25 at 04:23 AM, LN K reported that the nebulizer equipment is cleaned and rinsed once a day on the night shift. LN K reported that she did not rinse the nebulizer after each medication was administered. During an observation on 01/27/25 at 06:48 AM, R3's nebulizer equipment was intact and hanging on the side of nebulizer machine with a clear liquid substance noted in chamber. During an observation on 01/27/25 at 06:48 AM, Certified Nurse Aide (CNA)F and Certified Medication Aide (CMA) P applied PPE, prior to entering R3's room to provide care neither CNA F or CMA P performed hand hygiene before applying gloves. Incontinent care was provided to R3, neither CNA F or CMA P performed hand hygiene after they removed their gloves and applied new gloves to finish care. During care provided CNA F and CMA G placed soiled pajamas and bed pad onto the floor. After all care was administered CMA P reached behind her gown with her gloved hand and broke the ties on the gown and removed the gown and gloves at the same time. However, she did not roll the gown away from her she removed it quickly and just stuffed the gown and gloves into the garbage can. During an interview on 01/27/25 at 07:15 AM, CNA F reported that she should have performed hand hygiene prior to applying PPE and after she removed her gloves prior to applying new gloves. CNA F reported that soiled linen should not be placed on the floor that she should have placed a barrier over a garbage can then placed soiled linen on that. During an interview on 01/27/25 at 07:25 AM, CMA P reported that she washed her hands prior to applying her PPE. However, she did report that she had touched objects after she performed hand hygiene and should have washed her hands again. CMA P reported that she did not wash her hands after she removed her gloves and applied new gloves and reported she should have. CMA P also reported that soiled linen should not have been placed on the floor. During an observation on 01/27/25 at 07:20 AM, R6's catheter bag observed resting on floor with drain port locked but hanging free. CMA Q performed emptying of foley catheter drainage bag and removal of foley drainage bag and application of leg drainage bag for R6. CMA Q did not apply eyewear protection as part of her PPE during the care provided. During an interview on 01/27/25 at 07:39 AM, CMA Q stated they would not have done anything different. During an interview on 01/27/25 at 09:50 AM, Administrative Nurse C reported if a foley bag is found on the floor it should be cleaned with isopropyl alcohol and reassembled and washed out with three to one water vinegar mixture for 20 - 30 minutes, then hung to dry. Administrative Nurse C reported that staff should wear eye protection for splash hazard when emptying a foley bag. During an interview on 01/27/25 at 02:20 PM, Administrative Nurse C Infection Control Nurse reported she expected nurses to rinse out the nebulizer after each medication was administered and let equipment air dry on a paper towel. Administrative Nurse C reported that the night shift was expected to clean and rinse all resident's nebulizer equipment with the three to one water/vinegar mixture. Administrative Nurse C reported she expected all staff to perform hand hygiene after gloves were removed. The facility's policy Handwashing/Hand Hygiene dated 10/2023 documented this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Hand hygiene is indicated immediately after glove removal. The facility failed to maintain an effective infection control program related to the lack of proper hand hygiene when incontinent care was provided to R3 and improper removal of PPE after cares were performed. The facility staff failed to wear proper PPE when emptying a catheter, a drainage bag and when changing the leg bag to the gravity drainage bag. The facility failed to provide respiratory care consistent with professional standards of care for R3 and R134, regarding the cleaning of the nebulizer equipment after each use when medication was administered. This deficient practice had the potential to spread possible infections to the residents in the facility.

The facility census totaled 32 residents on three halls with a commons area where residents gathered for meals and activities. The facility had two medication carts and one nurse treatment cart that services the facility. Based on observation, interview, and record review, the facility failed to provide a safe environment by the failure to ensure a medication cart that contained prescription medications, narcotic medications in a locked box within the medication cart and over-the-counter (OTC - medications that do not require a prescription) and a nurse treatment cart that contained insulin (a medication used to treat diabetes [a disease when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin]), topical ointments and creams, remained locked when not in direct line of vision of the nurse, in an area where residents could access it. Findings included: - During an observation on 01/23/25 at 07:38 AM a medication cart was observed in the residents' hallway unlocked with keys hanging from the locking mechanism. A nurse treatment cart was next to the medication cart and was also unlocked and both were unattended. Three unknown staff members walked by the unlocked carts and did not secure the carts. During an interview on 01/23/25 at 07:42 AM, Licensed Nurse (LN) G identified the unlocked and unattended cart as the treatment cart and confirmed it contained insulins, topical ointments, medicated creams, wound care supplies. Additionally, LN G identified the medication cart that contained prescription medication, OTC medication and narcotics that were in a separate locked box within the cart. LN G verified the medication cart and treatment cart should be locked when not within line of site of staff member responsible for the carts. LN G identified the medication cart serviced approximately half of the residents, and the treatment cart serviced all of the residents in the facility. During an interview on 01/23/25 at 08:57 AM, Administrative Nurse B stated it was her expectation staff should lock all medication and treatment carts when not use or in line of sight of the staff responsible for the cart. During an observation on 01/27/25 at 05:00 AM, LN K left the nurse treatment cart unlocked and unattended in the nurse's office with the door open. The nurse's office was located in the hallway where two residents' hallways converge. During an interview on 01/27/25 at 05:11 AM, LN K identified the unlocked cart as the nurse treatment cart that contained insulins, topical ointments, medicated creams, wound care supplies and confirmed that the cart should be locked when not within an arm's reach without regard to where the cart is located. The facility identified 12 residents as confused and independently mobile. The facility's undated Storage of Medications policy documented that the facility would store all medications in a safe, sure and orderly manner and all compartments (drawers, cabinets, carts, etc.) would be locked when not in use and not left unattended if open or otherwise potentially available to others. The facility failed to provide a safe environment for the residents by the failure to ensure a medication cart and nurse treatment cart remained locked when not in direct line of vision of the licensed nurse responsible for the carts.

The facility reported a census of 32 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately revise three residents care plans. The facility failed to revise the care plan after Resident (R)19 who had increased exiting behaviors, and actual elopements (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) from facility on 10/12/23 and 02/14/24. AdditionallyThe facility failed to update and place appropriate fall interventions for R3 and R15 who had multiple falls. This failure placed the residents at risk for uncommunicated care needs. Findings included: - The Electronic Health Records (EHR) documented R19 had the following diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 012/23/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R19 had no behaviors or depression. R19 required set up for showers and was independent with all other activities of daily living (ADLs). R19 had no falls, and she was administered anti-psychotic (class of medications used to treat major mental conditions which cause a break from reality) medication, and anti-depressant (class of medications used to treat mood disorders) medication. The 01/03/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R19 had Alzheimer's and had severely impaired cognition. She was at risk for ADL declines, behaviors and communication deficiencies. Goal was to avoid decline or complications due to her cognitive impairment. The 10/01/24 Quarterly MDS documented a BIMS score of five, indicating severely impaired cognition. R19 had no depression and had behaviors one to three days with wandering. R19 was independent in all ADLs, she received anti-psychotic, and anti-depressant medications. She wore a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). The Care Plan documented the following: Staff were instructed to place a sign on the door for visitors to check with staff before allowing folks to leave facility, dated initiated 09/22/24. Staff provided a Wander Guard bracelet on R19. Staff instructed to check placement of Wander Guard each shift, date initiated 09/22/24. Staff instructed to check on R19 every 15 minutes to monitor my location for my safety, date imitated 09/22/24. Staff instructed to notify my family when R19 would come to the exit door frequently. Staff instructed to assist R19 away from the door. When weather permits, staff instructed to assist R19 outside in courtyard to walk with staff, date imitated 09/22/24. The 01/22/25 Physician Orders documented the following: Check placement of Wander Guard each shift. To use the tag reader, turn on the right button and right arrow. The press down arrow button until it stated tag test mode. Then press enter mode. Place reader near wander guard to receive the reading. Date ordered 09/22/24. Review of the Wandering Risk Scale for R19, dated 10/24/23 thru 12/20/24 documented R19 was a high risk to wander five out of the seven days. The 10/09/23 at 10:49 AM Progress Note revealed R19 punched the code on main entrance door and walked out of the facility and down the sidewalk. Staff observed R19 exiting and redirected R19 back into the facility. The 10/12/23 at 08:23 PM Progress Note revealed R19 entered the code to the exit door of hallway 300 and exited the facility witnessed by an unidentified nursing student. The nursing student immediately found the nurse to question if R19 was ok to be outside alone. The unidentified nurse and nursing student exited the facility and noted the property fence gait was open. R19 was located ambulating on the street. The 02/14/24 at 03:43 PM Progress Note revealed R19 exited the facility when a band member was leaving the facility. Unidentified band member alerted the staff. Two unidentified staff members immediately exited the facility and assisted R19 back into the facility. The 03/26/24 at 05:13 PM Progress Note revealed R19 had clothing in a mesh laundry bag, was in the main lobby near entrance door. R19 reported she would just follow them out when visitors attempted to leave facility. R19 was redirected away from the main entrance. The 04/14/24 at 01:53 Mood/Behavior Note revealed R19 had exiting seeking behaviors in front lobby. R19 would ask other residents and visitors to open the door for her. Review of Progress Notes from 04/15/24 thru 09/19/24 staff documented 15 exit seeking notes in EHR. The 09/22/24 at 07:08 PM 'Progress Note revealed R19 exited the facility at 03:48 PM when a visitor assisted R19 with the door so she could leave. An unidentified resident alerted staff that R19 was outside. Staff assisted R19 back into facility. During an observation on 01/22/25 at 10:00 AM, R19 had been wandering up and down the 300 hallway several times. R19 was well groomed, was wearing an outdoor vest, carried her black handbag and her walking cane under her arm. During an observation on 01/22/25 at 02:30 PM R19 wandered in hallway 300, she wore a burgundy coat and carried her black handbag. During an observation on 01/23/25 at 01:40 PM, R19 was seated in front lobby chair approximately 12 feet from the exit/entrance door. R19 watched the oxygen vendor man punch the code on the exit panel. During an interview on 01/23/25 at 02:00 PM, Certified Nurse Aide (CNA) R reported that R19 would exit seek all the time. CNA R reported that R19 wore a Wander Guard and that R19 would be looking for her family. CNA R reported that staff would re-direct R19 away from exit doors almost every day. CNA R reported that R19 would change her coat to different outdoor wear through out the day. During an interview on 01/27/25 at 04:06 AM, CNA H reported that R19 reported that she was told by the charge nurse not to check on R19 during the night as not to disturb R19. CNA H reported she would see R19 out of her room in the morning and that she was easy to redirect when needed. During an interview on 01/27/25 at 04:23 AM, Licensed Nurse (LN) K reported that she would check on R19 once at night and once in the morning, she reported that R19 would not like people coming into her room. LN K reported that R19 was an elopement risk and always wore a Wander Guard bracelet. LN K reported the Wander Guard bracelet would be checked each shift for placement and the alarm worked. LN K reported she would assist R19 toward the exit door to have the alarm sound to check for function. LN K reported there was a device to check the Wander Guard but was educated by other staff to use the exit door. During an observation on 01/27/25 at 05:06 AM noted an Explorer/ [NAME] Leaf binder in nurse's station. The binder contained R19's information and picture. During an interview on 01/27/25 at 03:31 PM, Administrative Nurse B reported that she would like to answer the surveyor's questions about R19's exit seeking behavior and the progress notes in the EHR that were noted prior to the facility state reportable # 0766 on 09/23/24 when Administrative Staff A could be present. During an interview 01/27/25 at 03:31 PM, Administrative Nurse B reported she expected the care plan interventions to be documented on the EHR in a timely manner and confirmed that did not always occur and expected the charge nurses to update the care plan in the EHR. During an interview on 01/27/25 at 04:07 PM, Administrative Staff A, reviewed the progress notes with surveyor, and Administrative Nurse B in regard to R19 exit seeking and elopement notes in EHR. Administrative Staff A reported she did not realize that R19 had an exit seeking note on 09/19/24 in EHR, she had an appalled look on her face. Administrative Staff A revealed she did not believe that R19 had a true elopement on 02/14/24. However, Administrative Staff A revealed she was not aware that R19 had exited the facility on 10/12/23 and she reported she would have done an investigation, and a report had she been aware. Administrative Staff reported that R19's care plan lacked interventions for exit seeking prior to 09/22/24 and reported that was unacceptable. The facility's undated Care Plans, Comprehensive Person-Centered documented a comprehensive person-centered care plan with measurable objectives and timetables would be developed and implemented for each resident and included revisions and updates if a desired outcome was not met The facility failed to review and revise R19's care plan prior to 09/22/24 for exit seeking and elopement behaviors. These deficient practices had the potential to lead to uncommunicated needs which could result in additional falls with the potential for injury or actual harm. - The Electronic Health Records (EHR) documented R3 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), pain and anxiety. The 02/28/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. R3 had a total mood severity score of zero, which indicated no depression, and she had one wandering behavior noted. R3 required moderate assistance with activities of daily living (ADL) such as toileting hygiene, showering, personal hygiene, and dressing. R3 required supervision for ambulation and transfer and set-up for eating. R3 was occasionally incontinent of bladder, and she had no falls. The 03/11/24 Falls Care Area Assessment (CAA) documented R3 was at risk for injuries resulting from falls and ADL declines, goal was to continue to avoid falls and injuries to resident. The 03/11/24 Cognitive Loss/Dementia CAA documented R3 was at risk for ADL declines, communication deficiencies and falls due to her cognitive impairment. Goal was to maintain her cognitive functioning without complication or decline. The 11/12/24 Quarterly MDS lacked a BIMS and total mood severity score. R3 required total assistance with all ADLs. R3 was non ambulatory, she had no behaviors or falls. The Care Plan documented the following: Staff were to encourage R3 to use call light for assistance, provide a safe environment with adequate low glare light, a working and reachable call light and personal items within reach dated 06/18/21. Staff were instructed R3 was a high fall risk due to my lack of safety awareness, dated 03/22/22. Staff were instructed to look in on R3 when passing room to make sure all needs were met as a green leaf symbol was placed outside R3's room date initiated 11/18/22. Staff were to provide reminders to R3 to wear appropriate footwear when ambulating and use walker, date initiated 05/16/23. Staff were instructed to offer toileting or check brief every couple of hours and provide incontinent care as needed date initiated 07/09/24. Staff were instructed to assist R3 to toilet before meals date initiated 07/09/24. Staff were instructed to provide R3 with a hi/lo bed and keep bed in lowest position whole R3 was in bed date initiated 07/30/24. The 06/09/24 at 10:15 PM Progress Note revealed staff found R3 on the bathroom floor, seated upright with legs out in front of her with her walker. The note documented R3 was confused and did not know what happened and was incontinent at that time. The 06/09/24 Fall Scene Investigation Report included an immediate intervention to re-educated R3 to use the call light (she won't remember more than likely) and to watch R3 closely as she has no alarm. The 07/09/24 at 12:31 PM Progress Note revealed staff found R3 seated on floor near her doorway in her room. Staff noted that R3's floor was partially wet from recently being mopped and a caution wet floor sign was appropriately placed. The 07/09/24 Fall Scene Investigation Report included an immediate intervention to check frequently on R3 and staff instructed to provide toileting before each meal. Additionally, the report documented R3 was last seen in bed at 11:40 AM with eyes closed and staff attempted to assist her up for lunch. Also noted R3's medications had been held that morning due to unable to wake R3 up to administer medications. The 07/30/24 at 05:38 AM Progress Note revealed R3 called out for help and staff found R3 on the floor, with her walker in front of her. Staff noted a large hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the right side of R3's face. R3 was transferred to the hospital. The 07/30/24 Fall Scene Investigation Report revealed that R3 was last seen in bed with her wheelchair and walker next to bed by an unidentified Certified Nurse Assistant (CNA) at 05:00 AM. During an interview on 01/22/25 at 09:35 AM, R3 could not recall if she had any falls. Observed a folded fall mat in R3's room propped up against a wall. During an observation on 01/27/25 at 04:03 AM, R3 was in bed placed in lowest position with a fall mat placed next to left side of bed, and R3's walker in reach on the fall mat. During an interview on 01/27/25 at 04:06 AM, CNA H reported that R3's walker was placed next to her bed per the care plan, she reported that R3 had not ambulated. CNA H verified that the fall mat on R3's floor was not on the care plan and CNA H reported she placed it on the floor as it was in R3's room. During an interview on 01/27/25 at 04:23 AM, Licensed Nurse (LN) K reported the staff would discuss an immediate intervention and write that down on the report. However, she reported that the care plan intervention in the EHR would be completed by administrative nurse staff, not by the charge nurses. During an interview on 01/27/25 at 01:55 PM, CNA F reported she would look on the EHR on a resident kardex to verify what cares, and devices a resident is required to be provided with. During an interview 01/27/25 at 03:31 PM, Administrative Nurse B reported she expected the care plan interventions to be documented on the EHR in a timely manner and confirmed that did not always occur. She expected the charge nurses to update the care plan in the EHR. Administrative Nurse B confirmed that R3 did not have a fall mat intervention on her current care plan. During an interview on 01/27/25 at 04:07 PM, Administrative Staff A reported that a care plan should be updated in a timely manner. Administrative Staff A revealed 30 days to update a care plan after an occurrence was unacceptable. The facility's undated Care Plans, Comprehensive Person-Centered documented a comprehensive person-centered care plan with measurable objectives and timetables would be developed and implemented for each resident and included revisions and updates if a desired outcome was not met The facility failed to revise R3's care plan for 30 days after a fall. This deficient practice had the potential to lead to uncommunicated needs which could result in additional falls with the potential for injury or actual harm. 46960 - Review of the Electronic Health Record (EHR) for Resident (R)15 included diagnoses of generalized dependence on wheelchair, dementia (a progressive mental disorder characterized by failing memory, confusion) and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The assessment documented that R15 utilized a walker and/or wheelchair for locomotion and documented one fall with injury since the previous assessment. R15 required partial/moderate assistance for toileting and personal hygiene, supervision/touching assistance for upper body dressing, setup/cleanup assistance for oral hygiene and was independent with eating. The ADL Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 05/13/24, documented R15 had limited range of motion to both lower extremities and required partial assistance for transfers and supervision for ambulation (walking). The Falls CAA dated 05/13/24 documented R15 had balance problems with walking and had decreased muscular coordination and used assistive devices. The Quarterly MDS dated [DATE], documented a BIMS score of 15, which indicated intact cognition. The assessment documented that R15 utilized a walker and/or wheelchair for locomotion and documented two or more non-injury falls and one fall with minor injury since the previous assessment. R15 required setup/cleanup assistance with bathing but was otherwise independent with cares. The 01/09/20 Care Plan, documented R15 was at risk for falls related to Parkinson's disease and poor safety awareness and listed the following interventions: On 07/27/20, staff would offer gentle reminders for R15 to use the call light for assistance and safety related to transfers, revised 03/27/21. On 08/24/23, staff would reeducate R15 related to call light use for assistance with cares. On 10/30/23, staff would encourage R15 to ask for additional assistance in the mornings related to morning stiffness before medications started working. On 11/30/23, staff would encourage R15 to dress in a seated position. On 12/01/23, staff would remind R15 to utilize his walker if he was observed attempting to walk without it. On 04/13/24, staff educated R15 related to poor decision making, initiated on 10/07/24. On 05/08/24, staff educated R15 related to poor decision making related to pushing another resident in their wheelchair while simultaneously attempting to ambulate with a walker, initiated on 10/07/24. On 08/10/24, staff educated R15 to use his scooter for locomotion while outside, initiated on 10/07/24. On 08/10/24, staff to provide stand-by assistance for all transfers, initiated on 10/07/24. Review of the five Fall Risk assessments from 02/08/24 through 01/08/24, revealed R15 was at risk for falls. Review of the Progress Notes dated 06/01/24 at 06:36 AM documented R15 reported to staff that he had fallen and only his right knee struck the ground. The facility failed to provide a fall investigation report for this fall that documented root cause analysis, immediate intervention to mitigate the risk of falls for the rest of the shift or a permanent care plan intervention. Review of the Fall Report on 09/12/24 documented a fall without injury. The report lacked an appropriate root cause analysis and immediate intervention to mitigate the risk of falls for the rest of the shift. The Progress Notes on 09/12/24 at 02:17 PM documented that R15 self-reported a fall during the night. The progress note documented that R15 reported he was walking with his walker in his room and his feet became tangled and he fell . The Fall Report dated 01/08/25 documented a fall without injury and lacked an appropriate root cause analysis or immediate intervention to mitigate the risk of falls for the rest of the shift. The Progress Notes dated 01/08/25 at 03:36 PM documented R15 had an unwitnessed fall with minor injury and was found by staff at 02:15 PM in his room. The Care Plan lacked an intervention related to the fall on 01/08/25. Observation on 01/22/25 at 10:41 AM, R15 was seated in the recliner in his room. Observation on 01/23/25 at 01:02 PM, R15 was seated in his motorized wheelchair in his room. Observation on 01/27/25 at 06:00 AM, R15 self-propelled his motorized wheelchair down the hallway into the dining area and retrieved a cup of coffee, then returned to his room. During an interview on 01/27/25 at 07:41 AM, Certified Medication Aide (CMA) Q revealed when a resident fell staff would ensure the resident was safe, then alert other staff that assistance was required, and would notify the nurse. Upon the arrival of the nurse, the staff would follow the instructions of the nurse. After the fall was over, the nurse would hold an impromptu meeting with the staff to discuss the risks and determine the cause of the fall and implement a new intervention. The staff would also fill out a report and give it to the nurse. CMA Q stated that if a resident self-reported a fall, then the same process would be followed. CMA Q further revealed that each resident had a care plan that directed the staff to provide individualized care to each resident. During an interview on 01/27/25 at 09:41 AM, Certified Nurse Aide (CNA) R revealed that in the event of a fall, staff would stay with the resident to ensure their safety and alert other staff for help using the two-way radio or call light system, then follow the instructions of the nurse after they arrived and assessed the resident. After the fall, the nurse would collect statements from the staff and have a small meeting to discuss why the fall happened and would collectively develop a new intervention for the resident. CNA R further revealed that each resident had a care plan which provided instructions for individualized care for each resident. During an interview on 01/27/25 at 04:23 AM, Licensed Nurse (LN) K reported that if a fall occurred, she would fill out a fall packet that had printed instructions on the front of the envelope. LN K reported she would assess the resident, notify family, physician, Administrative Staff A, and Administrative Nurse B of the event. LN K reported that she would complete the paperwork for neurological checks (a series of tests and questions that assess the function of the brain, spinal cord, and nerve), prior to occurrence form, and witness statements. She reported that she would complete required documentation in EHR for resident which included a risk management report. LN K reported the staff would discuss an immediate intervention and write that down on the report. However, she reported that the care plan intervention in the EHR is completed by administrative nurse staff, not by the charge nurses. During an interview on 01//27/23 at 09:50 AM Administrative Nurse C defined a fall as a change in plane (when a person unexpectedly changed from standing to sitting or lying positions or any combination thereof). Administrative Nurse C revealed if a resident fell (witnessed or unwitnessed), the staff would remain with the resident to ensure safety and alert additional staff for assistance which included the nurse. The nurse would assess the resident for injuries and initiate any care that was required and make the necessary notifications, additionally, the nurse would request paper reports from all of the staff to determine what happened before the fall and obtain witness statements if necessary. The nurse would hold a meeting with the staff to determine why the fall occurred and develop an immediate intervention to mitigate the risk of falls for the shift and included a care plan intervention. During an interview 01/27/25 at 03:31 PM, Administrative Nurse B reported she expected the care plan interventions to be documented on the EHR in a timely manner and confirmed that did not always occur and expected the charge nurses to update the care plan in the EHR. During an interview on 01/27/25 at 03:40 PM, Administrative Staff A defined a fall as a change in plane. Administrative Staff A confirmed the information regarding the fall on 06/01/24 constituted a fall and should have resulted in a fall investigation and confirmed that it did not exist. Administrative Staff A confirmed the above information related to fall investigation reports being incomplete and missing appropriate root cause analyses, immediate interventions and permanent care plan interventions and stated her expectation was for fall investigation reports to be accurate and contain appropriate root cause analyses, immediate interventions and permanent care plan interventions to mitigate the risk of future falls. The facility's undated Care Plans, Comprehensive Person-Centered documented a comprehensive person-centered care plan with measurable objectives and timetables would be developed and implemented for each resident and included revisions and updates if a desired outcome was not met The facility failed to review and revise R15's person-centered care plan related to accident hazards and falls when the facility failed to conduct appropriate fall investigations on 06/01/24, develop interventions to mitigate the risk of falls or develop care plan interventions to prevent additional falls on 09/12/24 and 01/08/25. These deficient practices had the potential to lead to uncommunicated needs which could result in additional falls with the potential for injury or actual harm.

The facility reported a census of 32 residents with 12 residents in the sample and four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment that remained free from accident hazards for four residents. The facility failed to identify, implement, and reevaluate fall prevention interventions to prevent falls for two residents. Resident (R) 15 had multiple falls with a lack of appropriate fall interventions. Additionally, the facility failed to implement new interventions to prevent R19 after she had an elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) from facility. The facility failed to put an effective smoking plan in place for R9. These deficient practices could potentially result in an injury. Findings included: - The Electronic Health Records (EHR) documented R9 had the following diagnoses depression, repeated falls, and hypotension (low blood pressure). The 11/11/24 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of five, which indicated severe cognitive impairment. Total severity score of zero which indicated no depression. R9 had behaviors noted. R5 required supervision assistance with activities of daily living (ADLs) of ambulation 150 feet and he was independent with the remainder of his ADLs. R9 had falls prior to admission and received an anti-depressant (class of medications used to treat mood disorders) and anti-coagulant (class of medication to thin blood to prevent clotting). The 11/15/24 Functional Abilities Care Area Assessment (CAA) documented: R9 was at risk for ADL declines and falls. Goal is for resident to maintain his independence without declines. The 11/15/24 Cognitive Loss/Dementia CAA documented R9 was at risk for ADL declines and falls due to cognitive impairment. Goal is to maintain his cognitive functioning without complications or decline. The 12/09/24 Quarterly MDS documented a BIMS score of 10, which indicated moderately impaired cognition. R9 was independent with ADLs, except required supervision with bathing. No falls noted. R9 received anti-depressant, and anti-coagulant medication. The Care Plan dated 01/22/25 lacked any documentation of R9's smoking. The EHR lacked any smoking evaluation/assessment that was reviewed on 01/22/25. The Physician Orders 01/22/25 lacked any orders regarding smoking. The Admission Data Collection dated 11/05/24 at 04:27 PM, documented R9 was a current smoker. However, it lacked any further documentation of R9 being a smoker. The 11/06/24 at 06:39 PM Progress Note documented R9's family member brought him in cigarettes. The 12/11/24 at 06:37 PM Progress Note revealed R9 would go outside for smoke breaks after his meals. During an interview on 01/22/25 at 09:55 AM, R9 reported that he was a smoker, and he was just going outside to smoke. R9 had a lighter and one cigarette in his front pocket of his jacket. He ambulated independently down hallway 300, punched to code into the exit panel and ambulated over to the designated smoking area. During an interview on 01/22/25 at 10:03 AM, Maintenance Director O reported that he was not sure if R9 could go outside to smoke independently. He reported the R9 had a staff member with him yesterday when he observed him smoking outside. During an interview on 01/23/25 at 08:20 AM, Certified Nurse Aide (CNA) R reported that R9 required staff supervision when he would want to smoke. CNA R reported that R would need to go locked cart and ask the charge nurse if he could have a cigarette. CNA R reported that if R9 had a lighter and cigarette in his pocket and went outside to smoke independently that would not be acceptable. CNA R reported that staff should look at the care plan to know the required care needed for smokers. During an observation on 01/23/25 at 08:26 AM thru 08:46 AM, R9 was assisted outside by CNA R to assist R9 with a cigarette break. During an observation on 01/23/25 at 12:50 PM, R9 exited independently outside hallway 300 exit door and ambulated to the designated smoking area. R9 pulled a cigarette and lighter out of his front pocket and lit the cigarette independently. R9 re-entered the 300 hallway door at 12:57 PM. During an interview on 01/23/25 at 01:31 PM, Licensed Nurse (LN) G reported that would give R9 his lighter and cigarette when he would request them. LN G reported the charge nurse only had a key for the locked lighters and cigarettes. LN G reported that it should be on R9's care plan and there should be a smoking evaluation for safety needs be completed. LN G reported she was unsure how often a smoking safety evaluation should be completed. LN G reported that she had not looked on EHR to verify that R9 could independently smoke, she reported she was trained that he could. LN G reviewed the EHR and reported that R9 did have a smoking evaluation assessment completed, and his care plan had documented that R9 could smoke independently. LN G then reported that the evaluation and care plan was implemented today on 01/23/25. During an interview on 01/23/25 at 01:59 PM, Administrative Nurse M reported that she had just completed R9's smoking evaluation and documented the smoking focus on R9's care plan just today. Administrative Nurse M reported she had noticed it had not been completed. Administrative Nurse M revealed that the smoking evaluation for safety and his care plan should have been completed when he admitted on [DATE]. Administrative Nurse M reported the R9 is independent with all his ADLs, and he should be able to smoke by himself. Administrative Nurse M reported when she completed the evaluation this morning, she charted no cognitive deficit that she had not looked at R9's BIMS and verified that in 11/2024 R9 had a BIMS score of five which indicated severely impaired cognition and in 12/24 R9 had a BIMS score of 10 which indicated moderately impaired cognition. Administrative Nurse M reported that the staff know the residents when asked how the staff would know R9's smoking privileges before the care plan was initiated today. During an interview on 01/27/25 at 03:31 PM Administrative Nurse B reported it was a concern that R9 did not have a smoking evaluation for safety, or his care plan initiated for smoking until 01/23/25 and expected staff to complete the assessments and care plan in the EHR when a resident was admitted . The facility's Smoking -Resident policy dated 10/2023 documented this facility has established and maintains safe resident smoking practices. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). Any smoking-related privileges, restrictions, and concerns are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. The facility failed to evaluate a cognitively impaired R9 smoking evaluation for safety and failed to care plan R9's smoking privileges when admitted 78 days ago. This deficient practices could potentially result in an injury. 46960 - Review of the Electronic Health Record (EHR) for Resident (R)15 included diagnoses of generalized dependence on wheelchair, dementia (a progressive mental disorder characterized by failing memory, confusion) and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The assessment documented that R15 utilized a walker and/or wheelchair for locomotion and documented one fall with injury since the previous assessment. R15 required partial/moderate assistance for toileting and personal hygiene, supervision/touching assistance for upper body dressing, setup/cleanup assistance for oral hygiene and was independent with eating. The ADL Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 05/13/24, documented R15 had limited range of motion to both lower extremities and required partial assistance for transfers and supervision for ambulation (walking). The Falls CAA dated 05/13/24 documented R15 had balance problems with walking and had decreased muscular coordination and used assistive devices. The Quarterly MDS dated [DATE], documented a BIMS score of 15, which indicated intact cognition. The assessment documented that R15 utilized a walker and/or wheelchair for locomotion and documented two or more non-injury falls and one fall with minor injury since the previous assessment. R15 required setup/cleanup assistance with bathing but was otherwise independent with cares. The 01/09/20 Care Plan reviewed 01/23/25, documented R15 was at risk for falls related to Parkinson's disease and poor safety awareness and listed the following interventions: On 07/27/20, staff would offer gentle reminders for R15 to use the call light for assistance and safety related to transfers, revised 03/27/21. On 08/24/23, staff would reeducate R15 related to call light use for assistance with cares. On 10/30/23, staff would encourage R15 to ask for additional assistance in the mornings related to morning stiffness before medications started working. On 11/30/23, staff would encourage R15 to dress in a seated position. On 12/01/23, staff would remind R15 to utilize his walker if he was observed attempting to walk without it. On 04/13/24, staff educated R15 related to poor decision making, initiated on 10/07/24. On 05/08/24, staff educated R15 related to poor decision making related to pushing another resident in their wheelchair while simultaneously attempting to ambulate with a walker, initiated on 10/07/24. On 08/10/24, staff educated R15 to use his scooter for locomotion while outside, initiated on 10/07/24. On 08/10/24, staff to provide stand-by assistance for all transfers, initiated on 10/07/24. Review of the five Fall Risk assessments from 02/08/24 through 01/08/24, revealed R15 was at risk for falls. Review of the Progress Notes dated 06/01/24 at 06:36 AM documented R15 reported to staff that he had fallen and only his right knee struck the ground. The facility failed to provide a fall investigation report for this fall that documented root cause analysis, immediate intervention to mitigate the risk of falls for the rest of the shift or a permanent care plan intervention. Review of the Fall Report on 09/12/24 documented a fall without injury. The report lacked an appropriate root cause analysis and immediate intervention to mitigate the risk of falls for the rest of the shift. The Progress Notes on 09/12/24 at 02:17 PM documented that R15 self-reported a fall during the night. The progress note documented that R15 reported he was walking with his walker in his room and his feet became tangled and he fell . The Care Plan on 09/12/24 documented staff reminded R15 to utilize the call light for assistance during the overnight hours, initiated on 10/07/24. The Fall Report dated 01/08/25 documented a fall without injury and lacked an appropriate root cause analysis or immediate intervention to mitigate the risk of falls for the rest of the shift. The Progress Notes dated 01/08/25 at 03:36 PM documented R15 had an unwitnessed fall with minor injury and was found by staff at 02:15 PM in his room. The Care Plan lacked an intervention related to the fall on 01/08/25. Observation on 01/22/25 at 10:41 AM, R15 was seated in the recliner in his room. Observation on 01/23/25 at 01:02 PM, R15 was seated in his motorized wheelchair in his room. Observation on 01/27/25 at 06:00 AM, R15 self-propelled his motorized wheelchair down the hallway into the dining area and retrieved a cup of coffee, then returned to his room. Observation on 01/27/25 at 09:37 AM, R15 was rested in the recliner in his room. During an interview on 01/27/25 at 07:41 AM, Certified Medication Aide (CMA) Q stated when a resident fell staff would ensure the resident was safe, then alert other staff that assistance was required, and would notify the nurse. Upon the arrival of the nurse, then staff would follow the instructions of the nurse. After the fall was over, the nurse would hold an impromptu meeting with the staff to discuss the risks and determine the cause of the fall and implement a new intervention. The staff would also fill out a report and give it to the nurse. CMA Q stated that if a resident self-reported a fall, then the same process would be followed. During an interview on 01/27/25 at 09:41 AM, Certified Nurse Aide (CNA) R revealed that in the event of a fall, staff would stay with the resident to ensure their safety and alert other staff for help using the two-way radio or call light system, then follow the instructions of the nurse after they arrived and assessed the resident. After the fall, the nurse would collect statements from the staff and have a small meeting to discuss why the fall happened and would collectively develop a new intervention for the resident. During an interview on 01/27/25 at 04:23 AM, Licensed Nurse (LN) K reported that if a fall occurred, she would fill out a fall packet that had printed instructions on the front of the envelope. LN K reported she would assess the resident, notify family, physician, Administrative Staff A, and Administrative Nurse B of the event. LN K reported that she would complete the paperwork for neurological checks (a series of tests and questions that assess the function of the brain, spinal cord, and nerve), prior to occurrence form, and witness statements. She reported that she would complete required documentation in EHR for resident which included a risk management report. LN K reported the staff would discuss an immediate intervention and write that down on the report. However, she reported that the care plan intervention in the EHR is completed by administrative nurse staff, not by the charge nurses. During an interview on 01//27/23 at 09:50 AM Administrative Nurse C defined a fall as a change in plane (when a person unexpectedly changed from standing to sitting or lying positions or any combination thereof). Administrative Nurse C revealed if a resident fell (witnessed or unwitnessed), the staff would remain with the resident to ensure safety and alert additional staff for assistance which included the nurse. The nurse would assess the resident for injuries and initiate any care that was required and make the necessary notifications, additionally, the nurse would request paper reports from all of the staff to determine what happened before the fall and obtain witness statements if necessary. The nurse would hold a meeting with the staff to determine why the fall occurred and develop an immediate intervention to mitigate the risk of falls for the shift and included a care plan intervention. During an interview 01/27/25 at 03:31 PM, Administrative Nurse B reported she expected the care plan interventions to be documented on the EHR in a timely manner and confirmed that did not always occur and expected the charge nurses to update the care plan in the EHR. During an interview on 01/27/25 at 03:40 PM, Administrative Staff A defined a fall as a change in plane. Administrative Staff A confirmed the information regarding the fall on 06/01/24 constituted a fall and should have resulted in a fall investigation and confirmed that it did not exist. Administrative Staff A confirmed the above information related to fall investigation reports being incomplete and missing appropriate root cause analyses, immediate interventions and permanent care plan interventions and stated her expectation was for fall investigation reports to be accurate and contain appropriate root cause analyses, immediate interventions and permanent care plan interventions to mitigate the risk of future falls. The facility's Falls - Clinical Protocol policy, dated 03/2018, documented for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. The facility failed to provide an environment free of accident hazards when the facility failed to conduct appropriate fall investigations on 06/01/24, develop interventions to mitigate the risk of falls or develop care plan interventions to prevent additional falls on 09/12/24 and 01/08/25. These deficient practices had the potential to lead to additional falls with the potential for injury or actual harm.

The facility reported a census of 32 residents with 12 residents sampled, including two residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly clean the nebulizer (a device for administering inhaled medications) after each medication was administered for Resident (R)3 and R134 in accordance with the standards of care This deficient practice had the potential to spread possible lung infections to the residents. During an observation on 01/22/25 at 09:34 AM, Licensed Nurse (LN) G removed the nebulizer equipment off f R3 after breathing treatment was completed. LN G placed the nebulizer equipment into a bag. LN G washed her hands, and she reported she would not rinse the nebulizer equipment after she had administered a breathing treatment as the nebulizer equipment was cleaned once a day on the night shift. During an observation on 01/22/25 at 02:35 PM, R134's nebulizer was intact with a clear liquid residue noted in chamber, that was placed in a bag. During an interview on 01/27/25 at 04:23 AM, LN K reported that the nebulizer equipment is cleaned and rinsed once a day on the night shift. LN K reported that she did not rinse the nebulizer after each medication was administered. During an observation on 01/27/25 at 06:48 AM, R3's nebulizer equipment was intact and hanging on the side of nebulizer machine with a clear liquid substance noted in chamber. During an interview on 01/27/25 at 02:20 PM, Administrative Nurse C Infection Control Nurse reported she expected nurses to rinse out the nebulizer after each medication was administered and let equipment air dry on a paper towel. Administrative Nurse C reported that the night shift was expected to clean and rinse all resident's nebulizer equipment with the three to one water/vinegar mixture. The facility's policy Departmental (Respiratory Therapy) - Prevention of Infection dated 11/2011, documented the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. Infection control considerations related to medication nebulizers/continuous aerosol after completion of therapy remove the nebulizer container, rinse the container with fresh tap water, and dry on a clean paper towel or gauze sponge. The facility failed to provide respiratory care consistent with professional standards of care for R3 and R134, regarding the cleaning of the nebulizer equipment after each use when medication was administered. This deficient practice had the potential to spread possible lung infections to residents.

The facility reported a census of 32 residents with 12 residents sampled and five reviewed for unnecessary medications. Based on observations, interviews and record review, the facility failed to ensure that four residents remained free of unnecessary psychotropic (any class of medications that alters mood or thought) medications when the facility failed to ensure the physician responded in a timely manner to monthly medication regimen reviews (MRR) for Resident (R)15, 19 and R25 related to psychotropic medications and for R3 when the physician failed to provide appropriate rational when they declined a pharmacy recommended gradual dose reduction (GDR) for psychotropic medications. These deficient practices had the potential to lead to the residents receiving medications unnecessarily. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R)15 included diagnoses of generalized dependence on wheelchair, dementia (a progressive mental disorder characterized by failing memory, confusion), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), hypertensive (high blood pressure) chronic kidney disease (CKD - a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluids from the blood), diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (MDD - major mood disorder which causes persistent feelings of sadness) with psychotic (any major mental disorder characterized by a gross impairment in reality perception) symptoms and hypothyroidism (condition characterized by hyperactivity of the thyroid gland). The Annual Minimum Data Set (MDS) dated 05/13/24, documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The assessment documented R15 had a PHQ-9 (a scale used to determine the presence of depression) score of zero which indicated no depression and had no behavioral symptoms related to psychosis. R15 utilized a walker and/or wheelchair for locomotion and documented one fall with injury since the previous assessment. R15 required partial/moderate assistance for toileting and personal hygiene, supervision/touching assistance for upper body dressing, setup/cleanup assistance for oral hygiene and was independent with eating. Additionally, the assessment documented R15 received antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications and antidepressant (class of medications used to treat mood disorders) medications. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 05/13/24 documented R15 had moderate cognitive impairment. The ADL Functional / Rehabilitation Potential (CAA) dated 05/13/24, documented R15 had limited range of motion to both lower extremities and required partial assistance for transfers and supervision for ambulation (walking). The Falls CAA dated 05/13/24 documented R15 had balance problems with walking and had decreased muscular coordination and used assistive devices. The Psychotropic Drug Use CAA dated 05/13/24 documented R15 took Seroquel (quetiapine - an antipsychotic medication) and Paxil (paroxetine - an antidepressant) and had no recent gradual dose reduction (GDR) attempt. The Quarterly MDS dated 10/29/24, documented a BIMS score of 15, which indicated intact cognition. The assessment documented R15 had a PHQ-9 score of zero, which indicated no depression and utilized a walker and/or wheelchair for locomotion and documented two or more non-injury falls and one fall with minor injury since the previous assessment. R15 required setup/cleanup assistance with bathing but was otherwise independent with cares. Additionally, the assessment documented R15 received antipsychotic and antidepressant medications. The 01/09/20 Care Plan reviewed 01/23/25, documented R15 took antipsychotic and antidepressant medications and instructed staff to monitor for possible side effects (unintended effects caused by medication use) and notify the charge nurse, initiated on 01/17/22 Review of the Physician Orders revealed the following: Seroquel (quetiapine fumarate - an antipsychotic medication), 25milligram (mg) tablet, give 0.5 tablet by mouth (PO) two times daily (BID) for behaviors related to MDD with psychotic symptoms and give one tablet PO in the evening (HS) related to MDD with psychotic symptoms, dated 07/27/22 at 08:00 PM. Paxil (paroxetine - an antidepressant medication), 20 mg, give one tablet po one time a day related to MDD with psychotic symptoms, dated 02/29/20 at 07:00 AM. Review of the pharmacy MRR reports revealed that on 12/16/24 the pharmacist recommended a GDR for Paxil (paroxetine) and Seroquel (quetiapine). The facility faxed the physician on 12/19/24 and 01/23/25 without a response from the physician. Observation on 01/22/25 at 10:41 AM, R15 was seated in the recliner in his room and appeared calm and relaxed. Observation on 01/23/25 at 01:02 PM, R15 was seated in his motorized wheelchair in his room and appeared calm and relaxed. Observation on 01/27/25 at 06:00 AM, R15 self-propelled his motorized wheelchair down the hallway into the dining area and retrieved a cup of coffee, then returned to his room. R15 appeared calm and relaxed with a pleasant/cheerful demeanor. Observation on 01/27/25 at 09:37 AM, R15 was rested in the recliner in his room and appeared calm and relaxed. During an interview 01/23/25 at 03:23 PM, Administrative Nurse B confirmed the above information related to the timeliness of the MRR and GDR request stated that her expectation is that the physician would respond within a week, and then a second request would be made. Additionally, Administrative Nurse B revealed that she does not expect a timely response from R15's physician. Administrative Nurse B stated that the facility does have a medical director that is not R15's physician and was unsure of what policy and/or procedures were in place to ensure timely follow-up from a physician who refuses to respond timely or appropriately to MRR or GDR requests. The facility's undated Medication Regimen Reviews policy documented that a consultant pharmacist would conduct a MRR of each resident who received medication in the facility at least monthly and as needed, if indicated. If the physician does not provide a timely or adequate response to the report or if no action has been taken, the consultant pharmacist would contact the medical director or administrator. The facility's undated Designation of a Personal Physician policy documented that residents in the facility had the right to choose a personal attending physician and exercise that right based on the physician's ability and willingness to meet pertinent responsibilities which included the physician must follow the facility's established guidelines governing the responsibilities of the physician to the resident and to the facility. Additionally documented should the resident's attending physician fail or refuse to fulfill their responsibilities to the resident in a timely manner, the facility may contact the medical director for order fulfillment and/or to assume resident care. The facility did not provide a policy specific to a GDR process as requested on 01/27/24. The facility failed to ensure that R15's medication remained free of unnecessary psychotropic medications when the facility failed to ensure that R15's physician responded in a timely manner to a GDR request from the consultant pharmacist. This deficient practices had the potential to lead to R15 receiving unnecessary psychotropic medications with negative physical and psychosocial outcomes. - The Electronic Health Records (EHR) documented R19 had the following diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 012/23/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R19 had no behaviors or depression. R19 required Set up for showers and was independent with all other activities of daily living (ADLs). R19 had no falls, and she was administered anti-psychotic (class of medications used to treat major mental conditions which cause a break from reality) medication, and anti-depressant (class of medications used to treat mood disorders) medication. The 01/03/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R19 had Alzheimer's and had severely impaired cognition. She was at risk for ADL declines, behaviors and communication deficiencies. Goal is to avoid declines or complications due to her cognitive impairment. The 10/01/24 Quarterly MDS documented a BIMS score of five, indicating severely impaired cognition. R19 no depression and had behaviors one to three days with wandering. R19 was independent in all ADLs, she received anti-psychotic, and anti-depressant medications. She wore a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). The Care Plan documented the following: Staff instructed took antipsychotic and antidepressant medications and instructed staff to monitor for possible side effects (unintended effects caused by medication use) and notify the charge nurse, initiated on 08/17/21. Review of the Physician Orders revealed the following: Remeron (Mirtazapine - an anti-depressant medication), 15 milligram (mg) tablet, give one tablet by mouth, one time a day for major depressive disorder (MDD - major mood disorder which causes persistent feelings of sadness) with severe psychotic (any major mental disorder characterized by a gross impairment in reality perception), date ordered 10/23/22. Citalopram Hydrobromide Oral Tablet (an anti-depressant medication), 20 mg tablet, give one tablet one time a day for MDD, with severe psychotic features, date ordered 02/26/23. Seroquel (quetiapine fumarate - an antipsychotic medication), 50 mg tablet, give one tablet by mouth, every evening for behavior, date ordered 04/04/24. Seroquel 50 mg tablet, give one tablet by mouth, in the morning for anti-psychotic related to dementia in other diseases without behavioral disturbances, psychotic disturbances, mood disturbances ad anxiety, date ordered 11/04/24. Review of the pharmacy medication regimen reviews (MRR) reports revealed that on 07/23/24 MRR R19 was currently on Citalopram 20 mg, Mirtazapine 15 mg and Quetiapine 25 mg in am and 50 mg at pm. The facility must attempt gradual dose reduction (GDR stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic medications to find the lowest effective dose. The facility lacked a physician response for the MRR. During an observation on 01/22/25 at 10:00 AM, R19 had been wandering up and down the 300 hallway several times. R19 was well groomed, was wearing an outdoor vest, carried her black handbag and her walking cane under her arm. During an observation on 01/22/25 at 02:30 PM R19 wandered in hallway 300, she wore a burgundy coat and carried her black handbag. During an observation on 01/23/25 at 01:40 PM, R19 was seated in front lobby chair approximately 12 feet from the exit/entrance door. R19 watched the oxygen vendor man punch the code on the exit panel. During an interview 01/23/25 at 03:23 PM, Administrative Nurse B confirmed the above information related to the timeliness of the MRR and GDR request stated that her expectation is that the physician would respond within a week, and then a second request would be made and was unsure of what policy and/or procedures were in place to ensure timely follow-up from a physician who refuses to respond timely or appropriately to MRR or GDR requests. During an interview on 01/27/25 at 11:10 AM Administrative Nurse B reported she could not locate the MRR or R19 for 07/23/24. During an interview on 01/27/25 at 03:31 PM, Administrative Nurse B reported that the diagnoses physician documented for Seroquel was unacceptable. The facility's undated Medication Regimen Reviews policy documented that a consultant pharmacist would conduct a MRR of each resident who received medication in the facility at least monthly and as needed, if indicated. If the physician does not provide a timely or adequate response to the report or if no action has been taken, the consultant pharmacist would contact the medical director or administrator. The facility did not provide a policy specific to a GDR process as requested on 01/27/24. The facility failed to ensure that R19's medication remained free of unnecessary medications when the facility failed to ensure that R19's physician responded in a timely manner to a GDR request from the consultant pharmacist. - The Electronic Health Records (EHR) documented Resident (R)3 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), pain and anxiety. The 02/28/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. R3 had a total mood severity score of zero, which indicated no depression, and she had one wandering behavior noted. R3 required moderate assistance with activities of daily living (ADL) such as toileting hygiene, showering, personal hygiene, and dressing. R3 required supervision for ambulation and transfer and set-up for eating. R3 was occasionally incontinent of bladder, and she had no falls. R3 received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antidepressants (class of medications used to treat mood disorders), and anti-anxiety (class of medications that calm and relax people) medications during the lookback period. The 03/11/24 Psychotropic Drug Use Care Area Assessment (CAA) R3 was administered Quetiapine (an anti-psychotic medication) for dementia with behavioral disturbance, Clonazepam (an anti-anxiety medication) for anxiety, and Mirtazapine (an anti-depressant medication) for depressive episodes. R3 was at risk for adverse consequences due to medication use, goal was to avoid adverse consequences of medication use and to have improvement in her behavior and depressive symptoms. The 11/12/24 Quarterly MDS lacked a BIMS and total mood severity score. R3 required total assistance with all ADLs. R3 was non ambulatory, she had no behaviors or falls. R3 received anti-psychotic, anti-depressant, and anti-anxiety medications during lookback period. The Care Plan documented the following: R3's medications would be reviewed by the pharmacist consultant monthly, and by a physician every 60 days, and by both as needed, date initiated 06/18/21. Staff instructed to look at Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for all listed drugs could be located in the physician orders and the EHR on medication administration record, date initiated 06/18/21. Review of the Physician Orders revealed the following: Remeron (Mirtazapine - an anti-depressant medication), 7.5 milligram (mg) tablet, give one tablet by mouth, one time a day for depression, date ordered 10/18/22. Seroquel (quetiapine fumarate - an antipsychotic medication), 50 mg tablet, give one tablet by mouth, tow times a day dementia with unspecified severity, with other behavioral disturbances, date ordered 04/18/23. Clonazepam (an anti-anxiety medication), 0.5 mg tablet, give one tablet, by mouth, two times a day, for anxiety/restlessness, date ordered 06/23/24. Clonazepam 0.5 mg tablet, give one tablet, by mouth, every four hours as needed for anxiety, date ordered 06/24/25. Review of the pharmacy medication regimen reviews (MRR) reports revealed that on 09/24/24 MRR R3 had received, Clonazepam 0.5 mg twice a day, and Clonazepam 0.5 mg tab every four hours as needed. Mirtazapine 15 mg po at bedtime, and Seroquel 50 mg twice a day. The facility must attempt a gradual dose reduction (GDR stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic medications to find the lowest effective dose. The facility lacked an appropriate physician response for the GDR with his only statement was disagree, dated 10/22/24. During an observation of 01/23/25 at 07:21 AM, R3 was seated in her wheelchair in the lobby with her eyes closed. During an observation of 01/27/25 at 06:48 AM, R3 received care from Certified Nurse Aide (CNA) F and Certified Medication Aide (CMA) P. R3 had no behaviors, followed requests and showed understanding to what staff were asking her to do. R3 kept her eyes closed most of the time During an interview 01/23/25 at 03:23 PM, Administrative Nurse B confirmed the above information related to the timeliness of the MRR and GDR request stated that her expectation is that the physician would respond within a week, and then a second request would be made and was unsure of what policy and/or procedures were in place to ensure timely follow-up from a physician who refuses to respond timely or appropriately to MRR or GDR requests. During an interview on 01/27/25 at 03:31 PM, Administrative Nurse B reported that the diagnoses physician documented for Seroquel was unacceptable. Additionally, she reported she was not aware that the Clonazepam as needed ordered required a fourteen day stop date and re-evaluation by physician. The facility's undated Medication Regimen Reviews policy documented that a consultant pharmacist would conduct a MRR of each resident who received medication in the facility at least monthly and as needed, if indicated. If the physician does not provide a timely or adequate response to the report or if no action has been taken, the consultant pharmacist would contact the medical director or administrator. The facility did not provide a policy specific to a GDR process as requested on 01/27/24. The facility failed to ensure that R3s medication remained free of unnecessary medications when the facility failed to ensure that R3's physician responded in a timely manner to a GDR request and with an appropriate response as to why no GDR was warranted from the consultant pharmacist. Additionally, the facility failed to have an as necessary anti-anxiety medication re-evaluated every fourteen days. - The Electronic Health Records (EHR) documented Resident (R)25 had the following diagnoses that included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), Alzheimer's disease, (progressive mental disorder characterized by failing memory, confusion),anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), insomnia (inability to sleep), hypertension (elevated blood pressure)depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (progressive mental disorder characterized by failing memory, confusion). The 06/04/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition, and a PHQ-9 (an assessment scale to determine the presence of depression) totaled 0. R25 had no behaviors to indicate psychosis (any major mental disorder characterized by a gross impairment in reality perception). R25 received an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), hypnotic (a class of medications used to induce sleep and treat insomnia) medication, opioid (class of drug used to treat moderate to severe pain) medication, antiplatelet (class medications that prevent platelets from clumping together and forming clots) medications and antidepressant (class of medications used to treat mood disorders) medications . The 06/14/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R25 is on Restoril (temazepam- a sedative/hypnotic medication), Geodon (ziprasidone- an antipsychotic medication), Seroquel (quetiapine - an antipsychotic medication), Pristiq (desvenlafaxine- antidepressant medication) and Lorazepam (Ativan- an antianxiety medication.) The 11/12/24 Quarterly MDS documented Brief Interview for Mental Status BIMS score of 99 staff unable to complete and lacked a PHQ-9th. R25 had behaviors of yelling and hitting. R25 received an antipsychotic, antianxiety, hypnotic, opioid, antiplatelet and antidepressant. On 11/25/24 the Care Plan documented Medical Doctor responded to gradual dose recommendations (GDR) request noting this is a chronic long-term issue and no changes would be made unless R25 had a significant change. Initiated 07/07/23. The 11/25/24 Care Plan documented R25 utilized the following medications: Pristiq (desvenlafaxine ER), Seroquel (quetiapine), Geodon (ziprasidone), Plavix (clopidogrel - a blood thinner medication), Restoril (temazepam), Lorazepam (Ativan), and Ultram (Tramadol - an opioid medication). Initiated on 07/01/22, staff would monitor and report adverse reactions (unintended effects caused by medication use) to medication to nurse if R25 exhibited signs and symptoms: falls, weight loss, fatigue, agitation, depression, lethargy, unsteadiness, confusion, poor appetite, constipation, diarrhea, bruising, and red eyes. The 11/25/24 Care Plan documented R25 utilized the following psychotropic medications (Geodon and Quetiapine) r/t dementia with psychotic disturbance. Initiated on 07/14/22, staff would monitor and report adverse reactions of psychotropic medications such as unsteady gait, tardive dyskinesia(abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting and any behavior symptoms not usual to the person. Care plan lacked documentation in accordance with how often a consult with pharmacy, health care provider to consider dosage reduction when clinically appropriate. Along with consulting pharmacist and physician would review medications to use the lowest possible effective dose. On 01/23/25, review of the Physician Orders revealed the following: Restoril (Temazepam), oral capsule 30 milligram (mg), give one tablet, by mouth (PO), as needed, at bedtime (HS), for sleep, ordered 09/03/24, end date indefinite. The order lacked a stop date or rationale for the continued use of the medication. Review of the Census tab on the EHR revealed that R25 admitted to the facility on [DATE]. Review of the electronic Medication Administration Record (eMAR) from 09/01/24 to 01/01/25 revealed R25 had received 16 doses of PRN Restoril (Temazepam) 30mg and lacked evidence of an ordered stop date. Review of the pharmacy monthly medication review (MRR) reports revealed that on 09/24/24 the pharmacist recommended a GDR for Geodon (ziprasidone- an antipsychotic medication). The facility faxed the physician on 10/14/24 and the physician disagreed without a date or a rationale which and was documented as noted by the facility on 10/22/24. On 10/22/24, Consultant Pharmacist recommended discontinuing the order for Restoril (Temazepam), scheduled for Once a day at bedtime (qHS) since there were two active orders with different dosages scheduled at this time. One order was for Restoril (Temazepam), 30mg qHS and the other was for Restoril (Temazepam) 15 mg qHS. Provider responded to discontinue the order for Restoril (Temazepam) 30 mg and keep the order of Restoril (Temazepam) 15 mg QHS on 10/22/24. Facility this on 11/4/24. On 12/16/24 Consultant Pharmacist recommended, reviewing and updating the missing side effects for Pristiq (desvenlafaxine) to residents chart. Provider has not responded. Observation on 01/22/25 at 09:05 AM R25 shirt appeared to have stains from uneaten food present. R25 had not been shaved and appeared unkept with hair unbrushed and face unwashed. Observation on 01/23/25 at 07:27 AM, R25 was laid on his couch rested with eyes closed appeared to be sleeping on his couch still dressed in the shirt which had the same appearance and food debris observed on 01/22/25. R25 appeared calm and relaxed. Observation on 01/23/25 at 09:08 AM, R25 was seated on his couch with his covers across his knees and bedroom lights turned off and appeared calm and relaxed. R25 had just finished with eating his breakfast and had just gotten some of his smokeless tobacco. Observation on 01/23/25 at 09:31 AM, R25 was administered his morning medications while seated on his couch and R25 appeared calm and relaxed with a pleasant/joking demeanor. R25 allowed staff to administer medications without difficulty and to aid with cares without difficulty. The facility failed to ensure that R25's medication remained free of unnecessary medications when the facility failed to ensure that R25's physician responded in a timely manner to a GDR request from the consultant pharmacist. During an interview on 01/27/25 at 01:08 PM, Administrative Nurse B confirmed the order for PRN Restoril (Temazepam) in R25's EHR lacked a stop date. Administrative Nurse B stated she was unaware of the regulatory requirement that PRN psychotropic medications required a 14 day stop date or documented an appropriate clinical rationale for continued use beyond the 14 days. The facility's Psychotropic Medication Use policy dated 07/2022 documented that for psychotropic medications that are antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The facility failed to ensure a 14-day stop date or physician rationale for continued use beyond the 14 days, for R25's PRN psychotropic medication, Restoril (Temazepam). This deficient practice had the potential for R25 to receive an unnecessary psychotropic medication.

The facility reported a census of 32 residents. The sample included 12 residents, with five reviewed for immunizations. The facility failed to provide proper documentation of vaccination or declination of vaccines for COVID-19 (vaccines designed to prevent COVID-19 [highly contagious respiratory virus]) for, Resident (R) R11. Also failed to provide documentation of pneumococcal (vaccines designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) for R84. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R) 11 lacked documentation that the COVID vaccine was offered or had been declined. Review of the Electronic Health Record (EHR) for Resident (R) 84 lacked documentation of any pneumococcal vaccine or COVID vaccine being given or declination of the vaccine(s). On 01/28/24 at 10:41 AM, Administrative Nurse C confirmed the requested proof of vaccines or declinations could not be found. Administrative Nurse B stated the Covid vaccine was not offered to R11 as he was not in the facility when the vaccines where being given. Administrative Nurse B stated she is not able to produce documentation of R84 vaccines currently. The facility did not provide a policy specific to a Pneumococcal or Covid Vaccine process as requested on 01/27/24. The facility failed to provide proof of vaccination or declination of vaccines for the COVID vaccine and pneumococcal vaccines for R11 and R84. This deficient practice had the potential to lead to an outbreak of respiratory infections with the residents in the facility.

The facility had a census of 31 residents with one main kitchen that served one dining room. Based on observation, interviews, and record review the facility failed to properly store food under sanitary conditions for all the residents of the facility. Findings included: - During the initial environmental tour of the dietary department on [DATE] at approximately 08:14 AM, the following concerns were identified: 1. An opened bag of brown sugar was found in an undated Ziplock bag located on a wire rack in the dry goods storage area. 2. Two quart sized Hiland Fresh Half & Half with an expiration date of [DATE] were found in the walk-in cooler. 3. Five quart sized Hiland Fresh Half & Half with an expiration date of [DATE]were found in the walk-in cooler. 4. Two quart sized Hiland Fresh Half & Half with an expiration date of [DATE] were found in the walk-in cooler. 5. One gallon sized Hiland Vitamin D Milk with an expiration date of [DATE] was found in the walk-in cooler. 6. One gallon sized Hiland Vitamin D Milk with an expiration date of [DATE] was found in the walk-in cooler. 7. Two gallon sized Hiland Lowfat Ice Cream Milk with an expiration date of [DATE] was found in the walk-in freezer. 8. One quart sized Hiland Cultured Lowfat Buttermilk with an expiration date of [DATE] was found in the walk-in freezer. 9. One opened bag of French fries was found in the walk-in freezer with no opened date written on the package. During the follow-up environmental tour of the dietary department on [DATE] at approximately 11:11 AM, the following concerns were identified: 1. Five quart sized Hiland Fresh Half & Half with an expiration date of [DATE]were found in the walk-in cooler. 2. One gallon sized Hiland Skim Milk dated [DATE]was found in the walk-in cooler. 3. Two gallon sized Hiland Lowfat Ice Cream Milk with an expiration date of [DATE]were found in the walk-in freezer. During an interview on [DATE] at 11:06 AM, Dietary Manager (DM) E stated she expected staff to rotate foods and make sure expired food items were discarded. DM E stated any food items taken out of their original packaging should be dated. Review of the Refrigerators and Freezers policy revised [DATE] revealed, All food shall be appropriately dated to ensure proper rotation by expiration dates .Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Review of the Food Receiving and Storage policy revised [DATE] revealed, All foods stored in the refrigerator or freezer will be .labeled and dated. The facility failed to properly store food items placed in a refrigerator, freezer, and in the dry goods storage area by not ensuring the food items were dated and not expired.

The facility census totaled 31 residents. Based on interview and record review, the facility failed to ensure all facility staff were trained on Abuse, Neglect, and Exploitation ([NAME]), Dementia Care, and Social Media annually. Findings included: - Review of staff training records for Certified Nurse Aide (CNA) F and CNA I lacked [NAME] training evidenced from 05/01/20 through 05/31/2021. Review of staff training records for CNA F and CNA J lacked Dementia care training evidenced from 05/01/20 through 05/31/21. Review of staff training records for CNA F, CNA G, CNA H, CNA I, and CNA J lacked Social Media training evidenced from 05/01/20 through 05/31/21. Interview with Administrative Nurse A and Administrative Nurse K on 06/02/21 at 03:20 PM revealed there was no method for monitoring in-services completed by CNAs. Both staff members encouraged staff to complete their training, but did not monitor it and stated that it was expected for all staff to have their training completed by the due date. Administrative Nurse K stated social media training was not tied together with any other training and was not completed by the facility since 2018. Review of the undated Facility Assessment stated [staff members] have ongoing yearly competencies, conducted and run by [Administrative Nurse K]. Administrative Nurse K was to ensure staff were current and up to date on their competencies. Review of the revised 05/2019 facility policy entitled In-Service Training Program, Nurse Aide revealed all personnel were required to attend regularly scheduled in-service training classes over 12 months, that included training in dementia management and abuse prevention. All training was to be placed in the employee's Record of In-Service by the department supervisor and maintained by the department supervisor. The facility failed to ensure all staff received training over [NAME], Dementia Care, and Social Media annually.

The facility reported a census of 31 residents, with 12 sampled, including five for unnecessary medications. Based on observation, interview, and record review, the facility failed to address the consultant pharmacist's recommendations for Resident (R)28, R23, R9, and R32. Findings included: - Review of R28's Physician's Orders Electronic Medical Record included a diagnosis of Diabetes Mellitus (DM) (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), Anxiety Disorder, Dementia (a progressive mental disorder characterized by failing memory, confusion), Hypertension ([CONDITION(S)])-(elevated blood pressure) and Gastroesophageal reflux disorder (GERD)- backflow of stomach contents to the esophagus). A review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed R28 received scheduled and as needed (PRN) pain medication, as well as seven out of seven days of antipsychotics (class of medications used to treat [CONDITION(S)] and other mental, emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). A review of the Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/14/21, documented R28 had a history of dementia and anxiety with several behaviors, including yelling, screaming, kicking, and abusive language. R28 had a historical brief interview for mental status (BIMS) of moderate to severely impaired cognition. Review of the [CONDITION(S)] Drug Use CAA dated 05/14/21 revealed R28 received [MEDICATION(S)] (antianxiety medication), [MEDICATION(S)] (antianxiety medication), [MEDICATION(S)] (antianxiety medication) and [MEDICATION(S)] (antidepressant). Review of the Quarterly MDS dated [DATE] documented a BIMS of 6, indicating severely impaired cognition. R28 received scheduled and PRN pain medication, as well as seven out of seven days of antipsychotics, antianxiety, and antidepressants. R28 also received five out of seven days of opioids (class of drug used to reduce pain). The review of the Care Plan, last revised on 05/30/21, revealed staff was to administer medications as ordered and document any side effects and effectiveness. Staff was to monitor R28 for behaviors and document episode(s). Review of the Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) regarding Resident (R) 28 documented the following: On the 03/2020 MRR and GDR, the consultant pharmacist stated that [MEDICATION(S)] (antianxiety medication) 0.25mg tablet PRN every 4 hours for agitation needed to have an end date of 14 days, per the Centers for Medicare and Medicaid Services (CMS) guidelines. The facility failed to act on this recommendation. On the 09/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] be considered for a GDR, per CMS guidelines. The facility failed to act on this recommendation. On the 10/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] be discontinued (stopped) due to lack of use. The facility failed to act on this recommendation. On the 11/2020 MRR and GDR, the consultant pharmacist recommended that yearly labs be completed. The facility failed to act on this recommendation. On the 12/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] be considered for a GDR, per CMS guidelines. The facility failed to act on this recommendation. On 01/2021, MRR and GDR, the consultant pharmacist, recommended that [MEDICATION(S)] and [MEDICATION(S)] be considered for a GDR, per CMS guidelines. The facility failed to act on these recommendations. An interview on 06/08/21 at 11:59 AM with Licensed Nurse (LN) B revealed the provider would come in and sign the orders from the pharmacy as needed. An interview on 06/08/21 at 09:30 AM with Administrative Nurse A and Administrative Nurse D revealed all MRRs and GDRs went directly to Administrative Nurse A after the Consultant Pharmacist completed them each month. If the recommendation were for the provider, Administrative Nurse A would fax the MRR and GDR to the provider and note when they sent it. When the provider finished with the MRR and GDR, they would be faxed back to the facility and signed with any updates, changes, or responses. Administrative Nurse A expected the nurses to complete a progress note about the response received from the provider and update any orders as needed. Interview with Consultant Pharmacist L on 06/09/21 at 01:34PM revealed she made multiple attempts to either schedule the PRN [MEDICATION(S)] or to add the 14-day limit on the PRN [MEDICATION(S)], per the CMS guideline for PRN [CONDITION(S)] drugs but received no response from the provider. The Consultant Pharmacist also made multiple attempts in a GDR to discontinue the [MEDICATION(S)] due to very little use of the medication but received no response from the provider. Consultant Pharmacist L stated the facility was supposed to send the recommendations to the provider and then the provider had a certain amount of time to respond back. If Consultant Pharmacist L did not have a response, she let it sit as a no response for three months, and on the third month, she would resend the recommendation. After it was sent twice, she did not send the recommendation anymore. Review of the facility's Medication Regimen Review policy revised 05/2019 revealed if the facility did not receive a timely response from the physician, they would contact the Medical Director or the Administrator. The facility failed to follow up on the consultant pharmacist recommendations for R28 timely. - Review of R23's Physician's Orders Electronic Medical Record included a diagnosis of [CONDITION(S)] (A-Fib; rapid, irregular heartbeat), [CONDITION(S)] (Heart condition that includes diseased vessels, structural problems, and blood clots), Depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and [CONDITION(S)] (elevated blood pressure). A review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed R23 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. R23 received seven out of seven days of anticoagulants (blood thinners). A review of the Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/02/21, documented R23 had a BIMS of 7, indicating severe cognitive impairment. Review of the Quarterly MDS dated [DATE] documented R23 had a BIMS of 10, indicating moderately impaired cognition. R23 received seven out of seven days of anticoagulants. The review of the Care Plan, last revised on 05/30/21, revealed R23 received [MEDICATION(S)] (blood thinner) and [MEDICATION(S)] (antihypertensive). Review of the Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) regarding R23 documented the following: On 01/2021, MRR and GDR, the consultant pharmacist, stated that [MEDICATION(S)] Sulfate (iron supplement) needed a strength for the medication added to the order. The facility failed to act on this recommendation until 06/08/21. An interview on 06/08/21 at 09:30 AM with Administrative Nurse A and Administrative Nurse D revealed all MRRs and GDRs went directly to Administrative Nurse A after the Consultant Pharmacist completed them each month. If the recommendation were for the provider, Administrative Nurse A would fax the MRR and GDR to the provider and note when they sent it. When the provider finished with the MRR and GDR, they would be faxed back to the facility and signed with any updates, changes, or responses. Administrative Nurse A expected that nurses to complete a progress note about the response received from the provider and update any orders as needed. Review of the facility's Medication Regimen Review policy revised 05/2019 revealed if the facility did not receive a timely response from the physician, they would contact the Medical Director or the Administrator. The facility failed to follow up on the consultant pharmacist recommendations for R23. - Review of R9's Physician's Orders Electronic Medical Record included a diagnosis of DM, [CONDITION(S)], [CONDITION(S)], Chronic pain, GERD, Major Depressive Disorder (MDD) (major mood disorder), and Chronic Kidney Disease. A review of the Annual Minimum Date Set (MDS) dated [DATE] documented a Brief Interview for Mental Statue (BIMS) score of 15, indicating intact cognition. R9 received scheduled and PRN pain medication. In addition, R9 received seven out of seven days of insulin (mediation that regulates the amount of glucose in the blood) and six out of seven days of opioids. Review of the Care Area Assessment) (CAA) dated 12/23/20 documented no applicable CAAs triggered. Review of the Quarterly MDS dated [DATE] documented a BIMS of 15, indicating intact cognition. R9 received scheduled and PRN pain medication. In addition, R9 received seven out of seven days of insulin and diuretics (medication to induce urination to reduce blood pressure). The review of the Care Plan, last revised on 01/13/21, revealed staff was to obtain, monitor, and document R9's blood glucose (BG; blood sugar) and report any BG greater than 400 to the provider. In addition, staff was to monitor and document R9 for pain and give medication as ordered. Review of the Electronic Health Records (EHR) Physician Orders documented the following orders: 10/02/18: BG check twice a week on Mondays and Thursdays for DM 03/02/19: BG check at bedtime PRN for DM 06/15/17: Hold Novolog insulin if BG is less than 120 07/06/17: Notify provider for BG less than 60 or greater than 350 11/27/19: [MEDICATION(S)] insulin 28units subcutaneously (SQ; in the fat) every day for DM 10/17/18: Novolog insulin 8units SQ twice a day for DM 12/19/18: Novolog insulin 6units SQ PRN for BG greater than 250 for DM Review of the 03/2021 through 06/2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following errors: 03/01/21: BG of 114, insulin was given 03/04/21: BG of 96, insulin was given 03/08/21: BG of 93, insulin was given 03/11/21: BG of 81, insulin was given 03/15/21: BG of 118, insulin was given 03/18/21: BG of 99, insulin was given 03/25/21: BG of 109, insulin was given 04/01/21: BG of 106, insulin was given 04/05/21: BG of 112, insulin was given 04/15/21: BG of 93, insulin was given 04/22/21: BG of 100, insulin was given 04/27/21: BG of 361, no PRN insulin was given 05/03/21: BG of 98, insulin was given 05/06/21: BG of 101, insulin was given 05/15/21: BG of 279, PRN insulin was given twice (documented in progress notes) 05/18/21: BG of 478, PRN insulin was given (documented in progress notes) 05/19/21: BG of 303, PRN insulin was given twice (documented in progress notes) 05/20/21: BG of 255, no PRN insulin was given 05/27/21: BG of 110, insulin was given 05/31/21: BG of 98, insulin was given Review of the Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) regarding R28 documented the following: On 01/2021, MRR and GDR, the consultant pharmacist, documented that both [MEDICATION(S)] (antiplatelet) and [MEDICATION(S)] (blood thinner) was being given to R9 and requested the facility clarify the orders with the provider. The facility failed to act on this recommendation until 06/08/21 by sending an Situation Background Assessment Recommendation (SBAR) communication form to the provider requesting clarification. An interview on 06/07/21 at 01:59 PM with Administrative Nurse A and Administrative Nurse D revealed neither staff member understood the orders placed in the chart and stated that the orders did not make sense. Both staff members were surprised to see that no one had caught the issues. An interview on 06/08/21 at 11:59 AM with Licensed Nurse (LN) B revealed the provider would come in and sign the orders from the pharmacy as needed. An interview on 06/08/21 at 09:30 AM with Administrative Nurse A and Administrative Nurse D revealed all MRRs and GDRs went directly to Administrative Nurse A after the Consultant Pharmacist completed them each month. If the recommendation were for the provider, Administrative Nurse A would fax the MRR and GDR to the provider and note when they sent it. When the provider was finished with the MRR and GDR, they would be faxed back to the facility and signed with any updates, changes, or responses. Administrative Nurse A expected that nurses to complete a progress note about the response received from the provider and update any orders as needed. Interview with Consultant Pharmacist L on 06/09/21 at 01:53 PM revealed R28 was on a sliding scale with her insulin, which meant R28 would receive an extra 6 units of insulin if her BG was 250 or more. R28 should have her BG tested before insulin is given. Consultant Pharmacist L stated that the order to test BG twice a week made no sense and did not follow the PRN insulin order. Consultant Pharmacist L continued by stating that any BG less than 120 indicated the scheduled Novolog insulin should have held but would require the BG to be checked before each meal. Consultant Pharmacist L stated that she did not look at BG often unless there was an issue occurring with R28, because she did not have access to see all the orders provided in the chart. Consultant Pharmacist L was not aware that extra PRN insulin was being given or that the BG was not being checked prior to meals. Review of the facility's Medication Regimen Review policy revised 05/2019 revealed the resident's medical record would be reviewed each month for medication errors and other irregularities including those related to documentation. If the physician did not provide a timely or adequate response, staff were to notify the Medical Director or the Administrator. The facility failed to follow up on the consultant pharmacist recommendations. - Review of Resident (R)32's signed Physician Orders dated 05/17/21 revealed a diagnosis of [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing). Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. No behaviors present or exhibited. R32 received an antidepressant and diuretic six days during the 7-day lookback period. Review of the Medicare 5-Day MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. R32 exhibited verbal behavioral symptoms directed towards others one to three days during the lookback period. R32 received an antipsychotic and antidepressant six days during the 7-day lookback period. Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 08/04/20 revealed R32 took [MEDICATION(S)] (an antidepressant medication). Review of R32's Care Plan dated 04/21/21 revealed R32 had an issue with anxiety and being very tearful at times. R32 took [MEDICATION(S)] as needed as her anxiety increased beyond management. R32's medications would be reviewed by the pharmacist consultant monthly, by a physician every 60 days, and by both as needed. Review of the Physician Orders revealed R32 had an order dated 05/24/21 for [MEDICATION(S)] (an antianxiety medication) 0.5 milligrams (mg), give one tablet by mouth every six hours as needed (PRN) for anxiety. R32 also had an order dated 04/12/21 for [MEDICATION(S)] 2 mg, give one tablet by mouth every six hours PRN for [CONDITION(S)]. Both of these orders exceeded the 14-day limit for PRN psychoactive medication use without a physician's reevaluation for appropriateness of use. Review of the April 2021 Electronic Medication Administration Record (EMAR) revealed R32 received PRN [MEDICATION(S)] 2mg five times during the month of April. Review of the Pharmacist Review dated 04/28/21 revealed R32 had a PRN order for [MEDICATION(S)] 2 mg. The pharmacist provided guidance as follows: Per CMS guidelines PRN anxiolytic medications are not appropriate for longer than 14 days without clinical rational and a stop date/re-evaluation dated listed .Please consider adding the .stop date into the patients chart. During an interview on 06/09/21 at 01:48 PM revealed Consultant Pharmacist L stated R32 had orders for PRN [MEDICATION(S)]. Consultant Pharmacist L stated she made the first recommendation to the facility on [DATE] and have not heard back from the facility. As of 05/26/21, R32 now had two orders for PRN [MEDICATION(S)]. Consultant Pharmacist L requested clarification on these two PRN orders, and it was her expectation that the facility followed-up with her concerns or recommendations. During an interview on 06/08/21 at 1:27 PM, Administrative Nurse A stated it was her expectation that PRN orders for [CONDITION(S)] medications be discontinued after 14 days or have a physician reevaluate the order for continued use. Review of the Medication Regimen Reviews policy revised May 2019 revealed, Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity .If the Physician does not provide a timely or adequate response, or the Consultant identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. The facility failed to act upon the Consultant Pharmacists concerns about the orders for R32's PRN [MEDICATION(S)] which exceeded the 14-day limit without a physician reevaluating the appropriateness for continued use on a PRN basis.

The facility reported a census of 31 residents, with 12 sampled and five reviewed for unnecessary medications. Based on interviews and record review, the facility failed to adequately follow the physicians' diabetic orders and document appropriately for Resident (R) 9. Findings included: - Review of R9's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R9 received scheduled and as needed (PRN) pain medication. R9 received insulin (mediation that regulates the amount of glucose in the blood) seven out of a seven-day observation period and opioids (class of drug used to reduce pain) six out of the seven-day observation period. R9 did not receive antipsychotics (class of medications used to treat [CONDITION(S)] and other mental emotional conditions). Review of the Care Area Assessment (CAA) dated 12/23/20 documented no applicable CAAs triggered. Review of the Quarterly MDS dated [DATE] documented a BIMS of 15, indicating intact cognition. R9 received scheduled and PRN pain medication. R9 received insulin and diuretics (medication to induce urination to reduce blood pressure) seven out of seven days of the observation period. R9 did not receive antipsychotics. Review of the Care Plan, last revised on 01/13/21, revealed staff was to obtain, monitor and document R9's blood glucose (BG; blood sugar) and report any BG greater than 400 milligrams per deciliter (mg/dl) to the provider. Staff was to monitor and document R9 for pain and give medication as ordered. Review of the Electronic Health Records (EHR) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 10/02/18: BG check twice a week on Mondays and Thursdays for DM 03/02/19: BG check at bedtime as needed (PRN) for DM 06/15/17: Hold Novolog insulin if BG is less than 120 mg/dl 07/06/17: Notify provider for BG less than 60 mg/dl or greater than 350 mg/dl 11/27/19: [MEDICATION(S)] insulin 28 units subcutaneously (SQ; in the fat) every day for DM 10/17/18: Novolog insulin 8 units SQ twice a day for DM 12/19/18: Novolog insulin 6 units SQ PRN for BG greater than 250 mg/dl for DM Review of the 03/2021 through 06/2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following: 03/01/21: Staff administered scheduled Novolog insulin with BG of 114 mg/dl (even with an order to hold insulin if less than 120). 03/04/21: Staff administered scheduled Novolog insulin with BG of 96 mg/dl. 03/08/21: Staff administered scheduled Novolog insulin with BG of 93 mg/dl. 03/11/21: Staff administered scheduled Novolog insulin with BG of 81 mg/dl. 03/15/21: Staff administered scheduled Novolog insulin with BG of 118 mg/dl. 03/18/21: Staff administered scheduled Novolog insulin with BG of 99 mg/dl. 03/25/21: Staff administered scheduled Novolog insulin with BG of 109 mg/dl. 04/01/21: Staff administered scheduled Novolog insulin with BG of 106 mg/dl. 04/05/21: Staff administered scheduled Novolog insulin with BG of 112 mg/dl. 04/15/21: Staff administered scheduled Novolog insulin with BG of 93 mg/dl. 04/22/21: Staff administered scheduled Novolog insulin with BG of 100 mg/dl. 04/27/21: Staff failed to administer PRN insulin with a BG of 361, the record further lacked evidence they notified the physician as ordered. 05/03/21: Staff administered scheduled Novolog insulin with BG of 98 mg/dl. 05/06/21: Staff administered scheduled Novolog insulin with BG of 101 mg/dl. 05/11/21: Staff administered PRN insulin for a BG of 450 mg/dl, but the record lacked evidence they notified the physician as ordered. 05/15/21: Staff administered PRN insulin twice with a BG of 279 mg/dl, (documented in progress notes), but only documented once in the MAR. 05/16/21: Staff did not notify the provider of a BG of 360 mg/dl. 05/18/21: Staff administered PRN insulin for a BG of 478 mg/dl, (documented in progress notes), but not documented in the MAR and failed to notify the provider. 05/19/21: Staff administered insulin twice with a BG of 303 mg/dl, (documented in progress notes), but only documented once in the MAR. 05/20/21: Staff failed to administer PRN insulin with a BG of 255 mg/dl. 05/27/21: Staff administered scheduled Novolog insulin with BG of 110 mg/dl. 05/31/21: Staff administered scheduled Novolog insulin with BG of 98 mg/dl. An interview with Certified Medication Aide (CMA) M on 06/07/21 at 01:30PM revealed I know her BG check pops up once a shift during the day. Both the nurse and the CMA can get the blood sugar. I do not give insulin as a med aide. Once a blood sugar is taken, I document manually into the chart and I tell the nurse. I do not know what her parameters are for blood sugars, but I always tell the nurse of a BG that is higher than 300 or lower than 70s. To my knowledge, she has never been symptomatic, but I would tell the nurse if she was. An interview with Licensed Nurse (LN) B on 06/07/21 at 10:08AM revealed Her BG is checked in the morning on the scheduled day but is not checked throughout the day. Her insulin is scheduled at noon and dinner time, and her long acting is at bedtime. I do not work night shift, but I am not sure if they check a BG before giving the long acting. Her BG this morning was 98 and will be getting her noon insulin. If she became symptomatic, we would check her BG and hold it if needed. She is cognizant and will tell staff if she is not feeling well. I have never had to call the provider for any BGs outside of the parameters. An interview on 06/07/21 at 01:59PM with Administrative Nurse A and Administrative Nurse D revealed there is a hold Novolog for BG less than 120, but these orders do not make sense. With the BG less than 120, the Novolog should be held, but it was not. She does not like to be woken up in the morning to have her sugar checked. Whoever put the order in, did not do it correctly. It should be set in the EMAR order to be required to enter the BG before giving the insulin. I do not know if you can give supplemental documentation currently. There is always a BG PRN order on the EMAR. Her BG was high in May because she had an [MEDICATION(S)] in the back and the provider was aware of this. But staff should have been notifying the provider of the high levels. She used to be checked for her BG TID, but she was doing so well, that the order was changed to twice a week. It looks like the Hold Novolog less than 120 was older than the check BG twice a week order. We need to discuss with the provider and get these orders clarified. We did not do a good job at catching this during the order change. Interview with Consultant Pharmacist L on 06/09/21 at 01:53PM revealed she is on a sliding scale with her BG. She should be tested before they give insulin. She is always going to get 8units at meals but anything over 250, she should be getting an extra 6 units. If there is going to be a sliding scale, you must test before giving the insulin, so the order to test twice a week does not make sense. There would be no way to know what the blood sugar is and when to give insulin. The BG of less than 120 should have been holding the insulin. I do not look at the blood sugars all that often unless there is an issue happening, because the orders I am able to see do not say anything about holding insulin. I do not have access to see the blood sugars, as I only have access to the EMAR. If it is not being documented in the EMAR, I do not know. A review of the revised 04/2007 Documentation of Medication Administration facility policy stated A nurse or CMA shall document all medications administered to each resident on the resident's MAR .[documentation] must include reason(s) why a medication was withheld, not administered, or refused. A review of the 04/2007 Medication Therapy facility policy stated .periodically, the staff and practitioner will review an individual's current medication regimen, to identify whether .the frequency of administration and duration of use are appropriate. The facility failed to adequately follow the physicians' diabetic orders and document appropriately for R9.

The facility reported a census of 31 residents, with 12 sampled, including five reviewed for unnecessary medications. Based on interview and record review, the facility failed to provide a stop date on the as needed (PRN) [CONDITION(S)] medication for Resident (R) 28 and R32. Findings included: - Review of R32's Physician's Orders in the Electronic Medical Record (EMR) included a diagnosis of Anxiety Disorder and Dementia (progressive mental disorder characterized by failing memory, confusion). A review of the Significant Change Minimum Data Set (MDS), dated [DATE], documented R28 received scheduled and as needed (PRN) pain medication, as well as seven out of the seven day observation period of antipsychotics (class of medications used to treat [CONDITION(S)] and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). Review of the Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/14/21 documented R28 had a history of dementia and anxiety with several behaviors including yelling, screaming, kicking, and abusive language. R28 had a historical Brief Interview for Mental Status (BIMS) score, which indicated moderate to severely impaired cognition. Review of the [CONDITION(S)] Drug Use CAA dated 05/14/21 R28 received [MEDICATION(S)] (antianxiety medication), [MEDICATION(S)] (antianxiety medication), [MEDICATION(S)] (antianxiety medication) and [MEDICATION(S)] (antidepressant). Review of the Quarterly MDS dated [DATE] documented a BIMS of 6, indicating severely impaired cognition. R28 received scheduled and as needed (PRN) pain medication, as well as antipsychotics, antianxiety, and antidepressants seven days of the seven day observation period. R28 also received five out of seven days of opioids (class of drug used to reduce pain). The review of the Care Plan, last revised on 05/30/21, revealed staff was to administer medications as ordered and document any side effects and effectiveness. Staff was to monitor R28 for behaviors and document episode(s). Review of the Electronic Health Records (EHR) Physician Orders documented an order for [MEDICATION(S)] (antianxiety medication) 0.5 milligram (mg) tablet, staff would give one tablet by mouth every four hours as needed for agitation started on 04/30/21, with no stop date identified. Review of 01/2021 through 06/2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented appropriate documentation of administrations of medications and monitoring of behaviors. Interview with Consultant Pharmacist L on 06/09/21 at 01:34PM revealed On 03/28/20, I asked for a 14-day limit on the [MEDICATION(S)] 0.25 mg every 4 hours PRN, with no response. On 10/21/20 I asked that the [MEDICATION(S)] be stopped due to non-use in 90 days, but received no response. A new dose of 0.5 mg every four hours PRN started on 04/30/21 with no end date. The facility is supposed to send the recommendations to the provider and then the provider has a certain amount of time to respond back. It depends on the provider as to when it is completed. If I do not have a response, I let it sit as a no response for three months, and on the third month, I resend the recommendation. After it is sent twice, I do not send it anymore. Review of the revised 12/2016 Antipsychotic Medication Use facility policy, documented the need to continue PRN orders for [CONDITION(S)] medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. The facility failed to provide a stop date on the PRN [CONDITION(S)] medication for R28. - Review of Resident (R)32's signed Physician Orders dated 05/17/21 revealed the following diagnoses: [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing). Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. No behaviors present or exhibited. R32 received an antidepressant and diuretic six days during the 7 day lookback period. Review of the Medicare 5-Day MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. R32 exhibited verbal behavioral symptoms directed towards others one to three days during the lookback period. R32 received an antipsychotic and antidepressant six days during the 7-day lookback period. Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 08/04/20 revealed: R32 took [MEDICATION(S)] (an antidepressant medication). Review of R32's Care Plan dated 04/21/21 revealed R32 had an issue with anxiety and being very tearful at times. R32 took [MEDICATION(S)] as needed as her anxiety increased beyond management. Review of the Physician Orders revealed R32 had an order dated 05/24/21 for [MEDICATION(S)] (an antianxiety medication) 0.5 milligrams (mg), give one tablet by mouth every six hours as needed (PRN) for anxiety. R32 also had an order dated 04/12/21 for [MEDICATION(S)] 2 mg, give one tablet by mouth every six hours PRN for [CONDITION(S)]. Both of these orders exceeded the 14-day limit for PRN psychoactive medication use without a physician's reevaluation for appropriateness of use. Review of the April 2021 Electronic Medication Administration Record (EMAR) revealed R32 received PRN [MEDICATION(S)] 2mg five times during the month of April. An observation on 06/07/21 at 08:23 AM revealed R32 rested in her bed after having breakfast. R32 was calm and did not exhibit any negative behaviors. During an interview on 06/07/21 at 01:17 PM, Certified Nurse Aide (CNA) C stated R32 did not really exhibit any negative behaviors, but did have a period of time where she stopped eating because she did not want to live. During an interview on 06/08/21 at 08:58 AM, Licensed Nurse (LN) B stated R32 did not exhibit any negative behaviors towards other residents or staff. LN B stated nursing staff monitored for behaviors, and there was a time when R32 would not eat or take medications. LN B stated R32 had not exhibited any anxious behaviors recently, but had PRN [MEDICATION(S)] available to use. During an interview on 06/08/21 at 1:27 PM, Administrative Nurse A stated it was her expectation that PRN orders for [CONDITION(S)] medications be discontinued after 14 days or have a physician reevaluate the order for continued use. Review of the Antipsychotic Medication Use policy revised December 2016 revealed, The need to continue PRN orders for [CONDITION(S)] medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. The facility failed to ensure the orders for R32's PRN [MEDICATION(S)] did not exceed the 14-day limit without a physician reevaluating the appropriateness for continued use on a PRN basis.

The facility reported a census of 38 residents. Based on interview and record review the facility failed to have a monitoring system in place to ensure they facility's certified nurse aide (CNA) staff completed 12 hours of competency training yearly. This had the potential to affect all residents in the facility. Findings included: - Review of five facility CNA training records revealed CNA P, CNA R, CNA S, CNA T and CNA U did not have the required 12 hours of CNA in-service/competency training. Interview with Licensed Nurse (LN) I on 08/22/19 at 09:37 AM revealed the facility did not have tracking in place to ensure CNA staff received at least 12 hours of annual in-service training. LN I stated she had a list of annual training requirements and stated there were more than 12 topics for in-services. LN I was not aware she needed to track the annual in-service training to ensure 12 hours were completed by CNA staff and stated she would be doing that from now on. Review of the facility policy, In-Service Training Program, Nurse Aide revised (MONTH) (YEAR), revealed the facility would complete a performance review of nurse aides at least every 12 months. The policy further revealed in-service training will be based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews .annual in-services must: a. ensure the continuing competence of nurse ides; b. be no less than 12 hours per employment year; c. address areas of weakness as determined by nurse aide performance reviews; records shall be filed in the employee's personnel file or shall be maintained by the department supervisor. The facility failed to have a monitoring system in place to ensure they facility's CNA staff completed 12 hours of competency training yearly. This had the potential to affect all residents in the facility.

The facility census totaled 38 residents. Based on interview and record review the facility failed to update the Facility Assessment to determine what resources were necessary to care for its residents completely during both day-to-day operations and during emergencies as needed and on an annual basis. Findings included: - The facility provided a Facility Assessment with a review date range of 03/07/2017 - 03/06/2018, revealed the assessment had not been updated since the review date range. The facility provided a copy of the Facility Assessment on 08/19/19. Interview with Administration Staff C on 08/26/2019 at 09:35 AM revealed the facility did have a Facility Assessment but he did not know the facility assessment needed to be updated yearly. Administrative Staff C stated his expectation was for an annual review of the facility assessment and the facility assessment to be updated with all resources necessary to care for the residents. Review of the Facility Assessment Policy revised in 2001, revealed the Facility Assessment was conducted annually to determine and update the facilities capacity to meet the needs of and competently care for the resident's during day-to-day operations. The facility failed to update the Facility Assessment to determine what resources were necessary to care for its residents completely during both day-to-day operations and during emergencies, as needed, and on an annual basis.

The facility census totaled 38 residents, with 16 residents included in the sample. Based on interview and record review the facility failed to maintain an Infection Prevention and Control Program by the failure to implement a system for preventing, identifying, reporting, investigating, and controlling infections/communicable diseases for all residents, staff, volunteers, and visitors. Findings included: - Review of the facility infection control documentation lacked any evidence of mapping, tracking, and/or trending of infections in the facility. Interview on 08/21/19 at 10:45 AM with Administrative Nurse J revealed the facility monitored infections in the facility by nurse-to-resident interaction and progress notes. The facility did not complete any mapping, tracking, or trending of infections in the facility. The facility just put together an infection control book in (MONTH) of 2019 and started using the book the day before the interview on 8/20/19. Administrative Nurse J reported three residents with urinary tract infections (Resident (R)31, R12 and R40) at the time of interview and failed to provide evidence of mapping, and/or tracking/trending of the infections. Review of the facility policy Infections-Clinical Protocol revised (MONTH) (YEAR) revealed the physician, facility infection preventionist, and staff would identify individuals with infections, which might represent infection transmission risks and implement relevant precautions. The facility failed to maintain an Infection Prevention and Control Program by the failure to implement a system for preventing, identifying, reporting, investigating, and controlling infections/communicable diseases for all residents, staff, volunteers, and visitors.

The facility census totaled 38 residents with 16 residents included in the sample. Based on interview and record review the facility failed to maintain an antibiotic stewardship protocol/program to optimize the treatment of [REDACTED]. Findings included: - The facility identified three residents with urinary tract infections (Resident (R)31, R12 and R40) at the time of the survey and failed to provide evidence to ensure those residents were prescribed the appropriate antibiotic for their infections and were monitored efficiently. Interview on 08/21/19 at 10:45 AM with Administrative Nurse J revealed the facility did not have an antibiotic stewardship program at the time of the interview. Administrative Nurse J stated the facility had the antibiotic stewardship team picked, but it was a work in progress. The facility just put together an infection control book in (MONTH) of 2019 and started using the book the day before the interview on 08/20/19. Review of the facility policy Infections-Clinical Protocol revised (MONTH) (YEAR) revealed nursing staff and the resident's physician/provider would monitor the progress of a resident with an infection until it resolved. Staff would evaluate and report at least weekly until the resident was stable and improving from the initial infection. The physician would help identify potential complications of an infection. If an initial course of antibiotics did not resolve an infection the physician would review the situation before prescribing another antibiotic. The facility failed to maintain an antibiotic stewardship protocol/program to optimize the treatment of [REDACTED].

The facility reported a census of 41 residents, with one resident sampled for cardiopulmonary resuscitation (CPR- emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). Based on interview and record review the facility failed to initiate CPR on a resident without an identified code status (signed documentation which indicated the status of a resident with respect to his/her desire for resuscitative efforts, unless the resident specifically requested not to be resuscitated) and the resident died . (#1) This placed resident #1 in immediate jeopardy. The facility also failed to ensure one staff member on every shift had training on how to perform CPR. This had the potential to affect 12 full code status residents. Findings included: - The admission orders [REDACTED]. Review of the medical record for resident #1 revealed the resident admitted to the facility on [DATE] with a good prognosis and his/her discharge plans included transfer to an assisted living facility when he/she could. The resident did not have a code status (signed documentation which indicated the status of a resident with respect to his/her desire for resuscitative efforts, unless the resident specifically requested not to be resuscitated) on file. Review of the [DATE] physician order revealed the resident admitted to the facility with current medications and treatments. Review of the facility investigation report dated [DATE] revealed two direct care staff, staff H and staff I notified licensed nurse F the resident didn't look good and was breathing funny. When licensed nursing staff F entered the resident's room the resident lay in bed peacefully. When licensed staff F approached the resident, he/she heard gurgling coming from the resident and the resident's skin felt moist and cold. Licensed nursing staff F performed a sternal rub, listened to the resident's heart sounds and attempted to obtain a blood pressure and pulse. Licensed nursing staff F performed another sternal rub and reported the resident had no heart sounds. The nurse noted no rise and/or fall of the resident's chest. The facility reported the resident expired [DATE] at 1:15 AM. The investigation report lacked evidence licensed nurse F obtained the resident's code status. Review of the nurse's note dated [DATE] at 1:15 AM licensed nursing staff F listened for 3 minutes for a heartbeat, could not get an oxygen level or pulse and staff performed a sternal rub and could not locate the resident's code status. Staff F notified the physician the resident had expired through the paging system at 1:41 AM and at 3:03 AM the physician gave consent to release the body. Review of licensed nursing staff F's cardiopulmonary resuscitation (CPR) status revealed the basic life support card for staff F had a recommended renewal date of [DATE] (over 10 months expired). Review of the facility investigation revealed the family member of resident #1 signed a notarized witness statement on [DATE] attesting he/she told the facility on [DATE] resident #1 had a do not resuscitate (DNR), but would not be able to get it until the next day. Interview with direct care staff H on [DATE] at 5:11 PM revealed he/she had never been asked about his/her CPR certification and no facility staff instructed him/her of which staff were CPR certified on each shift. Staff H stated the resident pressed his/her call light around 1:00 AM on [DATE] and the direct care staff could not get the resident to wake up and the resident looked gray in color and was not responsive, but the resident was still breathing. Staff H stated licensed nursing staff F came to the room and could not obtain vital signs and did a chest rub on the resident. Staff H stated the resident made a gurgling sound. Staff H stated he/she did not know the resident's code status and it was not on the computer. Staff H stated if he/she found a resident unresponsive he/she would check the computer and get the nurse. Staff H stated if he/she could not find the nurse he/he would start CPR. Staff H stated he/she took the CPR course on the previous Saturday. Staff H stated no one called emergency medical services (EMS) and stated the resident was very talkative and bubbly at the beginning of his/her shift. Interview with direct care staff I on [DATE] at 7:50 AM revealed around 1:00 a.m. the resident pressed the call light again and when direct care staff I and direct care staff H answered the call light the resident was unresponsive but still breathing. The resident's color was flush and grey in color, and staff I stated it was obvious something was wrong. Staff I stated the resident was still breathing and both direct care staff left the room to get licensed nursing staff F. Staff I stated licensed nursing staff F arrived to the room, applied a blood pressure cuff and O2 sat monitor and stated the resident expired. Staff I stated the resident was still breathing at the time but gurgling between breaths. Staff F did a sternal rub, told the direct care staff to stay in the room and staff F left the room. Staff I stated he/she assumed staff F left to call EMS. Staff I stated both direct care staff were not CPR certified and were just doing what the nurse instructed them to do. Staff I stated after staff F left the room, staff F called resident #1's family member and informed him/her resident #1 expired. Staff I stated he/she was now CPR certified and would have jumped in and started CPR now that he/she knows what to do in an unknown code status situation. During an interview with licensed nursing staff F on [DATE] at 3:41 PM revealed after 1:05 AM on [DATE] the two direct care staff reported to the nurse the resident looked and breathed funny (not defined by the nurse). Staff F stated he/she grabbed the vital signs kit and by the time he/she arrived at the resident's room, the resident expired. Staff F stated the resident had throat secretions and what he/she referred to as the death rattle. Staff F stated there were no heart or lung sound present and staff F did a sternal rub with no results. Staff F stated he/she did not put oxygen on at the time due to the secretions and staff F left the room to find the resident's code status. Staff F reported he/she did not locate the code status and he/she did not call EMS. Staff F reported he/she did not find out until the next morning that if there was no code status present and staff should have initiated CPR. Staff F stated he/she called the time of death around 1:15 a.m. Staff F stated the oncoming shift explained to Staff F CPR should have been started on resident #1, but staff F stated he/she did not put the oxygen on the resident because the resident already had the death rattle. Staff F did not suction the resident because he/she did not know the location of the suction equipment and stated he/she did not start CPR because he/she knew resident #1's airway was clogged. Staff F did a sternal rub and yelled the resident's name but the resident had already turned gray and the resident's chest did not rise and fall. Staff F did not know he/she was supposed to call EMS. Staff F stated the facility did not asked if he/she was CPR certified upon hire. Interview with administrative nursing A on [DATE] at 3:00 p.m. revealed he/she thought the staff left the code status blank for resident #1 and stated the staff had left the code status blank in the past for a resident if the staff did not know the code status of the resident. Staff A stated if facility staff did not know the code status they should treat the resident as a full code and did not think the lack of CPR certified staff contributed to what happened to resident #1 on [DATE]. Staff A verified there were no CPR certified staff on night shift from [DATE]-[DATE]. Staff expected all CPR certified direct care staff to start CPR if the resident did not have an active DNR. The direct care staff knew a resident's code status by finding it in the computer and/or the yellow codebook. Staff A stated they now marked CPR certified staff on each shift by placing an asterisk next to the CPR staff members name on the daily staffing sheet. Review of the facility policy on CPR revised on ,[DATE], revealed CPR certification was mandatory for all licensed nursing staff members and CPR must be initiated unless: the resident had a DNR order, the resident had obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition), or the initiation of CPR could cause injury or peril to the rescuer. The policy revealed CPR must be available at all times, in the location and at all locations functions. Upon hire, human resources or a designated staff member would ask all licensed nurses if they had a current CPR certification, make a copy of the CPR certification and place it in the employee's personnel file and the facility would proceed or arrange for CPR training within 180 days of hire if the licensed nurse did not hold a current CPR certification. The facility failed to initiate CPR on a resident without an identified code status and the resident died . (#1) This placed resident #1 in immediate jeopardy. The facility also failed to ensure one staff member on every shift had training on how to perform CPR. The facility abated the immediate jeopardy on [DATE] by implementation of the following corrective actions: All nursing staff would be educated and trained on the CPR policy and procedure, code status binder, how to utilize items on the crash cart and how to access the crash cart. The facility nurses would be trained on how to use the suction machine. All new hires would be trained on day 1 of orientation to ensure CPR policy/procedure, code status binder, how to utilize items on the crash cart and how to access the crash cart. The facility would complete monthly audits on all nurses on the following: CPR policy/procedure, how to utilize items on the crash cart and how to access the crash cart. If the facility nurse failed the audit, the nurse would have one-on-one training and then would demonstrate back to the trainer how to use the items on the crash cart, how to access the crash cart and CPR policy/procedure. If the nurse continued to fail, he/she would be unable to work the floor as a nurse until passing the audit and would be given other resources to assist them. The facility assigned a staff member to ensure all licensed staff employed by the facility had current CPR certifications within 30 days of hire. No nurses would be hired until they had a CPR certification. All CPR certifications would be reviewed the first week of every month to ensure all nurses have current CPR certifications. The facility would provide CPR training to keep all CPR certified staff up to date. The facility would audit all nurses for CPR certification and any nurse not CPR certified would not work as a charge nurse. The night nurse would be responsible for printing two advanced directives order lists. The list identified resident names alphabetically along with their code status. The advanced directive order list would be placed in two 3 ring binders one for the nurse's station and one for the facility van driver. The Quality Assurance Performance Improvement coordinator would audit the code status binders and the resident's code status to ensure they are correct, referring the actual physician's order. Every shift would have someone in nursing CPR certified to ensure CPR was available at all times. All staff who were CPR certified would be indicated by a red star on the nurse staffing schedule. If the CPR certified person called in or had to leave the center the nurse on-call would ensure the replacement was CPR certified or the on-call nurse would come in and work in their absence. Facility staff would review and sign the daily schedule sheets three days in advanced to ensure there would be someone CPR certified available at all times. The van driver would be educated on the CPR policy and procedure and the code status binder. All van drivers would be up to date with their CPR certifications. The facility educated and trained the nursing staff and van drivers until the staff development nurse returned to work from a family emergency. The deficient practice remained at a scope/severity of G.

The facility reported a census of 37 residents with 6 residents sampled. Based on interview and record review, the facility failed to provide timely and appropriate nursing assessment and monitoring by a licensed nurse following a change in condition with difficulty catching his/her breath and extreme pain for 1 of 2 residents (#14- a closed record) reviewed for death in the facility. The resident died in the facility after this change in condition with lack of adequate assessment. The facility also failed to notify the physician after the resident indicated he/she had excruciating pain in his/her neck and shoulder and could not breathe normally. These failures put the resident in immediate jeopardy. Findings included: - Review of resident #14's medical record revealed he/she admitted on [DATE] and died in the facility on [DATE]. Review of the signed physician orders dated [DATE] revealed [DIAGNOSES REDACTED]. to regulate the beating of the heart). Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. The resident was independent or required supervision only for most activities of daily living (ADLs). He/she received medications for pain on an as needed (PRN) basis and had pain almost constantly during the 5 day period prior to the assessment that made it hard to sleep at night and limited day-to-day activities. The resident rated his/her pain a 6 on a ,[DATE] scale (a standardized tool used to rate pain level on a scale ,[DATE] where 0 means no pain at all and 10 means worst possible pain). The resident also had shortness of breath with exertion. Review of the quarterly MDS dated [DATE] revealed no change in BIMS from the admission MDS. The resident required supervision and set-up for most ADLs and had no shortness of breath. The assessment lacked a pain assessment interview with the resident. The resident received scheduled medications, medications on a PRN basis and non-medication interventions for pain. Review of the resident's care area assessments (CAAS) dated [DATE] revealed CAAs triggered included: ADL/Functional: Resident had weakness and needed assistance with ADLs Pain: The resident had occasional pain. Review of the resident's care plan dated [DATE] revealed the following interventions last revised on: [DATE]: Monitor, document and report any signs or symptoms of altered cardiac output or pacemaker malfunction including difficulty breathing. The care plan lacked interventions related to the resident's pain, [MEDICAL CONDITION] and use of oxygen. Review of the signed physician orders revealed orders for medications for pain that included: [DATE]: [MEDICATION NAME] (a narcotic-like drug used to treat moderate to severe pain) give 50 milligrams (mg) by mouth every 6 hours PRN. [DATE]: Tylenol (a medication used to treat minor pain) 1000 mg by mouth give two times daily (BID). Review of the communication notes revealed the resident saw the physician on [DATE] and requested a scheduled dose of Tylenol BID and to continue his/her [MEDICATION NAME] PRN. The physician returned the fax with new orders for Tylenol 1000 mg PO BID. Review of the communication/visit with the physician dated [DATE] revealed staff faxed the resident's primary care physician (PCP) that the resident complained of coughing at night for two nights. Review of the physician progress notes [REDACTED]. The physician noted he/she increased the resident's supplemental oxygen to 3 liters per minute since the resident's last visit but he/she had no improvement. The resident stated since his/her last appointment he/she experienced more shortness of air that used to be only with exertion but now he/she had it even when he/she just sat and talked. Review of the progress notes revealed: On [DATE] at 12:38 PM the resident felt well and planned to attend a concert that evening. On [DATE] at 1:45 PM staff administered [MEDICATION NAME] 50 mg by mouth for pain and assessed the medication had relieved the resident's pain. On [DATE] at 1:11 AM staff administered [MEDICATION NAME] 50 mg by mouth for pain and assessed the medication had relieved the resident's pain. On [DATE] at 7:53 PM staff administered an [MEDICATION NAME] (a medication used to relieve [MEDICATION NAME] (an abnormal contraction of the smooth muscle of the bronchi, or branches leading from the trachea, or windpipe, to the lungs, that results in an sudden narrowing and obstruction of the respiratory airway)) breathing treatment (2.5 mg/3 milliliters (ml)) 0.083% for dyspnea (difficulty breathing) related to the resident's [MEDICAL CONDITION]. On [DATE] at 8:53 PM staff administered [MEDICATION NAME] Tablet 50 mg by mouth for pain after the resident complained of pain in his/her upper back, neck and shoulders. At 10:10 PM staff assessed the medication relieved the resident's pain and the resident slept peacefully with no signs of distress. On [DATE] at 10:10 PM staff administered an [MEDICATION NAME] breathing treatment (2.5 mg/3 ml) 0.083% for dyspnea related to the resident's [MEDICAL CONDITION] and noted the resident's oxygen saturation level (measure of how much oxygen the blood carried as a percentage of the maximum it could carry) rose to 95%. The progress note lacked documentation of the resident's oxygen saturation level prior to the breathing treatment. On [DATE] at 4:34 AM staff administered [MEDICATION NAME] (Tylenol) 1000 mg by mouth after the resident complained of pain in his/her shoulder and neck. At 4:42 AM the resident reported he/she had pain in his/her right ear, neck and both shoulders. Staff submitted a request for the resident to have an appointment to see the physician and notified the resident. On [DATE] at 9:48 AM staff administered an [MEDICATION NAME] breathing treatment (2.5 mg/3 ml) 0.083% for dyspnea (difficulty breathing) related to the resident's [MEDICAL CONDITION] after the resident reported he/she needed it. Staff noted the resident had wheezing (a [MEDICATION NAME] or rattling sound in the chest as a result of obstruction in the air passages) and had an appointment scheduled for early the following week to evaluate the resident's increased pain and breathing difficulty. The progress note lacked documentation of the resident's oxygen saturation levels prior to and after the breathing treatment. On [DATE] at 9:49 AM staff administered [MEDICATION NAME] 50 mg by mouth for pain and assessed the medication relieved the resident's pain. On [DATE] at 5:19 PM direct care staff G (certified to administer medications) administered [MEDICATION NAME] 50 mg by mouth for pain and noted the resident cried because he/she had such severe pain in his/her neck and shoulder that he/she could not catch his/her breath or verbally report a pain level. Staff G failed to notify the licensed nurse to further assess the resident. Staff failed to assess the resident between 5:19 PM and 5:51 PM. On [DATE] at 5:51 PM staff found the resident unresponsive and without a pulse or breathing. The resident had a DNR (Do Not Resuscitate - a written legal order to withhold cardiopulmonary resuscitation (CPR) in respect of the wishes of a person in case their heart stopped or they stopped breathing) in his/her medical record so staff did not perform CPR (Cardiopulmonary resuscitation - emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). At 6:00 PM staff contacted physician staff E and received orders to release the resident's body to a mortuary. Review of the vital signs record revealed staff documented the resident's blood pressures (B/P) as follows: [DATE]- ,[DATE] [DATE]- ,[DATE] [DATE]- ,[DATE] [DATE]- ,[DATE] [DATE]- ,[DATE] The vital signs record lacked documentation for recent B/Ps between [DATE] and the time of the resident's death at 5:51 PM on [DATE]. Review of the vital signs record revealed staff documented the resident's oxygen saturation levels as follows: [DATE]- 96% [DATE]- 94% [DATE]- 94% [DATE]- 94% The vital signs record lacked documentation for recent oxygen saturation levels between [DATE] and the time of the resident's death at 5:51 PM on [DATE] other than a single oxygen saturation level of 95% documented in the progress note on [DATE] after the resident received a breathing treatment. Review of the vital signs record revealed staff documented the resident's pulse as follows: [DATE]- 72 [DATE]- 67 [DATE]- 77 [DATE]- 83 [DATE] at 1:37 PM - 95 [DATE] at 9:22 PM - 89 [DATE]- 69 [DATE]- 82 The vital signs record lacked documentation for recent pulse checks between [DATE] and the time of the resident's death at 5:51 PM on [DATE]. Review of the resident's Medication Administration Record [REDACTED] The resident reported a pain level 7 on [DATE] at 4:34 AM and received Tylenol 1000 mg by mouth. Later that same day at 5:19 PM, staff G (certified to administer medications) administered [MEDICATION NAME] to the resident and documented the resident's pain level as 10 on ,[DATE] pain scale. Staff G (certified to administer medications) documented the resident had pain at a level 10 when according to the progress notes the resident had such severe pain in his/her neck and shoulder that he/she could not even get his/her breath enough to verbally describe his/her pain. During an interview on [DATE] at 4:05 PM direct care staff G (certified to administer medications) reported he/she took the resident a pain pill at 5:20 PM when the resident complained of pain. The resident had so much pain he/she could not verbalize a pain level or tell how bad he/she hurt. The resident's oxygen saturation level measured 80% so staff G (certified to administer medications) put oxygen on the resident and his/her saturation level increased to 95%. Staff G (certified to administer medications) stated he/she rubbed the resident's shoulders until the resident could talk and stated he/she felt better. Staff G (certified to administer medications) then left the resident without informing the nurse about the resident's episode of extreme pain, difficulty breathing and need for oxygen then went to the dining room to pass medications. During interview on [DATE] at 10:12 AM direct care staff A reported on [DATE] he/she took a meal to the resident in his/her room. Staff A stated the resident lay on his/her back and looked like he/she was asleep and had no response. Staff A checked the resident for a pulse and looked at his/her chest. The resident had no pulse or breathing so he/she ran to tell licensed nurse B. During an interview on [DATE] at 5:00 PM licensed nurse B reported the resident had pain in his/her neck and both shoulders and asked direct care staff G (certified to administer medications) for a [MEDICATION NAME] pain pill the evening he/she died . Staff B stated the resident's pain subsided after staff G gave the resident pain medication and rubbed his/her shoulders so the staff G did not report the resident's pain to the nurse. Staff G did not report the resident had such extreme pain he/she had cried and could not even verbalize a pain level. Staff B stated if staff G (certified to administer medications) had told him/her about the resident's extreme pain he/she would have assessed the resident and offered to send him/her to the emergency room based on the pain level. Two days prior to the resident's death he/she felt well enough to attend to a concert. Staff B stated no one called the doctor about the resident's episode of extreme pain, difficulty breathing and need for oxygen prior to his/her death. During an interview on [DATE] at 1:42 PM licensed nurse F reported when he/she worked he/she usually gave the pain medications. Staff F stated he/she required medication aides to report to him/her prior to giving a medication for pain. During an interview on [DATE] at 5:28 PM administrative nursing staff C reported certified medication aides (CMAs) should notify the nurse before giving a PRN pain medication so the nurse could assess the resident. Staff C stated that staff G (certified to administer medications) should have notified the charge nurse immediately after the resident indicated his/her pain significantly increased and he/she also had difficulty breathing on [DATE]. Staff C stated he/she would develop a plan that same day to educate all staff about reporting significant changes in clinical status. During an interview on [DATE] at 8:50 AM physician staff E reported staff had not informed him/her about the resident's episode of extreme pain and difficulty breathing on [DATE] but had informed him/her shortly after the resident died . During an interview on [DATE] at 2:55 PM physician staff D reported any time there was a significant change in a resident's clinical status, the physician on-call should be notified. Staff D stated had he/she received a report the resident had shoulder and neck pain so severe he/she cried and could not get his/her breath enough to verbalize a pain level to staff he/she would have sent the resident to the emergency room . Review of the facility policy dated ,[DATE] titled Medication Administration, Including Scheduling and Medication Aides revealed if using non-licensed personnel to dispense medications, the follow-up should be done by a licensed nurse. Nursing assessment was a function of a registered nurse. When the facility utilized medication aides, the delegating nurse was accountable for assessing a situation and making the final decision to delegate. PRN medications may be administered by a certified medication aide according to specific state regulations. In all cases, the licensed nurse must do the follow-up of the PRN medication. The facility failed to provide nursing assessment and monitoring by a licensed nurse for a resident, and also failed to notify the physician after the resident indicated he/she had excruciating pain in his/her neck and shoulder and could not breathe normally. These failures put the resident in immediate jeopardy. On [DATE] at 8:00 PM, the facility abated the immediate jeopardy by implementing the following: No CMA or license nurse could work the floor until completing education and training on the following: 1) State regulation - CMA cannot administer PRN medications without first a license nurse assessing the resident, directing what PRN medication to use, and then the licensed nurse must complete a follow-up assessment on the PRN medication. 2) Policy and Procedure on Medication Administration, including Scheduling and Medication Aides and Change in Condition. 3) Training on what is a Change in Condition. Starting [DATE] Director of Nursing Services (DNS) and Quality and Performance Indicator coordinator would review all Change in Condition for proper assessment, proper notification and proper follow up. The licensed nurse would notify DNS when there was a Change in Condition. This would be ongoing and all finding would be taken to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The deficient practice remained at a scope and severity of a G.

The facility had a census of 50 residents, with 23 residents reviewed. Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 of the 4 residents reviewed for accidents (#25). Resident #25 experienced 4 falls from 5/9/14 to 2/25/15, and staff failed to assess for causal factors after 2 of these falls to prevent additional falls. The resident fell on [DATE] at 2:30 PM, and hit his/her head, which resulted in a subdural hematoma (collection of blood on the surface of the brain) and a laceration which required sutures. In addition, the facility failed to ensure the residents' environment free of accident hazards in the whirlpool room, with sharp edges on the metal toilet paper holder, on the 300 hall and with the 5 bulletin boards (2 in the dining room and 3 which held the activity calendars), in 3 resident hallways, noted with exposed sharp metal edges. Findings included: - Resident #25, per the ECR (electronic care record), with [DIAGNOSES REDACTED]. The 11/11/14 annual Minimum Data Set recorded a BIMS (Brief Interview for Mental Status) score of 3 (severely impaired cognition). The resident required extensive assistance of 2 persons for bed mobility, supervision of set up help with transfers, walking in the room/corridor, used a walker, and had one non-major fall since admission or the prior assessment. The 12/4/14 CAAs (Care Area Assessment) included the following areas: Cognitive Loss/Dementia - The resident had cognitive impairment related to a [DIAGNOSES REDACTED]. The resident was disoriented and consistently required staff reminders/cueing with daily tasks. Falls - The resident had a fall this quarter. This particular fall occurred while he/she was up and walking. Staff noted the resident displayed agitated behaviors just prior to the fall. The resident had advanced dementia and poor decision making, poor safety awareness, and often forgot to bring his/her walker along with him/her. The resident had a [DIAGNOSES REDACTED]. The 2/11/15 quarterly Minimum Data Set recorded a BIMS score of 3 The resident required extensive assistance of 1 staff with bed mobility, extensive assistance of 2 staff with transfers, independent with walking in the room, required supervision with walking in the corridor and locomotion on the unit, used a walker, and had no falls since admission or the prior assessment. Staff recorded in the 12/12/14 care conference note at 10:49 AM, the resident continued to ambulate without his/her walker. The resident's last fall was in 9/14. Staff recorded to continue the current care plan. The 12/12/14 care plan had the following interventions: Intervention of 4/5/14 - Transfer abilities varied from independent to assistance of 2 staff. Intervention of 4/8/14 for a scoop mattress (mattress with raised edges). Intervention of 8/20/14 recorded the resident required occasional weight bearing support with ambulation and could use a walker independently at times. Intervention of 9/6/14, the resident was agitated and failed to use his/her walker. Present interventions remain appropriate. Intervention of 9/15/14 (9 days after the 9/6/14 fall), review and modify environmental hazards that could have caused or contributed to the fall. Make sure the resident's shoes are tied and the shoe strings are not hanging down so the resident could step on them. Monitor for equipment being placed safely in the common areas. Intervention of 2/26/15 - Personal alarm initiated post fall. Staff recorded the following fall assessments: The 8/11/14 fall assessment identified the resident at risk for falls, and staff needed to monitor the resident's ambulation as much as possible. The 9/6/14 fall assessment recorded a score of 23 which indicated at high risk for falls. The 2/26/15 fall assessment recorded a score of 18 which indicated at high risk for falls. Staff recorded the resident's 4 falls from 5/9/14 to 2/25/15 as follows: 1.) Nursing notes, dated 5/9/14 at 5:30 PM, recorded staff found the resident in another resident's room by the closet door, sitting on his/her bottom on the right hip area, with the resident's right leg bent at the knee and the left leg folded under the right leg. Nursing notes dated 5/13/14 at 12:12 PM, follow-up information to the fall on 5/9/14. Staff recorded the resident was up as he/she desired, or on some days, used a wheelchair. On the day of the fall, 5/9/14, the resident used a wheelchair to self propel around the special care unit. The resident attempted to get up out of the wheelchair, slid to the floor, and tried to ambulate and tripped on his/her shoestring that was untied. Staff implemented an intervention on 5/13/14 (4 days after the fall) for staff to review and modify the environmental hazards that could have caused or contributed to the fall. Staff needed to make sure the resident's shoes were tied and shoe strings were not hanging down where the resident could step on the shoestrings. 2.) Nurses notes, dated 6/3/14 at 3:24 PM, recorded staff found the resident on his/her knees when the resident fell from the recliner. Nurses notes, dated 6/10/14 at 2:52 PM, recorded follow-up to the 6/3/14 fall, the resident had dementia and confusion. The resident was in a recliner with his/her feet up while two aides were in the restroom, helping another resident. During that time, the resident apparently scooted to the end of the recliner and dropped to the floor. The resident ambulated without assistance using a walker and could get up by him/her self, but needed help getting up from the recliner. Staff failed to assess for causal factors to prevent additional accidents after the 6/3/14 fall. 3.) Nurses notes, dated 9/6/14 at 11:16 AM, recorded staff found the resident on the floor, lying on the right side, the right arm behind the resident, and the left arm across the resident's chest. Nurses notes, dated 9/15/14 at 11:30 AM, recorded follow-up to the 9/6/14 fall, the director of nursing viewed the surveillance video and saw the resident walking north in the special care unit hallway. The resident used the handrail and walked without his/her walker. There was a wheelchair parked by the wall in the dining room with only the foot pedals sticking out in the hallway, the rest of the wheelchair hidden behind the wall. The resident tripped over the foot pedal. Staff were to keep the area free of clutter. Staff recorded the care plan intervention for this fall was that present interventions remain appropriate. The facility failed to assess for causal factors after this fall to prevent additional falls. On the 12/10/14 physician's orders [REDACTED]. daily, on Tuesday, Thursday, and Saturday. Prior to this increase the Coumadin dose was 2 mg, daily. 4.) Nurses notes, dated 2/25/15 at 2:30 PM, recorded staff on the special care unit heard a loud noise and a resident called out for help from the common area. Staff came out of the bathing area and found the resident lying on his/her right side, mostly under the piano in the common area. Staff had just witnessed the resident within 5 minutes prior to fall, and the resident was not in any sign of danger at that time. The nurse came to special care unit and noted an active bleeding wound to the posterior area of the resident's head and blood on the piano above the foot pedals. The resident typically used a walker to assist with stable ambulation, but the walker was nowhere near the resident. The resident had been attempting to ambulate independently lately, without success, due to weakness and poor balance. The nurse noted approximately a 1 cm (centimeter) laceration to the back of the resident's head. Staff notified the resident's physician, with orders to transport to the emergency room for evaluation and treatment of [REDACTED]. The emergency room report of 2/25/15 at 3:56 PM revealed the resident had 2 lacerations on the back of his/her head. The resident's 2/25/15 CT (computerized tomography) of the head without contrast report revealed a right, mixed subarachnoid and subdural hematoma. At 6:37 PM, the emergency room documentation revealed staff repaired (sutured) the laceration and the resident returned to the nursing home. Emergency staff discharged the resident to the nursing home at 6:52 PM. At 3/25/15 at 4:37 PM, direct care staff K stated the resident passed away. Staff K identified the resident as a heavy wanderer and used a walker. Staff tried to keep a close eye on the resident, and would get the resident's walker for him/her, as the resident often forgot. On 3/26/15 at 9:01 AM, direct care staff N stated the resident wandered. The resident used a walker, and staff tried to stay with the resident as much as possible, but sometimes the resident would get up without staff present. On the day shift, whenever the resident got up, staff tried to walk with him/her. That was not always possible when staff were in another resident's room. Staff passed on to the next shift, the resident was leaning backwards when the resident walked. If staff were not with the resident, he/she would get up and walk by him/herself. The resident would never lay in his/her bed. Staff told the next shift to watch the resident, as he/she was leaning backwards when he/she walked. On 3/26/15 at 12:27 PM, direct care staff Y stated the resident would continually get up and sit down and did not like sitting. He/she tried to walk by him/herself. Toward the end of the resident's stay, the resident needed 1 to 2 staff assistance with ambulation which depended on the day. The resident needed 2 people and a chair behind him/her. The resident always required supervision. Direct care staff Y stated he/she thought the resident was at risk for falls, as the resident walked fast and would not use his/her walker. Staff needed to make sure the resident had his/her walker. The resident required cueing and supervision. On 3/26/15 at 1:23 PM, licensed staff I stated the resident was at risk for and had falls. Interventions included the use of gripper socks, keep the environment free from clutter, a scoop mattress, make sure his/her shoestrings were tied, and monitor equipment placed safely in the commons area. Staff needed to put interventions in place right away to prevent additional falls. On 3/26/15 at 3:51 PM, licensed administrative staff B verified the resident was a fall risk. Staff need to make sure specific interventions were developed, make sure those interventions were in place, and then monitor and evaluate those interventions. If an actual fall did occur, staff would review the fall, investigate, and put interventions in place. On 3/26/15 at 8 AM, consultant staff C verified the facility failed to implement an intervention following the 6/3/14 and the 9/6/14 falls. The facility's prevention and management of falls practice guidelines, issued on 9/12, recorded upon admission, each resident will be evaluated to determine his/her risk for falling to include implementation of interventions and monitoring the effectiveness of the interventions and modify the interventions. Trending analysis should focus on prevention. The interdisciplinary team should perform an analysis of the precipitating events for individual resident falls and evaluate potential interventions aimed at prevention of future falls. The facility failed to ensure adequate supervision and assistive devices to prevent accidents. The resident experienced 4 falls from 5/9/14 to 2/25/15, and staff failed to implement interventions after 2 of these falls to prevent additional falls. The resident then fell on [DATE] at 2:30 PM, hit his/her head, which resulted in a subdural hematoma (collection of blood on the surface of the brain), and a laceration which required sutures. - On 3/26/15 from 2:30 PM to 4:00 PM, the environmental tour, with maintenance staff F revealed the following areas/items in the residents environment that could cause injury to the residents: 1.) One of 15 resident room/corridor doors, on the 100 hall, contained a broken and splintered inside vertical edge, approximately 4 by 16 inches. Thus leaving this door edge with sharp splintered wood fragments. 2.) One of 15 resident bathroom doors, on the 100 hall, contained a broken and splintered edge along the inside vertical edge, approximately 4 by 6 inches. Thus leaving this door edge with sharp splintered wood fragments. 3.) The whirlpool bathroom contained 2 exposed metal toilet paper holder mounting brackets with sharp edges. 4.) In 2 resident hallways and the hallway to the dining room, 3 wood and metal bulletin boards, held the activity calendar. Each board contained 35 sheet metal sections with the metal edge turned outward approximately 1/16 of an inch. Four of these metal sections lacked a covering, which exposed the sharp metal edges, on each day of the survey. 5.) In the dining room, 2 wood and metal bulletin boards, held the menu for the week. One board contained 15 sheet metals sections with each containing a metal edge turned outward approximately 1/16 of an inch. Four of these sections lacked a covering, which exposed the sharp metal edges, on each day of the survey. The second menu board contained 3 sheet metals sections with each containing a metal edge turned outward approximately 1/16 of an inch, and all 3 of these sections lacked a covering on each end, which exposed the sharp metal edges on each day of the survey. The facility failed to maintain a resident environment as free of accident hazards as possible in the environment for the residents of the facility.

The facility had a census of 50 residents, with 6 residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure 2 of these 6 residents were free of unnecessary medications, including resident #25 who experienced a fall, hit his/her head, and sustained a brain bleed, related to a (non-therapeutic) level of the anticoagulant medication. The facility failed to complete adequate blood level monitoring for this resident who received medication to thin his/her blood. Furthermore, the facility failed to complete adequate blood pressure monitoring for resident #24 who received medication for elevated blood pressure readings. Findings included: - Resident #25 per the ECR (electronic care record) had [DIAGNOSES REDACTED]. The 11/1/14 annual Minimum Data Set recorded a BIMS (Brief Interview for Mental Status) score of 3 (severely impaired cognition), required extensive assistance of 2 persons for bed mobility, supervision of set up help with transfers, walked in the room/corridor, used a walker, had one non-major fall since admission or the prior assessment, and received an anticoagulant medication. The 12/4/14 CAAs (Care Area Assessment) for falls recorded the resident had a [DIAGNOSES REDACTED]. The 2/11/15 quarterly Minimum Data Set recorded a BIMS (Brief Interview for Mental Status) score of 3, required extensive assistance of 1 staff with bed mobility, extensive assistance of 2 staff with transfers, independent with walking in the room, required supervision with walking in the corridor and locomotion on the unit, used a walker, no falls since admission or the prior assessment, and received an anticoagulant medication. Staff recorded in the 8/5/14 care conference at 9:01 AM, the resident triggered for falls. Staff recorded the resident needed PT/INR ([MEDICATION NAME]/international normalized ratio - blood test used to determine the clotting factor of the blood) monthly, but the last PT/INR noted was on 5/6/14. Staff would address this issue with the nurses and schedule the blood test in the laboratory book. The care plan included an intervention on 2/12/14, for anticoagulant therapy - Monitor/document/report to health care provider signs/symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headache, nausea/vomiting, and significant or sudden changes in vital signs. Per the signed physician's orders [REDACTED]. At that time, the physician ordered for the resident to receive [MEDICATION NAME] 2 mg (milligrams) daily. Staff recorded in the 6/27/14 nursing notes at 1:06 PM, the resident refused to have the blood drawn. Review of the resident's clinical record lacked evidence of any additional attempts to obtain the resident's blood, for the ordered physician test. Staff recorded in the 8/13/14 nursing notes at 10:55 AM, the PT/INR not drawn as ordered. The original order was for monthly PT/INR blood draws but staff failed to put the order into the eMAR (electronic medication record) correctly. The mistake was found and corrected the following month. This resident was known to refuse blood draws, and refused in June. In July, 2014, staff failed to draw the resident's blood as ordered. The record lacked documentation which addressed the missed blood draw. Staff drew a PT/INR on 8/7/14. The director of nursing wrote scheduled blood draws in the laboratory book, and would re-educate and discuss the situation at the nurses' meeting scheduled for 8/14/14. Review of the PT/INR and physician's orders [REDACTED]. 5/6/14 - INR 2.6 (normal range 0.8-1.3) and PT 26.4 (normal range 8.0-14) 8/7/14 - INR 2.3 and PT 22.8 8/22/14 - INR 1.8 and PT 18 9/5/14 - INR 1.7 and PT 16.8. The physician ordered staff to recheck the PT/INR in 2 weeks. 9/25/14 (6 days late) - INR 2.8 and PT 21.6 10/29/14 - INR 1.8 and PT 18.0 On 10/30/14, the physician faxed to the facility an order with instructions for the resident to stay on the same dose of [MEDICATION NAME] and recheck on schedule. 12/8/14 - INR 1.6 and PT 15.6. Staff faxed the physician the results of this blood work. On 12/9/14 at 8:49 PM, the physician ordered for the resident to receive [MEDICATION NAME] 2 mg (milligrams), on Sunday, Tuesday, Thursday, and Saturday, and 3 mg on Monday, Wednesday, and Friday. On 12/9/14 at 8:55 PM, the physician's orders [REDACTED]. On 12/28/14, the physician ordered staff to obtain a PT/INR in 2 weeks. Review of the clinical record lacked evidence of this 2 week PT/INR drawn (due on 1/11/15), as ordered on [DATE]. Nursing notes, dated 2/25/15 at 2:30 PM, the resident experienced an unwitnessed fall and sustained a laceration to the resident's head. Staff transported the resident to a local emergency room for evaluation and treatment at 3:20 PM. The emergency room report of 2/25/15 at 3:56 PM, revealed the resident with a 2 cm (centimeter) laceration to the back of the head. The resident's 2/25/15 CT (computerized tomography) of the head without contrast report revealed a right, mixed subarachnoid and subdural hematoma (brain bleed). On 2/25/15 at 5:40 PM, the emergency room record revealed a PT of 63.2 (normal range of 9.7-11.6) and INR of 6.1. At 6:37 PM, the resident received Vitamin K 10 mg (milligrams) IM (intramuscularly) for the elevated blood test level. The resident was discharged back to the nursing home at 6:52 PM. On 3/26/15 at 1:23 PM, licensed staff I verified the ordered PT/INR of 9/5/14 to be done in 2 weeks (due on 9/19/14) and done on 9/25/14 was not done in an acceptable time frame. This licensed staff I also verified blood work ordered on [DATE] was not done. The nurses were putting the blood work due on a calendar, but now the nurses have to run a laboratory report and put it in the director of nurse's box. On 3/26/15 at 3:51 PM, licensed administrative staff B stated he/she had conducted 2 inservices about obtaining ordered blood work . He/she stated the orders go directly into the computer, the facility no longer had a laboratory book, and the order came up on the TAR (Treatment Administration Record) to ensure staff would complete the order. Staff needed to call the resident's physician when staff are unable to draw ordered laboratory work. On 3/25/15 at 6:16 PM, consultant licensed staff C verified the facility failed to obtain the 6/27/14 PT/INR as ordered. On 4/2/15 at 2:07 PM, administrative staff A reported the facility lacked a written policy for monitoring and obtaining blood work for anticoagulant therapy, and added, the physician directed when staff needed to obtain blood work to monitor the medication. The facility failed to obtain blood work to monitor the resident's anticoagulant therapy, as ordered by the physician. The resident experienced an increase in the therapeutic level of the medication, and then the resident had a fall with a head injury and a brain bleed, and required medication administration in the emergency room to treat the elevated blood levels. - Resident #24's Physician order [REDACTED]. 1.) [MEDICATION NAME], 10 mg (milligrams), by mouth, one time a day, ordered on [DATE]. 2.) [MEDICATION NAME], 10 mg, by mouth, one time a day, ordered on [DATE]. 3.) [MEDICATION NAME], 40 mg, by mouth, one time a day, ordered on [DATE]. A physician order [REDACTED]. The staff were to call the physician if the resident's systolic BP was less than 90 or if the diastolic BP was greater than 170. However, the physician order [REDACTED]. The resident's annual MDS (Minimum Data Set), dated 12/10/14, revealed the resident's BIMS (Brief Interview for Mental Status) of 15, which indicated the resident as cognitively intact. The resident was independent for all areas of functional status, except he/she required supervision of 1 person for dressing. The resident's care plan, last reviewed 11/4/14, directed staff that the resident had hypertension and the resident needed a BP taken daily. The vital signs section of the resident's medical record, revealed staff obtained the resident's BP last on 2/18/15, over a month prior. Staff completed the resident's BP for 5 days in February, 2015 and 18 days in January, 2015. A physician progress notes [REDACTED]. On 3/24/15 at 3:30 PM, the resident sat in the wheelchair, and looked at an envelope, without complaints. The resident reported he/she was able to transfer himself/herself. On 3/26/15 at 6:40 PM, administrative nursing staff B reported blood pressure medications (including the [MEDICATION NAME], and [MEDICATION NAME]) require weekly blood pressure monitoring, unless the facility obtained different specific orders by the resident's physician. Staff B confirmed the medical record lacked any monitoring of the resident's blood pressure since 2/18/15. The facility lacked a written policy in regards to medication monitoring of residents whom receive antihypertensive medication, per administrative staff A, on 4/2/15 at 2:06 PM. Staff A added, monitoring of the antihypertensive medications should be completed as directed by the physician. The facility failed to monitor efficiency and potential side effects of this resident's three antihypertensive medications, to ensure appropriate medication administration.

The facility reported a census of 49 residents with 23 selected for sample review. Based on observation, interview, and record review, the facility failed to ensure 3 of 3 residents, including (#52, 4 and 22) reviewed for pain, received appropriate pain control, and 1 of 1 resident reviewed for death, (# 65) received appropriate assessments to ensure the highest quality of life possible. Findings included: - The facility readmitted resident # 52 on [DATE], per the electronic clinical census record. [DIAGNOSES REDACTED]. The [DATE] admission MDS (minimum data set) identified the resident scored ,[DATE] on the BIMS (brief interview for mental status), indicating intact cognition, needed limited assistance of 1 staff for bed mobility, and supervision for transfers of 1 staff. The assessment further identified the resident needed extensive assistance of 2 staff for toileting and extensive assist of 1 staff for personal hygiene with occasional incontinence. The pain assessment identified the resident received PRN (as needed) medication, rarely experienced recent pain, but the pain affected the resident's sleep pattern. The resident scored the highest pain level at ,[DATE] on the pain scale. On [DATE] at 3:30 PM, administrative nursing staff C verified the [DATE] admission MDS as the most current comprehensive assessment completed for this resident. The [DATE] CAAs (care area assessments) for pain, lacked analysis of the triggered area of pain affecting the resident's sleep pattern. The [DATE] quarterly MDS (minimum data set) assessment, identified the resident scored ,[DATE] on the BIMS, indicating intact cognition, required extensive assistance of 2 staff for ADL's (activities of daily living), lacked identification of scheduled pain medications, received prn pain medications, frequently, limiting activities and the resident scored the worst pain at a level of ,[DATE]. The resident's [DATE] care plan lacked interventions for controlling the resident's pain. Review of the October and November, 2013 MAR's (medication administration records) and Physician Orders identified the resident received the following orders: 1. [MEDICATION NAME] Tablet, ,[DATE] mg (milligrams) every 4 hours, PRN for generalized pain, ordered [DATE]. The October, 2013 MAR indicated [REDACTED]. 2. [MEDICATION NAME] Tablet, ,[DATE] mg (milligrams) every 4 hours, PRN for pain related to generalized pain, ordered [DATE]. The November, 2013 MAR indicated [REDACTED]. 3. [MEDICATION NAME] HCL, 5 mg tablet, 1 or 2 tablets, up to 3 times a day, as needed for pain, ordered [DATE]. Review of the [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 9:45 AM the resident refused to provide an interview, related to extreme pain and feeling ill. On [DATE] at 8:05 AM observation identified the resident seated in their wheel chair, and reporting lots of pain. The resident further reported to staff that he/she requested pain medication earlier around 7 AM, but did not receive any pain medication, until around 8:00 AM. On [DATE] at 8:47 AM upon return to the resident's room, the resident continued in pain, moaning loudly and voicing their pain from 8:47 AM to 9:00 AM. The resident winced and cried out upon movement and stated they became entangled in the bed linens and strained their arm/shoulder during attempts to get out of bed. The resident's breakfast sat on an over-bed table in front of the resident, with only small bites eaten. The resident stated, they were unable to eat, due to pain. The resident reported they received their pain medication, approximately an hour after asking for it. On [DATE] at 2:18 PM, the resident rested in bed, laying on their back. The resident reported the pain level as lessened with the pain medication and looked forward to a bath, this afternoon. On [DATE] at 7:00 AM, the resident slept quietly in bed, without any distress noted. At 7:15 AM direct care staff V entered the resident's room and awakened the resident. At that time, the resident requested a hall tray for breakfast. Observation, on [DATE] at 9:00 AM, identified the resident received their pain medication, with the resident stating, "I requested them an hour ago." On [DATE] at 7:00 AM, the resident sat in the dining area for breakfast, smiling and reporting his/her pain was much better controlled today. Interview with the resident on [DATE] at 9:00 AM, reported, "I have a lot of pain and sometimes it takes too long to get the pain medicine. I got up at 6:30 AM and I asked for pain medication then but didn't get it until 8:55 AM. When the pain gets so bad, then it just ties me up into knots and it is just unbearable." The resident identified the pain currently located in their right shoulder and arm. Direct care staff V reported on [DATE] at 7:15 AM, the resident was independent with cares, and asked that staff awaken him/her in the AM. The staff reported the resident often asked for pain medication as soon as they awaken and does frequently express pain. On [DATE] at 9:10 AM, licensed nursing staff P reported the resident needs to be on a scheduled pain medication, however, due to time constraints the nurses have been unable to make those needed requests to the physician. The resident is not the only one, there are several residents who need routine medications for pain. Staff P reported the resident asked for pain medication every AM and every PM and as a nurse believed that when a resident requested pain medications that frequently, a request should be made for scheduled medication. On [DATE] at 2:35 PM, direct care staff S reported the resident's level of care varied with the day, and the resident does ask for assistance, if needed. Staff S reported the resident often complained of pain and requested pain medication. Staff S reported that when a resident complained of pain, that information is passed onto the charge nurse for medication administration, as needed. When asked about any non-medicinal interventions to relieve the resident's pain. Staff S reported, a lack of awareness of anything like that for this resident. On [DATE] at 2:28 PM, licensed nursing staff F, reported the resident, "Lately (he/she) has had numerous complaints of leg pain, and (the resident) keeps a close eye on the clock for time to get the next prn (as needed) medication. I'm not sure of any attempts to notify the doctor and do not see that in the progress notes..." On [DATE] at 1:00 PM interview with physician OO, reported the physician sees the resident often, is aware of the resident's frequent complaints of pain and does monitor their pain medications with every visit. Review of the facility policy, dated ,[DATE], for Pain Management, included: "All residents will receive interdisciplinary consultations on assistance in managing pain....The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological. The registered nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan." The facility failed to ensure this resident received pain management to ensure the highest level of functioning possible. - The facility admitted resident # 4 on [DATE], per the electronic clinical census record. [DIAGNOSES REDACTED].), and cervicalgia (pain in the cervical spine). The resident's [DATE] annual MDS (minimum data set) assessment, identified the resident scored ,[DATE] on the BIMS (brief interview of mental status), required only supervision with ADL's (activities of daily living) and identified the resident with generalized pain and [MEDICAL CONDITION] arthritis, received scheduled pain medications, prn pain medications, and received non-medicinal interventions. The [DATE] CAA (care area assessment) did not trigger pain. A [DATE] quarterly MDS identified a BIMS of ,[DATE], indicating intact cognition, required supervision of 1 staff for ADL's, with independent ambulation, received scheduled and PRN pain medications, received non-medicinal interventions, and the resident identified pain in the last 5 days, frequently, making it hard to sleep and limiting their day to day activities, while experiencing the worst pain of ,[DATE]. The resident's [DATE] care plan instructed staff the resident capable to call for assistance when in pain, repositioned self, asked for medications, telling how much pain is experienced and telling what increases or alleviates the pain. The care plan further noted pain is aggravated by falls or changes in weather. Observing and recording/reporting signs of pain to the charge nurse, included in the instructions as well. The care plan lacked identification of non-medicinal interventions to eliminate or reduce the need for pain medication. Review of the physician orders included the following orders noted for pain: 1. [MEDICATION NAME], 10 mg, 1 tablet, for neck pain related to cervicalgia, tid, prn (as needed), ordered [DATE]. 2. [MEDICATION NAME]/[MEDICATION NAME], 7XXX,[DATE] mg, 1 tablet, by mouth, every 6 hours, prn for pain not to exceed 3000 mg APAP in 24 hours, ordered [DATE]. 3. [MEDICATION NAME], 250 mg, 1 every 6 hours, prn, for pain, ordered [DATE]. Review of Nursing Notes included the following: [DATE] 1401 (2:01 PM), "Care plan review...continued c/o (complaint of) pain to low back...resident has been to the doctor and had x-rays of lumbar spine, but continues to have pain. [MEDICATION NAME] was discontinued at one point per resident request because of ineffectiveness. Pain continued to get worse, so nursing requested it again. Rash developed and again resident requested discontinuation. [DATE] 2211 (10:11 PM) "[MEDICATION NAME]/APAP given for ,[DATE] pain." [DATE] 2355 (11:55 PM) "Effective." [DATE] 0711 (7:11 AM) "[MEDICATION NAME], 250 mg, for pain; general discomfort." [DATE] 9:35 AM "Effective." Review of nursing notes, dated [DATE] to [DATE], identified the resident received PRN [MEDICATION NAME] or [MEDICATION NAME] nearly every night, PRN for pain. Also noted on several occasions resident seen by chiropractor for back adjustments. Review of the October, November, 2013, MARS (medication administration records) included the following: 1. [MEDICATION NAME], 10 mg, 1 tablet, as needed, for neck pain, related to cervicalgia, tid, lacked identification of use. 2. [MEDICATION NAME]/[MEDICATION NAME], 7XXX,[DATE] mg, 1 tablet, by mouth, every 6 hours, as needed, for pain, not to exceed 3000 mg APAP in 24 hours---MAR review [REDACTED]. During ,[DATE] the resident received the medication 26 times and noted as effective each time. 3. [MEDICATION NAME], 250 mg, 1 every 6 hours, as needed, for pain---MARS reviewed ,[DATE] identified the resident received the medication 17 times and effective each time, the ,[DATE] MAR indicated [REDACTED]. On [DATE] at 2:05 PM, identified the resident leaving the dining area, using roller walker for ambulation. The resident stated, at that time, "I'm hurting," in response to "how are you?" Inquiry regarding pain medication received today identified the resident reporting, "I had one (a pain pill) earlier today." On [DATE] at 3:15 PM, the resident reported having uncontrolled pain, at that time, while seated in the activity room. On [DATE] at 7:45 AM, the resident sat in a dining room chair, with a pillow at their back. The resident reported their back felt better today, and reported they experienced most of their pain at night. The resident further reported, "I don't get any thing routinely for the pain, I just have to ask for it. Sometimes I don't get it as quickly as needed." Interview with the resident on [DATE] at 3:54 PM identified the resident experienced pain on a daily basis, with the worst pain experienced at night. On [DATE] at 9:10 AM, licensed nursing staff P reported, "...the resident needs to be on a scheduled pain medication, however, due to time constraints the nurses have been unable to make those needed requests to the physician. (He/She) is not the only one, there are several residents who need routine medications for pain, including..." Staff P reported the resident asked for pain medication every AM and every PM and as a nurse believed that when a resident requested pain medications that frequently, a request should be made for scheduled medication. On [DATE] at 2:45 PM, direct care staff S reported the resident often reported pain, and the staff then notify the nurse. Interview on [DATE] at 6:00 PM, interview with direct care staff L reported the resident's sometimes must wait 45 minutes for PRN pain medications. Direct care staff R added that the staff member reported the excessive wait time to administrative staff without any resolution made as of this time. Licensed nursing staff F reported on [DATE] at 2:14 PM the resident sometimes received lotion and massage as a method of pain relief with non-pharmacological intervention, however, reported, "No, I haven't charted to that effect. When informed of the frequency of PRN's used, staff F reported the resident typically seemed to do well with the [MEDICATION NAME] and felt the MD should be notified to address the excessive PRN use and inquire about a routine dose being more effective at controlling the residents pain. On [DATE] at 3:45 PM, administrative nursing staff C reported the staff should have notified the physician of the resident's frequency of PRN pain medication usage. Review of the facility policy, dated ,[DATE], for Pain Management, included: All residents will receive interdisciplinary consultations on assistance in managing pain....The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological. The registered ruse will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan. The facility failed to ensure the resident maintained the highest practicable level of physical well-being, when staff failed to notify the physician of the resident's increase in pain level and maintain the highest level of pain control. - The facility admitted resident #22 on [DATE], per the electronic clinical record. [DIAGNOSES REDACTED]. The resident's [DATE] admission, MDS (minimum data set) assessment, identified the resident scored ,[DATE] on the BIMS (brief interview of mental status) testing, indicating intact cognition, required extensive assistance of 2 staff for most ADL's (activities of daily living), received scheduled pain medication regimen and PRN pain medications, non-medication interventions for pain, had pain in the past 5 days (of MDS), with almost constant pain, making it difficult to sleep at night, and the worst pain being "8" of 10. The CAA, dated [DATE], for pain indicated the resident's immobility is caused by several failed back surgeries, approximately 7 years ago, and received pain medicine. The resident sometimes had a hard time getting comfortable at night, and will verbalize his/her pain. The resident also admitted with a [MEDICAL CONDITION] without repair. The pain assessment, dated [DATE], identified pain present and the resident received pain medications. The [DATE] care plan included: 1. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased ROM, withdrawal or resistance to care. 2. Is on pain medication: report to the nurse any sign and symptom of non-verbal pain, changes in breathing, vocalizations, moans, yelling out, silence; mood/behavior more irritable, restless, aggressive, squirmy, constant motion, and eyes (no focus). 3. Resident's pain is rated using facial expression. Review of the physician orders for pain control included the following: 1. WMP (warm moist pack) to back area, for pain, tid (three times daily), ordered [DATE]. 2. [MEDICATION NAME] Gel 1%, apply 4 grams,[MEDICATION NAME], bid (twice daily), for lower back pain/lumbago, rub on pain in lower back or wherever complaining of pain bid. Do not use at same time as Aspercreme. Ordered [DATE]. 3. Tylenol, 2 tablets, 650 mg (milligrams), qid (four times a day), for pain/fever, give every 6 hours with [MEDICATION NAME]. Wake patient to give medication. Do not exceed 3000 mg of Tylenol per 24 hours. Ordered [DATE]. 4. [MEDICATION NAME] HCL tablet, 6 mg, qid, for generalized pain, give with Tylenol 650 mg, every 6 hours, can also use every 3 hours without Tylenol, prn (as needed). Ordered [DATE]. 5. [MEDICATION NAME] Solution, 20 mg/ml sl (sublingually), every 2 hours, prn pain or air hunger, ordered [DATE]. 6. [MEDICATION NAME] HCL, 6 mg every 3 hours, as needed for pain, ordered [DATE]. 7. APAP ([MEDICATION NAME]), 650 mg, every 4 hours, prn, Not to exceed 3000 mg per 24 hours, ordered [DATE]. 8. [MEDICATION NAME], 200 mcg (micrograms), [MEDICATION NAME], every 3 days for pain, ordered [DATE]. 9. Aspercreme 10%, apply to affected area, topically, tid (three times daily), for pain, ordered [DATE]. On [DATE] at 2:30 PM, the resident's spouse visited. During conversation the spouse reported having a concern with the amount of staffing and the impact on the resident's care. The spouse reported the resident had a lot of pain, and didn't feel it was controlled very well here. Reported the resident will ask for pain medication, then it might be another 30 minutes to an hour before he/she gets it. Then the pain is really bad. On [DATE] at 4:29 PM, direct care staff S and CC assisted with getting the resident up for supper. Resident groaned when rolled, each time, as staff dressed the resident. At 4:45 PM direct care staff L, administered medications to the resident. At that time the resident asked about a pain pill and the aide stated, "I'll give that to you with supper." Staff L, applied [MEDICATION NAME] gel to the resident's lower back along with a back rub. On [DATE] at 9:32 AM, licensed nursing staff P, inquired residents pain level, and the resident responded, "4." Staff P provided pain medication of APAP, 650 mg for pain. At 10:13 AM on [DATE], licensed nursing staff P applied 2 [MEDICATION NAME]es after removing the old patches. Noted during cares, the resident had a (now cold) WMP (warm moist pack) to the residents right lower back area. On [DATE] at 2:30 PM, the resident's spouse reported the resident had a lot of pain related to back surgeries, and fracture without repair, and needed routine pain medications. The spouse reported they did not understand why it took so long to get medications to the resident, except they felt the facility lacked enough staff to provide adequate and timely resident cares, including administration of medications. The spouse reported they planned to take the resident home, as soon as possible. On [DATE] at 2:50 PM, direct care staff S, reported the resident required mostly total care, and had frequent complaints of pain. On [DATE] at 9:10 AM, licensed nursing staff P reported, "...the resident needs to be on a scheduled pain medication, however, due to time constraints the nurses have been unable to make those needed requests to the physician. (He/She) is not the only one, there are several residents who need routine medications for pain, including..." Staff P reported the resident asked for pain medication every AM and every PM and as a nurse believed that when a resident requested pain medications that frequently, a request should be made for scheduled medication. Review of the facility policy, dated ,[DATE], for Pain Management, included: All residents will receive interdisciplinary consultations on assistance in managing pain....The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological. The registered nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan. The facility failed to provide timely pain administration to this resident to control his/her pain, in a timely manner, to ensure the highest practicable level of well-being. - Review of resident #65's closed record face sheet revealed the resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. primarily causes shortness of breath), [MEDICAL CONDITION] (abnormal condition that may affect the flow of oxygen to the heart), non-[MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure), and altered mental status. Review of the 5 day [DATE] MDS (Minimum Data Set) 3.0 Assessment recorded the resident rarely/never understood, independent cognitive skills, required limited assistance of 1 staff with bed mobility, transfers, supervision of walking in the room/corridor, supervision with other activities of daily living, and used a walker. Review of the Care Area Assessment Summary (CAAs), dated [DATE], triggered the following: Activities of Daily Living - This Resident has a self care deficit related to recent hospitalization for Anasarca (extreme generalized [MEDICAL CONDITION]), alcohol-Induced dementia, fluid overload, [MEDICAL CONDITION], hypertension, and has weakness, poor endurance, decreased safety ability and reduced ability to perform ADLs. (refer to Physical Therapy and Occupational Therapy evaluations and plan of treatment from [DATE] & [DATE]). The resident received Physical Therapy and Occupational Therapy to reach the highest level of function so that the resident may return home as the resident wants. Review of the 14 day MDS, dated [DATE], recorded no changes in activities of daily living status. Review of the plan of care dated [DATE], recorded the following: Monitor for and document changes in the resident's ability to express and comprehend language, memory. Weekly weight. The resident's care plan failed to address the resident's lower extremity [MEDICAL CONDITION] and oxygen therapy needs. On [DATE], the resident's physician ordered the resident's status as staff to Resuscitate, full code. Admission nursing notes of [DATE] at 3:40 PM, recorded the resident noted with [MEDICAL CONDITION] in the lower extremities. Staff documented on the [DATE] initial interdisciplinary data collection tool the resident noted with [MEDICAL CONDITION] of the feet. Staff documented in the [DATE] nursing notes at 7:50 PM, the resident was pleasant and cooperative. Ambulated with a walker without much assistance, mainly just stand by assistance. Resident was alert and oriented understood English well. Staff documented in the [DATE] nursing notes at 10 AM, interchange request/physician order received via fax with an order change from ProAir HFA inhaler to [MEDICATION NAME] HFA dose inhaler, one puff, every 2 hours as needed, order noted, pharmacy contacted, inhaler will be sent out stat, Pro Air inhaler empty, resident notified. Staff documented in the nursing notes on [DATE] at 12:30 PM, [MEDICATION NAME] HFA Aerosol Solution, 1 puff, inhale orally, every 2 hours, as needed for shortness of breath. Resident panting and complaining of shortness of breath while walking to the dinner table. The nursing notes lacked evidence of the resident's oxygen saturation level, Staff documented in the [DATE] nursing notes at 12:31 PM, resident panting and complaining of shortness of breath while walking to the dinner table. [MEDICATION NAME] HFA inhaler, one puff, as needed, administered. Resident ambulates with a walker, unassisted. The nursing notes lacked evidence of the resident's oxygen saturation level, Staff documented in the [DATE] nursing notes at 1:37 PM, [MEDICATION NAME] HFA Aerosol Solution, 1 puff inhaler, orally, every 2 hours as needed, for shortness of breath, administered. Staff recorded the administration was effective. Staff documented in the [DATE] nursing notes at 3:15 PM, the resident walking and riding the incumbent bicycle during Physical Therapy. Physical Therapy Aide reported that the resident's oxygen saturation level dipped to 80% on room air, oxygen applied at 2 liters per minute via nasal cannula started by the nurse. Physician notified. Review of the computerized vital signs sheet revealed staff recorded an oxygen saturation level of 88%, on [DATE] at 8:45 PM. The nursing notes lacked evidence staff notified the resident's physician of the resident's low oxygen saturation level. Review of the computerized vital signs sheet revealed staff recorded an oxygen saturation level of 96%, on [DATE] at 6:16 PM. On [DATE], the physician ordered a nocturnal pulse oximetry and [MEDICATION NAME] (an antihypertensive medication) 0.2 mg (milligrams), twice a day. On [DATE] at 8:02 PM, staff recorded an oxygen saturation level of 88%. The nursing notes lacked evidence staff notified the resident's physician of the resident's low oxygen saturation level. On [DATE], the physician ordered staff to titrate the resident's oxygen to maintain a level above 88% and ordered oxygen at 2 liters per minute per nasal cannula. On [DATE], the physician ordered [MEDICATION NAME] (diuretic) 2.5 mg, daily and nocturnal oxygen at 2 liter per minute per nasal cannula. On the front of the daily skilled nursing notes on [DATE], no time written, staff recorded on all three shifts a check mark to indicate lungs sounds checked but no additional assessment evidenced including lung sounds as clear, rales (respiratory sound consisting of discontinuous bubbling noises on auscultation of the chest during inspiration)/rhonchi (abnormal sound heard on auscultation of an airway obstructed by thick secretions), diminished, wheezes, etc. Staff documented on the [DATE] nursing notes, at 1:40 PM, the resident was alert oriented times 3. The resident was very short of breath today, oxygen at 2 liters. Oxygen saturation levels recorded at 84%, 87%, and 90%. Used inhaler as needed. The nursing notes lacked evidence staff notified the resident's physician of the resident's low oxygen saturation level. Staff documented in the [DATE] nursing notes at at 6:25 PM, the resident appeared short of breath. Wearing oxygen at 2 Liters. Temperature recorded as 100.6 F. (Fahrenheit) Encouraged the resident to drink fluids. Oxygen saturation recorded at 92%, and the resident with 2 plus [MEDICAL CONDITION] to the lower extremities. On the front of the daily skilled nursing note on [DATE], on the night and evening shifts, staff only documented a check mark to indicate checking the resident's lung sounds. The skilled notes lacked evidence of any additional lung assessment including clear, rales/rhonchi, diminished, wheezes, etc. The skilled nursing note lacked evidence the day shift assessed the resident's lung sounds. Staff recorded on the [DATE] nursing notes at 8 AM, the resident having shortness of breath. Staff asked the resident if the resident would like to go to emergency room and recorded the resident didn't want to go. At 12:30 PM, the resident continued to have shortness of breath, and the resident still did not want to go to the emergency room . At 10 PM, staff documented the resident had 2 plus [MEDICAL CONDITION] to the lower extremities, denied shortness of breath or discomfort. Staff documented will continue to monitor the resident. Staff documented oxygen saturation levels on the night and evening shift at 98%. Staff documented elevated oral temperatures of 100.4 F on the night shift, temperature of 100.7 F. on the day shift, and temperature of 98.9 F on the evening shift. The [DATE] daily skilled note, staff recorded a check mark to indicate checking the resident's lung sounds on the night, day, and evening shifts. The skilled notes lacked evidence of any additional lung assessment including clear, rales/rhonchi, diminished, wheezes, etc. The skilled nursing note lacked evidence the evening shift assessed the resident's lung sounds. Staff documented on the [DATE] nursing notes at 1:45 AM, the resident with a temperature of 97.5 F. and an oxygen saturation level of 95%. Staff recorded the resident had the oxygen in place and had slept in the recliner most of the night. Staff recorded on the day shift, no time recorded, the resident had a temperature of 98 F. At 8 PM, staff recorded the resident had no signs/symptoms of shortness of breath, had bilateral 2 plus [MEDICAL CONDITION] of the lower legs and feet, and with a temperature of 99.4 F. Staff documented on the [DATE] nursing notes at 3 AM, the resident transferred to the recliner halfway through the shift, as the resident had some difficulty breathing. Staff documented the resident's breathing was better sitting up. Staff documented the resident with a temperature of 100.9 F. The [DATE] skilled nursing note, staff recorded a check on the lung assessment section of the note, but review of the nursing notes lacked any additional documentation as to a description of the resident's lung sounds, such as clear, rales/rhonchi, diminished, wheezes, etc. Staff documented on the [DATE] nursing notes at 4 AM, staff checked on the resident at 0400 (4 AM), and the resident seemed to breathe better. Staff recorded the resident was back in bed. On the front of the daily skilled note on [DATE], staff recorded a check mark on the night shift of lungs sounds checked, but review of the nursing notes lacked any additional lung assessments, such as clear, rales/rhonchi, diminished, wheezes. The clinical record lacked evidence staff notified the physician from [DATE] at 6:45 PM when the resident first presented with an elevated temperature until staff recorded on the [DATE] nursing notes at 7:07 AM, that at 5:50 AM a CMA (Certified Medication Aide) went to the resident's room and found the resident without vital signs. Staff lowered the resident to the floor and staff started CPR (cardiopulmonary resuscitation). Licensed staff called emergency medical services. Emergency medical services (EMS) and police arrived at 0600 (6 AM) and took over CPR. At 6:20 AM, EMS transported the resident to the hospital. At 6:27 AM, staff paged the on call physician and notified the physician of the resident's condition. Staff recorded in the [DATE] nursing notes at 7 AM, staff called the hospital and were informed the resident had expired. Review of the [DATE] EMS report revealed the following: Call Type: [MEDICAL CONDITION] Urgency: Immediate Provider Impression: [MEDICAL CONDITION] Chief Complaint: Pulseless and apneic for 10 minutes Onset date/time: [DATE] at 5:50 AM Primary Symptom: Cardiorespiratory Arrest SUBJECTIVE: Called for a reported [MEDICAL CONDITION]. On arrival, found a [AGE] year male patient weighing 108 KG (kilograms), found laying on the bedroom floor. Doing CPR. Chief complaint of pulseless and apneic. Staff advise that they last saw patient at 4 AM. Staff found patient unresponsive at 5:50 AM and

The facility reported a census of 49 residents with 23 selected for sample review. Based on observation, interview, and record review, the facility failed to provide treatment and services to promote healing for 4 of 4 residents reviewed for pressure ulcers, including residents # 44, 52, 3 and 66. One resident experienced harm (# 44) when the facility failed to provide pressure relieving devices, follow recommendations made by the registered dietician, and failed to maintain dressings to the resident's re-developing areas. Findings included: - The facility admitted resident # 44 on 7/2/13, per the clinical face sheet, dated 7/2/13. [DIAGNOSES REDACTED]. The resident's 7/8/13 admission MDS (minimum data set) assessment identified the resident scored 13/15 on the BIMS (brief interview of mental status) testing, indicating intact cognition, and lacked identification of rejection of care. The assessment reflected the resident required extensive assistance of 2 staff for bed mobility and transfers, and identified the resident lacked pressure ulcers or scars over the bony prominences, but indicated the resident was at risk for the development of pressure ulcers. The CAA's (care area assessment), dated 7/8/13, included the resident needed assistance for all ADL's (activities of daily living), related to weakness and a recent fall. The pressure ulcer CAA identified no pressure ulcers at that time, but identified the resident at risk related to the resident being dependent on staff for bed mobility and incontinent. The CAA lacked completion and/or analysis of findings to determine the causal factors contributing to the resident's risk for pressure ulcers. The quarterly MDS, dated [DATE], identified the resident scored 8/15 on the BIMS testing, indicating moderately impaired cognition, lacked identification of rejection of care, and required extensive assistance of 1 staff for bed mobility and extensive assistance of 2 staff assistance for transfers. The assessment identified no weight loss, and identified a stage 1 or greater pressure ulcer, at risk for the development of pressure ulcers with unhealed pressure ulcers identified at a stage I. A Physical Nursing Data Collection Tool, dated 7/2/13, identified bruising and abrasions, but lacked identification of any pressure ulcer. A Braden Skin Risk Assessment, dated 7/2/13 scored the resident at 14, with subsequent assessments, dated 7/9, 7/16, 7/23 and 10/2/13 scored the resident at 14, indicating moderate risk for skin breakdown/pressure ulcers. The resident's 7/22/13 care plan instructed 2 staff to assist with all transfers and bed mobility/turning and toileting, related to risk for pressure ulcers. Review of the resident's nutritional needs, identified the resident assessed by the registered dietician on 7/21/13 and noted the resident gaining weight, with intact skin and nutrient needs not always met. The dietician recommended one can of Ensure, TID (three times daily), monitor the resident's PO intake, weight and labs. The resident's 10/5/13 care plan instructed staff: 1. The resident required 1 staff for repositioning and turning in bed and transfers. 2. Provide observation at meals related to nutritional problems. Weigh weekly. 3. Hospice care. 4. Assist to turn and reposition at least every 2 hours; reposition with 1-2 assistance of staff. 5. Resident prefers to be positioned in recliner, if not in bed. 6. Provide pressure relieving mattress on the resident ' s bed and a pressure relief cushion in the wheel chair. 7. Notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration, etc., noted during bathing or daily care. The care plan lacked identification of any nutritional shakes needed. A Care Plan Review, dated 10/5/13 at 12:05 PM identified the resident with intake at 75%, doing well and without significant changes. Review of physician orders [REDACTED]. 1. an order for [REDACTED]. 2. an order for [REDACTED]. 3. On 11/1/13 an order for [REDACTED]. 4. an order for [REDACTED]. 5. On 12/3/13, an order for [REDACTED]. 6. An order, dated 12/4/13 instructed staff, " DO NOT COVER WITH FOAM OR PAPER TAPE," on the mid spine [MEDICATION NAME] dressing. Review of the resident's Wound Flow Sheets identified: Left buttock: 8/8/13-- 0.5 x 0.5 cm (centimeter), without drainage, odor or pain and treatment with [MEDICATION NAME] dressing. 8/15/13-- Closed. 8/22/13-- Closed. 10/31/13-- 1.4 cm x 0.9 cm with 100% granulation tissue (new forming cells in the tissue), no drainage, odor or pain and treatment of [REDACTED]. 11/7/13--Closed. Right buttock: 10/24/13-- 0.9 cm x 0.5 cm 100% red granulation, no drainage, odor or pain, treatment with [MEDICATION NAME] dressing. 10/31/13-- 0.6 cm x 0.1 cm, 100% granulation, no drainage, odor or pain, treatment with [MEDICATION NAME] dressing. 11/7/13-- 1cm x 0.4 cm 100% red granulation, no drainage, odor or pain, treatment with [MEDICATION NAME] dressing. 11/14/13-- 0.6cm x 0.9 cm with 100% granulation and treatment with [MEDICATION NAME]. 11/21/13-- 0.3 cm x 0.5 cm with 100% granulation and treatment with [MEDICATION NAME] Mid Back bony prominence/spine: 8/8/13--not staged, 0.2cm x 0.2 cm no drainage, odor or pain, treatment with [MEDICATION NAME]. 8/15/13-- Closed 8/22/13-- Closed 10/3/13--1.9 cm x 2.0 cm with minimum drainage, sanguineous (relating to or color of blood; bloody), [DIAGNOSES REDACTED]tous (Redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection.), no odor or pain, treatment with [MEDICATION NAME] dressing. 10/10/13-- 0.5 cm x 0.6 cm with intact scab, no drainage, treatment with [MEDICATION NAME] dressing. 10/17/13--0.6 cm x 0.4 cm with intact scab, no drainage odor or pain, treatment with [MEDICATION NAME] dressing. 10/24/13-- 0.5 cm x 0.7 cm with 100% granulation, with minimum and sanguineous, no odor or pain, treatment with [MEDICATION NAME] dressing. 10/31/13-- 1.2 cm x 0.9 cm with 90 % granulation and 10% slough, moderate drainage, sero-sanguineous (bloody appearance) in color, without odor or pain and treatment with [MEDICATION NAME] dressing. 11/7/13-- 0.5 cm x 0.8 cm with 100% yellow slough, minimum drainage, no odor or pain, treatment with [MEDICATION NAME] and foam. 11/14/13-- 1.3 cm x 0.9 cm (missing documentation of the granulation), minimum drainage, sero-sanguineous in color, no odor or pain and treated with [MEDICATION NAME] and foam. 11/21/13-- 0.3 cm x 0.4 cm with 100% granulation, without odor or drainage and treatment with [MEDICATION NAME] and foam. All wound sheets reviewed lacked identification of staging. Hospice notes, dated 11/20/13, evidenced the hospice nurse applied a [MEDICATION NAME] dressing to the resident's back and right buttock. The Registered Dietician reviewed the residents nutritional needs on 11/26/13 and identified the resident had 2 wounds to the back and buttocks, which are healing slowly, noting the resident's weight had improved, receiving hospice care, lacked any labs to review and recommended 2 cal, 2 ounces TID. Review of Nursing notes, dated 12/5/13 at 1629 (4:29 PM) revealed staff faxed hospice regarding wound order changes. an order for [REDACTED]. Observation of the resident on 12/3/13 from 2:15 PM to 3:00 PM identified the resident resting in bed, on their back, with a waffle type air mattress to the bed. At 3:00 PM, the resident sat in their wheel chair, without a pressure reducing cushion for 30 minutes, to get a haircut, and then returned to bed, on their back. The resident remained in that position until 5:05 PM when direct care staff CC assisted the resident with arising for supper. Staff CC sat the resident onto the edge of the bed, after removing a pillow from under the resident's legs, for heel off-loading. Staff placed slippers on the resident ' s feet, a gait belt to the resident's waist and assisted the resident to a standing position. Staff CC encouraged the resident to walk to the bathroom for toileting. Staff CC checked the resident ' s incontinent brief, and noted the brief dry with a smear of bowel movement, then removed and placed a clean brief on the resident. Staff CC then provided good perineal care and applied A&D ointment to the buttocks area. Observation noted a reddened area with scaly peeling skin to the coccyx and buttocks area, approximately 3 cm x 3.5 cm and without a dressing present. Observation of the spine area identified an intact dressing. On 12/3/13 at 5:30 PM staff served the resident supper of ham, sweet potatoes, and a glass of water. Eating very well, without difficulty and consumed 100%. On 12/4/13 at 7:10 AM, direct care staff V, assisted the resident to a sitting position on the edge of the bed. Before assisting the resident to a sitting position, the resident rested on their back with an air mattress overlay and lacked any heel offloading or heel protectors, to their feet. Licensed nursing staff P, removed a dressing from the resident ' s lower spine area, revealing an opened area. Staff P reported the area had reopened, since his/her last assessment, reported completed on 11/30 or 12/1/13. The discarded dressing exhibited tan colored drainage. Staff P obtained clean supplies to cleanse the area, and completed a dressing change including cleansing with Normal Saline, and application of a [MEDICATION NAME] dressing. Observation identified an opened area with a black eschar area, approximately 1 inch in length, to the inner portion of the wound. Staff P, observed the resident's buttocks, upon request, and identified the area as reopened. The area appeared as dry scaly skin with several opened areas within the pear shaped reddened area, measuring approximately 2 cm at the top and 3 cm at bottom of the reddened area and 4 cm in length. Direct care staff V, inquired of the nurse if the resident needed barrier cream, and nurse P responded, "Yes, for now." Staff V assisted the resident to a seated position in the wheel chair, with only a folded bed pad in the seat for pressure reduction. Staff V also placed a small pillow to the resident ' s upper back. Nursing staff P reported the resident needed pressure reducing cushions to the wheel chair and the recliner, as well as at the resident ' s backside. On 12/4/13 from 7:30 AM - 8:25 AM the resident ate breakfast of pancakes with butter and syrup, milk, juice and coffee, consuming 100%. Ate independently and chose their breakfast from menu. On 12/5/13 at 7:00 AM, the resident sat in the wheelchair without a pressure reducing cushion in the seat or back area. On 12/5/13 at 8:31 AM, licensed nursing staff K, completed a wound assessment to the resident's back and buttocks. Staff K, removed a dressing from the residents spine area, cleansed the area with wound cleaner, sitting on a clean barrier on the bedside table, along with gauze in a package. The soiled dressing exhibited sero-sanguineous drainage. Staff K stated, the area had increased in size and developed eschar (A piece of dead cells that is cast off from the surface of the skin) in the wound. The area appeared reddened with a dark black center, circular in shape and approximately 1 cm in diameter. Following cleansing of the wound, staff placed a clean dressing to the resident's back, failing to change their gloves between the soiled and clean portion of the treatment procedure. Staff K reported the resident's back dressing lacked the foam dressing, and should be in place at all times, to cushion the area. Staff K then assisted the resident to stand with the walker to assess the buttocks area. The resident lacked a dressing to the buttocks area, and the staff measured the area, cleansed with wound cleaner then applied a [MEDICATION NAME] dressing to the buttocks area. The area appeared as approximately 4.5 cm x 2 cm to the right buttock and a small area, less than 1 cm, to the left buttock. Staff K further confirmed the resident lacked any pressure relieving devices for the back or seat of the resident ' s chairs. Following completion of the wound treatment, the staff picked up the gauze and wound cleaner spray bottle, removed the clean cloth barrier and sat the items down, directly onto the overbed table. Staff K then bagged their trash, then picked up the wound cleanser and gauze pads, and placed the items between their arm and clothing to carry out of the room and into the staff's office area. Staff placed the items on a table then set up to complete another resident's treatment. On 12/5/13 at 2:45 PM, the resident rested in bed, on their back. The resident lacked any heel protectors, as planned, and observation of the wheel chair and the recliner, lacked any pressure reducing cushions, as planned. No evidence of any nutritional shake/snack at that time. On 12/6/13 at 1:00 PM, the resident, while seated in the recliner, asked for toileting assistance. Inquiry of the resident, revealed the resident never had a pressure reducing cushion for his/her chairs, and stated, "I'm going to get some foam for my chairs. " On 12/2/13 at 2:43 PM licensed nursing staff O, reported the resident lacked any orders for nutritional shakes between or with meals. Additionally the staff reported the kitchen send out any shakes, etc, and then the nursing staff (CMA or LN) document the intake, even though they don't observe the intake. On 12/5/13 at 11:15 AM dietary staff D, reported the kitchen staff had been instructed to provide Ensure and other nutritional shakes, however, they do not document the intake amount anywhere. If they refuse it we notify the licensed staff. Interview on 12/2/13 at 2:25 PM with licensed nursing staff K reported after completing the wound assessments, the director of nursing was responsible for completing staging of the wounds. On 12/4/13 at 7:15 AM direct care staff V reported the resident needed assistance of 1 staff for all ADL's (activities of daily living), however resident did assist with dressing and hygiene, ambulated short distances only with a walker, and used a wheel chair, propelled by staff for longer distances. The staff reported the resident usually requested assistance for toileting, and staff offered toileting before and after meals, upon arising and before bed, needed pressure relieving methods such as turning and repositioning every 2 hours, air mattress to the bed, off- loading for the residents heels, and pressure reducing cushions to the wheel chair. Direct care staff S, reported on 12/4/13 at 2:35 PM, the resident currently had open areas to the spine and sometimes to the bottom, usually continent of bowel/bladder with some leakage, needed feet off loaded and the resident preferred to sleep on their back. Interview on 12/5/13 at 8:42 AM, with licensed nursing staff K, reported the resident had full body skin checks by the charge nurses weekly (documented in progress notes), and weekly wound care, including measurements, etc. weekly (documented on the Wound Care Flow Sheets). Staff K further reported they felt, the areas on the resident's buttocks, were related to moisture, instead of pressure. At 9:25 AM, staff K indicated a break in infection control procedure when they removed the clean field and placed the items onto the bedside table, then brought the items to other treatment area for use with another resident. On 12/5/13 at 3:37 PM licensed nursing staff K reported "I forgot," when asked about a pressure relieving cushion to the wheel chair. The staff reported the hospice group had suggested the [MEDICATION NAME] treatment and the facility staff implemented the foam for extra cushioning, as it often appeared red, even with a dressing to the area. Staff K reported the hospice nurses usually made recommendations for wound treatments for this resident and reported they never suggested any pressure relieving devices for the residents back area or for the seats of the chairs, nor did they recommend any supplements to aid in wound healing. On 12/6/13 at 3:09 PM, licensed nursing staff F, reported the resident ' s back and buttocks had re-opened areas. Interview with physician BB, on 12/10/13 at 2:45 PM identified the facility failed to notify the physician of the re-opening of the buttocks wound until 12/9/13. Had been aware of the spine area and would benefit from positioning devices to offload pressure from the spine and The physician reported the resident had hospice services, had experienced weight loss, and would benefit from positioning devices to offload pressure from the pressure ulcers. Dietary staff D reported on 12/12/13 at 11:16 AM the resident continued to receive a high protein, high calorie snack, such as a sandwich or yogurt, at 3 PM and 7 PM. Not aware of the resident receiving any Ensure or other nutritional supplement. Staff D reported the physician had not been faxed regarding the recommended 2 cal intake. On 12/12/13 at 1:30 PM consultant staff NN reported the facility do not allow any records regarding the residents removed from their facility. The staff had only consulted in November, 2013 and does not recall the resident. The facility policy, dated 1/12 for Pressure Ulcers: Skin Assessment and Prevention, included, "...A comprehensive assessment, which includes the Resident Assessment Instrument (RAI), will be completed by the registered nurse evaluating the resident's risk factors, the resident's skin condition, and the nature of the pressure to which the resident may be subjected. The assessment should identify which risk factors can be removed or modified. Risk factors are those factors that increase a resident's susceptibility to develop or impact healing times of pressure ulcers. They include, but are not limited to: Impaired/decreased mobility and decreased functional ability, Co-morbid conditions...6. Resident who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches...Any resident at risk will be placed on pressure redistribution surface as determined appropriate...8. Notify the MD of the ulcer and resident's condition to obtain orders for a treatment...12. When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication of change is identified) should include the following: an evaluation of the ulcer, if no dressing is present. An evaluation of the status of the dressing..." The facility failed to provide this dependent resident nutritional recommendations, as made by the registered dietician, turning and repositioning, pressure relieving devices, appropriate dressing changes and treatments to prevent the development of and worsening of pressure ulcers, when the resident's 2 stage II pressure ulcers, re-developed. - The facility admitted resident # 3 on 9/14/12, per the electronic clinical census record. The resident's 8/14/13 annual MDS (minimum data set) assessment, identified the resident scored 15/15 on the BIMS (brief interview of mental status), indicating intact cognition, needed supervision of 1 person physical assistance for bed mobility, independent with mobility, received a therapeutic diet, without identification of weight loss, had no unhealed pressure ulcers, and lacked identification of risk for pressure ulcers. The associated CAA (care area assessment), dated 8/14/13, for pressure ulcer lacked information. Review of the MDS's identified the resident discharged to the hospital on [DATE] and returned 10/17/13 with medicare therapy provided following return. An 11/11/13 quarterly MDS identified the resident scored 15/15 on the BIMS testing, indicating intact cognition, and needed limited assistance of 1 person physical assistance for bed mobility and transfers, independent with ambulation, lacked identification of weight loss and lacked identification for the risk of pressure ulcer development or the presence of a pressure ulcer. A 10/14/13 Physical Nursing Data Collection Tool, included identification of pressure ulcers to the bilateral heels, however, the assessment lacked any documentation to the size, description of tissue, etc. The resident's 9/4/13 care plan instructed staff: 1. I am independent with most ADL's (activities of daily living) and my spouse assists me at times. 2. I have urge incontinence. 3. I have an order for [REDACTED]. 4. I need a licensed nurse to inspect my skin at least weekly on bath days and document. Review of the clinical record lacked evidence of a return admission temporary care plan, and review of the 11/5/13 care plan, lacked evidence of interventions for pressure ulcers. The care plan lacked interventions for the pressure ulcers on the residents heels. The physician's orders [REDACTED]. Review of the Wound Care Flow Sheets included: Left Heel: 10/23/13--1 cm (centimeter) x 1.8 cm with 100% eschar, no drainage, odor or pain; treated with [MEDICATION NAME] dressing. 11/1/13--1 cm x 1 cm with 100% pink granulation, no drainage and treated with [MEDICATION NAME] dressing. 11/8/13--1 cm x 1 cm with 100% pink granulation. 11/14/13--0.9 cm x 0.9 cm with 100% pink granulation, treated with [MEDICATION NAME] dressings. 11/22/13--0.7 x 1.3 cm with 100% slough, moderate drainage, serous drainage and treatment with a [MEDICATION NAME] dressing. Review of nursing notes, from 11/17/13 to 12/2/13 lacked identification of full body skin assessments, as planned. Observation on 12/3/13 at 2:35 PM, identified the resident seated in an easy chair in his/her room, seated with feet flat on the floor and slippers noted to the resident's feet. At 2:45 PM on 12/3/13 the resident ambulated with bilateral canes, without difficulty noted. A therapist cued the resident from time to time. Interview on 12/4/13 at 7:05 AM, with direct care staff V, reported the resident as independent with all cares, and lacked awareness of any pressure relieving interventions. On 12/5/13 at 9:26 AM, licensed nursing staff K removed the resident's slippers and socks from the resident's feet. The staff reported the resident lacked a dressing to the resident's left heel. Staff K cleansed the area with wound cleanser, patted dry, measured, applied skin prep to the surrounding tissue, and then applied a clean dressing. Staff measured the wound at 0.9 cm x 1 cm, and reported the area getting smaller. Observation identified the wound bed with yellow slough. On 12/5/13 at 4:05 PM, direct care staff S, reported the resident independent with all cares, including putting his/her self to bed. The staff lacked awareness of any pressure relieving devices. Licensed nursing staff F, reported on 12/6/13 at 2:46 PM, the resident returned from the hospital with a dressing to the resident's heels, and reported the resident had been less mobile and exhibited lots of [MEDICAL CONDITION], at that time. Staff F reported a lack of awareness of any pressure relieving devices needed for this resident. On 12/12/13 at 8:50 AM, licensed nursing staff O, reported the resident's care plans lacked revision, related to the resident's pressure ulcers to bilateral heels, noted upon return from the hospital. Staff O further reported, the admission charge nurse is responsible for initiating a temporary care plan upon return or admission, and this could not be located in the resident's clinical record. The facility policy, dated 1/12 for Pressure Ulcers: Skin Assessment and Prevention, included, "...A comprehensive assessment, which includes the Resident Assessment Instrument (RAI), will be completed by the registered nurse evaluating the resident's risk factors, the resident's skin condition, and the nature of the pressure to which the resident may be subjected. The assessment should identify which risk factors can be removed or modified. Risk factors are those factors that increase a resident's susceptibility to develop or impact healing times of pressure ulcers. They include, but are not limited to: Impaired/decreased mobility and decreased functional ability, Co-morbid conditions...6. Resident who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches...Any resident at risk will be placed on pressure redistribution surface as determined appropriate...12. When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication of change is identified) should include the following: an evaluation of the ulcer, if no dressing is present. An evaluation of the status of the dressing..." The facility failed to provide treatments to maintain a dressing continuously to the residents's pressure ulcer on the left heel to ensure healing and failed to implement pressure relieving devices for this resident. - The facility admitted resident #22 on 11/1/13, per the electronic clinical census record. The resident's 11/8/13 admission MDS (minimum data set) assessment, identified the resident scored 15/15 on the BIMS (brief interview of mental status) testing, indicating intact cognition, required extensive assistance of 2 staff for most ADL's (activities of daily living), lacked identification of a pressure ulcer, but at risk. The assessment further lacked identification of weight loss or the need for a mechanically altered diet. The CAA, dated 11/8/13, for pressure ulcers indicated the resident at risk and identified a pressure relieving device on the bed and in the wheel chair. The analysis also noted the resident sat in a recliner, some during the day; with the resident at risk for pressure ulcers related to immobility, evidenced by the need for total assistance from staff and needed repositioning every 2 hours, along with assessment of the urinary catheter and oxygen tubing every shift. Braden Skin Risk Assessments, for predicting pressure sore risk, dated 11/2/13, 11/9/13 and 11/16/13 identified scores of 13, 14, and 14 respectively, with 13-14 indicating moderate risk. The Braden assessment identified an intervention guide might include: 1. Frequent turning with a planned schedule. 2. Use foam wedges for 30 degree lateral positioning. 3. Pressure reduction support surfaces. 4. Maximal remobilization. 5. Protect heels. 6. Manage moisture, nutrition, friction and shear. The 11/5/13 care plan instructed staff: 1. Has potential for pressure ulcer development: Use a bariatric pressure relieving /reducing device on bed. In bariatric (associated with obesity) bed due to height. 2. Assist to turn/reposition at least every 2 hours with 2 people and a turn sheet. 3. Provide pressure relieving mattress on bed, and cushion in wheelchair. 4. Heel protectors bilaterally when in bed. 5. Has a pressure ulcer on right buttock due to immobility. 6. Transfer resident to bed/chair to rest after meals. 7. Avoid positioning resident on the right buttock. 8. Notify nurse immediately of any new areas of skin breakdown; redness, blisters, bruises, discoloration, etc. noted during bath or daily care. 9. Has chronic pain ... Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased ROM, withdrawal or resistance to care. 10. Resident required weight bearing support to sit upright in bed with 2 staff assistance with a turn sheet, 2 staff to dress, eats independently, required weight bearing support assist of 2 staff with full body lift with an extra large sling. Wound Care Review documented on 11/30/13--1.0 cm (centimeter) x 2.4 cm with no drainage odor or pain and treated with [MEDICATION NAME] dressing to the right coccyx. The wound care review lacked staging. Review of a physician's orders [REDACTED]. On 12/3/13 at 2:19 PM, the resident rested in bed, on his/her back. At 2:30 PM the resident's spouse visited and expressed concern regarding the development of the pressure ulcer to the resident's buttocks. The family member reported the resident had never had a pressure ulcer prior to this one, and indicated the staff did at times reposition the resident onto their side, and never had any type of an air mattress on the bed. The mattress on the bed appeared to be a pressure reducing mattress. The spouse reported, when visiting, "The first time I knew anything about the area was the other night, when the hospice nurse was here. I saw the area and the hospice nurse did also." On 12/3/13 at 4:29 PM, direct care staff S and CC, assisted the resident with getting out of bed for supper. Direct care staff S and CC checked the resident's incontinent brief, dry, but with a small bowel movement smear. The resident's buttocks after cleansing, identified an approximately 2 cm (centimeter) by 0.5 cm pressure ulcer to the outer aspect of the left buttock, with the top layer of skin missing. Additionally, the inner aspect of the left buttock, exhibited a reddened area, not open. Staff provided perineal care to the resident including SafeGel to the buttocks area. Observation on 12/4/13 at 7:00 AM, identified the resident resting flat on their back in bed on a pressure reducing mattress. Intermittent observations at 7:15 AM, 7:30 AM, 7:45 AM, 8:00 AM, 8:22 AM identified the resident remained in the same position. At 8:30 AM staff provided the resident a breakfast hall tray and raised the residents head of bed to an approximate 70 degree angle. At 8:45 AM, on 12/4/13 the resident lowered the head of the bed to a 20-30 degree angle, after completing their breakfast. At 9:00 AM the resident had a visitor and again the resident adjusted the head of the bed to accommodate visiting with their friend. On 12/4/13 at 9:32 AM, licensed nursing staff P, reported the direct care staff are instructed to notify the charge nurse anytime a dressing is off a wound, so the nurse may re-dress the area. At that time the resident remained on their back. At 10:13 AM on 12/4/13, after locating an aide for assistance, licensed nursing staff P and direct care staff W repositioned the resident. A skin check identified the pressure ulcer to the left buttock lacked a dressing and the area reddened and open. The nurse failed to provide a dressing to the wound, at that time. Licensed nursing staff P did encourage the resident to reposition to their left side and staff W placed a long body pillow at the resident's back, with the resident in agreement. The staff lacked and failed to apply any heel protectors. Licensed staff P confirmed the resident lacked turning and repositioning for 3 hours and 13 minutes. Interview on 12/02/13 at 2:42 PM licensed nursing staff O reported the resident recently developed a coccyx wound. Licensed nursing staff K reported on 12/2/13 at 3:00 PM, the DON (director of nursing) is responsible for staging of the pressure ulcer, after the measurements are taken and documented on the wound care flow sheet. The staff lacked knowledge of why the area developed, and noted the physician notified on 12/3/13 of the development of the area. Interview on 12/3/13 at 2:30 PM, with a family member reported being very concerned regarding the development of the pressure ulcer to the resident's buttocks. The family reported the resident as dependent for care for several years now, and never developed a pressure ulcer. The fam

The facility had a census of 45 residents, with 17 residents selected for sample. Three sampled residents had pressure ulcers. Based on observation, interview and record review, the facility failed to provide 3 of 3 sampled residents with the necessary treatment and services (use of pressure reduction devices, timely repositioning, weekly assessment of wounds/skin as ordered) to promote healing and prevent new sores from developing. (Residents #13, 43, 74) Findings included: - Resident #43's clinical record included a 1/15/14 Significant Change MDS (Minimum Data Set) that identified the resident with long and short term memory problems, severely impaired decision making abilities, total dependence on staff for bed mobility and transfers, no risk of pressure ulcers and no current unhealed pressure ulcers and pressure reduction devices to the bed and chair. CAAs (Care Area Assessment summaries) for pressure ulcers completed on 1/23/14 noted resident #43's dependence on staff for turning and repositioning as well as the presence of a new, Stage 2 pressure ulcer on the coccyx (small triangular bone at the base of the spine). The current care plan, last reviewed on 1/29/14, noted the resident's potential for skin breakdown and directed staff to notify the nurse of any new areas of skin breakdown, redness, blisters, bruises, discoloration etc during bath or daily care. The care plan directed staff to "provide pressure relieving device on bed and chair....". The "Progress Notes" described resident #43's hospitalization and return to the facility on [DATE] on Hospice services. physician's orders [REDACTED]. A Braden skin assessment completed on 2/2/14 identified resident #43 as "very high risk" for skin breakdown. Wound documentation included: o 2/2/14 assessments by a licensed nurse which noted the presence of a pressure ulcer in the left gluteal fold (a fold of skin on the buttock) which measured 1.5 cm (centimeters) by 1.0 cm as well as a Stage 2 pressure ulcer on the sacrum (large triangular bone between the hip bones) . o 2/11/14 assessments by a licensed nurse which again noted the presence of a "healing Stage 2 pressure ulcer which measured 1.5 cm by 0.8 cm on the left gluteal fold as well as a "healing Stage 2 pressure ulcer on the sacrum. Review of the clinical record revealed no evidence of skin/pressure ulcer assessments in the 9 day time period between 2/2/14 and 2/11/14 as directed by physician's orders [REDACTED]. During observations on 2/3/14 at 1:10 p.m., 2/14/14 at 8:30 a.m., 2/14/14 at 9:45 a.m., 2/14/14 at 11:15 a.m. and 2/17/14 at 8:00 a.m., resident #43 sat in the geri-chair (a positioning chair) without benefit of a pressure reduction cushion in the seat as directed by the care plan. During all observations, resident #43 lacked the ability to verbalize his/her needs and had total dependence on staff for repositioning. During an observation on 2/14/14 at 9:45 a.m., Direct Care Staff G and H transferred resident #43 from the wheelchair to the bed. Close observation of the resident's skin revealed the presence of an open area near the coccyx and another open area on the left upper leg, lower buttock area. During an interview on 2/14/14 at 2:28 p.m., Licensed Nurse I reported resident #43 had pressure ulcers prior to the transfer to the hospital in late January and continued to have open areas upon return to the facility on [DATE]. During an interview on 2/18/14 at 10:30 a.m., Administrative Nurse B reported staff should place pressure reduction devices in chairs if the care plan directed them to do so. On 2/21/13, Nurse B emailed a document confirming licensed nurses failed to complete skin assessments weekly in the nine day time period between 2/2/14 and 2/11/14. The facility failed to provide resident #43 with the necessary treatment and services (weekly skin assessments, use of pressure reduction devices in the chair) to promote healing of existing pressure ulcers and prevent development of new pressure ulcers. - Resident #74's clinical record noted admission to the facility on [DATE]. According to the [DIAGNOSES REDACTED]. The 11/18/13 Admission MDS (Minimum Data Set) identified resident #74 with no cognitive impairment, the need for extensive assistance of two staff for bed mobility and transfers, an inability to walk, no risk of pressure ulcer development and no current or recently healed pressure ulcers. The 2/7/14 Quarterly MDS identified resident #74 with no cognitive impairment, continued dependence of two staff for bed mobility and transfers, an inability to walk, use of a wheelchair, and the presence of two Stage 2 pressure ulcers that were present at the time of admission or re-entry. Undated CAAs (Care Area Assessment summaries) completed after the 11/18/13 Admission MDS triggered for pressure ulcers. The pressure ulcer CAA did not include any additional assessments/analysis. The 2/11/14 Care Plan directed staff to "turn and reposition every 2 hours" and noted resident #74's need for assistance of 2 staff to reposition and turn in bed. According to the care plan, "The resident has bilateral (both sides) pressure ulcers.....assess/record/monitor wound healing weekly...." Review of "Progress Notes" revealed skin assessments and wound measurements on 1/23/14, 1/24/14,1/30/14 and 2/13/14. The clinical record included no evidence of skin assessments in the 14 day time period from 1/30/14 to 2/13/14. During observations on 2/13/14 from 12:55 p.m. to 5:00 p.m., resident #74 sat in his/her wheelchair. The resident had the ability to move about the facility independently in the wheelchair. On 2/14/14 at 7:30 a.m., resident #74 sat in his/her wheelchair in the doorway to his/her room. The resident remained in the wheelchair without benefit of a position change all morning. At 11:00 a.m., Direct Care Staff L responded to surveyor request for repositioning by stating, "(He/she) stays in that wheelchair until (he/she) tells us it's time to move. We don't move (him/her) until then." Resident #74 remained seated in the wheelchair without benefit of a position change until 1:00 p.m., a time period of 5 1/2 hours. During an observation on 2/14/14 at 1:00 p.m., Licensed Nurse E prepared to complete dressing changes on both of resident #74's heels. At the time of the observation, the left heel wound was approximately 99% closed and had no drainage. The right heel wound had a very small, pencil lead sized open area and had no drainage. The resident also had a protective dressing to the outer left great toe used to prevent skin breakdown due to malformations/contractures of the resident's toes/feet. During an observation on 2/17/14 at 7:30 a.m., resident #74 sat in a wheelchair in the dining room. Frequent observations revealed the resident remained in the wheelchair without benefit of a position change until 1:00 p.m.. In response to surveyor request for repositioning on 2/17/14 at 1:00 p.m., Direct Care Staff L confirmed the resident did not get out of the wheelchair since 7:30 a.m.. Direct Care Staff L again reported resident #74 lets staff know when he/she needs to use the bathroom and therefore isn't repositioned until he/she makes a request for repositioning. During an additional observation on 2/17/14 at 2:00 p.m., Direct Care Staff M and N transferred resident #74 from the wheelchair to the bed at surveyor request. The resident required extensive assistance of two for the transfer. The resident wore a heavily saturated incontinence brief which staff removed. Observation of the resident's buttocks revealed a large, approximately 3 inch by 2 inch area of nonblanchable redness that extended from the rectal area onto the left buttock. During this observation, Staff N confirmed staff do not reposition or toilet resident #74 unless he/she asks. The resident remained in his/her wheelchair without benefit of a position change from 7:30 a.m. to 2:00 p.m., a time period of 6 1/2 hours. During an additional observation on 2/18/14 at 9:20 a.m., resident #74's buttocks had no open areas and the previously nonblanchable area on the left buttock no longer existed. During an interview on 2/18/14 at 10:20 a.m., Administrative Nurse B reported staff should follow the care plan, and if the care plan directed staff to reposition a resident such as resident #74 every two hours then that's what they should do. In an emailed message sent on 2/21/14, Nurse B confirmed staff failed to complete weekly skin assessments for resident #74 in the 14 day time period between 1/30/14 and 2/14/14. The facility failed to provide resident #74 with the necessary treatment and services (weekly skin assessments, timely repositioning as directed by the care plan) to promote healing of existing pressure ulcers and prevent development of new pressure ulcers. - Resident #13's 12/16/13 annual MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 13 which indicated intact cognition. The resident performed ADLs (activities of daily living) independently, including bed mobility, walking, and transfers. The assessment indicated the resident was not "at risk" for pressure ulcer development with no unhealed pressure ulcers. The resident used a pressure reduction device on his/her bed. Resident #13's CAA (care area assessment) summaries revealed pressure ulcers did not trigger for further assessment. Resident #13's 10/1/13 nursing care plan directed staff to provide wound care as directed to the left second toe which had a wound from "overlapping" toes. According to the care plan, the toe required surgery, but the resident was not interested in surgical intervention. Review of the February 2014 TAR (treatment administration record) revealed staff dressed the toe using a [MEDICATION NAME] (type of wound treatment product) dressing and gauze between the toes to provide pressure relief. Review of the "Wound Data Collection" records for resident #13 included wound assessments of the resident's toe with wound measurements on 1/23/14, 1/30/14, 1/31/14, and 2/6/14. Measurements on 1/23/14, 1/30/14, and 1/31/14 revealed the wound on the left second toe measured 0.1 cm (centimeter) by 0.1 cm. The wound measured 0.2 cm by 0.3 cm on 2/6/14. As of 2/18/14, the last documented assessment of the wound with measurements was on 2/6/14, a period of 12 days since the last assessment with measurements. During an observation on 2/14/14 at 11:26 a.m., licensed nurse E set up supplies for the resident's dressing change on a bedside table. Nurse E wore gloves as he/she removed the old dressing from the resident's left second toe. Staff E then removed the gloves, washed his/her hands, and donned clean gloves before cleansing the wound with wound cleanser. The resident indicated the wound was "sore". Licensed nurse E stated that the facility wound nurse measured the wound on Thursdays. The wound on the toe had a circular shape with a red center and no drainage and approximately 0.3 cm in diameter, by observation. Licensed nurse E stated the wound was not open. Nurse E then reached in to his/her scrub top pocket and obtained bandage scissors to cut the dressings to fit the wound, then placed the scissors back in his/her pocket. Nurse E then placed the prescribed dressing on the resident's toe. After cleaning up his/her supplies, nurse E bent over to tie up a trash bag and his/her scissors fell on the floor. Nurse E picked up the scissors from the floor and placed them back in his/her scrub top. During an interview on 2/18/14 at 9:11 a.m., licensed nurse E stated that resident #13 had a pressure ulcer from his/her toes overlapping. Nurse E stated the wound nurse measured the wound weekly. Nurse E also stated he/she kept other items, such as pens in his/her scrub top and had not thought about the scissors not being clean prior to using them for cutting the dressing. During an interview on 2/18/14 at 10:43 a.m. administrative nurse B confirmed resident #13's clinical record lacked wound measurements for a period of 12 days and the wound should be measured/documented weekly. Nurse B further stated scissors used for dressing changes should be cleaned before using them for cutting dressing supplies. The facility's undated "Pressure Ulcer Assessment Process Flowchart" indicated staff should monitor wounds daily with weekly documentation and if no progress in healing within 2-4 weeks, then interventions should be reassessed and a referral considered. The facility failed to document wound assessment/measurements weekly and failed to provide a dressing change following accepted professional standards in order to prevent infection for resident #13.

The facility had a census of 50 residents, with 6 residents selected for sample. Based on observation, interview and record review, the facility failed to provide 1 of 6 sampled residents with the necessary care and services (removal of a tourniquet following insertion of an intravenous (inside the vein) catheter, assessment/documentation of the intravenous site each shift as directed by facility policy) to attain/maintain the residents' highest practicable physical well-being. Staff failed to remove a tourniquet from resident #2's arm after insertion of an intravenous catheter. The catheter remained in place for 17 hours before a licensed nurse noted "gross swelling" of the affected extremity and removed the tourniquet. Findings included: - Resident #2's clinical record included a 7/31/13 Annual MDS (Minimum Data Set) that identified the resident with severe cognitive impairment, the need for extensive assistance of two staff to bed mobility and transfers, functional limitations in range of motion of both upper and lower extremities, and no IV (intravenous) medications. CAAS (Care Area Assessments) dated 8/14/13 included no mention of intravenous fluids/medications. Resident #2's 8/21/13 care plan noted resident #2's need for extensive assistance with all ADLs (activities of daily living). The care plan did not include goals/interventions related to use of IV medications/fluids. physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. A later physician's orders [REDACTED]. Interdisciplinary Notes included the following: * 7/3/13 at 12:10 p.m.: "Continues on oral abx (antibiotics) and IV fluids ....at 1315 (1:15 p.m.) resident pulled out IV." * 7/3/13 at 3:00 p.m.: "Resident IV restarted in Rt (right) forearm with 22 gauge needle on first stick. Site with blood return and flushes well. Site taped with paper tape. Will monitor IV....". The entry was written by Licensed Nurse D. * 7/4/13 at 1:45 a.m.: "Resident continues on abt (antibiotic) of both IV fluids and oral pills for UTI (urinary tract infection)." The entry did not include assessment of the IV insertion site or the extremity in which the fluids and/or medications infused. * 7/4/13 at 8:00 a.m.: "Went in to check on resident, noticed (his/her) arm was grossly swollen. Upon further investigation noticed that tourniquet was left on after IV inserted last night." This documentation was written by Licensed Nurse E. Review of the clinical record revealed no assessments of resident #2's IV insertion site or the extremity in which the IV infused in the 17 hour time period between Licensed Nurse D started the IV and when Nurse E found the tourniquet still in place. An additional interdisciplinary note included the following: * 7/4/13 at 8:00 a.m.: "Went in to see if IV would flush. It didn't. Removed IV....Dr. (name) was called and gave order to restart IV in left arm, take pulse in R (right) arm which was 60 and strong. Hand grip was strong. Able to move right arm and fingers. Left order to measure R arm and fingers and measure R arm again in 4 hours. R upper arm measures 13 inches upper arm and 11 inches forearm; Left upper arm 12 inches and L (left) forearm 7 inches. Resident complains of pain to touch....." According to this entry, there was a 1 inch difference in measurement between the right and left upper arm and a 4 inch difference between the right and left forearm. An "Incident Detail" report dated 7/4/13 included, "Noticed that resident's right arm was grossly swollen and upon further investigation noticed that tourniquet was left on after IV was inserted. Tourniquet above elbow." During an observation on 8/28/13 at 8:45 a.m., Direct Care Staff J lifted the sleeve of resident #2's gown to allow visualization of the area where the tourniquet was found on July 4th, nearly 2 months earlier. A darker, thin, pigmented line much like a scar remained around nearly the entire circumference of the upper arm approximately 2 inches above the elbow. The discolored area was smooth to the touch and was not painful to the resident. During an interview on 8/22/13 at 2:20 p.m., Licensed Nurse D reported he/she started resident #2's IV on 7/3/13 shortly after the beginning of the shift. According to Nurse D, he/she had good blood return and the IV flushed easily before he/she connected the fluids and turned on the IV pump. Nurse D denied that the alarms on the pump sounded such as they would if there was an occlusion (blockage) of the line. Nurse D reported the IV fluids infused as ordered by the physician until early evening when the physician came to the facility, assessed the resident and ordered the fluids discontinued. Nurse D said he/she discontinued the fluids but left the IV catheter in place in order to access it for infusion of IV antibiotics later in the shift. According to Nurse D, the resident received the IV antibiotics later on his/her shift prior to 10 p.m. when the shift ended. Nurse D confirmed the clinical record lacked documentation of the IV insertion site after 3:00 p.m. when the IV was started. Nurse D also reported nurses on each shift should assess the IV site to make sure everything is "ok" but those assessments are not documented anywhere. Additionally, Nurse D reported resident #2's arm remained "pretty red for several days" and a "mark" left by the tourniquet remains on the upper arm. During an interview on 8/28/13 at 9:40 a.m., Licensed Nurse E reported he/she went into resident #2's room on the morning of 7/4/13 to do an initial assessment. According to Nurse E, he/she found the resident's right arm, "grossly swollen" and with "bluish" colored fingers. Upon closer examination Nurse E reported he/she found a tourniquet tightly placed around the resident's right upper arm just above the elbow. Nurse E recalled that resident #2 complained of pain in the right arm at the time staff discovered the tourniquet. During an interview on 8/29/13 at 10:45 a.m., Administrative Staff B confirmed Licensed Nurse D left a tourniquet around resident #2's upper arm and staff failed to notice it for approximately 17 hours. Administrative Staff B confirmed the clinical record included no evidence of assessment of the catheter site and/or extremity after Nurse D inserted the catheter on 7/3/13 at 3:00 p.m. Attempts to contact resident #2's physician were unsuccessful on 8/29/13 at 2:20 p.m. and 8/30/13 at 8:00 a.m.. According to the facility's "Peripheral Catheter Insertion" policy dated January 15, 2004 with the most recent revision date of July 1, 2012, "Assessment of peripheral catheter site is performed during dressing change, every 2 hours during continuous therapy, before and after administration of intermittent intravenous medication, at least once per shift when not in use....". The facility failed to provide resident #2 with the necessary care and services (removal of tourniquet following insertion of an intravenous catheter, assessment/documentation of the intravenous site each shift as directed by facility policy) to attain/maintain the residents' highest practicable physical well-being. Staff failed to remove a tourniquet from resident #2's arm after insertion of an intravenous catheter. The catheter remained in place for 17 hours before a licensed nurse noted "gross swelling" of the affected extremity and removed the tourniquet.

The facility had a census of 50 residents. The facility identified 3 residents with current pressure ulcers and the sample included all three residents. Based on observation, interview and record review, the facility failed to ensure that one resident who entered the facility without pressure ulcers did not develop an avoidable pressure ulcer, and failed to provide that resident with the necessary treatment and services (nursing assessments of the pressure ulcer dressing and adjacent skin at least daily, physician notification of changes to the pressure ulcer) to promote healing of the wound. (Resident #1) The facility failed to complete a thorough skin assessment upon resident #1's admission on 6/6/13, and failed to assess the resident's skin including the skin beneath an orthopedic boot/splint device for a total of 69 days at which time staff noted the presence of an unstageable pressure ulcer to the right heel. Based on observation, interview and record review, the facility also failed to provide 1 of 3 residents with current pressure ulcers with timely repositioning as directed by the care plan (Resident #2), and failed to complete weekly skin assessments for all three sampled residents as per facility policy and noted on the treatment record. (Residents #1, 2, 3) Findings included: - Resident #1's clinical record included interdisciplinary nurse's notes which documented the resident's admission to the facility on [DATE]. Discharge instructions dated 6/6/13 from the transferring facility listed the residents' medical diagnoses, including, "surgical stabilization of a fractured (broken)right tibia and fibula (both bones in the lower leg), fractured right clavicle (collar bone)." On 8/27/13, the clinical record included no evidence staff completed an MDS (Minimum Data Set) since resident #1's admission to the facility on [DATE]. The clinical record included no evidence staff completed a comprehensive care plan or a temporary care plan for resident #1 since readmission 6/6/13 even though the resident experienced a fracture which required use of a boot/splint, and developed a facility acquired pressure ulcer which required dressings and dressing changes. A Braden skin assessment completed on 6/7/13 identified resident #1 as "mild risk" for skin breakdown. The clinical record included no evidence of completion of additional Braden assessments since 6/7/13. A Physician's Progress Noted dated 6/7/13, the date after admission, noted resident #1's [MEDICAL CONDITION] lower leg and included, "....has a posterior splint RLE (right lower extremity). I am taking (him/her) out of that today. (His/her) heel is without pressure sore, no redness.... Has numerous fracture blisters and even abrasions over the lower extremity that are scabbed and healing. We have taken the staples out and the incisions are healing. No sign of infection. I will put (him/her) back in a stirrup splint to see if that will give more support.....will continue in the splint non-weight bearing." A Physician's Progress Noted dated 7/10/13 included, "....increased healing, start weight bearing next week, wear boot when up and around....". June and July 2013 TARs (treatment administration records) included, "I need a licensed nurse to inspect my skin at least weekly on bath days and document." Review of TARs for that two month time period revealed no evidence licensed nurses completed any of the weekly skin assessments. Review of Interdisciplinary Notes revealed no evidence of thorough skin assessments by licensed nurses from 6/6/13, the date of admission, until 8/14/13, a time period of 69 days. Interdisciplinary Notes dated 8/14/13 at 11:00 a.m. documented the presence of a "pressure area" on resident #1's right heel which measured 3.0 cm (centimeters) by 3.2 cm and covered with "100% eschar (dead tissue)." According to this entry, the wound had no drainage and no odor. The notes did not mention skin breakdown on resident #1's shin. A "Wound Flow Sheet" dated 8/22/13 noted ulcer measurements of 2.2 cm by 2.5 cm with the presence of moderate drainage and the presence of an odor. The documentation lacked mention of skin breakdown on resident #1's right shin. Review of the clinical record revealed no evidence the facility notified resident #1's physician of the presence of wound drainage and a malodor associated with the wound. A "Wound Flow Sheet" dated 8/27/13 noted no improvement or deterioration of the wound, with measurements remaining at 2.0 cm by 2.5 cm. Review of Interdisciplinary Notes and Wound Flow Sheets revealed no evidence of daily assessment of resident #1's unstageable right heel pressure ulcer and/or dressing. During an observation on 8/22/13 at 10:00 a.m., Licensed Nurses C and F prepared to change the dressing to resident #1's right heel. Upon Nurse C's attempts to remove the dressing it stuck to the wound and required moistening in order to loosen the dressing. Wound measurements at the time of this observation were 2.3 cm by 2.5 cm with eschar covering the entire area. The wound had bloody drainage. Resident #1 described the area as somewhat painful and rated a "3" on a 1-10 pain scale. The residents' right shin also had multiple areas covered with thick scabs. Neither Nurse C or Nurse F were aware of the cause of those areas of skin breakdown. During an interview on 8/21/13 at 3:25 p.m., Administrative Staff A reported resident #1 told staff he/she wasn't supposed to take the splint/boot off and that's why staff left it on 24 hours per day, 7 days a week. According to Staff A, staff told him/her the resident frequently refused to remove the boot. Staff A confirmed the clinical record lacked documentation of such refusals. During an interview on 8/22/13 at 9:45 a.m., resident #1 reported he/she had "some sort of cast" on the right leg at the time of admission to the facility on [DATE]. Shortly after admission, the resident reported the physician had the cast removed and placed the lower leg splint/boot. Resident #1 reported thinking he/she should wear the splint "every minute of every day" and therefore he/she never removed it. During an interview on 8/22/13 at 10:00 a.m., Licensed Nurse C reported therapy staff first noticed the presence of resident #1's heel wound on August 14th, 2013. According to Nurse C, the pressure ulcer on the right heel measured 3 cm by 3.2 cm on that day and had black eschar covering it and had no drainage. During an interview on 8/22/13 at 2:30 p.m., Licensed Nurse D reported charge nurses should complete weekly skin checks on bath days. According to Nurse D, those assessments are done "probably less than 25% of the time". Nurse D also reported the wound nurse does all wound documentation at the time of dressing changes and other nurses are not required to assess the wound and/or dressing routinely. During an interview on 8/27/13 at 3:30 p.m., Licensed Nurse G reported nurses should complete skin assessment weekly on bath days. Nurse G reported staff were recently informed of a need to do charting every shift about pressure ulcers and dressings, "but it hasn't been started yet". During an interview on 8/27/13 at 3:52 p.m., Direct Care Staff H reported resident #1 wore the right leg "boot" continuously in the time period from "shortly after admission" until when staff found the pressure ulcer. According to Staff H, "We wrapped that leg in a trash bag when we bathed (him/her) so it never even came off for baths." During an interview on 8/29/13 at 10:45 a.m., Administrative Staff B confirmed the clinical record included no evidence of a skin assessment upon admission on 6/6/13. Staff B also confirmed the clinical record lacked evidence of any skin assessments in the 69 day time period between admission on 6/6/13 and the date of discovery of the pressure ulcer on 8/14/13. According to Staff B, licensed nurses were recently advised of a need to chart about the wound and/or dressing each shift and noted that was a recent change. Staff B confirmed staff failed to notify resident #1's physician when drainage and malodor were noted from the pressure ulcer on 8/22/13 because the nurse thought the wound dressing was appropriate to handle the drainage and therefore there was no reason to notify the physician. Administrative Staff B also confirmed resident #1 was a readmission on 6/6/13 and therefore staff should have completed a Braden skin assessment weekly for the first four weeks as per facility policy. According to Staff B, the resident told staff he/she was supposed to wear the boot continuously so that is what staff did without contacting the physician for clarification. During a telephone interview on 8/29/13 at 2:40 p.m., Physician I reported staff should have removed resident #1's boot routinely when the resident was in bed or otherwise not active. According to Physician I, he/she expected staff to pay careful attention to the condition of the skin beneath the splint due to the high likelihood of development of pressure ulcers. Physician I stated lack of skin assessments for a resident wearing a splint for a time period of 69 days was "totally unacceptable". Physician I also reported he/she expected to be informed by the facility if any wound developed drainage and/or a malodor because that meant an infectious process was most likely occurring. The facility's "Pressure Ulcer Practice Guidelines" policy dated May 2001 with the most recent revision of 9/10, included the following: * "Each resident should have a head to toe skin assessment performed by a licensed nurse during the admission process....". * "The Braden Scale for Predicting Pressure Sore Risk (GSS #319) is completed when the resident is admitted to the center, weekly for the first four weeks after an admission for each resident at risk....". * "Residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes in their skin condition....". * "Weekly skin checks are recommended to be performed on all residents but especially those identified as "at risk," paying particular attention to .....the surfaces of the skin that come in contact with each other and any orthotic device, tube, brace of positioning device....". * "All significant abnormal findings/changes should be reported to the resident's primary care provider by the licensed nurse per GSS (Good Sam Society) procedures....". * "The center should have a system in place for daily observation of pressure ulcers/wounds which should include an evaluation of the ulcer....an evaluation of the status of the dressing if present.....the status of the area surrounding the ulcer....the presence of possible complications...whether pain, if present, is being adequately controlled including during the dressing change...". The facility failed to have systems in place to ensure assessment of resident #1's skin upon admission and periodically thereafter as directed by facility policy. Staff failed to clarify orders for splint removal with the resident's physician. Staff failed to assess the resident's skin for a total of 69 days even though the resident wore a splint device on the right lower leg continuously. The resident developed an unstageable avoidable pressure ulcer on the right heel. After development of the pressure ulcer, the facility failed to ensure daily assessment of the wound and/or dressing and failed to notify the physician of the development of wound drainage and a malodor. - Resident #2's clinical record included a 7/31/13 Annual MDS (Minimum Data Set) which identified the resident with severe cognitive impairment, the need for extensive assistance of two staff for bed mobility, total dependence on two staff for transfers, functional limitations in range of motion of the upper and lower extremities on both sides of the body, use of a wheelchair for mobility, no current pressure ulcers, use of pressure reduction devices for the bed and chair, and a turning/repositioning program. CAAs (Care Area Assessment summaries) dated 8/14/13 for "Pressure Ulcers" noted resident #2's risk for development of pressure ulcers and noted use of a pressure relieving mattress on the bed as well as a cushion in the wheelchair. The 8/21/13 care plan noted resident #2's need for extensive assistance of 2 staff for all ADLs (activities of daily living), need for assistance of 2 for turning and repositioning, "keep off coccyx", use of a pressure relieving mattress on the bed and a pressure relief pad in the wheel chair, and "make sure to reposition every 2 hours even at night." The care plan lacked interventions related to the presence of a current pressure ulcer on the coccyx. TARs (treatment administration records) for May, June and July 2013 included, "I need a licensed nurse to inspect my skin at least weekly on bath day and document." Documentation on the TARs included: * May 2013: no documentation of assessments 3 of 4 weeks * June 2013: no documentation of assessments 3 of 4 weeks A "Wound Flow Sheet" dated 7/22/13 noted the presence of a 1.2 cm (centimeter) by 0.3 cm. pressure ulcer on the coccyx (small triangular bone at the base of the spine). The wound had a depth of 0.2 cm. According to the documentation, staff applied a [MEDICATION NAME] (type of dressing) to the pressure ulcer. Review of the clinical record revealed no evidence of daily assessment of the pressure ulcer and/or dressing. During an observation on 8/22/13 at 9:15 a.m., Licensed Nurses C and G completed a dressing change to resident #2's pressure ulcer on the coccyx. At that time, the pressure ulcer measured 1 cm by 0.6 cm with a depth of 0.2 cm.. During that observation, resident #2 had socks on both feet and both heels rested directly on the mattress. Upon removal of the socks, the left heel had an approximate dime sized area of darker red discoloration which blanched when touched. The reddened area disappeared within 5 minutes of no pressure on the heel. At the time of the observation, resident #2's bed had a mattress with a pressure pad overlay on top of it. Between the pressure pad and the resident's skin were a bottom sheet, a thick "soaker pad", the resident's slacks and an incontinence brief. During an observation on 8/27/13 at 12:45 p.m., Direct Care Staff J and K transferred resident #2 from the wheelchair to the bed with a mechanical lift. Staff placed the resident in bed fully clothed, and again there was a bottom sheet, a soaker pad, slacks and an incontinence brief between the pressure pad and the resident's skin. The resident again had socks on his/her feet, with no pressure reduction devices placed on them. Both heels rested directly on the mattress. Resident #2 lay directly on his/her back when staff left the room. During frequent observations of resident #2's position on 8/27/13 at 1:30 p.m., 2:20 p.m. and 3:20 p.m., the resident remained totally on his/her back without benefit of a position change. At 3:35 p.m, Licensed Nurse G was informed of staff failure to reposition the resident for 2 hours and 50 minutes. Nurse G sent staff immediately into the room to reposition the resident at that time. During an interview on 8/22/13 at 9:30 a.m., Licensed Nurse C confirmed the presence of a pressure ulcer on resident #2's coccyx as well as the presence of a blanchable, reddened area on the left heel. During an interview on 8/22/13 at 2:30 p.m., Licensed Nurse D reported charge nurses should complete weekly skin checks on bath days. According to Nurse D, those assessments are done "probably less than 25% of the time". Nurse D also reported the wound nurse does all wound documentation at the time of dressing changes and other nurses are not required to assess the wound and/or dressing routinely. During an interview on 8/27/13 at 2:05 p.m., Direct Care Staff L reported staff should reposition resident #2 every two hours when they "check and change" him/her. According to Staff L, those position changes should be from side to side in order to keep the resident off the coccyx. Staff L denied knowledge of the need to limit the number of layers of fabric between the pressure pad and the resident's body. Staff L also denied use of heel protectors for resident #2's heels and reported the resident "hardly ever" moves his/her feet because of leg pain. Staff L reported staff use a foot cradle on the bed to keep linens off the resident's feet in an attempt to decrease pain. During an interview on 8/27/13 at 3:30 p.m., Licensed Nurse G reported nurses should complete skin assessment weekly on bath days. Nurse G reported staff were recently informed of a need to do charting every shift about pressure ulcers and dressings, "but it hasn't been started yet". During an interview on 8/29/13 at 10:45 a.m., Administrative Staff B reported staff should reposition resident #2 every two hours. The facility's "Pressure Ulcer Practice Guidelines" policy dated May 2001 with the most recent revision of 9/10, included the following: * "Weekly skin checks are recommended to be performed on all residents but especially those identified as "at risk," paying particular attention to .....the surfaces of the skin that come in contact with each other and any orthotic device, tube, brace of positioning device....". * "The center should have a system in place for daily observation of pressure ulcers/wounds which should include an evaluation of the ulcer....an evaluation of the status of the dressing if present.....the status of the area surrounding the ulcer....the presence of possible complications...whether pain, if present, is being adequately controlled including during the dressing change...". The facility failed to provide resident #2 with weekly skin assessments as directed by facility policy and the treatment record, failed to ensure placement of adequate pressure reduction devices to protect the integrity of the skin on resident #2's heels, failed to ensure daily assessment/documentation of an existing pressure ulcer/wound dressing, and failed to reposition the resident as directed by the care plan. - Resident #3's clinical record included a 7/3/13 Quarterly MDS (Minimum Data Set) which identified the resident with moderately impaired cognition, the need for stand by assistance with bed mobility and transfers, independence with ambulation, no risk of pressure ulcer development, no history of pressure ulcers, and use of a pressure reduction device for the bed. CAAs (Care Area Assessment summaries) dated 4/24/13 after completion of the Annual MDS noted resident #3's need for some staff assistance with ADLs (activities of daily living). According to the Pressure Ulcer CAA, the resident required assistance of staff for bed mobility and had no risk for developing pressure ulcers. The 5/1/13 care plan included no goals or interventions related to pressure ulcers. A 7/3/13 Braden Scale skin assessment identified resident #3 as "no risk" for skin breakdown. A "Wound Flow Sheet" dated 8/1/13 noted the presence of a pressure ulcer on resident #3's left medial (toward the middle/center) buttock which measured 1.0 cm (centimeters) by 1 cm. with "minimal drainage." Weekly wound assessments on 8/8/13 and 8/15/13 documented healing of the pressure ulcer. Review of the clinical record revealed no evidence of daily assessment of the pressure ulcer and/or dressing. TARs (treatment administration records) for May, June and July 2013 included, "I need a licensed nurse to inspect my skin at least weekly on bath day and document." Documentation on the TARs included: * May 2013: no documented assessments 3 of 4 weeks * June 2013: no documented assessments 4 of 4 weeks * July 2013: no documented assessments 3 of 4 weeks During an observation on 8/22/13 at 10:30 a.m., Licensed Nurse C removed a dressing from resident #3's buttock and noted the pressure ulcer was completely healed. The resident had no other evidence of skin breakdown. During an interview on 8/22/13 at 2:30 p.m., Licensed Nurse D reported charge nurses should complete weekly skin checks on bath days. According to Nurse D, those assessments are done "probably less than 25% of the time". Nurse D also reported the wound nurse does all wound documentation at the time of dressing changes and other nurses are not required to assess the wound and/or dressing routinely. During an interview on 8/27/13 at 3:30 p.m., Licensed Nurse G reported nurses should complete skin assessment weekly on bath days. Nurse G reported staff were recently informed of a need to do charting every shift about pressure ulcers and dressings, "but it hasn't been started yet". The facility's "Pressure Ulcer Practice Guidelines" policy dated May 2001 with the most recent revision of 9/10, included the following: * "Weekly skin checks are recommended to be performed on all residents but especially those identified as "at risk," .....". * "The center should have a system in place for daily observation of pressure ulcers/wounds which should include an evaluation of the ulcer....an evaluation of the status of the dressing if present.....the status of the area surrounding the ulcer....the presence of possible complications...whether pain, if present, is being adequately controlled including during the dressing change...". The facility failed to provide resident #3 with weekly skin assessments as directed by facility policy and the treatment record, and failed to ensure daily assessment/documentation of an existing pressure ulcer/wound dressing.

The facility had a census of 54 residents, with 21 residents sampled for review. Three of the 21 had nutritional concerns. Based on observation, interview, and record review, the facility failed to ensure 1 of the 3 sampled residents (#3) received nutritional supplements as ordered, substitutes of Resident #3's preference, and adequate assistance during meals for Resident #3 to maintain acceptable parameters of nutritional status. Resident #3 experienced harm as the resident experienced a 7.6% weight loss in 1 month and 10.7% (percent) weight loss in 3 months. Findings included: - Resident #3's 12/22/10 Quarterly MDS (Minimum Data Set) assessment identified the resident with severe cognitive impairment, required limited assistance of one person with eating, and problems with choking during meals. The MDS identified the resident received a mechanically altered and therapeutic diet, and recorded a weight of 159 pounds. The 12/9/10 Registered Dietitian Nutrition Assessment recorded the resident's weight as 160.2 pounds for November 2010 and noted the resident's decreased [MEDICATION NAME] level (3.3 g/dl (grams/deciliter)) as signs of [MEDICAL CONDITION]. Dietary Progress Notes dated 3/7/11 recorded the resident ' s weight as 153.4. The resident had a weight loss of 6 pounds over 1 month, received pureed diet and Glucerna supplements three times a day, and consumed 40-60% on average of the meals. The resident ' s 3/9/11 Significant Change MDS (Minimum Data Set) assessment identified the resident with severe cognitive impairment, required limited assistance of one person with eating, and had problems with choking during meals. The MDS identified the resident received a mechanically altered and therapeutic diet, and recorded a weight of 153 pounds. Record review revealed a Resident Dining assessment dated [DATE] that identified the resident needed a dining assistant to provide total assistance with meals. A 3/9/11 fax to the physician to requested a change from Glucerna to Ensure pudding three times a day or a high calorie food. On 3/18/11 the physician ordered Ensure pudding three times a day. The resident's current care plan dated 3/30/11 directed staff to provide total assistance with meals, monitor for signs of choking, give thickened liquids, and Ensure pudding at 10:00 A.M., 3:00 P.M., and 7 P.M. The records indicated staff recorded weights: 11/7/10 - 160.2 12/10/10 - 163.6 1/9/10 - 160.4 2/6/11 - 165.0 3/14/11 - 152.4 4/3/11 - 158.6 4/30/11 - 147.0 For a weight loss of: 11.6 pounds (7.6%) in April 2011 18.0 pounds (10.7%) in 3 months (4/30/11 to 2/6/11) 13.2 pounds (8.0%) in 6 months (4/30/11 to 11/7/10) Record review revealed that staff recorded April 2011 food intake for breakfast, noon, and evening meals to average 56% of the resident meals being consumed. The record also revealed that the resident received 0 morning snacks, 9 afternoon snacks, and 9 evening in the 30 days of April 2011 (18 of the 90 ordered). The facility's September 2009 Policy and Procedure for Residents with Impaired Nutrition and Nutritional Risk revealed that residents identified with impaired nutrition or at nutritional risk included: - significant weight change, gain or loss, (3 lbs (pounds) in 1 week, 5% in 1 month, 7.5% in 3 months, 10% in 6 months), - signs of [MEDICAL CONDITION] - abnormal [MEDICATION NAME] lab values - meal or fluid intake of less than 75 percent at most meals The facility's March 2009 Interventions for Nutritional Risk of Residents guidelines included: - snacks between meals - substitutions per individual preferences - provision of feeding assistance Observation on 5/4/11 at 11:55 A.M. revealed Resident #3 in a wheelchair at the dining room table in a slouched position. Record review revealed the menu for 5/4/11 was beef enchilada, Mexican rice, lettuce salad, and fruit crisp. Staff had placed a bowl of a white-colored puree and a bowl of an apricot-colored puree in front of the resident. No staff stayed to assist the resident to eat. The resident reached forward several times toward the bowls. At 12:02 P.M. the resident slid from the wheelchair onto the dining room floor. Staff removed the resident from the dining room. At 12:24 P.M., Survey staff DD observed three room trays delivered by staff. They did not deliver a room tray to Resident #3 and observation revealed that Resident #3 had not eaten anything in the dining room. The Dining Record printed on 5/11/11 for Resident #3's for the 5/4/11 noon meal intake revealed staff recorded 50% intake for the entree/casserole, 25% for potato/starch, 50% for the salad and the resident refused the vegetable. Observation on 5/5/11 at 3:11 P.M. revealed the Dietary Staff C delivered a cart with supplements to the nurses station. Dietary Staff C stated " We bring it down and nursing (staff) takes them around (to the residents). " At 3:24 P.M. Survey Staff DD asked Resident #3 if staff had given him/her the afternoon pudding. The resident stated, "They was going to bring one but they haven't brought it yet." Survey Staff DD asked the resident, "Do you want a snack?" Resident #3 stated, "Yes." One hour later (4:24 P.M.) the supplement labeled for Resident #3 remained on the cart at the nurses station. The record lacked evidence that the resident received the supplement. Observation on 5/10/11 at 11:30 A.M. revealed Resident #3 in a wheelchair at the dining room table when Dietary Staff C placed an insulated coffee cup with a white-colored puree and an insulated coffee cup of a green-colored puree. At 11:41 A.M. the resident leaned forward, touched a cup handle with his/her left hand but did not pick it up. The resident's right hand had a compression glove and he/she kept it close to his/her body. At 11:51 A.M. the resident asked Survey Staff EE to help him/her eat. Survey Staff EE advised Nursing Staff FF, who then advised Nursing F. Nursing Staff F began feeding the resident at 11:57 A.M. and stopped at 12:06 P.M. The resident sat at the table for 21 minutes (11:30 A.M. to 11:51 A.M.) before being assisted and staff assisted the resident for a total of 9 minutes (11:57 A.M. to 12:06 P.M.) The resident consumed a few bites of pureed pork, a few bites of the sweet potato, 25% of the green beans, 50% of the custard, and a few sips of thickened juice. Observation on 5/10/11 at 3:15 P.M. revealed the Dietary Staff AA delivered a cart with supplements to the nurses station that contained an Ensure pudding labeled for Resident #3. At 4:06 P.M., Direct Care Staff O and HH assisted the resident in his/her room and did not offer the snack to the resident. Observation revealed the supplement remained on the cart at 4:06 P.M. At 6:15 P.M. Direct Care Staff O stated that she thought Nursing Staff N delivered the supplements. On 5/11/11 at 1:33 P.M., Nursing Staff N stated she did help, but only delivered supplements to two other residents, not Resident #3. On 5/10/11 at 3:24 P.M. Dietary Staff C stated, "We are so short of help for feeding (the residents). "Resident #3 asked me to help him/her at lunch today." "Resident #3 should eat immediately because he/she hasn't been eating a lot lately. " Observation of the evening meal on 5/10/11 at 5:20 P.M. revealed the resident in his/her wheelchair at the dining room table. At 5:40 P.M. direct care staff began assisting the resident (20 minutes). The direct care staff asked the resident if he/she wanted carrots. The resident said, "No." Direct care staff asked if he/she liked carrots and the resident said, "No." The direct care staff did not offer a substitute and did not feed the resident the carrots. Staff provided thickened juice, thicken water, pureed biscuits and gravy, pureed carrots, and a pureed cookie in milk. Staff did not provide the pears as listed on the menu. Survey Staff DD informed Dietary Staff AA that the resident did not receive pears and Dietary Staff AA pureed pears and provided them to the resident. The direct care staff assisting the resident did not offer the pears after Dietary Staff AA provided them. Direct staff fed Resident #3 and Resident #30, left the table several times in 30 minutes and did not return after leaving the table 6:12 P.M. Resident #3 consumed 100% of the juice, 50% of the water, 50% of the biscuits and gravy, and 25% of the cookie, 0% of the carrots, and 0% of the pears. On 5/11/11 at 9:35 A.M. Direct Care Staff U stated that she had delivered the supplements and that Resident #3 did not have a supplement. At 10:00 A.M. Survey Staff DD asked Dietary Staff II if Resident #3 should get a supplement at 10:00 A.M. She presented a list that revealed Resident #3 received supplements at 3:00 P.M. and 7 P.M. During an interview on 5/11/11 at 10:10 A.M. Dietary Staff C stated that she was aware that Resident #3's supplements had been returned to kitchen several times. Dietary Staff C stated, "Some supplements are not being given; they (nursing staff) are short-staffed, too." At 11:55 A.M. Dietary Staff C presented the list that Direct Care Staff II had. Survey Staff DD advised of the 3/18/11 physician's orders [REDACTED]. Dietary Staff C acknowledged she had received the diet change order from nursing, but had not changed the list that dietary staff used to prepare the supplements. Therefore, the kitchen only supplied 2 supplements per day rather than the 3 ordered by the physician. On 5/12/11 at 8:58 A.M. Nursing Staff H stated she assisted the resident yesterday for a meal and noticed that Resident #3 had been getting assistance last in the dining room. She also stated that "We are short-staff so we have a difficult time getting to everyone right away. In summary the facility failed to ensure Resident #3 received his/her nutritional supplements between meals three times a day as care planned and ordered by the physician, to provide substitutes of the resident's preference, and to receive adequate assistance during meals to maintain his/her weight. The resident experienced harm of a severe weight loss of 11.6 pounds (7.6%) in 1 month and 18.2 pounds (10.7%) in 3 months.