Every finding on record at Advena Living at Fountainview

Based on record review, interview, and observation, the facility failed to ensure Resident (R) 1, who was dependent on staff for activities of daily living (ADLs) remained free from staff-to-resident abuse. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of multiple sites of muscle wasting and atrophy (wasting or decrease in size of a part of the body), epilepsy (brain disorder characterized by repeated seizures), hypotension (low blood pressure), and anxiety.The Quarterly Minimum Data Set (MDS), dated 06/30/2026, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had physical impairment on both sides of her lower extremities and was dependent on staff for most of her ADLs. The MDS lacked any documentation that R1 took anticoagulant (a class of medications used to prevent the blood from clotting) medication but did document that R1 took antiplatelet (a class of medication used to stop blood cells from sticking together) medication.The Functional Abilities Care Area Assessment (CAA), dated 10/25/2026, documented R1 had a history of muscle wasting, skin issues, and impaired mobility. The CAA documented staff would assist R1 to the extent necessary to complete tasks. The Care Plan, initiated 10/17/2026, documented R1 required maximum assistance from staff for bathing and dressing, was dependent on staff for personal hygiene, and required the assistance of two staff for transfer with a mechanical lift. The care plan documented R1 required the assistance of one staff for bed mobility.The Skin Evaluation Note, dated 07/06/2026, documented R1 had current skin issues. R1 had bruising to her left forearm which measured 3.5 centimeters (cm) by 3.5 cm, and 2.25 cm by 2.25 cm. R1 had bruising to her left elbow which measured 1 cm by 1 cm and another bruise on the left elbow which measured 1 cm by 1 cm. The note documented that R1's left wrist on the ulnar side had swelling.The Social Services Progress Note, dated 07/07/2026, documented Social Services Staff X met with R1 for a psychosocial follow-up regarding the allegation of abuse involving a staff member. R1 reported she was doing well. R1 reported she felt safe in the facility and denied any feelings of fear, distress, or concerns related to the incident.The Nursing Progress Note, dated 07/08/2026, documented a bruise to her left forearm.The Social Services Progress Note, dated 07/10/2026, documented R1 had elected to pursue criminal charges against Certified Nurse Aide (CNA) M regarding the alleged incident. Social Services Staff X continued to monitor and provide support to R1 as needed.The Facility Incident Report, dated 07/09/2026, documented on 07/06/2026 at approximately 08:00 PM, documented that Licensed Nurse (LN) G assisted R1 with care and noted several bruises to R1's left forearm which measured 3.5 cm by 3.5 cm, 2.25 cm by 2.25 cm, and 1cm by 1cm. LN G asked R1 where the bruises came from, and R1 stated the night before she received care from CNA M and CNA N. CNA N stepped out of the room and left CNA M to finish cares. R1 stated she tried to redirect CNA M regarding her care, and CNA M stated, I know what I am doing. R1 stated CNA M proceeded to grab her left arm, turn her, and pull her up. R1 stated she told CNA M that it hurt, and CNA M stated, That did not hurt. I did not hurt you. I know you hate me, and left the room. R1 stated she did not report this at the time of the incident because she did not want to make a big deal of it. The incident report documented that no staff could recall CNA M being alone in the room with R1, that no staff recalled witnessing any abuse by CNA M or other staff, and that CNA M stated the only time she was in the room alone with R1 was when she gave R1's roommate water. The facility terminated CNA M after several write-ups in her file for attendance and other non-care-related issues, and the facility felt CNA M did not uphold the organization's values.On 08/03/2026 at 10:00 AM, R1 sat in a wheelchair in the hallway. She had a pressure-relieving boot on her left foot and looked at her phone in her lap.On 08/03/2026 at 10:05 AM, R1 stated CNA M and CNA N had come in to get her up in the lift and put her to bed the night she obtained the bruises to her left arm. R1 showed her left arm and said, They are all healed now. R1 said CNA N left the room and left her alone with CNA M. CNA M grabbed her left arm, and since her skin was so loose, her skin rolled when CNA M grabbed her and moved her while in bed. R1 stated she told CNA M what she had done had hurt, and CNA M told her she had not hurt her. R1 stated she had not reported it because she did not want to make a big deal out of it, but after talking to her family, she realized if she did not do anything, CNA M could get away with what she had done and do it to someone else, so she decided to press criminal charges. R1 stated she felt safe at the facility, and since CNA M was gone, she had nothing bad to report about any staff.On 08/03/2026 at 01:00 PM, Administrative Staff A stated there was no proof that any abuse had happened. Administrative Staff A stated R1 was easily bruised from medication. Administrative Staff A stated CNA M was terminated after the incident, but not because of the alleged incident but because of a general attitude.The facility's Abuse Policy, revised August 2024, documented all allegations of abuse including physical, mental, emotional, verbal, and/or sexual abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source and any reasonable suspicion of a crime shall be promptly reported to local, state, and federal agencies and thoroughly shall be investigated by facility management. The administrator will ensure that any further potential abuse or mistreatment is prevented.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for five of five direct care staff reviewed, to ensure the residents received adequate cares. Findings included: - The facility failed to complete annual performance reviews for the five certified Medication Aide and/or Certified Nurse Aides (CMA/CNA) sampled that were employed by the facility for 12 months or greater as follows: 1. CNA M, hired 6/7/23 2. CNA N hired 4/3/23 3. CNA P hired 1/11/23 4. CNA Q hired 7/21/22 5. CMA S hired 2/22/23 On 1/23/25 at 12:48 PM, Administrative Staff A, confirmed the above findings. She stated she had been employed as administrator of the facility for approximately six weeks and could not explain why the sampled staff lacked annual performance evaluations. Administrative Staff A reported she had reviewed the personnel files and checked with human resources and could not locate performance evaluations for the direct care staff noted above. She agreed staff should have annual evaluations which identify their weaknesses and have an action plan to include training to address those identified areas. The facility lacked a policy to address annual performance evaluations for the direct care staff. The facility failed to conduct annual performance reviews for five direct care staff, to ensure the residents received adequate cares.

The facility identified a census of 47 residents. The facility identified 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 the gait belts were sanitized after each resident's use and further failed to ensure staff followed the protocols when a nurse provided a tube feeding for a resident. These deficient practices placed the residents at risk for infectious diseases. Findings included: - R37's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dysphagia, gastric ulcer, digestive system surgical aftercare, and gastritis. The Significant Change Minimum Data Set (MDS) dated [DATE] the staff assessment for mental status documented R37 had long and short-term memory problems and severely impaired cognition. R37 had loss of liquids/solids from mouth, held food in mouth/cheek, coughed or choked when swallowing, and had complaints of difficulty or pain with swallowing. Received 51% or more of calories and 501cc fluid or more per day through tube feeding. R37's Care Plan dated 10/01/24 documented nursing staff would administer tube feedings and R37 took nothing by mouth. R37's EMR under the Orders tab revealed the following physician orders: Jevity 1.5 bolus 240ml feeding four times daily. Flush with 75ml water before and after feeding for a total of 150ml water flush. On 01/23/25 at 09:49 AM, R37 laid in her bed, covered with a blanket, resting without signs of distress noted. On 01/23/25 at 09:49 AM, Licensed Nurse (LN) G was observed giving R37 her tube feeding without wearing the proper personal protective equipment, she had only gloves in place. On 01/23/25 at 09:49 AM, LN G stated she knew about the enhanced barrier precautions, confirmed she did not, and stated she should have. On 01/27/25 at 12:53 PM, Administrative Nurse E stated she would expect all staff to know and abide by the enhanced barrier precautions protocol. The facility's undated Enhanced Barrier Precautions (EBP) policy documented that the facility followed recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI). On the recommendation and approval of the facility Infection Preventionist in collaboration with the facility's Medical Director, Enhanced Barrier Precautions (EBP) are implemented as one intervention this facility uses to reduce transmission of resistant organisms that employs targeted Personal Protective Equipment (PPE) use during high contact resident care activities. Standard Precautions continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. The required PPE includes but is not limited to gloves and gowns prior to high-contact care activity. Change PPE before caring for another resident. The facility failed to ensure staff followed EBP protocol with tube feedings. This deficient practice placed the residents at risk for infection.

The facility reported a census of 47 residents with 14 residents sampled. Based on observations, interviews, and record review, the facility failed to ensure that one Resident (R) 6 had a current and valid Preadmission Screening and Annual Resident Review (PASARR). Findings included: - Review of the Electronic Health Record (EHR) for R6 included diagnoses of schizoaffective disorder bipolar type (mental illness is a combination of symptoms of schizophrenia and symptoms of a mood disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R6 had the diagnoses of anxiety, depression, and schizophrenia. Received antipsychotic, antianxiety, hypnotic, anticoagulant, antibiotic, diuretic, and opioid, with indications noted. The 01/09/20 Care Plan reviewed 09/24/24, documented R6 took medications and instructed staff to administer and monitor for and/or report possible side effects (unintended effects caused by medication use). Review of the Certificate of Care assessment dated [DATE], documented the assessment was good for one year. Observation on 01/23/25 at 10:20 AM revealed R6 seated in her wheelchair in her room. During an interview 01/23/25 at 03:23 PM, Administrative Nurse D confirmed R6 had a Care Assessment completed in 2020 and that was the only one completed. Administrative Nurse D stated that the regional director had informed them that this was the only assessment needed, unless a resident was to discharge to the community for greater than six months. The facility's Preadmission Screening and Annual Resident Review (PASARR) revised October 2024, documented the purpose of this policy was to ensure that individuals with mental illness and intellectual disabilities receive that care and serviced that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. The facility failed to ensure that one Resident (R) 6 had a current and valid Preadmission Screening and Annual Resident Review (PASARR).

The facility had a census of 47 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 25 who had a medication located in her room that was not secured. This failure placed the affected residents at risk for preventable accidents and related injuries. Findings included: - During the onsite survey, the surveyors identified a concern regarding the unsecured medications observed in one resident's room during interview. During an observation on 01/21/25 at 11:31 AM, R25 had a 16-ounce, spray wound cleaning medication on her over the bed table. The medication had a warning label Keep out of reach of children. During an observation on 01/22/25 at 11:07 AM, R25 had a 16-ounce, spray wound cleaning medication on her dresser. The medication had a warning label Keep out of reach of children. During an interview on 01/22/25 at 11:07 AM, R25's roommate R6 reported she was unsure why the spray bottle was there and that the staff must have forgotten it. During an interview on 01/23/25 at 08:10 AM, Certified Nurse Aide (CNA) N reported that residents should not have medications for wound care in their rooms. During an interview on 01/27/25 at 11:43 AM, License Nurse (LN) I reported she would not think that any wound care medication would be left at the bedside unsecured. During an interview on 01/27/25 at 12:53 PM, Administrative Nurse E reported that the wound cleanser should not be left unattended in any resident room. The facility's Control of Hazardous Chemicals policy dated October 2024 documented the facility was committed to eliminating ad controlling hazards that could cause injury of illness to our elders. The facility will meet the requirements of safety standards where there are specific rules about hazards or potential hazards in our facility. All substances with warning labels, including but not exclusive to Keep out of reach of children, will be locked and inaccessible at all times. The facility failed to ensure a safe environment free from accident hazards for R25. This placed the resident at risk for injury and preventable accidents.

The facility reported a census of 47 residents, which included one resident sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, for one Resident (R) 35. The facility failed to ensure safe storage of oxygen nasal cannula and oxygen tubing when not in use to prevent cross contamination and the spread of infection. Finding included: - Review of Resident (R)35's Physician Orders, dated 01/14/25, revealed diagnoses which included acute respiratory failure with hypoxia (inadequate supply of oxygen). The Admission Minimum Data Set, (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R35 received oxygen. The Care Plan, (CP), dated 01/21/25, directed staff to know the resident received oxygen via nasal cannula. The CP lacked direction regarding the maintenance and upkeep of the resident's oxygen supplies such as the storage of oxygen cannulas and tubing when not in use. The Physician Orders, revealed an order dated 12/20/24, which documented the resident required oxygen at one to two liters via nasal cannula, continuously. An observation on 01/21/25 at 12:43 PM, revealed the resident lying in the bed in his room. The resident's nasal cannula and oxygen tubing laid directly on the floor, next to his bed and without a storage bag present. During an interview on 01/21/25 at 12:48 PM, Certified Nurse Aide O, verified the above findings and stated oxygen tubing and nasal cannulas should be stored in a container when not in use to prevent cross contamination and the spread of infection. During an interveiw 01/22/25 at 01:18 PM, Administrative Nurse E stated oxygen tubing and nasal cannulas should be stored in a container when not in use to prevent cross contamination and the spread of infection. The facility policy Policies and Practices-Infection Control, dated 10/2024, lacked address of storage of nasal cannulas and oxygen tubing to prevent cross contamination and the spread of infection. The facility failed to provide appropriate respiratory care for R35, related to storage of oxygen nasal cannula when not in use to prevent cross contamination and the spread of infection.

The facility identified a census of 47 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to provide adequate pharmaceutical services to ensure Resident (R) 25 had their prescribed medications available in a timely manner for administration. This deficient practice placed both R25 and R38 at risk of delayed treatment, which could have adverse consequences. Findings included: - R25's Electronic Medical Record (EMR) from the Diagnoses 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), hyperlipidemia (condition of elevated blood lipid levels), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 0, which indicated severely impaired cognition. R25's Care Plan dated 06/27/24 documented nursing staff would administer medication as ordered, monitor for side effects, and notify the physician as needed. R25's EMR under the Orders tab documented the following physician orders: Atorvastatin (HMG-CoA reductase inhibitors -statins) tablet 20 milligrams (mg), give one tablet by mouth at bedtime for high cholesterol dated 03//21/24. Review of R25's Medication Administration Record (MAR) for January 2025 revealed R25's high cholesterol medication Atorvastatin which was ordered on 03/2/24 was documented as a 9 (not administered) from 01/08/25 through 01/17/25. On 01/21/25 at 01:22 PM, R25 sat in her wheelchair out in the common area. On 01/23/25 at 08:10 AM, Certified Nurse Aide (CMA) R revealed she would inform the nurse if a resident did not have an ordered medication for administration. She stated that she could call the pharmacy if the nurse instructed her to, but that the nurse had to enter it in the electronic medical record. CMA R stated that she made a list daily and went over it with the nurse, she also gave a copy of the list to the ADON. On 01/23/25 at 08:41 AM, Licensed Nurse (LN) G revealed that if a CMA came to her with a missing medication, she would look in the medication room and in the overflow drawer, if she did not find it, she would contact the pharmacy to ensure it had been ordered and would be delivered. On 01/27/25 at 12:53 PM, Administrative Nurse E stated she kept an eye on the missing medications and could not explain why this resident did not have this medication in the middle of the order as the medication was on the pharmacy refill list. The facility's Pharmacy Services Overview policy dated October 2024 documented the facility would accurately and safely provide or obtain pharmaceutical services, including provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Pharmacy services are available to residents 24 hours a day, seven days a week. The facility failed to provide adequate pharmaceutical services to ensure R25 received her prescribed medication. This deficient practice placed R25 at risk of delayed treatment which could have adverse consequences. - R38's Electronic Medical Record (EMR) from the Diagnoses 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) type II, polyneuropathy (neuropathy- weakness, numbness and pain from nerve damage, usually in the hands and feet), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. R38's Care Plan dated 08/15/24 documented nursing staff would administer medication as ordered, monitor for side effects, and notify the physician as needed. R38's EMR under the Orders tab revealed the following physician orders: Farxiga (medication used to treat DM) tablet 5 milligrams (mg), give one tablet by mouth daily for DM dated 12/21/24. Gabapentin (medication used to treat nerve pain) tablet 600 mg, give one tablet every six hours for neuropathy dated 11/20/24. Review of R38's Medication Administration Record (MAR) for December 2024 documented R38's Gabapentin which was ordered on 11/20/24 was documented as a 9 (not administered) from 12/11/24 through 12/13/24. DM medication Farxiga which was ordered on 12/21/24 was documented as a 9 (not administered) from 12/21/24 through 12/31/24. January 2025 MAR documented R38's DM medication Farxiga which was ordered on 12/21/24 was documented as a 9 (not administered) from 01/01/25 through 01/27/25. On 01/22/25 at 03:01 PM, R38 sat in her wheelchair in the hallway outside of her room. On 01/23/25 at 08:10 AM, Certified Nurse Aide (CMA) R stated she would inform the nurse if a resident did not have an ordered medication for administration. She stated that she could call the pharmacy if the nurse instructed her to, but that the nurse had to enter it in the electronic medical record and fax it to the pharmacy. CMA R stated that she made a list daily and went over it with the nurse, she also gave a copy of the list to the ADON. On 01/23/25 at 08:41 AM, Licensed Nurse (LN) G stated that if a CMA came to her with a missing medication, she would look in the medication room and in the overflow drawer, if she did not find it, she would contact the pharmacy to ensure it had been ordered and would be delivered. On 22/20/24 at 03:30 PM, Administrative Nurse E stated she kept an eye on the missing medications and could not explain why this resident did not have the gabapentin medication in the middle of the order as the medication was on the pharmacy refill list. Administrative Nurse E revealed the Farxiga was being waited on due to the insurance company was refusing to cover the medication. The facility's Pharmacy Services Overview policy dated October 2024 documented the facility would accurately and safely provide or obtain pharmaceutical services, including provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Pharmacy services are available to residents 24 hours a day, seven days a week. The facility failed to provide adequate pharmaceutical services to ensure R38 received her prescribed medication. This deficient practice placed R25 at risk of delayed treatment which could have adverse consequences.

The facility reported a census of 44 residents with seven residents selected for review, including two residents reviewed for allegations of abuse. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe environment, free from abuse for Resident (R)1 and R7. During cares on 10/26/23, Certified Nurse Aide (CNA) M grabbed R1 by the arm, which resulted in an injury to R1's left arm near her wrist, which required steri-strips (thin adhesive bandage used to close wounds or cuts) for wound closure. During cares for R7, CNA M was verbally rude and physically forced a shirt on him, which he voiced he did not want to wear. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), myopathy (muscle weakness due to a dysfunction in the muscle fibers), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). The Significant Change Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R1 lacked any behaviors of rejection of care. She required extensive assistance of one staff for bed mobility and dressing, and total dependence of two or more staff for transfers. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 06/23/23, revealed R1 had generalized weakness and required assistance with ADL. The Quarterly MDS dated [DATE], assessed R1 with a BIMS score of eight, indicating moderate cognitive impairment. R1 did not have any behaviors or rejection of care. She continued to require extensive assistance of one staff for dressing and bed mobility and continued to be totally dependent on two or more staff for transfers. The Care Plan, initiated on 06/17/23 revealed R1 had a left above the knee amputation, required assistance of two staff for transfers, was dependent on staff for repositioning and turning, and had a colostomy present (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). The Progress Notes dated 10/26/23 at 08:04 PM by Licensed Nurse (LN) G revealed staff administered Ativan (medication for anxiety) to R1, due to her anxiety, crying, and emotional. The Progress Notes dated 10/26/23 at 10:27 PM entered by LN G revealed at approximately 08:00 PM, Certified Nurse Aide (CNA) M assisted R1 with changing her shirt and R1 acquired a skin tear on her left arm, near her wrist. The skin tear measured 1.5 centimeters (cm) by 1.0 cm and required two steri-strips for wound closure. The Grievance/Concern Log Book revealed a Grievance/Complaint Report dated 10/27/23 that concerned R1 and was reported to Social Services staff (SS) X and Administrative Nurse D. The report revealed R1 said a CNA (CNA M) tried to get her out of bed forcefully. R1 did not want to get out of her bed. R1 reported CNA M grabbed her by the left arm and hurt her, and R1 kept stressing she did not want to get up and wanted to wait a little longer. R1 was so upset she was yelling at CNA M I'm not going with you. R1 stated CNA M's attitude was scary and she shouted at CNA M who then grabbed her. R1 stated she told her to leave my house and she did not want CNA M to touch her. R1 stated she reported this to her friend (R4). SS X asked R1 if she was scared and R1 stated yes. The report included a skin tear noted on R1's left arm. The Grievance/Concern Log Book revealed Grievance/Complaint Report dated 10/27/23 that concerned R7, and was reported to SS X and Administrative Nurse D. The staff asked R7 if he saw or heard anything that may have occurred through the night and R7 reported he heard someone crying down the hall, so he wheeled out into the hall and saw R1 crying really hard. R7 reported he tried to speak with R1 however, she was crying so hard he could not understand her and stated, I've never seen her that upset before. R7 stated he did not know what happened. The Witness Statement for 10/26/23 by CNA N revealed she answered R1's call light and when she walked into the room, R1 had her legs hanging out of the bed. R1 stated she wanted up and was not ready for bed. CNA N stated R1 was very distressed and emotional out in the dining area, telling staff and residents that she did not want her back in the room. The statement lacked who R1 referred to and what time this occurred. The Witness Statement for 10/26/23 by CNA O revealed CNA O was shadowing an unidentified CNA (CNA M) and when walking into R1's room, CNA M stated they were there to lay her down, change her colostomy bag, and put on her pajamas. CNA O stated R1 repeatedly said she did not want to change into her pajamas and lay down, however CNA M finally convinced her to lay down to change the colostomy bag. R1 stated she did not want CNA M to do it but would allow CNA O to change it, to which CNA O agreed. CNA O stated after changing the colostomy, she went to put a different shirt on R1, instead of pajamas, and CNA M stated, no it is time for bed and we need to put on the pajamas. CNA O stated CNA M forced the pajamas on R1, and R1 became a little combative because she did not want to wear the pajamas or stay in bed. R1 was upset and wanted to get out of bed and CNA M stated R1 does this all the time and would be fine and go to sleep. When leaving the room, CNA O noticed R1's arm was bleeding, and she reported the bleeding to the nurse. The statement lacked a time of the incident occurrence. The Witness Statement for 10/26/23 by LN G revealed R1 was upset and crying. When LN G asked her what happened, she said the CNA's giving her care were mean to her, she never wanted them in her room again, and they forced a shirt on her she did not want on. LN G stated R1 had a skin tear from her watch on her left lower arm near her wrist. LN G stated she confronted the CNAs (did not specify who) about this incident and they denied being mean or rough with R1. LN G called Administrative Nurse D and informed her of the situation, who told her to send CNA M home. LN G stated CNA M denied being mean and was questioning why she was being sent home and was trying to get confirmation from the other CNAs to prove her innocence. LN G stated the CNAs (did not specify who) that were in the room with CNA M had witnessed CNA M forcing the shirt on R1. The statement lacked what time the incident occurred. On 11/13/23 at 03:26 PM, when questioned if staff had ever handled her roughly, R1 stated she wasn't going to be here much longer and didn't want to do this. On 11/13/23 at 04:13 PM, Administrative Staff A stated R4 saw R1 cry. Social Service staff (SS) X went into R1's room. R1 told SS X that a CNA made her mad and that was why she was crying. Administrative Staff A stated the CNA was from the agency, it occurred at the beginning of the shift, and he was not there at the time from what he understood. The CNA (CNA M) wanted to get R1 up and she did not want to get up at the time and then stated CNA M was being mean to her. R1 told the nurse that CNA M had an attitude and was being rough. Administrative Staff A stated CNA M was sent home due to her general attitude, it was not a positive attitude, and a few of the residents did not like the way CNA M talked and portrayed herself. Administrative Staff A stated the agency was aware of the incident and CNA M was not to return to the building. On 11/13/23 at 04:20 PM Administrative Nurse D stated R1 identified CNA M, and LN G called her and said R1 was upset one of the aides had been rough with her and that is where she left it. Administrative Nurse D told LN G to find out who it was and send her home. Administrative Nurse D stated LN G called her around 09:00 PM. Administrative Nurse D stated she later called the CNA M's Agency she worked for and told them she was not to come back. On 11/13/23 at 04:28 PM Administrative Staff A stated from the way the information was given to him, the event was not reportable, and CNA M was sent home. On 11/15/23 at 09:22 AM, the surveyor could not reach CNA M's agency by phone. On 11/15/23 at 09:45 AM CNA O stated she worked from 06:00 PM to 06:00 AM on 10/26/23. CNA O stated CNA M transferred R1 to the bed and R1 was mad and did not want to go to bed, but her colostomy bag needed cleaned up. R1 did not want CNA M to touch her, so CNA O stepped in. CNA O stated R1 did not want a pajama shirt on, so she found another one in her closet, and she turned around and CNA M was yanking another shirt on R1. CNA O stated she would put this on and CNA M said, no she needs to put pj's on. CNA M stated she observed fresh blood on the resident's sheet and noticed R1's left wrist area had an opened, bleeding wound. After CNA O left R1's room, she reported the bleeding wound to the nurse, and CNA CNACNA P, and CNA N returned to the resident's room and transferred her into a wheelchair. CNA O stated when R1 arrived at the nurse's station, she was crying and upset. CNA O informed LN G about a battle between the two of them when R1 was trying to push the shirt off and CNA M was pulling it back down. When questioned if CNA M was abusive to R1, CNA O stated CNA M was verbally abusive to R1 and after watching her with the pajama shirt, CNA M was physically abusive with R1. CNA O stated the incident could have been prevented if CNA M would have allowed her to put the other shirt on. On 11/15/23 at 10:11 AM, Certified Medication Aide (CMA) S stated she worked on 10/26/23. CMA S stated LN G told CNA M that R1 wanted to get up, and CNA M had attitude and talking back to LN G. CNA M stated she had just laid R1 down. CMA S said when staff got R1 up and brought her up to the desk, R1 was crying and bawling her eyes out. CMA S stated while standing there R1 told LN G that CNA M was rude and rough with her. Then CNA M walked by and R1 told staff to get her away. CMA S stated R1 calmed down about an hour after CNA M left the facility and made aware that she was not coming back. On 11/15/23 at 01:44 PM, LN G stated she worked 10/26/23 and CNA M was rough with R1. LN G stated R1 had a watch on and when CNA M changed R1's shirt, the shirt caught her watch, that resulted in a wound. LN G stated R1 was very upset and in tears and did not want the girls in the room, they had forced a shirt on her that she did not want to wear. On 11/15/23 at 02:12 PM, Administrative Staff A stated Administrative Nurse D notified him of the incident on 10/26/23 at 08:30 PM when Administrative Nurse D text him, and he called her back and instructed her to get the aide out of there. Administrative Staff A stated he thought since he eliminated the problem right away by getting CNA M out of the building. Administrative Staff A stated it was portrayed to him that CNA M just had a negative attitude. The facility policy Abuse Prevention Program dated October 2021, revealed the residents have a right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to verbal, mental, sexual, or physical abuse. As part of the resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Administration will identify and assess all possible incidents of abuse and investigate and report any allegation of abuse within timeframes as required by federal requirements. The facility failed to ensure a safe environment free from abuse on 10/26/23 when CNA M grabbed R1's arm and forced a shirt on R1, resulting in a wound that required two steri-strips to close, made her stay in bed when she did not want to lay down, and made R1 emotionally upset and cry. - The Medical Diagnosis tab for R7 included diagnoses of metabolic encephalopathy (the functioning of the brain is affected by some agent or condition such as a viral infection or toxins in the blood), cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), dementia (progressive mental disorder characterized by failing memory, confusion), and post-traumatic stress disorder (PTSD- psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The Admission Minimum Data Set (MDS) dated [DATE] assessed R7 with a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 08/23/23 revealed R7 required assistance with ADLs. The Quarterly MDS dated [DATE] revealed R7 continued to have a BIMS score of 14. The Care Plan initiated on 08/22/23 revealed R7 could have a behavior problem and caregivers were to provide opportunity for positive interaction and attention and he would be assured that mutual respect would be given and received from mutual parties. R7 required minimum to moderate assistance of one staff for dressing. The Grievance/Concern Log Book revealed Grievance/Complaint Report dated 10/27/23, that concerned R7 and reported to Social Services staff (SS) X and Administrative Nurse D. The report revealed R7 reported a Certified Nurse Aide (CNA), (CNA M) had lots of attitude and got mad when asked to help place a long sleeve shirt on him. R7 said CNA M was even madder when she had to come back in to take the shirt off, because he got too hot. R7 reported the second time CNA M entered the room she threw his shirt at the nightstand and stormed out of the room. The Witness Statement for 10/26/23 by CNA P revealed she entered the room with CNA N to answer R7's call light and he was upset his needs were not met and stated a CNA (CNA M) was verbally rude. The Witness Statement for 10/26/23 by CNA N revealed she answered R7's call light and he stated CNA M was rude to him, she would not put his shirt on, and he was going to file a complaint. CNA N stated she assisted placing the shirt on and let the nurse know he was upset. The Witness Statement for 10/26/23 by CNA O revealed she was in R7's room with CNA M when she took off his long sleeve shirt. CNA O stated she proceeded to grab a short sleeve shirt from the closet to put on him and CNA M told her not to because he does this all night long and took the shirt from her and sat it on the nightstand. The Witness Statement for 10/26/23 by Licensed Nurse (LN) G revealed R7 had his call light on and when she answered it, he stated CNA M had forced a shirt on him when he wanted a short sleeve shirt on. On 11/13/23 at 04:13 PM, Administrative Staff A stated CNA M was sent home on 10/26/23 due to her general attitude and it was not positive. Administrative Staff A stated a few of the residents did not like the way she was talking and portraying herself including the nurses. Administrative Nurse A stated the agency was made aware of the incident and she was not to return to the building. On 11/13/23 at 04:20 PM, Administrative Nurse D stated LN G called her about another resident that was upset and one of the aides (CNA M) had been rough with her, and that is where she left it. Administrative Nurse D told LN G told her to find out who it was and send her home. Administrative Nurse D stated LN G called her around 09:00 PM, as she was not in the building when the incident occurred. Administrative Nurse D stated she later called CNA M's Agency she worked for and told them she was not to come back. On 11/14/23 at 01:50 PM, R7 stated he had a concern with an agency aide a few weeks ago. R7 stated he wanted to change shirts and when the gal (CNA M) threw his long sleeve shirt on the floor and was rude. When asked if she was abusive, R7 responded yes, I thought the girl was. R7 stated he filed a grievance about it. On 11/15/23 at 09:45 AM CNA O stated she worked on 10/26/23 from 06:00 PM to 06:00 AM. CNA O stated R7 complained he was hot, and while getting a short sleeve shirt out of the closet to replace his long sleeve one he wore, CNA M took the shirt away from her and tossed it to the nightstand stating we are not going to play this game. CNA O stated it was about two hours into her shift when this happened. On 11/15/23 at 10:11 AM, CMA S stated she entered R7's room with LN G to answer his call light. CMA S stated R7 said to not let CNA M in his room, she was rude and disrespectful to him. CNA M stated LN G then called Administrative Nurse D to report CNA M's behavior and incident she had with another facility resident. On 11/15/23 at 01:44 PM LN G stated she worked on 10/26/23 and CNA M refused to give him care or go in his room after an incident about his shirt. When contacting Administrative Nurse D about CNA M's behavior, she was instructed to send CNA M home. On 11/15/23 at 02:12 PM, Administrative Staff A stated Administrative Nurse D notified him of the incident on 10/26/23 at 08:30 PM when Administrative Nurse D text him, and he called her back and instructed her to get the aide out of there. Administrative Staff A stated he thought since he eliminated the problem right away by getting CNA M out of the building. Administrative Staff A stated it was portrayed to him that CNA M just had a negative attitude. The facility policy Abuse Prevention Program dated October 2021, revealed the residents have a right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to verbal, mental, sexual, or physical abuse. As part of the resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Administration will identify and assess all possible incidents of abuse and investigate and report any allegation of abuse within timeframes as required by federal requirements. The facility failed to prevent abuse on 10/26/23 when CNA M physically forced a shirt on R7 and was verbally rude to him.

The facility reported a census of 44 residents with seven residents selected for review including two residents reviewed for allegations of abuse. Based on interview and record review, the facility failed to report allegations of abuse to the State Survey Agency when an allegation was made by Resident (R)1 and R7 against Certified Nurse Aide (CNA) M on 10/26/23. R1 reported CNA M tried to get her out of bed forcefully, grabbed her by the arm and hurt her and R7 reported CNA M forced a long sleeve shirt on him when he wanted a short sleeve shirt on and CNA M treated R7 with verbal abuse by being rude. Findings included: - The Medical Diagnosis tab for Resident (R)1 included diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), myopathy (muscle weakness due to a dysfunction in the muscle fibers), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). The Significant Change Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. She required extensive assistance of one staff for bed mobility and dressing and required total dependence of two or more staff for transfers. R1 had range of motion impairment to both sides of her lower extremities and required a wheelchair for mobility. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 06/23/23 revealed R1 had generalized weakness and required assistance with ADL's. The Quarterly MDS dated [DATE] assessed R1 with a BIMS score of eight, indicating moderate cognitive impairment. The Care Plan initiated on 06/17/23, revealed R1 had a left above the knee amputation, required assistance of two staff for transfers, dependent on staff for repositioning and turning and had a colostomy present (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). The Progress Notes dated 10/26/23 at 10:27 PM entered by LN G revealed at approximately 08:00 PM, certified nurse's aide (CNA) M assisted R1 with changing her shirt and R1 acquired a skin tear on her left arm near her wrist. The skin tear measured 1.5 centimeters (cm) by 1.0 cm and required two steri-strips strips (thin adhesive bandage used to close wounds or cuts) for closure. The Grievance/Concern Log Book revealed Grievance/Complaint Report dated 10/27/23, that concerned R1 and reported to Social Services (SS) X and Administrative Nurse D. The report revealed R1 reported a CNA (CNA M) tried to get her out of bed forcefully. R1 reported the CNA M grabbed her by the left arm and hurt her, when R1 did not want to get up. R1 stated she was upset and yelled at the CNA (M) I'm not going with you the CNA's attitude was scary and R1 shouted at the CNA and CNA M grabbed her. The Witness Statement revealed on 10/26/23, CNA N revealed she answered R1's call light and when she walked into the room. R1 had her legs hanging out of the bed and stated she wanted up and was not ready for bed. CNA N stated R1 was very distressed and emotional out in the dining area, telling staff and residents that she did not want her back in the room. The statement lacked who R1 referred to and lacked a time of the alleged occurrence. The Witness Statement on 10/26/23 by Licensed Nurse (LN) G revealed R1 was upset and crying and when asked her what happened, she said the CNA's giving her care were mean to her, she never wanted them in her room again, and they forced a shirt on her she did not want on. LN G stated R1 had a skin tear from her watch on her left lower arm near her wrist. LN G stated she called Administrative Nurse D and informed her of the alleged occurrence and was instructed to send CNA M home. The Witness Statement on 10/26/23 by CNA O revealed CNA M forced pajamas on R1 after R1 had stated she did not want her pajamas on or to lay down. CNA O stated R1 was upset and did not want to stay in bed or wear the pajamas. On 11/13/23 at 04:13 PM, Administrative Staff A reported SS X had entered R1's room and was informed an aide was making her mad and that was why she was crying. Administrative Staff A reported the aide was from the agency, it occurred at the beginning of the shift, and he was not there at the time. The allegation was that CNA M wanted to get R1 up and she did not want to get up at the time and the stated CNA M was mean to her. R1 reported CNA M had an attitude. Administrative Staff A stated the CNA was sent home due to her general attitude, it was not a positive attitude, and a few of the residents did not like the way she talked and portrayed herself. Administrative Staff A stated the agency was made aware of the allegation and CNA M was not to return to the facility. On 11/13/23 at 04:20 PM, Administrative Nurse D stated LN G called her and said R1 was upset and one of the aides had been rough with her, and that is where she left it so LN G was told to find out who it was and send her home. Administrative Nurse D stated LN G called her around 09:00 PM, she was not in the building when the incident occurred. Administrative Nurse D stated she later called the agency CNA M worked for and told them She was not to come back. On 11/15/23 at 02:12 PM, Administrative Staff A stated he did not feel the event was reportable to the State agency when he informed staff to remove CNA M from the facility, however, he realized later he should have taken different steps and should have reported it to the State Agency. The facility policy Abuse Investigating and Reporting dated October 2021, revealed all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source . will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the facility. 2. The local/State Ombudsman. 3. The Resident's Representative of Record. 4. Adult Protective Services (where state law provides jurisdiction in long-term care). 5. Law enforcement officials. 6. The resident's attending physician. 7. The facility Medical Director. An alleged violation of abuse, neglect, exploitation, mistreatment (including injuries of unknown source) . will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility failed to report the alleged violations on 10/26/23 between CNA M and R1 to the State Survey Agency and other appropriate entities. - The Medical Diagnosis tab for Resident (R)7 included diagnoses of metabolic encephalopathy (the functioning of the brain is affected by some agent or condition such as a viral infection or toxins in the blood), cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), dementia (progressive mental disorder characterized by failing memory, confusion), and posttraumatic stress disorder (PTSD)- psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Admission Minimum Data Set (MDS) dated [DATE] assessed R7 with a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 08/23/23 revealed R7 required assistance with ADL's. The Quarterly MDS dated [DATE] revealed R7 continued to have a BIMS score of 14. The Care Plan initiated on 08/22/23 revealed R7 could have a behavior problem and caregivers were to provide opportunity for positive interaction and attention and he would be assured that mutual respect would be given and received from mutual parties. R7 required minimum to moderate assistance of one staff for dressing. The Grievance/Concern Log Book revealed Grievance/Complaint Report dated 10/27/23, that concerned R7 and reported to Social Services (SS) X and Administrative Nurse D. The report revealed R7 reported a Certified Nurse Aide (CNA), (CNA M) had lots of attitude and got mad when asked to help place a long sleeve shirt on him and was even madder when she had to come back in to take the shirt off because he got too hot. R7 reported the second time she entered the room she threw his shirt at the nightstand and stormed out of the room. The Witness Statement for 10/26/23 by CNA P revealed she entered the room with CNA N to answer R7's call light and he was upset his needs were not met and stated a CNA (CNA M) was verbally rude. The Witness Statement for 10/26/23 by CNA N revealed she answered R7's call light and he stated CNA M was rude to him, she would not put his shirt on, and he was going to file a complaint. CNA N stated she assisted placing the shirt on and let the nurse know he was upset. The Witness Statement for 10/26/23 by CNA O revealed she was in R7's room with CNA M when she took off his long sleeve shirt. CNA O stated she proceeded to grab a short sleeve shirt from the closet to put on him and CNA M told her not to because he does this all night long and took the shirt from her and sat it on the nightstand. The Witness Statement for 10/26/23 by Licensed Nurse (LN) G revealed R7 had his call light on and when she answered it, he stated CNA M had forced a shirt on him when he wanted a short sleeve one on. On 11/13/23 at 04:13 PM, Administrative Staff A stated CNA M was sent home on 10/26/23 due to her general attitude and it was not positive. Administrative Staff A stated a few of the residents did not like the way she was talking and portraying herself including the nurses. Administrative Nurse A stated the agency was made aware of the incident and she was not to return to the building. On 11/13/23 at 04:20 PM, Administrative Nurse D stated LN G called her about another resident that was upset and one of the aides (CNA M) that had been rough with her, and that is where she left it so LN G was told to find out who it was and send her home. Administrative Nurse D stated LN G called her around 09:00 PM, she was not in the building when the incident occurred. Administrative Nurse D stated she later called the agency CNA M worked for and told them She was not to come back. On 11/14/23 at 01:50 PM, R7 stated he had a concern with an agency aide a few weeks ago. R7 stated he wanted to change shirts and when the gal (CNA M) threw his long sleeve shirt on the floor and was rude. When asked if she was abusive, R7 responded yes, I thought the girl was. R7 stated he filed a grievance about it. On 11/15/23 at 02:12 PM, Administrative Staff A stated he did not feel the event was reportable to the State agency when he informed staff to remove CNA M from the facility, however, he realized later he should have taken different steps and should have reported it to the State Agency. The facility policy Abuse Investigating and Reporting dated October 2021, revealed all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source . will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the facility. 2. The local/State Ombudsman. 3. The Resident's Representative of Record. 4. Adult Protective Services (where state law provides jurisdiction in long-term care). 5. Law enforcement officials. 6. The resident's attending physician. 7. The facility Medical Director. An alleged violation of abuse, neglect, exploitation, mistreatment (including injuries of unknown source) . will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility failed to report the alleged violations on 10/26/23 between CNA M and R7 to the State Survey Agency and other appropriate entities.

The facility reported a census of 45 residents, with 3 residents sampled. Based on observation, interview, and record review, the facility failed to provide a safe environment for cognitively impaired and independently mobile Resident (R) 1 when the resident left the facility without staff supervision or knowledge. On 05/24/23 at around 04:40 AM, while on one-on-one staff supervision, R1 left the facility through a window he attempted to crawl out of prior, on 05/23/23. The staff located the resident 0.3 miles away from the facility, which is located in a heavily trafficked [NAME] area with speed limits of 35 miles per hour. This failure placed the resident in immediate jeopardy. Findings Included: - R1's diagnoses from the Electronic Health Record (EHR) included dementia (progressive mental disorder characterized by failing memory, confusion), mild cognitive impairment, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 05/15/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. R1 required limited assistance of one staff with all activities of daily living (ADL). R1 was unsteady, but able to stabilize without staff assistance. R1 did not have any range of motion impairments and did not use a wander/elopement alarm (a device/bracelet that sets off an alarm when a resident wearing one attempts to leave the facility without staff supervision). The 05/15/23 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R1 had dementia, could make his needs known, and used his call light. The 05/09/23 Care Plan documented on 05/25/23, staff added additional guidance that staff were to encourage R1 to participate in activities of interest and distract R1 with food, conversation, television, or books. Staff were to give medications as ordered. R1 had a wander/elopement alarm in place, staff were to complete an elopement risk evaluation, R1 had an actual elopement, R1 was to have one-on-one supervision, and R1 had been added to the elopement book, after the elopement. The 05/09/23 Elopement Risk assessment documented R1 was an elopement risk. The 05/09/23 Physician Orders documented an order for haloperidol 0.5 milligrams (mg) twice daily, discontinued on 05/21/23, and restarted on 05/24/23 for three times a day. As of 05/25/23, staff were to check placement and functionality of the wander/elopement alarm for R1, each shift. The Progress Note dated 05/23/23 at 06:30 PM documented R1 ambulated down the hall, became agitated, and yelled that another resident who stepped on his foot. Licensed Nurse (LN) D walked to the nurse's station and R1 followed her. LN D asked a Certified Nurse Aide (CNA) to keep R1 occupied while she called the provider. LN D got an order for haloperidol five mg one time only and to put R1 on one-to-one observation. An order for a psychiatric evaluation on 05/24/23. The Progress Note dated 05/23/23 at 06:54 PM, LN E documented that R1 wandered all day and staff took R1 outside for walks. The note documented R1 tore out the screen from a window in the sunroom and at approximately 06:00 PM, R1 climbed out the window. The staff brought him back into the building and noted R1 had no injuries. The Progress Note dated 05/24/23 at 02:30 AM, documented while R1 was on one-on-one staff observation, an unidentified CNA observed R1 turn around and slip away from the CNA. The staff found R1 in his room putting his shoes on. Another time the staff went to help another resident and R1 slipped away again. The unidentified CNA went to the bathroom and staff found R1 at the window in the sunroom with one leg outside. LN D then looked in the emergency pharmacy kit for the previously ordered one time dose of Haldol 5 mg. LN D found no 5 mg so she called the pharmacy and faxed the order to them for immediate delivery. The Progress Note dated 05/24/23 at 03:30 AM revealed staff gave R1 a snack and he was calm and pleasant. R1 continued to walk up and down the halls. The Progress Note dated 05/24/23 at 04:30 AM, revealed R1 remained with one-on-one observation at the nurse's station. The staff CNAs were beginning their last rounds when LN D asked them to take turns occupying R1, while LN D completed her charting. CNA F was first. Approximately 15 minutes later when CNA G, came to the nurse station and asked where R1 was, LN D looked around and CNA F was walking down the hall and R1 was nowhere in sight. LN D and CNA G began looking around the building, and when R1 was not found, they went to the window R1 had previously taken the screen out of, noticed the window was open even though they were certain they had closed it earlier, and noticed a motorcycle parked outside was tipped over. LN D gathered the staff and gave them flashlights and assignments in the search grid, to cover the perimeter of the building. As LN D went back into the facility, she noted Business Office Manager (BOM) C's car pulling into the driveway with R1 in the passenger seat. LN D and CNA G assisted R1 back into the facility. The Witness Statement for the incident on 05/24/23, for R1 by CNA F, documented while doing her rounds she overheard the nurse and another CNA asking if they had seen R1, who had previously eloped on day shift. They checked rooms and then the nurse gave flashlights to walk around the outside of the building. When walking back into the building, they were told another staff member, on her way to work, picked up R1 and brought him back to the building. It was about 04:45 AM. The Witness Statement for the incident on 05/24/23 for R1, by CNA G, documented R1 was exit seeking all night. At 04:45 AM, CNA G went to go start round and was getting ready to do her last person, and asked the nurse if she had seen R1, she said no. CNA G came to the window that R1 had tried to get out of all night. CNA G noticed the window was cracked, went out front and noticed a motorcycle was pushed over. CNA G ran and got the nurse, they went out front and started searching for R1. BOM C pulled in and said she had R1. R1 kept telling the staff that he was sorry and he just wanted to walk. The Witness Statement for the incident on 05/24/23 for R1, by CNA H, documented at approximately 04:48 AM CNA H attended to her rounds and call lights. When CNA H threw away her trash, the nurse gathered the staff to grab flashlights and to help find R1, who went out through the window. The Witness Statement for the incident on 05/24/23 for R1, by BOM C, documented on her way to work at 05:05 AM she noticed R1 walking in the grass with a jacket on and a red broom in his hands. BOM C turned around and pulled into a parking lot where BOM C got out of her car and walked towards R1. BOM C called R1 by his name and asked if he needed a ride. R1 stated he was on his two mile walk that he did every day. BOM C explained to R1 it was not safe to walk in the dark and R1 agreed. BOM C talked R1 into a ride and R1 got into the car. R1 asked BOM C if she was taking him back to the building, BOM C asked R1 if that would be okay, R1 said yes. BOM C called the facility and when she did not get an answer, she called Administrative Staff A to let him know of the situation. BOM C and R1 arrived at the facility at approximately 05:15 AM, and staff were in the parking lot looking for R1. BOM C assisted R1 out of her car, and the facility staff assisted R1 into the building. The Witness Statement for the incident on 05/24/23 for R1, by Administrative Nurse I, documented on 05/23/23 at approximately 07:28 PM, LN D called Administrative Nurse I, to inform him of R1 exit seeking. Administrative Nurse I recommended LN call the on-call provider for instructions or orders. At approximately 08:44 PM, LN D called again and stated the on-call provider ordered Haldol, 5 mg, by mouth once, and to follow up with a psychiatric consult tomorrow (05/24/23). LN D stated R1 was refusing any further medications, including oral, intramuscular injections, etc. Administrative Nurse I instructed LN D to keep R1 on one-on-one monitoring for the fore-seeable future. LN D acknowledged understanding of this. LN D also stated R1 was easily redirected and she suspected he would fall asleep soon. Administrative Nurse I instructed LN D to continue redirecting R1 during exit seeking episodes and to continue monitoring him one-to-one regardless of R1's behavior. LN D sent via text message at 06:06 AM to Administrative Nurse I stating R1 had eloped. Administrative Nurse I was told the emergency pharmacy kit did not contain the Haldol, but that the medication was being delivered STAT (urgent/ rush). Administrative Nurse I called LN D at 06:08 AM to confirm R1 was safe, that the one-to-ones were . (no further statement provided). On 05/30/23 at 09:30 AM through 05/31/21 at 10:00 AM R1 remained at the Behavioral Health Unit (BHU, a specialized unit for serious and unstable symptom management to prevent harm to them or others). Observation of the window R1 eloped from revealed two screws on both sides of the windowsill, which prevented the window from opening up all the way. On 05/30/23 at 03:30 PM, Administrative Nurse B revealed at the time of the elopement was not at the facility. Administrative Nurse B stated her first contact with R1 was the morning of 05/24/23, and when she spoke with R1 he was very apologetic and remorseful. R1 stated he did not want to leave the facility, and he just wanted to go for a walk. When asked why he went out the window R1 stated they had pissed him off and he just wanted to show them he could do it himself. Administrative Nurse B confirmed her expectations of staff were to follow provider orders, provide the care as ordered, and act in a professional caring manner, always. On 05/30/23 at 02:47 PM, Business Office Manager (BOM) C stated on the morning of 05/24/23, she was on her way to work early. It was dark. The street had some well-lit areas and some dark areas. She knew it was 05:05 AM as she had looked at the clock. She noticed the car in front of her go toward the center of the road and as she passed the same area, she saw R1, walking on the grass on the side of the road. R1 was in front of the fire station, which was one of the well-lit areas. BOM C did a U-turn and pulled into a parking lot. She got out of her car and approached R1. R1 did not appear to be hot or cold, nervous, or angry, shaken or flushed. R1's speech was clear and easily understood. R1 was properly dressed and carrying a red broom. BOM C asked R1 if he wanted a ride, and he said yes. R1 got in the car. BOM C called the facility and with no answer, so she called Administrative Staff A to inform him of the situation. BOM C and R1 arrived back at the facility and the staff assisted R1 into the building. On 05/30/23 at 02:20 PM, Maintenance Staff K stated after the incident he placed screws in the windowsills of all the windows in the resident's rooms as well as in the sunroom, to limit the opening to six inches. Maintenance Staff K confirmed this was completed after the elopement, though he said some of the resident's rooms had had them because of residents that attempted to leave through them. On 05/30/23 at 10:26 AM, Physician Extender J confirmed she received a call from the facility regarding the elopement at the time of elopement, at which time she gave an order to send R1 to the emergency room for evaluation and treatment due to violent behaviors. She stated she believed he had sustained no injury, per the facility staff report. The facility's reviewed 05/24/23 Wandering and Elopement policy, outlined steps for staff to follow in the event of a resident becoming unaccounted for including who to notify and when (including law enforcement and other appropriate agencies). The policy further directed staff to perform wandering and/or elopement assessments on admission/readmission, quarterly, and at significant changes in condition and to revise care plans as indicated. The care plan will include the use of wander alert bracelet, interventions, and times or conditions that increase the risk of elopement. The facility failed to provide a safe and secure environment for R1 who had impaired cognition and exit seeking behaviors, when he exited the facility, unsupervised, out of a window in the sunroom, and BOM C located him 0.3 miles away and returned R1 to the facility. On 05/30/23 at 05:00 PM, Administrative Staff A was provided the Immediate Jeopardy Template and notified the failure to provide a safe environment and adequate supervision to prevent elopement for R1, who was independently mobile and cognitively impaired, placed R1 in immediate jeopardy. The facility identified and implemented the following corrective actions completed 05/24/23 at 06:10 PM: 1. All staff in-service on facility Wandering and Elopement policy on 05/24/23 which ended at 06:10 PM. One staff member was out on FMLA (family medical leave of absence) with an unknown return date. She did return the call at 07:10 PM on 05/24/23 for in-service acknowledgment. All nurses were also in-serviced on the Medication and Treatment Order policy on 05/24/23 which was completed at 06:00 PM. Staff have been informed they will not be allowed to work until they sign the in-service form. 2. On 05/24/23 Wander Risk Assessments were done on all residents. 3. On 05/24/23 an elopement drill completed on 06:00 AM to 06:00 PM shift at 05:28 PM. 4. On 05/24/23 an elopement drill completed on 06:00 PM to 06:00 AM shift at 06:36 PM. 5. Medication review completed by Physician L, on 05/24/23 at 09:00 AM with medication changes that included the resident to restart Haldol 0.5 mg, three times a day. 6. On 05/23/23 at 08:00 PM, staff checked all alarms on the exit doors of the facility and functioned properly. They were checked again on 05/24/23 at 06:00 AM and functioned properly. All exit doors will continue to be checked twice a day on each shift (12-hour shifts) indefinitely. 7. On 05/24/23 upon return to the facility at approximately 05:20 AM, R1 placed on one on one for staff monitoring and continued until R1 was sent to a behavioral health unit on 05/24/23 at approximately 12:30 PM. 8. The facility installed screws in the windows to keep the windows from going up more than six inches. 9. Night shift (06:00 PM to 06:00 AM) LN D placed on suspension pending completion of the investigation, for failure to follow physician orders. On 05/26/23, the administrative staff terminated LN D. 10. Administrative Nurse I placed on suspension pending the completion of the investigation. On 05/26/23, the administrative staff terminated Administrative Nurse I. 11. On 05/24/23 the Elopement Risk binder reviewed and updated as necessary. 12. The facility will bring this to the next monthly QAPI (Quality Assurance and Performance Improvement) meeting. The surveyor verified the implemented corrective actions while onsite 05/31/23. Due to this, the deficient practice was deemed past noncompliance at a J scope and severity.

The facility reported a census of 44 with five residents reviewed including two residents reviewed for missing clothing. Based on observation, interview, and record review, the facility failed to ensure one of the residents reviewed, Resident (R)5, had her grievance followed up on when she reported a missing clothing item on 03/22/23. Findings included: - The Quarterly Minimum Data Set, dated dated dated [DATE] assessed R5 with a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The Resident Council/Grievance Follow Up Action Summary dated 03/22/23, revealed R5 stated she was missing black jean pants with [NAME] on them and her concern referred to the laundry department. The form lacked any action taken and any results of the action. It did include a submitted by signature of the Activity Director, Social Service Director, and the line for reported to administrator had a signature. The form included instructions to review the issue/concern and to respond to the concern by 04/05/23. On 04/24/23 at 02:48 PM, R5 stated the facility had not found her pants she was missing that were long, black, and had [NAME] on them. The staff said they looked for them but could not find them, they did not offer a solution or to replace them. R5 stated she thought staff may have given the pants to someone else. The staff would put her clothes in a plastic bag and take them to the laundry. On 04/24/23 at 02:51 PM, Social Service Staff X stated that a signature on the Grievance form was verifying that laundry had been told and was looking for the item and explained she gives the form to the administrator after signing the it and he follows up. Social Service Staff X stated she did not follow up on the concern personally of R5's missing pants and said she guessed any three of the staff who signed the form could, referring to the signature on the Grievance form. On 04/24/23 at 02:55 PM, Administrative Staff A stated the Grievance form from the resident council would go to the department head overseeing the area of concern, missing items go to social services. From there, the person overseeing the concern would fill out the form, bring it to Staff A for presentation, and Staff A would determine if the outcome was satisfactory with addressing the issue, and if not, the staff were to come up with a different solution. Administrative Staff A stated the form for R5 was not complete as it lacked action and corrective action and he would of kicked it back and Staff A explained that the signature on the administrator line was not his. Administrative Staff A stated he would need to consult with the facility policy and procedure for what to do if a missing clothing item could not be found. On 04/24/23 at 03:55 PM, Social Service Staff X stated she had not been following the correct process for the grievances and Consultant Staff GG educated her on the process. On 04/24/23 at 04:00 PM, Consultant Staff GG stated the facility was not following up on the grievances that she looked at, they were to put a response and corrective action and then take it to the administrator for signature. Consultant Staff GG stated she believed the time frame was a week, maybe two weeks from when social services handed the grievance to the department head for it to be resolved. Consultant Staff GG stated she believed if the item could not be found the facility would reach out to the family, depending on the resident cognitive status, and the facility would typically replace a pair of pants, it would be up to the administrator to make that decision. The facility policy for, Grievances/Complaints, Filing dated October 2021, revealed upon receipt of a grievance and/or complaint, the Grievance Officer would review and investigate the allegations and submit a written report of such findings to the administrator within five working days of the receiving the grievance and/or complaint. The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident, would be informed verbally and in writing of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator or his/her designee would make such reports within (lacked the number on the blank line of the form) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation would also be provided to the resident, and a copy would be filed in the business office. The facility failed to ensure an accurate procedure for the staff to followed up on R5's grievance of missing pants and failed to perform appropriate action to the concern she reported on 03/22/23.

The facility reported a census of 44 residents with five residents sampled including one sampled resident reviewed for medication errors. Based on record review and interview, the facility failed to follow physician orders for Resident (R)1. Findings included: - The Medical Diagnosis tab for R1 included a diagnosis of bulimia nervosa (an eating disorder characterized by bouts of overeating followed by self-induced vomiting). The Census tab revealed R1 admitted to the facility on [DATE] and discharged on [DATE]. The History and Physical dated 03/27/23 included diagnosis of bulimia nervosa and recurrent vomiting. The Physician Order dated 03/27/23, for R1, located under the miscellaneous tab in the electronic medical record (EMR), revealed an order which included Prozac (antidepressant medication), 10 milligrams (mg), by mouth, daily, for bulimia, and Reglan (medication used to treat the gastrointestinal tract), five mg, by mouth, before meals, three times a day. The Medication Administration Record for March 2023 and April 2023 for R1 lacked instructions for the staff to administer the Prozac and the Reglan. On 04/19/23 at 12:24 PM Administrative Nurse D stated he was not aware of the order. On 04/19/23 at 12:37 PM Administrative Staff A stated he expected the staff to follow physician orders. The facility failed to provide a policy for following physician orders. The facility failed to ensure R1 received medication ordered by the physician for 21 days from 03/28/23 through 04/17/23, his discharge date , when the facility failed to process the physician's orders.

The facility reported a census of 44 residents with five selected for review, including one resident reviewed for specialized rehabilitation services. Based on record review and interview, the facility failed to provide specialized rehabilitation services to Resident (R)1 as ordered by the physician as indicated for physical and occupational therapy services. Findings included: - The Medical Diagnosis tab for R1 included a diagnosis of intervertebral disc degeneration (a condition where one or more discs in the spine deteriorates) of the thoracic region (mid-region of the spine). The hospital Transfer Record dated 03/24/23 with a faxed time of 11:55 AM for R1, revealed orders for physical therapy and occupational therapy. The staff hand wrote on the form that they faxed the orders to the physician on 03/24/23. The hospital Transfer Record dated 03/24/23 with a faxed time of 02:19 PM for R1 revealed err written above where the physical and occupational therapy had been marked as an order. The Baseline Care Plan dated 03/24/23 for R1 revealed R1's goals was to receive therapy at some point and was wanting to move to a home or an assisted living facility. He required one person assist for personal hygiene, toilet use, dressing, bathing, bed mobility, transfers, locomotion, and did not ambulate. R1 used a wheelchair for mobility and had a history of falls. The care plan included for physician orders to see the current medication administration record, the treatment administration record, and current therapy orders. The Progress Notes dated 03/24/23 revealed R1 admitted to the facility for a less than 30 day stay and would like to get therapy when he could and if he could. R1 could stand and pivot with assist of two staff members for a very short period and could propel himself in the wheelchair which he used for mobility. R1 needed assistance to manage bowel and bladder incontinent episodes and assist of one for grooming. The Rehabilitation Screen form dated 03/27/23 for R1 revealed physical therapy and occupational therapy services indicated and under comments on the form revealed no funds at this time and signed by Consultant Staff HH. The facility Therapy Cases report dated 03/01/23 through 04/19/23 lacked therapy services provided for R1. On 04/19/23 at 12:18 PM, Consultant Staff HH and Consultant Staff II stated R1 had not been on their therapy caseload. Consultant Staff HH stated the nursing staff should provide them with any orders, would verbally tell them if a resident had orders when admitted , and would also be informed of any orders during the facility stand up meeting or if the doctor was at the facility for a visit, then nursing staff would notify therapy of any new order and a photo copy of the order would be made for the therapy file. On 04/19/23 at 12:24 PM, Administrative Nurse D stated during the morning stand up meeting therapy staff would be informed of therapy orders, and if a resident needed a therapy order, Consultant Staff HH would ask for orders and the doctor would be contacted. Administrative D stated R1 had no payor source for physical and occupational therapy, he was on Medicaid, and used a wheelchair and walked and did not have a need for therapy. On 04/19/23 at 12:37 PM, Administrative Staff A stated he would expect the staff to follow physician orders. On 04/19/23 at 01:05 PM, Administrative Nurse D stated R1 had a status of Medicaid pending and would not have accepted him as a resident if he had known R1 could not receive skilled therapy. Administrative Nurse D stated staff faxed the order page for the therapy to the doctor and verified the facility did not receive an order to discontinue therapy. On 04/19/23 at 01:15 PM, Administrative Nurse D provided the Rehabilitation Screen form for R1 dated 03/27/23 and stated R1 did need therapy. On 04/20/23 at 11:45 AM, Consultant Staff GG stated it was not common for the facility to not provide therapy if the resident had no payor source, and regardless of a resident required therapy per a doctor order or a therapy screen and if no payor source, then therapy would be provided, and the facility would have to pay for the services. The facility policy Requests for Therapy Services dated October 2021 revealed the Director of Nursing Services shall forward the order to the therapist. The facility failed to provide physical and occupational therapy services to this resident, as ordered by the physician.

The facility had a census of 42 residents. Based on observation, interview, and record review the facility failed to employ a full time certified dietary manager for the 42 residents who resided in the facility and received meals from the facility kitchen. This deficient practice placed the 42 residents at risk for receiving inadequate nutrition. Findings included: - On 01/17/23 at 08:50 AM, observation in the facility kitchen revealed damage to the ceiling covered with plastic and no staff working in the kitchen. Dietary Staff (DS) BB stated the damage was from a water pipe on 12/25/22 and the kitchen was shut down for repairs starting today. He stated the facility was buying takeout from Casey's, Firehouse Subs, IHOP, Arbys, Jimmies Eggs, [NAME] Sims BBQ, China One, Louie's Cafe, Subway and Olive Garden. Further observation revealed the double refrigerator in the kitchen held a large opened, undated bag of hotdogs, one chunk of ham without a date. The walk-in freezer had an opened, undated bag of French fries. The last date the temperature was logged 12/26/22. This was verified by DS BB at the time of the observation. The refrigerator temperature in the dining room was 40 and the temperature log stopped at 12/6/22. This was verified by DS BB at the time of the observation. On 01/19/23 at 08:12 AM, DS BB verified the facility had ladles in the kitchen but were using the serving spoons instead. He stated we are giving them plenty of food even though not measured. At 08:26 AM, DS BB handled toast with gloved hands to butter then place on plates. On 01/17/23 at 08:50 AM, DS BB verified he was the food service manager but was not certified, and in fact, had just started classes. On 01/19/23 at 10:00 AM, DS BB stated the registered dietician came to the facility every other Friday. He stated he had submitted to her the catering schedule and where the foods were to be obtained. On 01/23/23 at 05:15 PM, DS BB verified the registered dietician had not been to the facility for at least two months. Upon request the facility did not provide a Dietary Manager policy. The facility's Dietician policy, dated 20/2021, stated a qualified dietician would help oversee food and nutrition services provided to the residents. The facility's food services manager would receive frequently scheduled consultations. The facility's dietician was responsible for developing and implementing person centered education programs involving food and nutrition services for all facility staff, overseeing the food preparation, service and storage. The facility failed to employ a full time certified dietary manager for the 42 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for receiving inadequate nutrition.

The facility had a census of 42 residents. Based on observation, interview, and record review the facility failed to ensure foods remained at a safe, hot, holding temperature during the meal service. This deficient practice placed the 42 residents who received meals from the facility at risk for food borne illness. Findings included: - On 01/19/23 at 07:57 AM, Dietary Staff (DS) CC obtained breakfast food temperatures from ready to eat food brought to the facility from an outside source. DS CC stated when they brought the food in, it probably cooled. Temperatures included: White gravy : 145 degrees Fahrenheit (F) bacon: 131degrees F sausage: 130 degrees F fried potatoes: 128 degrees F scrambled eggs: 130 degrees F The temperature log indicated temperatures should be 140-165 degrees F. On 01/19/23, further observation at 08:00 AM, staff discovered the steam table outlet was not working and changed to another electrical outlet. At 08:38 AM, food temperatures were: Eggs: 120 degrees F Bacon: 140 degrees F Potatoes: 120 degrees F Gravy: 90 degrees F On 01/19/23 at 08:45 AM, DS BB stated as long as the food had not been out two hours it was ok. Staff warm up plates/food as requested. The facility's Food preparation and Service policy, dated 10/2021, stated food and nutrition services employees prepare and serve [NAME] in a manner that complies with safe food handling practices. The policy stated previously cooked food would be reheated to 165 degrees for at least 15 seconds. Proper hot and cold temperatures are to be maintained during food service. The facility failed to maintain food temperatures at a minimum of 135 degrees during the meals service, placing residents at risk for unpalatable food or food borne illness.

The facility had a census of 42 residents. Based on observation, interview, and record review the facility failed to store, prepare, and serve food to the residents of the facility in a safe, sanitary manner. This deficient practice placed the 42 residents of the facility who received their meals form the kitchen at risk for food borne illnesses. Findings included: - On 01/17/23 at 08:50 AM, observation in the facility kitchen revealed damage to the ceiling covered with plastic and no staff working in the kitchen. Dietary Staff (DS) BB stated the damage was from a water pipe on 12/25/22 and the kitchen was shut down for repairs starting that day. Further observation revealed the double refrigerator in the kitchen held a large opened, undated bag of hotdogs, one chunk of ham without a date. The walk-in freezer had an opened, undated bag of French fries. The last date staff logged the temperature was 12/26/22. The refrigerator temperature in the dining room was 40 and the temperature log stopped at 12/6/22. On 01/17/23 at 08:50 AM, observation revealed a dishwasher in the facility kitchen hooked up to Prestige Premier rinse and sanitizer, but no temperature or sanitation log could be found. On 01/19/23 at 07:57 AM, observation revealed DS CC obtained breakfast food temperatures using the same thermometer without cleaning between four different foods. When DS CC plated food for the residents he handled the bacon, sausages and biscuits with the same gloves hands, not tongs. On 01/19/23 at 08:26 AM, DS BB handled toast with gloved hands to butter then place on plates. On 01/19/23 at 10:00 AM, DS BB verified staff should not use hands to handle food items when plating meals, the thermometer should be cleaned after each food item, and dated food when opened. DS BB also verified staff should obtain and document the cold storage temperatures and dishwashing temperatures and sanitation. The facility's Food Receiving and Storage policy, dated 10/2021, stated all foods stored in the refrigerator or freezer would be covered, labeled, and dated. Functioning of the refrigeration and food temperatures would be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state specific requirements. Opened containers must be dated and sealed. The facility's Food preparation and Service policy, dated 10/2021, stated gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and to be discarded after each use. The facility's Dishwashing Machine Use policy, dated 10/2021, stated dishwashing machine that use hot water to sanitize must maintain hot water at 165 F. Dishwashing machine used with chemical sanitation must have a minimum concentration of 50-100 parts per million (ppm) chlorine or 150-200 ppm quaternary ammonium. The operator would check temperatures with each cycle and record the results in a facility log. The facility failed to store, prepare, and serve food to the residents of the facility in a safe, sanitary manner, placing the 42 residents of the facility who received their meals form the kitchen at risk for food borne illnesses.

The facility had a census of 42 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 01/19/23 at 01:20 PM, Administrative Nurse E stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse E stated she had completed most of or all the training modules but had not taken the test or received the certification. The Surveillance for Infections policy, dated October 2021 documented the Infection Preventionist will conduct ongoing surveillance for Healthcare- Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission -based precautions and other preventative measures. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpretation surveillance data. The Infection Control Committee and/or Quality Assurance and Performance Improvement (QAPI) Committee may be involved in interpretation of the data. The facility failed to ensure the person designated as the Infection Preventionist completed the required certification, placing the residents at risk for lack of identification and treatment of infections.

The facility had a census of 42 residents. Based on observation, interview, and record review the facility failed to ensure drugs were in locked storage when unattended by licensed staff. This deficient practice placed residents at risk for missing or tampered with medications. Findings included: - On 01/17/23 at 03:01 PM, observation revealed the facility's medication cart on the 100-hall unlocked and no nursing staff in sight. The drawers of medications were accessible. At 03:05 PM, Certified Medication Aide (CMA) S verified she had left the cart unlocked when she went to assist a resident in their room. On 01/19/23 at 04:10 PM, observation of the medication cart on the 100 hall revealed the cart unlocked and medication accessible with no licensed staff in sight of the cart. Administrative Staff A locked the cart as he went past. On 01/19/23 at 04:10 PM, Administrative Staff A verified staff were to lock the medication cart when leaving the area or when out of sight of the cart. The facility's Storage of Medications policy, dated 10/2021, documented drugs and biologicals are stored in locked compartments. The policy stated unlocked medication carts would not be left unattended. The facility failed to ensure drugs were in locked storage when unattended by licensed staff, placing the residents at risk for missing or tampered with medications.

The facility had a census of 42 residents. The sample included 12 residents of which five were reviewed for immunization status. Based on record review and interview, the facility failed to offer and provide and/or obtain informed refusals for influenza and pneumococcal vaccinations and failed to offer and provide the residents and/or their representative the current years Vaccine Information Statement (VIS-information sheets produced by the CDC [Centers for Disease Control and Prevention] that explained both the benefits and risk of vaccine to vaccine recipients for Resident (R)5, R10, R17, R29 and R35. This placed the affected residents at increased risk for illness and infection. Findings included: - R5's clinical record lacked evidence the current year Vaccine Information Statement form was provided to the resident and/or resident's representative, or an informed refusal was obtained. R10's clinical record lacked evidence the current year Vaccine Information Statement form was provided to the resident and/or resident's representative or an informed refusal was obtained. R17's clinical record lacked evidence the current year Vaccine Information Statement form was provided to the resident and/or resident's representative or an informed refusal was obtained. R29's clinical record lacked evidence the current year Vaccine Information Statement form was provided to the resident and/or resident's representative or an informed refusal was obtained. R35's clinical record lacked evidence the current year Vaccine Information Statement form was provided to the resident and/or resident's representative or an informed refusal was obtained. On 01/19/23 at 12:15 PM Administrative Nurse F verified the residents were offered the yearly influenza vaccine, but the facility failed to provide the current year CDC VIS and failed to obtain a yearly signed consent from the resident and/or their representative. The facility's Vaccination of Residents policy dated October 2021, documented residents would be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. The policy documented prior to receiving the vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations Current vaccine information statements are located at the CDC website for educational materials) Provision of such education shall be documented in the resident's medical record. The facility failed to offer and provide and/or obtain informed refusals for influenza and pneumococcal vaccinations for R5, R10, R17, 29 and R35 and failed to provide the current year VIS. This placed the affected residents increased risk for illness and infection.

The facility identified a census of 42 residents. The sample included 13 residents with five reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide dignity during dining for Resident (R) 28 who was brought to the dining room disheveled and then left unassisted while he dropped food all down the front of his shirt. This placed R28 at risk for impaired dignity and decreased psychosocial wellbeing. Findings included: - R28's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), history of cerebrovascular accident (CVA- stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and depression (mood disorder characterized by persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R28 had a Brief interview for Mental Status (BIMS) score of four which indicated severe cognitive impairment. He required extensive assistance of one staff member for dressing, and personal hygiene and he required supervision and set up assistance for eating. R28 required staff assistance for bathing. The MDS documented R28 had no rejection of cares. R28's Care Plan recorded R28 had self-care deficit related to CVA. The care plan further documented R28 preferred dressing/groomed routine in the morning, required extensive assistance with dressing needs, and set up and supervision for all meals. On 01/18/23 at 12:19 PM observation revealed R28 sat in the dining room, next to a table, in a Broda (specialty wheelchair) chair sliding forward in the seat of chair. His left arm, affected by the CVA, pressed against the table. R28 used his right arm and hand to reach across his body to fork food and bring it to his mouth. R28 dribbled mashed potatoes and macaroni and cheese from the left side of his mouth onto his shirt. No clothing protector had been provided for the resident. On 01/19/23 at 08:07 AM observation revealed R28 in the Broda chair dressed for the day. R28's hair had not been combed, and he was being taken to the dining room. On 01/19/23 at 08:18 AM observation revealed R28 sat in the dining room, slouched down in the seat of the Broda chair, with the table to his left side. He had no clothing protector on, and he ate independently by crossing his body with right hand and arm to eat. R28 had eggs on his shirt. On 01/19/23 at 08:30 AM, Administrative Staff A inquired if R28 would like a clothing protector and R28 replied he would, and a clothing protector was provided. On 01/23/23 at 09:05 AM observation revealed R28 in the dining room, hair uncombed, in a Broda chair slouched down in the seat with shoulder at table level and slightly reclined. R28 again had been placed at the table with left side against the table. R28 had to reach across his body with right arm to eat breakfast. On 01/19/23 at 09:25 AM Certified Medication Aide (CMA) R stated staff usually place R28 at the table, so he did not have to reach across his body to eat and did not know why he was not positioned correctly. On 01/23/23 at 09:20 AM, Administrative Nurse D stated at times R28 comb his hair, but staff should offer a comb or comb hair for him. Administrative Nurse D verified R28 should be seated up to the table in a position in which R28 did not have to cross his body to fork food to eat. The facility's undated, Right to Dignity policy, documented the facility will promote care for elders of the facility in a manner and in an environment that maintains and enhances each elder's dignity and respect in full recognition of the elder's individuality. Elders will be groomed as they wish including hair care. Each elder will be provided with independence and dignity during all dining experience regardless of the amount of assistance the elder required. Clothing protectors will be not be used unless requested by and care planned for the elder. The facility failed to provide dignity during dining for R28 who was brought to the dining room disheveled and then left unassisted while he dropped food down the front of his shirt. The placed R28 at risk for impaired dignity and decreased psychosocial well-being.

The facility reported a census of 42, with three selected for review for elopement (incident which a cognitive impaired resident with poor or impaired decision-making ability & safety awareness leaves the facility without the knowledge of staff). Based on record review, observation, and interview, the facility failed to provide adequate supervision for Resident (R) 1, who had known behaviors of wandering and exited the facility through an unsecure, unalarmed door without staff knowledge. Emergency Medical Services (EMS) personnel found R1 outside on the ground. The failure to provide adequate supervision and system management of the unlocked door, placed R1 and nine other residents identified as an elopement risk in immediate jeopardy for elopement. Findings included: - R1's electronically signed Physician order [REDACTED]. mood disorders, sleep disorders (changes in sleep patterns), [MEDICAL CONDITION] (severe mental disorders that cause abnormal thinking and perception) and altered mental status (changes in brain function). The Significant Change of Condition Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99. R1 did not complete the MDS interview. R1 had long and short term memory loss, unable to concentrate, and speaking slowly. R1 experienced acute onset of [MEDICAL CONDITION] with her behaviors fluctuating with inattentiveness and disorganized thinking. It was important for the resident to go outside on nice days. Resident had wandering behavior that occurred daily, which placed the resident at significant risk to a potentially dangerous place or significantly intrude on the privacy of activities of others, and the behavior worsened since the previous assessment completed on 08/31/20. The resident wore a wander/elopement alarm (Wander Guard) bracelet (that sets off an alarm when resident wearing one attempted to exit the building without an escort) daily. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/01/20, documented the resident could make her needs known at times and was able to understand when she required to be redirected. The resident could become aggressive with staff members. The resident was at risk for wandering, and she had Wander Guard placement. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 00 indicating she had severely impaired cognition. The resident rarely made decisions on her own due to her short-term and long-term memory impairment. The resident required a Wander Guard . The Care Plan dated 12/16/19, revealed the resident had an elopement risk and wandered related to impaired safety awareness. Her goal included she would not leave the facility unattended without the presence of the staff and her safety would be maintained. Staff educated regarding elopement risks and how to direct 1:1. Staff should monitor the Wander Guard alarms every shift and monitor the exit doors daily. Staff should keep the Wander Guard book at the nursing desk and update the book as needed. The Wander Guard was on R1's left wrist. Staff should monitor the Wander Guard for placement and function every shift. The revised Care Plan dated 06/26/20, directed staff to cover doorknobs, handles and tape on the floor. Staff members should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book. Staff should identify patterns of wandering and provide structured activities. Review of the Quarterly Wander Risk Assessment, dated 11/30/20, located in R1's electronic medical records (EMR), indicated her score was 13, which placed the resident at risk for elopement. According to https://www.wunderground.com/history/daily/KICT/date/2020-11-30, the outside temperatures were as follows: On 11/30/20 at 07:53 PM, the outside temperature was 32 degrees Fahrenheit (F), with wind speed at 0 miles per hour (MPH) and no precipitation. On 11/30/30 at 08:53 PM, the outside temperature was 31 degrees F, with wind speed of 10 MPH, and no precipitation. Interview on 12/03/20 at 08:33 AM, Administrative Nurse D reported she was notified by staff at the facility that R1 left the facility unsupervised at 09:20 PM when Law Enforcement notified the facility by phone that officers were at the front entrance of the facility with R1. Officers reported that a passerby called 911 where the resident had been visually seen lying on the ground next to the bench on the facilities property. Emergency Medical Services (EMS) arrived to assess R1. After EMS assessed R1, EMS transported R1 into the facility. The road in front of the facility was a two-lane highway that was moderately (less extreme) traveled at night. The speed limit on the road was 35 miles per hours. On 11/30/20 Licensed Nurse G completed the resident's Nursing Elopement Assessment due to R1 exited the facility unsupervised. The assessment found in R1 electronic medical records (EMR) documented staff obtained the resident's vitals and R1's temperature was 97.7 F (Fahrenheit) her heart rate was 102 beats per minute, her respirations were 18 per minute, her oxygen saturation was 96 percent and her blood pressure was 132/78 MmHg (millimeters of mercury ) . EMS transferred R1 to her room and placed her on her bed. LN G completed a neurological check (level of consciousness, pupil size & verbal response, extremity strength and movement, vital signs) and was within normal limits. Staff assessed the resident and observed the resident had a hematoma (collection of blood in the tissues of the body outside of the blood vessels) on the palm of her right hand and a hematoma on her face, under her right eye. At the time of the assessment, R1was relaxed, smiling, with occasional moaning or groaning due to pain. The Physical Assessment, located in in the resident's clinical records, revealed R1 wore a long sleeve purple shirt, black sweater, thick socks, and what appeared to be snow boots at the time she exited the facility. Review of the Elopement Investigation Witness statements, revealed on 11/30/20, Certified Medication Aide (CMA) R reported the last time she visually saw the resident was at 08:30 PM. On 11/30/20 Certified Nursing Assistant (CNA) O reported R1 paced the halls and facility in the evening of her elopement. R1 was last visually seen at 8:45 PM by CNA O and CNA P. Staff members redirected R1 to her room. Staff did not hear door alarms to indicate the resident exited the facility unsupervised. Review of the facility Investigation, on 12/03/20 , R1 obtained x-rays on 12/01/20 of her right hand and right wrist due to R1 complaining of pain and hematoma. Abnormalities were not found on the x-rays. Observation on 12/03/20 at 10:19 AM revealed R1 sat in a chair, with her cane on her right side. The resident was pleasant, and she participated in coloring activities. The resident had a Wander Guard on her left wrist. Observation on 12/03/20 at 10:45 AM, revealed Consultant staff HH ambulated the resident with a gait belt and a cane. Observation on 12/03/20 at 02:09 PM, revealed R1 showed no signs of wandering or exit seeking. R1 sat on the couch and rested with her eyes closed. The resident had a Wander Guard on her left wrist. Interview on 12/03/20 at 08:40 AM Maintenance Staff II stated there had been alarms on all the exit doors. The monitor located at the nurse's desk must always remain open to monitor the exit doors. We have a Wander Guard alarm at the front main exit door. He reported there were additional magnetic alarms on the double doors . Maintenance Staff II did not keep a log for the alarms. Maintenance could not confirm when the exit doors where last checked. Interview, on 12/03/20 at 08:48 AM, Administrative Nurse D reported staff saw the resident at approximately 08:45 PM. Staff was unaware which of the three dining room doors that R1 exited, however the facility had only one Wander Guard, at the front door, and staff determined the resident exited through the double exit doors by the dining room. Staff failed to close the double doors exiting hall 100/200 at 06:00 PM and failed to turn on the magnetic alarm and failed to close the entrance to the dining room and failed to turn on the magnetic alarm. The resident had increased restlessness and agitation. In the investigation, it was identified if the three exit doors located in the dining room were breeched or forced open, the alarm would no longer sound on the panel located at the nurse's station. Also, the computer program that notified staff of a forced door or door breach was not actively running on the nursing station computer at the time of the elopement. The functioning alarm log revealed at Dining Room door 2 there was a forced or door breach at 8:36 PM. Interview on 12/03/20 at 10:47 AM, CMA R reported the resident could ambulate without staff assistance. The door alarms should function by alerting staff if the exit doors opened. She was found by someone driving by and they called EMS. Staff was not aware she was gone until EMS and law Enforcement arrived at the facility, with the resident, to clarify if the resident lived at the facility. Interview on 12/03/20 at 02:48 PM CNA M stated R1 wandered frequently. R1 required supervision by staff and required staff to keep her occupied with individual activities. CNA M verified the resident would walk towards exit doors but was unsure if she had attempted to exit the building. Interview on12/03/20 at 02:57 PM CNA S stated R1 appeared to be bored and had confusion to changes in her routine due to COVID -19 (Coronavirus). Her behaviors increased since COVID-19. Interview, on 12/03/20 at 03:11 PM, CNA O stated she felt R1 had a very hard time with the facility locked down due to COVID-19. The facility's revised Elopement Policy, dated 12/04/20, documented the facility should ensure the safety of residents who were identified at risk for elopement, and staff should take precautions to ensure the resident's safety and well-being. The facility failed to provide adequate supervision for this resident, who had known behaviors of wandering, and exited the facility through an unsecure, unalarmed door without staff knowledge. R1 was found by a passerby, who called EMS, who found the resident outside on the ground. This placed this resident and nine other residents identified as elopement risk in immediate jeopardy. This deficient practice was cited as past non-compliance on 12/02/2020 at 12:00 PM, when the facility completed the following prior to the surveyor entering the facility on 12/03/2020 at 08:15 AM. The plan included: Maintenance Staff Audible door alarms placed on the three dining room doors that enter the dining room. Two additional alarms added to the back of the double doors near long term care and to the back of the double doors leading to the therapy room, on 12/1/20 at 3:00 PM. All staff education on the facility's Elopement Policy, initiated on 11/30/20 at 11:30 PM, with the majority of the staff education on 12/02/20 at 12:00 PM. The remaining staff education provided by 11/03/20 at 09:00 before the starting of their shift. In addition, all staff education included how to operate the program and expectations that the program monitored at all times. A focused Quality Assurance Performance Improvement (QAPI) initiated on 12/02/20 at 09:00 AM with the Administrator, Director of Nursing Services, Medical Director, and management team.

The facility reported a census of 44 residents with 13 of those residents identified at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review, the facility failed to maintain the toggle switch in the On position at the nurse's desk panel for the therapy room exit door, to alert staff by sound and light that the exit door opened. This failure placed the 13 residents assessed at risk for elopement to exit the facility without staff awareness. Resident (R) 1 exited the facility out of the therapy room exit door without staff knowledge, crossed a busy highway/street, and found by police on the opposite side of the street. The police then telephoned the facility staff to alert them to R1's elopement from the facility. Findings included: - The Admission Record revealed Resident (R)1 admitted to the facility on [DATE]. The History and Physical, dated 12/02/19, included [DIAGNOSES REDACTED]. The Discharge Return Not Anticipated Minimum Data Set (MDS), dated [DATE], assessed R1 with a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The assessment included that he had fluctuating inattentive behavior, disorganized thinking, no behavioral symptoms or rejection of care, and wandered four to six days of the seven day look back period. Furthermore, he received supervision for walking in his room and in the corridor, and supervision for locomotion on the unit (in room and adjacent corridor) and off the unit (distant areas of the facility). The Baseline Care Plan, dated 12/05/19 included that R1 needed setup help for walking and locomotion without assistive devices. He was alert, cognitively impaired, at risk for elopement, and wore a WanderGuard (bracelet that would set off an alarm when residents wearing one attempt to exit the building without an escort) was in place. The Wander Risk Assessment, dated 12/05/19, indicated the risk score to be determined. The assessment indicated the resident could follow instructions, was ambulatory, could communicate, had a history of [REDACTED]. Review of the Visual Checks document, revealed R1's wandering and elopement, with a starting date of 12/05/19 at 10:00 PM, included that the resident wandered and staff offered to toilet four times and the resident accepted through 01:15 AM on 12/06/19. On 12/06/19 at 01:45 AM, wandering began again and continued until 06:00 AM, then again at 06:45 AM until 10:00 AM. On 12/06/19 from 10:00 AM until 12/07/19 at 05:15 AM, R1 was in bed/asleep. He began wandering on 12/07/19 at 05:15 AM. On 12/07/19 at 01:00 PM, R1 wandered to the exit, set off the exit alarm at 01:15 PM, and at 01:30 PM wandered to exits and continued to set off alarms again at 03:00 PM. He continued to wander and set off alarms again at 04:30 PM. On 12/07/19 at 09:00 PM until 12/08/19 at 03:15 AM, he slept. On 12/08/19 at 03:15 AM, he was up walking the hall looking for the bathroom, then back to sleep at 03:30 AM. On 12/08/19 at 07:30 AM, he was up at the nurse's station. He was then wandering off and on. On 12/08/19 at 02:15 PM, 02:30 PM, and 02:45 PM, R1 was exit seeking. On 12/08/19 at 03:00 PM and 03:15 PM, he was in his room organizing, at 03:30 PM he was in room getting dressed, and at 03:45 PM, he was in his room organizing, and at 04:00 PM he was out of the building/eloped. In the electronic medical record (EMR), the Progress Note tab, revealed the following: 1. A Behavior Note, dated 12/06/19 at 09:54 PM, R1 wandered all shift setting off door alarms and went to bed at 09:00 PM. 2. An Admission Summary Note, dated 12/07/19 at 05:21 PM, R1 wandered most of the shift, remained confused about his surroundings, and did not understand his living there. 3. An Incident Note, dated 12/07/19 at 07:02 PM, R1 up wandering this shift, Tylenol administered per physician order [REDACTED]. Staff attempted to redirect with activities, at times was effective for short periods, fluids and toileting offered, and R1 continued with visual checks. 4. An Incident Note, dated 12/08/19 at 04:25 PM, revealed the facility staff received a call from the local police department at 03:52 PM, regarding R1 was out of the building. The staff assisted him back to the building, obtained vital signs, completed a skin assessment, and no injuries were noted. Staff notified the Director of Nursing (DON), R1's durable power of attorney, and the Advanced Practice Registered Nurse. 5. On 12/09/19 at 08:32 AM, a Late Entry Progress Note for 12/06/19 at 01:30 PM, included that R1 stated he wanted to leave, however staff continued to redirect R1 and the resident was reluctant to suggestion. Staff placed a Wander Guard on R1 as he stated he wanted to go home in hopes that he would be detoured from attempting to leave. The Investigation Report completed by the facility, dated 12/13/19, revealed that on 12/08/19 at 03:50 PM, an alarm sounded. The staff went to the nurses' station to see what alarm was sounding as the board was at the nurse station. The staff were dispersing to locate the alarm when they received a call from the police at 03:52 PM stating that they were with the resident outside of the facility. A staff went outside to get the resident and noted him to be on the other side of the street from the facility with the officer. The staff assisted the resident back into the front entrance door of the facility and the Wander Guard sounded. The alarm that was sounding at 03:50 PM was the therapy room door in which the resident exited from, which is alarmed with egress not the Wander Guard system. The resident wore jeans over sweatpants and a long sleeve hoodie sweatshirt with socks and shoes. According to wunderground.com on 12/08/19 at 3:52 PM, the weather was 50 degrees Fahrenheit and it was daylight outside. Interview on 12/23/19 at 11:43 AM, with Licensed Nurse (LN) I revealed she was not working at the time that R1 eloped, but confirmed he was exit seeking, was on 15-minute checks, and he had a Wander Guard in place. Interview on 12/23/19 at 02:39 PM, with Certified Nurse Aide (CNA) O revealed R1 was an elopement risk, he wandered often, and was independent with activities of daily living (ADL's) except for prompting to toilet and when to go to bed. The code for the exit doors were moved so they were not as highly visible because he would try to push the code to get out. He had a Wander Guard bracelet and it would sound before he got to the door. Staff needed to redirect him a lot. CNA O observed him trying to go out the exit door down the 200 hallway one time. Furthermore, she reported that there were not Wander Guard alarms at the hall exit doors, just at the main entrance. Interview on 12/23/19 at 03:30 PM, with CNA M revealed that R1 wandered, had a Wander Guard in place, and they used the On the Spot binder (a book the facility used to inform staff of new care interventions) to try and encourage activities with him, but it did not always work because he just wanted to leave. At the time of the elopement on 12/08/19, CNA M confirmed she did not hear any door alarms around that time and normally she could hear them when she was in the resident rooms. Interview on 12/23/19 at 03:57 PM, with CNA N revealed that he was working on the floor and on the same hall that R1 resided on the day of the elopement. R1 was on 15-minute checks. CNA N observed R1 in his room until he eloped. At 03:45 PM, R1 was in his room putting clothes on his bed. CNA N was sitting at the nurses' desk charting and received a call from the police that an unidentified couple noticed him in the grassy area and thought he looked out of place, so they called the police, and a policeman stayed with R1 until LN G and CNA N got to him. CNA N and LN G walked with R1 back through the front door at 03:54 PM. CNA N confirmed when sitting at the nurses' desk he did not hear a door alarm sound. He did recall hearing a beeping noise at the desk and failed to determine what it was, then remembered later that he heard it, but was unsure of the origin of the alarm. When questioned about the panel at the nurse's station, CNA N responded he was not sure if there was a panel for the exit doors or not to show where an alarm would originate. On 12/23/19 at 04:08 PM, Maintenance staff U set off the therapy exit door alarm. The alarm sounded loudly at the nurse's station and lit up at the panel to indicate the therapy exit door opened. Maintenance staff U explained he checked the exit doors the day after the elopement and the lights on the panel at the nurse's station worked. Maintenance staff U confirmed he checked the exit doors routinely once a month for the egress, the last check was in November, date unknown. Interview on 12/23/19 at 04:50 PM, with LN G revealed that she was on break when the elopement occurred of R1 on 12/08/19. Before she went on break, she asked where R1 was and was told that he was in his room. As LN G returned from the break room (which is across the hall from the nurse's station) she observed CNA N, sitting at the nurses's desk answering the phone. CNA N then reported the police called and he thought R1 was across the street. No alarm sounded at that time and LN G questioned the other staff if there was an alarm that sounded once staff realized he was out of the building. Prior to that event, during the shift LN G reported she kept hearing a random beep that sounded like a smoke detector when the battery was low. LN G walked around the facility and was unable to locate the source of the noise. Before the elopement occurred LN G reported she was having a problem with a group that was coming into the facility for an activity. They were coming in the building holding the door open and R1 was trying to go out, he was standing between the two sets of entrance doors at the main entrance. Furthermore, LN G confirmed that the door alarms could be heard down the hallways. There was a panel at the nurses' desk, the switches should not be in the Off position and thought that sometimes they might get bumped if someone stood there. Staff checked the therapy exit door and it sounded like a smoke detector when the battery was about dead. Interview on 12/23/19 at 05:14 PM, with Maintenance staff U confirmed that if the toggle switch was in the Off position, the alarm would not sound at the panel or light up when the code was put in. When the toggle switch was in the On position it should alarm and light up every time the door opened. Interview on 12/23/19 at 05:18 PM, with Maintenance staff U stated that he assumed the toggle switch was in the Off position at the panel at the nurse's station and that was why it did not sound when R1 went out the therapy exit door without the staff knowledge. On 12/23/19 at 05:40 PM, Maintenance staff U turned the toggle switch, at the nurses' desk panel, to the Off position to the therapy exit door. The mag lock was in a red (open) state and the door opened without placing a code in and did not alarm when it opened. The mag lock emitted three short beeps at intervals and not very loudly. Maintenance staff U confirmed this was how he found the door when he came into work on Monday 12/09/19 (the day after the elopement). A therapist informed Maintenance staff U it was beeping and he did not know what to do. Interview on 12/24/19 at 07:55 AM, with Maintenance staff U further explained that the therapy exit door did not have an alarm system at the door like the other doors making it hard to hear when it sounded. On 12/24/19 at 08:00 AM, Maintenance staff U confirmed how the alarm system worked with the surveyor, Administrative staff A, and Administrative Nurse D. Maintenance staff U explained that the toggle switch, on the panel at the nurse's station, was in the Off position and the mag lock was at an open state, on 12/08/19, which allowed R1 to exit the facility without staff knowledge. An alarm would have sounded only at the exit door, would have stopped alarming when the door released, and then would have repeated the three beeps at intervals until it was reset. Administrative staff A and Administrative Nurse D confirmed understanding. Observation, on 12/24/19 at 08:08 AM, revealed the toggle switches, at the nurses' desk panel, were in the Off positions for the exit doors in the therapy, dining room, main entrance, hall 2, and Carriage House. Therefore, the facility staff would not be aware when any of those doors opened. Observation, on 12/24/19 at 09:10 AM, revealed the toggle switch, at the nurses' desk panel was in the On position for the therapy exit door. Interview, on 12/24/19 at 09:31 AM, with consultant staff GG, who worked in the therapy department confirmed he did not work on 12/09/19 that PRN (as needed) Consultant staff II came in that day. He recalled a day when he came to work, but unable to recall the exact day, within the past two weeks that the exit door was making a repeated beep noise, so he notified Maintenance staff U, who then informed him of the code for the door to enter. Furthermore, he had not used the exit door before, and had not seen anyone else use the door. Interview on 12/24/19 at 09:38 AM with Consultant staff II, who worked in the therapy department, revealed that on 12/09/19 there was a buzzing noise, not a short beep noise with pauses between at the therapy exit door. It was not making any noise when she first came in to work, but after she had left the room to go work with a resident and returned to the room it was making that noise. She also went to the nurse's station and reported the noise. A staff member came and checked the door and was not able to make it stop. Consultant staff II reported that she figured out how to make the noise stop by putting in the code. Interview on 12/24/19 at 09:49 AM, with Administrative Nurse D confirmed that the facility did not have a policy for routinely checking the functionality of the door exit alarms. The facility failed to maintain the toggle switch in the On position at the nurse's desk panel for the therapy room exit door, to alert staff by sound and light that the exit door opened. This failure placed the 13 residents assessed at risk for elopement to exit the facility without staff awareness in immediate jeopardy, and allowed Resident (R) 1 to exit the facility out of the therapy room exit door without staff knowledge, cross a busy highway/street with a speed limit of 35 mile per hour, and was found by police on the opposite side of the street. On 12/24/19 at 11:14 AM, Administrative staff A and Administrative Nurse D were informed that they were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to ensure the exit door alarms remained activated to ensure the safety of 13 residents who were at risk for elopement. The facility provided an acceptable plan of removal of the immediate jeopardy on 12/24/19 at 03:12 PM. The plan included: 1. All staff will be in-serviced regarding the door alarm systems and monitoring panel at the nurses station. Staff will not be allowed to work the floor until signatures received. 2. Met with all QA (Quality Assurance) members to discuss survey teams findings including causes and solutions. The Medical Director and the Regional team have been notified. 3. The panel has had all switches placed into proper position so that the door alarms and panel with lights will sound. All switches have been taped into position. A box is being placed over the panel, secured to the wall, with small hole to access the reset button only. 4. The therapy door will be inspected to determine parts needed for Wander Guard alarm and fitted with Wander Guard system as soon as parts are available. The door will remain locked until parts received and the only key is with the therapy director. The therapy room door will be monitored by the charge nurse every shift and documented to ensure the door is locked. They will ensure it is locked by pressing on the egress. The survey team validated the immediate jeopardy was removed on 12/26/19 at 12:56 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of an [NAME] following the removal of the immediate jeopardy.

The facility reported a census of 50 residents with 18 selected for review, including three residents reviewed for behavioral health. Based on observation, record review, and interview, the facility failed to provide appropriate social services to meet the needs of one of the three residents reviewed, including Resident (R) 92, related to the grief she experienced after the death of a family member, while she resided at the facility. Findings included: - The signed Physician order [REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had a mood score of two, indicating she was depressed, feeling down, or hopeless . (The assessment completed before the death of the family member.) The Mood State Care Area Assessment (CAA) dated [DATE], did not trigger. The [MEDICAL CONDITION] Care Plan, dated [DATE], documented staff should refer the resident to a psychiatrist as needed. Attempt to identify environmental or basic needs that caused changes in her mood and behavior. The electronic record from [DATE] to [DATE] lacked documentation of the resident's family member's death. The Facility Assessment, dated [DATE], documented the facility would accept a resident who may develop mood disorders that included depression. The facility would manage mental health and care of individuals with depression and trauma. On [DATE] at 02:17 PM, the resident sat in her chair in her room. She visited freely regarding the death of her grandson and had tears in her eyes. On [DATE] at 02:17 PM, the resident reported her family member died the last part of (MONTH) 2019, while she lived at the facility. She reported if she was given a chance, she would like to visit with someone regarding the death. She did attend the funeral. Staff were aware of his death, because they were to assist her with fixing my hair and getting dressed appropriately, but the facility was short of help and was not able to help her get ready. She stated she had done a lot of crying over his death while she was by herself, but since the funeral, no one has visited with her about his death. On [DATE] at 11:49 AM, Certified Nurse Aide (CNA) Q, reported the resident spent a great amount of her time in her room. She appeared depressed at times. On [DATE] at 01:53 PM, Social Services X, reported she was unaware of the family member's death because nursing staff failed to report the death to her. On [DATE] at 03:29 PM, CNA MM, reported the resident went out to the funeral. She was upset about his death. She returned to the facility at approximately 09:30 PM and she went to bed. The nurses were aware the resident went out to the funeral. On [DATE] at 08:49 AM, Administrative Nurse D, reported she was unaware of the resident's family member's death until Social Services X reported this to her on [DATE]. Staff should console residents when grieving and she reported there must have been a break in the facility's communication system. When a resident had a death, or a major loss in their life, the facility should give the resident an opportunity to express the loss of a loved one. On [DATE] at 09:58 AM, Licensed Nurse (LN) H, reported staff should notify Social Services or the Activity Director when the resident experienced a death in her family. Staff should assist the resident the day of the funeral by assisting them to get dressed. On [DATE] at 10:04 AM, an unidentified family member reported the facility was aware of the death. He notified the facility in advance and requested staff to assist the resident in getting dressed appropriately for his memorial service. When he arrived at the facility to transport the resident, the resident sat in the dining room, unchanged, and not prepared to go out. He lacked time to get her prepared, so the resident went to the memorial service without being properly dressed. The facility's policy for Social Service Counseling Services, dated [DATE], documented the Social Service staff members would be available to provide psychosocial counseling services, and included crisis intervention services to the emotionally upset or distressed elder or family. The facility failed to provide medically appropriate social services to meet the resident's needs related to resident's grief over the death of a family member.

The facility reported a census of 43 residents. The sample of 8 consisted of 3 residents, reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or assistive devices to prevent falls and/or other accidents from occurring for 3 out of 3 residents reviewed, including, the facility's failure provide adequate supervision to a restless, confused resident (#1), on 7/2/19. Facility staff left the resident unattended in a common area next to the nursing station, when the resident attempted to stand, experienced an injury fall, resulting in a laceration to the head, which required emergency room treatment. There, it was found that the resident also sustained a [MEDICAL CONDITION] cervical vertebrae. Additionally, the facility failed to identify accident hazards and risks following a skin tear on 6/27/19, for resident #2. Furthermore, the facility failed to develop appropriate interventions following falls on 3/16/19, and 4/28/19, for resident #3. Findings included: - Resident #1's signed physician's orders [REDACTED]. The resident's annual MDS (minimum data set), dated 10/3/18, assessed the resident with a BIMS (brief interview for mental status) of 12, indicating the resident experienced moderate cognitive impairment. The resident required limited to extensive assistance from one to two staff to complete his/her ADLs (activities of daily living. The resident experienced two or more non-injury falls since his/her prior MDS assessment. The resident's CAA (care area assessment) for falls, dated 10/3/18, documented the resident experienced multiple falls, and was at continued risk for falling. The resident's 14-day MDS, dated [DATE], documented the resident with BIMS of 11, and that he/she experienced one non-injury fall since the prior assessment. The resident's care plan, dated 7/17/13, for falls, documented the resident was at risk for falling due to his/her poor safety awareness, decreased mobility, incontinence, decreased memory, and confusion. On 10/13/18, facility staff updated the resident's care plan to include that the resident required a fall mat, and a soft-touch call light instead of a regular call light. On 4/4/19, facility staff provided a scoop mattress to define the parameters of the bed. On 4/9/19, facility staff must assist the resident to bed following meals. Review of a nursing note, dated 7/2/19 at 7:05 PM, revealed that at 5:40 PM, licensed nursing staff J overheard a loud noise, responded to the noise, and found the resident face down on the floor, bleeding from a laceration on his/her head. Staff J notified the resident's responsible party, physician, hospice provider, and emergency medical services. The resident was sent to the emergency room for evaluation. Review of a nursing note, dated 7/3/19 at 2:05 AM, revealed that the resident returned to the facility from the emergency room . The hospital reported that the resident sustained [REDACTED]. The resident's [MEDICAL CONDITION] received steri-strips and a bandage. Review of the resident's emergency room report, dated 7/2/19, revealed hospital staff documented the resident sustained [REDACTED]. The resident recently experienced a general overall decline and previously admitted to hospice prior to the fall occurring. The resident sustained [REDACTED]. Hospital staff treated the laceration with steri-strips. Review of the resident's CT (computed tomography, an x-ray that produces cross-sectional images of the body) of the cervical spine, without contrast, dated 7/2/19, revealed that the resident sustained [REDACTED]. Review of the residents CT of the head and brain, without contrast, dated 7/2/19, revealed that the resident had signs of a fracture involving the non-visualized part of the base of the skull. On 7/11/19 at 5:15 AM, the resident slept in his/her bed, which was in the lowest position. A fall mat (a cushioned surface) lay on the floor next to the resident's bed. A soft touch call light rested on the resident's bed, near his/her hand. The resident's cervical collar was in place, and he/she displayed no signs of distress. On 7/11/19 at 9:30 AM, hospice staff K stated that he/she was part of the resident's hospice care team. Staff K stated that the resident signed on to hospice services after experiencing a general decline, shortly before his/her fall. Staff K confirmed that the resident continued to experience the decline following the fall, but that the resident did not experience an extreme decline following the fall. On 7/11/19 at 12:03 PM, administrative staff C stated that he/she heard the resident fall on 7/2/19. Staff C stated that he/she heard the resident call out, heard a loud thud, and emerged from the office that he/she was in to find the resident laying on his/her left side on the ground, tangled up in his/her wheelchair, with a large amount of blood pooling under his/her head. Staff C stated that licensed nursing staff J responded to the resident's fall. Staff C stated that he/she remained by the resident's side while staff J retrieved equipment to assess the resident and prepared the resident for transfer to the emergency room . Staff C stated that the resident cried out in pain when he/she moved his/her neck, so the staff did not move the resident. Staff C confirmed that the resident was left alone in the common area by staff. Staff C stated that the resident displayed restlessness throughout the day before the fall, and required one-on-one supervision frequently during the day, and that the resident was not safe to be left alone. Staff C stated that all of the staff knew that the resident could not be left alone, due to his/her increased restlessness that day. On 7/11/19 at 12:51 PM, direct care staff G stated that he/she was in the dining room with the resident on 7/2/19, assisting residents with eating, when the resident spilled water on him/herself, after he/she completed his/her meal. Staff G stated he/she wheeled the resident out of the dining room, and left the resident next to the nursing station, without supervision, and then went back to the dining room to assist other residents with eating. Staff G stated that he/she was aware that the resident displayed increased restlessness throughout the day, and was aware that the resident required constant supervision. Staff G stated that he/she asked new direct care staff H, who was walking down the hall, to inform direct care staff I, that the resident required assistance. Staff G then left the resident to return to the dining room, while staff H went to go find staff I. The resident remained next to the nursing station. On 7/11/19 at 2:21 PM, direct care staff H stated that he/she began employment at the facility about 2 weeks ago, a few days before the resident fell . Staff H stated that he/she did not see the resident fall, but confirmed that the resident was left unattended at the nursing station by staff. Staff H stated that prior to the fall, the resident displayed increased restlessness, and was anxious. On 7/11/19 at 2:55 PM, direct care staff I stated that he/she was the aide working the resident's hall on 7/2/19, the day the resident fell . Staff I stated that the resident was very restless, and was unsafe to be left by him/herself prior to the fall occurring. Staff I stated that he/she was in another resident's room, when direct care staff H entered the room and told him/her that the resident needed assistance, because he/she spilled water on him/herself, and that the resident was next to the nursing station. Staff I stated that he/she then left the room and went to the resident, but that the resident had already fallen by the time that he/she got to him/her. On 7/11/19 at 3:15 PM, licensed nursing staff D stated that the resident attempted to stand from his/her wheelchair after being left unattended by staff on 7/2/19. Staff D stated that his/her expectation of direct care staff would be that restless or anxious cognitively impaired residents would not be left unattended. On 7/11/19 at 3:25 PM, administrative nursing staff B stated that the resident displayed extreme restlessness prior to the fall, and required one-on-one supervision throughout the day, due to restlessness. Staff B confirmed that direct care staff G took the resident from the dining room, left him/her by the nursing station, and then left the resident without adequate supervision. The resident then attempted to stand, fell , and required emergency room treatment. Staff B stated that his/her expectation would be that staff would have ensured someone was with the resident, and that the resident would not have been left unattended. The facility policy for falls, updated 10/2015, documented that each resident would receive adequate supervision to prevent accidents. The facility failed to provide adequate supervision for a cognitively impaired resident at risk for falls who sustained a cervical vertebrae fracture and a laceration to his/her forehead. - Resident #2's signed physician's orders [REDACTED]. The resident's admission MDS (minimum data set), dated 8/14/18, assessed the resident with a BIMS (brief interview for mental status) of 10, indicating the resident experienced moderately impaired cognition. The resident was free of hallucinations and delusions, and did not display any physical or verbal behaviors. The resident required extensive assistance from one staff person to complete his/her ADLs (activities of daily living). The resident experienced a fall prior to admission, but was free of any falls following admission to the facility. The CAA (care area assessment) for ADLs, dated 8/14/18, documented the resident was alert to him/herself, and at times, what was happening around him/her. The resident would attempt to crawl on the floor at times. The resident's 30-day MDS, dated [DATE], assessed the resident with a BIMS of 8, a decline in his/her cognitive abilities. The resident's skin care plan, dated 8/6/18, documented the resident at risk for impaired skin integrity, related to incontinence and immobility. Facility staff must perform weekly skin checks, and notify the resident's physician, and responsible party, of any changes in his/her skin. Licensed nursing staff would document daily on any aspects of wound healing, including but not limited to positioning, nutrition/hydration interventions, pain related to any wounds, dressing integrity, and any related lab work. If the resident had any wounds, he/she must receive weekly wound monitoring. The resident's care plan lacked any specific interventions to prevent skin tears from occurring. Review of the resident's skin assessments, provided by administrative nursing staff B upon request, on 7/23/19, revealed that on 6/27/19, facility staff noted a skin tear to the resident's left upper arm. The skin tear measured 12 cm (centimeters) by 10 cm, or approximately 4 3/4 inches by 4 inches. Review of a nursing note, dated 6/27/19 at 6:40 AM, revealed that facility staff observed a skin tear to the resident's left upper arm. Facility staff documented that the confused resident, alert only to him/herself, attempted to scratch his/her arm, and caused the skin tear. Facility staff cleansed the area, and applied a bandage. The nursing note lacked documentation of an intervention to prevent further injuries from occurring. On 7/1/19, facility staff completed a skin check, following observation of a bruise to the left upper arm, measuring 11 cm by 10 cm, or 4 1/3 inches by 4 inches. On 7/22/19 at 2:33 PM, direct care staff L stated that the resident recently developed a small scab on his/her left arm, that he/she would sometimes pick at. Staff L was not aware of the resident's skin tear, or any other skin issues. Staff L stated that the resident experienced confusion, and didn't always know what was going on around him/her. On 7/22/19 at 3:22 PM, direct care staff M stated that the resident experienced confusion, and did not always know what was going on. Staff M was unaware of the resident's skin tear, or bruise. On 7/22/19 at 3:55 PM, licensed nursing staff J stated that the resident experienced confusion, and could not accurately recall recent events, due to his/her poor cognition. Staff J stated that the resident recently obtained a skin tear around the end of June. Staff J recalled that facility staff found the skin tear on the resident's arm at around shift change, and that the skin tear was large. Staff J stated that the skin tear appeared to encompass the resident's entire upper arm. Staff J stated that facility staff determined the resident scratched him/herself, but that the resident had no prior history of doing something like that before. On 7/22/19 at 4:19 PM, administrative nursing staff B stated that he/she was not sure if the facility investigated the resident's skin tear, put interventions in place to prevent further skin tears from occurring, or reported the incident to the State agency. On 7/24/19 at 11:20 AM, administrative nursing staff B confirmed that the facility failed to complete an investigation into the resident's skin tear, to identify the root cause and implement further interventions to prevent reoccuring injuries. The facility policy for falls, updated 10/2015, documented that each resident would receive adequate supervision to prevent accidents. The facility policy for skin, updated 03/2016, documented that skin assessments would be completed weekly. The facility failed to identify the root cause and implement further interventions to prevent reoccuring injuries for this resident, who sustained a skin tear from unknown causes to his/her left upper arm. The facility failed to thoroughly investigate the injury, failed to determine any probable causes of the injury, and failed to implement an intervention to prevent further injuries from occurring. - Resident #3's signed physician's orders [REDACTED]. The resident's significant change MDS (minimum data set), dated 6/11/19, assessed the resident with a BIMS (brief interview for mental status) of 5, indicating the resident experienced severe cognitive impairment. The resident required extensive assistance from one staff person in order to complete his/her ADLs (activities of daily living), and did not experience any falls since his/her prior MDS assessment. The resident's CAA (care area assessment), for falls, dated 6/11/19, documented the resident free of falls since his/her prior assessment. The resident's care plan, for falls, dated 7/21/14, documented the resident at risk for falling related to his/her medication use. The resident required grab bars for use in his/her bathroom, and must wear nonskid socks. On 4/10/18, facility staff applied nonskid strips to the resident's bathroom floor, to prevent the resident from slipping. On 3/16/19, the resident experienced a fall, and facility staff collected a urine sample for analysis. On 4/7/19, following a fall, facility staff must assist the resident to bed if he/she was tired. On 4/28/19, following a fall, facility staff received education to follow the resident's plan of care. Review of a nursing note, dated 3/17/19 at 6:49 AM, revealed that at 8:45 PM on 3/16/19, the resident was found on the floor. The resident stated that he/she was attempting to get in his/her wheelchair, to go to bed. The intervention, listed in the resident's care plan, was to collect a urine sample for analysis. This intervention failed to address the causative reasons for the resident's fall, and failed to immediately reduce the resident's risk of falling again. Review of a nursing note, dated 4/7/19 at 4:19 PM, revealed that at 4:15 PM, facility staff found the resident on the floor next to his/her bed. The resident stated that when he/she came to, he/she was on the floor. The intervention for the fall, listed in the resident's care plan, was that facility staff would assist the resident to bed, when he/she became tired. Review of a nursing note, dated 4/28/19 at 4:38 PM, revealed that at 10:50 AM, facility staff found the resident on the floor. The resident stated that he/she wanted to get into bed. The intervention for the fall, listed in the resident's care plan, was that facility staff received education to follow the resident's plan of care. This intervention failed to address the causative reasons for the resident's fall, and failed to immediately reduce the resident's risk of falling again. On 7/11/19 at 9:35 AM, the resident rested in his/her bed, covered by a blanket. He/she wore glasses, and his/her wheelchair was next to his/her bed, with locked brakes. The resident's call light was within reach of his/her bed. The resident rested peacefully, with closed eyes. On 7/11/19 at 2:43 PM, the resident rested in his/her bed, alert. The resident made eye contact, but did not speak or respond to a verbal greeting. The resident appeared well-dressed and well-groomed, and had his/her call light within reach. On 7/11/19 at 2:21 PM, direct care staff H stated that facility staff on duty at the time of the fall implemented immediate fall interventions, such as non-skid socks. Staff H stated that fall interventions must reduce the risk of the resident falling again. Any resident who was tired, or restless, should be helped to bed. On 7/11/19 at 2:55 PM, direct care staff I stated that fall interventions must be put in place after a resident fell , and must reduce the risk of the resident falling again. Any resident who was tired, or restless, should be helped to bed. On 7/11/19 at 3:15 PM, licensed nursing staff D stated that fall interventions were put in place at the time of the fall, after reviewing the resident's care plan. Staff D stated that staff education would not be an appropriate fall intervention, because that implied that staff failed to follow the plan of care at the time of the fall. Staff D stated that fall interventions must immediately reduce the risk of the resident falling again. On 7/11/19 at 3:25 PM, administrative nursing staff B stated that nurses and other staff on duty at the time of the fall implemented fall interventions at the time of the fall, and that administration reviewed fall interventions for appropriateness. Staff B confirmed that staff reeducation to follow the plan of care, as well as collection of a urine sample, failed to be appropriate fall interventions. The facility policy, updated 10/2015, for Falls, documented that fall interventions would be implemented for each fall. The facility failed to develop appropriate interventions following falls on 3/16/19, and 4/28/19, for this resident, to prevent further falls.

The facility reported a census of 41 residents with 18 selected for sample review. Based on observation, interview, and record review, the facility failed to ensure 6 sampled residents of the 7 reviewed for accidents remained free of falls/injury and repeated bruising. These 6 residents included: (#51) for elopement from the facility without staff knowledge and falls, (#4, #28 and #49 with repeated falls, (#22) with repeated skin bruising, and (#21) for elopement risk without precautions and repeated skin wounds/issues. Additionally, environmentally the facility failed to maintain an environment as free as possible for the residents of the facility. Findings included: - The facility admitted resident #51 on 4/9/13, per the ECR (electronic care record). [DIAGNOSES REDACTED]. psychosis (any major mental disorder characterized by a gross impairment in reality testing). The resident's 4/30/14 annual MDS (minimum data set) assessment, identified the resident severely impaired of cognition, wandered daily and exhibited problems with concentration nearly daily. Physical functionality indicated the resident needed limited assistance with transfers and walking with set-up and supervision. The 5/9/14 CAA (care area assessment) lacked identification of causal factors, related to dementia and/or falls and/or elopement. A 4/11/14 Elopement/Wandering Risk assessment identified the resident ambulated independently, with purposeful exit seeking, had greater than 120 days without an elopement incident, with aimless and night locomotion, increased confusion in PM (evening) and lacked a history of elopement in the past 6 months. The resident's 4/29/13 care plan instructed staff: 1. Maintain a wanderguard (bracelet type alarm which sounds at an exit door), on the resident and monitor function and placement, per protocol. (The facility lacked a protocol, when requested.) 2. The activity care plan for diversional activity, included sitting in the sunroom, provision of a sewing basket, gardening magazines, walking outdoors, offering beverage/snacks, enjoys animal planet television channel or movies with animals, and/or folding laundry. 3. If wandering away from the unit staff to stay with the resident, converse and gently persuade the resident to walk back to the designated area, with the staff. 4. Take for a walk in the butterfly garden if wanting to go outside. 5. If agitated, allow time to calm down in a quiet environment and re-approach in 5-10 minutes. 6. The falls care plan, dated 4/29/13 included the addition of a chair alarm to the recliner, on 5/6/14. The physician orders [REDACTED]. Nursing notes, dated 5/14/14 at 3:34 PM, identified the staff missed the resident at lunch time and when not finding the resident, staff checked on the patio of the resident's hall. Staff found the resident outside without staff knowledge, on the ground and beside the fence. (The exit door wanderguard alarm was not sounding.) On 6/4/14 at 8:03 AM, observation identified the resident, sitting in a recliner with a wanderguard bracelet noted to the resident's left wrist, stood from the recliner in the resident's room, without the personal alarm attached to the chair, sounding. The resident walked into the hallway and immediately began to ambulate towards the exit door. Staff responded to the resident's roommate's call light and redirected the resident away from the door, placing a gait belt to the resident's waist, then ambulated with the resident towards the dining room, for breakfast. The staff failed to maintain the functioning of a chair alarm, as planned. On 6/5/14 at 8:15 AM, the resident stood from a chair in the lobby area,and proceeded to ambulate down the hall towards the exit door. The resident passed 3 staff members, while ambulating down the hall, towards the exit door. The resident was stopped by administrative staff A, and redirected down the hall. On 6/9/14 at 5:15 PM, the resident stood up from the bed, awakening from a nap. The resident appeared confused and unsure of what to do, sat down in the bedside chair, then stood and transferred into the bed again. A pressure sensitive alarm, noted in the bed, failed to sound and the recliner chair, lacked an alarm at this time. Multiple observations of the resident throughout the survey, lacked identification of the resident participating in planned diversional activities, to prevent wandering. The resident was noted to wander aimlessly on numerous occasions. The facility failed to direct the resident to activities of interest, as planned in the resident's care plan. On 6/9/14 at 8:00 AM, administrative nursing staff B, reported a list of 7 residents, including this resident, needed wanderguards. On 6/9/14 at 9:40 AM, direct care staff V reported the resident wandered frequently on a daily basis, and staff are instructed to redirect the resident away from any unsafe areas, including exit doors. Staff V further reported the resident used a wanderguard bracelet that will alarm when the resident opened any exit door. The staff reported those alarms are turned off at the nursing desk area. Staff V reported the staff are expected to monitor closely, any resident with a wanderguard alarm, however, the staff was unable to report which residents had wanderguard alarms. Staff V further noted the resident used a low bed, with a fall mat and an alarm in bed, but not in the chair. On 6/10/14 at 8:50 to 8:55 AM interview with direct care staff O, W, and N, revealed the staff lacked awareness of which residents used wanderguards. On 6/10/14 at 10:18 AM, direct care staff O, reported this resident as a wanderer, mobile independently, and needed frequent monitoring. On 6/10/14 at 11:50 AM, administrative nursing staff B and D reported being on duty but away from the nursing unit when the elopement occurred. Staff B further confirmed, after being made aware the alarm failed to sound to alert staff of the resident exiting the building unattended, Staff B failed to determine which staff member turned off the monitoring alarm, allowing this resident to go outside the building, unattended. Direct care staff EE, reported on 6/10/14 at 12:15 PM, the resident did not attend any activities, per an activity log, nor did the staff document or recall providing any one to one activities the day of the elopement (May 14, 2014). Staff EE further reported the staff try to keep the wanderers involved in things to keep them from wandering and identified 5 residents required monitoring. The 03/04 facility policy for Elopements, included, nursing personnel must report and investigate all reports of missing residents. The 12/11 policy for Accidents and Incidents, included, all accidents or incidents involving residents, occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/ charge nurse shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: date/time of accident, nature of the injury, circumstances surrounding the accident, area the accident occurred, names and statements of witnesses and resident, time of notifications to the physician and the family, condition of the resident, any corrective action taken, and follow-up. Additionally, the policy directed the charge nurse to submit the original document to the director of nursing services within 24 hours of the incident/accident and the director would ensure that the administrator received a copy of the report of each occurrence. The 12/07 Fall Risk Assessment, policy and procedure, identified the nursing staff, physician, consulting staff and other members of the interdisciplinary team will seek to identify and document resident risk factors for falls. The facility failed to ensure adequate supervision and assistive devices to ensure this wandering confused resident, identified at risk for elopement, did not exit the facility without staffs knowledge. Furthermore, the facility failed to ensure this resident's planned interventions remained functional to prevent repeated falls for the resident. - The facility admitted resident #28 on 11/8/10, per the ECR (electronic care record), and discharged on [DATE]. The resident's 4/26/14 quarterly MDS (minimum data set) identified the resident unable to complete the BIMS (brief interview for mental status) assessment and staff identified the resident as moderately impaired of cognition, required extensive assistance of 1-2 staff for ADL's (activities of daily living), used a wheelchair for mobility, and lacked identification of falls. The resident's 2/13/14 care plan, instructed staff the resident needed: 1. Make sure the resident has eye glasses on. 2. Concave mattress to mark the perimeter of the bed. 3. May ambulate with front wheeled walker and assist of staff. 4. Keep recliner free of clutter. 5. Assist of 1-2 with ADL's and transfers. 6. Wheelchair primary mode of locomotion. 7. (6/11/13) Check every 3 hours overnight and toilet, if awake. 8. Will often kneel on the floor between the bed and recliner. 9. (12/18/13) Grab bar in bathroom to assist with transfers. 10. (12/18/13) Provide toilet riser with arms. 11. (2/6/14) Educate staff not to leave the resident unattended in the wheelchair in the resident's room. 12. (3/28/14) Monitor closely. 13. (4/4/14) Check resident every hour at night to ensure safety and prevent falls. 14. (5/3/14) Visual checks every 30 minutes for 24 hours. 15. (5/6/14) Staff educated to not leave the resident in the living room without supervision. 16. (5/8/14) Obtain urine analysis with a culture and sensitivity, if positive. Start antibiotic medication. 17. (5/26/14) Visual check for safety every 30 minutes for 72 hours. 18. (6/3/14) Unobserved fall from bed, resident educated to call for help. (An intervention to educate a resident with cognitive impairment is not appropriate as the resident forgets.) Review of the nursing notes, from 5/3/14 to 6/4/14, identified the following incidents: 1. On 5/3/14 at 11:18 AM, the staff found the resident on the floor, beside the bed, without a fall mat in place. Assessment identified no injury, with resident able to make needs known. 2. On 5/7/14 at 4:48 PM, the hospice nurse reported a bloody sock on the resident's right leg, with a crescent shaped skin tear under the sock. The resident reported someone kicked him/her this morning. Further review of nursing notes lacked any follow-up regarding the accusation of abuse. 3. On 5/8/14 at 7:23 PM, the staff found the resident on the floor of his/her bedroom at 3:15 PM (1515), without injury. 4. On 5/21/14 at 9:20 PM, staff found the resident on a padded mat beside the bed. No injury determined. This was documented as a late entry. 5. On 5/21/14 at 9:29 PM, an additional late entry documented that on 5/20/14 the staff found the resident on a mat, by the bed with a second fall occurring 2 hours later. 6. On 5/26/14 at 6:28 PM, the staff documented the staff found the resident lying on the floor mat next to his/her bed, when staff entered the room to get the resident for supper at 5:15 PM. The resident unable to verbalize what occurred, and staff noted no injury. 7. On 6/4/14 at 7:54 AM, staff documented the resident continued on fall follow-up after a fall on third shift. The fall (on 6/3/14), lacked documentation in the nursing notes. 8. On 6/4/14 at 8:25 AM, staff documented the resident on the floor, with assessment identifying no injury. Review of the resident's ECR identified fall investigations initiated for the 5/6/14, 5/8/14, and 5/20/14 falls. However, the investigations lacked identification of the cause of the falls. Additionally, review of the care plan identified a lack of interventions and/or appropriate interventions for the resident related to falls/incidents. A 1/30/14 Fall Risk Data Set scored the resident at 13 with (7-18 at high risk). Observation on 6/3/14 at 2:44 PM, identified the resident laying on the floor with their head propped against the night stand. The remainder of the residents body rested on a fall mat on the floor beside the bed. Licensed nursing staff D assessed the resident for injury, before assisting the resident back onto the bed, and providing the resident a ball of yarn. The resident reported he/she attempted to get the yarn, causing the fall. This observation, as previously noted, lacked identification in the resident's clinical record. On 6/9/14 at 8:45 AM, direct care staff V reported the resident as a fall risk, with a low bed and a fall mat, at bedside. Staff V further reported the resident usually checked and changed, and toileted at request, staff encouraged the resident to attend a lot of activities in the facility, due to the high fall risk, and sat at the assisted table for meals, due to requiring cueing and supervision. Administrative nursing staff B reported, on 6/11/14 at 4:00 PM, the resident had repeated falls and staff failed to conduct an investigation into any of the above noted falls. Staff B reported when instructing the nursing staff to conduct an investigation for every incident of unknown origin, the staff responded indicating they would not get anything else done, but investigations. The staff confirmed the falls needed investigation, to determine if neglect occurred. Additionally, Staff B reported the staff are required to implement new interventions following falls, although it does become difficult to determine a new intervention, with a resident who falls as frequently as this resident. The 12/07 Fall Risk Assessment, policy and procedure, identified the nursing staff, physician, consulting staff and other members of the interdisciplinary team will seek to identify and document resident risk factors for falls. The 12/11 policy for Accidents and Incidents, included, all accidents or incidents involving residents, occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/ charge nurse shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: date/time of accident, nature of the injury, circumstances surrounding the accident, area the accident occurred, names and statements of witnesses and resident, time of notifications to the physician and the family, condition of the resident, any corrective action taken, and follow-up. Additionally, the policy directed the charge nurse to submit the original document to the director of nursing services within 24 hours of the incident/accident and the director would ensure that the administrator received a copy of the report of each occurrence. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated falls for this resident with multiple falls. - The facility admitted resident # 22 on 4/6/10, per the ECR (electronic care record), with [DIAGNOSES REDACTED]. The 4/5/14 significant change MDS (minimum data set), identified the resident severely impaired of cognition, required extensive assistance of 2 staff for most ADL's (activities of daily living), with bilateral lower extremity ROM impairment, needed a wheel chair for mobility, and lacked identification of falls. The CAA (care area assessment) for cognition lacked identification of any causative factors. The resident's 3/18/14 care plan instructed staff: 1. Skin assessment, per protocol. 2. Dress in pants and long sleeves, if allowed, to help protect skin. 3. Monitor skin for redness, tears, open areas, discoloration, blisters, and notify the nurse for intervention. 4. When resistive to care, leave the resident alone, and reapproach in 5-15 minutes. Review of the resident's physician orders [REDACTED]. 5/23/14-- Cleanse non-approximated skin tear to the left outer shin, every other day, until healed. 5/29/14-- Clean wounds (left shin, left calf and right shin) with wound cleanser, apply poly ox powder to wound beds and cover with border gauze dressing every other day and prn. Review of the wound assessments for the resident included: 4/11/14 New wound--right inner shin, abrasion, 2 cm (centimeter) length x 3 cm width, with unknown origin of occurrence. 4/15/14 New wound--right calf--8 cm length, skin tear, with unknown origin. 5/2/14 Existing wound--right inner shin, deteriorated condition, a weekly update, accident/other trauma, measures 2 cm x 1.5 cm. 5/2/14 Existing wound--right calf 5.5 cm x 3.0 cm skin tear, deteriorated condition, started 4/15/14. 5/21/14 Existing wound--right inner shin, improved condition, 1 cm x 1.4 cm abrasion. 5/22/14 Existing wound--right calf lacked dimensions on the weekly assessment. 5/22/14 New wound -- left lateral shin and upper outer calf measured 1.2 cm x 1.3 cm, related to a fall. 5/30/14 right inner shin abrasion, started on 4/11/14, with unknown cause of origin. Review of nursing documentation in nursing notes lacked identification of the occurrences of skin impairments on 4/11/14 and 4/15/14 or 5/30/14. On 6/04/14 at 9:44 AM, observation identified the resident with a large dressing to the right lower extremity, and the left leg with redness and dry scaly skin. On 6/4/14 at 4:15 PM, observation identified the resident moved about in the dining room, with other residents and staff present, propelling him/her self in the wheelchair, using hands and legs to self propel. The resident exhibited a dressing to the right leg, however, the resident's left leg was not visible. On 6/8/14 at 1:43 PM, direct care staff V and K, assisted the resident to rest in bed. During cares, noted the resident dressings to the left and right legs with the left leg being very edematous. Direct care staff K reported, at that time, a lack of awareness of how/when/why the resident had dressings to their legs or of any special precautions needed. On 6/9/14 at 3:30 PM, administrative nursing staff B reported the documentation and and completion of assessments by nursing staff is very hit and miss. Furthermore, staff B reported investigations, following incidents/accidents had not been being completed. Staff B further noted the residents leg wounds are an ongoing issue, as the resident does self propel him/her self in the wheelchair. When asked about interventions implemented in the past to reduce the risk of injury, the staff reported being unaware of any other attempted interventions. When asked if geri-sleeves (a thick protective fabric) for the legs ever attempted, or padding of the wheelchair legs, the staff reported being unaware of other attempts. Staff B identified the nursing staff failed to document on a routine, weekly basis regarding the resident's wounds. The 12/11 policy for Accidents and Incidents, included, all accidents or incidents involving residents, occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/ charge nurse shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: date/time of accident, nature of the injury, circumstances surrounding the accident, area the accident occurred, names and statements of witnesses and resident, time of notifications to the physician and the family, condition of the resident, any corrective action taken, and follow-up. Additionally, the policy directed the charge nurse to submit the original document to the director of nursing services within 24 hours of the incident/accident and the director would ensure that the administrator received a copy of the report of each occurrence. The 12/07 Fall Risk Assessment, policy and procedure, identified the nursing staff, physician, consulting staff and other members of the interdisciplinary team will seek to identify and document resident risk factors for falls. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated accidents with repeated bruises/skin tears to the resident's legs. - Resident # 21 admitted to the facility on [DATE] per the 12/11/13 MDS (minimum data set) entry record. The 12/25/13 admission MDS identified the resident with long and short term memory problem, with moderately impaired cognition. The resident required limited assist with walking in and out of the room, without any impairment with functional limitation in range of motion, and uses a wheelchair for mobility. The resident identified at risk for pressure ulcers, none present at present time, and no other skin issues identified. The assessment documented the resident with a history of falls. The 5/11/14, significant change MDS documented the resident required extensive assistance with most ADLs (activities of daily living), had 1 fall without injury and 1 fall with minor injury. The 5/15/14 behavior CAA (care area assessment) documented, a care plan will be will be developed to address the resident's wandering in the facility. He/she is able to propel self and likes to move about the facility. The 5/15/14, pressure ulcer CAA (care area assessment) documented the resident with potential for impaired skin integrity. The 4/7/14 care plan documented as follows related to falls: Fall matt beside the bed. On 5/15/14, the resident fell in the sunroom. Staff educated to make sure the alarms on the chair, on 6/3/14. On 5/20/14, the resident fell in the hallway, crawling on hands/knee. Staff educated to make rounds, on 6/3/14. On 5/29/14, the resident fell in his/her room. Staff to do 30 minute checks, on 6/3/14. Ambulate the resident when he/she becomes agitated or anxious. On 3/20/14, Hi/low bed. Keep bed in the lowest position when in bed. On 4/5/14, (Spouse) attempted to transfer without staff assistance. Encourage him/her to use the call light when needing resident transferred. Ensure appropriate footwear when out of bed. Observation on 6/4/14 at 11:58 AM, revealed the resident dressed in short pants, with multiple abrasions various and scabs over both lower legs. On 6/8/14 at 5:30 PM, the resident repeatedly standing and sitting back down in the wheelchair, in the commons area, with activity /social service staff H and administrative staff C at the residents side. Staff C reminded the resident he/she was in a wheelchair and assisted the resident to stand then sit again, with a front wheeled walker in front of the resident. The resident continued to push the walker in front as he/she moved the wheelchair with his/her feet toward the dining room, with staff walking beside the wheelchair. On 6/9/14 at 7:35 AM, the resident in the wheelchair propelling him/herself down the hall towards the nurses desk. On 6/9/14 at 7:35 AM, direct care staff W reported the resident would often try to stand, but really could no longer walk. Staff W reported when the resident does this, staff will stand beside him/her and put a gait belt on the resident. Staff W reported the resident usually did this several times. The staff reported the resident does have some bruises and scabs because he/she goes all over in the wheelchair and will often bump into things. Direct care staff W added, the resident had an alarm on the wheelchair. I thought he/she had a wander guard, but don't see it now. On 6/10/14 at 2:15 PM, licensed nursing staff M, reported the resident often had skin tears. Staff M verified the nurses are to document anything the aides document on the bath sheets, and added often the aides don't document it. He/she reported the direct care staff are used to seeing things like scabs and bruises on his/her skin because he/she always has areas on the skin. Review of the resident's medical record from 3/23/14 to 5/29/14 revealed six notes related to falls with skin tears or abrasions. On 6/10/14 at 4:00 PM, administrative staff B changed the dressings on the resident's left lower calf with abrasions, reported from a fall. Staff B then cleaned and dressed an abrasion area on the resident's left shoulder. Also noted multiple scabbed areas on the resident's lower legs and an abrasion on the resident's left elbow. Staff B verified the areas should be documented in the weekly skin assessments. Administrative staff B, reported the facility had not tried any alternate interventions to protect the resident's skin from the repeated abrasions or skin tears/scabs. On 6/11/14 at 10:09 AM, Administrative staff B reported, skin assessments are documented in the computer. The bath aides monitor the skin with the bath sheets. The sheets go to the nurse. The nurse is to review the skin issues identified. The facility 12/2010, policy and procedure for Accidents and Incident documents: If the underlying causes cannot be identified or corrected, staff will try various relevant interventions, based on assessment, of the nature or category of filling, until falling reduces or stops or a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) The 12/07 Fall Risk Assessment, policy and procedure, identified the nursing staff, physician, consulting staff and other members of the interdisciplinary team will seek to identify and document resident risk factors for falls. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated accidents with repeated abraisions/ bruises/skin tears to the resident's legs and skin. - Resident # 49's 10/29/13 admission MDS (minimum data set) identified the resident with a BIMS (brief interview for mental status) score of 6 ( 0-7 indicates cognition is severely impaired), with a history of falls, and 2 non-injury falls since admission. The 10/29/13 cognition CAA (care area assessment) identified the resident able to recognize family, has poor memory, recall, and decision making skills, impulsivity and lack of safety awareness. The 10/29/13 fall CAA, documented the resident with a history of frequent falls and multiple falls since admission, related to impulsivity and attempting independent transfer. The resident uses a wheelchair for mobility, with staff assist, transfers and assistance of 2 staff as the resident has episodes of combativeness, the resident not ambulatory as he/she has some ankle instability and at times will stop bearing weight. He/she will use the call light at times, but does not wait for staff to respond, and will attempt to do things on his/her own. The resident's 4/17/14, care plan documented the resident with impaired cognition, and added further instructions for the staff as follows: Keep instructions simple and short, offer 2 choices when encouraging decisions. Re-orient as appropriate, do not argue or agitate the resident. Provide cueing, prompting, and assist for personal care as needed. Observe for changes in cognitive status. Addition on 11/16/13, the resident has a history of falls/climbing/crawling out of bed onto the floor related to impulsivity. Addition on 1/15/14, Staff will routinely check on the resident every 15-30 minutes while awake to anticipate needs. Addition on 3/15/14, Remote control for electric bed will be disconnected and placed in drawer by staff when finished caring for the resident. Addition on 6/5/14, Re-educate staff to check on resident frequently. Addition on 6/7/14, Bed alarm when lying in bed. The 4/11/14 fall risk assessment revealed a score of 13, which identified the resident as a high fall risk. On 6/5/14 at 8:46 AM, observation revealed the resident yelling and sitting on the floor in his/her bedroom. Consultant staff Z and administrative staff B assisted the resident, when the resident began yelling that his/her diaper was not on. Review of the facility fall investigation for 6/5/14 revealed the therapy staff reported the resident on the floor yelling. The resident reported he/she crawled out of bed. The intervention to prevent repeated falls documented: Staff re-educated regarding need to check on the resident frequently. Resident will crawl out of bed and onto the floor. On 6/7/14 at 5:45 PM, direct care staff R opened the resident's door, and found the resident on the floor in front of the door. Direct care staff Q, came in and put a gait belt on the resident, and staff assisted the resident to the wheelchair, with slipper socks on bilaterally. Staff R asked the resident if he/she crawled to the door, and the resident reported they had. Direct care staff R reported this was normal behavior for the resident, and added the resident does not always remember to use the call light. Staff R added further, explained the resident often was found crawling on the floor, but was okay because the behavior was care planned. Review of the facility fall investigation for 6/7/14, revealed the resident found in the doorway yelling, and when asked reported he/she had crawled out of bed. Passive range of motion done to upper and lower extremities,vital signs taken. The immediate post fall intervention documented, staff to check on the resident frequently. On 6/8/14, intervention added: Place pressure sensitive bed alarm pad on the bed to alert staff when the resident is attempting to get out of bed. On 6/8/14 at 6:02 PM, licensed nurse BB, reported when there is any change of surface for the resident, it was considered a fall and the facility had to complete the procedure for a fall. On 6/10/14 at 1:30 PM, direct care staff N, assisted the resident to transfer from the wheelchair to his/her bed. No brace noted on the resident's left ankle, and the bed lacked the pressure alarm pad. The staff reported the resident had an alarm on the wheelchair, but not when in bed. The 12/11 policy for Accidents and Incidents, included, all accidents or incidents involving residents, occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/ charge nurse shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: date/time of accident, nature of the injury, circumstances surrounding the accident, area the accident occurred, names and statements of witnesses and resident, time of notifications to the physician and the family, condition of the resident, any corrective action taken, and follow-up. Additionally, the policy directed the charge nurse to submit the original document to the director of nursing services within 24 hours of the incident/accident and the director would ensure that the administrator received a copy of the report of each occurrence. The 12/07 Fall Risk Assessment, policy and procedure, identified the nursing staff, physician, consulting staff and other members of the interdisciplinary team will seek to identify and document resident risk factors for falls. The facility failed to provide adequate supervision and/or assistive devices to prevent repeated falls for this resident. - The facility admitted resident #4 on 1/30/04 per the ECR (electronic care record), with [DIAGNOSES REDACTED]. (progressive mental disorder characterized by failing memory, confusion). The resident's annual 3/15/14 MDS (Minimum Data Set) identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff with bed mobility, transfers, locomotion on and off the unit did not occur, required total assistance of 1 staff with locomotion on the unit and extensive assistance of 1 staff with locomotion off the unit and dressing, balance not steady, only able to stabil

The facility had a census of 43 residents, with 4 residents reviewed for skin issues. Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest physical well-being and promote healing for 3 sampled residents reviewed for skin issues, including resident #7 with a raised hematoma like area on the leg and 2 residents with skin tears (#3 and #2). Findings included: - Review of resident #7's face sheet revealed the facility admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed staff transferred the resident to a local hospital for surgical repair of an incarcerated ventral hernia and discharged back to the facility on [DATE]. Review of the resident's clinical record revealed staff transferred the resident to a local hospital for a [MEDICAL CONDITIONS] (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), and parotid [MEDICAL CONDITION] (inflammation of the salivary gland that lies at the side of the face, below and in front of the ear) and returned to the facility on [DATE]. Review of the Care Area Assessment Summary (CAAs), dated 3/25/13, triggered the following areas: Pressure Ulcers - [MEDICAL CONDITION] to bilateral lower extremities, no other skin issues. ADL (Activities of Daily Living) Function - Requires 1-2 staff for ADLs and transfers. Review of the 14 day, 9/15/13 MDS (Minimum Data Set) 3.0 Assessment, identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff for bed mobility, total dependence of 2 staff for transfers, extensive assistance of 1 staff with eating, used a wheelchair, with a surgical wound and a wound infection. Review of the 9/12/13 plan of care recorded the following: Moderate/maximum assistance of 1-2 staff with ADLs and transfers, may use sit-to-stand lift if the resident felt weak. Wheelchair primary mode of locomotion. Skin assessments per facility protocol. Monitor skin for changes and notify nurse for intervention. Pressure relieving mattress to bed, cushion to wheelchair. Staff assistance of 2 with repositioning per protocol. Review of the report entitled wound assessments in the computerized clinical record, revealed the following documentation: 9/3/13 - Left lateral shin, present upon admission, fading purple/blue bruise which measurements of 25 cm (centimeters) by 10 cm. 9/6/13 - Weekly update - surgical incision. Front of left leg - bruise 25 cm x 10 cm. 9/13/13 - Weekly update - surgical incision. Front of left leg - bruise 25 cm x 10 cm. The resident's clinical record lacked any further recorded skin assessments conducted, and revealed the resident discharged went back to the hospital on [DATE]. While in the hospital, the physician's orders [REDACTED]. Staff recorded in the 10/12/13 re-admission nursing notes at 7:45 AM, resident oriented to person only. No [MEDICAL CONDITION] noted. Multiple bruises noted on the resident's arms from laboratory or IVs (intravenous) sticks in the hospital. Review of the clinical record lacked any skin assessment of the resident's legs conducted by staff when the resident returned to the facility from the hospital. Review of the nursing notes and the computerized clinical record from 10/12/13 at 11:15 AM through 10/21/13 at 3:16 PM lacked any documentation about any bruising or discoloration identified and/or assessed to the resident ' s left lateral leg area. Hospice notes recorded in the resident's record revealed the following: The 10/11/13 nursing comprehensive assessment only recorded a wound on the resident's RLQ (right lower quadrant). No other skin areas marked or recorded on the assessment. On 10/12/13 - nursing assessment - skin integrity with wound on RLQ On 10/14/13 - nursing assessment - skin integrity wound on RLQ on abdomen. On 10/14/13 - HHA (home health aide) provided a complete bed bath - no comments added on the bath form by the aide. On 10/15/13 - Nursing - no wound assessment done. On 10/16/13 - Nursing clinical note - skin integrity abdominal wound On 10/16/13 - HHA provided a complete bed bath - no comments added on the bath form by the aide. On 10/17/13 - Clinical note nursing - skin integrity, changed dressing on ABD (abdomen). On 10/18/13 - Clinical note nursing - skin integrity - abd wound changed daily and prn (as needed). Pitting [MEDICAL CONDITION] BLE (bilateral lower extremities). On 10/21/13 - Clinical note nursing 2+ [MEDICAL CONDITION] BLE On 10/22/13 - Clinical note nursing - 2+ [MEDICAL CONDITION] BLE. Beginning [MEDICATION NAME] 20 mg po. Blood filled [MEDICAL CONDITION] 8 cm (centimeter) by 6 cm length left outer calf. 10/22/13 - Skin assessment and wound care record - Red blisters as in blood blister left outer leg. 8 cm x 6 cm. The clinical record lacked evidence of weekly skin assessments which identifed and/or addressed the skin condition of the resident's lower legs. On 10/22/13, after staff assessed the area on the resident's left leg and 10 days after readmission from the hospital and 1 month and 1 day after the initial assessment of the area, staff recorded, in the computerized wound assessment report, the following: Left lateral shin, area deteriorated. Wound identified on 9/3/13, present upon admission, length 25 cm x 10 cm, dark purple/blue. Physician notified. Bruise still noted to left lateral calf. Pooling had developed. Physician and daughter notified. The physician responded with no treatment required. On 10/22/13 at 8:10 AM, observation revealed the resident in a low bed. At 8:30 AM, direct care staff J and licensed staff G assisted the resident from the bed to the wheelchair, with a gait belt. At that time, observation revealed an extremely purplish, red hematoma type area on the entire length of the resident's left lateral leg. Surveyor V informed licensed staff G of the area on the resident's left lateral leg. At that time, licensed staff G reported the area measured approximately 7 inches long by 4 inches wide at the widest area. Observation revealed the resident had facial grimacing when licensed staff G palpated the area, especially at the upper portion of the area. At that time, licensed staff G reported the hospice nurse examined the resident the day before, and added, "Everyone gets weekly skin assessments." On 10/22/13 at 3:11 PM, licensed staff C stated, "I was not aware of the area on (the resident's) left lateral leg." On 10/22/13 at 3:11 PM, administrative licensed staff E stated, "Upon admission (on 10/12/13), the nurses are supposed to do a head to toe assessment. That was not done. There was no assessment done when the resident went out to the hospital on [DATE]..." On 10/22/13 at 2:20 PM, licensed hospice staff M stated, "It was not like that. I saw (the resident) yesterday morning and the area was red but not like this. (The resident) was in a wheelchair when I saw (the resident), and I didn't get a chance to look at (the resident's) legs very well. It was certainly not anything like that. Pretty nasty isn't it." At 4 PM, this licensed hospice staff M stated, "The hospice aide was here yesterday and gave (the resident) a bed bath. Our aides are real good about reporting anything out of the ordinary. This is a total surprise to all of us today." On 10/22/13 at 2:20 PM, licensed staff G stated, "I have not notified the doctor about (the resident's) left lower leg yet. (The resident) came back with an area on (the resident's) leg from the last hospitalization , left leg swollen. The admitting nurse should have assessed the area. Communication has been dropped." On 10/22/13 at 3:33 PM, licensed staff G measured the area on the resident's left lateral leg with measurements of 22 cm x 18 cm of the raised hematoma like area. On 10/22/13 at 5:40 PM, licensed staff G stated, "I called the resident's doctor about the area on (the resident's) left lateral leg. The doctor re-ordered the [MEDICATION NAME] (diuretic) 20 mg (milligrams), daily, instructed staff to apply ABD (abdominal) pads to the area and wrap the leg with coban and to draw a BMP (basic metabolic panel) on the next lab day." The facility's policy for skin tears, care of abrasions and minor breaks, revised on 12/07, recorded, "Purpose: The purpose of this procedure is to guide the prevention and treatment of [REDACTED]...10. Perform additional wound care per physician's orders [REDACTED]. The facility failed to adequately assess, monitor, and provide treatment to this area to promote healing of this resident's left leg area . The area declined as it became reddened and painful, as the resident exhibited pain with facial grimacing when staff palpated the area. - Resident #2 admitted to the facility on [DATE], per the 10/11/13 signed physician orders. The 9/17/13 significant change MDS (minimum data set) assessment identified the resident with moderately impaired cognition, required extensive assist with all activities of daily living. The CAA (care area assessment) for ADL's (activities of daily living) with the 9/17/13 MDS documented: "ADL, CAA- Requires assist from staff for ADL and meals. Hoyer lift for transfer..." The 9/4/13 care plan identified the resident: ... Potential for skin breakdown due to decreased mobility, diabetes, and incontinence. Skin assessment per facility protocol . Monitor skin for changes and notify the nurse for interventions..." Physician orders [REDACTED]., ? moon shaped. Treatment, cleanse with normal saline or wound cleanser. Apply TAO (triple antibiotic ointment), dry dressing and cover with protective sleeve Change QD (every day) and PRN (as needed). The 10/11/13 physician progress notes [REDACTED]. Family very upset about their perceived lack of skin care and not notifying them. Continue local wound care." Observation, on 10/16/13 at 10:00 AM, revealed the resident lying on the bed, with eyes closed. The bed height in the lowest position. The resident observed with padded protectors on legs bilaterally over slipper socks, and call light within reach. On 10/16/13 at 12:25 PM, direct care nursing staff N stated," I found the two skin tears on the resident's left leg on Oct. 10, 2013. I reported it to the nurse, it was licensed nursing staff G. I found the skin tears when I was getting the resident up for breakfast between 7:00 -7:30 AM. I took (him/her) to the dining room, but do not know when the nurse looked at it. " On 10/17/12 at 10:30 AM, the resident's family visiting in the resident's room reported, " I came by on Thursday 10/10/13 around 4:00 PM to see my parent. We were in the sitting room and I saw areas on both of (his/her) legs. There were 2 open areas on the left leg and they were weeping with dried blood around the edges. There was no dressing on the leg at all. The right leg had a large bruise on the lower leg. Direct care staff N told me he/she found the areas that morning when he/she got my parent up that morning, and had told the charge nurse. I called the facility on my cell phone, I asked if there was anything on the books about my parent's legs. The staff member reported there was nothing on the books about it. I told the staff member about the areas and that they were weeping. I also told him/her that direct care staff N told me the areas were found that morning and nothing had been done. Administrative nurse B came and looked at them. Licensed nursing staff G, returned with supplies and dressed the left leg. I expressed to licensed nursing staff G and the administrative staff B, I thought it was unconscionable that it had waited so long, and asked why I had not been notified, but never got a straight answer. I discussed this with administrative nursing staff B that night and (he/she) told me they would check into it and the doctor might start an antibiotic for my parent. I came in early the next day 10/11/13, and told them I called the doctor to come and check my parent the evening before. I stayed until the doctor arrived around 12:15 PM. The doctor removed the dressing on the wounds, and after the exam, said (he she) would stop at the desk and tell the staff the wound needed redressed. The doctor only stayed a few minutes. At 1:45 PM the bandages remained off. I called the facility on my cell phone. The dressing was not replaced until around 3:00 PM. At 4:00 PM I went to administrative staff A's office and stated what had happened." On 10/22/13 11:12 AM, licensed nursing staff G, changed dressing on the skin tear on the resident's left leg. The 2 wounds presented semicircular in shape the lower one measured 3 x 2 cm. (centimeters) and the top one measured 3.7 X 3 cm. The nurse then checked the right leg, observation revealed a blue colored bruise on the later side of the leg, measured 4 X 2.25 cm. On 10/22/13 at 11:22 AM, licensed nursing staff G, stated, "I was working the 6:00 PM-10:00 PM that day when the skin tears were found. I think the resident's family was here and saw the areas first. I was not able to approximate the edges, that is why you can see the gap. The doctor was notified, but the family called before we did. I was working that day from 6:00 AM-2:00 PM also. I can't say if direct care staff N told me about the skin tears or not. (He/She) well could have told me that morning, but I don't remember. I did put the initial dressing on the areas, but it was later that afternoon. The areas had dried blood around them and the wound edges were set. I wet the areas with wound wash but was unable to approximate the edges, I guess it had been too long. The resident's medical record documented in the nurse's notes, "10/10/13 at 6:18 PM, Skin Tear/Left lateral Shin/ Resident received 2 skin tears to the left lateral lower leg on unknown date. Writer of this note sent communications to primary care physician for the following treatment order, wound 1.4 x 2.5 centimeter, ? moon shaped, cleansed with normal saline or wound cleanser: triple antibiotic ointment, dressing." On 10/23/13 at 8:45 AM. administrative nursing staff E verified, " The nurse's notes fail to document anything about the skin tears until 10/10/13 at 6:18 PM, and further commented the computer lacked any documentation in the medical record from 10/6/13 to 10/10/13, the dates entered into the computer. On 10/23/13 at 9:10 AM, administrative nursing staff C reported," I did work the evening shift on 10/10/13. I left early and another nurse took over at 6:00 PM. I did not receive any report about the resident having skin tears. " On 10/23/13 at 10:00 AM direct care staff I stated, " I was at the desk when direct care staff N brought the resident to the nurses' desk and told licensed nursing staff G about the skin tears found while getting the resident up before breakfast. Licensed nursing staff G, said he/she would look at it later. I have no idea when the wound was checked. I didn't say anything about it in the statement I made about it, because nobody asked me." The 2/16/09 standing physician orders [REDACTED]..Protocol for skin tears- cleanse with normal saline or wound cleanser, allow are to air dry or pat dry, approximate the skin tear flap/tissue, if present, apply steri strips , a petroleum -based protective ointment, cover with dry dressing. Change daily and PRN (as needed) till healed. If no improvement in 14 days notify physician for treatment change." The facility December 2007 policy and procedure for Skin Tears-Abraisions and Minor Breaks, care of, socumented: "The Purpose of this procedure is to guide the prevention and treatment of [REDACTED]. If skin remains around the edges of the abraision, gently approximate the edges with a sterile tongue depressor or cotton swab..." The facility failed to identify, assess, and provide timely treatment for [REDACTED]. The wound beds became dry and unable to approximate before facility staff provided treatment, thus prolonging the healing process. - Review of resident #3's face sheet revealed the facility admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's 8/21/13 admission MDS (Minimum Data Set) 3.0 Assessment recorded a BIMS (Brief Interview for Mental Status) score of 10 (a score of 8-12 indicated moderately impaired cognition), required total assistance of 2 staff with bed mobility, transfers, walking in the room/corridor did not occur, and physical assistance of 1 staff with locomotion on and off the unit Review of the Care Area Assessment Summary (CAAs), dated 8/22/13, triggered the following areas: Cognitive Loss/Dementia - Has some confusion and forgetfulness, [DIAGNOSES REDACTED]. ADL (Activities of Daily Living) Functional - Requires assistance with all ADLs and toilieting. Hoyer lift for transfers. Pressure Ulcers - Resident admitted with 2 Stage 1, 2 stage 11 and 1 stage 3 pressure ulcers from another facility. Wounds are currently being treated per order and have showed some improvement. Resident is being repositioned per staff and has pressure relief mattress in place. Prefers to stay in bed most of time but will get up with some encouragement from staff. The 8/9/13 initial care plan addressed impaired skin integrity, nutrition, altered skin integrity, and recorded a closed area to the resident's left hip, with a treatment order of skin prep to the affected area daily. Review of the 8/29/13 plan of care: Assist with positioning per facility protocol Pressure relief to bed and chair Needs wound care as ordered by the Doctor Skin assessments per protocol Monitor for changes in resident's skin status that may indicate worsening of pressure ulcer and notify the physician. Hoyer lift for transfers Review of the resident's wound healing reports, dated 9/26/13, 10/3/13, and 10/10/13 only assessed the resident's pressure ulcers. The report failed to identify and/or address any compromised skin conditions, including the skin tear on the resident's left elbow. The resident's clinical record lacked any additional wound healing reports after 10/10/13. Review of the nursing notes before 9/26/13, on 9/26/13, and after 9/26/13 lacked any documentation about alternation of skin integrity to the resident's left elbow region. Review of the clinical record lacked any additional documentation in the nurses' notes until 10/14/13 at 10:14 PM when the resident's family came to the facility, with concerns about the resident's hydration, and requested the resident sent to a local hospital. Review of the resident's hospital 10/15/13 admission nursing notes, at 12:20 AM, licensed staff recorded a dressing removed from the left elbow that was a 2 by 2 gauze per the family's request. Staff recorded the dressing had a date of 9/26/13 and had rust colored drainage that had saturated the 2 by 2 dressing but had dried. Staff recorded the area as a possible skin tear area under the dressing that appeared almost healed but still slightly discolored. On 10/15/13 at 7:43 PM, the resident's child T reported, "... The date on the dressing on (the resident's) left arm was dated 9/26/13. I took a picture of the dressing. No one told us what happened to (the resident's) arm..." On 10/22/13 at 2:30 PM, direct care staff L stated, "We (The aides) reported drainage on the left elbow with a dressing dated 9/26/13. I know that (the dressing) was on longer than it should have been. (The resident) was in long sleeves when (the resident) went to the hospital, and no one did anything with the dressing. I don't know why the resident had a dressing on (the resident's) left elbow. I was working on the night (the resident) went to the hospital..." On 10/22/13 at 2:45 PM, direct care staff K stated, "...(The resident) had a patch on (the resident's) left elbow and there was a rusty colored drainage from that area oozing onto (the resident's) bed pad and it was dated 9/26. I told (licensed staff P), the nurse, about the patch. (Licensed staff P) said they would take care of it. I don't know if (licensed staff P) did or not. It was nasty." On 10/17/13 at 8:20 AM, observation revealed the resident lacked a dressing in place on the left elbow area, with no open areas noted. The facility's policy for care of skin tears, revised on 12/07, recorded, "Purpose: The purpose of this procedure is to guide the prevention and treatment of [REDACTED]. The side and description of the abrasion or wound. 2. The date and time the abrasion was discovered. 3. The date and time the injury occurred, if known. 4. The date and time the wound care was given. 5. The name and title of the individual performing the wound care. 6. Information (i.e., bleeding, size of the wound, tissue loss, etc.) obtained when inspecting the wound..." The facility's skin system policy and procedure, revised on 8/08, recorded, "...Purpose: As agents of the Quality Assurance Committee...will review the skin status of all residents and coordinate appropriate interdisciplinary interventions to maximize skin integrity. 1. All residents will be assessed on admission, readmission, and quarterly and with each change in condition assessment for their individual risk for skin compromise...2. All residents on admission...must have skin assessment then continue on weekly schedule...6. A weekly skin assessment will be completed by a licensed nurse and kept as part of the medical record..." The facility failed to provide the necessary care and services to maintain physical well-being, as staff failed to adequately assess, monitor, and provide adequate treatment for [REDACTED]. The resident had the same dressing in place on the left elbow from 9/26/13 until 10/15/13, without any documentation in the clinical record about the skin impairment and/or treatment to the resident's left elbow.

The facility had a census of 43 residents, with 4 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 prevent new sores from developing for 2 sampled residents with facility acquired pressure ulcers. Resident #3 developed a Stage 3 pressure ulcer on the right outer hip. Resident #4 developed a reoccurring Stage II pressure area to the left buttock. Findings included: - Review of resident #3's face sheet revealed the facility admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. reaction characterized by apprehension, uncertainty and irrational fear). Review of the resident's 8/21/13 admission MDS (Minimum Data Set) 3.0 Assessment recorded a BIMS (Brief Interview for Mental Status) score of 10 (a score of 8-12 indicated moderate cognitive impairment), required total assistance of 2 staff with bed mobility and transfers, walking in the room/corridor did not occur, physical assistance of 1 staff with locomotion on and off the unit, extensive assistance of 1 staff with eating, total dependence of 2 staff with toileting, had an indwelling catheter, no mobility devices marked, at risk of developing pressure ulcers, had Stage 1 or higher pressure ulcer, 2 Stage 1 pressure ulcers present, 2 Stage 2 pressure ulcers present, 2 Stage 2 pressure ulcers present on admission, the date of the oldest Stage 2 pressure ulcer noted on 8/9/13, 1 Stage 3 on admission, the measurements of the Stage 3 or 4 pressure ulcer recorded as length of 1.1 cm (centimeters) and width of 0.7 cm, depth not assessed, tissue type for ulcer at most advanced stage recorded as slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous, pressure reducing device to chair/bed marked, a turning/repositioning program, nutrition/hydration checked, pressure ulcer care checked, and application of ointments/medications checked. Review of the Care Area Assessment Summary (CAAs), dated 8/22/13, triggered the following areas: Cognitive Loss/Dementia - Has some confusion and forgetfulness, [DIAGNOSES REDACTED]. ADL (Activities of Daily Living) Functional - Requires assistance with all ADLs and toilieting, Hoyer lift for transfers, can feed self if so chooses, needs set-up assistance with meals. Nutritional Status - Resident prefers to eat in room rather than in dining room, is able to feed self with set up assist, does drink shakes and eats what so chooses. Pressure Ulcers - Resident admitted with 2 Stage 1, 2 stage 11s and 1 stage 3 pressure ulcers from another facility. Wounds currently being treated per order and have showed some improvement. Resident being repositioned per staff and has pressure relief mattress in place. Prefers to stay in bed most of time but will get up with some encouragement from staff. Maybe having some pain issues but does not admit this to staff. Initial care plan, completed on 8/9/13, addressed impaired skin integrity, nutrition, and altered skin integrity. Area closed to the left hip, with treatment order for skin prep applied to affected area daily. Review of the 8/29/13 plan of care recorded the following: Assist with positioning per facility protocol "...every two hours" Pressure relief to bed and chair. Needs wound care as ordered by the Doctor. Needs referral to a dietician to evaluate resident nutritional status. House shakes twice a day, between meals. Skin assessments per protocol. Monitor for changes in resident's skin status that may indicate worsening of pressure ulcer and notify the physician. Hoyer lift for transfers The facility assessed the resident's braden scales (tool used to identify residents as risk for the development of pressure ulcers) as follows: 8/9/13 =14 moderate risk 8/16/13 = 13 moderate risk 8/23/13 = 14 moderate risk 8/30/13 = 15 mild risk 9/5/13 = 14 moderate risk 9/12/13 = 13 moderate risk 9/19/13 = 14 moderate risk 9/26/13 = 14 moderate risk 10/10/13 = 14 moderate risk Staff recorded on the admission wound assessment form in the resident's computerized clinical record, the following: 8/9/13 (day of admission) - Pressure ulcer right buttock close to the crack, upon admission. Stage 3, no drainage, 2.0 cm (centimeter) by 2. cm, depth 0.25 cm. 100% [MEDICATION NAME] tissue, border definition, well defined, normal healthy skin. Current weight 137.20 pounds. Treatment to right buttock, cleanse with normal saline or wound cleanser, apply santyl and Calcium Alginate to wound bed, cover with bordered gauze, change daily and prn (as needed) till healed. 8/9/13 (day of admission) - Left buttock, nickel sized ulcer, upon admission. Stage 3 pressure ulcer with length of 2 cm, width of 2 cm, and depth of 0.25 cm. 100% [MEDICATION NAME] tissue, border well defined, normal healthy skin. Cleanse with NS, apply Santyl and Calcium alginate to wound bed. Cover with bordered gauze change daily and prn till healed. Staff failed to identify any compromised skin integrity on the right outer hip area on the admission wound assessment. This wound assessment did not match the MDS assessment completed on 8/21/13. On 8/9/13, the physician ordered a treatment of [REDACTED]. Review of the resident's wound healing report revealed the following: 8/17/13 - Pressure ulcer left buttock - Stage I which measured 0.25 cm by 0.25 cm Pressure ulcer left lower back - Stage I which measured 0.5 cm by 0.5 cm. Pressure ulcer right lower back - Stage 2 which measured 3.0 cm by 3.0 cm This wound report lacked evidence of any assessment of the resident's right hip area. 8/21/13 - Pressure ulcer right buttock - Stage 3 which measured 1.2 cm by 1.7 cm. Open area 100% slough 1.1 cm by 0. 7 cm, no drainage noted. New treatment order to cleanse with normal saline wound cleaner, apply santyl and calcium alginate to wound bed only, cover with dry dressing and change daily and prn. The 8/29/13 wound assessment only recorded measurements of the right buttock stage 2 pressure ulcer of 1 cm by 7 cm, no depth. The 9/5/13 wound assessment only recorded measurements for the right buttock pressure ulcer of a Stage 2 pressure ulcer, 1 cm by 0.7 cm and no depth. Review of the clinical record lacked evidence of any additional wound assessments until 9/12/13 (22 days after the previous wound assessments conducted on 8/21/13) of the pressure ulcers on the left buttock and on the left lower back. The 9/12/13 wound assessment only recorded measurements for the right buttock pressure ulcer of a Stage 2 pressure ulcer, 1 cm by 0.7 cm and depth of 0.25 cm. The 9/19/13 wound assessment measurements recorded the following: Pressure ulcer right buttock - Stage 2 which measured 1.0 cm by 0.75 cm. The 9/26/13 wound assessment measurements recorded the following: Pressure ulcer right buttock - Stage 2 which measured 1.0 cm by 0.75 cm. Staff failed to record measurements for the right buttock pressure ulcer on 10/3/13. The 10/10/13 wound assessment measurements recorded the following: Pressure ulcer right buttock - Stage 3 which measured 1.15 cm by 0.95 cm. Hospital staff recorded on the 10/15/13 hospital's wound/skin assessment flow sheet, completed at admission, the following identified skin concerns: Right hip - measurements of 1.1 cm by 1.1 cm, with rolled edges, 95% adhered yellow exudate, a small amount of serosanquinous drainage, with 5% granulation tissue present, and localized [MEDICAL CONDITION]. Right buttock - proximal measurements of 1.5 cm x 2.0 cm and distal measurements of 1.2 by 1.0 cm, edges attached, 50% of yellow exudate, a scant amount of serosanquinous drainage, 50% granulation tissue, and periwound blanachable. Review of the serum blood levels in the resident's clinical record revealed: On 8/23/13, the resident's protein level tested at 5.8 (normal range of 6.2-8.1) and [MEDICATION NAME] level tested at 2.8 (normal range of 3.4-4.8). At that time, the physician ordered staff to provide protein shakes, twice a day. Review of the clinical record lacked documentation staff provided the protein shakes, twice a day, as ordered, and lacked the intake percentage of shakes. On 8/23/13, the resident's serum white blood count tested at 17.1 (normal range of 4.8-10.3). On 9/27/13, the resident's serum protein tested at 5.7 and [MEDICATION NAME] tested at 2.5. On 10/17/13 at 8:15 AM, observation revealed the resident at a local hospital in bed, with a low air loss mattress in place. Observation of the hospital's wound care staff's treatment revealed the staff removed a dressing from the resident's lower back area. At that time, licensed staff W described the area as a deep tissue injury and with no open areas noted. Observation revealed the area a deep red in color and measured approximately 2.0 cm. Then licensed staff W removed a dressing from the resident's right and left lower buttock and stated, the area resulted from friction. After cleansing the area, the wound team applied skin prep and a foam dressing to the area. At that time, observation revealed no dressing in place on the left. hip and no open areas noted. Then the wound team turned the resident to the left side and removed a right hip dressing and described the condition of the wound the same as when first assessed on 10/15/13. At that time, observation revealed an open area which measured approximately 2 cm in diameter and with 100% slough. After cleansing the area, the wound team cleansed the area with normal saline and applied a [MEDICATION NAME] dressing. On 10/17/13 at 11:15 AM, administrative licensed staff B stated, "(The resident) came from (another nursing facility). According to (the other nursing home), (the resident) came to them with pressure ulcers. (The resident) had a Stage I on the spine, on the sacrum four areas, 2 on each side, 2 were Stage 2 and 2 were Stage 1. (The resident) had a reddened groin area. (The resident) had a stroke and kind of gave up... Sometimes (the resident) would say to leave (the resident) alone. (The resident} needed a lot of help with ADLs. (The resident) could position self. Had a pressure relieving device in chair and bed. Didn't like the low air loss mattress...We don't have a designated staff to do weekly skin assessments.". On 10/17/13 at 12:45 PM, administrative licensed staff E stated, "(The resident) didn't want to get out of bed. (The resident) was usually able to tell you what (the resident) wanted. (The resident) didn't want the low air loss mattress...(The resident) was admitted with pressure ulcers." On 10/23/13 at 8:51 AM, this administrative licensed staff E stated, "The previous nursing home recorded a red area on the left hip and that is the hip we were doing skin prep to that area. The left hip was red, not open, and had a scar area there also. We must have been so focused on (the resident's) left hip, we overlooked (the resident's) right hip. I was not here the first week (the resident) was admitted ." On 10/22/13 at 2:30 PM, direct care staff L stated, "...(The resident) used a hoyer lift. (The resident) was difficult to get up. (The resident) was stiff. (The resident) refused to eat a lot. (The resident) had sores on (the resident's) bottom..." On 10/22/13 at 2:45 PM, direct care staff K stated, "(The resident) was stiff and had a catheter... )The resident) had patches on (the resident's) bottom..." The facility's skin system policy and procedure, revised on 8/08, recorded, "...Purpose: As agents of the Quality Assurance Committee...will review the skin status of all residents and coordinate appropriate interdisciplinary interventions to maximize skin integrity. 1. All residents will be assessed on admission, readmission, and quarterly and with each change in condition assessment for their individual risk for skin compromise...2. All residents on admission...must have skin assessment then continue on weekly schedule...6. A weekly skin assessment will be completed by a licensed nurse and kept as part of the medical record..." The facility's undated pressure ulcer assessment quick reference guide recorded, "1. Assess the pressure ulcer initially and re-assess it at least weekly, documenting findings..." The facility's repositioning policy, revised 4/07, recorded, "The purpose of this procedure is to provide guidelines for the assessment of resident positioning needs...and to prevent skin breakdown...A turning/repositioning program includes a continous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated..." The facility failed to provide the necessary treatment and services to ensure this resident did not develop a facility acquired pressure ulcer. The facility failed to conduct consistent weekly skin assessments of all affected areas, as per the facility's policy. The facility's last skin assessment, dated 10/10/13, failed to identify any concerns of the resident's right hip area. Upon hospitalization on [DATE], 5 days after the facility's last skin assessment, hospital staff identified a Stage 3 pressure ulcer on the right hip area. The facility failed to adequately assess, monitor, and provide adequate treatment to prevent the development of this facility acquired Stage 3 pressure ulcer. - Review of resident #4's face sheet revealed the facility admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. enough insulin made or the body can't respond to the insulin), [MEDICAL CONDITION] (a condition when the heart output is low and the body becomes congested with fluid), and dementia (progressive mental disorder characterized by failing memory, confusion). Review of the resident's 5/17/13 annual Minimum Data Set recorded a BIMS (Brief Interview for Mental Status) score of 8 (a score of 8-12 indicated moderately impaired cognition), required extensive assistance of 2 staff for bed mobility and toilet use, extensive assistance of 1 staff for transfers, independent with eating, used a walker/wheelchair, formal skin assessment instrument/tool indicated and a clinical assessment, at risk of developing a pressure ulcer, currently with no pressure ulcer, a pressure reducing device bed/chair in place, and applications of ointments/medications indicated. Review of the Care Area Assessment Summary (CAAs), dated 5/31/13, triggered the following areas: Cognitive Loss/Dementia - [DIAGNOSES REDACTED]. ADL (Activities of Daily Living) Function - Requires extensive assistance of 1 staff with ADLs and transfers, wheelchair is primary mode of locomotion, can propel self short distances but tires easily. Resident is able to ambulate short distances with walker and assistance of staff but generally will refuse to do this. PT/OT (Physical Therapy/Occupational Therapy) are in process of bringing resident onto service for strengthening and gait training. Nutritional Status - Resident is able to feed self a regular diet in the dining room, does at times require set-up assistance and encouragement. Weight is up over last 6 months but weight may continue to fluctuate due to [DIAGNOSES REDACTED]. Pressure ulcer - Risk for skin breakdown due to incontinence and impaired mobility, [DIAGNOSES REDACTED]. Staff applies skin prep to left heel, twice a day, for [MEDICATION NAME] secondary to history of recurrent venous stasis ulcer. Wears briefs to wick away moisture from the skin, pressure relief to bed and chair. Resident also takes [MEDICATION NAME] which may cause increase in bleeding and bruising. Review of the 8/16/13 quarterly MDS (Minimum Data Set) 3.0 Assessment recorded a BIMS (Brief Interview for Mental Status) score of 6 (a score of 0-7 indicated severely impaired cognition), required extensive assistance of 1 staff for bed mobility, transfers, walking in the room/corridor, locomotion on and off the unit, eating, toilet use, and personal hygiene, used a walker and/or wheelchair, had a stage I or greater pressure ulcer, a scar over a bony prominence, or a non-removable dressing/device, a formal assessment instrument/tool and a clinical assessment used, at risk of developing a pressure ulcer, had one or more unhealed pressure ulcers at Stage 1 or higher, one stage 1 pressure ulcer with [MEDICATION NAME] tissue present, 1 venous/arterial ulcer present, pressure reducing device for the chair/bed, a turning/repositioning program, pressure ulcer care, and application of ointments/medications. Review of the 8/22/13 plan of care recorded the following: Encourage fluid intake unless contraindicated. Staff assistance of one with transfers/toileting Reposition per protocol Staff assistance of 1-2 staff with repositioning/bed mobility Pressure reducing device to the bed and the chair Skin assessments per protocol, monitor for open areas, tears, redness, blisters and notify nurse for intervention Skin prep to left heel, twice a day Will occasionally request to sleep in recliner An intervention, dated 8/21/13, recorded a treatment order to protect new skin, small [MEDICATION NAME] dressing to coccyx to protect new skin, and change every 3 days and as needed. Wheelchair is primary mode of locomotion Bed mobility required extensive assistance of 1-2 staff Transfers required extensive assistance of 1 staff On 5/3/13, staff scored the resident with a score of 15 on the resident's braden scale (a tool used to assess if a resident at risk for the development of a pressure ulcer). A score of 15 indicated the resident at mild risk for the development of a pressure ulcer. The 7/3/13 registered dietitian recorded a wound note which read, "Resident with impaired skin integrity to right side of coccyx, not opened." On 8/2/13, the staff faxed the resident's physician a fax which read, "Found open stage 2 ulcer to the left buttock, approx. (approximately) 1 cm (centimeter) by 1.5 cm." Review of the 10/13 TAR revealed an order, dated 10/17/13, to the resident's left buttock to cleanse the area with wound cleanser, apply a [MEDICATION NAME] dressing to the buttock, and change every 3 days until healed. Staff recorded on the 10/20/13 fax to the resident's physician the resident noted with a 1 cm by 1.5 cm decubitus on the left lower buttocks, area cleansed with wound cleanser and a [MEDICATION NAME] dressing applied. The physician agreed to this treatment. Review of the 10/21/13 body image of the left buttock's wound assessment revealed staff marked the pressure area on the body image located on the left inner buttock area. On 10/22/13 at 12:06 PM, licensed administrative staff E verified the area marked on the body image was the location of the resident's left inner buttock area. Staff recorded in the 10/21/13 nursing notes, at 12:48 PM, the dressing changed to the left buttock, cleansed with a wound cleanser, and applied a [MEDICATION NAME] gel pad to the area. Staff recorded the wound open, with a small amount of blood, and measured 1 cm x 1.25 cm. On 10/16/13 at 10:50 AM, observation revealed the resident asleep in a recliner in the resident's room. Observation revealed the recliner had a gel cushion in the seat of the recliner. At 12 noon, observation revealed the resident still in the recliner. At 12:40 AM, observation revealed the resident in a wheelchair in the resident's room. At that time, the resident stated the area on the resident's bottom was sore. On 10/16/13 at 1:40 PM, observation revealed direct care staff H pushed the resident from the dining room to the resident's room. Observation revealed the wheelchair had an extra cushion in the seat. At 1:55 PM, direct care staff H and J transferred the resident from the recliner to the wheelchair. The direct care staff H and J reported the resident's brief was wet and also soiled. When these direct care staff J and H assisted the resident to stand, observation revealed an open area on the resident's left lower buttock which measured approximately 2 cm by 2 cm and lacked any type of dressing in place. At that time, direct care staff J stated, "We have been putting moisture barrier cream on the area." Review of the shower report, on 10/17/13 revealed direct care staff S gave the resident a shower at 9:48 AM on 10/17/13. On 10/17/13 at 2:45 PM, observation revealed the resident in bed on the resident's back. At that time, licensed staff G entered the resident's room and rolled the resident to the resident's right side and verified the area on the resident's left buttock lacked the first layer of skin present. This licensed staff G cleansed the area with wound cleanser, and stated, "(The resident is supposed to have a dressing on it (the left buttock area) but lacked a dressing in place. (The resident) had a shower this morning and my best guess is the dressing came off then." Next, this licensed staff G measured the open area on the resident's left inner buttock with measurements of 1 cm x 1.25 cm and applied a [MEDICATION NAME] dressing." On 10/16/13 at 10:30 AM, licensed staff C reported the resident had a facility acquired Stage II pressure ulcer on the resident's bottom. On 10/16/13 at 12:40 PM, direct care staff J reported the resident had no open areas on the resident's bottom and added, "They (the open areas) are healed." This direct care staff added, "(The resident) does has a patch on (the resident's) bottom. If the patch gets dirty, I will remove it and tell the nurse. We apply extra barrier cream if note any redness. Turn the resident every 2 hours. (The resident) usually sits in the recliner. She is not doing that now so the area will heal." On 10/16/13 at 5:45 PM, licensed staff G reported the resident did not have any open wounds, and staff applied barrier cream to the resident's bottom. On 10/16/13 at 4:40 PM, licensed staff P stated, "(The resident) did have a treatment to (the resident's) coccyx, was discontinued on 10/20/13. The CNAs (certified nurse aides) are not to sit (the resident) in the recliner. We turn (the resident) every 2 hours..." On 10/17/13 at 11:50 AM, licensed staff G stated, '(The resident) had a [MEDICATION NAME] dressing on (the resident's) bottom and change the dressing every 3 days and as needed. At that time, this licensed staff G stated, "(The resident) should have a dressing in place. (The resident) likes to sit a lot. The area is a reoccurring area...Apply skin barrier..." On 10/22/13 at 2:30 PM, direct care staff L stated, "...(The resident has an open area on (the resident's) bottom. We apply barrier cream, and try to reposition (the resident) every 1 hour..." On 10/22/13 at 9:41 AM, direct care staff S stated, "(The resident) didn't have a dressing on (the resident's) bottom when I gave (the resident) a shower last Thursday (10/17/13). I told the nurse and (the nurse) was going to put a dressing on." The facility's skin system policy and procedure, revised on 8/08, recorded, "Policy:...2. A resident having a pressure sore receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing..." The facility's undated Pressure Ulcer Assessment policy recorded, "...3.4. Use pressure ulcer assessment findings to plan interventions that will best promote healing..." The facility failed provide the necessary treatment and services to promote healing and prevent new sores from developing. The resident had a facility acquired Stage 2 pressure area to the left inner buttock area which staff reported was a reoccurring area. The resident lacked a dressing in place from, at least, 10/16/13 at 1:40 PM until 10/17/13 at 2:45 PM.