Every finding on record at Winfield Rest Haven II, LLC

The facility reported a census of 40 residents with 14 residents selected for review which included three residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure staff secured one Resident (R)35 in the whirlpool bath chair which resulted in a fall from the chair onto the floor and R35 obtained a forehead laceration that required eight sutures in the emergency room . Findings included: - Review of Resident (R)35's medical record revealed diagnoses that included hemiplegia (paralysis of one side of the body) on the right dominant side, cerebral vascular accident (CVA/stroke, sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), seizure disorder (violent involuntary series of contractions of a group of muscles), agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and expressive aphasia (condition with disordered or absent language function). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS indicated the resident had no impairments in his upper or lower extremities. The ADL [Activity of Daily Living] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/25/24, documented the resident had functional limitations and weakness to his right upper and lower extremity and used a wheelchair. The resident required substantial assistance with transfers and bathing. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of five. The resident had one sided impairment of the upper extremity and was dependent on staff for transfers and bathing. The Care Plan, revised 08/01/24, instructed staff the resident was dependent of two staff for bathing/showering twice a week and as needed. The Care Plan revised 09/20/24, instructed staff the resident was dependent on one to two staff for bathing/showering twice a week and as needed. Staff instructed to place a safety belt on the resident if a bath was taken. The Fall Risk Evaluation dated 07/16/24, assessed the resident with decreased muscular coordination, intermittent confusion, and a total score of 13 (greater than 10 indicated a high risks for potential falls). Review of R35's medical record Fall Note revealed on 09/19/24 at 08:49 PM, the resident fell from the whirlpool bath chair when the CNA transferred the resident out of the whirlpool, without the safety belt on. The resident hit his head on the floor and sustained a laceration above his right eye and transported to the emergency room for evaluation. Review of the emergency room report, dated 09/19/24, revealed the laceration above the right eyebrow, required eight sutures. During an observation on 12/03/24 at 08:13 AM, Certified Nurse Aide (CNA) NN and CNA Q, provided morning care to the resident. The resident could not voluntarily move his right arm and exhibited weakness in his right leg. CNA NN and CNA Q transferred the resident with a mechanical lift from his bed into his wheelchair. CNA Q stated the resident was not able to stand to transfer. During an interview on 12/03/24 at 02:30PM, CNA O revealed staff provided extensive assistance for ADLs and utilized the mechanical lift to transfer the resident since he could not stand. During an interview on 12/03/24 at 03:28 PM, CNA MM revealed on 09/19/24 at approximately 08:00 PM, she provided a whirlpool bath to R352. CNA MM stated she did not apply the whirlpool bath chair safety belt to the resident and stood beside the resident as she transferred him out of the bathtub. CNA MM said while R35 was seated in the chair, he leaned forward and fell on to the floor, and sustained a laceration to his forehead. CNA MM stated prior to the R35's fall, she did not consistently use the safety belt on the whirlpool bath chair. CNA MM stated now the facility required all residents to wear the safety belt when taking a bath. During an interview on 12/03/24 at 03:40 PM, Administrative Nurse D revealed she expected staff to apply the safety belt on residents when utilizing the whirlpool bath chair, to keep residents safe. During an interview on 12/04/24 at 10:00 AM, Administrative Staff A stated the use of the safety belt was required for all residents who utilized the whirlpool bath chair, except for two residents who have refused to allow staff to apply the belt (R 35 was not one of the two who refused). Administrative Staff A stated she expected staff to ensure the resident was safe in the chair during the bath and when moving the resident in and out of the whirlpool to keep a hand on the resident. Administrative Staff A stated she provided instruction on safe bathing practice for staff to include holding firmly onto the resident when transferring in and out of the whirlpool and use of the safety belt for all residents. The facility policy Bath, Shower/Tub dated February 2018, instructed staff to assist the resident out of the tub or shower and hold firmly to the resident and move slowly. The policy lacked additional safety instructions. The facility failed to ensure staff used the safety belt for R35 during transfer out of the whirlpool bath, which resulted in a fall with a laceration and required eight sutures.

The facility reported a census of 40 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS), assessment for two of the 14 residents. Residents (R)35 had an inaccurate assessment regarding impairment in extremities, and R12 had an inaccurate assessment regarding the use of positioning bars as a restraint. Findings included: - Review of Resident (R)12's medical record revealed diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), osteoarthritis(degenerative changes to one or many joints characterized by swelling and pain), and ataxia (impaired ability to coordinate movement). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The resident used two bed rails daily and was marked as a restraint. The Physical Restraint Care Area assessment dated [DATE], assessed the resident used quarter rails on the bed to promote independence/participation with bed mobility, and documented the side rails did not prevent him from getting in and out of bed. The Care Plan dated 11/11/24, instructed staff the resident utilized the quarter rails to promote independence/participation with bed mobility and they did not prevent him from getting in and out of the bed. The Siderail Use assessment dated [DATE], documented the resident currently used the side rail for positioning or support. During an observation on 12/03/24 at 07:53 AM, the resident grabbed the positioning rail on the right side of the bed and pulled himself over with staff assistance. During an interview on 12/03/24 at 08:00 AM, CNA Q revealed the resident used the positioning bar for assisting staff to turn him in bed. CNA Q said the resident was able to grab the bar on the right and left side of the bed to turn. CNA Q said the resident did not try to get out of bed himself and the rail was not big enough to keep him in bed. During an interview on 12/03/24 at 02:49 PM, CNA O revealed the resident used the positioning rail to assist with turning himself from side to side. CNA O stated the resident did not try to get out of bed. During an interview on 12/04/24 at 11:30 AM, Administrative Staff A confirmed the side rail (positioning rail) was not used as a restraint and the MDS was incorrectly coded. The facility utilized the RAI (Resident Assessment Instrument) manual for MDS completion. The facility failed to ensure R12's use of the positioning rail was accurately coded as not a restraint on the MDS. - Review of Resident (R)35's medical record revealed diagnoses that included hemiplegia (paralysis of one side of the body) on the right dominant side, cerebral vascular accident (CVA/stroke, sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), seizure disorder (violent involuntary series of contractions of a group of muscles), agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and expressive aphasia (condition with disordered or absent language function). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS indicated the resident had no impairments in his upper or lower extremities. The ADL [Activity of Daily Living] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/25/24, documented the resident had functional limitations and weakness to his right upper and lower extremity and used a wheelchair. The resident required substantial assistance with transfers and bathing. The Quarterly MDS dated [DATE], assessed the resident with a BIMS score of five. The resident had one sided impairment of the upper extremity and was dependent on staff for transfers and bathing. The Care Plan, dated 01/22/24, instructed staff the resident was dependent of two staff for bathing/showering twice a week and as needed. The resident required use of a mechanical lift for transfers. During an observation on 12/03/24 at 08:13 AM, Certified Nurse Aide (CNA) NN and CNA Q, provided morning care to the resident. The resident could not voluntarily move his right arm and exhibited weakness in his right leg. CNA NN and CNA Q transferred the resident with a mechanical lift from his bed into his wheelchair. CNA Q stated the resident was not able to stand to transfer. During an interview on 12/03/24 at 02:30PM, CNA O revealed staff provided extensive assistance for ADLs and utilized the mechanical lift to transfer the resident since he could not stand. Interview, on 12/04/24 at 11:30 AM, with Administrative Staff A, revealed the resident could not actively move his right arm and used his left hand to feed himself. The resident had weakness in his right leg and could not stand or walk so staff utilized the mechanical lift for transfers. Interview, on 12/04/24 at 12:00 PM, with Consulting Staff GG, revealed she completed the MDS with use of staff assessments of the resident and did not physically see the resident to confirm the accuracy of the compilation of staff assessments. Consulting Staff GG confirmed the Admission MDS dated [DATE] assessed the resident with no limitations in his upper and lower extremities, but the ADL Functional/Rehabilitation Potential CAA indicated the resident had functional limitations and weakness to his right upper and lower extremities which made the MDS inaccurate. The facility utilized the RAI (Resident Assessment Instrument) manual for MDS completion. The facility failed to accurately assess R35's impairment in his upper extremity as required.

The facility reported a census of 40 residents. The sample of 14 residents included two residents reviewed for enhanced barrier precautions. Based on observation, interview, and record review the facility failed to review and/or revise care plans for two residents, Resident (R) 26 and R30 to include enhanced barrier precautions related to residents with catheters and nephrostomy tubes. Findings included: - Review of Resident (R) 26's Physician Orders, (PO) dated 11/21/24, included diagnoses of transient ischemic attack (TIA- TIA- temporary episode of inadequate blood supply to the brain), cerebral infarction (CVA/stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), morbid obesity (severely overweight), and incontinence with catheter use associated with terminal illness. The Significant Change in Status Minimum Data Set, (MDS), dated [DATE], documented the resident with the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. She had frequent incontinence of urine with an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The Quarterly MDS dated [DATE], documented the resident had a BIMS score of 14, which indicated no cognitive impairment. The resident required a urinary catheter. The Urinary Incontinence and Indwelling Care Area Assessment, (CAA), dated 07/29/24, documentation included the resident admitted to hospice services on 07/26/24 with diagnose of congestive heart failure, incontinent of bowel and bladder with indwelling catheter, had episode of extreme confusion with behaviors. She required staff assistance with her activities of daily living (ADLS). The Care Plan, dated 11/18/24, directed staff to know R26 had an indwelling foley Catheter related to incontinence of bladder and a terminal condition. The Care Plan lacked instruction to staff regarding the required use enhanced barrier precautions (EBP) and associated personal protective equipment (PPE) during the provision of care for a resident with an indwelling catheter to prevent cross contamination and the spread of infection. The Physician Order dated 11/21/24, included an 08/15/24 order for a 16 French (catheter size), foley catheter. On 12/03/24 at 10:12 AM, R26's door had an Enhanced Barrier Precaution (EBP) sign that directed staff in the use of required personal protective equipment (PPE-which included gowns), for the provision of direct care for residents with catheters. A container with (PPE) was located outside of the resident's room entrance. Administrative Nurse E entered R 26's room without applying the required isolation gown. Upon entering the room Certified Nurse Aide (CNA) P was present in the room bathing the resident. During the observation CNA P also handled the resident's catheter and initiated the removal of her catheter collection bag without the use of an isolation gown. Administrative Nurse E further assisted CNA P with bathing the resident, peri-care, and catheter care without the application of an isolation gown to prevent cross contamination and the spread of infection. On 12/03/24 at 10:25 AM CNA P identified the resident as requiring an indwelling catheter. She stated staff should follow the required application of PPE when providing direct care to residents with catheters. Appropriate enhanced barrier precautions included gowns when providing direct care to residents to prevent cross contamination and the spread of infection. She confirmed R 26's catheter leaked, and she should have applied an isolation gown prior to providing care to the resident to prevent cross contamination and the spread of infection. On 12/03/24 at 01:26 PM, Administrative Nurse E, confirmed the above findings. She stated the care plan provided the staff with guidance regarding the individual needs of the residents. Administrative Nurse E stated she and CNA P should have worn an isolation gown during R26's catheter care and personal hygiene to prevent cross contamination and the spread of infection. The facility policy Care Plans, Comprehensive Person-Centered dated 03/2022, documented a comprehensive person-centered care plan to meet the resident's physical, psychosocial and functional needs for each resident to include the right to receive services in keeping with person-centered care. The facility failed to review and/or revise care plans for (R)26 related to enhanced barrier precautions associated PPE provided for residents with catheters. 28560 - Review of Resident (R)30's medical record revealed diagnoses that included renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes) with dependence on dialysis (a procedure that removes excess fluid and waste from the blood when the kidneys are no longer functioning properly) and hydronephrosis (a condition that occurs when urine builds up in the kidneys causing them to swell and stretch). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The ADL [Activity of Daily Living] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/07/24, assessed the resident with chronic kidney disease and received hemodialysis and had hydronephrosis, which necessitated suprapubic (a tube placed through the skin and into the balder to drain urine from the bladder) and nephrostomy catheters (tubes that enter the kidneys from incisions through the skin to drain the build up of urine). The Care Plan reviewed 10/31/24, instructed staff the resident had a suprapubic catheter and bilateral nephrostomy catheters. The care plan lacked instruction for EBP (Enhanced Barrier Precautions). Observation, on 12/03/24 at 01:25 PM, revealed Certified Nurse Aide (CNA) Q, donned gloves, and a gown to empty the resident's suprapubic catheter and bilateral nephrostomy catheters. The resident's room door contained signage that the resident was on EBP with PPE (personal Protective Equipment) in a cabinet in the room. During an interview on 12/04/24 at 10:30 AM, Administrative Nurse D confirmed the resident was on EBP due to the presence of the suprapubic catheter and nephrostomy tubes. During an interview on 12/04/24 at 12:00 PM, Consulting Staff GG revealed the facility staff should indicate on the care plan if the resident was on EBP. The facility policy Care Plans, Comprehensive Person Centered revised March 2022, instructed staff to revise the care plan as information about the resident and resident condition changes. The facility failed to review and revise R30's care plan to include EBP as required.

The facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to ensure staff donned appropriate PPE (personal Protective Equipment) for three of five residents on enhanced barrier precautions (EBP, an intervention to reduce the transmission of infections during high contact care activities) to prevent the spread of infection. Residents (R)23, R29 and R26. Findings included: - Observation on 12/03/24 at 10:30 AM, revealed Licensed Nurse (LN) G provided Resident (R)29 PEG tube percutaneous enteral gastric tube (a feeding tube that passes through the skin and enter into the stomach to administer nutrition, fluids, medication) dressing change and administration of water. LN G donned gloves but did not don a gown to change the dressing or administer water through the PEG tube. The resident's room lacked signage for staff awareness of the need for PPE (Personal Protective Equipment) for Enhanced Barrier Precautions an intervention to reduce the transmission of infections during high contact care activities. Observation on 12/03/24 at 02:00 PM, revealed LN G provided wound care to R23. LN G donned gloves but did not don a gown. LN G leaned across the resident's bed and her clothing came in contact with the resident's bedding to access the resident's right heel. LN G stated the resident had a chronic wound to his right foot, but it was not open at this time and did not think EBP were necessary. During an interview on 12/04/24 at 11:59 AM, Administrative Nurse D confirmed R29 was on EBP for her PEG tube and R23 for his right heel wound (who had MRSA in the wound culture 02/20/24). Administrative Nurse D stated she expected staff to follow the EBP guidelines when providing high contact resident care. The facility policy Enhanced Barrier Precautions revised March 2024 instructed staff to don gloves and a gown prior to performing high contact resident care activity. The facility failed to ensure staff utilized EBP for the provision of high contact resident care for R29 and R23 to prevent the spread of infection to the residents of the facility. 36881 - Review of Resident (R)26's Physician Orders, (PO) dated 11/21/24, included diagnoses of transient ischemic attack (TIA- TIA- temporary episode of inadequate blood supply to the brain), cerebral infarction (CVA/stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), morbid obesity (severely overweight), and incontinence with catheter use associated with terminal illness. The Significant Change in Status Minimum Data Set, (MDS), dated [DATE], documented the resident with the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. She had frequent incontinence of urine with an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The Quarterly MDS dated [DATE], documented the resident had a BIMS score of 14, which indicated no cognitive impairment. The resident required a urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment, (CAA), dated 07/29/24, included the resident admitted to hospice services on 07/26/24 with a diagnosis of congestive heart failure, incontinence of bowel and bladder with indwelling catheter, and episodes of extreme confusion with behaviors. She required staff assistance with her activities of daily living (ADLS). The Care Plan, dated 11/18/24, directed staff to know R26 had an indwelling foley Catheter related to incontinence of bladder and a terminal condition. The Care Plan lacked instruction to staff regarding the required use of enhanced barrier precautions (EBP) and associated personal protective equipment (PPE) during the provision of care for a resident with an indwelling catheter to prevent cross contamination and the spread of infection. The Physician Order dated 11/21/24, included an 08/15/24 order for a 16 French (catheter size), foley catheter. On 12/03/24 at 10:12 AM, R26's door had an Enhanced Barrier Precaution (EBP) sign that directed staff in the use of required personal protective equipment (PPE-which included gowns), for the provision of direct care for residents with catheters. A container with (PPE) was located outside of the resident's room entrance. Administrative Nurse E entered R 26's room without applying the required isolation gown. Upon entering the room Certified Nurse Aide (CNA) P was present in the room bathing the resident. During the observation CNA P also handled the resident's catheter and initiated the removal of her catheter collection bag without the use of an isolation gown. Administrative Nurse E further assisted CNA P with bathing the resident, peri-care, and catheter care without the application of an isolation gown to prevent cross contamination and the spread of infection. On 12/03/24 at 10:25 AM CNA P identified the resident as requiring an indwelling catheter. She stated staff should follow the required application of PPE when providing direct care to residents with catheters. Appropriate enhanced barrier precautions included gowns when providing direct care to residents to prevent cross contamination and the spread of infection. She confirmed R 26's catheter leaked and she should have applied an isolation gown prior to providing care to the resident to prevent cross contamination and the spread of infection. On 12/03/24 at 01:26 PM, Administrative Nurse E, confirmed the above findings and stated the resident's catheter bag leaked urine and the resident was wet so she requested help from CNA P to change the resident and replace her catheter bag. Administrative Nurse E confirmed she failed to apply the required PPE when administering direct care to R26 with an indwelling catheter. Administrative Nurse E stated she and CNA P should have worn an isolation gown during R 26's catheter care to prevent cross contamination and the spread of infection. The facility policy Enhanced Barrier Precautions, dated 03/2024, included enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resistant care activities when contact precautions do not otherwise apply. High-contact resident care activities requiring the use of gowns include bathing, dressing, toileting, transferring, and device care or use of catheters. The facility failed to provide safe and sanitary care with the use of EBP to prevent cross contamination and the spread of infection for R26.

The facility reported a census of 40 residents with 14 residents sampled including five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor one Resident (R)35 for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms). Findings included: - Review of Resident (R)35's electronic medical record (EMR) revealed a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He received antipsychotic medication (drugs used to treat psychosis-related conditions and symptoms) on a routine basis during the assessment period. The Psychotropic Drug Care Area Assessment (CAA), dated 10/02/24, documented the resident had right side weakness due to a history of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of artery to the brain) and anxiety. The Quarterly MDS, dated [DATE], lacked assessment of the resident's cognitive status. He received antipsychotic medication on a routine basis during the assessment period. The Care Plan, revised 10/11/24, instructed staff the resident received antipsychotic medication and staff were to monitor the resident for possible side effects of the medication. Review of the resident's EMR revealed the following Physician Orders: Seroquel (an antipsychotic medication), 25 milligrams (mg), by mouth (PO), at hour of sleep (HS), for restlessness and agitation (characteristics of anxiety), ordered 06/20/24. The physician discontinued (DC'd) this order on 08/24/24. Seroquel, 50 mg, PO, every day for anxiety, ordered 06/20/24. The physician discontinued this order on 08/24/24. Seroquel 25 mg, PO, at HS, related to restlessness and agitation, ordered 08/24/24. Review of the resident's EMR revealed an Abnormal Involuntary Movement Scale (AIMS) assessment (a clinical outcome scale used to assess abnormal movements in people who take antipsychotic medications), dated 10/09/24, which indicated the resident had no involuntary movements. No other AIMS assessments were documented in the resident's EMR. Review of the resident's Medication Administration Record (MAR) from 06/20/24 through 12/03/24, revealed the resident received all scheduled doses of his medication. On 12/04/24 at 11:03 AM, Administrative Staff A stated the facility had not complete an AIMS assessment on the resident when the physician first ordered the antipsychotic medication in June, as they should have. The facility did complete the AIMS assessment in October. Administrative Staff A confirmed there were no other AIMS assessments completed for the resident and said the facility expected staff to complete the assessment at least every 90 days. The facility policy, Antipsychotic Medication Use, revised July 2022, included: An AIMS assessment will be completed upon the initiation of antipsychotic medications and then quarterly thereafter. The facility failed to complete the AIMS assessments for monitoring of adverse reactions for R35 who received antipsychotic medication.

The facility reported a census of 36 residents with 14 residents sampled. Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for the staff and residents of the facility, regarding the storage of supplies directly on the floor. Findings included: - During an environmental tour on 02/15/23 at 10:13 AM with Maintenance Staff U, revealed the following areas of concern: 1. One soiled workroom on A hall had one box of 50 face shields and two boxes of 75 disposable isolation gowns which rested directly on the floor. 2. The shower room on C hall had a shower corner which contained broken vinyl. 3. One supply closet on D hall had a closet which contained three cases (24 count) and one 12-pack of soda, which rested directly on the floor. On 02/15/23 at 10:13 AM, Housekeeping staff U stated supplies should not be stored directly on the floor. The facility policy for Receipt and Storage of Supplies and Equipment, revised November 2009, included: All supplies and equipment must be stored in accordance with the manufacturer's recommendations. The facility failed to provide a safe and sanitary environment for the staff and residents of the facility.

The facility reported a census of 36 residents with 14 residents sampled including two residents reviewed for accidents. Based on observation, interview and record review, the facility failed to follow fall interventions, which resulted in a non-injury fall for one Resident (R)30. Findings included: - The Physician Order Sheet (POS), dated 12/27/22, documented Resident (R)30 had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS), dated [DATE], lacked documentation of the resident's cognition. She required extensive assistance of two staff for bed mobility and total assistance of two staff for transfers. She had unsteady balance and was only able to stabilize with staff assistance. She had no falls since admission to the facility. The Falls Care Area Assessment (CAA), dated 04/19/22, documented the resident was non-ambulatory, had unsteady balance and used a wheelchair for mobility. Staff used a mechanical lift for transfers. The quarterly MDS, dated [DATE], lacked documentation of the resident's cognition. She required extensive assistance of two staff for bed mobility and total assistance of two staff for transfers. She had unsteady balance and was only able to stabilize with staff assistance. She had two non-injury falls since the prior assessment. The care plan for falls, revised 11/28/22, instructed staff to anticipate the resident's needs. Staff were to supervise the resident while in her wheelchair and not leave her unattended in her room while in her wheelchair and to ensure the resident had a fall mat on the floor next to her bed. Review of the resident's electronic medical record (EMR), revealed fall assessments completed on 01/06/23, 12/23/22, 11/29/22, 10/18/22, 09/06/22 and 07/13/22, which placed the resident at a high risk for falls. Review of a fall investigation, dated 12/22/22, revealed the resident had a fall in her room on 12/22/22. Staff had left the resident in her wheelchair, unattended, in her room when the resident attempted to get up from the wheelchair on her own to toilet herself and fell to the floor of the bathroom. The resident had no injuries from the fall. On 02/14/23 at 10:21 AM, Certified Medication Aide (CMA) S stated staff were not to leave the resident unattended in her wheelchair in her room because the resident had a history of falls. On 02/15/23 at 10:50 AM, Certified Nurse Aide (CNA) N stated staff were to transfer the resident to her bed or recliner when leaving her in her room due to the resident having a history of falls. On 02/14/23 at 07:30 AM, Licensed Nurse (LN) G stated the resident was not to be left unattended in her wheelchair while in her room because the resident would attempt to get up on her own. On 02/15/23 at 10:15 AM, Administrative staff A stated, staff were not to leave the resident unattended in her room while in her wheelchair due to the resident having a history of falls. On 12/22/22, the resident had a non-injury fall from her wheelchair when staff left her unattended in her room while still in her wheelchair. The facility policy for Falls and Fall Risk, Managing, revised march 2018, included: The staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk for falls. The facility failed to follow fall interventions, as care planned, to prevent a non-injury fall for this dependent resident with a history of falls and a diagnosis of Alzheimer's disease.

The facility reported a census of 36 residents with 14 residents sampled including one resident reviewed for respiratory. Based on observation, interview and record review, the facility failed to obtain an order for oxygen for one Resident (R)5, who required as needed (PRN)oxygen usage. Findings included: - Review of Resident (R)5's electronic medical record (EMR), revealed a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She did not use oxygen while a resident. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 11/08/22, documented the resident was generally independent with bed mobility, transfers and ambulation. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 12, indicating moderately impaired cognition. She did not use oxygen while a resident. The care plan, revised 02/09/23, lacked staff instruction for the use of oxygen. Review of the resident's EMR revealed no documentation of the resident requiring the use of oxygen due to shortness of breath (SOB) on the night of 02/12/23. The EMR also lacked documentation of the standing order being initiated for the use of oxygen. Review of the facility's standing orders, included: Oxygen at two liters (L), via nasal cannula (NC), as needed (PRN), for respiratory distress. On 02/13/23 at 01:54 PM, the resident sat up in her recliner visiting with a visitor while in her room. The resident had no evidence of SOB. The oxygen concentrator sat next to her recliner, turned off. On 02/14/23 at 09:37 AM, the resident sat in her wheelchair in her room while having her fingernails painted. The resident had no evidence of SOB. The oxygen concentrator sat in the resident's room, turned off. On 02/13/23 at 01:54 PM, the resident stated through the night she had felt very SOB and the staff had to give her oxygen. The resident stated she had worn the oxygen throughout the night but had not required the oxygen since getting up for the day. On 02/15/23 at 08:25 AM, Certified Nurse Aide (CNA) M stated the resident had an oxygen concentrator in her room and she would use the oxygen from time to time. On 02/15/23 at 08:29 AM, Certified Medication Aide (CMA) R stated the resident required the oxygen during the night of 02/12/23 due to her oxygen level dropping. Staff had not removed the oxygen concentrator from her room since that time. On 02/15/23 at 10:30 AM, Licensed Nurse (LN) H stated staff would need to initiate an order for oxygen from the standing orders when a resident required the use of oxygen. On 02/15/23 at 10:15 AM, Administrative Staff A stated the nurse would be able to initiate oxygen from the standing orders, but would need to write the order out, add it to the resident's orders and have it signed by the physician. Administrative Staff A confirmed the oxygen order had not been initiated from the standing orders and sent for the physician's signature. The facility policy for Oxygen Administration, revised October 2010, included: Staff should verify that there is a physician's order for the use of oxygen. The facility failed to obtain an order for the use of oxygen for this resident.

The facility reported a census of 36 residents with 14 residents sampled, including one resident reviewed for notification of change. Based on observation, interview and record review, the facility failed to notify the physician of a change of condition for one Resident (R)5, regarding the need for the implementation of oxygen. Findings included: - Review of Resident (R)5's electronic medical record (EMR), revealed a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She did not use oxygen while a resident. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 11/08/22, documented the resident was generally independent with bed mobility, transfers and ambulation. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 12, indicating moderately impaired cognition. She did not use oxygen while a resident. The care plan, revised 02/09/23, lacked staff instruction for the use of oxygen. Review of the resident's EMR revealed no documentation of the resident requiring the use of oxygen due to shortness of breath (SOB) on the night of 02/12/23. The EMR also lacked documentation of the resident's physician being notified of the resident's change in condition which required the initiation of oxygen. Review of the facility's standing orders, included: Oxygen at two liters (L), via nasal cannula (NC), as needed (PRN), for respiratory distress. On 02/13/23 at 01:54 PM, the resident sat up in her recliner visiting with a visitor while in her room. The resident had no evidence of SOB. The oxygen concentrator sat next to her recliner, turned off. On 02/14/23 at 09:37 AM, the resident sat in her wheelchair in her room while having her fingernails painted. The resident had no evidence of SOB. The oxygen concentrator sat in the resident's room, turned off. On 02/13/23 at 01:54 PM, the resident stated through the night she had felt very SOB and the staff had to give her oxygen. The resident stated she had worn the oxygen throughout the night but had not required the oxygen since getting up for the day. On 02/15/23 at 10:30 AM, Licensed Nurse (LN) H stated staff would need to initiate an order for oxygen from the standing orders when a resident required the use of oxygen. The physician would need to be notified of the need to initiate oxygen. On 02/15/23 at 10:15 AM, Administrative Staff A stated the nurse would be able to initiate oxygen from the standing orders and would need to notify the physician of the change of condition which required the initiation of oxygen. The facility lacked a policy for physician notification of change of condition. The facility failed to notify the physician of this resident's change of condition.

The facility reported a census of 36 residents with 14 residents sampled including one resident reviewed for hospice care. Based on observation, interview and record review, the facility failed to ensure Resident (R)30's medical record contained an order for hospice care, following admission to the facility. Findings included: - The Physician Order Sheet (POS), dated 12/27/22, documented Resident (R)30 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and adult failure to thrive (a decline in older adults with multiple chronic medical conditions). The admission Minimum Data Set (MDS), dated [DATE], lacked documentation of the resident's cognition. She required extensive assistance of two staff for bed mobility, locomotion on the unit, dressing and personal hygiene. The resident received hospice services while a resident. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/19/22, documented the resident was on hospice and had a diagnosis of Alzheimer's disease. The quarterly MDS, dated [DATE], lacked documentation of the resident's cognition. She required extensive assistance of two staff for bed mobility, dressing and toilet use. The resident received hospice services while a resident. The care plan for hospice, revised 01/26/23, instructed staff the resident was receiving services from hospice care. On 02/13/23 at 03:32 PM, the resident rested in bed with her eyes closed. No evidence of pain or discomfort. On 02/14/23 at 10:18 AM, the resident rested in bed with her eyes closed. No evidence of pain or discomfort. On 02/14/23 at 10:21 AM, Certified Medication Aide (CMA), S stated the resident received hospice care. Hospice supplied some of the resident's medications. On 02/15/23 at 10:50 AM, Certified Nurse Aide (CNA) N stated the resident received hospice care. On 02/14/23 at 07:30 AM, Licensed Nurse (LN) G stated the resident was on hospice at the time of her admission to the facility. On 02/15/23 at 09:50 AM, Administration staff A stated the resident was on hospice at the time of her admission to the facility. Administration staff A confirmed the resident's medical record lacked an order for hospice. The facility policy for Hospice Program, revised July 2017, included: It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. The facility failed to have an order for hospice in the resident's medical record for this dependent resident receiving hospice care.

The facility reported a census of 20 residents which included three residents sampled for appropriate and timely notification of the termination of all Medicare Part A services for coverage reasons. The facility failed to provide the NOMNC (Notification of Medicare Non-Coverage) when all covered services ended for coverage reasons for residents (R)18, R 71, and R 72. The facility failed to issue SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice), which must be issued to inform the beneficiary of potential liability for the non-covered stay) in a timely manner, for two residents, that remained in the facility in a non-covered stay R 18 and R 71. Furthermore, the facility failed to submit a claim for appeal of decision of non-coverage to Medicare A upon request of R 71. Findings included: 1. Resident (R)18's last covered day (LCD) of Medicare part A services was 02/23/21. The resident remained in the facility. The SNF ABN, (Skilled Nursing Facility Advance Beneficiary Notice) Form CMS- provided to the resident, signed on 02/03/21, two days after the LCD, verses two days prior to the termination of Medicare A services. Additionally, the NOMNC (Notice of Medicare Non-Coverage) Form CMS 123, was not provided to the resident that remained in the facility, for notification of termination of Medicare A benefits due to noncovered services, as required. Furthermore, the SNF ABN, Form CMS- provided to the resident and signed on 02/25/21, 2 days after LCD. The resident selected Option one (demand Submission request) and chose to continue therapy. The facility lacked evidence of submitting a demand bill to Medicare A for determination as requested by the resident. 2. Resident 71's last covered day (LCD) of Medicare part A services was 02/01/21. The resident remained in the facility. The SNF ABN, Form CMS- provided to resident, signed on 02/03/21, two days after the LCD verses two days prior to the termination of Medicare A services. Additionally, the NOMNC (CMS 123) was not provided to the resident that remained in the facility, for notification of termination of Medicare A benefits due to noncovered services, as required. 3. Resident 72's LCD of part A services was 02/11/21. She discharged Home. The NOMNC (CMS 123) was not provided to the resident that remained in the facility, for notification of termination of Medicare A benefits due to noncovered services, as required. On 08/25/21 at 02:11PM, Administrative A verified the discrepancies as noted above. She stated she had addressed the issue with Advanced Beneficiary Notices and the time frame reviewed was not during her tenure. She reported the demand submission was not done and agreed option one would indicate a need for a demand submission to Medicare A for a determination of continued coverage. The undated facility policy Medicare Denial Notices (Advanced Benefit Notification-ABN), documented the facility will provide written notification to residents with necessary information to decide whether to appeal a decision to terminate Medicare care and services at least three days prior to the planned change in payor status or discharge. (appeal: a formal request by a resident or responsible party for reconsideration of a coverage decision for skilled healthcare and services and medical benefits. The denial letter will be provided to the resident and/or responsible party no later than three calendar days prior to the planned discharge. The denial letter will contain both CMS Form and CMS . The facility failed to provide the NOMNC when all covered services ended for coverage reasons and failed to issue SNFABN (which must be issued to inform the beneficiary of potential liability for the non-covered stay) in a timely manner. Furthermore, the facility failed to submit a claim/appeal to Medicare A as requested for the residents of the facility.

The facility reported a census of 22 residents. Based on interview, the facility failed to designate one or more individuals as the infection preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) and who had completed the specialized training in infection prevention and control. Findings included: - On 11/16/20 at 10:30 Administrative Staff Nurse D revealed that she was responsible for the Infection Prevention and Control Program (IPCP), and she lacked certification as an Infection Preventionist (IP). Furthermore, she revealed the facility lacked a certified IP. The facility policy Antibiotic Stewardship Program, dated, 10/31/18, included the IP would be responsible for infection surveillance and multi-drug resistant organism (MDRO) tracking. The facility failed to designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program (IPCP) and who had completed the specialized training in infection prevention and control, as required.

The facility reported a census of 22 residents. Based on record review and interview, the facility quality assessment and assurance committee failed to meet at least on a quarterly basis and as needed to identify issues with respect to which quality assessment and assurance activities are necessary. Findings included: - On 11/17/20 at 01:40 PM, Administrative Nurse D revealed that the facility had not had any QA meetings since April of 2020. The facility policy Quality Assurance Performance Improvement Policy (QAPI)/(QAA), dated 07/25/19, included that the facility will ensure that all staff will consistently develop processes and systems to provide safe, effective, and optimal care and services to each elder residing at or receiving services from the facility and all staff, family members, visitors, vendors, volunteers will benefit from optimal processes and systems to facilitate elder care and services. The QAPI committee will meet at least monthly and Medical Director will attend the meeting in person at least quarterly. The facility quality assessment and assurance committee failed to meet at least on a quarterly basis, as required to ensure identification of deficient practice and to develop corrective action.

The facility reported a census of 22 residents. Based on interview and record review, the facility failed to consistently utilize an antibiotic stewardship program that included tracking and monitoring of antibiotic use for the residents of the facility. Findings included: - The facility lacked infection control tracking logs for the month of October and November of 2020. On 11/17/20 at 12:47 PM, Administrative Nurse D confirmed that the infection control logs were incomplete for October, 2020 and November 2020 for the residents. Furthermore, she revealed she was not aware the assigned facility staff were not completing the logs. The facility policy Antibiotic Stewardship Program, dated 10/31/18, included that it was the policy of the facility to implement an antibiotic stewardship program which will promote appropriate use of antibiotics while optimizing the treatment of [REDACTED]. The infection preventionist (IP) will be responsible for infection surveillance and multi drug resistant organism (MDRO) tracking and will collect and review data. The IP will review and report antibiotic usage data including numbers of antibiotic prescribed and the number of residents treated each month. The facility failed to consistently utilize an antibiotic stewardship program that included tracking and monitoring of antibiotic use for the residents of the facility.

The facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to follow the Center for Medicare and Medicaid Services (CMS) and Center for Disease Control and Prevention (CDC) recommended practices to prevent transmission of COVID-19. The facility failed to provide a face mask to four residents, Resident (R) 1, R2, R5, and R6, prior to staff providing direct cares per facility policy. The failure to provide the residents masks or facial covering during cares increased the risk of transmission of the pandemic COVID-19 virus to all of the residents of the facility. Findings included: - Observation on 06/17/2020 at 02:57 PM, upon entering the resident's room, there were already two staff members assisting R2 to transfer to the bed. The resident did not have on a mask. The resident's mask was on the bedside table. Staff provided personal care and laid the resident down in the bed. Observation on 06/17/2020 at 03:10 PM revealed Certified Nurse Aide (CNA) R and CNA P assisted R 5 to transfer from her recliner into the bathroom. Staff failed to apply a face mask on the resident. Observation on 06/17/2020 at 05:08 PM revealed CNA S and CNA P were in R 6's room. The resident used the commode. The resident did not have on a face mask. Observation on 06/17/2020 at 5:54 PM revealed CNA S and CNA P went into R 1's room. They provided cares to the resident, by checking brief and repositioning without placing a mask on the resident. On 06/17/2020 at 09:32 AM, Certified Nurse Aide (CNA) M and N reported when a resident received cares the residents should wear a facemask. On 06/17/2020 at 10:36 AM, Administrative Nurse C reported when quarantined, the residents remained in their rooms. Staff should always wear a face mask. When the staff provided cares to the resident, the resident would also wear a face mask. On 06/17/2020 at 11:41 AM, Licensed Nurse (LN) G reported all residents should wear a face mask when staff provided cares for them. On 06/17/2020 at 01:58 PM, CNA O reported, staff have to place a mask on the resident anytime they provided care in the resident's room. On 06/17/2020 at 05:16 PM, CNA P reported when staff entered R 2's room, the resident did not have a face mask on. Staff forgot to apply the resident's face mask with cares. CNA P verified staff failed to apply the face mask for R5 and R6. CNA P further reported staff sometimes forget to apply the resident's masks while staff provided cares and were aware residents should wear face masks when staff provided cares. On 06/17/2020 at 05:22 PM, Administrative Nurse B, reported she expected all staff to place a mask on the resident prior to do any and all cares. The facility policy (Facility Name), not dated, but signed, directed staff that face masks shall always be worn by the staff while in the facility. Resident's will wear masks when out of their rooms and will cover their face with a mask and/or tissue when staff are in their room providing cares. When staff perform resident care, the resident will have a mask in place, unless not appropriate such as oral care and having a meal. The facility failed to properly offer and/or place a face mask or tissue on the four residents prior to provision of cares. This deficient practice had the potential to affect all residents of the facility for the transmission of the COVID-19 virus.

The facility reported a census of 35 residents. The sample included three for review of abuse. Based on observation, interview and record review, the facility failed to prevent physical abuse to one Resident (R) 1, of the three sampled residents, by a night shift certified nurse aide. On 02/05/2020 at 09:55 PM, Certified Nurse Aide (CNA) D pushed an ice chest cart into R1's wheelchair and right foot with enough force to turn the resident's wheelchair around 90 degrees. Findings included: - The electronic medical record evidenced the facility admitted Resident (R) 1, on 10/03/2016. The primary care physician listed [DIAGNOSES REDACTED].) The Minimum Data Set (MDS) significant change assessment, dated 10/16/19 scored the resident, at 05/15 on the Basic Interview for Mental Status (BIMS), which indicated she had severe cognitive impairment. The Care Area Assessment (CAA), dated 10/16/19 for cognition included, the resident had a BIMs score of 5 with [DIAGNOSES REDACTED]. The assessment for activity of daily living included, the resident had muscle weakness and difficulty in walking for therapy. The resident was recently requiring more assistance from staff. The Care Plan dated 4/22/19, included the resident was at risk for wandering as evidenced by high risk for wandering on Wander Risk Assessment (3/12/19). When the resident was exit seeking and wandering, staff were to provide 1:1 with the resident or staff could set-up the resident with activities. The resident has an activities of daily living (ADL) self-care performance deficit related to the dementia, and impaired balance. The resident used a wheelchair for long distance travel and when experiencing weakness. On 02/12/2020 at 11:30 AM, R1 moved about the facility in her wheelchair without need for assistance. She could not remember or express any information related to the abuse incident with the staff member. On 02/12/2020 at 11:30 AM, Administrative Nurse B explained that on 02/07/2020, a staff member reported an unrelated incident which caused the administrative staff to review the hallway video, dated 02/05/2020, on the night shift. At that time, the administrative staff became aware of the abuse to R1 by a night shift certified nurse aide. The resident did not experience any injury. The review of the observed video at that time occurred as described below: On 02/05/2020 at 9:55 PM, R1 moved about the facility foyer in her wheelchair. The resident then proceeded to move over to the south side of the nurse's station blocking the hall's area between the nurse's station and the copy machine. Certified Nurse Aide (CNA) D pushed an ice chest roller cart, from the hall to the hall's opening, stopped and asked R1 to move. The resident failed to move. Instead the resident then raised her right foot up to block the cart from being moved past her. At that time, CNA D pushed the cart into the resident's wheelchair and the right foot making the wheelchair immediately make a 90 degree turn to the left. The CNA then proceeded and moved past the resident with the cart. The resident continued to follow the CNA down another hall and said, Call the police, Call the police. The CNA then told R1, from 1/2 down the hall away from the resident to, Be quiet, go back up front, residents are sleeping. Then the CNA stated, I don't need to mind you. Shu fly. The resident then backed her wheelchair up to the start of the hallway and another CNA assisted the resident to the nurse's desk area. On 02/12/2020 at 12:30 P.M., Administrative Nurse B verified she and Administrative staff A called CNA D to the facility, on 02/07/2020, interviewed and then terminated her. They notified the police, the medical director, the resident's physician, and family. They also reported the incident to the state hot line and started an investigation. They immediately started to retrain staff on abuse. The administrative nursing staff completed skin assessments on all residents with impaired cognition. No bruising, redness or injuries were noted to any of the residents. The facility policy, reviewed and dated 10/13/2017, included that employees, residents, physicians consultants, volunteers, family members, legal guardians, friends, or other individuals do not have the right to administer abuse, corporal punishment and involuntary seclusion to any resident in the facility. Any act of abuse or neglect can result in immediate termination, legal action and potential loss of license or certification. The facility failed to ensure no physical abuse to this cognitively impaired dependent resident, when the staff member pushed the resident's wheelchair with enough force to move the resident in the wheelchair 90 degrees, out of the staff member's way with an ice chest cart.

The facility reported a census of 35 residents. Based on observation, interview, and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility reported the Licensed Administrator worked forty hours per week, but was not physically in the building. Findings Included: - Review of a complaint to the federal regulatory agency alleged the facility was not reporting the licensed administrator's hours accurately on the PB[NAME] An auditing company notified the facility on 11/27/19 the payroll and timecard details would be reviewed for the time frame of 7/1/19-9/30/19. The auditing company chose two of the largest, consecutive pay periods based on PBJ hours the facility submitted to determine if the facility reported paid and allowable hours as required for PB[NAME] The Audit sampled nine employees which included Administrative Staff A, 2 registered nurses (RNs), two licensed practical nurses (LPNs), and four certified nurse's aides (CNA's), all with the highest hours of the two consecutive pay periods. The audit revealed the process used to verify Administrative Staff A was in the facility 40 hours per week included. Based on the time sheet detail, the audit revealed that the only staff member that did not utilize the time clock was Administrative Staff [NAME] The interviews of staff provided by the audit company were as follows: Interview on 01/03/20 at 11:30 AM Administrative Staff A revealed that he was working on a college degree and was not in the building two days per week, but was available by phone 24 hours a day, 7 days a week during the review time. He revealed he was unsure if he had a written agreement/contract for these hours. Staff A revealed his schedule was 6:30 AM - 3:30 PM and the typical work schedule was Monday - Friday 9 AM- 5:30 PM. Staff revealed he was not aware that only hours worked onsite were to be submitted into PB[NAME] Interview on 01/03/20 at 2:20 PM with unidentified staff F revealed that he/she worked 40 hours per week onsite and clocked in and out. Staff F revealed he/she occasionally worked on weekends and worked less than 40 hours per week. Staff F revealed the board of directors for the facility told Staff A that he had to work on weekends in (MONTH) 2019 since he was only working 3 days per week. Staff F revealed that Staff A was never there on Saturdays and was only in the facility on Sunday from 2 PM-5 PM to attend church. Staff F revealed that another staff member had been instructed to put Staff A on the PBJ system for 8-hour days, 5 days a week. Staff F revealed that a normal work week for Staff A was Monday 7 AM-10 AM, Tuesday 7:30 AM-12:15 PM, Wednesday 7 AM-12 PM, and was not in the facility on Thursday or Fridays. Interview on 1/3/2020, no time given, with unidentified staff G revealed he/she was an hourly employee at the facility, clocked in and out, and worked 8 hours per day. Staff G revealed that Staff A was not in the facility 8 hours on Mondays or Tuesdays, worked from 2 PM-5 PM on Sundays and was never in the building on Saturdays. Staff G further revealed Staff A had not been in the facility on Thursday or Friday since (MONTH) of 2019. Staff G was aware that the hours for Staff A were being reported as 8 hours a day, 5 days a week onsite. An undated and untimed interview with Staff H revealed that he/she clocked in and out and worked in the facility 5 days a week. Staff H revealed that Staff A was in the facility on the weekends when he/she was working. An interview on 011/07/20 at 4:45 PM with Staff I revealed that he/she clocked in and out and worked every other weekend. He/she was unaware if Staff A was in the facility on the weekends for 8 hours and had only seen him at church one time. Review of a Timecard Report for Staff A verified from 4/10/19-4/30/19 and from 7/1/19-9/30/19 there were no valid punches in the time clock system. Observation on 02/02/2020 (Sunday) at 10:15 AM revealed staffing of an RN, one certified medication aide (CMA), four CNAs and one housekeeping/laundry staff on duty. Staff A was not in the building. An interview on 02/02/20 at 10:20 AM with Dietary Staff BB reported she worked every other weekend in the facility. She reported that Staff A was not in the facility at time of the interview. Staff BB further verified Staff A was in the facility two weeks ago for approximately 5 minutes. Staff BB revealed that recently Staff A had been in the facility Monday -Friday as he finished his schooling. Interview on 02/02/20 at 10:50 AM with Administrative Nurse [NAME] revealed that Staff A had not been in the facility full time since he started his continuing education in (MONTH) 2019. She revealed Staff A had Staff X input his time on the PBJ at 8 hours, 5 days a week, onsite, even after he finished the education on 01/10/2020. Staff [NAME] revealed the second week of (MONTH) 2020, staff A was in the facility all day on Monday and Wednesday, and half days on Thursday and Friday. Administrative Nurse [NAME] revealed that Staff A did not clock in and told the auditing company that the clock didn't recognize his handprint and could not clock in that week. Staff A was not clocking in. Administrative Nurse [NAME] stated she did not feel the governing body was aware of Staff A's lack of hours in the facility nor the falsification of the hours submitted to the PB[NAME] Staff [NAME] revealed she had concerns of Staff A not being in the facility when needed. She revealed that Staff A was not in the facility when the State Agency survey team was in the building in (MONTH) 2019. She revealed that Staff A came the second day of survey and chose to not be present at the findings meeting with the survey team. Nurse [NAME] further revealed she called him on several occasions related to resident or staff incidents and he failed to return the call for 3 to 4 hours, thus delaying decision making regarding these incidents. Interview on 02/02/20 at 2:00 PM Administrative Assistant Staff Y revealed she received instruction to enter 40 hours per week into the time system for Staff A, who was salary based. Staff Y revealed that she began doing this on 07/01/2019. Staff Y confirmed all other facility staff used the time clock for time keeping records. On 1/10/20 Staff Z notified Staff Y that going forward Staff A would be entering his time on the time clock and that it would be used for the PBJ information. The facility's undated Compensation procedure revealed that all non-exempt employees are required to use the timekeeping system to record their hours worked and required to clock in and out for time off and other leave tracking purposes. The facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility reported the Licensed Administrator worked forty hours per week, but was not physically in the building.

The facility reported a census of 33 residents, with 14 residents reviewed. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for one Resident (R) 22 of the 14 sampled residents, for assessments before and after [MEDICAL TREATMENT] services. Findings included: - Review of the Physician order [REDACTED]. The annual Minimum Data Set, (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. She was independent with bed mobility, transfers, locomotion, transfers, eating, toileting, and personal hygiene. She was steady moving on and off the toilet, and with surface to surface transfers. She had both lower extremities impaired used a wheelchair and was always continent of bowel and bladder. She received special treatment of [REDACTED]. The Activities of Daily Living (ADL) CAA (Care Area Assessment), dated 05/01/19, documented the resident needed a little more assistance due to decrease in vision. The resident would be assisted/supervised with ADLs. The quarterly MDS, dated [DATE], documented R22 with a BIMS of 15, and was currently on [MEDICAL TREATMENT]. The care plan for end stage [MEDICAL CONDITION], dated 11/08/19, documented the resident required [MEDICAL TREATMENT] three times a week. Nursing were to check for bruit and thrill (vibrations felt/heard to ensure blood pumped and not clotted) every shift. (left lower extremity). She was to be transported to [MEDICAL TREATMENT] per facility staff on Tuesday, Thursday and Saturday to arrive at 07:00 AM, and pick up afterwards at approximately 11:00 AM. [MEDICAL TREATMENT] staff to provide blood pressures prior to and after [MEDICAL TREATMENT]. The resident's care plan lacked comprehensive instructions for conducting adequate assessments before and after the resident's [MEDICAL TREATMENT] services. The PO dated 11/13/19, ordered on [DATE], to continue [MEDICAL TREATMENT] care on Tuesday, Thursday and Saturday's. On 12/10/19 at 11:54 AM, R22 returned from [MEDICAL TREATMENT]. Continued observations of the resident until 02:50 PM, revealed the staff failed to complete an assessment to the resident's fistula or obtain vital signs On 12/10/19 at 02:50 PM, Licensed Nurse (LN) H, confirmed she did not get vital signs or check R22's fistula upon the resident's return from [MEDICAL TREATMENT]. She stated the orders stated to only check every shift and that she usually checked the resident's fistula before she left for [MEDICAL TREATMENT] and so it would not get checked again until on the second shift. On 12/10/19 at 02:44 PM, LN H explained that this resident had an order to do checks for bruit and thrill to the port in her thigh. She had this ordered every shift and LN H checked it this morning before she went to [MEDICAL TREATMENT] and because nurses do 12-hour shift, this gets checked twice daily. LN H further explained she did not check it since the resident returned from [MEDICAL TREATMENT] as she already checked it this morning. There was not an assessment completed after the resident returned to facility from [MEDICAL TREATMENT]. On 12/10/19 at 03:00 PM, Administrative Nurse D stated the resident gets assessed every shift for vital signs and the fistula for bruit and thrill. The [MEDICAL TREATMENT] would not let the resident leave until they were stable and did not believe this resident needed evaluation or to have it care planned to evaluate the resident upon returning to the facility from [MEDICAL TREATMENT]. The Lippincott Manual of Nursing Practice, 11th edition, documented, [MEDICAL TREATMENT] patients . close monitoring . complications of vascular access . including infection, uncontrolled bleeding, clotting of access . hemodynamic status .including [MEDICAL CONDITION], fluid intake and output, hypo/hypertension . before and after [MEDICAL TREATMENT] . The undated facility policy Care Plan Update, instructed staff to complete care plan to provide quality and efficient care of each resident. The facility failed to develop a comprehensive care plan for [MEDICAL TREATMENT] to include assessments evaluation of R22 before and after [MEDICAL TREATMENT] services.

The faciltiy reported a census of 33 residents. The 14 residents sampled included five reviewed for unnecesary medications. Base on interview and record review, the facility consulting pharmcist failed to identify the irregularity of the facility failure to administer insulins as per the physician orders [REDACTED]. Findings included: - The signed physician's orders [REDACTED]. The annual Minimum Data Set, (MDS), dated [DATE], documented R21 with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. She received insulin on the seven day look back period, for seven days. The Nutrition CAA (Care Area Assessment), dated 03/29/19. Revealed the resident was a diabetic and on insulin. Her blood sugars alternated from high to low and she did have parameters to instruct staff of when to notify the physician. The quarterly MDS dated [DATE], BIMS of 15, had no other changes from the previous assessment. The care plan dated 12/05/19, instructed that the consulting pharmacist would conduct a monthly medication regimen review. The primary care physician would be made aware of any recommendations made by the consulting pharmacist during the monthly medication review. Staff would follow any adjustment in the medication regimen or additional corrective action. The PO dated 11/13/10, included an order on 08/05/19, for [MEDICATION NAME] flex pen, [MEDICATION NAME] (insulin), six units to be given at hour of sleep, and instructed to be administered only if the resident's blood sugars were over 300. Review of the resident's monthly electronic medication administration records (E-MAR), revealed the following; In (MONTH) 2019, the staff administered the insulin 14 times, when the resident's blood sugars were under 300 and ranged from 144 to 299. In (MONTH) 2019, the staff administered the insulin 25 times, when the resident's blood sugars were under 300 and ranged from 100 to 260. In (MONTH) 2019, the staff administered the insulin 27 times, when the resident's blood sugars were under 300 and ranged from 120 to 292. In (MONTH) 2019, the staff administered the insulin 19 times, when the resident's blood sugars were under 300 and ranged from 106 to 255. The consulting pharmacist monthly medication reviews for August, (MONTH) and (MONTH) 2019, documented no irregularities. The consulting pharmacist's monthly medication review for (MONTH) 2019, documented to please review the resident's [MEDICATION NAME] orders. There was an hour of sleep physician's orders [REDACTED]. The staff administered the insulin 15 times this month and the resident's blood sugars had never been over 300, according to values noted on the medication administration record. On 12/12/19 at 10:52 AM, LN G, confirmed the above insulin should not have been administered at the resident's hour of sleep when the resident's blood sugar was under 300. On 12/12/19 at 11:30 AM, consultant pharmacy staff GG stated he did not find the discrepancies on the insulin being given by the staff, when the resident's blood sugars were under 300, until (MONTH) and the verified that he did not find this in his reviews for August, (MONTH) or (MONTH) of 2019. On 12/12/19 at 12:22 PM, Administrative Nurse D, stated the pharmacist comes to the facility monthly and they should have found these discrepancies. The undated facility policy for Drug Regimen Review instructed the consultant pharmacist would perform a drug regimen review on each resident living in this facility at least monthly. The drug regimen review would identify specific reviews of following of physician orders. The facility consulting pharmacist failed to identify this irregularity of the facility staff's administration of insulin to the resident, on multiple occasions, over four months, when the blood sugar was below the physician ordered parameters to administer the insulin.

The facility reported a census of 33 residents, with 14 residents reviewed, including one reviewed for [MEDICAL TREATMENT]. Based on observation, interview and record review, the facility failed to monitor the shunt ([MEDICAL TREATMENT] access port) and blood pressure when returning from [MEDICAL TREATMENT] for the one sampled Resident (R) 22, for [MEDICAL TREATMENT]. Findings included: - Review of the Physician order [REDACTED]. The annual Minimum Data Set, (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. She was independent with bed mobility, transfers, locomotion, transfers, eating, toileting, and personal hygiene. She was steady moving on and off the toilet, and with surface to surface transfers. She had both lower extremities impaired used a wheelchair and was always continent of bowel and bladder. She received special treatment of [REDACTED]. The Activities of Daily Living (ADL) CAA (Care Area Assessment), dated 05/01/19, documented the resident needed a little more assistance due to decrease in vision. The resident would be assisted/supervised with ADLs. The quarterly MDS, dated [DATE], documented R22 with a BIMS of 15, and was currently on [MEDICAL TREATMENT]. The care plan for end stage [MEDICAL CONDITION], dated 11/08/19, documented the resident required [MEDICAL TREATMENT] three times a week. Nursing were to check for bruit and thrill (vibrations felt/heard to ensure blood pumped and not clotted) every shift. (left lower extremity). She was to be transported to [MEDICAL TREATMENT] per facility staff on Tuesday, Thursday and Saturday to arrive at 07:00 AM, and pick up afterwards at approximately 11:00 AM. [MEDICAL TREATMENT] staff to provide blood pressures prior to and after [MEDICAL TREATMENT]. The PO dated 11/13/19, ordered on [DATE], to continue [MEDICAL TREATMENT] care on Tuesday, Thursday and Saturday's. On 12/10/19 at 11:54 AM, R22 returned from [MEDICAL TREATMENT]. Continued observations of the resident until 02:50 PM, revealed the staff failed to complete an assessment to the resident's fistula or obtain vital signs On 12/10/19 at 02:50 PM, Licensed Nurse (LN) H, confirmed she did not get vital signs or check R22's fistula upon the resident's return from [MEDICAL TREATMENT]. She stated the orders stated to only check every shift and that she usually checked the resident's fistula before she left for [MEDICAL TREATMENT] and so it would not get checked again until on the second shift. On 12/10/19 at 02:44 PM, LN H explained that this resident had an order to do checks for bruit and thrill to the port in her thigh. She had this ordered every shift and LN H checked it this morning before she went to [MEDICAL TREATMENT] and because nurses do 12-hour shift, this gets checked twice daily. LN H further explained she did not check it since the resident returned from [MEDICAL TREATMENT] as she already checked it this morning. There was not an assessment completed after the resident returned to facility from [MEDICAL TREATMENT]. On 12/10/19 at 03:00 PM, Administrative Nurse D stated the resident gets assessed every shift for vital signs and the fistula for bruit and thrill. The [MEDICAL TREATMENT] would not let the resident leave until they were stable and did not believe this resident needed evaluation or to have it care planned to evaluate the resident upon returning to the facility from [MEDICAL TREATMENT]. The Lippincott Manual of Nursing Practice, 11th edition, documented, [MEDICAL TREATMENT] patients . close monitoring . complications of vascular access . including infection, uncontrolled bleeding, clotting of access . hemodynamic status .including [MEDICAL CONDITION], fluid intake and output, hypo/hypertension . before and after [MEDICAL TREATMENT] . The undated facility policy for Hemo-[MEDICAL TREATMENT] Policy, instructed staff on a post-[MEDICAL TREATMENT] nursing assessment which should include assessment of the thrill and bruit of the access site each shift. The facility failed to assess the resident's shunt for thrill and bruit, or blood pressure upon return from [MEDICAL TREATMENT] services, to ensure no clots or bleeding at the site.

The facility reported a census of 36 resident, with 3 residents sampled for review of elopement. The facility identified 2 residents as elopement risks, included in the sample. Based on observation, interview and record review, the facility failed to provide adequate supervision and/or assistive devices to prevent 1 (#01) of the 3 sampled residents from leaving the facility without staff knowledge. A neighbor called the facility to inform the staff of the resident's exit from the facility. The confused resident ambulated through the grass in the backyards of several houses, and crossed 2 streets, before staff found the resident in another backyard approximately 2 blocks from the facility. Findings included: - The electronic medical record, evidenced the facility admitted resident #01 on 5/10/18. The physician listed senile degeneration of the brain (progressive mental disorder characterized by failing memory, confusion) as the resident's main [DIAGNOSES REDACTED]. Social service notes, included admission interviews with the family, dated 5/10/18, and revealed the resident was independent with all ADL's (activities of daily living) with reminders and limited supervision, and continent of bladder and bowel. The admission progress notes, on 5/10/18, documented the resident ambulated without difficulty and without assistive devices. The staff documented the resident as oriented to person only, and completely disoriented to time, place, or situation. On 5/10/18, the facility completed a BIMS (brief interview for mental status) to determine the resident's cognition and determined severe cognitive impairment, with a score of 06 of 15. The initial assessment for wandering risk, dated 5/10/18, scored the resident at 9.0 (low risk). The baseline care plan, included an addition on 5/11/18, which identified the resident at risk for elopement related to a dementia diagnosis. The facility identified the resident at risk for elopement but failed, at that time, to include interventions or instructions to the staff related to supervision of the resident to prevent elopement incidents. On 5/11/18 at 9:01 A.M., progress notes documented the resident opened the D hall door, during the morning. The exit door alarm sounded and the door closed, without the resident going through to the outside. On 5/11/18 at 5:16 P.M., documentation in progress notes, included the resident was in the lobby area with clothes packed in a pillow case. The resident said someone was coming to pick him/her up. On 5/11/18 at 7:30 P.M., progress notes documented, the resident was again present in the lobby area carrying his/her clothes. The resident reported he/she was waiting for family to pick him/her up. The staff easily redirected the resident. The facility investigation and progress notes, on 5/13/18 at 4:50 P.M., another resident's family member called and notified the facility they saw the resident walk out the front door with a visitor. The facility staff were unable to find the resident and started searching the facility inside and outside. On 5/16/18 at 2:30 P.M., interview with licensed nursing staff D, revealed he/she worked at the time of the resident's elopement from the building. Staff D reported the resident was slightly red faced upon return to the facility without injury. Staff D verified the following witness statement, dated 5/15/18, documented another resident's family member, notified staff D that he/she thought a resident was outside. Staff looked outside and did not see the resident. Staff started looking inside and outside of the building. Another staff began driving around the block. Staff D then received a telephone call from the other resident's family member, that he/she found the resident on the corner of 2 streets. Interview with the other resident's family member, on 5/16/18 at 3:35 P.M., revealed the visitor caught up with the resident walking in a yard, 2 blocks from the facility. The family member stopped and visited with the resident detaining him/her, until the facility staff arrived and returned the resident to the facility in a private vehicle. An incident report documented the staff found the resident, and returned to the facility, on 5/13/18 at 4:50 P.M. The resident was without injury. The temperature high per weather. com for the city, was 90 degrees F. for 5/13/18. The resident wore slacks, shirt, shoes and socks. Nursing staff D assess the resident upon return and documented vitals within normal range, including a temperature of 98 degrees. The resident had some facial redness but no perfuse sweating. Observation, on 5/1/18, revealed the facility was in a residential area, and the two streets crossed by the resident, had speed limits of 30 miles per hour. Observation, on 5/16/18 at frequent intervals, from 10:00 A.M. to 4:30 P.M, revealed a staff member was with the resident, both inside and outside of the facility. The resident walked without the need for assistance or assistive devices. On 5/16/18 at 3:10 P.M., licensed nursing staff C explained he/she posted a sign on the front door on 5/11/18, which stated, Visitors please do not let anyone follow you out the door. You may be letting out a resident who should not leave unattended. The neighbor (who observed the resident leave the facility), on 5/16/18 at 3:35 P.M., reported the resident not walking in the street but walking in yards. The resident would have crossed two streets with minimal traffic and a speed limited to 30 miles per hour. The facility elopement/missing elder policy lacked instructions for the staff on how to proceed when the staff noted a resident missing. The facility failed to ensure adequate supervision and/or assistive devices, to keep this confused wandering resident from exiting the facility without staff knowledge. The resident wandered from the building, through several backyards of houses, crossed 2 streets, and was found in another backyard, approximately 2 blocks from the facility by a bystander, who previously notified the facility, the resident was outside. This deficient practice placed the resident in immediate jeopardy. The investigation revealed the facility was in past-noncompliance as of 5/14/18 at 10:30 P.M., when the facility completed the following: 1. The facility placed the resident on one to one with staff supervision, at all times, since the elopement. 2. The staff updated the resident's care plan to include various activities to redirect the resident when restless/wandering. 3. The facility held a risk management meeting and notified the medical director of the incident, on 5/14/18 at 9:00 A.M. 4. The facility updated the elopement/missing elder policy on 5/14/18, to include instructions for the staff on how to proceed when the staff noted a resident missing. 5. All staff received education of the policy update, with completion on 5/14/18 at 10:30 P.M.

The facility reported a census of 37 residents. The sample included 13 residents with 1 resident reviewed for accidents. Based on observation, interview, and record review, the facility failed to failed to provide supervision and assistive devices and failed to determine the root cause analysis after a fall to develop and implement effective interventions to prevent repeated falls that resulted in a fractured right tibia (shinbone), and a right femoral medial condyle fracture (one of the two projections on the lower extremity of femur (thigh bone)). Findings included: - The signed physician's orders [REDACTED].#16, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 8/4/17, revealed the resident had a BIMS (brief interview for mental status) score of 15, indicating intact cognition. He/she required supervision with no set up for transfers and toileting. The resident did not ambulate, and used a wheelchair for mobility. The 30 day MDS, dated [DATE],revealed the resident had a BIMS score of 14. He/she required supervision of 1 staff assistance for toileting, and used a wheelchair and walker for mobility. Review of the Fall Assessment, dated 8/3/17, with a score of 40, revealed the resident at moderate risk for falling. The ADL (activity of daily living) CAA (care area assessment), dated 9/6/17, documented the resident required supervision with ADL's because he/she had unsteady gait at times. When the resident is not strong enough or thinks that he/she is too unsteady, he/she will use the call light and ask for assistance. Resident is alert and oriented, and able to make his/her needs known. The Falls CAA documented the resident was a fall risk. He/she had a history of [REDACTED]. The accident care plan, dated 8/9/17, documented the resident had a history of [REDACTED]. 1.) The resident is independently ambulatory in his/her room with a front wheel walker, dated 2/7/17. 2.) In addition, encourage the resident to use a call light for assistance when necessary. Staff will promptly answer the resident's call light, dated 2/8/17. 3.) In addition, non-skid socks, on at bedtime, and removed in the morning, dated 8/31/17. 4.) In addition, one staff required to assist the resident to and from the toilet at midnight and 4:00 am, dated 9/5/17. Review of the nurse's notes, from 8/29/17 to 9/26/17, documented on 8/31/17 at 3:15 am, the resident fell in his/her room by the bed. The resident attempted to transfer him/her self, missed the wheelchair, and fell to the floor. The resident lacked shoes or socks. The intervention indicated the resident non- skid socks applied at bedtime, and removed in the morning. On 9/2/17 at approximately 1:00 am, the resident fell in his/her bathroom. The resident was alert and oriented at the time of the fall. The resident complained of right ankle and right knee pain, rated 7 out of 10. Staff administered Ibuprofen ( an over the counter pain medication). At 9:50 am, the resident requested an x-ray of his/her knee due to pain and swelling. Staff transported the resident to the hospital by the facility transportation. The resident returned to the facility on [DATE], and as a result of the fall, received a [DIAGNOSES REDACTED]. The resident required a right leg/knee immobilizer, and he/she was unable to bear weight. Review of the accident report, dated 9/2/17, revealed the resident fell at 1:00 am, and he/she complained of right ankle and right knee pain. The resident's condition before the fall was normal for the resident. Staff notified the physician at 6:15 am by fax. Review of the right knee X-ray report, dated 9/2/17, documented a nondisplaced medial femoral condyle fracture (one of the two projections on the lower extremity of femur (thigh bone)). Review of the specialist office visit form, dated 9/5/17, documented the resident had a medial tibal/lateral shinbone) fracture, a medial femoral condyle fracture, and a right ankle sprain. On 9/26/17 at 10:00 am, observation revealed the resident sat in the wheelchair with an immoblizer to his/her right lower leg, elevated with the wheelchair leg support. The resident had shoes on. On 9/27/17 at 8:58 am, the resident was in his/her bedroom recliner, with his/her feet elevated, and an immobilizer on his/her right lower leg. The resident had shoes on. Signage in the resident's bathroom guided staff to apply non-skid socks, revised 9/17/17. On 9/27/17 at 4:30 pm, the resident sat in the wheelchair with his/her right lower leg immobilizer in place, and his/her right leg elevated. The resident had shoes on. On 9/25/17 at 12:55 pm, the resident reported he/she had 2 falls, and was unsure of the dates. His/her first fall was by the bed, then a couple of nights later, fell in the bathroom and broke his/her right leg, foot, and knee. The resident stated he/she was barefoot at the time of the second fall, and continued to not wear socks at night because he/she does not wear socks at night, and preferred to be barefoot. On 9/26/217 at 5:21 pm, direct care staff C, reported the resident's care guides posted on the back of the resident's bathroom door in a folder, that included fall interventions. On 9/27/17 at 1:43 pm, licensed nursing staff E, reported the resident fell on the night of 8/31/17. The intervention for the fall was for him/her to wear non-skid socks at night, and the socks were removed in the morning. The resident fell again on 9/2/17, around 6:45 in the morning, and fell in front of the toilet, that resulted in a fracture in a right femoral condyle fracture. Licensed nursing staff E identified direct care staff should read the resident's care guide on the back of their bathroom door daily. On 9/27/17 at 3:43 pm, administrative nursing staff B, verified the resident lacked the non-skid socks when he/she fell on [DATE], as care planned for the fall intervention for the previous fall of 8/31/17. Administrative nursing staff B, verified the resident's injuries possibly caused because the resident did not wear the non-skid socks at night, which increased his/her fall risk. On 9/27/17 at 5:00 pm, administrative staff A, verified the intervention for the 8/31/17 fall required the resident to wear non-skid socks, and the resident did not have the non-skid socks on when he/she fell on [DATE] that resulted in fractures. On 9/28/17 at 10:28 am, direct care staff F, reported the resident fell in the bathroom. The resident turned on the call light, and when staff entered the room, the resident was on the bathroom floor. Direct care staff F verified the resident never wears socks at night, and has not worn socks since the falls. On 9/28/17 at 12:13 pm, physician G, identified the resident had 2 falls. Staff discussed the interventions that included the resident was to wear non-skid socks. Physician G reported if staff applied the resident's non-skid socks, the resident's fractures could possibly been prevented. He/she verified the 9/2/17 fall resulted in the fractures. The facility's fall and head injury policy, dated 2/1/14, lacked guidance for monitoring fall interventions placed following a fall. The facility failed to provide supervision and assistive devices and failed to determine the root cause analysis after a fall to develop and implement effective interventions to prevent repeated falls for this resident that resulted in a fractured right tibia, and a right femoral medial condyle fracture.

The facility reported a census of 40 residents. The 21 residents selected for review, included 3 for nutritional status. Based on observation, interviews, and record review, the facility failed to ensure that 1 (#7) of the 3 selected resident's weight maintained acceptable parameters of body weight. The resident experienced a 15 pound /10.14 % weight loss. Findings included: - The medical record of resident #7 documented admission to the facility on [DATE], per the undated resident face sheet. The Nutritional assessment, dated 6/21/13, documented the resident on a NCS (no concentrated sweets) and NAS (no added salt), regular consistency diet. The assessment further documented the resident's height of 65 inches and weight is 140 pounds. The resident's ideal body weight is 112-138 pounds. The residents's usual body weight is 144-147 pounds, and a BMI (body mass index) of 23. The resident required 1570 estimated calorie needs, and 1590 milliliters of fluids a day. The 6/21/13, significant change MDS (minimum data set), completed due to a decline in ADLs (activities of daily living), identified the resident with a BIMS (brief interview for mental status) score of 12 (8-12 indicated moderately impaired cognition). The assessment further documented the resident required supervision with eating. The assessment documented under nutritional status, height 65 inches, and weight 140 pounds. The assessment documented no loss of 5% in last month or loss of 10% or more in the last 6 months. The CAA (care area assessment) completed with the 6/21/13, significant change MDS, documented under analysis, "The resident receives NCS/NAS (no concentrated sweets/no added salt) diet with small portions. This area of concern will be care planned due to resident is diabetic." A 6/21/13 dietary progress note documented: " Significant change, receives a NCS/NAS diet with small portions, His/her weight is 140 lbs. height is 65 " inches. The IBM (ideal body weight) is 112-138 pounds and the BMI (body mass index) is 23. Resident has had no significant weight loss or gain. Resident denies signs and symptoms of a swallowing disorder and does not show any during visual observation, This resident does wear upper and lower dentures and states they fit good and has no problems chewing with them. The resident is able to feed self without special devices, and wears glasses. The resident is able to make needs/ wants known. Resident lab values are NA (sodium) - 132, K (potassium)- 3.06, glucose-107, BUN (blood, urea, nitrogen)- 52.4, creatinine -.44, and calcium-9.0. resident is consuming 50-75 % of meals." per dietary staff F. The 7/12/13 nutritional assessment documented, "Resident significant change secondary to [MEDICAL CONDITION]. Resident is now a 'feeder,' appetite has declined according to the dietary staff., Resident prefers sugar free soda pop floats with meals, or in place of meals. Resident has lost 4 pounds, which may be promoted secondary to use of [MEDICATION NAME] (a diuretic - medication to promote the formation and secretion of urine)..", per dietary consultant staff G. (The resident had lost 15 pounds from 1/6/2013 through 7/10/13.) The clinical record failed to evidence any nutritional assessment of the gradual weight loss prior to this 7/12/13 assessment. The June 26, 2013, care plan documented : Potential for fluid volume deficit. -Assess for dehydrating and report to physician PRN - Encourage resident to consume all fluids offered, assist as needed - Honor beverage preferences and provide - Monitor for signs of dehydrating (tenting skin, dry mouth, and so forth. - Weigh resident weekly Cognition mildly impaired: Short term memory loss with independent decision making. - Establishes own goals and makes own decisions. This care plan, and the prior 2/21/13 care plan failed to evidence further instructions for staff in dietary area. The resident's weight on, 1/6/13, documented 148 pounds, per the facility weight variance report. the report further documented : On 2/6/13, weight of 145 pounds. On 3/6/13, weight of 144 pounds. On 4/10/13,weight of 145 pound. On 5/8/13, weight of 143 pounds On 6/5/13, weight of 140 pound. On 7/3/13, weight of 138 pounds. On 7/10/13, weight of 133 pounds - 15 pounds/10.14 % in 6 months On 7/17/13, weight of 132 pounds 7/24/13 at 10:01 AM, direct care staff V stated " I do the weights, the residents are weighed weekly unless the doctor has given an order to hold the weights or to weigh more often I give the weights to the dietary manager. I'm not sure what happens then." Observation revealed the resident's weight today as 131 pounds. (A loss of 2 more pounds in 14 days.) The resident experienced a total weight loss of 15 pounds equal to 10.14 % in 6 months. On 7/18/13 at 1:55 PM, The resident stated, "I can have whatever I want to eat, I really like hamburgers, so that is what I usually have at lunch and sometimes for supper. Yes, they bring snacks to me. I really like Coke floats, so I have them often. I use the diet Cokes because I am diabetic. They taste so good to me. Sometimes I have them more than once a day " On 7/17/13 at 12:13 PM, The resident served food ordered. The hamburger was 1/2 size, and complete with lettuce, tomato, and pickles. The resident ate 1/4 of the sandwich (a half hamburger) and a few fries. The resident asked for ice cream, when staff brought it he/ she started putting it in to the diet soda and the family assisted. The resident consumed all of the float. (Pop was 8 ounce size with the ice cream). On 7/17/13 at 12:31 PM, the resident's family stated, " My (parent) had a [MEDICAL CONDITION] about a month ago, and is served 1/2 portions, because his/her appetite decreased. My sibling is the one they notify with information about changes. I know (my parent) had a hard time eating the full amount, and is doing better with the 1/2 portions, but still doesn't eat all of that. I know (my parent) has lost weight. I am sure the facility called my sibling about it. He/She is the main contact person." On 7/22/13 at 3:20 PM, A different family member stated, "I think they are good to my (Parent), I know there is weight loss, I am here often. I don't remember anyone telling me." On 7/22/13 at 5:10 PM, administrative nursing staff C, stated, "The dietary manager faxes the doctors when a resident has weight loss. He/She is the one that keeps up with all of that. Then dietary staff F tells the nursing department because he/she is not a nurse and can't write orders, if the physician orders something." On 7/22/13 at 6:00 PM administrative staff D stated, "The dietary manager does the notification of the weight loss to the doctor. He/she sends faxes to notify them. The problem is some of the doctors never return the faxes to address the issues. I'm not sure if follow up is done for the faxes sent. There is a box at the desk the nurses are to put a copy of the return faxes from the doctors in for the dietary manager. If there is a order change, the dietary manager has to check if the order was written and placed in the record. The charge nurses' don't up-date the care plans. The MDS/Care Plan nurse does that, and I think the director of nurses does sometimes. I know one doctor is notorious for not responding to the faxes. " On 7/23/13 at 11:00 AM, administrative nursing staff B stated," We do not add anything to the resident's diets unless directed to by the physician. If they are a weekly weight the dietary manager reviews it weekly and if a monthly weight she does it monthly. We do not send the physician notice of the cumulative weight loss, just from week to week or month to month." On 7/24/13 at 10:20 AM, administrative nursing staff B, stated "I assigned administrative nursing staff C and D, to check the resident's record for any notification to the physician and the family related to the weight loss. The charge nurses are to notify the family of weight loss. They should know they need to do that, if they see the fax to the doctor for weight loss, that is just common sense." On 7/24/13 at 11:00 AM, administrative nursing staff C and D reported they checked the resident's record and were unable to find any documentation that the physician or the family were notified of the resident's weight loss in the record." On 7/24/13 at 11:29 AM, the physician's licensed nursing staff JJ reported, "I checked the record and can locate no notification or documentation of weight loss for this resident, from the facility." On 7/24/13 at 11:33 AM, licensed nursing staff I stated, "We do notify families if there is weight loss. I was not aware this resident lost weight. I have not seen any sheets come through that say that he/she had weight loss." On 7/24/13 at 11:46 AM, dietary staff F, stated , " He/ She might have been a resident that I missed notifying the doctor on. I don't notify the families. I think the nurses do that." On 7/24/13 at 12:55 PM consultant dietary staff G stated, "It has been about 3 weeks since I was there. I do not have my records with me here. If a resident lost weight, I tell the dietary manager to check to see if the resident is on diuretics (a medication which promotes the formation and secretion of urine) and if they have [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). Then make the loss if it an actual loss. I can't say anything about this resident's weight loss because I do not have my records." The facility failed to provide the requested policy and procedure which addressed weight loss. The facility failed to ensure that the resident maintained acceptable parameters of nutritional status, evidenced by the weight loss of 10.14 % in 6 months. The facility failed to notify the physician and failed to develop and provide interventions to ensure proper intake to maintain the resident's normal body weight.

The facility reported a census of 38 residents, with 8 selected for sample review for accidents. Based on observation, interview, and record review, the facility failed to ensure 5 of the 8 residents reviewed for accidents, received adequate supervision and/or assistive devices to prevent repeated falls including; resident # 60 with inappropriate intervention; residents # 31 and #20 with no interventions following a fall; and residents #3 and #10 with planned interventions not followed. Findings included: - The facility readmitted resident #10 on 6/14/13, per admission orders [REDACTED] [DIAGNOSES REDACTED]. The resident's 6/20/13 admission MDS (minimum data set) assessment, identified the resident scored 8/15 on the BIMS (brief interview of mental status), indicating moderately impaired cognitive skills, required extensive assistance of 1-2 staff for most ADL ' s (activities of daily living), experienced a fall with a fracture prior to admission, and lacked identification of any falls since admission. The 6/25/13 CAA (care area assessment), included the resident received PT/OT (physical and occupational therapy) services related to a fractured hip, had 2 falls since the previous MDS, with falls and fracture. The CAA lacked identification of the causal factors contributing to the resident fall. A 6/14/13 Fall Risk assessment identified a score of 13 with 10 or above representing high risk for falls. The facility failed to ensure consistent care and treatment for [REDACTED]. The resident ' s 6/26/13 clinical record care plan instructed staff the resident needed: 1. Reminders of the need for assistance with ADL ' s. 2. A pivot pad for transfers. 3. Hip precautions, including an abduction pillow at night. 4. Ensure placement of the call light within reach at all times when the resident in their room and reminders to use the call light. 5. Analyze previous falls by the resident to determine pattern/trend. 6. Remind the resident to not ambulate or transfer without assistance. 7. Wheel chair for transport. 8. A pressure sensitive floor mat beside bed and chair. 9. A personal alarm at all times. Review of the [DATE] readmission, "Nurse Aide Information Sheet," noted to weight bear as tolerated, gait belt and walker, and wheel chair with staff for mobility out of room ... The staff posted this information sheet, in the Kardex, located in the Clean Storage Room on D Hall. A 8/12/13 Nurse Aide Information Sheet, located in the resident's restroom, inside a folder, documented the resident a fall risk, needed hourly fall safety checks, a falling star on the door, ...a pressure sensitive fall mat by bed or chair, alarms, call light, pivot pad for transfers, weight bear as tolerated, hip precautions, abductor pillow at night, and personal alarm on person ... Observation on 9/9/13 at 2:30 PM, identified direct care staff B, assisted the resident from the wheel chair and into the recliner, in their room. Staff failed to use a pivot pad, as planned during the transfer and failed to place the fall mat in front of the resident ' s recliner chair, as planned. At 4:26 PM on 9/9/13, direct care staff M and P assisted the resident with arising, from their low bed and transferred the resident into their wheel chair. Staff P removed the alarming floor pad, raised the bed from the low position, donned the resident ' s TED hose and shoes, and then applied a gait belt to assist with transferring the resident into the wheel chair. Staff failed to utilize a pivot pad, as planned. On 9/11/13 at 3:05 AM, observation identified the resident resting in a low fowlers position in the bed with a fall mat at bedside. Review of the visual fall check form, located on the bathroom door, lacked identification of any signatures since 2200 on 9/10/11. Observation of the visual check form on 9/11/13 at 8:00 AM, identified the form initialed through the night, until the current time. The resident remained asleep in bed. On 9/12/13 at 8:30 AM, direct care staff N and O assisted the resident with arising cares, stood the resident from the bed, with slipper shoes, using a gait belt, however, failed to use a pivot pad as care planned for, and seated the resident into their wheel chair. Resident shuffled their feet to sit down into the wheel chair. Staff then wheeled the resident to the bath room and repeated the process of transferring the resident to the toilet. Inquiry of direct care staff O, identified the resident did not use the pivot pad any longer, as therapy had taken the device to the therapy room. The staff further identified the resident did not always have the abduction wedge between their legs when awakening in the AM, and understood it was to be used at all times when the resident slept at night. Direct care staff E reported on 9/11/13 at 4:30 AM, the resident a fall risk, although no falls recently, used a pressure sensitive floor mat, every hour checks, a low bed, and a pressure sensitive alarm that speaks to the resident when standing up, instructing the resident to not stand up alone. On 9/11/13 at 2:27 PM, direct care staff J, reported the resident used a talking alarm, low bed, pressure sensitive fall mat and on hourly check, with no recent falls. On 9/11/13 2:49 PM, direct care staff K,reported the resident used alarms, a fall mat, a low bed, frequent checks, and needed a pivot pad for transfers, due to a history of leg injury. On 9/11/13 at 1:30 PM, administrative nursing staff A, reported the staff are expected to sign the visual check sheet every time the check is made, and not saved for the end of shift signing. 9/12/13 at 8:45 AM, interview with consulting staff Q, reported, after speaking with the therapist, the resident continued to require the pivot pad/disc for transfers. On 9/12/13 at 8:50 AM, direct care staff M, reported the IDT (interdisciplinary team) changed the resident's plan of care at the last care plan meeting, (a few weeks ago) to use a front wheeled walker and gait belt for transfers instead of the pivot pad. The staff stated this was noted to the care plan on the resident's door and should match the care plan in the chart as well as the information on the Kardex for consistent care. At 8:57 AM, direct care staff M reported the information documented in the resident's room noted the pivot pad as prn (as needed), and also stated to transfer with a front wheeled walker, gait belt and 2 person staff assist. The staff confirmed this differed from the other care plans, and all three care plans, are required to match in the resident's care needs. The facility failed to ensure this staff followed the interventions planned to prevent repeated falls for this resident with planned adaptive transfer device (a pivot pad) for transfers and every hour visual checks. - The facility admitted resident #3 on 2/4/08, per the clinical face sheet, dated 7/28/10. The resident's annual 8/9/13 MDS (minimum data set) assessment, identified the resident scored 5/15 on the BIMS (brief interview of mental status) indicating severely impaired cognitive status, needed extensive to total dependence of 1-2 staff for ADL's (activities of daily living), and identified the resident without falls. The 8/23/13 CAA (care area assessment) triggered for falls and evidenced the resident needed 2 staff and a mechanical lift for all transfers, with a long history of falls due to not asking and/or waiting for assistance with transfers. The resident's 8/12/13, "Fall Risk Assessment," identified a score of 16 with 10 or above representing high risk for falls. The resident's 8/14/13 care plan instructed staff: 1. Keep call light within reach. 2. Wear appropriate foot wear. 3. One staff to assist me with my wheel chair mobility. 4. Hourly fall safety checks. 5. Falling star for fall identification risk. 6. Unable to maintain a edge of bed seated position. 7. Restorative plan of care when chooses to participate. 8. Floor mat next to bed, started on 8/12/13. 9. Personal alarm on resident at all times, started 8/12/13. Review of the, "Fall Check List," at 3:15 AM on 9/11/13, identified the residents form lacked any initialing to the check list after 2200 (10:00 PM), to verify the staff checked the resident every 30 minutes. Review of the resident's nursing notes, documented on 8/12/13 at 3:15 AM, the resident experienced a fall out of the bed, with a head injury, and with first aid required. On 9/9/13 at 12:08 PM, observation identified the resident seated in the dining room, in their wheel chair, with a personal alarm on their wheel chair and attached to their clothing. On 9/9/13 at 1:46 PM, direct care staff I and T assisted the resident with toileting then positioned the resident onto their back in bed. Direct care staff I, reported the resident needed a low bed with a fall mat, and a personal alarm in bed and chair. On 9/9/13 at 4:55 PM, direct care staff B, reported the resident required fall safety checks with notation of a shooting star to their door way. Staff B further reported, " The residents are checked at least hourly and (this resident) is on a 30 minute check, due to a recent fall. When the residents are checked, sometimes it is just a walk by and the staff don ' t always sign the sheets hourly, but staff sign the form every time they go into the resident ' s room. If just walking by might not sign it every 30 minutes. " On 9/9/13 at 5:35 PM, direct care staff R and B, assisted the resident with arising cares. Direct care staff B, reported the resident mostly dependent on staff, except for eating, and would sometimes assist with dressing/undressing. Licensed nursing staff G reported on 9/11/13 at 3:25 AM, the staff member received training, related to falls, to include assessment of the resident, with first aid and/or call 911. The staff member further reported, "I would notify the DPOA/RP (durable power of attorney/responsible party) and the doctor immediately following the incident, if any significant injury." At 5:15 AM on 9/11/13, observation identified the staff initialed the, " Fall Check List, " and confirmed, " We caught the signatures up to the current time, during the most recent check, of the resident." On 9/11/13 at 12:44 PM, telephone interview with licensed nursing staff W, reported the resident fell out of bed on 8/12/13 at approximately 3:15 AM. "I had been down the hall, on the hour to check on the resident. I responded when hearing a noise, and found the resident on their belly towards their left side and noted blood and a hematoma to the right forehead. The resident's bed was in the lowest position with a ? rail in the raised position, at the time. The resident had slept well that night, and at 3:00 AM had been asleep. The resident had interventions of a low bed, keeping call light within reach, and on frequent visual checks, as the only interventions at that time, for falls. Staff stated, during the interview, "I didn't feel immediate notifications were needed and asked the next shift to pass onto the family and doctor. The resident was very alert at the time and a staff member stayed with the resident until he/she fell asleep and slept soundly." On 9/11/13 at 1:30 PM, administrative nursing staff A reported the staff are expected to sign the visual check sheet every time the check is made, not saved for the end of shift to sign. On 9/11/13 at 1:39 PM, direct care staff J, reported, "Not aware of the resident ever attempting to get up alone, just would sometimes sit on the edge of the bed, as an indicator of being ready to get up." Staff further added, "The resident had been on hourly visual checks, bed in the lowest position, and got the mat, alarm and ? hour checks after the last fall." On 9/11/13 at 2:51 PM, direct care staff K, reported the resident needed a low bed, visual checks, alarms, regular toileting, and turning and repositioning every 1-2 hours. On 9/12/13 at 3:29 PM, interview with administrative nursing staff A, reported an all staff in-service related to falls occurred following this resident's fall. The Fall Prevention Policy and Procedure, undated, included, " ...The nurse/staff on duty at the time of the fall will implement immediate interventions necessary to correct the situation, causing the fall, if possible ...After a fall occurs, the director of nursing and/or the MDS coordinator will be notified as soon as possible. An investigation will be initiated to determine the reason for the fall considering environment, resident cognition, needs and condition, care plan, medications, [DIAGNOSES REDACTED]. ..The care plan team will meet weekly. Falls that occurred in the prior week will be discussed and interventions reviewed/revised ..." The facility failed to complete visual monitoring of the resident every 30 minutes, as planned, to prevent repeated falls for this resident with a history. - The clinical face sheet revealed resident #20, readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set) 3.0 dated 6/7/13, revealed the resident with moderate impaired decision making, inattention, and disorganized thinking. The resident required for ADL's, extensive staff assistance for bed mobility, transfers, and toileting. The resident required a walker and wheelchair for mobility, and experienced 1 injury fall since the last MDS, dated [DATE]. The Fall Assessment, dated 7/27/13, with a score of 22, and a score of 10 or more represents HIGH RISK. The care plan last a reviewed on 6/12/13, documented the following: " --Be sure call light is within reach and encourage to use it for assistance. --Promptly respond to all requests for assistance. --Anticipate and meet needs. --Floors even and free from spills or clutter. --Bed in low position at night. --Personal items within reach. Provide diversion and distraction. --Ensure that resident is wearing appropriate footwear (shoes, bedroom slippers, non-skid socks when ambulating or up in wheelchair). --Resident is non-compliant with staff requests at times, doesn't comply with safety issues, i.e. not using walker and making him/her at risk for falls. --Remind resident to use walker due to unsteady on his/her feet. --Post signs to remind resident to use walker. --Use of wheelchair for safety as needed. --Monitor for availability of walker in resident's room, if missing, check dining room/rest of building and return to resident. --Body alarm on resident due to fall risk (body alarm written in pencil and lacked a date as to when initiated)." Care Plan update Forms included:" Fall, 7/27/13, Reassessment Date: 8/27/13. Fall: Resident will have no falls thru 8/27/13. Approach: Every 15 minute visual checks. A body alarm to be worn at all times." The Nurse Aide's Information Sheet, updated on 8/9/13, documented the resident is non-compliant with staff request at times. Body Alarm, to be worn at all times. Wanderguard: yes, on left wrist. Elopement potential: yes, on routine visual checks. The information sheet, lacked instruction as to the frequency of the visual checks. Observation revealed the resident has 1 hour fall safety check sheet in his/her bathroom with his/her name and room number on one sheet. The fall safety check sheet lacked documentation of where the resident was at 3:00 PM and 4:00 PM. Furthermore, review of the Visual checks; place the resident at 15 minute intervals, not 1 hour. The Injury Investigation Report dated 9/9/13, documented at 8:01 PM, in resident's room and no witness. "Summary of final conclusion as to cause of injury: Resident states he/she was getting up to go walking and forgot his/her walker. DON (Director of nursing) concludes resident attempted to get up on own, lost his/her balance and fell . PLAN OF CORRECTION: Resident has body alarm, fall safety checks. Educate resident and staff on fall safety. Ensure to the best of facilities ability of any further falls. " The nurse ' s notes, dated 9/8/13 at 8:00 PM, documented the following: "(Direct care staff K) notified this nurse that resident is on the floor. The nurse observed resident on the floor in his/her own room beside his/her bed. Resident in a supine position. AROM (active range of motion) to all extremities, neuro checks initiated, obtained a 1.5 cm (centimeter) skin tear to left elbow. Per physician order [REDACTED]. DC (discontinue) all treatments when healed. No other injuries noted at this time." The nurse 's notes, dated 9/9/13 at 3:00 AM, documented, "Continue on fall f/u (follow up) with neuro ' s. Vital signs stable, neuro check WNL (within normal limits). Rest well, denies pain, able to follow commands, opens eyes spontaneously, and only answers simple questions per norm." The nurse's notes, dated 9/9/13 at 9:15 PM, 9/10/13 at 2:00 AM, 9/10/13 at 8:15 PM, and 9/11/13 at 3:00 AM, documented no signs of pain and vital signs remained normal. On 9/9/13 at 1:38 PM and 4:08 PM, the resident rested quietly in bed, on the left side, with eyes closed, the bed in the low position, and the call light in reach. The resident with a personal alarm in place, and the alarm base attached (clipped) to the resident headboard. On 9/9/13 at 6:04 PM, direct care staff B and C, assisted the resident onto the side of the bed, put on his/her socks, shoes, and pants. A gait belt on the resident, transferred the resident with staff assist of 2 to a standing position. Using the rolled walker the staff ambulated the resident to the bathroom. The resident had difficulty following simple 1 step instructions from the staff. The resident then ambulated with rolled walker by direct care staff R to the dining room, with a gait belt. On 9/11/12 at 3:00 AM, check of the resident's hourly fall checks revealed the form lacked any documentation since 12 midnight. The resident rested quietly in bed on his/her back with his/her eyes closed. The bed in the lowest position and with a personal alarm in place. On 9/11/13 at 4:35 AM, check of the resident's hour fall checks from revealed staff had filled in and initialed all of the blanks from 12 midnight through 4:30 AM. Interview, on 9/9/13 at 4:15 PM, direct care staff B reported, " If the nurse/CNA (certified nurses aide) does not tell us in report, I have to look in the care plan. The resident is on the Falling star program, and has a fall safety check list every hour. We go every hour, we may not always get them signed. " On 9/9/13 at 4:50 PM, licensed nursing staff D reported, "The aides are to observe and document where the resident is. If it is every hour then they (the CNA's) are to check (initial and document where the residents are) at the time they are suppose too. I try to go around and check to make sure they (the checks) are being done." On 9/9/13 at 5:00 PM, administrative nursing staff A reported, "The nurses also chart on the residents as often the direct care staff do. They have their own sheet at the desk. There are 2 forms (one in room and one at the desk), to make sure the sheets are being filled in. The nurses have been doing them also. The nurse's sheets are for resident #19 and resident #60, have not been filled in their rooms. Furthermore the nurse's sheet for resident #19 has not been filled in for the nurses. Having to do a lot of education for documentation, (writing in pencil in the care plan and interventions) and the fact the care plan lacked an intervention for the resident. They are on the CNA care plan in the room. The nurses are not to write on the ones in the chart." On 9/11/12 at 3:26 AM, licensed nursing staff G reported, "The aides check the residents who are on the 15 minute, 30 minute, or 1 hour checks by going to the resident's room and checking the residents. I believe they chart in their (CNA) Kardex. I am not real familiar with the aide's paper work." On 9/11/13 at 3:45 AM, direct care staff E reported, "I have the single resident's on the fall safety check, and I go and check the resident every hour. In their (the resident's) room, is a Kardex and it has the sheet (fall safety check) where we document where the resident is and then initial on the other sheet. We are to do this every hour." On 9/11/13 at 4:10 AM licensed nursing staff G reported, "I wasn't here the night of the fall, I don't know of any new intervention (implemented after the resident's fall on 9/8/13)." On 9/11/13 at 4:20 AM, direct care staff E reported, "The resident had a personal alarm and an hourly fall check before the fall. I don't know of a new intervention (implemented after the resident's fall on 9/8/13)." On 9/11/13 at 1:05 PM, direct care staff F reported, "The resident had a fall recently, (he/she) has a body alarm, and make sure the call light is in reach. That is the last intervention I know of." On 9/11/13 at 1:10 PM, licensed nursing staff F reported, "I would place an intervention on the report sheet and let the staff know (verbally) immediately of an intervention to prevent falls." On 9/11/13 at 2:10 PM, administrative nursing staff L reported, "I was instructed to use pencil and not date when adding an intervention to the care plan. I have not added any new interventions to (his/her) care plan since this last fall." On 9/11/13 at 3:00 PM administrative nursing staff A reported, "The staff is notified by the communication book. They are to read it when they come on, it is mandatory. The nurses are to pass on the new intervention in report, and they (the nurses) also have their own book they use to be sure and pass on information during the report. The nurses are not to write on the care plan. We have found that if they do, the CNA care plan and the clinical care plan will not match because they (the nurses) will forget to chart the new intervention in the right place and we (DON/MDS coordinator) will not be notified. I have meetings with the staff to educate them on the new interventions. I have given the MDS coordinator the new interventions, unsure why the new interventions are not on the care plan." The undated facility policy for Fall Prevention Implementation documented the following: " ...The interviewing nurse/staff on duty at the time of the fall will implement immediate interventions necessary to correct the situation causing the fall if possible. " The facility failed to develop and implement new interventions to prevent further falls for this resident identified as a fall risk. - The clinical face sheet revealed resident #31, readmitted to the facility on [DATE], with the following diagnoses; stroke (the sudden death of brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain), debility (feebleness, weakness or loss of strength), pneumonia(inflammation of the lungs), and backache. The quarterly MDS (minimum data set), dated 7/26/13, revealed a BIMS (brief interview for mental status) score of 9, indicating moderately impaired cognition. The resident independent with ADL's (activities of daily living) for bed mobility, transfers and ambulation. The resident's balance steady and does not have any limitations in range of motion concerns. The resident used a walker for mobility, is occasionally incontinent of urine, and did not have any falls. The resident received an antianxiety medication in the 7 days during the assessment period. The Fall Assessment, dated 8/30/13, with a score of 5, indicated the resident not at risk for falls. A score of 10 or more represents HIGH RISK for falls. The care plan, reviewed on 7/31/13, documented the following: "-- Potential for falls related to history of falls. --Assist resident with ambulation, transfers as needed. --Place call light within easy reach. --Keep floors clear of clutter. --Report and document all falls per facility protocol. --Provided activities that minimize the potential for falls while providing diversion and distraction. --Ensure that resident is wearing appropriate footwear (shoes, bedroom slippers, non-skid socks) when ambulation or up in w/c (wheelchair). --Provide safety reminders. " --Cognitive function impaired: Increase in confusion at times, short term memory loss, with independent decision making." The resident's care plan lacked a new planned intervention, following a fall by the resident, on 9/1/13. The Nurse Aide's Information Sheet, updated 8/9/13, documented the following: "Locomotion per rolling walker, and staff assist of 1." The Injury Investigation Report dated 9/4/13, documented a fall on 9/3/13, "...(Resident's room, sitting on floor in front of recliner)... SUMMARY OF FINAL CONCLUSION AS TO CAUSE OF INJURY: Resident attempted to sit in recliner and misjudged how close he/she was. Resident states, "I thought I was close enough." PLAN OF CORRECTION: Educated resident on fall safety, use of call light for help. Educated staff to monitor resident when up and around for safety..." The nurses notes, dated 9/2/13 at 1:30 AM, documented, "Resident continues on antibiotic for pneumonia, also on fall follow-up, no complaints of pain this shift." Observation, on 9/9/13 at 12:20 PM, revealed the resident used a rolled walker, and ambulated in the hall, with gait steady. On 9/9/13 at 1:22 PM, the resident ambulated from the dining room to the room by self with rolled walker, gait steady. Interview, on 9/9/13 at 4:15 PM direct care staff B reported, "The resident is independent. (He/she) uses a walker." On 9/11/13 at 4:45 AM, direct care staff E reported, "The resident is usually independent, but if (he/she) feels (he/she) needs help the resident will turn (his/her) light on. I have been helping the resident tonight. I don't know of any intervention for a fall." On 9/11/13 at 5:47 AM, direct care staff I reported, "The resident has been sick lately. (He/she) usually comes out for meals and eats well. I don't know of a new intervention for (his/her) fall." On 9/11/13 at 1:05 PM, direct care staff F reported, "The resident is independent with ambulation and uses a walker. (He/she) has been ill lately and will use his/her call light to call for assistance if (he/she) is not feeling well." On 9/11/13 at 4:45 AM, licensed nursing staff G reported, "There is not an intervention for a fall that I am aware of." On 9/11/13 at 1:10 PM, licensed nursing staff H reported, "I would place an intervention on the report sheet and let the staff know (verbally) immediately of an intervention to prevent falls." On 9/11/13 at 2:10 PM, administrative nursing staff L reported, "I will have to look at the care plan. I don't remember an intervention for the fall at this time." On 9/9/13 at 5:00 PM, administrative nursing staff A reported, "Having to do a lot of education for documentation, (writing in pencil in the care plan and interventions) and the fact the care plan lacked an intervention for the resident. They are on the CNA care plan in the room. The nurses are not to write on the ones in the chart." On 9/11/13 at 3:00 PM, administrative nursing staff A reported, "The staff is notified by the communication book. They are to read it when they come on, it is mandatory. The nurses are to pass on the new intervention in report, and they (the nurses) also have their own book they use to be sure and pass on during the report. The nurses are not to write on the care plan. We have found that if they do, the CNA care plan and the clinical care plan will not match because they (the nurses) will forget to chart the new intervention in the right place and we (DON/MDS coordinator) will not be notified. I have meetings with the staff to educate them on the new interventions. I have given the MDS coordinator the new interventions, unsure why the new interventions are not on the care plan." The undated facility policy for Fall Prevention Implementation documented the following: "...The interviewing nurse/staff on duty at the time of the fall will implement immediate interventions necessary to correct the situation causing the fall if possible." The facility failed to develop new interventions to provide adequate supervision and assistive devices to prevent further falls for this resident with a history of falls. - The clinical face sheet revealed resident #60, admitted to the facility 6/13/13, with the [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 6/19/13, revealed the resident had a BIMS (brief interview for mental status) score of 7, indicating severely impaired cognition, with disorganized thinking, that fluctuates, comes and goes, and changes in severity. The resident wandered which occurred 4-6 days. The resident required limited staff assistance of 2 for bed mobility and transfers. The resident required 1 staff assistance to walk in room, locomotion off the unit, and toileting. Balance not steady, does not use any mobility devices, and no issue with functional range of motion. The resident occasionally incontinent of urine and no falls since admission. The CAAS (care area assessment summary), dated 6/13/13, revealed for Cognition: "Resident does not have new onset of cognitive loss. Resident was placed in facility, Family being unable to care for (him/her) any longer. Has had a decline in continence and has issues with decision making abilities ... " ADL's: "Resident needs 1 staff assist for all ADL's except for dressing. Needs 1 staff extensive assist for dressing as seen during look back period 6/13/13." Falls: "Resident is at risk for falls due to antipsychotic medications, and unsteady gait during look back period 6/13/13-6/19/13." The Fall Assessment, dated 6/13/13, documented a score of 4, a score of 10 or more represented HIGH RISK. The Resident Fall tracking log, dated 9/7/13, at 5:00 PM, documented, "In the resident's room, with the following internal risk factors: Psychiatric/Cognitive, Neuromuscular, and history of falls. External Risk Factors: Walker, medication: cardiovascular; walking, reaching up/down." The care plan reviewed on 6/26/13, documented the following: "--I am at risk for falls since my gait is not always steady and I don't always retain verbal cues. --Remind me to use walker. (Written in pencil on the care plan and without a date) --Make sure my call light is where I can reach it. Remind me when you leave the room where it is and that I need to use it if I want to get up or go to the bathroom. --Make sure that I am wearing appropriate foot wear (shoes, bedroom slippers, non-skid socks) when I am awake. --Body alarm used for Safety-TS (written in pencil on the care plan and lacked date of intervention. --I am forgetful and confused since I have been diagnosed with [REDACTED]. I change my mind often, but I really like to follow my regular daily routine. --Be sure to orient me as part of our conversation while you are providing care. --Give me clear, simple directions. --If I should be more confused than you normally see me, or I don't remember details about my day, notify my nurse. Often times this means that I am having health complications, which my nurse will be able to assess. --I need assistance of 1 person with my ADL's. --Dressing- I need someone to help me with this, but I like to be able to choose what clothes I want to wear. --I am usually continent but at times I'm incontinent and I wear a brief 'just in case' I need someone to walk with me to the bathroom and assist me when I go to the bathroom." The Nurse Aide's Information Sheet, updated 8/14/13, documented, the resident oriented, confused at times, forgetful at times. The resident walks with a walker, 1 staff assist and a gait belt. Updated 9/11/13, 1 hour Fall Safety Checks. Remind reside

The facility reported a census of 38 residents with 16 selected for sample review. Based on observation, interview, and record review the facility failed to ensure 3 of 5 residents, reviewed for pressure ulcers, received adequate monitoring with appropriate treatment of [REDACTED]. Findings included: - The facility admitted resident #65 on 8/22/13, per the clinical face sheet, dated 8/22/13. The resident's 8/29/13 admission MDS (minimum data set) assessment, identified the resident scored 15/15 on the BIMS (brief interview of mental status), indicating intact cognitive status. The resident required extensive assistance of 2 staff for most ADL's (activities of daily living), including bed mobility and transfers. The assessment lacked identification of any pressure ulcers. The Braden assessment for pressure sore risk, dated 8/22/13, scored the resident at 16, with 12 or less representing high risk. On 9/12/13, the resident's clinical record lacked a comprehensive care plan, due on 9/12/13. The initial care plan, designated as "Nurse Aide's Information Sheet," by administrative nursing staff A, as the initial care plan and as the care plan for care by the CNA's (certified nurse aides), lacked inclusion of pressure ulcers, treatments for pressure ulcers, pressure relieving devices or the residents risk for weight loss and pressure ulcer development. The resident's admission 8/22/13 skin assessment, identified discoloration and reddened areas to the resident's feet. However, it lacked identification of any pressure ulcer. The following skin assessment, dated 9/5/13 identified reddened areas to the resident's buttocks, feet and lower legs and identified a pressure ulcer, to the resident's buttocks. Review of the 8/2013 MAR/TAR (medication/treatment administration record) identified a weekly skin assessment with a circled initial on 8/29/13, under the weekly skin assessment, with documentation on the back, "Skin assessment not done." A nursing note, dated 9/1/13 at 7:13 AM, documented, "L.E. (late entry), 8/27/13 at 0930 weekly skin assessment, ...buttocks showed reddish splotches ..." The 9/5/13 Pressure Ulcer Log, identified a stage II, facility acquired pressure ulcer 0.1 x 0.2 cm (centimeter) to the left gluteal (lower buttock) with notifications made and added to the care plan (which staff failed to include). Review of the September, 2013, treatment record identified a weekly skin assessment completed on 9/6/13 and next scheduled for 9/13/13. The treatment record further noted to treat left gluteal pressure ulcer, stage II with dressing change every 3 days and prn (as needed). Discontinue (the treatment) when healed and monitor x 7 days after healing. Initialed as the dressing changed on 9/5/13, 9/8/13, and 9/11/13. The nursing notes lacked identification of the wound status with dressing changes on those dates, as planned. Interview with administrative nursing staff A, at 10:00 AM on 9/12/13, reported, "Any nurse changing the dressing should document the condition of the wound at the time of the dressing change." On 9/12/13 at 10:05 AM, the resident seated in their room, in a wheelchair with a pressure relieving cushion, watched television. The resident reported the staff very good to help him/her and encouraged the resident to get off of their bottom at times. The resident reported, "I slept in my recliner at home. I don't like sleeping in a bed, and when I do, I have to lay on my back. I can't lay on my side or stomach and sleep." The resident further reported he/she frequently toileted him/her self, getting out of bed and transferring into the wheelchair, and toileting their self, then getting back into bed, without assistance. Observation at 3:45 PM on 9/12/13, identified the resident weight shifting themselves independently, while seated in the wheel chair. Interview with licensed nursing staff Z, on 9/12/13 at 8:30 AM, identified themselves as the wound care nurse, worked 2-3 days per week, completing skin assessments, wound measurements, etc, and provided the measurements weekly, by e-mail to the management of the facility. Interview with administrative nursing staff A, on 9/12/13 at 9:45 AM, reported being unaware of any other residents with pressure ulcers in the building, other than the 2 healed areas identified on the 8/21/13 Pressure Ulcer Log (for different residents). Staff A reported being unaware of this resident's pressure ulcer, and indicated staff failed to communicate these areas to them as planned. On 9/12/13 at 11:45 AM, interview with direct care staff Y, reported the resident participated in cares, needed some help with set-up and with hygiene. Staff Y explained the resident with a [MEDICATION NAME] dressing on their buttocks this morning, when assisting the resident with hygiene, and not aware of what type of sore under the dressing. Interview with licensed nursing staff Z, on 9/12/13 at 2:00 PM, identified a problem with communication of changes/new pressure ulcers from the daily nursing staff. "A copy of the wound form, identifying the presence of a pressure ulcer/wound, is supposed to be put in the office for the skin nurse. However, That does not always happen. Some of the communication problem is still being worked on." Licensed nursing staff S, reported on 9/12/13 at 2:34 PM, being unaware the resident currently with a pressure ulcer to the buttocks. Staff reported the resident needed assistance with repositioning and often refused to reposition as recommended, but stated, "I didn't know an area had developed." Direct care staff K, on 9/12/13 at 3:59 PM, reported the resident complained for the past couple of weeks of their bottom being sore. However, the staff lacked awareness of the development of a pressure ulcer. The Skin Integrity/Wound Care program, undated, included instructions to provide a systematic approach and monitoring process for skin integrity/pressure ulcer care. The Pressure Ulcers, Prevention Policy, dated 12/9/10, included "...To prevent the development of pressure ulcers in residents whenever possible... Institution of measures to reduce the effects of pressure, friction, and shear." The facility failed to complete timely skin assessments/monitoring for pressure ulcer management, to ensure proper care and treatment for [REDACTED]. - The facility admitted resident # 19 on 10/6/09, per the clinical face sheet, dated 5/12. The resident's 6/21/13 significant change MDS (minimum data set) assessment, identified the resident scored 4 on the BIMS (brief interview of mental status), indicating severely impaired cognition, required total assistance of 1-2 staff for ADL's (activities of daily living), including transferring and bed mobility, required extensive assistance of 1 staff for eating, identified weight loss, at risk for the development of pressure ulcers, and with an unhealed stage I pressure ulcer. The 7/1/13 CAA (care area assessment), evidenced the resident with, "A history of pressure ulcers, and scored 20 on a Braden Scale assessment (an assessment rating the resident's risk for pressure ulcer development)." The resident's 6/26/13 care plan, instructed staff: 1. Fluid filled cushion and covered with sheep skin in recliner. 2. Geomatt foam/gel cushion in wheel chair, started on 7/11/13. 3. Observe, document and notify the physician regarding changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size and stage of ulcer. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, and discoloration noted, during bathing or daily care. 4. Monitor nutritional status and serve diet as ordered, monitoring intake and recording. 5. Obtain and monitor laboratory/diagnostic work, as ordered. Report results to physician and follow-up, as indicated. 6. Provide supplemental protein, amino acids, vitamins, and minerals, as ordered, to promote wound healing. 7. Notify the family of any new area of skin breakdown. 8. Skin risk assessment on admission and at regular intervals. Notify the appropriate staff of changes in the skin assessment. The care plan lacked identification of the resident's need for a mechanical lift, and total dependence for mobility needs, including a turning and repositioning program, every 2 hours. On 8/24/13, a physician order [REDACTED].) Monitor every shift until healed. Review of the pressure ulcer log, included: 8/15/13 -- A stage II, on the right gluteal, and noted as healed. 8/21/13-- No documentation noted. 8/30/13--Noted on 8/24/13 the above mentioned area, reopened and measured 0.8 x 1.4 cm, with notifications made on 8/24/13. 9/5/13--Stage II, on the right gluteal, measured 0.6 cm by 1 cm. Review of the nursing notes, from 8/26/13 to 9/12/13 failed to identify the condition/size/appearance of the wound, at the time of the dressing changes. On 9/9/13 at 1:07 PM, direct care staff T and I assisted the resident with toileting, and then transferred the resident with a mechanical lift onto the bed. Staff completed perineal care. Observation at this time of the resident's buttocks areas identified an approximate 2 cm, [MEDICATION NAME] to the right buttock. Direct care staff I reported the resident totally dependent of staff for all ADL's (activities of daily living) , including cueing to hold onto the rail during turning. On 9/11/13 at 5:30 AM, direct care staff U and licensed nursing staff G provided check and change toileting for the resident, with perineal hygiene provided. Licensed nursing staff G removed a rolled [MEDICATION NAME] dressing and cleansed the wound, measuring approximately 1.5 cm diameter area, with the top layer of skin missing. Staff G placed a [MEDICATION NAME] dressing to the area, then staff positioned the resident onto their left side. Direct care staff U reported the resident needed check and change toileting, and position changes every 2 hours for pressure relief. Direct care staff J reported on 9/11/13 at 2:16 PM, the resident always with a dressing to the buttocks area, for the past month or so. The resident typically turned side to side, needed a wedge behind the resident's back to aide in the resident remaining side lying, and needed pressure relieving devices to the bed and all chairs. On 9/11/13 at 2:41 PM, direct care staff K reported the resident had problems with pressure ulcers, needed turning side to side and is one of the last residents out of bed and back to bed following meals. Interview with licensed nursing staff Z, on 9/12/13 at 8:30 AM, identified the staff as the wound care nurse, worked 2-3 days per week, completing skin assessments, wound measurements, etc, and provided the measurements weekly, by e-mail to the management of the facility. Interview with administrative nursing staff A, on 9/12/13 at 9:45 AM, reported being unaware of any residents with pressure ulcers in the building, other than the 2 healed areas identified on the 8/21/13 Pressure Ulcer Log (for different residents). Staff A reported being unaware of this resident's pressure ulcer, and indicated staff failed to communicate these areas to them as the planned system. Licensed nursing staff Z reported, on 9/12/13 at 10:00 AM, the resident's pressure ulcer reoccurred recently, after being healed, and felt the area likely reoccurred due to inadequate turning and pressure relief. On 9/12/13 at 10:00 AM, administrative nursing staff A reported a lack of awareness the resident's wound reopened, as staff failed to report the information. Administrative nursing staff A further reported the licensed staff completing dressing changes are responsible for documenting in nursing notes, regarding the condition of the wound, and reported staff failed to document their findings. Interview with licensed nursing staff Z, on 9/12/13 at 2:00 PM, identified a problem with communication of changes/new pressure ulcers from the daily nursing staff. "A copy of the wound form, identifying the presence of a pressure ulcer/wound, is supposed to be put in the office for the skin nurse. However, that does not always happen. Some of the communication problem is still being worked on." The Skin Integrity/Wound Care program, undated,included instructions to provide a systematic approach and monitoring process for skin integrity/pressure ulcer care. The Pressure Ulcers, Prevention of policy, dated 12/9/10, included to prevent the development of pressure ulcers in residents whenever possible. Institution of measures to reduce the effects of pressure, friction, and shear. The facility failed to monitor and provide treatment and services to prevent reoccurrence of a pressure ulcer for this dependent resident. - The clinical face sheet, revealed resident #38, admitted on [DATE] to the facility. The annual MDS (minimum data set), dated 12/14/12, revealed a BIMS (brief interview for mental status) score of 9, indicating severely impaired cognition. The resident required for ADL's (activities of daily living) extensive staff assistance of 2 for bed mobility, transfers, toilet use, and required total dependency of staff for personal hygiene. The resident required a walker and a wheelchair, frequently incontinent of urine, at risk for pressure ulcers, no pressure ulcers currently, and with a pressure reducing device for the chair and bed. The CAAS (care area assessment summary), dated 12/28/12, documented the following: "Cognition: Resident unable to recall after 5 minutes as seen on mini mental. ADL's: Resident receives assistance with ADL's of 2 staff as seen on daily skilled nurses notes during assessment period. Pressure Ulcer: Resident at risk for pressure ulcers due to Braden scale and score of 14...Resident has pressure reducing mattress on bed with pressure reducing cushion in wheelchair see nurses notes on 12/17/12." The quarterly MDS 3.0 dated 8/30/13, revealed a BIMS score of 3, indicating severely impaired cognition. The resident required extensive staff assistance of 2 for bed mobility, transfer, toilet use, and dependent on staff for personal care. Mobility per wheelchair. The resident frequently incontinent, occasionally incontinent of bowel, at risk for developing a pressure ulcer, no current pressure ulcers, and interventions included pressure reducing device for chair/bed. The Braden Scale for Predicting Pressure Sore Risk Assessment, dated 6/15/13, with a score of 13 (a score of 12 or less represents HIGH RISK for pressure sore). The care plan reviewed last on 9/4/13, documented the following: "--I use 2 staff for all transfers. --I am usually continent but...I do wear pull-up type brief "just in case" I do need assistance to use the bathroom. If I do have an "accident", I will need your assistance. --Please help with me with cleansing myself if I have an "accident". --Alert my nurse if you notice any redness or irritation of my skin during my daily cares. --In order to keep me as continent as possible take me to toilet every 2-3 hours when I request and provide manage care as appropriate. --Proper alignment when I'm in my recliner, my buttocks to back of chair and use of pillows to left side." The Nurses Aide's Information Sheet (in the staff storage room), updated on 8/13/13, documented, "Be sure proper alignment in recliner with buttocks to back of chair, use pillow at left side. Turn and reposition every 2 hours, with 2 staff assistance. The Nurses Aide's Information Sheet (in the resident's room), updated 8/8/13, is the same information in the staff storage room. The Bath Aide Report Sheet, dated 8/23/13, documented the resident with bruises, but no other skin issues noted. The Nurses Skin Screening, dated 8/27/13, documented the resident with only old bruises to the elbows. The Bath Aide Report Sheet, dated 8/30/13, documented the resident with bruises and an open lesion, cuts, lacerations, abrasion noted to the right buttocks, and no skin ulcers. The Nurses Skin Screening, dated 8/30/13, documented the resident with a pressure ulcer, Stage II, to buttock; arms and hands with discolorations; and bruises to the elbows. The Pressure Ulcer Log, dated 8/30/13 documented the following: "Stage II, right gluteal (buttocks), 1.4 cm (centimeter) by 1.1 cm. Interventions: positioning pillows, application of dressing, turning/reposition program, and wheelchair cushion." The Bath Aide Report Sheet, dated 9/3/13, documented the resident unchanged from the previous assessment on 8/30/13, except now with reddened area to the coccyx. The Pressure Ulcer Log, dated 9/5/13, documented the following: "Stage II, right gluteal, 1.0 cm by 0.6 cm. Interventions: positioning pillows, application of dressing, turning/reposition program, and wheelchair cushion." The pressure ulcer log lacked documentation of the resident now with a Stage II pressure ulcer to the left gluteal. The Bath Aide Report Sheet, dated 9/6/13, documented the only change from the previous assessment on 9/3/13, as the resident without any reddened areas and does not have any [MEDICAL CONDITION], cuts, lacerations, or abrasions. The Pressure Ulcer Log, dated 9/12/13, documented the following: "Stage II, right gluteal, 0.1 cm by 0.1 cm. Interventions: positioning pillows, application of dressing, turning/reposition program, and wheelchair cushion." The physician orders, initiated 8/28/13, and signed on 8/30/13, for wound care to the resident's right gluteal documented, "Cleanse with wound cleaner/normal saline. Cover with [MEDICATION NAME]. Change every 3 days and prn (as needed). Monitor every shift until healed." The August, 2013, CMA (certified medication aide) Treatment Sheet, documented the 8/28/13 physician order. Checked at 6 AM on the 28th. This order then changed to the Nurses Treatment sheet, and documented the [MEDICATION NAME] to be changed on the 10-6 shift. The treatment nurse documented on 8/30/13, on 10-6 shift, the [MEDICATION NAME] to right gluteal replaced due to coming off. The September, 2013 Nurses TAR/MAR (treatment administration record/medication administration record), documented the following regarding the left gluteal area: "Open area to left gluteal. Clean with normal saline. Cover with [MEDICATION NAME], change every 3 days and prn (as needed). DC (discontinue) all treatment when healed." Start date of 9/2/13. Review of the Nurses MAR/TAR revealed on 9/2/13 on 2-10 shift, lacked documentation as treatment checked." The September, 2013 Nurses TAR/MAR, documented the following regarding the right gluteal area:" Wound care to right gluteal. Cleanse with wound cleanser/normal saline. Cover with [MEDICATION NAME]. Change every 3 days and prn. Monitor every shift until healed. Review of the Nurses MAR/TAR revealed on 9/2/13 on 2-10 shift, lacked documentation as treatment checked." The nurse's notes, dated 8/20/13 at 9:10 PM, documented, "Resident weekly skin assessment, scalp, face, etc., chest, abdomen, back, buttocks, hips, ankles and feet within normal limits. Arms and hands dry, with old bruise noted bilaterally. Legs dry, skin warm." The nurse's notes, dated 8/28/13 at 3:00 AM, documented, "Staff observed a stage 2 pressure ulcer on resident right gluteal. Measures 1.5 cm by 1.0 cm. Cleansed with wound cleanser/normal saline. Covered with [MEDICATION NAME]. To be changed every 3 days and as needed. Monitor every shift until healed. Physician order [REDACTED]. The nurse's notes, dated 8/29/13 at 8:59 AM, documented, "Prepared fax sent to physician regarding Stage II, right gluteal, 1.5 cm by 1 cm, cleanse with normal saline, cover with [MEDICATION NAME]. Awaiting response." The nurse's notes, dated 9/2/13 at 1:15 AM, documented, "Dressing changed to decubitus ulcer, [MEDICATION NAME] applied after cleaning with normal saline, to right gluteal." The nurse's notes, dated 9/3/13 at 3:30 AM, documented, "Rash (blister like) noted to groin, scrotum, and inner thighs. No open area's. Baza applied..." The nurse's notes, dated 9/5/13 at 9:00 AM, documented, "Received signed wound care form, dated 8/28/13 from physician regarding stage II." Observations, on 9/12/13 at 10:20 AM and 11:10 AM the resident rested quietly in a low bed. Lying on his/her left side with a pillow behind the resident's back. The wheelchair contained a 2 inch cushion in the seat and the recliner held a 1-2 inch cushion. On 9/12/13 at 11:30 AM, direct care staff J and N entered into the resident's room, asked the resident if he/she was ready to get up. The resident reported, "yes". Then they provided peri care to the resident. The resident noted with two, 2 cm disk of [MEDICATION NAME] to each gluteal (right/left) area with the date of 9/12/12 and staff initials. The resident then transferred using a gait belt and 2 staff to the wheelchair with a cushion. On 9/12/13 at 12:50 PM, direct care staff J and Y transferred the resident from his/her wheelchair to the toilet, with [MEDICATION NAME] noted as intact to the resident's buttocks. On 9/12/13 at 3:50 PM, direct care staff B and K repositioned the resident, from his/her left side to his/her right side. Observation revealed the right buttock a 2 cm [MEDICATION NAME] disk in place, while now the resident's left buttock lacked the [MEDICATION NAME], and no open areas noted on the resident's left buttock. On 9/12/13 at 8:30 AM, licensed nursing staff Z reported, "I work 2-3 days a week. I do the wound/skin assessments weekly, and turn in the report to the director of nursing per e-mail." On 9/12/12 at 9:45 AM, administrative nursing staff A reported, "I am unaware of the resident having a pressure ulcer. I had not received any newer pressure ulcer logs, than the 8/21/13 log." Discussed the 2 recent logs and he/she reported, "I did not know about these." On 9/12/13 at 12:05 PM, direct care staff J reported, "The resident has two areas (open areas) that is why there are two [MEDICATION NAME]. (He/she) got one shortly after the first one." On 9/12/13 at 12:10 PM, licensed nursing staff S reported, "The resident developed the other area (pressure ulcer, left gluteal) shortly after the first. The staff are to reposition (him/her) from one side to the other every hour. Then I have them get the resident up in (his/her) recliner because (he/she) likes to watch TV. The resident has a cushion to (his/her) wheelchair and bed. I have passed this on to the staff and the other shifts. The other shifts tell me they are doing this." On 9/12/13 at 12:30 PM, licensed nursing staff Z, reported, "All the beds have a therapeutic mattress." Check of the mattress revealed it is a therapeutic mattress. On 9/12/13 at 2:00 PM, licensed nursing staff Z identified a problem with communication of changes/new pressure ulcers from the daily nursing staff. A copy of the wound form which identifies the wound is to be placed in the office, however, (he/she) stated, "That doesn't always happen. Some of the communication problem is still being worked on. I am now to e-mail the director of nursing the wound log and give (him/her) a copy along with the dietary manager." On 9/12/13 at 2:14 PM, licensed nursing staff S reported, "I would fill out a wound form, send a copy to the doctor, then give a copy to licensed nursing staff Z. I would have a report with the CNA's, and notify the director of nursing when (he/she) comes in. I would keep monitoring the area, assess daily at least once a shift to make sure the [MEDICATION NAME] has not fallen off. The residents are laid down without briefs or pants. We have done this since I started here and I have asked the cognitive residents. They don't mind." On 9/12/13 at 4:15 PM, administrative nursing staff A reported, "No one knows how this pressure ulcer started. I have not done a root cause effect. That is with QAPI (quality assurance performance improvement). I don't know why it happened and have not looked into it because I did not know of it." The Skin Integrity/Wound Care Program, undated, included instructions to provide a systematic approach and monitoring process for skin integrity/pressure ulcer care. The Prevention of Pressure Ulcers policy, dated 12/09/10, documented, "It is the policy of this facility to prevent the development of pressure ulcers in residents whenever possible. Institution of measures to reduce the effects of pressure, friction, and shear." The facility failed to complete timely pressure ulcer monitoring to ensure proper care and treatments for healing of the resident's pressure ulcers.

The facility had a census of 40 residents, with 5 of the 21 sampled residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure these 4 sampled residents (#10, 12, 19, & 20) received adequate supervision and assistive devices to prevent accidents. Residents #10 and #19 experienced harm from falls with fractures, and resident #12 experienced harm from a fall with extensive bruising and swelling to the right lower jaw. Findings included: - Review of resident #10's face sheet revealed the facility admitted the resident to the facility on [DATE] and returned to the facility on [DATE] at 3:30 PM, following a fractured left hip with surgical intervention, and [DIAGNOSES REDACTED]. (progressive mental deterioration characterized by confusion and memory failure). Review of the 1/4/13 significant change MDS (Minimum Data Set) 3.0 Assessment recorded a BIMS (Brief Interview for Mental Status) score of 8 (a score of 8-12 indicated moderately impaired cognition), required extensive assistance of 2 staff with bed mobility, transfers, walking in the room/corridor did not occur, required limited assistance of 1 staff with locomotion on and off the unit, used a wheelchair, one fall since admission/entry or reentry or prior assessment, and 2 falls with major injury. Review of the Care Area Assessment Summary (CAAS), dated 1/22/13, triggered the following areas: Cognitive Loss/Dementia - Resident scored 8 on BIMS which indicated moderate impairment according to the RAI (Resident Assessment Instrument) manual. Very short term memory. Resident at times will not use call light to ask for assistance and when reminded, the resident will often state, "I just forgot". The resident thinks the resident can do things without assistance in regards to safety. Will care plan. ADL (Activities of Daily Living)Functional/Rehabilitation Potential - Secondary to falls with fractures in recent months resident does require 2 staff for all transfers, bed mobility, toileting, bathing as seen on daily skilled nurses notes during assessment period. Utilized a wheelchair for all mobility in and out of room at times propelled by staff. Will care plan. Falls - Receiving PT/OT (Physical Therapy/Occupational Therapy) services at this time related to fracture of hip and elbow. Resident has had 2 falls since last MDS. Had fall on 11/29/12 and was found on the floor with a result of right hip fracture and a fall on 1/1/13 that resulted in a fracture of the left elbow. Will care plan. The 5/10/13 quarterly MDS recorded a BIMS score of 7 (a score of 0-7 indicated severely impaired cognition), required extensive assistance of 2 staff with bed mobility, transfers, walking in the room/corridor did not occur, required limited assisted assistance of 1 staff with locomotion on and off the unit, used a wheelchair, one fall since prior assessment, and 2 falls with major injuries. The 6/20/13 re-admission MDS coded a BIMS score of 8, required extensive assistance of 2 staff with bed mobility and transfers, walking in the room/corridor did occur, required limited assistance of 1 staff with locomotion on and off the unit, used a wheelchair, hip fracture, UTI in the last 30 days, had a fall in the last month, had a fall in the last 2-6 months,and had a fracture related to a fall in the 6 months prior to admission/entry or reentry, Review of the 6/25/13 CAAS triggered the following areas: Cognitive Loss/Dementia - Resident at times will not use call light to ask for assistance and when reminded the resident will often state, "I just forgot". The resident thinks the resident can do things without assistance regards to safety. Will care plan. ADL Functional/Rehabilitation Potential - Secondary to falls with fractures in recent months resident does require 2 staff for all transfers, bed mobility, toileting, bathing as seen on daily skilled nurses notes during assessment period. Utilized a wheelchair for all mobility in and out of room at times propelled by staff. Will care plan. Falls - Resident has had a history of [REDACTED]. Resident has had 2 falls since last MDS. Had fall on 11/29/12 was found on floor with result of right hip fracture and fall on 1/1/13 that resulted in fracture of left elbow. Resident also fell on [DATE] with a left hip fracture. Will care plan. The care plan recorded the following: Intervention dated 11/30/12 - Increase staff assist and supervision when the resident displayed signs of increased confusion. Keep door of the resident's room open to increase supervision, monitor frequently every shift. Intervention dated 1/2/13 - Hourly fall safety checks - falling star reminder on the resident's door. Intervention dated 1/1/13 - Resident continues on PT (Physical Therapy). Therapist instructed non-weight bearing left arm. Intervention dated 1/4/13 - OT (Occupational Therapy) evaluation Intervention dated 1/4/13 - May have ROM (range of motion) to the left shoulder and elbow. Intervention dated 3/16/13 - Pressure sensitive talking bed alarm, daughter-in-law's voice stating the resident needed to push the call light before getting out of bed. Assure pressure sensitive talking bed alarm positioned under shoulders/upper body. The resident's 6/14/13 current care plan, located in the resident's clinical record, documented the following interventions: Need 1 staff to walk with me using my walker and gait belt. I sometimes will get up without asking for assist and/or using my call light Will use a wheelchair only on occasion when I'm feeling fatigued. Make sure the call light is within reach at all times when in room. Will need reminders to use it since I have problems with my memory. For fall interventions, staff recorded in the care plan the following interventions: Analyze previous falls by the resident to determine whether a pattern/trend can be addressed. Give the resident verbal reminders not to ambulate or transfer without assistance Use a wheelchair to transport the resident. Instruct family/significant others to ask for help with needs on the resident's behalf. The resident's 6/14/13 care plan failed to include the fall interventions from the previous care plan. The 6/26/13 care plan conference summary recorded the resident continues to have severe memory loss and has had multiple falls with major injury. Staff recorded the resident's fall risk remained high due to memory issues. Falls/safety - Keep resident in sight of help. Constantly remind the resident to ask for help and to use the call light. Staff recorded on the resident's 11/9/12 fall risk assessment, the resident with a score of 14 (a total score of 10 or above represents high risk for falls.) The next fall risk assessment found in the clinical record, with a date of 6/14/13, scored the resident with a score of 13 (a total score of 10 or above represents high risk for falls.) Staff recorded in the 1/1/3 nursing notes, at 1:45 AM, staff found the resident on the floor in the resident's bathroom Upon assessment, staff identified the resident's left elbow with edema (swelling resulting from an excessive accumulation of fluid in the body tissues) and bruising. Staff notified the resident's physician by fax at 8;28 AM, with a response from the physician at 5:10 PM, with an order to send the resident to the emergency room for an evaluation. The resident returned from the emergency room with a [DIAGNOSES REDACTED]. Staff recorded in the 1/26/13 nursing notes, at 8:45 PM, staff observed the resident sitting on the floor with the resident's back against the resident's bed. Upon assessment, staff identified a 2.5 cm (centimeter) by 4.5 cm bruise to the resident's upper middle back. Review of the previous care plan and the current care plan lacked evidence of interventions following this fall to prevent additional falls. Staff recorded in the 2/1/13 nursing notes, at 8:30 PM, staff observed the resident on the floor, sitting on the resident's buttocks in front of the resident's wheelchair. Upon assessment, staff identified redness to the resident's right lateral (pertaining to the side, away from the middle) thigh and to the left lower back. Review of the previous care plan and the current care plan lacked evidence of interventions following this fall to prevent additional falls. Staff recorded in the 2/28/13 nursing notes, at 10:05 AM, the housekeeper notified the nurse the housekeeper observed the resident slide off the resident's bed onto the resident's padded mat. Staff recorded the nurse found the resident sitting on the floor upon entering the resident's room. Upon assessment, staff identified no injuries. The resident stated, "I was trying to get out of bed into my wheelchair and my wheelchair moved so I slid onto the floor." Review of the previous care plan and the current care plan lacked evidence of interventions following this fall to prevent additional falls. Staff recorded in the 3/3/13 nursing notes at 10:15 PM, staff called the nurse to the resident's room. Upon entering the resident's room, the nurse found the resident on the floor, lying on the resident's right side on the mat alarm. The resident stated, "Was coming back from the bathroom." Upon assessment, staff identified no injuries. At 11:35 PM, staff assisted the resident to the resident's bed. Staff recorded the resident had right hip pain with ambulation and required 2 extensive assist with front wheeled walker and a gait belt. Staff recorded the resident had difficulty bearing weight on the resident's right leg. Staff notified the doctor, with an order to send the resident to emergency room for an evaluation for right hip pain. Staff recorded the resident returned to the facility on [DATE] at 2:35 AM with no fracture identified. Staff recorded a fall mat with alarm remains in place, the bed in the low position, and the call light in reach. Review of the previous care plan and the current care plan lacked evidence of interventions following this fall to prevent additional falls. Staff recorded in the 3/6/13 nursing notes, at 9:30 AM, the resident had difficulty standing and putting pressure on the resident's right side. Staff recorded the resident grabbing the right upper thigh and grimacing in pain. At 9:50 AM, staff notified the physician of the resident's pain with an appointment scheduled at 1:30 PM. At 5 PM, the resident returned to the facility with physician's orders [REDACTED]. Review of the previous care plan and the current care plan lacked evidence of interventions following this fall to prevent additional falls. Staff recorded in the 3/16/13 nursing notes, at 10 AM, a bed alarm installed with a voice command. Staff implemented this intervention 10 days after the 3/6/13 fall which resulted in a fine fracture of the resident's upper femur (the thigh bone). Staff recorded in the 3/17/13 nursing notes, at 1:30 AM. the resident continues on hourly checks, a new voice command floor alarm in place, and a mat alarm also in place. A nurse aide information sheet reviewed on 5/15/13 recorded, "Hourly fall safety checks, Falling star reminder on door, fall prevention - pressure sensitive floor mat - place by bed or chair - alarms call light. Pressure sensitive talking bed alarm tells resident to push call light. 2 staff for transfers with gait belt. Wheelchair for all locomotion, can self propel. Mental status oriented to person, agitated at times, forgetful, alert. Staff recorded in the 5/16/13 fax to the physician, at 7:20 PM, the resident sat down on the floor in front of the resident's toilet. Upon assessment, staff identified no injuries. Review of the previous care plan and the current care plan lacked evidence of interventions following this fall to prevent additional falls. Staff recorded in the 6/9/13 nursing notes, at 1:15 PM, the resident fell while transferring self from the toilet to the wheelchair. Upon assessment, staff identified no apparent injuries, and the resident denied any pain. Staff performed range of motion and recorded range of motion within normal limits. Staff notified the resident's family and physician. Staff placed a personal alarm on the resident. At 4:06 PM, staff recorded hearing the resident screaming down the hall, "Help me." A nurse recorded observing the resident complaining of extreme left hip pain. Staff recorded the medication aide gave the resident Lortab (pain medication) at 2:30 PM with effectiveness. The nurse palpated the resident's left hip without the resident wincing. Staff recorded the resident's left foot turned out and the left leg shorter than the right leg. Staff recorded the resident stated having pain in the inguinal area. Staff paged the resident's physician, with an order to send to the emergency room for an evaluation. Staff recorded emergency medical services arrived at 4:01 PM. At 6:15, staff recorded the hospital staff called to inform the facility the resident transferred to a Wichita hospital for surgery for [REDACTED]. On 6/14/13, staff recorded the resident returned to the facility after surgical repair of a fractured left hip. The 6/14/13 Nurse Aide Information Sheet recorded, "Med (Medicare) A PT/OT (Physical Therapy/Occupational Therapy), weight bearing as tol. (tolerated) 2/1 (2 to 1 staff) assist, gait belt, walker, wheelchair. Staff for mobility out of room. Hip precautions. Abduction pillow. Use pivot pad for transfers. Floor pad. Alarm." The 7/13 Nurse Aide Information Sheet recorded the resident on Med A for PT/OT and elopement potential. On 7/22/13 at 4 PM, observation revealed direct care staff T waiting in the resident's room for another staff to come and help this direct care staff member assist the resident to the wheelchair. At 4:30 PM, direct care staff O came into the resident's room, applied a gait belt to the resident, as the resident sat in the recliner. Staff assisted the resident to stand on a pivot pad to assist with the transfer from the recliner to the wheelchair, took the resident in the wheelchair to the resident's bathroom, and transferred the resident to the toilet. During these cares, the resident repeatedly asked when the resident broke the resident's hip. At 4:27 PM, after providing perineal care, the direct care staff members transferred the resident back into the wheelchair, attached the personal alarm to the back of the resident's top, and transported the resident in the wheelchair to the dining room. On 7/23/13 at 7:20 AM, observation revealed the resident in the dining room in a wheelchair with a personal alarm attached to the back of the wheelchair and the back of the resident's upper garment. On 7/23/13 at 8:16 AM, observation revealed the resident in the wheelchair in the door of the resident's bathroom. Then the resident propelled self out of the bathroom doorway into the resident's room and then back to the bathroom doorway. At 8:21 AM, the resident's personal alarm sounded. Licensed staff U immediately responded to the alarm and reattached the personal alarm to the alarm box, attached to the back of the wheelchair. At 8:27 AM, direct care staff V and M came into the room, applied a gait belt, and used the pivot pad on the floor to the transfer the resident from the wheelchair to the toilet. At 8:33 AM, after performing perineal care, these direct care staff transferred the resident from the toilet to the resident's wheelchair. The resident informed the staff the resident wanted to lay down in bed. At 8:38 AM, staff applied a gait belt on and transferred the resident from the wheelchair to the bed. Staff failed to use the pivot pad for the transfer. The resident's bed alarm sounded when the resident sat down on the bed. Staff clipped the personal alarm to the head board of the resident's bed and to the left shoulder of the resident's upper garment. Staff applied an abduction pillow placed between the resident's legs. Staff placed a floor mat on the floor on the left side of the resident's bed. Direct care staff M demonstrated how the floor mat worked by stepping on the floor mat, an alarm sounded and the corridor call light went off. Staff failed to lower the resident's bed to the low position. On 7/23/13 at 2:27 PM, observation revealed a blue falling star taped to the outside of the resident's door. Observation revealed the resident asleep in the recliner with the resident's feet elevated, a personal alarm clipped to the resident, and the fall mat under the foot rest of the resident's recliner. On 7/22/13 at 4 PM, direct care staff U stated the resident fell prior to this direct care staff's employment at the facility. This direct care staff stated, "(The resident )has a fall pad with alarm, sensor pad alarm in bed that talks, and a personal alarm in (the resident's) chair. (The resident) is 2 person assist with transfers. We use the abduction pillow when (the resident) is in bed." On 7/22/13 at 3:30 PM, licensed staff E stated, "(The resident) is confused, disoriented and very forgetful. (The resident) is getting PT and OT. (The resident) has a floor mat and a personal alarm. (The resident) has had these quite some time. The personal alarm was the last thing added. The CNAs (certified nurse aides) have a care plan on the resident's bathroom door and in the cardex in the treatment room." On 7/23/13 at 7:50 AM, direct care staff L stated, "(The resident) had some falls. (The resident) has a sensor mat on the floor with an alarm which sets off the call light, a personal alarm, a talking alarm on the bed. I think the personal alarm was added. We do hourly checks on (the resident) and chart on a paper on (the resident's) bathroom door." On 7/23/13 at 8:40 AM, direct care staff M stated, "(The resident's) bed is in the low position mainly at night." On 7/23/13 at 10:58 AM, administrative licensed staff B stated, "Fall assessments should be completed on admission, hospital return, re-admission, quarterly, annually, and significant change. (The resident's) previous care plans were before my time..." On 7/23/13 at 11:23 AM, licensed staff D stated, "(The resident) propels self in (the resident's) wheelchair. (The resident) did not have a personal alarm in place at that time (in reference to the 6/9/13 fall.) (The resident) was sitting in the bathroom, knees down. (The resident) stated (the resident) was getting off the toilet. (The resident's) ROM (range of motion)was WNL (within normal limits). We lifted (the resident) back into the wheelchair and then back to bed. (The resident) said (the resident) was not hurting at all. I started the incident report. I don't know if anything was added for interventions. (The resident) already had hourly checks in place, a floor mat with alarm, and a talking bed alarm. Now (the resident) has a personal alarm on..." On 7/23/13 at 2:08 PM, direct care staff W stated, "I was walking down the hall to pass meds (medications). (The resident) has a habit of closing the door when (the resident) is in the wheelchair. I opened (the resident's) door and I couldn't see (the resident). I went into (the resident's) room. (The resident) was in front of the toilet on the floor. (The resident) had fallen. (The resident) stated (the resident) had lost (the resident's) balance and fell down. I told (the resident) to stay put, got the nurse, and (the nurse) did ROM which was OK. (The resident) didn't have a personal alarm at that time. The PA (personal alarm) was applied after the fall. At that time of the fall, (the resident) had a talking bed alarm, a floor mat with alarm on the floor, and hourly checks. (The resident) propels self in the wheelchair. (The resident's) bed should be in the low position whenever (the resident) is in bed." On 7/24/13 at 9:45 AM, administrative licensed staff B verified the facility failed to initiate interventions after the falls on 1/26/13, 2/1/13, 2/28/13, after the resident fell on [DATE] with a fractured right hip, no intervention implemented after the 5/16/13 fall to the floor, and then the resident fell on [DATE] with a fractured left hip. On 7/24/13 at 11:20 AM, licensed staff D stated we do not have a policy for the falling star program as it was from the former administration and we have not been initiating it as a new intervention for falls. The facility's fall prevention policy, revised on 6/2013, recorded, "It is the policy of (name of facility) to identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury...Every resident will be evaluated for falls upon admission and subsequently thereafter when the resident's condition changes or at least quarterly...Based on the results of the falls assessment, the interdisciplinary team will determine the best approach to implement for fall prevention, adjust the care plan...and implement comprehensive fall prevention management approach...Any resident experiencing a pattern of falls...or an injury from a fall will be referred for a falls assessment to be completed by the nurse or therapist..." The facility failed to ensure this sampled resident received adequate supervision and assistive devices to prevent accidents. The resident experienced 7 falls in a period from 1/1/13 to 6/9/13 and experienced harm as 3 of these falls resulted in fractures. The facility failed to implement interventions following the falls on 1/26/13, 2/1/13, 2/28/13, and then the resident fell on [DATE] and sustained a right femur fracture. The facility failed to implement interventions for 10 days after this fracture. The facility failed to implement interventions following the fall on 5/16/13, and the resident fell on [DATE] and sustained a fractured left hip. In addition, the facility failed to evaluate the resident's fall risk, in accordance to the facility's policy. The facility only evaluated the resident's fall risk on 11/9/12 and 6/14/13. - The clinical record face sheet revealed resident #12, readmitted on [DATE], with the following diagnosis; psychosis (any major mental disorder characterized by a gross impairment in reality testing), anxiety state (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness and hopelessness), osteoporosis (disorder characterized by abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The annual MDS (minimum data set), dated 1/11/13, revealed the resident had a BIMS (brief interview for mental status) score of 9, indicating moderately impaired cognition. The resident with behavioral symptom of rejection of care for 1-3 days, and the behavior is worse. The resident is independent in ADL's (activities of daily living). The resident's balance is steady and used a walker for mobility. The resident is frequently incontinent of urine and always continent of bowel. The MDS documented no falls since prior assessment. The resident received an antipsychotic, antianxiety, and antidepressant medication. The quarterly MDS 3.0 dated 4/25/13, revealed the resident had a short term/long term memory problem, and moderately impaired decision making. The resident had inattention continuously, disorganized thinking, and altered level of consciousness, which fluctuates. No behaviors documented. The resident continued to be independent in ADL's, balance is steady and used a walker for mobility. The resident continued to be frequently incontinent of bladder and always continent of bowel continence, no falls since prior assessment. The resident continued to receive an antipsychotic, antianxiety, and antidepressant medication. The CAAS (care area assessment summary), dated 1/25/13, and the CAT (care area triggered) work sheet revealed the following: -ADL's: "Resident mainly independent with ADL's, but does require prn (as needed) assistance with reminders and cues for hygiene and assistance with bathing." -Falls: "Resident has history of falls and of not using walker. Resident has had no falls since last MDS..." The Fall Assessment, dated 10/19/12, with a score of 7, a score of 10 or more represents HIGH RISK. (The record lacked any Fall Assessments since 10/19/12). A skin assessment, dated 7/17/13, documented, Bruising to chin and right cheek with slight edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Right upper arm continues with bruising, related to recent fall. No open areas. Lacks documentation of the size of the bruising to right cheek and right upper arm. The care plan, reviewed 5/8/13, documented the following: The resident has a potential for falls related to medications and mental state: --Assist resident with ambulation, transfers as needed. --Place call light in easy reach, and remind him/her to use when needing assistance. --Keep floor clear of clutter. --Report and document all falls per facility protocol. --PT (physical therapy) services as ordered by physician. The care plan without new intervention for falls on 6/14/13, 7/11/13 and 7/17/13. The resident has potential for alteration in cognitive status related to [DIAGNOSES REDACTED]. --Allow resident sufficient time to answer questions. --Listen attentively --Ask resident to repeat statement --Praise resident for efforts and accomplishments. --Provide calm, unhurried environment. --SSD will visit 1:1 1 or 2 times a monthly for verbalization and to voice concerns. The current CNA (certified nurse aide) information sheet and care plan, documented the following: Resident gets up around 6:30 AM by self and goes to bed per daily choice. Bladder: -independent with prompts and assist prn, managed care prn, wears pull ups. -continent. -incontinent at times. -assist with 1 staff as resident request. Bowel: -bathroom. -continent, monitor for resident flushing briefs/wipes. -assist as resident request. Eye sight: -good -wears glasses. Locomotion: -walks with walker. -1 assist as resident requests. -fully ambulates as tolerated. Privileges: -up ad lib. Mental: -oriented at times. -confused at times. -agitated at times. -forgetful at times. -depressed at times. -moody at times. -alert. Nurses notes, dated 6/14/13 at 10:00 AM, documented, "Staff alerted this nurse that resident was on floor. Resident was found kneeling at his/her doorway with front wheeled walker in front of him/her. Resident was assisted back to his/her recliner. No injury was apparent but resident stated, 'he/she bumped the back of his/her head. Neuro checks were initiated. Vital signs within normal limits, see graphic. DPOA (durable power of attorney) and spouse notified. Will notify 2nd shift charge nurse to notify doctor, as he/she hasn't answered his/her cell times 3." The nurses notes, dated 6/14/13 at 5:30 PM, documented,"Resident complained of pain left leg/hip, refuses to bear weight. physician on call paged. Telephone order received, sent to the emergency room at hospital for X-ray left leg/hip, status [REDACTED]. Spouse takes resident to emergency room ..." The nurses notes, dated 6/14/13 at 8:45 PM, documented, "The resident returns from the emergency room with [DIAGNOSES REDACTED]. Four, Narco 5 mg (milligram), sent with resident from the hospital emergency room (given to CMA). Resident alert and oriented, denies pain at this time." On 07/24/13 at 9:45 am, the surveyor requested the facility investigation, and asked whether the facility had reported this fall. Administrative nursing staff B reported, "Did not know about the fall, so no report or investigation done, or the care plan updated." Nurses notes, dated 7/11/13 at 4:30 PM, documented, "The resident observed on floor by Administrative nursing staff, a 0.5 cm (centimeter) laceration to right upper lip. Pressure applied due to bleeding. Bruising noted to chin, right shoulder, and bilateral (both) arms. Active range of motion to all extremities, and neuro checks initiated. At 4:56 PM, call placed to doctors office to notify of fall. Left message to have doctor call this nurse back. At 5:03 PM, call placed to resident's DPOA to notify of fall, voiced understanding. At 5:05 PM, Doctor returned call. Notified of resident observed on floor at 4:30 PM. 'Noted' telephone order 1.) Apply ice pack to right upper lip PRN (as needed). [DIAGNOSES REDACTED]. At 5:10 PM, DPOA notified of order above. Incident on July 11, 2013: The witness statement, dated June 11, 2013, documented the following: "I (Administrated staff D) was in my office and heard a faint voice saying 'Somebody please help me!' I went to investigate and found resident face down on his/her floor inside his/her closet with a blouse and sweater next to him/her. There was a moderate amount of blood on the floor around his/her head. I called out to CNA for assistance and started assessing the resident. Resident rolled to supine (lying horizontally) position with assist and blood was coming from right upper lip. Range of motion done and within normal limits without complaints of pain. Resident states, 'face hurts'. Face cleaned up and resident assisted off floor with Hoyer lift. Licensed nurse J took over from there." The nurses notes, dated 7/12/13 at 4:15 AM, documented,"The resident observed resting well. Continues with neruo (neurological) checks at this time. Denies complaints of pain at this time. Will continue to monitor." The nurses notes dated 7/13/13 at 12:35 AM, documented, "The resident tearful, incontinent of urine in bed, linens changed. Scab to right upper lip. Resident states 'I'm not lying' over and over and also 'I didn't mean to.' Very emotional and paranoid. At 8:00 AM, documented, "Resident continues on FFU (fall follow up) with neuro's. Resident with complaints of upset related to incontinent episode thru noc (night). Reassurance offered, routine Xanax for anxiety given. Up to dining room for breakfast. At 7/13/13 at 9:50 PM, Resident continues on fall follow up with neuro. No complaints notes. Vital signs as graphed on flow sheet." The nurses notes, dated 7/14/13, at 1:30 AM, documented the following, "Appears to rest well, vital signs stable. Continue fall follow up. Vital signs stable and neuro checks within normal limits. Continue to have bruising to chin and bilateral arms, scab noted to upper right lip. At 7/14/13 at 7:30 PM "...Completed fall follow up. Vital signs as graphed on flowsheet. The documentation lacked measurement documentation of the bruising." The nurses notes, dated 7/15/13 at 1:20 PM, "Resident was found lying on the floor of bathroom, in his/her room, by adjoining roommate. Resident was kneeling in front of walker, that was laying on floor. Nurse assessed resident, vital signs within normal limits, denies complaints of pain, ambulated to bed. Nurse notified residents DPOA and doctor. At 7:10 PM, "Resident continues on fall follow up. No complaints noted. Vital signs as graphed on flowsheet. Will continue to monitor." At 11:45 PM, "Resident complains of back hurting. Rates pain as an 8 on a 1-10 pain scale. PRN : Lortab 5/500 mg (milligrams) one by mouth given to resident by this nurse. Resident continues on fall followup with no new injuries noted related to fall on 7/15/13." Incident on July 15, 2013, documented the following: -The facility incident/accident report, dated 7/15/13,

The facility had a census of 40 residents, with 21 residents reviewed of which included one resident (#48) reviewed for pressure ulcers. Based on interviews and record review, the facility failed to ensure this resident who entered the facility without a pressure ulcer did not develop a pressure ulcer. The resident developed 2 Stage II avoidable pressure ulcers on the right foot while a resident in the facility. Findings included: - Review of resident #48's closed record face sheet revealed the facility admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the 4/10/13 admission MDS (Minimum Data Set) 3.0 Assessment recorded a BIMS (Brief Interview for Mental Status) score of 9 (a score of 8-12 indicated moderately impaired cognition), independent with bed mobility, required supervision with transfers and walking in the room, required limited assistance of 1 staff with walking in the corridor, locomotion on and off the unit, no mobility devices marked, the resident not at risk of developing a pressure ulcer, currently had no pressure ulcer, skin tears marked, and applications of ointments/medications marked. Review of the Care Area Assessment Summary (CAAS), dated 5/6/13, revealed pressure ulcers did not trigger. The 4/19/13 14 day MDS identified the resident as independent with bed mobility and transfers and walking in the room, required limited assistance of 1 staff with walking in the corridor, and locomotion on and off the unit, no mobility devices marked, not at risk for developing a pressure ulcer, currently had no pressure ulcer, and a lesion on the foot marked. The 5/3/13 discharge MDS identified the resident with no pressure ulcers. The 4/3/13 nurse aides' information sheet, also used as the initial care plan, recorded the following: Self - turn and position, continent of bowel/bladder, independent with walking in the room, 1 staff assistance with a gait belt, fully ambulates out of room with assistance, to the bathroom up ad lib, oriented, alert and well adjusted, assistance with dressing, assistance as needed with grooming; Medicare Part A, needs to sit up for 30 minutes after each meal. Remind the resident to use the call light for help. No special equipment or supportive equipment (i.e. pillows, special mattress, foam rubber) marked. A notation on the back of this information sheet revealed this form reviewed on 4/17/13. The clinical record lacked documentation the facility developed further interventions after the development of the pressure ulcer. The resident's 4/3/13 Braden scale (an assessment to identify residents at risk for the development of a pressure ulcer) recorded a score of 22 (a total score of 12 or less represents high risk). Staff recorded the resident not at risk for the development of a pressure ulcer. The clinical record lacked any documentation facility staff completed routine skin assessments with bathing to identify problem areas timely. The 4/3/13 admission nursing notes at 11:15 AM recorded the resident's skin warm and dry, no skin breakdown noted. At 12 noon, the resident scored a 22 on the Braden scale, at very low risk to develop pressure sore due to ability to move freely in bed and reposition self as needed. Review of the 4/13 TAR (Treatment Administration Record) revealed the following: 4/14/13 - Wound care: Nursing order to apply skin repair cream to bilateral feet and ankles BID (twice a day) for dry skin. On 4/23/13, the physician changed the order to [MEDICATION NAME] Cream to feet, twice a day, for 7 days for tinea pedis (chronic superficial fungal infection of the feet). Review of the TAR revealed the [MEDICATION NAME] Cream treatment discontinued on 4/30/13. Staff initially recorded on the wound report of 4/17/13 (14 days after admission) a new Stage II pressure ulcer to the right lateral (pertaining to the side, away from the middle) foot which measured 0.3 cm (centimeters) by 0.3 cm with serosanguinous (wound drainage of a semi-thick reddish fluid) drainage and dressing of Duoderm, change every 3 days and as needed. Staff recorded in the 4/17/13 nursing notes, at 8:20 PM, an open area to the resident's right lateral ankle (0.4 cm x 0.4 cm) cleanse with NS (normal saline), cover with Duoderm, change every 3 days and prn (as needed), monitor every shift till healed. Also, an open area on the right lateral foot (0.3 cm x 0.3 cm), cleanse with normal saline, cover with Duoderm, change every 3 days and as needed, monitor every shift until healed. On 4/18/13, staff faxed the physician on a physician's standing order form for wound care of the right lateral foot with measurements of 0.3 cm x 0.3 cm, cleanse with normal saline and cover with Duoderm, change every 3 days and prn, monitor every shift until healed and right lateral ankle, measurements of 0.4 cm x 0.4 cm, cleanse with NS, cover with Duoderm, change every 3 days and prn, monitor every shift until healed. Staff recorded in the 4/21/2 nursing notes, at 1:30 AM, the resident reported the right foot felt better since putting the Duoderm on. Staff recorded in the 4/24/13, at 2:15 PM, a right ankle red abrasion area 0.4 cm x 0.4 cm. Stage II pressure ulcer to right lateral foot measured 0.3 cm x 0.3 cm and 0.1 depth, continue to monitor every shift and cover with Duoderm. Nurse asked the resident if the resident's shoes rubbed the resident's feet wrong, and the resident said, "No. I've had those shoes for about 3 or 4 months." At 4 PM, staff faxed the resident's physician to continue the Duoderm treatment, and the physician approved the continued treatment. Staff recorded in the 4/27/13 licensed skilled nursing notes, on the night shift, Duoderm to the right outer foot and the right ankle. Staff recorded in the 4/28/13 licensed skilled nursing notes, on the night shift, Duoderm to the right ankle and the right lateral foot due to pressure areas. Staff recorded in the 4/29/13 licensed skilled nursing notes, on the night shift, Duoderm to open pressure areas to the right ankle and the right lateral foot. The resident's bilateral heels off loaded on pillows by staff. Staff recorded in the 5/1/13 licensed skilled nursing notes, on the night shift, Duoderm to the right outer foot and ankle. Staff recorded in the 5/2/13 licensed skilled nursing notes, on the night shift, Duoderm to the pressure areas to the right lateral foot and the right lateral ankle. The resident's right foot off loaded on pillow by staff. Staff recorded in the 5/3/13/ licensed skilled nursing notes, on the night shift, Duoderm to the lateral ankle and the left lateral side of foot related to pressure areas. Staff recorded in the 5/3/13 nursing notes the resident discharged to home with spouse. Review of the resident's clinical record lacked evidence of any wound measurements after the measurements recorded in the 4/24/13 nursing notes which recorded the right lateral foot pressure area had deteriorated with a depth of 0.1 cm. On 7/22/13 at 12:50 PM, direct care staff BB reported the resident required assistance of 2 staff for transfers, and added, "(The resident) was able to turn in bed by (the resident's) self.". On 7/22/13 at 3:15 PM, licensed staff E verified the resident lacked a pressure ulcer on the resident's foot when staff admitted the resident to the facility. This licensed staff stated, "(The resident was in bed quite a bit. I don't recall if (the resident) had a pressure reducing mattress on (the resident's bed). I am the wound nurse and try to measure wounds weekly. (The resident) had a stage II pressure ulcer on (the resident's) right lateral foot with Duoderm dressing to be changed every 3 days and as needed. The area developed from pressure. Initially, the area had no depth but then developed some depth." The facility's undated policy for prevention of pressure ulcers recorded, "...Preventive Actions;...Use pillows or wedges to keep...ankles from touching each other. When in bed, place pillow under legs from mid-calf to ankle to keep heels off the bed...Additional items and indicators on the MDS assessment form that identify residents at risk of pressure ulcer development include...Diabetes..." The facility failed to ensure this resident did not develop a pressure ulcer while in the facility. The resident, admitted to the facility without a pressure ulcer. The facility failed to perform routine assessments of this resident's skin condition. The resident developed 2 stage II pressure ulcers to the right foot 11 days after admission to the facility. This resident experienced harm due to the lack of assessment and the development of these facility acquired stage II pressure ulcers.

The facility reported a census of 39 residents, with 3 selected for review. Based on observation, interview, and record review, the facility failed to ensure adequate supervision and/or assistive devices to prevent repeated accidents for 1 selected resident #01, who sustained a fractured hip and then a fractured elbow during consecutive falls. Findings included: - Resident #01's medical record facesheet, documented admission to the facility on [DATE], and included diagnoses; Alzheimers disease (A progressive mental deterioration characterized by confusion and memory failure.), fracture of right greater trochanter (Fractured hip). The admission MDS (minimum data set) assessment, dated 2/13/12, documented a BIMS (brief interview for mental status) score of 4 indicating severe cognitive impairment, and resisted assistance with cares on 1-3 days per week. The resident required limited assistance of 1 staff for all ADLs (activities of daily living needs), except being independent with eating. The assessment further identified the resident's balance during transitions/walking, as not steady, and only able to stabilize with human assistance. The assessment documented no limits in the resident's range of motion ability. The resident used a walker and a wheelchair for mobility and experienced no falls since admission to the facility. The significant change in status, MDS, dated [DATE], and the quarterly MDSs dated 5/25/12 and 8/17/12, documented no changes in cognition/behaviors, However, the resident's balance during transitions/walking, improved then declined, but the resident never able to stabilize without human assistance. The resident used a walker without the use of a wheelchair and then again required the use of a wheelchair. However, the assessments documented the resident sustained [REDACTED]. The quarterly MDS, dated [DATE], documented, the BIMS score lowered to 6, indicating severe cognitive impairment, and without behaviors. The resident required limited assistance of 1 staff for dressing/toileting/hygiene, but independent at that time with bed mobility, transfers, and walking. The resident's balance during transitions and walking documented as steady at all times. The resident received no pain medications or indicated any signs of pain. However, the resident sustained [REDACTED]. The plan of care, dated 11/21/12, included the following interventions: 1.) "I had a fall with the result of a hip fracture prior to my admission to this facility." 2.) "3/12/12, I prefer to walk by myself even though for my safety I need someone to walk with me. Keep an eye on me and if you see me having difficulty, walk with me." Written in, and crossed out dated 11/30/12. 3.) "4/23/12, Check on me routinely to make sure I am safe, my needs are met. Remind me to use my call light for help." 4.) "9/24/12, Increase assistance with transfers/ambulation/mobility as required due to fall, c/o (complaints of) pain right side." Written in, and crossed out, dated 11/30/12. Nurses notes, dated 11/29/12 at 8:30 PM, documented, "Resident found by CNA (certified nurse aide) on floor in front of (his/her) recliner. Resident stated that (he/she) thinks that (he/she) slipped off onto floor... ROM (range of motion) done, moving all extremities. Resident complains of some right knee pain but was able to bend and extend right leg with difficulty. 325 mg (milligrams) Tylenol (2) given for discomfort. Neuro checks initiated, fax prepared to be sent to (the physician) during regular business hours. No injuries." Nurses notes, dated 11/29/12 at 2400 (12:00), documented, "Assisted resident to BR (bathroom) with 2 extensive assist per wheelchair. Resident with pain to right knee/leg and swelling noted to RLE (right lower extremity). Has difficulty bearing weight to right leg... Confused, asks, 'Does my (child) know I'm here?'" Nurses notes, dated 11/30/12 at 8:40 AM, documented the facility staff notified the resident's physician and received orders to send the resident to the emergency room for x-ray of the leg. The resident left per ambulance for the hospital at 9:00 AM. Nurses notes, dated 11/30/12 at 11:00 AM, documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. The emergency room physician gave new orders for non-weight bearing to the right leg for 1 week, to follow-up with the resident's primary care physician, and for Norco (Narcotic pain medication) every 4 hours as needed for pain. On 1/31/13 at 12:00 PM, direct care staff O reported prior to the fall on 11/29/12, the resident would take themselves to the bathroom during the night. On 1/31/13 at 7:00 PM, per telephone, direct care staff D reported at the time of the resident's fall on 11/29/12, the staff would do checks on the residents every 2 hours, and attempted to take the resident to the bathroom at those times. Following the resident's fall on 11/29/12, with hip fracture the facility updated the resident's plan of care as follows: Additions dated 11/30/12, included; 1.) "Increase staff assist and supervision when I display signs of increased confusion." 2.) "Non-weight bearing right leg, transfers with 2 staff assist/gait belt. May use pivot board (pivot with lift). Wheelchair for mobility." Written in, and crossed out, dated 1/4/13. 3.) "12/7/12, PT (physical therapy) to strengthen muscles right hip and leg. Help in ambulation." Nurses notes, dated 12/31/12 at 10:10 AM, documented, "...x2 (two staff) limited assistance for transfer, toileting and bed mobility, w/c (wheelchair) with staff assistance to DR (dining room). B/B (bowel/bladder) continent and incontinent at times. Wears brief." Nurses notes, dated 1/1/13 at 1:45 AM, documented, "Resident with call light on. Found on floor by CMA (certified medication aide). States (he/she) was getting back from BR (bathroom) and tripped, w/c and walker were tangled up per CMA. Left elbow pain, edema noted to tip of left elbow, elbow with ROM (range of motion) intact. No other injuries noted. Was last seen in bed at 12:40 AM by this nurse. Resident very forgetful. No short term memory. Reminded again to call for assist and showed how to use call light...." Nurses notes, dated 1/1/13 at 6:00 AM, documented, "Fax prepared to be sent to (the resident's primary care physician) related to the resident's fall and left elbow injury/edema/bruising. To be sent during office hours." Nurses notes, dated 1/1/13 at 6:12 PM, documented the facility staff called the hospital and paged the physician, who provided orders to send the resident to the emergency room for evaluation of the left arm. The facility staff sent the resident to the emergency room at 7:01 PM, per the facility company vehicle. Nurses notes, dated 1/2/13 at 12:00 PM, documented, "Discharge instructions from ER (emergency room ) visit 1/1/13, found in front cover of chart. Resident form, x-ray was done. Avulsion fracture of left elbow, sling to left arm, hold in place with ace to remind patient not to move arm...." Nurses notes, dated 1/2/13 at 12:20 PM, documented, "...Initiated hourly fall safety checks with falling star symbol reminder for door of room." The significant change in status MDS, dated [DATE], documented a BIMS score of 8, indicating moderate cognitive impairment, with rejection of cares on 1-3 days per week. The resident required extensive assistance of 2 staff for bed mobility, transfers, toileting, did not walk and used a wheelchair. The resident required extensive assistance of 1 staff for hygiene and dressing, and limited assistance of 1 staff for locomotion. The resident's balance during transitions included not steady, only able to stabilize with human assistance. The resident received pain management medication, and reported occasional pain at scale of 6 out of 10. The resident sustained [REDACTED]. The resident's current care plan included: 1.) "1/2/13, Hourly fall safety checks. falling star reminder on resident's door." 2.) "1/4/12, May weight bear right hip." The plan of care lacked appropriate interventions to provide adequate supervision and assistive devices to prevent further falls for the resident. On 1/30/13 at 9:35 AM, administrative licensed nurse J provided a resident roster with identified residents with falls/accidents in November and December, 2012 and also January, 2013. Staff J identified these residents and then also identified dated incidents with injury. This roster identified the resident with a fall on 1/26/13, and identified a bruise to the mid back. In reference to further questioning, related to the resident's incidents of falls on 11/29/12 and 1/1/13, which resulted in fractures, staff J explained, "I just missed those incidents on the list. (Another staff member) helped me to log/track the residents incidents." On 1/30/13 at 10:15 AM, the resident sat in the bedside recliner with feet elevated. The resident reported they had fallen lately and stated, "I just can't seem to stay on my feet anymore. Sometimes I use the walker and sometimes I use the wheelchair." The resident expressed inability to remember anything specific about either of the two falls which caused the fractures, except that, "They hurt." The resident's room contained laminated signs hanging from the walker and from the bedside table, to remind the resident not to get up unassisted and to call for help. On 1/30/13 at 1:50 PM, consultant staff P assisted the resident with exercises in the resident's room at the bedside. Staff P assisted the resident to stand from the wheelchair with a gait belt to sit on the edge of the bed. Staff P instructed the staff to scoot themselves forwards towards the edge of the bed and the resident struggled to complete this task until staff P provided assistance. Staff P then instructed the resident to push themselves up from the bed with their hands/arms to a standing position but the resident again required assistance and reported pain in the right upper hip region. Staff P explained working with the resident for approximately the prior 2 weeks and the resident repeated they had not fallen when explaining the right upper hip pain. Staff P then assisted the resident onto the bed to rest. On 1/30/13 at 5:35 PM, direct care staff L and M entered the resident's room to provide cares. The resident rested on the bed quietly. The staff assisted the resident to roll onto the side and a skin check revealed a fading darkened bruise to the mid back area, approximately 4 inches in diameter. The staff assisted the resident from the bed and onto a bedside commode, following the resident's request for the bathroom. The resident complained of pain in the right upper hip/lower rib area during cares. Staff L called licensed nurse Q to the resident's room to check on the resident's pain. Staff Q reported no knowledge of a fall or the fading bruise to the resident's mid back. Staff L reported hearing the night staff found the resident sitting on the floor against the side of the bed, a few nights ago, and that might of caused the bruise. Direct care staff L and M verified the resident frequently got themselves out of the bed, especially in the evenings/nights, and explained the staff do not hear the resident until it is too late, and they find the resident up from the bed. The staff explained, even with all of the "reminder" signs, the resident gets up without staff and the resident should not do that. On 1/31/13 at 3:40 PM, telephone interview with direct care staff R, revealed the staff worked the nights the resident fell and fractured the hip and elbow. Staff R stated, "(He/She) has real bad dementia and didn't remember, so no matter how many times you tell (him/her) not to get up, (he/she) would. There were times we would catch (him/her) in the bathroom. No matter how often we went to check (him/her). We didn't start the hourly checks until after (he/she) fractured the elbow. We would always go down there but we didn't document anything and didn't have anything else in place to keep (him/her) in bed. The hourly checks started but was not really helping as we still often find (him/her) up and out of bed." On 1/31/13 at 7:00 PM, per telephone interview with direct care staff D, reported working with the resident during the nights of the falls with fractured hip and elbow. Staff D, explained, "(The resident) would get (themselves) up out of bed and the staff would just try to catch (him/her) if they heard (him/her)." On 2/1/13 at 9:00 AM, per telephone interview with licensed staff H, reported working the nights of the resident's falls on 11/29/12 and 1/1/13. Staff H explained, after the elbow fracture, the facility moved the resident closer to the nurses station. "(The resident) doesn't ever call. We don't use any alarms as it is a privacy thing. Last night we saw the resident in bed, (the resident) moves pretty quick, and was found later in the bedside recliner. We didn't even know (the resident) was up. (The resident had put the call light on but only because (the resident) couldn't get to the wheelchair or the walker. (The resident was already up and in the bathroom one night last week when we found (the resident). We have signs everywhere but (the resident) doesn't pay attention to those." The facility staff failed to provide this resident with a history of falls and fluctuating mental/physical ability, with appropriate interventions to prevent repeated falls. The resident experienced repeated falls which resulted in a hip fracture and a elbow fracture to the resident.