Every finding on record at Winfield Senior Living Community

The facility identified a census of 72 residents. The sample included 13 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 72 residents residing in the facility. Findings Included: - On 02/05/25, Administrative Nurse D provided a Facility Assessment updated 08/08/24. A review of the facility assessment revealed the following: The facility assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The facility assessment lacked staffing levels required for each shift, to include, evenings and weekends. The facility assessment indicated the facility would develop a comprehensive staffing plan utilizing the staffing model. The facility assessment lacked informed contingency plans for events that did not require activation of the facility's emergency plan but had the potential to impact resident care. The facility assessment noted the facility would determine the resources necessary to care for residents successfully throughout the day, night, weekends, and emergencies. The facility assessment failed to identify the means of input gathered from the residents and their representatives when formulating the assessment data. On 02/05/25 at 01:27 PM, Administrative Nurse D stated the facility assessment was revised annually. She stated staffing requirements were determined by the acuity of the facility and each unit's needs. She stated she met with the facility's leadership team to review the facility assessment annually. The facility's policy, Facility Assessment, revised 10/2018, indicated the facility assessment was conducted yearly to determine and update the facility's capacity to meet the needs of the residents. The policy indicated the assessment would identify the specific nursing and staffing requirements, nursing services, treatment options, and emergency management. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 72 residents residing in the facility.

The facility identified a census of 47 residents. The facility identified three residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure used face masks were stored or disposed of in a sanitary manner, the facility further failed to ensure all oxygen cannulas were stored in a sanitary manner and further failed to ensure a Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) program specific to the facility was put in place. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 02/04/25 at 10:57 AM, R36's nasal cannula was thrown over her wheelchair, and the nasal cannula was not stored in a sanitary manner. On 02/05/25 at 12:02 PM, the nasal cannula was thrown over a blue oxygen canister in the dining room, the nasal cannula was not stored in a sanitary manner. The facility lacked documentation of the implementation of a water system program for waterborne contamination, specifically for legionella diseases. On 02/05/25 at 12:55 PM, Administrative Staff A stated the facility was unable to provide any additional information specific to the facility for legionella. On 02/06/25 at 10:27 AM a used blue mask with makeup on the inside of the mask was laid on the personal protective (PPE) cart, the cart sat outside of the room of a resident with COVID-19 (highly contagious respiratory virus). On 02/06/25 at 12:49 PM, Certified Nurse's Aide (CNA) M stated all respiratory equipment not in use should be stored in a plastic bag with the resident's name written on the bag. CNA M stated face masks should be thrown away or stored in a plastic bag. On 02/06/25 at 01:00 PM, Licensed Nurse (LN) G stated all nasal cannulas should be stored in a plastic, drawstring bag, with the resident's name written on the bag. LN G stated mask should be thrown away when the staff are finished with the mask. LN G stated she did not know about the Legionella program. On 02/06/25 at 01:26 PM, Administrative Nurse D stated all respiratory equipment, including nasal cannulas not in use, should be stored in a plastic bag. Administrative Nurse D stated she was unsure what the legionella program was. She stated all used masks should be thrown in the trash; masks should never be left on a cart. The facility's Personal Protective Equipment revised 10/18 documented personal protective equipment appropriate to specific task requirements was always available. The facility's Legionella Water Management Program revised 09/22 documented the facility was committed to the prevention, detection, and control of waterborne contaminations including legionella. The purpose of the water management program was to identify areas in the water system where legionella bacteria can grow and spread and to reduce the risk of legionnaire's disease. The facility failed to ensure used face masks were stored or disposed of in a sanitary manner, the facility further failed to ensure all oxygen cannulas were stored in a sanitary manner and further failed to ensure a Legionella disease program specific to the facility was implemented. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 47 residents. The sample included 13 residents with one medication room and four medication carts. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This placed the residents at risk for misappropriation and/or diversion of controlled substances. Findings included: - On 02/04/24 at 07:20 AM, a review of the December 2024, January, and February 2025 Narcotic Count Sheet on the 100, 200, 300, and 500 halls and the over stock narcotics, revealed a missing signature either for the on-coming nurse or the off-going nurse for the morning shift on 01/30, 01/31, 02/01, 02/02, and 02/03. On 02/04/24 at 07:20 AM, a review of the December 2024, January, and February 2025 Narcotic Hand Count Sheet on the 100, 200, 300, and 500 halls and the overstock narcotics revealed a missing signature either for the on-coming nurse signature or the off-going nurse for the evening shift on 01/26, 01/29, 02/01, and 02/03. On 02/04/24 at 01:00 PM, Licensed Nurse (LN) G stated each nurse or Certified Medication Aide (CMA) was to count with the on-coming and off-going nurse daily. She stated nursing staff were not supposed to leave the facility until the narcotic count was correct. On 02/06/24 at 01:26 PM, Administrative Nurse D said she expected anyone on the medication carts to count with the oncoming nurse each shift. The facility's Controlled Substances policy revised 04/19 documented the facility complies with all laws, regulations, and other requirements, related to handling, storage, disposal, and documentation of controlled medication. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count should be documented and reported to the director of nursing services immediately. The facility failed to ensure an accurate reconciliation of controlled medications was completed. This deficient practice placed residents at risk of medication misappropriation and diversion.

The facility reported a census of 72 residents. Based on observations, record reviews, and interviews, the facility failed to ensure safe medication storage of one of its four medication carts. This deficient practice placed the resident at risk for diversion and ineffective medication regimen. Findings Included: - On 02/04/25 at 07:01 AM, an inspection of the 100 Hall revealed an unsecured treatment cart outside of Resident (R) 21's. R21's door was closed. No staff were present in the hallway to monitor the cart. An inspection of the cart revealed medications and wound care supplies for R21 in the top drawer. On 02/04/25 at 07:05 AM, Administration Nurse E walked down the hall and verified that the cart was left unlocked. She stated staff were expected to lock the cart. Administrative Nurse E secured the cart. On 02/06/25 at 01:07 PM, LN I stated the medication carts were to be locked when not in use. On 02/06/25 at 01:28 PM, Administrative Nurse D stated staff were expected to lock the cart during medication passes and treatment when entering the resident's rooms. The facility's Storage of Medications revised 11/2020 indicated drugs and biologicals were expected to be always stored in a locked compartment or area. The facility failed to ensure safe medication storage of one of four medication carts. This deficient practice placed the residents at risk for diversion and ineffective medication regimen.

The facility identified a census of 47 residents. The sample included 13 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 1, R12, R27, and R28. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R1's clinical record revealed the PCV13 was administered on 10/06/17 and the Pneumococcal Polysaccharide Vaccine (PPSV23) was administered on 10/12/18. R1's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Review of R12's clinical record revealed the PCV13 was administered on 12/28/16 and the PPSV23 was administered on 03/29/21. R12's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Review of R27's clinical record revealed the PPSV23 was administered on 03/29/21. R27's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Review of R28's clinical record revealed the PCV13 was administered on 07/19/16 and the PPSV23 was administered on 02/21/23. R28's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. On 02/05/25 at 03:14 PM, Administrative Nurse E, the facility Infection Preventionist, stated she was responsible for tracking the resident's immunization status. Administrative Nurse E stated she had overlooked R1, R12, R27, and R28's PCV20 immunization status. The facility's Pneumococcal Vaccine policy last revised 08/2016 documented all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status would be conducted within five working days of the resident's admission if not conducted prior to admission. The facility failed to offer and administer PCV20 or obtain informed declinations for R1, R12, R27, and R28, who were eligible to receive the vaccination. This placed R1, R12, R27, and R28 at increased risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.

The facility identified a census of 47 residents. The sample included 13 residents with two residents reviewed for hospitalization . Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R) 44. This deficient practice placed R44 at risk of delayed care or uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses 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 an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R44's Admission Minimum Data Set (MDS) completed 11/08/25 documented a Brief Interview for Mental Status (BIMS) score of ten indicating mild cognitive impairment. The MDS indicated he required substantial staff assistance with transfers, bathing, toileting, dressing, and bed mobility. The MDS indicated he used a wheelchair for mobility. R44's Functional Abilities Care Area Assessment (CAA) completed 11/13/24 noted he required total assistance from two staff for his activities of daily living (ADL). The CAA instructed staff to encourage R44 to participate in his care as he was able. R43's EMR recorded a Discharge Assessment-Return Not Anticipated MDS which recorded R44 discharged to the acute hospital on 11/19/24. R44's Care Plan initiated 11/01/24 indicated he was at risk for a decline of his ADLs, increased falls, and nutritional impairments related to his medical diagnoses. The plan indicated he required substantial to total staff assistance for bed mobility, bathing, transfers, personal hygiene, dressing, and bathing. R44's EMR under Progress Notes revealed a Skilled Progress Note completed on 11/19/24. The note revealed that R44 was sent out to an acute care facility for emergency evaluation related to low sodium levels per the physician's request. The note revealed that R44's representative was verbally notified about his hospital transport. R44's clinical record lacked evidence of written notification of the facility-initiated transfer which included the location and reason for the transfer provided to R44 or his representatives. The facility was unable to provide this documentation as requested on 02/06/25. On 02/06/25 at 01:27 AM Administrative Nurse D stated the facility only verbally notified the resident or designated representative on the transfers. She stated the facility did not provide written notification of transfers to them. The facility was unable to provide a policy related to transfers or notification requirements as requested on 02/06/25. The facility failed to provide written notification of the reason and location for the facility-initiated transfer to the hospital for R44 or his representative. This deficient practice placed R44 at risk of delayed care or uncommunicated care needs.

The facility reported a census of 72 residents. The sample included 12 with 12 residents reviewed for care plan revisions. Based on observations, interviews, and record review, the facility failed to revise Resident (R)12's care plan to reflect her current transfer requirements. The facility additionally failed to revise R23's hospice care planned interventions. These deficient practices placed the residents at risk for impaired care due to uncommunicated care needs. Findings included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) noted diagnoses of dysphagia (difficulty swallowing), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), cognitive-communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), major depressive disorder (major mood disorder), and a history of falls. R12's Quarterly Minimum Data Set (MDS) completed 12/06/24 revealed a Brief Interview for Mental Status Score of nine indicating moderate cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she was dependent on staff assistance for bed mobility, dressing, bathing, toileting, and transfers. The MDS noted she had one non-injury fall since her last assessment. R12's Functional Abilities Care Area Assessment (CAA) completed 03/20/24 indicated she required substantial assistance from staff to complete her activities of daily living (ADL). The CAA indicated a plan of care will be created to address her needs and minimize her risks. R12's Care Plan initiated on 04/25/25 revealed she required assistance with her ADLs related to her impaired mobility, weakness, and difficulty walking. The plan noted she required assistance from one staff for oral care, bathing, bed mobility, dressing, and toileting (04/05/23). The plan noted she required assistance from one staff for transfers with the use of a gait belt and her walker (04/05/23). The plan noted she was at risk for falls related to her medical diagnoses. On 10/07/24 R12's fall interventions were updated due to a non-injury fall that occurred during transfer during toileting care. The intervention instructed the use of a Hoyer lift on her for safe transfers. The facility did not resolve or cancel R12's gait belt transfer requirement. On 02/05/25 at 07:12 AM, Staff transferred R12 from her bed to her wheelchair with the Hoyer lift. R12 was wheeled to the dining room for breakfast. On 02/06/25 at 01:01 PM, Certified Nurse's Aide (CNA) M stated the care plan should reflect the most current and active interventions for the residents. She stated R12 was a Hoyer lift only due to her fall risk and her plan should have been updated to reflect her transfer requirements. She stated staff were to report conflicting care interventions to Administrative Nurse D. On 02/06/25 at 01:27 PM, Administrative Nurse D stated the care plans were reviewed quarterly but could be updated with new interventions. She stated that R12 required a Hoyer lift and two staff for transfers due to her weakness and fall history. The facility was unable to provide a policy related to care plan revisions as requested on 02/06/25. The facility failed to revise R12's care plan to reflect her current transfer requirements. This deficient practice placed R12 at risk for impaired care due to uncommunicated care needs. 41037 - R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and chronic kidney disease (CKD - is a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R23 required substantial to maximum staff assistance for transfers. The MDS documented R23 had received dialysis services during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R23 was dependent on staff assistance for transfers. The MDS documented R23 had received dialysis services during the observation period. R23's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 10/25/24 documented she was continent of bowel and bladder. R23's Care Plan dated 1/14/21 documented the staff would monitor for renal failure. The plan of care documented the staff would monitor R23's lab work and weight as ordered. The plan of care documented the dietary staff were to regulate R23's protein and potassium intake. The plan of care documented the staff would monitor for signs or symptoms of infection. The plan of care dated 07/13/22 directed the staff to monitor thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with a stethoscope that may occasionally also be palpated as a thrill) as indicated. The plan of care directed staff to notify the physician if the staff were unable to feel the bruit and thrill. The plan of care dated 01/12/23 directed the staff to send a snack and/or meal to dialysis with her. The plan of care documented the staff would send a communication form with R23 on Tuesday, Thursday, and Saturday for dialysis days. The plan of care dated 01/31/23 documented a fistula (abnormal passage from an internal organ to the body surface or between two internal organs) was placed in R23's right arm. The plan of care dated 01/31/23 directed the staff not to obtain blood draws from R23's right arm. The plan of care documented the facility would transport R23 to and from the dialysis center. The plan of care dated 05/04/23 directed the staff to only obtain R23's blood pressure from her left arm. The care plan lacked revised dialysis days of Monday. Wednesday, and Friday. The care plan also lacked direction for nursing staff to monitor R23's fluid restriction. R23's EMR under the Orders tab revealed the following physician orders: May use dialysis dry weight to obtain weekly or monthly weight information, in the afternoon every Monday, Wednesday, or Friday for weight monitoring dated 01/12/24. Obtain vital signs before the resident leaves and when the resident returns from dialysis on Monday, Wednesday, and Friday. Include dry weight from the dialysis center in the afternoon every Monday, Wednesday, and Friday for monitoring and in the morning every Monday, Wednesday, and Friday for monitoring dated 09/25/24. On 02/06/25 at 09:45 AM, R23 laid on her right side asleep on her bed. On 12/06/25 at 12:45 PM, Certified Nurse Aide (CNA) M stated she thought R23 had dialysis on Monday, Wednesday, and Friday but was not too sure. CNA M stated that R23 was usually gone for dialysis when she arrived at work. CNA M stated she had access to a resident's care plan. CNA M stated she would refer to a resident's care plan for any care items for each resident. CNA M stated she documented R23's fluid intake under the point-of-care charting. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated everyone had access to a resident's care plan. LN G stated she had noticed that R23's care plan had the incorrect days listed for dialysis. LN G stated she was not sure who tracked or monitored R23's fluid restriction. LN G stated a nurse should be monitoring the fluid intake for R23 who received dialysis services. On 02/06/25 at 01:26 PM, Administrative Nurse D stated she would not necessarily expect the dialysis days to be on the resident's care plan because the days for dialysis change for the holidays. Administrative Nurse D stated everyone did have access to the resident's care plan. Administrative Nurse D stated dietary monitored R23's fluid restriction. Administrative Nurse D stated the CNAs and dietary staff would document R23's fluid intake. Administrative Nurse D stated the LNs did not document fluid intake or monitor the fluid restriction for R23. The facility's Residents ESRD/Hemodialysis policy last revised 09/2010 documented residents with end-stage renal disease (ESRD) would be cared for according to currently recognized standards of care. The facility would communicate with staff all aspects of how the resident's care would be managed, including: How the care plan would be developed and implemented, and how information would be exchanged between the facilities. The comprehensive care plan would reflect the resident's needs related to ESRD/dialysis care. The facility failed to revise R23's plan of care to include the change in dialysis days and monitoring of her fluid restriction related to CKD. These deficient practices placed R23 with unmet care needs or complications related to dialysis.

The facility identified a census of 72 residents. The sample included 13 residents with one reviewed for quality of care. Based on interviews, observations, and record review, the facility failed to evaluate Resident (R)27's risks and abilities related to handling hot liquids. This deficient practice placed R27 at risk for preventable accidents and injuries. Findings included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) noted diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), muscle weakness, need for assistance with personal care, cerebral infarction (stroke - the 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), altered mental status, and type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R27's Quarterly Minimum Data Set (MDS) completed 01/09/24 revealed a Brief Interview for Mental Status Score of four indicating severe cognitive impairment. The MDS revealed no upper or lower extremity impairments and indicated she used a wheelchair for mobility. The MDS indicated she required set-up and clean-up assistance for meals. The MDS noted she was dependent on staff assistance for oral hygiene, toileting, bathing, dressing, bed mobility, and transfers. The MDS documented no swallowing disorders. R27's Functional Abilities Care Area Assessment (CAA) completed 10/17/24 indicated she had left-sided hemiparesis and cognitive impairment. The CAA noted she required substantial to total staff assistance for all her activities of daily living (ADLs). R27's Care Plan initiated on 12/14/23 indicated she required assistance with her ADLs related to her medical diagnoses. The plan noted she required set-up assistance with her meals (12/14/23). The plan instructed staff to monitor for signs of difficulty chewing or swallowing (12/14/23). The plan instructed staff to monitor her for symptoms of hydration deficits including dry lips, poor urine output, and dry gums (12/14/23). The plan noted her diet was a No Concentrated Sweet (NCS) diet with regular texture and thin liquids (12/14/23). The plan lacked documentation related to R16's recent coffee spill incident. R27's EMR under Progress Notes revealed a Nursing Note completed on 12/23/24. The note indicated R27 was in the dining room as she waited for breakfast, The note revealed she spilled down the front of herself. The note indicated she was assessed with no redness, blisters, or pain. The note revealed that R27 was unable to state what happened or how she spilled her coffee. R27's EMR revealed no documentation that indicated the facility followed up with a risk assessment to ensure R27 could safely manage hot liquids, if she required assistance, or if she required special utensils for heated drinks. On 02/04/25 at 09:01 AM, R27 reported she had spilled coffee on herself but was not able to identify what caused the spill. She stated she sometimes struggled to hold the cups. On 02/05/25 at 07:22 AM, R27 sat in the dining room. R16 was provided a cup of coffee. The coffee had no lid. R16 consumed her coffee without incident. On 02/06/25 at 12:50 PM, Certified Nurse's Aide (CNA) M stated that R27 sometimes had difficulty completing her ADLs and required substantial staff assistance. She stated staff were expected to ensure the coffee temperatures were not too hot and provide lids for residents who had difficulty holding their drinks. She stated residents that who were at risk for spilling their drinks were provided cups with lids. She stated she sometimes provided R27 with lids for her coffee cups. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated residents that who had hot liquid spills or had difficulty holding their cups were expected to be assessed for safety and the need for special cups with lids. She stated the care plans should reflect potential risks related to residents who may have needed special utensils to prevent spills. On 02/06/25 at 01:26 PM, Administrative Nurse D stated staff were expected to assess residents after spills to ensure no injuries occurred. She stated the kitchen also made sure the temperature of drinks was at safe levels. She was not sure if R27 had an assessment completed after her coffee spills to identify her needs with hot liquids. The facility's policy Quality of Care (undated) indicated the facility was expected to provide the highest level of care while promoting a safe person-centered care environment. The policy noted staff were expected to follow all safety protocols. The policy indicated the facility was expected to prioritize individual preferences, choices, and unique needs to promote person-centered care. The facility failed to evaluate R27's risks and abilities related to handling hot liquids. This deficient practice placed R27 at risk for preventable accidents and injuries.

The facility identified a census of 47 residents. The sample included 13 residents with three residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 38 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R38 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R38's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), cerebrovascular accident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R38 had limited ROM on one side of his lower extremity. The MDS documented R38 required substantial to maximum staff assistance with dressing. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R38 required partial to moderate staff assistance for dressing. R38's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/29/24 documented he had experienced a change in functional abilities related to a recent hospitalization . R38's Care Plan dated 05/16/24 documented the staff would encourage him to participate in his therapy program if applicable. The plan of care documented the staff would encourage R38 to use adaptive equipment. On 02/05/25 at 02:54 PM, R38 sat in his wheelchair next to his bed and watched TV. R38's left arm rested on his thigh; his left hand hung downward with fingers slightly closed. R38 stated he did not have anyone who assisted him with ROM to his left hand related to the case he did not have insurance to cover the cost of therapy. On 12/06/25 at 12:45 PM, Certified Nurse Aide (CNA) M stated she was not sure if any staff provided ROM for R38's left side. CNA M stated she would walk R38 to the dining room. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated she was not sure if the facility had any restorative programs in place for the residents at this time. On 02/06/25 at 01:26 PM, Administrative Nurse D stated the CNAs would provide any restorative programs for the residents. Administrative Nurse D stated the residents would be referred to therapy if they had a decline in ROM. Administrative Nurse D stated the resident would then be referred again after another decline in ROM. Administrative Nurse D stated the resident would only be placed on a restorative program if recommended by therapy. The facility's Resident Mobility and Range of Motion policy revised on 07/17 documented that residents would not experience an avoidable reduction in ROM. Residents with limited ROM would receive treatment and services to increase and or prevent a further decrease in ROM. Residents with limited mobility would receive appropriate services, equipment, and assistance to maintain or improve mobility unless a reduction in mobility was avoidable. The care plan would include specific interventions, exercises, and therapies to maintain, and prevent avoidable decline in and or improve mobility and ROM. The facility failed to ensure R38 received services and treatment for his contractures to prevent an avoidable reduction of ROM. This deficient practice left R38 at risk for further decline and discomfort.

The facility identified a census of 72 residents, the sample included 13 with two reviewed for accidents. Based on interviews, record review, and observations, the facility failed to ensure Resident (R)16's safety related to following her care-planned fall interventions. This deficient practice placed R16 at risk for preventable falls and injuries. - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) noted diagnoses 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 an artery to the brain), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and orthostatic hypotension (blood pressure dropping with change of position). R16's Significant Change Minimum Data Set (MDS) completed 01/09/24 revealed a Brief Interview for Mental Status Score of four indicating severe cognitive impairment. The MDS documented no upper or lower extremity impairments and noted she used a wheelchair for mobility. The MDS indicated she was dependent on staff assistance for bed mobility, transfers, dressing, oral hygiene, and bathing. The MDS noted she had a history of falls. R16's Falls Care Area Assessment completed 12/31/24 indicated she required assistance from staff related to her impaired mobility, poor cognition, and medical diagnoses. The MDS noted she was at high risk for falls related to her prescribed medications and medical diagnoses. R16's Care Plan initiated on 09/12/24 indicated she required assistance with her activities of daily living (ADL). The plan indicated she required assistance from one staff for bathing, dressing, toileting, bed mobility, and transfers. The plan noted she was at risk for falls related to her medical diagnoses. The plan instructed staff to ensure her environment was clutter-free and her call light was within reach. The plan indicated she was to be transferred with one staff and a gait belt while ambulating (10/08/24). The plan documented she was to always have a Dysem (non-slip mat) in her chair (01/08/24). R16's EMR under Progress Notes revealed a Nursing Note completed on 10/09/24. The note indicated she had a witnessed minor-injury fall on 10/09/24 while attempting to ambulate herself to the restroom. The note revealed she suffered a skin tear on her right hand. The note revealed staff were educated to use a gait belt and touch assistance during ambulation. A review of the facility's Fall Investigation #1817 completed 10/09/24 was completed. The report's root-cause section of the fall report identified staff did not utilize a gait belt or provide touch assistance while witnessing her ambulating. On 02/05/25 at 07:56 AM, R16 sat in her recliner in her room. An inspection of her recliner revealed she had no Dycem in place. On 02/05/25 at 02:33 PM, R16 rested in her recliner. R16 had no Dycem mat in place. On 02/06/25 at 01:23 PM, R16 rested in her recliner. R16 had no Dycem mat in place. On 02/06/25 at 12:50 PM, Certified Nurse's Aide (CNA) M stated R16 was a high fall risk due to her cognitive impairment and poor mobility. She stated that R16 required staff to use a gait belt and touch assistance for all transfers. She stated staff were expected to ensure R16's Dycem mat was in place before transferring her to her recliner. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated that R16's Dycem mat should be moved with her while she transferred to her recliner. She stated staff were to ensure it was in place before allowing her to sit down. On 02/06/25 at 01:27 PM, Administrative Nurse D stated staff were expected to follow and ensure the care planned interventions were in place for each resident. She stated that R16's Dycem should have been in place to prevent her from slipping out of her recliner. The facility's Fall Guidelines revised 10/2010 documented that residents were identified for risk of falls and had interventions implemented to reduce the risk of falls. The policy noted fall risk screening would be completed on admission, quarterly for healthcare, annually for assisted living, when there was a significant change of condition, and as applicable, after a fall. The facility failed to ensure R16's safety related to following her care-planned fall interventions. This deficient practice placed R16 at risk for preventable falls and injuries.

The facility identified a census of 47 residents. The sample included 13 residents with two reviewed for nutrition. Based on observation, record review, and interviews the facility failed to identify and implement nutritional interventions related to Resident (R) 26'scontinued weight loss. This deficient practice placed R26 at risk for malnourishment-related complications. Findings included: - R26's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit, dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R26 had weight loss and was not on a physician-prescribed weight loss program during the observation period. R26's Nutritional Status Care Area Assessment (CAA) dated 12/31/24 documented he had weight loss over the past six months. R26's Care Plan dated 02/15/24 documented he was on a regular diet. The plan of care documented the staff would encourage adequate intake as needed. The plan of care documented the staff would monitor R26 for any difficulty with chewing, swallowing, dehydration, or signs and symptoms of aspiration. The plan of care documented the staff would notify the physician of any weight changes. The plan of care documented the staff would obtain R26's weight per facility protocol. The plan of care documented the registered dietician (RD) would consult as indicated. The plan of care documented the staff would offer snacks between meals and as needed. The plan of care dated 02/22/24 documented the staff would obtain R26's food preferences and offer alternatives as needed. The plan of care documented the staff would provide additional fluids of R26's choice. The plan of care documented the staff would provide dietary set-up assistance, encourage, and cue R26 as needed. The plan of care dated 08/12/24 documented the staff would provide a supplement per RD recommendations. The plan of care dated 10/15/24 documented the staff would offer the house supplement in the morning. The plan of care dated 12/06/24 documented the staff would offer Boost (liquid nutritional supplement) two times a day. The plan of care dated 01/24/25 documented the staff would offer Boost Fruit Breeze two times daily. Review of R26's EMR under the Weights/Vital Signs tab reviewed from 06/01/24 through 01/01/25 revealed a weight loss of 26.4 pounds. R26's EMR under the Orders tab revealed the following physician orders: Regular diet, regular texture, and thin consistency for liquids dated 03/28/24. Boost two times a day for supplement 90 milliliters (ml) supplement ordered 12/06/24 and discontinued on 01/23/25. Boost Fruit Breeze two times a day for supplement 90ml chart amount consumed supplement dated 01/23/25. Review of R26's EMR under the Progress Notes tab revealed a Nutrition Note dated 04/17/24 at 03:55 PM documented the Rd reviewed R26's readmission orders. No recommendations were noted. A Nutrition Note dated 12/06/24 documented RD reviewed R26 clinical record related to weight loss. R26's current weight was 192 lbs. which was a weight loss of seven pounds in 30 days and a weight loss of 13 lbs. in 90 days. Documented R26 remained on a regular diet. R26 received 90ml of house supplement in the morning. R26's clinical record reviewed, and house supplement was discontinued and recommended Boost twice a day. On 02/05/25 at 08:11 AM, R26 ambulated with his walker from the dining to his room. R26 sat in his recliner next to his bed and watched TV. On 12/06/25 at 12:45 PM, Certified Nurse Aide (CNA) M stated she was not aware of any weight loss related to R26. CNA M stated she was not aware of any interventions for R26 to enhance his meals or snacks. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated she was not aware of any weight loss for R26. On 02/06/25 at 01:26 PM, Administrative Nurse D stated she expected dietary to communicate any weight loss to the nursing department related to R26. The facility's Weight Assessment and Intervention policy revised on 09/08 documented that the multidisciplinary (IDT) team would strive to prevent, monitor, and intervene for undesirable weight loss for residents. The Dietitian would review the Weights Record to follow individual weight trends over time. Negative trends would be evaluated by the IDT. The physician and the IDT team would identify conditions and medications that would be causing weight loss or increasing the risk of weight loss. The facility failed to identify an ongoing weight loss and implement nutritional interventions related to R26's weight loss. This also placed R26 at risk for malnourishment-related complications.

The facility identified a census of 47 residents. The sample included 13 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 23 had a physician order for hemodialysis that included an indication. The facility also failed to follow a physician's order for fluid restriction for R23. These deficient practices placed her at risk of adverse outcomes and physical complications related to dialysis. Findings included: - R23's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and chronic kidney disease (CKD - is a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R23 required substantial to maximum staff assistance for transfers. The MDS documented R23 had received dialysis services during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R23 was dependent on staff assistance for transfers. The MDS documented R23 had received dialysis services during the observation period. R23's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 10/25/24 documented she was continent of bowel and bladder. R23's Care Plan dated 1/14/21 documented the staff would monitor for renal failure. The plan of care documented the staff would monitor R23's lab work and weight as ordered. The plan of care documented the dietary staff were to regulate R23's protein and potassium intake. The plan of care documented the staff would monitor for signs or symptoms of infection. The plan of care dated 07/13/22 directed the staff to monitor thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with a stethoscope that may occasionally also be palpated as a thrill) as indicated. The plan of care directed staff to notify the physician if the staff were unable to feel the bruit and thrill. The plan of care dated 01/12/23 directed the staff to send a snack and/or meal to dialysis with her. The plan of care documented the staff would send a communication form with R23 on Tuesday, Thursday, and Saturday for dialysis days. The plan of care dated 01/31/23 documented a fistula (abnormal passage from an internal organ to the body surface or between two internal organs) was placed in R23's right arm. The plan of care dated 01/31/23 directed the staff not to obtain blood draws from R23's right arm. The plan of care documented the facility would transport R23 to and from the dialysis center. The plan of care dated 05/04/23 directed the staff to only obtain R23's blood pressure from her left arm. R23's EMR under the Orders tab revealed the following physician orders: Assess thrill and bruit, every shift for dialysis. Check for patency by auscultation and palpating the shunt site. Feel for the thrill, palpate the shunt with your fingers. Hear a bruit with your stethoscope, put the scope on the shunt, and listen for the whoosh, whoosh sound dated 04/21/23. Fluid restriction 40 ounces (oz) or less over 24 hours which is 1200 milliliters (ml) or less: 250ml with meals. Nursing in room-day/evening/night-100ml and med pass 50ml, every day and night shift related to CKD dated 01/03/24. May use dialysis dry weight to obtain weekly or monthly weight information, in the afternoon every Monday, Wednesday, or Friday for weight monitoring dated 01/12/24. Obtain vital signs before the resident leaves and when the resident returns from dialysis on Monday, Wednesday, and Friday. Include dry weight from the dialysis center in the afternoon every Monday, Wednesday, and Friday for monitoring and in the morning every Monday, Wednesday, and Friday for monitoring dated 09/25/24. Dialysis access site monitoring: Assess the left arm shunt site each shift for signs and symptoms of infection such as redness, tenderness, warmth, and/or swelling at the site. If any of these conditions are present notify the medical provider dated 10/01/24. Review of R23's clinical record lacked a physician order for dialysis. R23's clinical record lacked documentation of her fluid restriction was monitored for fluid overload or dehydration. On 02/06/25 at 09:45 AM, R23 laid on her right side asleep on her bed. On 12/06/25 at 12:45 PM, Certified Nurse Aide (CNA) M stated she thought R23 had dialysis on Monday, Wednesday, and Friday but was not too sure. CNA M stated that R23 was usually gone for dialysis when she arrived at work. CNA M stated she had access to a resident's care plan. CNA M stated she would refer to a resident's care plan for any care items for each resident. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated R23 should have a physician order for dialysis which included the indication for dialysis. LN G stated she was not sure who tracked or monitored R23's fluid restriction. LN G stated a nurse should be monitoring the fluid intake for R23 who received dialysis services. On 02/06/25 at 01:26 PM, Administrative Nurse D stated she would expect there to be an order for R23's dialysis. Administrative Nurse D stated dietary monitored R23's fluid restriction. Administrative Nurse D stated the CNAs and dietary staff would document R23's fluid intake. Administrative Nurse D stated the LNs did not document fluid intake or monitor the fluid restriction for R23. The facility's Residents ESRD/Hemodialysis policy last revised 09/2010 documented residents with end-stage renal disease (ESRD) would be cared for according to currently recognized standards of care. The facility would communicate with staff all aspects of how the resident's care would be managed, including: How the care plan would be developed and implemented, and how information would be exchanged between the facilities. The comprehensive care plan would reflect the resident's needs related to ESRD/dialysis care. The facility failed to monitor R23's fluid restriction and ensure she had a physician for dialysis. These deficient practices placed R23 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 47. The sample included 13 residents with four residents reviewed for dementia care. Based on observation, record review, and interviews, the facility failed to ensure staff provided the necessary person-centered activities and interventions to address R13's dementia (a progressive mental disorder characterized by failing memory, and confusion) diagnosis which included the need for close supervision to prevent the resident from wandering and falls. This deficient practice placed R13 at risk of ineffective treatment and decreased quality of care. Findings included: - R13's Electronic Medical Record (EMR) documented diagnoses of dementia, heart failure (a condition where the heart is unable to pump blood effectively), hypertension (HTN - elevated blood pressure), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R13's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had both long and short-term memory problems. R13 had moderately impaired cognitive skills for daily decision-making. R13 displayed signs of delirium (sudden severe confusion, disorientation, and restlessness) with inattention, disorganized thinking, and altered level of consciousness that fluctuated. R13 displayed the behavior of wandering. R13 had trouble concentrating during the look-back period. R13 required maximal assistance from staff with her activities of daily living (ADL) and functional abilities. R13 used a wheelchair to assist with mobility. R13 had a fall with injury since the prior assessment. R13's Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R13 displayed signs of delirium with inattention and disorganized thinking. R13 required maximal assistance to total dependence on staff for her ADLs and function abilities. R13 had a fall with a major injury since the prior assessment. R13's Cognition Care Area Assessment (CAA) dated 09/30/24 documented she had been positive for the coronavirus (COVID - highly contagious respiratory virus). She needed consistent redirection as she would not remain in her room. R13 was very confused, argumentative with the staff, and sometimes refused care. R13's Care Plan last revised on 01/20/25 directed staff that she was able to make her own decisions on what activities she would like to participate in. Staff were directed to encourage R13 to participate in activities if needed. Staff were to engage R13 in activities of interest. Staff were to monitor R13 for patterns that would cause her to display exit-seeking. Staff were directed to cue, re-orient, and supervise the resident as needed. Staff were to ensure call light and items (items not specific) were within reach. Staff were directed to keep R13's routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Staff were directed to provide R13 with items of her interest (coloring, balls of yarn, sit with her), and a place where the activity can be enjoyed, for close visual observation by staff, a preferred leisure activity of the resident to reduce wandering. Staff were directed that R13 required staff assistance of one with a gait belt for toileting and transfers. Staff were to educate R13 on the use of her call light and ensure the call light was within reach. Staff were directed to ensure a clutter-free environment for R13 with adequate lighting and personal items within reach. R13's care plan lacked person-centered staff direction for a resident with dementia on what activities R13 preferred or attended. A review of R13's Event Calendar Report for November 2024, December 2024, and January 2025 documented her main activity attendance was independent activities from 06:00 AM to 07:00 AM. R13 did not participate in group exercises provided daily. On 02/04/25 at 10:36 AM, R13 sat in her wheelchair in the main television area of the memory unit. R13 had a cervical collar (a brace used to support and protect your neck and spinal cord) on and her head was leaning forward toward her chest. On 02/05/25 at 08:30 AM, R13 sat in her wheelchair at the dining table feeding herself at times. R13 had her cervical collar on and would rest leaning her head forward. On 02/05/25 at 02:15 PM, R13 sat in her wheelchair in the television area with other residents watching tv. One staff member was present on the memory care unit but was providing care to another resident and was not present with the residents in the room. On 02/05/25 at 09:02 AM, Certified Medication Aide (CMA) R stated she worked on the memory care unit quite a bit. CMA R stated most of the time she was the only staff on the unit so in the morning she was responsible for getting all the residents changed, dressed, and brought out for breakfast in the morning. CMA R stated there were a few residents who would attend activities off of the unit but R13 did not. CMA R stated with her being the only staff on the unit she was not able to provide activities often to the residents. CMA R stated on some days during the week another staff would come to assist her in the afternoons so she could bathe the residents. On 02/06/25 at 01:21 PM, Activity Z stated that she was the activity person and was part-time. Activity Z stated the facility did have monthly activity calendars. Activity Z stated she would come back to the memory unit and do a balloon toss or simple crafts with the residents. On 02/06/25 at 01:26 AM, Administrative Nurse D stated that the activity director did do a lot with the residents on the memory unit when she could. Administrative Nurse D stated another aide would come to the unit a couple of days of the week for several hours to assist the CMA when she needed to give residents baths or do activities when able to. Administrative Nurse D stated the facility's Facebook page had many pictures of activities that the facility did and many of the pictures were from activities done on the memory unit. The Dementia policy last revised in April 2013 documented that individuals with dementia who had end-stage, or terminal status would have appropriate management including pertinent limitations on life-sustaining medical treatments. The physician would help staff adjust the interventions and overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, and changes in the resident or family wishes. The Activity Programs policy last revised in June 2018, documented the activities program was provided to support the well-being of the residents and to encourage both independence and community interaction. Activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program was ongoing and included facility-organized group activities, independent individual activities, and assisted individual activities. Activities were not necessarily limited to formal activities being provided by activities staff. Other facility staff, volunteers, visitors, residents, and family members may also provide the activities. Individualized and group activities were provided that: reflect the schedules, choices, and rights of the residents; reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents. Residents were encouraged, but not required, to participate in scheduled activities. The facility failed to ensure staff provided the necessary person-centered activities and interventions to address R13's dementia diagnosis which included the need for close supervision to prevent the resident from wandering and falls. This placed R13 at risk for This deficient practiced placed R13 at risk for risk ineffective treatment and decreased quality of care.

The facility reported a census of 72 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to ensure the Consulting Pharmacist (CP) identified and made recommendations related to Resident (R) 12's Midodrine (medication used to raise low blood pressure) medication. This placed R12 at risk for unnecessary medications and potential side effects. Findings included: - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) noted diagnoses 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 an artery to the brain), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and orthostatic hypotension (blood pressure dropping with change of position). R16's Significant Change Minimum Data Set (MDS) completed 01/09/24 revealed a Brief Interview for Mental Status Score of four indicating severe cognitive impairment. The MDS documented no upper or lower extremity impairments and noted she used a wheelchair for mobility. The MDS indicated she was dependent on staff assistance for bed mobility, transfers, dressing, oral hygiene, and bathing. The MDS noted she had orthostatic hypotension. R16's Functional Abilities Care Area Assessment completed on 12/31/24 indicated she required assistance from staff related to her impaired mobility, poor cognition, and medical diagnoses. The MDS noted she was at a high risk for falls related to her prescribed medications. R16's Care Plan initiated 09/12/24 indicated she was at risk for cardio/circulatory complications related to her orthostatic hypotension. The plan instructed staff to monitor for signs and symptoms related to cardiac stress, complete vitals as ordered, and administer her medications as ordered. R16's EMR under Physician's Orders revealed a discontinued order for staff to administer ten milligrams (mg) of Midodrine by mouth three times a day for orthostatic hypotension. The order was started on 09/12/24 and discontinued on 12/12/24. No blood pressure monitoring parameters were listed in the orders. R16's EMR under Physician's Orders revealed an active order (started 12/14/24) for staff to administer five milligrams of Midodrine by mouth two times a day for low blood pressure. No blood pressure monitoring parameters were listed in the orders. R16's EMR under Medication Administration Record (MAR) revealed her afternoon Midodrine medication was administered on 12/06/24. The MAR revealed her systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was 177 millimeters of mercury (mmHg) over her Diastolic blood pressure (minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) of 72mmHg at (177/72 mmHg). R16's MAR revealed her evening dose of Midodrine was given on 01/10/25. The MAR revealed her blood pressure was 142/85 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/17/25. The MAR revealed her blood pressure was 140/71 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/19/25. The MAR revealed her blood pressure was 146/76 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/20/25. The MAR revealed her blood pressure was 142/73 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/26/25. The MAR revealed her blood pressure was 143/74 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/30/25. The MAR revealed her blood pressure was 154/76 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/31/25. The MAR revealed her blood pressure was 156/69 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 02/01/25. The MAR revealed her blood pressure was 145/80 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 02/02/25. The MAR revealed her blood pressure was 158/63 mmHg at the time the medication was given. A review of the facility's Monthly Medication Review from 01/01/2024 through 02/01/2025 revealed no pharmacy notes or recommendations related to R16's Midodrine medication. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated midodrine medication should be held if the resident blood pressure was higher than the ordered amount or the risk of causing hypertension (high blood pressure). She stated the order should have included parameters and staff should have verified the medication with the physician. She stated the parameters for midodrine were usually to hold for SBC above 120mmHg. She was not sure if the pharmacy monitored the parameters for Midodrine. On 02/06/25 at 01:26 PM, Administrative Nurse D stated staff should hold the medication and notify the prescriber if they feel the medication was given outside the parameters or potential adverse effects. She stated the pharmacy reviews all resident's medication and sends the reports back to the facility. She stated she was not informed that R16's medication was being given with high blood pressure. The facility was unable to provide a policy related to monthly pharmacy reviews as requested on 02/06/25. The facility failed to ensure the CP identified and made recommendations related to R12's Midodrine medication. This placed R12 at risk for unnecessary medications and potential side effects.

The facility reported a census of 72 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to ensure safe medication administration for Resident (R)12's Midodrine (medication used to raise low blood pressure) medication. This placed R12 at risk for unnecessary medications and potential side effects. Findings included: - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) noted diagnoses 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 an artery to the brain), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and orthostatic hypotension (blood pressure dropping with change of position). R16's Significant Change Minimum Data Set (MDS) completed 01/09/24 revealed a Brief Interview for Mental Status Score of four, indicating severe cognitive impairment. The MDS documented no upper or lower extremity impairments and noted she used a wheelchair for mobility. The MDS indicated she was dependent on staff assistance for bed mobility, transfers, dressing, oral hygiene, and bathing. The MDS noted she had orthostatic hypotension. R16's Functional Abilities Care Area Assessment, completed on 12/31/24, indicated she required assistance from staff related to her impaired mobility, poor cognition, and medical diagnoses. The MDS noted she was at a high risk for falls related to her prescribed medications. R16's Care Plan, initiated 09/12/24, indicated she was at risk for cardio/circulatory complications related to her orthostatic hypotension. The plan instructed staff to monitor for signs and symptoms related to cardiac stress, complete vitals as ordered, and administer her medications as ordered. R16's EMR under Physician's Orders revealed a discontinued order for staff to administer ten milligrams (mg) of Midodrine by mouth three times a day for orthostatic hypotension. The order was started on 09/12/24 and discontinued on 12/12/24. No blood pressure monitoring parameters were listed in the orders. R16's EMR under Physician's Orders revealed an active order (started 12/14/24) for staff to administer five milligrams of Midodrine by mouth two times a day for low blood pressure. No blood pressure monitoring parameters were listed in the orders. R16's EMR under Medication Administration Record (MAR) revealed her afternoon Midodrine medication was administered on 12/06/24. The MAR revealed her systolic blood pressure (SBP - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was 177 millimeters of mercury (mmHg) over her Diastolic blood pressure (minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) of 72mmHg at (177/72 mmHg). R16's MAR revealed her evening dose of Midodrine was given on 01/10/25. The MAR revealed her blood pressure was 142/85 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/17/25. The MAR revealed her blood pressure was 140/71 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/19/25. The MAR revealed her blood pressure was 146/76 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/20/25. The MAR revealed her blood pressure was 142/73 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/26/25. The MAR revealed her blood pressure was 143/74 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/30/25. The MAR revealed her blood pressure was 154/76 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 01/31/25. The MAR revealed her blood pressure was 156/69 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 02/01/25. The MAR revealed her blood pressure was 145/80 mmHg at the time the medication was given. R16's MAR revealed her evening dose of Midodrine was given on 02/02/25. The MAR revealed her blood pressure was 158/63 mmHg at the time the medication was given. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated midodrine medication should be held if the resident blood pressure was higher than the ordered amount or the risk of causing hypertension (high blood pressure). She stated the order should have included parameters and staff should have verified the medication with the physician. She stated the parameters for midodrine were usually to hold for SBC above 120mmHg. On 02/06/25 at 01:26 PM, Administrative Nurse D stated staff should hold the medication and notify the prescriber if they feel the medication was given outside the parameters or potential adverse effects. The facility's Medication and Treatment Orders policy revised 07/2016 indicated medications were administered based upon the practitioner's order and intended use. The policy noted that licensed staff will administer medication using safe administration guidelines and practices ensuring the correct dose, medication, time, route, and strength. The policy indicated the prescriber might be contacted for medication concerns. The facility failed to ensure safe medication administration for R12's Midodrine medication. This placed R12 at risk for unnecessary medications and potential side effects.

The facility identified a census of 47 residents. The sample included 13 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication or a documented physician rationale for antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, and a gradual dose reduction was not attempted for Resident (R) 26. The facility also failed to ensure R1 had physician rationale for continued use of as-needed psychotropic (alters mood or thought) medications for an extended period beyond 14 days. These deficient practices placed the residents at risk for adverse medication effects and unnecessary medications. Findings included: - R26's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit, dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R26 had received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an antianxiety (a class of medications that calm and relax people) medication during the observation period. The MDS documented no gradual dose reduction (GDR) was completed and there was no physician documentation that GDR was clinically contraindicated for R26. R26's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/31/24 documented he received antianxiety medication and antidepressant (a class of medications used to treat mood disorders) medication. R26's Care Plan dated 02/15/24 documented the staff would administer his medication as ordered. The plan of care documented the staff would monitor for possible dose reduction. R26's EMR under the Orders tab revealed the following physician orders: Olanzapine (antipsychotic) oral tablet five milligrams (mg) give one tablet by mouth two times a day related to violent behaviors dated 11/29/24. On 02/05/25 at 08:11 AM, R26 ambulated with his walker from the dining to his room. R26 sat in his recliner next to his bed and watched TV. On 02/06/25 at 01:05 PM, Licensed Nurse (LN) G stated the director of nursing would ensure the correct indication was listed for any antipsychotic medication. LN G stated she added the diagnosis given by the physician writing the order. On 02/06/25 at 01:26 PM, Administrative Nurse D stated she had noticed the physician had not documented a rationale for no GDR or an approved indication for his antipsychotic medication for R26's psychotropic medications. Administrative Nurse D stated the facility was going to reach out to the physician for documentation for the rationale. The facility's Medication and Treatment Orders policy last revised 07/16 documented that orders for medications and treatments would be consistent with principles of safe effective order writing. Medications would be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist monthly. The facility failed to ensure an appropriate indication or a documented physician rationale for R26's Olanzapine medication and a physician rationale for no GDR on all of his psychotropic medication. This placed R26 at risk for unnecessary psychotropic medications and related complications. 41713 - R1's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (a major mood disorder that causes persistent feelings of sadness) and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R1's Annual Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required partial assistance when bathing. R1 used a wheelchair and a walker to assist with mobility. R1 received an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and an anticoagulant (a class of medications used to prevent the blood from clotting) on a scheduled basis. R1's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/29/24 documented she currently had orders for Prozac (an antidepressant medication) daily, trazodone (an antidepressant medication) for depression, and Buspar (an antianxiety medication). Staff were to encourage expressions of feelings and provide reassurance and validation of feelings as needed. Nursing was to monitor for potential side effects of her medications and notify the physician of any concerns with the medications or mood state. R1's Care Plan last revised on 12/20/24 directed staff to administer medications as ordered. The care plan directed staff the Psychotropic Review Committee would meet for gradual dose reduction, risk versus benefit, and review medications. R1's Orders tab of the EMR documented an order dated 02/01/24 for Ativan (an antianxiety medication) 0.5 milligrams (mg) by mouth every six hours as needed for anxiety. The Consultant Pharmacist's monthly Medication Regimen Review (MRR) on 02/04/25 documented a recommendation for a rationale for the continued use of the as-needed (prnPRN) Ativan. The physician's response dated and noted on 02/04/25 documented to continue the order for two months for anxiety. The physician's response lacked a reason and or rationale for the continued use. On 02/05/25 at 12:15 PM, R1 sat in her wheelchair and propelled herself down the hallway from the dining room. On 02/06/25 at 01:26 PM Administrative Nurse D stated she would receive the monthly pharmacy reviews and forward them to the physicians for them to sign. Administrative Nurse D stated she would then send the nursing recommendations to the nurse and then she would document the physician's responses and send the papers on to medical records to be scanned in. Administrative Nurse D stated she had not realized the physician had not documented a rationale for the continued use of R1's Ativan. The facility's Medication and Treatment Orders policy last revised 07/16 documented that orders for medications and treatments would be consistent with principles of safe effective order writing. Medications would be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist monthly. The facility failed to ensure the physician provided an appropriate rationale for the continued use of PRN Ativan for R1. This deficient practice placed the R1 at risk for unnecessary medication administration and related complications.

The facility reported a census of 40 residents, with three residents sampled. Based on observation, interview, and record review the facility failed to revise Resident (R)1's care plan to reflect interventions related to R1's personal hygiene. Findings included: - Review of the Physician Order dated 06/20/24 revealed Resident (R) 1 had the following diagnoses: dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion) and prolapse bladder (a condition that occurs when the muscles and ligament that support the bladder weaken and causing the bladder to bulge into the vaginal canal). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. R1 was independent with Activities of Daily Living (ADLs). Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed R1 had a (BIMS) score of 08, which indicated moderately impaired cognition. The MDS noted R1 refused bathing. The Care Plan dated 06/20/24 revealed R1 required one person assistance with ADLs due to decreased mobility and dementia. The care plan further noted staff were to ask R1 if she wanted a bath, daily. The care plan documented R1 would refuse (bathing) and the staff were to notify the charge nurse and noted the staff must approach three times. The care plan lacked revision to include notification of the resident's family member when R1 refused to bathe. Review of the Bathing Sheets from 06/30/24 to 07/23/24 indicated R1 did not receive a bath for 24 days. The Physician Order dated 08/14/24 revealed an order for R1 to have a bath daily. Review of the Nurses Notes on 08/17/24, 08/18/24, 08/21/24, 08/23/24, 08/25/24 R1 refused her bath, and the facility did not contact R1's family member. Review of the Nurses Notes from 06/02/24 to 08/23/24 indicated R1 did refuse bathing, the notes lacked evidence of notification to R1's family member. During an observation on 08/26/24 at 10:30 AM, R1 sat in a recliner in the commons area. R1 then ambulated to her room, using her front wheeled walker, without difficulty. R1 clothes looked clean, and no foul odors were observed. Interview with R1's family member on 08/26/24 at 12:06 PM revealed the staff were to give R1 a daily bath, and if R1 refused to take a bath the facility staff were to contact me. During an interview on 08/26/24 at 12:40 PM, revealed Certified Nurse Aide (CNA) D revealed the staff did offer a bath daily. CNA D said R1 preferred to have her baths at night before bedtime but with them now on day shift, R1 refuses the bath. If R1's family member was in the facility, she will help to encourage her to take a bath. CNA D said she did know the staff did not follow the protocol of documenting like they are suppose too when a resident refuses a bath During an interview on 08/26/24 at 02:00 PM, Licensed Nurse (LN) C revealed R1 liked her bath before going to bed, but staff moved her shower to the day shift because the facility had a bath aide on the day shift. LN C did not know the staff were to contact R1's family member if R1 refused to take a bath. During an interview on 08/26/24 at 02:50 PM Administrative Nurse B knew the nurses were to contact R1's family member if R1 refused a bath. The facility's policy Care Plans, Comprehensive Person-Centered dated March 2023 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents condition change. The facility failed to revise R1's care plan to reflect interventions related to R1's personal hygiene.

The facility reported a census of 40 residents, with three residents sampled. Based on observation, interview, and record review the facility failed to ensure staff provided Resident (R)1 the necessary bathing services to maintain good grooming and personal hygiene. Findings included: - Review of the Physician Order dated 06/20/24 revealed Resident (R)1 had the following diagnoses: dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion) and prolapse bladder (a condition that occurs when the muscles and ligament that support the bladder weaken and causing the bladder to bulge into the vaginal canal). Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. R1 was independent with Activities of Daily Living (ADLs). Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed R1 had a (BIMS) score of 08, which indicated moderately impaired cognition. The MDS noted R1 refused bathing. The Care Plan dated 06/20/24 revealed R1 required one person assistance with ADLs due to decreased mobility and dementia. The care plan further noted staff were to ask R1 if she wanted a bath, daily. The care plan documented R1 would refuse (bathing) and the staff were to notify the charge nurse and noted the staff must approach three times. Review of the Bathing Sheets from 06/30/24 to 07/23/24 indicated R1 did not receive a bath for 24 days. The Physician Order dated 08/14/24 revealed an order for R1 to have a bath daily. Review of the Nurses Notes on 08/17/24, 08/18/24, 08/21/24, 08/23/24, 08/25/24 R1 refused her bath, and the facility did not contact R1's family member. Review of the Nurses Notes from 06/02/24 to 08/23/24 indicated R1 did refuse bathing, the notes lacked evidence of notification to R1's family member. During an observation on 08/26/24 at 10:30 AM, R1 sat in a recliner in the commons area. R1 then ambulated to her room, using her front wheeled walker, without difficulty. R1 clothes looked clean and no foul odors were observed. Interview with R1's family member on 08/26/24 at 12:06 PM revealed the staff were to give R1 a daily bath, and if R1 refused to take a bath the facility staff were to contact me. During an interview on 08/26/24 at 12:40 PM, revealed Certified Nurse Aide (CNA) D revealed the staff did offer a bath daily. CNA D said R1 preferred to have her baths at night before bedtime but with them now on day shift, R1 refuses the bath. If R1's family member was in the facility, she will help to encourage her to take a bath. CNA D said she did know the staff did not follow the protocol of documenting like they are suppose too when a resident refuses a bath During an interview on 08/26/24 at 02:00 PM, Licensed Nurse (LN) C revealed R1 liked her bath before going to bed, but staff moved her shower to the day shift because the facility had a bath aide on the day shift. LN C did not know the staff were to contact R1's family member if R1 refused to take a bath. During an interview on 08/26/24 at 02:50 PM Administrative Nurse B knew the nurses were to contact R1's family member if R1 refused a bath. The facility's undated policy Bath/Shower Policy and Procedure Manual included to provide residents with safe hygiene, and thorough bathing assistance, document bathing assistance provided. The facility failed to provide R1 with necessary bathing services to maintain good grooming and personal hygiene.

The facility reported a census of 43 residents with 14 residents sampled, including one resident reviewed for hydration. Based on observation, interview, and record review, the facility failed to provide adequate hydration for dependent resident R99, who was observed with dry lips and mouth, deep grooves in her tongue, an empty water cup, water out of reach of the resident, several staff provided cares but did not offer water, R99 cried and moaned asking for water, and her EMR recorded she received only two to four cups of water daily from 04/12/23-04/18/23. Findings included: - Review of Resident (R)99's electronic medical record (EMR), included a diagnosis of rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). The resident admitted to the facility on [DATE], which revealed no Minimum Data Sheet (MDS) was available for review. The Care Plan for Activities of Daily Living (ADL), dated 04/12/23, instructed staff the resident required setup assistance with her meals. The Care Plan for a diuretic (medication to promote the formation and excretion of urine), dated 04/12/23, instructed staff to encourage appropriate fluid intake for R99. Review of the Dietary Profile, dated 04/18/23, documented the resident was to have regular fluids. The record lacked evidence the resident was on a fluid restriction for any reason. Review of the resident's EMR revealed from 04/12/23 through 04/18/23, the resident received 500 to 960 cubic centimeters (cc) of fluids, daily. The staff documented no other fluid intake. One cup of fluid is equivalent to 236.5 cc of fluid, meaning R99 received about two to four cups of fluid daily from 04/12/23-04/18/23 [per mayoclinic.com women need 11.5 cups of water daily]. On 04/17/23 at 10:04 AM, the resident sat in her recliner in her room. The resident moaned and cried and stated she was very thirsty. An empty water cup sat on the bedside table in front of the resident, while the resident was observed with dried lips and mouth, and her tongue was observed with deep grooves present. On 04/18/23 at 08:48 AM, Licensed Nurse (LN) H entered the resident's room to visit with her briefly and failed to offer the resident a drink of water, at that time. On 04/18/23 at 11:30 AM, the resident rested in bed. The resident stated I want some water, please, please. The water cup sat out of reach on the resident's bedside table. The resident had dry lips and mouth with visible grooves in her tongue. The resident continued to call out for water at 11:40 AM. At 11:44 AM, Administrative Nurse D entered the room at the request of Consultant Staff GG. The resident stated to Administrative Nurse D that she was dying of thirst. Administrative Nurse D held the cup of ice water and the resident consumed approximately six ounces of water. On 04/18/23 at 11:49 AM, Certified Nurse Aide (CNA) J stated the resident was able to get drinks from her water cup on her own. CNA J said the ice water was filled at least once a shift and the staff should offer residents a drink of water, with all cares. On 04/18/23 at 03:30 PM, CNA M stated staff were to offer water to residents when cares were done. On 04/19/23 at 09:38 AM, CNA L stated staff would fill ice water cups around 10:00 AM every morning. Staff were to offer water to the residents when giving cares, but sometimes staff would forget. On 04/19/23 at 09:38 AM, CNA K stated staff should offer water to residents every time cares were given. On 04/19/23 at 10:45 AM, LN H stated the resident could hold her cup and drink fluids on her own. Her ice water should be kept within reach of her while she was in her room and kept full of ice water. On 04/19/23 at 11:51 AM, Administrative Nurse D stated if a resident had dry lips and mouth and grooves in their tongue, they would need a drink of water. Water should be kept within reach of all residents and staff should always offer resident a drink of water with all cares. The facility policy for Resident Hydration and Prevention of Dehydration, revised October 2022, included: Nurses will assess for signs and symptoms of dehydration during daily care. CNAs will provide and encourage intake of a bedside snack and meal fluids, on a daily and routine basis as part of daily care. The facility failed to provide adequate hydration for dependent resident R99, who was observed with a dry lips and mouth, deep grooves in her tongue, an empty water cup, water out of reach of the resident, several staff provided cares but did not offer water, she cried and moaned asking for water, and her EMR recorded she received only two to four cups of water daily from 04/12/23-04/18/23.

The facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility. Findings included: - The initial environmental tour of the kitchen, on [DATE] at 09:10 AM, with Dietary Staff CC, revealed the following items/areas of concerns: 1. The snack refrigerator contained a pitcher of pre-made lemonade with prep date of [DATE] and lacked an expiration date. 2. Two foil covered pans labeled mix berry cobbler sitting on cart in the kitchen area. Dietary Staff CC identified them as being at room temperature. The side-by-side double door refrigerator contained the following concerns: 1. A large container of tartar sauce with an open date of [DATE], lacked an expiration date. 2. A large container of thousand island salad dressing with an open date of [DATE], lacked an expiration date. A large container of Cesar salad dressing with an open date of [DATE], lacked an expiration date. On [DATE] at 09:10 AM, Dietary Staff CC stated the premade lemonade should be used within two to three days then discarded. Additionally, Staff C stated that the pans of cobbler were cooked on the previous day and were set out to cool overnight and then would be warmed back up for dinner service later that day. She further, stated that the salad dressings and tartar sauce should be discarded 30 days after opening. On [DATE] at 10:10 AM, Dietary Staff BB stated that the foods should be discarded when the expired date has been reached or if the quality of the foods was compromised. The 2020 Food Storage (Dry, Refrigerated, and Frozen policy states that all food items will be labeled with the date by which it should be used or discarded and to see Date Marking Guidelines for examples. The undated, untitled document of foods list, identified by Dietary Staff BB as the Date Marking Guidelines documented that salad dressings, bottled and opened should be refrigerated after opening and placed in storage for ,d+[DATE] months. The recipe for mixed berry cobbler, provided by Dietary Staff BB, documented that for service it should be maintained at 135 degrees Fahrenheit or above. If cooling/holding at room temp, it should be discarded after 4 hours. The facility failed to store and prepare food under sanitary conditions for the residents in the facility. This created the potential for the spread of food borne illnesses to the residents of the facility.

The facility reported a total of 41 residents with three residents in the sample with one resident reviewed for lack of supervision. Based on observation, record review, and interview the facility neglected to ensure cognitively impaired Resident (R) 1's safety while she remained outside of the facility, unsupervised, from 03:00 PM to approximately 04:50 PM (1 hour and 50 minutes), in temperatures of about 97 degrees Fahrenheit (F). The facility further failed to check on the resident's wellbeing or provide her fluids. This failure resulted in R1 having an altered mental status, a body temperature of 102.5 degrees F, required emergency medical services response, and she transferred/admitted to the local hospital. This failure placed R1 in immediate jeopardy. Findings included: - Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Date Set (MDS) dated [DATE], revealed a Brief Mental Interview Status (BIMS) score of seven, indicating severely impaired cognition. Review of the resident's ability to perform activities of daily living (ADL) revealed R1 as independent with walking in room and corridor. The resident required set up help only with locomotion on and off the unit no falls indicated. The Quarterly MDS dated [DATE], revealed (BIMS) score of four, which indicated severely impaired cognition. R1 continued to be independent with ADLs with one fall indicated during the seven day look back period. The Cognitive Loss/ Dementia CAA dated 12/22/21, revealed R1 had dementia and could not recall the year, month, or day of the week. R1 reported it was 2016, a workday, cold outside, probably February, and could not recall the three words asked during the assessment. The Care Plan with a target date of 12/07/22, instructed staff that R1 required assistance with ADL's, had decreased mobility, poor safety awareness, and impaired mental status. R1 used a walker and staff were to provide stand by assistance for safety and to use a wheelchair as needed. A Nurses Note dated 09/03/22 at 05:16 PM, by Licensed Nurse (LN) C revealed R1 sat on the porch in the sun. When LN C attempted to assist R1 inside the facility for supper, R1 had difficulty with ambulation. LN C placed a gait belt around R1's waist and assisted her to stand. R1 was unable to move her legs and she was placed in a wheelchair and brought into the building. LN C noted R1 had altered mental status and was not responding well. R1's temperature on a temporal thermometer measured 102.5 degrees F. Ice packs were placed under each of the resident's arms and cold wash cloths were placed on her head and neck. LN C placed a call to the physician and obtained an order to send the resident to the emergency room for evaluation and treatment. A Nurses Note dated 09/03/22 at 07:30 PM, revealed hospital staff called the facility to inform them the resident was being kept overnight for fluids and oral potassium (a medication to increase low potassium level). The Hospital Admission Record dated 09/03/22 at 05:22 PM, revealed the resident admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's surveillance video revealed the following timeline, which establishes the exact amount of time R1 remained outside the facility in 97-degrees F weather, and Licensed Nursing staff did not check on R1 from 03:00 PM until 04:40 PM on 09/03/22: 09/03/22 at 03:00 PM, Certified Nurse Aide (CNA) F let R1 outside on the porch. 09/03/22 at 03:11 PM, LN C in the area and did not check on R1. 09/03/22 at 03:15 PM, LN C left the lobby without checking on R1, who remained outside in the heat, sitting on the porch. 09/03/22 at 03:52 PM, LN C in the lobby with another resident. 09/03/22 at 04:03 PM, LN C left the lobby. 09/03/22 at 04:10 PM, LN C in the lobby. 09/03/22 at 04:11 PM, LN C left the lobby. 09/03/22 at 04:15 PM, CNA F in the lobby. 09/03/22 at 04:17 PM, CNA F left the lobby. 09/03/22 at 04:35 PM, CNA F was in the lobby and propelled an unidentified resident out of the lobby. 09/03/22 at 04:40 PM, LN C exited the front lobby doors and checked on R1 sitting outside. 09/03/22 at 04:44 PM, LN C returned into the building for LN D to assist with R1. 09/03/22 at 04:50 PM, LN C and LN D assisted R1 into the building using a wheelchair. 09/03/22 at 05:07 PM Emergency Medical Services arrived at the facility. 09/03/22 at 05:15 PM, R1 left with EMS. Interview, on 09/27/22 at 07:10 PM, with LN C revealed on 09/03/22 she took her lunch at 02:45 PM and returned to the facility at 03:15 PM. LN C stated R1 was sitting outside in the heat, on the porch. LN C stated at 04:15 PM, R1 was outside on the porch. LN C reported she thought the resident was outside about one hour or less and not sure on how long she was out there. LN C revealed R1 drank one and half glasses of water when she was brought back into the facility. R1 was warm and her temporal temperature was 102.5 degrees F. Staff placed ice bags under both of the resident's arms and staff further placed a cool cloth on R1's head and neck. LN C stated she contacted the physician and received orders to send R1 into the emergency room for evaluation and treatment. Interview, on 09/27/22 at 07:30 AM, with LN D revealed on 09/03/22 at 03:15 PM, LN C requested help with R1 who was sat in a chair outside the front door. R1 appeared to have an altered mental status, due to her temperature being 102.5 degrees F, ice bags and cool clothes were placed under the arms, head, and neck. After R1 left the building, staff discovered that a Certified Nurse Aide (CNA) F had taken R1 outside between 04:00 PM and 04:20 PM. Interview, on 09/27/22 at 12:10 PM, with Certified Nurse Aide (CNA) F indicated between 04:00 PM and 04:30 PM the CNA assisted the resident outside. CNA F was unaware if R1 had any fluids with her. Interview, 09/27/22 at 09:28 PM, with Administrative Staff B stated she expected staff to supervise a resident with cognitive impairment who requested to go outside. Administrative Staff B stated the facility did not have a policy on monitoring of residents while outside. The facility failed to ensure R1's safety while she sat outside of the facility on the porch for a minimum of 1.25 hours in extreme heat of 97 degrees F and was transferred to the emergency room with a temperature of 102.5 degrees F and altered mental status. On 09/27/22 at 04:35 PM, Administrative Staff A and Administrative Nurse B were provided with the IJ template by email to notify them that the facility failed to ensure proper safety on 09/03/22 when Resident R1 (cognitively impaired) was left outside on the porch in the sun for unknown duration of time during extreme heat of 97 degrees (F). The deficient practices were likely to cause serious harm, injury, or death. The failure to ensure a safe environment during extreme inclement weather constituted immediate jeopardy for this resident. The facility identified and corrected the deficient practice on 09/27/22 at 06:25 PM, when the following was implemented: 1. All staff were educated on the routine resident's checks. 2. The facility established a monitoring log on residents sitting outside, 3. The facility placed a thermometer at the front entrance and gazebo. 4. Implemented administrative staff conducting random routine resident checks daily each shift for seven days then weekly for four weeks results of all audits will be forwarded to the QAA committee for review. The facility identified and corrected the deficient practice on 09/28/22 at 08:00 AM, for the incident on 09/03/22, with the education completed on 09/27/22 at 06:25 PM, implementing monitoring of the cognitively impaired residents who must have a staff member, friend, or family member with them while outside at all times. If temperatures are below 50 degrees (F) or above 90 degrees (F) residents are encouraged to come back into the building after 30 minutes. The surveyor verified the implementation of the IJ removal plan while on site on 09/28/22, the deficient practice remained at a G scope and severity.

The facility reported a census of 43 residents and identified 10 that resided on the memory care unit. The sample of four residents included three reviewed for accidents. Based on observations, interview, and record review, the facility failed to provide an environment as free as possible of accident hazards for one of the three residents, cognitively impaired Resident (R1), on 08/12/22 at 01:01 PM, when the facility staff removed the bathroom door from the residents' room and placed the bathroom door in another room just across the hall, that was unsecured and unoccupied, on the Memory Care Unit. On 09/25/22, at approximately 01:12 PM, Certified Nurse Aide (CNA) M observed that R1 was not in her room. CNA M observed the door to the unsecured and unoccupied room entrance door stood open and the removed bathroom door stood leaning against the bathroom wall, that was previously leaning against the wall across from the bathroom. CNA M observed R1 in the room lying on her back, with knees upward, holding her head, and with a golf ball size red circle noted to the back of her head. CNA M notified Licensed Nurse G immediately. At approximately 01:15 PM, LN G called 911 to have R1 transported to the Emergency Department (ED) for evaluation and treatment by Emergency Medical Services (EMS). These failures placed R1 in immediate jeopardy and placed the other 9 residents of the memory care unit at risk for harm or injury. Findings included: - R1's 09/28/22 signed Physician Orders Sheet (POS) documented the facility admitted the resident on 02/14/22 with the following diagnoses: [CONDITION(S)] (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), disorders of bone density and structure, multiple sites (your bones have changed in more than one place), dementia (progressive mental disorder characterized by failing memory, confusion), and non-displaced fracturing (broken bone in one location without change of alignment) involving the midline calvarium (bones which cover and protect the brain) with overlaying soft tissue swelling. The 02/21/22 Admission Minimum Data Set (MDS) documented the resident had a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. She required limited assistance with transfers and supervision with ambulating. The resident was not steady on her feet, and able to stabilize without staff assistance. The resident did not utilize a mobility device. The 02/24/22 Cognitive Loss/Dementia Care Area Assessment (CAA) documented the resident frequently wandered into other residents' rooms while residing in a previous Long-Term Care (LTC) facility. The resident continued to wander into other residents' rooms in the current facility's secured memory unit. The 02/24/22 Activities of Daily Living [ADL] Functional Rehabilitation Potential Care Area Assessment (CAA) documented the resident required assistance with ADL related to impaired mobility. R1 wore a Wander Guard (device worn by residents that trigger an alarm to alert staff when the resident came within range of the transmitter, usually posted near an exit door) for safety. The 02/24/22 Falls Care Area Assessment (CAA) documented the resident was at risk for falls related to impaired mobility. The 08/13/22 Quarterly MDS documented the resident had a BIMS score of four , which indicated severely impaired cognition. The resident required one-person extensive assistance with toileting and one-person supervision with transfer and ambulating. The resident was not steady, but able to stabilize without staff assistance. The resident did not utilize a mobility device. The resident's Fall Care Plan, dated 02/18/22, instructed staff to provide appropriate footwear when transferring and ambulating, remind the resident to use the call light for safety, ensure a clutter free environment, adequate lighting, and that personal items were within her reach. A revision on 08/12/22, included staff to ensure the resident was wearing non-skid soled house slippers. The Nurse's Note dated 09/25/22 at 02:48 PM revealed LN G documented on 09/25/22 at 01:12 PM staff observed R1 lying supine (on her back) on the floor, knees bent, and her hands were holding the right side of her head. An assessment revealed a golf ball sized, red area to the back of the resident's head. The resident's cognition declined, she was slower to respond, had her eyes closed, and would only speak when staff stated her name. At approximately 01:14 PM, LN G called the physician to send the resident to the Emergency Department (ED) for evaluation and treatment. At approximately 01:15 PM, LN G called 911 for R1 to be transported to the ED by Emergency Medical Services (EMS). EMS arrived at the facility at 01:25 PM and transported the resident to the ED. The Nurse's Note on 09/25/22 at 04:54 PM documented LN G received a call from the ED with the computerized tomography (CT) Scan (diagnostic imagining scan that emphasizes on a specific area) results indicating a subdural hematoma (collection of blood on the surface of the brain and nondisplaced skull fracture. The Nurse's Note on 09/25/22 at 05:16 PM, documented the resident turned from the acute hospital on comfort care as requested by the resident's family member. Review of the resident's head CT Scan, completed on 09/25/22 at the ED, revealed a small subdural hematoma, and anon-displaced fracturing involving midline calvarium with overlying soft tissue swelling. On 09/29/22 at 10:30 AM, LN G reported that on 09/22/22 at approximately 01:13 PM, CNA M informed her R1 fell in the unoccupied, unsecured room in the memory care unit. LN G reported she observed the resident lying supine, with knees bent, and the resident holding the right side of her head. LN G reported the (unsecured) door fell against the bathroom wall and was being removed from the unoccupied room by staff when she arrived. LN G reported upon assessment she observed a golf ball size, red circle to the back of the resident's head and said the resident showed decline from her normal baseline. LN G reported when the resident returned from the acute hospital, she appeared lethargic (a feeling of fatigue, tiredness and exhaustion both physically and mentally), did not respond to verbal stimuli (stimulation in verbal communication), kept her eyes closed, or showed no facial expression (gesture with facial muscles) for approximately 48 hours. LN G reported approximately three days after the fall on 09/25/22, the resident returned to her normal baseline. On 09/29/22 at 10:45 AM, CNA M reported R1 was not in her room when she completed visual checks, prior to her going on her break at 01:30 PM (on 09/22/22). CNA M noted the unoccupied room door stood open. CNA M reported when she entered the room, a brown door was leaning against the bathroom wall. CNA M reported she moved the door from the bathroom wall and leaned the door against the wall across from the bathroom. R1 was lying on her back, on the floor, with knees bent, and holding her head with both hands. CNA M reported she immediately called LN G to advised her that R1 fell in the unoccupied room. On 09/29/22 at 10:50 AM, Maintenance staff U reported he did not know who asked him to remove the bathroom door. Maintenance staff U reported he was in a hurry, and he placed the door in the unsecured and unoccupied room (on the memory care unit). He reported he failed to place the door in a secured location. Review of the facility's video surveillance revealed on 08/12/22 at 01:01 PM, the staff removed the bathroom door and placed it in the unsecured room. On 09/29/22 further review of the facility video surveillance, from 09/25/22 at 12:35 PM, revealed the resident stood at the nurse's desk in the Memory Care Unit and the door to the unsecured room was not open. Later that same day, at approximately 01:40 PM, the staff removed the bathroom door from the unsecured room and placed it in a different secured room. On 09/29/22 at 01:22 PM, Administrative Nurse D reported the maintenance staff should not have left the door in the unsecured and unoccupied room. On 10/03/22 at 10:52 AM, Administrative Staff A reported the door should have been placed in a secured location after the staff removed the door. The door was removed on 08/12/22 at 01:01 PM, from a room and placed in the unoccupied, unsecured room across the hall (in the memory care unit). The facility Hazardous Areas, Devices and Equipment Policy, Revised 07/2017, documented it was the policy that all hazardous areas will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The policy documented a hazard is defined open areas or items that should be locked when not in use. The facility failed to provide an environment as free of accidental hazards as possible for the 10 cognitively impaired residents residing in the memory care unit, including Resident (R1), when on 08/12/22, at 01:01 PM, the facility staff removed the bathroom door from the residents' room, and placed the bathroom door in an unsecured and unoccupied room next to the resident's room on the Memory Care Unit. On 09/25/22 at approximately 01:12 PM, CNA M observed R1 was not in her room. CNA M observed the door to the unsecured and unoccupied room entrance door was opened and the bathroom door from the resident's room was leaned against the bathroom wall, that was previously leaning against the wall adjacent from the bathroom . CNA M observed R1 in the unsecured room lying on her back, with knees upward, holding her head, and with a golf ball size red circle noted to the back of her head. CNA M notified Licensed Nurse G immediately. At approximately 01:15 PM, LN G called 911 to have R1 transported to the Emergency Department (ED) for evaluation and treatment by Emergency Medical Services (EMS), where the resident was found to have a subdural hematoma and fractured skull. These failures placed R1 in immediate jeopardy. The facility provided an acceptable plan of removal of the immediately jeopardy, on 10/03/22 at 04:45 PM. The plan included the following: 1. The unsecured door was removed on 09/27/22. 2. Maintenance educated on Removal of Unsecured Door on 09/27/22. 3. Unoccupied rooms in Memory Care have been secured on 10/03/22. 4. All staff were educated on the Need to Ensure Environment Free of Accident Hazard and Appropriate Supervision for Cognitively Impaired Resident's on 10/03/22 beginning at 03:47 PM, that were currently working. Sign posted that no one is allowed to work until educated on P/P. 5. Staff members who have not had education will be educated prior to working their next shift. 6. New hires will be educated upon hire. 7. Complete a Full House Environmental Round on the Memory Care Unit. On 10/03/22 at 04:45 PM, the survey team verified onsite that the facility implemented the IJ removal plan, the deficient practice remained at a G scope and severity.

The facility reported a census of 40 residents with 13 included in the sample. Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR- emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.) on one sampled Resident (R)1, who had a Full Code (CPR desired to be performed if found without respiration and/or a pulse) status when staff found her unresponsive and without a pulse. This failure had the potential to also affect the 13 other residents of the facility that desired resuscitation which could lead to serious harm or death. This practice placed the other 13 residents in immediate jeopardy. Findings included: - The Medication Review Report, dated [DATE], for R1, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], assessed R1 with a Brief Interview of Mental Status score of 13, which indicated intact cognition. The Care Plan, initiated [DATE], indicated that R1 was a full code and instructed the staff to attempt resuscitation. The Electronic Medical Record (EMR), under the Orders tab, indicated R1 had a status of Full Code. The Progress Notes, dated [DATE] at 05:55 AM, revealed unidentified facility staff called Licensed Nurse (LN) G to R1's room at 05:05 AM where she was found to be absent of vital signs. The note lacked information regarding the resident's code status and/or if staff initiated CPR. The Progress Notes dated [DATE] at 06:00 AM revealed R1's color was grayish/yellow with a waxy appearance, eyes fixed, face drawn with her jaw slightly ajar, and her body very cool to the touch and difficult to manipulate. The staff could not locate a pulse when assessed apical, brachial, or pedal. The follow-up note lacked information to include if the staff checked her code status and initiated CPR. On [DATE] at 10:12 AM, Certified Nurse Aide (CNA) M stated she was not CPR certified. She went into R1's room on [DATE] at 05:00 AM and she was not moving, her hands were cold, her face was warm, and her eyes and mouth were open. CNA M stated she did not know what to do so she went and got Certified Medication Aide (CMA) R. He entered the resident's room, looked at R1, then went and told LN G, who responded and listened for R1's heartbeat. The staff present did not attempt CPR. On [DATE] at 10:31 AM, CMA R stated he was CPR certified. CMA R further explained on [DATE] at 05:00 AM, CNA M alerted him that R1 was not breathing. CMA R went into R1's room and she looked like she had passed away. CMA R alerted LN G and assessed the resident for a pulse on her neck, which was warm, and noted he did not feel one. CMA R stated R1's color was pale, with her eyes and mouth open. CMA R stated the nurse did not have him check for R1's code status or instruct him to initiate CPR and LN G did not initiate CPR. On [DATE] at 12:47 PM, LN G stated she was three to four rooms down the hall from R1's room when CMA R stated that [R1] was gone. LN G grabbed her stethoscope, assessed skin temperature, and stated R1 was very cold on her arm, feet, and her face. LN G stated she did not hear or feel a pulse, her arm was kind of stiff, difficult to manipulate, and her skin was gray/yellow in color with a waxy appearance. LN G stated she did not check R1's code status and did not initiate CPR as she thought R1 was gone and there was nothing that I could do, it would have not changed the outcome. On [DATE] at 01:51 PM, Administrative Nurse D stated she expected LN G to start CPR when R1 was found unresponsive. The facility policy Emergency Procedure-Cardiopulmonary Resuscitation, dated [DATE], included that if an individual (resident, visitor, or staff member) was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS shall initiate CPR unless: it was known that a DNR [Do Not Resuscitate] order that specifically prohibits CPR and /or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis) and/or the performance of CPR would be medically futile. Begin CPR if the adult victim is unresponsive not breathing normally (ignoring occasional gasps), and without a pulse. The facility failed to initiate CPR on R1, who had a Full Code status when staff found her unresponsive and without a pulse. This failure to initiate CPR for residents that desire resuscitation had the potential to lead to harm or death. This practice placed R1 and 13 other residents of the facility with a Full Code status in immediate jeopardy. On [DATE] at 04:40 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy (IJ) template, informed of the IJ, and notified immediate action was needed to ensure staff initiate CPR for residents who desire resuscitation. The facility provided an acceptable plan for removal of the immediate jeopardy on [DATE] at 05:12 PM. The removal plan included a full house audit for code status, training of all employees on requirements of performing CPR, CPR education of all future employees on CPR education, audits to validate staff knowledge of the facility emergency procedure, with results of audits forwarded to the Quality Assurance Performance Improvement (QAPI) committee for review. The survey team validated the immediate jeopardy was removed on [DATE] at 09:00 AM/PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at an E scope and severity, following the removal of the immediate jeopardy.

The facility reported a census of 34 residents, with 4 residents sampled for accidents. Based on observation, record review and interview, the facility failed to ensure one of the 4 sampled residents (#1), received adequate supervision and failed to develop and implement timely and effective interventions to prevent falls, which resulted in a head injury with increased confusion which required hospitalization and sutures to the resident's head. Additionally, the facility failed to ensure adequate supervision and assistive devices for resident's # 3 and 4 to prevent repeated falls. Findings included: - Per the census data, the facility admitted resident # 1, on 1/4/17 and the resident discharged to the hospital on [DATE], with a [DIAGNOSES REDACTED]. A Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status score of 14/15, which indicated intact cognition. The resident expressed he/she felt tired, had trouble with sleep, and appetite concerns and lacked other mood or behavioral concerns. The assessment identified the resident required limited assistance of staff for most ADLs (activities of daily living) including locomotion and mobility; the resident used a walker for mobility. The assessment indicated the resident lacked falls, prior to or since admission. The facility assessed the resident at high risk for falls on 1/4/17 and on 1/21/17. The resident's care plan, developed on 1/18/17, included the following interventions: 1. Anticipate and meet the resident's needs. 2. The resident needed assistance with a toileting program. The care plan lacked interventions for an individualized toileting plan for this resident. 3. Ensure the resident's call light was within reach and encourage the residents to use it for assistance, as needed. The resident needed prompt response to all requests for assistance. 4. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred. 5. Fall risk assessment, completed by the nurse. 6. Labs (laboratory tests) per the PCP (primary care provider) orders. 7. Pharmacy consults for drug regimen review. 8. Dietician consults for nutritional needs, for strengthening. 9. PT (physical therapy) evaluate and treat, as ordered or PRN (as needed). 10. On 2/1/17 staff added to increase visual checks, related to a fall during the night. The care plan lacked interventions following, each of the 3 falls the resident experienced, to prevent further falls. Review of the resident's falls included: On 1/21/17 at 11:56 AM, nursing notes documented the resident was on follow-up for an unwitnessed fall, that occurred prior to 7:04 AM. The resident denied pain associated with the fall. Staff notified the physician via fax, and family visited the facility and received notification of the reported fall. An assessment identified the resident had bruising to his/her bilateral knees and a bruise to the left elbow. An undated, incomplete investigation of the fall, provided by the facility, identified the resident failed to report to the staff, at the time, the fall occurred and got his/her self up off the floor. Staff noted the bruising and inquired about the fall, from the resident. The clinical record lacked evidence the facility completed a root cause analysis to determine the cause of the fall, and failed to develop and implement any additional interventions to prevent further falls for this resident. Nursing notes, on 2/1/17 at 1:00 AM, identified the staff found the resident lying on the floor, on his/her back in his/her bedroom. The resident reported to staff he/she got up to go to the bathroom. The staff assisted the resident to a sitting position, and noted a 1-2 cm (centimeter) laceration to the back of the resident's scalp. The staff assisted the resident back into bed, cleaned the wound and initiated neurological checks. The clinical record lacked evidence the facility completed a root cause analysis to determine the cause of the fall, and failed to develop and implement any additional interventions to prevent further falls for this resident. Further nursing notes documented included: Nursing note on 2/1/17 at 5:00 AM, noted approximately a half dollar size hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the back of the resident's scalp, under the laceration. Nursing note on 2/1/17 at 6:05 AM, staff noted the resident sitting on the floor of his/her room. No new injuries assessed. Staff assisted the resident back into bed. Review of the incomplete, undated investigation conducted by the facility included a Transfer Form (to hospice house), dated 2/3/17, from the hospital indicated the resident admitted to the hospital after the fall with a puncture wound/hematoma to the back of the head, which required sutures. The investigation file contained several witness statement and three of the statements were dated 2/22/17 (20 days after the resident admitted to the hospital.) On 2/23/17 at 10:42 AM, direct care staff H reported the resident required help with everything, as he/she was blind. However, the resident continued to attempt to get up on his/her own and tried to be as independent as possible. The staff reported they were unaware of any falls with the resident, but they attempted to keep the resident's area free of obstacles and the staff checked on the resident frequently. On 2/23/17 at 1:05 PM, licensed nursing staff C, reported he/she came on duty when the resident was receiving a shower before being sent to the hospital. The staff member reported he/she looked at the back of the resident's head and observed a hematoma, approximately 2.5 cm (centimeter) in size. An open slit in the skin was present in the center of the hematoma. The staff called for EMS (emergency medical services). On 2/23/17 at 1:27 PM, licensed nursing staff D reported that morning, he/she assisted with assessing the resident, and the resident's vital signs were within normal range. The resident's head was not actively bleeding at the time; however a moderate amount of dried blood was present in the resident's hair and on the resident's bedding. The staff noted the resident appeared confused, did not respond to questions about pain, but was mumbling as though he/she was in pain. On 2/23/17 at 1:40 PM, direct care staff I, reported the early morning hours of 2/1/17 the other CNA (certified nurse aide) reported the resident fell . When entering the room, staff I noted the resident was on the floor, on his/her back, and the resident had blood under his/her head. The staff reported the fall area was located more towards the bathroom. The resident stated his/her head hurt. The nurse assessed the resident then assisted in getting the resident back into bed. When the resident fell the second time, staff noted the resident sitting on his/her bottom, in pretty much the same area. Again the nurse assessed him/her and staff assisted the resident back into bed. On 2/23/17 at 1:55 PM, direct care staff J reported the resident didn't ask for much, and he/she got up on his/her own, a lot. On 2/23/17 at 1:59 PM, licensed nursing staff E reported that the resident's pain medications had been decreased due to the resident seeming more lethargic (sleepy, decreased alertness) and the staff members were watching him/her closely, checking on the resident about every 15 minutes, on the evening before the falls occurred. (The clinical record lacked documentation of this.) When the staff found the resident there was some blood, which the staff reported would be expected with a head injury. Staff reported that when observing the area, the staff had difficulty in seeing the cut area. The bleeding stopped, and the nurse did not notice a big change in him/her, vital signs were good and neuros checked out okay. Staff reported they continued to keep a close watch on the resident. The staff found the resident on the floor again around 6:00 AM, this time sitting upright on his/her bottom. By that time the on-coming shift arrived and the other nurse checked the resident. Assessing a change in the resident's mental status, staff decided to send the resident for evaluation at the hospital. On 2/23/17 at 3:35 PM, direct care staff M reported staff assisted the resident with cares the evening before the falls, and did not notice any changes in the resident, before the falls occurred. On 2/23/17 at 4:55 PM, direct care staff N reported the staff offered toileting to the resident about every 1.5 to 2 hours, before the falls and reported the resident lacked a specific toileting plan. On 2/24/17 at 7:12 AM, licensed nursing staff F reported he/she came on duty the morning of 2/1/17 and was told the night charge nurse was with the resident, due to a fall. The nurse went into the resident's room to assist the other licensed nurse. Staff F reported they were unable to visualize the area on the resident's head, so they requested the bath aide to provide a shower to the resident. The staff noted dried blood on the carpet and also dried and fresh blood spots on the linens of the bed. Staff reported the wound bled slightly, at that time. The resident was moaning, counting, and not responding to questions, when asked. Staff reported the spot of blood on the floor was in the pathway to the bathroom, as though the resident may have been attempting to go to the toilet. On 2/24/17 at 7:27 AM, direct care staff O, reported he/she showered the resident the morning of 2/1/17, as directed by the charge nurse. Staff O reported the resident responded to directions, such as standing, when assisted with use of a gait belt, and holding the wash cloth over his/her eyes while wetting the resident's hair. However, the resident was not responding verbally when questioned about pain. The resident, when seen in his/her room was moaning, Oh God, Oh, God, repeatedly. When taken into the shower and receiving the shower the resident, changed to counting, 1 to 10 over and over. Staff noted a bruise in the center of the residents back, during the shower and when washing the residents back the resident flinched. Again, staff inquired about pain, with the resident continuing to count. On 2/24/17 at 7:50 AM, agency direct care staff P, reported he/she found the resident on the floor with both falls. The first fall, per staff P, the resident was on his/her back and the staff did not immediately note any blood. Staff P summoned the nurse and another aide and the nurse checked the resident for injury. When staff assisted the resident into a sitting position the staff noted the blood. Staff believed the resident was not responding to questions at that time and seemed confused. Also, staff P believed the resident was continent, at that time, and staff did not toilet the resident. Staff assisted the resident into bed, and then when doing rounds the staff checked in on the resident and found the resident sleeping, each time. Sometime later the staff found the resident sitting on the floor again. Again staff summoned the nurse and the other aide, the nurse assessed the resident and the CNA's assisted the resident back into bed. When asked about any intervention in between the falls, to keep the resident safe, the staff thought the nurse looked for an alarm and could not find one. Otherwise the staff just continued to check on the resident. The Falls Clinical Protocol, dated 4/2013 included the staff would evaluate and document falls, including when and where the fall happened and any observations of the events. Based on assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions until falling reduces or stops. The facility failed to provide adequate supervision and develop and implement timely and effective interventions to prevent repeated falls for this resident, identified at high risk for falls and who experienced a change in cognition with a head injury, which required emergency room treatment, including sutures. - An admission Minimum Data Set, dated dated [DATE], identified resident #3 unable to complete the Brief Interview for Mental Status assessment with long and short term memory intact, with modified independence in daily decision making, and some difficulty in new situations only. Staff assessed the resident with trouble concentrating, feeling tired and without other mood or behavioral concerns. The assessment indicated the resident needed extensive assistance for most ADL's (activities of daily living); including transfers, was not steady with balance, lacked any rom (range of motion) impairment, and used a wheelchair for mobility. Staff assessed the resident had a fall history and without falls since admission. A Care Area Assessment for ADL's, dated 2/6/17, included the resident was recently seen in the emergency room and then admitted to the facility for muscle weakness and frequent falls. The staff use a pivot disc with 2 staff assistance for transfers, needed extensive assist with most ADL's, and was occasionally incontinent of bladder. The resident worked with skilled therapy for strengthening. The Care Area Assessment for falls, dated 2/6/17, included the resident was at risk for falls related to muscle weakness and a new environment. Fall risk assessments identified the resident at high risk for falls on 1/27/17 at score of 20 and on 2/4/17, with score of 19. Review of the 2/20/17 care plan included the following interventions, all dated 2/7/17: The resident needed extensive assistance of 2 staff for pivot disc transfers. Monitor/document /report PRN (as needed) for 72 hours to the doctor for signs/symptoms of pain, bruises, changes in mental status of new onset such as confusion, sleepiness, inability to maintain posture, and agitation. Extensive assistance of 2 staff with the sit to stand lift. Provide activities that promote exercise and strength building where possible or provide 1 to 1 activities, if bedbound. PT (physical therapy) consultation for strength and mobility. Skilled therapy for rehabilitation to prior level of function. The facility failed to implement an intervention related to the resident's fall on 2/4/17 when the resident experienced a fall related to the use of a voiding device. Review of a nurses note which identified a fall on 2/4/17 at 5:15 AM, indicated the resident's roommate came into the hallway yelling regarding the resident's fall. Staff documented he/she observed the resident on the floor. The resident wore his/her glasses and was barefoot. The bottom sheet was slid towards the edge of the bed, with bed pads on the floor, and the top sheet and bedspread lay at the foot of the bed and mostly rested on the floor. Staff completed active and passive range of motion to all extremities and joints without complaint from the resident. The resident stated he/she sat on the edge of the bed to urinate when he/she slid off of the bed. The floor in front of the bed was damp. On 2/16/17 at 1:46 PM, weekly Medicare meeting notes revealed the resident continued with poor balance requiring maximum assistance of 2 staff for transfers, ambulated 12 feet with a front wheeled walker and required extensive assistance with a history of sleeping in his/her recliner. The documentation identified the resident needed maximum assistance of 2 staff for toileting. On 2/23/17 at 7:20 AM, the resident sat in a recliner in his/her room, fully clothed, with regular socks on his/her feet. A urine collection bottle sat on the overbed table beside the resident's recliner. On 2/23/17 at 8:25 AM, the resident sat in the wheelchair in the main dining room for breakfast, fully clothed and with shoes on his/her feet. The resident ate independently and visited with tablemates. On 2/23/17 at 4:10 PM, direct care staff N and R assisted the resident to transfer from the recliner to the toilet using the sit to stand lift. Staff provided a safe transfer with the resident holding onto the lift grab bars to maintain an upright position. Direct care staff H reported on 2/23/17 at 2:13 PM, the staff transferred the resident using a sit to stand lift, used 2 staff, tried to keep clutter down, kept the call light in reach and staff encouraged the resident to use the call light when requiring assistance. On 2/23/17 at 2:09 PM, direct care staff K reported the staff toileted the resident using a sit to stand lift, with 2 staff members. The staff were unaware of any falls with the resident and reported that information of changes to the resident's care needs are passed on in report, and if the staff aren't on duty that day, sometimes it is missed getting passed on. Administrative nursing staff B, verified on 2/23/17 the fall investigation should identify the cause of the fall and include an intervention to reduce the risk of further falls. The facility policy and procedure for Falls Clinical Protocol, dated 4/2013, included the staff would evaluate and document falls, including when and where the fall happened and any observations of the events. Based on assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions until falling reduces or stops. The facility failed to provide adequate supervision and assistive devices to prevent repeated falls for this resident, identified at high risk for falls. - An admission MDS dated [DATE] included resident #4, was unable to complete the Brief Interview for Mental Status assessment, exhibited long and short term memory impairment and was severely impaired of daily decision making. The resident exhibited inattention, disorganized thinking, had little interest in doing things, trouble with sleep, felt tired, had trouble concentrating, and had behaviors. The resident required extensive assistance of staff for ADL's (activities of daily living) including transfers and mobility, was unsteady, had rom (range of motion) impairment to one side of the upper extremity and both sides of the lower extremities. The resident used a walker and wheelchair for mobility. The resident had a fall history and documented the resident experienced falls since admission. A 12/30/16 Care Area Assessment for Falls included, the resident had a history of [REDACTED]. The resident needed extensive assistance with ADL's, related to poor safety awareness, impulsiveness, and being hard of hearing. Additionally, the resident received hospice services related to a brain mass and exhibited a shuffling gait with poor stride. Staff assessed the resident at high fall risk, evidenced by fall risk assessments on 12/14/16, scoring the resident at 21 and on 12/24/16 with a score of 28. The resident's care plan, initiated on 10/17/16, included the following: Be sure call light is within reach and encourage the resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. Encourage adequate rest breaks throughout the day. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Follow facility fall protocol. Uses a chair/bed electronic alarm. Ensure the device is in place, as needed. PT (physical therapy) evaluation and treat, as ordered. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family and caregivers as to causes. The facility failed to review and revise the plan of care and implement new interventions, relevant to the 2 actual falls on 12/24/16 and a fall on 12/27/16, to prevent re-occurring falls. Nursing note, dated 12/24/16 at 3:23 PM, documented the staff observed the resident sliding out of his/her chair, 2 times. The resident was free from injury, and was incontinent the first time the resident slid out of the chair. The resident denied need, and lacked sign or symptom of pain. Staff documented the plan to continue monitoring the resident and note changes as they arise. Nursing notes, documented on 12/24/16 at 8:39 PM, the staff found the resident on the floor of the resident's room, where the resident had been seated in the recliner. Staff found no injury on assessment, with the resident yelling and hitting at staff. Staff placed a mattress on the floor, to help prevent injury to the resident should the resident slide off the bed. The resident wriggled off the bed and onto the fall mat later that shift. Staff at that time, positioned the resident towards the wall, instead of the door and dimmed the lights in the room, in attempt to quiet the resident. Nursing notes on 12/27/16 at 9:35 AM, documented the staff found the resident on the floor. No injury was noted. On 12/29/16 at 1:55 PM, nursing notes documented the resident experienced multiple falls in the last 7 days, the resident was very impulsive, and with poor safety awareness. Recommended for the resident not to be in his/her room in the wheelchair unattended and/or placed in a recliner. Staff planned to attempt a low bed at this time. Review of the incomplete, undated facility investigations identified the facility failed to review the falls and identify and implement interventions to prevent repeated falls. On 2/23/17 at 10:42 AM, direct care staff H reported the resident needed help of staff for everything, but he/she still always tried to do for him/herself. The resident's room was kept clear of clutter, ambulated with 2 staff and had a low bed with a fall mat beside the bed. On 2/23/17 at 3:55 PM, direct care staff R reported the resident had several falls, used a low bed for the resident and a fall mat beside the bed. The staff were aware the resident had several falls in the facility but lacked knowledge of interventions for those specific falls. Administrative nursing staff B, verified on 2/23/17 at 4:05 PM, the fall investigation should identify the cause of the fall and include an intervention to reduce the risk of further falls. On 2/24/17 at 8:45 AM Administrative staff A reported the resident was quite good at removing the pressure sensitive and personal body alarms from his/her bed/chair and quieted the alarms by pulling on the wiring, etc. The alarms became ineffective and were removed and likely did not function during the fall. The facility policy and procedure for Falls Clinical Protocol, dated 4/2013, included the staff would evaluate and document falls, including when and where the fall happened and any observations of the events. Based on assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions until falling reduces or stops. The facility failed to provide adequate supervision and assistive devices to prevent repeated falls for this resident, identified at high risk for falls.

The facility reported a census of 28 residents. Based on observation, interviews and record review, the facility failed to provide adequate supervision for 1 (#01) of 3 sampled residents. The resident exited the facility without staff knowledge ambulated approximately two-tenths of a mile from the facility in a residential area with a posted 20 mile an hour speed limit, with an outside temperature of 93.9 degree Fahrenheit (F). The resident was found by staff that left the faciity on meal break. This deficient practice placed the resident in immediate jeopardy. Findings included: - The medical record evidenced the facility admitted resident #01 on 6/6/16 from their assisted living due to mental issues. The physician listed [DIAGNOSES REDACTED]. The resident returned from treatment in a behavior unit to his/ her assisted living apartment last week. This proved to be unsuccessful, therefore, the resident admitted for short term skilled services in long term care. The 6/13/16 admission MDS (minimum data set) assessment identified the resident with a BIMS (brief interview for mental status) which indicated a moderately impairment of cognition. The resident was independent with activities of daily living. The CAA (care area assessment), dated 6/13/16, for cognition included resident had fluctuating issues with cognition depending on how he/she was doing that day and the level of his/her mental health issues at that time. The resident reported having issues sleeping as well, due to his/her brain not shutting down. The activity of daily living (ADL) care area assessment identified the resident with modified independence with his/her ADL. The psychosocial well being care area assessment identified the resident liked to keep to him/her self and not do activities. Also included the resident suffered from mental health problems for the majority of his/her life and has always had this issue. Per interview with administrative nursing staff B, on 6/29/16 at 9:40 A.M., the facility had not identified the resident as an elopement risk and the resident care plan did not include the problem of elopement risk/wanderer habits. The resident scored a 1 (very low risk) on the wandering risk tool on admission. Per interview with administrative staff A, on 6/29/16 at 9:00 A.M., administrative nursing B and a corporate nurse G, while driving to lunch, noted the resident walking in the grass 0.2 of a mile south of the facility, on 6/22/16 at approximately 11:30 A.M. Staff stopped and offered the resident a ride back to the facility, which the resident accepted. Upon return to the facility, staff evaluated the resident and found him/her without injury. At that time, the resident told the staff, a lady put the door code in on the front door and he/she opened the door and walked out. Therefore, the alarms did not sound. The resident also commented, the president told him/her that he/she could no longer live there and to leave. Per progress note, dated 6/22/16 at 4:24 P.M., when the resident eloped, he/she was fully dressed with a sweater over his/her arm, wearing sun glasses and carrying a purse. The temperature outside, at that time, measured 93.9 degrees F., per www.wunderground.com. Upon return to the facility, on 6/22/16 at 11:30 A.M., the medical record progress notes documented administrative nursing staff B and C assessed the resident, provided fluids, notified the physician and family, placed staff one on one with the resident and placed a wanderguard on the resident. Staff noted the resident uninjured, vitals within normal limits, temperature 97.4 and without excessive sweating. The resident continued with one on one staff supervision until he/she transferred to a behavior unit, on 6/23/16, as soon as a bed was available. The facility investigation confirmed the staff the resident last noted in the facility by direct care staff E, on 6/22/16 at 10:50 A.M. (45 minutes before found outside), walking in the hallway. On 6/29/16 at 8:30 A.M., observation revealed the facility was in a residential neighborhood with streets posted with 20 mile per hour speed limit signs. The facility elopement policy, dated 12/2007, included the following policy statement: Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. When a departing individual returns to the facility the director of nursing or chare nurse shall: Examine the resident for injuries; notify the attending physician; notify the resident's legal representative (sponsor) of the incident; complete and file report of incident/accident; and document the event in the resident's medical record. The facility failed to provide adequate supervision for this cognitively impaired resident who exited the facility, without staff knowledge, ambulated approximately two-tenths of a mile in a residential area with a 20 mile an hour posted speed limit. The temperature was 93.9 degrees F. This deficient practice placed the resident in immediately jeopardy. After review of the facility's corrective actions, this was determined to be past non-compliance. The facility actions included: 1. Set up elopement books at the nurses stations. 2. Audited wandering risk tools to ensure quality tools done. 3. Note high risk residents and updated book and interventions. 4. New pre-admission screening assessment to be completed and included in medical report. 5. On call nurse to contact charge nurse twice during on call shift to check on elopement risk residents. 6. Sign on front door to alert visitor about resident safety. 7. Sign off sheet for motion detector checks on halls 1-3. 8. Moved medication cart to entryway of hall 3 to allow better sight to front door. 9. Change door code on front door. 10. In-service all staff regarding prevention of elopements. 11. Will institute 1:1 with exit seeking behaviors. On 6/25/16 the facility completed in-service of all employees regarding prevention of elopements which included: l. All staff participate in observing residents for sign of exit seeking, speaking of wanting to leave packing belongings, or any other signs that a resident may be at increased risk for elopement. 2. Staff report any behavior as listed in #1 to charge nurse or to facility administrator. 3. Signs are posted on the door to alert staff and visitors to notify staff if resident is trying to leave and to obtain permission from staff before allowing a resident to go out the door. 4. Sensors on hall 1,2 and 3 doors are kept on. 5. Med Aide cart is now parked mere med room door in front lobby. Med Aide is to help watch front door. 6. If resident presents exit seeking behaviors, and immediate one on one observation starts and continues until care plan is in place to ensure resident's safety. 7. Alarms are to be kept on in front lobby, dining room and nurses station. When alarm sounds, staff will visually observe door to ensure no resident has exited that door. 8. Nurse on call will contact charge nurse twice during on call hours to ensure elopement prevention strategies are in place. 9. Residents are asked to notify staff if they notice any signs of impending elopement. 10. Staff performing one on one will have resident in their eye sight at all times. 11. Add wanderguard immediately if exit seeking or attempting elopement. Test wanderguard before applying. 12. There is an elopement book a that ensures station with information about residents at risk for elopement. Any resident exhibits signs of elopement, they are to be added to elopement book. This deficiency was cited as past non-compliance.

The facility had a census of 32 residents, with 3 residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing and to prevent new pressures sores from developing for 2 of the 3 residents reviewed for pressure ulcers (#3 and 4). Resident #3 had a facility acquired Stage II pressure ulcer which developed on 4/16/15 which developed into an unstageable pressure ulcer on 6/26/15. Findings included: - The facility admitted resident #3 on 3/31/05, per the 6/29/15 signed POS, with [DIAGNOSES REDACTED]. The resident's 3/4/15 annual Minimum Data Set identified the resident with short and long term memory problems, severely impaired decision making skills, total dependence on 2 staff with bed mobility, transfers, and toilet use, functional limitations in upper and lower extremities on both sides, used a wheelchair, no stage I or higher pressure ulcer, clinical assessment used, at risk of developing a pressure ulcer, a pressure reducing device for chair/bed, and on a turning/repositioning program. The resident's 3/11/15 CAAs (Care Area Assessment Summary) triggered the following area: Pressure Ulcer - The resident was incontinent of bowel and bladder and required check and changes to be performed by staff daily. The resident was unable to acknowledge or make needs known with toileting and wore briefs. The resident required staff to reposition him/her ever 1-2 hours and as needed each shift. The resident had contractures and was at risk for developing pressure areas. The resident was care planned to be repositioned every 1-2 hours and as needed, as well as, checked and changed. The resident's 5/22/15 quarterly MDS (Minimum Data Set) identified the resident with short and long term memory problems, severely impaired decision making skills, required total dependence of 2 staff with bed mobility and transfers, functional limitations in the upper and lower extremities on both sides, used a wheelchair, did not have a stage I or higher pressure ulcer, was at risk of developing a pressure ulcer, a pressure reducing device used on the chair/bed, on a turning/repositioning program. The resident's 7/14/15 care plan had the following interventions: Intervention dated 1/16/15, whenever possible, place rolled up wash cloths in the resident's hands to absorb moisture and reduce potential wounds. The resident had bilateral contractures of his/her lower extremities and upper extremities. Intervention of 4/2/15 recorded the resident had contractures of the upper and lower extremities and did not like objects placed in his/her hands. Please have staff wash his/her hands gently with soap/water and dry thoroughly. Intervention of 7/3/15 - The resident to see the wound physician for the wound to right thumb. Please notify him/her of changes or problems between appointments. Intervention of 8/13/15, directed staff the wash cloth changed to inflatable carrots to the left hand and a blue soft roll with strap to the right hand. The restorative aide to clean the resident's hands and change out the device every morning. (rolled washcloths, palm protectors, carrots, soft rolls, hand cones - all are devices used to position the hand to assist in lifting and holding the fingers away from the palm of the hand and for keeping the fingers separated.) Staff recorded on the resident's 12/12/14 Braden assessment, the resident at moderate risk of developing a pressure ulcer, with a score of 13. Licensed staff recorded in the 4/9/15 progress notes at 1:35 PM, the weekly skin assessment completed. The progress notes did not identify any compromise of the resident's skin on the left thumb. Licensed staff recorded in the 4/16/15 licensed nurse weekly skin assessment the resident had an open ulcer on the left thumb. The assessment lacked any measurements of the open ulcer on the left thumb. Staff recorded in the 4/16/15 progress notes, at 3 PM, the resident noted with a Stage II area to the left thumb, unable to measure the area due to a severe contracture and the resident's behavior when attempted. Staff notified the resident's physician who ordered staff to apply a foam pad to the Stage II pressure ulcer on the left thumb and secure with tape daily till resolved. Review of the resident's clinical record lacked any additional documentation or assessment of the resident's Stage II left thumb pressure ulcer from 4/16/15 until the 5/7/15 weekly skin assessment. Staff recorded on the 5/7/15 licensed nurse weekly skin assessment the resident had an open ulcer to the left thumb. The assessment lacked any measurements of the open ulcer. Review of the resident's clinical record lacked any documentation or assessment of the resident's left thumb ulcer from 5/7/15 until 6/19/15 when hospice staff recorded the area on the resident's left thumb measured 3 cm (centimeters) long by 2 cm wide, wound bed color was red and the tissue identified as superficial. Staff recorded on the 6/25/15 pressure ulcer record the area measured 3.1 cm by 3.0 cm, unstageable, greenish slough, and palm protector used. On 6/26/15 at 1:15 PM, staff recorded the resident had a contracture of the left hand. Staff had placed padding in the resident's left hand due to a small slit in the pad of the left thumb. The area to the pad of the left thumb measured 2.1 cm by 3.0 cm with greenish slough and very foul odor. The resident's thumb was swollen. Staff used palm protectors as a preventive measure. Staff notified the resident's physician who ordered staff to apply skin prep to the wound edges, apply Santyl ointment to the wound bed only, and cover with foam, wrap with gauze, and change daily until the slough resolved. On 7/1/15, staff recorded in the wound book, the resident had an unstageable pressure ulcer to the left thumb which measured 3 cm by 2 cm. and treatment of [REDACTED]. The resident to see the wound physician in 1 week. Staff recorded in the 7/3/15 nursing notes, an appointment made for the resident to see the wound physician weekly. A wound culture, obtained on 07/01/15 and with results available on 07/06/15, evidenced the thumb wound with moderate growth of proteus mirabilis (a bacteria) and entercoccus faecalis (a strepococcal bacteria). On 7/8/15, the physician's note read to discontinue the dressings, paint with [MEDICATION NAME] daily, follow-up in 2 weeks, and [MEDICATION NAME] (antibiotic) 500 mg (milligrams), daily, for 10 days. The wound measured 3 cm x 2 cm, with odor present. Staff recorded in the 7/9/15 pressure ulcer record the wound was unstageable, measured 3.0 x 2.0, had a small amount of yellow drainage, yellow gold slough, and surrounding tissue swollen. Staff recorded in the 7/14/15 pressure ulcer record the wound was a Stage III, measured 3.2 cm x 2.4 cm, moderate amount of exudate, and surrounding tissue bleeding. On 7/15/15, the physician's note read for staff to apply grips to the left , hand on continuously except off to wash the resident's hand before meal and bathing. Staff to give a [MEDICATION NAME] dose when manipulating the hand to put on the grip. Staff to apply a 4 by 4 dressing with [MEDICATION NAME] ointment to the open area, adhere with coban self adhesive, and change daily. The physician discontinued all the other hand wound orders. On 7/20/15, staff recorded in the progress notes, the left thumb area continued to have a small amount of yellow slough and the thumb remained swollen. On 7/20/15, staff recorded in the pressure ulcer record, the left thumb pressure ulcer was a Stage III, measured 3.0 cm x 2.0 cm, moderate amount of exudate and had a foul order. On 7/22/15, the physician's note read to resume Aguacel Alginate with foam dressing to the unstageable pressure ulcer to the left thumb. On 7/27/15, staff recorded in the pressure ulcer record, the left thumb pressure ulcer was a Stage II, measured 2.4 cm by 2.3 cm, wound was moist at the surrounding tissue from the contracture. On 8/3/15, staff recorded in the pressure ulcer record, the left thumb pressure ulcer was a Stage II, measured 1.5 cm x 1.0 cm, serous exudate, and no signs of infection. Staff recorded in the 8/5/15 progress notes, the wound much improved, less size, wound bed was red and healthy, no slough or odor. Current treatment of [REDACTED]. The resident continues to see the wound physician. On 8/12/15, staff scored the resident with a score of 12 (a score of 12 or less indicated the resident at high risk of developing a pressure ulcer) on the Braden assessment. The only pressure ulcer risk assessment completed since the one completed on 12/12/14. On 8/12/15 at 7:45 AM, observation revealed the resident sat in the dining room in the wheelchair. Observation revealed both of the resident's hand held in a clinched manner and no palm devices in place in the resident's hands. On 8/12/15 at 9:15 AM, direct care staff K pushed the resident in the wheelchair to the shower room and attempted to open the resident's left hand. Observation revealed a foam dressing in place in the palm of the resident's left hand. At 9:25 AM, licensed staff B opened the resident's left hand and revealed an open area on the inner side of the resident's left thumb, at the first joint, and a dark discolored area just below that area, with a small amount of bloody drainage on the foam dressing. On 8/12/15 at 10:10 AM, observation revealed licensed staff C cleansed the area with wound cleanser, applied the Calcium Alginate on a foam dressing, and placed the dressing to the left thumb. Observation revealed no palm protectors applied. On 8/16/15 at 10:39 AM, observation revealed the resident in his/her room in the wheelchair, with no palm protectors or carrots in place in the resident's hands. Observation revealed the palm protectors and the carrots on the window ledge in the resident's room. On 8/12/15 at 9:30 AM, licensed administrative staff B stated the open area on the resident's left thumb had improved. Licensed administrative staff B stated the resident did have an appointment weekly with the wound doctor, but now had appointments with the wound doctor every other week. Licensed administrative staff B stated staff need to keep wash cloths in the resident's hands, but the resident will pull the wash cloths out. On 8/16/15 at 11:45 AM, licensed administrative staff B verified the resident lacked the hand cones, as planned. On 8/16/15 at 10:22 AM, licensed staff C stated the area on the resident's left thumb had improved, and the resident was keeping the carrots in place in his/her hands. On 8/18/15 at 9:52 AM, licensed administrative staff B stated possibly the staff did not do the wound measurements when staff identified the area on the resident's left thumb. Licensed staff B stated staff are supposed to do weekly skin assessments, and we knew staff were not getting the measurements done. At 10:35 AM, licensed administrative staff B verified the resident's clinical record lacked evidence staff notified the physician when the wound first developed on 4/16/15 until 6/26/15 when the wound had greenish slough and a foul odor present. On 08/18/15 at 3:10 pm, the physician's licensed nursing staff L stated there was no evidence of communication between the physician and the facility regarding the resident's wound from 04/16/15 when the physician ordered the initial treatment of [REDACTED]. The facility's pressure ulcer/skin breakdown policy, revised on 2/14, recorded the nurse shall describe an document/report the full assessment of the pressure ulcer including location, stage, length, width and depth, presence of exudates or necrotic tissue. 08/18/15 at 4:12 pm, licensed nursing staff M stated, through written statement, the area on the resident's thumb had been initially discovered on or about 04/16/15 during bathing and it was a very superficial laceration about 0.6 cm in size. He/she further stated that the physician had given orders to treat it using foam padding and he/she believed it had healed in less than a week, about 4 days. He/she stated the facility staff continued the treatment of [REDACTED]. The facility failed to provide the treatment and services necessary promote healing and prevent the development of a pressure ulcer for this resident. The facility identified on 4/16/15 the resident had a Stage II pressure ulcer on the left thumb. Staff failed to conduct weekly skin assessments which included measurements to assess the healing or lack of healing of the pressure ulcer. On 6/26/15, the resident's left thumb pressure area had greenish drainage, with a foul odor. On 7/1/15, staff recorded the area as unstageable. On 7/8/15, the resident received an antibiotic for the infected left thumb pressure ulcer. - The facility admitted resident #4 on 4/8/11, per the 5/11/15 signed POS, with [DIAGNOSES REDACTED]. The resident's 5/8/15 CAAs (Care Area Summary assessment) triggered the following areas: Cognitive Loss/Dementia - Poor memory recall. Both short term and long term memory impairments. The resident had difficulty making self understood. Sometimes understands others. [DIAGNOSES REDACTED]. Pressure Ulcers - The resident was dependent for all mobility. The resident had a history of [REDACTED]. The resident's 8/4/15 quarterly Minimum Data Set identified the resident with short and long term memory problems, total dependence of 2 staff with bed mobility, transfers, toileting, and personal hygiene, used a wheelchair, at risk of developing a pressure ulcer, currently did not have a pressure ulcer, preventive devices of a pressure reducing device in the chair/bed, and on a turning/repositioning program. The resident's 7/16/15 care plan had the following interventions: Bed mobility - Required 2 staff to reposition and turn the resident in bed every 1-2 hours and as needed. Transfer - Required assistance of 2 staff, using a mechanical lift for transfers. An intervention dated, 8/10/15, directed staff to apply Baza cream, three times a day, and as needed, to the resident's right buttock. Staff to get the resident up last and the first resident assisted to bed after meals. Staff to ensure the resident up no longer than 2 hours. Cushion in the seat of the resident's wheelchair. The nurse will document progress of healing weekly and notify the physician in 2 weeks if the area was not improving. On 2/4/15, staff recorded a score of 13 (moderate risk of developing a pressure ulcer) on the resident's Braden assessment (tool used to identify residents at risk for the development of a pressure ulcer). On 3/11/15, staff recorded a score of 11 on the resident's Braden assessment. A score of 12 or less indicated the resident at high risk of developing a pressure ulcer. Staff recorded on the 8/10/15 weekly pressure ulcer report, the resident developed a pressure ulcer on the right inner buttock, unstageable, and measured 1.0 cm (centimeters) x 1.2 cm. Staff recorded the area had a dry brown scab present, staff needed to turn the resident every 2 hours, pressure relieving mattress on the bed, wheelchair cushion, last up and first down. High protein supplements given to the resident. Staff notified the resident's physician who ordered Baza cream to the area, three times a day. Staff recorded on the 8/12/15 pressure ulcer report, the area on the resident's right inner buttock measured 0.4 cm x 0.5 cm, a stage II pressure ulcer. On 8/16/15 at 10 AM, observation revealed the resident sat in a wheelchair in the television/lobby area. At 11:01 AM, direct care staff I pushed the resident in the wheelchair to the resident's room. At 11:04 AM, direct care staff H and J transferred the resident from the wheelchair to the resident's bed with a mechanical lift. Observation revealed an area on the resident's right buttock with an apparent scab over the area, which measured approximately 0.5 cm x 0.5 cm. Staff applied Baza cream to the resident's right buttock after staff cleansed the resident's perineal area and right buttock with premoistened wipes. On 8/12/15 at 10:24 PM, licensed administrative staff B stated, at first, the area on the resident's right buttock was unstageable, as there was a scab over the area. On 8/12/15 at 12:21 PM, direct care staff E stated staff needed to reposition the resident every 2 hours. On 8/12/15 at 2:22 PM, direct care staff F stated staff needed to reposition the resident every 2 hours. On 8/12/15 at 4:20 PM, direct care staff G stated the resident required total assistance of staff for cares, and staff try to reposition the resident every 2 hours. On 8/16/15 at 11 AM, direct care staff H reported staff transferred the resident to the wheelchair around 7 AM, and after breakfast, placed the resident in the TV area. Direct care staff H stated the resident had not received any cares since staff placed the resident in the TV area. The facility's repositioning policy, revised on 4/13, recorded repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Residents who are in a chair should be on an every 2 hour repositioning schedule. The facility failed to provide the necessary treatment and services to promote healing and to prevent new pressures sores from developing for this resident, who developed a facility acquired Stage II pressure ulcer on the right buttock.

The facility reported a census of 32 residents. The sample included 15 residents, including 2 reviewed for pressure ulcers. Based on observation, record review and interview, the facility failed to implement effective interventions to prevent the development of pressure ulcers for 1 (#31) of 2 residents sampled for pressure ulcers. Findings included: - The current physicians order sheet documented resident #31 admitted on [DATE], with the following [DIAGNOSES REDACTED]. The clinical record also evidenced the resident underwent [REDACTED]. The significant change MDS 3.0, (minimum data set), dated 5/29/13, revealed the resident had a BIMS (brief interview for mental status) score of 12, indicating moderately impaired cognition. The resident required for ADL's (activities of daily living) extensive staff assistance for bed mobility, transfer, toilet use, with functional limitation in range of motion to 1 side both upper and lower extremities and mobility per walker and wheelchair. The resident is frequently incontinent of bowel and bladder. The resident is at risk for pressure ulcers, and the resident received a pressure relieving device for chair/bed, and the resident is not on a turning/repositioning program. The CAA'S (care area assessment), dated 6/2/13, for pressure ulcers documented the resident needs help with bed mobility, has limited mobility and uses his/her wheelchair to mobilize. The resident has memory impairment, and needs to be reminded and assisted with toileting. The resident is at risk for skin breakdown. Interventions will be implemented to prevent breakdown. The resident now needs more staff physical assist with bed mobility, wheelchair mobility, and toileting. The quarterly MDS 3.0, dated 11/13/13, revealed the resident had a BIMS score of 9, indicating moderately impaired cognition. The resident required for ADL's extensive staff assistance for toileting; limited staff assistance for bed mobility, and transfers. The residents balance not steady, no concerns with functional limitation in range of motion, for mobility the resident used a walker and wheelchair. The resident is frequently incontinent of urine and always continent of bowel. The resident at risk for pressure ulcers, none noted and the resident received a pressure relieving device for chair /bed and the resident is not on a turning /repositioning program. The clinical record lacked evidence that an assessment of the resident's ADL abilities after his/her return from the hospital following back surgery was done. The Braden Scale for Predicting Pressure Sore Risk Assessment, dated 11/14/13, with a score of 17. The resident is a mild risk (15-18). The clinical record lacked reassessment of risk after the resident's back surgery. The plan of care for skin integrity, dated 11/27/13, documented: Observe skin daily with care/bath for residents at risk. Report any changes, concerns to nurse i.e.: skin tears, bruises Requires 1 staff assist to move up in bed. Reposition with turning side to side. I need extensive assist of 1 staff for toileting. I wear pull up briefs to protect my dignity. Staff to perform peri-care as needed to keep me clean and dry. I want toileted every 2-3 hours and prn (as needed), when I get up, before/after meals, and before bedtime. night shift toilet as needed: Updated: 1/8/14: Per primary care physician, okay to see facility wound doctor. Updated: 1/9/14: Right heel-pressure ulcer stage 1. Left heel pressure ulcer blood blister. The plan of care failed to address an individualized turning/repositioning plan, and lacked interventions for the treatment of [REDACTED]. Review of the residents weekly skin assessments for December, 2013 and January, 2014, documented the resident had no open areas. Physician's orders, dated 1/6/14, documented the resident to receive OT (occupational therapy)/PT (physical therapy) treatment due to recent back surgery and decline in ambulation and activities of daily living. A Fax communication to the Physician form, dated 1/7/14 at 4:00 AM, documented the resident with pressure ulcers on both heels, with the left measuring 2 cm (centimeters) by 1 cm, and the right heel measuring, 1 cm by 0.5 cm. Bilateral heel protectors applied. Staff also requested an order to send the resident to the wound doctor. The clinical record lacked evidence that a registered dietitian assessed the resident since the development of these pressure ulcers. Review of the Pressure Ulcer Monthly Report, dated January 9, 2014, revealed on 1/7/14 (date of initial finding) the resident had an In-house acquired, right heel pressure ulcer which measured 1.0 cm by 1.2 cm. Pressure redistribution devices in place, boots and pressure mattress. Stage one. Left Heel pressure ulcer, facility acquired, which measured 1.4 cm by 2.4 cm appears as a blood blister, boots and pressure mattress now in place. The wound care progress notes, dated 1/9/14, documented the right heel ulcer as a stage 1 and the left heel ulcer as a blood filled blister with [DIAGNOSES REDACTED] ( redness or inflammation of the skin) of the big toes. Furthermore, documentation evidenced a "good" arterial doppler study, although the left peripheral pulses were non-palpable at that time. The wound report also documented the resident had an [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person ' s nutritional status). Physician orders, dated 1/9/14, documented to apply skin prep to heels and for staff to put boots on the resident at all times when the resident is in bed. Observation, on 1/14/14 at 12:30 PM, revealed the resident sitting in a wheelchair in the dining room. The resident ate a bowl of ham and beans with crumbled corn bread in it. Observation at 12:55 PM revealed the resident ate 90% of meal. On 1/14/14 at 2:15 PM, direct care staff X pulled the covers back from the residents feet. The resident was wearing light cotton socks and was on a pressure reducing mattress lying on his/her back. Direct care staff X asked the resident where his/her booties were and the resident replied, "I don't wear them." On 1/14/14 at 3:00 PM, observation revealed the resident resting quietly in bed on his/her back, direct care staff Q provided the resident a house shake. At 3:15 PM the resident was in the same position and staff had not put the booties on his/her heels and the heels were resting on the bed. The resident consumed 100% of the shake at 3:30 PM. The resident did not have any booties on the feet and the heels were resting on the bed. At 3:45 PM, staff had not changed the resident's position nor had staff elevated the heels off the bed. On 1/14/14 at 3:53 PM, observations revealed direct care staff Q and W checked the resident for incontinence of urine (the resident lying on their back). Staff Q asked which side the resident wanted to lay on and the resident reported, "toward the door". Staff repositioned the resident, toward the door. Observation, at this time, revealed no booties on the resident ' s heels. Direct care staff Q stated they would go look for some booties for the resident. Staff returned at 4:15 PM and placed heel protectors (booties) on the resident. On 1/15/14 at 4:30 AM, direct care staff Y and Z, entered the residents room. Staff Y explained they were going to check and reposition the resident. Staff Z checked the resident's brief and reported it was wet. Staff provided peri care. Observation, at that time, revealed that there was no redness on the coccyx or buttocks. At 4:45 AM, Staff Y and Z repositioned the resident on his/her back, elevated the resident's feet/heels on 2 pillows, and placed the heel protectors. Intermittent observation at 5:15 AM, 5:45 AM, 6:15 AM, 6:45 AM, 7:00 AM, 7:15 AM, 7:45 AM identified staff did not change the resident's position. (a time frame of 3 hours). On 1/15/14 at 7:46 AM, direct care staff AA and BB, checked the resident. The staff repositioned the resident to the left side, with a pillow behind the back, and between the knees and under the heels. Heel protectors in place. On 1/15/14 at 10:00 AM, observation revealed the resident sitting in wheelchair with tennis shoes and socks on. On 1/15/14 at 8:43 AM, direct care staff BB and licensed nursing staff D, placed skin prep to the area on the right heel and, measured the area at approximately 1 cm (centimeters), light brown/tan in color, with no fluid. The left heel measured approximately 3 cm by 2.5 cm, purple discoloration noted, no drainage noted. Staff BB and D then repositioned the resident on the left side, with a pillow the resident's back, and booties were in place. Observation, on 1/16/14 at 11:21 AM, revealed physician V here to assess the residents heels. The physician documented, at this time, the left heel has a decompressed blood blister and the right heel has slight softness and the toes blanched. The left heel is a stage 2 and measures 1.9 cm x 3.5 cm, with the wound depth documented as partial thickness with no exudate (fluid which drains from an open wound) and surrounding skin intact with 100% (percent) eschar (dead tissue) which was black and hard and the right heel was unstageable and measures 1.1 cm x 2.0 cm with 100% eschar and surrounding skin intact with no exudate. The progress note further documented the resident as S/P (status [REDACTED]. Direct care staff W reported, on 1/14/14 at 3:09 PM, the resident is a 2 person assist for toileting. The resident had back surgery, and now it takes two staff assist for transfers and the resident should be turned and repositioned every 2 hours. Staff reported there was no special mattress, and the resident wears tennis shoes when up. Staff also reported the resident usually stays in bed all shift from 2PM to 10 PM. On 1/14/14 at 3:12 PM direct care staff Q reported the resident now wears moon boots when in bed and verified the resident did not have them on at this time (during the 01/14/14 at 3:00 PM observation documented above). Staff stated they had not been able to find the boots since coming on shift between call lights, passing water and other duties. Staff Q stated that the nurses tell the CNA's verbally of any new intervention, and put it on the kiosk (certified nurses aide electronic documentation program), and then provide a mini inservice where we read and sign it. On 1/14/14 at 4:00 PM, licensed nursing staff E reported the staff are to turn the resident every 2 hours, check and change the resident for incontinence, and apply both heel protectors when in bed. Staff stated they did not know the resident did not have them on. On 1/15/14 at 9:00 AM, licensed nursing staff D reported, "The resident is to have heel protectors on and be repositioned every 2 hours by staff. Staff D stated that he/she monitor's the staff to make sure. Staff D also stated that "We (nurses) treat his/her heels with skin prep, and the wound doctor comes every Thursday." On 1/15/14 at 12:42 PM, administrative nursing staff B reported, The resident has a pressure reducing mattress, likes to lay on his/her back a lot, and likes a pillow behind his/her knees. We try not to float the heels, because we are trying not to breakdown the coccyx. Staff stated that he/she called a staff meeting with the two shifts on 1/9/14, and told them he/she needed the booties. We did a teachable moment. There are 2 closets set up where we keep heel protectors. He/she stated she/he was not aware the resident was not wearing them yesterday. On 1/16/14 at 11:21 AM, physician V reported the resident had a kyphoplasty and stated that is probably why the heel blisters occurred. Physician V also stated that the resident can wear tennis shoes, if he/she does not ambulate much but would rather he/she have multi purpose podus or prevalon boots on. On 1/16/14 3:55 PM, physician U reported that she/he had reviewed faxes from the facility and did not see where she/he had been notified of the areas on the heels. Physician U also stated that he/she wondered if the kyphoplasty did not cause the wounds. He/she stated it is not unusual for a patient to have skin breakdown like this after surgery. He/she stated, "If the resident does not move around much, (heel breakdown) is something they (facility staff) would need to watch for." On 1/16/14 at 4:45 PM, consultant staff C reported that staff should review the Hands On Care plan (the CNA care plan) and approaches every day and document when they reposition the resident. When you see the dates and staff names documented, it means the resident has been repositioned. Staff C further stated that he/she knew repositioning a resident every 2 hours was considered a facility routine in daily practice for all residents and it would not be written on the plan of care, but if a resident needed positioning every hour it would be on the care plan. Staff C verified the use of the heel protectors and/or boots did not get placed on the Hands On Care plan for the CNA's to know they needed to be used. Review of the Hands On Care Plan (the plan used by the CNA's to take care of the resident) for the resident revealed a plan to address repositioning, and evidenced the resident required 1 assist of staff for repositioning in bed and in the chair and staff should ensure that the pressure relieving cushion was in place when the resident is up in chair. It further noted the resident had a surgical procedure on 12/12/13. The plan failed to instruct staff on how often the resident needed to be repositioned and failed to address the need to float the residents heels or have the heel protectors/booties on. Review of the facility Policy and Guidelines for Routine Daily Practice, dated July 2012, documented the following: "Purpose; To ensure that care plans are resident centered and specific to the unique needs of each resident and do not include expected routine daily practices. Policy: Routine daily practices are services that are expected to be provided to all residents and not captured on the care plan or specifically documented in the medical record. Care plans should reflect resident centered items that are unique to that resident's care. Exceptions to routine daily practice related to medical needs, personal preference, and/or resident choice will be reflected on the care plan. Guidelines: 1. These guidelines are considered routine daily practice and will NOT be noted on care plans or specifically documented in the medical record." Review of the nursing routine daily practice guidelines lacked mention of repositioning a resident every 2 hours," as a facility routine intervention. The facility failed to assess this resident following back surgery to determine the resident's risk for pressure ulcers and failed to put interventions in place to prevent the development of pressure ulcers. The resident developed two facility acquired pressure ulcers to the heels. Furthermore, the facility failed to reposition the resident in a timely manner and failed to ensure staff applied heel protectors and elevate the heels to keep pressure off the resident's heels to promote healing of these facility acquired pressure ulcers.

The facility identified a census of 41 residents, with 30 residents reviewed. The sample of 30 residents included 3 (#49, #45, #14) for fecal impaction,1 (#5) for lack of [MEDICAL TREATMENT] monitoring, 1(#55) for failure to provide timely pain management, and 1 (#60) for lack of laboratory monitoring related to [MEDICATION NAME] (anticoagulation medication) use. Based on observation, record review and interview the facility failed to adequately assess and implement intervention for 1 resident (#49), after no bowel movement for 8 days which placed this resident in immediate jeopardy. Findings included; - Review of the resident #49's closed medical record revealed the resident admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The resident's admission MDS (minimum data set), dated [DATE], identified the resident with a BIMS (brief interview for mental status), score of 11, indicating moderately impaired cognition. The resident required extensive staff assistance of two for bed mobility, transfers and toileting. The resident's balance was unsteady moving off and on the toilet, functional limitation in range of motion to the lower extremities on both sides, and used a wheelchair for mobility. The resident was occasionally incontinent of urine and was always continent of bowel. Constipation was not identified. The resident received a routine pain medication regimen. The resident's quarterly MDS, dated [DATE], documented unchanged ability/condition since the [DATE] assessment above. Staff recorded on the resident's CAA (care area assessment) dated [DATE], for cognition, "The resident is alert and oriented times three, a BIMS score of 11, showing that he/she has short term memory deficit. The resident having chronic pain, ...and is on [MEDICATION NAME] 7.5 mg (milligrams) three times a day." For ADL's (activities of daily living), ..."The resident is very weak, then with the DJD ([MEDICAL CONDITION] joint disease) to spine and chronic pain, he/she required much care. He/she is occasionally incontinent of bladder, and unable to get to the bathroom on time." For urinary incontinence constipation/impaction not identified." The resident with chronic DJD of spine, which requires extensive assistance of 2 for toileting and is occasionally incontinent of bladder." When requested facility was unable to locate the resident's admission bowel assessment on [DATE] at 1:00 PM. The resident's Bowel Assessment, dated [DATE], lacked whether the resident was continent or incontinent of bowel, frequency of bowel movement, and history of bowel movements. Recommendation was, to increase fluid intake. The initial Interdisciplinary Data Collection Tool, undated, recorded the resident was continent of bowels, had constipation and a pattern for bowel movements every ,[DATE] days. The care plan, dated [DATE], for alteration in elimination, directed staff the resident required assistance of 2 to transfer, adjust clothing, cleansing/pericare, and used the toilet and/or urinal. The care plan lacked interventions related to the resident's constipation. The physician orders, dated [DATE] documented, [MEDICATION NAME], 17 Grams, (a laxative) by mouth daily, for constipation. The physician orders, dated [DATE], documented the physician ordered Senna S, (a laxative) 2 tablets by mouth, twice daily for constipation. The physician orders, dated [DATE], documented [MEDICATION NAME], 25 mg/100 mg, 1 by mouth 4 times daily for [MEDICAL CONDITION]; Calcium + D, 600 mg, 1 by mouth daily for other general symptoms; [MEDICATION NAME], 2 puffs each nare daily for allergies [REDACTED]. The physician orders, dated [DATE], [MEDICATION NAME] 7.5 mg/500 mg by mouth every 4 hours as needed for pain. These medications all had potential side effects of constipation. Review of the resident's bowel movement record for [DATE], recorded the resident had a bowel movement averaging approximately every 4 days. Review of the resident's bowel movement record from [DATE] through [DATE], revealed the resident lacked documentation of a bowel movement from [DATE] through [DATE] (7 days). The resident had a small, soft bowel movement on [DATE]. From [DATE] through [DATE] (4 days), the record lacked documentation of a bowel movement. On [DATE], staff recorded the resident had a large formed bowel movement. From [DATE] through [DATE] (6 days), the record lacked documentation of a bowel movement. On [DATE], staff recorded the resident had having a small formed bowel movement. From [DATE] through [DATE] (8 days), the record lacked documentation of a bowel movement. Review of the resident's MAR (medication administration record) for [DATE], revealed the resident continued on routine [MEDICATION NAME] and Senna, and with a PRN (as needed) order for Milk of Magnesia (a laxative), 30 cc (cubic centimeter) every 48 hours PRN (as needed) for no bowel moment, with a physician order [REDACTED]. The MAR indicated [REDACTED]. Review of the resident's MAR for [DATE], revealed the resident's routine medication unchanged for constipation, however the resident received (staff initials noted) Milk of Magnesia on the 5th and 6th. The documentation notes on the back of the MAR, lacked documentation as to the date, time, order/instruction, reason, and result/progress for these two days. The MAR indicated [REDACTED]. The clincal record lacked documentation as to the date, time, order/instruction, reason and result/progress note of the medication. The nurses notes, dated [DATE], at 4:30 PM, documented the resident's vital signs, blood pressure ,[DATE], pulse 78, respirations 20, temperature 98.0 degree Fahrenheit, and oxygenation saturation at 97 percent on room air. The resident returned from the emergency room with an order to follow up with his/her primary care physician in 2 to 3 days for [MEDICAL CONDITION]. An appointment scheduled on [DATE]. The nurses notes, dated [DATE], at 11:38 AM, documented the resident went to an appointment with physician LL, with no mention of constipation reported to the physician. The resident returned with orderswhich included, decrease [MEDICATION NAME] to 50 mcg, change every 3rd day, and regular toileting schedule. The nurses notes, dated [DATE] at 3:55 PM, documented staff completed an assessment on the resident. "Decreased level of consciousness, and increase in complaints of pain and vital signs within normal limits. ...physician LL has been updated." ( No mention of constipation) even though the resident had no bowel movement times four days. The nurses notes, dated [DATE] at 1:25 PM, documented, " The CNA (certified nurses aide) reports the resident not acting within normal limits for resident. Observed lethargy, slurred speech, need for increased assistance for transfers. Vital signs, blood pressure ,[DATE], pulse 108, respirations 18, temperature 99.7 degree Fahrenheit, and oxygenation 82 percent on room air. Oxygen applied at 2 liters/per nasal canual per nursing order at 12:15 PM. Oxygen saturation at 12:40 PM, 89 percent. Rubs heard in the upper lobes, middle and lower lobes, and very diminished. Physician LL updated. New order noted, 1.) Decrease [MEDICATION NAME] to 25 mcg [MEDICATION NAME], change every 3 days pain, 2.) oxygen 2 liters per nasal canula as PRN to keep saturations above 90 percent." (No mention of constipation), although the resident went 5 days without a bowel movement. The nurses notes, dated [DATE], at 5:30 AM, documented, "The resident complained of nausea and vomiting this AM. No bowel moment charted since [DATE]. Bowel sounds positive all 4 quadrants present. No signs or symptoms of pain with palpations of abdomen. Milk of Magnesia administered per order. Will continue to monitor and report to on coming shift." The nurses notes, dated [DATE], at 2:53 PM, documented, "The resident continues to complain of difficulty with a bowel movement. The resident "grunting" even while not on the toilet. No complaints of nausea/vomiting this shift. Milk of Magnesia given 2 times this shift with 240 cc (cubic centimeters) of prune juice. The family was in the facility and aware that the resident was having difficulty with bowel movement. No pain noted with palpitation. Physician LL paged at 10:30 AM and 1:00 PM, no return call." The facility failed to make further attempts to notify the physician of the resident's lack of bowel movement in 7 days and his/her change in conditions. The nurses notes, dated [DATE], at 1:30 AM, documented, " The resident with decreased level of consciousness. Responds to name, but immediately goes back to sleep. Difficulty taking sips of water. Vital signs, blood pressure ,[DATE], pulse 124, respirations 32, and oxygenation saturation 76 percent on room air. Oxygen applied at 2 liters per nasal canula. Saturations improved to 83 percent, PRN [MEDICATION NAME] crushed and put applesauce and administered. The head of the bed elevated at 45 degrees, will continue to monitor." The facility failed to notify the physician of the residents change of condition at this time. The nurses notes, dated [DATE], at 6:12 AM, documented, " (hospital) called to page physician LL, switchboard notifies a physician MM is on call. At 6:20 AM, Physician MM responds to the page and orders obtained to transport to (the hospital) emergency room to evaluate and treat." The nurses notes, dated [DATE], at 10:28 AM, documented, " The nurse called the hospital emergency room for an update on the residents condition. The nurse reports the resident passed at 7:30 AM related to asphyxiation ( state of inability to breathe) leading to [MEDICAL CONDITION]. The Physician MM to call the family." The (hospital) emergency room notes, dated [DATE], at 7:24 AM documented the resident with emesis in suction bottle of 600 ml (milliliters), plus saturated bedding and large amount on the floor. The emesis had fecal odor. On [DATE], at 10:30 AM, administrative nursing staff B reported, "I do not have a bowel program instructing the staff what medications to give and when to give if there is not a BM (bowel movement) . I have nothing in writing telling them (the CNA's) when to notify the nurse of a resident not having a bowel movement. I was not monitoring the bowel movements before this happened, no one had been. It is the CNA's and the nurses responsibility to monitor the bowel movements." On [DATE] at 1:45 PM, licensed nursing staff H, reported, "The printer did not work for me and I could not print out the no Bowel Moment report, and other people did not want to do it. Then it was just dropped. The printer works now." On [DATE] at 3:37 PM, administrative staff A,reported, "The staff member is (licensed nursing staff) password had expired, is why he/she had trouble getting on the computer." On [DATE] at 4:26 PM licensed nursing staff U reported,"The No BM report is suppose to be done daily. I then give the report to the medication aide, and licensed nursing staff H, would print it off, and I would show it to the aides. They (CNA's) would go ask the independent resident's, because they (independent resident's) are usually the one's on the No BM list. If the resident has not had a bowel movement, the medication aide will give the resident something." On [DATE] at 4:15 PM, direct care staff FF reported, " If the nurse ran off the report sheet, the day shift CMA (certified medication aide) would give the resident's a laxative if they have an order The day shift CMA would give it (the list) to me, and I would follow up on the laxative. I had not seen a No BM report sheet for about a month before the resident passed away. On [DATE] at 5:50 PM direct care staff M, reported, "I had not seen a No BM Report sheet when I first started working (had been PRN) or during orientation. I was not told when to report to the nurse if a resident does not have a bowel movement." On [DATE] at 3:30 AM, licensed nursing staff I, reported, "The printer had not been working for about a month. I had not been able to print the No BM report. I printed the report on [DATE]. during my shift, and realized the resident had not had a bowel movement since [DATE]. I gave the resident PRN Milk of Magnesia and reported on to the next nurse. I did not call the doctor." On [DATE] at 3:45 AM, direct care staff W reported, "The resident always had hard stools. I would chart them on the kiosk." On [DATE] at 12:06 PM, physician consult NN reported, " We are unable to release any information related to the resident, without authorization from the family. " The facility policy, dated reviewed ,[DATE], for Bowel Assessment, documented, " Purpose: To assess bowel function appropriately and to identify effective bowel management programs Definitions 1.) Constipation: If the resident has 2 or fewer bowel movements during the seven day look back period or if for most bowel movements their stool is hard and difficult for them to pass (no matter what the frequency of bowel movements). 2.) Fecal Impaction: A large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This mass may be so hard that the resident is unable to move it from the rectum. Watery stool from higher in the bowel or irritation from the impaction may move around the mass and leak out, causing soiling, often a sign of a fecal impaction. Assessment 1.) During a 72 hour period, use the Hands On care plan application to document bladder function on the Voided Record. If your center is using paper to document, establish elimination patters, including times, volume, circumstances and frequencies of incontinent episodes, use Bladder and Bowel Flow Sheet. 3.) After the 72 hour observation has been completed, the Bowel Assessment should be completed for residents who are incontinent or who have problems with elimination such as constipation or a history of impaction's or a change in condition which affects elimination patterns. The No BM Alert Report may be reviewed to assist in the analysis of elimination pattern and a summary of the individual bowel regimen should be written on the Bowel Assessment." The facility failed to provide on-going monitoring, assessment and interventions for this resident's lack of bowel movements for 8 days which placed the resident in immediate jeopardy. The immediate jeopardy was abated on [DATE] at 4:00 PM, however, the deficient practice remained at a scope and severity of G. The facility implemented the following policy and instructions: - On [DATE], Administrator and Nursing Consultant had corporate office change the NO BM report to notify nurses on day 2 of no bm and smalls and the report now includes the last date of a BM and whether it was a small, medium, or large. - Letter passed out for each charge nurse with his/her name on [DATE] - Letter stated: - Each charge nurse each shift must print the NO BM report - Each charge nurse each shift will identify residents without BM's for 2 or more days - Each charge nurse must list interventions that were done for those residents without current bowel eliminations on the bottom of no BM report - The No BM Report must be turned into the DNS (director of nursing), (put under door) before each charge nurse leaves his/her shift - Failure to complete these forms will result in disciplinary action - Day and evening shift C.M.A.'s (certified medication aide) and C.N.A.'s (certified nurses aide) on [DATE] educated on reporting and documenting bowel eliminations - The week of [DATE]th, 2012, nurses were active in getting laxative orders for residents that did not have them - If no results with fleet enema, notify physician for further recommendation immediately - QA (quality assurance) to meet on [DATE] to discuss bowel procedure and audits - DON (director of nursing) or designee to audit weekly for 8 weeks, bi weekly for 4 weeks, and then monthly to ensure staff is following procedures - Will be reviewed monthly by QA team to ensure consistency for following protocol and interventions The scope and severity remains at a G level. - Review of resident #45, clinical record revealed staff admitted the resident on [DATE], with the following [DIAGNOSES REDACTED]. The resident is #45's significant change MDS 3.0 (minimum data set) dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 14, indicating cognition intact. The resident required extensive staff assistance of 2 for bed mobility, transfers, and toilet use. Frequently incontinent of urine and always incontinent of bowel. Taking an antidepressant, anticoagulant and a diuretic. The resident annual MDS 3.0, dated [DATE], revealed the resident with short term memory loss, and moderately impaired decision making (decisions poor, cues/supervision required). The resident required extensive staff assistance of 2 for bed mobility, transfers, and toilet use. Frequently incontinent of urine and always continent of bowel. Taking an antidepressant, anticoagulant and a diuretic. Review of the CAAS (care area assessment summary), dated [DATE], revealed, "The resident in a decline in condition. Resident required assist to eat and placed on a pureed diet and nectar thickened liquids because he/she having trouble swallowing." The Bowel assessment, dated [DATE], documented the resident continent of bowel, no issues at this time. Review of the resident's bowel movement record from [DATE] revealed lack of documentation of a bowel movement including: From [DATE] through [DATE] (5 days). The resident had a bowel movement on [DATE] a large/hard. From [DATE] through [DATE] (10 days), lacked documentation of a bowel movement. The resident had a large formed BM on [DATE]. From [DATE] through [DATE] (5 days), lacked documentation of a bowel movement. On [DATE], the resident had a bowel movement, a large formed. From [DATE] through [DATE] (6 days), lacked documentation of a bowel movement. On [DATE], the resident with a large hard bowel movment. From [DATE] through [DATE] (7 days), lacked documentation of a bowel movement. On [DATE] the resident with a large formed bowel movement. The physician orders, dated [DATE], documented the physician ordered, [MEDICATION NAME] (stimulant) suppository, 10mg, 1 rectally as needed for constipation. The MAR for September and October for 2012 laced documentation of administration of the medication to the resident. The care plan reviewed on [DATE], revealed, do not leave me unattended on the toilet, I will get up on my own. Failed to include constipation needs. On [DATE] at 4:05 PM, the resident transferred from the bed to the wheelchair by direct care staff L, personal alarm placed on the resident. The resident toileted, incontinent of urine, pericare provided, a clean incontinent brief placed on the resident. On [DATE] at 11:07 AM, direct care staff JJ reported, " We chart the bowel movements on the kiosk. If the resident hasn't had a bowl movement after 3 days we are to let the nurse know." On [DATE] at 4:15 PM, direct care staff O reported, " I chart the bowel movements on the kiosk. We let the nurse know if the resident complains of any problem with his/her bowels." On [DATE] at 1:41 PM, licensed nursing staff H reproted, " The CNA's (certified nurses aide) are to chart the BM's (bowel movements) on the kiosk every shift." On [DATE] 2:43 PM, licensed administrative staff B reported, " The nurses are to print a No BM report every shift, and to give an intervention and make sure the resident has a bowel movement. They then fill in what they did and give me the report at the end of the shift. The CNA's (certified nurses aide) are to document on the kiosk and on a paper flow record if the resident had a BM, so that if the CNA becomes busy and forgets to chart on the kiosk, we can look at the paper flow record." The facility policy, dated reviewed ,[DATE], for Bowel Assessment, documented, " Purpose: To assess bowel function appropriately and to identify effective bowel management programs Definitions 1.) Constipation: If the resident has 2 or fewer bowel movements during the seven day look back period or if for most bowel movements their stool is hard and difficult for them to pass (no matter what the frequency of bowel movements). 2.) Fecal Impaction: A large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This mass may be so hard that the resident is unable to move it from the rectum. Watery stool from higher in the bowel or irritation from the impaction may move around the mass and leak out, causing soiling, often a sign of a fecal impaction. Assessment 1.) During a 72 hour period, use the Hands On care plan application to document bladder function on the Voided Record. If your center is using paper to document, establish elimination patters, including times, volume, circumstances and frequencies of incontinent episodes, use Bladder and Bowel Flow Sheet. 3.) After the 72 hour observation has been completed, the Bowel Assessment should be completed for residents who are incontinent or who have problems with elimination such as constipation or a history of impaction's or a change in condition which affects elimination patterns. The No BM Alert Report may be reviewed to assist in the analysis of elimination pattern and a summary of the individual bowel regimen should be written on the Bowel Assessment." The facility failed to provide on-going monitoring and assessment of this resident's bowel elimination to prevent further constipation or fecal impaction to the resident. - According to the clinical face sheet, the facility admitted resident #14 on [DATE]. Review of the physician's orders [REDACTED]. Review of the annual Minimum Data Set (MDS) 3.0 Assessment, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9 of 15, indicated moderately impaired cognition impairment, required extensive assistance of 1 to 2 staff for all activities of daily living and functional limited range of motion with impairment to both upper and lower extremities on one side of the body. The MDS lacked identification of the [DIAGNOSES REDACTED]. Review of the Care Area Assessment (CAAs), dated [DATE], recorded, "the resident with drug-related discomfort requiring treatment and/or prevention: constipation, reduced dietary bulk (observation of food intake) lack of exercise, history of falls out of bed, food intake less than 50% per day, and tended to be constipated." Review of the quarterly Minimum Data Set 3.0 Assessment, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6 of 15, severe cognitive impairment, required extensive assistance of 1 to 2 staff for all activities of daily living and functional limited range of motion with impairment to both upper and lower extremities on one side of the body. The MDS lacked identification of the [DIAGNOSES REDACTED]. Review of the bowel assessment, dated [DATE], recorded the resident incontinent of bowel 2 to 3 times weekly all or most of the time, medium soft bms (bowel movements), history of constipation, and received medications [MEDICATION NAME] and Milk of Magnesia as needed (PRN). Review of the plan of care, dated [DATE], recorded alteration in self care related to prior left brain [MEDICAL CONDITION], weakness, dementia, right [MEDICAL CONDITION]. The plan of care directed staff to administer medications as ordered, and monitor for adverse consequences of all medications. Review of the facility provided, hand written, 3-day bowel pattern, compared with the computerized BM monitoring log revealed: [DATE] at 8 PM, continent of large hard bm [DATE] at 10:14 AM, continent of large hard bm [DATE] at 4:30 AM, incontinent of large hard bm [DATE] at 3 PM, incontinent of small soft bm [DATE] at 9:40 PM, incontinent of medium soft bm [DATE] at 7:30 PM, incontinent of small soft bm. Review of the physician orders [REDACTED]. [MEDICATION NAME] 2 tablets, orally daily for constipation, dated [DATE] (discontinued on [DATE]); Milk of Magnesia 30 cubic centimeters (cc) orally daily as needed (PRN) for no bowel movement, dated [DATE]; Senna S, 2 tablets orally, daily for constipation, dated [DATE]; [MEDICATION NAME] 10 milligrams, rectal suppository, PRN no movement in 3 days, dated [DATE]; and Fleets enema rectally, each day if no result with Milk of Magnesia and PRN [MEDICATION NAME] suppository, dated [DATE]. Furthermore the resident also received the physician ordered [MEDICATION NAME] 37.5 micrograms every 3 days, for pain, dated [DATE], which can increase constipation. Review of the MAR, dated [DATE], revealed the following: Staff administered PRN Milk of Magnesia on [DATE] for "no bowel movement in 3 days". Staff further recorded the resident spit out all the Milk of Magnesia. The record lacked evidence staff evaluated the effectiveness of the PRN medication. Staff administered PRN Milk of Magnesia on [DATE] for "difficulty having bowel movement". The record lacked evidence staff evaluated the effectiveness of the PRN medication. Review of the computerized bowel movement monitoring recorded: No bm from [DATE] until [DATE].(5 days) No bm from [DATE] until [DATE] (12 days). Review of the MAR, dated [DATE], documented the physician discontinued the [MEDICATION NAME] 2 tablets daily, on [DATE] and ordered Senna S, daily. Further review of the MAR indicated on order". The clinical record lacked evidence the staff notified the physician of the lack of medication. Review of the computerized bowel movement monitoring recorded: No bm from [DATE] to [DATE] (5 days). No bm from [DATE] to [DATE] (4 days). No bm from [DATE] to [DATE] (11 days). Review of the MAR, dated [DATE], revealed the following: Staff administered PRN Milk of Magnesia on [DATE]. The record lacked evidence that staff evaluated the effectiveness of the PRN medication. Staff administered PRN Milk of Magnesia on [DATE] at 12 noon and documented "No results" on ,[DATE] shift. Staff administered PRN Milk of Magnesia on [DATE] (illegible time) and documented "No results" on the ,[DATE] shift. Staff administered PRN [MEDICATION NAME] suppository on [DATE] at 8:30 AM, for "no reported bm". The record lacked evidence that staff evaluated the effectiveness of the PRN medication. Review of the computerized bowel movement monitoring recorded: No bm from [DATE] to [DATE] (7 days). No bm on [DATE] to [DATE] (3 days). No bm from ,[DATE] to [DATE] (3 days). No bm from [DATE] to [DATE] (4 days). Review of the nursing notes, dated [DATE] timed ,[DATE] shift, documented PRN Milk of Magnesia given for NO BM without result. Staff recorded "Vault full of hard BM. Primary care physician faxed for new PRN order for constipation, awaiting response." Review of a resident BM (bowel movement) questionnaire interview, dated [DATE], documented the resident not regular, every 3 days, received a laxative weekly, received a laxative most often timely. Recorded for the question, does the CMA (certified medication aide)/Nurse ask if you had results from the laxative, "no, because they must assist me for toilet grooming." The resident experienced constipation within the last 30 days. Documented under the note section, "Stool noted in vault - soft - Milk of Magnesia given." The MAR indicated [REDACTED]. The clinical record lacked evidence of a physician order [REDACTED]. Nursing notes, documented on [DATE] at 10:30 AM, the resident with a large amount of hard BM in the commode. Nursing notes, on [DATE] at 1:49 PM, documented "facsimile received from the physician with new orders for 1) [MEDICATION NAME] suppository 10 milligrams, one rectally each day if no bm in 3 days, and 2) Fleets enema. Called the pharmacy with the order. Resident had outstanding bill and pharmacy wouldn't fill until the bill resolved. Administrative nursing staff B spoke with the resident's responsible party who said they would call the pharmacy to address the bill." Observation, on [DATE] at 8:45 AM, revealed direct care staff N and Q transferred the resident from the wheelchair to the bed with a mechanical Hoyer lift. Direct care staff N provided personal cares to the resident as the resident had a small soft bowel movement. On [DATE] at 9:45 AM, direct care staff Y reported that the resident required a total mechanical lift for transfers and sometimes had a hard time having bowel movements. On [DATE] at 3:40 PM, direct care staff T reported that staff record bowel movements, urinary voiding and activities of daily living in the (computer program) KIOSK. On [DATE] at 10:25 AM, licensed nursing staff C reported facility staff contacted the resident's family regarding the new orders for laxatives and pharmacy saying couldn't fill it because of bill. Licensed nursing staff C reported, the resident had a bowel movement prior to the facility getting that medication. On [DATE] at 3:00 PM, administrative nursing staff B reported it is the nurses and direct care staff's job to monitor residents bowel movements. Administrative nursing staff B acknowledged he/she had not monitored the staff before now. On [DATE] at 3:15 PM, licensed nursing staff D reported the nurses are supposed to print out the report from the facility computer website (the No BM, No Bath report), every shift and then turn the report into the director of nursing. The printer had not been working and couldn't get the report. The report documents what staff had given, (i.e...Milk of Magnesia) If night shift gives Milk of Magnesia and day shift gives Milk of Magnesia, without results, we call the physician to get an order for [REDACTED]. On [DATE] at 4:14 PM, direct care staff FF reported, "The facility previously had a list printed out daily by the nursing staff that recorded PRN laxatives administered. The list passed down from shift to shift for who had received laxatives with or without results. The report has not been available lately. When a direct care staff reported to me the resident with no bowel movement for 3 days, tell the charge nurse. Previously, could look in the computer KIOSK for bowel movements, however direct care staff and certified medication aides only see the last 24 hours. The nurses can look back further. "We don't count a small bowel movement as a sufficient bowel movement." On [DATE] approximately 3:30 PM, consultant staff HH revealed, completion of 5 chart audits on MARS each month for documentation and looking for sufficient documentation. Identified that there are problems with documentation and follow up for PRN medications for constipation (laxatives). Laxatives given for constipation given (i.e. MOM), lack documentation for the effectiveness. Review of the facility provided policy, Documentation of Medication, dated [DATE], documented,"...The following information will be documented in the medical record upon admission of medications: ...Reason for administration if PRN drug given and resident response to medication...Notify physician if any side effects, adverse consequences or any readings outside the parameters established by the physician." Review of the facility provided policy, Bowel Assessment, dated [DATE], revealed, "Documentation of Medication, dated ,[DATE], the reason for administration if PRN drug given and resident response to medication." Review of the policy, Bowel Assessment, dated [DATE], revealed, "Constipation: If the resident has two or fewer bowel movements during the seven-day look-back period or if for most bowel movements their stool is hard and difficult for them to pass (no matter what the frequency of bowel movements ) (RAI section H). Fecal Impaction: A large

The facility census totaled 41 residents with 8 residents included in the sample. The sample included the review of 2 residents with pressure ulcers and 1 resident at risk for the development of pressure ulcers. Based on observation, interview, and record review, the facility failed to provide services to promote healing through a failure to contact the physician after a pressure ulcer increased in size and new pressure ulcers developed and failed to assess and determine causal factors for 1 of 2 residents with pressure ulcers (#3). Resident #3 developed a pressure ulcer that increased in size within 14 days, and also developed an additional 2 ulcers in the same time frame, for a total of 5 ulcers. Based on interview and record review, the facility failed to provide the preventative skin observations for a resident with declining health and abilities to prevent pressure ulcers from developing for 1 of 1 residents at risk for the development of pressure ulcers. (#2) Findings included: - Review of a physician's office notes, located on a document entitled a "Clinic Referral," and signed by the physician on 12/9/11, identified resident #3 with the following Diagnoses: [REDACTED]. Review of the annual MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 1/17/11 identified the resident without cognitive impairments, required supervision from one staff with bed mobility, transfers, at risk for the development of pressure ulcers, without skin breakdown, on a pressure reducing device for both the chair and bed, and on a turning/repositioning program. Review of the Pressure Ulcer CAA (Care Area Assessment-a further assessment) dated 1/26/11 identified the following: "[AGE] year old (gender) resident with weakened hand grips and limitation in ROM (Range of Motion) to shoulders, who occasionally needs assistance with bed mobility. He/she is overweight and trying to lose weight. Resident is also depressed and more so now, since after the Holidays and is on an antidepressant. Resident is overweight, sits up in chair most of the day and has DM (diabetes mellitus)." Review of the quarterly MDS with an ARD of 9/19/11 identified the resident without cognitive impairments, required extensive assistance from one staff with bed mobility, toilet use, at risk for the development of pressure ulcers, and without any breaks in the skin, on a pressure reducing device for the chair and bed, on a turning repositioning program and on a nutrition or hydration intervention to manage skin problems. Review of the care plan, dated 10/6/11, instructed staff to provide the following care: "Support surfaces wheelchair memory foam cushion. I refuse to allow staff to remove bed pad from wheelchair; this decreases the cushion effects of the memory foam. Observe skin daily with care/bath for residents at risk. Report any changes, concerns to nurse. Elevate heels when I have acute [MEDICAL CONDITION]/encourage me to elevated feet when I am watching TV in my room (reminder I do not sleep in my bed). Provide treatment as ordered. I have spray bottles in my bathroom to use for perineal grooming. One for soap and water, the other for rinsing. I can stand for short intervals while you spray abdominal folds and groin areas. Call nurse for treatment after grooming each shift." Review of the Wound Sheets identified on 11/30/11 staff documented the resident had 3 open areas on the left side (1) and right sides (2) of his/her perineum that measured 2.5cm (centimeters) in length and 1.4 cm in width (left side), 1 cm x 1 cm and 3 cm x 1 cm (right side). Staff identified that they treated the open areas with [MEDICATION NAME] (an antifungal cream or lotion). The following week, staff again documented the resident's open areas. The staff only documented the one on the left side, and the area showed slight improvement, measuring 2.4 cm in length (an improvement from the 2.5 cm from the previous week) and 1.4 cm in length. Again, the staff documented they continued to use [MEDICATION NAME] on the area. On 12/15/11 staff again conducted a skin assessment. The measurement of the same open area on the left side revealed a marked increase in size, with measurements of 8 cm in length and 3 cm in width. In addition, staff identified 2 additional open areas on the resident's perineum. The areas identified "center right" 2 cm x 2 cm x 1 cm in depth, and "center left" 1 cm x 1 cm. Again the staff identified they treated the areas with [MEDICATION NAME]. The documentation lacked evidence of physician notification or change in treatment. Review of the December, 2011, TAR (Treatment Administration Record) revealed that on 8/31/11 the physician ordered staff to apply [MEDICATION NAME] to "affected areas" until healed. Review of the TAR revealed staff had written in "QD (every day) on 6-2 (day shift)." Staff signed the treatment daily since 8/31/11. Review of the insert printed for [MEDICATION NAME] cream at www.accessdata.fds.gov/drugsatfda_docs/label/2008/ 7s038lbl.pdf revealed the following guidance "When using [MEDICATION NAME] Cream or Lotion in the groin area, patients should use the medication for 2 weeks only, and apply the cream or lotion sparingly. Patients should wear loose-fitting clothing. Notify the physician if the condition persists after 2 weeks." Review of the physician progress notes [REDACTED]. The physician addressed issues with the resident's skin on his/her legs, but nothing about the increased open areas on the perineal area. The staff identified on the note the reason for the visits. On 12/9/11 the resident saw the physician for a "Routine" visit, and the reason for the 12/20/11 visit staff documented as a "F/U (follow up)." Neither of these progress notes identified that staff made the physician aware of the increased size or the increased number of pressure ulcers. Observation on 12/19/11 at 9:45 a.m., direct care staff A assisted the resident to bathe in the shower room. Staff A stated the resident had a rash "on his/her bottom area." When asked to take a look-the resident stood, and then turned to sit on the shower chair. As the resident turned, observation of the resident's perineal area, buttocks, and inner thighs revealed a large area of dull, red excoriation. Within the perineal area, observation revealed a large open area, uncovered, and without ointment. Once the resident sat, Staff A lifted the resident ' s abdominal fold to show the skin beneath. The skin revealed a very moist, very red, environment and covered with a thick, white ointment. This rash extended from one side of the abdominal fold to the other and extended down between the resident's legs. When asked what the staff did for the resident, staff A stated that the staff washed the resident well each day and then applied [MEDICATION NAME] (a moisture barrier ointment). When asked about the area/s on the resident's "backside" staff A said they had reported it to the nurse and that the resident had been to the doctor about it. When asked what caused it, the resident stated it was from "sitting too much." When asked what the staff did to help heal the area, staff A stated he/she did not know because "the nurses are the ones who do that treatment. " Interview with Administrative Nurse B on 12/20/11 at 3:50 p.m. revealed staff "should not have used" the [MEDICATION NAME] ointment for as long as they did. Also, nurse B confirmed staff "should have called the doctor" when the resident's pressure ulcer increased in size and new ones developed. On 12/20/11 at 3:50 p.m., Administrative Nurse B provided the facility's policy on Pressure Ulcer Practice Guidelines. The policy contained the following guidance to staff regarding ongoing skin assessments: "Any abnormal findings/changes (redness, rashes, bruises, open areas, etc.) should be documented in the Skin Module of the Hand Held or appropriate facility forms (if utilized) and reported to the licensed nurse assigned to the resident for assessment and follow up. Abnormal findings/changes should be reported to the resident's primary care provider and family/responsible party by the licensed nurse per (facility) procedures. Documentation of the primary care provider notification, orders received, family notification and resident response to any treatment should follow (facility) procedures as well." The policy also had guidance regarding wound assessments. The procedure included: "All significant abnormal findings/changes should be reported to the resident's primary care provider by the licensed nurse per (facility) procedures. Documentation of primary care provider notifications, orders received, family notification and resident response to any treatment should follow (facility) procedures as well." The facility failed to notify the physician and obtain a new treatment when a resident's pressure ulcer increased in size and new pressure ulcers developed. The facility also failed to follow the manufacturer's guidance and contact the physician after using [MEDICATION NAME] for 2 weeks without healing a rash. - Review of the recapitulation of orders, signed on 10/17/11 identified resident #2 with the following Diagnoses: [REDACTED]. Review of the annual MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 6/20/11 identified the resident with severely impaired cognition, required extensive assistance from two staff with bed mobility, transfers, personal hygiene, at risk for the development of pressure ulcers, and without skin breakdown, on a pressure reducing device for the chair and bed, on a turning/repositioning program and on a nutrition or hydration interventions to manage skin problems. Review of the quarterly assessment with an ARD of 9/12/11 revealed the resident continued to have severely impaired cognition, required extensive assistance from two staff with bed mobility, transfers, personal hygiene, at risk for the development of pressure ulcers, and without skin breakdown, on a turning/repositioning program, and a pressure reducing device for bed and chair. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 7/1/11 identified the following: "Resident is [AGE] year old (gender) that requires staff assistance at meals, declining appetite, mostly incontinent of bowel and bladder and at risk for pressure ulcers. He/she has advanced [MEDICAL CONDITION] with cognitive loss, anxiety and on a psychoactive med, has diabetes mellitus, [MEDICAL CONDITION], and depression and is on Hospice for End of Life status. Needs frequent repositioning and check and change resident every 2-3 hours." Review of the care plan, dated 10/4/11, directed staff to inspect skin daily during care; report changes to licensed nurse, observe skin condition, involve/educate resident and/or family members, no more than 30 degree side lying position and/or head elevation in bed (unless contraindicated), assess lower extremities for arterial insufficiency and/or [MEDICAL CONDITION], pad and/or protect fragile skin, position body with pillows/support devices, offload pressure to Right toe bunions by leaving shoes off, keeping skin clean and dry, turning and repositioning when in bed every 2 hours, turning and repositioning in chair every 2 hours, and hydrogel dressing every day. On 12/19/11 at 9:37 a.m. licensed nursing staff H told Consultant I that the resident's bunion was open. Nurse H told Consultant I that the bunion had healed, but then "it busted open again." Nurse H stated the bunion had healed up nicely the last time with a particular dressing, and Consultant I asked if the staff had the supplies for the dressings, and nurse H said no. Consultant then made a phone call to see about having the dressing and treatment supplies delivered to the facility. Review of the facility's Wound sheet for the right great toe revealed staff had documented on an open area below the right great toe from 10/4 through 11/30/11. On 12/4/11, staff documented the area as "healed" and directed staff to leave the area open to air. The staff failed to re-assess the area when it re-opened, including measurements and characteristics of the area. Review of the care plan revealed staff failed to update the care plan to reflect the re-opening of the area, to include any new interventions to promote healing and prevent the area from opening again. Observation on 12/19/11 at 11:00 a.m. revealed consultant I assisted the resident to the resident's room. Once there, consultant I removed the resident's socks off both feet, noticed a dressing on the resident's right foot, and removed it. Observation revealed the dressing lacked a date, contained dried blood as well as a discolored drainage, greyish brown in color. Observation of the open area revealed it was located below the great toe, and situated towards the bottom of the foot rather than the side. Observation revealed the area was open and oozed a small amount of blood when consultant I removed the dressing. Consultant I cleansed the area and applied a dry gauze, folded in sections, then secured the gauze with kerlix to hold it in place. When asked, the resident agreed that the dressing change "hurt a little bit." On 12/20/11 at 9:25 a.m. direct care staff D confirmed the area on the resident's right foot had opened up after it had been closed for a while. When asked how long it had been open, staff D lacked knowledge. When asked what he/she did to help the area to heal, he/she said the only thing the staff did was to apply heel protectors when the resident lay in bed. When asked if the heel protectors only protected the heels, staff D agreed that the heel protectors did not do much to protect the area by the toes. When asked what if he/she knew what caused the area to open again, staff D said they did not know. On 12/20/11 at 3:50 p.m., Administrative Nurse B identified the staff only applied the heel protectors to the resident's heels because the staff could not do anything else since the resident kept their feet crossed, even when in bed. Nurse B agreed that the heel protectors on the resident's feet did not protect the resident's bunion areas when the resident laid on their side in bed. The facility failed to assess an open area on a resident's foot, and develop and implement new interventions to promote healing and prevent additional occurrences of pressure ulcers.

The facility identified a census of 40 residents, with 3 sampled for risk of pressure ulcers. Based on observation, interview, and record review, the facility failed to implement appropriate interventions to prevent the development of an avoidable, unstageable, pressure ulcer for 1 of the 3 sampled residents #12. Findings included: - According to the clinical record, the facility readmitted resident #1, on 1/16/12, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set 3.0 assessment, dated 1/20/12, revealed a BIMS (Brief Interview for Mental Status) score of 7, (that indicated a score of 0-7 as severe mental impairment). This same Minimum Data Set recorded the resident experienced a fall prior to admission, required limited assistance from staff for bed mobility, transfers, personal hygiene, toilet use, functional limitation in range of motion to the lower extremity on one side, and received scheduled pain medication. Further review revealed the resident with no pressure areas, identified the resident at risk for pressure ulcer development and staff performed formal and clinical skin assessments. Interventions implemented and recorded on the Minimum Data Set included pressure-reducing device for chair, pressure-reducing device for bed, a turning/repositioning program, and application of ointments/medications. Review of the CAAs (Care Area Assessment summary), dated 1/25/12, recorded the resident admitted to the facility after a fall, poor short-term memory even after cueing, required assistance of 2 staff members for bed mobility due to his/her immobility, wheelchair bound, sat in a recliner all day, at risk for developing pressure ulcer and subjected to pressure and friction. Review of a Braden assessment, dated 1/17/12, scored the resident 19, that indicated a score of 15-18 at mild risk for pressure ulcers. Review of a dietary assessment tool, dated 1/18/12, identified the resident ' s skin intact. Review of the resident ' s initial care plan, dated 1/16/2012, recorded the resident with an alteration in self-cares related to a fall that altered his/her ability to bear weight on the left extremity and slept in a recliner. The plan of care further identified the resident with an alteration in mobility related to a fall with left knee pain, manifested by inability to transfer independently or move in bed and a fall risk. Interventions directed assistance of 2 staff members for transfers, assistance with mobility, and non-weight bearing left leg, This plan of care addressed alteration in comfort and directed staff to reposition the resident, administer medications as ordered, observe for signs and symptoms of pain and report to the charge nurse. The initial plan of care, dated 1/16/12, lacked evidence of interventions to prevent the development of pressure ulcers. Review of the clinical record on 2/1/12 recorded a revision to the plan of care, on 1/26/12, that identified the resident with a pressure area to the left heel related to spending most of his/her time in a recliner, decreased movement to the left extremity related to knee pain and recorded interventions that directed staff to: - Off load feet. - Encourage standing when in wheelchair/recliner every 2 hours. Review of the Treatment Administration Record (TAR), dated January 2012, recorded a skin assessment on 1/19/12 recorded the resident with no skin issues at this time. Staff initialed the treatment of [REDACTED]. The record revealed staff applied no skin treatments to the resident ' s feet from 1/20/12 to 1/27/12. Review of Interdisciplinary team notes, dated 1/26/12 and timed 11:43 A.M., recorded the resident left the facility to see a physician and returned with a new order for foot cream twice daily. Review of physician order, dated 1/27/12, directed staff to apply heel cream twice daily and ordered physical therapy treatments. Review of the clinical record revealed a Standard of Care meeting report, dated 1/27/12 timed 1:30 P.M. that reviewed the resident related to a pressure area on the left heel, spent day and night in a recliner, decreased mobility related to a recent fall with left knee issues and mobile by way of a wheelchair. Review of the Wound Flow Sheet, dated 1/27/12, revealed an unstageable heel pressure wound that measured 6 centimeters by 7 centimeters, and recorded the resident experienced pain. Continued review of the January 2012, TAR revealed that, on 1/28/12, staff recorded a dark circular area to the left heel, painful to touch and foot cream applied per physician order. Review of the Wound Flow Sheet, dated 2/1/12, recorded an unstageable heel pressure wound that measured 4 centimeters by 6 centimeters, and recorded the resident experienced pain. Review of dietary progress notes, dated 1/31/12, recorded an unstageable left heel wound and directed staff to consider a multivitamin with minerals for additional nutritional support and continue a protein snack at bedtime. Review of the February 2012, TAR recorded a skin treatment to apply lotion to the resident ' s feet twice daily. Observation, on 2/1/12 at 10:20 A.M. revealed the resident sat in a recliner in his/her room with the footrest up and a pillow under his/her legs. The resident wore white socks and house slippers. During the interview, the resident reported his/her knee not as painful, taking pain medications, and expressed that he/she experienced pain when trying to transfer or put weight on his/her left heel. On 2/1/12 at 1:30 P.M., the resident sat in his/her recliner with both feet up, on the recliner footrest, and wore a bunny boot and sock on his/her left foot. On 2/1/12 at 2:20 P.M, the resident sat in his/her recliner, feet hung over the end of the footrest, on the recliner, without a pillow under the resident ' s legs. On 2/1/12 at 2:25 P.M., direct care staff F, provided the skin treatment to the resident ' s feet. Observation revealed a round blackened area, approximately 4 centimeters in diameter, on the resident ' s left heel. On 2/2/12 at 9:30 A.M., the resident sat in the recliner in his/her room with the recliner footrest up, sheepskin bootie on the left foot and the resident ' s left heel rested against the edge of the recliner footrest. Observation revealed no pillow in place underneath the resident ' s legs to elevate and relieve pressure from the footrest to eliminate pressure to the resident ' s left heel. On 2/2/12 at 2:30 P.M., the resident sat in his/her recliner with the foot rest up, a booty on the left foot, and his/her heels rested against the end of the recliner footrest. Observation revealed no pillow underneath the resident ' s legs to elevate and relieve pressure on the resident ' s heels from the footrest. The resident stated, " I ' m not having knee pain anymore, by my heel still hurts. " On 2/1/12 at 7:15 A.M., administrative nursing staff G reported that nursing staff perform treatments as ordered by the physician and measured wounds weekly. On 2/1/12 at 8:10 A.M., licensed nursing staff N identified the resident with a pressure ulcer. On 2/1/12 at 2:04 P.M., direct care staff G reported the resident required 2 staff for transfers as his/her left knee gave out with transfers, used a wheelchair for mobility, and wore a booty for a left heel sore. Direct care staff G revealed that staff recorded any abnormal findings for residents ' skin during baths, in the hand-held computer pad. On 2/1/12 at 2:50 P.M., licensed nursing staff D reported the resident ' s skin was intact and good condition on admission. The physician identified the resident ' s left heel ulcer during a clinical visit out of the facility. Licensed nursing staff D reported preventative interventions included pillows to offload pressure to the resident ' s heels, heel protectors on and nursing staff perform treatments recorded on the TAR as ordered by the physician. On 2/1/12 at 2:50 P.M., direct care staff J and I revealed that any skin issues identified with cares/bathing reported to the charge nurse and not recorded by the staff in the hand-held computer pad. On 2/1/12 at 4:45 P.M., licensed nursing staff H revealed that nursing staff complete the initial skin assessment and chart weekly skin assessments on the TAR. On 2/2/12 at 9:00 A.M., administrative nursing staff C, revealed that direct care staff record abnormal skin conditions in the hand held computer pilots. A review of the facility printed computer Skin Observation Report (CNA (certified nurse aide) bath monitoring), on 2/2/12 at 9:15 A.M., lacked evidence of any data or documentation from 1/16/12 through 2/2/12. On 2/12/12 at 9:30 A.M., Consultant staff F, reported during the initial physical therapy evaluation, on 1/31/12, the resident complained of pain related to the pressure ulcer on the left heel. On 2/2/12 at 12:45 P.M., administrative nursing staff B reported, " On 1/27/12, the resident ' s heel appeared as mushy and possibly a blood-filled blister. " Administrative nursing staff B continued that, " On 2/1/12, the area appeared firm, blister resolving and eschar (unstageable) appearance. " On 2/2/12 at 1:20 P.M., administrative nursing staff B confirmed the resident developed the pressure area after admission and that staff should use interventions to place a soft bootie on the resident ' s left foot and elevate the resident ' s legs with a pillow to decrease pressure from surfaces. Review of the facility provided policy for, Pressure Ulcers, dated March 2007, recorded, " Based on the resident ' s comprehensive assessment, the center will utilize prevention and assessment interventions to ensure that a resident entering the center without pressure ulcers does not develop a pressure ulcer unless the individual ' s clinical condition demonstrates that this was unavoidable. " Review of the facility provided policy for, Pressure Ulcers: Skin Assessment and Prevention, dated 1/2012, recorded, " Risk factors are those factors that increase a resident ' s susceptibility to develop or impact healing times of pressure ulcers, i.e. ...impaired/decreased mobility and decreased functional ability. This same policy directed that, " 1) A systemic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown and documented on the nursing assistant ' s documentation record. The nursing assistant responsible for this will report any abnormal findings or sings of skin impairment to the licensed nurse. 2) Residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches. 3) The interdisciplinary teams should determine any modifications that are necessary to the resident ' s plan of care. " The facility failed to ensure this cognitively impaired resident with limited mobility and without pressure ulcers and assessed at risk for pressure ulcers, received the necessary care and services to prevent an unstageable pressure ulcer on the heel. The facility failed to demonstrate staff assessed and implemented adequate interventions to prevent the development of an avoidable pressure ulcer. The facility failed to develop and consistently implement any interventions for prevention of pressure ulcers until this resident developed a left heel pressure ulcer that measured 6 centimeters by 7 centimeters identified by a physician during a clinic visit.