Every finding on record at Via Christi Village Pittsburg

The facility reported a census of 74 residents. Based on observation, interview, and record review, the facility failed to ensure a clean environment in one of the four neighborhoods regarding soiled, stained privacy curtains in a shower room in one of the four neighborhoods. Findings included: - During a brief environmental tour of C Court, on 10/14/24 at 09:25 AM, the following areas of concern noted: Two privacy curtains contained multiple areas which were dirty and stained. On 10/21/24 at 09:49 AM, Housekeeping/Maintenance Staff U stated housekeeping was responsible for ensuring the privacy curtains in the shower rooms were clean. The privacy curtains needed to be washed or replaced. The facility lacked a policy regarding the maintenance/cleaning of the shower curtains. The facility failed to ensure a clean environment in one of the four neighborhoods regarding soiled, stained privacy curtains in a shower room in one of the four neighborhoods.

The facility reported a census of 74 residents with 20 residents selected for review. Based on observation, interview, and record review, the facility failed to provide care plan meetings for four Residents (R) 13, R2, R7 and R57, as required. Findings included: - Review of Resident (R)2's medical record revealed diagnosis that included end stage renal (kidney) disease. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The resident received dialysis services (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). The Quarterly MDS dated [DATE], indicated a BIMS score of 12, which indicated moderate cognitive impairment. The resident received dialysis services. The Cognitive Loss Care Area Assessment (CAA), dated 02/29/24, assessed the resident received dialysis treatments and was at risk for nutritional and fluid volume imbalance. The Care Plan dated 08/20/24, instructed staff the resident received dialysis treatments and staff were to assess the access site for bleeding and to make sure the blood pressure was stable before the resident resumed activity. Interview, on 10/16/24 at 10:07 AM, with Social Service Staff X, revealed several care plan meetings with the resident/responsible party were not completed and confirmed the care plan updated on 08/20/24 did not include the resident/responsible party. The facility policy Care Plans-Comprehensive Person-Centered revised 09/2023, instructed staff the resident/resident representative will be encouraged to anticipate in the resident assessment and care planning conference wit the residents' permission. The facility failed to provide a care plan meeting for this resident/resident representative as required. - Review of Resident (R)13's medical record revealed diagnoses that included hemiplegia (paralysis of one side of the body) after cerebral infarction (cerebrovascular accident (CVA) [stroke] - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. R13 had functional limitation in range of motion impairment on one side of the upper and lower extremities. The Communication Care Area Assessment (CAA), dated 12/15/23, assessed the resident with left sided hemiplegia and required extensive assistance with most activities of daily living. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had functional limitation in range of motion impairment on one side of the upper and lower extremities. The resident was dependent on staff for personal hygiene. The Care Plan, reviewed 08/14/24, instructed staff the resident required extensive assistance with bathing/showering on Monday and Thursday mornings. Interview, on 10/16/24 at 10:07 AM, with Social Service Staff X, revealed several care plan meetings with the resident/responsible party were not completed and confirmed the care plan updated on 08/14/24 did not include the resident/responsible party. The facility policy Care Plans-Comprehensive Person-Centered revised 09/2023, instructed staff the resident/resident representative will be encouraged to anticipate in the resident assessment and care planning conference with the residents' permission. The facility failed to provide a care plan meeting for this resident/resident representative as required. - Review of Resident (R)7's medical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) dementia (progressive mental disorder characterized by failing memory, confusion) and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The Cognitive Loss Care Area Assessment (CAA) assessed the resident had continued decline in cognition with severely impaired memory. The resident had difficulty responding with garbled speech. The Care Plan reviewed 09/24/24, instructed staff the resident was dependent on staff for activities of daily living, was incontinent of bowel and bladder, had alteration in mood, at risk for pressure ulcers and included other interventions for medical conditions. Interview, on 10/16/24 at 10:07 AM, with Social Service Staff X, revealed several care plan meetings with the resident/responsible party were not completed and confirmed the care plan updated on 09/24/24 did not include the resident/responsible party. The facility policy Care Plans-Comprehensive Person-Centered revised 09/2023, instructed staff the resident/resident representative will be encouraged to anticipate in the resident assessment and care planning conference with the residents' permission. The facility failed to provide a care plan meeting for this resident/resident representative as required. 34056 - Review of Resident (R)57's electronic medical record (EMR) revealed a diagnosis of colon cancer (a disease that occurs when cells in the colon grow out of control). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident readmitted to the facility from an acute hospital. The resident's Brief Interview for Mental Status (BIMS) score was 15, indicating intact cognition. It was somewhat important to the resident to have a family, or a close friend involved in discussions about his care. The Return to Community Referral Care Area Assessment (CAA), dated 06/06/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. Review of the resident's care plan, revised 09/04/04, instructed staff the resident did not plan to remain in the facility long-term, but planned to discharge to an assisted living facility when room was available. Review of the resident's EMR, from 01/01/24 through 10/16/24, revealed the resident had not had a care plan meeting since 01/09/24. On 10/14/24 at 08:58 AM, the resident stated he had not had a care plan meeting. On 10/16/24 at 08:21 AM, Social Service Staff X stated the resident had not had a care plan meeting since 01/09/24. He missed care plan meetings in March and July due to the facility not having a social worker for the residents of that neighborhood. Care plan meetings were to be held every three months. On 10/16/24 at 07:39 AM, Administrative Nurse D stated residents should have care plan meetings every three months. The resident had not had a care plan meeting since 01/09/24. The facility policy for Care Plans, revised 10/2021, included: The resident's representative will be encouraged to participate in the resident's care planning conference with the resident's permission, at least quarterly and with a significant change. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. The facility failed to have care plan meetings every three months for this resident.

The facility reported a census of 74 residents. Based on observation, interview, and record review, the facility failed to ensure all resident equipment in one of the four neighborhoods were in clean, safe condition, regarding one toilet seat riser with legs and handles. Findings included: - During a brief environmental tour of C Court, on 10/14/24 at 09:25 AM, the following areas of concern were noted: A toilet seat riser had multiple rusty areas over all four legs. The plastic toilet seat had a crack where it met residents' buttocks area. On 10/21/24 at 09:49 AM, Housekeeping/Maintenance Staff U stated the toilet seat riser needed to be thrown away.Housekeeping/Maintenance Staff U stated the facility had extra toilet seat risers available for when one needed replaced. The facility lacked a policy for the maintenance and upkeep of resident equipment. The facility failed to ensure all resident equipment in the C Court neighborhood was clean and in safe condition.

The facility reported a census of 74 residents with 20 residents included for review, which included two residents reviewed for activities of daily living. Based on observation, interview, and record review, the facility failed to ensure two Resident (R)13 and R37 received grooming assistance. Findings included: - Review of Resident (R)13's medical record revealed diagnoses that included hemiplegia (paralysis of one side of the body) after cerebral infarction (cerebrovascular accident (CVA) [stroke] - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. R13 had functional limitation in range of motion impairment on one side of the upper and lower extremities. The Communication Care Area Assessment (CAA), dated 12/15/23, assessed the resident with left sided hemiplegia and required extensive assistance with most activities of daily living. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of nine, which indicated moderate cognitive impairment. The resident had functional limitation in range of motion impairment on one side of the upper and lower extremities. The resident was dependent on staff for personal hygiene. The Care Plan, reviewed 08/14/24, instructed staff the resident required extensive assistance with bathing/showering on Monday and Thursday mornings. Observation, on 10/15/24 at 08:25 AM, revealed the resident positioned in his wheelchair, eating breakfast in the common dining room. The resident's left arm was in a sling. The resident had several days' worth of facial hair. Observation, on 10/16/24 at 08:08 AM, revealed the resident seated in his wheelchair in the dining room. The resident continued with several days' worth of facial hair and stated his face felt itchy. Interview, on 10/16/24 at 08:08 AM, with Certified Nurse Aide (CNA) O, revealed the resident was cooperative with bathing, and did not know why he was not shaved on his bath day. Interview, on 10/16/24 at 10:01 AM, with Licensed Nurse (LN) H, revealed the resident occasionally yelled out at staff, and wanted to go home. LN H stated the resident was independent prior to the CVA and had an adjustment period. LN H stated the resident was generally cooperative with cares and could make his needs known. Interview on 10/21/22 at 10:30 AM, with Administrative Nurse D, revealed she would expect staff to provide personal hygiene. The facility policy Quality of Life-Dignity date 01/2024, instructed staff to provide care to the residents that promotes and enhances the quality of life, dignity and individuality. The facility failed to ensure this dependent resident received grooming to maintain personal comfort and appearance to enhance dignity. - Review of Resident (R) 37's medical record revealed diagnoses that included hemiplegia (paralysis of one side of the body) after cerebral infarction (cerebrovascular accident (CVA) [stroke] - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive function. The resident had no impairment in functional range of motion in extremities. The resident required set up assistance for eating and was dependent on staff for personal hygiene. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 05/02/24, assessed the resident required extensive assistance for most ADLs due to a decline with a recent diagnosis of Parkinson's disease ( slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). Increased staff support was required to meet ADL's and most care area to maintain a neat, odor free appearance. The Cognitive Loss CAA dated 05/02/24, assessed the resident was able to feed herself. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of 12, which indicated moderate cognitive impairment. The resident required set up assistance for eating and was dependent on staff for personal hygiene. The Care Plan reviewed 08/01/24, instructed staff the resident preferred to feed herself and required staff assistance for supervision and set up for meals and hygiene. Observation, on 10/14/24 at 09:27 AM, revealed the resident seated in the dining room, finished with breakfast. The resident had a brown substance running down from the left lower lip to bottom of her chin. A laboratory personnel questioned Certified Medication Aide (CMA) T, to identify the resident and then propelled the resident to her room, to obtain a blood sample, then returned the resident to the dining room. CMA T did not wipe the brown substance from the resident's face. Observation, on 10/16/24 at 11:03 AM, revealed the resident seated in her wheelchair in her room. A red substance was noted from her left lower lip down to the bottom of her chin. Observation, on 10/16/24 at 11:51 AM, revealed the resident seated in her wheelchair at the dining room table with the red substance still on her face. Licensed Nurse (LN) I, obtained a blood sugar and then administered insulin to the resident and did not wipe the red substance from her face until requested. LN I stated the resident preferred to feed herself, and staff should provide personal hygiene afterward. Interview on 10/21/22 at 10:30 AM, with Administrative Nurse D, revealed she would expect staff to provide personal hygiene. The facility policy Quality of Life-Dignity date 01/2024, instructed staff to provide care to the residents that promotes and enhances the quality of life, dignity and individuality. The facility failed to provide personal hygiene related to facial hygiene to this resident that required staff assistance.

The facility reported a census of 74 residents with 20 residents sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one Resident's (R)27's, regarding the care and maintenance of her personal humidifier. Findings included: - Review of Resident (R)27's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/18/24, documented the resident had a diagnosis of dementia with confusion and forgetfulness. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of one, indicating severe cognitive impairment. The care plan, revised 10/14/24, lacked staff instruction regarding the care and maintenance of the resident's personal humidifier. On 10/15/24 at 08:00 AM, the resident had a humidifier in her room in the on position with mist coming from the spout of the machine. The spout and nebulizer chamber (a round disc or white circle in the base of the unit that vibrates to create a mist) of the machine had a heavy build-up of a hardened, white substance. On 10/16/24 at 08:00 AM, the resident's humidifier remained in her room with mist coming out of the spout of the machine. The heavy build-up of the hardened, white substance remained in the spout and nebulizer chamber. On 10/16/24 at 09:41 AM, Certified Medication Aide (CMA) R stated she believed the night shift staff was responsible for the care of the resident's humidifier. On 10/16/24 at 09:54 AM, CMA S stated she was unsure of who was responsible for the care of the resident's humidifier. On 10/21/24 at 09:15 AM, Administrative Nurse E stated the care plan should include staff instruction on the care and maintenance of resident's personal humidifiers. The facility policy for Care Plans, revised 10/2021, included: Comprehensive care plans shall be completed for each resident with measurable goals and outcomes. The care plan shall include resident specific care needs. The facility failed to complete a comprehensive care plan to include staff instruction for the care and maintenance for this dependent resident with a personal humidifier.

The facility reported a census of 74 residents with 20 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plans for two Residents (R)59 and R 70, regarding footrests for their wheelchairs. Findings included: - Review of Resident (R)59's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She utilized a wheelchair for mobility and was able to mobilize 150 feet with two turns with set-up assistance only. The Activities of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/26/24, documented the resident required extensive assistance of one staff for mobility with the wheelchair. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She utilized a wheelchair for mobility and required partial to moderate staff assistance with wheeling 150 feet with two turns. The care plan for ADLs, revised 04/22/24, lacked staff instruction regarding the use of footrests for her wheelchair while being propelled by staff. Review of the resident's EMR from 10/01/24 through 10/15/24, revealed the resident required limited to total staff assistance with locomotion on the unit with her wheelchair. On 10/14/24 at 09:40 AM, Certified Nurse Aide (CNA) M propelled the resident in her wheelchair from the commons area to the shower room to toilet. The resident's shoed feet skimmed the floor during the transport. The wheelchair lacked footrests. On 10/15/24 at 12:12 PM, CNA N propelled the resident in her wheelchair from the dining room table to the shower room to toilet. The resident's shoed feet skimmed the floor during the transport. The wheelchair lacked footrests. On 10/16/24 at 09:54 AM, Certified Medication Aide (CMA) S propelled the resident in her wheelchair in the commons area. The resident's shoed feet were tucked underneath the seat of the wheelchair and the toes of her shoes skimmed the floor. The wheelchair lacked footrests. On 10/14/24 at 09:40 AM, CNA M stated the resident's wheelchair did not have footrests because the resident would propel herself in the wheelchair at times. On 10/15/24 at 12:12 PM, CNA N stated the resident's wheelchair did not have footrests because the resident would propel herself in the wheelchair at times. On 10/16/24 at 09:54 AM, CMA S stated the resident would self-propel in her wheelchair at times so staff did not use footrests on her wheelchair. On 10/15/24 at 09:39 AM, Licensed Nurse (LN) G stated the staff should ensure resident's had footrests on their wheelchairs when they were being propelled by staff. On 10/21/24 at 08:57 AM, Administrative Nurse E stated all nurses were able to review and revise resident care plans. It was the expectation for the use of footrests to be included on the resident's care plan. The facility policy for Care Plans, revised 10/2021, included: Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The facility failed to review and revise this dependent resident's care plan to include staff instruction regarding the use of footrests while being propelled by staff. - Review of Resident (R)70's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She utilized a wheelchair for mobility with substantial to maximal assistance of staff. The Activities of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/18/24, did not trigger. The care plan for ADLs, dated 09/11/24, lacked staff instruction regarding the use of appropriate footrests for her wheelchair while being propelled by staff. Review of the resident's EMR, from 10/01/24 through 10/15/24, revealed the resident required limited to extensive assistance with locomotion on the unit with her wheelchair. On 10/14/24 at 09:24 AM, Certified Nurse Aide (CNA) M propelled the resident in her wheelchair from the dining room to the shower room to toilet. The resident's right foot lacked support and dangled between the footrests of the wheelchair. On 10/14/24 at 12:07 PM, the resident sat in her wheelchair at the dining room table. The resident's feet dangled between the footrests of the wheelchair, several inches above the floor. On 10/16/24 at 07:30 AM, the resident sat in her wheelchair at the dining room table. The resident's right ankle rested on the outer edge of the footrest. On 10/16/24 at 09:17 AM, the resident sat in her wheelchair at the dining room table. The resident's feet were between the footrests of the wheelchair and only the toes of her feet reached the floor. On 10/14/24 at 09:24 AM, CNA M stated she had not noticed the resident's feet not resting properly on the footrests of the wheelchair. On 10/15/24 at 09:39 AM, Licensed Nurse (LN) G stated the staff should ensure resident's had appropriate footrests on their wheelchairs when they were being propelled by staff. LN G confirmed the resident's feet did not rest appropriately on the footrests of the wheelchair and one or both feet tended to fall in between the two footrests of the wheelchair. On 10/21/24 at 08:57 AM, Administrative Nurse E stated all nurses were able to review and revise resident care plans. It was the expectation for the use of footrests to be included on the resident's care plan. The facility policy for Care Plans, revised 10/2021, included: Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The facility failed to review and revise this dependent resident's care plan to include staff instruction regarding the use of footrests while being propelled by staff.

The facility reported a census of 74 residents with 20 residents sampled, including two residents reviewed for positioning. Based on observation, interview, and record review, the facility failed to properly position two Residents (R)59 and R 70, regarding footrests for their wheelchairs. Findings included: - Review of Resident (R)59's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She utilized a wheelchair for mobility and was able to mobilize 150 feet with two turns with set-up assistance only. The Activities of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/26/24, documented the resident required extensive assistance of one staff for mobility with the wheelchair. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She utilized a wheelchair for mobility and required partial to moderate staff assistance with wheeling 150 feet with two turns. The care plan for ADLs, revised 04/22/24, instructed staff the resident was independent with her wheelchair. Review of the resident's EMR from 10/01/24 through 10/15/24, revealed the resident required limited to total staff assistance with locomotion on the unit with her wheelchair. On 10/14/24 at 09:40 AM, Certified Nurse Aide (CNA) M propelled the resident in her wheelchair from the commons area to the shower room to toilet. The resident's shoed feet skimmed the floor during the transport. The wheelchair lacked footrests. On 10/15/24 at 12:12 PM, CNA N propelled the resident in her wheelchair from the dining room table to the shower room to toilet. The resident's shoed feet skimmed the floor during the transport. The wheelchair lacked footrests. On 10/16/24 at 09:54 AM, Certified Medication Aide (CMA) S propelled the resident in her wheelchair in the commons area. The resident's shoed feet were tucked underneath the seat of the wheelchair and the toes of her shoes skimmed the floor. The wheelchair lacked footrests. On 10/14/24 at 09:40 AM, CNA M stated the resident's wheelchair did not have footrests because the resident would propel herself in the wheelchair at times. On 10/15/24 at 12:12 PM, CNA N stated the resident's wheelchair did not have footrests because the resident would propel herself in the wheelchair at times. On 10/16/24 at 09:54 AM, CMA S stated the resident would self-propel in her wheelchair at times so staff did not use footrests on her wheelchair. On 10/15/24 at 09:39 AM, Licensed Nurse (LN) G stated the staff should ensure resident's had footrests on their wheelchairs when they were being propelled by staff. On 10/21/24 at 08:57 AM, Administrative Nurse E stated it was the expectation for staff to use footrests while propelling residents in their wheelchairs. The facility policy for Safe Patient Transport in Wheelchair, approved 01/2024, included: Staff shall use a safe technique when transporting residents in their wheelchairs, including ensuring the resident's feet rest comfortably on the footrests. The facility failed to properly position this dependent resident in her wheelchair while propelling her by not having footrests for the resident's feet. - Review of Resident (R)70's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She utilized a wheelchair for mobility with substantial to maximal assistance of staff. The Activities of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 09/18/24, did not trigger. The care plan for ADLs, dated 09/11/24, instructed staff the resident could utilize a wheelchair, as needed (PRN), depending on her steadiness. Review of the resident's EMR, from 10/01/24 through 10/15/24, revealed the resident required limited to extensive assistance with locomotion on the unit with her wheelchair. On 10/14/24 at 09:24 AM, Certified Nurse Aide (CNA) M propelled the resident in her wheelchair from the dining room to the shower room to toilet. The resident's right foot lacked support and dangled between the footrests of the wheelchair. On 10/14/24 at 12:07 PM, the resident sat in her wheelchair at the dining room table. The resident's feet dangled between the footrests of the wheelchair, several inches above the floor. On 10/16/24 at 07:30 AM, the resident sat in her wheelchair at the dining room table. The resident's right ankle rested on the outer edge of the footrest. On 10/16/24 at 09:17 AM, the resident sat in her wheelchair at the dining room table. The resident's feet were between the footrests of the wheelchair and only the toes of her feet reached the floor. On 10/14/24 at 09:24 AM, CNA M stated she had not noticed the resident's feet not resting properly on the footrests of the wheelchair. On 10/15/24 at 09:39 AM, Licensed Nurse (LN) G stated the staff should ensure resident's feet rested appropriately on the footrest of the wheelchair while being propelled by staff. On 10/21/24 at 08:57 AM, Administrative Nurse E stated it was the expectation for staff to ensure resident's feet reached the footrest of their wheelchairs appropriately. The facility policy for Safe Patient Transport in Wheelchair, approved 01/2024, included: Staff shall use a safe technique when transporting residents in their wheelchairs, including ensuring the resident's feet rest comfortably on the footrests. The facility failed to properly position this dependent resident in her wheelchair while propelling her.

The facility reported a census of 74 residents with 20 residents sampled, including one resident reviewed for respiratory services. Based on observation, interview, and record review, the facility failed to properly clean and maintain a humidifier (a device for keeping the atmosphere moist in a room) in one Resident's (R)27's room. Findings included: - Review of Resident (R)27's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/18/24, documented the resident had a diagnosis of dementia with confusion and forgetfulness. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of one, indicating severe cognitive impairment. The care plan, revised 10/14/24, lacked staff instruction regarding the humidifier. On 10/15/24 at 08:00 AM, the resident had a humidifier in her room in the on position with mist coming from the spout of the machine. The spout and nebulizer chamber (a round disc or white circle in the base of the unit that vibrates to create a mist) of the machine had a heavy build-up of a hardened, white substance. On 10/16/24 at 08:00 AM, the resident's humidifier remained in her room with mist coming out of the spout of the machine. The heavy build-up of the hardened, white substance remained in the spout and nebulizer chamber. On 10/16/24 at 09:41 AM, Certified Medication Aide (CMA) R stated she believed the night shift staff was responsible for the care of the resident's humidifier. On 10/16/24 at 09:54 AM, CMA S stated she was unsure of who was responsible for the care of the resident's humidifier. On 10/21/24 at 09:15 AM, Administrative Nurse E stated she was unsure of how often humidifiers should be cleaned and stated the nurses would be responsible for the care and cleaning of the humidifiers. The facility policy for Water Management Program to Reduce Legionella Exposure, revised 0/2018, included: A water management program shall assist in reducing the risk for Legionella from growing and spreading due to residents' usage of devices, such as humidifiers. The facility failed to properly clean and maintain this dependent resident's personal humidifier.

The facility reported a census of 74 residents with 20 residents selected for review, which included one resident reviewed for dialysis (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). Based on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one Resident (R)2 who received dialysis three times a week. Findings included: - Review of Resident (R)2's medical record revealed diagnoses that included end stage renal (kidney) disease. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The resident received dialysis services (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). The Quarterly MDS dated [DATE], indicated a BIMS score of 12, which indicated moderate cognitive impairment. The resident received dialysis services. The Cognitive Loss Care Area Assessment (CAA), dated 02/29/24, assessed the resident received dialysis treatments and was at risk for nutritional and fluid volume imbalance. The Care Plan date 08/20/24, instructed staff the resident received dialysis treatments and staff were to assess the access site for bleeding and to make sure the blood pressure was stable before the resident resumed activity. Review of the Dialysis Communication form revealed staff to assess the resident's pulse, respirations, blood pressure, temperature, pain level. Staff were to access site evaluation and indication of changes in his condition prior to dialysis, and after the resident returned to the facility from the dialysis treatment. Review of the Dialysis Communication form from 09/23/24 through 10/16/24 revealed the following areas of concern: The form dated 09/30/24, 10/14/24 and 10/16/24 lacked a pre- dialysis and post- dialysis assessment. The forms dated 09/23/24, 09/25/24, 09/27/24, 10/02/24, 10/07/24, 10/09/24 and 10/11/24 lacked post dialysis evaluations. Review of the Nurse's Progress Notes from 09/23/24 through 10/16/24 lacked documentation of pre and or post evaluations of the resident. Interview, on 10/15/24 at 08:58 AM, with the resident, revealed he received dialysis on Monday, Wednesdays, and Fridays. The resident stated he had a fistula (a surgical joining of an artery and vein to use as an access device for the treatment) in his left arm. Interview, on 10/21/24 at 11:57 AM, with Licensed Nurse (LN) I, revealed licensed staff should assess the resident prior to going to dialysis and upon return and document the assessments on the Dialysis Communication form, located in a binder that the resident would take to dialysis with him. Interview, on 10/21/24 at 12:15 PM, with Administrative Nurse D, revealed she would expect staff to assess the resident pre and post dialysis and document on the Dialysis Communication form or in a progress note. The facility policy Dialyses reviewed 01/2024, instructed staff to assess the access site for dialysis, and document on the treatment administration record. The policy instructed staff to utilize the communication tool to receive a report on the resident to the community after each session, or if the dialysis center provided a verbal report, staff instructed to document the report in the resident's medical record. The facility failed to evaluate this resident's status pre dialysis three out of 10 dialysis treatments from 09/30/24 through 10/16/24 and failed to evaluate this resident's status post dialysis treatment 10 out of 10 times from 09/30/24 through 10/16/24 to ensure the resident had no adverse effects of the treatment. .

The facility reported a census of 74 residents with 20 residents selected for review, that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)2, received medications within the physician ordered parameters. Findings included: - Review of Resident (R)2's medical record revealed diagnoses that included end stage renal (kidney) disease. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The resident received dialysis services (a procedure to remove excess toxins and waste products from the blood when the kidneys fail). The Quarterly MDS dated [DATE], indicated a BIMS score of 12, which indicated moderate cognitive impairment. The resident received dialysis services. The Cognitive Loss Care Area Assessment (CAA), dated 02/29/24, assessed the resident received dialysis treatments and was at risk for nutritional and fluid volume imbalance. The Care Plan dated 08/20/24, instructed staff the resident received dialysis treatments and staff were to assess the access site for bleeding and to make sure the blood pressure was stable before the resident resumed activity. A Physician's Order dated 10/10/24, instructed staff to administer Midodrine, (a medication used to increase blood pressure) 10 milligrams, three times a day for low blood pressure and hold if the systolic blood pressure (SBP the first number of the blood pressure which indicates the pressure in the heart when it pumps out blood) is greater than 140 millimeters of mercury (mmHg). Review of the October 2024 Medication Administration Record (MAR) revealed the following areas of concern: On 10/11/24 at 02:00 PM, staff administered Midodrine to the resident with a blood pressure of 142/87. On 10/12/24 at 02:00 PM, staff administered Midodrine to the resident with a blood pressure of 161/90. On 10/13/24 at 10:00 PM, staff administered Midodrine to the resident with a blood pressure of 152/87. On 10/14/24 at 06:00 AM, staff administered Midodrine to the resident with a blood pressure of 152/76. On 10/15/24 at 06:00 AM, staff administered Midodrine to the resident with a blood pressure of 174/74. On 10/16/24 at 02:00 PM, staff administered Midodrine to the resident with a blood pressure of 143/82. On 10/17/24 at 06:00 AM, staff administered Midodrine to the resident with a blood pressure of 175/98. On 10/17/24 at 02:00 PM, staff administered Midodrine to the resident with a blood pressure of 144/81. On 10/18/24 at 06:00 AM, staff administered Midodrine to the resident with a blood pressure of 152/81. On 10/18/24 at 02:00 PM, staff administered Midodrine to the resident with a blood pressure of 153/84. On 10/20/24 at 02:00 PM, staff administered Midodrine to the resident with a blood pressure of 168/100. On 10/21/24 at 06:00 AM, staff administered Midodrine to the resident with a blood pressure of 145/86. Interview, on 10/21/24 at 10:30 AM, with Administrative Nurse E and Administrative Nurse E, confirmed the above and stated they would expect staff to following the parameters as ordered by the physician. The facility policy Health Care Provider Orders reviewed 01/2024, instructed staff to record the medication and any specified parameters with medication orders. The facility failed to ensure staff administered this resident's Midodrine, used to increase blood pressure was administered following the physician's ordered parameters to prevent adverse reactions.

The facility reported a census of 74 residents with 20 residents sampled, that included six residents reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to assess one Resident (R)44, for adverse effects of an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions). Findings included: - Review of Resident (R)44's medical record revealed diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion) with behavior disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear),and pseudobulbar affect (a neurological disorder that causes uncontrollable and inappropriate episodes of laughing or crying). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of one, which indicated severe cognitive impairment. The resident received antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions). The Delirium Care Area Assessment (CAA) assessed the resident received antipsychotic medication daily for violent behaviors and was stable. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of one, and the resident received antipsychotic medications. The Care Plan reviewed 09/12/24, instructed staff the resident received antipsychotic medications with Black Box (a safety warning the FDA [Food and Drug Administration] issued for serious side effects of medication) and staff were to monitor for adverse effects due to medications. A Physician's order dated 03/12/24, instructed staff to continue Olanzapine (an antipsychotic) 5 milligrams, daily, for violent behaviors. Observation, on 10/14/24 at 08:57 AM, revealed the resident seated in her wheelchair in the common living area. The resident was tearful, and unable to respond verbally. Observation, on 10/15/24 at 08:10 AM, revealed the resident seated in her wheelchair, feeding herself breakfast. The resident had a flat affect and responded with mumbling nonsensically. Interview, on 10/17/24 at 12:30 PM, with Administrative Nurse E, revealed she would expect staff to assess the resident for antipsychotic side effects using the AIMS (Abnormal Involuntary Movement Scale) tool to determine if the resident was experiencing side effects of Olanzapine which included extra pyramidal (a group of side effects that include involuntary movements, tremors, involuntary movements of the tongue) adverse effects. Administrative Nurse E confirmed staff completed the last AIMS on 03/25/24 and staff should assess the resident with the AIMS every three months. The facility policy Behavioral Assessments, Intervention and Monitoring revise 10/2024, instructed staff to ensure he resident has minimal complications associated with the management of altered or impaired behaviors through nonpharmacological or pharmacological interventions. The Interdisciplinary Team will review and discuss interventions and AIMS or other findings. The facility failed to ensure this resident who received antipsychotic medication did not display adverse effects of the medication through assessment of extra pyramidal movements.

The facility reported a census of 74 residents, with 20 sampled. Based on observation, interview and record review, the facility failed to use proper hand hygiene while completing wound care for one Resident (R)27. Findings included: - Review of Resident (R)27's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She was at risk for the development of pressure ulcers (PU) and had no unhealed PU at the time of the assessment. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 01/18/24, documented the resident spent most of her time in her recliner and required assistance with positioning. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of one, indicating severe cognitive impairment. She was at risk for the development of PUs with no unhealed PU at the time of the assessment. The PU care plan, revised 10/14/24, instructed staff the resident utilized pressure reducing devices for her chair and bed. Review of the resident's EMR revealed a Braden assessment (used to determine the risk of a resident developing a PU), dated 09/24/24, which placed the resident at a high risk for the development of PUs. Review of the resident's skin assessments, included the following: On 10/04/24, the resident developed a stage II PU (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed), that measured 1.2 centimeters (cm) in length (L) by 0.5 cm width (W) by 0.1 cm depth (D), to her coccyx (area at the base of the spine). On 10/09/24, the stage II PU measured 0.8 L by 0.5 cm W by 0.1 cm D. Review of the resident's EMR revealed the following physician's order: Cleanse the wound with wound cleanser, pat dry and cover with a bordered foam dressing, ordered 10/06/24. On 10/16/24 at 09:33 AM, Administrative Nurse F entered the resident's room to change the dressing to her wound. Administrative Nurse F cleansed the wound with wound cleanser and patted the area dry. Administrative Nurse F then measured the wound without changing her gloves or performing hand hygiene. On 10/16/24 at 09:35 AM, Administrative Nurse F stated she had not changed her gloves after cleansing the resident's wound and before measuring the wound. She stated she should have changed gloves and performed hand hygiene but did not. On 10/21/24 at 09:15 AM, Administrative Nurse D stated it was the expectation for staff to change gloves and perform hand hygiene after cleansing a wound and before measuring the wound. The facility policy for Wound Care/Dressing Change, revised 05/2023, included: When changing the dressing to a resident's wound staff shall don gloves and cleanse the wound per orders. Staff shall then remove their gloves, perform hand hygiene, and don clean gloves. The facility failed to perform proper hand hygiene while completing this resident's wound care.

The facility reported a census of 81 residents. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to prevent the staff neglect of Resident (R) 1. On 11/27/23 at 08:45 AM Certified Medication Aide (CMA) R entered cognitively impaired R1's room and observed R1 on the floor with her legs extended in the doorway of the closet. CMA R administered medications to R1 while she remained on the floor, and then left the resident's room. CMA R failed to report to any staff member that R1 was on the floor. At 12:45 PM, four hours later, CNA M heard noises coming from R1's room and when she entered the residents' room, she observed R1 sitting on the floor next to her bed. CNA M asked Housekeeping Staff U, who was also in the room, to immediately get Licensed Nurse (LN) G. The nurse assessed R1 and noted the resident had pain in her left hip, her left leg was rotated outward and appeared to be shorter than her right leg. R1 was transported to the Emergency Department (ED) by Emergency Medical Services (EMS) and was diagnosed with a left hip fracture which required surgical repair. This deficient practice placed R1 in immediate jeopardy. Findings included: - Resident (R)1's ''Physician Order Sheet'' (POS) dated 04/23/24, documented diagnoses which included: vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (elevated blood pressure), seizure (violent involuntary series of contractions of a group of muscles), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), narcolepsy (excessive sleepiness in the daytime and may also suddenly fall asleep during any activity), bilateral (both) hearing loss (keeps sound from passing through your ear canal and/or middle of ear), and mixed receptive-expressive language disorder (a condition that affects how people express themselves and understand what others say). R1's 03/02/23 ''Significant Change of Condition Minimum Data Set'' (MDS), documented the resident was admitted from acute care on 06/15/21. She had a ''Brief Interview of Mental Status'' (BIMS) score of three, which indicated severely impaired cognition. She had inattention, disorganized thinking, and she was vigilant (startled easily to any sound or touch). The resident required extensive assistance with bed mobility, transfers, toileting, and limited assistance with ambulating. She was frequently incontinent of bowel and bladder. The ''Cognitive Loss/Dementia Care Area Assessment'' (CAA), dated 03/08/23, documented the resident had confusion and forgetfulness. The resident's BIMS interview documented the resident had long and short-term memory deficits. The ''Falls Care Area Assessment (CAA), dated 12/08/23, documented the resident was at risk for falls due to an unsteady gait and poor safety awareness. The resident ambulated independently with verbal cues and redirection for safety. R1's 11/02/23 ''Quarterly MDS'', documented the resident had a BIMS score of three, which indicated severely impaired cognition. She had inattention, disorganized thinking, and she was vigilant (startled easily to any sound or touch.) The resident required extensive assist with bed mobility, transfers, toileting, and limited assist ambulating. She was frequently incontinent of bowel and bladder. R1's 10/30/23 ''Fall Risk'', evaluation documented a score of three. The score of zero to 15 indicated minimal risk for falls. The Altered level of cognitive function related to vascular dementia Care Plan'', dated 11/03/23, instructed staff to call the resident by her name, and to keep routine consistent to decrease confusion. R1's Fall Care Plan, dated 11/03/23, instructed staff to keep pathways clear and provide adequate lighting, keep the resident's bed at the appropriate height, encourage the resident to wear non-slip socks, assist the resident with using her wheelchair for mobility when the resident was unsteady, and offer to assist her to a couch or easy chair after meals. R1's ADL Care Plan dated 11/03/23, instructed staff the resident required extensive assist with one staff for bed mobility, transfers, and toileting. Review of a Nurses Note on 11/27/23 at 05:17 PM, revealed Housekeeping Staff U notified Licensed Nurse (LN) G that the resident was on the floor in her room. CNA M also notified LN G. N G entered the resident's room and observed the resident sitting on her bedroom floor beside her bed. The resident was non-verbal and unable to answer staff questions. Upon further assessment, the resident guarded her left leg and hip during a range of motion (ROM) assessment. The resident's left leg was rotated outward with some length difference from her right leg. LN G contacted Administrative Nurse D and Administrative Staff A of the incident. LN G called the resident healthcare provider for an order to transfer the resident to the Emergency Department (ED) by Emergency Medical Service (EMS). Review of the facility's investigation revealed CMA R observed the resident on the floor on 11/27/23 at 08:45 AM with her legs extended in the doorway to the closet. CMA R waved and said Hi, [R1]. CMA R reported that the resident smiled and laughed after being greeted. CMA R then administered medications while the resident remained on the floor and CMA R left the resident's room. CMA R did not advise anyone that the resident was on the floor. Review of the hospital records revealed R1's diagnostic images of her pelvis and two views of the left hip, dated 11/27/23, demonstrated a displaced (bones moved enough to create a gap) comminuted (broken in at least two places) intertrochanteric (top part of the thigh bone) femur (thigh bone) fracture. R1's hospital discharge summary, dated 12/01/23, documented the resident resided in a long-term facility and sustained a left intertrochanteric fracture (hip fracture). Review of a Nurses Note dated 12/01/23 at 01:00 PM documented the resident readmitted to the facility from acute care hospital. R1 sustained a left intertrochanteric fracture (hip fracture). Observation on 05/06/24 at 06:00 AM, revealed the resident was in bed resting with her eyes closed. Observation on 05/06/24 at 08:45 AM, revealed the resident ambulated with her walker to the dining room table with staff providing stand-by assistance. Review of CMA R's witness statement dated 11/27/23 at 08:45 AM, revealed CMA R entered the resident's room to administer her medications. She observed the resident sitting on the floor near the closet. CMA R said, Hi [R1] and waved at the resident. The closet door was opened, and it seemed as if she was messing around in her closet. CMA R administered the resident her medications and left the resident sitting on the floor and left the room. CMA R reported in her statement I didn't think anything of it because I have known the resident to do her own thing while still needing help. Review of Certified Nurse Aide (CNA) M's witness statement revealed on 11/27/23 at 12:45 PM, CNA M was assisting another resident when she heard R1's squealing. She entered R1's room to discover R1 was on the floor next to her bed. LN G was immediately notified. On 05/06/24 at 10:00 AM, Housekeeping U reported she was at the door of the resident's room and CNA M asked her to notify LN G that the resident was on the floor. On 05/07/24 at 12:23 PM, LN G reported that on 11/27/23 at approximately 12:45 PM, CNA M notified her that she found R1 sitting in her room on the floor next to her bed. LN G reported the resident required assistance with bed mobility, transfers, toileting, and ambulating. The resident was non-verbal and unable to verbalize her needs and would not be able to tell staff how she fell . LN G notified Administrative Nurse D of the fall. The resident guarded her left hip and left leg. Her left leg appeared to be shorter than her right leg. Staff had R1 transferred to the ED by EMS. LN G reported that she asked CMA R to assist her with R1. While CMA R was assisting LN G with R1, CMA R notified LN G that she observed R1 on the floor in her room with her legs extended in the doorway of her closet and administered R1 her medications and left R1 on the floor without alerting any other staff. The facility's Abuse Prevention Policy, dated 06/2022, documented the residents have the right to be free from abuse, neglect and to be protected from abuse and neglect from community associates. On 05/06/24 at 03:38 PM, Administrative Staff A was provided the Immediate Jeopardy template and notified the facility failed to protect R1 from neglect on 11/27/23, when CMA R found cognitively impaired R1 on the floor in her room, with her legs extended in the doorway of her closet and CMA R administered R1 her medications and left R1 on the floor without alerting any other staff. R1 remained on the floor for four hours, until another CNA (CNA M) heard R1 squealing from R1's room and alerted the LN. R1 had pain in her left hip, leg length difference and rotation and required emergent transport to the hospital and for surgical repair of a left hip fracture. This failure placed R1 in immediate jeopardy. The immediate jeopardy was determined to first exist on 11/27/23 at 12:45 PM. The facility identified and implemented corrective actions on 11/27/23 to include the following: 1. The facility educated all staff on the topics of Falls, Abuse, Neglect and Exploitation, and Timely Reporting. 2. R1 was assessed by Administrative Nurse D on 11/27/23 and no adverse effects noted. 3. R1's care plan related for falls reviewed by the Interdisciplinary Team and fall interventions were appropriate. 4. Staff education provided for all clinical staff on 11/27/23 at 02:00 PM and completed prior to the onsite survey. Due to the corrective actions completed prior to the onsite survey the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 83 residents. The sample included three residents reviewed for pain-controlled substance medication. Based on observation, interview, and record review, the facility failed to prevent a medication error when Licensed Nurse (LN) I failed to document in Resident (R)1's Electronic Health Records (EHR). On 02/28/24 at 06:00 AM, LN I administered oxycodone (opioids [narcotic analgesics]), five milligram (MG) tablet, as an as needed (PRN) pain medication. On 02/28/24 at 08:00 AM, two hours later, LN H administered R1's scheduled oxycodone, which was to be administered one hour prior to leaving for dialysis (a blood purifying treatment given when kidney function in not optimum), for pain. The facility failed to ensure no use of as needed (PRN) administered within a six-hour time frame of the scheduled doses, as ordered by the physician. This failure caused R1 to receive two doses of oxycodone, five mg, two hours apart. Findings Included: - The signed Physician Order Sheet (POS) for R1, dated 02/28/24, documented R1 admitted to the facility on [DATE], with the following diagnoses that included pneumonia (inflammation of the lungs) and pain. The Admission Minimum Data Set, dated dated [DATE], documented the resident had a Brief Interview of Mental Status of eight, that indicated moderately impaired cognition. The residents Pain Care Plan dated 02/22/24, guided staff that resident rated his pain on a scale of four out of 10. The Physician's Orders included Oxycodone, five milligrams (mg), one tablet, by mouth, every Monday, Wednesday, and Friday, one hour prior to leaving for dialysis and as needed (PRN) every six hours as needed for pain. Ensure no use of as needed script within six-hour time frame of the scheduled doses, dated 02/23/24. Review of the Controlled Drug Receipt/Record/ Disposition Form, revealed on 02/28/24 at 06:00 AM, Licensed Nurse (LN) I signed out for R1's Oxycodone, five milligrams. At 08:00 AM, LN H signed out for R1's Oxycodone. Review of the Medication Administration Record (MAR) on 02/28/24, revealed the MAR lacked documentation of the Oxycodone at 06:00 AM medication. On 02/28/24, at 05:56 AM, the progress notes revealed R1 refused cares but allowed the nurse to administer his medications. On 3/07/24 at 11:41 AM, Licensed Nurse (LN) I reported R1 requested to take his pain medication early. LN I reported that she administered his as needed oxycodone and verified she did not document the administration in the MAR. She reported that she did log it on the controlled substance control log. On 03/07/24 at 03:13 PM, Administrative Nurse D reported staff should document the date, time, and staff initials on the bubble pack of medication, check the control substance log and EHR. Administrative Nurse D stated staff should not have a medication error if nursing staff were following the correct way to administer medications. The facility's Medication Administration Policy, revised 12/2021, documented that the individual administering must verify three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The individual administering the medication is to document on the Medication Administration Record after giving each medication and before administering the next one. The facility failed to prevent a medication error when Licensed Nurse (LN) I failed to document in Resident (R)1's Electronic Health Records (EHR). On 02/28/24 at 06:00 AM, LN I administered oxycodone (opioids [narcotic analgesics]), five milligram (MG) tablet, as an as needed (PRN) pain medication. On 02/28/24 at 08:00 AM, two hours later, LN H administered R1's scheduled oxycodone, which was to be administered one hour prior to leaving for dialysis (a blood purifying treatment given when kidney function in not optimum), for pain. The facility failed to ensure no use of as needed (PRN) administered within a six-hour time frame of the scheduled doses, as ordered by the physician. This failure caused R1 to receive two doses of oxycodone, five mg, two hours apart.

The facility reported a census of 76 residents, with two residents sampled for cardiopulmonary resuscitation (CPR-an emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). Based on record review and interview, the facility failed to ensure one Resident (R)1 received the care he chose in regards to CPR. Findings included: - Resident (R)1 admitted to the facility on [DATE] with diagnoses that included complex tachyarrthymias (abnormal heart rhythms with a rate of 100 or more beats per minute), pacemaker placement, and coronary artery disease ([CAD] abnormal condition that may affect the flow of oxygen to the heart). The admission Minimum Data Set(MDS), dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of seven, indicating he had severely impaired cognition. The resident was not on hospice services. The MDS tracking assessment, dated [DATE], revealed the resident discharged to an acute hospital. The MDS Entry Tracking record, dated [DATE], revealed the resident readmitted to the facility from an acute hospital. Review of the facility's electronic health records revealed a Do not resuscitate (DNR or no code is 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) order, signed by the physician on [DATE]. Review of the clinical records revealed the following: On [DATE] at 12:35 PM, the resident's durable power of attorney (DPOA) for healthcare and DNR signed by the resident and faxed to the resident's physician. On [DATE] at 05:10 AM, staff entered the resident's room to administer his morning medication and assist the certified nurse's aide (CNA) with moving the resident up in the bed. Upon moving the resident, the resident jerked very quickly and began to have Choppy breathing. The resident became unresponsive, and the nurse initiated CPR due to code status believed to be a full code. The CNA called Emergency Medical Services (EMS) and another nurse came down (from another unit) to assist with the code (CPR). When EMS arrived, they took over CPR. The nurse went to print off paperwork and saw the resident was DNR status. The nurse informed EMS. EMS wanted to see the copy, however, staff was unaware in the electronic charts the DNR form located, so she called the director of nursing (DON). The DON called the social worker, and the social worker called the nurse to find the DNR orders under the advanced directives tab. While on the phone, EMS stopped CPR. The physician notified by EMS and the time of death was at 05:45 AM. On [DATE] at 09:45 AM, Administrative staff A reported the nurse went in to help with resident cares. During the time she was in the resident's room, the resident's heart stopped, and she immediately began CPR. The resident declined within the past few weeks, and the nurse was unaware that the resident's code status changed from CPR to DNR, so the nurse imitated CPR. The resident's door name plates on the door indicate a quick reference for code status. The white background on the resident's name should indicate if the resident was a DNR. The green background should reference if a resident was a Full code (to initiate CPR). On [DATE] at 11:52 PM, Licensed Nurse (LN) G reported, while doing routine cares, she assisted the CNA to reposition the resident in the bed. When staff repositioned him, the resident jerked, and within a few seconds, the resident was unresponsive. LN G grabbed the crash cart and her and another nurse from another unit, continued CPR until EMS started. She reported she performed CPR on the resident for approximately 10 to 15 minutes before EMS arrived and took over CPR. Once EMS responded, LN G left the room to print off the resident's records for transport to the hospital, however, once she looked at the electronic records, she knew at that time, the resident was a DNR. She then informed EMS of the DNR status. EMS continued CPR until they could review the signed DNR form, and LN G was unaware where the signed form was in the electronic records. She reported I knew he was a full code, but it must have changed. She did not think to look at the door) for a quick reference, but reported the background was white (to reference a DNR status). The facility's policy for Procedure: Advance Directive and Code status, dated ,d+[DATE], revealed advance directives will be respected in accordance with state law and community policy. The facility failed to honor this resident's wish,when the resident lacked the presence of vital signs (pulse and respiration), as the resident chose in regards to CPR, when staff initiated CPR on a resident that did not want cardiopulmonary resuscitation, and had a current DNR in his medical record.

The facility identified a census of 79 residents and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 12/13/22 at 07:06AM an initial walkthrough of the facility's kitchen was completed. An inspection of the kitchen's walk-in refrigerator revealed that the air-conditioning unit was leaking clear liquid. The fluid was dripping down onto several shelves stored below the unit. An inspection of the shelves revealed two bags of collard greens, one box of cut okra, and one box of hot dogs were covered in ice. On 12/19/22 at 01:20PM Dietary Staff BB stated that staff should be going in an inspecting the storage areas daily for cleanliness and equipment function. He was not aware of the leak in the freezer unit but would report it to the director. A review of the facility's Food Storage policy dated 01/2019 indicated that all foods stored in the walk-in refrigerator units will be stored above the floor on racks, shelves dollies, or other surfaces that facilitate cleaning. The policy noted that food storage areas shall be clean and dry at all times. The facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents at risk related for food borne illnesses and food safety concerns.

The facility identified a census of 79 residents. The sample included 18 residents with one resident reviewed for dignity. Based on observations, interviews, and record reviews, the facility failed to provide Resident (R)5 with dignity during basic cares. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), epilepsy (brain disorder characterized by repeated seizures), intellectual disabilities, muscle weakness, Lennox-Gastuat syndrome (severe condition with recurrent epileptic seizures starting from early childhood), and dysphagia (swallowing difficulty). R5's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) could not be completed due to severe cognitive impairment. The MDS indicated that she was totally dependent on two staff for transfers, locomotion (on and off unit), toileting, and bathing. A review of R5's Cognitive Loss Care Area Assessment (CAA) dated 04/07/22 recorded the resident had aphasia (loss of ability to understand or express speech) and cannot make needs known to staff. The CAA instructed staff should anticipate her needs. R5's Care Plan for cognitive loss dated 07/23/22 indicated that staff were to speak to R5 before providing cares. The care plan noted that she was, on occasion, able to let staff know what she liked through non-verbal communication. The care plan indicated that she was oriented to person and played an active role in decision making with her resident representative. On 12/14/22 at 07:25AM R5 was transferred from her bed to her high-back wheelchair by Certified Nurses Aid (CNA) M and CNA N. Both staff completed hand hygiene upon entering the room and wiped down the Hoyer (full body) lift, and moved the sling into position. CNA M positioned the lift while CNA N connected the sling to the lift. R5 was raised off the bed and slowly moved towards the lift. CNA M lowered R5 into the wheelchair while CNA N guided her into position. Once seated, CNA N buckled R5's seatbelt. After completing the transfer CNA M took off R5's shirt without announcing her intent to do so or offering R5 privacy. R5's shirt was changed, and staff moved R5 to the dining room for breakfast. On 12/19/22 at 10:22AM CNA N stated that residents should be provided care in a private environment where they felt comfortable. She stated that staff should always close the door while providing care and utilize the curtain in the room if other people are in the room. On 12/19/22 at 02:15PM Administrative Nurse D stated that staff were expected to ensure the residents have privacy during cares. He stated that staff should always ask permission to perform a task and move a resident to their room. A review of the facility's Quality of Life policy 12/2021 noted that all resident will be treated with dignity and respect. The policy noted that staff will promote, maintain, and protect the resident's privacy. The facility failed to provide R5 with dignity when removing R5's clothing. This deficient practice placed the residents at risk for decreased psychosocial well-being.

The facility identified a census of 79 residents. The sample included 18 residents with 18 residents reviewed for care plan revisions. Base on observation, record review, and interviews, the facility failed to revise care plan interventions related to Resident (R)26's ongoing exit seeking behaviors and need for a Wanderguard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). This deficient practice placed R26 at risk for wandering related accidents and unmet care needs. Findings Included: - The Medical Diagnosis section within R26's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (inability to sleep), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R26's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted that he wandered daily and his wandering placed at him at significant risk of getting to a potentially dangerous place. The MDS noted that R26 could walk under supervision of staff. A review of R26's Behaviors Care Area Assessment (CAA) indicated that R26 had wandering behaviors. The CAA noted that he has tried to exit different doors but stopped when the alarms sounded. The CAA noted that his main issue was him leaving the unit. The CAA noted that he was a high elopement (when a resident leaves the facility or safe area without staff knowledge and supervision) risk and care plan interventions would be implemented. A review of R26's Care Plan created 05/31/22 noted under Safety recorded that R26 would have a community elopement evaluation and monitoring process (05/31/22), orientation to the community (05/31/22), and monitor behavior changes (05/31/22). The plan noted under Behaviors that staff were to divert his attention (06/09/22), intervene as necessary to ensure safety (06/09/22), talk to him in a calm voice (06/09/22), and encourage him to participate in activities (06/14/22). The care plan noted that R26 would remove his clothing and walk around the court and encouraged staff to intervene (06/15/22). The care plan did not include information related to his WanderGuard device. R26's Elopement Risk Screening completed 11/19/22 indicated that he was independently mobile and cognitively impaired. The screening noted that he wandered aimlessly and voiced a desire to leave the facility. The screening revealed he was at risk for elopement. A review of R26's EMR revealed a Nursing Admission Note dated 06/01/22 indicating R26 had wandering behaviors with attempts to leave the unit. A Nursing Note dated 06/25/22 indicated R26 walked off the unit out into the indoor atrium unit. The note indicated that staff found him standing next to the balcony looking down at the first floor. The note indicated that he became agitated after staff instructed him that he could not leave. A Social Service dated 11/21/22 indicated that R26 continued to wander on and off the unit at times. A Nursing Note dated 12/04/22 noted that R26 had cut his WanderGuard off of his wrist. A Nursing Note dated 12/08/22 noted that R26 was placed on one to one supervision due to his exit seeking behaviors. A Nursing Note dated 12/10/22 indicated that staff could not find R26 in his room or on the unit. The note indicated that staff found him in another resident's room using the toilet. A Nursing Note dated 12/15/22 noted that R26 continued to have exit seeking behaviors and was fixated on going outside. On 12/13/22 at 07:30AM R26 wandering around F Court unit. He was clean and well-groomed. R26 then sat down at the dining hall tables and ate his breakfast. On 12/19/22 at 01:20PM R26 left the F Court unit and was standing in the atrium looking down at the lower court. R26 stated that he was looking for a way down but was unaware how to get down. R26 sat in a rocking chair outside the activity's office. On 12/19/22 at 10:22AM CNA N stated that she was not sure where the WanderGuard devices were tracked or if staff check placement of them daily. She stated that if a resident does get too close to the exit doors the alarm will go off and staff will respond. On 12/19/22 at 10:45AM Licensed Nurse (LN) I stated that she was not sure how tracking of the WanderGuards were being completed. She was not aware of staff checking of the bracelets positioning, testing, and replacing the WanderGuard after expiration . On 12/19/22 at 02:00PM Administrative Nurse D stated that direct care staff should be reviewing the resident's care plan for updates as much as they can. He stated that the MDS Coordinator starts the plan and nurses can add intervention as needed. A review of the facility's Elopement Prevention policy 05/2021 noted that care plan interventions will be implemented for residents of higher risk. The facility did not provide a Care Plan policy as requested on 12/19/22. The facility failed to revise the care plan with interventions related to R26's ongoing exit seeking behaviors and need for a Wanderguard. This deficient practice placed R26 at risk for wandering related accidents and unmet care needs.

The facility identified a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were provided for Resident (R) 30's wheelchair to prevent his feet from dragging on the floor. This deficient practice placed R30 at risk for accidents and injuries. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, dementia (progressive mental disorder characterized by failing memory, confusion), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R30 required extensive assistance of two staff members for activities of daily living (ADLs). The Quarterly MDS dated [DATE] documented R30 had severely impaired cognition. The MDS documented that R30 required extensive assistance of two staff members for ADLs. R30's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/16/22 documented R30 required extensive assistance of two staff members for most ADLs and transfers. R30's Care Plan dated 05/09/22 documented R30 required limited assistance of one staff member with wheelchair mobility. On 12/13/22 at 09:34 AM Certified Nurses Aide (CNA) O pushed R30 from his room into the dining room area as his bilateral feet slid along the floor with no foot pedals on the wheelchair. On 12/14/22 at 12:15 PM CNA O pushed R30 from his room into the dining room area as his bilateral feet slid along the floor with no foot pedals on the wheelchair. On 12/15/22 at 12:51 PM an unidentified female nursing staff member started to push R30's wheelchair with no foot pedals from the dining room. R30 asked the staff not to push the wheelchair too fast On 12/19/22 at 11:22 AM Certified Nurses Aide (CNA) P stated R30 propelled himself in the wheelchair at times. CNA P stated resident should have foot pedals on their wheelchair to prevent injuries from falls. CNA P stated R30 was able to hold his feet up when staff pushed him in the wheelchair. On 12/19/22 at 11:44 AM Licensed Nurse (LN) J stated every resident should have foot pedals on their wheelchair when the staff propel the wheelchair to prevent injuries or falls. LN J stated R30 could propel himself in the wheelchair occasional, but staff did push R30's wheelchair frequently. LN J stated R30 was usually able to pick up his feet when staff pushed him the wheelchair but not always. On 12/19/22 at 01:53 PM Administrative Nurse D stated for safety every resident should have foot pedals on their wheelchair if staff would be pushing them in the wheelchair, unless it was care planned otherwise. The facility's Quality of Life- Accommodation of Needs policy last reviewed December 2021 documented the facility's environment and staff behaviors would be directed toward assisting the resident in maintaining and/or achieving independent function, dignity and well-being. The resident's individual needs and preferences, including the need for adaptive devices and modification to the physical environment, would be evaluated upon admission and reviewed on an ongoing basis. The facility failed to ensure foot pedals were provided for R30's wheelchair to preventhis feet from dragging on the floor. This deficient practice placed R30 vulnerable for possible injuries.

The facility identified a census of 79 residents. The sample included 18 residents with one reviewed for activities. Based on observations, interviews, record review, and policy review, the facility failed to ensure Resident (R) 30 was provided with a meaningful activity program to address his assessed needs. This placed him at risk for impaired psychosocial wellbeing including boredom, agitation and restlessness. Findings Included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, dementia (progressive mental disorder characterized by failing memory, confusion), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R30 required extensive assistance of two staff members for activities of daily living (ADLs). The Quarterly MDS dated [DATE] documented R30 had severely impaired cognition. The MDS documented that R30 required extensive assistance of two staff members for ADLs. R30's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/16/22 documented R30 required extensive assistance of two staff members for most ADL's and transfers. R30's Care Plan recorded R30 had a diagnosis of depression (persistent feeling of sadness and loss of interest), agitation and restlessness. An intervention dated 05/09/22 directed staff to assist the resident to make new friends in the facility and participate in scheduled activities; provide R30 with a calendar of events. The care plan, dated 05/09/22, further directed staff to offer and assist R30 to activities of his choice. R30 enjoyed watching the news, history programs, sports western movies. He enjoyed gardening, being outdoors walking and Bible study. The care plan further directed R30 preferred activities in the morning, afternoon and evening in his own room and on the court. Review of R30's daily activity charting for October 2022 revealed R30 went to Noodling on Friday 10/07/22, and manicures on 10/09/22. ON Monday 10/10/22 R30 had cards and visiting with a volunteer and then on Wednesday, 10/19/22, he attended Sit and Fit exercise group as well as celebration for his court mates' birthdays. Review of the October 2022 activity calendar revealed Sit and Fit exercise group was offered every Wednesday. R30's court (C Court) had manicures scheduled one day, (Sunday 10/09/22). The calendar revealed there were no scheduled activities for C Court every other Saturday (10/08/22 and 10/22/22) and other than the one day for manicures, the only activity on Sundays was Sunday Morning Mass. Review of R30's daily activity charting for November 2022 revealed R30 had one-to-one activities visit on 11/04/22 which was a scheduled podiatrist (foot doctor) visit. ON Sunday 11/06/22 there was a one-to-one activity visit for nail care. O Monday 11/07/22 R30 participated in Big Nickel and on Friday 11/11/22 he attended the Veterans' Day celebration. On Wednesday 11/16/22 R30 participated in the Sit and Fit exercise group and again on Wednesday 11/30/22. Review of the November 2022 activity calendar revealed Sit and Fit exercise group was scheduled every Wednesday. There were two Saturdays (11/5/22 and 11/19/22) with no scheduled activities and other than manicures on 11/06/22, the only activity for Sunday on R30's court was Sunday Morning Mass. Review of the available documentation for December 2022 revealed R30 had one-to-one activities of nail care on Sunday 12/04/22. On Tuesday 12/06/22 R30 attended the Christmas Caroling with kids. A one-to-one activity event was recorded for 12/07/22 (Wednesday) for activities with R30 at R30s' doctor appointment and on Tuesday 12/13/22 R30 looked at the newspaper with staff. Review of the December 2022 Activity Calendar revealed three Saturdays on C Court with no scheduled activities (12/03/22, 12/17/22 an d12/24/22) and other than 12/04/22 there were no activities on C court on Sundays except Sunday Morning Mass. On 12/14/22 at 07:56 AM R30 laid on the bed in the lowest position with floor mat next to the bed. On 2/14/22 from 08:00 AM to 12: 15 PM the TV was on the news channel then changed to a Christmas movie and then changed to a modern music station during lunch. Three residents sat in the recliners and wheelchairs asleep. On 12/15/22 from 12:15 PM to 02:55 PM TV was on in the common area on modern music station. On 12/19/22 11:55 AM R30 sat in the wheelchair propelled self on the unit. TV was on in the common area. Two residents sat in recliners asleep. On 12/19/22 at 11:22 AM Certified Nurse Aide (CNA) P stated the activities on the units were watching movies, coloring sheets sometimes and some of the residents have word search or fill in books in their rooms. CNA P stated there are some group activities during the week, but not all the residents participate. On 12/19/22 at 11:44 AM Licensed Nurse (LN) J stated there was no group activities on the units on a regular basis, but there were group activities off the unit a couple times a week. LN J stated they watched TV on the units and family visited at times. LN J stated R30's son visited often. On 12/19/22 at 11:52 AM Activity Director Z stated there was no daily activities scheduled for each unit, but a couple of group activities provided during the week. Activity Director Z stated there was weekend activities, an activity staff member came in on the weekend and painted nails on one unit every weekend. Activity Director Z stated there were activity baskets on the units for the nursing staff to do activities with the residents. Activity Director Z stated she would educate the staff about the activity baskets and the I-pads that were kept in the activity office. On 12/19/22 at 01:53 PM Administrative Nurse D stated there was group activities during the week. Administrative Nurse D stated the residents watched movies on the units. The facility's Activities policy dated 01/2022 recorded the community provided for an ongoing program of activities to support residents in their choices of activities, both facility- sponsored group and individual activities and independent activities. It further recorded residents were encouraged to choose the types of recreation, cultural and religious activities and social events they preferred to participate in. The policy further directed staff would record the activity attendance and participation of the resident in both group and individual activities. The facility failed to ensure a meaningful resident centered activity program including weekend activities for R30 which placed him at risk for impaired psychosocial wellbeing including boredom, agitation and restlessness.

The facility reported a census of 70 residents with three residents reviewed for accident hazards. Based on record review and interview, the facility failed to provide appropriate assistance to one of the three residents, Resident (1), when assisting the resident to walk without use of a gait belt (belt used to help transfer a person from one place to another or to assist when walking). While walking with the staff, R1 fell forward when she tripped over her shoe that had slipped off. The fall resulted in a comminuted (bone splinters) displaced (traumatic bone break where two ends of the bone separate out of their normal positions) and angulated (out of alignment) fracture (broken bone) of the right midshaft (away from the farthest point of origin or attachment) humerus (bone of the upper arm) and a minimally displaced fracture of the left humeral neck. Findings included: - The diagnosis tab in the Electronic Medical Record (EMR), for Resident (R)1, included diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), history of falling, muscle weakness, and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 with having a short and long-term memory problem and severely impaired decision making. R1 did not reject care and required limited assistance of one staff for walking and extensive assistance of two staff for transfers. Her balance during transitions and walking was not steady and required staff assistance to stabilize. She had no functional impairment to her upper or lower extremity range of motion and did not use any devices for mobility. She had no falls since the prior assessment. The Annual MDS dated [DATE] revealed no changes to the assessment except R1 required extensive assistance of two staff for walking. The Care Plan, dated 02/16/22, revealed R1 had a potential to fall related to her impaired safety awareness due to her dementia (progressive mental disorder characterized by failing memory, confusion) and her history of falls. R1 required extensive assistance of one to two staff to walk with her using hand hold assistance and the staff were to encourage proper footwear. The Fall Risk assessment, dated 02/10/22, assessed R1 as a high fall risk. The Interdisciplinary [IDT] Note, dated 04/29/21 at 09:46 PM, revealed Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) N were walking R1 to her room when her Croc (a rubber type shoe) shoe came off of her foot and she tripped on it. R1 went down on both knees and staff assisted her to a lying position on the floor so they could alert the nurse. No injury at the time of the fall, denied pain, and had full range of motion to her upper and lower extremities with no differences noted between sides of her body or change from baseline when assessed. R1 denied pain with range of motion. Once R1 was in bed she started to cry, but it was due to fear of falling and she had made the statement Oh I can't do that. Oh no. The IDT note, dated 04/30/22 at 12:46 PM, revealed R1 had pain with movement to her right arm during breakfast. R1 was sitting in dining room chair with her right arm down at her side, the staff raised her arm and placed on a pillow. R1's elbow was swollen and painful to the touch and no pain noted to her right shoulder or wrist with range of motion. The staff assisted R1 with standing using a gait belt stabilizing arm and transferred from the dining room chair to a wheelchair then to bed. Staff contacted Emergency Medical Services (EMS) for ambulance transport to the emergency room for further evaluation. R1 exited the building with EMS at approximately 10:30 AM. At approximately 12:20 PM the emergency room staff reported R1 had bilateral humeral fractures, the right being worse than the left and would be transferred to a different hospital with surgery planned tomorrow morning. The hospital History and Physical, dated 04/30/22 included the diagnostic imaging results of R1's right shoulder which revealed a minimally displaced left humeral neck fracture and a right humeral comminuted, displaced, and angulated fracture. On 06/22/22 at 12:17 PM CMA R stated on 04/29/22 he was on the right side of R1 holding her hand and CNA N was on the left side of R1 holding her hand. They were walking with her from the couch to her room to get her ready for bed. R1 required two staff to walk with her. While walking with her, CNA N gasped, I had been looking forward and I turned and saw R1 falling to her knees, then she caught herself with her hands and laid down on the floor on her left side. She screamed at that time. I went and told Licensed Nurse (LN) G, and when we returned to R1 she was not screaming, more so hollering, which she would do when we would stand her up to walk or take her to the bathroom normally. R1 did not have a gait belt on when we walked with her and did not think R1 would allow one to be put on. CMA R stated he had never used a gait belt as she would just get up holding on to the staff's hands. After LN assessed her, we assisted her to a sitting position on the floor, applied a gait belt, bent both of her knees, and assisted her to stand up and walk to her bed. On 06/22/22 at 12:46 PM, CNA N stated on 04/29/22 with assistance of CMA R, they assisted R1 to get up from the recliner she was sitting in to walk to her room to get her ready for bed. R1 required extensive assistance of two as she resists to stand. R1 would kind of lean her body back while walking, so we support her weight and try to lean her forward. CMA R was on R1's right side and she was on her left and a gait belt was not in place. CNA N stated you could not put anything on her our around her and if you put her in a wheelchair she would scream, and normally the staff would just link arms with her while walking. CNA N stated she had her right arm around R1's back and her left arm under R1's left arm, like side hugging and CMA R had his left arm linked under R1's right arm. CNA N stated she did not know what R1's care plan said on how to walk with her, and no instructions were given to hold her hands or use a gait belt when walking with her. While walking R1 she tripped over her shoe and leaned forward to catch herself and we tried to catch her but could not. The fall happened really fast. CNA N was not sure if her knees hit first when R1 fell but she ended up lying on the floor on her left side. LN G and CMA R assisted her from the floor to a standing position by linking their arms under R1's and did not use a gait belt. On 06/22/22 at 02:42 PM LN G stated she was the nurse on duty when R1 fell on [DATE], she did not witness the fall, she was on a different court (unit) at the time. CMA R and CNA N were not following the care plan as it said to use a gait belt. They said they had their arms under hers and no gait belt in place when she fell . On 06/22/22 at 03:02 PM CNA M stated that R1 would scream and holler at times when a gait belt would be applied and knew there were times when staff did not put one on her. On 06/22/22 at 03:18 PM Administrative Nurse D stated the determination of the cause of R1's fall was inappropriate shoes for walking and the staff were not using a gait belt. She had been known in the past to be aggressive when staff attempted to put a gait belt on her. CMA R and CNA N stated they had not used a gait belt when walking with her but did not say if they tried to nor did I ask them. Our standard of care includes use of a gait belt when staff walk with a resident and would not necessarily be in the care plan to use one. I did immediate verbal education with them on using a gait belt. The facility lacked a policy for when gait belts should be utilized. The facility failed to use a gait belt when walking with R1, who tripped on her shoe, fell forward, and tried to catch herself with her arms, which resulted in fractures, to her right and left (arms) humeral bones.

The facility reported a census of 74 residents with 22 selected for review, which included eight residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure appropriate fall interventions were in place by determining the causal factors of the fall for four of the eight sampled residents. Of these Resident (R) 47 fell and sustained a nasal fracture and forehead laceration which required 11 sutures, with R2 and R33 experiencing repeated falls. The facility further failed to investigate and develop interventions for one of the eight residents, R51 who sustained repeated skin tears to the arms on three occasions. Findings included: - Review of R 47's Physician Order Sheet, dated 04/07/21, revealed diagnoses that included repeated falls, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with polyneuropathy (nerve damage in multiple nerves), hypertension (elevated blood pressure) and dementia (progressive mental disorder characterized by failing memory, and confusion). The Annual Minimum Data Set, dated dated [DATE], assessed the resident with a Brief Interview for Mental Status score (BIMS) of 14, which indicated normal cognitive status. The resident required extensive assistance of two staff for bed mobility, transfers, and locomotion on the unit. The resident required staff assistance to maintain balance and had no impairments in range of motion in her upper or lower extremities. The Falls Care Area Assessment (CAA), dated 04/01/21, assessed the resident as having a high risk for falls. The facility determined the falls were a result of the resident transferring herself without asking for assistance of staff or using her call light. The resident required frequent reminders to ask for assistance but continued to attempt self-transfers. The resident was able to propel herself when in a wheelchair. The resident received therapy services for training and safety training. The Care Plan, dated 02/15/21 and revised 05/05/21 instructed staff to know the resident had a memory problem with impaired decision-making skills and an impaired ability to comprehend due to dementia. The resident was blind in her right eye. The resident could propel herself when in the wheelchair for short distances. The resident was continent of bladder with occasional incontinent episodes. Staff were advised the resident chose to not request help with transfers at times, due to impulsiveness. The resident had a fall mat beside the low bed and a transfer bar. The resident should wear nonskid socks, had a soft touch call light, and nonskid strips on the fall mat. The care plan instructed staff to perform frequent visual checks of the resident. The resident required therapy for safety awareness and transfer techniques. Staff should encourage the resident to call for assistance as she had poor safety awareness. The Safety Event Entry-Working Copy dated 03/03/21 revealed dietary staff found the resident on the floor in her room on 03/01/21 at 02:15 PM. The resident stated she tried to find her remote. Measures in place included a low bed, assist rail, and nonskid socks. The facility failed to identify the casual factors of the resident's fall. The resident said she fell trying to reach for the remote. The new intervention for this fall indicated to obtain general lab per physician order. The facility obtained a urinalysis (UA) on 03/01/21 which was negative for urinary tract infection (UTI). The Safety Event Entry-Working Copy dated 03/16/21 at 09:15 AM, revealed the resident was found on the floor with her head near the dresser and her legs on the bedside table, with the wheelchair next to the foot of the bed. The resident reported she was reaching forward to secure her cell phone charger on the bedside table and she slid off the edge of her wheelchair. The resident finished eating breakfast 15 minutes prior to the fall and propelled herself back to the room. The resident fell asleep during breakfast. The facility failed to identify the casual factors of the resident's fall. The resident said she was reaching for her cell phone charger on the table. The intervention for this fall was to complete a medication review and lab work. The facility obtained a UA on 03/19/21 (3 days after the fall), which revealed a UTI, then on 03/22/21, (3 days later and 6 days after the fall), the physician started the resident on antibiotics for the UTI. The Safety Event Entry-Working Copy dated 03/17/21 reported the resident was found on 03/17/21 at 01:00 PM, sitting in her room on the fall mat, the resident attempted to transfer herself from her wheelchair to bed. No immediate intervention was put in place. An intervention, dated 03/19/21 (2 days later), instructed staff to encourage the resident to wait for staff and use a mechanical lift if needed. The Safety Event Entry-Working Copy dated 04/24/21, documented on 04/24/21 at 09:20 AM, staff found the resident in her room on the floor. The resident reported she attempted to transfer herself from her wheelchair to her bed and fell , striking her head on the floor. The intervention for this fall was to encourage the resident to propel her wheelchair close enough to the bed for safe transfers. The Safety Event Entry-Working Copy dated 05/04/21, revealed staff found the resident in her room, on the floor on 05/04/21 at 12:40 PM. The resident sustained a puncture wound to her middle forehead, had blood coming from both nostrils, and had a large skin tear with fat exposure to her right forearm. The facility failed to identify the casual factor of the resident's fall in her room. Review of the Emergency Department Provider Report, dated 05/04/21, revealed the resident required 11 sutures to the laceration on her forehead, sustained a laceration to her right forearms, and had a closed nasal bone fracture. Observation, on 05/10/21 at 08:45 AM, revealed the resident propelled herself in her wheelchair towards her room. The resident had sutures in a cross formation on her forehead, and the top of her right hand had extensive bruising, with the right forearm wrapped with a dressing. The resident used the ball of her foot to propel herself, leaning forward in the chair. The resident's bed was in a low position and a fall mat was beside the bed. The resident's wheelchair had a self-locking device in place. The resident attempted to move in her wheelchair onto the fall mat beside her bed and reached forward with her outstretched arm towards her bed. Interview, at the same time with Certified Medication Aide (CMA) S, revealed staff needed to transfer the resident either to the toilet or bed after meals, but often the resident finished her breakfast and attempted to transfer herself to her bed before staff were done assisting other residents with eating their breakfast. CMA S stated they were in a dilemma when they left the residents still eating breakfast to transfer the resident, because she took a lot of time. Observation, on 05/12/21 at 09:45 AM, revealed Licensed Nurse I and Administrative Nurse E, removed the resident's dressing from her right forearm. The resident had an extensive skin tear with an area not approximated deep layered skin, exposing subcutaneous fat, measuring two by four centimeters. Administrative Nurse E cleansed the area and redressed it with Vaseline gauze, and wrapped it with elastic gauze wrap. Interview, with LN I at that time, revealed the resident was alert at times and cooperated with staff, but staff needed to keep her within their line of sight as she would try to transfer herself and did not use her call light. Interview on 05/11/21 at 09:26 AM with CNA Q revealed the resident required two staff for transfers. Staff transferred the resident to bed or toilet as she preferred, after meals. CNA Q stated the resident tried to transfer herself from her wheelchair to her bed, but had an anti-slide device in the chair, anti-tip bars on the wheelchair, and a low bed. Interview on 05/11/21 at 02:01 PM with Therapy Consultant Staff (TCS) II revealed the resident was not safe to transfer herself from the wheelchair to the bed and required much cueing. The resident attempted to follow TCS II with the process of transferring but could not remember the steps. The resident was somewhat drowsy during the exchange. TCS II stated the resident had poor safety awareness. Interview on 05/11/21 at 03:15 PM with CNA MM revealed the resident required two staff to transfer, staff kept the resident's bed in a low position, and kept her door open to keep an eye on her. Interview on 05/12/21 at 02:44 PM, with CNA P revealed the resident had variable levels of alertness. CNA P stated the resident did not like to wait for staff assistance, did not use her call light, and tried to transfer herself. CNA P stated he was working when the resident last fell . CNA P stated the resident finished meals sooner that other residents and staff were often assisting residents that needed staff assistance with eating. CNA P stated staff tried to get her up last for meals, but the resident still finished her meals sooner than others and took herself to her room, did not use a call light, and attempted to transfer herself Interview on 05/13/21 at 10:45 AM with Administrative Nurse F, revealed staff provided multiple interventions for fall prevention. Interview on 05/13/21 at 11:00 AM with Administrative Nurse D, revealed the resident had a normal BIMS score, but did require staff assistance for transfers. Administrative Nurse D stated multiple interventions were developed for the resident and the resident had multiple falls. Administrative Nurse D explained she thought staff had interventions in place for the resident's falls and that the Quality Assurance (QA) nurse reviewed the falls. On 05/13/21 at 11:20 AM, Administrative Nurse F reported being responsible for QA and that she reviewed the interventions put in place and then determined if they were appropriate. Nurse F explained she did the cause analysis on the falls but those were in the facility QA program so were unavailable for review. The facility policy Accidents and Incidents-Investigating and Reporting revised 01/2020, instructed staff accidents shall be investigated and reported and interventions initiated. The facility failed to determine the root cause for the resident's multiple falls and failed to develop appropriate interventions for these repeated falls, with the most recent fall resulting in nasal fracture, a laceration to her forehead which required 11 sutures and a laceration (skin tear) to her right arm exposing subcutaneous tissue - Review of resident (R)51's Physician Order Sheet, dated 05/04/21, revealed diagnoses included [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) with visual hallucinations, dementia (progressive mental disorder characterized by failing memory, confusion) and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set, dated dated [DATE], assessed the resident with severe cognitive deficits, required extensive assistance of two staff for bed mobility, transfers and locomotion on the unit. The resident had no functional impairment of her upper or lower extremities. The Falls Care Area Assessment (CAA), dated 07/23/21, assessed the resident required staff assistance with ambulation and could propel herself in her wheelchair. The resident had decreased safety awareness and was at increased risk for falls/injury. A Nurses' Note, dated 05/01/21, documented the resident sustained two skin tears on her left elbow when Certified Nurse Aide staff assisted the resident to the bathroom and the resident stuck her arm out, which caused two skin tears on her upper left forearm, one measured 6 by 0.1 centimeters (cm) and another 3.5 by 0.1 cm. The Skin Evaluation Record, dated 05/10/21, documented a four cm C shaped left elbow skin tear. The resident had fragile aging skin and bumped the elbow. Staff to try Geri sleeves again. The Skin Evaluation Record, dated 05/13/21, documented a right calf skin tear which measured 4 by 1.5 cm. Observation, on 05/10/21 at 04:10 PM, revealed the resident seated in her wheelchair. Her left elbow contained a crescent shaped skin tear approximately 3.5 cm and within this another skin tear approximately 2 cm. The resident did not have protective sleeves on. Interview, on 05/11/21 at 03:15 PM, with Certified Nurse Aide (CNA) MM, revealed the resident propels herself backwards and backs into things and may have gotten the skin tears from running into things. Observation, on 05/13/21 at 08:00 AM, revealed the resident seated in her wheelchair with CNA Q propelling her. The resident had a skin tear on her left elbow area in a crescent shape, approximately 2 cm. The resident positioned her unprotected left arm above the wheel on the wheelchair (no positioned on her lab) nearly touching the wheel as CNA Q propelled the resident. Interview, on 05/23/21 at 10:30AM with Administrative Nurse E, confirmed the lack of interventions and investigations for the skin tears. Administrative Nurse E stated she thought at one point in time the resident wore protective sleeves but could not find that intervention on the resident's care plan to instruct the staff. The facility policy Skin Tears - Abrasions and Minor Breaks, dated 12/2016, instructed staff the to complete the investigation of causation and implement interventions to prevent additional abrasions. The facility policy Accidents and Incidents-Investigating and Reporting, dated 01/2020, instructed staff to investigate and initiate interventions. The facility failed to investigate and initiate interventions to prevent skin tears in this dependent resident with repeated multiple skin tears. - The Physician Order Sheet (POS), dated 04/06/21, documented Resident (R)2 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He required extensive assistance of two staff for bed mobility, transfers and toilet use. His balance was not steady, and he was only able to stabilize with staff assistance. He used a walker and a wheelchair for mobility and had two non-injury falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 03/11/21, documented the resident had decreased safety awareness related to impaired cognition and used a wheelchair for most mobility needs. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severely impaired cognition. He required limited assistance of one staff for bed mobility, transfers, and toilet use. He had two non-injury falls since the prior assessment. The falls care plan, updated 04/16/21, instructed staff to keep the resident's pathways clear and to provide adequate lighting due to the resident's decreased safety awareness. Staff were to ensure the resident had on appropriate foot wear at all times, to put him on the couch or the recliner following meals, and to initiate a toileting diary to determine appropriate toileting times for the resident. Review of the resident's electronic medical record (EMR), revealed a fall assessment, dated 04/16/21, which placed the resident at a high risk for falls. Review of the facility's fall report, documented 04/16/21, included: Staff discovered the resident on the floor in the commons room lying on his right side, propped up on his right elbow. His range of motion (ROM) was intact and he had no injuries. Staff assisted him up to his wheelchair with extensive assistance of two and taken to the bathroom. The resident had been incontinent of bowel. The fall report lacked analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall. Review of the facility's fall report, documented 02/18/21, included: The staff discovered the resident lying on the floor of his room. Resident complained of right hip pain. The resident's ROM was intact and his neuro signs were within normal limits (WNL). The fall report lacked an analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall. On 05/11/21 at 12:20 PM, the resident sat in his wheelchair in the dining room eating lunch. The resident wore appropriate footwear and an anti-rollback break was in place to the back of his wheelchair. On 05/11/21 at 01:10 PM, the resident rested in bed. The fall floor mat was in place on the floor next to his bed. The bed was in the lowest position. On 05/12/21 at 01:33 PM, Licensed Nurse (LN) G stated, when a resident falls the nurse will complete an assessment. The nurse was to initiate a fall intervention immediately to prevent further falls. On 05/13/21 at 09:40 AM, Administrative Nurse D, stated it was his expectation that the nurse immediately initiate a fall intervention following each fall. The facility failed to initiate interventions following this dependent resident's two falls. The facility policy for Falls, last approved 12/2019, included: The documentation of the identified interventions should be maintained in the resident's clinical record. The facility failed to timely implement adequate interventions to prevent further falls for this dependent resident. - The Physician Order Sheet (POS), dated 04/07/21, documented Resident (R) 33 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. He required extensive assistance of two staff for bed mobility, transfers and toilet use. He had no falls since admission to the facility. The Falls Care Area Assessment (CAA), dated 03/22/21, documented the resident had not had any falls since admission to the facility and was at risk for falls due to an unsteady gait. Staff were to assist the resident with transfers and mobility. The Falls Care Plan, dated 03/15/21, instructed staff the resident was at risk for falls due to him being a recent admission to the facility. Staff were to keep his pathway clear, provide adequate lighting, and keep his bed at an appropriate height. Review of the resident's electronic medical record, revealed a fall assessment, dated 03/30/21, which placed the resident at a high risk for falls. Review of the facility's fall report, documented 03/23/21, included: The resident attempted to get up from his bed without assistance and was found on his back on the floor of his room. He had no injuries from the fall. The fall report lacked an analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall tp prevent further falls. Review of the facility's fall report, documented 03/30/21, included: Staff discovered the resident on the floor of the hallway. He had stood up from his wheelchair, lost his balance and fell to the floor. Staff were unable to reach him before he landed on the floor. He received no injuries from the fall. The fall report lacked an analysis for the fall. The staff did not initiate an immediate intervention following this non-injury fall to prevent further falls. On 05/11/21 at 11:49 AM, the resident sat in his wheelchair in the dining area. He wore appropriate shoes. On 05/12/21 at 09:39 AM, Certified Nurse Aide (CNA) PP, checked on the resident who was sleeping in his bed. The resident had a fall floor mat next to his bed and worse non-slip socks. On 05/12/21 at 01:33 PM, Licensed Nurse G stated, when a resident fell , the nurse will complete an assessment. The nurse was to initiate a fall intervention immediately to prevent further falls. On 05/13/21 at 09:40 AM, Administrative Nurse D, stated it was his expectation that the nurse immediately initiated a fall intervention following each fall. The facility failed to initiate interventions following this dependent resident's falls. The facility policy for Falls, last approved 12/2019, included: The documentation of the identified interventions should be maintained in the resident's clinical record. The facility failed to timely implement adequate interventions to prevent further falls for this dependent resident.

The facility reported a census of 72 residents. The sample of 23 residents included 4 reviewed for nutrition. Based on observation, interview, and record review, the staff failed to develop and implement timely interventions to prevent weight loss for two Residents (R) 2 and R15, and one R#9 for weight gain, of the 4 residents sampled for nutrition. Specifically R2, from 05/02/19 through 06/02/19, lost 17 pounds/11.89% in 1 month, (the 05/02/19, weight of 143 pounds, and the 06/02/19 weight of 126 pounds) and from 07/03/19 through 07/10/19, R2 lost eight pounds/6.2% in 8 days, (the 07/03/19 weight of 129 pounds, and the 07/10/19 weight of 121 pounds). Findings included: The facility reported a census of 72 residents. The sample of 23 residents included 4 reviewed for nutrition. Based on observation, interview, and record review, the staff failed to develop and implement timely interventions to prevent weight loss for two Residents (R) 2 and R15, and one R#9 for weight gain, of the 4 residents sampled for nutrition. Specifically R2, from 05/02/19 through 06/02/19, lost 17 pounds/11.89% in 1 month, (the 05/02/19, weight of 143 pounds, and the 06/02/19 weight of 126 pounds) and from 07/03/19 through 07/10/19, R2 lost eight pounds/6.2% in 8 days, (the 07/03/19 weight of 129 pounds, and the 07/10/19 weight of 121 pounds). Findings included: - Resident (R) 2's signed Physician order [REDACTED]. UTI (urinary tract infection). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident admitted [DATE], from an acute hospital with a BIMS (brief interview for mental status) score of seven indicating severe cognitive impairment. The resident lacked exhibited depression mood indicators or behaviors. The resident required the staff to set-up meals and provide supervision with eating. The resident had no functional limitation in range of motion ROM in the upper or lower extremities. R2's height of 62 inches and weight of 139 pounds (lbs.), did not indicate a weight gain or loss. R2 received a therapeutic mechanical altered diet. The resident had no natural teeth or tooth fragments. The resident received anti-anxiety and antidepressant medication for seven days of the look back period. The Quarterly MDS, dated [DATE], documented changes included BIMS score of five, indicating severe cognitive impairment. The resident had a depression indicator score of one related to feeling down, depressed or hopeless for two-six days of the look back period. The resident's weight of 129 documented the resident experienced a significant weight loss and was not on a physician prescribed weight loss regimen. The resident received antibiotics for four days of the look back period. The Nutrition Care Area assessment dated [DATE], documented the resident required set-up assistance with eating and supervision; received NAS (no added salt), mechanical soft diet, and consumed 51-75% of most meals. The resident's current weight was stable and revealed an increase in BMI (body mass index). She was edentulous (without natural teeth) and chose not to wear her dentures. The resident was without chewing or swallowing concerns. The staff would continue to monitor weights and intake per facility protocol or physician orders. The Care Plan for nutrition, initiated 05/31/17, instructed the staff: To record food intake at each meal. Offer appropriate substitutes for uneaten food. The resident comes out to the table for meals and feeds herself without difficulty. The resident received a NAS/Mechanical soft diet, The resident was edentulous. Monitor for tolerance to present diet and intervene as needed to maintain oral intake at meal time. Care plan updates for nutrition, dated 06/17/19, instructed the staff: Offer R2 super cereal (fortified hot cereal/extra calories) at breakfast, as tolerated. Add Benecal (caloric nutritional supplement) to R2's biscuit and gravy. Additionally, a care plan update, dated 06/18/19, instructed the staff to weigh the resident weekly. Review of R2's weight tracking revealed the following weights: On 02/06/19, weighed 140 lbs. On 05/02/19, weighed 143 lbs. (weights stable from 02/2019 through 5/2/19). On 06/02/19, weighed 126 lbs., R2 experienced a weight loss of 17 pounds/11.89% in one month. On 07/03/19, weighed 129 lbs. R2 experienced a weight gain of three lbs. On 07/10/19, weighed 121 lbs. R2 experienced a weight loss of eight pounds/6.2% in eight days. The physician orders, dated 08/02/19, documented the following orders related to nutrition: Ice cream shake, by mouth, every day for supplement, at 10:00 AM, with start date of 12/14/18. Supercereal at breakfast, by mouth, every day for supplement, ordered 06/19/19. [MEDICATION NAME] 7.5 kcal/ml (milliliter), oral liquid (caloric nutritional supplement), by mouth every day add to gravy, ordered 06/19/19 and discontinued on 08/02/19. Ensure plus (lactose-reduced food supplement), 0.05 gram 1.5 kcal/ml, oral liquid by mouth two times a day, ordered 07/10/19. Diet order- NAS, Mechanical Soft diet, Ensure BID, Benecaloric daily, Supercereal daily, ordered on, 07/29/19. [MEDICATION NAME] 7.5 kcal/ml oral liquid (caloric nutritional supplement), by mouth three times every day, ordered 08/02/19. Mechanical Soft Diet; low spice diet, ordered 08/02/19 Review of the R2's Medication Administration Records) (MAR), for (MONTH) 2019 and (MONTH) 2019, failed to reveal the percentage of Ensure R2 consumed. Review of the Dietary Notes and Risk Assessments revealed the documentation included: On 04/16/19 at 8:46 AM, the quarterly Nutrition Service Note and Nutrition Risk Assessment were completed and documentation revealed the resident would not be referred to the registered dietician. On 07/08/19 at 03:53 PM, the quarterly Nutrition Risk Assessment documentation included R2's diet order as NAS mechanical soft with no fluid restrictions. The resident feeds herself independently and consumes 51-75%. The resident had no swallowing problems with height of 62 inches and a weight of 129 lbs. (pounds). The resident's IBW (ideal body weight) was 110 lbs, with a usual body weight range of 99-121lbs. The resident's BMI (body mass index) of 23.9 and identified the resident had a significant weight loss. On 07/08/19 at 3:53 PM, the quarterly Nutrition Service Note and quarterly Nutrition Risk Assessment completed and documentation revealed the resident would not be referred to the registered dietician with, Will not refer to RD (registered dietitian) review. Review of Interdisciplinary Team Progress Notes dated 06/02/19 through 08/08/19, revealed the medical record lacked documentation of the resident's significant weight loss on 06/02/19 and 07/10/19, as noted above. On 08/06/19 at 06:01 PM, the resident fed herself 75%-100% of the meal, which consisted of ham, corn bread, broccoli cheese, potatoes, chopped meat, grape juice, and 1 bite of the lemon bar. She got up from the table and left the dining room independently. On 08/07/19 at 08:45 AM, R2 fed herself breakfast, which consisted of cream of wheat, (super cereal, 100%), banana slices (couple of bites), 1/2 glass of orange juice, water glass. The staff did not serve the resident the biscuits and gravy, and the resident explained she had what she wanted. On 08/08/19 at 04:59 PM, Certified Nursing Assistant (CNA) TT and Licensed Nurse (LN) J weighed the resident. R2's weight was 126 pounds. Both LN J and CNA TT verified the procedure for obtaining weights was accurate and that the resident did not appear to have lost weight in the last 3 months On 08/06/19 at 04:34 PM, the resident stated she liked sweets, but did not like greasy foods. She explained she did not like to eat a lot because she did not want to stretch her stomach. She reported her weight as around 100 lbs. most of her life. Additionally, R2 reported the facility gave her snacks when she wanted them. On 08/06/19 at 01:43 PM, CNA UU reported the individual needs and preferences of the residents communicated through the resident care guide/care plan. The MDS coordinator updated the resident care guides to reflect new interventions when changes in the resident's condition occur. Staff UU stated she was made aware of R2's weight loss, felt the weight loss was due to confusion, but did not see a difference in her weight over the past few months. She reported the interventions for the resident's weight loss included the staff provided the resident with ensure, as supplement; weigh R2 weekly; encourage her to eat more; and provide her with a lot of cueing and redirection when the resident gets up from the table. Staff UU stated the dietary staff document the meal intake, and the CMA (Certified Medication Aides) document in the MARs when they provide supplements to the resident but did not document percentage taken by the resident. On 08/06/19 at 04:56 PM, Dietary Aide (DA) FF reported the resident received a regular, mechanical soft diet, with ground meat. She stated R2's intake varied, some days really good, some days she ate 1/2 of her meal and she averaged a meal intake around 50-75%. Staff FF stated the resident usually eats from all the food groups and did not require assistive devices. The resident liked biscuits and gravy at breakfast and drank plenty of fluid. The staff also offered the resident snacks throughout the day. The resident could get snacks, at all of the time. On 08/07/19 at 10:45 AM, CNA (Certified Nursing Assistant) VV explained the individual needs and preferences of the residents were communicated through the resident care guide/care plan, and the nurse notified the CNAs of changes in the care plan. She reported R2 sometimes only picked at the food, and some days she eats it all. Staff VV stated the resident liked sweets, staff tried to get her to eat ice cream, and offered alternative when she leaves food on her plate. Staff VV reported the resident usually eats 85-100%, breakfast was her favorite meal, and she liked supercereal. The staff obtain monthly weights at a minimum and then weekly weight for residents identified to have a weight loss concern. She stated she was not aware of the resident's weight loss. On 08/07/19 at 12:47 PM, LN (Licensed Nurse) K reported the residents' needs and preferences were in the care plan. LN K was not aware of the resident's weight loss. The medication aides give the supplements. On review of the resident's medication record staff K verified the weight loss and orders as noted above. On 08/08/19 at 10:24 AM, CDM, (Certified Dietary Manager) CC confirmed the weight loss, physician orders, nutritional notes and assessments. She confirmed R2 should have been referred to the registered dietician for recommendations after the weight loss on 06/02/19 and 07/10/19; and the follow-up on the weight loss was not timely to prevent further weight loss. Additionally, CDM CC confirmed the care plan was not updated to reflect changes in the interventions to address weight loss and nutritional status for increase of Benecal to three times a day on 08/02/19 and diet order changed to Mechanical soft, no spice. On 08/08/19 at 2:13 PM, LN (Licensed Nurse) J stated he was not aware of the resident's significant weight loss that occurred on 06/02/19 and 07/10/19. The weight loss related to dementia, the resident wondered away from meals more frequently, and takes herself to the bathroom. The staff goes to her room and walk her back to the table. LN J verified the resident received supplements of ensure and benecal. The resident usually ate 78-80% of breakfasts and 50% of lunch. LN J described the resident as more anxious in the evenings over the last 6 weeks and with a decrease in her attention span. Staff J stated a significant weight loss should be reported to the nurse immediately, and an intervention should be implemented at the time of the notification. LN J was not aware of the weight loss that occurred on 06/02/19 or 07/10/19. He stated the facility protocol for weight loss was the weights were forwarded from the court/unit to the CDM, who then referred to the Dietician. The dietician sends recommendations to the nurses. The nurses implement the recommendations and send out the orders for signature. Staff J confirmed the weight loss triggered 07/29/19 and the RD (Registered Dietician) addressed the weight loss in the note of 08/07/19. On 08/08/19 at 04:41 PM, LN J called the physician's office and verified the clinical record lacked documentation of the physician being notified by the facility of the acute weight loss noted on 06/02/19 and 07/10/19. On 8/08/19 at 5:34 PM, Administrative Nurse D, confirmed the above findings; the facility failed to intervene for the resident's identified significant weight loss on 6/2/19 and 7/10/19 in a timely manner to prevent further weight loss. He stated the facility system to address weight loss lacked an immediate address of significant weight loss in a timely manner and was in need of revision On 8/12/19 at 9:48 AM, Administrative Nurse [NAME] verified R2 experienced a significant weight loss and the facility did not reassess the resident nutritional needs. He verified the weight loss for R2 as noted above and confirmed the medical record lacked notification of the physician of R2's weight loss. Staff [NAME] confirmed the physician should have been notified by the nurse, dietician, or kitchen manager, when the staff obtained the resident's weight, and not wait for a weight risk meeting to address a concern for a significant weight loss. The lack of the facility to address R2's weight loss represent a system failure to immediately notify the physician and intervene to prevent further weight loss. She verified the lack of reassessment before adding a supplement. Review of the resident's labs drawn on 06/12/19, revealed the protein and [MEDICATION NAME] levels as with in normal limits. Staff notified the RD of the weight loss on 06/13/19, 11 days after identification of the weight loss. The medical record lacked the % of the supplement consumed by the resident. On 08/12/19 at 11:15 AM, Consultant staff KK confirmed the resident's weight as stable between (MONTH) and (MONTH) of 2019. The weight loss on 06/02/19 and 07/10/19 represented a significant weight loss which should have been addressed by staff immediately. Staff KK reported the staff reviewed the resident's weights at the risk meeting on 06/12/19 and interventions were put in place on 06/13/19. Additionally, staff KK confirmed the physician had not been notified of the significant weight loss. The facility policy for Significant Weight Loss, dated 01/2019, documentation included . appropriate interventions shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. A report should be generated from the electronic medical record (EMR) system identifying all residents with a significant weight loss in 30 days, 90 days, and/or 180 days. The RD (Registered Dietician) should make recommendations for nutritional interventions based on the information obtained from the weekly Resident at Risk Review huddle meetings. The RD recommendations should be reviewed and initiated by nursing associates. A nursing or nutrition associate should notify the health care provider of any significant weight change that is unexplainable or in which the RD has requested a nutritional intervention. The policy lacked direction for the immediate address and physician notification of a significant weight loss to prevent further weight loss. The facility failed to implement timely interventions to prevent further weight loss for this cognitively impaired resident with significant weight loss from 05/02/19 through 06/02/19, lost 17 pounds/11.89% in 30 days/one month, and from 07/03/19 through 07/10/19, lost eight pounds/6.2% in 8 days for the resident. - Observation, on 08/06/19 at 12:25 PM, revealed Resident (R) 9 sat at the dining room table and looked at a plate of meat loaf, mashed potato's and gravy, carrots, hot roll with margarine, and peach crumble. At 12:28 PM, certified nurses aide (CNA) MM encouraged R9 to eat. She continued to sit and stare at her food. At 12:31 PM, CNA QQ encouraged R9 to eat and she started feeding herself slowly. At 12:35 PM, CNA QQ left the table to assist another R to eat, and R9 continued to feed herself. She ate approximately half of her mashed potato's and gravy, and then started to feed herself the dessertt. At 12:45 PM, she completed eating. R9 ate 1/2 of her potato's and gravy, her deserrt, and drank her fluids. Observation, on 08/06/19 at 05:31 PM, revealed the meal served was baked ham, baby bakers, broccoli with cheese sauce, corn bread with margarine, and lemon cheesecake bars. The spouse was beside R9 and had set-up the plate and was verbally encouraged her to feed herself. At 05:50 PM, she had fed herself all the potato's, and broccoli with cheese sauce, corn bread, and almost all of her ham. At 05:56 PM, she finished her meal, and ate 100%. Interview, on 08/05/19 at 8:30 AM, with R9's spouse stated she gained alot of weight and told the staff to stop the ensure and the ice cream. The spouse did not want her to gain a lot of weight. On 08/06/19 at 03:03 PM, CNA MM stated the care plans would inform her of R9's care. She was a two person assistance with a mechanical lift and staff propelled the wheelchair for her. Usually in the morning R9's spouse would feed her. At noon today R9 did not want to eat, with her dementia. CNA MM was not sure if the resident did not like the food or what but usually really ate good. On 08/07/19 at 10:00 AM, certified dietary manager (CDM) CC stated she was not sure if R9 was on a supplement now. R9 had been eating well, expecially breakfast and supper. On 08/07/19 at 02:59 PM, CNA OO stated R9 fed herself, and might require some cueing from the staff, but she eats very well. The staff would get her weight and document it in the KIOSK (electronic medical record) under the weight tracking, but the staff were unable to see the last previous weight put in the record, so the staff could not tell if she gained or lost weight. On 08/07/19 at 02:06 PM, licensed nurse (LN) H stated she remembed the order for the supplements but not when it was obtained. R9 ate well 51-75% of her meals. But after a while the spouse asked for the supplements to be stopped because R9 had gained to much weight. R9 was not sick, just the increase in the calories which caused her to gain weight. She was not sick medically during the time frame. The CNA's would obtain the weight and then they would put it in the computer. LN H stated she was not informed of any weight changes by the aides. On 08/07/19 at 04:00 PM, administrative nurse [NAME] stated that the facility certified dietary manager was responsible over the residents' weights. On 08/08/19 at 12:14 PM, Registered Dietician (RD) KK stated the weight loss was from a previous stay, so she advised the physician to increase R9's Ensure and add ice cream at supper. She was unaware the R9's spouse did not want her to gain a lot of weight. She reviewed the weights every month, and did not notice a significant weight gain in the last 6 months. On her Febraury 2019, spread sheet she identfied in 90 days a 10.6% weight gain and 30 days 9.95% weight gain. She would usually request R9 to be reweighed by the staff and it looked like she did not and she should have made the resident a weekly weght. Her expectation was the facility staff and herself should have identified the resident's weight gain sooner. On 08/08/19 at 04:16 PM, administravie nurse D stated his expectation with the resident's weight gain should have been identified in (MONTH) 2019, and possibly stopped the supplement and revised the care plan. Administrative nurse D would have thought CDM CC and the RD KK would have notified him and they could have stopped the supplement. He had never had this happen before. Review of the facility's policy titled, Significant Weight Loss/Gain, revised on 01/19, instructed that the facility would provide appropriate nutritional interventions to residents who have a significant weight change is identified as weight loss or gain of 5% in 30 days, or 10% in 180 days. A resident with a weight change of five pounds or greater should be reweighed to determine an accurate weight. The accurate weight should be entered in the resident's medical record. A report should be generated identifying all resident's with a significant weight change in 30 days, 180 days. At the weekly resident at risk review huddle, the IDT (interdiciplinary team) should discuss residents who triggered for a significant weight loss and who lose more than 5 pounds since the last weight. The RD should make recommendations for nutritional interventions. The facility failed to monitor and identify timely the interventions to address R9's significant weight gain from 01/06/19 to 02/06/19, when she weighed 160 pounds, a weight gain of 15 pounds or 10.42 % in 35 days. From 02/06/19 through 03/06/19, R9 weighed 172 pounds, a weight gain of 12 pounds or a 7.5% weight gain in 38 days, or an overal weight gain of 30 pounds, or 18.86 % of weight in 58 days. - Resident (R) 15's, signed Physician order [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], revealed R15 had a BIMS (brief interview for mental status) score of five, indicating severely impaired cognition. R15 required supervision for eating. The R15 without swallowing or dental issues and weighed 143 pounds. Review of the Nutrition Care Area Assessment (CAA), dated 02/20/19, advised nutrition did not trigger for further investigation. The Quarterly MDS, dated [DATE], revealed the no changes from the Admission MDS dated [DATE]. Review of the Nutrition Care Plan, found in R15's electronic medical record (EMR), reviewed on 05/21/19, advised she would have nutritional needs met, and would not have an unplanned significant weight change over the next review period. Interventions included offer R15 the diet as prescribed, snacks daily, offer a minimum of 480 cc (cubic centimeters) of fluids daily, weigh weekly/monthly, monitor meal intake daily, she received a regular diet, and she may not eat her evening meal during supper time. Please offer her meal later in the evening after everyone had left the dining room if she did not eat during supper. Review of her EMR Physician Orders, found under attachments, advised the physician ordered on [DATE], weekly weights. On 02/15/19, the physician ordered a regular diet. Review of a Nutrition Risk Assessment found in R15's EMR under assessments, dated 2/14/19, advised the she received a regular diet, fed herself, had a good appetite, and her meal intake ranged from 51-75%. She had missing/broken/edentulous, and without difficulty swallowing. R15 weighed 141 pounds, a body mass index of (BMI) of 24.1, within normal limits (normal BMI range was 18.5 to 24.5), required 1625 calories per day, 65 Gm (grams) of protein a day, and 1625 cc of fluids a day. She had a good appetite with a regular diet and the regular diet was appropriate and would continue with the diet, monthly weights, and meal intake. Review of the weights, found in R15's EMR, located under weight tracking identified on 07/01/19, R15 weighed 145 pounds. On 07/15/19, R15 weighed 140 pounds. On 07/22/19, R15 weighed 143 pounds. On 07/29/19, R15 weighed 136 pounds. On 08/05/19, R15 weighed137 pounds. R15 with a weight loss of 8 pounds, or 5.52% weight loss. The meal intake documentation found under P[NAME] (point of care) in the EMR, from 07/01/19 through 08/01/19, identified R15's meal intake for breakfast ranged from 76-100%; for lunch 76%; and for dinner the resident with an intake 51-75%. The At Risk Review, located in the EMR, found under assessments of R15, dated 07/17/19, identified she weighed 140 pounds, on this day, and received a regular diet. Continue to monitor weights and to re-evaluate. R15 eats after everyone else leaves the room. R15's Nutritional assessment dated [DATE], located in the EMR, found under assessments advised the physician ordered a regular diet, and fed herself independently. Her meal intake was 51-75%, and food preferences obtained. R15 with broken/missing/edentulous teeth, and without swallowing issues. She weighed 136 pounds, ideal body weight (IBW) was 120 pounds, IBW range was 108-132 pounds, with a BMI of 23.3. R15 with a significant weight loss in the last six months. Review of R15's dietary meal card on 08/06/19, identified the resident was to receive a regular diet and a beverage. Review of the Dietitian/Physician faxed Communication, dated 08/07/19, found in R15's EMR under Assessment section documented the physician notified of a significant weight loss of 5.4% in 30 days, and a 11% for 90 days. Recommended offering her Ensure Plus BID (twice a day) and Thrive every day for added calories and protein and continue with a regular diet. The physician agreed with the recommendation. Observation on 08/06/19 at 12:25 PM, R15 sat at the dining room table with a hamburger, seasoned carrots, mashed potato and gravy, and dessert. At 12:43 PM, she had completed her hamburger, dessert, and was able to feed herself. At 12:57 PM, she stood up from the table and ambulated to her room. R15 did not eat anymore, and staff did not encourage the resident to eat. On 08/06/19 at 05:25 PM, the meal served included baked ham, baby bakers, broccoli with cheese sauce, corn bread, margarine, and lemon cheesecake bars. At 05:46 PM, she sat in her room was not served dinner. R15 with numerous packages cheese and crackers in her room. When asked if she liked those crackers the she responded those were not her crackers. At 05:52 PM, administrative staff C, took R15 her dinner tray and tried to encourage her to eat the meal, however the she stated it was time for breakfast and she would take coffee and toast. At 05:58 PM, R15 was served toast and coffee. Interview on 08/06/19 at 03:03 PM, Certifeid nurses aide (CNA) MM stated she feds herself, and was not aware of her with weight loss. She does not always come out of her room for meals, however if she does come out of her room, she would usually eat almost all of the meal. If she stayed in her room she would only eat half of her meal. CNA MM stated she would obtain aweight and place it in the computer. On 08/06/19 at 05:36 PM, CNA RR stated R15 refused to come out for dinner, so CNA RR would ask her again and if she does not come out she would take her a tray. She does this a lot in the evening because her dementia, and did not always eat a lot. R15 offered snacks, and she would eat them. On 08/06/19 at 06:05 PM, Dietary Cook EE stated she could always count on R15 to eat a hamburger or toast for meals. On 08/07/19 at 10:42 AM, Certified dietary manager CC (CDM) verified she reviewed the weights and would notify the appropriate staff of any weight loss. She was not aware of R15 with a 5.52% weight loss in 30 days. On 08/07/19 at 02:06 PM, Licensed Nurse (LN) H stated R15 ate 100% of meals when she was at the table. Once in awhile she would not come out for supper and then she would say it was to late to eat and go to bed. They were able to get her to eat something when that happens. LN H reviewed R15's weights and stated she was not loosing weight, and the her weight fluctuated, just a couple of pounds here and there, and she does not retain fluids. R15 does not recieve supplements she could see. R15 could make her wants and needs known of what she wanted to eat. During the interview, LN H received orders from the physician at 2:38 PM, and the physician ordered Ensure and Thrive daily for weight loss. On 08/07/19 at 04:00 PM, Administrative nurse F verified the facility was not aware of R15 with 5.52% weight loss or 8 pounds in 30 days. She reported the physician was notified of the resident's weight loss, and received an order for [REDACTED]. On 08/08/19 at12:38 PM, Register Dietician (RD) KK reported she was just the consultant and was in the build monthly. CDM CC would send her a weight spread sheet weekly and she monitored the meal intakes. If there was a five pound weight change in a week, then the resident would be discussed during the at risk meeting, on Thursdays at 01:00 PM. Whenever she printed off the weights for the month they may not alway be completed. The facility weights need to be completed by the 7th, and any reweighs completed by the 10th. RD KK noticed the R15 was reweighed at 138 pounds. CDM CC sent the report out this morning and she reviewed the report and sends out the recommendations to the phsyician which she did. CDM KK sends the monthly weights out between the 7th and the 10th of each month. On 08/08/19 at 03:34 PM, administrative nurse D stated the facility would weigh the residents at least monthly, and as ordered by the physician. He looks at weight with a loss of 5% in 30 days and 10% in six months. The facility meets monthly to review weights in QA (quality assurance meeting). Residents at risk meetins are held weekly, every Thursday, and would review the residents with weight loss, from the report he received from CDM CC. Then Licesed Nurse YY sets up the list of residents for the risk meeting and sends it out to everybody. This is when he would review the weights. If R15 was on a monthly weight protocol, then he would hold a monthly meeting, if the resident was a weekly weight, then he would review the weights weekly when the CDM CC brought them to him. The physician would decide which resident should be on weights weekly/monthly and the physician would go by the RD KK's recommendation. Administrative staff D stated he expected to be notified of a resident with any weight loss, and the physician should be notified to obtain nutritional orders if the physician wants. Review of the facility's policy titled, Significant Weight Loss/Gain, revised on 01/19, advised the facility would provide appropriate nutritional interventions to residents who have a significant weight change is identified as weight loss or gain of 5% in 30 days, or 10% in 180 days. A resident with a weight change of five pounds or greater should be reweighed to determine an accurate weight. The accurate weight should be entered in the resident's medical record. A report should be generated identifying all residents with a significant weight change in 30 days, 180 days. At the weekly resident at risk review huddle, the IDT (interdisciplinary team) should discuss residents who triggered for a significant weight loss and who lose more than five pounds since the last weight. The RD should make recommendations for nutritional interventions. The facility failed to monitor and implement timely effective interventions to address this R15's who had a 5.52% weight loss in 35 days, with a loss of 8 pounds from 07/01/19 (145 pounds) through 08/05/19 (137 pounds). (TRUNCATED)

The facility reported a census of 73 residents. The sample of 3 residents included all reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure, 1 of the 3 sampled residents, (#01) wore the planned non-slip socks in bed, to prevent further falls, when the resident got out of the bed, fell and sustained a fractured elbow. Findings included: - The medical record evidenced the facility admitted resident #01 on 12/30/17. The physician documented [DIAGNOSES REDACTED]. The annual MDS (minimum data set) assessment, dated 11/8/18, identified the resident with severe cognitive impairment with a BIMS (brief interview for mental status) score of 3/15. The resident required limited assistance of one staff for transfers, locomotion and toileting. The resident's balance was not stable but could stabilize him/herself, used a walker for mobility with independent walking and had no falls since the prior assessment. The CAAs (care area assessments), dated 11/8/18, for cognition and falls, instructed the staff to refer to observations and the interview process. The Quarterly MDS, dated [DATE], revealed the only changes since 11/8/18, included the resident experienced 1 fall since the prior assessment without any injury. The care plan, dated 12/16/17, included, instructions to the staff to make sure the resident had non-skid socks on while in bed and when getting up, make sure the resident had shoes on before getting out of bed or out of a chair. The facility investigation, dated 2/11/19 at 10:00 P.M., revealed direct care staff C assisted the resident with getting ready for bed, with the TV off. At 10:15 P.M., direct care staff D heard a noise and found the resident on his/her back on the floor. Staff noted the TV now turned on. At that time, direct care staff D reported the resident did not have on the slipper socks or non-skid footwear, at the time of the fall. The resident sustained [REDACTED]. Staff called the EMS (emergency medical service). At 10:45 P.M., the resident left the facility for transport to the local ER (emergency room ) for evaluation. The resident returned to the facility with family, on 2/12/19 at 1:50 A.M., with [DIAGNOSES REDACTED]. Instructions also included to follow-up with his/her primary care physician and an orthopedic surgeon. The resident's x-ray report, dated 2/12/19, a CT (computerized tomography) results were negative for fractures except for a left nondisplaced fracture at the proximal ulna (elbow) with diffuse bony demineralization. On 2/27/19 at 1:20 P.M., observation revealed the resident seated at a dining room chair with a sling on the left upper extremity. While feeding himself/herself with the right hand. The resident smiled and commented that he/she was left handed, so this was new for him/her (eating with his/her right hand). On 2/28/19 at 3:00 PM, licensed nurse F verified the resident's care plan included the intervention for staff to ensure the resident had non-skid socks on in bed, and that the staff failed to ensure they were on the resident, on the night of the fall on 1/30/19. The facility's policy, dated 1/18, for falls, included; The documentation of the identified interventions should be maintained in the resident's clinical record and available to the direct care staff. The facility failed to ensure the resident had non-skid socks on his/her feet, a safety precaution as care planned, to prevent falls, when staff assisted the resident to bed. The resident got out of the bed and fell . The resident sustained [REDACTED].

The facility reported a census of 72 residents, with 3 residents selected for review of accidents. Based on observation, interview and record review, the facility failed to provide a safe transfer for 1 of the 3 sampled residents, (#1). The resident's affected left leg/foot bent back under the chair as the staff lowered the resident into the chair. The resident experienced a [MEDICAL CONDITION] during this transfer. Findings included: - The electronic medical record evidenced the facility admitted resident #01 on 4/9/16. The physician listed [MEDICAL CONDITION] (paralysis characterized by motor or sensory loss in the lower limbs and trunk), muscle weakness and left knee contracture, as [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 2/2/18 and the quarterly MDS, dated [DATE], documented the resident with cognitive impairment. He/she required extensive assistance for bed mobility, toilet use and dressing. The resident was total dependent in need of 2 staff for transfers. The CAA (care area assessment), dated 2/2/18, for activity of daily living included the need for assistance with his/her ADLs (activities of daily living). The resident had poor balance, required extensive assistance from staff to stabilize and was at risk for falls. He/she needed extensive assist from 2 staff with bed mobility, transfers, dressing and toileting. The care plan, dated 8/10/17, instructed the resident required limited to extensive assistance with daily ADLs related to [MEDICAL CONDITION]. The resident required extensive assistance of 2 staff with transfers using arm/leg cradle technique, do to his/her choice not to utilize the hoyer (mechanical) lift and gait belt. The non-weight bearing resident was at risk for falls due to poor balance and the need for total assist with transfers. A progress note, dated 8/20/18 at approximately 11:00 A.M., documented following a shower, 2 staff members dressed the resident's upper body. Then while 1 staff member held the resident up, (hugging around resident from the front), the other staff member, pulled up the resident's slacks. The aide continued and put the resident's wheelchair up behind the resident to sit. During this dressing/transfer from the shower chair into the wheelchair, the resident's foot become trapped under the wheelchair. As the 1 staff member, holding/transferring the resident, lowered the resident into the wheelchair, both staff members heard a pop. The 2 staff then placed the resident from the wheelchair into his/her bed, and the resident complained of pain in his/her left groin with flexion of the left leg. Licensed nursing staff C assessed the resident and noted swelling to the left hip/groin/upper thigh areas. Staff notified the physician's assistant and received orders for a mobile x-ray, of the abdomen and left hip. Later, on 8/20/18, the mobile x-ray unit notified the facility the resident's X-ray revealed a left [MEDICAL CONDITION]. On 8/29/18 at 9:10 A.M., licensed nursing staff B explained that licensed nursing staff C, did notify the primary care physician of the [MEDICAL CONDITION] report, on 8/20/18. The physician returned a call to the facility and reported the resident was not a surgical candidate, therefore there was no need for an orthopedic referral. Observation, on 8/29/18 at 8:30 A.M., revealed the resident resting on his/her back. At 9:00 A.M., the resident shifted himself/herself with a bed trapeze. At 12:50 P.M. certified staff D and F provided indwelling catheter care, preventative skin care and repositioned the resident. The resident's skin displayed any discoloration or swelling in left hip area. The resident had no complaint of pain. On 8/29/18 at 9:00 A.M., certified nursing staff D reported, he/she went into the spa to assist certified staff E transfer the resident from the shower. Certified nursing staff D reported he/she faced the resident, wrapped both arms around the resident's upper torso and lifted the resident up to allow certified staff E to pull up the resident's slacks. As staff D turned to put the resident into the wheelchair he/she asked staff E if the resident's feet were ok and heard an answer of yes. When staff D sat the resident down there was a pop. Staff E reported the resident's feet were bent under the w/c and the w/c had to be backed up to get the resident's feet from under the wheelchair. Licensed nurse C, on 8/29/18 at 12:10 P.M., reported she assessed the resident following the incident and the resident complained of left groin pain. The staff called the physician and he/she ordered x-rays. On 8/30/18 at 2:40 A.M., certified staff E reported he/she had worked the day shift and bathed resident #01 a couple of times. After the resident's bath, he/she would put the resident back to bed with another nursing staff member, using the cradle method of transfer. On 8/20/18 he/she had given the resident a shower and dried the resident, then called for assistance. This time the plan included dress the resident and place him/her into a wheelchair. She reported certified staff D lifted the resident and he/she pulled up the slacks. When he/she went to push the wheelchair under the resident she accidentally pushed the chair over the other staff members foot. Staff E thought staff D was talking about his/her own foot when he/she asked if the foot was ok and staff E answered yes. Staff D then lowered the resident into the wheelchair and his/her foot was caught and they heard the pop sound. On 8/29/18 at 1:45 P.M., licensed nursing staff G provided a copy of the facility's safe lifting and moving of patient policy, dated 12/2017. At that time staff G stated, I could not find anything to that specific condition. The policy did include manual lifting of residents shall be eliminated when feasible. Nursing associates shall access individual residents' needs for transfer assistance on an ongoing basis. Such assessments shall include resident's preferences for assistance. The facility failed to provide a safe transfer for this paraplegic resident, when staff failed to control the resident's affected left leg/foot, which went back under the chair, which resulted in the resident experiencing a [MEDICAL CONDITION].

The facility reported a census of 81 residents, with 3 residents sampled and reviewed for medications. Based on observation, interview, and record review, the facility failed to administer [MEDICATION NAME] (diuretic- water pill) 40 milligrams, daily, as ordered by the physician, to 1 (#02) of the 3 sampled residents, for 3 consecutive days. The staff sent the resident to the emergency room , when the resident experienced increased [MEDICAL CONDITION] (swelling), shortness of breath and tightened chest. The resident received intravenous [MEDICATION NAME] in the emergency room . Findings included: - Resident #02's electronic medical record documented, the resident admitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set) assessment, dated 4/19/18 included a BIMS (brief interview for mental status) score of 15, indicating intact cognition. The plan of care, dated 1/20/18 instructed the staff the resident had a potential for fluid imbalance related to [MEDICAL CONDITIONS]. The staff were to monitor the resident for new or increased [MEDICAL CONDITION] (swelling- fluid build-up) and notify the physician. The staff were also instructed to administer the resident's medications per the physician's orders [REDACTED]. A physician's orders [REDACTED]. ADHF is a common and potentially serious cause of acute respiratory (breathing) distress). Review of the current May, (YEAR), MAR (medication administration record), revealed it contained the physician's orders [REDACTED]. However, the dates for 5/23/18, 5/24/18 and 5/25/18, were left blank without explanation as to why the staff failed to administer the medication as ordered daily, for 3 consecutive days. Nurses notes, dated 5/25/18, at 4:50 P.M., revealed the resident reported experiencing chest tightness and indigestion. Licensed nursing staff C notified the primary care physician and received orders to send the resident to the ER (emergency room ) for evaluation. A family member transported the resident to the ER for the evaluation. The resident returned to the facility on [DATE] at 10:00 P.M., with a [DIAGNOSES REDACTED]. On 5/30/18 at 2:40 P.M., the ER personal, explained the ER staff administered intravenous (into the vein) [MEDICATION NAME], 40 mg. (milligrams), while the resident was in the ER. The ER physician returned the resident to the facility with orders including; Increase [MEDICATION NAME], to 80 mg., daily for 3 days then resume the normal dose of [MEDICATION NAME], 40 mg, daily. Also give KCL (potassium supplement to prevent [DIAGNOSES REDACTED] during diuretic therapy), 20 meq. (milliequivalents), by mouth, daily, for 4 days. The facility instructions also included physician order [REDACTED]. Nurses notes, on 5/25/18, documented upon the resident's return to the facility, the nurse documented the resident's oxygen saturation level was low at 63% on room air (acceptable oxygen saturation is 90 % or above). The nurse also documented the resident had right sided facial and hand swelling, which the resident's family member pointed out to the nurse. On 5/30/18 at 5:25 P.M., licensed nurse D, explained, upon the resident's hospital return on 5/25/18, he/she put the new physician's orders [REDACTED]. At that time, staff D noted the [MEDICATION NAME], 40 mg, daily by mouth, physician order, dated 1/12/18. Staff D further explained the medication staff failed to administer the [MEDICATION NAME] medication as ordered, on 5/23, 5/24, and 5/25/18 as ordered. Further interviews on 5/30/18 at 10:30 A.M., with licensed nurse E revealed medication aides F and G, failed to report the lack of [MEDICATION NAME] medication available in the medication cart, as well as the staff failure to administer the medication. Nurse E reported the staff failed to reorder the [MEDICATION NAME] medication. Observation, on 5/30/18 at 11:00 A.M., verified the resident walked well with family by his/her side. At that time, a family member he/she notified the facility they wanted the resident's medications purchased from a local pharmacy from now on. On 5/30/18 at 2:10 P.M., licensed nurse B explained the facility staff weighed the resident monthly prior to the incident with the missed [MEDICATION NAME] doses. The last previous weight, on 5/9/18, was 134.4 pounds. He/she verified the facility staff failed to obtain another weight on the resident until 5/30/18 (today- 5 days after the ER visit return), and obtained a weight of 135 pounds. The facility failed to administer the resident's [MEDICATION NAME] medication daily for 3 consecutive days, as ordered by the physician. The resident experienced [MEDICAL CONDITION] exacerbation, was sent to the ER, where he/she received intravenous [MEDICATION NAME] for treatment of [REDACTED].

The facility reported a census of 75 residents with 23 residents identified as full codes (to start CPR (cardio-pulmonary resuscitation) if their heart stops). Based on interview and record review, the facility failed to initiate CPR to one resident without a DNR (do not resuscitate) order when his/her heart stopped. The facility failed to know or have documentation of the resident's or family wishes related to the resident's advanced directives, and the resident died . This placed the resident in immediate jeopardy. (#01) Findings included: - The facility admitted resident #01 on [DATE]. The MDS (minimum data set) assessment, partially completed on [DATE], indicated the resident demonstrated severe cognitive impairment. On [DATE] at 6:00 A.M., the resident transferred and admitted to the hospital with [REDACTED]. He/she remained in the hospital on IV (intravenous) antibiotics until [DATE]. The facility readmitted the resident on [DATE]. Staff assessment indicated the resident required total assistance for activities of daily living. The clinical record failed to contain instructions on advance directive/code status upon the resident's return. Nurses notes, on [DATE], at 7:30 P.M., revealed licensed nursing staff C administered the resident's feeding per gastric tube (tube inserted through the abdominal wall into the stomach, used for providing nutritional feedings) as ordered. At that time, he/she noted the resident with short periods of apnea (temporary absence of breathing) with some snoring respirations. Staff administered oxygen at 4 L/NC (liters/nasal cannula) to the resident with his/her head elevated 45 degrees. On [DATE] at 1:10 P.M., licensed nurse C acknowledged working at the time of the resident's death. Staff C explained he/she suctioned the resident's mouth and throat on [DATE] at 7:15 P.M. Following the suctioning he/she proceeded to another facility unit to administer medications to residents. At 9:30 P.M. nurse C reported he/she checked on the resident, with direct care staff D, by phone who reported the resident coughed a few times but remained with the head of the bed elevated. At 10:30 P.M., direct care staff D reported to licensed nurse C that he/she entered the resident's room and noted the resident not breathing. Nurse C explained he/she entered the resident's room and noted the resident without respirations or heart rate. Nurse C explained he/she only worked with this resident for 2 days and was unaware of his/her advance directives (code status). The licensed nurse confirmed due to the appearance of the resident's skin color, and the fact that the resident had not been observed for 35 minutes, that the time of death could not be determined, therefore, staff did not initiate CPR (cardiopulmonary resuscitation). Review of nurse C's personal file, revealed a CPR basic life support certificate current until ,[DATE]. review of the resident's medical record revealed [REDACTED]. On [DATE] at 3:00 P.M., social service staff E explained that the intake person should have obtained and documented the advance directive for a full code or DNR, (do not resuscitate) on the face sheet of the resident's medical record, at the time of admission/readmission. The resident's hospital history summary record, from [DATE] to [DATE], revealed the resident without a DNR order and that apparently the family wanted everything done for him/her, as according to the patient. On [DATE] at 4:45 P.M., administrative staff A explained prior to this incident the residents' code status was on the medical records face sheets, and at times on the report sheets, but that depended on which unit, as they were different. The facility policy, dated 2017 included, if an individual resident, visitor or staff member is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: 1). If it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis). 2). If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physician's orders [REDACTED]. The facility failed to have a system in place at admission/readmission to ensure the resident's wishes for advance directives (DNR) were in place. Furthermore, the facility failed to perform CPR on the resident who lacked a DNR status. This placed the 23 residents with advanced directives for initiation of CPR in immediate jeopardy. This immediate jeopardy was abated on [DATE] at 4:58 P.M., (12 days later) when: 1.) Current resident records were reviewed on [DATE], by the director of nursing and again on [DATE], by the licensed social worker, for accuracy of each residents' advanced directives. 2.) Doors to the residents' rooms, by each residents' name, were marked red or green per magnets, to signify DNR or full code status, as of [DATE] by the director of nursing. 3.) Education of all staff started on [DATE] and ended on [DATE] at 4:58 P.M., and included the policy for CPR. The education also included how to identify the residents' code status with the red/green magnets on the doors by the residents' names. The colored magnets corresponded with the residents advance directives stipulated on their medical records. 4.) On [DATE] and completed on [DATE] at 4:58 P.M., the facility nurses completed education on code status and advance directives guidelines. Nursing associates unable to complete the re-education by [DATE], will be provided the in-service prior to returning to the next scheduled shift. Advance directives will be maintained on the computer face sheets and court report sheets. During the admission or readmission process, advance directives will be reviewed for code status. Those found without advanced directives or code status will be documented as full code until the status can be determined. 5.) Newly hired staff will be in-serviced during orientation on the CPR policy and procedures, prior to providing direct resident care. 6.) The director of nursing and social services/ or designees, will review quarterly all of the residents' advanced directives/code status for accuracy. 7.) Findings will be reviewed by the interdisciplinary team during QAPI for 90 days or until substantial compliance is achieved. This deficient practice remained at a scope and severity of an E.

The facility reported a census of 38 residents. The sample included 11 residents, including 3 reviewed for nutrition. Based on observation, record review, and interview, the facility failed to monitor 2 (#127 & #50) of 3 residents reviewed, for significant weight loss and lacked timely physician notification of weight loss. Resident #127, lost 12 pounds/8.51% in 11 days and 14.18% in 20 days after admission to the facility. Resident #50 lost 21 pounds or 15 % in approximately 90 days. Findings included: - Resident #127's signed physician orders, dated 1/12/17, documented the resident admitted on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 9/26/16, revealed the resident had a BIMS (brief interview for mental status) score of 9, indicating moderately impaired cognition. The resident required supervision with eating and set up assistance. The resident without swallowing issues, weighed 141 pounds, or dental concerns. The resident received antidepressant and antibiotic medication. Weight loss was not documented because at the time of the MDS completed the facility had not obtained the residen'ts weight. The CAA (care area assessment), dated 9/30/16 for ADL's (activities of daily living), failed to address the resident's eating ability. The CAA for nutrition did not trigger. The significant change MDS, dated [DATE], revealed the following changes only from the 9/26/16 MDS: the resident had a BIMS score of 14, indicating intact cognition. The resident required limited staff assistance for transfers, and ambulation. The resident weighed 141 pounds, without swallowing concerns, with a feeding tube, and received over 51% intake and an average fluid intake per day of 501 cc (cubic centimeters)/day. The resident received antibiotic medication. The CAA (care area assessment), for ADL's dated 12/13/16, documented the resident ambulated with a front wheeled walker with staff assistance. The CAA for a feeding tube, documented the resident recently had a PEG tube placed and continued to have proper oral intake at meal times. Staff would monitor the residents weight weekly. The admission care plan, dated 9/23/16, documented the resident would gain weight or maintain his/her weight. The resident received a regular diet, was able to feed himself/herself, and for meals, required staff assistance for set up. The resident was to receive Ensure (a high calorie supplement) if he/she ate less than 50% (percent) of his/her meal. The resident exhibited appetite and ate 51-75% of meals. At each meal, the staff were to record the percentage the resident ate. The staff were to offer appropriate substitutes for uneaten food. The staff weighed the resident weekly and/or monthly. The residents IBW (ideal body weight) was 160 pounds, with an IBW range of 144-176 pounds. The residents admission weight was 141 pounds. Staff reviewed and updated the care plan on the following dates, (after the significant weight loss noted on 10/6/16) with new interventions On 10/13/16, the resident was to receive Ensure Plus with meals daily, and encourage fluids. On 10/16/16, Speech therapy (ST), recommended the resident to receive nectar thickened liquids. On 10/26/16, dietary initiated the Yellow flag program (a high calorie and high protein supplements and food to gain weight) for the monitoring of the residents weight and adding additional protein and calories to the diet. On 10/26/16, the resident was to eat all meals sitting in an upright position, in a standard chair with supervision. The resident required thickened liquids due to aspiration ([MEDICAL CONDITION] condition of the lungs caused by inhaling foreign material or vomit) On 11/14/16, the resident required honey thickened liquids, small bites and sips only, and no straws. The resident was to clear his/her throat following each swallowing, with a subsequent dry second swallow. The resident was to be upright and alert for all oral intake. The significant change MDS, dated [DATE], revealed the following changes only from the 9/26/16 MDS: the resident had a BIMS score of 14, indicating intact cognition. The resident required limited staff assistance for transfers, and ambulation. The resident weighed 141 pounds, without swallowing concerns, with a feeding tube, and received over 51% intake and an average fluid intake per day of 501 cc (cubic centimeters)/day. The resident received antibiotic medication. The CAA (care area assessment), for ADL's dated 12/13/16, documented the resident ambulated with a front wheeled walker with staff assistance. The CAA for a feeding tube, documented the resident recently had a PEG tube placed and continued to have proper oral intake at meal times. Will monitor the residents weight weekly. The physician orders, dated 9/21/16, documented the physician ordered on [DATE], the resident to was receive a regular diet. The resident's clinical note, identified an admission weight of 141 pounds on 9/19/16. The resident's electronic clinical record identified the resident's weight on 9/30/16, as 129 pounds. The resident had a 12 pound weight loss in 9 days or 8.5% significant weight loss. The resident's medical record lacked documentation of a reweigh, or notification of the physician for further instruction. The clinical record identified the resident weighed 121 pounds on 10/6/16, an additional 8 pound weight loss, or a 6.2% weight loss in 6 days. This was a total of 20 pounds in 15 days (14.184% in 15 days). The residents medical record lacked documentation the staff reweighed the resident. On 11/1/16, the resident weighed 121 pounds. Review of the admission nutrition services progress note, dated 9/23/16, documented the resident's appetite was good. The resident received a regular diet, without food allergies [REDACTED]. The resident ate approximately 51-75% of meals and the resident's weight was below IBW range. Additional comments included the staff to provide alternates for food dislikes, and offer a supplement when the resident consumed 50% or less of the meal. Snacks and supplements were available as needed, and refer to the RD (registered dietitian) for evaluation. The resident's electronic clinical record, identified an [MEDICATION NAME] level on 9/26/16, 2.3 units of measure, which was low. The normal range was 3.7 to 4.8. The resident's Protein level was 6.9 units of measure, normal. On 10/6/16, the facility sent a multidisciplinary screening to the physician, informing him/her the resident had weight loss and about the change in his/her oral intake. Furthermore, the staff requested a ST (speech therapy) evaluation for the resident's episodes of coughing frequently on fluids and the resident's weight loss. The screening failed to inform the physician of the resident's 20 pound weight loss in 15 days. The physician returned signed screening on 10/12/16, for ST, 6 days later. A progress note, dated 10/13/16, documented the resident vomited after ST completed his/her evaluation. Staff notified the PA (physician assistant) and obtained orders as follows: 1.) [MEDICATION NAME], (nausea), 4 mg )milligrams), by mouth every 8 hours as needed for nausea/vomiting. 2.) Ensure Plus with every meal for weight loss 3.) Encourage fluids. The clinical record still lacked evidence the facility staff notified the physician of the 20 pound (significant weight loss) of the resident. The new admission nutrition assessment by the consultant staff R, dated 10/26/16, documented the resident weighed 121 pounds, IBW of 160 pounds; IBW range 144-176 pounds; and weighed 76% of IBW. The resident had dysphagia, with ST (speech following). The resident received a regular diet, nectar thickened liquids, and Ensure Plus three times a day. The resident had a weight change from 141 pounds on admission, with a weight loss of 20 pounds. According to the assessment the resident needed 1655 calories per day; 66 grams of protein a day, and fluid needs of 1655 cc (cubic centimeters)/day. Assessment: The residents weight is below the IBW range and had a weight loss since admission. Staff R questioned the weight accuracy. The residents appetite appears varied, based on 25-75% of meals documented. The resident wanted to stay in his/her room and eat meals. The ST changed the liquid consistency and a supplement was being given. Recommendations: yellow flag program, offer a super donut or a super cookie twice a day due to weight loss, and varied oral intake. May want to consider [MEDICATION NAME] (antidepressant) for appetite stimulation. The staff to obtain weekly weights and daily meal intake. On 10/26/16, the facility sent the Dietitian/Physician Faxed Communication form, dated 10/26/16, to the physician and documented staff R's recommendations from the 10/26/16 nutrition assessments, along with the information the resident weighed 121 pounds, and had a 20 pound weight loss since admission. (The first time the staff notified the physician of the weight loss) On 10/30/16, received the physician signed Dietitian/Physician faxed communication form, dated 10/26/16, and new orders say OK as above. The order for the [MEDICATION NAME], required clarification. Review of the residents meal intake in September 2016, identified the resident ate approximately 50-75% of meals. Staff offered the resident substitutes and he/she consumed the substitutes sporadically, approximately 25-75% of the times served. The meal intake record for October 2016, identified the resident basically ate 50-75% and consumed substitutes sporadically, with intake approximately 25-50%. The November 2016, meal intake record identified the resident's meal intake started to improve and the resident averaged 75-100%, and did not require a substitute. The September 2016, MAR (medication administration record) revealed the resident without ordered supplements at that time. The October 2016 MAR, revealed the resident received Ensure Plus on 10/13/16, after meals. On 10/30/16, the Yellow Flag program initiated, to offer super donut or super cookie twice daily for weight loss and varied oral intake. The November 2016 MAR indicated [REDACTED]. The resident weight, on 11/1/16, was 121 pounds. On 3/2/17 at 8:33 AM, administrative staff Q, stated the resident had a little bit of a weight loss. The resident was on the yellow flag program to fortify the food, and ate super donuts. When a resident was admitted , the resident should be weighed weekly for the first month, and then if there was not a weight issue, monthly. If a resident is on the yellow flag program, the resident should be weighed weekly. Each court has a weight book, where the staff track the residents weights. Staff Q stated he/she had a program which would calculate the residents percentage of weight loss. If the resident had a 4 pound weight loss or gain, then he/she would give administrative staff D the names of the residents to be reweighed by the end of the day. Staff Q was not sure if the nursing staff documented the reweighs in the Kiosk (CNA (certified nursing assistant) electronic documentation). Staff Q stated he/she just referred to the registered dietician to review the resident's nutritional status. On 3/2/17 at 11:23 AM, direct care staff V stated the staff offered the resident everything because he/she would eat everything. When the resident first admitted to the facility he/she did not eat much, however within a month the resident started gaining weight. The resident did not care for his/her thickened liquids. When he/she weighed a resident, he/she doesn't accept the first weight. Staff V would weigh the resident until he/she had 2 weights the same before stopping, and report an abnormal weight to his/her supervisor. On 3/2/17 at 11:38 AM, dietary staff U stated the resident received thickened liquids. He/she gave the resident foods which were easy to swallow and that he/she liked, like applesauce and banana's. For lunch and dinner, the resident had some type of soup and a grilled cheese sandwich. Staff U did not remember if the resident had fortified foods. On 3/2/17 at 9:36 AM, administrative nursing staff D stated at the end of the month he/she would print out the court assignments for each court. The court staff would record the weights on the assignment sheet, which administrative staff Q would review and inform staff D of which resident needed reweigh. Then he/she would generate a new list for each court and ask staff to reweigh the resident. Staff Q would then put the reweighs into his/her spread sheet and then would let staff D know of any weight changes. On 3/7/17 at 8:27 AM, licensed nursing staff N stated the court assistant would document the amount of the supplement consumed on the Kiosk, and then on the MAR, (medication administration record) because we would have to put the percentage of how much the resident ate because the staff was to supplement with ensure. The resident usually ate 75% to 100% of the meal. Staff N did not remember if the resident received snacks and if so, or what kind of a snack he/she received. On 3/7/17 at 3:02 PM, licensed nursing staff F stated when the resident came in he/she did not eat too bad, however then he/she started to decline. If the resident received supplements and special foods, it would be documented in the Kiosk by the CNA (certified nurse's aide). On 3/7/17 at 3:16 PM, direct care staff S stated the resident's meal intake was pretty good. The resident did not enjoy his/her thickened liquids, and staff would offer them a little bit at a time, and then the resident would drink. Staff S did not remember giving the resident a lot of supplements. Staff S documented the supplements on the MAR, and place our initials that we gave the supplement, or we can place it in the Kiosk under supplement intake. On 3/8/17 at 9:46 AM, administrative staff B stated the facility had a weekly weight meeting, or had not been informed the weights may be incorrect. Administrative staff D should have the record of the reweighs. The physician should be notified of a weight loss and the staff should have reweighed the resident, at the time staff identified the weight loss. On 3/8/17 at 12:00 PM, administrative staff Q stated the residents food preferences were obtained on admission by social services and entered into the computer. Staff Q reported he/she could not find any reweighs for the resident. On 3/8/17 at 1:30 PM, administrative staff D stated he/she did not have any reweighs for the resident. On 3/7/17 at 1:04 PM, consultant staff R stated the facility staff felt the admission weight was not accurate, the facility staff should do a reweigh whenever a weight loss was noted. Staff R thought the facility documented the residents reweighs in the computer. The resident started on Ensure plus on October 13, 2016, and the Yellow Flag program on October 30, 2016. The resident ate what he/she wanted to eat. The court assistance staff (dietary staff) were to communicate with Staff Q regarding the residents diet and meal intake. Staff R did not document the communication. The court assistant (dietary cook) also record in the Kiosk the residents meal intake and if the resident received a snack. Staff notified staff R of the residents weight loss and interventions on October 6, 2016. On 3/8/17 at 2:25 PM, physician assistant staff P stated he/she did not have an issue with the resident losing weight because of the residents weight. The initiation of the fortified foods, super donut, and supplements, were all alright for weight loss, but he/she did not want to initiate a medication to stimulate the appetite. Staff P thought he/she was notified on October 27, 2016 of the weight loss. On 3/10/17 at 8:35 AM, administrative nursing staff B stated nursing staff should notify the physician of weight loss. The facility policy for significant weight loss, dated 12/27/14, identified a significant weight change was identified as a weight loss or gain of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months. Each resident should be weighed on a monthly basis. All residents with a weight change of 5 pounds or greater should be re-weighed to determine an accurate monthly weight, and entered into the weight tracking program. A report should be generated from the program identifying all residents with a significant weight change. A monthly weight meeting should be led, organized and scheduled by the RD and cover residents with significant weight changes, residents on the Yellow flag program and resident's identified by the ministry staff to be of concern. The RD, DON (director of nursing) and Director of Nutrition Services were required to attend. The RD should make recommendations for nutritional interventions based on the information obtained from the monthly weight meetings. The RD recommendations should be reviewed and initiated by the nursing staff. The physician should be notified of any significant weight change that was unexplainable or in which the RD has requested a nutritional intervention. The facility failed to identify the resident's initial weight loss, failed to develop a plan to further prevent weight loss and failed to notify the physician of the weight loss until 6 days later. This resulted in actual harm for this resident with a significant weight loss of 8.5% in 11 days, 14.18% in 17 days. - Resident #50's physician orders, dated 2/7/17, documented the resident had a [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 7/14/16, revealed the resident had a BIMS (brief interview for mental status) score of 13, indicating intact cognition. The resident required extensive staff assistance for transfers, and locomotion; and for eating supervision. The resident had functional limitation in range of motion to the lower extremity on both sides, and mobility per wheelchair. The resident without swallowing issues, weighed 136 pounds, received a therapeutic diet, and without dental concerns. The resident received a diuretic (medication to promote the formation and excretion of urine) medication. The CAA (care area assessment), for nutrition dated 7/26/16, documented the resident's weight was 136 pounds with an ideal body weight (IBW) of 172 pounds. An IBW range should be 156-185 pounds. The resident consumed 75-100% of a regular, NAS (no added salt diet), NAF (no added fat diet), with double meat portions. The resident had lower and upper dentures which fit properly. The resident was at risk for weight loss due to daily use of [MEDICATION NAME] (a diuretic). The resident experienced a 10 pound weight loss over the last month, which could be attributed to the use of [MEDICATION NAME] and loss of fluid due to [MEDICAL CONDITION] or improper weight as the resident with several attachments on his/her wheelchair when being weighed. The CAA for dental documented the resident without natural teeth and dentures fit properly at this time. The quarterly MDS, dated [DATE], revealed the only changes from the 10/22/16 MDS: locomotion on/off the unit extensive staff assistance; extensive staff assistance for toilet use; and for personal hygiene limited staff assistance. The resident weighed 120 pounds, with weight loss and not on a physician-prescribed weight loss regimen, and on a therapeutic diet. The resident received an antidepressant (a mood enhancing medication), and a diuretic medication. The residents care plan, reviewed on 10/28/16, for nutrition, dental, and fluid maintenance documented the resident goal was to maintain his/her current weight or to gain weight. The following interventions were in place: --The resident was on a no added salt or fat diet, received double meat, and participated in the Yellow flag program (a program to add added calories to a residents diet, to increase the residents weight). --The residents weight may fluctuate as the resident with [MEDICAL CONDITION] and received [MEDICATION NAME] daily. --The resident may have weight fluctuations due to changes in fluid balance or because the resident can be difficult to weight due to padding on his/her wheelchair. The residents appetite was usually 75-100%. The resident was on the yellow flag program. --The resident was endentulous, but had a full set of dentures that fit well. The resident tolerated his/her present diet without difficulty and denied any oral discomfort or problems with dentures. --Keep fresh water or beverage of preference within reach. --Monitor the residents weight per order. The physician ordered, on 11/9/15, Regular Ensure three times daily. The physician ordered, on 3/24/16, Ensure plus three times daily, and discontinued 11/30/16. The physician ordered, on 4/21/16, NAF, NAS with double meat diet. The physician ordered, on 11/30/16, Ensure Plus, 1 can, three times a day. The physician ordered, 11/30/16, [MEDICATION NAME] Powder, 1 scoop three times a day. The physician ordered, on 2/12/17, [MEDICATION NAME], 40 mg (milligram), 1 by mouth daily. The physician ordered, on 3/3/17, to change the residents diet to regular, with regular consistency. On 3/2/17 at 1:30 PM, review of the residents diet card, listed the resident to receive double meat, on the Yellow flag program, and [MEDICATION NAME]. The residents weight record in the clinical record documented the following weights: On 9/1/16: 140 pounds. On 10/1/16: 134 pounds. The resident had a 6 pound weight loss in 1 month or a 4.28% weight loss. The resident without reweigh. The clinical record lacked evidence staff reweighed the resident. On 11/1/16: 131 pounds. The resident had a 9 pound weight loss in 2 months, or a 6.42% weight loss. Furthermore, the record lacked a reweigh of the resident. The clinical record lacked evidence the facility assessed and placed other interventions to prevent further loss until 11/30/16, one day prior to obtaining the 12/1/16 weight. The resident was already receiving Ensure and addition of [MEDICATION NAME]. On 12/1/16: 119 pounds. The resident experienced a weight loss of 21 pounds or 15% in approximately 90 days. On 12/2/16: 119 pounds. On 12/23/16: 120 pounds. On 12/30/16: 120 pounds. On 1/6/17: 119 pounds. On 2/1/17: 118 pounds. The residents meal intake, per the Kiosk documented the following. From 9/1/16 through 9/30/16, ranged from 75-100%. From 10/1/16 through 10/31/16, ranged from 75-100%. From 11/1/16 through 11/30/16, ranged from 50-75%. From 12/1/16 through 12/31/16, ranged from 75-100%. From 1/1/17 through 1/30/17, ranged from 50-75%. From 2/1/17 through 2/28/17, ranged from 75-100%. From 3/1/17 through 3/7/17, ranged from 50-100%. Review of the residents December 2016, MAR (medication administration record), revealed the CMA's (certified medication aide) initials with a circle around the initials for the Ensure. The circle around the CMA's initials usually indicated a resident refused the ensure or was not given the Ensure at the meal times. The clinical record lacked documentation on the follow up page on the MAR indicated [REDACTED]. For the January 2017 MAR, averaged 16 days out of 31 days. For February 2017 MAR, 24 days out of 28 days lacked follow up documentation. The residents December 2016 MAR, for the [MEDICATION NAME], with the CMA's initials circled, however unknown as to if the resident refused, or the supplement was not given, due to lack of follow up documentation averaged 21 days out of 27 days. For January 2017, 23 days out of 31 days; and for February 2017, 26 days out of 28 days lacked follow up documentation. The significant change nutrition assessment, dated 8/8/16, documented the resident weighed 140 pounds. IBW-172 pounds, IBW range of 156-189 pounds; percentage of IBW was 81.9%. The resident received a NAS, double meat, fortified foods diet. The resident also received Ensure Plus three times a day, and [MEDICATION NAME] three times a day. The resident had a weight loss of 10 pounds in 6 months. The residents calorie needs were 2,240 calories a day; required 77 grams of protein a day; and 2,240 cc (cubic centimeters) per day. The resident's clinical record lacked any recent laboratory findings. Assessment: the residents weight was below the IBW range, however the most recent weight reflected a weight gain. The weight changes could occur related to fluid balance issues due to resident with an order for [REDACTED]. Recommendation: to continue with the current diet of NAS, double meat, fortified foods, Ensure Plus three times a day, [MEDICATION NAME] three times a day, and continue with the Yellow flag program. The staff were to obtain weekly weights and document daily meal intake. The Dietitian/Physician Faxed Communication form, dated 11/28/16, identified the resident weighed 132 pounds. Diet Order was for NAF, and NAS. The dietitian recommendations: The resident with a weight loss of 15 pounds in 6 months. On 10/24/16, the resident started on [MEDICATION NAME] (an antidepressant medication), 30 mg, 1 time a day. Recommend a diet clarification for the diet order to read NAS, double meat, fortified foods, Ensure Plus three times a day, [MEDICATION NAME] three times a day. Add Gelatein (protein based Jello) twice a day, and offer a super donut with coffee for breakfast if the resident desires for aide in wound healing and weight stabilization. Review of the residents clinical notes, and assessments lacked documentation of the physician notification (11/28/16) and follow-up on 11/30/16) of the resident with a weight loss on 10/1/16, 15 pound weight loss on 11/1/16, 21 pounds or 15% weight loss in 90 days until 11/30/16. On 3/1/17 at 12:37 PM, the resident completed his/her lunch of chicken fried steak, mashed potatoe's, green beans, a yeast roll, and angel food cake with cherries, and without milk. The resident stated the meal was good, he/she just wasn't hungry since having breakfast, and he/she doesn't usually eat lunch. The resident did not eat the chicken fried steak, or the green beans, but did eat the angel food cake with cherries, and mashed potatoe's. On 3/1/17 at 1:37 PM, the resident resteed in bed, and direct care staff T brought the resident his/her Ensure to drink and the resident declined his/her Ensure at this time. At 2:30 PM, the resident requested direct care staff T to bring him/her the Ensure. The resident drank 100% of the Ensure. On 3/2/17 at 12:45 PM, the resident sat at the dining room table eating a chili dog and drinking his/her Ensure. The resident also had a lettuce salad and a piece of chocolate cake. The resident stated he/she did not like chocolate and was not a salad eater. The resident did not have a glass of milk, however the resident was drinking Ensure. On 3/2/17 at 12:45 PM, review of the resident's diet card revealed the resident with a NAS (no added salt), NAF (no added fat) diet, double meat, with [MEDICATION NAME], and a yellow smiley face. At 12:46 PM, dietary staff Z stated the yellow smiley face on the residents diet card meant the resident was on a Yellow flag program. On 3/7/17 at 8:30 AM, review of the residents diet card revealed the resident was on a regular diet, with [MEDICATION NAME], and a smiley face. At 8:34 AM, dietary staff Z stated the residents diet changed since last week. On 3/7/17 at 8:35 AM, the resident was sitting up in bed and ate all but 2 bites of a pancake. The resident also had 4 strips of bacon to eat. At 9:00 AM, the resident completed his/her meal. The resident drank 120 cc (cubic centimeters) of cranberry juice and coffee, the resident did not have any milk. On 3/7/17 at 9:40 AM, direct care staff X took the resident to be weighed in his/her wheelchair. Staff X cleared the scale, and the resident weighed 184 pounds in his/her wheelchair. Staff X then weighed the residents wheelchair, after clearing the scale and the wheelchair weighed 69 pounds. The resident weighed 115 pounds, a weight loss of 5 pounds or a 4.2% in 30 days Staff X stated he/she would always clear the scale to 0 before weighing a resident. On 3/1/17 at 12:53 PM, direct care staff T stated the resident does not like the [MEDICATION NAME]. No matter what he/she would mix the [MEDICATION NAME] in the resident could taste it, and the [MEDICATION NAME] would make him/her sick, so the resident won't drink the [MEDICATION NAME]. Staff X stated he/she would give the resident the Ensure either at lunch or after lunch. Today he/she would give the Ensure before the resident goes to bed, after lunch On 3/2/17 at 8:33 AM, administrative dietary staff Q stated the resident was on the Yellow flag program, and fortified foods. If a resident was on the Yellow flag program, then the staff were to obtain weights weekly. Each court had a weight sheet where the staff tracked a residents weight. Staff Q stated the facility had a weekly weight meeting in which the staff reviewed the residents weights. Monthly the facility had a meeting with the whole team including the registered dietician. The staff on the courts recorded the weights in the Kiosk. Then he/she would enter the weights into a program that would calculate the percentage of weight loss or gain a resident had. If a resident had a 4 pound weight loss or gain, then he/she would give the list of residents to administrative nursing staff D. Staff D would then request each court to reweigh residents on the list, to be completed by the end of the day. Staff Q was unsure if nursing staff put the reweighs in the Kiosk. Furthermore, staff Q explained he/she would have the reweighs in his/her system. On 3/2/17 at 10:45 AM, direct care staff T stated the resident would drink the Ensure two times a day, but that was pushing it. For breakfast the resident just ate eggs, bacon, and pancakes. Staff weighed the resident weekly because of weight loss. On 3/2/17 at 10:55 AM, dietary staff Z stated he/she was supposed to give the resident double meat, and try to get the resident to drink the Ensure. The resident had days he/she did not want to eat, but he/she would go ahead and fix the meal and the resident would eat some of it. Staff Z asked the resident if he/she wanted the double meat and the resident would refuse, and he/she did not want to overwhelm the resident with all the food. The resident had a yellow smiley face on the meal cards and should receive fortified foods, but the resident would only eat the mashed potatoe's. The resident does not like bread or sweets very much. On 3/2/17 at 12:50 PM, dietary staff Z stated he/she did not give the resident double portions of meat for lunch, because the resident would not eat 2 hot dogs. On 3/2/17 at 12:51 PM, direct care staff T stated he/she usually documented he/she gave the supplement on the MAR indicated [REDACTED]. On 3/2/17 at 3:56 PM, direct care staff AA stated the resident would eat approximately 25-75% of the meal. If the resident ate under 25% of the meal, staffwould offer a protein shake, and the resident was not on a special diet. <

The facility reported a census of 84 residents with 11 selected for review including 3 residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to develop and implement interventions to prevent the development of an unstageable pressure ulcer for 1 (#27) of the 3 residents reviewed for pressure ulcers. Findings included: - Review of resident #27's physician order [REDACTED].{stroke}), history of falls, muscle weakness and major [MEDICAL CONDITION](abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The annual MDS (minimum data set), dated 4-26-16, assessed the resident with a BIMS (brief interview for mental status) score of 11, indicating moderate cognitive deficit (8-12), required extensive assistance of 2 persons with bed mobility, transfer, and toilet use. The resident had functional impairment in range of motion on bilateral upper extremities and no impairment in lower extremities. The resident was frequently incontinent of bladder and always continent of bowel. The resident was at risk for development of pressure ulcers but had none since prior assessment. No interventions were listed in place for prevention. The quarterly MDS, dated [DATE], assessed the resident with a BIMS score of 2 indicating severe cognitive deficit (0-7), required extensive assistance of 2 persons with bed mobility, transfer, toilet use, required assistance with locomotion on the unit, had no functional impairment of upper or lower extremities and was frequently incontinent of bladder and occasionally incontinent of bowel. The resident required supervision with eating and was at risk for pressure ulcer development with no current or none since prior assessment, and no interventions were listed in place for prevention. The resident's weight was 202 pounds. The CAA (care area assessment) for pressure ulcers, dated 4-27-16, assessed the resident at risk for potential skin impairment due to weight of the resident, amount of pressure applied to bony prominences, and potential for skin trauma and discolorations due to the thin fragile skin of the resident. The care plan, revised 1-9-17, advised staff the resident was able to reposition him/herself when in bed and in his/her recliner, but sometimes needed limited or extensive assistance especially in the evening when tired. Staff advised the resident had a history of [REDACTED]. The care plan lacked any planned preventive measures. Furthermore,the care plan lacked an update after the development of pressure ulcers (detected on 2-27-17) for use of pressure reducing boots or other interventions to promote healing and prevent worsening. The resident care summary assessment, dated 2-7-17, lacked an update for interventions for the pressure ulcer. The Braden score (an assessment of the risk for pressure ulcer development), dated 9-30-16, assessed the resident with a score of 16, indicating risk for pressure ulcer development. A nurses' note, dated 2-9-17, documented the resident had an x ray of his/her right foot with results of no fracture and generalized soft tissue swelling without focal soft tissue pathology. A nurses' note to the physician, dated 2-27-17 at 4:26 pm, documented the development of a wound to the resident's right outer ankle as 2 by 2 cm (centimeter) with a scab. This note further described two open areas in the wound bed measured 0.25 cm and a second one less than 0.25 cm. with a small amount of yellow colored drainage noted in the wound bed. The outer aspects of the wound appeared red. Staff applied triple antibiotic ointment and Duoderm (an occlusive dressing). Staff requested the physician to review and advise and requested a referral to the wound physician. A nurses' note, dated 2-28-17, documented the results of a right ankle x ray, done 2-27-17, included a soft tissue ulcer laterally to the right foot malleolus(outer bone of the ankle). A physician's orders [REDACTED]. Observation, on 3-1-17 at 12:20 pm, revealed the resident sat in his/her recliner in his/her room. The resident's right and left feet were positioned without a pressure relieving device. Two pressure relieving protective footwear boots were on the resident's bed. The resident's bed contained a standard pressure relieving mattress. Intermittent observations, at 12:30 pm, 12:45 pm, 1:00 pm, 1:15 pm, 1:30 pm, 1:45 pm, 2:00 pm, 2:15 pm, 2:30 pm, 2:45 pm, 3:00 pm, 3:15 pm, 3:30 pm and 3:45 pm, 3 hours and 40 minutes, at which time staff applied pressure relieving foot wear and direct care staff S and L repositioned the resident by lifting him/her with the incontinence pad and placing a pillow under the resident's left hip while sitting in his/her recliner. The resident did not attempt to reposition him/herself during that time. The recliner lacked a pressure relieving cushion. Interview, on 3-1-17 at 4:10 pm, with direct care staff L revealed the resident had days in which he/she could stand and pivot, but today staff repositioned the resident with pillows. Observation, on 3-2-17 at 7:27 am, revealed the resident positioned on his/her back in bed with pressure relieving footwear on bilateral feet. Observation continued 7:45 am, 8:00 am, 8:15 am (at which time direct care staff M raised the resident's head of bed up to administer medications, 8:30 am, 8:45 am. 9:00 am, 9:15 am and 9:22 am, at which time direct care staff J, assisted the resident with breakfast of super cereal (a cream of wheat type cereal fortified with butter sugar and whole milk) and a high protein drink. Staff M or J did not offer the resident a turning or toileting opportunity until 10:08 am (2 hours and 41 minutes), at which time the resident was incontinent of urine and stool. Interview, on 3-2-17 at 9:45 am, with direct care staff J, revealed the resident remained in bed for breakfast and would get up in the recliner later on in the morning for lunch. Staff J stated the resident could reposition him/herself. Interview, on 3-2-17 at 10:00 am, with direct care staff M, revealed the resident declined considerably and could no longer feed him/herself and was dependent on staff for all activities of daily living including bed mobility. Observation, on 3-2-17 at 12:37 pm, revealed direct care staff J, M, and V transferred the resident into his/her recliner. The recliner lacked a pressure relieving cushion. The resident had a pressure relieving boot to his/her right foot, but lacked a pressure relieving device to his/her left foot. Observation, on 3-2-17 at 1:45 pm revealed licensed nursing staff N removed the Duoderm from the resident's right foot, and obtained measurements of the right malleolar (outer bone of the ankle) ulcer area of 1.7 by 1 cm (centimeter) which contained yellows slough (dead tissue, usually cream or yellow in color) and an area .5 by .3 cm (centimeter) of brown eschar (dead tissue). The wound drained serosanguinous (semi-thick reddish drainage) drainage. The right foot had a red area on the anterior mid ankle of 2 by .4 cm. Licensed nursing staff N stated the right foot and ankle were swollen, and the resident received x-ays for determination of status after the fall (2-11-17). Staff N stated the wound physician would not be available until 3-3-17 to evaluate the resident. Staff N cleansed the area with normal saline, and applied Duoderm. Staff N stated he/she did not know what stage the ulcer was, or if Duoderm was the appropriate dressing for this draining wound. Staff N stated he/she floated (worked) to other units and did not know if the wound changed. The resident lacked a pressure relieving device to his/her left foot. Interview, on 3-2-17 at 2:10 pm, with administrative staff C, revealed staff thought the ulcer on the resident's right malleolus was due to gout (a form of arthritis caused by uric acid), as his/her uric acid (a substance in the blood that can form painful crystals in joints or kidney stones) level was elevated, the foot was swollen, and there was a small area of yellow/white on the malleolus before the area opened. Staff C stated the facility did not have standing orders for wounds. Staff C stated the resident should have pressure relieving devices on both feet. Observation, on 3-7-17 at 10:41 am, revealed the resident positioned in bed. A blue zero gravity boot was on the resident's right foot, but not on the resident left foot. Licensed nursing staff E, unwrapped the resident's right ankle Kerlix and removed the dressing, The resident winced in pain with the movement of this foot. The pressure area surface was brown in color without drainage. Staff E cleansed the area and applied the honey alginate dressing and wrapped the foot with Kerlix. The resident winced in pain with movement of the right foot. Nursing staff E stated the resident should have the zero gravity boots on both feet due to the resident's lack of movement in bed. Interview, on 3-7-17 at 11:18 am , with consulting wound physician H, revealed he/she felt the area on the resident's ankle wound was due to pressure and was unstageable (full thickness tissue loss) with slough. Staff H stated the resident may have had gout in his/her joint, but due to immobility and pressure upon the ankle, a pressure ulcer developed. The facility policy for skin care protocol, revised 4-28-10, advised staff to document perceived modifiable and non-modifiable conditions, measure, describe and document areas noted on the skin assessment and notify the primary care physician of assessment and indicate whether standing orders have been implemented or request new orders for treatment. Staff to complete the initial plan of care, initiate dietary recommendations for skin care protocol for nutrition services and monitor weekly complete the Braden risk assessment upon admission and then quarterly. The facility failed to provide measures to prevent pressure ulcer development for this cognitively impaired immobile resident who experienced harm when he/she developed an unstageable pressure ulcer to his/her ankle.

The facility reported a census of 92 residents with 5 residents sampled. Based on observation, interview and record review, the facility failed to transfer and ambulate in a safe manner to prevent accidents for 1 (#1) of the 3 residents sampled with physician ordered weight bearing restrictions. Staff ambulated the resident while on toe touch weight bearing (TTWB) restrictions with an incomplete fracture (a fracture that does not extend through the full width of a bone), which then displaced, and required surgical repair. Findings included: - The physician's orders [REDACTED].#1 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 12/16/15, documented the resident's BIMS (brief interview for mental status) score of 8, indicating moderately impaired cognition. The resident required extensive assist of 1 staff for transfers and walking in room/corridor, and used a walker and wheelchair for mobility. The resident was not steady, and only able to stabilize with staff assist when walking, with no impairment in the upper or lower extremity in functional limitation of ROM (range of motion). The [DIAGNOSES REDACTED]. The 14 day MDS, dated [DATE], documented walking did not happen, and the resident had lower extremity impairment on one side in functional limitation in ROM, with no other changes from the previous assessment. The CAA (care area assessment) for ADLs (activities of daily living), dated 12/16/15, documented the resident had impaired mobility due to a fall with a fracture at home. The hospital history and physical, dated 12/13/15, documented the resident did not have significant pain, allowed range of motion of the right hip, and had an incomplete fracture of the femoral neck (upper part of the femur). The resident would be admitted to a skilled nursing facility where continued restrictive weight bearing status could be monitored to allow the fracture to heal without surgical intervention. The admission care plan, dated 12/16/15, documented the resident required limited assist of 1 staff with all ADLs. The care plan lacked identification of toe touch weight bearing restrictions. The resident care summary assessment, dated 12/16/15, documented the resident required assist of 1 staff for transfers and used a walker and/or wheelchair with assist of 1 staff for mobility. The care summary lacked identification of toe touch weight bearing restrictions. The hospital discharge/admission orders [REDACTED]. The nurse's note, dated 12/28/15 at 9:42 PM, documented staff reported to the nurse the resident's hip looked funny. The resident guarded the right hip and the right leg was significantly shorter than the left. The resident was sent to the hospital for further evaluation by ambulance and admitted for right femur fracture. The hospital history and physical, dated 12/28/15, documented the pelvic x-ray showed a right sub-capital neck fracture (upper femur fracture), now angulated and overriding since the prior exam. The hospital physician's assessment, dated 12/29/15, documented the resident with a recent hip fracture, which had been minimally displaced and treated with conservative non-operative means. The resident had been mobilizing with increasing pain and presented to the emergency department yesterday. The resident now displaced the right femoral neck fracture and will require right hip hemiarthroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact). Observation of the resident, on 1/27/16 at 5:34 PM, revealed the resident sat at the dining room table eating, with a four wheeled walker at his/her side. On 1/28/16 at 1:15 PM, staff approached the resident, placed a gait belt on the resident and assisted him/her to ambulate to the bathroom. On 1/28/16 at 10:10 AM, direct care staff C stated staff know what to do for the residents from report and the resident care book, where each resident had a sheet that summarized their care needs, called the resident care summary assessment. When the resident first arrived he/she was non-weight bearing (NWB) on the right leg, and gradually became TTWB, which is where you keep the resident's foot on yours when pivot transferring and the resident's do not put any pressure on that foot. Staff C did not see anyone ambulate the resident, but was told direct care staff D had. On 1/28/16 at 10:33 AM, licensed nursing staff E reported the resident was TTWB when he/she first arrived because of a right leg fracture. The CNA's (certified nursing assistants) were to follow the care summary assessment sheets when providing resident care. The nurse on duty on admission is responsible to place the care summary in the book and be sure it is accurate to the resident's needs and then update the care summary sheet when there is any change in the resident's care. The admission care summary assessment for the resident did not have a weight bearing restriction listed, it just said he/she required assist of 1 staff for transfers, so staff E stated he/she could understand how a CNA would have ambulated the resident when he/she should not have. On 1/28/16 at 11:22 AM, direct care staff D reported he/she walked the resident 12/24/15. Staff D transferred the resident with full weight bearing from the bed to the walker, and walked him/her to the dining room. A family member of the resident approached and said the resident was not supposed to walk. But, staff D continued to walk the resident down the hall to the wheelchair and used it to get the resident the rest of the way to the dining room. Staff D stated he/she used shift report and resident care summary sheets to know what care to provide for the residents. I did not read the resident care summary that day, but had on days before and I do not remember it saying the resident had any weight bearing restrictions. Staff D saw the walker in the resident's room, and walked him/her. On 1/28/16 at 4:08 PM, administrative nursing staff B reported the resident admitted with a partial fracture and TTWB status. Staff B was aware that a CNA ambulated a resident. The resident care summary assessment should be used by staff to direct the care they provide, and it should identify when there are weight bearing restrictions. Staff B did identify that the resident's care summary assessment was not accurate. Staff B stated he/she thought the MDS nurse updated the care summary but apparently they were not, and did not know who was responsible for updating the sheets. Staff B stated this was a problem the facility needed to fix. The facility failed to follow physician's orders [REDACTED]. The resident admitted with a partial fracture and weight bearing restrictions. Staff ambulated the resident, the fracture then became displaced and required surgical repair.

The facility reported a census of 88 residents, of which 14 residents, including 12 female residents resided on 1 of the 6 courts in the facility. Based on observation, record review and interview, the facility failed to ensure 2 female residents (#8 and #7), residing on this unit remained free of sexual abuse by sampled resident #03, which placed all of the female residents in immediate jeopardy. Findings included: - The electronic medical record (EMR) evidenced the facility admitted resident #03, on 12/14/12. Physician's [DIAGNOSES REDACTED]. The resident's minimum data set assessment, dated 5/11/15, documented the resident as unable to complete the brief mental interview due to severe cognitive deficit, in need of supervision only with transfers and ambulation with a walker and did not receive psychoactive medications (chemical substance which changes brain function and alters thoughts and mood). The care area assessment, dated 5/11/15, for behaviors included, wanders on the court, at times enters other resident's rooms. The care plan, updated 5/11/15 included, watch the resident when on the court for any signs of wandering. Redirect the resident when he/she is upsetting others. The plan of care failed to address inappropriate sexual behavior toward other gender residents. A facility fax to the physician on 3/5/15 included: Staff has reported the resident is having some episodes of increased behaviors. Refusing baths/showers frequently. Going into other resident rooms and difficult to redirect. Making verbally inappropriate comments. Nurses notes, on 4/27/15 at 4:30 P.M., documented, resident (#03) took another resident's (other gender, #08's) hand and put it over his/her private parts. The staff member re-directed the resident. Approximately 10 minutes later, resident (#03) did the same thing to another resident (other gender, #07). Medical record review revealed both residents/victims (#08 and #07) had severe cognitive deficits. The EMR evidenced no further documentation of these incidents. On 6/16/15 at 1:20 P.M., direct care nursing staff E described the incident and recalled reporting the incidents to licensed charge nurse C. Direct care nursing staff E stated he/she documented the incident on the KIOSK (direct care staff's computer program used for daily documentation) and gave a signed statement. The charge nurse then reported the incidents to administrative staff A. Review of KIOSK documentation, dated 4/27/15 at 10:47 A.M. and 4:11 P.M., evidenced the resident displayed wandering and inappropriate sexual behaviors toward residents and staff. On 5/22/15 at 5:01 P.M., nurses notes documented a direct care staff member blocked a doorway to keep the resident (#03) out of another resident's room. The resident (#03) yelled at staff, You better move, you're gonna get yourself raped. On 6/5/15 at 2:20 P.M., the medical record documented the primary care physician visited the resident in the facility and reviewed the clinical record, however, the resident's inappropriate behavior was not addressed and no new orders were written. On 6/9/15 (no time), indirect care staff H (other gender) documented a concern form that included, resident (#03) going into the kitchen area and was asked to please leave. The resident hit staff over and over and grabbed one (other gender) staff's breasts. On 6/11/15, in answer to this concern, a follow-up by administrative nursing staff B included, instructions to the staff to keep at arms length away from resident (#03). Use softer voice tones when redirecting, do not block the residents way. Continue to offer diversional activities or walk the resident on the hall. Nurses notes, on 6/10/15 at 4:10 P.M., documented, two staff members offered the resident candy as staff tried to redirect him/her. The resident grabbed at staff. The resident was asked not to hit. He/she became physically aggressive by shoving his/her walker into 2 staff members. The resident grabbed the staff members breast. The resident was told that was inappropriate and to not do it again. As the resident was walking past another staff member he/she grabbed the staff's buttock. Once again the resident was told that was not appropriate behavior. The resident finally agreed and was taken back to his/her court because of his/her need to use the bathroom. On 6/16/15 at 2:10 P.M., observation revealed the resident, seated in the TV area, reached out and grabbed and pushed resident #7, who was sitting in a wheelchair, away from him/her. Then resident #3 yelled at resident #7. On 6/16/15, interviews with 5 alert and oriented other gender residents, from 9:00 A.M. through 10:20 A.M., revealed: One resident stated, I'm afraid of him/her, he/she doesn't belong here. He/she hits a lot. Picks on the confused residents. Another resident stated, Yes, he/she has frequent inappropriate behaviors. He/she opens my bathroom door and looks in. Another resident stated, He/she asked me to go to bed with him/her. Has said I'll do anyone I want. Roams around a lot. Another resident stated, Came close to touching me inappropriately. Another resident stated, Don't trust him/her, he/she hits and grabs inappropriate body parts of staff when they step between him/her and other residents. On 6/17/15 at 10:20 A.M., a visitor reported the resident #3 tried to get in bed with (other gender resident #7), several months ago. The visitor reported a grievance was voiced at that time. On 6/17/15 at 4:00 P.M., licensed nursing staff B acknowledged administrative staff A had been aware of the incidents since 4/27/15 and had failed to complete any investigations. The administrative staff was currently out of the facility and city. On 6/17/15 at 4:40 P.M., social services staff F acknowledged the 4/27/15 witness statement, written by direct care staff E, had been shredded. Administrative staff A had told staff F the incident was not abuse, it was inappropriate behavior so no other action needed to be taken. The facility abuse, neglect and exploitation prevention and reporting policy, dated 8/26/13, included: It is the policy of the facility to ensure that reasonable steps are taken to assure that residents are not subject to any type of abuse or neglect from staff, volunteers, visitors or other residents. When an incident of ANE is suspected the ministry takes reasonable steps to immediately investigate the situation, provide safety for the resident, and report the situation to the appropriate state agency(s) immediately. On 6/17/15 at 1:10 pm (a month and 21 days after the incidents), the facility notified the physician and requested a psychiatric evaluation and possible medications for the behaviors exhibited by this resident. The physician declined the evaluation and only started the resident on an antidepressant. The facility failed to ensure 2 female resident's residing on this court remained free of sexual abuse by this resident, thus placing all 12 female residents in immediate jeopardy for sexual abuse. The facility abated the immediate jeopardy on 06/18/15 at 5:00 pm by initiating the following: Continuous 1:1 supervision of the resident beginning 06/17/15 and care planned to continue until further notice. Development of a plan for monitoring the resident's behaviors including documentation of resident behaviors every shift, social service monitoring of documentation for further action, discussion daily in stand-up meetings of any inappropriate resident behaviors, follow-up with physicians on an ongoing basis, development of a plan of care for inappropriate behaviors displayed by residents, and monitoring provided through the facility's quality assurance committee, with oversight by the Director of Nursing Weekly audits to be conducted by the administrator to follow through with the grievances. All Staff will be educated on all aspects of the facility ANE policy and grievance procedure, including a total review of the facility's abuse policy including what abuse is, who should report, possible signs/indications of abuse, who staff should report suspect abuse to, how to contact the local state agency, what happens if the abuse is substantiated, and what happens if staff do not feel a concern about abuse is being taken care of properly. Inservice education to all staff was completed on 06/18/15 at 5:00 pm. The facility abated the immediate jeopardy, on 06/18/15 at 5:00 pm, however, the citation remains at a scope and severity of a E.

The facility reported a census of 88 residents, of which 14 residents, including 12 female residents resided on 1 of the 6 courts in the facility. Based on observation, record review and interview, the facility failed to protect these 12 residents from possible sexual abuse, which placed them in immediate jeopardy. Furthermore, the facility failed to thoroughly investigate and report to the state agency two incidents of sexual abuse of 2 female residents #8 and #7, by sampled resident #03. Findings included: - The electronic medical record (EMR) evidenced the facility admitted resident #03, on 12/14/12. Physician's [DIAGNOSES REDACTED]. The resident's minimum data set assessment, dated 5/11/15, documented the resident as unable to complete the brief mental interview due to severe cognitive deficit, in need of supervision only with transfers and ambulation with a walker and did not receive psychoactive medications (chemical substance which changes brain function and alters thoughts and mood). The care area assessment, dated 5/11/15, for behaviors included, wanders on the court, at times enters other resident's rooms. The care plan, updated 5/11/15 included, watch the resident when on the court for any signs of wandering. Redirect the resident when he/she is upsetting others. The plan of care failed to address inappropriate sexual behavior toward other gender residents. A facility fax to the physician on 3/5/15 included: Staff has reported the resident is having some episodes of increased behaviors. Refusing baths/showers frequently. Going into other resident rooms and difficult to redirect. Making verbally inappropriate comments. Nurses notes, on 4/27/15 at 4:30 P.M., documented, resident (#03) took another resident's (other gender, #08's) hand and put it over his/her private parts. The staff member re-directed the resident. Approximately 10 minutes later, resident (#03) did the same thing to another resident (other gender, #07). Medical record review revealed both residents/victims (#08 and #07) had severe cognitive deficits. The EMR evidenced no further documentation of these incidents. On 6/16/15 at 1:20 P.M., direct care nursing staff E described the incident and recalled reporting the incidents to licensed charge nurse C. Direct care nursing staff E stated he/she documented the incident on the KIOSK (direct care staff's computer program used for daily documentation) and gave a signed statement. The charge nurse then reported the incidents to administrative staff A. Review of KIOSK documentation, dated 4/27/15 at 10:47 A.M. and 4:11 P.M., evidenced the resident displayed wandering and inappropriate sexual behaviors toward residents and staff. On 5/22/15 at 5:01 P.M., nurses notes documented a direct care staff member blocked a doorway to keep the resident (#03) out of another resident's room. The resident (#03) yelled at staff, You better move, you're gonna get yourself raped. On 6/11/15 (no time), in answer to this concern, a follow-up by administrative nursing staff B included, instructions to the staff to keep at arms length away from resident (#03). Use softer voice tones when redirecting, do not block the residents way. Continue to offer diversional activities or walk the resident on the hall. On 6/16/15 at 2:10 P.M., observation revealed the resident, seated in the TV area, reached out and grabbed and pushed resident #7, who was sitting in a wheelchair, away from him/her. Then resident #3 yelled at resident #7. On 6/16/15, interviews with 5 alert and oriented other gender residents, from 9:00 A.M. through 10:20 A.M., revealed: One resident stated, I'm afraid of him/her, he/she doesn't belong here. He/she hits a lot. Picks on the confused residents. Another resident stated, Yes, he/she has frequent inappropriate behaviors. He/she opens my bathroom door and looks in. Another resident stated, He/she asked me to go to bed with him/her. Has said I'll do anyone I want. Roams around a lot. Another resident stated, Came close to touching me inappropriately. Another resident stated, Don't trust him/her, he/she hits and grabs inappropriate body parts of staff when they step between him/her and other residents. On 6/17/15 at 10:20 A.M., a visitor reported the resident #3 tried to get in bed with (other gender resident #7), several months ago. The visitor reported a grievance was voiced at that time. On 6/17/15 at 4:00 P.M., licensed nursing staff B acknowledged administrative staff A had been aware of the incidents since 4/27/15 and had failed to complete any investigations. The administrative staff was currently out of the facility and city. On 6/17/15 at 4:40 P.M., social services staff F acknowledged the 4/27/15 witness statement, written by direct care staff E, had been shredded. Administrative staff A had told staff F the incident was not abuse, it was inappropriate behavior so no other action needed to be taken. The facility abuse, neglect and exploitation prevention and reporting policy, dated 8/26/13, included: It is the policy of the facility to ensure that reasonable steps are taken to assure that residents are not subject to any type of abuse or neglect from staff, volunteers, visitors or other residents. When an incident of ANE is suspected the ministry takes reasonable steps to immediately investigate the situation, provide safety for the resident, and report the situation to the appropriate state agency(s) immediately. The facility failed to initiate measures to protect the 12 female residents residing on this one unit when resident #3 displayed sexually inappropriate behavior towards 2 of these residents, which placed these residents in immediate jeopardy. Furthermore, the facility failed to thoroughly investigate and report to the state agency, as required, these two incidents of sexual abuse. The facility abated the immediate jeopardy on 06/18/15 at 5:00 pm by initiating the following: Continuous 1:1 supervision of the resident beginning 06/17/15 and care planned to continue until further notice. Development of a plan for monitoring the resident's behaviors including documentation of resident behaviors every shift, social service monitoring of documentation for further action, discussion daily in stand-up meetings of any inappropriate resident behaviors, follow-up with physicians on an ongoing basis, development of a plan of care for inappropriate behaviors displayed by residents, and monitoring provided through the facility's quality assurance committee, with oversight by the Director of Nursing Weekly audits to be conducted by the administrator to follow through with the grievances. All Staff will be educated on all aspects of the facility ANE policy and grievance procedure, including a total review of the facility's abuse policy including what abuse is, who should report, possible signs/indications of abuse, who staff should report suspect abuse to, how to contact the local state agency, what happens if the abuse is substantiated, and what happens if staff do not feel a concern about abuse is being taken care of properly. Inservice education to all staff was completed on 06/18/15 at 5:00 pm. The facility abated the immediate jeopardy, on 06/18/15 at 5:00 pm, however, the citation remains at a scope and severity of a E.