Every finding on record at Wellington Health and Rehab

The facility reported a census of 43 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses. Findings included:- Observation of the kitchen and food storage areas on 08/24/25 at 09:40 AM revealed the following areas of concern:Walk-In Cooler:A white Styrofoam cooler on the top shelf, with no date and no label, contained several rolled-up items in foil. Dietary Staff CC opened one of the foil packets and reported it was hot dogs from a facility picnic the previous Thursday.Free-standing freezer:One bag of cooked bacon with no date or label.One brown bag in a zip lock bag with no date or label.One bag of sealed French fries with no date.One bag of hash browns unsealed.One bag of ready-to-bake chocolate chip cookies with no date or label.During an interview on 08/24/25 at 10:10 AM, Dietary Staff CC reported that all food items required an open date and were required to be sealed properly.During an interview on 08/25/2025 at 11:20 AM, Certified Dietary Manager BB stated she expected staff to label, date, and seal all food properly.During an interview on 08/25/25 at 01:00 PM, Administrative Staff A stated he expected all food items to be stored, sealed, labeled, and dated properly.The facility's policy Food Safety Requirements, dated 10/2024, documented food shall be received and stored in a manner that complies with safe food handling practices. All food stored in the freezer or refrigerator will be covered, labeled, and dated.

The facility reported a census of 43 resident. The sample included 12 residents with three residents sampled for accidents. Based on observation, interview, and record review, the facility failed to complete a thorough root cause analysis to identify causative factors and/or failed to implement the care planned interventions to prevent further falls for Resident(R) 38 and R28. This deficient practice placed the residents at risk for further falls and associated injuries. Findings included- R38's Electronic Health Record (EHR) documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), a history of falling, and muscle weakness. R38’s 03/25/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R38 required supervision with most activities of daily living (ADLs), except set up for wheelchair mobility, bed mobility, and upper dressing. The MDS documented R38 had one fall with minor injury. R38’s 04/13/25 Falls Care Area Assessment (CAA) documented staff attempt to minimize serious injury with frequent toilet cueing, placing the call light in reach, and utilizing non-skid footwear. The CAA noted a padded beanie head protector would be applied upon arousal; staff would ambulate the resident, otherwise the resident would use a wheelchair for mobility. R38’s 06/25/25 “Quarterly MDS” documented a BIMS of six. ADLs remained the same as the Annual MDS. The MDS documented R38 had one non-injury fall. R38’s “Care Plan” dated 08/01/25, directed staff to provide a bed and chair alarm; check and change every two hours while the resident was in bed for the next 10 days. Staff were instructed to provide supervision assistance with ADLs while R38 was awake. R38’s “Fall Risk Evaluation” dated 03/16/25, 06/16/25, and 6/18/25 documented R38 was a low risk for falls. R38’s “Fall Risk Evaluation” dated 07/23/25, 08/01/25, and 08/22/25 documented R38 was a high risk for falls. R38’s “Progress Note” dated 8/1/25 at 09:35 PM, documented the resident self-propelled out of his room, dove out of his wheelchair when he struck the door jam. Staff placed R38 on fall precautions, and a bed and chair alarm were placed as interventions. During an observation on 08/24/25 at 02:54 PM, R38 was in bed. There was no bed alarm observed on his bed. A personal alarm was noted on the wheelchair. During an interview on 08/25/25 at 10:37 AM, Certified Nurse Aide (CNA) M reported that the alarm that is on his wheelchair should be moved to the bed when staff assist R38 to bed. CNA M reported that R38 required the alarm on his wheelchair and bed. During an interview on 08/26/25 at 10:05 AM, Licensed Nurse (LN) H stated she expected staff to have all fall interventions per the resident's care plan. During an interview on 08/26/25 at 10:30 AM, Administrative Nurse D reported she expected staff to follow the care plan and to always have the fall interventions in place. The facility policy titled Fall and Fall Risk, Managing F689” dated 06/2025, documented if position alarms were utilized as an intervention, the staff would monitor their placement per an established schedule. - R28's Physician Orders” dated 08/20/25, documented diagnoses of neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system,) hypertension (high blood pressure), type 2 diabetes (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), psychosis (any major mental disorder characterized by a gross impairment in reality perception)disturbances, mood and behavior disturbances), chronic kidney disease, abnormal posture, and repeated falls. R28's 03/02/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS noted R28 had no functional impairment in range of motion (ROM) of his upper or lower extremities. He required supervision or touching and/or partial moderate assistance from staff for completion of activities of daily living (ADLs). The resident used a walker as a mobility device, and staff provided partial moderate assistance for dressing. He had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and was always continent of bowel without constipation. The resident fell two to six months prior to admission. No documentation of falls after admission. R28 received occupational therapy (OT) on one day of the look-back period for 40 minutes and physical therapy (PT) one day of the look-back period for 45 minutes. R28's Quarterly MDS dated [DATE] documented changes from the above MDS, which included a BIMS score of 11, indicating moderate cognitive impairment. R28 received as-needed (PRN) pain medication. He reported occasional pain frequency and rated pain as rarely or did not interfere with sleep or ADLs. The “Falls Care Area Assessment” (CAA), dated 03/03/25, was triggered for falls related to him falling before admission to the facility. He had periods of confusion/tremors. R28's Care Plan dated 03/05/25 identified the resident as at high risk for falls related to a history of falls prior to admission. The plan directed staff to position, empty, and monitor his indwelling urinary catheter; administer his medications as ordered, and monitor for side effects and effectiveness. The plan directed staff to ensure R28 wears appropriate footwear, such as non-skid socks or shoes, when ambulating or mobilizing in a wheelchair, and keep the environment and floors free from spills and/or clutter. Staff were to provide adequate glare-free lighting, a reachable call light, the bed in low position at night, handrails on the walls, and personal items within reach. Additional fall interventions initiated after falls to prevent further falls included assisting R28 to the toilet after breakfast, initiated 03/17/25. The plan directed staff to reinforce to the resident to call for assistance, directed the use of a leg bag during the day, initiated on 07/05/25. R28's “Progress Notes documented a note on 07/04/25 at 06:37 PM, which noted R28 notified the nurse that he went to the bathroom and was trying to button up his pants, lost his balance, and fell. He got himself up and ambulated to his bed. The new intervention was to provide staff training regarding infection control related to the use of a leg bag during the day. Additionally, staff were to remind the resident to call for assistance for toileting. R28's “Progress Notes documented a note on 07/19/25 at 04:10 PM, noted that R28's roommate reported that his roommate (R28) was on the floor. The nurse entered R28’s room and noted him lying with his mid-upper back and head resting on his recliner, facing the door. He reported his right elbow and cheek hurt a little. He stated he was at the sink refilling his water glass when he got the shakes, and then just went down. Upon assessment, R28 had a slight redness noted on his right cheek. Two staff members assisted the resident to a standing position, then to his bed. He was shaky and not confident in his movement, but with encouragement and redirection, staff were able to get him stabilized and situated on the side of the bed. The staff explained to R28 that he needed to call for assistance when getting up to ambulate for the rest of the day, as he had complained of the shakes. The resident voiced his understanding. His call light was within reach on the side of his bed. Therapy services for continued evaluation and guidance with ADLs. R28's Electronic Health record (EHR) lacked evidence that a new intervention was implemented to prevent further falls. On 07/19/2025 at 10:18 PM, R28's EHR recorded an “Alert Charting for Fall follow-up” note that documented R28 stated he got tangled up in his catheter tubing. The investigation lacked consideration of the resident’s report of causative/contributing factors as part of the root cause analysis and lacked an associated intervention to prevent further falls. R28's “Progress Notes documented a note on 08/05/25 at 04:30 AM, which noted R28 sat on the floor near the restroom with his walker. The call light was attached to the pillow, and his bed was in the lowest position. R28 reported he was on his way to the restroom to have a bowel movement and lost his balance. Staff assisted the resident to the toilet and then to bed. Interventions directed staff to continue to remind resident to use the call light for assistance and therapy to continue to provide oversight, evaluation, and guidance. R28's EHR lacked evidence that a new intervention was implemented to prevent further falls. The Progress Notes documented a note on 08/21/25 at 04:15 PM that noted R28 attempted to transfer to the bathroom to have a bowel movement. He experienced tremors and lost his balance. The investigation lacked a root cause analysis and lacked a new appropriate intervention to prevent further falls. On 08/24/25 at 11:41 AM, R28 lay on his side on his bed with his legs over the side of the bed. He wore tennis shoes. Additionally, the resident’s catheter urine collection bag and tubing were positioned on the walker in the dignity bag. The resident reported he placed the collection bag in the dignity bag and then carried it when he went to the bathroom to have a bowel movement. On 08/25/25 at 11:48 AM, R28 lay in bed with a pillow roll behind his back. The catheter collection bag was positioned in a dignity bag with the tubing and bag hanging on his wheelchair beside the bed. On 08/25/25 at 11:54 AM, CNA M, entered R28’s room and asked him if she could help him with anything. R28 said no. CNA M asked if R28 wanted to go to the dining room for lunch, and he said yes. She asked if he wanted to go to the bathroom, but he said no. On 08/24/2025 at 11:41 AM, R28 stated he was supposed to turn on his call light when needing to go to the bathroom, but when he needs to go, he forgets to use his call light. He stated he had fallen going into the bathroom to have a bowel movement. He said he did not have to go to the bathroom for his bladder because the bag collected his urine. He said he did have trouble moving the bag and tubing, and he got tangled up sometimes. He said the bag is heavy when it is full. On 08/25/25 at 07:17 PM, R28’s representative said R28 had dementia, and his difficulty retaining instructions and limited safety awareness with toileting were concerning. She confirmed the facility was aware of the concerns related to the resident’s multiple falls. She stated R28 was supposed to have a catheter leg collection bag on during the day because he maneuvers his own catheter bag and tubing, and he gets tangled in it. On 08/25/25 at 11:54 AM, CNA M stated R28 was able to transfer himself with staff assistance when he gets shaky. She reported R28 knew when he needed to have a bowel movement and would turn on his call light for staff to walk with him to the bathroom. CNA M stated the resident was at risk for falls when he gets shaky, but he was good about letting the staff know when he needed to walk, and the staff assisted him to prevent him from falling. On 08/26/25 at 12:36 PM, Administrative Nurse E confirmed R28 was supposed to have a leg bag for urine collection for his catheter because the resident had fallen related to getting tangled in the catheter tubing and collection bag when transferring himself and toileting. She confirmed the care plan conference dated 08/21/25 included the discussion of the resident’s fall and review of the existing interventions. Administrative Nurse E said the use of a leg bag as a fall intervention was discussed and added to the Treatment Administration Record (TAR) on 08/22/25 to ensure staff would check for the leg bag placement. On review of the resident’s TAR, she confirmed the staff had signed the leg bag as used from 08/22/25 to current date, but said the leg bag had not been used because the resident refused, though it was not documented. Additionally, she verified the resident’s fall on 08/21/25 lacked a thorough investigation, with an intervention initiated to prevent further falls. On 08/26/25 at 12:56 PM, Administrative Nurse F confirmed on 08/21/25, staff identified concerns related to the resident’s multiple falls, and interventions were discussed during a care plan conference. She confirmed R28 had a diagnosis of dementia and often forgot to use his call light when going to the bathroom. Administrative Nurse F verified R28's Care Plan included to use a leg bag for the collection of urine from the catheter to prevent the resident from getting tangled in the straight drain urine collection bag and tubing when toileting himself. On 08/26/25 at 01:10 PM, Administrative Nurse F verified the staff had signed R28's TAR to indicate the resident had the leg bag in place, and he did not have a leg bag in place. She reported the direct care staff confirmed the leg bag had not been used as an intervention to prevent falls since 07/09/25. The facility policy titled Fall and Fall Risk, Managing F689” dated 06/2025, documentation included, “ . based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling.”

The facility reported a census of 43 resident. The sample included 12 residents with two residents sampled for pain management. Based on observation, interview, and record review, the facility failed to monitor, treat and provide interventions including medication and non-pharmacological measures to manage Resident (R) 28's pain in accordance with his goals and preferences. This deficient practice placed the resident at risk for unmanaged pain, a decline in function and impaired quality of life. Findings included- R28's Physician Orders dated 08/20/25, documented diagnoses of neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system,) hypertension (high blood pressure), type 2 diabetes (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), psychosis (any major mental disorder characterized by a gross impairment in reality perception)disturbances, mood and behavior disturbances), chronic kidney disease, abnormal posture, and repeated falls.R28's 03/02/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS noted R28 had no functional impairment in the range of motion (ROM) of his upper or lower extremities. He required supervision or touching and/or partial moderate assistance from staff for completion of activities of daily living (ADLs). The MDS noted R28 did not receive scheduled or as needed (PRN) medications for pain or non-medication interventions for pain. R28 received high-risk medications, which included opioids, during the look-back period. R28's Quarterly MDS dated [DATE] documented changes from the above MDS, which included a BIMS score of 11, indicating moderate cognitive impairment. R28 received PRN pain medication. He reported occasional pain that rarely interfered with sleep or his ADL. He continued to receive opioid medication during the look-back period.The Cognitive Loss/Dementia and Care Area Assessment, (CAA), dated 03/03/25, documented R28 had a BIMS score of 10 and required reminders and cues 10; He had periods of confusion. The Pain CAA did not trigger.R28's Care Plan dated 03/05/25 noted the resident had impaired cognitive function/ and directed staff to monitor, document, and report to the provider any changes in cognitive function, specifically changes in: decision-making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The plan directed staff to give medications as ordered. The care plan did not address the resident's pain or list non-pharmacological interventions to address pain.The Physician Order Sheet (POS) dated 08/20/25, included the following orders: Oxycodone ( opioid pain medication) 5 milligrams (mg), give half a tablet by mouth every six hours as needed for moderate to severe pain ordered 02/27/25.Acetaminophen 325 mg, two tablets by mouth every four hours for pain PRN, do not exceed 3 grams per day.R28's Medication Administration Record (MAR) dated 06/01/25 through 08/25/25, revealed R28's oxycodone was not administered.R28's MAR dated 06/01/25 through 08/25/25 documented the acetaminophen 325mg, two tablets, was given as follows:06/24/25 at 11:50 AM for pain rated a 7 out of 10 (0-10 scale where zero equals no pain and 10 equals the worst pain imaginable).06/30/25 at 08:32 AM, for pain rated 5.07/16/25 at 12:08 PM, for pain rated 5.08/05/25 at 11:00 AM, for pain rated 7.08/05/25 at 05:45 PM, for pain rated 8.08/06/25 at 012:48 PM, for pain rated 6.08/09/25 at 06:34 PM, for pain rated 6.08/10/25 at 00:17 AM, for pain rated 6.All the above pain medications were described as being effective.Review of R28's Mar or Treatment Administration Record (TAR) from 08/11/25 through 08/25/25 lacked indication the staff monitored, offered, or provided pain relief measures.On 08/25/25 at 11:48 AM, R28 laid in bed with a pillow roll behind his back. He reported he had pain in his back and beneath his right upper arm, but said he had not reported his pain to the staff. He turned his call light on. On 08/25/25 at 11:54 AM, Certified Nurse Aide (CNA) M entered R28's room and asked the resident if she could help him with anything. R28 said no. R28 did not report the presence of pain he had described six minutes earlier.On 08/25/25 at 11:59 AM, CNA M confirmed R28 did not report pain and said the resident did not recall why he had turned his call light on. CNA M reported the resident often complained of back pain, and the pillow that was behind his back was put there by the staff because it seemed to help. CNA M stated that when a resident reported pain, the staff would try to make the resident comfortable and notify the nurse, who should assess the resident. She confirmed R28 had dementia and sometimes forgot what he turned his light on for, but he would turn on his call light to let the staff know if he needed something. CNA M stated she would notify the nurse he reported pain. On 08/25/25 at 07:17 PM, R28's representative confirmed the facility was aware of the concerns related to R28's pain. She stated R28 would use his call light; however, he may forget why he turned the call light on for assistance, and if the staff does not specifically ask if he is having pain, he will not remember to tell them. R28's representative reported a meeting was held with the facility staff on 08/21/25, where they discussed the resident's increased pain. The staff agreed they would contact the physician to request acetaminophen on a scheduled basis rather than just upon request, since he could not remember to express to the staff when he had pain. R28's representative expressed concern that the pain would result in a decline in the resident's ability to ambulate and said he was using his wheelchair more often.On 08/26/25 at 12:36 PM, Administrative Nurse E confirmed that the care plan conference dated 08/21/25 included the discussion of the R28's pain and the request of his representative for the facility to contact the physician and ask for scheduled acetaminophen to manage the resident's pain. Additionally, upon review of R28's physician orders, progress notes, and care plan, Administrative Nurse E confirmed nothing had been done to address R28's pain in response to the concerns voiced by the resident's representative in the care plan conference on 8/21/25.On 08/26/25 at 12:56 PM, Administrative Nurse F confirmed the 08/21/25 care plan conference where staff identified concerns related to R28's pain and the interventions that were discussed. She confirmed the resident had a diagnosis of dementia and often forgot to use his call light. The facility policy titled F697, Pain Assessment and Management, dated 04/2025, documentation included discussion with the resident (or legal representative) his or her goals for pain management, and satisfaction with the current level of pain control. Staff should assess and re-assess the resident's pain and the consequences of pain upon admission, quarterly, and with new pain.

The facility reported a census of 43 resident; there were 12 residents in the sample. Based on observation, interview and record review the facility failed to maintain an infection program related to. Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resident organisms which employ targeted gown and glove use during high contact care) when providing dressing changes on a abdominal peritoneal dialysis (a home-based treatment for kidney failure that uses the patient's own abdominal lining as a filter to remove waste and excess fluid from the blood) catheter for Resident (R) 2. This placed the resident at risk for infection. Findings included:- R2's Physician Orders in the Electronic Medical Record (EMR) dated 08/19/25 revealed the following diagnoses: chronic kidney disease stage five (a condition where the kidneys gradually lose their ability to filter waste products from the blood) and type two diabetes (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R2's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R2 required supervision or touch assistance with activities of daily living (ADLs) and received peritoneal dialysis. R2's Quarterly MDS dated [DATE] documented no changes from the 12/01/24 MDS. R2's Care Plan dated 02/25/25 documented R2 has a dialysis catheter placement on 01/30/25. The plan directed staff to use Enhanced Barrier Precautions, and gowns and gloves should be worn during the following high-contact resident care activities: dressing, bathing or showering, transferring, providing hygiene, changing briefs or toileting, and wound care. On 08/25/25 at 08:15 AM, R2 was in the dining room for breakfast. R2 had a knee brace on the right knee. On 08/25/25 at 10:20 AM, R2 was in activities with the other residents playing a game. On 08/25/25 at 02:20 PM, Licensed Nurse (LN) G prepared the equipment to change R2's dressing over her peritoneal site on the lower left side of the resident's abdomen. LN G wore gloves during the procedure but did not wear a gown during the dressing change. On 08/25/25 at 03:37 PM, LN G stated she should have had a gown on before cleaning R1's catheter site. On 08/25/25 at 04:05 PM, Administrative Nurse D stated she expected staff to wear both gown and gloves for residents with EBP. The facility's policy Multidrug-Resistant Organism (MDRO) and Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident activities.

The facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to post Nurse Staffing information for Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, the resident census, and the total number of actual hours worked by each category, daily as required. Findings included: - Review of Daily Staff Posting Sheets, dated 07/01/24 through 12/31/24, and 08/15/25 through 08/25/25, revealed the facility lacked adjustment to the Daily Staff Posting Sheets, for actual staff hours worked versus scheduled hours worked by the direct care staff.On 08/26/25 at 10:36 AM, Administrative Staff B reported her responsibilities included to make sure all the lunches were removed for any hourly employee on a monthly basis and the nursing hours were accurately submitted to the corporate office. She verified she did not report or address the redesignation or call-in coverage otherwise.On 08/26/25 at 03:38 PM, Administrative Staff A confirmed the Daily Staff Posting Sheets, noted above, lacked documentation to reflect the adjustments for call-ins, meal breaks, and change in coverage. Additionally, he reported he was not aware that the Daily Staff Posting Sheets, should be adjusted to reflect changes in the scheduled direct care staff. The facility policy, Nursing Services F725, F726, dated 08/2025, documentation included the community provides adequate staffing with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

The facility reported a census of 40 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to ensure good infection control techniques for residents in the facility by the failure to change gloves and perform hand hygiene when going from soiled to clean while providing wound care for one resident, Resident (R18), and while providing incontinent care on residents and the failure to disinfect the full body mechanical lift after use on R7 who required use of the lift for transfers. Findings included: - Observation on 10/31/23 at 02:20 PM revealed Certified Nursing Assistant (CNA) E and CNA F entered R7's room. Both staff donned (applied) gloves. CNA E first took a tissue and wiped a large amount of mucous from the resident's left nostril. Staff pulled R7's covers down and the disposable brief the resident wore was untaped and pulled down in front. CNA E used wet wipes and spray cleaner to clean the resident's genital area in front, then both CNAs repositioned the resident, and CNA E proceeded to use wipes and spray to cleanse the resident's buttock and peri area. While wearing the same soiled gloves, CNA E obtained a clean brief and unfolded the brief. She then placed it to the back of the resident. The resident was then turned to his back and the brief was positioned into place and taped on the resident. CNA E then got a wet wipe (without changing her gloves from the perineal care) and proceeded to wipe the resident's nose again. Staff removed their gloves, and both CNAs opened the bedroom door and left the room, without hand hygiene. Interview on 10/31/23 at 02:35 PM, CNA E reported that was how she usually changed residents but then stated she maybe should have changed her gloves before she wiped the resident's nose. CNA E reported she did not think to perform hand hygiene after she removed her gloves. Observation on 11/01/23 at 01:02 PM, Certified Nursing Assistant (CNA) G and CNA H transferred R7 to bed using the Hoyer lift. The resident was placed in bed and turned to his left side to remove the sling. The resident was soiled, and his brief unfastened and removed. CNA G used wet wipes to clean the resident's buttocks of feces (bowel movement) while the resident laid on a cloth incontinent pad. She then placed a clean brief on the resident while he was still on the incontinent brief. Staff failed to change her gloves or provide hand hygiene after the incontinence care. The resident was then turned to the other side and CNA H removed the soiled incontinent pad and handed it to CNA G who then tossed it directly onto the bare floor. CNA H taped the resident's clean brief in place with no glove changing or hand hygiene. The resident was then pulled up in bed and repositioned. CNA H gathered the trash bag out of the can and placed a clean bag in the can with same gloves. She then picked up the soiled pad off the floor and left the room with her soiled gloves on. CNA G removed her gloves and lacked hand hygiene before moving R7's wheelchair out of the way of the lift. CNA G then propelled the mechanical lift to the hall into a cubby storage for the lifts. Staff failed to disinfect the mechanical lift after use. Interview on 11/01/23 at 01:25 PM, CNA G stated she did not think to change gloves or clean hands after she removed her gloves. She verified she always put the soiled pads on the floor. She did not know she had to clean the lift after using it on a resident and had not done that when she used the lift on any resident. On 11/01/23 at 01:40 PM, Administrative Nurse B reported she expected the staff to change gloves and perform hand hygiene when going from soiled to clean when providing incontinent care on a dependent resident. Staff were not to place soiled items directly on the floor. In addition, Administrative Nurse B reported mechanical lifts should be cleansed between resident use. The facility's policy for Handwashing/Hand Hygiene dated 09/23, revealed hand hygiene needed to be completed after removal of gloves. A policy for glove usage requested on 11/01/23 with no policy provided. The facility's policy for Cleaning and Disinfection of Resident-Care Items and Equipment dated 09/23, revealed durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. The facility failed to ensure infection control techniques for residents in the facility by the failure to change gloves and perform hand hygiene when going from dirty to clean while providing incontinent care on residents and the failure to disinfect the mechanical lift after use on R7 who required use of the lift for transfers. 46960 - The 10/30/23 Electronic Health Records (EHR) documented that Resident (R18) had the pertinent diagnosis of Diabetes Mellitus Type 2 (DM2 - when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). The 06/23/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition. R18 was at risk for impaired skin integrity and had an open lesion. The 06/23/23 Pressure Ulcer/Injury Care Area Assessment (CAA) documented an old wound behind her knee which required treatment. R18's physician order included staff to cleanse wound with a generic wound cleaner, pat dry, apply skin prep (a solution, when applied to the skin, forms a protective waterproof barrier on the skin), fill the wound bed with calcium alginate (a dressing placed into a wound bed that promotes wound healing), cover with border gauze (a specialized dressing placed over chronic or large wounds that contains three specialized layers that are non-adherent, highly absorbent, and waterproof), daily, ordered 10/04/23. On 11/01/23 at 01:35 PM, Administrative Nurse C performed wound care on R18's chronic wound on her left leg. Administrative Nurse C performed hand hygiene, applied gloves and removed the soiled dressing, then discarded the soiled dressing in the trash can and removed her gloves. Administrative Nurse C applied new gloves, however, failed to perform hand hygiene before applying new gloves. Administrative Nurse C then cleaned R18's wound with a commercially available wound cleanser and gauze, discarded the soiled gauze in a trash can and removed her gloves, and applied new gloves, without hand hygiene. Administrative Nurse C then wiped around the wound with skin prep and placed calcium alginate into the wound bed then removed her gloves, failed to perform hand hygiene and did not apply new gloves, then placed a border gauze dressing. Administrative Nurse C then performed hand hygiene. On 11/01/23 at 01:47 PM, Administrative Nurse C acknowledged the lack of appropriate hand hygiene between the different phases of wound care and lack of gloves when applying the final dressing to the wound. Administrative Nurse C stated that hand hygiene should have been performed when gloves were changed and that gloves should have been worn when placing the final dressing. On 11/01/23 at 02:10 PM, Administrative Nurse B stated that the expectation for the staff was to change gloves and perform hand hygiene when going from dirty to clean phases of wound care. The facility failed to provide a policy related to glove use as requested on 11/01/23. The facility failed to provide a policy related to wound care as requested on 11/01/23. The facility's Infection Control policy dated 10/2022, documented that the facility would maintain practices to prevent the spread of communicable and contagious diseases and would follow accepted national standards such as those from the Centers for Disease Control (CDC - a national public health agency of the United States and federal agency under the Department of Health and Human Services). The facility failed to ensure appropriate hand hygiene and glove use during wound care. This deficient practice had the potential to lead to delayed wound healing and spread of communicable and contagious diseases in the facility.

The facility reported a census of 40 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one sampled resident, Resident (R)35, related to the use of the resident's continuous positive airway pressure (CPAP, a non-invasive mechanical ventilator that provides respiratory support to decrease the work of breathing) machine. This placed the resident at risk for uncommunicated care needs. Findings include: - The 02/27/23 Electronic Health Records (EHR) documented R35 had the following diagnoses that included echinococcus granulosis infection of the lung (a parasitic infection that causes cysts and tumor-like growths), malignant neoplasm (cancer) of the lower respiratory tract (lung) and pneumonitis (inflammation of lung tissue) due to inhalation of solids and liquids. The 09/28/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R35 required limited or extensive assistance of two staff for all cares except eating which required supervision and setup. The assessment documented that R35 did not receive oxygen or non-invasive mechanical ventilator (CPAP) use. The 09/28/23 Care Area Assessment (CAA) lacked documentation related to oxygen therapy or CPAP use. The 10/31/23 Care Plan documented the resident had chronic lung disorders and instructed staff to give oxygen therapy as ordered by the physician. The care plan lacked instructions related to CPAP use. The Physician Orders in the EHR lacked orders related to oxygen therapy or CPAP use. The 09/27/23 to 10/31/23 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation related to administration of oxygen, changing of oxygen tubing, care of oxygen concentrator or humidifier, administration of CPAP use and care of CPAP equipment. The Progress Notes documented the following: 1. On 10/04/23 at 02:20 AM, R35 used the CPAP. 2. On 10/18/23 at 08:15 PM, R35 used the CPAP and oxygen per physician order. 3. On 10/19/23 at 11:13 PM, R35 used the CPAP and oxygen. 4. On 10/20/23 at 04:30 AM, the resident's CPAP was in place and functioning. 5. On 10/21/23 at 08:13 PM, R35 used the CPAP at night. 6. On 10/22/23 at 08:18 PM, R35 used the CPAP at night. 7. On 10/23/23 at 09:15 PM, the resident's CPAP was in place while sleeping. 8. On 10/24/23 at 12:00 AM, R35 used oxygen and the CPAP. 9. On 10/25/23 at 12:45 AM, R35 removed the CPAP to take a medication. 10. On 10/28/23 at 07:47 PM, the resident's CPAP and oxygen was in place. 11. On 10/29/23 at 12:23 AM, R35 was in her recliner with the CPAP in place. 12. On 10/30/23 at 08:47 PM, R35 utilized the CPAP while at rest. 13. On 10/31/23 at 05:34 AM, R35 was in the recliner with the CPAP in place. On 10/30/23 at 11:42 AM, R35 observed to be sitting in her recliner with the CPAP machine on her over-the-bed table next to her recliner with the tubing and the mask intact and stored beside the CPAP machine. R35 had her oxygen therapy via nasal cannula. On 10/31/23 at 08:34 AM, R35 observed to be in her recliner. The CPAP machine observed on the over-the-bed table next to her recliner with the tubing and the mask intact. R35 had her oxygen on via nasal cannula. On 11/01/23 at 09:59 AM, R35 observed to be sitting in her recliner. The CPAP machine remained on her over-the-bed table next to her recliner with the tubing and the mask intact. R35 had her oxygen on via nasal cannula. On 10/31/23 at 02:51 PM, R35 revealed that she utilized the CPAP and oxygen therapy in the hospital prior to being admitted to the facility. R35 further stated that staff had not performed any cleaning or maintenance to the CPAP machine since she came to the facility (09/27/23). On 10/31/23 at 03:10 PM, Certified Nurse Aide (CNA) F revealed that R35 required oxygen and had no experience with assisting R35 with her CPAP mask as the resident only wore it at night. On 10/31/23 at 03:20 PM, Licensed Nurse (LN) I revealed R35 wore the CPAP at night while sleeping and required oxygen all the time. Stated that the CPAP tubing was configured to deliver oxygen therapy as well. On 10/31/23 at 03:55 PM, Administrative Nurse D, revealed that information from MDS assessments was gathered from various parts of the EHR that included progress notes and nursing assessments as well as visual assessments of the resident performed by Administrative Nurse D. Administrative Nurse D confirmed that the MDS assessment dated [DATE] lacked documentation of oxygen therapy and CPAP use. On 11/01/23 at 02:14 PM, Administrative Nurse B revealed that her expectation was for all assessments including MDS assessments to be accurate. The facility's Comprehensive Assessment policy dated 08/2022, documented that residents would receive an accurate assessment reflective of the resident's status at the time of the assessment by staff who were qualified to assess and knowledgeable about the resident's status. The facility failed to accurately complete the MDS for R35 related to oxygen and CPAP use. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 40 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan for Resident (R)35, related to the use of the resident's continuous positive airway pressure (CPAP, a non-invasive mechanical ventilator that provides respiratory support to decrease the work of breathing) machine. This placed the resident at risk for uncommunicated care needs. Findings include: - The 02/27/23 Electronic Health Records (EHR) documented R35 had the following diagnoses that included echinococcus granulosis infection of the lung (a parasitic infection that causes cysts and tumor-like growths), malignant neoplasm (cancer) of the lower respiratory tract (lung) and pneumonitis (inflammation of lung tissue) due to inhalation of solids and liquids. The 09/28/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R35 required limited or extensive assistance of two staff for all cares except eating which required supervision and setup. The assessment documented that R35 did not receive oxygen or non-invasive mechanical ventilator (CPAP) use. The 09/28/23 Care Area Assessment (CAA) lacked documentation related to oxygen therapy or CPAP use. The 10/31/23 Care Plan documented the resident had chronic lung disorders and instructed staff to give oxygen therapy as ordered by the physician. The care plan lacked instructions related to CPAP use. The Physician Orders in the EHR lacked orders related to oxygen therapy or CPAP use. The 09/27/23 to 10/31/23 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation related to administration of oxygen, changing of oxygen tubing, care of oxygen concentrator or humidifier, administration of CPAP use and care of CPAP equipment. The Progress Notes documented the following: 1. On 10/04/23 at 02:20 AM, R35 used the CPAP. 2. On 10/18/23 at 08:15 PM, R35 used the CPAP and oxygen per physician order. 3. On 10/19/23 at 11:13 PM, R35 used the CPAP and oxygen. 4. On 10/20/23 at 04:30 AM, the resident's CPAP was in place and functioning. 5. On 10/21/23 at 08:13 PM, R35 used the CPAP at night. 6. On 10/22/23 at 08:18 PM, R35 used the CPAP at night. 7. On 10/23/23 at 09:15 PM, the resident's CPAP was in place while sleeping. 8. On 10/24/23 at 12:00 AM, R35 used oxygen and the CPAP. 9. On 10/25/23 at 12:45 AM, R35 removed the CPAP to take a medication. 10. On 10/28/23 at 07:47 PM, the resident's CPAP and oxygen was in place. 11. On 10/29/23 at 12:23 AM, R35 was in her recliner with the CPAP in place. 12. On 10/30/23 at 08:47 PM, R35 utilized the CPAP while at rest. 13. On 10/31/23 at 05:34 AM, R35 was in the recliner with the CPAP in place. On 10/30/23 at 11:42 AM, R35 observed to be sitting in her recliner with the CPAP machine on her over-the-bed table next to her recliner with the tubing and the mask intact and stored beside the CPAP machine. R35 had her oxygen therapy via nasal cannula. On 10/31/23 at 08:34 AM, R35 observed to be in her recliner. The CPAP machine observed on the over-the-bed table next to her recliner with the tubing and the mask intact. R35 had her oxygen on via nasal cannula. On 11/01/23 at 09:59 AM, R35 observed to be sitting in her recliner. The CPAP machine remained on her over-the-bed table next to her recliner with the tubing and the mask intact. R35 had her oxygen on via nasal cannula. On 10/31/23 at 02:51 PM, R35 revealed that she utilized the CPAP and oxygen therapy in the hospital prior to being admitted to the facility. R35 further stated that staff had not performed any cleaning or maintenance to the CPAP machine since she came to the facility (09/27/23). On 10/31/23 at 03:10 PM, Certified Nurse Aide (CNA) F revealed that R35 required oxygen and had no experience with assisting R35 with her CPAP mask as the resident only wore it at night. CNA F revealed that she did not know if oxygen was on the care plan and said that the CPAP was on the care plan. On 10/31/23 at 03:20 PM, Licensed Nurse (LN) I revealed R35 wore the CPAP at night while sleeping and required oxygen all the time. Stated that the CPAP tubing was configured to deliver oxygen therapy as well. On 10/31/23 at 03:55 PM Administrative Nurse D confirmed that the comprehensive care plan lacked documentation of oxygen therapy and CPAP use. On 11/01/23 at 02:14 PM, Administrative Nurse B revealed that her expectation was the care plans to be complete with all interventions. The facility's Comprehensive Care Plans policy dated 08/2022, documented that the facility would develop an individualized care plan based on a thorough assessment. The facility failed to develop a person-centered comprehensive care plan for R35 related to oxygen therapy and CPAP use. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 40 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to address edema (swelling resulting from an excessive accumulation of fluid in the body tissues) for Resident (R) 140's lower extremities. This deficient practice had the potential to place R140 at an increased risk for development of additional medical problems. Findings included: - R140's Electronic Medical Record (EMR) included a diagnosis of congestive heart failure (CHF - a condition with low heart output and the body slowly becomes congested with fluid), localized edema and diabetes mellitus, type 2 (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The 10/23/23 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. No behaviors documented with rejections of cares. R140 received a diuretic (a class of medications used promote the formation and excretion of urine) medication during look-back period. The 10/23/23 Care area assessment (CAA) lacked documentation related to lower extremity edema. The 10/30/23 Care Plan lacked documentation related to lower extremity edema. The Physician's orders included Lasix (furosemide - a diuretic) 40 milligrams (mg) once daily, related to localized edema, ordered 10/17/23. Review of the Progress Notes from 10/16/23 to 10/30/23, lacked documentation of lower extremity edema. The EHR Assessments documented: 1. On 10/23/23 at 09:19 PM, a weekly skin assessment performed by Licensed Nurse (LN) J documented No to the question if the resident currently had edema to lower extremities. 2. On 10/30/23 at 01:47 PM, a weekly skin assessment performed by Administrative Nurse C documented No to the question if the resident currently had edema to lower extremities. On 10/30/23 at 10:36 AM (three hours and 11 minutes before the 10/30/23 weekly skin assessment), R140 observed seated in his recliner with his legs elevated and swelling observed to both lower legs with a shiny appearance and a rust-colored discoloration to the skin. On 10/31/23 at 08:01 AM, R140 observed seated in the dining area with other residents present, both ankles visible with shiny appearance and rust-colored discoloration to his skin. On 10/31/23 at 09:55 AM, R140 observed in his recliner with his legs elevated and swelling observed to both lower legs with a shiny appearance and a rust-colored discoloration to the skin. On 11/01/23 at 10:00 AM, R140 observed in his recliner with his legs elevated and swelling continued to both lower legs with a shiny appearance and a rust-colored discoloration to his skin. On 10/30/23 at 10:40 AM, R140 revealed that his legs had been swollen and discolored for a while but was unable to specify how long. On 10/31/23 at 03:10 PM, Certified Nurse Aide (CNA) F revealed that she did not know of any interventions for R140's lower extremity edema other than to remind him to elevate his legs as much as practical. On 10/31/23 at 03:20 PM, LN I stated she was unaware of any edema to R140's lower extremities. LN I assessed R140's legs and reported R140's legs had grade three (moderate or approximately six millimeter [mm] indent with mild pressure [lasting five seconds] that remained present for approximately 30 seconds after release) pitting edema. On 10/31/23 at 03:41 PM, Administrative Nurse B stated that she was unaware of R140's edema and stated that her expectation was for skin assessments to be accurate. The facility failed to address edema of R140's lower extremities. This deficient practice had the potential to place R140 at an increased risk for development of additional medical problems.

The facility reported a census of 34 residents. Based on record review and interview, the facility failed to ensure ongoing antibiotic stewardship to ensure appropriate antibiotic use. Findings included: - Review of the notebook containing a log of infection tracking for January 2022, revealed a Physician Order, dated 01/05/22, instructed staff to administer to resident (R)24, [MEDICATION(S)] (anantibiotic) 500 milligrams (mg), twice a day, for urinary tract infection, but lacked culture results. This resident's medical record lacked the IDT (Inter Departmental Team) assessment for antibiotic use compliance utilizing assessment tools such as Loeb's ( a criteria with a minimum set of signs and symptoms which when met indicate that the resident likely has an infection and antibiotics may be indicated) or McGeer's criteria (a tool used for identification of symptoms of infection for antibiotic use.) Review of the infection tracking log for February 2022, revealed two unsampled residents admitted to the facility from acute care on antibiotics for urinary tract infections, but lacked identification of organisms. Review of the infection tracking log for March 2022 revealed one unsampled resident admitted from acute care on antibiotics for a urinary tract infection but lacked identification of organisms. A Physician Order, dated 03/31/22 instructed staff to administer to R 14, [MEDICATION(S)], 500 mg, three times a day, for urinary tract infection, but lacked the IDT assessment for antibiotic use compliance. Review of the infection tracking log for April 2022, revealed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Note, dated 04/07/22, documented the resident had a large amount of white discharge from his penis. The resident's medical record lacked IDT assessment for antibiotic use compliance. Review of the infection tracking log for April 2022, revealed a Physician Order, dated 04/12/22, instructed staff to administer to R 18, [MEDICATION(S)] (an antibiotic,) 500 mg, three times a day, for ten days for urinary tract infection. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R 18's medical record lacked the IDT assessment for antibiotic use compliance. Interview, on 04/13/22 at 3:30 PM, with Licensed Nurse (LN) H, revealed she utilized standard of care assessment for residents with a change in condition. LN H stated she did not know about specific criteria for infection assessment documentation in the electronic medical record. Interview, on 04/14/22 at 10:30 AM, with LN G, revealed she uses general nursing assessment for a resident's change in condition and did not know specific criteria for documentation in the electronic medical record. Interview, on 04/14/22 at 10:45 AM, with Administrative Nurse E, confirmed lack of cultures/results and lack of IDT review for compliance with antibiotic stewardship. Interview, on 04/14/22 at 11:30 AM, with Administrative Nurse D, revealed she would expect staff compliance with the antibiotic stewardship program. The facility policy Infection Control Program- Antibiotic Stewardship F881 instructed staff that the infection prevention and control program included protocols to establish a system for the use and monitoring of adverse effects of antibiotics such as Loeb Criteria for the initiation of antibiotics and McGeer Criteria for infection surveillance. The facility failed to ensure an ongoing antibiotic stewardship program to monitor infections including culture results to determine organism prevalence in the facility and antibiotic appropriateness to prevent the adverse effects of antibiotics.

The facility reported a census of 34 residents with 15 residents sampled, including two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure appropriate safety measures were used while staff ambulated Resident (R)133. The resident fell and received a skin tear to the resident's right wrist. Findings included: - Resident (R)133's electronic medical record (EMR), under the Med Diagnosis tab, included: [CONDITION(S)] (CHF) -a condition with low heart output and the body becomes congested with fluid) and altered mental status (an abnormal state of alertness or awareness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He required limited assistance of one staff for walking in his room. His balance was not steady and he was only able to stabilize with staff assistance. He had no impairment in functional range of motion (ROM). He had one fall with an injury since admission to the facility. The Falls Care Area Assessment (CAA), dated 04/07/22, documented the resident was at risk for falling and had a fall since admission. The care plan for falls, dated 04/03/22, instructed staff that the resident had impaired cognition, an unsteady gait and difficulty with balance. The resident was able to ambulate short distances with the use of his front wheeled walker and a gait belt. Review of the resident's EMR, under the Assessments tab, included a fall assessment, dated 03/30/22, which placed the resident at a high risk for falls. Review of the resident's EMR, under the Progress Notes tab, dated 04/03/22, included documentation that the resident had been ambulating with a staff member and his walker, when he became weak and was assisted to the floor. The resident received a skin tear to his right wrist which measured 1.5 by 3.6 centimeters (cm). The staff had not been using a gait belt while ambulating the resident and the nurse gave immediate re-education to the staff member of the importance of always using a gait belt while ambulating a resident. On 04/13/22 at 10:48 AM, Certified Nurse Aide (CNA) P and N transferred the resident from his bed to the wheelchair with the use of a gait belt and extensive assistance of two staff. The resident was able to bear weight and pivot during the transfer without difficulty. On 04/13/22 at 10:48 AM, CNA P stated, staff were to always use a gait belt while transferring the resident as he was weak at times. On 04/13/22 at 01:08 PM, CNA N stated, the resident required more assistance with ambulating at times, depending on the day. Staff would always use a gait belt to ensure his safety. On 04/14/22 at 07:53 AM, Licensed Nurse (LN) G stated, the staff are to use a gait belt while transferring and ambulating all residents. On 04/14/22 at 10:21 AM, Administrative Nurse D stated, the CNA who was ambulating with the resident at the time of the fall on 04/03/22 was not utilizing a gait belt. It was the expectation that a gait belt be used at all times while ambulating with the resident. The facility policy for Falls and Fall Risk Management, dated 04/22, included: The Interdisciplinary Team (IDT) will identify and implement relevant interventions to try to minimize serious consequences of falling. The facility failed to use appropriate safety measures while ambulating with this dependent resident, which resulted in a fall. The resident received a skin tear to his right wrist.

The facility reported a census of 34 residents with 15 residents sampled, including one Resident (R)23 reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to toilet this dependent resident, as care planned. Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The resident required extensive assistance of two staff for toileting. She was incontinent of bladder and frequently incontinent of bowel. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 03/22/22, documented the resident relied on the staff for toileting and proper perineal (peri) care. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential CAA, dated 03/22/22, documented the resident was able to voice her needs appropriately but was not always able to ask for help due to dementia (progressive mental disorder characterized by failing memory, confusion). The quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She required extensive assistance of one staff for toileting. She was frequently incontinent of bladder and always incontinent of bowel. The care plan for toileting, dated 04/06/22, instructed staff to toilet the resident upon awakening, after meals and at bedtime. Review of the resident's electronic medical record (EMR), under the Tasks tab, included: the resident required limited to extensive staff assistance of one to two staff for toileting. She had episodes of bladder continence and incontinence. The resident's EMR lacked a 72- hour voiding diary. On 04/12/22 at 08:31 AM, Certified Nurse Aide (CNA) O, took the resident from the dining room to her room following breakfast. CNA O transferred the resident from the wheelchair to the bed. CNA O failed to offer the resident a toileting opportunity. On 04/13/22 at 11:09 AM, CNAs N and P entered the resident's room to get her up for lunch. The resident slept in her bed between breakfast and lunch. CNAs provided peri care due to the resident having been incontinent of urine in her brief. The staff failed to offer a toileting opportunity to the resident. On 04/12/22 at 08:31 AM, CNA O stated, she did not offer to toilet the resident before putting her into bed following breakfast. Staff were to toilet the resident before and after each meal. On 04/13/22 at 09:46 AM, CNA M stated, staff were to toilet the resident every two hours, but would sometimes just change her brief instead of toileting her. On 04/14/22 at 09:27 AM, CNA Q stated, the resident was usually continent when staff would toilet her. Staff were to toilet the resident every two hours. On 04/14/22 at 07:53 AM, Licensed Nurse (LN) G stated, staff were to toilet the resident upon awakening, before and after meals and anytime staff got her up from bed. The resident was often incontinent but could be continent when taken to the toilet in the bathroom. The facility did not complete a three -day voiding diary to determine her voiding pattern. On 04/13/22 at 02:47 PM, Administrative Nurse D stated, the facility did not have a three- day voiding diary for the resident. Staff were to take the resident to toilet every two hours. The facility policy for Urinary Continence and Incontinence, dated 04/2022, included: The nursing staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The facility failed to toilet this dependent resident, as care planned.

The facility reported a census of 32 residents. Based on observations and interviews the facility failed to store and prepare food under sanitary conditions in the kitchen for the residents in the facility. Findings included: - The following environmental kitchen tour, on 9/21/20 at 8:13 AM, revealed the following areas or items of concerns; 1. The Sunfire oven contained an excessive grease and grime build-up on the doors and the hinges. 2. The Vulcan cook stove contained an excessive grease and grime build-up on the doors and door handles, as well as both sides of the oven. 3. The Frame around the ventilation hood above the Vulcan cook stove, contained excessive paint chipping. On 09/22/20 at 01:48 PM, Administrative Staff A and Maintenance Staff U both were unaware of the areas of concerns found in the kitchen. The facility's Kitchen policy, revised 11/2017, included that the facility shall keep the food service areas and equipment in clean, good repair and free from chipped areas that may affect their use or proper cleaning. The facility failed to store and prepare food under sanitary conditions in the kitchen for the residents in the facility.

The facility reported a census of 32 residents. Based on observation and interview, the facility failed to maintain a safe, clean and sanitary environment in the kitchen for the residents in the facility. Findings included: - The following environmental kitchen tour, on 9/21/20 at 08:13 AM, revealed the following areas or items of concerns; 1. The ceiling over the sink, next to the dishwasher, contained a white vent that hung downward away from the ceiling, with a rust colored substance on it. 2. In the middle of the kitchen, next to the preparation sink, were cabinets with two green drawers and three green doors which all contained excessive paint chipping over the outsides. 3. The Aide preparation area, contained cabinets with two green sliding doors and three drawers which all contained excessive paint chipping over the outsides. On 09/22/20 at 01:48 PM Administrative Staff A and Maintenance Staff U both were unaware of these environmental concerns in the kitchen areas. The facility lacked a policy for safe, clean and sanitary environment in the facility's kitchen. The facility failed to maintain a safe, clean, and sanitary environment in the kitchen for the residents in the facility.

The facility reported a census of 32 residents with 15 sampled for review. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for one Resident (R)31 of the 15 sampled resident, to include Diabetes Mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Findings included: - The signed Physician order [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She needed one-person physical assistance for bed mobility, transfers, walking in room, locomotion, dressing, toileting and personal hygiene. She was on insulin (used to treat diabetes to regulate the amount of glucose in the blood) for seven days of the look back period. The discharge MDS, dated [DATE], documented a return anticipated. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 07/16/2020, documented the resident requires one-person physical assistance for all ADL's. She was alert and oriented with pleasant confusion. The care plan, dated 07/08/2020, lacked documentation for instructions for the care for this resident related to the [DIAGNOSES REDACTED]. The PO dated 09/11/2020, had the following orders; On 07/07/2020, [MEDICATION NAME] (an oral medication that helps control blood sugar levels) extended release, 24 hours, five milligram (mg) daily for DM. On 08/26/2020, [MEDICATION NAME] FlexTouch (a long acting insulin used to improve blood sugar control) injector, six units, subcutaneous at bedtime for DM. On 8/24/2020 at 12:50 PM, the EMR (electronic medical record), documented staff observed R31 for increased confusion, skin was warm and clammy (unpleasantly damp and sticky or slimy to touch), and with the blood sugar (BS) checked at 12:40 PM and recorded elevated at 411. The staff notified the physician and received a new order for [MEDICATION NAME] 10 units, and to follow up in one hour. On 8/24/2020 at 02:37 PM, the EMR documented the staff rechecked the resident's BS at 12:45 PM, and the BS resulted at 518. The staff notified the physician notified with 10 units of [MEDICATION NAME] given. Staff rechecked the BS again at 14 :00 PM, with the BS results of 513. The staff notified the physician, and received an order to send R31 by EMS (Emergency Medical Services) to the hospital. On 8/25/2020 at 04:03 PM, the EMR documented R31 admitted to the hospital with [REDACTED]. On 09/23/2020 at 01:43 PM, LN (Licensed Nurse) G confirmed there was no care plan instructions for DM for this resident. On 09/24/2020 at 11:39 PM, Administrative Nurse D confirmed that it was her expectation that there should have been a nursing care plan with instructions for DM for this resident. The Care Plan policy, dated 01/2020, instructs the care plan of an individual is person centered care that included measurable objectives to meet the medical needs is developed for each individual. It should incorporate identified problem area and reflect treatment goals, timetables and objectives in measurable outcomes and aide in preventing or reducing declines in the resident's functional status. The comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment. The facility failed to develop a comprehensive care plan related to DM, for this resident who had DM and required hospitalization for elevated blood glucose readings.

The facility reported a census of 32 residents with 15 sampled for review. Based on observation, interview, and record review the facility failed to review and revise the plan of care for one Resident (R) 12, of the sampled residents to include instructions to staff for adequate sanitation of oxygen equipment to prevent respiratory infections. Findings included: - The signed Physician order [REDACTED]. leads to a build-up of fluid in the lungs and surrounding body tissues). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required extensive two-person assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She used oxygen with breathing. The Quarterly MDS, dated [DATE], documented the resident with a BIMS of 14, indicating cognition intact. There were no changes in ADLs and she continued with the use of oxygen. The care plan, dated 09/08/2020, document orders for oxygen at two liters (L) per nasal cannula (nc- a tubing for oxygen delivery through the nose), to be worn at bedtime. However, the care plan lacked any other instructions to the staff related to adequate sanitation of the oxygen equipment, to prevent respiratory infections. A physician order, dated 05/23/18, instructed the staff to provide the resident with oxygen at two L, via nc at bedtime. On 09/21/2020 at 02:31 PM, the resident rested in the bed. The resident's coiled oxygen tubing rested directly on the floor and unbagged. On 09/22/2020 at 07:57 AM, the resident's oxygen tubing remained directly on the floor unbagged. On 09/23/2020 at 08:11 AM, the resident sat in a recliner eating breakfast. The resident's oxygen tubing remained directly on the floor. On 09/21/2020 at 12:55 PM, R12 stated she uses oxygen each night but was unable to reach the oxygen tubing while in bed. The staff would take it from her in the bed and put it onto the oxygen concentrator. On 09/23/2020 at 12:13 PM, Certified Nurse Aide (CNA) NN stated the tubing and cannula are to be kept in a bag next to the humidifier. It should never be on the floor. On 09/32/2020 at 01:43 PM, Licensed Nurse (LN) G confirmed that the resident's oxygen tubing should never be on the floor but in a dated bag on the oxygen concentrator. The facility lacked a policy for oxygen tubing. The facility failed to review and revise the resident's care plan to include instructions for the sanitary oxygen usage to prevent respiratory infections for the resident.

The facility reported a census of 32 residents with 15 residents sampled, including five sampled for review of accidents. Based on observation, interview and record review, the facility failed to implement planned interventions to prevent further falls for one of the five sampled residents, Resident (R) 83, and failed to implement interventions with foot rests on the wheelchairs while being propelled by staff, for two of the five sampled residents, R20 and R11, who required them to prevent falls from the wheelchairs. Findings included: . The signed Physician order [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He required limited assistance of one for bed mobility, transfers, walking, locomotion, toileting, and personal hygiene. His balance was unsteady and was able to stabilize without staff assistance. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/19/2019, documented the resident was at risk for increased confusion, falls, and injuries related to decreased safety awareness. He had memory and recall deficits, contributing factors of dementia. The Activity of Daily Living (ADLs) Functional/Rehabilitation CAA, dated 12/19/2010, documented R83 was at risk for falls, had increased unrelieved pain, and decreased range of motion. The Quarterly MDS, dated [DATE], documented the resident had severely impaired cognition, He needed extensive, two-person assistance for bed mobility, transfers, and toileting. He needed extensive one-person assistance for locomotion, dressing, and personal hygiene. His balance was unsteady and he was only able to stabilize with human assistance. He had impaired range of motion to one side of a lower extremity and used a walker and a wheelchair. He had a recent surgery with repair of a fractured pelvis, hip, leg, knee or ankle, and required active skilled care. The Falls care plan, dated 09/08/2020, documented on 02/05/2020, the resident was at risk for falls due to the desire to ambulate independently and not requesting help. Staff were to ensure proper footwear such as nonskid shoes or socks when he ambulated. A fall investigation, dated 05/21/2020 at 11:45 AM, revealed the resident fell in the bathroom and stated he was trying to go to the bathroom. He fell due to his foot slipping due to improper footwear. The staff added an intervention to remove his regular socks removed from his room, and put in a work order for non skid strips to be placed in front of the toilet. (During the survey process there were no non-skid strips in the bathroom.) On 05/21/2020, the care plan documented the resident fell with an intervention to place non-skid strips on his the bathroom floor in front of the toilet. On 05/28/2020, the care plan documented a fall resulted in a laceration to his left ear and left arm. Physical therapy and Occupational therapy were to evaluate him for strengthening and balance. The room was de-cluttered and staff placed his most used items within his reach, with the urinal being made available. The staff placed colorful signs in his room and bathroom to remind the resident to use the call light for assistance. A fall investigation, dated 05/29/2020, documented the resident fell beside his bed. He stated he had gone to the bathroom and was coming back. He was sent to the emergency room for further evaluation as he was feeling dizzy. To prevent further falls, the staff decluttered his room and rearranged the furniture. The staff received an order for [REDACTED]. (Already implemented on 05/28/2020) Staff posted signs as visual cues to remind the resident to call for assistance. However, the facility staff failed to complete a fall assessment following this fall to ensure appropriate interventions. A fall investigation, dated 07/07/2020 at 06:30 AM, documented the resident fell in the hallway and his wheelchair was found sitting outside of the bathroom door facing the entryway. The resident sustained [REDACTED]. On 07/07/2020, the care plan documented the resident had a fall which required hospitalization . He had gotten up from his wheelchair without assistance and fell . The staff placed anti-rollbacks on his wheelchair. Observations, during the survey process revealed the resident's bathroom floor lacked the (05/21/2020) planned non-skid strips to prevent further falls. On 09/23/20 at 12:13 PM, Certified Nurse Aide (CNA) NN stated this resident was one of the first residents to be assisted to toilet and lay down after meals. The wheelchair could not be left next to his bed as he would self-transfer. On 08/23/2020 at 01:43 PM, Licensed Nurse (LN) G confirmed the facility did not do fall assessments following a fall. She stated that when a resident falls the nurse completed an assessment and if there was an injury, give the resident first aide. The nurse would then fill out a risk management form in the electronic medical record and put in a new intervention for falls to decrease the risk of him falling again. This resident's planned interventions for falls were to include the call light within his reach, the bed in the low position, a reminder sign, anti-tips on his wheelchair and a grab bar on the bed for stabilization. On 09/24/20 at 09:17 AM, Administrative Nurse D stated it would be her expectation that there be strips on the floor of the bathroom as care planned (05/21/2020). The facility policy for Assessing Falls and Their Causes, included: When a resident falls the staff will complete a fall risk assessment and ensure appropriate interventions are taken to prevent future falls. The facility failed to implement the planned intervention of placing non-skid strips on the resident's bathroom floor and failed to complete a fall risk assessment after falls to ensure appropriate interventions were taken to prevent future falls for the resident. The signed Physician order [REDACTED].#20, dated 09/11/2020, documented the resident with the following Diagnoses: [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of nine, indicating severely impaired cognition. She required extensive assist of one for bed mobility, transfers, locomotion and personal hygiene. She was unsteady and only able to stabilize with human assistance. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/30/2020, documented the resident has a [DIAGNOSES REDACTED]. Scored a nine on her BIMS interview. She was able to communicate needs and wants to staff verbally. The Activity of Daily Living Functional (ADLs) /Rehabilitation CAA, dated 03/30/2020, documented R20 required extensive assistance of one staff member for most ADL's. The Quarterly MDS, dated [DATE], documented the resident with a BIMS score of 11, indicating moderately impaired cognition. She had disorganized thinking present and required extensive one-person assistance for all ADL's. Review of Electronic Medical Record (EMR), Task tab, revealed the resident used a wheelchair for locomotion and required a range of staff assistance, ranging from supervision to extensive assistance of one staff for locomotion on the unit. On 09/23/20 at 09:45 AM, Certified Nurse Aide (CNA) NN went into the resident's room to get her for a shower. The resident was able to transfer herself from the recliner to the wheelchair without difficulty. There were no foot pedals on the wheelchair and the resident's feet skimmed along on the floor as CNA NN pushed the wheelchair. On 09/23/2020 at 09:45 AM, CNA NN explained that the resident did not propel herself while in her wheelchair as she was not able to. She did not have foot pedals on her wheelchair. On 09/24/20 at 09:17 AM, Administrative Nurse D stated it would be her expectation that there be foot pedals on a wheelchair when a resident was being pushed by staff. The facility lacked a policy for foot pedal use with residents in wheelchairs being propelled by staff. The facility failed to implement appropriate intervention of the use of foot pedals, to prevent falls from the wheelchair, with the prevention of the resident's feet from skimming along on the floor and causing the resident to fall out. - The signed admission orders [REDACTED]. The Admission Minimum Data Set, dated dated [DATE], documented R11 had short and long-term memory loss, and needed extensive assistance with bed mobility and transfers. R11 received antidepressant, antianxiety, diuretic, and opioid medication daily. The Falls Care Area Assessment, (CAA) documented R11 was legally blind and required assistance from staff for all activities of daily living, and the staff were to keep the resident's call light within her reach at all times. R11's mobility care plan, dated 07/14/2020, instructed staff that the resident used a wheelchair for mobility. On 09/21/2020 at 12:20 PM, Certified Nurse Aide (CNA) P propelled R11 in the wheelchair, without footrests as her feet skimmed along on the floor. On 09/22/2020 at 08:34 AM, CNA Q propelled R11 from the dining room to her room without footrests as her feet skimmed along on the floor. On 09/23/2020 at 09:32 AM, Licensed Nurse (LN) G propelled R11 from the dining room to the nurses' station in her wheelchair without foot pedals and feet skimming along the floor. On 09/23/20 at 11:29 AM, CNA Q verified R11 did not have foot pedals on the wheelchair because R11 had the ability to self-propel. On 09/23/2020 at 01:50 PM, LN G verified the residents should have foot pedals when being pushed by staff in wheelchairs because you would not want them to plant their feet causing a fall. On 09/24/2020 at 12:50 PM, Administrative Nurse D verified that residents who are propelled in wheelchairs by staff were to have foot pedals for safety. These are necessary to prevent accidents. Furthermore, on 09/22/2020 at 02:00 PM, R11 sat in a recliner in her room. The resident's call light was lying on the bed, and out of reach of the resident. On 09/22/2020 at 04:15 PM, CNA MM verified that R11's call light was on the bed, out of reach. On 09/23/20 at 09:53 AM, as R11 sat in her recliner, Certified Medication Aide (CMA) R verified R1l could not reach her call light. On 09/24/2020 at 0745 AM, LN H verified R11's call light was behind the bed, out of her reach, and that the call light should be within R11's reach. On 09/22/2020 at 04:15 PM, CNA MM, stated the call light should be in R11's lap, because R11 could feel things and use her hands well enough to feed herself so she could use the light if she needed assistance. On 09/23/2020 at 01:50 PM, LN G verified R11 should always have the call light within reach because she could not see. On 09/24/2020 at 12:50 PM, Administrative Nurse D verified that residents were to have their call light for safety and that they are necessary to prevent accidents and provide a safe environment. The facility was unable to provide a policy regarding the use of foot pedals when staff propel the residents in wheelchairs. A facility policy titled Answering the Call Light, dated 01/2020, instructed staff when the resident is confined to a chair be sure the call light is within easy reach of the resident. The facility failed to provide safe transport of the resident when in the wheelchair, with the failure to apply the footrests and her feet skimmed along on the floor. Furthermore, the facility failed to ensure the resident's call light remained within her reach, in case she required assistance, and to prevent accidents.

The facility reported a census of 32 residents. The 15 residents sampled included 1 reviewed with indwelling urinary catheters and 1 reviewed for urinary incontinence. Based on observation, interview and record review, the facility failed to implement an individualized toileting plan for one of the residents sampled for urinary incontinence to promote as much normal bladder function as possible for Resident (R) 8. The facility also failed to maintain sanitary placement for one of the one sampled residents with indwelling urinary catheter, R84, to prevent urinary tract infections. Findings included: . The signed Physician order [REDACTED]. [MEDICAL CONDITIONS] (a type of bacteria that causes diarrhea and inflammation of the colon). The Entry Tracking Minimum Data Set (MDS), dated [DATE], documented the resident admitted on [DATE], from an acute hospital. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/11/2020, documented the resident had verbal behaviors directed at others. The resident had no identified cognitive loss or dementia noted. The Urinary/Catheter (CAA), dated 09/11/2020, documented R84 had an indwelling urinary catheter related to [MEDICAL CONDITION]. The drainage bag was to be kept below the bladder at all times. Catheter care was to be completed every shift and as needed. The catheter was to be changed as scheduled. Output was to be monitored every shift and any abnormalities of urine or output was to be reported to the physician. The indwelling catheter care plan, dated 09/10/2020, documented the resident had a catheter related to [MEDICAL CONDITION] and frequent urinary tract infections. On 09/21/2020 at 11:03 AM, the resident was in the wheelchair, with the catheter collection bag dragging directly on the floor under the wheelchair. The catheter collection bag lacked any type of protective bag or dignity bag cover. On 09/22/2020 at 02:59 PM, Certified Nurse Aide (CNA) O and CNA M entered the resident's room to transfer him from the wheelchair to the bed. The full red bag (used for the disposal of potentially infectious biohazardous waste by health care facilities) was resting directly on the floor and tied at the top. The staff completed urinary catheter care and tied the waste up in the red bag of trash in the resident's room. The staff then removed the red bag out of the red barrel, tied it, and left it resting directly on the floor in his room, without a barrier. On 09/21/2020 at 04:26 PM, the resident rested in the bed. The resident's urinary catheter collection bag was lying directly on the floor. On 09/23/2020 at 12:13 PM, CNA NN stated the resident was in isolation for [MEDICAL CONDITION]. A dignity bag should be placed on the catheter bag when the resident leaves the room. The collection bag should not be left directly on the floor. On 09/23/2020 at 01:43 PM, Licensed Nurse (LN) G confirmed that urinary catheter bags should not be on the floor. The facility had bags to keep the collection bags in so that the catheter bag was not seen and was not on the floor. On 09/24/2020 at 09:43 AM, Administrative Nurse D stated it would be her expectation that catheter bags or red bags should not be left sitting on the floors. The facility policy for Waste Disposal, revised December 2008, included: All infectious waste shall be handled and disposed of in a safe and appropriate manner. The facility failed to cover the indwelling urinary catheter bag and placed it directly on the floor along with the red isolation type bags laying on the floor, which increased the risk for urinary tract infections for this resident. - The signed Physician order [REDACTED]. An annual Minimum (MDS) data set [DATE], documented R8 as cognitively intact. R8 required staff assistance for toileting and did not have a bowel or bladder toileting program. The Urinary Incontinence and Indwelling Catheter care area assessment, dated 07/13/2020, documented R8 was frequently incontinent of urine. An incontinence care plan, revised 12/11/2019, identified R8 had a scheduled toileting plan and instructed staff to offer the resident the bathroom prior to meals or activities. The POS, dated 9/11/2020, documented R8's order for Myrbetriq extended release 25 milligrams by mouth every morning, for urge incontinence. The resident's Electronic Medical Record (EMR) lacked a bowel and bladder diary. An EMR documentation report, dated 09/24/2020, documented R8's three-hour interval toileting schedule, which included toileting at 10:00 AM. On 09/22/2020 at 09:45 AM, Certified Nursing Assistant (CNA) M and CNA O assisted R8 to the toilet. R8's brief observed saturated with urine and had feces. On 09/24/2020 at 10:04 AM, CNA M verified R8's bed was wet, pants were wet and that R8 smelled of urine. On 09/23/2020 at 01:15 PM, CNA N stated R8 was generally incontinent on the toileting schedule. 09/23/2020 at 01:50 PM, Licensed Nurse G verified R8 had a toileting schedule, and that the nurses intervened if R8 refused. On 09/24/2020 at 12:27 PM, Administrative Nurse D verified the lack of a completed bowel and bladder diary in the resident's electronic medical record. Administrative Nurse D verified a bladder diary was essential to develop an appropriate individualized toileting program. A facility policy titled Urinary Continence and Incontinence - Assessment and Management Guidelines F690, date unavailable, instructed nursing staff to appropriately screen for and manage individuals with incontinence. The facility failed to implement an individualized toileting plan to promote continence for this incontinent resident.

The facility reported a census of 32 residents with 15 sampled for review, including two for respiratory care. Based on observation, interview and record review, the facility failed to provide proper sanitation of respiratory equipment for the two sampled residents, Residents (R) 12 and R83, who received oxygen therapy, to prevent respiratory infections for these two residents. Findings included: - The signed Physician order [REDACTED]. leads to a build-up of fluid in the lungs and surrounding body tissues). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required extensive two-person assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She used oxygen with breathing. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 02/13/2020, documented the resident requires two-person physical assistance for all ADL's. The Quarterly MDS, dated [DATE], documented the resident with a BIMS of 14, indicating cognition intact. There were no changes in ADLs and she continued with the use of oxygen. The care plan, dated 09/08/2020, document orders for oxygen at two liters (L) per nasal cannula (nc- a tubing for oxygen delivery through the nose), to be worn at bedtime. The PO dated 08/03/2020, had the following orders; On 05/23/18, Oxygen at two L via nc at bedtime. On 09/21/2020 at 02:31 PM, the resident rested in the bed. The resident's coiled oxygen tubing rested directly on the floor and unbagged. On 09/22/2020 at 07:57 AM, the resident's oxygen tubing remained directly on the floor unbagged. On 09/23/2020 at 08:11 AM, the resident sat in a recliner eating breakfast. The resident's oxygen tubing remained directly on the floor. On 09/21/2020 at 12:55 PM, R12 stated she uses oxygen each night but was unable to reach the oxygen tubing while in bed. The staff would take it from her in the bed and put it onto the oxygen concentrator. On 09/23/2020 at 12:13 PM, Certified Nurse Aide (CNA) NN stated the tubing and cannula are to be kept in a bag next to the humidifier. It should never be on the floor. On 09/32/2020 at 01:43 PM, Licensed Nurse (LN) G confirmed that the resident's oxygen tubing should never be on the floor but in a dated bag on the oxygen concentrator. The facility lacked a policy for oxygen tubing. The facility failed to provide safe sanitary oxygen therapy to this resident by letting the cannula/tubing touch on the floor and raising the potential for the resident to get respiratory infections. . The signed Physician order [REDACTED]. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He required limited assistance of one for bed mobility, transfers, walking, locomotion, toileting, and personal hygiene. He required the use of oxygen. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/19/2019, documented the resident was at risk for increased confusion, falls, and injuries related to decreased safety awareness. He had memory and recall deficits, both contributing factors of dementia. The Quarterly MDS, dated [DATE], documented the resident had severely impaired cognition, He needed extensive, two-person assistance for bed mobility, transfers, and toileting. He needed extensive one-person assistance for locomotion, dressing, and personal hygiene. The oxygen care plan, dated 09/08/2020, documented the resident used oxygen therapy due to shortness of breath related to heart failure. The resident's oxygen setting was to be at two liters (L) per nasal cannula (nc- tubing used to deliver oxygen through the nose), while in bed. Oxygen concentrator humidifier and tubing changed, and the filter to be cleaned every Sunday, on the third shift. A physician order, dated 01/17/2019, instructed the staff to provide the resident with oxygen at two L per nc while in bed, related to shortness of breath. A physician order, dated 02/05/2019, instructed the staff to provide the resident with oxygen concentrator humidifier, the tubing to be changed and filter cleaned every Sunday on the third shift. On 09/21/2020 at 08:40 AM, the resident's oxygen tubing lay directly on the floor next to the bed, while the resident was not in his room. Closer observation of the tubing on the floor revealed it lacked a date of the last time staff changed the tubing. On 09/21/2020 at 04:29 PM, the resident's oxygen cannula remained without a date, as well as the oxygen's humidifier container. The resident's nasal cannula was lying inside of the trash can. On 09/23/2020 at 08:09 AM, the resident's oxygen tubing was strung from the oxygen concentrator to the bed. The tubing went directly across on the trash can and the top of the dirty urinal, dated 08/23/2020, to the resident's bed, where the canula rested by the resident's pillow, unbagged. On 09/23/2020 at 03:17 PM, the resident was resting in the bed with the oxygen on and in use. On 09/23/20 at 12:13 PM, Certified Nurse Aide (CNA) NN stated this resident used oxygen while in bed. When staff remove the oxygen cannula/tubing, they tuck the tubing into his bed or through the handle of the concentrator so it is not dragging on the floor. He would use the urinal and it was kept by his bed on the trash can and the staff emptied it as needed. On 08/23/2020 at 01:43 PM, Licensed Nurse (LN) G confirmed the resident did use oxygen when he was in bed. The tubing was changed every Sunday on night shift and the humidifier container was changed at that time as well. Staff should put a dated baggy on the humidifier container to keep the resident's oxygen tubing in. On 09/24/2020 at 09:43 AM, Administrative staff D stated it would be her expectation that oxygen tubing be stored in a dated bag on the humidifier and should not come into direct contact with the floor. The facility lacked a policy for oxygen tubing. The facility failed to provide sanitary oxygen therapy to this resident, when the cannula/tubing touched directly on the floor, trash can, urinal, and staff did not replace the cannula when contaminated, increasing the risk for the resident to get respiratory infections.

The facility reported a census of 32 residents with 15 residents sampled, including five sampled for review of unnecessary medication. Based on observation, interview and record review, the facility failed to accurately monitor blood sugar parameters for two of the five sampled residents, including Resident (R)9 and R18. Findings included: - The signed Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status Score (BIMS) of 9, indicating moderately impaired cognition. She received insulin for seven of the seven day look back period. The Nutrition Care Area Assessment (CAA), dated 02/17/2020, documented she was at risk for [MEDICAL CONDITION] (high blood sugar) and [DIAGNOSES REDACTED] (low blood sugar). The Annual MDS, dated [DATE], documented 02/17/2020, documented the resident had a BIMS score of 15, indicating intact cognition. She was on insulin for seven of the seven day look back period. The Diabetes care plan, dated 09/08/2020, documented blood sugars are to be done as ordered. The Physician Orders, dated 08 /03/2020, instructed staff to obtain blood sugars before meals and at bedtime, and to notify the physician of blood sugars that were over 325. Review of the Electronic Medical Record (EMR), documented out of parameter blood sugars without physician notification on: August 19/2020, blood sugar of 339. September 01/2020, blood sugar of 335. September 14/2020, blood sugar of 337. September 21/2020, blood sugar of 356. On 09/23/3030 at 01:43 PM, Licensed Nurse (LN) G confirmed the above high blood sugars that lacked monitoring with physician notifications for further instructions. On 09/24/2020 at 11:39 AM, Administrative Nurse D stated it would be her expectation that the blood sugars should be monitored to know when to call the physician for further instructions. The facility failed to provide an applicable policy for monitoring blood sugars for diabetic residents. The facility failed to accurately monitor blood sugar parameters with the failure to notify the physician for further instructions, as ordered, on 4 occasions with the blood sugar levels above 325. - The signed Physician order [REDACTED]. A significant change Minimum Data Set, dated dated [DATE], documented R18 as moderately cognitively impaired and received insulin daily. A nutrition care plan instructed the staff to obtain accuchecks as ordered, initiated on 10/17/2019. The POS, dated 09/11/2020, documented the following physician orders: [MEDICATION NAME]100 units/ml inject 13 units subcutaneous with meals, for diabetes mellitus [MEDICATION NAME]100 units/ml inject 20 units subcutaneous daily, for diabetes mellitus Blood sugar checks by fingerstick four times a day, with instruction to notify the physician for blood sugar results greater than 300. Review of R18's Vitals tab in the electronic medical record, for August and September 2020, documented blood sugars were greater than 300 on eight days, with the physician notified for further instructions on two of those days. The facility staff failed to clarify further instructions with the physician as ordered, on six occasions, when the resident's blood sugar results were above 300. The six elevated blood sugar results ranged from 308 to 388. On 09/24/2020 at 11:15 AM, Administrative Nurse D verified the facility staff contacted the physician, with elevated blood sugar results as ordered, on only two of the eight days, and that nurses are expected to notify the physician of all elevated blood sugars as ordered. The facility was unable to provide an applicable policy. The facility failed to notify the physician to obtain further instruction for safe monitoring of this diabetic resident's six elevated blood sugar levels.

The facility reported a census of 39 residents with 3 residents selected for sample review. Based on observation, interview, and record review, the facility failed to ensure one resident (#1) of 3 reviewed received supervision and care to remain free of sexual abuse. Resident #2 approached resident #1 and touched him/her in an inappropriate sexual manner. This failure resulted in immediate jeopardy for resident 1 when staff failed to adequately supervise resident #2 who again inappropriately touched resident #1, two more times in a time frame of approximately 1 hour and 15 minutes. Findings include: - Resident #1's [DIAGNOSES REDACTED]. A significant change MDS (minimum data set), dated 8/30/18, included a cognition assessment identifying the resident with long and short-term memory problems and moderately impaired of daily decision making. The resident exhibited inattention, and disorganized thinking, as well as reporting feeling down/depressed, exhibited loss of appetite and felt tired. The 9/12/18 CAA for cognition included: a significant change assessment conducted related to the resident beginning hospice services. The staff identified the resident at risk for increased confusion related to anxiety and exhibited decreased safety awareness. The resident's cognition declined since the most recent hospitalization , and staff expected further decline related to the [DIAGNOSES REDACTED]. Resident #2's most recent quarterly MDS, dated [DATE], included a BIMS (brief interview of mental status) score of 13/15, indicating intact cognition. The assessment further identified the resident required extensive assistance of staff for mobility, however, staff verified the resident was independent with mobility when in his/her wheelchair and required extensive assistance with ambulation with the roller walker. A care plan, dated 8/29/18 for resident #2, lacked evidence of a plan which would indicate resident #2 displayed any inappropriate sexual behaviors prior to these 3 incidents. Review of nursing notes, on 10/29/18 at 12:00 PM to 1:15 PM, lacked evidence of any documentation of the 3 reported incidents. However, a late entry, dated/timed 10/29/18 at 2:01 PM evidenced documentation of the third incident with resident #1 sitting at the nurse's station, with resident #2 seated next to his/her right side. Licensed nursing staff D stood at the nursing station with both resident's in his/her peripheral vision. Staff D noticed resident #2 patting down resident #1, in the area of his/her right breast, and then moved his/her hand down to resident #1's hand. Staff D quickly removed resident #1 from the situation and took resident #1 to his/her room; staff assisted with laying the resident down. Staff placed resident #2 on fifteen-minute checks while in his/her room and direct line of vision with staff when out of his/her room. Review of skin assessments, dated 10/31/18, for resident #1 lacked identification of any unusual bruising. Observation, on 11/1/18 at 10:20 AM, identified resident #1 rested with his/her eyes closed. At 11:05 AM, licensed nursing staff B completed a skin check, and while speaking to the resident, the resident opened his/her eyes slightly, however, did not make attempt at speaking or moving any extremities. The skin inspection lacked evidence of any skin concerns. Interview, on 11/1/18 at 1:08 PM, with direct care staff H reported during lunch time, on 10/29/18 at approximately 12:00 PM he/she delivered the residents tray to his/her table. That day resident #2 had been sitting with resident #1 at a 2-person table (not either resident's usual tables). Resident #2 sat real close in his/her wheelchair, next to resident #1 in his/her wheelchair. When getting close by, staff H observed the resident with his/her hand on the front of resident #1's chest and had pulled to the side the residents sweater and clothing protector. Staff H quickly instructed resident #2 to not do that to resident #1 and stated that was not appropriate. Staff H reported resident #1 did not appear upset, however, while assisting with feeding the resident, he/she did not eat as well as normal. Resident #2 returned to his/her own table for the meal. When staff H finished feeding resident #1, he/she moved the resident to the nursing desk area, where the charge nurse was. Staff H verified that he/she did not say anything, at that time, to staff D, and returned to assisting other resident's out of the dining room. When passing by resident #1, staff H noticed resident #2 seated beside resident #1 and had his/her hand, down the front of resident #1's shirt. Staff H immediately removed resident #2 from the area and went to notify the DON (director of nursing) on what occurred with both incidents. On 11/1/18 at 1:27 PM licensed nursing staff D reported, the third incident occurred after staff H went to report the 2 prior incidents to administrative nursing staff I. Staff D observed resident #2 with his/her hand patting resident #1's shoulder and then moving his/her hand down the front chest area of resident #1, ending with placing his/her hand on top of the other resident's hand. Licensed nursing staff D, immediately removed resident #1 from the area and assisted with transferring the resident into bed. The staff then informed the DON of the incident and placed resident #2 on 15-minute checks and line of sight observation, whenever the resident came out of his/her room. Interviews with other staff included the following: On 11/1/18 at 11:51 AM, activity/social services staff E reported the male resident had been a tablemate of the resident since his/her admission. Resident #2 always appeared to be kind and consoling to resident #1, holding his/her hand when resident #1 appeared anxious and crying. On 11/1/18 at 11:59 AM, direct care staff F reported resident #2 had never been observed being inappropriate with any staff/resident prior to the incident on 10/29/18. Staff F reported being on duty on 10/29/18, however lacked any interaction with either resident. On 10/30/18 resident #2 left the dining room, telling another staff member that he/she needed to use the bathroom. However, upon leaving the dining room, the resident turned towards the opposite hall (resident #1's hall) and headed directly towards resident #1's room. Staff F re-directed resident #2, and when asking where he/she was going the resident replied he/she did not know. Staff F instructed resident #2 it was time for breakfast and the resident then returned to the dining area. On 11/1/18 at 12:32 PM, activity/social services staff G reported resident #2 had exhibited some behaviors, however, nothing sexual in nature. Staff G reported that the resident especially exhibited some defiant behaviors with his/her roommate, but had been very kind to resident #1, who had declined and had some anxiety problems. The facility policy and procedure for Abuse Prevention Program, dated 11/2017, evidenced Residents have the right to be free from abuse. The facility policy and procedure for Resident to Resident Altercations, dated 11/2017, evidenced Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents and occurences of such shall be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. If two residents are involved in an altercation, staff will seperate the residents. Provide and document redirection and provide protection as required by the situation. The facility failed to provide adequate supervision after the first incident of inappropriate sexual touching, which placed resident #1 in immediate jeopardy, as 2 more incidents of sexual abuse occurred, all of which occured in a time frame of approximately 1 hour and 15 minutes. The facility abated the immediate jeopardy on 11/2/18 at 2:20 PM as follows: 1. The facility placed resident #2 on 15-minute checks when in his/her room and staff monitored the resident with a line of sight observation when the resident was out of his/her room, following the 3rd incident on 10/29/18 at approximately 1:15 PM. 2. The facility transferred resident #2 to a behavioral health unit for evaluation and treatment on 10/31/18 at 5:15 PM. 3. The facility completed in-service education to all staff members, except 3, by 11/1/18 at 3:30 PM. The remaining staff members will receive education prior to returning to on-duty status. 4. The facility conducted interviews with alert and oriented residents ensuring no other abuse occurred, completed on 11/2/18 at 1:00 PM. 5. The facility held a quality assurance meeting with staff and the medical director on 11/2/18 at 2:20 PM. The deficient practice remains at a scope and severity of a D.

The facility reported a census of 37 residents with 3 selected for sample review. Based on observation, interview, and record review, the facility failed to ensure 1 resident (#1) of 3 reviewed received supervision and assistive devices to ensure the resident remained safely inside the facility in a safe and supervised environment, when an unalarmed door was left unlocked and allowed the resident to exit the facility, without staff's knowledge. This deficient practice placed this resident in immediate jeopardy, and placed the additional 7 residents, identified as elopement risks in potential immediate jeopardy, as well. Findings included: - Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status of 14/15 indicating intact cognition, and documented the resident exhibited inattention, and disorganized thinking, but lacked identification of wandering as part of the assessment. The resident required supervision of staff for ADLs (activities of daily living) and was as always steady. The 1/5/18 Care Area Assessment for cognition included: the staff identified the resident was at risk for increasing confusion, anxiety, falls, and injuries related to his/her decreased safety awareness. A Wandering & Elopement Evaluation, dated 12/23/17, documented the resident with moderate risk, however, the document was not complete. The Brief Interview for Mental Status lacked completion, Section B Wandering/Exit Seeking patterns lacked completion and Section C Factors did not identify the resident as a recent admission. The evaluation identified the resident lacked safety awareness. The Wandering and Elopement Evaluation, dated 1/18/18, summarized the resident required 1 to 1 supervision when out of his/her room, and when exit seeking. Additionally, interventions included ensuring placement of a wanderguard, securing doors, increased supervision, provision of re-direction when the resident was exit seeking, initiating Scavenger hunts for the resident, filling out applications/ paperwork and other activities to keep the resident busy. Review of the 12/23/17, initial and baseline care plan lacked any mention of exit seeking/wandering or interventions for the resident's safety. Review of nursing notes included: On 1/7/18 at 2:47 PM, staff noted the resident pacing throughout the facility, and entering other resident's rooms. Staff redirected the resident multiple times, and when noting the resident unsteady encouraged the resident to rest. The resident complied for approximately 10 minutes and then continued with exit seeking behaviors. Staff noted the resident attempted to follow visitors out the front door, with staff re-directing the resident to the commons room. On 1/12/18 at 9:46 AM, identified the resident experienced a recent change in condition shortly after the resident's admission. The resident began experiencing hallucinations, and placing him/her self on the floor and crawling around. Based on prior behavioral health unit reports and prior placement of the resident in an assisted living facility, staff noted this as abnormal behavior, for the resident. The resident began stating the desire to go home, since the resident's sibling visited last week. Additionally, the resident began hovering near the exits. The resident wore a wanderguard, which locks the doors when the resident stands near the door. Currently, the resident does not push on the doors, but does state the desire to go home. On 1/11/18, the staff found the resident knocking on the front door. Additionally, the resident was frequently refusing cares and meal intakes decreased. The plan included to encourage alternative meals when the resident refused a meal, with re-orientation to assist with adjustment to the facility. Stay in contact with DPOA (durable power of attorney)/sibling for assistance when confusion increased. Allow the resident to crawl (if he/she is not harming him/her self or others) so not to induce and/or increase agitation. Review of medications with the physician with medication changes implemented. Staff to provide frequent visual checks for safety and checking of wanderguard for placement and function. On 1/15/18 at 11:40 AM, staff documented the resident wandered and exhibited exit seeking behaviors all morning, and was easily re-directed. On 1/15/18 at 6:50 PM, staff documented the resident exhibited violent behavior to direct care staff with staff trying multiple times to re-direct the resident. The staff noted increased agitation and exit seeking behaviors. On 1/17/18 at 11:47 PM, staff documented the resident was found by a visiting family member outside in the parking lot at approximately 6:40 PM. The staff noted the resident passing by the nursing desk at 6:36 PM, when the staff administered medication to another resident. Staff noted the resident did not leave the parking lot, and staff immediately performed a skin assessment, upon return into the facility. No new skin issues were identified, and the wanderguard was in place on the right wrist. The resident lacked evidence of any frostbite and vital signs were identified as BP (blood pressure) 120/77, P (pulse) 91, R (respirations) 18, T (temperature) 97.7 (above baseline temperature of 96.6), and O2 (oxygen saturation) 93%. Staff noted the outdoor temperature as 34 degrees Fahrenheit. Staff immediately initiated one to one supervision with the resident and made notifications. The Administrator and the DON (director of nursing) returned to the building and provided education with all staff members regarding elopement. Additionally, staff received instructions to initiate one to one supervision anytime a resident displayed exit seeking behaviors. The Maintenance director returned to the facility to check the functionality of the door and alarms. Furthermore, an update of tasks in P(NAME) (point of care-a computer program) for CNA (certified nurse aide) charting, was made to include CNA documentation of exit seeking behavior, identifying any one on one by staff and asking was the resident safe? Staff documented the resident wore jeans, a button up shirt, over an undershirt, long tube socks and tennis shoes when out of the building. On 1/25/18 at 9:20 AM, the resident stood in the hallway, near the resident's room, with a nearby staff member present. At that time licensed nursing staff C requested the resident walk with him/her towards the hallway exit door and checked the resident's wanderguard/roam alert bracelet for operation. A soft beep, beep, beep was heard, until the staff disengaged the alarm. On 1/25/18 at 10:00 AM, the resident rested on the bed with his/her eyes closed. The resident's wanderguard alarm remained on the resident's right wrist area. The resident observed in the television area, wandering in the area. At 11:30 AM, on 1/25/18 the resident wandered towards the nursing area and housekeeping staff H asked the resident if he/she had lunch. The resident voiced concern about his/her blanket and the staff offered to walk the resident to his/her room to place the blanket on the resident's bed. The staff and resident walked to the resident's room, where the resident left the blanket and then returned to the nursing area. As passing by the dining room entrance another staff asked the resident to come in for lunch and the resident indicated he/she had no money. The staff indicated to the resident, the resident's sibling had paid for his/her meals the other day when he/she visited and the resident agreed to go eat. At 1:15 PM on 1/25/18, the resident stood near the nursing desk with multiple staff in attendance. Administrative nursing staff B suggested to the resident they start a scavenger hunt and the resident asked what that was. The staff and resident began walking off as the staff explained what they were looking for. At 2:50 PM on 1/25/18, the resident remained in the television area with other residents and 1 staff member present. Administrative nursing staff B reported on 1/25/18 at 8:50 AM, the elopement was the first since he/she worked at the facility, but did identify an additional 7 residents assessed at risk for elopement. The staff reported that on 1/17/18 a vendor for one on the hospice organizations entered the facility to remove a bariatric bed. To remove the bed, the delivery person, unlatched the stationary door of the front double doors, and failed to notify any staff member of doing so. Additionally, the delivery person failed to re-latch the door after removing the bed from the facility. Interviews with the nursing staff indicated they were unaware the second stationary door that is kept in a locked position had been unlocked during that time. The resident had been doing some exit seeking, such as standing in the lobby area and looking outside, however, staff B reported being unaware the resident pushed on any exit doors. The resident must have pushed on the unlocked door, which did not alarm, because it is always kept locked, and exited the building, for a brief period. Our investigation identified the resident was last seen at 6:36 PM and the family members returned the resident into the building at 6:40 PM. The staff were all immediately in-serviced on elopement policy and procedure. The staff explained the doors are alarmed with keypads, for silent exiting by staff, and a wanderguard system at the main entrances monitors and locks down when residents with wanderguard bracelets are at the doors. Additionally, a roaming alert system monitors for residents with bracelets who are nearing exit doors. Maintenance staff E on 1/25/18 at 10:31 AM, reported to a nursing staff on 1/17/17 that the resident was wandering more than usual, and staff E re-directed the resident from various doors that day, however, did not actually see the resident attempt to open a door. The staff recalled that a lot of things were going on that day, and one thing that occurred was that a vendor removed some equipment from the facility. Staff E indicated that he/she did observe the vendor both doors open, during passing, but as the staff was moving other beds him/her self did not assist the vendor and was not aware the door was left unlatched. Staff E reported that he/she checks all exit doors, every morning, as a part of the maintenance rounds and never had a problem with the alarms not functioning. The staff recalled that the vendor removed the bed around 12:30 PM. Therefore, from 12:30 PM to 6:40 PM, over 6 hours, any of the 8 residents identified as elopement risk could have exited the facility without staff knowledge. On 1/25/18 at 1:14 PM, direct care staff G reported the resident had a history of [REDACTED]. Staff G indicated the resident did not necessarily attempt to open the doors, however, he/she went to the doors and windows a lot, just standing there. On the day the resident got outside, the resident had been going to the door and one time, maintenance staff E requested that staff G re-direct the resident away from the door. At that time the staff member took the resident to the dining area and gave the resident a snack and drink, with the resident sitting and resting for a while. Direct care staff D reported on 1/25/18 at 2:33 PM, the resident had gotten outside, and a visiting family member brought the resident back into the building. On 1/25/18 at 3:55 PM, administrative staff A reported the resident was in constant eye sight of an assigned employee throughout the day, when the resident was outside of his/her room. The staff reported the facility had backed off somewhat from having anyone one on one with the resident, as the resident had become increasing agitated. Therefore, the staff were being more discreet and watching from a distance. On 1/31/18 at 1:50 PM, the delivery service driver reported the facility had a bed for pickup and he/she picked the bed up on 1/17/18. Because of the size of the bed, it required both front doors to be open during the removal of the bed and reported that maintenance staff E assisted in the removal of the bed. The driver reported being unsure who actually unlocked the double doors on that date. The facility policy on Elopement, dated 11/17, included residents would be evaluated for elopement and wandering risk to identify the resident's risk for elopement. Evidence for such would be documented and interventions initiated, reviewed or modified based upon the risk. New wandering behaviors or attempted elopements would be noted on the 24-hour report, discussed in daily clinical meetings and documented in the nursing notes related to the effectiveness of the interventions. The facility failed to maintain a safe environment, including adequate supervision and assistive devices to ensure the safety of the 8 residents of the facility identified at risk for elopement. A door at the entrance of the facility, planned to be locked always when not in use, was left unlocked for approximately 6 hours, and resident #1 exited through the unlocked door and walked out into the facility parking lot. The resident remained outside in the parking lot for approximately 4 minutes, without staff knowledge that the resident had exited the building, placing this resident in immediate jeopardy and placing the remaining 7 residents, identified at risk for elopement, at risk of immediate jeopardy. The deficiency was cited as past non-compliance, as of 1/18/18 at 2:00 PM, when the facility implemented and completed the following: 1. The staff placed the resident on 1:1 visual supervision while out of room. A staff member monitored the door. The Maintenance Director placed screw in door latch so that latch can not be released without assistance from a staff member. Door alarms checked for proper working order. Wanderguard/roam alert checked for proper working order. 2. Director of Nursing/designee will audit resident's assessment to establish wandering/elopement assessment is completed accurately. Clinical Reimbursement Coordinator/designee will audit residents care plans to establish that care plan is up to date with accurate patient centered interventions. Maintenance Director/designee will audit doors with wanderguard/roaming guard to establish door alarm is in proper working function. 3. Community staff was educated on elopement policy on 01/18/2018. The last employee was trained by 10:20pm. Please see attached in-service for details covered in the in-service. Licensed nursing staff educated on assessments and care plans on 01/18/2018. The last employee was trained by 1:20pm. Please see attached in-service for details covered in the in-service. Additionally, nurse management team in-serviced on interdisciplinary team meeting and patient at risk meeting. The last employee was trained at 2:20 PM. Please see attached in-service for details covered in the in-service. Maintenance Director educated on door alarm monitoring documentation on 01/18/2017; he was trained by 2:20 pm. 4. Follow up and monitoring will be reviewed by clinical team for accurate and prompt assessment and care plan interventions through interdisciplinary team meetings. Follow up monitoring will be reviewed by administrator on completion of door alarm monitoring. 5. A Quality Assurance Meeting was held with the internal QA team as well as the Medical Director on 1/18/18 at 2:00 PM. Ongoing QAA/QAPI team will monitor compliance daily x 2 weeks, weekly x4 weeks, and monthly ongoing.

The facility reported a census of 37 residents, with 14 residents selected for review including one resident reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to provide adequate care and treatment for one (# 17) resident reviewed for pressure ulcers. The resident developed two unstageable pressure ulcers to the feet. Findings included: - The 8/3/16, significant change MDS (minimum data set) documented resident #17 with a BIMS (brief interview for mental status) score of 11 which indicated moderately impaired cognition, required extensive assistance with most activities of daily living, used a wheelchair for mobility, was not at risk for development of a pressure ulcer and had no pressure ulcers. The assessment further documented the use of a pressure reduction device for the bed, chair, and the resident on a nutrition/hydration program. The differences with the 3/21/16 significant change MDS, included, the resident used a walker, with supervision, for mobility and lacked a pressure reduction device for the chair. The 8/3/16 pressure ulcer CAA (care area assessment), documented the resident was at risk for impaired skin integrity due to decreased activities of daily living function and incontinence. The staff should monitor his/her skin condition as needed, perform weekly skin assessments, and provide incontinence care after each incontinent episode. The assessment documented further he/she did not have any pressure ulcers at the time of the assessment. The 8/5/16 care plan documented the resident had a potential for impairment to skin integrity, used a pressure reducing mattress, while in bed and a chair cushion to protect his/her skin. The facility gave education to the resident/family/caregivers of the causative factors an measures to prevent skin injury. The staff was to encourage good nutrition and hydration in order to promote healthy skin. He/she had a history of [REDACTED]. The care plan lacked an individualized turning/repositioning program for the resident and lacked interventions to protect the resident's heels/ankles/feet. The care plan lacked interventions added after the discovery of the pressure ulcers. The resident's skin assessment, on 8/8/16, documented the right ankle with a 4 X 3 centimeter, suspected deep tissue injury, pressure area, and the left heel with a 2.5 X 2.5 centimeter, suspected deep tissue injury, pressure area. This assessment lacked any description of the wounds appearance. The prior, weekly skin assessment dated [DATE] documented the resident had a bruise to his/her right knee, scabs on the right abdomen and right elbow, otherwise the resident's skin was intact. The 8/15/16 laboratory report documented the resident's [MEDICATION NAME] level( the test to measure the main protein in human blood). The test result was 3.5 g/dl (grams/deciliter) which was within normal levels. On 8/19/16 at 10:00 AM, dietary staff J reported the dietician sent a recommendation to start fortified foods, on 8/11/16, and he/ she failed to see the recommendation until 8/18/19, when checking the record. Dietary staff J reported the nursing staff had the recommendation now to notify the doctor and the family. Dietary staff J verified the resident had lost weight, and reported he/she had no interventions added. On 8/17/16 at 9:30 AM, observation revealed the resident fully dressed, with protective booties and foot pedals sitting in his/her wheelchair at table in the dining room, feeding his/her self the meal. He/she had regular texture food: scrambled eggs, sausage, fruit loop cereal, 2 (6 oz.) glasses of water, 1(8 oz.) glass of juice, and 1 (8 oz.) glass of milk. The resident ate 100 %, fed herself, and drank the milk, juice and 1 glass of water. On 8/18/16 at 4:08 PM, licensed nursing staff E reported the resident had no special instruction related to weight loss, and no special intervention he/she knew of to prevent weight loss. On 8/18/16 at 8:25 AM, direct care staff D and direct care staff N assisted the resident to the bathroom, staff D removed the wheelchair foot pedals and assisted the resident with protective booties on both feet, to transfer to the stool The staff appropriately cared for the resident and then assisted him/her back to bed. Staff floated his/her heels on a foam device in the bed. On 8/18/16 at 8:44 AM, licensed nursing staff E and direct care staff D, changed the dressings on the resident's ankles/heels. The areas observed included the inner aspect of the right foot below he ankle and the toward the heel and the outside area of the left foot below the ankle toward the heel. Licensed nursing staff measured the areas. The left ankle was 4 X 3 centimeters, without depth, discolored, pale purple with a 0.3 X 0.3 centimeter lighter center. The right heel measured 4 X 3 centimeters, and had black eschar. Licensed nursing staff E reported he/she notified the physician for treatment orders, responsible party, the administrative staff. On 8/18/16 at 8:59 AM, licensed nursing staff E reported the left ankle looked much better, and the right ankle looked about the same. When he/she first saw the wounds on 8/8/16 the right ankle had black eschar an the left one presented as a blister. Staff E added the resident's heels looked fine before he/she was off for several days, and added the direct care staff lacked reporting of any open areas before 8/8/16. On 8/18/16 at 9:30 AM, direct care staff D reported he/she discovered the areas on the resident's heels/ankle areas and reported them to licensed nursing staff E, on 8/8/16. On 8/18/16 at 4:40 PM, direct care staff H reported he/she and staff D reported to the charge nurse about the resident's heels when they discovered them on 8/8/16. He/she reported the resident did not complain of pain with his/her heels. On 8/19 /16 at 10:30 AM, licensed nursing staff T, reported he/she did the skin assessment on 7/28/16, and the resident's heels were clear. He/she reported the resident did not voice any pain, and the staff repositioned the resident every 2 hours. On 8/19/16 at 2:00 PM, administrative nursing staff L reported the ulcers on the resident's ankles happened quickly. He/she reported one week the skin assessment lacked documentation of any concerns and the next both heels/ankles had ulcers. He/she reported, on 8/15/16, he/she spoke with the physician and received an order for [REDACTED]. He/she verified the facility failed to put intervention in place to prevent the development of the pressure ulcers. On 8/25/16 at 4:55 PM, consultant dietary staff Z reported he/she reviewed the resident on 8/11/16, and recommended fortified foods, due to his/her weight loss. Consultant staff reported he/she was concerned the facility failed to begin the fortified foods when he/she recommended them on 8/11/16, and reported he/she was unaware the resident had pressure ulcers, and would review the resident again on the next visit. On 8/30/16 at 10:00 AM, physician staff AA reported he/she was concerned with the pressure ulcers the facility found on his/her heels. Physician staff AA reported he/she saw the resident last week, and both heels were improving. He/she added the treatment was off loading the heels and the application of the dressing with the cut out to prevent pressure on the areas. The 5/2013, facility policy for prevention of pressure ulcers documented: The staff should immediately report any signs of a developing pressure ulcer to the supervisor. The care process should include efforts to stabilize, reduce, or remove underlying risk factors for the resident. The facility failed to ensure appropriate interventions, including an individualized turning and repositioning program and devices to float and prevent pressure to the residents's feet, put in place to prevent the development 2 unstagable pressure ulcers to this resident's feet to prevent the development of pressure ulcers for this resident.

The facility reported a census of 37 residents. The 14 sampled residents included 3 residents reviewed for nutrition. Based on observation, interview, and record review, the facility failed to effectively identify and act upon the significant weight loss of 3 residents, (#1,#13 #17). Resident #1 who lost 11 pounds in 15 days, and the faciliy failed to consistently monitor his/her meal intake, resident #13 who experienced a weight loss of 23 pounds, (11 %), in one month, and in addition the facility failed to follow the recommended interventions for weight loss for resident #17. Findings included: - Resident # 13 admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The 1/12/16 significant change MDS (minimum data set) documented the resident with a BIMS (brief interview for mental status) score of 15 which indicated intact cognition, and the assessment indicated it was very important to have snacks available between meals, required extensive assist with eating and had coughing/choking during meals or when swallowing liquids. The 1/12/16 nutrition CAA (care area assessment) documented the resident currently received a pureed diet and honey thickened liquids. The resident was compliant with his/her diet, and ate 100% at most meals. The 3/28/16 nurse's notes documented a fax received from the physician to discontinue weekly weights due to the resident received hospice services and continued to decline in both condition and weight. The 7/3/16 quarterly MDS documented the resident lacked choking/coughing during meals or when swallowing. The 7/20/16 care plan instructed staff the resident received a regular/pureed diet with honey thickened liquids, staff needed to offer to assist him/her at meals; he/she did feed him/her self, but became sleepy at times and needed staff to remind him/her to eat. The plan of care lacked instructions to staff regarding provision of supplements or substitutes when the resident had inadequate meal intake. review of the resident's medical record revealed [REDACTED]. 2/8/16=206 pounds 2/15/16=206 pounds 2/24/16=204 pounds 2/24/16=204 pounds 3/4/16=184 pounds 3/9/16=183 pounds 3/21/16=183 pounds 3/29/16=180 pounds 8/19/16=176 pounds Review of the resident's documented weights revealed, on 2/8/16 the resident weighed 206 pounds, on 3/9/16, the resident weighed 183 pounds, a loss of 23 pounds in a month, an 11% loss. The 1/7/16, annual dietician's assessment documented the resident was on Hospice and had lost weight. The review indicated the resident had declined in his/her disease process and showed a significant weight loss x 30 & 90 days: Down 17.3 pounds in the past year, his/her current weight was 196.9 pounds. He/she received a regular/pureed, diet with honey consistency liquids. He/she needed tray set-up with meals. His/her appetite was down 50-75%. Diet shakes (since 12/31/15) gave him/her diarrhea and discontinued on 1/4/16. Recommend to offer Ensure or Boost which were lactose free supplements. The 4/13/16 quarterly dietician's assessment documented the resident's weight was declining as was his/her health. Weekly weights have been discontinued per hospice due to his/her declining condition. Last weight was 180.3 pounds. The resident showed a significant weight loss of -8.4% in 90 days, -15.8% in 180 days, and received a regular/pureed texture/honey consistency diet, and feed him/ herself. His/her appetite was 50-100%. Continue with current diet regimen. The registered dietician failed to recommend any further interventions to assist the resident to maintain his/her weight. Review of the meal intake/snacks record revealed the resident's intake documented as follows: May 2016: 65 % of breakfast meals, 74 % of lunch meals, and 35 % of dinner meals. June 2016: 73 % of breakfast meals, 55 % of lunch meals, and 33 % of dinner meals. July 2016: 85% of breakfast meals, 62% of lunch meals, and the dinner meals documented 50% for 2 days, and the rest were blank. The record lacked documentation of a meal replacement/substitute offered for any of the meals. The facility's documentation of snacks included only 10 days in July 2016, 7-1-10,2016. The resident refused the AM snack on 7/2-4/16, and the rest lacked any documentation. The facility lacked other documentation of snacks for the resident. On 8/16/16 at 8:30 AM, observed the resident lying in bed, with a meal tray on an over bed table, with a plate of pureed food, and thickened liquids. The resident reported he/she fed herself, and usually had breakfast in his/her room. The resident ate 90% of scrambled eggs, 50% of meat, 100 % of cereal, he/she drank 4 of ounces of juice, and 8 ounces of water both thickened, without staff assistance. 8/16/16 at 4:25 PM, the resident lay in bed, and reported he/she he/she usually did not get snacks. He/she reported the staff came around sometimes and had pudding or ice cream, but not every day. The resident reported he/she was not hungry. On 8/18/16 at 6:30 PM, resident #13 asked direct care staff U, to help him/her. The resident ate 100 % and took all liquids, with the staff feeding him/her. The resident held the glasses when the staff handed each to him/her. The staff stated he/she was not familiar with how the resident ate, because it was the first day he/she worked with the resident. On 8/17/16 at 9:00 AM, direct care staff H reported the resident was on Hospice and staff did not weigh the resident. When the resident returned the last time from the hospital the weights stopped. He/she reported the resident usually had supper in his /her room and at times other meals also. Direct care staff H reported staff did not have to stay with the resident while he/she ate. On 8/17/16 at 1:00 AM, licensed nursing staff E, reported the facility did not weight the resident and added the resident was on hospice. Licensed nursing staff E added he/she lacked awareness as to why staff no longer weighed the resident. On 8/18/16 at 3:10 PM, licensed consultant nursing staff V reported to his/her knowledge the facility weighed the resident monthly, but would check with the office. He/she reported hospice did not weigh the resident, and added the resident admitted to hospice on 12/29/15, with [DIAGNOSES REDACTED].) He/she added he/she lacked awareness of any special dietary interventions for weight loss for the resident. At 3:30 PM, licensed consultant staff V reported the hospice office reported the weekly weights discontinued on 3/28/16, but had no documentation about staff doing the monthly weights. 8/18/16 at 5:10 PM, direct care staff C reported the resident got a pureed diet and had thickened liquids, and usually had a hall tray for supper, and would feed him/herself. Direct care staff C reported staff did not usually stay with the resident, he/she was able to feed his/herself, and he/she usually ate 75 -100 %. On 8/19/16 at 10:00 AM, dietary staff J reported the resident had shakes TID (three times a day) in December 2015, then it was changed to Ensure, and reported the resident got the shakes about 4 days, and then the Ensure. Dietary staff J added the shakes were discontinued related to a milk allergy, but had no information about why the Ensure was discontinued, or why staff failed to develop any additional dietary interventions. He/she reported being unaware the facility staff was supposed to be weighing the resident monthly, and thought all the weights were discontinued. Dietary staff J added the current dietician, sent recommendation to start fortified foods, 8/11/16, but he/she failed to see the recommendation and the nurses did not get the information to notify the physician for orders until 8/18/19. On 8/19/16 at 11:30 AM, administrative nursing staff L reported he/ she was unaware the dietician recommenced any supplements or fortified foods as interventions for the resident, and verified none were written in the care plan, and was unaware the facility staff were supposed to be weighing the resident. On 8/19/2016 at 10:18 AM, administrative nursing staff B, reported to his/her knowledge the resident did not receive a supplement, and verified the dietary staff J reported he/she received an e-mail on 8/11/16, about recommendation to start fortified foods. Staff B verified the recommendation did not go to the nurses to send to the physician for orders until 8/18/16. Administrative staff B reported he/she was unaware that the staff was not weighing the resident. On 8/22/16 at 2:13 PM, physician staff S reported the resident was on hospice and with the resident's disease process weight loss would occur. He/she added the resident was admitted to the hospital in December 2015, and at that time he/she was not expected to live. Physician staff S added he/she was unaware the resident was not being weighed at all, but was not aware the resident was not receiving the ensure supplement, and was unaware of the number of pounds the resident had lost at this time. He/she reported staff should assist the resident with meals, and reported the resident was an expected weight loss. On 8/25/16 at 4:55 PM, consultant staff Z reported he/she received information from the facility about the resident on 8/11/16, and had him/her on the list to review at the next visit. Consultant staff Z reported he/she recommended to start fortified foods, and told the dietary manager to add the resident to the resident list to review at the next visit. The 9/2012, weight assessment and intervention policy documented: Any weight change of 5% or more since the last weight assessment will be retaken for confirmation, and if the weight change is verified, nursing will notify the registered dietician per facility protocol. The threshold for significant unplanned and undesired weight change will be based on the following criteria: 1 month- 5%, weight change is significant; greater than 5% is severe. 3 months- 7.5 %, weight change is significant; greater than 7.5% is severe. 6 months- 10% weight change is significant; greater than 10% is severe. Assessment information shall be analyzed by the interdisciplinary team and whether and to what extent weight stabilization or improvement can be anticipated. The facility failed to monitor weights for this resident, and provide the Ensure as recommended consistently and failed to assist the resident and or offer substitutes when the resident failed to consume his/her provided diet. The resident lost 23# in one month/11% weight loss. - Resident #1's signed physician orders, dated 8/10/16, documented the resident had the following Diagnoses: [REDACTED]. The quarterly MDS (minimum data set), dated 4/22/16, documented the resident was unable to conduct the BIMS (brief interview for mental status). The resident had long term and short term memory impairment, and the resident's cognitive skills for daily decision making were severely impaired cognition. The resident was dependent on 1 staff for eating. The resident's weight was 124 pounds on the assessment, and the resident did not have a weight loss or gain. The annual MDS, dated [DATE], documented the resident was dependent on 1 staff for eating. The resident's weight was 113 pounds. The resident had a weight loss of 5% or more in the last month, or loss of 10% or more in the last 6 months. The resident was on a mechanically altered, therapeutic diet (foods prepared for minimal chewing and easy swallowing). The nutrition CAA (care area assessment), dated 7/21/16, documented the resident was at risk for weight loss and malnutrition. The assessment documented to maintain or improve the resident's intake, maintain current weight and nutritional status without an unplanned significant weight loss. The care plan, dated 5/6/15, revision on 4/25/16, guided staff to administer multivitamin, encourage intake of food and fluids, and if the resident slept thru the meal, staff would provide a meal at a later time. Staff were to monitor and record the resident's intake of pureed foods, and offer available substitutions if the resident did not like the food served. Revision of the care plan, dated 2/17/16, guided staff to provide extensive assistance of 1 staff for meals. The care plan, dated 8/3/16, guided staff to encourage oral intake of food and fluids, and if the resident slept thru the meal, staff would provide a meal at a later time. Staff were to monitor and record the resident's intake of the pureed, fortified foods, and provide the resident with extensive assistance of 1 for eating. Review of the resident's weights record evidenced: On 2/8/16, 125 pounds. On 5/ 10/16, 125 pounds. On 6/28/16, 125 pounds. On 7/12/16, 114 pounds, an 11 pound weight loss and an 8.8 % (percent) weight loss in 15 days. On 7/18/16, 113 pounds, a 12 pound weight loss and a 9.6 % weight loss in days in 21 days. Review of the nutrition note, on 7/16/16, evidenced staff placed the resident on a weekly weight; however, no nutritional intervention was initiated for the resident's weight loss. On 7/18/16, the resident weighed 113 pounds, a 12 pound weight loss and a 9.6 % weight loss in days in 21 days. Review of the PAR ( patient at risk) note, on 7/19/16, evidenced the resident lost 12 pounds in 30 days, and staff requested a physician order [REDACTED]. On 7/21/16, the physician ordered a regular fortified diet with a pureed texture. Review of the registered dietician's assessment, dated 7/26/16, revealed the resident weighed 113.6 pounds, and documented the weight loss as significant, and the resident's meal intake as inadequate. The registered dietician recommended fortified foods ( already ordered by the physician on 7/21/16). Review of the facility's meal monitoring for the resident, from 5/1/16 to 7/31/16, revealed a lack of documentation and record breakfast intake 6 of 92 opportunities, lunch intake 8 of 92 opportunities, and evening meal 61 of 92 opportunities. The meal intakes which staff documented, revealed the resident consumed approximately to 100 % of breakfast and lunch, and 0 to 50% of the evening meal, with the exception of the 75 meals not documented, in this time frame. Review of the resident's diet card, evidenced the resident received fortified, pureed diet. The facility menu included 6 foods which were to be fortified. The recipes for fortified foods included oatmeal, soup, cream of wheat, whole milk, rice, and mashed potatoes. On 8/16/16, at 12:30 pm, the staff fed the resident 100 % of pureed meat and vegetables. The resident failed to receive any of the fortified foods on the facility menu list. On 8/17/16 at 6:10 pm, the staff fed the resident 100% of a pureed chicken with gravy, sweet potatoes, peas, and mixed fruit. Observation revealed staff failed to provide the resident any of the fortified foods on the list. On 8/18/16 at 8:00 am, staff fed the resident a pureed diet of muffin, cream of wheat, and scrambled eggs. The resident ate 100%. On 8/17/16 at 5:10 pm, direct care staff C, reported the resident required a pureed diet, and stated the resident required to be fed by staff. On 8/18/16 at 9:31 am, direct care staff D, stated the resident was on a pureed diet, and staff fed him/her. On some days, the resident would open his/her mouth, and other days, the resident would not eat or drink. Direct care staff D reported the resident would refuse to eat approximately 4 times a week. On 8/18/2016 at 11:47 am, dietary staff K, stated he/she cooked the meals, and was unaware this resident required fortified foods. Dietary staff K stated he/she made no changes for fortified foods in the menu or preparation of the meals. Dietary staff K verified he/she did not follow a recipe for fortified foods. On 8/18/16 at 1:55 pm, dietary staff H, stated the resident ate better on some days, than other days. He/she did not offer the resident alternative food items, because the resident required a pureed diet. On 8/19/16 at 2:13 pm, administrative nursing staff B, reported he/she reviewed the weights, and if the resident was underweight, staff reviewed the weights weekly. He/she would expect staff to initiate an intervention before the resident experienced significant weight loss. On 8/18/16 at 11:47 am, dietary staff J, stated if dietary staff K was unaware of what fortified foods were, then the staff was not following the physician ordered fortified food diet for the resident. Dietary staff J verified the resident did not have an intervention in place to prevent weight loss. On 8/24/16 at 10:59 am, physician Q, verified staff should follow the physician order [REDACTED]. The facility's policy for weight assessment and intervention, revised September 2012, documented the interdisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss. In addition, the facility's policy for therapeutic diets, revised December 2008, directed the food service manager would ensure each resident received his/her diet as ordered by the physician. The facility failed to effectively identify and act upon the significant weight loss in a timely manner, and failed to ensure this cognitively impaired dependent resident received the physician ordered fortified food diet. Furthermore, the facility failed to consistently monitor the resident's meal intake. The resident lost 11#/8.8% in 15 days then lost another pound equal to 12#/9.6% weight loss before physician notification and intervention. - The 8/3/16 significant change MDS (minimum data set) documented resident #17 with a BIMS (brief interview for mental status) score of 11 which indicated moderately impaired with cognition and required limited assistance with eating. The assessment further documented the resident's weight as 137 pounds, and identified him/her as a weight loss, and not on a physician ordered weight loss regime. The 8/3/16 CAA (care area assessment) for nutrition documented the resident was at risk for [MEDICAL CONDITION], [DIAGNOSES REDACTED], weight loss, dehydration, and malnutrition and decrease skin turgor. Staff needed to maintain or improve his/her intake and maintain current weight, and is an unplanned weight loss. Offer him/her assistance with eating as needed and provide extra encouragement with foods and fluids. The 3/21/16, significant change MDS documented the resident's weight as 148 pounds. The 8/5/16 care plan instructed staff the resident fed his/her self without assistance but occasionally need encouragement, and liked to wear a clothing protector on his/her lap, to monitor and evaluate any weight loss, to determine percentage lost and follow facility protocol for weight loss . Weigh the resident per orders The care plan recorded the dietician needed to evaluate and make recommendations, for the resident. His/her weight has recently returned back to his/her baseline. Review of the resident's weight record revealed the following weights: 02/10/16 - 148 pounds 03/01/16 - 150 pounds 04/04/16 - 148 pounds 05/24/16 - 148 pounds 06/28/16 - 147 pounds 07/26/16 - 140 pounds 08/01/16 - 137 pounds The resident's weight record documented the resident lost weight 7 pounds (4.76%) in one month from 6/28/16 - 7/25/16, and 11 pounds, (7.42%) in little over 3 months, from May 24/16 - 8/1/16. A 7/29/16 consultant dietary staff report documented the resident's weight as 139 pounds, and documented the resident had weight loss, was on a therapeutic low concentrated sweets, regular diet; and received no supplements. The 8/3/16 registered dietician (RD) evaluation documented the resident weighted 137 lb. and his/her usual body weight was 142 pounds, and his/her ideal body weight range was 125-145 pounds, with no supplements or specialized items used. The dietician documented the resident's intake the past 7 days as good 75-100% and ideal body weight within the recommended range. The RD made no new recommendations. On 8/17/16 at 9:30 AM, observation revealed the resident sitting in his/her wheelchair at table in the dining room, feeding his/her self the meal. He/she had regular texture food: scrambled eggs, sausage, fruit loop cereal, 2 (6 oz.) glasses of water, 1(8 oz.) glass of juice, and 1 (8 oz.) glass of milk. The resident ate 100 %, fed herself, and drank the milk, juice and 1 glass of water. On 8/18/16 at 4:08 PM, licensed nursing staff E reported the resident had no special instruction related to weight loss, and no special intervention he/she knew of to prevent weight loss. On 8/19/16 at 10:00 AM, dietary staff J reported the dietician sent a recommendation to start fortified foods, on 8/11/16, and he/ she failed to see the recommendation until 8/18/19, when checking the record. Dietary staff J reported the nursing staff had the recommendation now to notify the doctor and the family. Dietary staff J verified the resident had lost weight, and reported he/she had no interventions added. On 8/19/16 at 10:30 AM., licensed nursing staff T, reported staff sent the request for fortified foods to the physician, and called the family. He/she verified the resident lacked a dietary intervention on the care plan for the weight loss. On 8/19/16, at 2:00 PM, administrative nursing staff L verified the care plan lacked addition of fortified food for weight loss. On 8/25/16 at 4:55 PM, consultant staff Z reported he/she reviewed the resident on 8/11/16, and recommended fortified foods, due to his/her weight loss. Consultant staff Z reported he/she recommended to start fortified foods, and reported he/she would review the resident again on the next visit. The physician was unable to be reached by phone. The 9/2012, weight assessment and intervention policy documented: Any weight change of 5% or more since the last weight assessment will be retaken for confirmation, and if the weight change is verified, nursing will notify the registered dietician per facility protocol. The threshold for a significant unplanned and undesired weight changed will be based on the following criteria: 1 month- 5%, weight change is significant; greater than 5% is severe. 3 months- 7.5 %, weight change is significant; greater than 7.5% is severe. 6 months- 10% weight change is significant; greater than 10% is severe. Assessment information shall be analyzed by the interdisciplinary team and whether and to what extent weight stabilization or improvement can be anticipated. The facility failed to follow intervention for this resident that lost 11 pounds in 3 months from May 24, 2016 to August 1, 2016.

The facility reported a census of 39 residents with 3 residents sampled for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of the 3 sampled residents (#1) who received a second degree burn on the thigh after spilling hot cocoa on himself/herself. Findings included: - The physician's order [REDACTED].#1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission minimum data set (MDS), dated [DATE], documented the resident ' s brief interview for mental status score of 6, indicating severely impaired cognition and required total dependence of 1 staff for eating. The quarterly MDS, dated [DATE], documented no change from the previous assessment. The care area assessment, dated 8/11/15, for activities of daily living documented the resident was at risk for loss of independence and decreased range of motion. The care plan, dated 8/6/15, lacked direction to staff for assistance with eating/drinking. The update, on 10/10/15, directed staff to use a safety cup with lid, serve hot liquids only in the dining room at the table with a lap protector and staff to assist the resident due to the resident spilled hot chocolate onto his/her lap. The care plan lacked an update regarding the burn the resident received from the spill with direction to provide wound care and monitor the burn for healing. The hot liquids safety evaluation, dated 8/6/15, documented the resident was a new admission, with a varied mood. The resident refused his/her meal. There was no documentation of further assessment regarding hot liquid safety prior to the accident on 10/10/15. The nurse ' s note, dated 10/10/15 at 1:12 PM, documented the resident was in the dining room this morning having a cup of hot chocolate per his/her norm, when the beverage spilled onto the upper left thigh, soaking onto his/her jeans. The skin assessment revealed slight redness to the upper thigh, measuring 6 cm long by 5 cm wide. The resident voiced discomfort and staff administered Ibuprofen 400 mg (milligram) for pain relief, staff will continue to monitor. The nurse ' s note, dated 10/10/15 at 8:30 PM, documented the resident with an open blister where the resident spilled hot cocoa this morning. The upper portion of the skin peeled back about half way from the top of the wound. The blistered area was approximately 2 inches by 2 inches, with some seepage noted on the island dressing that covered the wound. Staff administered the resident Tylenol for pain. The resident will now use a cup with a lid, drink hot liquids only in the dining room at the table with a lap protector on and staff were to assist the resident with hot liquids. The skin assessment, dated 10/10/15 at 8:00 PM, documented the resident with an open blister from spilled cocoa measuring 1 inch x 2 inch, seeping a small amount of serous (clear, thing and watery) drainage on the front of the left thigh. The nurse ' s note, dated 10/13/15 at 9:18 PM, documented the area to the left upper thigh covered with bordered dressing, drainage noted from the open wound, approximately half dollar size. Also noted were two 1st degree type burns, measuring approximately 6 to 8 cm x 1 cm each and one approximately quarter sized. The resident reported it was sore, but denied the need for pain medication. The skin assessments, dated 10/17/15, 10/21/15, and 11/11/15, lacked identification of the burn. The physician's order [REDACTED]. The skin assessment, dated 10/28/15, documented the hot liquid burn from hot chocolate, required twice daily dressing changes due to green exudate (drainage) on the front of the left thigh. The weekly non-pressure skin report, dated 10/30/15, documented burn to the front of the left thigh, measuring 5 x 3 (no scale of measurement given such as cm or inches) with purulent exudate (thick, yellow/green drainage commonly referred to as pus). The wound bed with slough (moist yellow or gray dead tissue) and the surrounding skin was reddened. On 11/13/15 at 3:18 PM, Licensed Nursing Staff C provided wound care to the resident ' s burn site. Staff C removed the old dressing, which revealed a moderate amount of green thick drainage on the dressing. The wound appeared with green and yellow slough on the wound bed, the peri-area (wound border) without redness or inflammation, and pink edges to the interior edge of the wound, which measured 2 cm x 3.4 cm. Staff C changed his/her gloves, cleansed the burn with normal saline soaked gauze, applied Silvadene crème to the wound bed using an applicator, changed gloves, and applied a bordered gauze 4 inch by 4 inch dressing as ordered. On 11/13/15 at 3:31 PM, Licensed Nursing Staff C reported the resident received the burn from drinking hot cocoa, and spilling it on his/her self. The cocoa burned the resident ' s left thigh. Staff C stated the resident required supervision for eating/drinking prior to the accident. Staff C reported staff failed to fully assess the resident for hot liquid safety prior to the accident and the resident was not able to drink without staff assistance without spilling the drink. On 11/13/15 at 8:15 AM, direct care staff D stated the resident frequently spilled drinks on him/herself if staff did not help him/her with them. The resident did not have lids on his/her drinks prior to the accident. On 11/13/15 at 3:57 PM, direct care staff E reported the resident had to have help with drinks, prior to the accident. Staff E stated the resident did not hold drinks very well and would spill them all over him/herself, which required staff to frequently change the resident's clothing. During the investigation, it was not determined which staff member provided the resident with the hot cocoa prior to breakfast, on 10/10/15. Direct care staff working on 10/10/15, reported dietary staff would have made the drink for the resident. Dietary staff working on 10/10/15, were unable to recall who made and served the resident ' s cocoa that day. On 11/13/15 at 4:15 PM, Administrative Nursing Staff B reported a hot liquid safety assessment was done on admission, quarterly and with a significant change in resident ' s abilities. Staff B expected the nurse performing the hot liquid safety assessment to observe the resident eat a meal as part of the assessment and was not aware the resident refused the meal during the assessment. Staff B thought the resident ' s had been determined safe to drink hot liquids. Staff B had no knowledge that the resident frequently spilled drinks on him/herself. Staff B expected the care plan to be updated to reveal the wound when the accident happened, to include monitor of the treatment, healing, and orders related the wound. Staff B confirmed staff failed to update the care plan to include this information. On 11/17/15 at 3:53 PM, administrative nursing staff F reported that if a resident is frequently spilling drinks on themselves, staff F expect staff to chart this in the medical record, for the nurse to re-assess the resident for hot liquid safety and to notify administrative nursing staff. On 11/13/15 at 4:00 PM and 11/17/15 at 7:50 AM, messages were left for the physician, who had not returned the call. The facility provided Hot Beverage Safety Policy, not dated but in place at the time of the resident's accident per Administrative Staff A on 11/17/15 at 1:40 PM, documented resident's needing assistance with hot berverages would include a resident who demonstrates impaired orientation in one or more area of person, place or time. Residents will receive at minimum supervision if any of the above areas are noted. The facility failed to provide adequate supervision for the resident to safely drink hot chocolate. The resident spilled the drink, and received a 2nd degree burn on the left thigh.

The facility census totaled 33 residents with 1 resident sampled for the facility's provision of social services. Based on observation, interview and record review, the facility failed to provide social services that supported the mental health for a resident with a history of mental illness. (#15) The resident exhibited repeated, continuous aggressive behaviors over 6 months that involved other residents and staff in the facility. Findings included: - Review of a CARE (Client, Assessment, Referral, and Evaluation) Assessment, dated [DATE] identified the resident had a [DIAGNOSES REDACTED]. The CARE assessment indicated the need for a referral for a Level II assessment to determine the continued need for behavioral health services. Review of an admission MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of [DATE] revealed resident #15 with moderately impaired cognition, felt little interest or pleasure in doing things ,[DATE] days during the previous 2 weeks (nearly every day), and for ,[DATE] days of the previous 14 days (or occasionally) felt tired or having little energy, felt bad about them self, or that they were a failure or had let their family down, or had trouble concentrating on things, such as reading the newspaper or watching television. The assessment also identified the resident experienced hallucinations, but exhibited no behaviors, such as resisting care, wandering, or verbal or physical aggression, and did not receive psychological therapy. Review of the Psychosocial Well-Being and Mood CAAs (Care Area Assessments, a further assessment) revealed they were triggered, but staff failed to complete them. Review of the care plan, dated [DATE], revealed the following interventions for staff: "Remove resident from group activities when behavior is unacceptable, allow resident to discuss anger, when resident becomes physically abusive, keep distance between resident and others (e.g. residents, staff, visitors), when resident becomes physically abusive, move to a quiet, calm environment, set expectations and limits for resident, praise resident when behavior is acceptable, maintain a calm, slow, understandable approach to the resident, offer one step verbal steps for tasks, allow extra time for comprehension, provide care, activities, and a daily schedule that resembles the resident's previous lifestyle, if resident has hallucinations/delusion, do not confront or try to reason, offer reassurance, convey an attitude of acceptance toward the resident avoid over-stimulation (noise, overcrowding, other physically aggressive residents), assess whether the behavior endangers the resident and/or others and intervene if necessary, notify physician if fears and anxiety begin to negatively impact resident's care or safety, orient to facility routines as needed, reassure resident that he/she is safe, encourage family and friends to visit, explain all procedures to resident and/or family, discuss fears and anxiety with an open, accepting attitude, encourage resident to verbalize fears and anxiety, and approach resident in a calm, unhurried manner." Review of the nurse's notes revealed the following entries: On [DATE] at 7:58 p.m. Charge Nurse C documented "Observed resident in w/c (wheelchair) in TV room kicking (other) resident in shins with both feet while (other) resident standing over (gender) swinging fists. CMA (certified medication aide) et (and) this nurse intercepted. Resident denies pain from altercation at this time. No injury noted. Vs (vital signs) wnl (within normal limits). This nurse asked resident what had upset (gender). Resident stated, "I was watching the Hallmark channel et (and) (the other resident) just walked up et changed to golf! Golf is just stupid et it upsets me!" Vs wnl (vital signs within normal limits). Resident returned to rm (room) at this time. Stated, "I'll just go to my room et watch the Hallmark channel." Fax sent to Dr and DPOA (Durable Power of Attorney) contacted per D.O.N. (Director of Nurses) Will continue to monitor." On [DATE] at 2:42 p.m., Charge Nurse D wrote the following: "Resident having behaviors over other resident's in the TV room watching the football games on TV. Resident stated 'That's all that jack ass does is watch sports.' and points to (other) resident. Other residents informed resident that they were all watching the football game. Resident continued to stay in TV room even though (gender) 'Hates football.' Resident getting into fridge in the kitchen. Staff and nurse having trouble with redirection working. Gave PRN (as needed) meds (medications). Will continue to monitor." On [DATE] at 5:15 p.m., Charge Nurse E documented the following: "Resident was found this evening wandering into other resident's rooms. (First resident's room) who was asleep and (second resident's room) who did not like (gender) in (gender) room. Instructed resident (gender) was not to go into other resident's rooms. Verbalizes understanding. Returns to (gender) room and have had no more problem." On [DATE] 9:35 a.m., Charge Nurse D wrote "Resident agitated and aggressive with staff over TV program. Resident was not in day room when other residents asked if they could watch another program. Staff changed channel to program that 5 (genders) agreed upon. Resident then wheeled self into day room began screaming at staff that everyone changes (gender) channel. When staff attempted to redirect (gender) to watch (gender) TV in (resident's) room, (the resident) stated."That is not my TV!" "TV name on it". This nurse informed resident that day room TV was a facility TV and that (the resident) would either have to watch what the others were watching or go to (the resident's) room and watch a program there. This is becoming a frequent issue with this resident. Even leading to physical violence from this resident. Will continue to monitor resident." On [DATE] at 8:10 p.m., Charge Nurse C documented the following: "This resident watching TV in chair in TV rm. Another resident attacked (this resident), snatching (the resident's) stocking cap from (the resident's) head & attempting to take eye glasses out of (the resident's) hand. Other resident stated 'Thought was remote control.' Resident denies any pain or discomfort. Stated '(That resident) didn't hit me or anything. Just took my hat and tried to take my glasses.' This resident was visibly upset by altercation. States 'okay'." On [DATE] at 7:41 p.m. Charge Nurse F documented in the nurse's notes: "Resident cont (continues) to have conflict with another resident with behaviors. Other resident tried to take (resident #15's) w/c (wheelchair) while (the resident) was sitting in another chair in the dining room and (resident #15) pushed (the other resident's) hand away and hollered at (the other resident) to stop. Event witnessed by CMA. Will cont (continue) to monitor." Review of a quarterly MDS, with an ARD of [DATE] revealed the resident continued to have moderate cognitive impairment, continued to experience little interest or pleasure in doing things ,[DATE] days during the previous 2 weeks (nearly every day), and also continued to feel tired or with having little energy, felt bad about them self, or that they were a failure or had let their family down, or had trouble concentrating on things, such as reading the newspaper or watching television for ,[DATE] days of the previous 2 weeks. The assessment identified the resident experienced hallucinations, but assessed the resident with no behaviors, such as resisting care, wandering, or verbal or physical aggression, and did not receive psychological therapy. Review of the care plan revealed staff did not revise the care plan to develop a behavioral plan to help staff monitor and address the resident's aggressive behaviors. The medical record revealed Social Services did not attempt to seek psychological therapy for the resident to help with the behaviors. On [DATE] at 10:19 p.m. Charge Nurse D documented the following in the nurse's notes: "Resident screaming and staff separated this resident from another resident. Altercation did occur. No apparent injury." On [DATE] at 3:06 p.m. Social Service Staff H reviewed the resident's plan of care and documented the following progress note: the resident experienced moods with behaviors and "is very aggressive and this gets (the resident) in trouble with other residents." On [DATE] 5:20 p.m., Administrative Nurse J documented in the nurse's notes that the resident "left TV room to come to med cart (independently). (After) taking meds (the resident) returned to the TV room. A confused res had sat in the chair (the resident) had been sitting in. (Resident #15) told (the confused resident) to get out of (gender) chair. (The confused resident) didn't comply and (resident #15) began yelling and cursing at (the confused resident). Staff heard (resident #15), and attempted to intervene. (Resident #15) continued to yell at (the confused resident) and before staff could remove (resident #15) from the situation (resident #15) threw a full glass of water on (the confused resident) sitting in the chair, and verbally threatened another res standing nearby. (Social Service staff) notified and took res into (their) office to speak to (resident #15) regarding the inappropriate behaviors. (Resident #15) verbally threatened (Social Service Staff) and was belligerent. (Social Service Staff) called DON (Director of Nurses) who stated to give res a prn (as needed medication). Res has order for Ativan (anti-anxiety) prn and was given Ativan 0.5mg (milligrams) per (doctor's order) from ekit (emergency kit) (after) obtaining approval from pharmacist. DPOA notified of resident's behavior. Fax to Dr re: behavior." Review of a quarterly MDS with an ARD of [DATE] identified the resident continued to exhibit moderately impaired cognition, now identified an improvement in their moods, as they only had trouble falling asleep or staying asleep ,[DATE] days out of the previous 14 day assessment period, lacked behaviors and remained without psychological therapy. Review of the care plan revealed staff did not develop a behavioral health plan, but revised the care plan to contact pharmacy for med review and recommendation and obtain DPOA consent for PRN psychological consult. Review of the record revealed that the pharmacist reviewed the resident's medications, but made no suggestions for changes related to behaviors, and Social Service Staff H failed to contact the DPOA for consent to obtain the psychological consult. Review of a nurse's note, dated [DATE] at 12:30 p.m. revealed the facility sponsored a BBQ. The resident stood in line to participate in the BBQ; Earlier the resident complained of tooth pain and stated they couldn't chew the food served at the lunch for the residents. Due to this information, Administrative Dietary Staff G told the resident that since their food needed modification, the resident would not be able to chew the food at the BBQ as staff did not modify, or grind, any of the meat. The resident "began screaming in front of approx ,[DATE] visitors disrupting the BBQ. (The resident) was stating (they) must have had a seizure during the (night) due to (the) tooth pain, and (the resident) could have swallowed (their) tongue and died , and that no one gave a damn." Staff attempted to calm the resident, but the resident continued to exhibit verbal abuse to the staff. Administrative Nurse J gave the resident the choice "to talk quietly in public area or leave the Dayroom. Res stated 'let ' s go then'. (Administrative Nurse J) started to wheel res out of dayroom when (the resident) planted (their) feet on the floor and began attempting to hit (Administrative Nurse J)." Observation on [DATE] at 9:30 a.m. revealed the resident seated in a recliner in the lobby, watching TV. The resident actively watched the television. Additional observation on [DATE] at 9:10 a.m. revealed the resident again in the lobby, watching TV. Nurse Aide B, on [DATE] at 5:15 p.m., stated "the resident can have behaviors" and "likes to think that one of the chairs in the lobby is (the resident's), and if there are any other residents seated in one of those chairs it upsets (gender)." When asked what Staff B did when the resident became upset, Staff B said "We are to try and divert (the resident's) attention and try to help (the resident) calm down, go to (their) room, or take the other residents away so (the resident) doesn't get violent." On [DATE] at 9:36 a.m. Social Service Staff H stated they reviewed the CARE assessments when the resident's were admitted to the facility. If the CARE assessments suggested mental health assistance, then Staff H planned to contact the DPOA to get their permission and determine if the DPOA had a preference as to which therapist assisted the resident. Staff H confirmed the resident did not receive psychological therapy. When shown the CARE assessment and asked why they did not continue on with the mental health services, Staff H stated they missed it. Social Service Staff H confirmed the facility had them work part time at 20 hours a week due to the facility's low resident census. Staff H stated they not only had to keep up with all their social service responsibilities, but they also helped Activity Staff A when the Staff A needed to transport a resident to a doctor's appointment as Staff A also worked as the transportation department. Staff H also assisted with marketing of the facility and attended local government meetings as a representative of the facility and assisted the nurse aides at meal times to make sure the residents ate their meals. Staff H stated they had a hard time getting all their work done, and didn't feel as if they were able to get all their work done in 20 hours a week. On [DATE] at 6:30 p.m., Staff H stated they had called the resident's DPOA to obtain permission for psychological therapy and they planned to call a therapist in the next few days to initiate the therapy. The facility failed to provide social services to obtain psychological support for over 6 months for a resident with a history of mental illness that exhibited multiple behaviors that included aggression and involved other residents and staff.

The facility reported a census of 33 residents with 3 residents sampled for accidents. Based on observation, interview, and record review the facility failed to ensure 1 of 3 sampled residents (# 19) received adequate supervision to prevent further falls and injuries, which resulted in the need for emergency care to assess and treat a laceration and injury to the resident ' s nose, for a resident that had a history of [REDACTED]. Findings Included: - Review of resident # 19's annual MDS 2.0 with an assessment reference date of 6-19-10 identified the resident with short and long term memory impairment and rarely/never made decisions. The MDS identified the resident had highly impaired vision and only hears in special situations. The MDS identified the resident required limited assistance of one person for transfers and walking, had an unsteady gait, and was at risk for falls and had fallen in the last 31-180 days prior to this MDS assessment. Review of the resident's quarterly MDS (Minimum Data Set, a required assessment) 3.0 with an assessment reference date of 3-18-11 identified the resident with short and long term memory impairments and required extensive assistance of one staff member for transfers and toileting. The MDS identified the resident used a wheelchair for locomotion and propelled self, did not use any type of restraint, and was at risk for falls and had fallen in the last month prior to the assessment. The MDS also identified the resident was unsteady and only able to stabilize with human assistance during transfers. Review of the resident's [DIAGNOSES REDACTED]. Review of the resident's Fall Risk assessment dated [DATE], in the resident's medical record, identified the resident at high risk for falls. The assessment identified the resident had poor vision but failed to correctly identify the resident was legally blind and that the resident used a wheelchair, identified the resident only had balance problems while walking, identified that the resident had 1-2 falls in the last 3 months prior to this fall assessment, and the assessment failed to identify the resident had some perceptional and neuromuscular/functional impairments; such as: impaired hearing, impaired vision, incontinence, and unsteady gait. The fall assessment identified that no further referrals were indicated or appropriate and identified to continue the resident's current plan of care. The resident's care plan, updated 5-20-11, identified the resident used a merri walker and was at risk for falls related to the resident's [DIAGNOSES REDACTED]. Interventions included in the care plan were to not leave the resident in rooms unattended, restorative program initiated, exercise group 5 times a week and as needed, be aware of the resident ' s location, encourage the resident to ask for assistance, remove/redirect from obstacles in way/path, visual checks every 30 minutes and as needed. The care plan also identified the resident had limited mobility and propelled themselves in a wheelchair and identified when the resident self propelled their wheelchair to observe for catching or pinning arms and hands in or near handrails, doorways. Record review of the resident's progress notes from the last 4 months, revealed the resident had a total of 3 falls in the last 4 months at the facility. Review of the documentation in the progress notes revealed the resident fell out of their wheelchair on 3-11-11 in their room and interventions included were to not leave the resident alone in their room. The next fall documented in the progress notes dated 4-17-11 revealed the resident missed the seat to their merri walker and tipped over their merri walker in the hallway. Interventions included were to use a gait belt in between the resident's legs and secure around the PVC pipe on the hand rest and under the seat on the merri walker. The last fall documented in the resident's progress notes dated 5-28-11 revealed the resident tipped their merri walker over in the living room. Staff documented after the fall on 5-28-11, in the progress notes, the resident had a "gash on right side of forehead between eyebrow and nose, 2 slits on nose and it is bent, has a 1 cm (centimeter) skin tear to left hand at base of thumb". The documentation in the progress notes, failed to include specific measurements of the "gash and slits " . The resident was treated and released from the hospital for the injuries from the fall and received steri strips applied to the resident ' s face. The progress note dated 5-29-11 revealed documentation that stated the resident reported pain to their nose and face and reported tenderness when the area was touched. The progress note dated 5-31-11 revealed documentation that identified yellowing on the skin around the resident ' s forehead and nose areas where they had obtained injuries from the fall on 5-28-11 but failed to specify the size of the yellowed areas. The progress note dated 6-6-11 revealed yellowing around the resident's forehead and nose where they had fallen on 5-28-11. The documentation failed to specify the size of the bruising. Observation on 6-7-11 at 4:00 p.m. revealed the resident walking in their merri walker up and down the hallway. The resident was observed wearing white socks without grippers on the bottom of the socks, without shoes on their feet, and the resident ambulated down the hallway with their merri walker without staff present. Observation at 4:35 p.m. revealed the resident ambulated down the hallway in their merri walker without staff present, wearing the same socks without shoes on both of their feet. Observation at 5:15 p.m. revealed the resident ambulated down the hallway with their merri walker with their head down, with the same white socks on their feet without shoes on. Staff failed to ensure the resident's foot wear was appropriate for ambulation. Observation on 6-8-11 at 11:58 a.m. revealed the resident independently propelled the merri walker into the chapel and placed themselves in an area out of sight of the nursing staff. At 12:15 p.m. the resident moved to a different area closer to the doors in the chapel, in an area now visible to the nursing staff. At 12:18 p.m. nurse aide N and nurse aide M went into the chapel and propelled the resident to their table and removed the resident from their merri walker to eat lunch. The resident's care plan included staff should be aware of the resident's location and should not be left in rooms by themselves. Observation on 6-13-11 at 1:16 p.m. revealed the resident seated in their merri walker in a resident's room with the overhead lights off, not their room, with their eyes closed and their head leaned down. The resident's care plan identified the resident was not to be alone in rooms without staff present. Interview on 6-9-11 at 5:29 p.m. with nurse aide B revealed that the resident had fallen at the end of May and had obtained a cut to their head. Nurse aide B revealed staff left the weight scale platform area (the area that residents stand on to be weighed) down and created an uneven walking surface and the resident went over that with their merri walker and tipped over onto their side and fell . Nurse aide B revealed they were upset because the scale shouldn't have been left down and the resident was injured as a result of that. Nurse aide B revealed that they had received training that included to never leave the weight scale platform down. Nurse aide B also reported, because of the frequent changes in staff, not all of the new staff had been trained to put the weight scale platform up after each use. Nurse aide B revealed there had been staff hours cut and it had been very difficult to give care and monitor the residents at the same time. Nurse aide B revealed "my nurse helps me as much as they can but they've got to do their stuff too and sometimes can't get to everything" . During an interview on 6-13-11 at 2:38 p.m. physical therapy staff Y revealed the resident had not received the restorative program they had created for the resident because there had not been enough nursing staff to complete the restorative program. The resident's care plan identified the resident would receive their restorative program weekly. During an interview on 6-13-11 at 3:46 p.m., administrative nurse J confirmed the facility failed to thoroughly investigate falls, initiate and update interventions, ensure the resident had proper foot wear when ambulating, and failed to supervise the resident to prevent further accidents. Administrative nurse J revealed expressed unawareness regarding if the merri walker needed to be used with a gait belt because the merri walker had been at the facility for a while. Administrative nurse J revealed they had not reviewed the manufacturer's guidelines and thought that strap that went with the merri walker was no longer at the facility. The facility failed to provide adequate supervision to prevent further accident and injuries, which resulted in the resident requiring emergency medical care at the hospital to a cut on the resident's forehead after a fall.

The facility census totaled 33 residents with 2 included in the sample for weight loss. Based on observation, interview and record review the facility failed to comprehensively assess the the significant weight loss, failed to accurately and consistently monitor the administration of a supplement and failed to revise the care plan to develop new interventions when 2 of 2 sampled residents (#40 and #42) continued to lose weight to ensure the weight loss was unavoidable. Both residents lost over 10% in less than 6 months, a significant amount of weight. Findings included: - Review of the admission MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 3/3/11 identified resident #42 with moderately impaired cognition, short and long term memory problems, required limited assistance from one staff with eating, no eating or chewing problems and with a weight of 137 pounds. Review of the CAT (Care Area Trigger-a trigger legend that identified what areas required further assessment based on the answers from the MDS) revealed the Nutritional CAT did not trigger to identify weight loss. The ADL (Activity of Daily Living) area did trigger as an area that required further review, but staff failed to complete the CAA (Care Area Assessment, a further assessment), which provided the opportunity for staff to describe the resident's eating habits, which is an ADL. Review of the care plan, dated 3/4/11, included the following guidance to staff: report daily intake of 50% or less and/or weight loss to physician ASAP (As soon as possible), offer between meals snacks and hydration, provide alternative nutrition if resident eats less than 50% of meal, encourage resident to eat at least 75% of meals, provide diet as physician ordered, and weekly weights. According to the facility's computerized documentation, review of the resident's weights revealed the following: 2/22/11: 141.4 pounds 3/2/11 137.4 pounds 3/6/11 137.4 pounds 3/14/11 130.8 pounds 3/20/11 132.2 pounds 3/27/11 130.6 pounds 4/6/11 131.2 pounds The facility failed to revise the care plan or develop interventions prior to the 10.2 pound weight loss (7.2% of weight loss) between 2/22/11 and 4/6/11. According to the Dietitian's reports, the facility changed Consultant Dietitians. The previous Dietitian's last report, dated 2/11/11, identified the dietitian completed assessments and dietary notes for all the residents "on my list." Resident #42 had not been admitted at that time, so would not be on that Dietitian's report. The next Dietitian visit and report, provided by Dietitian P and dated 4/7/11 (almost 2 months later), revealed Dietitian P assessed resident #42. Dietitian P, on 4/7/11, documented the following: "Resident admitted to the facility 2/22/11. Resident receives a regular diet and has variable intake. Current wt (weight) is 130# and admit wt was 137# which is a 4% wt loss since admission. Resident has Alzheimer ' s dementia and intake varies with degrees of dementia. Recommend shakes tid (three times a day) to increase calories and stabilize wt. Ht (height) is 69 inches and BMI (Body Mass Index, indicator of healthy weight range) =19 which is the low end of acceptable BMI range. Continue with current plan of care with recommendations." Review of the facility's computerized documentation of the resident's weights after the dietitian's identification of the resident's weight loss revealed the following: 4/10/11 128.6 pounds 5/1/11 125 pounds 5/8/11 128.2 pounds 5/15/11 128 pounds 5/30/11 126.6 pounds According to the documentation, the resident continued to lose weight. The resident lost a total weight of 14.8 pounds or 10.4% in 100 days, a significant amount of weight loss. Review of the care plan revealed the facility failed to revise the care plan to address the continued weight loss. Review of Dietitian P's report on their most recent visit, dated 5/27/11, revealed Dietitian P did not review the resident's weights to identify and address the resident's continued weight loss. Observation on 6/8/11 at 8:16 a.m. revealed the resident sat at a table in the dining room. The dietary staff served the resident a breakfast of toast, cream of wheat, and a fried egg, and 2 bacon slices, plus 8 oz of milk, 8 oz of water, and 4 oz orange juice. Observation revealed the resident immediately started to eat independently. On 6/8/11 at 8:35 a.m., observation revealed the resident finished eating and stood up to walk away from the table. The resident ate all of the food. Activity staff A asked the resident if they enjoyed the breakfast and the resident said "It was the best stuff." Staff A failed to offer the resident any more food. Observation of the noon meal on 6/8/11 at 12:09 p.m. revealed dietary staff served the resident a noon meal of a slice of turkey, mashed potatoes and gravy, and yellow squash. The resident started to eat independently. At 12:30 p.m., observation revealed the resident finished eating, so they stood up and started walking around the dining room. Staff served (the resident) another plate of the food, but the resident continued to walk around the dining room. The resident did not eat any more of the second plate and staff failed to encourage the resident to sit and eat. Observation on 6/9/11 at 8:15 a.m. revealed the resident sat in the dining room, waiting on staff to serve the breakfast meal. Staff served the resident scrambled eggs, toast and hot cereal. The resident ate all of the food at 8:53 a.m. and left the dining room independently. Staff failed to offer more food. Observation on 6/9/11 at 10:45 a.m. revealed Dietary Staff Q, brought out snacks from the kitchen to the nursing area on a cart for the nursing staff to pass. There were 10 small Styrofoam cups with lids that held a small scoop of cottage cheese on ice, and 4 glasses of 2-cal (another dietary supplement), and 3 glasses of 6 ounces of Instant Breakfast shakes. Nurse R identified the contents of each container and identified the names on each container. Nurse R stated that staff were to give the resident an Instant Breakfast shake. Observation on 6/9/11 at 10:50 a.m. revealed Nurse Aide O passed the snacks, and gave the glass to the resident to drink. Observation revealed the resident drank the entire shake. On 6/9/11 at 11:54 a.m., Medication Aide S stated that all the Instant Breakfast shakes were documented in the MARs (Medication Administration Records). "However, some of the others are documented in a different book, or they used to when I worked the floor. I'm not real sure where they document those at so you had better ask the CNAs who pass out the snacks to make sure." Review of the resident's June 2011 MAR indicated [REDACTED]. On 6/9/11 at 12:00 noon. Nurse Aide O, who passed out snacks that morning, identified the nurse aides document the supplements in the ADL (Activities of Daily Living) book under the section called "fluids." Review of the ADL book revealed the CNAs documented at least 120cc (cubic centimeters) of fluid for shift for every resident, even those that didn't get supplements. When asked to clarify, Nurse Aide O stated that staff documented the administration of water or juice to some and supplements to others. Nurse Aide O agreed the ADL book lacked identification of the type of fluid staff administered, so it wasn't clear if staff actually administered the supplements as ordered, or if they gave water. Nurse Aide O identified the facility used to document the supplements and snacks in a separate book, but they "must not be doing that anymore." The facility lacked a system to ensure the consistent and accurate monitoring of the intake of supplements and snacks. Observation on 6/9/11 at 12:10 p.m. revealed the resident sat at a table in the dining room. Staff served the resident chicken fried steak and gravy, beets, French fries, and peaches. The resident ate everything except the peaches and then got up and left. None of the 3 nurse aides who sat assisting other residents at a nearby table stopped the resident to encourage the resident to eat more. On 6/9/11 at 12:47 p.m. Administrative Dietary Staff G saw that the resident had left the dining room and said "Where did (the resident) go? I need to go find out if (they) want another plate." At 12:50 p.m., observation revealed the resident returned to the dining room, with Staff G, who then went and got another plate of food and sat it in front of the resident at the table. The resident started to eat immediately. On 6/9/11 at 3:30 p.m. Administrative Dietary Staff G identified they were made aware of weight loss in the residents when they ran a computerized report that identified those with weight loss. The report identified for Staff G those residents with a significant amount of weight loss. Staff G stated after they ran the report weekly, they got together with either Administrative Nurse J or Administrative Staff L and then they talked about what they are going to do to help the resident. Staff G stated usually the intervention involved adding a supplement to the resident's diet, such as Instant Breakfast Shakes or 2-cal. Staff G identified the staff needed Doctor's orders for both supplements. On 6/9/11 at 5:01 p.m., Nurse Aide B said that generally when a resident was losing weight, the "nurse will tell me if they are losing weight. Usually they give them snacks, or shakes or something like that." Staff B stated they were not aware if the resident was losing weight or if they received supplements. On 6/13/11 at 12:15 p.m., Administrative Staff J said the resident used to not eat well, when the resident first came in they wouldn't eat. Staff sent the resident to a Behavioral Health Unit and when they came back the resident ate everything the staff gave them. When asked why the resident continued to lose weight and if the facility had notified the physician of the continued weight loss, Staff J stated they just didn't know. They planned to look for physician notification, but failed to provide any documentation. The facility failed to conduct a comprehensive assessment on a resident's weight loss, failed to notify the physician of the weight loss, failed to accurately and consistently monitor the administration of a supplement, and failed to revise the care plan to develop new interventions when the resident continued to lose weight to ensure the weight loss was unavoidable. The resident went from 141.4 pounds to 126.6 pounds in 100 days, a loss of 14.8 pounds, or 10.4% of weight loss, a significant amount of weight loss. - Review of an admission MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 1/14/11 identified resident #40 with slight cognitive impairment, short and long term memory problems, inattention, required extensive assistance of one staff member with eating, on a mechanically altered, therapeutic diet, and with a weight of 149 pounds. Review of the Nutritional Status CAA (Care Area Assessment--a further assessment) revealed it triggered but staff failed to complete the CAA. The care plan, dated 2/1/11, included the following interventions for staff: encourage meal intakes to 75%, encourage fluid intake to 2000 cc(cubic centimeters)/day, dietary consult, monitor food and fluid intake daily and record, weight per physician orders, offer choices of menu items, provide meals and snacks as ordered. Review of the facility's computerized documentation of the resident's weights revealed the following: 1/7/11 149.4 pounds 1/10/11 142.0 pounds 1/16/11 139.4 pounds 1/23/11 138.4 pounds 1/31/11 132.0 pounds 2/6/11 130.6 pounds On 2/11/11 at 2:12 p.m. the Consultant Dietitian assessed the resident and wrote the following note: "Please reweigh (the resident) to confirm that 17# (pound) weight loss. (The resident) was put on IB (Instant Breakfast) shakes at snack time on 1/26/11 which should help stabilize weight. Check to make sure (the resident) is consuming these. Also add 4 oz (ounces) Ensure (an additional supplement) at meals TID (three times a day)." The medical record lacked notification to the physician of the resident's weight loss. Review of the MARs (Medication Administration Records) for February and March 2011 revealed they lacked an entry for staff to document the administration of the Instant Breakfast shakes or the Ensure. Review of the facility's computerized documentation of the resident's weights revealed the following: 2/14/11 130.4 pounds 2/21/11 125.2 pounds 3/2/11 129.8 pounds 3/6/11 130 pounds The resident lost a total of 19.4 pounds, or 12%, in 90 days, a significant weight loss. Review of the facility's documentation for the resident's meal intake for February 2011 revealed that the resident was hospitalized for [REDACTED]. The staff served the resident 60 meals during the month. Of the 60 meals, the resident consumed at least 75% at 38 of them, or 64% of their meals. Of the other 36%, staff failed to document if they followed the care plan and offered a substitute of the resident's liking, or if they encouraged the resident to eat at least 75%. Review of the nurse's notes revealed on 3/8/11, the resident was discharged from the facility. On 6/9/11 at 12:00 noon. Nurse Aide O identified the nurse aides document the supplements in the ADL (Activities of Daily Living) book under the section called "fluids." Review of the ADL book revealed the CNAs documented at least 120cc (cubic centimeters) of fluid for shift for every resident, even those that didn't get supplements. When asked to clarify, Nurse Aide O stated that staff documented the administration of water or juice to some and supplements to others. Nurse Aide O agreed the ADL book lacked identification of the type of fluid staff administered, so it wasn't clear if staff actually administered the supplements as ordered, or if they gave water or some other type of fluid. Nurse Aide O identified the facility used to document the supplements and snacks in a separate book, but they "must not be doing that anymore." On 6/13/11 at 12:15 p.m., when told of the concerns regarding the lack of physician notification of the resident's weight loss, and lack of accurate and consistent monitoring of supplement intake, as well as if staff followed the care plan and offered additional foods or alternative foods when the resident ate less than 50%, Administrative Staff J shook their head yes and said they agreed. The facility failed to conduct a comprehensive assessment of the resident's weight loss through a failure to accurately and consistently monitor the resident's dietary supplemental intake, notify the physician of the resident's weight loss and a failure to follow the care plan and encourage the resident to eat 75% of their meals. The resident lost a total of 19.4 pounds, or 12% of their weight in 90 days, a significant amount of weight loss.