Every finding on record at Westy Community Care Home

Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 31 residents who resided in the facility and received their meals from the kitchen. Findings included:- On 07/26/2026 at 08:35 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 07/27/2026 at 09:30 AM, Dietary Staff BB verified she was the certified dietary manager and had been in the position for one month. Dietary Staff BB stated the facility had six residents with a pureed diet. On 07/28/2026 at 01:00 PM, Administrative Staff A verified Dietary Staff BB was not certified and stated the previous dietary manager quit a month ago and Dietary Staff BB started and will be enrolled in the Certified Dietary Manager classes soon. The facility's Certified Dietary Manager policy, dated 06/26/2026, documented the facility would employee a qualified Dietary Aupervison/Certified Dietary Manager responsible for organizing, directing, staffing, monitoring, and evaluating all food service operations to ensure compliance with facility policies, resident care standards, infection prevention practices, food safety requirements, and nutrition standards. The Dietary Supervisor shall possess successful completion of a state-approved Certified Dietary Manager certification program.

Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when staff failed to secure chemicals safely from access by the seven cognitively impaired, independently mobile residents who resided in the facility's memory care unit. Findings included:- On 07/26/2026 at 07:55 AM, observation revealed an unlocked kitchenette door where one twenty-four ounce (oz) spray bottle of One Step Disinfectant Cleaner, with the warning keep out of reach of children, in the storage cabinet. Continued observation revealed R23 was in the unlocked kitchenette, and there were no staff in the area. He opened a coffee carafe, unscrewed the lid, and poured the coffee into his cup, then screwed the lid on and walked over to the dining room table, sat down, and drank the coffee. Continued observation revealed an electric cooking griddle approximately 15 inches by 20 inches, with the lid on the griddle turned off, still warm to the touch and could be readily turned on with a dial. One staff was in the shower house giving a resident a shower and the other aide went to the main facility commons area to help with residents. The kitchenette and dining room were left unattended by staff for approximately eight minutes. On 07/27/2026 at 07:35 AM, observation revealed Certified Nurse Aide (CNA) M assisted residents in the memory care unit serving breakfast. At 07:45 AM, CNA M left the kitchenette/dining room to get another resident to come to the dining room. CNA M left the dining room unattended for approximately two minutes. Observation revealed two residents were eating their breakfast and one was drinking coffee. Ongoing observation revealed the kitchenette was unattended by staff and the electric cooking griddle had the lid open with scrambled eggs on the griddle and the temperature dial turned to low. On 07/27/2026 at 08:10 PM, Administrative Nurse D verified the kitchenette cabinet storage door should be closed and locked and chemicals out of reach from the residents. Administrative Nurse D verified the kitchenette/dining rooms should not be left unattended while cognitively impaired residents are in the room, verified the electric cooking griddle should be turned off and not in use, and verified the coffee should not be accessible for residents to pour their own drinks, especially with hot liquids. The facility's Control of Hazardous Chemicals policy, dated 01/31/2024, documented the facility was committed to eliminating and controlling hazards that could cause injury or illness to our residents. The facility would meet the requirements of safety standards where there are specific rules about hazards or potential hazards in the facility. The policy documented all hazardous chemicals in each workspace would be labeled with the identity of the chemical and the appropriate hazard warnings. All hazardous chemicals are to be always locked to avoid accessibility to any resident in the facility. The facility's Safe Serving of Coffee and other Hot Liquids and Handling of Hot Surfaces policy, date 07/06/26, documented coffee and other hot beverages would be consumed at 155 to 175 degrees Fahrenheit (F) noting that the temperature can result in burns if the beverage contacts the skin or mucous membranes. Residents at risk for handling hot liquids the following measures would be implemented: Access to coffee would be supervised. Assistive devices would be offered as necessary, including but not limited to sealed covers on all hot liquids and prohibition of straws for hot liquids, and hot liquids would be cooled prior to allowing the residents to handle them. The staff would limit access to hot liquids in the dining room to the coffee thermos carafes no more than 30 minutes before meals. The thermos carafes would remain in the kitchen until staff is available in the dining room for meal service. Hot beverages would not be left unattended without accessibility of hot beverages of choice in carafes or carriers with secured covers to reduce the risk of accidental dispensing.

Based on observation, interview, and record review, the facility failed to store medications and biologicals adequately when staff failed to discard expired stock medication from the emergency kit. Findings included:- On 07/28/2026 at 01:30 PM, observation of the facility emergency kit in the medication room revealed an expiration date of 05/19/2026 with the following: Ceftriaxone (antibiotic medication) 1 gram (g), two bottles, expiration 05/2026. Epinephrine (a hormone medication that reverses severe allergic reactions) 50 milligrams (mg), two bottles, expiration 11/2025. Lidocaine (anesthetic medication) 50 mg, two bottles, expiration 4/2026 Naloxone (opioid receptor antagonist medication, reverses opioid overdose) Hydrochloride 2 mg, one Injection pen, expiration 4/2026. Glucagon (medication that increases blood sugar) Emergency Kit that contains one mg vial of glucagon, and sterile water to be mixed with the glucagon. Amoxicillin (antibiotic medication) 500 mg, four tablets, expiration 5/19/2026 Amoxicillin and Clavulanate Potassium tablet (antibiotic medication) 500-125 mg, four tablets, expiration 05/04/2026. Cefdinir (antibiotic medication) 300 mg, four tablets, expiration 05/14/2026. Ciprofloxacin (antibiotic medication) 250 mg, eight tablets, expiration 05/18/2026. Cephalexin (antibiotic medication) 250 mg, two capsules, expiration 05/15/2026. Nitrofurantoin (antibiotic medication) 100 mg, four tablets, expiration 05/18/2026 Doxycycline (antibiotic medication) 100 mg, four tablets, expiration 05/04/2026. Warfarin (blood thinner medication) one mg, six tablets, expiration 12/22/2025. Potassium Chloride (potassium supplement medication) four tablets, expiration 12/02/2025. Clonidine (antihypertensive medication) 0.1 mg, four tablets, expiration 12/26/2025. Lisinopril (medication that lowers blood pressure) 10 mg, four tablets, expiration 12/05/2025. Furosemide (diuretic medication) 20 mg, eight tablets, expiration 05/14/2026. Phytonadione (coagulant medication) 5 mg, four tablets, expiration 10/02/2025. Prednisone (corticosteroid medication) (5 mg, four tablets, expiration 05/11/2026. Fluconazole (antifungal medication) 150 mg, one tablet, expiration 03/2026 On 07/28/26 at 01:40 PM, Administrative Nurse D verified the expired E kit medications and verified the pharmacy was to check the medication periodically for expired medications and discard expired medications. Administrative Nurse D was not sure when the pharmacy had checked the E-kit and stated he would call the pharmacy that day and have them bring a new E-kit and remove the expired medications. The facility's Emergency Pharmacy Services and Emergency Drug kits policy, dated 07/26/2026, documented and emergency supply of medications, including emergency drugs, antibiotics, controlled substances, and products for infusion, is supplied by the provider pharmacy in limited quantities, in compliance with applicable state regulations. The emergency supply of medications is provided in portable, sealed containers. Emergency kits are inventoried by the pharmacy provider at least every 30 days for completeness and expiration dating the contents, and the date of inventory is noted on the outside of the kit.

Based on record review, interview, and observation, the facility failed to provide care for Resident (R)7 in a manner that protected and promoted their dignity. Findings included:- On 07/27/2026 at 07:52 AM, observation revealed R7 sat at the dining room table. Licensed Nurse (LN) G had R7 wheel over to the medication cart in the commons area adjacent to the dining room. LN G obtained R7's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R7's right index finger. Continued observation revealed two residents were seated in the dining room eating breakfast, while staff and a visitor were in the dining room and commons area within view. On 07/27/2026 at 10:00 AM, Administrative Nurse D stated staff should not check residents' blood sugar readings in the dining room; staff should take the residents to their room or to a private area. The facility's Right to Dignity policy, dated 04/16/2025, documented the facility would promote care for the residents of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality. The policy documented all staff would refrain from any practice that could be considered demeaning to a resident.

Based on record review and interview, the facility failed to notify Resident (R) 36's family when R36 had a change in condition. Findings included:- R36's Electronic Medical Record (EMR) documented R36 had a diagnosis of localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues).R36's Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview of Mental Status (BIMS) of two, which indicated severely impaired cognition. The MDS documented R36 required partial, moderate staff assistance with most activities of daily living (ADLs). The MDS documented R36 used oxygen therapy. R36's Care Plan, revised 04/13/2026, documented R36 required diuretic (medication used to help produce and excrete urine) therapy for her edema. The plan instructed staff to administer medications as the physician ordered, monitor side effects, and report any lab results to the physician. The plan documented R36 had altered respiratory status and instructed staff to monitor R36 for signs and symptoms of respiratory distress and report to the physician as needed. The Nurses Note, dated 04/17/2026 at 07:32 PM, documented the resident was being treated for fluid overload and was showing some improvement from yesterday. Her lung sounds were diminished but clear to the bases; less oxygen was needed that day. Her oxygen saturation (percentage of oxygen in the blood) was 92% on room air (RA) when R36 sat upright. The Nurses Note, dated 04/19/2026 at 12:15 PM, documented the resident was having labored breathing and feeling tired, with slight wheezing (a high-pitched whistling or squeaky sound that happens because the airways in the lungs are narrow or blocked) heard in R36's lungs bilaterally. The note recorded R36 was on four liters of oxygen per face mask. The resident complained of lower back pain and received pain medication. The note documented that staff provided R36 with a breathing treatment and placed her on four liters of oxygen per nasal cannula. R36 ate lunch per her request and then afterwards staff placed R36 in a recliner with four liters of oxygen per mask, and R36's saturations were 98-99 %. The note documented R36's oxygen saturations ranged from 92-98% all afternoon while on four liters of oxygen. R36's clinical record lacked evidence that the physician and family were informed of R36's change related to an increased oxygen need of four liters per mask that occurred on 04/19/2026. On 07/28/2026 at 12:27 PM, Licensed Nurse (LN) G stated she faxed the physician but did not document it and does not remember if she notified the family because they were already aware R36 was having problems with breathing and required oxygen at times. On 07/28/2026 at 12:30 PM, Administrative Nurse D verified the facility or the physician's office lacked documentation that the physician was notified and stated the physician's office had received a fax from the following day but not from 04/19/2026. The facility's Nurse Notification of Physician, Resident and Representative of Changes Policy, undated, documented it was the responsibility of licensed nurses employed at the facility to notify the resident's physician/designee, the resident and the representative if/ when the resident's clinical condition may require or requires physician intervention to consult with the resident's physician when there is any significant change in the resident's physical, mental or psychosocial status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility.

Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale, which included unsuccessful attempts at nonpharmacological symptom management and risk versus benefits for the continued use for Resident (R)29's and R12's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. Findings include:- 1.R29's Electronic Medical Record (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion with agitation including verbal and physical aggression, wandering and hoarding), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R29's Quarterly Data Set (MDS), dated [DATE], recorded R29 had moderately impaired cognition. The MDS recorded R29 required staff supervision with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 03/20/2026, recorded R29 received antipsychotic medication and had a diagnosis of depression and dementia with behavioral disturbance. R29's Psychotropic Medication Care Plan, dated 06/17/2026, recorded the nurse would administer medications as prescribed by the physician and monitor for side effects and effectiveness. The care plan documented R29 used Zyprexa (antipsychotic) medication for Dementia with unspecified severity with agitation. The Physician's Order, order dated 04/22/2026, directed the staff to administer Zyprexa oral tablet 5 milligrams (mg), one tablet at bedtime for a diagnosis of dementia, unspecified severity with agitation. R29's EMR lacked documentation of nonpharmacological approaches that were attempted but unsuccessful for behavioral management and lacked evidence of a physician's rationale, including risk versus benefits for the Zyprexa. On 07/28/2026 at 11:00 AM, observation revealed R29 lying in bed with eyes closed. 2.R12's Electronic Medical Record (EMR) documented that R12 had a diagnosis of psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R12's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R12 had a Brief Interview of Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The MDS documented R12 required substantial/maximal staff assistance with most activities of daily living (ADLs). The MDS documented R12 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the look back period. R12's Care Plan, revised 07/28/2026, documented R12 received risperidone and instructed staff to administer the medication as the physician ordered. The plan instructed staff to monitor for side effects and the medication's effectiveness, and to consult with the pharmacy and physician to consider a dosage reduction when clinically appropriate, at least quarterly. The Physician Order, dated 04/04/2025, instructed staff to administer to R12 risperidone 1 milligram (mg), tablet two times a day related to vascular dementia (decreased blood flow to areas of the brain). R12's EMR, reviewed for the time period of 07/14/2025- 07/14/2026 lacked evidence that the CP identified and reported R12's risperidone did not have an acceptable indication for use and/or a physician-documented rationale with risks versus benefits and the nonpharmacological interventions that were attempted and failed. On 07/26/2026 at 02:011 PM, observation revealed R12 sat quietly in a chair in the living room area by a window. On 07/28/2026 at 11:30 AM, Administrative Nurse D verified R29 received Zyprexa for a diagnosis of dementia with agitation and verified R12 received Risperdal for a diagnosis of vascular dementia and stated the facility would contact the physician for appropriate documentation for the resident's use of antipsychotic medications. The facility's Psychoactive Medications policy dated 03/14/2025 recorded the residents drug regimen must be free from unnecessary drugs that are used in excessive doses, for excessive duration, without adequate indication, without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences, which indicates the dosage should be reduced or discontinued. The policy recorded that residents who receive psychoactive medications receive gradual dose reductions and behavioral interventions, including individualized non-pharmacological interventions unless clinically contraindicated, in an effort to discontinue these drugs. Every psychotropic. Medication would be initiated with a signed Informed Consent to ensure the physician has reviewed with the resident and/or resident representative the potential adverse effects of the order of any psychoactive medication. The physician order for a psychotropic drug would include both a qualifying Diagnosis for the medication and a list of specific target behaviors which the staff would monitor during the medication administration. The physician must certify that psychotropic medication is necessary to treat a specific condition/behavior.

Based on observation, record review, and interview, the facility failed to provide Resident (R) 6 and/or their representatives with a written notification of transfer for facility-initiated transfers and a bed hold policy upon transfer to the hospital. The facility further failed to notify the long-term care ombudsman (LTCO) of transfers to the hospital. Findings included:- Resident (R) 6's Discharge Minimum Data Set (MDS) dated [DATE] documented a planned discharge to an acute hospital with a return anticipated.R6's Entry MDS, dated 04/23/2026, documented a re-entry to the facility from an acute hospital.On 07/29/2026 at 11:30 AM, the bed hold, written notification of transfer, and LTCO notification were requested from the facility for R6. The facility was unable to provide the requested information regarding R6's transfers to the hospital on [DATE].On 07/29/2026 at 11:30 AM, Social Services (SS) X stated that Administrative Staff A and she had been discussing who would be responsible for sending notifications to the Ombudsman and family, but they had not decided, so the notifications were not provided. Administrative Staff A stated she was responsible for providing residents or their representatives with the bed hold policy and verified it had not been provided when R6 was transferred to the hospital.On 07/29/2026 at 02:00 PM, Administrative Staff A verified the Ombudsman notification had not been provided when R6 was transferred to the hospital and stated the facility had recently obtained a new Ombudsman, and she did not give her contact information. The facility's Bed Hold Policy, undated, was a form for residents or representatives to fill out when they were transferred to the hospital or therapeutic leave.The facility's Ombudsman Notification and Monthly Discharge Log Policy documented the facility would maintain a monthly discharge log and provide notification to the designated LTCO office regarding resident discharges, transfers, and anticipated returns to the facility.

The facility had a census of 31 residents and one kitchen. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for the 31 residents who reside in the facility and received their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: - On 09/16/24 at 08:10 AM, observation revealed the kitchen staff finishing the morning meal and preparing the midday meal. Dietary Staff CC stated the Dietary Manager had the day off and planned on returning within the survey period. On 09/18/24 at 08:30 AM, Dietary Staff BB reported he is in the process of obtaining a certified dietary manager course. The facility's Organizational Plan and Roles of Key Staff policy, dated 2020, documented in states without an established minimum standard, the following qualifications of the Dining Service Manager should be considered: Certified Dietary Manager credential. The facility failed to employ a full-time Certified Dietary Manager for 31 residents who reside in the facility, which placed the residents at risk of inadequate nutrition.

The facility had a census of 31 residents. Based on observation, interview, and record review the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Service (CMS) for Fiscal Year (YR) 2023 Quarter (Q) 4, FY 2024 Q1, Q2, and Q3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days. (FY 2023 Quarter 4: 11 dates and FY 2024 Quarter 1: 5 days, Quarter 2:25 days and Quarter 3: 5 days). A review of the facility's licensed nurse data or the dates listed on the PBJ revealed a licensed nurse on duty 24 hours a day seven days a week. On 09/18/24 at 10:00 AM, observation revealed a licensed nurse on duty in the facility. On 09/18/24 at 11:51 AM Administrative Staff A reported the facility sent the payroll information to a corporate office and it was submitted to the PBJ from there. She stated there was a nurse on duty at all times, and the information submitted was not accurate. The facility's Mandatory Submission of Uniform Format Staffing Information (PBJ-Payroll Based Journal) policy, dated 09/18/24, documented the facility will electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by Centers for Medicare and Medicaid Services. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 31 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) completed the specialized training in infection prevention and control. This placed the 31 residents in the facility at risk for lack of identification and treatment of infections. Findings included: - On 09/17/24 at 01:15 PM, Administrative Nurse E stated she was responsible for the IPCP and was in the process of taking the class. Administrative Nurse E confirmed she was not certified. The facility's Infection Control Policy, dated 03/13/23 documented the IP was responsible for overseeing the Infection Control program and was required to have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related fields, and be qualified by education, training, experience, or certification. The policy documented that the IP was required to work at least part-time at the facility, have completed specialized infection prevention and control training, and participate in the Quality Assurance Performance Improvement (QAA) committee regularly. The facility failed to ensure the staff person designated as the IP possessed the required certification, placing the residents at increased risk for infections.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer and administer or obtain an informed declination, or a physician-documented contraindication for Resident (R)3, R6, R20, R21, and R22, pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease. Findings included: - Review of R3, R6, R20, R21, and R22's clinical medical records lacked evidence the facility or the resident representative received or signed consent or informed declination for the current pneumococcal vaccine PCV20. The records lacked evidence of a physician-documented contraindication. On 09/17/24 at 01:15 PM, Administrative Nurse E stated the facility only offered the PVC20 to new residents but did not have documentation that it was ever offered and declined. The facility's Flu/Pneumonia Vaccine policy, dated 01/31/24, documented influenza and pneumonia vaccines would be administered by appropriately qualified personnel who are following facility procedures, without the need for an individual physician evaluation or order other than the signed standing orders. Each person offered the vaccine(s) would be provided with current information from the CDC and Federal Drug Administration regarding the benefits and risks of the vaccine. Every year, a log documenting how many people (residents, staff, and volunteers) receive influenza and Pneumovax vaccine, as well as the number who refused and did not receive the vaccination. The resident's clinical record would document that the resident and/or surrogate decision-maker was provided education regarding the benefits and potential side effects of the vaccines. The documentation would include whether the resident received the vaccines or refused to receive the immunizations due to medical contraindications or refusal. The facility failed to offer the pneumococcal PCV20 vaccinations per CDC recommendations. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

The facility had a census of 31 residents. The sample included 12 residents of which two were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure pressure-reducing devices functioned correctly to prevent the worsening of pressure ulcer/injury for Resident (R) 20's coccyx (area at the base of the spine) wound. This placed the resident at risk for delayed healing or worsening of an existing pressure ulcer. Findings included: - The Electronic Medical Record (EMR) documented R20 had diagnoses of unspecified symptoms and signs involving cognitive functions and awareness, tremors, anorexia (lack or loss of appetite), urinary incontinence, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had severe cognitive impairment and rejection of care behavior for one to three days during the observation period. R20 was independent with eating and required supervision with lower body dressing, and personal hygiene. R20 was independent with rolling side to side in bed, transferring from chair to bed and bed to chair, and required supervision and touch assistance with toilet transfers. R20 had occasional incontinence of urine and frequent incontinence of bowel. The MDS further documented that R20 had occasional moderate pain which affected sleep and interfered with therapy and day-to-day activities. R20 had weight loss and received a therapeutic diet. R20 had two Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers/injuries. R20 had a pressure-reducing device for the chair and bed and received pressure ulcer care, application of nonsurgical dressings and ointment/medication, and nutritional/hydration interventions to manage skin issues. R20's Pressure Ulcer Care Area Assessment (CAA), dated 03/07/24, documented R20 had a new Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) and Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcers. R20 spent a great deal of time in his recliner and refused position changes. The CAA further documented a new onset of urinary incontinence. R20's Care Plan, dated 03/12/24, documented R20 spent a great deal of time in the recliner, refused position changes, and slept through the night in his recliner at times. R20 had an air mattress on the bed and staff was directed to encourage R20 to offload pressure to his coccyx. The care plan further directed staff to identify and document potential causative factors and eliminate and resolve them when possible. The Physician Order, dated 09/06/24, directed staff to use wound cleanser to cleanse the wound, pat dry, and cover it every three days. The Wound-Weekly Observation Tool dated 09/12/24 documented a Stage 2 coccyx wound (acquired on 04/05/24) which measured eight millimeters (mm) in length and eight (mm) in width. R20 had a ROHO cushion (pressure relief cushion that is made of soft, flexible air cells) in the wheelchair and recliner. R20 needed position changes, and dressing changes every three days and as needed, and received Prostat (a concentrated protein drink). The Progress Note dated 09/17/24 documented R20 still had two small open areas on his bottom. On 09/17/24 at 08:55 AM, observation revealed R20 sat in his recliner with his feet elevated. R20 reported he had a sore on his bottom about the size of a pencil eraser. R20 reported staff had provided a cushion for his recliner and wheelchair. The resident verified he slept in his recliner, due to laying in bed was uncomfortable for him. R20 stated the staff had instructed him to change positions to help the pressure sore heal and said he had dressing changes to the area. On 09/18/24 at 10:44 AM, observation revealed Licensed Nurse (LN) G provided a dressing change to R20's coccyx area. R20 had a ROHO-type cushion in the seat of the recliner that had lost air and gone flat. LN G verified the cushion went flat when pressure was applied and said that therapy had provided the cushion and LN G would contact the therapy staff to check the function of the cushion. On 09/18/24 at 10:54 AM, Administrative Nurse D reported therapy services provided the pressure relieving cushions for R20, but the nursing staff was responsible for checking the cushion for proper inflation. Administrative Nurse D stated he would educate staff on how to ensure this was done. The facility's Wound Management policy, dated 01/26/24, documented the facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers unless the individual's clinical condition demonstrates they are unavoidable. A commitment to the Wound Management Program is demonstrated by the implementation of processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. Wound management principles include and are not limited to the control or elimination of causation factors such as pressure, shear, friction, moisture, and circulatory impairment. The facility failed to ensure that R20's pressure-reducing cushion functioned correctly. This placed R20 at risk for delayed healing or worsening of an existing pressure ulcer.

The facility had a census of 31 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that staff failed to follow the physician's orders to administer insulin (controls the amount of sugar in the blood by moving into cells) and medications to treat Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). This placed the resident at risk for physical decline and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Parkinson's disease, diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin during the observation period. The Annual MDS, dated [DATE], documented R2 had moderately impaired cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin. R2's Care Plan, dated 8/05/24 and initiated on 01/16/21, directed staff to administer medications as ordered and to monitor and document side effects and effectiveness. The update, dated 03/18/22, directed staff to obtain Accu-checks (blood glucose monitoring test), administer insulin per the physician's order, and update the physician per request related to blood glucose readings. The Physician's Order, dated 11/25/19, directed staff to administer Sinemet (medication used to treat Parkinson's disease), 25-100 milligrams (mg). two tablets, by mouth, every eight hours, for Parkinson's disease. R2's Medication Administration Record dated July 2024 lacked documentation that staff administered the Sinemet medication on the following days: 07/11/24 at 06:00 AM 07/23/24 at 06:00 AM R2's Medication Administration Record dated August 2024 lacked documentation that staff administered the Sinemet medication on the following days: 08/04/24 at 06:00 AM R2's Medication Administration Record dated September 2024 lacked documentation that staff administered the Sinemet medication on the following days: 09/02/24 at 10:00 PM The Physician's Order, dated 05/13/24, directed staff to administer Novolog (a fast-acting insulin), 15 units, subcutaneous (under the skin), three times per day, for diabetes mellitus type two. R2's Treatment Administration Record dated July 2024 lacked documentation the insulin was administered on the following days: 07/10/24 in the evening 07/29/24 in the evening The Physician's Order, dated 07/22/24, directed staff to administer insulin glargine (a long-acting insulin), 35 units, subcutaneous, twice per day, for diabetes mellitus type two. R2's Treatment Administration Record dated August 2024 lacked documentation the insulin was administered on the following days: 08/17/24 at 07:00 PM 08/21/24 at 07:00 PM. R2's Treatment Administration Record dated September 2024 lacked documentation the insulin was administered on the following days: 09/14/24 at 07:00 PM. The Medication Regimen Review for the months of July, August, and September 2024 lacked evidence the CP identified and reported R2 had not been administered the ordered medication and insulin. On 09/17/24 at 12:25 PM, observation revealed Licensed Nurse (LN) G washed her hands, obtained gloves, wiped R2's finger with alcohol, obtained his blood sugar, and told him he did not need his insulin. On 09/18/24 at 11:13 AM, Administrative Nurse D stated he had not been made aware by the CP that R2 had not received the as-ordered medication and insulin. The facility's Consultant Pharmacist Services Provider Requirements policy, dated 09/18/24, documented that the consultant pharmacist provided pharmaceutical care services and reviewed the medication regimen of each elder in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and finding in the elder's clinical record. The CP communicates potential or actual problems related to medication therapy orders to the responsible physician and the Director of Nursing and reviews medication administration records, physician orders, and administration of the medications to the elders. The CP also monitors to ensure the appropriate review is documented in the elder's clinical record. The facility failed to ensure the CP identified and reported that staff failed to follow the physician's orders to administer insulin and medications to treat Parkinson's disease. This placed the resident at risk for physical decline and an ineffective medication regimen.

The facility had a census of 31 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to administer medication as ordered by the physician for one resident, Resident (R) 2, who received insulin (controls the amount of sugar in the blood by moving into the cells) and medications to treat Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). This placed the resident at risk for unnecessary medication side effects and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Parkinson's disease, diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin during the observation period. The Annual MDS, dated [DATE], documented R2 had moderately impaired cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin. R2's Care Plan, dated 8/05/24 and initiated on 01/16/21, directed staff to administer medications as ordered and to monitor and document side effects and effectiveness. The update, dated 03/18/22, directed staff to obtain Accu-checks (blood glucose monitoring test), administer insulin per the physician's order, and update the physician per request related to blood glucose readings. The Physician's Order, dated 11/25/19, directed staff to administer Sinemet (medication used to treat Parkinson's disease), 25-100 milligrams (mg), two tablets, by mouth, every eight hours, for Parkinson's disease. R2's Medication Administration Record dated July 2024 lacked documentation that staff administered the Sinemet medication on the following days: 07/11/24 at 06:00 AM 07/23/24 at 06:00 AM R2's Medication Administration Record dated August 2024 lacked documentation that staff administered the Sinemet medication on the following days: 08/04/24 at 06:00 AM R2's Medication Administration Record dated September 2024 lacked documentation that staff administered the Sinemet medication on the following days: 09/02/24 at 10:00 PM The Physician's Order, dated 05/13/24, directed staff to administer Novolog (a fast-acting insulin), 15 units, subcutaneous (under the skin), three times per day, for diabetes mellitus type two. R2's Treatment Administration Record dated July 2024 lacked documentation the insulin was administered on the following days: 07/10/24 in the evening 07/29/24 in the evening The Physician's Order, dated 07/22/24, directed staff to administer insulin glargine (a long-acting insulin), 35 units, subcutaneous, twice per day, for diabetes mellitus type two. R2's Treatment Administration Record dated August 2024 lacked documentation the insulin was administered on the following days: 08/17/24 at 07:00 PM 08/21/24 at 07:00 PM. R2's Treatment Administration Record dated September 2024 lacked documentation the insulin was administered on the following days: 09/14/24 at 07:00 PM. On 09/17/24 at 12:25 PM, observation revealed Licensed Nurse (LN) G washed her hands, obtained gloves, wiped R2's finger with alcohol, obtained his blood sugar, and told him he did not need his insulin. On 09/17/24 at 03:19 PM, LN G stated R2 required three different insulins and stated that after the insulin was administered, it was documented in the medical record. On 09/18/24 at 11:13 AM, Administrative Nurse D stated if R2 had not received his insulin, staff were to document in the medical record the reason why it was not administered. The facility's Administering Medications Using Electronic Medication Administration Record policy, dated 09/16/24, documented the facility administered medications in a safe manner and completed accurate and timely real-time documentation of all medication administration using the Electronic Medical Record (eMAR) system utilized in the facility. All medications would be administered to every resident as ordered by a physician in a safe and sanitary manner. If the resident or representative refused medication or the resident was unable to take medication as scheduled, click the appropriate box on the eMar as not done and provide a documented explanation. The facility failed to administer medications as ordered by the physician for R2, who received insulin and Parkinson's disease medication. This placed the resident at risk for unnecessary medication side effects and an ineffective medication regimen.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) were used for Resident (R) 20 who had an ongoing pressure ulcer and dressing change. The deficient practice placed the resident at risk of infectious disease processes. Findings included: - On 09/17/24 at 08:55 AM, observation revealed R20's door had an EBP sign and supply tote with personal protective equipment (PPE) of gloves, gowns, and eye protection shields next to the door. R20 sat in his recliner with his feet elevated. R20 reported he had a sore on his bottom about the size of a pencil eraser. R20 said he had dressing changes to the area. On 09/18/24 at 10:44 AM, observation revealed Licensed Nurse (LN) G provided a dressing change to R20's coccyx area. LN G washed her hands, placed disposable gloves on, and proceeded to assist R20 into the bathroom. LN G removed the dressing from R20's coccyx area and cleansed it with wound cleanser. LN G reported she had forgotten to bring a dressing for the wound and left the room. Upon returning to the room, LN G placed gloves on and dressed the wound. LN G had not donned a gown while assisting R20 in the bathroom or during the dressing change. On 09/18/24 at 10:48 AM LN G verified she had not worn a gown and should have during R20's care and dressing change. On 09/18/24 at 10:54 AM, Administrative Nurse D verified LN G should have worn a gown during R20's care and dressing change. The facility's Enhanced Barrier Precautions (EBP) policy, dated 05/04/24, documented the facility follows recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI). On the recommendation and approval of the facility's Infection Preventionist in collaboration with the facility's Medical Director, Enhanced Barrier Precautions are implemented as one intervention this facility uses to reduce transmission of resistant organisms that employ targeted PPE use during high-contact resident care activities. The facility failed to ensure staff used EBP while caring for R20, who had an ongoing pressure ulcer and dressing change. The deficient practice placed the resident at risk for facility-acquired infections.

The facility identified a census of 34 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review, observation, and interview, the facility failed to implement interventions to prevent a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer to Resident (R) 1's left buttock and then failed to provide routine treatment and nutritional interventions to promote healing of R1's pressure ulcer. This deficient practice placed R1 at risk for pressure ulcer development, pain, infection, and complications from delayed healing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of fracture (broken bone) of the left neck of the femur (thigh bone), weakness, and low back pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 12 which indicated moderately impaired cognitive function. The MDS documented R1 did not have any pressure ulcers or skin alterations, R1 was at risk for developing pressure ulcers, and R1 had a pressure-reducing device for her chair and for her bed. The Medicare/5 Day MDS, dated [DATE] documented therapy GG codes dated 01/03/24. The GG codes documented R1 required substantial staff assistance with toileting, bathing, bed mobility, and transfer. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 07/26/23, documented R1 required assistance with bed mobility, was at risk for friction (the mechanical force exerted when skin is dragged across a surface) and shearing (the separation of skin layers caused by friction or trauma) from sliding in bed, and was at risk for maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces or wounds for extended periods) due to R1's increased incontinence events. The CAA documented pressure ulcers/injuries would be addressed in R1's Care Plan to avoid complications. R1's Care Plan, dated 01/21/24, documented R1 had the potential for pressure ulcer development due to dehydration and immobility. The care plan documented R1 would have intact skin, free of redness, blisters, or discoloration. The plan directed staff to ensure R1 had a pressure-reducing cushion in her recliner, monitor R1's nutritional status, and follow the facility policies for the prevention/treatment of skin breakdown. The Braden Scale for Predicting Pressure Ulcer Risk, dated 01/22/24, documented R1 was at risk for developing pressure ulcers with a score of 16. The assessment documented R1 was slightly limited in sensory perception (has some sensory impairment which limits the ability to feel pain or discomfort in one or two extremities); R1 was occasionally moist (requiring an extra linen change approximately once a day); R1 walked occasionally but spent most of her time in a chair or bed; and R1's nutritional intake was probably inadequate. The Skin Assessment, dated 01/17/24, documented R1's integumentary (skin) system was intact. The Skin Assessment, dated 01/26/24, documented R1's integumentary system was intact. The Skin Assessment, dated 01/31/24, documented R1's skin was intact, and lotion was applied. The Skin Assessment, dated 02/07/24, documented R1's integumentary system was intact. The Skin Assessment, dated 02/14/24, documented R1's integumentary system was intact. The Health Status Note, dated 02/16/24, documented the area to R1's coccyx (area over the tailbone) was cleaned with soap and water, and the dressing was changed. There was a foul smell noted. Staff faxed R1's primary care physician and requested a soft brace for R1's right wrist due to a nodule. The EMR lacked measurements of the wound, description of the wound, description of the peri-wound, and if there were any signs and symptoms of infection. The Health Status Note, dated 02/19/24, documented the bandage to R1's left buttock was changed and noted malodor. The EMR lacked measurements of the wound, description of the wound, description of the peri-wound, and if there were any signs and symptoms of infection. The Skin Assessment, dated 02/21/24, documented R1's skin was intact. The Health Status Note, dated 02/20/24, documented R1's dressing to her left buttock was clean, dry, and intact. The Health Status Note, dated 02/23/24 at 03:35 AM, documented R1's left buttock had an open area with purulent (producing or containing pus) drainage and the peri-wound (area around the wound) was pink and inflamed, with malodor noted. R1 denied pain in the area. The wound bed was surrounded by thick white drainage. The wound measured 0.8 centimeters (cm) by 1.4 cm. Staff updated R1's primary care physician and requested wound care orders. The Health Status Note, dated 02/23/24 at 04:35 PM, documented a new order to apply Santyl (a prescription enzyme used to help break up and remove dead skin and tissue of a wound) to the wound bed daily and cover with Optifoam; continue to monitor closely, and follow up in one week or sooner for concerns. R1's Treatment Administration Record (TAR) dated February 2024 documented an order for Santyl to be placed in the wound bed and covered with Optifoam. The TAR documented the treatment was completed for 02/24/24 and 02/25/24. The facility did not receive the Santyl medication until the afternoon of 02/26/24. On 02/26/24 at 09:00 AM, R1 sat in her wheelchair at the nurse's desk and asked someone to put her hearing aid in. On 02/26/24 at 09:01 AM observation of R1's room revealed she had a Roho cushion (pressure relief cushion that is made of soft, flexible air cells) in the recliner in her room. Her bed had a regular mattress with no overlay. On 02/26/24 at 09:30 AM, R1 observed self-propelling in her wheelchair around the facility. On 02/26/24 from 10:00 AM to 11:00 AM, R1 sat in her wheelchair at a puzzle table and put a puzzle together with a friend. On 02/26/24 at 11:00 AM, R1 sat in her wheelchair at the lunch table and drank coffee. On 02/26/24 at 12:00 PM, R1 sat in her wheelchair and ate lunch. Staff had not repositioned R1 since 09:00 AM or offered toileting. On 02/26/24 at 01:00 PM, R1 left the lunch table and went to her room. On 02/26/24 at 01:10 PM, observation revealed Licensed Nurse (LN) G assisted R1 to the bathroom. R1's incontinence brief was soaked with urine. LN G then performed a dressing change to R1's left buttock. LN G removed the old dressing which had yellow drainage on it. LN G did not measure the wound. The wound was covered with yellow slough (dead tissue, usually cream or yellow in color) LN G cleansed the wound with wound cleanser and the yellow slough remained adhered to the wound. LN G applied Santyl to the wound bed and then covered the wound with an Optifoam dressing. Observation of R1's wheelchair where she sat all morning revealed a fabric pillow cushion and a zippered pouch that appeared to have items in it. On 02/26/24 at 09:00 AM, R1 stated she thought she got the wound on her buttock from sliding up and down in bed. She said she was not able to scoot herself up in bed very well, so she thought she just wore the skin down. On 02/26/24 at 10:30 AM, Administrative Nurse D stated the facility had not received the Santyl from the pharmacy yet, so staff waited to perform the dressing change to R1's left buttock until they received the medication. Administrative Nurse D stated the facility had been using the Optifoam dressing on the wound without the Santyl medication. Administrative Nurse D stated she thought R1 developed a pressure ulcer due to pain, R1 had a lot of lower back pain and was on opioid (narcotic) medication for pain. Administrative Nurse D stated R1 was thin and did not eat well all the time. Administrative Nurse D stated the registered dietitian had not been contacted regarding R1's wound. On 02/26/24 at 11:30 AM, Certified Nurse Aide (CNA) M stated since R1 broke her left hip in December 2023, she spent all her time in her wheelchair. CNA M said that before R1's left hip fracture, R1 had spent most of her time in her recliner. CNA M stated R1 had been up in her wheelchair since 01:30 AM that morning per night shift report. CNA M stated R1 had a pillowed cushion in her wheelchair that her family brought in for her. On 02/26/24 at 01:20 PM, LN G stated R1's wound was a pressure ulcer and had yellow slough in the wound bed. The Skin Integrity Policy, 02/26/24, documented based on the comprehensive assessment of the resident, facility staff will ensure that the resident who enters the facility without a pressure sore will not develop a pressure sore unless the resident's clinical condition demonstrates that the condition was unavoidable. Identification and evaluation of risk factors are decreased mobility and decreased functional ability, cognitive impairment, under-nutrition, and malnutrition including significant weight loss with mobility/positioning concerns, any decline in clinical status or co-morbid diagnoses affecting mobility/positioning or ability of the skin to endure effects of pressure. The nurse will conduct a full-body skin assessment for each resident to ensure no risks have developed. The Pressure Ulcer Policy, dated 01/26/24, documented all residents will be assessed for skin risk using the Braden Scale: upon admission or re-admission, weekly for the first four weeks, with an MDS significant change in condition, change in cognition, and with any acute medical condition. These residents will have a pressure-reducing device for their bed and/or chair. If the resident develops or has a pressure ulcer/wound, the nursing staff will document weekly on either the wound sheet or in the nurse's notes the status of the pressure sore/wound including size, depth, drainage, tunneling, odor, and degree of healing. For residents with wounds, the intactness of the dressing, skin around the wound, and any signs or symptoms of infection are noted on each shift. All residents at risk or with skin breakdown (wound or pressure ulcer) will have a dietary consult. Recommendations should include necessary laboratory data. Those residents to be found at risk are noted to be at risk on their care plan with individualized interventions. If the resident has a Stage II or higher, a significant change MDS will be completed. The nursing staff will be able to verbalize who they report skin issues to. Professional nursing staff should be aware of all wounds, treatment in use, and degree of healing. The facility failed to implement interventions to prevent a Stage 3 pressure ulcer from developing to R1's left buttock and failed to provide the physician-ordered treatment and other routine interventions such as RD involvement to promote the healing of R1's pressure ulcer. This deficient practice placed R1 at risk for pressure ulcer development, pain, infection, and complications from lack of healing.

The facility identified a census of 34 residents with three residents reviewed for care and treatment of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 received treatment and care in accordance with professional standards of practice related to CHF. This deficient practice placed R2 at risk for complications from congestive heart failure that included weight gain, edema (swelling), and difficulty breathing. Findings included: - R2's Electronic Medical Record (EMR) documented R1 had diagnoses of acute on chronic diastolic congestive heart failure, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R2 weighed 193 pounds and had a five percent weight gain in the last month; R2 was not on a physician-prescribed weight gain regimen. The MDS recorded R2 received a diuretic (medication to promote the formation and excretion of urine). The Activity of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA), dated 10/25/23, documented R2 required substantial assistance with ADL care, toileting, and mobility both with walking and wheelchair propulsion. The Pressure Ulcer/Injury CAA, dated 10/25/23, documented R2 was at risk for pressure ulcer due to immobility and incontinence. Staff monitored R2's skin when they provided care. R1's Care Plan, dated 01/26/24, documented R2 required maximum assistance from staff for bathing, bed mobility, dressing, personal hygiene, toilet use, and transfer. The plan directed staff to monitor, document, and report any signs and symptoms of CHF: dependent edema of legs and feet, periorbital (around the eyes) edema, shortness of breath upon exertion, weakness, weight gain, crackles, and wheezes upon auscultation (listening) of the lungs, and weakness or fatigue. The Weights and Vitals, dated 01/01/24 documented R2 weighed 179.8 pounds. The Weights and Vitals, dated 02/06/24, documented R2 weighed 193.1 pounds which indicated a 13.3 pound weight gain. R2's clinical record lacked evidence staff notified R2's primary care physician. The Health Status Note, dated 02/10/24, documented R2 had audible expiratory wheezing at intervals. The Health Status Note, dated 02/12/24, documented R2 complained to a certified nurse aide (CNA) that he had a hard time breathing. When the nurse approached R2, he stated he was much better at that point. The note documented R2 had bilateral (both sides) lower extremity edema. The Alert Note, dated 02/13/24, documented a CNA notified the nurse R2 presented with new onset edema in his bilateral thighs going up to his hips. R2 had a baseline of chronic edema to his bilateral lower extremities due to CHF. The CNA notified the nurse R2 was wheezing while lying down in bed. R2's lung sounds were clear but diminished. R2 voiced pain, a 10 on a zero to ten scale (pain scale where zero equals no pain and 10 the worst pain imaginable) that felt like a stabbing ice pick to his right lateral (towards the side) abdomen. Staff administered R2 his as-needed albuterol (medication used to clear airways) inhaler for dyspnea (difficulty breathing). The note documented that staff would pass on to the day shift staff to notify R2's primary care physician of the 13.3-pound weight gain over a time period of one month, new onset edema to bilateral thighs, bilateral hips, and distention to the right lateral abdomen. The Health Status Note, dated 02/13/24, documented that R2's primary care physician was notified of his change in condition. The Health Status Note, dated 02/13/24, documented the facility received new orders to increase R2's Lasix (diuretic medication) to 40 milligrams (mg) twice a day for five days and give potassium 20 milliequivalents (mq) for five days. Staff were to obtain daily weights, and a Basic Metabolic Panel (BMP-laboratory blood test) on 02/19/24; and monitor for increased edema. The Health Status Note, dated 02/14/24, documented R2 had 2+ pitting edema (swelling resulting from an excessive accumulation of fluid in the body tissue demonstrated by the application of pressure to the swollen area with a finger which causes an indentation) to his left lower extremity and 3+ pitting edema to his right lower extremity. R2's right hip contained fluid pockets. R2's skin was tight and shiny in appearance. R2's lung sounds were clear but the left lobe was diminished. R2's respirations were even and unlabored. A review of R2's clinical record revealed the facility failed to follow R2's primary care physician's orders to obtain a BMP on 02/19/24. The facility obtained the BMP on 02/21/24 and received the results on 02/26/24. The results of the BMP showed R2's potassium level was 3.8 millimoles per liter (mmol/L) and R2's sodium level was 140 milliequivalents per liter (mEq/L). On 02/26/24 at 11:45 AM, observation revealed R2 sat in a chair in his room. R2's pajama pant legs were pulled up revealing his lower extremities. R2's had obvious edema to both legs with the right greater than the left. R2's right lower leg was taut and shiny. R2 rubbed his right lower leg. On 02/26/24 at 11:45 AM, R2 stated his right leg was really swollen and it hurt. R2 stated no one had obtained his weight yet that day. On 02/26/24 at 01:00 PM, Administrative Nurse E verified the lab was drawn on 02/21/24, not 02/19/24 as the doctor ordered it to be drawn. Administrative Nurse E verified she just received the results of the BMP back. On 02/27/24 at 10:00 AM, Administrative Nurse D verified the staff had not identified R2's 13.3-pound weight gain and verified the staff did not notify R2's primary care physician. The facility's undated Quality Assurance Performance Improvement Policy, documented the facility would ensure that all staff will consistently develop processes and systems to provide safe, effective, and optimal care and services to each resident residing at or receiving services from the facility. The governing body of this facility understands and supports processes and systems of care that are coordinated and collaborative with the mission of continuously improving performance involving every department and discipline for every resident served. The facility lacked a Quality Care Policy. The facility failed to ensure R2 received treatment and care in accordance with professional standards of practice related to CHF. This deficient practice placed R2 at risk for complications from congestive heart failure which placed him at risk for weight gain, edema, and difficulty breathing.

The facility identified a census of 33. The sample included three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without staff knowledge and supervision). Based on observation, record review, and interviews, the facility failed to ensure interventions used to prevent elopement (window alarms) were functional and tamper-resistant. The facility further failed to accurately assess and identify Resident (R)1's elopement risk. R1 was cognitively impaired, lived on a secured memory unit, and had a history of wandering; though, the latest elopement assessment performed on 01/08/24 indicated the resident had no wandering and was at low risk for elopement. On 01/24/24 at approximately 12:05 PM R1 moved her couch and a table away from her window, opened the window and screen, and exited the facility via the window. The alarm on the window did not sound and R1 proceeded to walk down a steep hill to the sidewalk which went around the building, towards the front of the building. Certified Nurse Aide (CNA) M observed that R1 was outside, from the kitchen window. CNA N continued to watch R1 from the window while another staff went outside and talked R1 into coming back into the building. Staff assessed R1 and noted no injuries. The facility failed to adequately identify elopement risk and failed to ensure interventions in place to prevent elopement were fully functional. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of major depressive disorder (major mood disorder), restlessness and agitation, and age-related cognitive decline. The Quarterly Minimum Data Set, dated dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented R1 had behaviors not directed towards others (pacing, rummaging, vocal symptoms) one to three days during the look back period. The MDS documented R1 had wandered one to three days during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/11/23, documented R1 exhibited confusion, disorientation, and forgetfulness. The Falls CAA, dated 04/11/23, documented R1 had impaired balance during transitions and impaired balance to maintain a seated position. The Activity of Daily Living/Rehabilitation Potential CAA, dated 04/11/23, documented R1 had changing cognitive status and mood decline. R1 required assistance with her activities of daily living due to weakness, poor coordination, and poor balance. R1's Care Plan documented R1 was an elopement risk and directed staff to distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books (04/30/23). The plan also directed staff to try toileting, walking inside or outside, reorientation strategies including signs, pictures and memory boxes. R1's Care Plan documented R1 required cueing and minimal assistance with activities of daily living. The Elopement Risk Evaluation, dated 01/08/24, documented R1 had a score of eight and was a low risk for elopement. The facility failed to documented R1 had a history of elopement. The Behavior Note, dated 04/30/23, documented R1 followed behind a visitor and exited the building. Staff saw R1 exit the building and brought her back inside. The Behavior Note, dated 01/23/24, documented R1 had shown a very noticeable increase in exit seeking behaviors. R1 had become aggressive with other residents and had become physically aggressive towards staff when staff did not let R1 off of the secured memory unit. R1 stood directly behind the entry door into the memory care unit and attempted to push past staff to exit the memory care unit. The Health Status Note, dated 01/24/24, documented Licensed Nurse (LN) G viewed camera footage and witnessed R1 go into her room. CNA M went directly to R1's door and opened it to make sure R1 was in her room. At 12:07 PM a report came across the radio R1 was outside. A code green was called. CNA N was instructed to keep her eyes on R1. R1 was outside walking along the fence the along the building approximately twenty-five feet from her window. Staff went downstairs from the assisted living building and was able to bring R1 back into the facility without difficulty. It was calculated by cameras and staff R1 was outside no longer than two minutes. R1 had on a long sweater. The temperature was 37 degrees Fahrenheit (F). R1's primary care physician and responsible party were notified. The Alert Note, dated 01/28/24, documented R1 attempted to elope out of her window again. The window alarms sounded and staff successfully diverted R1's attention away from the window. The Facility Incident Report, dated 01/24/24, documented on 01/24/24 at approximately 12:05 PM, R1 had left the hallway of the memory care unit after talking to CNA M. R1 entered her room and closed the door. R1 moved her couch and table away from the window, turned off the window alarm, opened the window and screen, and went out the window. According to video footage, CNA M walked to the kitchen and looked out the window and saw R1 walking outside. CMA M quickly went outside and brought R1 back to the building. R1 was at the door outside of the assisted living building. R1 wore a long light blue cardigan with a long sleeved gray shirt underneath, navy pants, and black shoes. The outside temperature was 36 degrees F and skies were cloudy without wind. A skin assessment was performed immediately after which revealed intact skin without bruises or other abnormalities. CNA N's Witness Statement, dated 01/24/24, documented CNA N had seen R1 enter her room at 12:05 PM. CNA N then went back to the kitchen and CNA M followed her. CNA M noticed R1 outside. R1 wore a blue knitted cardigan with a gray shirt underneath, navy blue slacks, and black shoes. CNA M and CNA N ran down the hall. CNA N radioed there was an elopement. CNA N went into R1's room and noticed R1's window was open and her couch was moved away from the wall/window. CNA N monitored R1 out the window until other staff made contact with R1. CNA M's Witness Statement, dated 01/24/24, documented at approximately 12:05 PM CNA M saw R1 walking into her bedroom. CNA M walked back to the kitchen for dinner/lunch service and as CNA turned towards the window on the east wall of the dining room saw R1 walking outside along the wall on the west side of the assisted living wing. CNA M told CNA N to radio for help and CNA M headed outside. CNA M ran around the back of the facility down the north road and toward R1. R1 was making her way down the hill and toward the lower-level assisted living door. R1 attempted to make entry into the door. CNA M assisted R1 into the lower level of the assisted living building. R1's clothing appeared clean with no signs of mud or water or other indications of having fallen. LN G's Witness Statement, dated 01/24/24, documented at 12:07 PM it was reported over the radio R1 was outside. LN G called a code green. LN G instructed CNA N to keep her eyes on R1. LN G instructed other staff members to go outside and around the building from different directions. R1 was witnessed walking around the building. Another licensed nurse was able to get to R1 first and she assisted R1 back into the building. R1 had not been outside more than two minutes. The temperature was 37 degrees F. R1 had a long sweater and tennis shoes on. On 01/31/24 at 09:30 AM, observation revealed R1 up and wandering the hallway on the secure memory unit. R1 complained of back pain and wanted her dirty clothing taken to the laundry. R1 went in and out of her room numerous times in a short period. On 01/31/24 at 09:45 AM, observation revealed the window alarms were working, the windows were only able to be raised approximately four inches, and tape had been placed over the window alarm to help deter residents from turning the alarms off. On 01/31/24 at 10:45 AM, CNA M stated R1 wandered frequently. CNA M stated she saw R1 out the kitchen window on 01/24/24 and she was walking unsteadily down the hill. On 01/31/24 at 11:00 AM, Administrative Nurse D stated the facility had not been checking to make sure the alarms on the windows were working prior to this elopement. Administrative Nurse D stated she didn't even know the windows had alarms on them. Administrative Nurse D stated all staff had been educated regarding elopements, window alarms, and how to open the windows on the secure memory unit in case of emergency. Administrative Nurse D stated the window alarms are now checked on every shift to ensure they are functioning. The Elopement Policy, dated 10/23/23, documented it was the facilities wish to ensure the safety of those residents that have been identified as being at risk for elopement. It is the policy of this facility to identify those residents at risk for elopement and take precautions to ensure their safety. Special secure living units are provided by the facility and additional security including WanderGuard door locking system is provided. The facility failed to adequately identify elopement risk and failed to ensure interventions in place, to prevent elopement, were fully functional. This deficient practice placed R1 in immediate jeopardy. On 01/25/24 the facility identified and completed the following corrective actions: education with all staff regarding the Elopement Policy/Missing Elder Policy, the facility-initiated window checks/alarm checks on all of the windows on the memory care unit, Elopement Drill was performed, and education presented regarding the Elopement Risk Binder found at the nurse's desk, screws were placed in the outside windows to only allow the windows to raise 4 inches. All corrective actions were completed before the onsite survey; therefore, the deficient practice was deemed past noncompliance and remained at a J scope and severity.

The facility identified a census of 31 residents with three residents reviewed for resident rights. Based on record review, observation, and interview, the facility failed to protect Resident (R) 1's right to dignity. This deficient practice placed R1 at risk for impaired psychosocial wellbeing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of early on-set Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), convulsions (involuntary series of contractions of a group of muscles), and extrapyramidal (movement disorders as a result of taking certain medications) and movement disorder. The Annual Minimum Data Set (MDS), dated [DATE], documented the Brief Interview for Mental Status (BIMS) could not be completed because R1 was rarely understood. Per staff interview, R1 had short term memory problems and long-term memory problems. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living (ADL) except eating for which R1 was totally dependent on one staff. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/14/23, documented R1 was severely impaired for making decisions regarding tasks of daily life. R1 displayed inattention which fluctuated in severity and R1 wandered four to six days during the observation period. The Psychosocial Well Being CAA, dated 07/14/23, documented R1 had little pleasure or interest in doing things. R1's Care Plan, revised 07/27/23, documented R1 had impaired communication related to Alzheimer's disease. The care plan documented R1 would be able to communicate basic needs. The care plan directed staff to use R1's preferred name, staff were to identify themselves to R1 with each interaction and make eye contact with R1. The plan directed staff to reduce distractions, use consistent simple directive sentences, provide R1 with necessary cues, and stop and return if R1 was agitated. The Facility Grievance Form, dated 10/02/23, documented Certified Nurse Aide (CNA) O had been informed by one of R1's representatives that CNA M was telling people that when CNA M put R1 to bed the previous night, or the night before that, R1 grabbed CNA M by her neck and forced CNA M to make out with R1. CNA M's undated Witness Statement, documented CNA M was assigned to work on the hallway where R1 resided. CNA M noticed R1 was starting to get antsy while seated in a recliner. CNA M went over to R1 as R1 was attempting to stand up by herself. CNA M assisted R1 to stand. CNA M stated R1 leaned over and kissed CNA M on the side of the neck and placed a hand on CNA M's lower buttock. CNA M stated she leaned away from R1 and told R1 they were going to go for a walk and moved R1's hand from her buttock. Licensed Nurse (LN) G came over to assist CNA M with ambulating R1 in the hallway and then back to the recliner. CNA M stated she did not tell any other staff member of the event. CNA P's Witness Statement, dated 10/02/23, documented CNA P said another CNA told her that R1 had grabbed CNA M's buttock and made out with CNA M's neck. CNA P stated she had never witnessed the behavior from R1. CNA N's Witness Statement, dated 10/02/23, documented CNA M told CNA N that R1 groped her and made out with her. The other staff that were working had already heard about it. CNA N noted an agency CNA then came and told CNA N the same story. CNA N stated she accidentally told R1's representative about the rumor. CNA N stated she realized telling the rumor to R1's representative was wrong. CNA Q's Witness Statement, dated 10/03/23, documented CNA Q stated CNA M was transferring R1 to a reclining chair. CNA M had her arms around R1 to stabilize her and R1 gave CNA M a kiss on the cheek. Later in the day, CNA M stated multiple times R1 had groped her and tried to make out with her. CNA MM's Witness Statement, dated 10/03/23, documented CNA MM stated CNA M came to her and told her that R1 had groped her and kissed her neck. CNA NN's Witness Statement, dated 10/03/23, documented CNA M made statements to CNA NN That R1 had groped her and was making out with CNA M's neck. CNA M talked about R1 in an inappropriate manner. CNA NN stated CNA M had made these comments in front of other staff. Licensed Nurse (LN) G's Witness Statement, dated 10/04/23, documented LN G was on the memory unit when R1 started to get restless. CNA M assisted R1 to her feet with a gait belt. R1 leaned her head on CNA M's shoulder. CNA M laughed and said, Oh, [R1] you're so nice. LN G stated she went over to assist CNA M with ambulating R1. R1 leaned into CNA M again and gave CNA M a quick kiss on the jaw line. LN G, CNA M, and R1 laughed. CNA M stated, Well let's keep walking. R1 leaned into CNA M for a few steps, and then continued to walk down the hallway. The Facility Incident Report, dated 10/10/23, documented on 09/25/23 at around 04:23 PM CNA M and LN G walked with R1. R1 leaned heavily on CNA M as R1 had difficulty with her balance. R1 kissed CNA M on the neck twice and grabbed the back of CNA M's shirt to help steady herself. CNA M and LN G walked R1 from the memory care living room down the hallway and back to the living room recliner. According to multiple staff witness statements, CNA M told staff R1 groped CNA M and made out with her neck. R1's representative wanted a complete investigation by the facility to prove that nothing else had happened. The facility interviewed all of the staff that were there during this time period. All witness statements showed CNA M made statements exaggerating the kiss and the pulling of back of her shirt. The facility reviewed video footage and identified CNA M had not put R1 to bed without another staff member with her. From the investigation, witness statements, and video footage, the facility deducted that CNA M exaggerated inappropriately about an innocent kiss. The investigation included employee training and/or in-service which covered the prevention and reporting of abuse, neglect, and exploitation as well as protection of privacy and procedure for reporting to family completed on 10/02/23. On 10/10/23 at 10:30 AM, observation revealed R1 laid in bed listing to music. On 10/10/23 at 10:35 AM, CNA NN stated that R1 was completely dependent on staff for all her cares, even eating. CNA NN stated that R1 would kiss staff on the cheek or hand in appreciation of her cares. CNA NN stated R1 was completely non-verbal, and that was how she demonstrated her gratitude and affections for the staff caring for her. On 10/10/23 at 10:45 AM, CNA PP stated that she never misunderstood R1's affection for sexual behavior or action and said that anyone that did was not thinking right. CNA PP stated R1 would give quick pecks on the cheek or neck in appreciation for cares due to being non-verbal and having early onset Alzheimer's. CNA PP stated that she had heard the rumors that CNA M had said about R1, and she did not think it was nice. On 10/10/23 at 11:30 AM, Administrative Staff A stated CNA M had been dismissed from working at the facility following the investigation. Administrative Staff A stated CNA M denied ever spreading rumors about R1. Administrative Staff A stated the witness statements from other CNAs all had the same story. Administrative Staff A stated CNA N should have never disclosed the rumors to R1's representative and CNA N was educated on all communication with the family needed to go through the nurse. Administrative Staff A stated R1's representative was upset with the facility that this had occurred and wanted a complete investigation into the situation and stated that he was going to turn the incident into the police for investigation. Administrative Staff A stated CNA M should not have spread rumors or discussed the resident's cares in a negative or unnecessary manner. Administrative Staff A stated CNA N should not have reported the rumors to R1's family members. On 10/10/23 at 02:45 PM, R1's representative stated they were upset that staff spread rumors about their loved one. R1's representative said the facility should take care of R1 and not allow anything bad to happen to her. The Resident Rights Policy, dated 10/01/23, documented each resident residing in the facility has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the facility without interference, coercion, discrimination or reprisal. No staff member or contracted provider will hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights. It is the responsibility of all who work at the facility to advocate and protect the rights of each resident. All staff members are trained on this Resident Right Policy at the time of employment, before providing care to residents and at least annually to ensure full understanding and competency. The facility failed to protect R1's right to dignity. This deficient practice placed R1 at risk for impaired dignity and decreased psychosocial wellbeing.

The facility had a census of 30 residents. The sample included 13 residents, with four reviewed for falls. Based on observation, record review, and interview, the facility failed to implement the care planned interventions for Resident (R) 3, who had multiple falls related to inappropriate footwear, with one fall resulting in rib fractures (broken bones). The facility further failed to identify and implement interventions to prevent falls for R5, who had multiple falls. This placed the resident at risk for further falls and avoidable injury. Findings included: - R3's Electronic Medical Record (EMR) recorded diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), transient ischemic attack (TIA-a temporary disruption in the blood supply to part of the brain), and incontinence (lack of voluntary control over urination). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented moderately impaired cognition and indicated R3 required supervision and set up assistance with toileting, dressing, personal hygiene, and independent with ambulation in her room, bed mobility, and transfers. The MDS further documented R3 had unsteady balance, no functional impairment, and had no falls. R3's Annual MDS, dated [DATE], documented R3 had moderately impaired cognition and required extensive assistance of one staff for transfers, toileting, ambulation in her room, and limited assistance of one staff for ambulation in corridors, personal hygiene, and dressing. The MDS further documented R3 had unsteady balance, occasional incontinence, no functional impairment, and had one non-injury fall. The Fall Care Area Assessment [CAA], dated 02/02/23, documented R3 had moderately impaired cognition, and ambulated with a walker. R3, at times, would not accept assistance from staff for toileting and dressing. The CAA further documented R3 was alert and oriented, and her mood changed frequently. R3 had episodes of refusing to allow evaluations or assistance and participated in activities of her choice. The Fall Assessments, dated 04/18/22, 07/27/22, and 02/02/23, all documented R3 was a high risk for falls. The Fall Care Plan, dated 03/31/22, directed staff to ensure R3's call light was within reach and to call for assistance; encourage R3 to participate in activities that promoted exercise, and have therapy evaluate and treat as needed. An update, dated 04/19/22, documented R3 required one staff for assistance with toileting, set up assistance of one staff for dressing, and directed staff to ensure R3 wore appropriate footwear with nonskid soles when she ambulated. An update, dated 08/10/22, directed staff to ensure R3 wore shoes or gripper socks when she ambulated and provide reminders if R3 did not wear shoes. An update, dated 02/21/23, directed staff to ensure R3 wore nonskid slipper socks to bed. The Fall Investigation, dated 08/10/22, documented at 03:48 PM, R3 slipped and fell in her room. The investigation documented the fall was unwitnessed, R3 had gait imbalance, and ambulated without staff assistance. The investigation recorded R3 had improper footwear on, and she obtained an abrasion (scrape) to her left elbow. The Fall Investigation, dated 10/24/22, documented at 03:25 PM, R3 slipped and fell in her room. The investigation documented the fall was unwitnessed, R3 had gait imbalance, and did not receive any injury. The Fall Investigation, dated 02/20/23, documented at 12:42 AM R3 slipped when she lost her balance and scooted to the door to call for assistance. The investigation documented R3 had gait imbalance and improper footwear. The Fall Investigation, dated 02/21/22, documented at 08:00 AM, R3 stated she tried to get out of bed to go to the bathroom, was unable to stand, and slid to the floor. The investigation further documented R3 did not have on any socks at the time of the fall, and nonskid socks were applied. The investigation noted R3 did not receive any injury. The Nurse's Note, dated 02/21/23 at 04:29 PM, documented R3 reported right breast pain and stated that earlier in the day she heard a pop and started to have severe pain. The note further documented R3 stated she often had acid reflux and refused to go to the emergency room for evaluation. The note documented the nurse administered antacid medication (used to treat heartburn) and pain medication. The Nurse's Note, dated 02/22/23 at 09:17 AM, documented R3 complained of pain under her right breast and continued to refuse to go to the emergency room for an x-ray (a photograph or digital image of the internal composition of part of the body) or to have the physician evaluate her. The note further documented R3 requested medication for her heart burn and requested to stay in her bed because she was sore. The Nurse's Note, dated 02/22/23 at 12:39 PM, documented the nurse contacted the physician due to R3 had extreme discomfort under her right breast. The note further documented R3 did not have any swelling or redness in the area, continued to decline transfer to the emergency room , and did not want the physician notified. The noted documented R3 continued to have heart burn and the physician ordered a scheduled antacid. The Nurse's Note, dated 02/25/23 at 08:40 AM, documented R3 complained of severe pain under her right breast that was rated as a 10 out of 10 (a 0 to 10 pain scale with zero as no pain and 10 representing the worst pain imaginable). The nurse assessed the area under the resident's right breast and did not see any swelling, redness, or bruising. The area was symmetrical (made up of exactly similar parts facing each other) upon palpation on each side of her chest. The note documented R3 winced in pain with each movement. The nurse contacted the emergency room , who suggested R3 be sent to the walk-in clinic. The note documented R3 agreed to go to the clinic for evaluation. The Physician Orders, dated 02/25/23, directed staff to administer Aleve (over the counter pain medication), 220 milligrams (mg), by mouth, every eight hours for pain; and Tylenol (medication for minor aches and pains), 650 mg, by mouth, every four hours for five days, for pain. The order further directed staff to apply a heat pack every two hours alternating with an ice pack every two hours as needed. The order directed staff to encourage R3 to deep breath and use an incentive spirometer (a handheld device used to help improve the functioning of lungs) every two hours while awake. The order directed staff to have R3 hold a pillow to her chest when coughing due to R3 had fracture of ribs 3, 4, and 5. The Nurse's Note, dated 02/27/23 at 02:38 PM, documented R3 had increased pain and agitation and the current pain medication was not effective for reducing pain. The Physician Order's, dated 02/27/23, directed staff to hold the resident's Tylenol and administer Norco (narcotic medication for moderate to severe pain), 5/325 mg, by mouth every four hours as needed for pain, and a Salanpas (pain patch), to the right chest, every 12 hours, as needed for pain. On 03/28/23 at 09:08 AM, observation revealed R3 had gripper socks on while in bed but Certified Nurse Aide (CNA) R had to adjust them and put one of them back onto her foot. Further observation revealed CNA R assisted R3 to sit on the side of her bed, placed a gait belt around the resident's waist, and CNA R and CNA S had the resident stand up. R3 required extra assistance to stand, she slowly grabbed her walker and slowly walked with staff down the hall to the shower room with just the gripper socks on her feet. On 03/27/23 at 11:20 AM, CNA R stated R3 had fallen many times due to not calling for assistance. CNA R further stated R3 used to walk without assistance. CNA R stated even though staff remind R3, R3 gets up before staff get to her to assist her. On 03/28/23 at 10:09 AM, Administrative Nurse E stated R3 refused assistance and would get up on her own because she felt she could still take care of herself. Administrative Nurse E stated after a fall, the team would meet to discuss the fall and would try to come up with new interventions and verified she would not get the new intervention into the computer right away. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated R3 was alert and orient and did not feel R3 had cognitive impairment, just behaviors. LN G stated R3 does not like to call for assistance even though they remind her often because she still thinks she can get up on her own. On 03/28/23 at 1:30 PM, Administrative Nurse D stated the staff tried multiple times to get the resident to go to the emergency room when she fell but she refused. The facility's Fall Prevention Protocol policy, undated, documented the facility provided care and services that ensured the elders environment remained as free from accident hazards as was possible and each elder received adequate supervision and assistive devices to prevent accidents. Each elder would be assessed for the causal risk factors for falling at the time of admission, upon return from a health facility, ad after every fall in the facility. The team would develop a plan for service to improve or maintain the elders standing and sitting balance and other interventions to reduce the elder's risk for falls, the plan would include specific individualized information about the elder's routine and personal habits that may place the elder at risk for falls and every team member was responsible for checking the care plan who are at risk for falls. The facility failed to ensure R3, who had multiple falls related to lack of appropriate footwear, had adequate staff supervision and assistance with footwear leading to a fall which resulted in three rib fractures and pain. - The Electronic Medical Record (EMR) documented R5 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), epilepsy (brain disorder characterized by repeated seizures), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition and required limited assistance of two staff for bed mobility, transfers, toileting and locomotion. The MDS further documented R5 had unsteady balance, occasional bladder incontinence, no functional impairment, and had two or more non-injury falls. R5's Quarterly MDS, dated [DATE], documented R5 had severely impaired cognition and required extensive assistance with bed mobility, transfers, locomotion, toileting, and personal hygiene. The MDS further documented R5 had unsteady balance, frequent bowel and bladder incontinence, no functional impairment, and had two or more falls. The Fall Care Area Assessment [CAA], dated 07/22/22, documented R5 required a wheelchair for mobility due to increased weakness, increased confusion and instability. The Fall Risk Assessments, dated 0/23/22, 10/18/22, 11/05/22, 01/16/23, documented the resident was a high risk for falls. The Fall Care Plan, dated 11/03/20, documented R5 would have on appropriate footwear and/or nonskid socks during transfers. The update, dated 06/03/22, documented new shoes were ordered for the resident. The update, dated 07/30/22, documented a motion sensor was placed in her room. The update, dated 08/19/22, documented R5 had a high/low bed to be kept in the lowest position. The update, dated, 08/21/22, directed staff to utilize as needed medication when the resident had increased anxiety. The update, dated 12/29/22, directed staff to place a second motion sensor in her room. The update, dated 01/05/23, documented anti-roll back brakes were installed on her wheelchair. The update, dated 03/10/23, directed staff to not leave the resident unattended in her room while she was in her wheelchair. The EMR documented falls on these dates: 06/17/22, 06/19/22, 06/28/22, 08/07/22, 08/21/22, 08/26/22, 11/07/22, 11/26/22, 12/29/22, 01/20/23, and 03/01/23. R5's clinical record lacked evidence of resident centered interventions placed after each fall to prevent future falls. The clinical record lacked evidence the facility performed a thorough root cause analysis to attempt to identify R5's needs or reasons she continued to fall. On 03/21/23 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) R placed a gait belt around R5's waist, CNA R and CNA S took ahold of the gait belt and assisted the resident to stand up, pivot and sit down on the bed. Further observation revealed CNA R took off the resident's shoes and swung her legs onto the bed, took off R5's glasses, covered her up and attached the call light the R5's blanket. CNA R lowered R5's bed, placed a fall mat next to the bed, placed a motion sensor on the mat, and turned on another motion sensor that was on the wall by the resident's door before leaving the room. On 03/21/23 at 11:30 AM, CNA R stated R5 had the double motion sensor and fall mat because of R5's many falls. CNA R stated R5 was very quick and would try to transfer herself and would fall, On 03/28/23 at 10:09 AM, Administrative Nurse E stated R5 got up on her own and had a lot of falls and when the team got together, if they did not feel the interventions needed changed, they kept them the same and it was difficult to always come up with a new intervention. Administrative Nurse E stated after a fall, the team would meet to discuss the fall and would try to come up with new interventions and verified she would not get the new intervention into the computer right away. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated the motion detector had been placed in R5's room within the last three months. LN G said because of all R5's falls, staff watched R5 closely because she was quick and when they did not get to her in time, she would fall. On 03/28/23 at 01:30 PM, Administrative Nurse D stated the resident had a lot of falls and interventions were implemented by the team. Administrative Nurse D stated the nurses do not update the care plan at that time but may try and work to that at some point. The facility's Fall Prevention Protocol policy, undated, documented the facility provided care and services that ensured the elders environment remained as free from accident hazards as was possible and each elder received adequate supervision and assistive devices to prevent accidents. Each elder would be assessed for the causal risk factors for falling at the time of admission, upon return from a health facility, ad after every fall in the facility. The team would develop a plan for service to improve or maintain the elders standing and sitting balance and other interventions to reduce the elder's risk for falls, the plan would include specific individualized information about the elder's routine and personal habits that may place the elder at risk for falls and every team member was responsible for checking the care plan who are at risk for falls. The facility failed to identify causative factors and implement person centered interventions to prevent falls for cognitively impaired R5, who had a multiple falls. This placed the resident at risk for further falls and injury.

The facility had a census of 35 residents. The sample included three residents reviewed for elopement risk. Based on observation, record review, and interview, the facility failed to adequately monitor and supervise cognitively impaired Resident (R) 1, when he exited the facility without staff's knowledge, and was outside in 10 degree Fahrenheit (F) weather for approximately 15 minutes before he knocked on the door for staff to let him in. This deficient practice placed R1 in immediate jeopardy and had the potential to affect the other 14 residents at risk for elopement. Findings included: - R1's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had short and long-term memory problems and moderately impaired cognition. The MDS documented the resident had inattention, disorganized thinking, physical behavior symptoms directed toward others, and wandered. The MDS documented the resident required total staff assistance for bed mobility, transfers, personal hygiene, extensive assistance for walking in his room and corridors, dressing, toileting, and limited assistance for locomotion on and off the unit, and bathing. The MDS documented the resident used a walker and wheelchair for mobility. The Cognition Care Plan, dated 01/02/2020 directed staff to ask R1 yes or no questions to determine his needs, provide necessary cues, and stop and return later if he became agitated. The care plan directed staff to reduce distractions, face the resident when speaking to him, and make eye contact. The Elopement Risk Assessment, dated 01/29/2020 documented R1 at low risk for elopement. The Nurse's Note, dated 02/13/2020 at 07:45 PM (late entry) documented at approximately 07:45 PM, Certified Medication Aide (CMA) R heard pounding on the locked hallway door next to the copy room. CMA R found R1 seated in a lawn chair in the outside courtyard. R1's lawn chair was up against the door, so staff went around to another side of the facility to get to him. CMA R assisted R1 back inside the facility and Licensed Nurse (LN) G assessed the resident. The note documented R1's skin was cool but not cold to touch, no skin discoloration, and his vital signs were within normal limits. Staff assisted R1 back to the memory care unit and to bed. The Nurse's Note, dated 02/14/2020 at 09:36 AM (late entry), documented staff immediately notified Administrative Nurse D of R1's elopement and Administrative Nurse D directed staff to return R1 to the memory care unit. The Facility's Investigation, dated 02/14/2020, documented on 02/13/2020, at 07:30 PM, R1 propelled his wheelchair into an unlocked office, opened an unlocked mechanical room door which lead outside to the courtyard, and exited the facility. The investigation documented the resident wore a short-sleeved tee-shirt, sweatpants, and socks, and the outside temperature was 10 degrees F. The facility camera video for 02/13/2020 at 07:25 PM, showed R1 in his wheelchair, as he propelled himself around the front lobby/television area, chapel, and the administrative offices. At 07:28 PM, R1 opened an office door, went inside, and was not longer visible on the camera. At 07:45 PM, video showed CMA R walked toward an exit door, and at 07:55 PM, the video showed R1 in the outside courtyard, sitting in a lawn chair that was up against the exit door. On 02/25/2020 at 12:10 PM, observation revealed R1 sat in his wheelchair on the memory care unit and propelled himself around with no exit seeking behavior. On 02/25/2020 at 09:37 AM, CMA R stated on 02/13/2020 as she passed medications, she observed R1 in his wheelchair, wandering in the front living room area and chapel, but did not see him try to open any doors. CMA R stated she passed medications and assisted another resident into bed. CMA R returned to the medication cart and at approximately 07:45 PM heard pounding on the exit door. CMA R went to the door and observed R1 outside in a lawn chair that was pushed up against the door. CMA R was unable to open the door, so she went to another part of the facility to enter the courtyard. CMA R stated she returned to the facility, obtained a wheelchair, and brought R1 back inside. On 02/25/2020 at 10:00 AM, Maintenance Staff (MS) U stated he thought the door to the mechanical room was locked when he left the facility at approximately 04:00 PM on 02/13/2020. MS U stated he did not verify the mechanical room door was locked and the door should always be locked. On 02/25/2020 at 12:45 PM, Administrative Nurse D stated R1 was on a trial program to determine if he would be safe to move from the memory care unit. The program allowed R1 on the health care part of the facility during the day and return to the memory care unit at bedtime. Administrative Nurse D stated there was no policy or procedure in place for monitoring or supervising R1 when he was not on the memory care unit. Administrative Nurse D verified the door to the office and the mechanical room was not locked but should have been. On 02/25/2020 at 05:30 PM, Administrative Staff A stated the door to the mechanical room should always be locked. On 02/26/2020 at 08:15 AM, LN H stated she worked the day shift on 02/13/2020 and did not notice R1 showed exit seeking behavior, but it was normal for R1 to wander and propel his wheelchair around the facility. LN H stated R1 was on a trial to move from the memory care unit at the time he exited the facility. On 02/26/2020 at 12:00 PM, LN G stated she worked the night shift (07:00 PM-07:00 AM) on 02/13/2020 and was not aware R1 had exited the facility until he knocked on the exit door at 07:45 PM. LN G stated CMA R went outside to get R1 and brought him inside. LN G stated she performed a full assessment on R1, and staff assisted him back to the memory care unit and to bed. The facility's Elopement Policy, dated 10/03/2018, documented the facility would ensure the safety of residents who have been identified at risk for elopement, and the facility would take precautions to ensure their safety and well-being. The policy defined elopement as an incident in which a resident who has impaired decision-making ability and is oblivious to their own safety needs, leaves the facility without the knowledge or supervision of staff. The facility failed to have a policy and procedure in place for transitioning a resident from the memory care unit at the time R1 eloped. The facility failed to adequately monitor and supervise R1 from potential accident hazards when he eloped from the facility into 10 degree F weather without staff's knowledge, placing the resident at risk for potentially serious outcomes, frostbite (injury caused by freezing of the skin and underlying tissues), hypothermia (medical emergency that occurs when body temperature falls below 95 degrees F), heart problems, or death. This deficient practice placed the resident in immediate jeopardy. The facility removed the immediacy when Administration stopped R1's trial and placed him back in the memory care unit on 02/13/2020. Administration educated MS U on 02/14/2020 regarding ensuring all maintenance/utility closet doors are always locked. MS U replaced the lock on the mechanical room door on the evening of 02/25/2020. The facility implemented in-service education for all staff on 02/26/2020 regarding the Abuse, Neglect, and Exploitation policy, Elopement Policy, and Transition Trial of Resident from the Memory Care Unit. This deficient practice remained at a scope and severity of a [NAME]

The facility had a census of 32 residents. The sample included 14 residents, of which 2 residents were reviewed for elopement. Based on observation, record review and interview the facility failed to accurately assess risks and provide adequate supervision to prevent an elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without knowledge of staff) for 1 of 2 sampled residents. Resident #24, who was cognitively impaired with poor safety awareness and had a history of [REDACTED].#24 in immediate jeopardy for accident hazards. The facility failed to ensure Resident #9's environment remains as free of accident hazards as is possible, who had a major fall with injury. Findings Included: - The physician order [REDACTED].#24 had the following Diagnoses: [REDACTED]. sadness, worthlessness and hopelessness). The quarterly (MDS) Minimum Data Set assessment, dated 04/30/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 4 (severe cognitive impairment), hallucinations, delusions, and had wandering behaviors. The MDS recorded the resident required extensive staff assistance with transfers, had impaired balance, and used a wheelchair for mobility. The quarterly MDS assessment, dated 08/01/18, recorded the resident had a BIMS of 4 (severe cognitive impairment), inattention, disorganized thinking, and had physical and wandering behaviors. The MDS also recorded the resident had impaired balance, was unable to walk and used a wheelchair for mobility. The 11/29/17 (CAA) Care Area Assessment for falls recorded the resident had poor safety awareness, unsteady balance and a history of wandering and falls. The 09/11/18 care plan recorded the resident had self care deficit due to cognitive impairment, episodes of restlessness and agitation, rejected cares at times and was a fall risk with a history of falls. The care plan directed staff to assist the resident as needed with (ADLs) Activities of Daily Living and reapproach the resident, when he/she was agitated and/or rejected cares. The care plan lacked interventions to address the resident's elopement risks or wandering behaviors. The facility's elopement assessment, dated 11/29/17, recorded the resident had severe cognitive impairment and wandered aimlessly throughout the facility. The assessment recorded the resident was not an elopement risk. The 03/24/18 at 12:34 AM, nurse's note recorded the resident was agitated/restless, hallucinating, and attempting to exit the building. The 04/05/18 at 12:01 AM, nurse's note recorded the resident was angry and agitated, and attempted to exit the facility by throwing a chair through the glass exit door. The 06/22/18 at 3:42 PM, nurse's note recorded the resident had a non-injury fall, while agitated and attempting to leave the building. The 07/18/18 at 2:02 PM, nurse's note recorded the resident hit and yelled at staff, while he/she attempted to leave the building. The 09/21/18 at 6:00 AM, nurse's note recorded the resident had hallucinations and attempted to leave the building. Review of the resident's medical record lacked documentation staff reassessed the resident for elopement risk after observing and recording multiple incidents of exit seeking behaviors. The 09/27/17 at 3:37 PM, nurse's note recorded a passerby reported the resident outside on the ground next to concrete steps by the south exit door. The note recorded staff did not hear a door alarm and assessed the resident had no injuries or distress. The note further recorded staff viewed the security video and observed the resident exited the building after a therapy client entered through the door, and the resident fell , when he/she attempted to go down the stairs in his/her wheelchair. The facility's fall investigation report, dated 09/27/18, recorded a passer-by reported the resident outside on the ground, and staff found the resident on the asphalt driveway next to his/her wheelchair and the steps. The report recorded staff assessed the resident without injuries, and the resident stated he/she was trying to go to the bar. The report recorded staff viewed the security video, observed a visitor enter and close the exit door, the resident opened and exited the door in his/her wheelchair, the alarm did not sound and the resident fell , while attempting to go down the steps in his/her wheelchair. The report further recorded staff discovered the door alarm deactivated for 40 seconds, when the inside keypad code was entered or the outside door button was pushed, and determined this was the reason the door had not alarmed, when the resident eloped. On 10/01/18 at 3:10 PM, observation revealed the south exit door had a keypad alarm code and a sign near the keypad directed visitors Please wait for light to turn red before leaving area. Thank you (placed after the elopement). Continued observation revealed the keypad alarm code and outside door button deactivated the door alarm for 24 seconds (alarm deactivated for 40 seconds at time of the elopement). Continued observation revealed the following environmental hazards outside the facility: 1) 3 concrete steps approximately 10 feet from the exit door 2) Steeply sloped asphalt driveway at the bottom of the steps. Asphalt driveway is cracked, rough and has potholes. 3) At the end of the driveway, approximately 40 feet, a drainage ditch with 3-4 foot rock walls and concrete/asphalt bottom 4) Concrete wheelchair ramp next to the steps, and connects to the sidewalk - sidewalk was steeply sloped, curved and ran parallel to a drainage ditch with a rock wall and concrete bottom. On 10/03/18 at 10:01 AM, observation revealed the resident independently propelled his/her wheelchair up and down the hallway without staff supervision. On 10/01/18 at 3:02 PM, Nurse I stated the resident had impaired cognition, frequently resisted cares and/or redirection, and wandered every day throughout the facility in his/her wheelchair. Nurse I stated the resident had a history of [REDACTED]. Nurse I stated staff were not aware the resident eloped from the south door, as the door alarm had not sounded. On 10/02/18 at 1:50 PM, Administrative Staff A stated staff had not assessed the resident's elopement risk since 11/29/17, and/or developed a care plan to monitor the resident's wandering. Administrative Staff A stated the south exit door alarm deactivated for 40 seconds, when the door was opened, and the resident eloped without staff's knowledge. On 10/03/18 9:56 AM, Nurse Aide Q stated the confused resident often had agitation and angry behaviors (yelling, hitting, reject cares) directed toward staff. Nurse Aide Q stated the resident wandered every day in the halls and sometimes into other resident's rooms. Nurse Aide Q stated staff had not developed a care plan to address the resident's wandering and elopement risk. On 10/03/18 at 3:38 PM, Nurse Aide R stated the resident frequently resisted cares, and wandered in/his wheelchair in the halls every day. Nurse Aide R stated the resident often tried to exit the facility and staff had difficulty redirecting the resident. Nurse Aide R stated staff had not developed a care plan to address the resident's wandering and elopement risk. The facility's undated Elopement Policy directed staff to complete an elopement risk assessment to address changes in the resident's cognition, safety awareness, wandering and exit seeking behaviors. The policy directed staff to develop individualized care plan interventions to address the resident's elopement risks. The policy further directed staff to develop a safe door alarm system to protect the residents. The facility failed to accurately assess risks and provide adequate supervision to prevent an elopement for Resident #24, who was cognitively impaired with poor safety awareness and had a history of [REDACTED]. The resident exited the facility from a deactivated alarmed exit door without staff knowledge, which placed Resident #24 in immediate jeopardy. This deficient practice was abated when the facility implemented the following on 10/04/18: As of 09/28/18 the door alarm timer was decreased to 24 seconds and a sign posted to wait for the red light and not let residents out of the building. As of 10/03/18 the resident was moved to a locked dementia unit As of 10/03/18 any resident deemed an elopement risk will have an elopement assessment completed with appropriate interventions addressed in the care plan As of 10/03/18 any new admission will be assessed for elopement risks and every quarter or when exit seeking behaviors occur. On 10/03/14 and 10/04/18 staff were educated on the newly developed elopement policy and elopement risk assessment The deficient practice remained at the scope and severity of a D. - Resident #9's (POS) physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/19/18, documented the resident had a (BIMS) Brief Interview for Mental Status Score of 15, which indicated intact cognition. The assessment revealed the resident was independent with transfers, toileting, ambulation in his/her room and required 1 staff assistance for ambulation in the corridor. The assessment further revealed the resident had no falls. The 5-day Medicare MDS, dated [DATE], documented the resident had a BIMS of 15 which indicated intact cognition. The assessment revealed the resident required limited assistance of 1 staff for transfers, toileting and independent with ambulation. The assessment further revealed the resident had 1 fall with major injury. The 7/30/18 (CAA) Care Area Assessment for falls documented the resident at risk due to a history of falls. The CAA further documented staff assisted the resident in a walk-to-dine program and as needed. The 8/6/18 care plan documented the resident at risk for falls and directed staff to complete a fall risk assessment per facility protocol, encourage the resident to call for assistance, and use a wheelchair for mobility. (initiated on 10/20/14) Review of the care plan lacked further interventions after the resident's fall on 4/25/18. Review of the medical record lacked a fall risk assessment after the resident's fall on 4/25/18. The 7/25/14 physician's orders [REDACTED]. The 10/7/14 physician's orders [REDACTED]. The 3/30/17 physician's orders [REDACTED]. The 4/25/18 at 10:10 AM, fall investigation documented the resident tossed a ball to staff, leaned forward too far and fell out of his/her wheelchair. The investigation further documented the resident hit the right side of his/her head on the floor. The staff applied ice to the resident's head which had a hematoma (a collection of trapped in the tissues of the skin or in an organ, resulting from trauma). Review of the medical record revealed staff initiated neurological checks as ordered and were within normal limits. The 4/25/18 at 1:54 PM, nurse's notes documented the resident had fallen out of his/her wheelchair after tossing a red ball to the director of nursing. The resident's right foot became caught under his/her chair and caused the resident to lean forward too far and fall out of his/her wheelchair. The 4/25/18 at 7:21 PM, nurse's note documented the resident complained of knee pain and staff administered his/her scheduled pain medication. The 4/26/18 at 6:00 PM, nurse's note documented the resident stated his/her leg hurt. The 4/28/18 at 5:22 AM, nurse's note documented the resident's complained his/her right rib area was sore but no bruises were noted. The 4/28/18 at 4:30 PM, nurse's note documented the resident complained his/her right upper body was sore and staff administered tylenol 325 mg, 2 tablets, by mouth for the complaint of pain. The 4/29/18 at 12:05 AM, nurse's note documented staff administered tylenol 325 mg, 2 tablets, by mouth for the complaint of pain. The 4/30/18 at 8:19 AM, nurse's note documented the resident stated he/she had upper body spasms (involuntary muscle movements). The note documented staff notified the nurse and called the physician. The 4/30/18 at 8:35 AM, nurse's note documented staff administered [MEDICATION NAME], 5-325 mg, 2 tablets, by mouth, for pain and faxed the physician. The 4/30/18 at 10:30 AM, nurse's note documented the staff received an order for [REDACTED].>The 5/1/18 at 3:17 AM, nurse's note documented the resident had complained of pain but declined pain medication. The note further documented no results of the x-rays reported to the nurse. The 5/1/18 at 8:56 AM, nurse's note documented the nurse contacted the physician to report the resident continued to have upper body spasms. The note further documented the clinic was unaware the resident was having upper body spasms and the physician would come to the facility to see the resident. The 5/1/18 at 10:05 AM, nurse's note documented the physician stated he/she would like to admit the resident to the hospital for testing and pain management due to the x-ray results of right sided effusion/hemothorax (a medical condition where blood pools in the pleural cavity, or the space between the chest wall and the lungs). The 5/4/18 at 12:34 PM, nurse's note documented the resident returned to the facility with a [DIAGNOSES REDACTED]. On 10/3/18 at 8:34 AM, observation revealed the resident independently propelled him/herself down the hall and to his/her room. Further observation revealed the resident locked his/her wheelchair, used his/her left hand to brace his/herself on the arm of the wheelchair, stood and pivoted to the recliner. On 10/3/18 at 4:02 PM, Nurse Aide P stated the resident called when he/she required assistance and staff walked with the resident to meals. On 10/4/18 at 8:00 AM, Licensed Nurse H stated fall assessments are completed upon admission and with every fall. Licensed Nurse H verified the staff had not completed a fall assessment or updated the care plan with interventions after the resident had fallen out of his/her wheelchair 4/25/18. The 11/1/16 facility Fall Prevention Protocol documented each elder at the facility would be provided services and care that ensured that the elder's environment remained as free from accident hazards as possible ad each elder received adequate supervision and assistive devices to prevent accidents. The protocol further documented each elder would be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility, and after every fall in the facility. The facility failed to ensure the environment remained as free of accident hazards as is possible, for Resident #9, who had a major fall with injury, placing the resident at risk for further falls.

The facility had a census of 35 residents. The sample included 10 residents with 1 resident reviewed for quality of care. Based on record review and interview, the facility failed to provide necessary services by clinical standards of practice to avoid physical harm, pain, mental anguish or emotional distress to Resident #1 when staff failed to obtain the physician ordered UA (Urinalysis-test to check urine for abnormalities) for 13 days, obtain the physician ordered stool sample, continue to assess the resident's urinary status, and deficient nursing practice, caused Resident #1 to have multiple episodes of bleeding after improper catheter insertion, which placed the resident in immediate jeopardy. Findings included: - The 1/30/18 POS (Physician order [REDACTED].#1 had [DIAGNOSES REDACTED]. (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major [MEDICAL CONDITION] (major mood disorder that causes a persistent feeling of sadness and loss of interest), [MEDICAL CONDITION] without lower urinary tract symptoms (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and acute prostatitis (the sudden onset of inflammation in the prostate). The quarterly (MDS) Minimum Data Set assessment, dated 11/29/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 9, indicating moderately impaired cognition, with physical and verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, rejection of care, and wandering occurred 1 to 3 days in the 7 day look back period. The MDS recorded the resident was totally dependent on 2 staff for bathing, required extensive assistance of 1 staff for personal hygiene, limited assistance of 1 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, supervision with 1 staff assistance for locomotion off the unit, and supervision with setup help only for eating. The MDS recorded the resident's balance was not steady, but able to stabilize without staff assistance, used a walker and wheelchair for mobility, and was occasionally incontinent of bowel and bladder. The quarterly MDS, dated [DATE], recorded the resident had a BIMS score of 5, indicating severe cognitive impairment with no wandering. The MDS recorded the resident was totally dependent on 2 staff assistance for personal hygiene, required extensive assistance of 2 staff for bed mobility, transfers, locomotion on the unit, dressing, extensive assistance of 1 staff for locomotion off the unit, supervision with 1 staff assistance for eating, and toileting activity occurred only once or twice with 2 staff assistance. The MDS recorded the resident used a wheelchair for mobility, was frequently incontinent of bladder, and always incontinent of bowel. The 8/21/17 (ADLs) Activities of Daily Living (CAA) Care Area Assessment documented the resident was usually independent with his/her ADLs, would pivot transfer to and from different surfaces, and was able to dress himself/herself. The CAA documented the resident had difficulty with hygiene after going to the bathroom, generally did not allow staff to assist him/her, but staff continued to monitor and provide assistance as he/she tolerated. The 8/21/17 Incontinence/Catheter CAA documented the resident was occasionally incontinent of bladder, was independent to and from the bathroom, came out to the main living areas with soiled pants at times, and usually would change if staff directed him/her. The 9/26/17 care plan recorded the resident had a self care deficit due to dementia (progressive mental disorder characterized by failing memory), confusion, and impaired mobility. The care plan recorded the resident required assistance of 1 staff member as he/she allowed, and he/she used a walker or wheelchair for mobility. The care plan directed staff to provide peri-care after each incontinent episode as the resident would allow, monitor for signs and symptoms of a [MEDICAL CONDITION] urinary tract infection such as burning, pain, discolored urine, odor and confusion, offer to toilet the resident before and/or after meals, and the resident wore incontinent briefs for dignity and protection. The medical record lacked any updates regarding bowel and bladder assistance. The 1/5/2018 at 1:47 PM, nurse's note recorded Consultant Physician JJ came to the facility to see the resident, and ordered a UA with a C&S (culture and sensitivity test that identifies disease-causing microorganism, and determines which antibiotics are sensitive to (effective against) the identified microorganism) if indicated. The medical record lacked evidence of documentation of assessments between 1/5/18 and 1/11/18 of the resident's urine after the physician ordered the UA on 1/5/18. The 1/11/2018 at 6:03 AM, nurse's note recorded staff explained to the resident he/she needed a UA. Staff asked the resident to urinate in a cup, and the resident yelled NO! The note recorded staff explained to the resident a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) would be used to obtain the UA. The note recorded staff attempted to catheterize the resident, he/she kicked and yelled, finally calmed down, but staff were unable to pass the catheter into the bladder. The note recorded staff removed the catheter and the order to obtain the UA would be communicated to the oncoming shift. (6 days after the physician ordered the UA) Review of the medical record lacked documentation that Nurse G attempted to obtain the UA via straight catheter on 1/15/18, 1/16/18, 1/17/18, and 1/18/18, but was unable to obtain the sample due to him/her not being able to advance the catheter into the resident's bladder, lacked documentation of any bleeding, assessment of the resident's urinary system, or how the resident tolerated the procedure. Further review of the medical record lacked evidence staff notified the physician of the repeated failed attempts to obtain the UA on 1/11/18, 1/15/18, 1/16/18, 1/17/18, and 1/18/18. The 1/18/2018 at 11:10 AM, nurse's note recorded staff obtained the resident's UA by using a straight catheter, per sterile technique. The 1/18/2018 at 2:29 PM, nurse's note recorded staff collected a UA by catheterization and sent the urine sample to the physician's office. The 1/18/18 urinalysis report, received at 4:16 PM, documented the resident's urine was yellow and abnormally cloudy, with trace amounts of glucose, and no blood in the urine. (Normal urine values: color-yellow, clarity-clear or cloudy, glucose < or = 130 (mg) milligrams/(dl) deciliter) The 1/19/2018 at 9:05 AM, nurse's note recorded the resident slid out of his/her wheelchair that morning at 8:25 AM. The note recorded staff witnessed the fall, the resident had no injury, and vital signs: blood pressure 164/95, pulse 81, temperature 96.3, respirations 16. (normal vital signs: temperature 98.6 Fahrenheit, blood pressure <120/<80, pulse 50-90, respirations 12-18, oxygen saturation 100% on room air) The medical record revealed staff obtained vital signs on 1/19/18 at 11:30 AM: blood pressure 141/88, pulse 145, respirations 14, and oxygen saturation 98% on room air. The 1/19/2018 at 12:22 PM, nurse's note recorded staff observed a substantial amount of blood in the resident's brief. The note recorded the resident's vital signs were in normal limits (pulse 145 at 11:30 AM), and the nurse attempted to call the physician. The note recorded before the nurse could call the physician, staff called him/her back into the resident's room because staff changed the resident's incontinent brief and the new incontinent brief already had a large amount of blood with a pool of blood on the resident's genital area. The note recorded the nurse called the physician and received orders to send the resident to the local hospital. When the (EMS) Emergency Medical Service arrived, the resident's blood pressure was low and pulse was high. The note recorded EMS staff stated it would be better to take the resident to a tertiary hospital (hospital that has advanced support services and specialized care and treatment). The nurse called the physician and received orders to send the resident to the tertiary hospital. The 1/19/18 hospital (H&P) history and physical examination [REDACTED]. The resident was unable to give information for the H&P due to altered mental status/lethargy, so information came from verbal report given to the ED by the nursing facility. The facility staff reported the resident was more lethargic than usual and had slid out of his/her wheelchair to the floor earlier that morning. Staff assessed the resident, assisted him/her back into his/her chair, and monitored the resident. Later the resident was more lethargic with altered mental status, noted to have blood in his/her brief, and staff called EMS for transport to the ED for further evaluation. Hospital staff found the resident met [MEDICAL CONDITION] criteria (a potentially life-threatening complication of an infection, many doctors [MEDICAL CONDITION] as a three-stage syndrome, starting [MEDICAL CONDITION] and progressing through [MEDICAL CONDITION] to septic shock), with [MEDICAL CONDITION] Urinary Tract Infection and therefore admitted him/her to the (ICU) Intensive Care Unit for further monitoring and treatment. The 1/24/18 hospital Discharge Summary documented the resident arrived in the ED via EMS from a nursing facility due to lethargy/AMS (altered mental status), a fall, and septic from a urinary source: [MEDICAL CONDITION] secondary to Proteus UTI, and Proteus Mirabilis UTI (a type of bacteria that can be found in the intestines, however, when it is spread into the urinary system, it can cause infection), likely acute bacterial prostatitis (a bacterial infection of the walnut sized prostate gland, located below the bladder, in front of the rectum, and surrounds the urethra, the tube through which urine exits the body), which typically starts suddenly and may include flu-like symptoms. Review of the resident's medical record lacked evidence of documentation of the resident's return to the facility on [DATE]. The 1/29/2018 at 9:36 AM, nurse's note recorded staff asked the physician about the resident's return to the facility on [MEDICATION NAME](antibiotic medication), 500 (mg) milligrams, (BID) twice a day, for 6 weeks. The note recorded the resident had constant loose stools and staff requested the physician start the resident on [MEDICATION NAME] (dairy food or supplement containing live bacteria that replace or add to the beneficial bacteria normally present in the gastrointestinal tract). The 1/29/18 return fax from the physician directed staff to start a [MEDICATION NAME] daily, use universal precautions/isolation (the practice, in medicine, of avoiding contact with patient's bodily fluids, by means of wearing nonporous articles such as medical gloves, goggles, and face shields, ensure the resident resides by himself/herself) due to diarrhea, and obtain a stool sample to test for [MEDICAL CONDITION] (,[MEDICAL CONDITION]. Difficille-contagious bacteria characterized by foul smelling frequent bowel movements). Review of the resident's medical record lacked evidence staff obtained the physician ordered stool sample. The 1/31/2018 at 6:53 PM, nurse's note recorded Consultant Physician JJ saw the resident and ordered staff to obtain a UA with C&S. The 2/2/2018 at 3:12 PM nurse's note recorded the physician's office called about the stool sample, stated they had not received it, and asked if the resident still had diarrhea. The note recorded the resident no longer had diarrhea, the nurse stated he/she wanted to see what the physician said, and waited on a response from the physician. (4 days after the stool sample was ordered) The 2/9/2018 at 9:34 AM nurse's note recorded the resident continued antibiotics for a UTI, and the clinic had called and ordered a UA for the resident. The note recorded staff obtained the UA using a catheter, per sterile technique, without difficulty or drainage noted after catheterization. The 2/9/18 urinalysis lab report documented the urine was cloudy, with a moderate amount of non-hemolyzed blood (blood cells remain intact), 2+ protein, red and white blood cells too numerous to count, and 1+ bacteria, and documented a urine culture was indicated. (Normal urine values: color - yellow, clarity - clear or cloudy, blood < or = to 3 (RBCs) Red Blood Cells, protein < or = to 150 mg/dl, RBCs < or = to 3 RBCs/hpf (high power field), (WBC) White Blood Cells < or = to 2-5 WBC/hpf, bacteria-none) The 2/11/2018 at 12:44 PM, nurse's note recorded staff found a small amount of blood in the resident's brief, and would continue to monitor the resident. The clinical record lacked evidence staff notified the resident's physician. The 2/12/2018 at 2:09 PM, nurse's note recorded the resident was awake, and able to move his/her wheelchair back and forth. The nurse asked the resident if he/she felt ok, and the resident responded yes. Staff assessed the resident's skin color was a little pale and he/she was diaphoretic (excessive sweating), vital signs were: blood pressure 150/90, pulse 132, respirations 18, temperature 97.6, oxygen saturation 94%, finger stick blood sugar 188. The note recorded the resident denied pain, had bloody urine, was assisted to bed, and the nurse notified the physician of the resident's condition. The 2/12/2018 at 2:14 PM, nurse's note recorded the resident's lab results returned documenting the UA showed a few abnormals, with no new physician orders. The 2/12/2018 at 2:43 PM, nurse's note recorded the facility received orders to send the resident to the hospital, by way of EMS. The 2/12/18 hospital H&P documented the resident was admitted with a [DIAGNOSES REDACTED]. The hospital medical record, dated 2/19/18, documented the resident discharged from the hospital back to the the nursing facility on 2/19/18 with orders for [MEDICATION NAME] (strong bacterial antibiotic), 1 G (gram) vial, inject (IV) Intravenous (to inject the medication into a vein via syringe or intravenous tubing) every 12 hours for 8 days, [MEDICATION NAME] trough (blood test to determine rates of absorption and clearance of the antibiotic) weekly, start on 2/20/18. (Review of the medical record lacked evidence staff obtained the [MEDICATION NAME] trough as physician ordered) The 2/19/2018 at 9:58 PM, nurse's note recorded at 5:17 PM, the resident returned to the facility from the hospital, in a wheelchair. The note recorded a blood pressure reading of 122/72 and the resident had a urinary catheter to dependent drainage, draining clear yellow urine. The 2/20/2018 at 10:36 PM, nurse's note recorded staff administered [MEDICATION NAME] per physician's orders [REDACTED]. The medical record lacked evidence of documentation the staff assessed the resident's urine between 2/19/18 and 2/23/18. The 2/23/2018 at 1:34 PM, nurse's notes recorded the resident was not feeling well, had 2 small emesis (vomit), and did not want to eat. The notes recorded the resident's vital signs were blood pressure 118/72, pulse 68, respirations 16, oxygen saturation 93%, and temperature 99.3. The notes recorded the resident rested comfortably, and the urinary catheter to dependent drainage, with light yellow urine. The clinical record lacked evidence staff notified the physician. The 2/24/2018 at 6:46 PM, nurse's note recorded at 6:45 PM the resident had emesis, and lung sounds were coarse (abnormal lung sounds). The resident's blood pressure was 190/120, temperature 102.7, pulse 124, respirations 42, oxygen saturation 80% on room air. Two staff assisted the resident up into the wheelchair, then to the recliner and staff changed his/her bedding, and recorded the resident had audible wheezes (to breathe with difficulty usually with a [MEDICATION NAME] sound), called the on call physician, and received orders to send the resident to the hospital. The staff called EMS at 7:10 PM, and the resident left the facility at 7:35 PM. (On 3/20/18 at 1:25 PM Administrative Nurse D stated the 2/24/18 at 6:46 PM nurse's note was inaccurately charted, and the date was 2/23/18 at 6:46 PM.) The 2/23/18 emergency room note documented the resident had [DIAGNOSES REDACTED]. After a long discussion with the patient's family members, the family wanted the resident to continue as a (DNR) Do Not Resuscitate, continue current treatments, nothing heroic done, and wanted the resident to remain in the hospital at that time. The note recorded the patient's family members realized that he/she was critically ill and his/her prognosis (likely course of a disease or illness) was poor. The 2/23/18 at 12:01 AM, hospital urinalysis lab report documented abnormal results of 2+ protein, 1+ [MEDICATION NAME], and 2+ blood. (Normal urine values: protein < or = to 150 mg/dl, [MEDICATION NAME] - none, blood < or = to 3 RBCs) The 2/24/18 at 12:30 AM, nurse's notes recorded the hospital called the facility and wanted to know when the last dose of [MEDICATION NAME] was given and if it was given IV. The note recorded the staff nurse reported to the hospital it was IV, and staff administered the last dose that evening (2/23/18). The hospital nurse reported the resident had aspiration pneumonia and tested positive for Influenza A. The 2/28/18 hospital Discharge Summary documented prior to admission, the overnight physician had a discussion with the resident's family members regarding the patient's poor prognosis and current treatment plan. The note recorded the patient was a DNR/DNI (Do Not Resuscitate/Do Not Intubate), and the family members did not want any heroic measures including vasopressor agents (medication to increase blood pressure) and decided to proceed with hospice care. The resident's antibiotics and treatment were stopped, and he/she was discharged to a hospice house. On 3/6/18 at 1:58 PM, (CMA) Certified Medication Aide M stated when the resident first came to the facility he/she required 2 staff assistance to ambulate (walk), then at the end, staff used 2 people with a sit to stand lift, and then a full lift to transfer him/her, as he/she was non ambulatory at that time. CMA M stated the first time the resident had bleeding from his/her genital area), he/she was sent to the hospital and came back to the facility on an antibiotic. The second time the resident went to the hospital, he/she was bleeding from his/her genital area again. CMA M stated the resident was incontinent of bowel and bladder. CMA M stated the resident was not coming back to the facility, as he/she was now in a hospice facility. On 3/6/18 at 2:42 PM Administrative Nurse E stated the resident went from a 2 person pivot transfer to a full lift transfer, he/she was incontinent of bowel and bladder, and did not have a catheter on admission. Administrative Nurse E stated when the resident went to the hospital the first time (1/19/18), he/she had bleeding from his/her urethra (small tubular structure that drains urine from the bladder), and came back 2-3 days later. Administrative Nurse E stated initially staff collected urine for a UA, catheterized the resident, he/she started bleeding, and was diagnosed with [REDACTED]. Administrative Nurse E stated the resident was not expected to return and he/she was at a hospice house. On 3/6/18 at 3:18 PM, Administrative Staff A verified the resident's medical record lacked documentation in the nurse's note of the resident's return to the facility on [DATE] after his/her admission to the hospital on [DATE] although an assessment was completed on 1/24/18. Administrative Staff A stated the first bleeding episode occurred after the the facility received an order to obtain a UA on 1/5/18, but staff had not documented attempts to obtain the UA until 1/11/18. Administrative Staff A stated staff attempted to catheterize the resident on 1/11/18, and were unable to obtain a sample until 1/18/18 with a straight catheter. Administrative Staff A stated it sounded like the catheter was what caused the bleeding per the physician. Administrative Staff A stated the second time the resident went to the hospital, staff received an order on 2/9/18 for a UA, and it was obtained per straight catheter on 2/9/18. Administrative Staff A stated the resident started bleeding on 2/11/18, he/she had a high temperature that started on 2/12/18, was admitted to the hospital on that day, and came back to the facility on [DATE]. Administrative Staff A stated on 2/23/18 the resident was not feeling well, and was admitted to the hospital with [REDACTED]. Administrative Staff A stated the resident returned to the facility on the intravenous antibiotic [MEDICATION NAME]. On 3/7/18 at 1:16 PM, Administrative Nurse D stated staff should have documented in the nurse's notes when the resident came back to the facility on [DATE]. On 1/5/18 Nurse G received the physician's orders [REDACTED]. Administrative Nurse D was not sure why staff had not obtained the UA until 1/18/18. Administrative Nurse D stated he/she was not sure why staff had not obtained a stool sample, as physician ordered on [DATE], and verified staff should have obtained the sample. Administrative Nurse D stated the resident had an enlarged prostate, and the repeated catheter insertion could have irritated things, which caused the bleeding. On 3/7/18 at 1:54 PM, Nurse G stated he/she was the one who received the 1/5/18 physician order [REDACTED]. Nurse G stated he/she tried to obtain the UA 4 times, and did not document it. Administrative Nurse E told him/her to go up and over the prostate to get the UA, and that was why it had not worked. Nurse G stated he/she attempted to obtain the UA on 1/15/18, 1/16/18, 1/17/18, and 1/18/18. Nurse G stated after he/she was unable to obtain the UA on 1/18/18, he/she then told Administrative Nurse E, who obtained the UA on 1/18/18. Nurse G stated on 1/19/18, the resident started bleeding, saturating his/her incontinent brief with blood in about 15 minutes, the blood was pooled on his/her genital area. The resident did not complain of pain, when EMS came to pick up the resident on 1/19/18, his/her heart rate was very rapid. On 3/15/18 at 2:21 PM, Physician HH stated the resident had no history of UTIs prior to his/her ER visit. Physician HH stated he/she [MEDICAL CONDITION] from a urinary source, likely it was more acute prostatitis because it usually occurred with a more sudden onset. Physician HH stated he/she was not aware of the nurse performing multiple failed attempts to insert the catheter to obtain the UA, the multiple attempts could have caused trauma to the prostate that led to the bleeding, or led to a UTI (catheter associated infection). Physician HH stated the delay in obtaining the UA probably did not exacerbate [MEDICAL CONDITION] if the UA on 1/18/18 came back clear, but not notifying the physician of the failed multiple attempts could have delayed the diagnoses, the facility should have called the physician after 2-3 failed attempts. Physician HH stated the facility staff needed further education on catheter insertion, and should not have waited 13 days to obtain the UA or notify the physician. Physician HH stated the resident had hematuria (bloody urine) from multiple attempts of inserting the catheter, when he/she came to the hospital on [DATE], he/she came in with a [DIAGNOSES REDACTED]. Physician HH stated he/she did not treat the resident on that visit, and the information came from his/her hospital record. Physician HH stated the incidents of the failed catheter attempts and the bleeding that followed potentially started a line of issues and/or errors, that ultimately led to the resident's decline and death. The facility's Abuse, Neglect & Exploitation policy, dated 11/1/16, the purpose is to ensure that all elders of the facility will be free of physical, emotional, and neglectful treatment. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The DON or registered nurse on duty will assess the elder who may be a victim of possible abuse, neglect, or mistreatment. The facility failed to provide necessary services by clinical standards of practice to avoid physical harm, pain, mental anguish or emotional distress to Resident #1, when staff failed to obtain the physician ordered UA for 13 days. Staff further failed to obtain the physician ordered stool sample, continue to assess the resident's urinary status, and deficient nursing practice, caused Resident #1 to have multiple episodes of bleeding after improper catheter insertion. This deficient practice resulted in multiple hospitalization s evidenced by [DIAGNOSES REDACTED]. The facility abated the immediate jeopardy on 3/15/18, after completion of the following: staff education and training on proper catheterization (including competency training), policy and procedure for receiving and completing lab orders, following physician orders [REDACTED]. The Director of Nursing or designee would conduct random weekly audits and report findings to the monthly QAPI committee for further review. The deficient practice remained at a scope and severity of a G.

The facility had a census of 35 residents. The sample included 10 residents. Based on observation, record review, and interview, the facility failed to employ nursing staff 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 for Resident #1 who was hospitalized on multiple occasions related to improper catheterizations and/or assessments. Findings included: - The 1/30/18 POS (Physician order [REDACTED].#1 had [DIAGNOSES REDACTED]. (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major [MEDICAL CONDITION] (major mood disorder that causes a persistent feeling of sadness and loss of interest), [MEDICAL CONDITION] without lower urinary tract symptoms (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and acute prostatitis (the sudden onset of inflammation in the prostate). The quarterly (MDS) Minimum Data Set assessment, dated 11/29/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 9, indicating moderately impaired cognition, with physical and verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, rejection of care, and wandering occurred 1 to 3 days in the 7 day look back period. The MDS recorded the resident was totally dependent on 2 staff for bathing, required extensive assistance of 1 staff for personal hygiene, limited assistance of 1 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, supervision with 1 staff assistance for locomotion off the unit, and supervision with setup help only for eating. The MDS recorded the resident's balance was not steady, but able to stabilize without staff assistance, used a walker and wheelchair for mobility, and was occasionally incontinent of bowel and bladder. The quarterly MDS, dated [DATE], recorded the resident had a BIMS score of 5, indicating severe cognitive impairment with no wandering. The MDS recorded the resident was totally dependent on 2 staff assistance for personal hygiene, required extensive assistance of 2 staff for bed mobility, transfers, locomotion on the unit, dressing, extensive assistance of 1 staff for locomotion off the unit, supervision with 1 staff assistance for eating, and toileting activity occurred only once or twice with 2 staff assistance. The MDS recorded the resident used a wheelchair for mobility, was frequently incontinent of bladder, and always incontinent of bowel. The 8/21/17 (ADLs) Activities of Daily Living (CAA) Care Area Assessment documented the resident was usually independent with his/her ADLs, would pivot transfer to and from different surfaces, and was able to dress himself/herself. The CAA documented the resident had difficulty with hygiene after going to the bathroom, generally did not allow staff to assist him/her, but staff continued to monitor and provide assistance as he/she tolerated. The 8/21/17 Incontinence/Catheter CAA documented the resident was occasionally incontinent of bladder, was independent to and from the bathroom, came out to the main living areas with soiled pants at times, and usually would change if staff directed him/her. The 9/26/17 care plan recorded the resident had a self care deficit due to dementia (progressive mental disorder characterized by failing memory), confusion, and impaired mobility. The care plan recorded the resident required assistance of 1 staff member as he/she allowed, and he/she used a walker or wheelchair for mobility. The care plan directed staff to provide peri-care after each incontinent episode as the resident would allow, monitor for signs and symptoms of a [MEDICAL CONDITION] urinary tract infection such as burning, pain, discolored urine, odor and confusion, offer to toilet the resident before and/or after meals, and the resident wore incontinent briefs for dignity and protection. The medical record lacked any updates regarding bowel and bladder assistance. The 1/5/2018 at 1:47 PM, nurse's note recorded Consultant Physician JJ came to the facility to see the resident, and ordered a UA (test to check urine for abnormalities) with a C&S (culture and sensitivity test that identifies disease-causing microorganism, and determines which antibiotics are sensitive to (effective against) the identified microorganism) if indicated. The medical record lacked evidence of documentation of assessments between 1/5/18 and 1/11/18 of the resident's urine after the physician ordered the UA on 1/5/18. The 1/11/2018 at 6:03 AM, nurse's note recorded staff explained to the resident he/she needed a UA. Staff asked the resident to urinate in a cup, and the resident yelled NO! The note recorded staff explained to the resident a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) would be used to obtain the UA. The note recorded staff attempted to catheterize the resident, he/she kicked and yelled, finally calmed down, but staff were unable to pass the catheter into the bladder. The note recorded staff removed the catheter and the order to obtain the UA would be communicated to the oncoming shift. (6 days after the physician ordered the UA) Review of the medical record lacked documentation that Nurse G attempted to obtain the UA via straight catheter on 1/15/18, 1/16/18, 1/17/18, and 1/18/18, but was unable to obtain the sample due to him/her not being able to advance the catheter into the resident's bladder, lacked documentation of any bleeding, assessment of the resident's urinary system, or how the resident tolerated the procedure. Further review of the medical record lacked evidence staff notified the physician of the repeated failed attempts to obtain the UA on 1/11/18, 1/15/18, 1/16/18, 1/17/18, and 1/18/18. The 1/18/2018 at 11:10 AM, nurse's note recorded staff obtained the resident's UA by using a straight catheter, per sterile technique. The 1/18/2018 at 2:29 PM, nurse's note recorded staff collected a UA by catheterization and sent the urine sample to the physician's office. The 1/18/18 urinalysis report, received at 4:16 PM, documented the resident's urine was yellow and abnormally cloudy, with trace amounts of glucose, and no blood in the urine. (Normal urine values: color-yellow, clarity-clear or cloudy, glucose < or = 130 (mg) milligrams/(dl) deciliter) The 1/19/2018 at 9:05 AM, nurse's note recorded the resident slid out of his/her wheelchair that morning at 8:25 AM. The note recorded staff witnessed the fall, the resident had no injury, and vital signs: blood pressure 164/95, pulse 81, temperature 96.3, respirations 16. (normal vital signs: temperature 98.6 Fahrenheit, blood pressure <120/<80, pulse 50-90, respirations 12-18, oxygen saturation 100% on room air) The medical record revealed staff obtained vital signs on 1/19/18 at 11:30 AM: blood pressure 141/88, pulse 145, respirations 14, and oxygen saturation 98% on room air. The 1/19/2018 at 12:22 PM, nurse's note recorded staff observed a substantial amount of blood in the resident's brief. The note recorded the resident's vital signs were in normal limits (pulse 145 at 11:30 AM), and the nurse attempted to call the physician. The note recorded before the nurse could call the physician, staff called him/her back into the resident's room because staff changed the resident's incontinent brief and the new incontinent brief already had a large amount of blood with a pool of blood on the resident's genital area. The note recorded the nurse called the physician and received orders to send the resident to the local hospital. When the (EMS) Emergency Medical Service arrived, the resident's blood pressure was low and pulse was high. The note recorded EMS staff stated it would be better to take the resident to a tertiary hospital (hospital that has advanced support services and specialized care and treatment). The nurse called the physician and received orders to send the resident to the tertiary hospital. The 1/19/18 hospital (H&P) history and physical examination [REDACTED]. The resident was unable to give information for the H&P due to altered mental status/lethargy, so information came from verbal report given to the ED by the nursing facility. The facility staff reported the resident was more lethargic than usual and had slid out of his/her wheelchair to the floor earlier that morning. Staff assessed the resident, assisted him/her back into his/her chair, and monitored the resident. Later the resident was more lethargic with altered mental status, noted to have blood in his/her brief, and staff called EMS for transport to the ED for further evaluation. Hospital staff found the resident met [MEDICAL CONDITION] criteria (a potentially life-threatening complication of an infection, many doctors [MEDICAL CONDITION] as a three-stage syndrome, starting [MEDICAL CONDITION] and progressing through [MEDICAL CONDITION] to septic shock), with [MEDICAL CONDITION] Urinary Tract Infection and therefore admitted him/her to the (ICU) Intensive Care Unit for further monitoring and treatment. The 1/24/18 hospital Discharge Summary documented the resident arrived in the ED via EMS from a nursing facility due to lethargy/AMS (altered mental status), a fall, and septic from a urinary source: [MEDICAL CONDITION] secondary to Proteus UTI, and Proteus Mirabilis UTI (a type of bacteria that can be found in the intestines, however, when it is spread into the urinary system, it can cause infection), likely acute bacterial prostatitis (a bacterial infection of the walnut sized prostate gland, located below the bladder, in front of the rectum, and surrounds the urethra, the tube through which urine exits the body), which typically starts suddenly and may include flu-like symptoms. Review of the resident's medical record lacked evidence of documentation of the resident's return to the facility on [DATE]. The 1/29/2018 at 9:36 AM, nurse's note recorded staff asked the physician about the resident's return to the facility on [MEDICATION NAME](antibiotic medication), 500 (mg) milligrams, (BID) twice a day, for 6 weeks. The note recorded the resident had constant loose stools and staff requested the physician start the resident on [MEDICATION NAME] (dairy food or supplement containing live bacteria that replace or add to the beneficial bacteria normally present in the gastrointestinal tract). The 1/29/18 return fax from the physician directed staff to start a [MEDICATION NAME] daily, use universal precautions/isolation (the practice, in medicine, of avoiding contact with patient's bodily fluids, by means of wearing nonporous articles such as medical gloves, goggles, and face shields, ensure the resident resides by himself/herself) due to diarrhea, and obtain a stool sample to test for [MEDICAL CONDITION] (,[MEDICAL CONDITION]. Difficille-contagious bacteria characterized by foul smelling frequent bowel movements). Review of the resident's medical record lacked evidence staff obtained the physician ordered stool sample. The 1/31/2018 at 6:53 PM, nurse's note recorded Consultant Physician JJ saw the resident and ordered staff to obtain a UA with C&S. The 2/2/2018 at 3:12 PM nurse's note recorded the physician's office called about the stool sample, stated they had not received it, and asked if the resident still had diarrhea. The note recorded the resident no longer had diarrhea, the nurse stated he/she wanted to see what the physician said, and waited on a response from the physician. (4 days after the stool sample was ordered) The 2/9/2018 at 9:34 AM nurse's note recorded the resident continued antibiotics for a UTI, and the clinic had called and ordered a UA for the resident. The note recorded staff obtained the UA using a catheter, per sterile technique, without difficulty or drainage noted after catheterization. The 2/9/18 urinalysis lab report documented the urine was cloudy, with a moderate amount of non-hemolyzed blood (blood cells remain intact), 2+ protein, red and white blood cells too numerous to count, and 1+ bacteria, and documented a urine culture was indicated. (Normal urine values: color - yellow, clarity - clear or cloudy, blood < or = to 3 (RBCs) Red Blood Cells, protein < or = to 150 mg/dl, RBCs < or = to 3 RBCs/hpf (high power field), (WBC) White Blood Cells < or = to 2-5 WBC/hpf, bacteria-none) The 2/11/2018 at 12:44 PM, nurse's note recorded staff found a small amount of blood in the resident's brief, and would continue to monitor the resident. The clinical record lacked evidence staff notified the resident's physician. The 2/12/2018 at 2:09 PM, nurse's note recorded the resident was awake, and able to move his/her wheelchair back and forth. The nurse asked the resident if he/she felt ok, and the resident responded yes. Staff assessed the resident's skin color was a little pale and he/she was diaphoretic (excessive sweating), vital signs were: blood pressure 150/90, pulse 132, respirations 18, temperature 97.6, oxygen saturation 94%, finger stick blood sugar 188. The note recorded the resident denied pain, had bloody urine, was assisted to bed, and the nurse notified the physician of the resident's condition. The 2/12/2018 at 2:14 PM, nurse's note recorded the resident's lab results returned documenting the UA showed a few abnormals, with no new physician orders. The 2/12/2018 at 2:43 PM, nurse's note recorded the facility received orders to send the resident to the hospital, by way of EMS. The 2/12/18 hospital H&P documented the resident was admitted with a [DIAGNOSES REDACTED]. The hospital medical record, dated 2/19/18, documented the resident discharged from the hospital back to the the nursing facility on 2/19/18 with orders for [MEDICATION NAME] (strong bacterial antibiotic), 1 G (gram) vial, inject (IV) Intravenous (to inject the medication into a vein via syringe or intravenous tubing) every 12 hours for 8 days, [MEDICATION NAME] trough (blood test to determine rates of absorption and clearance of the antibiotic) weekly, start on 2/20/18. (Review of the medical record lacked evidence staff obtained the [MEDICATION NAME] trough as physician ordered) The 2/19/2018 at 9:58 PM, nurse's note recorded at 5:17 PM, the resident returned to the facility from the hospital, in a wheelchair. The note recorded a blood pressure reading of 122/72 and the resident had a urinary catheter to dependent drainage, draining clear yellow urine. The 2/20/2018 at 10:36 PM, nurse's note recorded staff administered [MEDICATION NAME] per physician's orders [REDACTED]. The medical record lacked evidence of documentation the staff assessed the resident's urine between 2/19/18 and 2/23/18. The 2/23/2018 at 1:34 PM, nurse's notes recorded the resident was not feeling well, had 2 small emesis (vomit), and did not want to eat. The notes recorded the resident's vital signs were blood pressure 118/72, pulse 68, respirations 16, oxygen saturation 93%, and temperature 99.3. The notes recorded the resident rested comfortably, and the urinary catheter to dependent drainage, with light yellow urine. The clinical record lacked evidence staff notified the physician. The 2/24/2018 at 6:46 PM, nurse's note recorded at 6:45 PM the resident had emesis, and lung sounds were coarse (abnormal lung sounds). The resident's blood pressure was 190/120, temperature 102.7, pulse 124, respirations 42, oxygen saturation 80% on room air. Two staff assisted the resident up into the wheelchair, then to the recliner and staff changed his/her bedding, and recorded the resident had audible wheezes (to breathe with difficulty usually with a [MEDICATION NAME] sound) called the on call physician, and received orders to send the resident to the hospital. The staff called EMS at 7:10 PM, and the resident left the facility at 7:35 PM. (On 3/20/18 at 1:25 PM Administrative Nurse D stated the 2/24/18 at 6:46 PM nurse's note was inaccurately charted, and the date was 2/23/18 at 6:46 PM.) The 2/23/18 emergency room note documented the resident had [DIAGNOSES REDACTED]. After a long discussion with the patient's family members, the family wanted the resident to continue as a (DNR) Do Not Resuscitate, continue current treatments, nothing heroic done, and wanted the resident to remain in the hospital at that time. The note recorded the patient's family members realized that he/she was critically ill and his/her prognosis (likely course of a disease or illness) was poor. The 2/23/18 at 12:01 AM, hospital urinalysis lab report documented abnormal results of 2+ protein, 1+ [MEDICATION NAME], and 2+ blood. (Normal urine values: protein < or = to 150 mg/dl, [MEDICATION NAME] - none, blood < or = to 3 RBCs) The 2/24/18 at 12:30 AM, nurse's notes recorded the hospital called the facility and wanted to know when the last dose of [MEDICATION NAME] was given and if it was given IV. The note recorded the staff nurse reported to the hospital it was IV, and staff administered the last dose that evening (2/23/18). The hospital nurse reported the resident had aspiration pneumonia and tested positive for Influenza A. The 2/28/18 hospital Discharge Summary documented prior to admission, the overnight physician had a discussion with the resident's family members regarding the patient's poor prognosis and current treatment plan. The note recorded the patient was a DNR/DNI (Do Not Resuscitate/Do Not Intubate), and the family members did not want any heroic measures including vasopressor agents (medication to increase blood pressure) and decided to proceed with hospice care. The resident's antibiotics and treatment were stopped, and he/she was discharged to a hospice house. On 3/6/18 at 2:42 PM Administrative Nurse E stated when the resident went to the hospital the first time (1/19/18), he/she had bleeding from his/her urethra (small tubular structure that drains urine from the bladder), and came back 2-3 days later. Administrative Nurse E stated initially staff collected urine for a UA, catheterized the resident, he/she started bleeding, and was diagnosed with [REDACTED]. On 3/6/18 at 3:18 PM, Administrative Staff A verified the resident's medical record lacked documentation in the nurse's note of the resident's return to the facility on [DATE] after his/her admission to the hospital on [DATE] although an assessment was completed on 1/24/18. Administrative Staff A stated the first bleeding episode occurred after the the facility received an order to obtain a UA on 1/5/18, but staff had not documented attempts to obtain the UA until 1/11/18. Administrative Staff A stated staff attempted to catheterize the resident on 1/11/18, and were unable to obtain a sample until 1/18/18 with a straight catheter. Administrative Staff A stated it sounded like the catheter was what caused the bleeding per the physician. Administrative Staff A stated the second time the resident went to the hospital, staff received an order on 2/9/18 for a UA, and it was obtained per straight catheter on 2/9/18. Administrative Staff A stated the resident started bleeding on 2/11/18, he/she had a high temperature that started on 2/12/18, was admitted to the hospital on that day, and came back to the facility on [DATE]. Administrative Staff A stated on 2/23/18 the resident was not feeling well, and was admitted to the hospital with [REDACTED]. On 3/7/18 at 1:16 PM, Administrative Nurse D stated staff should have documented in the nurse's notes when the resident came back to the facility on [DATE]. On 1/5/18 Nurse G received the physician's orders [REDACTED]. Administrative Nurse D was not sure why staff had not obtained the UA until 1/18/18. Administrative Nurse D stated he/she was not sure why staff had not obtained a stool sample, as physician ordered on [DATE], and verified staff should have obtained the sample. Administrative Nurse D stated the resident had an enlarged prostate, and the repeated catheter insertion could have irritated things, which caused the bleeding. On 3/7/18 at 1:54 PM, Nurse G stated he/she was the one who received the 1/5/18 physician order [REDACTED]. Nurse G stated he/she tried to obtain the UA 4 times, and did not document it. Administrative Nurse E told him/her to go up and over the prostate to get the UA, and that was why it had not worked. Nurse G stated he/she attempted to obtain the UA on 1/15/18, 1/16/18, 1/17/18, and 1/18/18. Nurse G stated after he/she was unable to obtain the UA on 1/18/18, he/she then told Administrative Nurse E, who obtained the UA on 1/18/18. Nurse G stated on 1/19/18, the resident started bleeding, saturating his/her incontinent brief with blood in about 15 minutes, the blood was pooled on his/her genital area. The resident did not complain of pain, when EMS came to pick up the resident on 1/19/18, and his/her heart rate was very rapid. On 3/15/18 at 2:21 PM, Physician HH stated the resident had no history of UTIs prior to his/her ER visit. Physician HH stated he/she [MEDICAL CONDITION] from a urinary source, likely it was more acute prostatitis because it usually occurred with a more sudden onset. Physician HH stated he/she was not aware of the nurse performing multiple failed attempts to insert the catheter to obtain the UA, the multiple attempts could have caused trauma to the prostate that led to the bleeding, or led to a UTI (catheter associated infection). Physician HH stated the delay in obtaining the UA probably did not exacerbate [MEDICAL CONDITION] if the UA on 1/18/18 came back clear, but not notifying the physician of the failed multiple attempts could have delayed the diagnoses, the facility should have called the physician after 2-3 failed attempts. Physician HH stated the facility staff needed further education on catheter insertion, and should not have waited 13 days to obtain the UA or notify the physician. Physician HH stated the resident had hematuria (bloody urine) from multiple attempts of inserting the catheter, when he/she came to the hospital on [DATE], he/she came in with a [DIAGNOSES REDACTED]. Physician HH stated he/she did not treat the resident on that visit, and the information came from his/her hospital record. Physician HH stated the incidents of the failed catheter attempts and the bleeding that followed potentially started a line of issues and/or errors, that ultimately led to the resident's decline and death. Upon request, the facility failed to provide a policy regarding nursing staff competency. The facility failed to employ nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure Resident #1's safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being, after he/she was hospitalized on multiple occasions related to improper catheterizations and/or lack of assessments, placing the resident at risk for further infection.

The facility had a census of 29 residents. The sample included 16 residents, of which 3 residents were reviewed for nutrition. Based on observation, record review and interview the facility failed to develop and implement timely interventions and failed to adequately monitor meal intakes to prevent significant weight loss for 1 of 3 sampled residents, who lost 10 (lbs) pounds or 6.49% in 1 month, and staff failed to document meal and supplement intakes as recommended by the (RD) Registered Dietician. (#19) Findings included: - Resident #19's quarterly (MDS) Minimum Data Set assessment, dated 12/14/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 9 (moderately impaired cognition) with inattention. The MDS also indicated the resident required extensive assistance with transfers, dressing, personal hygiene and limited assistance with eating. The MDS further indicated the resident had a stable weight and required a mechanical altered diet (ground foods/cut in small bites), related to swallowing problems. The 08/21/16 annual (CAA) Care Area Assessment for nutrition indicated the resident was at risk for weight loss, due to the resident's poor appetite and swallowing problems. The 01/13/17 revised care plan indicated the resident was at risk for nutritional problems related to poor appetite and swallowing difficulties. The care plan directed staff to provide the resident with a house supplement at meals, ice cream for an afternoon and bedtime snack, and to monitor all of the resident's intake. The care plan lacked documentation to direct staff when the resident refused meals or ate poorly. The weight record indicated the following weights for the resident: 12/28/16 - 161.0 (lbs) pounds 01/13/17 - 154.0 lbs 01/26/17 - 154.0 lbs 02/08/17 - 148.0 lbs 02/20/17 - 143.5 lbs 02/27/17 - 144.0 lbs (6.49% weight loss in 1 month since 01/26/17) 03/09/17 - 144.5 lbs The 01/13/17 (RD) Registered Dietician Progress Note revealed the resident weighed 154 lbs and had lost 7 lbs in 2 weeks. The RD directed staff to provide the resident with a fortified milk shake, 3 times a day, and to monitor the resident's intake and weight. The 01/13/17 physician's orders [REDACTED]. The 02/15/17 RD Progress Note revealed the resident weighed 143 lbs and had a significant weight loss in the past 60 days. The progress note indicated the resident received a fortified milk shake three times a day and 4 ounces of Med Pass 2.0 nutritional supplement, three times a day, as ordered by the physician on 01/13/17. The RD directed staff to continue to monitor the resident's intake and weight and notify the RD as needed. Review of the 03/01/17 RD Progress Note revealed the resident weighed 143.5 lbs, which was a significant weight loss of 10.87% in 90 days. The progress note indicated the resident continued to receive Med Pass 2.0 three times a day, fortified health shake three times a day and ice cream two times a day. The RD directed staff to continue the current dietary plan and monitor the resident's intake and weight. The meal intake record from 01/14/17 to 03/08/17 (54 days and/or 162 meal intakes) revealed staff had not recorded the resident's meal intake 44 times. Continued review of the meal intake record revealed staff recorded the resident had a 0% meal intake 30 times and a less than 25% meal intake 42 times. The supplement intake record from 01/14/17 to 03/08/17 (54 days and/or 162 supplement intakes) revealed the staff documented the resident's supplement intake 29 times. The resident's medical record revealed no documentation the facility monitored the resident's ice cream snack intake. On 03/07/17 at 12:22 PM, observation revealed the resident sat in his/her wheelchair, at the dining room table, and ate and drank independently. Continued observation revealed the resident ate less than 25% of his/her meal and staff did not offer an alternate food choice. On 03/08/17 at 12:29 PM, observation revealed the resident sat in his/her wheelchair near the nurse's station and refused to eat lunch. Continued observation revealed staff offered the resident some chocolate milk and the resident drank a few sips. On 03/08/17 on 11:02 AM, Nurse Aide I stated the resident had a poor appetite and often refused meals or ate only a few bites. Nurse Aide I also stated the resident frequently refused his/her supplements and snacks, and verified no staff documentation of snack intake. On 03/08/17 at 1:47 PM, Administrative Nurse B stated the resident had a recent significant weight loss due to a his/her poor appetite. Administrative Nurse B stated the resident received fortified shake supplements three times a day and ice cream snacks two times a day as a nutritional intervention to prevent continued weight loss. Administrative Nurse B stated dietary staff should accurately monitor the resident's meal, supplement and snack intake and report to the Registered Dietician as needed. On 03/08/17 at 1:58 PM, Nurse G stated the resident had a recent significant weight loss and continued to refuse meals, supplements, and snacks. Nurse G stated dietary staff should accurately monitor the resident's intake and inform the Registered Dietician of the resident's poor appetite. On 03/09/17 at 8:17 AM, Dietary Staff J stated dietary staff should accurately monitor and document the resident's meal and supplement intake as directed by the Registered Dietician. Dietary Staff J stated the facility had no system in place to monitor the resident's snack intake as directed by the Registered Dietician. On 03/13/17 at 9:10 AM, Registered Dietician K stated the facility should have a system in place to accurately monitor and document the intake of meals and nutritional supplements for residents at risk for weight loss and inform him/her and the physician of the resident's nutritional status. On 03/13/17 at 11:15 AM, Physician's Nurse L stated the physician expected the facility to accurately monitor the resident's meal and supplement intake and inform the physician of the resident's nutritional status. The facility's Unintentional Weight Loss Policy, dated 07/2016, directed staff to monitor meal intakes for residents at risk for weight loss and to accurately monitor the RD recommendations for nutritional interventions, such as supplements and snacks. The facility failed to develop and implement effective interventions and failed to adequately monitor meals and nutritional interventions to prevent significant weight loss for Resident #19.

The facility reported a census of 38 residents, with 6 residents in a dementia care unit (a unit for confused residents with memory and/or cognitive deficits). The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to protect (opposite gender) residents from abuse when resident #1 (with a history of inappropriate touching) kissed and inappropriately touched (opposite gender) resident #2 on 2/27/17. This deficient practice placed the (opposite gender) residents of the facility in immediate jeopardy. Findings included: - The March 2017 physician's orders [REDACTED].#1 included a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented staff assessed resident #1 with moderately impaired cognition and one incident of behavior directed toward others during the assessment period. He/she was independent with activities of daily living (ADLs) such as walking, dressing and toilet use. The MDS documented the resident received antipsychotic (medication used to treat mental disorders), anti-anxiety (medication used to treat restlessness) and anti-depressant (medication used to relieve feelings of sadness) medications. The Care Area Assessment (CAA) dated 3/30/16 for [MEDICAL CONDITION] medication recorded the resident received [MEDICATION NAME] (antipsychotic medication used to treat mental disorders). The CAA recorded the resident exhibited inappropriate behaviors. The quarterly Minimum Data Set ((MDS) dated [DATE] documented resident #1 had no changes in his/her cognitive or functional abilities and received anti-depressants. The care plan dated 10/20/2016 documented the resident had ineffective coping skills and directed staff to encourage the resident to express his/her emotion such as sadness, guilt and anger. The care plan lacked documentation to address any specific behaviors or one on one monitoring. Review of the facility nurse's notes dated 2/27/17 at 2:43 P.M. documented direct care staff R called the nurse to the dementia care unit. Direct care staff R reported when he/she finished assisting another resident, he/she observed resident #1 standing over (opposite gender) resident #2 who sat in a wheelchair and kissed him/her. Resident #1 had his/her hand down resident #2's shirt. Direct care staff R immediately intervened and told resident #1 the behavior was unacceptable. The nurse spoke to resident #1 and expressed the behavior was inappropriate and unacceptable. The nurse's note dated 2/28/17 at 10:42 A.M recorded staff observed resident #1 leaving the dementia care unit and looking down the hall as if he/she was looking for someone. When instructed by staff he/she needed to go back to the dementia care unit, resident #1 argued, yelled and used profanity. According to the facility's investigation, direct care staff R's notarized witness statement documented he/she assisted another resident with toileting, who resided in the dementia care unit. Staff R documented he/she observed resident #1 lean over a wheelchair, kiss and inappropriately touch (opposite gender) resident #2. Direct care Staff R separated the residents and called the Assistant Director of Nursing (ADON). On 03/06/17 at 3:25 PM, direct care staff R stated when the resident to resident abuse incident occurred on 2/27/17, the facility did not have enough staff on duty to allow for coverage of the special care unit. The special care unit doors were open that day and no staff were assigned to work on the unit. Staff R further stated he/she worked 4 to 5 days per week and in the last 4 to 6 weeks, this happened at least 5 times that he/she was aware of. On 3/9/17 at 1:00 PM family member T stated his/her parent lived on the secured unit and he/she visited frequently. The doors to the unit were consistently open over the past 6 months. When family member T inquired about this with facility staff, he/she was told it was due to the facility being short staffed. The facility's initial report from administrative nursing staff D dated 2/27/17 documented resident #1 admitted to a behavioral health unit from 2/2/17 to 2/14/17 due to this same behavior of sexual advances toward staff and other residents. On 3/2/17 at 10:33 A.M. administrative staff A and administrative nursing staff D stated when resident #1 returned from the behavioral health unit, staff were expected to continue one on one supervision of resident #1. The clinical record lacked documentation of one on one monitoring from 2/14/17 to 3/2/17. On 3/1/17 at 5:45 P.M. resident #2 sat in a wheelchair in the dining room. On 3/1/17 at 5:46 P.M. resident #1 reclined with his/her feet up on the secure unit and watched television. On 3/1/17 at 5:57 A.M. administrative licensed nursing staff D stated resident #1 had previous behaviors of mostly slapping at staff. Staff D reported on 1/18/17 resident #1 tried to kiss an unsampled (opposite gender) resident. Staff D further stated staff intervened before any physical contact was made. On 3/2/17 at 1:00 P.M. administrative staff A stated there were 2 (opposite gender) residents and 3 (like gender) residents in addition to resident #1 in the dementia care unit, and all walked without assistance. Staff A stated some of the residents came out of the dementia care unit for meals and activities. Staff A further stated (opposite gender) resident #2 wandered in his/her wheelchair and spent some time in the dementia care unit due to resident #2 needed a quiet environment. Staff A stated a direct care staff was present on the dementia care unit at the time of the incident on 2/27/17. This direct care staff did not call for assistance prior to toileting another resident, and this was what caused the incident on 2/27/17. The undated facility's Preventing Elder Abuse, Neglect and Misappropriation of Elder Property policy recorded staff would be educated on methods to assist an elder to control aggressive and disruptive behavior, and adequate staffing would be scheduled to provide assistance to all elders who required it. The facility failed to protect (opposite gender) residents from abuse when resident #1 kissed and inappropriately touched (opposite gender) resident #2 on 2/27/17. This deficient practice placed the (opposite gender) residents in immediate jeopardy. The facility abated the immediate jeopardy on 3/2/17 at 11:59 P.M. by implementing the following: Staff immediately transferred resident #2 to the regular unit in the facility; staff transferred the 2 (opposite gender) residents who resided in the dementia care unit to the regular unit; staff in-serviced about the facility's Abuse, Neglect, and Exploitation policy and monitoring of resident to resident altercations; Director of Nursing will review statements and incident reports daily for possible resident to resident altercations, and this incident will be reviewed during the next Quality Assurance meeting. The deficiency remained at a scope and severity of an E.

The facility reported a census of 38 residents, with 6 residents on a dementia care unit (a unit for confused residents with memory and/or cognitive deficits). The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview, the facility failed provide an environment free from abuse when resident #1 (with a history of inappropriate touching) kissed and inappropriately touched (opposite gender) resident #2 on 2/27/17. This deficient practice placed resident #2 in immediate jeopardy. Findings included: - The March 2017 physician's orders [REDACTED].#1 included a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented staff assessed resident #1 with moderately impaired cognition and one incident of behavior directed toward others during the assessment period. He/she was independent with activities of daily living (ADLs) such as walking, dressing and toilet use. The MDS documented the resident received antipsychotic (medication used to treat mental disorders), anti-anxiety (medication used to treat restlessness) and anti-depressant (medication used to relieve feelings of sadness) medications. The Care Area Assessment (CAA) dated 3/30/16 for [MEDICAL CONDITION] medication recorded the resident received [MEDICATION NAME] (antipsychotic medication used to treat mental disorders). The CAA recorded the resident exhibited inappropriate behaviors. The quarterly Minimum Data Set ((MDS) dated [DATE] documented resident #1 had no changes in his/her cognitive or functional abilities and received anti-depressants. The care plan dated 10/20/2016 documented the resident had ineffective coping skills and directed staff to encourage the resident to express his/her emotion such as sadness, guilt and anger. The care plan lacked documentation to address any specific behaviors or one on one monitoring. Review of the facility nurse's notes dated 2/27/17 at 2:43 P.M. documented direct care staff R called the nurse to the dementia care unit. Direct care staff R reported when he/she finished assisting another resident, he/she observed resident #1 standing over (opposite gender) resident #2 who sat in a wheelchair and kissed him/her. Resident #1 had his/her hand down resident #2's shirt. Direct care staff R immediately intervened and told resident #1 the behavior was unacceptable. The nurse spoke to resident #1 and expressed the behavior was inappropriate and unacceptable. The nurse's note dated 2/28/17 at 10:42 A.M recorded staff observed resident #1 leaving the dementia care unit and looking down the hall as if he/she was looking for someone. When instructed by staff he/she needed to go back to the dementia care unit, resident #1 argued, yelled and used profanity. According to the facility's investigation, direct care staff R's notarized witness statement documented he/she assisted another resident with toileting, who resided in the dementia care unit. Staff R documented he/she observed resident #1 lean over a wheelchair, kiss and inappropriately touch (opposite gender) resident #2. Direct care Staff R separated the residents and called the Assistant Director of Nursing (ADON). On 03/06/17 at 3:25 PM, direct care staff R stated when the resident to resident abuse incident occurred on 2/27/17, the facility did not have enough staff on duty to allow for coverage of the special care unit. The special care unit doors were open that day and no staff were assigned to work on the unit. Staff R further stated he/she worked 4 to 5 days per week and in the last 4 to 6 weeks, this happened at least 5 times that he/she was aware of. On 3/9/17 at 1:00 PM family member T stated his/her parent lived on the secured unit and he/she visited frequently. The doors to the unit were consistently open over the past 6 months. When family member T inquired about this with facility staff, he/she was told it was due to the facility being short staffed. The facility's initial report from administrative nursing staff D dated 2/27/17 documented resident #1 admitted to a behavioral health unit from 2/2/17 to 2/14/17 due to this same behavior of sexual advances toward staff and other residents. On 3/2/17 at 10:33 A.M. administrative staff A and administrative nursing staff D stated when resident #1 returned from the behavioral health unit, staff were expected to continue one on one supervision of resident #1. The clinical record lacked documentation of one on one monitoring from 2/14/17 to 3/2/17. On 3/1/17 at 5:45 P.M. resident #2 sat in a wheelchair in the dining room. On 3/1/17 at 5:46 P.M. resident #1 reclined with his/her feet up on the secure unit and watched television. On 3/1/17 at 5:57 A.M. administrative licensed nursing staff D stated resident #1 had previous behaviors of mostly slapping at staff. Staff D reported on 1/18/17 resident #1 tried to kiss an unsampled (opposite gender) resident. Staff D further stated staff intervened before any physical contact was made. On 3/2/17 at 1:00 P.M. administrative staff A stated there were 2 (opposite gender) residents and 3 (like gender) residents in addition to resident #1 in the dementia care unit, and all walked without assistance. Staff A stated some of the residents came out of the dementia care unit for meals and activities. Staff A further stated (opposite gender) resident #2 wandered in his/her wheelchair and spent some time in the dementia care unit due to resident #2 needed a quiet environment. Staff A stated a direct care staff was present on the dementia care unit at the time of the incident on 2/27/17. This direct care staff did not call for assistance prior to toileting another resident, and this was what caused the incident on 2/27/17. The undated facility's Preventing Elder Abuse, Neglect and Misappropriation of Elder Property policy recorded staff would be educated on methods to assist an elder to control aggressive and disruptive behavior, and adequate staffing would be scheduled to provide assistance to all elders who required it. The facility failed to provide an environment free from abuse when resident #1 kissed and inappropriately touched (opposite gender) resident #2 on 2/27/17. This deficient practice placed resident #2 in immediate jeopardy. The facility abated the immediate jeopardy on 3/2/17 at 11:59 P.M. by implementing the following: Staff immediately transferred resident #2 to the regular unit in the facility; staff transferred the 2 (opposite gender) residents who resided in the dementia care unit to the regular unit; staff in-serviced about the facility's Abuse, Neglect, and Exploitation policy and monitoring of resident to resident altercations; Director of Nursing will review statements and incident reports daily for possible resident to resident altercations, and this incident will be reviewed during the next Quality Assurance meeting. The deficiency remained at a scope and severity of a G.

The facility identified a census of 43 residents. The sample included 3 residents, reviewed for falls. Based on interview and record review, the facility failed to complete a thorough and adequate root cause analysis and failed to develop and implement timely and effective interventions for 1 of 3 residents sampled for falls. (#1) Resident #1 fell on [DATE] at 7:00 PM and transferred to the hospital for complaint of hip pain. The resident returned to the facility at 11:40 PM the same day as the X-rays were negative. Staff failed to implement appropriate and effective interventions to prevent further falls upon his/her return from the hospital. The resident then fell again on 10/26/15 at 2:30 AM (approximately 3 hours after return from the hospital) and subsequently admitted to the hospital with [REDACTED]. - Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) of 6, indicating severely impaired cognition. The resident displayed inattention which fluctuated. The resident required extensive assist with bed mobility, transfers, walking in room, locomotion on unit, dressing, toilet use and personal hygiene. The resident only walked in corridor occurred once. The resident was not steady, but able to stabilize without staff assist with all balance during transitions and walking. The resident had no range of motion impairment, and used a walker or wheelchair for locomotion. The resident had 2 non-injury falls since admission/entry or re-entry or the prior assessment. The resident was frequently incontinent of bowel and bladder. The resident received anti-psychotic medications daily. The resident did not receive therapy, and received restorative for walking and communication 3 of the last 7 days. The 4/15/15 admission MDS recorded the resident with a BIMS of 3, indicating severely impaired cognition. The resident displayed inattention and disorganized thinking which fluctuated. The resident required extensive assist with bed mobility, dressing, toilet use and personal hygiene, limited with transfers, walking, locomotion, eating. The resident was not steady but able to stabilize without staff assist with turning around; stead at all times with all others. The resident had no range of motion impairment, and used a walker for mobility. The resident was always incontinent of urine and frequently incontinent of bowel. The resident had no falls since admission or previous assessment. The Care Area Assessments (CAAs) dated 4/16/15 revealed the following: Cognitive loss/dementia: The resident had short term memory deficits. He/she was alert and oriented to person. Staff report that he/she can voice his/her wants and needs but doesn't. Incontinence: The resident was incontinent of bladder. Staff was to offer the resident the toilet before and after meals and provide pericare with each incontinent episode. Falls: The resident was at risk for falls due to his/her forgetfulness and incontinence. The resident had not had any falls since admission to the facility. He/she did have a call light sensor in his/her room so staff was aware he/she was getting up as for the daytime he/she needed supervision. Staff was to continue to monitor and encourage the resident to use his/her walker. Fall risk assessments dated 6/13/15, 8/9/15, 8/28/15, 10/11/15, 10/25/15 and 11/3/15 all recorded the resident was at high risk for falls. The care plan dated 10/21/15 recorded the resident was chronically confused related to dementia. The resident was at risk for falls due to his/her confusion. The resident ambulated with a walker and stand by assist, also needed assist of one with transfers. Staff was to complete a fall risk assessment per facility protocol, consider medication regime with assessment, and provide a contour mattress. If the resident had a new onset of falls, staff was to assess for lab abnormalities, signs/symptoms of infection and check vital signs, and implement individualized strategies to enhance communication. Staff was to observe the resident for balance and mobility issues, observe for signs/symptoms of dementia, fluid volume deficit and update the physician as needed. Staff was to recognize that when people attend to another task while walking such as carrying a cup of water clothing or supplies they were more likely to fall, the resident had motion sensor that triggered call light when it catches movement. The Fall Risk Team (FRT) met on falls from 6/12 and 6/13 in service on 6/17 to discuss the importance of the care plans and following the interventions in place. The FRT met in regards to falls on 8/9. The resident was currently on case load and therapy would address balance while he/she was on it. Staff received an in service that the resident needs to be in the front living room so he can be monitored by staff. The FRT met on the fall from 8/28. The resident was currently taking an antibiotic and staff was to monitor at this time to see if it will help with signs and symptoms. Staff was to encourage the resident to toilet every 2 hours while awake. The resident was not always cooperative, staff was to aide in pericare and provide balance to facilitate self-cleansing or the staff provided when unable. Staff was to monitor signs/symptoms of a urinary tract infection. Fall investigations revealed the following: On 6/12/15, the resident had a fall at 10:25 AM, with the last visual check of the resident 10:15. The resident was laying on his/her left side on living room. The leg of his/her walker caught on the piano leg. On 6/13/15, the resident had a fall at 9:00 AM. The door was closed and the resident was on his/her back on the floor next to the bed, head at dresser, with a skin tear to left elbow. The motion sensor call light was not on per the nurse and the call light was not sounding when aide entered room. On 8/9/15 at 3:00 PM, the resident was seen 5 minutes prior by staff. The resident said he/she sat down too fast, stood up, lost balance and fell . The care plan change was the resident would be in the main living room to monitor. On 8/9/15 at 7:00 PM, staff found the resident on the floor in the TV room. The intervention was for staff to do orthostatic blood pressures and send results to doctor. Per record review, the orthostatic blood pressures were not done timely. When staff completed the blood pressures, there were no significant findings and there was no further investigation to determine the cause of the fall and no additional interventions to prevent further falls. On 8/28/15 at 9:30 PM, the resident said he/she was trying to go to the bathroom. Staff last saw the resident in bed at 9:25 PM. The root cause was a possible urinary tract infection. The FRT met and will monitor already on Bactrim (antibiotic) to determine if urinalysis is needed. On 10/25/15 at 7:00 PM, staff found the resident on the floor, the resident said he/she was going to the bathroom. The resident ambulated with a walker, and had a silent alarm. The root cause was resident was that the resident was not tired, and staff documented restlessness. CNA staff was reeducated about bed times. Staff put the resident to bed because he/she was restless. The resident had gotten up 2 times after supper and been caught walking. The intervention put in place after this fall was to wait longer to put the resident to bed. there were no additional appropriate interventions put in place after this fall to prevent further falls anytime other than the evening shift. On 10/26/15 at 2:30 AM, the resident had returned from the ER at 11:40 PM. The motion detector was in place but failed. Root cause was all interventions were in place. The motion sensor was working when placed. After the fall, staff noted the battery had lost connection. Staff contacted maintenance and inspected all units, replacements were available, and provided staff communication. The Hospital Summary of Care Notes dated 10/26/15 included the resident had 2 falls today and had frequent falls. The physician visit note dated 11/4/15 at 11:36 AM recorded the resident was recently hospitalized after a cerebral hemorrhage. During an interview on 11/19/15 at 1:49 PM, direct care staff G stated for fall prevention the resident had a motion sensor, gripper socks, used a walker, had a contour mattress and had hourly checks. The sensor sets off the call light, and it lights up just like a regular call button so you can't tell if they set off the motion sensor or used the call light. The sensor sets off call light, and it lights up just like a regular call light button so can't tell if they set off motion or pushed their call light. During an interview on 11/19/15 at 3:20 PM, direct care staff F stated the resident could not use his/her call light was under supervision, and staff were to keep him/her nearby with other fall risk residents. If the resident was anxious, he/she would come out to the living room and have someone with him/her. The resident was not supposed to be in the TV room alone. During an interview on 11/19/15 at 3:29 PM, licensed nursing staff C stated the resident used a walker, and needed stand by assist and a gait belt when walking. The resident was not in a wheelchair until he/she came back from the hospital then transfers changed. Staff had to watch the resident pretty closely as he/she stood up frequently and forgot he/she needed help. The resident had a sensor monitor. During an interview on 11/19/15 at approximately 3:00 PM, administrative staff A and administrative nursing staff B stated the resident had falls one day apart, 8/9 and 8/10 both in the south TV room. It was an intervention to do orthostatic blood pressures after the 8/9/15 fall, they were not done until 8/18, approximately 10 days later. There were no significant findings from the orthostatic blood pressures and no additional interventions put in place. On 10/25 at 7:30 PM, the resident had a fall. The bed motion sensor linked to the call light was going off, and when staff got there the resident was already on the floor. The resident complained of hip pain and was sent to the hospital. The x-ray was negative, and the resident returned from the ER at 11:40 PM. The intervention staff put in place was to put the resident to put the resident to bed later. They felt this was why he/she fell . The resident then fell from bed again, on 10/26/15 at 2:30 AM and went to the hospital and was diagnosed with [REDACTED]. The floor nurses on duty at the time of the fall are expected to put an immediate intervention in place, then the FRT meets the next working day to review it. The alarm was malfunctioning on the second fall. The facility provided undated Fall Prevention and Management Policy and Procedure recorded the purpose was to initiate preventative approaches, provide appropriate strategies and interventions directed to resident, environmental factors and staff, and monitor and evaluate residents' outcome. The policy instructed staff that a licensed nurse would put an immediate intervention into place, and the fall response team would review the incident and complete a post fall investigation and update the care plan with appropriate interventions to prevent further incident and future incidents of falling. The facility failed to complete an adequate root cause to determine the cause of the fall and failed to develop and implement timely and effective interventions to prevent falls for this cognitively impaired, dependent resident who fell and sustained a subdural hematoma.

The facility reported a census of 44 with 3 residents sampled. Based on observation, interview and record review the facility failed to provide adequate supervision to prevent falls for one cognitively impaired resident who fell from the bath chair and sustained a laceration to the head that required staples (#1) and failed to follow the care plan to prevent falls for one resident. (#3) Findings included: -Resident #1's 4/25/15 Quarterly Minimum Data Set (MDS) revealed he/she scored a 6 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severely impaired cognition. He/she required extensive assistance of two staff for bed mobility, transfer, toilet use and personal hygiene. He/she required total dependence of one staff for bathing. He/she was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, turning around, moving on and off the toilet and surface to surface transfer. He/she was always incontinent of bowel and bladder, complained of pain occasionally and had no falls since the prior assessment. Review of the Functional/Rehabilitation Care Area Assessment (CAA) dated 3/6/15 revealed he/she remained 1 assist with dressing and grooming, required 2 assist and the sit to stand lift (a mechanical device used for assistance with transfer) to ensure safety. He/she can follow simple cues and reminders and was encouraged to do as much as possible for himself/herself. Review of the Fall CAA dated 3/6/15 revealed he/she was at risk for falls due to his/her confusion and history of falls. Staff transferred him/her with two assist and the sit to stand lift. He/she was able to move himself/herself around in the wheelchair. Review of resident #1 ' s Fall Risk Assessments revealed on 6/12/15 he/she had a score of 13, with 10 or more being high risk for falls. Review of the revised care plan dated 7/21/15 revealed he/she had chronic confusion. The plan instructed staff that due to his/her confusion the lift chair in his/her room would be unplugged. The plan instructed staff to use the sit to stand lift for transfers with 1-2 staff assistance. The plan instructed staff to do frequent checks on him/her. An update on 6/12/15 instructed staff due to his/her poor trunk control he/she needed to be assisted by two staff for transfer. Review of a nurses note (NN) dated 7/6/15 at 8:29 A.M. revealed the nurse was called to the shower room at 6:10 A.M. to find the resident laying on his/her left side. The note revealed blood was noted on the left side of his/her forehead by the hair line. He/she voiced no complaints of pain at this time. The resident had been sitting in the shower chair approximately three feet in the air and was being weighed when she fell . His/her neurological exam (the assessment of sensory and motor responses) was stable. A call was made to the emergency room physician and while waiting for the physician to call back the resident complained of left sided shoulder pain. The shoulder was palpated and he/she complained of pain. He/she had a cut on the left side of his/her head just behind the hair line. A bruise was noted on his/her right hand and the left knee. The emergency room (ER) report dated 7/6/15 revealed the resident presented to the emergency room with a scalp laceration that measured 2 centimeters (cm). The report revealed his/her pupils were round and reactive to light and the tympanic membranes (eardrum) were clear. Review the CT (computerized tomography) scan revealed a large scalp hematoma (bruise) present over the mid and left frontal region of the head but no skull fracture was seen. The chest x-ray revealed no acute findings. The ER report revealed that 4 staples were placed at the sight of the scalp laceration. Review of the fall investigation dated 7/6/15 revealed the resident was on the bath chair in the bath house being weighed by direct care staff O. Staff O revealed he/she walked away from the resident to write the weight down and heard a thud. Staff O revealed the resident hit his/her head first and that the strap on the tub chair was not in use at the time of the fall. Staff failed to review and revise the residents care plan to prevent further falls and the investigation did not identify the root cause of the fall. On 7/29/15 at 10:00 A.M., the resident sat in a recliner; he/she was slumped over to the left side and appeared to be sleeping. On 7/29/15 at 1:40 P.M. direct care staff P and R transferred the resident from his/her wheelchair to a recliner in the lobby area for an activity. Staff P and R used the sit to stand lift; the resident was able to follow simple commands but appeared to have left sided weakness. The resident tolerated the transfer without difficulty and when placed in the recliner he/she leaned towards the left side. Interview on 7/29/15 at 11:09 A.M. direct care staff Q revealed the resident required the use of the sit to stand lift for transfers. He/she stated the resident required assistance with all activities of daily living including transferring, personal hygiene and toileting. Staff Q stated that the facility had one staff that did the baths, but that all staff should be trained to do them. He/she confirmed the strap to the bath chair should be used when a resident is in the bath chair. Interview on 7/29/15 at 1:30 P.M. with direct care staff P confirmed that staff were to use the bath chair strap when a resident was in the chair. Interview on 7/29/15 at 1:50 P.M. licensed staff H revealed that the resident required assistance with all of his/her activities of daily living. He/she required assistance of one staff with his/her bathing and should not be left unattended on the bath chair. Staff H confirmed the strap on the bath chair should be used at all times. Interview on 7/29/15 at 3:30 P.M. administrative nursing staff D revealed that direct care staff O was counseled on the use of the bath strap for the bath chair and that it must be used at all times. The facilities revised 9/10/12 Whirlpool Orientation Checklist revealed that staff should make sure the safety belt is applied correctly applied and to use the top belt as needed, especially for those residents with poor upper body control or a history of leaning. The facility failed to provide adequate supervision to prevent falls for one cognitively impaired resident who fell from the bath chair and sustained a laceration to the head that required staples. -Resident #3's 6/22/15 Quarterly Minimum Data Set (MDS) revealed he/she had severely impaired cognitive skills for daily decision making. He/she required extensive staff assistance of 2 people for activities of daily living except for eating. He/she was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, walking or moving on and off the toilet and used a wheel chair for mobility. He/she was always incontinent of urine and occasionally incontinent of bowel. He/she did not complain of pain and had two non-injury falls since the prior assessment. The resident's Fall Care Area Assessment (CAA) dated 6/6/14 did not have an analysis of findings to address the needs for care planning. The resident's revised care plan dated 7/6/15 revealed he/she was at risk for falls due to his/her vision impairment and dementia (progressive mental disorder characterized by failing memory, confusion). The plan revealed he/she had a sensor alarm in his/her room to trigger the call light with movement, to place the call light close to him/her when he/she is in the room unsupervised and remind him to use it. The plan instructed staff to not leave him/her unattended in the bathroom, activity or hairdressing room. He/she had a contour mattress for safety and comfort and he/she was to be on 15 minute checks. On 1/20/15 an intervention was placed that he/she was not to be left in a wheelchair unattended, he/she should be transferred to a recliner. On 3/18/15 an intervention revealed that staff were in-serviced about the importance of following the care plan, when he/she is in the wheelchair the leg rests need to be in place. On 4/18/15 an intervention revealed that he/she was not to be unattended when out of bed. On 5/4/15 an intervention revealed that staff were educated on the policy and procedure for falls and to follow the care plan. On 5/16/15 the care plan revealed that he/she frequently stood up and sat down to reposition himself, he/she usually sits back down in the chair but at times lost balance and fell . On 6/5/15 an intervention was placed to walk him/her to the bathroom and to the dining room for a snack. On 6/5/15 a revision was made to place him/her in daycare on the wing due to increased restlessness. On 7/5/15 and 7/6/15 and revision was made to educate new staff on him/her being left unattended on the toilet and with him/her being on the daycare wing. A nurse's note (NN) on 3/18/15 at 7:28 P.M. revealed a crash was heard in the living room area and the resident was leaning against the coffee table, he/she was assessed and placed back in the recliner. A NN on 4/18/15 at 10:27 P.M. revealed at 7:35 P.M. the resident was noted to be lying on his/her stomach with his/her head laying on his/her arm. He/she stated he/she needed to get up . The note revealed the fall was witnessed by a visitor who walked past and stated the resident stood up and when he/she went to sit back in the chair he/she missed the chair and sat on the floor and then laid down. There was not bruising noted and he/she denied pain. The note stated he/she had been restless all evening and had been standing up and down. Spouse and physician were notified. A NN dated 5/16/15 at 3:20 P.M. revealed that he/she was found on the floor in a prone position with his/her head resting on the floor. When the resident was asked if he/she fell the answer was no , when asked if he/she laid on the floor the answer was uh-huh. The resident denied pain and had a small reddened area to the left knee. Some light weakness was noted from the left arm. A NN dated 6/5/15 at 8:04 P.M. revealed staff left the living room area and when his/her back was turned he/she noted the resident to be on the floor next to a recliner. Resident was evaluated and assisted up to the recliner. A NN on 6/19/15 at 8:31 P.M. revealed the resident had been sitting in a chair and had gotten up and sat on the floor. Resident was assessed and assisted to a wheel chair and taken to the nurses ' station for one on one monitoring. A NN on 7/6/15 at 2:44 P.M. revealed the certified nurses assistant (CNA) notified the nurse that the resident was on the floor in the front bathroom. He/she had been taken into the bathroom and left unattended. The family and doctor were notified. A NN on 7/7/15 at 3:51 P.M. revealed a family member witnessed him/her sit down on the floor in the dining room. He/she had been seated at the first table in the dining room in a chair near the wall. He/she ambulated a few steps, became wobbly and sat down on the floor. The fall investigations for the fall on 3/18/15, 4/18/15, 5/16/15, 6/19/15, 7/5/15 and 7/6/15 did not address casual factors of the residents falls and how future falls would be prevented. On 7/29/15 at 9:15 A.M. he/she sat in a recliner in the living room with legs extended and slid down to the edge of the chair. Staff R asked the resident to push him/herself up in the chair, which he/she did with minimal assistance. On 7/29/15 at 11:30 A.M. direct care staff R and S transferred him/her with a gait belt and a stand pivot transfer to the wheelchair. The staff assisted him in to the bathroom and Staff R remained with him/her. Interview on 7/29/15 at 11:15 A.M. direct care staff Q revealed the resident required assistance with all activities of daily living including transferring, personal hygiene and toileting. Staff Q stated that the resident was not to be left unattended while in the bathroom or the dining room. Staff were to transfer him/her to a recliner in the day area so he/she could be monitored. Interview on 7/29/15 at 1:50 P.M. licensed staff H revealed that the resident required assistance with all of his/her activities of daily living. Staff H revealed that the resident was not to be left unattended while on the toilet or in the dining room and he/she would stand up on his/her own at times. Staff H revealed that if an intervention was placed after a fall that the CNA ' s are made aware of it by report and through email on the computer system when they log in. Staff H confirmed that staff should follow the care plan when it came to caring for this resident. Interview on 7/29/15 at 3:30 P.M. administrative nursing staff D revealed staff had been repeatedly reminded to follow the care plans. He/she confirmed that had the care plan been followed some of the falls could have been prevented and interventions needed to be appropriate for the fall. He/she also confirmed that the investigations did not assess for casual factors. The Fall Prevention and Management Policy and Procedure revealed that the purpose of the program was to identify residents at risk for falls, initiate preventative approaches, provide appropriate strategies and interventions directed towards the resident, environmental factors and staff monitor and evaluate resident outcome. The policy also stated the Fast Response Team will review incidents and update the care plan with appropriate interventions to reduce/prevent further incidents of falling. The facility failed to follow the care plan, failed to identify root cause of the falls and provide adequate supervision and appropriate interventions for this cognitively impaired resident with a history of falls.

The facility identified a census of 45 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to develop and implement timely, appropriate and effective interventions to prevent falls for 1 of 3 resident sampled for falls, who experienced 21 falls within 6 months, fell and sustained a subdural hematoma (collection of blood on the surface of the brain) and laceration which required emergency room treatment of [REDACTED].#1). Findings included: - Resident #1's [DIAGNOSES REDACTED]. The 1/28/14 Admission Minimum Data Set (MDS) recorded the resident with a Brief Interview for Mental Status (BIMS) score of 5, which indicated severely impaired cognition. The resident required limited assist with all activities of daily living (ADLs) except eating which was independent; balance was steady at all times, no limitation in range of motion, used a walker for ambulation, was always continent of bowel and bladder; had a fall in the last month and the last 2-6 months prior to admission/entry or re-entry; and 1 non-injury fall since admission/entry or reentry or prior assessment. The Care Area Assessment (CAA) dated 1/28/14 for cognitive loss/dementia recorded the resident had short term memory deficits. The resident was not supposed to get up on his/her own but did frequently. The CAA dated 1/28/14 for falls recorded the resident was at risk for falls due to his/her confusion and history of falls. He/she had a fall since admission to the facility but was not hurt. The fall risk assessments revealed a score of 25 on 6/9/14, 6/23/14 and 7/22/14. (16 and above indicated high risk) The Care Plan dated 4/9/14 recorded the resident was at risk for falls due to confusion and included interventions of walker for transfers, walking and locomotion; If new onset of falls, assess for lab abnormalities, signs and symptoms of infection and check vital signs; and observe for balance and mobility issues. The post fall assessments, CNA (certified nurse's aide) fall reports, nurses notes and care plan revealed the following incidents and interventions: 1/17/14 9:00 A.M. staff found the resident sitting on the floor in the living room; staff applied a personal alarm while in recliner or dining room chair and a motion alarm in place when in bed 1/20/14 no time recorded the resident slid onto floor from recliner; intervention personal alarm 3/1/14 2 AM staff observed the resident slide down the wall; intervention was for the resident to be in the living room when awake 3/5/14 no time recorded staff found the resident sitting on the floor pulling on the divider curtain, staff sat with resident 3/6/14 9 AM staff found the resident on the floor with his/her buttock in front of bed, the resident held his/her alarm that was sounding 3/10/14 1:15 AM staff found the resident walking in the hallways and he/she dropped to his/her knees; the resident had a recent medication and physician change, appointment made to check the resident's shunt 3/10/14 5:15 AM staff found the resident scooting forward in recliner onto footrest and tipped over; the resident had a recent medication and physician change, appointment made to check the resident's shunt 3/10/14 4:30 PM staff found the resident on the floor; the resident had a recent medication and physician change, appointment made to check the resident's shunt 3/14/14 9:35 AM staff found the resident on the floor in the living room; the intervention was the staff was having shunt checked for blockage with neuro surgeon 3/15/14 2:35 PM staff found the resident sitting up from a laying position on his/her left side; the intervention was the staff was having shunt checked for blockage with neuro surgeon 4/28/14 4:30 PM resident was on his/her knees beside the walker on the floor; intervention for contour mattress 5/17/14 4:45 AM staff found the resident sitting on the floor outside his/her bathroom; intervention frequent checks 5/21/14 3:40 PM staff found the resident sitting on his/her bathroom floor; intervention encourage resident to stay in living room while awake 5/25/14 10:40 PM staff observed the resident crawling on the floor in his/her room; intervention continue 15 minute checks 6/9/14 8:15 AM staff found the resident lying on the floor next to his/her bed; intervention was to continue the current plan of care 6/22/14 11:53 PM staff found the resident on the floor in his/her room; intervention was to offer activities 6/22/14 11:53 P.M. called to room: upon entering room observed resident lying on his/ her right side on floor with his/her head under the frame of the bed and beside stationary leg of the bed and large pool of blood under right arm, shoulder and head with an 8 cm laceration mid forehead to top of nose, bleeding profusely. 6/23/14 12:40 A.M. order received to transfer to the ER. 6/23/14 3:30 A.M. recorded the resident returned from the ER at this time with [DIAGNOSES REDACTED]. The Patient Visit Information from Mercy Regional Health Center dated 6/23/12 recorded the resident had [DIAGNOSES REDACTED]. The resident was seen in the emergency room for a forehead laceration following a fall. He/she also had a small bleed on his/her brain. Please continue to exercise serious fall precautions on this resident given his/her numerous frequent falls. Remove his/her sutures in 7 days. 6/23/14 no time recorded resident was on the floor; moved to room next to nurses station 6/27/13 3:05 PM the resident slid from a chair and fell to side and hit his/her head; intervention was to offer activities 6/30/14 6:49 AM staff found the resident lying on the floor; no reassessment to determine cause, continue current plan of care 7/2/14 3:55 AM staff found resident on the floor in his/her room; intervention was fall mat by the bed 7/3/14 5:25 AM staff found the resident on the floor; intervention was day care on dementia unit (resident spends the day on the dementia unit) 7/6/14 5:45 PM staff found resident getting up without assist and slid out of the chair; intervention larger recliner in the living room 7/10/14 5:40 A.M. staff found the resident on the floor in his/her room; no reassessment to determine cause, family consult to discuss his/her routines and ideas Observations on 7/23/14 on the unit revealed the following: 9 residents were on the unit throughout the day. 8:59 AM The resident sat at the dining room table. His/her glasses were on and clean. 10:07 AM The resident was on the unit, sleeping in a recliner. He/she attempted to get out of the recliner unassisted. Direct care staff C offered him/her a snack, which he/she accepted. 1 staff person on the unit at this time. 10:25 AM The resident sat at the dining room table with another resident and direct care staff C was doing a card activity. There was only 1 staff person on the unit at this time. 10:30 AM The resident attempted to stand from the table. Direct care staff C came from down the hall into the dining/living area and asked the resident to stay sitting for a few minutes as he/she was getting another resident up from bed. There was only 1 staff person on the unit at this time. 10:44 AM Direct care staff C came back to dining/living area told the resident he/she was almost done with the other resident in the bathroom and that he/she would be back in just a couple minutes. 12: 45 PM Direct care staff C assisted the resident with a gait belt and using his/her walker from the dining room into the bathroom then back to his/her recliner in the living room. There was only 1 staff person on the unit at this time. 1:40 PM The resident attempted to get out of his/her recliner, and direct care staff C asked the resident what he/she needed. Direct care staff C asked the resident to sit back until he/she took the other 2 residents to the bathroom. There was only 1 staff person on the unit at this time. 3:10 PM resident observed sitting in recliner on the unit. Noted an approximate 8 cm scar midline of his/her forehead. During an interview on 7/23/14 at 9:00 A.M. administrative nursing staff A stated the resident's room was on the main unit. He/she slept on the main unit because he/she was having a lot of falls and this way could be closer to the nurses' station. During the day the resident went to the dementia unit. During an interview on 7/23/14 at 1:32 PM, direct care staff D stated staff completed 15 minute checks on the resident, there were no alarms in the building any more, the resident had a low bed and used a walker. During an interview on 7/23/14 at 2:25 PM, direct care staff C stated he/she sat with the resident and talked at times, he/she needed toileted often, he/she would not stay in bed, we have no alarms in the building now. Direct care staff C stated he/she worked day and sometimes evening shift. He/she was the only staff person on the unit for 9 residents. He/she completed medication passes, passed trays for meals, got residents up and toileted them. During an interview on 7/23/14 at 2:03 P.M., licensed nursing staff H stated the resident was on 15 minute checks, had a fall mat, there were no alarms in the building, the resident could use the call light but usually forgot. The resident did have a fall from the bed when he/she received 8 sutures. During an interview on 7/23/14 at approximately 3:00 PM, administrative nursing staff B stated the resident had a low bed and now a fall mat. Staff did 15 minute checks on the resident and they moved him/her to a room right next to the nurses' station. The facility discontinued all alarms in the building on April 1st, but must not have removed them all from the care plans. Administrative nursing staff stated the staffing on the unit was 1 staff member on day and evening shift and a float when they call for help. On night shift, staff opened the doors to the unit and there are 2 aides and a nurse for the whole facility, depending on how the unit was doing. During an interview on 7/24/14 at 6:33 A.M., licensed nursing staff G stated the resident fell around shift change and received the laceration that required sutures and a subdural hematoma. We just cannot keep the resident in bed. He/she did not have a fall mat at the time of that fall. The resident is in a low bed and staff does 15 minute checks on all residents. During an interview on 7/24/14 at 4:20 P.M., direct care staff E stated he/she found Resident #1 the night he/she fell and went to the emergency room and received sutures. At the time of the fall there were no alarms used in the whole building. Only two certified nurse aides and 1 nurse were working in the entire facility. The undated facility policy and procedure for fall prevention and management recorded the fast response team would review the incident and update the care plan with appropriate interventions to reduce or prevent further incident and future incidents of falling. The facility failed to develop timely and appropriate interventions to prevent falls for this cognitively impaired resident with a history of multiple falls who fell and sustained a laceration requiring sutures.

The facility reported a census of 43 residents. The sample included 3 residents. Based on observation, interview and record review the facility failed to follow interventions as planned to prevent future falls for 1 (#10) of 3 residents, and failed to provide an environment free of potential accident hazards for 1 (#12) of 3 residents Findings included: - Review of the annual Minimum Data Set (MDS) 3.0 dated 6/29/14 for resident #10 revealed the Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. The resident was independent with acts of daily living and used a walker for mobility. The resident was continent of bladder and bowel, received scheduled pain medication and had 1 major injury fall since the last assessment. No therapies had been received. Review of the comprehensive plan of care dated 8/20/14 revealed the staff were to ensure the call light was within reach when the resident was unattended in his/her room, encourage the resident not to sit in his/her room mates chair, was independent to ambulate with his/her front wheeled walker, and staff replaced the bathroom door with a curtain. Review of the fall assessment completed 6/24/14 revealed a score of 11 which indicated a moderate risk for falls. Review of the fall investigation dated 8/12/14 at 12:45 P.M. revealed the resident ambulated from lunch and turned around to locate his/her roommate and lost his/her balance and fell . Review of the care plan dated 8/12/14 revealed the staff were to place a bell on his/her roommate's walker to let the resident know when the roommate was behind him/her, (so he/she would not have to turn around to make sure his/her roommate was following him/her). Review of the fall assessment completed 8/12/124 revealed a score of 12 which indicated a moderate risk for falls. Review of the fall investigation dated 8/20/14 at 10:00 A.M. revealed the resident fell in his/her bathroom while attempting to close the bathroom door. Review of the care plan dated 8/20/14 revealed staff were to replace the bathroom door with a privacy curtain. On 9/3/14 at 1:20 P.M. the resident sat in the recliner in his/her room and the roommate's walker lacked the bell as planned. Interview on 9/3/14 at 1:20 P.M. the resident stated the staff had not placed a bell on his/her roommate's walker. Interview on 9/3/14 at 2:36 P.M. direct care staff O stated there was not a bell on the roommate's walker. Interview on 9/3/14 at 4:26 P.M. the resident stated the staff had placed a bell on the roommate's walker this afternoon. Interview on 9/3/14 at 4:26 P.M. direct care staff P stated the bell was placed on the roommate's walker that day. Interview on 9/3/14 at 4:13 P.M. licensed staff H stated he/she was not aware of a bell on the roommate's walker. The care plans were updated by the director of nurses and the MDS coordinator. Interview on 9/3/14 at 4:58 P.M. administrative staff D stated he/she expected the interventions for fall prevention were completed. The facility failed to place a bell on the resident's roommate's walker as care planned for fall prevention. - Review of the admission Minimum Data Set (MDS) 3.0 dated 2/13/14 for resident #12 revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The resident was totally dependent for 2 person assistance for bed mobility and transfers, totally dependent for 1 person for toileting, required extensive assistance with one person assistance for dressing and personal hygiene, required limited assistance with locomotion off the unit. The resident used a wheelchair for mobility, the resident was frequently incontinent of bladder and bowel, had a fall within the last 2-6 months. Review of the quarterly MDS 3.0 dated 8/3/14 revealed a BIMS score of 5 which indicated severe cognitive impairment. The resident had disorganized thinking and inattentive behavior. The resident was totally dependent for 2 person assistance for toileting, extensive assistance with one person for bed mobility, transfers, dressing, personal hygiene, and locomotion off the unit. The resident used a wheelchair for mobility, the resident was frequently incontinent of bladder and bowel, had 2 non-injury falls, and 1 injury fall since last assessment. Review of the comprehensive care plan dated 8/25/14 revealed the staff were to monitor the resident every 15 minutes, may use a 1/4 side rail to aid in mobility, and the resident may use own bed due to history of a fall from the bed. Review of the Assistive Device assessment dated [DATE] revealed the resident did not require assistance for bed mobility, positioning or transfers, the resident demonstrated enough cognitive ability to be aware of the purpose of the positioning bar to use it appropriately, and it was to increase functional mobility. On 9/3/14 at 2:41 P.M. the resident sat in the wheelchair in the lobby area. On 9/3/14 at 4:26 P.M. the resident's bed had a side rail/transfer bar with a 7 ? inch by 17 ? inch opening and a lift chair with the remote on the seat of the chair. On 9/3/14 at 2:37 P.M. direct care staff O stated the resident had poor short term memory and the resident used the electronic control to raise and lower the lift chair and did not use the side rail/transfer bar. On 9/3/14 at 4:23 P.M. direct care staff P stated the staff used the sit to stand lift and did not use the transfer bar. The resident occasionally sat in the recliner in the room, and after all residents were in bed he/she started 15 minute checks on the resident. On 9/3/14 at 2:47 P.M. licensed staff I stated the resident required total assistance with toileting, dressing, transfer, and personal hygiene, used a sit to stand transfer lift with 2 staff, staff were only to assist the resident to the lift chair when family were with the resident, and the side rail/transfer bar was used occasionally. On 9/3/14 at 4:19 P.M. licensed staff H stated the staff were to do every 15 minute checks, the resident was provided the remote control for the lift chair, and the resident would use the side rail/transfer bar independently in bed. On 9/3/14 at 5:06 P.M. administrative nursing staff D stated the transfer bar assessment tool was completed prior to application, and the lift chair was provided by family. Review of the Bed Safety policy dated 2001 provided by the facility revealed the facility was to review the gaps within the bed system were to be within the dimensions established by the Federal Drug Administration (FDA). According to the FDA Guidelines dated March 2006, siderail spacing should be 4 3/4 inches by 4 3/4 inches or less to prevent entrapment of the head. The facility failed to provide a policy on lift chair assessments. The facility failed to assess for the use of the electric lift chair by this cognitively impaired and dependent resident and failed to ensure a safe environment regarding the side rail/transfer bar spacing.

The facility had a census of 53 residents. The sample included 4 residents, who had a history of [REDACTED].#1), who had multiple unsupervised falls with injuries that required hospitalization . Findings Included: - Resident #1's medical record revealed a Physician order [REDACTED]. The annual (MDS) Minimum Data Set 3.0 assessment, with (ARD) Assessment Reference Date 02/05/12, indicated the resident had short and long term memory problems with severely impaired decision making skills. The MDS indicated the resident had inattention, disorganized thinking, altered level of consciousness and verbal behaviors directed towards others. The MDS also indicated the resident required extensive assistance with transfers and ambulation. The MDS further indicated the resident had no history of falls. The 02/15/12 care plan indicated the resident had uncontrolled movements, agitation with behaviors and was very impulsive due to his/her [DIAGNOSES REDACTED]. The care plan directed 1 or 2 staff to use a gait belt to assist the resident with transfers and ambulation. The care plan also directed the staff to stay with and supervise the resident as necessary to ensure the resident's safety. The resident's agitation and behaviors had increased in the past 2 months and the following medications had been added to the resident's medication regimen: 1) Depakote 250 (mg) milligrams two times a day for behaviors as ordered by the physician on 02/09/12 2) Ativan 2 mg three times a day as needed for agitation as ordered by the physician on 03/17/12 3) Valium 10 mg every 6 -8 hours as needed for severe agitation as ordered by the physician on 03/19/12 4) Lamictal 50 mg two times a day for behaviors as ordered by the physician on 03/22/12 The 03/05/12 Fall Risk Assessment indicated the resident was a high risk for falls. The assessment also indicated the resident had intermittent confusion, received psychotropic medications and had a history of [REDACTED]. The 03/31/12 at 9:45 PM, nurse's note and 03/31/12 Fall Incident Report indicated the staff found the resident sitting on the floor in his/her room. The nurse's note indicated the resident had a 2 inch laceration on the center of his/her forehead. The nurse's note indicated the resident had no other injuries. The 04/02/12 at 8:00 PM, Nurse/Physician Communication indicated the resident had fallen at 12:20 PM, 2:00 PM, 4:30 PM and 6:50 PM. The communication indicated the resident had hit his/her head one time during a fall and neurological checks were initiated. review of the resident's medical record revealed [REDACTED]. The 04/04/12 at 10:31 AM, nurse's note indicated the staff found the resident on the floor in his/her room and no injuries were noted. The 04/04/12 Fall Incident Report indicated the staff found the resident on the floor in his/her room and no injuries were noted. The 04/06/12 at 6:34 PM, nurse's note indicated the resident had fallen at 8:30 AM, 12:00 PM and 2:50 PM. The clinical record lacked evidence of a resident assessment. The 04/06/12 at 8:30 AM, Fall Incident Report indicated the staff found the resident on the floor in his/her room and no injuries were noted. The 04/06/12 at 12:00 PM, Fall Incident Report indicated the staff found the resident on the floor between the bathroom door and his/her chair. The report indicated no injuries noted. The 04/06/12 at 2:50 PM, Fall Incident Report indicated the resident ambulated without assistance from his/her room and fell . The report indicated the resident had a red area on the right side of his/her head. The 04/07/12 at 11:53 PM, nurse's note indicated the resident fell at 4:30 PM while trying to use the bathroom and hit his/her head on the shower. The nurse's note also indicated the (CNAs) Certified Nurse Aides were instructed to frequently check on the resident. The nurse's note further indicated the resident was found on his/her hands and knees in the hallway at 6:15 PM. The 04/07/12 at 12:20 PM, Fall Incident Report indicated the staff found the resident on the floor in his/her room and no injuries were noted. The 04/07/12 at 2:00 PM, Fall Incident Report indicated the resident ambulated without assistance in the hall, returned to his/her room and was found sitting on the floor. The report indicated no injuries were noted. The 04/07/12 at 4:30 PM, Fall Incident Report indicated the resident had recently been administered a suppository and fell while trying to get to the bathroom. The report indicated a CNA witnessed the fall and the resident hit his/her head on the shower. The 04/08/12 at 10:57 PM, nurse's note indicated the staff found the resident on the floor in his/her room at 6:50 PM and was found on the floor in the doorway of his/her bathroom at 7:15 PM. The 04/08/12 at 7:00 AM, Fall Incident Report indicated the resident fell while ambulating without assist in the hall. The report indicated the resident hit his/her head on the floor and reopened a laceration on his/her forehead. The 04/08/12 at 6:50 PM, Fall Incident Report indicated the staff found the resident on the floor in his/her room and no injuries were noted. The 04/09/12 at 4:45 PM, nurse's note indicated the staff found the resident on the floor in his/her room at 9:15 AM. The nurse's note indicated the resident had a 0.5 (cm) centimeter laceration on the right side of his/her head and a bruise on the right hip. The nurse's note also indicated the staff found the resident on the floor in his/her room at 10:40 AM and no injuries were noted. The nurse's note further indicated the staff observed the resident ambulated without assistance in the hall and fell at 12:25 PM with no injuries noted. The 04/09/12 at 9:53 PM, nurse's note indicated the staff notified the resident's family at 8:10 PM of the resident's 4th and 5th falls today. The nurse's notes also indicated the resident had a possible head injury, decreased level of consciousness and possible aspiration pneumonia. The 04/10/12 at 1:09 AM, nurse's note indicated the staff found the resident on the floor with his/her head and back against the wall at 8:20 PM (10 minutes after notifying the resident's family of his/her 4th and 5th falls today and a possible head injury). The 04/09/12 at 9:15 AM, Fall Incident Report indicated the staff found the resident on the floor in his/her room and the resident had a laceration on the right side of his/her head. The 04/09/12 at 10:40 AM, Fall Incident Report indicated the staff found the resident on the floor in his/her room and the resident had an abrasion on top of his/her head. The 04/09/12 at 12:25 PM, Fall Incident Report indicated the staff observed the resident ambulated without assist and fell backwards onto buttocks and right side. The report indicated no injuries were noted. The 04/09/12 at 5:45 PM, Fall Incident Report indicated the staff found the resident sitting in his/her room with his/her head and back against the wall. The report indicated no injuries were noted. The 04/09/12 at 7:45 PM, Fall Incident Report indicated the staff found the resident on the floor in his/her room with his/her left side of the body and head against the wall. The report indicated no injuries were noted. The 04/09/12 at 8:20 PM, Fall Incident Report indicated the staff found the resident on the floor with the back of his/her head against the wall. The report indicated the resident had multiple abrasions on the back of his/her head and bruises on his/her right hip and elbow. This was the resident's 6th fall today and the 5th time the resident had hit his/her head during a fall today. As stated above, this fall happened 10 minutes after notifying the resident's family of his/her 5 previous falls today with a possible head injury and decreased level of consciousness. On 04/09/12 at 11:11 PM, the resident was admitted to the hospital with [REDACTED]. The 04/10/12 Hospital Admission Assessment nurse's notes indicated the facility reported the resident had fallen multiple times hitting his/her head the past several days. The nurse's note indicated the physician had ordered a Computed Tomography Scan (imaging study to detect inflammation and/or injury) of the resident's head due to multiple falls with head injury. The 04/10/12 Hospital Admission Assessment skin assessment indicated the following injuries: 1) left scapula - 12.5 cm by 3.0 cm bruise: purple, green, brown and yellow in color with multiple scabbed areas along the bruise 2) right hip - 19.0 cm by 3.5 cm bruise: purple, green and blue in color 3) right elbow to right humerus - 30.0 cm by 10.0 cm bruise: green, yellow and brown in color with red hard area on right humerus measuring 11.3 cm by 8.0 cm 4) right wrist - 5.0 cm by 7.0 cm: red in color with surrounding yellow, green, and brown bruising 5) right inner thigh - 7 circular bruises: brown/red in color 6) upper/center forehead - 6.4 cm by 4.2 cm bruise: yellow, purple and brown in color with two lacerations 2 cm and 3 cm 7) entire right knee (sides, below and above) - brown, yellow, green and red bruising 8) right shin - multiple small bruises 9) right ankle - 3.0 cm by 3.0 cm: red and brown color 10) entire left knee (sides, below and knee) bruise: red, brown, blue and purple in color 11) left upper thigh with 5 small circular bruises: red and brown in color 12) left hip - 5.4 cm by 3.5 cm bruise: yellow green and purple in color 13) left wrist - 2.1 cm by 2.8 cm bruise: red and brown in color Resident complains of discomfort with movement. review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. The many extensive and deep bruises, as reported above in the Hospital Admission Assessment, were not assessed by the staff after the resident's 20 falls. On 04/17/12 at 10:02 AM, Aide C stated the resident required a gait belt and 1 to 2 person assistance with transfers and ambulation. Aide C also stated the resident had a history of [REDACTED]. Aide C further stated the staff provided the resident with one on one supervision at times to prevent falls. On 4/17/12 at 10:15 AM, Aide D stated the resident required a gait belt and 1 to 2 person assistance with transfers and ambulation. Aide D stated the resident had agitation and behaviors at times and staff provided supervision as necessary to prevent falls. On 04/17/12 at 10:25 AM, Nurse F stated the resident required a gait belt and 1 to 2 person assistance with transfers and ambulation. Nurse F stated the resident had increased agitation with behaviors and multiple falls recently. Nurse F stated the nurses assessed, documented and monitored the resident for injuries after each fall. On 4/17/12 at 2:27 PM, Nurse G stated the resident had multiple falls due to his/her agitation and non-compliance with staff assistance. Nurse G stated all falls and followup assessments for injuries should be documented and monitored. Although the facility's nursing staff stated the nurses monitored, assessed and documented the resident after each fall, the facility failed to provide assessment documentation. The facility failed to provide adequate supervision to prevent falls for Resident #1, who sustained head lacerations, abrasions and decreased level of consciousness which required hospitalization . Upon hospitalization , the staff assessed the resident with numerous bruises in various stages throughout the resident's body.