Every finding on record at Aspen Health and Wellness

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for the residents of the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from May 2024 through May 2025, lacked evidence of trending organism identifications in December 2024, January 2025, and February 2025. The facility was unable to provide evidence of trending upon request. A review of Resident (R) 34's Electronic Medical Record EMR documented Ciprofloxacin (antibiotic medication) HCL ophthalmic (eye) solution, installed two drops in both eyes three times a day for bacterial conjunctivitis (infection of the eye) for seven days, dated 06/01/25. A review of R12's EMR documented Ofloxacin (antibiotic) ophthalmic solution instilled two drops in both eyes four times a day for conjunctivitis/blepharitis (eye and eyelid infection) for seven days, dated 05/20/25. A review of the antibiotic surveillance binder lacked tracking and trending of eye infections for R34 and R12. On 06/25/24 at 02:04 PM, Administrative Nurse E stated that the tracking and trending were done in real-time to ensure clusters of infections were monitored and education was given to staff as needed. Administrative Nurse E stated he could not contest any months before March 2025. He stated the facility had a few infection preventionists before March. Administrative Nurse E stated the facility did do tracking for the months of March, April, and May; he stated the Administrator had those months in her binder. The facility's Infection Surveillance reviewed 03/25 documented a system of infection surveillance serves as a core activity of the facility's infection prevention and control program. The purpose was to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections.

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure sufficient staffing to ensure adequate resident care and call light response. This placed the facility residents at risk for a decline and inadequate resident care being completed. Findings Included: - A review of the facility's Payroll-Based Journal (PBJ -Staffing Data Report) from 04/01/22 through 03/31/25 indicated the facility triggered for One Star Staffing for Fiscal Year (FY) 2024 Quarter Three 04/01/24-06/30/24), FY 2024 Quarter Four (07/01/24-09/30/24), FY 2025 Quarter One (10/01/24-12/31/24), and FY 2025 Quarter Two (01/01/25-03/31/25). The Resident Council Minutes for 04/14/25 noted concerns that residents were not getting their showers completed on their assigned shower days. The form noted the residents were being told: Staff were too busy to give a shower. The form's response section indicated the shower schedules were reviewed to verify preferences due to discrepancies between preferences and scheduled dates. The Resident Council Minutes for 05/12/25 noted concerns that call lights and resident care were not being completed in a timely manner. The Resident Council Minutes for 06/09/25 noted under concerns the council reported call lights were not being answered within a reasonable timeframe. The form's staff response indicated staff were educated on answering the call light within a reasonable time and to communicate with the resident if they need more time while assisting others. On 06/24/25 at 02:00 PM, the facility's Resident Council stated ongoing concerns related to call light response times and following the bathing schedules. The council reported ongoing issues related to low weekend and evening staffing. The council reported repeated concerns related to being told by staff that the facility did not have enough staff to complete care tasks. (Refer to Citation F565) On 06/24/25 at 09:30 AM, R21 sat in her wheelchair in her room. R21's hair was greasy and uncombed. R21's fingernails were dirty and untrimmed. She stated was upset because the facility was not properly bathing her. She stated she had not received her Sunday bath in the last three weeks and was made to wait until Thursday. She stated the facility did not have enough staff on Sundays to complete bathing. A review of her EMR indicated she missed her last three Sunday baths. (Refer to Citation F677) On 06/26/25 at 01:20 PM, Administrative Nurse E stated no concerns related to insufficient staffing. He stated the facility utilized agency staff to cover open shifts. He stated staff were expected to follow the care plans and provide care according to each resident's needs. On 06/26/25 at 01:30 PM, Administrative Staff A stated the facility had an ongoing issue with staff telling the residents that the facility did not have enough staff to complete care. She stated the facility had educated staff about the correct level of staff required to care for each resident. The facility's Staffing, Sufficient and Competent Nursing policy, revised 04/2025, indicated the facility was to provide sufficient and competent staff to ensure the completion of care and services for all residents in accordance with resident care plans and the facility assessment.

The facility identified a census of 58 residents. The facility identified fifteen 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 reviews, observations, and interviews, the facility failed to ensure trash was stored and contained properly. The facility further failed to ensure that catheter bags were kept off the floor. The facility further failed to ensure that respiratory equipment, such as a BIPAP (a type of noninvasive ventilation used to assist breathing) mask, a nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask, and a nasal cannula, was stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - An initial walkthrough of the facility was completed on 06/24/25 at 07:05 AM. Certified Nurse's Aide (CNA) O was dragging a large white trash bag with trash, and a large white trash bag of laundry down the hall. The laundry and trash were not contained. On 06/24/256 at 07:05 AM, R32 slept in her bed. R32's bed was in a low position. R32's urinary catheter collection bag was hung on the side of her bed. Her collection bag lay directly on the floor, filled with yellow urine. On 06/24/25 at 07:28 AM, R25 laid on his bed. R25's BIPAP mask was laid directly on the bedside table, and his nebulizer mask lay on top of the BIPAP machine. R25's BIPAP mask and nebulizer mask were not stored in a sanitary manner. On 06/24/25 at 07:40 AM, R12 was asleep on the bed with her lower extremities off to the left side of the bed. R12's indwelling urinary catheter drainage bag with dark amber urine laid directly on the floor facing the entrance door to the room. On 06/24/25 at 07:30 AM, in R59's room, a nasal cannula tubing was wrapped around the handle of portable oxygen canisters in a cylinder stand. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that trash and laundry should be transported in the large barrels for trash and laundry that contain lids. LN G stated that all respiratory equipment should be placed in a dated bag. She stated that catheters should never touch the floor. On 06/26/25 at 02:04 PM, Administrative Nurse D stated there were laundry and trash containers with lids to transfer trash. Administrative Nurse D stated that respiratory equipment should be placed in a bag when not in use. She stated urinary catheter bags should not be on the floor; the urinary catheter bags could be placed in a wash basin if needed to ensure the catheter did not lay on the floor. The facility's Indwelling Urinary Catheter Care reviewed on 03/25 documented it was the policy of the facility that each resident with an indwelling catheter would receive catheter care daily and as needed to promote hygiene, comfort, and decrease the risk of infection. The facility's Infection Control policy, reviewed 10/24, documented the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the equality assurance and performance improvement program. It was the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards.

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences for the residents on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for March 2024, April 2025, May 2025, and June 2025 was completed. A review of Sunday for the majority of each month revealed the residents were only offered a self-led activity packet for an activity. On 06/25/24 at 02:00 PM, the facility's Resident Council reported that the weekend activities were inconsistent with what was scheduled. The council reported on Sunday's the residents did not always receive staff-led activities. The council stated they were often offered puzzles or packets to complete individually. The council reported that the facility was often short-staffed on Sundays. They stated the activities staff did not work on Sundays, and staff were often too busy to complete activity groups. On 06/26/25 at 12:38 PM, Activities Staff Z stated the facility had a staff member to come in on weekends and complete activities. She stated the facility provided shopping trips and had volunteers come in on Saturdays. She stated the facility was to have staff-led activities each day of the week. She stated the facility also provides activity packets for the residents. On 06/26/25 at 01:30 PM, Certified Nurse's Aide (CNA) M stated that activities staff often came in on Saturdays to complete the groups. She stated the facility provided a packet with puzzles, games, coloring pages, and drawings for residents to complete on Sundays. The facility's Activities Programming policy, revised 05/2025, indicated the facility would provide activities that meet the residents' needs and interests to support their physical, mental, and psychosocial well-being.

- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal hygiene. The Significant Change Minimum Data Set (MDS) dated 08/07/24 documented R12 moderately impaired cognition. The MDS documented R12 had an indwelling catheter. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. The Quarterly MDS dated 05/06/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented that R12 had a limited range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) of her upper extremities. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. R12's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/13/24, lacked analysis. The facility was unable to provide the documentation upon request. R12's Care Plan, dated 09/03/24, documented the nursing staff would secure R12's catheter to facilitate the flow of urine to prevent kinking of the tubing. The plan of care documented the nursing staff would position R12's catheter bag and tubing below the level of her bladder and away from the entrance of the door to her room. R12's EMR under the Orders tab revealed the following physician orders: Indwelling catheter size 18 French with a 30 cubic centimeter (cc) bulb for diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) dated 12/05/24. On 06/24/25 at 07:40 AM, R12 was asleep on the bed with her lower extremities off to the left side of the bed. R12's indwelling urinary catheter drainage bag with dark amber urine laid directly on the floor facing the entrance door to the room. R12's call bell was on the bedside table, which was out of her reach. On 06/26/25 at 12:38 PM, Licensed Nurse (LN) G stated R12's urinary catheter drainage bag should be placed below the level of R12's bladder and never be placed on the floor. On 06/26/25 at 01:09 PM, Certified Nurse Aide (CNA) M stated R12's catheter drainage bag should always be kept below R12's bladder. CNA M stated the drainage bag should be in a privacy bag and placed on the frame of the bed. CNA M stated the drainage bag should never be placed on the floor. On 06/26/25 at 02:50 PM, Administrative Nurse D stated she expected a catheter drainage bag to be placed in a privacy bag, kept below the level of the resident's bladder, and never be placed on the floor. The facility's Indwelling Urinary Catheter Care policy, last revised 03/2025, documented it was the policy of the facility that each resident with an indwelling catheter would receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. - R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R52 had received antidepressant (a class of medications used to treat mood disorders) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and hypnotic (a class of medications used to induce sleep) medication during the observation period. The MDS documented R52 required partial to moderate staff assistance with toileting. The MDS also documented R52 required supervision to hand touch staff assistance with personal hygiene. The MDS documented R52 was occasionally incontinent of urine and was not on a toileting program. The Quarterly MDS dated 03/24/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R52 had received diuretic medication, antidepressant medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The MDS documented R52 was independent with toileting and personal hygiene. The MDS documented R52 was occasionally incontinent of urine and was not on a toileting program. R52's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 07/17/24, lacked analysis. The facility was able to provide the analysis documentation after the survey. R52's Care Plan, dated 09/15/24, documented she was to wear disposable briefs, and staff would change her every two hours and as needed. The plan of care documented staff would check her as required for incontinence and provide peri-care assistance. The plan of care dated 06/23/25 documented R52 required partial to moderate assistance with toileting hygiene. R52's EMR under the Assessment tab revealed the following LN-Bowel and Bladder Evaluation dated 05/13/25, which indicated R52 was a possible candidate for a Bowel and Bladder re-training. R52's EMR lacked documentation, and the toileting program was attempted. On 06/24/25 at 07:40 AM, R52 was at breakfast. R52's room had a strong urine odor noted from her bed and floor. On 06/25/25 at 07:19 AM, R52 laid on her bed, and she sat up on the side of her bed. R52's room still had a urine odor in the room. On 06/26/25 at 12:38 PM, Licensed Nurse (LN) G stated she would fill out the LN-Bowel and Bladder Evaluation at times. LN G stated if the assessment indicated the resident was a good candidate for a toileting program, she would let the assisted director of nursing or Administrative Nurse D know the assessment results. LN G stated R52 never refused assistance when staff offered. On 06/26/25 at 01:09 PM, Certified Nurse Aide (CNA) M stated R52 was independent with everything. CNA M stated R52 never asked for any assistance. On 06/26/25 at 02:50 PM, Administrative Nurse D stated each resident was assessed at the time of admission, quarterly, or with any changes. Administrative Nurse D stated that if a resident was a good candidate for a toileting program, the interdisciplinary team (IDT) and therapy would evaluate and determine a plan for that resident. The facility did not provide a policy related to toileting programs.- R10's Electronic Medical Record (EMR) documented the following diagnoses hypertension (HTN - elevated blood pressure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), atrial flutter (a type of abnormal heart rhythm where the heart's upper chambers beat too quickly and regularly), 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), seizures (violent involuntary series of contractions of a group of muscles), and neuromuscular dysfunction of the bladder (a condition where the nerves and muscles that control the bladder don't work together properly, leading to issues with urine storage and emptying). R10's Annual Minimum Data Set (MDS) dated 04/04/25 documented he had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. R10 had impairment of both upper and lower extremities on one side. R10 required a wheelchair to assist with mobility. R10 required substantial/maximal staff assistance with his functional abilities for his activities of daily living (ADL). R10 was dependent on staff for toileting and bathing. R10 required an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). R10's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 04/15/25 documented he was at risk of complications of having an indwelling catheter and incontinence of bowel. R10's diagnoses include a CVA with right-sided hemiplegia/hemiparesis, aphasia, neuromuscular dysfunction of the bladder requiring a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag), contracture of the right hand, atrial flutter, DM, and seizures. This places R10 at risk of further skin breakdown. R10's Care Plan, last revised on 03/07/25, directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance of the room door. The Care Plan directed staff to monitor, record, and report to the physician for signs and symptoms of a urinary tract infection (UTI-an infection in any part of the urinary system). The Care Plan directed staff that R10 had an indwelling catheter as ordered. R10's Order Summary Report documented an order dated 09/15/24 to document output every shift. A review of R10's March 2025Treatment Administration Record (TAR) in the EMR revealed R10's urinary catheter output was not documented on four of 62 opportunities. A review of R10's April 2025 TAR in the EMR revealed R10's urinary catheter output was not documented on six of 60 opportunities. A review of R10's May 2025 TAR in the EMR revealed R10's urinary catheter output was not documented on eight of 62 opportunities. A review of R10's June 2025 TAR in the EMR revealed R10's urinary catheter output was not documented on five of 50 opportunities. On 06/25/25 at 07:46 AM, R10 was propelled by staff in his wheelchair to the dining room. R10 had his feet on the foot on pedals. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that the certified nurse aides (CNA) were responsible for emptying the catheter bag at the end of each shift. LN G stated that CNA's were to report to the nurse what the output amount was and if any irregular color or smell was noted. LN G stated the nurse was responsible for ensuring that the output amount was documented, and a progress note would be charted if any irregularity had been noted. LN G stated that the physician should be notified of any irregularities or changes in the urine. LN G stated R10 had a history of frequent UTIs. On 06/26/25 at 02:40 PM, Administrative Nurse D stated that anyone who had a catheter should have the output documented by the nurses. Administrative Nurse D stated the CNA was responsible for emptying the catheter bag at the end of the shift and reporting the amount and any irregularities to the nurse. The facility lacked a policy regarding residents with a catheter and or UTI prevention.- The Medical Diagnosis section within R35's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and need for assistance with personal cares. R35's Quarterly Minimum Data Set (MDS) completed 04/04/25 noted a Brief Interview for Mental Status (BIMS) score of eleven, indicating mild cognitive impairment. The MDS noted no upper or lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he required partial to moderate assistance from staff for bathing, toileting, and dressing. The MDS noted he was frequently incontinent of bowel and bladder, but had no toileting program in place. The MDS noted he rejected care from staff for four to six days during the review. R35's Behavioral, Functional Abilities, and Urinary Incontinence Care Area Assessments (CAA) were not completed or available for review. R35's Care Plan initiated on 09/03/24 indicated he was at risk for his activities of daily living (ADLs) deficit due to her medical diagnoses. The plan indicated he required supervision to partial assistance for bathing, bed mobility, personal hygiene, transfer, toileting, and bathing. The plan noted he had bowel and bladder incontinence. The plan instructed staff to administer his medication as ordered for bowel regulation, provide disposable briefs, and check him for incontinence as required. The plan lacked interventions to prevent incontinence episodes or to determine if toileting interventions were attempted. R35's EMR under Assessments revealed a Bowel and Bladder Evaluation completed on 05/01/25. The evaluation revealed R35 was a possible candidate for bowel and bladder retraining. On 06/25/25 at 07:08 AM, R35 slept in his bed. R35's room smelled heavily of urine. An inspection of the floor around his bed revealed urine residue on the floor. The floor was sticky. On 06/26/25 at 08:11 AM, an inspection of R35's room revealed his floor was sticky around his bed. His room smelled heavily of urine, and the bed sheet was wet with urine. On 06/26/25 at 12:38 PM, License Nurse (LN) G stated R35 had urinary incontinence and used briefs. She was not sure if he had an individualized toileting program. She stated his room often smelled heavily of urine. She stated residents were screened for incontinence upon admission and provided toileting interventions if they were deemed a candidate. On 06/26/25 at 02:11 PM, Administrative Nurse E stated R35 had urinary incontinence and would often urinate on the floor. He stated he was moved to a different room and could not have a roommate due to his incontinence issues. He stated all residents were screened upon admission and provided interventions. The facility's Bowel and Bladder Incontinence policy, revised 03/2025, indicated the facility was to screen all residents at risk for bowel and bladder incontinence and provide interventions that minimize the risks related to the development of infections, skin breakdown, and urinary tract infections (UTI). The facility identified a census of 58 residents. The sample included 14 residents, with four residents observed for bowel and bladder function. Based on observation, record reviews, and interviews the facility failed to ensure Resident (R) 4 had a 22 French Foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) available for insertion for his suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder), the facility further failed to ensure R 12's catheter bag was not placed on the floor. The facility further failed to ensure the monitoring of R10's output was documented in his Electronic Medical Record (EMR), and further failed to establish a toileting program for R52 and R35. This deficient practice placed R4, R12, R10, R35, and R52 at risk of catheter-related complications and further urinary tract infections. Finding included: - R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (high blood), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), muscle weakness, lack of coordination, reduced mobility, cognitive communication deficit, absence of right leg below the knee, absence of left leg above the knee, chronic pain, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R4 needed set up or cleanup for eating, partial/moderated assistance from staff for toileting, and was dependent on staff for bathing. The MDS documented R4 had an indwelling catheter or suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder). R4's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 06/07/24 lacked analysis. R4's Care Plan dated 10/10/24 documented R4 had a suprapubic catheter related to neurogenic dysfunction of the bladder. R4's plan of care documented R4 would be free from catheter-related trauma. R4's plan of care dated 04/24/25, the staff were to position the catheter tubing below the level of the bladder, and away from the entrance door. The plan of care for R4 directed staff to change the catheter bag and tubing as ordered using 22-Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) with 20 milliliters (ml), and provide catheter care every shift. R4's EMR under the Orders tab revealed the following physician orders: Urinary catheter anchors every shift dated 03/19/25. Urinary catheter site care, cleanse with soap and water every shift, dated 03/19/25. Indwelling catheter suprapubic, 22 French Foley 20ml in balloon for neurogenic bladder dated 03/19/25. R4's EMR under Nursing notes dated 6/19/25 documented R4's catheter was leaking. Order received to change catheter every 30 days as needed (PRN). Notified the supply person to order 22 French Foley catheters. On 06/25/25 at 08:10 AM, R4 laid on his bed with several white hand towels. R4 stated that the hand towels were to be put around his suprapubic catheter. R4 stated he had told nursing his supra pubic catheter was leaking. R4 stated that nursing informed her she would have to order a 22 French catheter, as the facility did not have the Foley catheters on hand. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated the facility had Foley catheters on hand. She stated Foley catheters were kept in the storage room. LN G stated that if a resident needed his catheter for a super pubic catheter change, the nurse on duty would be able to change the catheter or try other non-invasive things first. On 06/26/25 at 2:04 PM, Administrative Nurse D stated the facility always has extra Foley catheters on hand. Administrative Nurse D stated the nurse would be able to change the catheter if the catheter was leaking. The facility's Indwelling Urinary Catheter Care policy review 03/25 documented it was the policy of the facility that each resident with an indwelling catheter would receive a catheter daily and as needed to promote hygiene, comfort, and decrease the risk of infection.

The facility reported a census of 58. Based on observations, record reviews, and interviews, the facility failed to resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - A review of the facility's Resident Council Minutes from 06/24 through 06/25 indicated the council had recurring concerns with the food choices, menus, temperatures, and availability. The minutes also noted concerns related to maintaining and cleaning the shower rooms. The Resident Council Minutes for 07/22/24 noted under new business concerns, facility staff were not following the resident bathing schedules. The minutes indicated staff would walk into the room, turn off the call light, and exit the room. The form's staff response indicated staff were educated on following the shower schedule and call light response. The Resident Council Minutes for 08/12/24 noted under new business concerns that facility staff were still not following the resident's bathing schedule. The Resident Council Minutes for 08/12/24 noted under old business concerns that facility staff were not following the resident's bathing schedule. The Resident Council Minutes for 04/14/25 noted concerns that residents were not getting their showers completed on their assigned shower days. The form noted the residents were being told: Staff were too busy to give shower. The form's response section indicated the shower schedules were reviewed to verify preferences due to discrepancies between preferences and scheduled dates. The Resident Council Minutes for 05/12/25 noted under concerns that call lights and resident cares were not being completed in a timely manner. The Resident Council Minutes for 06/09/25 noted under concerns the council reported call lights were not being answered within a reasonable timeframe. The form's staff response indicated staff were educated on answering the call light within a reasonable time and to communicate with the resident if they need more time while assisting others. On 06/24/25 at 02:00 PM, the Resident Council stated ongoing concerns related to call light response times and following the bathing schedules. The council reported ongoing issues related to low weekend and evening staffing. The council reported repeated concerns related to being told by staff that the facility did not have enough staff to complete care tasks. On 06/26/25 at 01:11 PM, Activities Staff Z stated the council reported issues on the completed forms, and the forms were turned into the designated department for review. She stated that each department was responsible for responding to the concerns, and the designated person would report back to the council with their answers. On 06/26/25 at 01:30 PM, Administrative Nurse E stated staff were expected to follow the bathing schedules for each resident and to answer the call lights within a reasonable amount of time. He stated staff were expected to ensure the call lights remained within reach and functional. On 06/26/25 at 01:30 PM, Administrative Staff A stated the facility had an ongoing issue with staff telling the residents that the facility did not have enough staff to complete care. She stated the facility had educated staff about the correct level of staff required to care for each resident. The facility's Resident Council policy 06/2025 indicated the facility will provide communication between the council and designated staff. The policy noted the facility would respond and address issues reported by the facility.

- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal hygiene. The Significant Change Minimum Data Set (MDS) dated 08/07/24 documented R12 moderately impaired cognition. The MDS documented R12 had an indwelling catheter. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. The Quarterly MDS dated 05/06/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented that R12 had a limited range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) of her upper extremities. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. R12's Falls Care Area Assessment (CAA) dated 08/13/24 lacked analysis. The facility was able to provide the documentation after the survey. R12's Care Plan, dated 09/03/24, documented R12 required two staff members to assist with transfers with the use of a Hoyer (total body mechanical lift) lift. The plan of care documented that the nursing staff would keep R12's needed items within her reach. The plan of care dated 05/20/25 documented a fall from bed on 05/18/25 at midnight. The intervention was R12 was given a soft call light with a bright colored tape. The facility's call light system had stopped working on 04/21/25. R12's EMR under the Progress Notes tab revealed the following: Interdisciplinary Team (IDT) note dated 01/16/25 at 01:51 PM was to review R12's fall on 01/15/25. R12 attempted to transfer herself from her bed. The intervention was to request a bolster (mattress with raised edges) overlay for R12's mattress. On 03/11/25 at 12:36 PM, a Fall Committee IDT note documented R12 was found on the floor in the activity room. The root cause of the unwitnessed fall was R12 had slid out of her chair. Intervention was the Consultant Pharmacist would complete a medication review, and therapy would elevate her wheelchair. On 05/20/25 at 10:41 AM, a Fall Committee IDT note documented the IDT had met to review R12's fall on 05/15/25, which was an unwitnessed fall. Staff documented R12 was unable to remember to use her call light, and the fall intervention would be to replace R12's call light with a soft-touch call. The facility's call light system had stopped functioning on 04/21/25. On 05/27/25 at 11:08 AM, a Fall Committee IDT note documented the IDT had met to review R12's unwitnessed fall on 05/27/25 at midnight. R12 was found on the floor mat beside her bed. The root cause analysis was that R12 had slid out of her bed onto the floor. Intervention was to request a bariatric (associated with obesity) bed for R12. R12's EMR under the Assessments tab revealed the following LN-Fall Risk Evaluation dated 05/27/25, documented she was a high fall risk. On 06/25/25 at 07:18 AM, R12 laid asleep on her bed, her call bell was out of her reach. The call bell was provided by the facility due to the facility's call light had stopped functioning on 04/21/25. R was on the bedside table. R12's bedside table was outside her reach. R12's soft call light with the bright colored tape was not present. On 06/26/25 at 07:20 AM, R12 was asleep on her bed, and the call bell provided by the facility was on the bedside table outside R12's reach. On 06/26/25 at 12:38 PM, Licensed Nurse (LN) G stated staff would find R12 on the floor. LN G stated the nurse should place a new fall intervention on the resident's care plan to help prevent further falls and possible injuries. LN G stated that the fall interventions could be found on the resident's care plan and the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). LN G stated the nurse was responsible for ensuring the resident's fall interventions are in place, and everyone's responsibility to ensure the call bells are within their reach. On 06/26/25 at 01:09 PM, Certified Nurse Aide (CNA) M stated she had access to the Kardex but not the resident's care plan. CNA M stated it was everyone's responsibility to ensure call bells are within the resident's reach and fall interventions are in place. On 06/26/25 at 02:50 PM, Administrative Nurse D stated everyone was responsible for ensuring the resident's call bells are within the resident's reach. Administrative Nurse D stated everyone was also responsible for ensuring the resident's fall interventions were in place to prevent further falls and possible injuries. The facility's Fall Management System policy, last reviewed/revised 04/2025, documented it was the policy of the facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The facility had a census of 58 residents. The sample included 14 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure electrical panels and cleaning chemicals in a safe, locked area, and out of reach of the ten cognitively impaired, independently mobile residents. The facility additionally failed to ensure Residents (R) 59, R49, and R12's preventative fall interventions were being followed. This placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 06/24/25 at 08:03 AM, an inspection of the central hallway revealed an unsecured room entry door was left propped open. The door was labeled Staff Only. An inspection of the room revealed five unlocked electrical panels on the wall. An inspection of the panel revealed the warning high voltage -the danger of electric shock on the inside of the panel. On 06/24/25 at 08:30 AM, Certified Nurse Aide (CNA) M closed the door and stated the room was an area staff could use. She stated residents were not allowed in the room. On 06/26/25 at 02:11 PM, Administrative Nurse D stated the central closet should be locked at all times. She stated the residents should not have access to areas with potential hazards. A review of the facility's Home-like Environment policy, revised 02/2025, indicated the facility was to ensure a safe, clean, and comfortable environment for the residents. - The Medical Diagnosis section within R59's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and need for assistance with personal cares. R59's Quarterly Minimum Data Set (MDS) completed 03/19/25 noted a Brief Interview for Mental Status (BIMS) score of eight, indicating mild cognitive impairment. The MDS noted no upper or lower extremity impairments. The MDS noted he used a walker for mobility. The MDS noted he was independent with bathing, toileting, mobility, and dressing. The MDS noted he was frequently incontinent of bowel and bladder, but had no toileting program in place. The MDS noted he rejected care from staff for four to six days during the review. R59's Functional Abilities Care Area Assessments (CAA) completed on 12/31/24 indicated he began hospice services. The CAA noted he required verbal cues and redirection to complete his activities of daily living (ADL). The CAA noted he had confusion at times and would urinate in cups in his room. R59's Care Plan initiated on 03/04/20 indicated she was at risk for ADL deficit due to her medical diagnosis. The plan indicated he could independently complete walking, bathing, transferring, dressing, and toileting. The plan indicated he was at risk for both communication issues and falls related to his medical diagnosis. The plan instructed staff to ensure his call light remained within his reach and for staff to encourage its use. On 06/24/25 at 07:05 AM, R59 slept in his bed. R59's call light was pushed up underneath the front of his mattress between the mattress and the bed springs. The call light was out of his reach. At 10:22 AM, R59's call light remained underneath his mattress and out of his reach. On 06/25/25 at 01:30 PM, R59 rested in his bed. His call light remained stuffed underneath his mattress and out of his reach. On 06/26/25 at 01:30 PM, Certified Nurse's Aide (CNA) M stated that the call lights or call bells were to remain within the reach of each resident. She stated staff were expected to reposition the devices each time they entered to room to ensure they remained accessible to the residents. On 06/26/25 at 02:11 PM, Administrative Nurse D stated the call devices were to be within the resident's reach at all times. She stated that staff were to ensure the resident could reach the lights and operate them. The facility's Fall Prevention policy, revised 01/2025, stated the facility was to assess the risks related to each resident based upon their comprehensive assessment and follow the implemented interventions to minimize the risks.- R49's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hyperlipidemia (condition of elevated blood lipid levels), hypertension (high blood pressure), osteomyelitis (local or generalized infection of the bone and bone marrow) of sacral, pressure ulcer of sacral area Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone), schizoaffective disorder (a mental health condition characterized by a combination of symptoms from schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought)) and a mood disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), reduced mobility, contracture (abnormal permanent fixation of a joint or muscle), muscle weakness, need for assistance with personal care, repeated falls, and communication deficit (difficulties with communication that arise from impairments in cognitive difficulties with communication that arise from impairments in cognitive processes). The Quarterly Minimum Data Set (MDS) for R49 dated 05/23/25 recorded a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS recorded R49 had falls since admission. The MDS documented R49 had two non-injury falls and one fall with injury during the observation period. R49's Falls Care Assessment (CAA) dated 11/24/24 documented R49 used a wheelchair for mobility propelled by staff. The CAA documented R49 used a Hoyer (total body mechanical lift) for transfers. The CAA documented R49 was incontinent of bowel and bladder and needed staff assistance. The CAA documented R49 had no new falls since the last assessment. R49's Care Plan dated 01/06/25 documented R49 was at risk for falls related to osteomyelitis (local or generalized infection of the bone and bone marrow). The plan of care for R49 dated 03/25/25 documented R49 had a fall in his bedroom from his wheelchair. The intervention was staff would offer to lay him down or reposition him. The plan of care for R49 dated 04/02/25, documented R49 had a fall from his bed, and the intervention would be to place a fall mat next to his bed on the left side and ensure the bed was in a low position. R49's plan of care dated 04/30/25 documented R49 had a fall in his bedroom, and the intervention was staff to ensure R49's call light was within his reach. On 06/24/25 at 07:35 PM, R49 laid on his bed. R49's blue fall mat was folded up at the end of the empty bed in his room. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that all staff have access to the care plan. LN G stated that all falls have an intervention put in place with each fall. LN G stated nursing communicates with the Certified Nursing Aides (CNA) to ensure they were aware of the interventions put in place. LN G stated that all nursing staff were responsible for ensuring the interventions were always in place. On 06/26/25 at 01:28 PM, CNA M stated she did not have full access to the care plan. CNA M stated she did have access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA M stated that if there was an intervention for a fall, she would be able to see what the intervention was in the Kardex and in Tasks. CNA M stated that the nurses also communicated with the CNAs to ensure all interventions were put in place. On 06/26/25 at 02:04 PM, Administrative Nurse D stated CNAs have access to the Kardex and Tasks. She stated that if the nurse checks the box, the interventions pull over to the Kardex. Administrative Nurse D stated that the LN has access to the full care plan. She stated it was everyone's responsibility to ensure fall prevention and interventions were put in place. The facility's Fall Management System policy, last reviewed/revised 04/2025, documented it was the policy of the facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

The facility identified a census of 58 residents. The sample included 14 residents. Three residents were sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 13, R12, and R57 call lights were within their reach. This deficient practice left R13, R12, and R57 vulnerable to unmet care needs due to the inability to call for staff assistance. Findings Included: - On 06/24/25 at 07:00 AM, an inspection of R13's (vulnerable resident unable to self-transfer) laid on her bed, R13's call light lay on the over-the-bed table. R13's over-the-bed table was pushed away from her. She was unable to reach her call light. On 06/24/25 at 07:40 AM, R12 (a cognitively impaired, unable to transfer herself) was asleep on the bed with her lower extremities off to the left side of the bed. R12's indwelling urinary catheter drainage bag with dark amber urine laid directly on the floor facing the entrance door to the room. R12's call bell was on the bedside table, which was out of her reach. On 06/25/25 at 07:18 AM, R57 (an impaired resident unable to transfer himself) laid on his bed in a low position, no call bell was noted. On 06/25/25 at 07:18 AM, R12 laid asleep on her bed, and her call bell was out of her reach. The call bell was provided by the facility due to the facility's call light had stopped functioning on 04/21/25. R was on the bedside table. R12's bedside table was outside her reach. R12's soft call light with the bright-colored tape was not present. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated call bells should always be within the reach of each resident. LN G stated that nursing was rounding on residents often since the call light system was not working. On 06/26/25 at 01:28 PM, Certified Nurse Aide (CNA) M stated staff were expected to ensure the call bells were within the resident's reach. CNA M stated staff were rounding frequently on residents since call lights had been down. On 06/26/25 at 02:04 PM, Administrative Nurse D staff were expected to ensure the residents had access to their call bells. She stated staff were checking residents every 30 minutes and ensuring the call bells were within the residents' reach. The facility did not provide an accommodation of needs policy specific to call lights.

The facility identified a census of 58 residents. The sample included 14 residents, with three residents reviewed for hospitalization and/or discharge. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19 and his representative were provided with a bed hold policy that included the facility's per diem rate to hold a bed. The facility failed to ensure R19, and his representative was provided a written notification of transfer upon his transfer to the hospital. The facility failed to ensure that a discharge summary and a recapitulation of stay were completed upon R61's discharge from the facility. This placed R19 and R61 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN- elevated blood pressure), cirrhosis (chronic degenerative disease of the liver) of the liver, carcinoma (cancer that forms in epithelial tissue) of the liver, and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R19's Discharge Minimum Data Set (MDS) dated 02/08/25 documented an unplanned discharge to an acute hospital with a return anticipated. R19's Entry MDS dated 02/12/25 documented a re-entry to the facility from an acute hospital. The facility failed to provide a written notification of transfer and a bed hold policy to R19 and his representative prior to his transfer to the hospital on [DATE]. R19's Discharge MDS dated 03/07/25 documented an unplanned discharge to an acute hospital with a return anticipated. R19's Entry MDS dated 03/12/25 documented a re-entry to the facility from an acute hospital. The facility failed to provide a written notification of transfer and a bed hold policy to R19 and his representative prior to his transfer to the hospital on [DATE]. R19's Discharge MDS dated 5/12/25 documented an unplanned discharge to an acute hospital with a return anticipated. R19's Entry MDS dated 05/15/25 documented a re-entry to the facility from an acute hospital. The facility failed to provide a bed hold policy to R19 and his representative prior to his transfer to the hospital on [DATE]. R19's Annual MDS dated 06/03/25 documented he had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R19 used a wheelchair to assist with mobility. R19 required partial assistance from staff with toileting and bathing. R19 did not have an active discharge plan in place for the resident to return to the community. R19's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/10/25 documented he had severely impaired cognition. R19 has had a recent hospitalization due to acute illnesses. R19 required partial assistance from staff for toileting and bathing. R19 planned to remain at the facility. R19's Care Plan, last revised on 05/16/25, directed staff that R19 intended to remain in the facility for long-term care (LTC). The Care Plan directed staff to assist him with discharge plans if the current LTC plans change. The Care Plan directed staff to review the discharge plan with R19 as needed. On 06/25/25 at 07:18 AM, R19 propelled himself in his wheelchair to the dining room. On 06/26/25 at 01:51 PM, Social Services X stated it had been her understanding that a new bed hold did not have to be completed upon the transfer to the hospital since a bed hold was completed at admission. Social Services X stated that they had completed the Confirmation of Transfer & Bed Hold Provision part of the facility's Bed Hold/Discharge Notification form. The facility's Bed Hold revised, on January 2025, documented that the resident, or the resident's representative shall be informed in writing of their right to exercise the bed hold provision of 10 days upon admission and provide a second notice before transfer from the facility to a general acute care hospital or at the start of a resident's therapeutic leave. In the event of an emergency transfer, the second notice would be provided within 24 hours. The notice shall include: the duration of the state bed-hold policy; the amount required to be paid by the resident or by the resident's payor source to hold the bed for the duration of the bed-hold period; that insurance may or may not cover such costs and, accordingly, the resident may have some liability for payment of uncovered costs; and the facility's policy regarding bed-hold periods permitting the resident to return. The information shall be provided to the resident and/or his/her representative in a language they could understand. - R61's Electronic Medical Record (EMR) documented diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and hypertension (HTN- elevated blood pressure). The EMR documented R61 admitted the facility on 05/02/25 and discharged the facility on 05/09/25. R61's admission Minimum Data Set (MDS) had not been completed. R61's Care Area Assessment (CAA) had not been completed. R61's Care Plan initiated on 05/05/25, directed staff to establish a pre-discharge plan with the resident, family/caregivers, and evaluate the progress and revise the plan as needed. An Orders Note scanned into R61's Misc. tab of the EMR documented an order to admit R61 for respite stay from 05/02/25 to 05/17/25. R61's Discharge Note dated 05/09/25 at 02:13 PM, documented the writer had been notified that R61 was approved for another facility and wanted her transferred today. The interdisciplinary team (IDT) was notified of the discharge request. R61's spouse picked up her belongings. R61's spouse received her medications from the charge nurse. R61's spouse voiced his appreciation to the staff and for the care R61 received while at the facility. A review of R61's EMR revealed that a Discharge Summary had not been completed by staff that included a recapitulation of the stay. On 06/26/25 at 02:09 PM, Administrative Nurse E stated that typically a discharge summary would be completed upon a resident's discharge, but in R61's case, it was a sudden discharge, so it had not been completed as it should. Administrative Nurse E stated R61 was transferred to the new facility, and her medications were provided. The facility's Discharge Summary policy dated April 2025, documented when the facility anticipated a resident's discharge, the discharge summary shall include, but not be limited to the following: A recapitulation of the resident's stay that included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. A final summary of the resident's status; a reconciliation of all pre-discharge medications with the resident's post-discharge medications; a post-discharge plan of care that was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which would assist the resident to adjust tohis or her new living environment. The post-discharge plan of care shall indicate where the individual plans to reside, any arrangements that have been made for the resident's follow-up care, and any post-discharge medical and non-medical services. A final summary of the resident's status at the time of discharge would be filed in the resident's medical record and be available for release to authorized persons and agencies, with the consent of the resident or the resident's representative.

The facility identified a census of 58 residents. The sample included 14 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 34 with the discharge from hospice services. This deficient practice placed R34 at risk for unidentified care needs. Findings included: - R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (swallowing difficulty), and aphasia (a condition with disordered or absent language function). The Annual Minimum Data Set (MDS) dated 02/12/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. The Quarterly MDS dated 05/13/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. R34's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/17/25, documented she had received hospice services for additional supportive care. R34's Care Plan, dated 09/12/24, documented the facility would work cooperatively with hospice team to ensure her spiritual, emotional, intellectual, physical, and social needs were e met. R34's EMR under the Orders tab revealed the following physician orders: Admit to hospice services with the diagnosis of senile degeneration (cognitive decline associated with old age), dated 04/18/25. On 06/25/25 at 09:47 AM, R34 was asleep as she sat reclined in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the activity room. On 06/24/25 at 09:04 AM, R34's legal representative stated R34 had been discharged from hospice services in the past month. On 06/26/25 at 07:10 AM, Licensed Nurse (LN) H was unable to locate R34's hospice communication book. LN H stated she had not had to use R34's hospice communication book recently and would not know who would have R34's hospice communication book this early in the morning. LN H stated that the social services staff may be able to help locate it. On 06/26/25 at 07:20 AM, Social Services Staff X stated R34 had been discharged from hospice services on 05/20/25. Social Services Staff X stated she was not sure why there was a current order for hospice services for R34 that was still active. On 06/26/25 at 09:10 AM, Administrative Nurse F stated she had not been notified that R34 had been discharged from hospice services on 05/20/25. Administrative Nurse F stated she had heard that R34 was to be discharged from hospice services, but there was never an order written by the physician. Administrative Nurse F stated she had initiated a Significant Change MDS this week related to R34's discharge from hospice. On 06/26/25 at 02:50 PM, Administrative Nurse D stated she would expect hospice would communicate and work with the facility. Administrative Nurse D stated she would expect the hospice services to provide the discharge order. Administrative Nurse D stated she was the person responsible for ensuring there was collaboration between the hospice provider and the hospice provider. The facility was unable to provide a policy-related MDS.

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3's Care Plan had been revised to direct staff that she was safe to self-administer her physician-ordered Voltaren gel (a pain-relieving gel). This placed R3 at risk of unsafe medication administration and adverse effects. Findings included: - R3's Electronic Medical Record (EMR) documented diagnoses of embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) of the deep veins of the right lower extremity, malignant neoplasm (an abnormal growth of cells that has the potential to invade and destroy nearby tissues or spread to distant parts of the body) of the breast, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and diabetic neuropathy (nerve damage caused by diabetes, often leading to pain, numbness, and tingling, particularly in the hands and feet). R3's Annual Minimum Data Set (MDS) dated 10/16/24 documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R3 used a wheelchair to assist with mobility. R3 required supervision to partial/moderate assistance from staff for her activities of daily living (ADL). R3 had a urinary ostomy (surgical opening from an area inside the body to the outside) and was always continent of bowel. R3's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/21/24 documented she was at risk for alteration of her functional abilities and complications from decreased mobility related to her current diagnoses. R3 had an 11-day hospitalization. R3 currently required one staff and partial/moderate assist for toilet hygiene, bathing, upper and lower body dressing, and transfers from bed to chair. R3 utilized a manual wheelchair for mobility. R3's Care Plan last revised on 04/04/25 directed staff to administer medication as ordered for neuropathy; observe for adverse effects and report to the physician as needed. R3's Care Plan lacked staff direction on self-administration of her physician-ordered Voltaren. R3's Order Summary Report in the EMR documented a physician's order dated 12/30/24 for Voltaren external gel one percent (1%) to apply topically to the affected joints every six hours (6) hours as needed for pain. Use two (2) grams (gm) of unsupervised self-administration. May leave medication at the bedside. R3's Assessments tab of the EMR lacked an assessment for Self-Administration of Medications. On 06/25/25 at 10:06 AM, R3 stated she has had her Voltaren gel in her room since it had been ordered, and she applied it herself when she needed to. R3 stated she had never been assessed to self-administer the medication that she could recall. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that any resident should be assessed to be safe to self-administer medication. LN G stated she would expect the care plan to be updated to reflect that R3 could self-administer or apply her Voltaren. On 06/26/25 at 02:06 PM, Administrative Nurse E stated that R3's care plan should have been revised to let staff know if she was safe to self-administer her Voltaren. The facility lacked a policy for care plan revision.

- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal hygiene. The Significant Change Minimum Data Set (MDS) dated 08/07/24 documented R12 moderately impaired cognition. The MDS documented R12 had an indwelling catheter. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. The Quarterly MDS dated 05/06/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented that R12 had a limited range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) of her upper extremities. The MDS documented R12 was dependent on staff assistance for toileting and bathing. The MDS documented R12 had one non-injury fall during the observation period. R12's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 08/13/24, lacked analysis. The facility was able to provide the documentation after the survey. R12's Care Plan, dated 09/03/24, documented she was dependent on staff assistance for bathing. R12's EMR under the Reports tab and Bathing task was reviewed for the following dates: 02/11/25 to 06/20/25 (120 days). The EMR documented 10 Shower (SH) on 02/04/25, 02/07/25, 02/18/25, 04/18/25, 05/02/25, 05/13/25, 05/20/25, 05/27/25, 05/30/25, and 06/06/25, two Sponge Bath were documented on 02/21/25 and 05/16/25, one Resident Refused (RR) on 05/06/25, and 21 Not Applicable (NA) were documented on 02/11/25, 02/14/25, 02/25/25, 02/28/25, 03/04/25, 03/07/25, 03/11/25, 03/14/25, 03/18/25, 03/28/25, 04/01/25, 04/04/25, 04/08/25, 04/11/25, 04/15/25, 04/22/25, 04/29/25, 05/09/25, 05/23/25, 06/03/25, and 06/10/25. R12's clinical record lacked evidence that she was unavailable for care during the 120 days reviewed. R12's notes lacked documentation regarding bathing refusals or attempts to offer alternatives. On 06/25/25 at 07:18 AM, R12 laid asleep on her bed, her call bell was out of her reach. The call bell was provided by the facility due to the facility's call light had stopped functioning on 04/21/25. R was on the bedside table. R12's bedside table was outside her reach. R12's soft call light with the bright colored tape was not present. On 06/26/25 at 12:38 PM, Licensed Nurse (LN) G stated that each resident had assigned days for bathing at least two times a week. LN G stated that if a resident were to refuse their bath, the staff would reapproach again to offer them bathing options. LN G stated that if the resident refused the bath/shower, it would be documented in their EMR. On 06/26/25 at 01:09 PM, Certified Nurse Aide (CNA) M stated each resident was offered at least two baths each week. CNA M stated that if a resident were to refuse their bath, the staff would return later and offer again. CNA M stated the refusal would be documented in the resident's EMR under tasks. On 06/26/25 at 02:50 PM, Administrative Nurse D stated that each resident was able to choose the day and type of bath. Administrative Nurse D stated she runs the bathing report to ensure each resident was provided a bath. The facility's Activities of Daily Living (ADL) policy, last revised 01/2025, documented a resident's abilities in ADLs do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This included the president's ability to bathe, dress, groom, transfer, ambulate, toilet, eat, and use speech, language, or other functional communication systems. Nursing assistants would provide assistance with ADLs based on the resident's individualized plan of care. The facility identified a census of 58 residents. The sample included 14 residents, with 14 reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide Residents (R) 21 and R12 with consistent bathing opportunities. This deficient practice placed both residents at risk for impaired psycho-social well-being and skin breakdown. Findings Included: - The Medical Diagnosis section within R21's Electronic Medical Records (EMR) included diagnoses of end-stage renal disease, absence of left leg, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and need for assistance with personal care. R21's Quarterly Minimum Data Set (MDS) completed 03/07/25 noted a Brief Interview for Mental Status (BIMS) score of 13, indicating mild cognitive impairment. The MDS noted bilateral upper and lower extremity impairments, and she used a wheelchair for mobility. The MDS noted she was dependent on staff assistance for bathing, toileting, dressing, personal hygiene, and bed mobility. The MDS noted she had frequent bowel and bladder incontinence. R21's Functional Abilities Care Area Assessment (CAA) completed 12/09/24 indicated she required extensive assistance from staff to complete her activities of daily living. The CAA noted she used a wheelchair for mobility and a Hoyer lift (full-body mechanical lift) for transfers. The CAA noted she was incontinent of bowel and bladder and required assistance with toileting, peri-care, and clothing management. R21's Care Plan initiated on 09/05/24 indicated she was at risk for ADL deficit due to her medical diagnoses. The plan noted she was dependent on staff assistance for bathing, toileting, transfers, dressing, wheelchair ambulation, and bed mobility. The plan noted she had urinary incontinence and was at risk for skin breakdown and infections. The plan instructed staff to inspect her skin during bathing and daily care. The MDS noted she was at risk for skin breakdown. A review of R21's EMR under Documentation Survey Report from 06/01/25 through 06/26/25 (26 days reviewed). The report indicated she preferred to have a bath twice weekly (Sundays and Thursdays). The report indicated she received bathing on 06/01/25, 06/05/25, 06/12/25, and 06/19/25. The report indicated she did not receive her scheduled Sunday bath or 2nd weekly bath for the week of 6/8, 6/15, and 6/22. R21's EMR indicated no rationale or refusals for the missing bathing occurrences. On 06/24/25 at 09:30 AM, R21 sat in her wheelchair in her room. R21's hair was greasy and uncombed. R21's fingernails were dirty and untrimmed. She stated was upset because the facility was not properly bathing her. She stated she had not received her Sunday bath in the last three weeks and was made to wait until Thursday. She stated the facility did not have enough staff on Sundays to complete bathing. On 06/26/25 at 12:38 PM, License Nurse (LN) G stated staff were required to sign off on Sundays; she stated staff must make three attempts before accepting the refusal. She stated refusals were marked in the EMR. She stated that the missing bathing would be offered on the next shift or the next day. On 06/26/25 at 01:30 PM, Certified Nurse's Aide (CNA) M stated R21 often refused staff assistance, but it should have been marked in the EMR as offered. She stated that direct care staff were expected to provide three attempts before telling the nurse. She stated the nurse would then talk to the resident. She stated that staff would provide the resident with a bath upon request. On 06/26/25 at 02:11 PM, Administrative Nurse D stated staff were expected to provide the residents' bathing based upon the residents' preference and scheduled days. She stated staff were expected to make multiple attempts at bathing and reschedule bathing for the next shift or day if missed. The facility's Activities of Daily Living (ADL) policy, last reviewed 09/2024, indicated all residents would be provided ADL assistance and consistent bathing opportunities for all residents. The policy noted residents would be assessed for their specific care needs and provided interventions.

The facility identified a census of 58 residents. The sample included 14 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for weights to monitor for edema and fluid overload for Resident (R) 52. This deficient practice placed R52 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R52 had received antidepressant (a class of medications used to treat mood disorders) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and hypnotic (a class of medications used to induce sleep) medication during the observation period. The Quarterly MDS dated 03/24/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R52 had received diuretic medication, antidepressant medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. R52's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/17/24 lacked analysis. The facility was able to provide the documentation after the survey. R52's Care Plan, with a revision date of 11/05/24, documented the nursing staff would administer medications as ordered. The plan of care documented nursing staff would observe for adverse effects and report to the physician as needed. R52's EMR under the Orders tab revealed the following physician orders: Spironolactone (diuretic) oral tablet 50 milligrams (mg), give one tablet by mouth in the morning for edema dated 01/29/25. Weigh in the morning every Monday and Thursday for fluid overload. Call the physician if a weight of greater than (>) five pounds in a week for four weeks, dated 06/05/25. Furosemide (diuretic) oral tablet 20mg (Lasix), give two tablets (40mg) by mouth in the morning for Fluid overload, dated 06/05/25. Review of R52's EMR, Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 06/05/25 to 06/24/25 lacked evidence weights were obtained as ordered by the physician. Under the Vital Sign tab revealed a weight recorded on 06/23/25 of 152.6 pounds. R52's clinical record lacked evidence the physician was notified of the lack of weights. On 06/25/25 at 07:19 AM, R52 laid on her bed, and she sat up on the side of her bed. R52's room still had a urine odor in the room. On 06/26/25 at 02:50 PM, Administrative Nurse D stated she would expect the physician's order to be followed, and the medication was administered as ordered. Administrative Nurse D stated that the physician should be notified of the lack of weight monitoring for edema and fluid overload. The facility's Pharmacy Services/Nursing Services policy last revised 01/2025 documented it was the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the president's plan of care.

The facility identified a census of 58 residents. The sample included 14 residents, with 14 residents. Based on observation, record review, and interviews, the facility failed to include Resident (R) 34 or her representative in the development and planning of the resident's care plan. This deficient practice placed R34 at risk of impaired care and decreased autonomy. Findings included: - R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (swallowing difficulty), and aphasia (condition with disordered or absent language function). The Annual Minimum Data Set (MDS) dated 02/12/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. The Quarterly MDS dated 05/13/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. R34's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/17/25 documented she had received hospice services for additional supportive care. R34's Care Plan, dated 09/12/24 documented the facility would work cooperatively with hospice team to ensure her spiritual, emotional, intellectual, physical, and social needs were met. Review of R34's EMR lacked documentation of a care plan meeting was provided and who attended the care conference for the past 12 months. The facility was able to provide a copy of a letter sent to R34's representative on 01/30/25 and 05/16/25. The EMR lacked a IDT- Care Plan Review documented under the Assessment tab. On 06/25/25 at 09:47 AM, R34 was asleep as she sat reclined in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the activity room. On 06/24/25 at 09:04 AM, R34's legal representative stated he was her representative and he was not aware of any care conference or care plan meetings that had been held for R34. On 06/26/25 at 01:52 PM, Social Services Staff X stated she scheduled the care plan meeting off the MDS schedule. Social Services Staff X stated she did not have an answer to why R34 had no documentation that a care plan had taken place in the past 12 months. Social Services Staff X stated she would complete the IDT- Care Plan Review assessment after the care plan meeting. On 06/26/25 at 02:50 PM, Administrative Nurse D stated her, or her assisted director of nursing should attend the resident's care plan meetings. Administrative Nurse D stated she had not attended any care plan meetings at this time, but she had just taken that position in the last 2 weeks. Administrative Nurse D stated the IDT- Care Plan Review assessment should be completed after each care plan meeting. The facility's Care Planning-Interdisciplinary Team policy last revised 03/2025 documented the interdisciplinary team is responsible for the development of resident care plans. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. If it was determined that participation of the resident or representative was not practicable for development of the care plan, an explanation is documented in the medical record.

The facility identified a census of 58 residents. The sample included 14 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 25's Bilevel positive airway pressure (noninvasive ventilation used to assist breathing) mask, nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and nasal cannula (a medical device that delivers supplemental oxygen or other therapeutic gases to a patient through two small, flexible tubes inserted into the nostrils) was stored in a sanitary manner. This placed R25 at an increased risk for respiratory infection and complications. Findings included: - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN - elevated blood pressure, obstructive sleep apnea (an open airway during typical breathing during sleep and a blocked airway), pulmonary edema (accumulation of extravascular fluid in the lung tissues), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, contracture (abnormal permanent fixation of a joint or muscle) of the right hand, muscle weakness, need for assistance with personal care, and aphasia (condition with disordered or absent language function). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R25 was dependent on staff for all activities of daily living (ADL), except eating, and needed supervising/touch assistance. The MDS documented R25 had impairment on both sides of his body. The MDS documented R25 used supplemental oxygen and a non-invasive medical ventilator. R25's Functional Abilities Care Area Assessment (CAA) dated 06/16/24 documented R25 was dependent on ADLs. The CAA documented R25 used a Broda chair (specialized wheelchair with the ability to tilt and recline) for mobility propelled by staff, and a Hoyer (total body mechanical lift) for transfers. The CAA documented R25 had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) and required assistance with peri-cares and clothing management. R25's Care Plan dated 09/05/24 documented R25 had chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), obstructive sleep apnea, and would be free of any signs of respiratory infections. The plan of care documented staff would administer R25's BiPAP (type of non-invasive ventilation used to assist breathing) as ordered and monitor for any signs of respiratory insufficiency. The plan of care dated 02/05/25 documented R25 required his head of the bed to be elevated or extra pillows at night due to shortness of breath when he laid flat. The plan of care documented R25 would take off his BIPAP mask and put it on his bedside table or the floor. R25's plan of care lacked staff direction for the care of R25's BIPAP mask, nebulizer mask, and oxygen nasal tubing. R25's EMR under the Orders tab revealed the following physician orders: BIPAP while sleeping, BIPAP settings 24/18 centimeters water pressure, backup rate 12 every night shift, dated 01/28/25. Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg) per three milliliters(ml), three ml inhale orally four times a day related to COPD, dated 01/28/25. BIPAP cleaning on Friday per directions. One time a day, every Friday, for CPAP cleaning tubing and mask with warm soapy water and air dry, dated 04/15/25. On 06/24/25 at 07:28 AM, R25 laid on his bed. R25's BIPAP mask was laid directly on the bedside table, and his nebulizer mask was laid on top of the BIPAP machine. R25's BIPAP mask and nebulizer mask were not stored in a sanitary manner. On 06/25/25 at 07:08 AM, R25 laid on his bed, with the head of the bed elevated. R25's BIPAP mask and nebulizer mask were laid on the bedside table. R25's oxygen cannula lay on the floor beside R25's bed. R25's BIPAP mask, nebulizer mask, and oxygen cannula were not stored in a sanitary manner. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that the BIPAP mask, nebulizer mask, and nasal oxygen tubing were to be stored in a dated plastic bag. LN G stated all nurses were responsible for ensuring respiratory equipment was stored per the facility protocol. On 06/26/25 at 01:25 AM, Certified Nurse's Aide (CNA)M stated that all respiratory equipment should be placed in a plastic bag. CNA M stated it was the responsibility of the CNA taking care of each resident to ensure the respiratory equipment was not in use and was stored appropriately. On 06/26/25 at 02:04 PM, Administrative Nurse D stated that all respiratory equipment not in use should be stored in a dated plastic bag. Administrative Nurse D stated that staff are educated on the appropriate way to store respiratory equipment not in use. Administrative Nurse D stated that all staff are responsible for ensuring the respiratory equipment was placed in a plastic bag when not in use. The facility's Infection Surveillance reviewed 03/25 documented a system of infection surveillance serves as a core activity of the facility's infection prevention and control program. The purpose was to identify infections and to monitor adherence to recommended infection prevention and control practices to reduce infections and prevent the spread of infections.

- R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R52 had received antidepressant (a class of medications used to treat mood disorders) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and hypnotic (a class of medications used to induce sleep) medication during the observation period. The Quarterly MDS dated 03/24/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R52 had received diuretic medication, antidepressant medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. R52's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/17/24 lacked analysis. The facility was able to provide the documentation after the survey. R52's Care Plan, with a revision date of 11/05/24, documented the nursing staff would administer medications as ordered. The plan of care documented nursing staff would observe for adverse effects and report to the physician as needed. R52's EMR under the Orders tab revealed the following physician orders: Midodrine (anti-hypotensive medication) HCI tablet, five milligrams (mg) give one tablet by mouth two times a day related to hypotension. Do not give if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was greater than (>) 140 millimeters (mm) of mercury (Hg) dated 01/30/25. Review of R52's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 05/01/25 to 06/14/25 (45 days), midodrine was given outside the physician-ordered parameters eight times on the following dates: On 05/01/25 blood pressure (BP) 144/81 mmHg. On 05/02/25 BP 143/83 mmHg. On 05/24/25 BP 144/90 mmHg. On 05/26/25 BP 144/77 mmHg. On 05/27/25 BP 149/73 mmHg. On 05/30/25 BP 143/80 mmHg. On 06/01/25 BP 148/91 mmHg. On 06/14/25 BP 150/98 mmHg. On 06/25/25 at 07:19 AM, R52 laid on her bed, she sat up on the side of her bed. R52's room still had a urine odor in the room. On 06/26/25 at 02:50 PM, Administrative Nurse D stated she would expect the physician's order to be followed and the medication was administered as ordered. Administrative Nurse D stated she would expect the CP to identify and report that the physician's order was not followed and given outside the ordered parameters. The facility's Pharmacy Services/Nursing Services policy last revised 01/2025 documented it was the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the president's plan of care. The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure staff monitored Resident (R) 10's blood pressure and pulse prior to administering his antihypertensive (a class of medication used to treat high blood pressure) medication, metoprolol. The facility failed to ensure R3 was safe for the self-application of her Voltaren gel ( a topical medication used to relieve pain). The facility failed to ensure staff administered R52's midodrine (a medication used to treat low blood pressure) within the physician-ordered parameters. This place R10 and R52 at risk for unnecessary medication administration and related complications. Findings included: - R10's Electronic Medical Record (EMR) documented the following diagnoses hypertension (HTN - elevated blood pressure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and atrial flutter (a type of abnormal heart rhythm where the heart's upper chambers beat too quickly and regularly). R10's Annual Minimum Data Set (MDS) dated 04/04/25 documented he had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. R10 had impairment of both upper and lower extremities on one side. R10 required a wheelchair to assist with mobility. R10 required substantial/maximal staff assistance with his functional abilities for his activities of daily living (ADL). R10 was dependent on staff for toileting and bathing. R10 received an antiplatelet (medications that prevent platelets, a type of blood cell, from clumping together and forming blood clots) and a hypoglycemic (medications used to lower blood glucose levels in individuals with diabetes) medication on a regular basis. R10's Cognitive Loss Care Area Assessment (CAA) dated 04/15/25 documented he was at risk of complications of cognitive loss/dementia related to multiple current diagnoses 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) with right sided hemiplegia/hemiparesis (weakness and paralysis on one side of the body), HTN, DM, aphasia (condition with disordered or absent language function), contracture (abnormal permanent fixation of a joint or muscle) of the right hand, and atrial flutter. R10's BIMS score was a seven, which indicated severe impairment. Staff were to continue to anticipate his needs and provide re-orientation as needed. R10's Care Plan, last revised on 03/07/25, directed staff to administer his antihypertensive medications as ordered and to observe for adverse effects. The Care Plan directed staff to hold medication as ordered, observe for adverse effects, and report to the physician as needed. R10's Order Summary Report in the EMR documented a physician's order dated 05/02/25 for metoprolol tartrate oral tablet 25 milligrams (mg) to be given twice daily by mouth for HTN. Hold and notify MD if the systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 90 or the pulse was less than 60. A review of R10's Medication Administration Record (MAR) in the EMR for May 2025 revealed that R10's blood pressure and pulse lacked monitoring on 59 of 59 opportunities prior to the administration of his physician-ordered metoprolol. A review of R10's MAR in the EMR for June 2025 revealed that R10's blood pressure and pulse lacked monitoring on 15 of 50 opportunities prior to the administration of his physician-ordered metoprolol. A review of R10's Progress Notes in the EMR from 05/02/25 to 06/09/25 lacked any staff notes that the physician was notified of the lack of blood pressure and pulse readings prior to administration of metoprolol. On 06/25/25 at 07:46 AM, R10 was propelled by staff in his wheelchair to the dining room. R10 had his feet on the foot pedals. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that if a medication had parameters on the order, then she would expect the blood pressure and or the pulse to be taken prior to administering the medication. LN G stated she was unsure as to why R10's blood pressure and pulse had not been taken and documented in the MAR as ordered. On 06/26/25 at 02:40 PM, Administrative Nurse D stated that a physician's order that included parameters for blood pressure and pulse monitoring, she expected staff to obtain the reading and report to the nurse and physician as needed. Administrative Nurse D could not speak as to why the blood pressure and pulse reading had not been taken for R10 prior to being administered his metoprolol. Administrative Nurse D stated R10's MAR for May and June did have the slots to document the blood pressure and pulse. The facility policy Physician Orders, last revised in January 2025, documented that it was the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It was the policy of this facility to accurately implement orders in addition to medication orders, only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

- R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (swallowing difficulty), and aphasia (a condition with disordered or absent language function). The Annual Minimum Data Set (MDS) dated 02/12/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. The Quarterly MDS dated 05/13/25 documented R34 had severely impaired cognition. The MDS documented R34 had received hospice services during the observation period. R34's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/17/25, documented she had received hospice services for additional supportive care. R34's Care Plan, dated 09/12/24, documented the facility would work cooperatively with hospice team to ensure her spiritual, emotional, intellectual, physical, and social needs were met. R34's EMR under the Orders tab revealed the following physician orders: Admit to hospice services with the diagnosis of senile degeneration (cognitive decline associated with old age) dated 04/18/25. On 06/25/25 at 09:47 AM, R34 was asleep as she sat reclined in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the activity room. On 06/24/25 at 09:04 AM, R34's legal representative stated R34 had been discharged from hospice services in the past month. On 06/26/25 at 07:10 AM, Licensed Nurse (LN) H was unable to locate R34's hospice communication book. LN H stated she had not had to use R34's hospice communication book recently and would not know who would have R34's hospice communication book this early in the morning. LN H stated that the social services staff may be able to help locate it. On 06/26/25 at 07:20 AM, Social Services Staff X stated R34 had been discharged from hospice services on 05/20/25. Social Services Staff X stated she was not sure why there was a current order for hospice services for R34 that was still active. On 06/26/25 at 09:10 AM, Administrative Nurse F stated she had not been notified that R34 had been discharged from hospice services on 05/20/25. Administrative Nurse F stated she had heard that R34 was to be discharged from hospice services, but there was never an order written by the physician. On 06/26/25 at 02:50 PM, Administrative Nurse D stated she would expect hospice would communicate and work with the facility. Administrative Nurse D stated she would expect the hospice services to provide the discharge order. Administrative Nurse D stated she was the person responsible for ensuring there was collaboration between the hospice provider and the hospice provider. The facility's End of Life: Hospice and/or Palliative Care policy, last revision/review date of 01/2025, documented it was the policy of this facility to provide dignified and compassionate end-of-life care for terminally ill or dying residents. Through continuing interdisciplinary assessment, individualized plans would be developed and implemented to address prevention and relief of symptoms and the resident's physical, intellectual, emotional, social, spiritual, and practical needs. Support and reassurance for family and friends close to the resident would be an integral part of the plan. The facility identified a census of 58 residents. The sample included 14 residents, with two residents reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider for Resident (R) 13, and further failed to ensure collaboration between the nursing home and hospice services for R34. This deficient practice created a risk for missed or delayed services and impaired care for R13 and R34. Findings Included: - R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of malnutrition, epilepsy (brain disorder characterized by repeated seizures), adult failure to thrive, cognitive communication deficit(difficulties with communication that arise from impairments in cognitive processes like attention, memory, and executive functions, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), encounter for palliative care, dysphagia (swallowing difficulty), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R13's Significant Change Minimum Data Set (MDS) dated 06/03/25 documented a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented R13 needed assistance from staff for all activities of daily living (ADL). The MDS documented R13 received hospice services during the observation period. R13's Cognitive Loss / Dementia Care Area Assessment (CAA) dated 06/03/25 documented R13 was at risk of complications of cognitive loss/dementia related to cerebral infarction, adult failure to thrive, and epilepsy. R13 was admitted to hospice, and hospice was to provide additional support as needed. R13's Care Plan dated 05/28 documented R13 had a terminal prognosis related to malnutrition and was admitted to hospice services on 05/28/25. Staff were to adjust the provision of ADLS to compensate for the resident's changing abilities. Staff were to encourage participation to the extent the R13 wished to participate. Staff were to encourage R13 to express her feelings, and listen with non-judgmental acceptance and compassion. The plan of care for R13's documented Hospice Certified Nurse's Aide (CNA) was to provide showers with visits approximately two times weekly, and the hospice nurses would visit one to two times weekly as R13 could tolerate. The hospice social worker and Chaplain would provide visits as needed. R13's plan of care dated 06/02/25 documented hospice provider would supply incontinent supplies as needed; briefs, gloves, wipes, and medications were to come from the facility's pharmacy, even those covered by hospice. The facility would work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. A review of the hospice communication binder revealed R13 was admitted to hospice services on 05/28/25. A review of the hospice binder lacked documentation a CNA or Licensed Nurse (LN) had been to the facility for care for R13, the last documentation in R13's hospice binder documented a social worker had been to see R13 on 06/10/25. On 06/30/25 at 07:00 AM, the facility sent documentation of CNA and LN visits. The Email communication documented that the facility would put each visit in the hospice binder for R13. On 06/24/25 at 08:25 AM, R13 laid on her bed, covered with a blue blanket. On 06/25/25 at 01:17 PM, R13 laid in her bed. R13 was awake. On 06/25/25 at 02:22 PM, the hospice provider stated he was just made aware that the CNA and LN had not documented in R13's binder. He stated he would be in the facility to see R13 today and ensure the correct documentation was in R13's binder. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that hospice provided a book that was kept behind the nurse's station. LN G said the nursing staff could find what was provided and when hospice would be in the facility for each resident in the hospice book. LN G stated she would be able to look in the hospice binder to see what days the aide and nurse were in the facility to do care or bathing with the resident. On 06/26/25 at 01:28 PM, Certified Nurse's Aide (CNA) M stated the nurse on duty let the CNAs know who was on hospice. She stated that hospice aides communicate with the facility staff to ensure the facility knows what supplies they bring and when they give showers. CNA M stated she could also look in the hospice binder to see when the aide was in the facility. On 06/26/25 at 02:04 PM, Administrative Nurse D stated staff would be able to see collaboration of care in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), or in the hospice binder located behind the nurse's station. Administrative Nurse D stated that the hospice providers communicate with the facility's nursing staff. The facility's End of Life: Hospice and/or Palliative Care policy, last revision/review date of 01/2025, documented it was the policy of this facility to provide dignified and compassionate end-of-life care for terminally ill or dying residents. Through continuing interdisciplinary assessment, individualized plans would be developed and implemented to address the prevention and relief of symptoms and the resident's physical, intellectual, emotional, social, spiritual, and practical needs. Support and reassurance for family and friends close to the resident would be an integral part of the plan.

The facility identified a census of 58 residents. The sample included 14 residents, with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R)13. This placed R13 at increased risk for pressure ulcer development. Findings Included: - R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of malnutrition, epilepsy (brain disorder characterized by repeated seizures), adult failure to thrive, cognitive communication deficit (difficulties with communication that arise from impairments in cognitive processes like attention, memory and executive functions), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), encounter for palliative care, dysphagia (swallowing difficulty), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R13's Significant Change Minimum Data Set (MDS) dated 06/03/25 documented a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented R13 needed assistance from staff for all activities of daily living (ADL). The MDS documented R13 was at risk of developing pressure ulcers. R13's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 06/03/25 documented R13 was at risk for alteration in skin integrity related to cerebral infarction, adult failure to thrive, and epilepsy. The CAA documented she was admitted to hospice services. The CAA documented R13 had a poor appetite and was incontinent of bowel and bladder. The CAA documented R13 wished to remain in bed most of the time and requires staff to turn and reposition approximately every two hours, and as needed. R13's Care Plan dated 01/31/25 documented a pressure ulcer or was potentially for pressure ulcer development of the right great toe related to decreased mobility, and malnutrition. R13's plan of care documented R13 had a deep tissue injury to the left great toe to heal without complications. The plan of care documented that staff would treat R13's deep tissue injury per physicians' orders, and staff were to apply heel protectors when in bed as a preventative measure. R13's Braden Scale for Prediction Pressure Sore Risk dated 04/30/25 documented a score of 11, indicating a high risk for pressure ulcers. R13's physician's orders under the Orders tab revealed the following orders: Heel protectors bilateral when in bed as a preventive measure every shift for pressure dated 02/26/25. On 06/24/25 at 08:25 AM, R13 laid on her bed, covered with a blue blanket. R13's boots were in her Broda chair, R13 did not have boots on her heels, and her heels laid directly on the mattress. On 06/25/25 at 02:30 PM, R13 laid in her bed, R13's boots were in her Broda chair. R13 did not have boots on her heels, and her heels her heels laid directly on the mattress. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that all nursing staff have access to the care plan. LNG stated it was the CAN's duty to apply boots when the resident was placed in bed. LN G stated it was the nurse on duty to round and ensure the boots were applied to the residents' heels. On 06/26/25 at 01:17 PM, Certified Nurse's Aide (CNA) M stated she had access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA M stated she could not see the full care plan, but could see what interventions needed to be done each shift for her residents. On 06/26/25 at 02:04 PM, Administrative Nurse D stated that if the residents' boots applied to heels were an order, the order would show on the Treatment Administrative Record (TAR). Administrative Nurse D stated the CNAs have access to the Kardex and Task, and the information should be seen in both places. The facility's Pressure Ulcer Prevention policy, reviewed on 01/25, documented skin inspections/assessments would be completed on admission for all facility residents. The risk for pressure ulcer development would be evaluated on admission and at other pertinent periods of admission for all residents using the Braden Scale for pressure ulcer risk. Residents and families were to be encouraged to participate to the extent possible in the care and prevention of skin breakdown. Any resident with a Braden score of 12 or less should have interventions initiated based on the risks identified to protect and promote skin integrity.

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the Consulting Pharmacists (CP) identified when staff administered R52's midodrine (a medication used to treat low blood pressure) outside the physician-ordered parameters. This placed R52 at risk for unnecessary medication administration and related complications. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hypotension (low blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), Muscle weakness, unsteady on her feet, and the need for assistance with personal care. The admission Minimum Data Set (MDS) dated 07/12/24 documented a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R52 had received antidepressant (a class of medications used to treat mood disorders) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and hypnotic (a class of medications used to induce sleep) medication during the observation period. The Quarterly MDS dated 03/24/25 documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R52 had received diuretic medication, antidepressant medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. R52's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/17/24 lacked analysis. The facility was able to provide the documentation after the survey. R52's Care Plan, with a revision date of 11/05/24, documented the nursing staff would administer medications as ordered. The plan of care documented nursing staff would observe for adverse effects and report to the physician as needed. R52's EMR under the Orders tab revealed the following physician orders: Midodrine (anti-hypotensive medication) hci tablet, five milligrams (mg), give one tablet by mouth two times a day related to hypotension. Do not give if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was greater than (>) 140 millimeters (mm) of mercury (Hg) dated 01/30/25. Review of R52's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 05/01/25 to 06/14/25 (45 days), midodrine was given outside the physician-ordered parameters eight times on the following dates: On 05/01/25 blood pressure (BP) 144/81 mmHg. On 05/02/25 BP 143/83 mmHg. On 05/24/25 BP 144/90 mmHg. On 05/26/25 BP 144/77 mmHg. On 05/27/25 BP 149/73 mmHg. On 05/30/25 BP 143/80 mmHg. On 06/01/25 BP 148/91 mmHg. On 06/14/25 BP 150/98 mmHg. Review of the Monthly Medication Review (MMR) from September 2024 to May 2025 lacked evidence the CP identified and reported midodrine was given outside the physician-ordered parameters. On 06/25/25 at 07:19 AM, R52 laid on her bed, and she sat up on the side of her bed. R52's room still had a urine odor in the room. On 06/26/25 at 02:50 PM, Administrative Nurse D stated she would expect the physician's order to be followed, and the medication was administered as ordered. Administrative Nurse D stated she would expect the CP to identify and report the physician's order was not followed and given outside the ordered parameters. The facility was unable to provide a policy related to pharmacy responsibility for MMR.

The facility identified a census of 58 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3 had been assessed for the ability to self-administer her physician-ordered Voltaren gel (a pain-relieving gel). This placed R3 at risk of unsafe medication administration and adverse effects. Findings included: - R3's Electronic Medical Record (EMR) documented diagnoses of embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) of the deep veins of the right lower extremity, malignant neoplasm (an abnormal growth of cells that has the potential to invade and destroy nearby tissues or spread to distant parts of the body) of the breast, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and diabetic neuropathy (nerve damage caused by diabetes, often leading to pain, numbness, and tingling, particularly in the hands and feet). R3's Annual Minimum Data Set (MDS) dated 10/16/24 documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R3 used a wheelchair to assist with mobility. R3 required supervision to partial/moderate assistance from staff for her activities of daily living (ADL). R3 had a urinary ostomy (surgical opening from an area inside the body to the outside) and was always continent of bowel. R3's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/21/24 documented she was at risk for alteration of her functional abilities and complications from decreased mobility related to her current diagnoses. R3 had an 11-day hospitalization. R3 required one staff and partial/moderate assist for toilet hygiene, bathing, upper and lower body dressing, and transfers from bed to chair. R3 utilized a manual wheelchair for mobility. R3's Care Plan last revised on 04/04/25 directed staff to administer medication as ordered for neuropathy; observe for adverse effects and report to the physician as needed. R3's Care Plan lacked staff direction on self-administration of her physician-ordered Voltaren. R3's Order Summary Report in the EMR documented a physician's order dated 12/30/24 for Voltaren external gel one percent (1%) to apply topically to the affected joints every six hours (6) hours as needed for pain. Use two (2) grams (gm) of unsupervised self-administration. May leave medication at the bedside. R3's Assessments tab of the EMR lacked an assessment for Self-Administration of Medications. On 06/25/25 at 10:06 AM, R3 stated she has had her Voltaren gel in her room since it had been ordered, and she applied it herself when she needed to. R3 stated she had never been assessed to self-administer the medication that she could recall. On 06/26/25 at 12:37 PM, Licensed Nurse (LN) G stated that any resident who had an order that included self-administration should first be assessed to ensure the safe administration of the medication. LN G could not state whether R3 had been assessed for the safe administration/application of the Voltaren. On 06/26/25 at 02:06 PM, Administrative Nurse E stated that it had been noticed after a Self-Administration Assessment was requested by the nursing facility surveyor (NFS), that an assessment had not been completed for R3 to be able to safely administer her Voltaren. Administrative Nurse E stated that he had completed the self-administration assessment of R3 this morning. The facility policy Self-Administration of Medications dated 01/25, documented the clinician would provide an opportunity for the patient to administer his/her own medications. The clinician would: teach the patient the purpose and side effects of medications and the patient's role in identifying and preventing medication errors; assist the patient in setting up the medications for the first time; assess the patient' ability to self-administer medications correctly and document the patient's response and understanding to teaching; answer questions/concerns expressed by the patient and the family/caregiver regarding the patient's self-administration of medications; document the information given to the patient regarding the medication, date, and time medications was to be given, teaching the side effects, and any pertinent observations made, in the patient's clinical record, as appropriate.

The facility identified a census of 62 residents. The sample included three residents reviewed for weight loss. Based on record review and interviews, the facility failed to implement interventions to prevent further weight loss for Resident (R) 1 after she experienced a significant weight loss, and the facility implemented an initial intervention in September 2024. R1 continued to experience significant weight loss and Consultant GG followed R1 but did not recommend further interventions to prevent weight loss and the facility failed to implement further weight loss prevention interventions. This deficient practice resulted in a significant weight loss of 25.6% for R1. Findings included: - R1 admitted to the facility on [DATE] and transferred to the hospital on 12/26/24. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness, mild intellectual abilities, cognitive communication deficit, need for assistance with personal care, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R1 required set-up or clean-up assistance with eating and had no weight loss/gain since admission. The Quarterly MDS dated [DATE], documented a BIMS score was not assessed. R1 required set-up or clean-up assistance with eating and R1 had weight loss not from a prescribed weight-loss regimen. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 07/09/24, lacked an analysis of findings. The Activities of Daily Living (ADLs) - Functional/Rehabilitation Potential CAA dated 07/09/24, lacked an analysis of findings. The Nutritional Status CAA dated 07/09/24, lacked an analysis of findings. R1's Care Plan dated 10/14/24, documented R1 had an alteration in self-care and directed staff to know R1 required set-up assistance with eating. R1's Care Plan dated 10/14/24, documented R1 had a risk for alteration in nutrition and directed staff to monitor and report to R1's medical doctor as needed for any signs and symptoms of decreased appetite, nausea and vomiting, unexpected weight loss, and complaints of stomach pain. The plan directed staff provided diet and nutritional supplements to R1; staff administered vitamin replacements as ordered; and staff monitored and reported to R1's medical doctor signs and symptoms of dysphagia (difficulty swallowing). R1's EMR revealed the following orders: An order with a start date of 07/11/24 and discontinued date of 09/05/24 for Juven (supplement used to support wound healing and lean body mass) two times a day for wound healing. An order with a start date of 07/11/24 and discontinued date of 11/20/24 for liquid protein (supplemental protein) 30 milliliters (mL) two times a day (BID) for wound healing. An order with a start date of 09/17/24 for Mighty Shakes (supplemental shakes to provide dietary calories and protein for malnutrition recovery) three times a day (TID) for weight loss. An order with a start date of 09/17/24 and completion date of 10/17/24 for twice weekly weight for one month to monitor for weight loss; an order with a start date of 11/20/24 for liquid protein 30 mL twice daily. An order with a start date of 12/02/24 to weigh three times a week for two weeks for weight loss on Monday, Wednesday, and Friday. Review of R1's Medication Administration Record (MAR) from 09/17/24 to 12/26/24 revealed a lack of evidence that staff monitored the resident's Mighty Shake intake percentages with administration TID. R1's EMR documented the following weights: 220.0 pounds (lbs.) on 07/03/24, 199.0 lbs. on 09/04/24, 199.0 lbs. on 09/06/24, 194.0 lbs. on 09/10/24, 195.8 lbs. on 09/23/24, 185.6 lbs. on 09/28/24, 187.0 lbs. on 09/30/24, 178.2 lbs. on 10/07/24, 182.6 lbs. on 10/10/24, 179.0 lbs. on 10/14/24, 187.4 lbs. on 11/01/24, 172.2 lbs. on 11/06/24, 163.6 lbs. on 12/01/24, 166.8 lbs. on 12/04/24, 164.6 lbs. on 12/09/24, and 164.2 lbs. on 12/13/24. R1 had 25.6% significant weight loss between 07/03/24 to 12/01/24. R1's Task tab of her EMR revealed a task, revised 08/28/24, for Snacks scheduled at 08:00 PM daily. R1's EMR revealed the following: A Weight Change Note on 09/10/24 at 10:48 AM documented a weight warning and a weight of 199 lbs. Consultant GG requested a reweigh related to weight loss indicated and noted they suspected an error in the weight entry. A Weight/Skin Committee Interdisciplinary Team (IDT) note on 09/17/24 at 12:30 PM documented R1 needed a reweigh, had weight loss noted as trending, and Consultant GG following the weight loss. R1 received a regular diet with no supplements recommended at that time. A Physician Progress Note on 09/17/24 at 04:08 PM documented nursing reported a significant weight loss and R1 ate 50 to 75% of her meals. The provider gave R1 a Mighty Shake which she drank. The note indicated an order to check R1's protein with her next labs, staff continued to follow weights, Consultant GG followed R1, staff encouraged oral intake, R1 received liquid protein, and the provider added Mighty Shakes TID. A Physician Progress Note on 09/27/24 at 04:35 PM documented the facility continued to monitor R1's weights, Consultant GG followed R1, and staff continued supplements as directed. A Nursing Note on 10/01/24 at 11:47 AM documented the IDT reviewed R1 at a weekly risk review for questionable weight loss of 12 lbs. in one month. The note documented the facility put an intervention to reweigh R1 in place. R1 continued on a regular diet with 75 to 100% meal intake, R1 received liquid protein BID, and R1 received Mighty Shakes TID. The facility continued the current plan of care. A Physician Progress Note on 10/10/24 at 02:56 PM documented R1 reported she was hungry and the provider gave her some crackers. The note documented the plan to continue to monitor weights and continue supplements with Consultant GG following. A Weight Change Note on 10/15/24 at 01:30 PM documented a weight of 179.0 lbs. Consultant GG reviewed R1's weights related to weight loss and Consultant GG questioned accuracy of the weights. R1 continued on a regular diet with regular texture and thin liquids with 76 to 100% intake at mealtimes. R1 received Mighty Shakes TID with 100% intake, which left Consultant GG suspicious of accuracy in weights. Consultant GG requested a reweigh. A Physician Progress Note on 10/15/24 at 03:10 PM documented R1 had a good appetite and ate 100% of meals. The note documented a plan to continue to monitor R1's weights and continue supplements as directed with Consultant GG following the resident. The provider questioned the accuracy of R1's weights as R1 ate 100% of her meals and snacks. A Physician Progress Note on 10/25/24 at 04:15 PM documented R1 participated in therapy services. The note documented a plan to continue to monitor R1's weights and continue supplements as directed with Consultant GG following. The provider questioned accuracy of R1's weights as R1 ate 100% of her meals and snacks. A Physician Progress Note on 10/29/24 at 01:15 PM documented R1 ate well. The note documented a plan to continue to monitor weights and continue supplements as directed with Consultant GG following. The provider questioned accuracy of R1's weights as R1 ate 100% of her meals and snacks. A Weight Change Note on 11/05/24 at 12:23 PM documented a weight of 187.4 lbs. R1 had weight loss with current interventions in place noted as R1 started on a new psychotropic (medication that alters mood or thought) medication that may cause weight gain and R1 was less active and resting more. The note documented the facility worked on getting R1 mentally stable. R1 received a regular diet with 76 to 100% intake at meals and received Mighty Shakes TID. The note documented the facility continued R1's plan of care. A Weight Change Note on 11/19/24 at 12:52 PM documented a weight of 172.2 lbs. R1 had a questionable 15 lbs. weight loss in three days with no current interventions in place. R1 had behaviors that made her noncompliant with cares. R1 received a regular diet with 76-100% intake and Mighty Shakes. The note documented the facility continued R1's plan of care. A Physician Progress Note on 11/29/24 at 06:44 PM documented R1 had agitation, behaviors, urine frequency, and mobility deficits. The note documented a plan to obtain labs and a UA, and the facility continued to monitor weights and continued supplements as directed while Consultant GG followed. A Physician Progress Note on 12/02/24 at 04:53 PM documented R1 seen for weight loss and nursing reported R1 ate well and had supplements ordered. The note documented a plan to continue to monitor weights with weights obtained three times a week for two weeks and continue supplements as directed while Consultant GG followed. A Weight Change Note on 12/03/24 at 01:31 PM documented a weight of 163.6 lbs. Consultant GG reviewed R1's weights related to weight loss with what appeared to be some inconsistent weights. R1 received nutritional supplements TID and a regular diet with 76 to 100% intake. A Physician Progress Note on 12/13/24 at 03:54 PM documented R1 started on antibiotics for leukocytosis but the facility did not obtain the UA. Nursing reported R1 had a good appetite despite noted weight loss and she received supplements ordered per Consultant GG. The note documented a plan to continue to monitor weights and continue supplements as directed while Consultant GG followed. A Weight Change Note on 12/17/24 at 12:19 PM documented a weight of 164.2 lbs. R1 received a regular diet with 76 to 100% intake and Mighty Shakes TID. The note documented to continue with current plan of care. A Nursing Note on 12/22/24 at 12:48 PM documented R1 refused to eat breakfast and lunch. Staff offered R1 different options for her meals, but she still refused. A Physician Progress Note on 12/23/24 at 04:42 PM documented nursing reported R1 was lethargic that morning and did not get up to eat. R1's family voiced concern about significant weight loss. The note documented a plan to do laboratory tests STAT (immediately), continue to monitor weights with Consultant GG following, continue supplements as directed, discuss medications with psychiatry, and consider routine cancer screenings. A Nursing Note on 12/26/24 at 09:49 AM documented R1 was transported to the hospital on a stretcher by ambulance following a temperature spike. On 01/13/25 at 02:34 PM, Certified Nurse Aide (CNA) M stated the CNAs obtained resident weights and Administrative Nurse D and Administrative Nurse E monitored weights. She stated she prevented resident weight loss by encouraging residents to eat more, giving more water, giving alternative meals and snacks throughout the day. CNA M stated if a resident received Mighty Shakes, the kitchen placed the shakes on the trays or the Certified Medication Aide (CMA) or nurse gave the shakes. She stated she did not know about R1's weight loss. On 01/13/25 at 02:37 PM, CMA R stated the CNAs obtained weights and wrote them down for the nurse to put into the computer. She stated the CMAs gave supplemental shakes and documented intake percentages. CMA R stated if she saw a Mighty Shakes order without percentage documentation, she would ask the nurse to change it. She stated she prevented resident weight loss by encouraging residents to eat. On 01/13/25 at 02:42 PM, Licensed Nurse (LN) G stated the CNAs obtained the weights and the nurses helped. She stated the nurses, Administrative Nurse D, and Administrative Nurse E monitored for weight changes. LN G stated she prevented weight loss by encouraging residents to eat and administering supplements or appetite stimulants. She stated the CMAs gave the supplemental shakes and documented percentages on Mighty Shakes. LN G stated she had never put percentage documentation on a Mighty Shake order. She stated R1 had weight loss, but she did not remember if R1 received supplements or not. She stated staff struggled to get R1 up for meals and R1 refused a lot of meals. LN G stated R1 slept through a lot of meals but staff offered meals when she woke up. On 01/13/25 at 03:00 PM, Administrative Nurse D stated the CNAs obtained resident weights and told the nurse who put them into the computer. She stated the IDT monitored weights and Consultant GG looked at weights once a week during weekly risk meetings. Administrative Nurse D stated the facility put weight loss interventions on the MAR and in the care plan. She stated the kitchen delivered Mighty Shakes and magic cups (fortified frozen supplement) on their trays and the CMA or nurse passed Med Pass (supplemental shake) or Glucerna (supplemental shake) supplements. Administrative Nurse D stated she did not know if Mighty Shakes had intake percentages documented with administration, but staff should document intake with meals. She stated R1 was a busy person, she would start eating then leave so staff redirected her back to her meal. R1 sometimes ate in the main dining room but she would yell and needed to eat in her room. Administrative Nurse D stated Consultant GG documented in her notes when she reviewed R1. She stated R1 had medication changes and she did not know if R1 slept more because of medication changes. On 01/13/25 at 03:04 PM, Administrative Nurse E stated R1 always moved around, and staff redirected her to eat meals with difficulty sometimes. He stated a couple of times, the facility reweighed R1 then put her on Mighty Shakes TID and liquid protein 30 mL. On 01/16/25 at 04:16 PM, Consultant GG stated when she reviewed residents, she assessed their appetite; if they had any difficulty swallowing or chewing; and if they had any nausea, vomiting, constipation, diarrhea, or weight fluctuations. She stated she talked to the resident and asked their allergies and preferences then she tried to work with the kitchen on their preferences. Consultant GG stated she visited the facility once a week and reviewed flagged weights in the risk meeting. She stated R1's weights bounced around, but she assessed if it was a clinically significant change and if there were any interventions to put in place. She stated R1 had a supplement in place, received medication reviews, had laboratory tests done, had medication changes, and the provider evaluated to figure out what was going on. Consultant GG stated R1 had a couple of weights that required reweighs and she tried to figure out if staff weighed R1 with foot pedals or not for accuracy. She stated sometimes R1 rested more, and the facility re-evaluated all of R1's psychotropic medications to see if that caused her to sleep more. Consultant GG stated she believed the kitchen provided R1 with fortified foods while honoring her preferences but she did not work in the kitchen so she could not attest to that. She stated the facility had snacks available at the nurse's station but she did not pass snacks so she could not attest to R1 receiving them. She stated she reviewed the documentation in R1's chart and supplemental shakes had percentages for her to track intake. Consultant GG stated R1 had a lot of behaviors and was very finicky. She stated there were other things that took place that constituted as an intervention to look at R1's whole picture because medication reviews and laboratory tests added a piece to the puzzle. She stated she did not suggest snacks as an intervention, and she could not answer if R1 received fortified foods. Consultant GG stated medication changes could affect weight and R1 had a lot of behavior documentation. She stated she felt the facility did everything they could and put interventions into place to figure out R1's weight loss. The facility's Nutrition policy, revised December 2024, directed facility approaches to address weight loss included an ongoing search for the cause of the weight loss and once the facility identified the cause, the facility made relevant care plan changes and evaluated ongoing interventions. The policy directed if the dietitian determined a resident had a significant change in their condition, the facility offered additional nutrition to those residents with options that included super cereal, large portions, between meal snacks, and commercial nutritional supplements. The facility's Nutrition Status Management policy, revised December 2024, directed if there was a significant change in the resident's condition related to weight or nutrition, the dietitian made recommendations to offer additional nutrition to those residents with options that included fortified cereal, large portions, between meal snacks, and commercial nutritional supplements. The policy directed IDT and the dietitian monitored and evaluated the resident's response or lack of response to the interventions and revised or discontinued the approaches or justified the continuation of current approaches. The facility failed to implement interventions to prevent further weight loss for R1 after she experienced a significant weight loss, and the facility implemented an initial intervention in September 2024. R1 continued to experience significant weight loss and Consultant GG followed R1 but did not recommend further interventions to prevent weight loss and the facility failed to implement further weight loss prevention interventions. This deficient practice resulted in a significant weight loss of 25.6% during her admission.

The facility identified a census of 83 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to prevent an incident of resident-to-resident sexual abuse when Resident (R) 1, who had a history of inappropriate sexual behaviors with a recent escalation, exposed his genitals to R2, a cognitively impaired resident unable to consent. This deficient practice resulted in a negative reaction from R2 and placed the residents at risk for impaired psychosocial well-being including fear and embarrassment, and risk for ongoing sexual abuse. Findings Included: - R1's Electronic Medical Record (EMR) documented diagnosis of obsessive-compulsive behavior (OCD - an anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning), unspecified dementia (progressive mental disorder characterized by failing memory, confusion), and cognitive communications deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The MDS further documented R1 had other behavioral symptoms not directed toward others that occurred for one to three days of the observation period. The MDS documented R1 as independent for mobility and walking. The MDS further documented R1 used a wheelchair and could propel himself independently. The Functional Abilities Care Area Assessment (CAA), dated 01/09/24, documented R1 admitted to the facility after a recent stay at a psychiatric facility and had diagnoses of obsessive-compulsive behavior and dementia. R1's Care Plan with an initiated date of 01/03/24 documented R1 had a history of sexually inappropriate behavior in a previous facility where he exposed his penis and fondled a female resident. R1's Care Plan documented R1 as at risk for behaviors and had diagnoses of obsessive-compulsive behavior and dementia. R1's Care Plan with an initiated date of 01/12/24 directed staff to evaluate behavior patterns and try to remove causes for behavior. R1's Care Plan with an initiated date of 04/03/24 documented staff educated R1 on inappropriate behaviors. A Provider Progress Note dated 01/04/24, documented R1 newly admitted from another facility. The note further documented R1 displayed new onset sexually inappropriate behavior. A Nurses Note dated 03/30/24, documented that while nurses were in R1's room taking care of R1's roommate, R1 began pleasuring himself and showed a Certified Nurse Aide (CNA) his genitals. A General Note from eRecord dated 04/01/24 documented R1 tried to enter another resident's room and was redirected. The note further documented that R1 had shown interest in the resident in that room. A Nurses Note dated 04/03/24, documented R1 exhibited sexual behavior in front of staff by pleasuring himself and then exposing himself to staff. The note further documented R1 inappropriately touched staff in activities and R1 was educated on inappropriate behavior. A Behavior Note dated 04/21/24 documented R1 attempted to follow a female resident into her room and was redirected by staff. A Nurses Note dated 04/24/24, documented R1 had behaviors of inappropriately touching himself in a public area. A Nurses Note dated 06/30/24 documented three staff sat at the nurses' station when they heard a female resident (R2) yell out and at that time it was witnessed that R1 stood to the right side of R2 as she sat in her Broda chair (specialized wheelchair with the ability to tilt and recline), and staff could only see the back of R2's Broda chair and R1's back. The note further documented as staff approached to investigate, they noted R1 had his pants pulled down part way with his penis exposed to R2. Staff intervened and removed R2 from the area and R1 pulled his pants up and sat down in a chair in the TV room where the incident occurred. The note further documented R1 was placed on one-to-one observation with staff, staff attempted to contact the resident's family, police were notified, and the executive director of the facility was contacted. A Complaint Investigation Witness Statement dated 06/30/24, documented Certified Medication Aide (CMA) R heard R2 scream while CMA R was at the nurses' station. The statement documented CMA R went into the TV room and saw R1 standing to the right side of R2 with his penis out. The statement documented when R1 noticed staff he pulled his pants up and sat down. R2 was moved to the nurses' station. A Complaint Investigation Witness Statement dated 06/30/24, documented R1 and R2 were watching TV in the activity room and Licensed Nurse (LN) G heard R2 yell out. The statement documented LN G went to investigate with two other staff and found R1 standing close to R2's face with his pants halfway down. The statement documented R1's penis was out and next to R2's face and mouth. Staff brought R2 to the nurses' station while R1 remained in the TV room and was placed on one-to-one supervision. A Complaint Investigation Witness Statement dated 06/30/24, documented LN H was at the nurse's station and heard R2 yell. The statement documented LN H looked in the direction of the yelling and observed R1 as he stood over R2 with his penis exposed. The statement further documented CMA R removed R2 from the TV room and placed her at the nurses' station. On 07/03/24 at 01:10 PM, R2 was in her room and laying in her bed awake looking upward toward the ceiling. R2 did not answer basic yes or no questions. She looked around and made some noises under her breath but did not respond with an answer. On 07/03/24 at 03:45 PM, CNA M stated the facility provided abuse, neglect, and exploitation education through an online training module and the education included sexual abuse. CNA M stated R2 was non-verbal and communicated through actions such as making faces if she was in pain or turning away if she did not like something while staff assisted with meals. CNA M stated R2 was dependent on staff for everything. CNA M stated that without staff intervention R2 would not have been able to stop R1. CNA M stated she saw in R1's EMR that he was sexually aggressive, and that staff had to redirect him from going into female resident's rooms CNA M stated staff usually kept an eye on R1 and if they did not see him, then they would go look for him. She stated she was aware that R1 had masturbated in front of staff before. CNA M stated the intervention to prevent R1 from sexually inappropriate behavior was for staff to redirect him. CNA M stated she considered what R1 did to R2 as abuse and harassment. On 07/03/24 at 03:50 PM LN I stated she worked at the facility for about three months but had not received any abuse training at this current facility. LN I stated R2 was non-verbal, but would smile sometimes. LN I stated she had never heard R2 say a word and that she has no way to communicate. LN I stated that she was not aware of any specific intervention in place for R1 prior to this incident that could have prevented his behavior and that she was not aware if R1 had been inappropriate with other residents before this incident. LN I stated R1 was placed on one-to-one supervision after the incident and that she would hope interventions would be put in place for R1 going forward. LN I stated that what R1 did to R2 would be a form of abuse. On 07/03/24 at 03:58 PM Administrative Nurse D stated R2 was able to answer yes and no questions; however, providing care for R2 was more about anticipating her needs and R2 could laugh, or cry, but that sometimes her cry sounded more like a laugh. Administrative Nurse D stated while R2 was in her Broda chair she was completely dependent on staff and could not get around on her own at all. Administrative Nurse D stated she was not aware of another incident where R1 exposed himself at the facility and stated she knows that R1 spent time with another female resident and that they would eat together, or watch TV together, but she never heard of there being anything that was sexually inappropriate between them. Administrative Nurse D stated the intervention for R1 to prevent sexually inappropriate behavior was for staff to redirect him if he was doing it. Administrative Nurse D stated she believed the incident between R1 and R2 would be a form of abuse as R2 was unable to consent. Administrative Nurse D stated R1 was sent out to a psychiatric facility for evaluation and treatment and that the facility was seeking placement for him at a facility with a male-only unit. She stated if R1 returned to the facility before placement was found, that he would be placed on one-to-one supervision until placement was found for him. On 07/03/24 at 04:33 PM Administrative Staff A stated abuse, neglect, and exploitation education was provided for staff during orientation and annually for all staff. Administrative Staff A stated R2 had a BIMS of zero (indicating severe cognitive impairment), but she could give yes or no answers that were consistent. Administrative Staff A stated when he spoke with R2 about the incident, he asked if R1 had touched her, or her mouth, and R2 stated no. Administrative Staff A stated that he asked R2 each question twice and was told no each time. Administrative Staff A stated he was not aware that R2 could answer questions, that R2 was probably better at responding during the day than in the evenings, and that when R2 normally tried to speak it was garbled sounds. Administrative Staff A stated R2 could not have gotten away from R1 without staff intervention, but staff responded to the incident when they heard her scream. Administrative Staff A stated R1 had not exposed himself to other residents at this facility prior to this incident and he had not heard of R1 exposing himself to staff prior to this incident. Administrative Staff A further stated when R1 first arrived at the facility they had not seen any behaviors from him so staff were just observing him, and if they saw anything they would address it moving forward, but he was not aware of anything in the facility prior to this incident. Administrative Staff A stated the incident between R1 and R2 would be considered abuse. Administrative Staff A further stated R1 was placed on one-to-one supervision and sent out to a psychiatric facility. He stated the plan moving forward was to find placement in an all-male unit. He stated the facility was working with R1's guardian to help in the process, and if R1 had to return before placement was found, that R1 would remain on one-to-one supervision until he could be placed at another facility. The facility provided an Abuse Prevention Program policy with a review date of 03/22/24, documenting the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. Identification of occurrences and patterns of potential mistreatment, abuse, neglect, and or misappropriation. The policy documented sexual abuse is non-consensual sexual contact of any type with a resident. The facility failed to prevent an incident of resident-to-resident sexual abuse when R1, exposed his genitals to cognitively impaired R2 who was unable to consent. This deficient practice placed the residents at risk for impaired psychosocial well-being including fear and embarrassment, and risk for ongoing sexual abuse. R2 screamed and demonstrated a negative reaction at the time of the abuse. The scope and severity were determined to be actual harm based on the reasonable person concept due to the circumstances of R2's cognitive impairment and inability to self-identify and express her feelings regarding the abuse.

The facility identified a census of 79 residents. The sample included three residents with two reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure Resident can 1 remained free from accidents when Certified Nurse Aide can (CNA) M propelled R1 down the hallway in her wheelchair, without a foot pedal for her right leg/foot. This caused R1's foot to get stuck under the wheelchair and resulted in a fracture (broken bone) to her right leg. The facility further failed to prevent accidents for R2 when CNA N failed to utilize two people with a Hoyer lift (total body mechanical lift) transfer which resulted in R2 slipping out of the lift sling and landing on the floor. This deficient practice placed R2 at risk for injuries and physical complications. Findings included: - The Diagnoses of R1's Electronic Medical Record (EMR) documented diagnoses of acquired absence of left leg above knee, other abnormalities of gait (manner or style of walk) and mobility, and generalized muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance with two staff for bed mobility, dressing, and toileting; supervision with setup help only for personal hygiene; and total dependence with two staff for transfers and locomotion. R1 had impairment on both sides for upper and lower extremities and used a wheelchair. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 15, which indicated intact cognition. R1 required extensive assistance with two staff for bed mobility, dressing, toileting, and personal hygiene; she required total dependence with one staff for locomotion on the unit, and locomotion off of the unit only occurred once or twice with one staff assistance. R1 was totally dependent on two staff for transfers. R1 had impairment on both sides for upper and lower extremities and used a wheelchair. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential CAA [CAA] dated 05/16/23, documented R1 needed extensive assistance of two staff for bed mobility and dressing; supervision with personal hygiene; and dependence with two staff for transfers, toileting, and bathing. R1 had impairment to both legs and used a wheelchair. R1's Care Plan dated 05/14/22 and revised 08/02/23, documented R1 needed extensive assistance of two staff for bed mobility, dressing, and personal hygiene. She was dependent on two staff for transfers, toileting, and bathing and required setup help and assistance as needed for meals. R1 had impairment to both legs and used a wheelchair. The Care Plan documented an intervention, initiated 05/14/22 and revised on 08/02/23, that directed R1 had right sided weakness, above the knee amputation of her left leg, and partial amputation of her right foot. The Care Plan documented an intervention initiated 05/14/22 that directed R1 was dependent on one staff for wheelchair use as she did not walk. An X-ray Report dated 11/25/23 for R1's right knee, performed in the hospital, revealed R1 had an area that was highly suspicious for a nondisplaced fracture of the proximal (nearer to a point of reference or attachment) tibia (one of two lower leg bones) and a computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) scan was suggested for further evaluation. The CT Scan Report for R1's right lower extremity dated 11/25/23, performed in the hospital, revealed R1 had a subtle, acute, nondisplaced transverse (perpendicular to the bone) fracture of the proximal tibia and subtle, acute, nondisplaced transverse fracture of the fibula (other bone in the lower leg). In a notarized Witness Statement on 11/27/23, CNA M stated on 11/25/23 around 07:45 AM, she just finished getting R1 dressed and into her wheelchair then went to check on another resident. When she came back, she offered to push R1 down to the small dining room for breakfast and asked R1 if she was ready to go. R1 asked for her purse and mask and when asked by CNA M again if she was ready to go. R1 stated yes, she was ready. CNA M stated they went down the hall and R1 picked up her foot on the way to the small dining area. She stated they were not even five feet into the dining room when R1 dropped her foot and screamed ow. CNA M stated she immediately stopped and asked R1 what was wrong to which R1 replied her ankle hurt and she thought she heard it crack. R1 stated she thought she needed an x-ray. CNA M stated she asked R1 if she needed her footrest and R1 stated yes. She stated she got R1's footrest and put it onto her wheelchair. While CNA M put it in place, R1 said ow, it hurts. CNA M stated she asked R1 if she was going to be okay and R1 repeated that she needed an x-ray. CNA M stated she told R1 she would put her in her normal spot at the table and tell the nurse what happened. CNA M stated the nurse proceeded to order the x-ray while R1 ate breakfast and around 09:30 AM, she asked to be taken back to her room. She stated she took R1 down the hall when R1 complained of pain; they asked the nurse when the x-ray would be done. The nurse stated whenever the x-ray people got there as there was no time frame. CNA M stated R1 said she needed to go to the hospital as she could not wait that long. CNA M noted she took R1 back to her room until transportation picked her up to take her to the hospital. On 11/29/23 at 12:53 PM, R1 sat in her wheelchair in her room with the right-side foot pedal in place and a knee/leg immobilizer on her right leg. She stated on 11/25/23 when her and CNA M came out of her room for breakfast, CNA M pushed her wheelchair but did not put her foot pedal on. R1 stated CNA M was pushing her down the hallway fast and she tried to keep her right leg up. When CNA M stopped to talk to a man in the dining room, R1's foot went to the floor because she was tired of holding it up. R1 stated she did not think CNA M was going to take off as fast as she did. When she pushed her to her table, R1's foot was dragging under the wheelchair, and she told CNA M to stop. R1 stated at that point, her right leg hurt bad, and she had heard it pop. On 11/29/23 at 02:03 PM, CNA M stated on 11/25/23, she got R1 dressed and in the wheelchair and put the pedal in place that R1 used for her short leg. She said she asked R1 if she needed anything else before going to the dining room and R1 wanted her purse and mask. CNA M asked her once more if she was ready to go and R1 said she was, and CNA M told her to pick her right foot up. CNA M stated she propelled R1 in her wheelchair down the hall and turned into the small dining room, but as they were walking in, she told another resident she might want to move. She stated as she was propelling R1, R1 yelled ow, ow it popped and CNA M stopped after R1 said ow and asked her if she wanted her footrest. CNA M stated R1 stated her right leg really hurt. She stated she told R1 she would put R1 in her spot then tell the nurse and R1 stated she wanted an x-ray. CNA M stated the nurse ordered the x-ray after breakfast, but R1 did not want to wait that long for the x-ray and wanted to go to the hospital. CNA M stated a couple of weeks prior, R1 had told her she did not like the right foot pedal because it made it hard to get close to the table when she ate in the small dining room. CNA M stated she was able to hold her foot up but at some point, she did end up dropping her leg and that was when she got the fracture. She stated she was educated that if staff pushed a resident in their wheelchair, they needed foot pedals regardless of the residents' wishes as it was safety first. On 11/29/23 at 02:17 PM, Licensed Nurse (LN) H stated staff kept residents safe during wheelchair propulsion by always using foot pedals, making sure nothing was dragging from the wheelchair, and watching their speed. On 11/29/23 at 02:28 PM, Administrative Nurse D stated on 11/25/23, the charge nurse called and reported that R1 hurt her foot while staff were pushing her in the wheelchair. She stated R1 did not want to wait for an x-ray and wanted to go to the hospital, so she was sent out. Administrative Nurse D stated CNA M said she did not use a foot pedal because R1 had requested she did not use it a couple of weeks ago. She stated she expected residents to have foot pedals on their wheelchairs during propulsion for safety if they were unable to hold their feet up. On 11/29/23 at 02:47 PM, Administrative Staff A stated he expected if staff were pushing a wheelchair, they used foot pedals to keep the resident safe. The facility's Accidents policy, dated 04/01/23, directed the facility ensured each resident received adequate supervision and assistive devices to prevent accidents. The facility failed to ensure R1 remained free from accidents when can M propelled R1 down the hallway in her wheelchair, without a foot pedal for her right leg/foot. This caused R1's foot to get stuck under the wheelchair and resulted in a fracture to her right leg. - The Diagnoses tab of R2's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (cerebrovascular accident [CVA] or 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) affecting right dominant side. The Annual Minimum Data Set (MDS) dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R2 required extensive assistance with two staff for bed mobility and personal hygiene; total dependence with one staff for transfers, locomotion, dressing, and toileting, and was independent with setup help only for eating. The Quarterly MDS dated [DATE], documented R2 had a BIMS score of 14, which indicated intact cognition. R2 was dependent with chair/bed-to-chair transfers and toilet transfers. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment [CAA] dated 01/18/23, documented R2 had a CVA with residual dysphasia (impairment in the production of speech) and right-sided deficits. R2's Care Plan dated 01/12/21 and revised on 07/24/23, documented R2 had limited range of motion in his right side due to stroke and he had hemiplegia. The Care Plan documented an intervention initiated 01/13/21 that directed R2 was dependent with assistance of two to three staff to turn in bed and transferred using a Hoyer lift. R2's EMR revealed a Nurses Note on 11/28/23 at 07:56 PM that documented CNA N yelled into the hallway she needed help now, R2 was on the floor. Licensed Nurse (LN) G and CNA O ran to R2's room and observed him laying over the legs of the Hoyer lift with sling still attached above him. R2 was left in the position he was observed in while LN G instructed CNA O to stay with R2 while she called emergency medical services (EMS). Per EMS instruction, staff were to leave R2 in the same position until they arrived. EMS arrived, assessed R2, and took him to the hospital. R2's EMR revealed a Nurses Note on 11/29/23 at 05:32 AM that documented R2 was admitted to the hospital for observation after the fall and was negative for fractures. In a notarized Witness Statement on 11/28/23, CNA N stated on 11/28/23, she was assisting R2 with a Hoyer lift transfer by herself to bed when she noticed the lift sling was up too far and not under his bottom far enough. She stated she pulled the lift sling down the best she could then proceeded to lift R2 into the air and pushed the lift and R2 over to the bed. CNA N stated once she got to the side of R2's bed, he started sliding out of the sling. She stated she tried to catch him but could not because she transferred him by herself for which she knew better. CNA N stated he never hit his head and did not yell like he was in pain. She stated she told R2 to give her a second because she needed help and she yelled for help in the hallway. CNA N stated the nurse, and another CNA came to R2's room to see what she was talking about. In a notarized Witness Statement on 11/28/23, LN G stated on 11/28/23, CNA N yelled into the hallway that she needed help now, R2 was on the floor. LN G stated she and CNA O ran to R2's room and observed him laying over the legs of the Hoyer lift with sling still attached above him. CNA N stated to the paramedics that she had moved R2 by herself and described how he slid out of the sling. On 11/29/23 at 02:03 PM, CNA M stated residents were kept safe during Hoyer lift transfers by using two people at all times, going slow and easy, and always making sure the resident was okay. She stated two people were used for Hoyer lift transfers because one staff used the machine while the other staff made sure the resident was positioned properly. On 11/29/23 02:17 PM, LN H stated staff kept residents safe during Hoyer transfers by communicating which straps on the sling were latched onto the lift, making sure the resident was positioned well before hooking them up, and always using two staff. She stated one staff stood in front of the resident and one behind the resident to watch their feet when lifting up and watching for pain. On 11/29/23 at 02:28 PM, Administrative Nurse D stated on 11/28/23, CNA N went into R2's room and he said he wanted to go to bed. She stated CNA N transferred R2 by herself and stated that she knew better, and the sling was up too high on his body. Administrative Nurse D stated she asked CNA N why she did not ask for help and CNA N stated she had no idea and that she knew better. Administrative Nurse D stated she expected staff to have two people at all times for Hoyer lift transfers, no exceptions. On 11/29/23 at 02:47 PM, Administrative Staff A stated he expected staff to always have two staff members present during Hoyer lift transfers. He stated two staff were used to make sure that the resident was safe, positioned correctly, and was kept steady while one staff controlled the lift and the other controlled the resident. The facility's Lifting Machine, Using a Mechanical policy, last revised July 2017, directed at least two nursing assistants were needed to safely move a resident with a mechanical lift. The facility failed to prevent accidents for R2 when CNA N failed to utilize two people with a Hoyer lift transfer which resulted in R2 falling out of the lift sling and landing on the floor. This deficient practice placed R2 at risk for injuries and physical complications.

The facility identified a census of 64. The sample included three residents reviewed for pressure ulcers Based on record review and interviews the facility failed to prevent a pressure injury to Resident (R) 1's left elbow. R1 admitted to the facility on [DATE] with a left humerus (bone of the upper arm) fracture and required a sling immobilizer at all times, except during bathing and dressing. The facility failed to remove R1's LUE immobilizer in order to thoroughly assess his skin. This deficient practice resulted in a stage four (pressure injury which extends full thickness through tissue to exposed bone and/or tendon) pressure injury to R1's left elbow. Findings included: - R1's electronic medical record (EMR) documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] recorded R1 had a Brief Interview for Mental Status (BIMS) score of eight which indicated cognitive impairment. He required extensive assistance of one to two staff for all activities of daily living (ADLs) except eating, for which he required set up assistance. The MDS documented R1 was at risk for developing pressure injuries. It recorded R1 had no pressure injuries on admission to the facility. The MDS documented R1 had a pressure reducing device for his bed. The Pressure Ulcer/Injury Care Area assessment dated [DATE] recorded R1 was at risk for pressure injuries related to immobility and increased need for assistance with ADLs. The Care Plan dated 07/27/20 recorded R1 had a self-care deficit. It stated R1 required total dependence on one staff member for showering twice weekly and as needed. R1 also required extensive assistance of one staff member for bed mobility and dressing. The Care Plan recorded R1 had incontinence and was at risk for impaired skin integrity and instructed staff to observe his skin during weekly skin assessments. The Care Plan lacked interventions related to the use of the immobilizer for the left upper extremity. It did not state interventions which directed staff on how and when to remove the immobilizer, and lacked interventions related to pressure reductions and prevention of pressure injuries related to a medical device. The Care Plan did not specify interventions related to positioning of R1 in his wheelchair for offloading. It also did not state interventions which directed staff on how to care for the wound, assessment of potential complications with regards to the wound including pain and infection. The Discharge Paperwork sent from the hospital to the facility recorded R1 had a [MEDICAL CONDITION] proximal humerus. It recommended that R1 remain in a shoulder immobilizer at all times besides bathing and dressing. He was non-weightbearing on the left upper extremity. The immobilizer was in place for four to six weeks. The paperwork also listed another physician's orders [REDACTED]. The paperwork listed the following physician orders, dated 07/08/20: Non weight bearing on the left upper extremity. May get up to the chair. The head of the bed elevated to 30 degrees for comfort only. Wrist range of motion (ROM) as tolerated. Elbow range of motion with removal of immobilizer for bathing and dressing. The Skin Observation Evaluation in the EMR dated 07/09/20 recorded bruising to the left upper arm. There was no mention of a wound to the elbow in this assessment. The Skin Observation Evaluation in the EMR dated 07/17/20 recorded a left arm bruise secondary to fracture and right arm bruising. There was no mention of a left elbow wound in this assessment. A Progress Note dated 07/19/20 documented R1's skin was warm and dry and the color was within normal limits. A Progress Note by Consultant Physician HH dated 07/21/20 recorded R1 was seen on that day to follow up for swelling of the left wrist and increased temperature. The document recorded left hand [MEDICAL CONDITION] (swelling) and bruising. Consultant HH documented he did not feel an x-ray was necessary. The West Side Bath Assignment sheet dated 07/22/20 recorded R1 had no skin issues. An Orthopedic (related to bone) Physician Assessment by Consultant Physician GG completed on 07/23/20 documented a physical exam which revealed R1 had a sling immobilizer to the left upper extremity. The document recorded a diagnostic study of two view x-rays revealed routine healing of the left proximal humerus fracture. The plan directed R1 to continue the sling immobilizer and continue no weightbearing status. It directed R1 to anticipate immobilization for six to eight weeks. The review of systems did not mention skin issues and only recorded hypertension (elevated blood pressure), [MEDICAL CONDITION], and [MEDICAL CONDITION]. The Skin Observation Evaluation in the EMR dated 07/29/20 recorded a bruise secondary to a fracture on the left arm and bruising to the right arm. There was no mention of a left elbow wound in this assessment. A Care Plan Note dated 08/04/20 documented R1's therapy was limited by restrictions to his left arm which was in an immobilizer. R1 leaned on his elbow while sitting per the note. An Occupational Therapy (OT) Treatment Encounter Note dated 08/04/20 documented OT provided R1 a wider wheelchair with a reclining back and a two-inch foam seat cushion. The note recorded the wheelchair allowed extra ROM for the left upper extremity (LUE) in the immobilizer. R1 leaned on the LUE in the prior wheelchair, had increased LUE [MEDICAL CONDITION], and inability to extend the left wrist. The note further recorded R1 frequently sat in a wheelchair for several hours a day, slept, and leaned to the left side which resulted in poor positioning. The Skin Observation Evaluation in the EMR dated 08/05/20 recorded a bruise secondary to a fracture on the left arm and bruising to the right arm. There was no mention of a left elbow wound in this assessment. An Orthopedic Physician Assessment by Consultant GG completed on 08/06/20 included the therapist had concerns about R1 related to the swelling in R1's LUE and his leaning sideways on the wheelchair arm. The physical exam recorded notable swelling in the distal left arm and elbow region. At the hand, R1 was unable to extend his thumb, wrist, and fingers. The impression documented radial nerve palsy (condition which causes weakness, pain or decreased function of the hand and wrist) of the left upper extremity, probable positional. The plan recorded Consultant GG suspected palsy was due to the sling strap being excessively tight versus positional with R1's leaning sideways on the wheelchair arm. The plan directed to discontinue the immobilizer and eliminate him leaning on that side. The Physical Therapy (PT) Treatment Encounter Note dated 08/06/20 recorded Therapist II spoke with Consultant GG regarding R1. The resident had a drop wrist with radial nerve palsy most likely from positioning and not the fracture. The note recorded Consultant GG suggested to ensure padding was present when R1 sat in the wheelchair due to left sided leaning. Review of the 7/27/20 Care Plan lacked revision with placement of the padding in R1's wheelchair for positioning or discontinuation of the immobilizer. The PT Treatment Encounter Note dated 08/07/20 recorded Therapist II noted [MEDICAL CONDITION] and warmth to R1's upper extremity. Therapist II notified nursing staff. On 08/10/20 at 04:24 PM, a Skin and Wound Evaluation assessment documented a medical device related pressure injury. It further recorded the wound was full thickness with skin and tissue loss, stage four, on the left elbow. The wound measured 3.9 centimeters (cm) in length and 2.6 cm in width. The wound bed was 50 percent (%) slough (dead tissue, usually cream or yellow in color) and 50% eschar (dead tissue). It also recorded evidence of infection as redness and inflammation. The note documented the wound had a moderate amount of bloody drainage and faint odor. The note also recorded [MEDICAL CONDITION] extending greater than four cm around the wound. The Order Report Summary, under the Orders tab in the EMR documented an order dated 08/10/20 for the wound care consulting company to evaluate and treat. The Order Report Summary listed an order, dated 08/10/20 ordered [MEDICATION NAME] ointment (enzyme prescribed to break town dead tissue in order to promote wound healing) applied to the left elbow topically every day for wound healing. It further noted to cleanse the wound with wound cleanser, apply calcium alginate (specialized absorbent dressing), apply a nickel thick layer of [MEDICATION NAME] ointment, and cover with a dry dressing. Progress Note Details recorded the wound assessment performed by the wound consultant company on 08/11/20. R1 was seen for evaluation and management of an undiagnosed wound/[MEDICAL CONDITION]. The wound assessment, in the note, documented a stage four pressure injury with measurements of 4.1 cm in length, 3 cm width, and 0.3 cm depth. Joint and adipose (fat tissue) were exposed. There was a moderate amount of yellow drainage noted which had a mild odor. The wound bed was 25% slough, 75-100% granulation (new tissue growth). The note also recorded the wound had symptoms of infection at the time of the visit. It also documented R1 had an ulcer caused from pressure that was full thickness tissue loss with exposed bone, tendon, or muscle. It noted the affected body part was immobile and also indicated nursing staff noted it was directly from positioning. It noted the nursing staff determined the area of breakdown was consistent with applied external force. The note documented debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) was performed to the left elbow wound at that time. The Order Report Summary , dated 08/11/20 ordered [MEDICATION NAME] (used to treat infection) ointment to the left elbow every day for the wound. It directed to cleanse with wound cleanser, put the ointment on the calcium alginate rope, stuff loosely into the wound edges on the left elbow, and then cover the center area with a bordered gauze. A PT Treatment Encounter Note dated 08/12/20 at 12:58 PM recorded Therapist II observed R1 with LUE [MEDICAL CONDITION], odor, and warm to touch when supine in bed. The note recorded R1 had increased confusion that day. A Skin Condition Note on 08/12/20 at 06:20 PM recorded R1 had a wound on his left elbow. The wound bed was pale with redness and bruising. Purulent (producing or containing pus) drainage was present with an odor. Staff performed wound treatment and R1 tolerated it well. A Progress Note recorded an assessment performed by Consultant HH on 08/13/20. The note recorded R1 had increased confusion and a urinalysis was pending. The note documented a wound to the left elbow and directed to continue wound care. A Nurse Note dated 08/15/20 at 01:31 PM recorded R1 had an elevated temperature. Staff notified Consultant HH and ordered R1 to go to the emergency room for evaluation and treatment. In an interview on 08/31/20 at 01:00 PM, Certified Nurse Aid (CNA) M stated R1 admitted on her hallway when he came to the building. She said staff removed R1's immobilizer to put his shirt on and the nurses looked at his skin at that time. CMA M provided care to R1 for the first 14 days and then he moved to a different hallway, out of isolation. CNA M stated when R1 was on her hallway his arm was good. She stated she heard he developed a wound. In an interview on 08/31/20 at 01:42 PM, Licensed Nurse (LN) G stated she was initially notified of the wound on 08/10/20. LN G said generally, the therapy department did everything regarding the immobilizer. The wound company came in the next day, did wound rounds, and debrided it at that time. When the wound consultant debrided it, it was to the bone. In an interview on 08/31/20 at 02:25 PM, LN H said she looked over the residents' skin weekly and made sure to document it. When someone had a splint, brace, or immobilizer, staff might elevate the area. LN H stated staff used the physician's orders [REDACTED]. Sometimes the orders say to remove the device at night, others say leave it on all the time. In that case, we just look at the skin and make sure that things are looking good. LN H stated she would periodically assess the skin of area affected by a splint or device. In an interview on 08/31/20 at 03:30 PM, Therapist JJ stated R1 had two different immobilizers and both were soft. She stated the area on R1's arm started out as a skin tear from his fall at home. Therapist JJ said therapy staff noted R1 developed [MEDICAL CONDITION] on the left arm and when they noted the [MEDICAL CONDITION], they immediately started to look for a bigger wheelchair. In an interview on 08/31/20 at 04:30 PM Administrative Nurse D stated staff should document everything noted on the skin and any new changes. She confirmed there should have been an order for [REDACTED]. Administrative Nurse D further revealed that she did not understand why the order for the immobilizer was not put into the chart and could not explain why it did not reflect on the MAR. She stated that she was not aware of a skin tear to R1s' elbow and the wound was not reported until 08/13/2020 to the wound care nurse. Administrative Nurse D further revealed that if an area is noted to be open by a nurse and therapist, she expected it to be documented in the chart. Administrative Nurse D verified, upon review of therapy documentation on 07/31/2020, R1 had [MEDICAL CONDITION] and an open are on his left elbow. Administrative Nurse D expected the doctor to be notified of the open area. Administrative Nurse D expected something to be noted in the chart for the device ordered. She stated the care plan did not represent an accurate picture of R1. She expected the care plan to reflect the immobilizer. The immobilizer would typically be placed on the care plan and then flow to the Kardex to alert staff. On 09/03/20 at 09:45 AM Consultant HH declined to comment on R1 or the situation, and stated he would need to check with the facility. The facility policy Preventative Skin Care Program revised 08/22/17 records the facility will implement preventative measures through ongoing monitoring of resident's at risk for skin breakdown. The resident's response to the preventative measures will be monitored and altered to meet resident's needs. The facility failed to ensure staff removed R1's LUE immobilizer in order to thoroughly assess his skin. This deficient practice resulted in a stage four pressure injury to R1, who was at risk for skin breakdown.

F225 -IJ The facility identified a census of 77 residents. Three residents were sampled. Based upon observation, interview, and record review, the facility failed to protect the 53 opposite gender residents from resident (#1) from repeated inappropriately sexually touching opposite gender cognitively impaired resident (#2). This deficient practice placed the 53 opposite gender residents in immediate jeopardy. The facility also failed to report and investigate these allegations of abuse. Findings included: -The Physician ' s Order Sheet dated 09/30/16 recorded resident #1 ' s [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] recorded resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, moderate cognitive impairment, was able to make him/herself understood and understood others, and exhibited no signs of [MEDICAL CONDITION]. The resident rejected cares and exhibited wandering behaviors which significantly intruded on the privacy or activities of others. The resident required limited assistance of one person for transfers used a wheelchair and/or walker for mobility. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 6, severe cognitive impairment, exhibited physical behavioral symptoms directed towards others, and rejected care. The resident was independent with transfers. The resident ' s balance was not steady, but he/she was able to stabilize without staff assistance and used a wheelchair and/or walker for mobility. The Care Area Assessment (CAA) for Activities of Daily Living (ADL) function dated 07/12/16 recorded the resident had impaired judgement. Review of the care plan titled Behavior Management Plan Data Sheet dated 10/12/16 recorded the resident ' s behaviors exhibited included territorial and protective of space; physically inappropriate behaviors, placing his/her hand on the leg of a resident of the opposite sex without consent, , and placing his/her hand inside the clothing of a resident of the opposite sex and on outside of that resident ' s pants on the thigh/pelvis area. The identified triggers included dementia, mild cognitive impairment, mood disorder, and history of [MEDICAL CONDITION]. The measures to avoid these resident behaviors included maintain routines; explain any changes prior to occurring such as a new tablemate, or seating; and redirect quickly, firmly, and clearly. The interventions recorded to manage behaviors included: staff observation in high activity areas such as the dining room, halls, and activity room; ask how he/she was feeling and listen nonjudgmentally; notify the nurse of any threatening or aggressive verbalizations; respond firmly and clearly with simple sentences such as That behavior would not be acceptable ; notify his/her family member of concerns or issues as the family member was very involved and supportive, and the resident respected and observed the family member ' s direction and advice. On 10/26/16 revision of the care plan included of one to one (1:1) caregiver/observation continuous to avoid contact with residents of the opposite sex, with continued ability to move as desired in the facility and attend activities of choice with 1:1 caregiver, and do not allow seating next to residents of the opposite sex. The care plan for psychosocial well-being dated 7/20/16 recorded the resident ' s psychosocial well-being was altered and the resident was at risk for further decline. An undated intervention documented the resident was friendly with resident of the opposite sex who lived in the facility, sat with him/her by the nursing station and they held hands, consensual and both residents ' families were aware and enjoyed the company of my friend . Staff discontinued the intervention on 10/24/16 due to the resident of the opposite sex transferred to another facility. Staff implemented a new intervention to facilitate telephone calls to friend at the new location. The resident required frequent reminders about interactions with residents of the opposite sex was not appropriate to place his/her hand on the knees of others without their consent with a onetime occurrence with no further issues also discontinued 10/24/16. The care plan revision on 10/30/16 documented 1:1 caregiver/observation, caregiver to encourage resident to interact in small groups or individualized activities, the caregiver was to monitor for close proximity with residents of the opposite sex, offer outside activities in good weather, engage in conversation, and reinforce time reality. Review of the Physician ' s Telephone orders revealed: 9/26/16 [MEDICATION NAME] (a medication used to improve cognition and behavior of people with Alzheimer's) 5 milligrams (mg) orally every day at bedtime for one month the 10 mg orally every day at bedtime 10/9/16 Send to emergency room for behavior/psychiatric evaluation 10/10/16 Psychological evaluation and treatment for [REDACTED]. 10/27/16 Discontinue [MEDICATION NAME] Review of the Psychiatric Services Note dated 9/26/16 documented the patient had been touching a resident of the opposite sex. The nursing staff had talked to him/her and he/she apparently stopped. The resident was guarded, seemed suspicious today, a poor listener, and poor memory. The resident had a resident of the opposite sex as close friend and did not attend any activities. The physician recorded [DIAGNOSES REDACTED]. Review of the Psychology Practice note dated 10/10/16 documented the patient was referred for evaluation of anxiety/inappropriate behavior. The patient was alert and cooperative. The responses were uniformly brief and often non-committal. The plan was to provide psychotherapy to assist the resident with behavioral stability and confusion/disorientation. Review of the nursing note dated 9/13/16 timed 1:00 P.M. as a late entry for 9/12/16 at 10:30 A.M. documented the resident sat by the nurses ' station when staff observed the resident touching a resident (#2) of the opposite sex on his/her thighs and private area. A certified nursing assistant (CNA) that noticed this asked him/her to stop and moved the resident of the opposite sex away from resident #1. Less than two minutes later resident #1 had moved near resident #2 again and had his/her hand in the inner thighs or private area on top of the other resident ' s pants. The writer talked to resident #1 and told him/her that he/she could not do that and moved resident #2 to the television/activities room. Staff notified the Director of Nursing and Unit Manager. Staff continued to monitor the residents to prevent this from happening. The clinical record lacked documentation of how staff monitored the resident or what interventions were put in place to prevent further incidents. Nursing note dated 10/27/16 at 11:25 A.M. recorded staff notified the physician that resident #1 had increased inappropriate sexual behavior and a recent altercation with another resident on 10/19/16. The physician ordered to discontinue the medication [MEDICATION NAME] and continue to monitor behaviors at this time. Nursing note dated 10/28/16 timed 9:00 P.M. recorded the resident inappropriately touched cognitively impaired unidentified opposite gender residents and staff placed the resident on 1:1 supervision. During an observation on 11/7/16 at 9:26 A.M. the resident laid on his/her back in bed with his/her eyes closed. Staff sat beside the bed in a chair. During an observation on 11/7/16 at 5:10 P.M. the resident sat in a wheelchair in the dining room eating the evening meal. Staff sat in a chair at the table with the resident. During an observation on 11/8/16 at 9:14 A.M. the resident laid on the bed with eyes closed. The room lights were out and staff sat in a chair at his/her bedside. During a private interview with resident #1 on 11/8/16 at 12:34 P.M. the resident had a puzzled facial expression when asked by this surveyor about touching a resident of the opposite sex inappropriately. He/she reported no recollection of touching another resident. The resident had a flat affect(lack of emotional expression), and his/her answers to questions were brief. He/she acknowledge a resident of the opposite sex friend who had moved from the facility, when asked by this surveyor, stated had not seen him/her in months . When asked about concerns he/she may have, he/she stated he/she was concerned about allegations may be facing, who wouldn ' t be? During an interview on 11/7/16 at 9:26 A. M. direct care staff O, revealed he/she was currently assigned as the 1:1 caregiver, and had never witnessed the resident touch another resident inappropriately. Review of the facility ' s investigation identified three separate dates when the resident had touched a cognitively impaired resident of the opposite sex inappropriately, the dates and result of the investigation are as listed below: Review of the facility ' s investigation for the resident-to-resident sexual abuse which occurred on 9/12/16 revealed a notarized witness statement dated 10/28/16 by direct care staff P which recorded he/she witnessed resident #1 seated in a wheelchair with his/her back to the nursing station and resident #2 seated closely in a wheelchair faced towards resident #1. Resident #1 pushed on resident #2 ' s pelvic area with his/her left hand and was messing with resident #2. The witness statement documented the staff reported this occurrence to license nursing staff H. During an interview on 11/7/16 at 9:38 A.M. licensed nursing staff H reported on 9/12/16, direct care staff P reported resident #1 was attempting to touch resident #2, while both residents sat in wheelchairs at the nursing station. Direct care staff P moved resident #2 away from resident #1, but both residents remained at the nursing station. Licensed nursing staff H reported he/she was observing the residents and witnessed resident #1 with his/her flat hand at the waistline on top of clothing of resident #2, and by the time he/she stepped over to intervene, resident #1 had slid his/her hand down between resident #2 ' s legs on top of the clothing. He/she placed resident #2 in the activity room and reported the incident to the director on nursing (DON) immediately. Licensed nursing staff H reported staff placed the resident on 1:1 staff observation on 10/26/2016. During an interview on 11/7/16 at 12:48 P.M. administrative nursing staff E reported he/she did not recall the exact date, but staff reported to him/her that resident #1 placed his/her hand placed on resident #2 ' s leg, on the upper thigh area. He/she reportedly spoke with the resident about the occurrence, they discussed the fact this was inappropriate behavior with a cognitively impaired resident. Resident #1 reported understanding of the conversation and he/she had not witnessed any further touching between the two residents since that conversation. On 11/8/16 administrative nursing staff E reported he/she observed resident #1 seated at the nurses ' station and resident #2 approached him/her on the right side and reached out his/her hand and resident #1 reached back and they held hands. Resident #1 sat next to an identified friend, another resident, and when the friend reacted negatively of resident #1 holding resident #2 ' s hand, resident #1 told resident #2 to stop. The friend did not like resident #1 holding resident #2 ' s hand He/she further reported being notified of the incident of touching which occurred on 9/12/16 involving resident #1 and resident #2. Administrative nursing staff E spoke with resident #1 privately and informed him/her that residents with dementia were not able to consent to touching; touching a resident of the opposite sex in any way without their consent could potentially be deemed as a sexual predator, or could be considered abuse and was not allowed. Resident #1 verbalized understanding and reported he/she would not do it again. Review of the facility investigation for the resident-to-resident sexual abuse which occurred on 10/19/16: On 11/7/16 at 12:56 P.M. direct care staff Q revealed on 10/19/16 he/she was alerted by dietary aid DD who stated look he/she ' s rubbing his/her belly He/she observed resident #1 sitting with his/her back to the nursing station, resident #2 was seated facing direct care staff Q with his/her hand placed on the belly of resident #2 inside his/her shirt. Direct care staff Q stated the nurse informed resident #1 no you can ' t do that and either the nurse or the resident removed the resident ' s hand from under the shirt. Dietary staff DD witness statement dated 10/30/16 reported one resident was next to another and he/she put his/her hand inside the other resident ' s pants. During an interview on 11/7/16 at 2:09 P.M. dietary staff DD reported he/she witnessed resident #1 touch resident #2 ' s belly under his/her shirt and reported it to direct care staff Q whom he/she thought was the nurse in charge. Review of the facility investigation for the resident-to-resident sexual abuse which occurred on 10/24/16: During an interview on 11/7/16 at 2:03 P.M. dietary staff EE reported he/she heard dietary staff FF talking to another employee about resident #1 attempting to place his/her hand up resident #2 ' s clothing or something, and instructed dietary staff FF to report the observation to the Director of Nursing and Administrator. He/she called the Director of Nursing personally and reported dietary staff FF had something he/she needed to report to her. On 11/7/16 at 2:16 P.M. dietary staff FF confirmed his/her notarized witness statement dated 10/28/16 reported when delivering the snack cart at 7:30 P.M. on Monday evening he/she witnessed resident #1 place his/her hand in resident #2 ' s pants. Resident #2 had his/her shirt pulled up and you could see his/her stomach, and resident #1 had his/her hand under resident 2 ' s pants. He/she asked resident #1 what he/she was doing and to stop doing it. Resident #1 reported to have responded verbally negative and left the activity room. Dietary staff FF did not report incident to anyone that evening, but reported it to administrative nursing staff E the next day while in the dining room. On 11/8/16 administrative nursing staff E confirmed his/her notarized witness statement dated 10/28/16 reported he/she was not notified at any time of the 10/28/16 incident. He/she further reported that he/she had observed the nursing note on 10/26/16 dated 9/12/16, it was the first time he/she had seen or heard the words private area regarding the 9/12/16 resident-to-resident incident. During an interview on 11/7/16 at 10:57 A.M. administrative staff A, administrative nursing staff D, and administrative nursing staff F reported on 10/27/16 while obtaining witness statements for another investigation, nursing administration revealed that resident #1 touched resident #2 not on the leg, but the private area on 9/12/16. Administrative nursing staff D stated licensed nursing staff H notified him/her, but was under the impression it had been on the upper thigh area. He/she had instructed administrative nursing staff E to speak to resident #1 personally. Administrative nursing staff E reported back to administrative nursing staff D with a reenactment of his/her hand placed in the inner knee area. The investigation revealed two other occurrences of resident-to-resident sexual abuse on 10/12/16 and 10/24/16. Staff placed the resident on1:1 supervision on 10/26/16. During an interview on 11/8/16 at 1:04 P.M. administrative nursing staff F stated that while he/she did not see the immediate jeopardy, he/she acknowledged non-compliance on the part of the facility, and the facility had identified the concern, which was brought to light during another investigation. Although staff received education a month earlier, staff needed more education so administrative nursing staff F initiated the education. The facility educated all staff on Abuse, Neglect, and Exploitation reporting. Staff interviewed all verbal residents, and completed head to toe skin assessments. Review of the facility policy dated 6/14/11 recorded sexual abuse defined as an act of a sexual nature committed for the sexual gratification of the abuser and in the presence of a person without the person ' s informed consent. In the event inappropriate sexual behaviors were exhibited by a resident, the staff member ' s first responsibility was to protect the involved residents and/or other residents who were present or had the potential to come into contact with the suspected perpetrator. The facility failed to protect residents of the opposite gender from sexual abuse by a resident with a history of inappropriate touching behavior. This deficient practice placed 53 residents of the opposite gender in immediate Jeopardy. This deficient practice was past non-compliance based on staff interventions on November 2, 2016, when the facility placed resident #1 on continuous 1:1 staff observation until placement in a facility with a behavioral health unit could be obtained. Resident #1 would have a mental health consultation with support services weekly. Staff interviewed every resident with a BIMS score of 8 or higher to insure their safety. All residents with documented behaviors had their care plan reviewed and updated as appropriate. The facility in-serviced all staff on Abuse, Neglect, and Exploitation (ANE) with an emphasis on reporting, unusual event notification, and alleged or suspicion of ANE.

The facility identified a census of 77 residents. Three residents were sampled. Based upon observation, interview, and record review, the facility failed to provide an environment free from abuse when staff failed to prevent resident (#1) from inappropriately sexually touching (other gender resident) #2 on 9/12/16, 10/19/16 and 10/24/16. This deficient practice placed cognitively impaired resident (#2) in immediate jeopardy. Findings included: -The Physician ' s Order Sheet dated 09/30/16 recorded resident #1 ' s [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] recorded resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, moderate cognitive impairment, was able to make him/herself understood and understood others, and exhibited no signs of [MEDICAL CONDITION]. The resident rejected cares and exhibited wandering behaviors which significantly intruded on the privacy or activities of others. The resident required limited assistance of one person for transfers used a wheelchair and/or walker for mobility. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 6, severe cognitive impairment, exhibited physical behavioral symptoms directed towards others, and rejected care. The resident was independent with transfers. The resident ' s balance was not steady, but he/she was able to stabilize without staff assistance and used a wheelchair and/or walker for mobility. The Care Area Assessment (CAA) for Activities of Daily Living (ADL) function dated 07/12/16 recorded the resident had impaired judgement. Review of the care plan titled Behavior Management Plan Data Sheet dated 10/12/16 recorded the resident ' s behaviors exhibited included territorial and protective of space; physically inappropriate behaviors, placing his/her hand on the leg of a resident of the opposite sex without consent, and placing his/her hand inside the clothing of a resident of the opposite sex and on outside of that resident ' s pants on the thigh/pelvis area. The identified triggers included dementia, mild cognitive impairment, mood disorder, and history of [MEDICAL CONDITION]. The measures to avoid these resident behaviors included maintain routines; explain any changes prior to occurring such as a new tablemate, or seating; and redirect quickly, firmly, and clearly. The interventions recorded to manage behaviors included: staff observation in high activity areas such as the dining room, halls, and activity room; ask how he/she was feeling and listen nonjudgmentally; notify the nurse of any threatening or aggressive verbalizations; respond firmly and clearly with simple sentences such as That behavior would not be acceptable ; notify his/her family member of concerns or issues as the family member was very involved and supportive, and the resident respected and observed the family member ' s direction and advice. On 10/26/16 revision of the care plan included of one to one (1:1) caregiver/observation continuous to avoid contact with residents of the opposite sex, with continued ability to move as desired in the facility and attend activities of choice with 1:1 caregiver, and do not allow seating next to residents of the opposite sex. The care plan for psychosocial well-being dated 7/20/16 recorded the resident ' s psychosocial well-being was altered and the resident was at risk for further decline. An undated intervention documented the resident was friendly with resident of the opposite sex who lived in the facility, sat with him/her by the nursing station and they held hands, consensual and both residents ' families were aware and enjoyed the company of my friend . Staff discontinued the intervention on 10/24/16 due to the resident of the opposite sex transferred to another facility. Staff implemented a new intervention to facilitate telephone calls to friend at the new location. The resident required frequent reminders about interactions with residents of the opposite sex was not appropriate to place his/her hand on the knees of others without their consent with a onetime occurrence with no further issues also discontinued 10/24/16. The care plan revision on 10/30/16 documented 1:1 caregiver/observation, caregiver to encourage resident to interact in small groups or individualized activities, the caregiver was to monitor for close proximity with residents of the opposite sex, offer outside activities in good weather, engage in conversation, and reinforce time reality. Review of the Physician ' s Telephone orders revealed: 9/26/16 [MEDICATION NAME] (a medication used to improve cognition and behavior of people with Alzheimer's) 5 milligrams (mg) orally every day at bedtime for one month the 10 mg orally every day at bedtime 10/9/16 Send to emergency room for behavior/psychiatric evaluation 10/10/16 Psychological evaluation and treatment for [REDACTED]. 10/27/16 Discontinue [MEDICATION NAME] Review of the Psychiatric Services Note dated 9/26/16 documented the patient had been touching a resident of the opposite sex. The nursing staff had talked to him/her and he/she apparently stopped. The resident was guarded, seemed suspicious today, a poor listener, and poor memory. The resident had a resident of the opposite sex as close friend and did not attend any activities. The physician recorded [DIAGNOSES REDACTED]. Review of the Psychology Practice note dated 10/10/16 documented the patient was referred for evaluation of anxiety/inappropriate behavior. The patient was alert and cooperative. The responses were uniformly brief and often non-committal. The plan was to provide psychotherapy to assist the resident with behavioral stability and confusion/disorientation. Review of the nursing note dated 9/13/16 timed 1:00 P.M. as a late entry for 9/12/16 at 10:30 A.M. documented the resident sat by the nurses ' station when staff observed the resident touching a resident (#2) of the opposite sex on his/her thighs and private area. A certified nursing assistant (CNA) that noticed this asked him/her to stop and moved the resident of the opposite sex away from resident #1. Less than two minutes later resident #1 had moved near resident #2 again and had his/her hand in the inner thighs or private area on top of the other resident ' s pants. The writer talked to resident #1 and told him/her that he/she could not do that and moved resident #2 to the television/activities room. Staff notified the Director of Nursing and Unit Manager. Staff continued to monitor the residents to prevent this from happening. The clinical record lacked documentation of how staff monitored the resident or what interventions were put in place to prevent further incidents. Nursing note dated 10/27/16 at 11:25 A.M. recorded staff notified the physician that resident #1 had increased inappropriate sexual behavior and a recent altercation with another resident on 10/19/16. The physician ordered to discontinue the medication [MEDICATION NAME] and continue to monitor behaviors at this time. Nursing note dated 10/28/16 timed 9:00 P.M. recorded the resident inappropriately touched cognitively impaired unidentified opposite gender residents and staff placed the resident on 1:1 supervision. During an observation on 11/7/16 at 9:26 A.M. the resident laid on his/her back in bed with his/her eyes closed. Staff sat beside the bed in a chair. During an observation on 11/7/16 at 5:10 P.M. the resident sat in a wheelchair in the dining room eating the evening meal. Staff sat in a chair at the table with the resident. During an observation on 11/8/16 at 9:14 A.M. the resident laid on the bed with eyes closed. The room lights were out and staff sat in a chair at his/her bedside. During a private interview with resident #1 on 11/8/16 at 12:34 P.M. the resident had a puzzled facial expression when asked by this surveyor about touching a resident of the opposite sex inappropriately. He/she reported no recollection of touching another resident. The resident had a flat affect(lack of emotional expression), and his/her answers to questions were brief. He/she acknowledge a resident of the opposite sex friend who had moved from the facility, when asked by this surveyor, stated had not seen him/her in months . When asked about concerns he/she may have, he/she stated he/she was concerned about allegations may be facing, who wouldn ' t be? During an interview on 11/7/16 at 9:26 A. M. direct care staff O, revealed he/she was currently assigned as the 1:1 caregiver, and had never witnessed the resident touch another resident inappropriately. Review of the facility ' s investigation identified three separate dates when the resident had touched a cognitively impaired resident of the opposite sex inappropriately, the dates and result of the investigation are as listed below: Review of the facility ' s investigation for the resident-to-resident sexual abuse which occurred on 9/12/16 revealed a notarized witness statement dated 10/28/16 by direct care staff P which recorded he/she witnessed resident #1 seated in a wheelchair with his/her back to the nursing station and resident #2 seated closely in a wheelchair faced towards resident #1. Resident #1 pushed on resident #2 ' s pelvic area with his/her left hand and was messing with resident #2. The witness statement documented the staff reported this occurrence to license nursing staff H. During an interview on 11/7/16 at 9:38 A.M. licensed nursing staff H reported on 9/12/16, direct care staff P reported resident #1 was attempting to touch resident #2, while both residents sat in wheelchairs at the nursing station. Direct care staff P moved resident #2 away from resident #1, but both residents remained at the nursing station. Licensed nursing staff H reported he/she was observing the residents and witnessed resident #1 with his/her flat hand at the waistline on top of clothing of resident #2, and by the time he/she stepped over to intervene, resident #1 had slid his/her hand down between resident #2 ' s legs on top of the clothing. He/she placed resident #2 in the activity room and reported the incident to the director on nursing (DON) immediately. Licensed nursing staff H reported staff placed the resident on 1:1 staff observation on 10/26/2016. During an interview on 11/7/16 at 12:48 P.M. administrative nursing staff E reported he/she did not recall the exact date, but staff reported to him/her that resident #1 placed his/her hand placed on resident #2 ' s leg, on the upper thigh area. He/she reportedly spoke with the resident about the occurrence, they discussed the fact this was inappropriate behavior with a cognitively impaired resident. Resident #1 reported understanding of the conversation and he/she had not witnessed any further touching between the two residents since that conversation. On 11/8/16 administrative nursing staff E reported he/she observed resident #1 seated at the nurses ' station and resident #2 approached him/her on the right side and reached out his/her hand and resident #1 reached back and they held hands. Resident #1 sat next to an identified friend, another resident, and when the friend reacted negatively of resident #1 holding resident #2 ' s hand, resident #1 told resident #2 to stop. The friend did not like resident #1 holding resident #2 ' s hand He/she further reported being notified of the incident of touching which occurred on 9/12/16 involving resident #1 and resident #2. Administrative nursing staff E spoke with resident #1 privately and informed him/her that residents with dementia were not able to consent to touching; touching a resident of the opposite sex in any way without their consent could potentially be deemed as a sexual predator, or could be considered abuse and was not allowed. Resident #1 verbalized understanding and reported he/she would not do it again. Review of the facility investigation for the resident-to-resident sexual abuse which occurred on 10/19/16: On 11/7/16 at 12:56 P.M. direct care staff Q revealed on 10/19/16 he/she was alerted by dietary aid DD who stated look he/she ' s rubbing his/her belly He/she observed resident #1 sitting with his/her back to the nursing station, resident #2 was seated facing direct care staff Q with his/her hand placed on the belly of resident #2 inside his/her shirt. Direct care staff Q stated the nurse informed resident #1 no you can ' t do that and either the nurse or the resident removed the resident ' s hand from under the shirt. Dietary staff DD witness statement dated 10/30/16 reported one resident was next to another and he/she put his/her hand inside the other resident ' s pants. During an interview on 11/7/16 at 2:09 P.M. dietary staff DD reported he/she witnessed resident #1 touch resident #2 ' s belly under his/her shirt and reported it to direct care staff Q whom he/she thought was the nurse in charge. Review of the facility investigation for the resident-to-resident sexual abuse which occurred on 10/24/16: During an interview on 11/7/16 at 2:03 P.M. dietary staff EE reported he/she heard dietary staff FF talking to another employee about resident #1 attempting to place his/her hand up resident #2 ' s clothing or something, and instructed dietary staff FF to report the observation to the Director of Nursing and Administrator. He/she called the Director of Nursing personally and reported dietary staff FF had something he/she needed to report to her. On 11/7/16 at 2:16 P.M. dietary staff FF confirmed his/her notarized witness statement dated 10/28/16 reported when delivering the snack cart at 7:30 P.M. on Monday evening he/she witnessed resident #1 place his/her hand in resident #2 ' s pants. Resident #2 had his/her shirt pulled up and you could see his/her stomach, and resident #1 had his/her hand under resident 2 ' s pants. He/she asked resident #1 what he/she was doing and to stop doing it. Resident #1 reported to have responded verbally negative and left the activity room. Dietary staff FF did not report incident to anyone that evening, but reported it to administrative nursing staff E the next day while in the dining room. On 11/8/16 administrative nursing staff E confirmed his/her notarized witness statement dated 10/28/16 reported he/she was not notified at any time of the 10/28/16 incident. He/she further reported that he/she had observed the nursing note on 10/26/16 dated 9/12/16, it was the first time he/she had seen or heard the words private area regarding the 9/12/16 resident-to-resident incident. During an interview on 11/7/16 at 10:57 A.M. administrative staff A, administrative nursing staff D, and administrative nursing staff F reported on 10/27/16 while obtaining witness statements for another investigation, nursing administration revealed that resident #1 touched resident #2 not on the leg, but the private area on 9/12/16. Administrative nursing staff D stated licensed nursing staff H notified him/her, but was under the impression it had been on the upper thigh area. He/she had instructed administrative nursing staff E to speak to resident #1 personally. Administrative nursing staff E reported back to administrative nursing staff D with a reenactment of his/her hand placed in the inner knee area. The investigation revealed two other occurrences of resident-to-resident sexual abuse on 10/12/16 and 10/24/16. Staff placed the resident on 1:1 supervision on 10/26/16. During an interview on 11/8/16 at 1:04 P.M. administrative nursing staff F stated that while he/she did not see the immediate jeopardy, he/she acknowledged non-compliance on the part of the facility, and the facility had identified the concern which was brought to light during another investigation. Although staff received education a month earlier, staff needed more education so administrative nursing staff F initiated the education. The facility educated all staff on Abuse, Neglect, and Exploitation reporting. Staff interviewed all verbal residents, and completed head to toe skin assessments. Review of the facility policy dated 6/14/11 recorded sexual abuse defined as an act of a sexual nature committed for the sexual gratification of the abuser and in the presence of a person without the person ' s informed consent. In the event inappropriate sexual behaviors were exhibited by a resident, the staff member ' s first responsibility was to protect the involved residents and/or other residents who were present or had the potential to come into contact with the suspected perpetrator. The facility failed to ensure cognitively impaired resident #2 ' s environment was from sexual abuse by a resident with a history of inappropriate touching behavior. This deficient practice placed resident #2 in immediate Jeopardy. This deficient practice was past non-compliance based on staff interventions on November 2, 2016, when the facility placed resident #1 on continuous 1:1 staff observation until placement in a facility with a behavioral health unit could be obtained. Resident #1 would have a mental health consultation with support services weekly. Resident #2 had a social services assessment on 10/27/16 and repeated on 11/2/16 to assess for any emotional distress. Staff interviewed every resident with a BIMS score of 8 or higher to insure their safety. All residents with documented behaviors had their care plan reviewed and updated as appropriate. All facility staff were in-serviced on Abuse, Neglect, and Exploitation (ANE) with an emphasis on reporting, unusual event notification, and alleged or suspicion of ANE.

The facility identified a census of 77 residents, and the sample size was 24, with 3 residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to develop and implement appropriate interventions to prevent the development and worsening of two stage 2 ulcers one which progressed to unstageable for resident #43. The facility also failed to implement planned interventions and failed to follow physician's orders [REDACTED].#55. Findings Included: - Review of resident #43's unsigned physician order [REDACTED]. Review of the annual MDS (Minimum Data Set) dated 10/28/15 documented a BIMS (Brief Interview for Mental Status) score of 2, which indicated severe cognitive impairment. He/she did not exhibit any behaviors. The resident required extensive assistance of two staff for bed mobility, transfer, dressing, and toileting; walking in room and corridor did not occur; extensive assistance of one staff with locomotion on and off the unit and personal hygiene; and independent with setup only for eating. The resident had a Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) or greater ulcer, was at risk for pressure ulcers, and had one or more unhealed pressure ulcers at Stage 1 or higher, one Stage 2 (partial thickness loss of dermis presented as a shallow open ulcer with a red or pink wound bed, without slough (a mass of dead tissue separating from an ulcer) and could also present as an intact or open/ruptured blister) ulcer that was present on admission. The resident had interventions of a pressure reducing device for the chair and bed, received nutrition and hydration interventions, and pressure ulcer care of nonsurgical dressings, ointments, and medications. The resident was not on a turning and repositioning program. Review of the quarterly MDS (Minimum Data Set) dated 1/6/16 documented a BIMS score of 4, which indicated severe cognitive impairment. The resident required extensive assistance with two staff for bed mobility, transfer, and toileting; walking in room and corridor did not occur; supervision of one staff with locomotion on the unit; locomotion off the unit occurred only once or twice with one staff assistance; and extensive assistance of one staff with dressing, eating, and personal hygiene. The resident had a Stage 1 or greater pressure ulcer, was at risk for pressure ulcers, had two Stage 2 pressure ulcers, one of which was present on admitted d 10/21/15, and one unstageable/deep tissue injury. The resident had interventions of a pressure reducing device for the chair and bed, nutrition and hydration interventions, and pressure ulcer care of nonsurgical dressings, ointments, and medications. Review of the Cognitive Loss/Dementia CAA (Care Area Assessment) dated 11/3/15 documented the resident admitted after a hospital stay for altered mental status, dementia, and paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking). The resident required extensive assistance of two staff for activities of daily living (ADLs) and mobility. Review of the Pressure Ulcer CAA dated 11/3/15 documented the resident had a history of [REDACTED]. He/she had a right leg prosthesis from a right [MEDICAL CONDITION], and required extensive assist for keeping skin clean and dry. He/she was at risk for developing a pressure ulcer and had a pressure ulcer on 10/23/15. The Initial care plan dated 10/21/15 documented the resident was incontinent of urine and bowel and staff were to check every 2 hours for incontinence, provide protective skin care with every episode of incontinence, assess skin condition with skin review, implement assessment process for bowel and bladder incontinence, and assist with transferring, ambulation, and bed mobility. The Pressure Ulcer care plan dated 11/10/15 documented he/she was at risk for pressure ulcers with left malleolus (a bony projection with a shape likened to a hammer head, especially each of those on either side of the ankle) present on admission, left heel found on 1/1/16, and buttock ulcer found on 1/14/16. The care plan instructed staff to use pressure relief devices such as float (elevate) heels, chair cushion, moisture barrier or lotion, observe skin condition for changes, provide treatments as ordered by physician, nutritional interventions per physician order, Physical and Occupational Therapy to screen, evaluate, and treat as ordered; offer hydration with toileting and incontinent care, evaluate for pain prior to dressing change and medicate as ordered, continue weekly skin assessments, and report any areas to the nurse. The Nutritional Care plan dated 11/10/15 documented nutritional concerns related to diabetes, ulcers, therapeutic diet, and edentulous (lacking natural teeth) with dentures. The care plan (instructed staff to serve diet as ordered, weights monthly, place on NAR (Nutritional at Risk Plan), identify likes and dislikes, provide supplements as ordered, labs as ordered, encourage family support with diet limitations, observe for signs and symptoms of dehydration, discomfort or condition changes; dietitian to evaluate as needed. The Incontinent of Bowel care plan dated 11/10/15 documented he/she was at risk for skin breakdown and constipation, to use incontinent pads for the bed, provide briefs and assist with placement, and provide preventative skin care as ordered. The Incontinent of Bladder care plan dated 11/10/15 documented the resident was at risk for further skin breakdown, and instructed staff to check for incontinent episodes frequently. The resident would participate in the habit toileting program, and staff would provide briefs and assist with placement, use incontinent pads for bed, and provide preventative skin care as ordered. The ADL Care plan dated 11/10/15 documented the resident required extensive assist of two staff with toileting and one staff assistance with personal hygiene and bathing. The Braden Scale score dated 10/21/15 was 16 which indicated the resident was at risk for skin breakdown. The Speciality mattress screen dated 10/21/15 documented based on the resident's current overall physical condition and risk factors, he/she could not benefit from the use of a speciality mattress. The Unavoidable Pressure Ulcer Clinical Condition Algorithm dated 10/22/15 documented the resident did not have any of the primary risk factors for developing unavoidable pressure ulcers. Order dated 11/24/15 documented staff would perform a skin assessment weekly on Tuesday on the 7-PM shift. The resident would use a wheelchair cushion to reduce pressure and staff would elevate heels with pillows/heel bench to relieve pressure when the resident was in bed. A physician order [REDACTED]. The Speciality mattress screen dated 1/21/16 documented based on the resident's current overall physical condition and risk factors, he/she could not benefit from the use of a speciality mattress. A physician order [REDACTED]. The Weekly Skin Observations dated 1/12/16 documented a the resident had painful right arm, scabs on both upper extremities, and an open area to the right buttock. The resident had a right buttock/sacrum ulcer and on 1/14/16 the physician ordered for staff to apply a Duoderm dressing every 3 days. The Weekly Skin Observations dated 1/19/16 documented a scab to the resident's right knee, open area to his/her buttocks, a left knee abrasion, and a left foot ulcer, darkened area. A physician order [REDACTED]. The Unavoidable Pressure Ulcer Clinical Condition Algorithm dated 1/21/16 documented the resident did not have any of the primary risk factors for developing unavoidable pressure ulcers. A Dietary note dated 1/22/16 documented the resident weighed 195 lbs., had a regular diet, food intake of 65 percent (%), gained +4.2% in 9 days, and started on [MEDICATION NAME] 1 packet twice a day for 14 days. The Weekly Skin Observations dated 1/26/16 documented the resident had scratches to both upper extremities, left knee abrasions, left foot ulcer, open area to right buttocks, and left heel dark area. A Wound progress note dated 1/28/16 documented the resident had a new ulcer noted to left buttock, which was open and appeared excoriated. The wound area was straight and opposite to the open area on the right buttock. Staff notified Occupational Therapy for wheelchair assessment. The physician order [REDACTED]. The Admission/new onset/weekly wound analysis dated on 1/21/16 documented #1 wound ( the left malleolus pressure ulcer) identified on 10/21/15 , initial stage 2, deepest unstageable (ulcer known but not stageable due to non-removable dressing/device or due to the coverage of the wound bed by slough or eschar (a dry, dark scab or falling away of dead skin), and open, 1.7 centimeters (cm) length, 1.6 cm width, depth 0.2 cm, serous exudate (drainage), no odor, 85 percent (%) granulation ( new connective tissue and tiny blood vessels that formed on the surfaces of a wound during the healing process) and wet, 15% necrotic (death of cells or tissue), clean with normal saline and 4x4 gauze pad daily, medicate with [MEDICATION NAME] blue/saline (sterile absorptive foam dressing) moistened, 4x4 dressing foam daily, improved status, and wound surrounded by 2.0 cm x 2.0 cm purplish area of suspected deep tissue injury (localized area of discolored --darker than the surrounding area tissue) intact skin or blood-filled blister related to damage of underlying soft tissue from pressure and/or shear. The Admission/new onset/weekly wound analysis dated on 1/28/16 documented #3 wound ( left heel) identified on 1/1/16, pressure ulcer, initial and current stage suspected deep tissue injury, closed area, 1.9 length, 2.4 width, less than 0.1 cm depth, no exudates or odor noted, dry, necrotic tissue 100% hard blackish eschar, periwound black, warm +1 [MEDICAL CONDITION], medication skin prep daily, improved, area was stable, hardened but not open, pillows/heel bench to off load heel while in bed dated 1/28/16. The Admission/new onset/ weekly wound analysis dated on 1/28/16 documented #4 wound (right buttock) identified 1/14/16, pressure ulcer, initial and deepest stage 2, 0.7 cm length, width 0.7, less that 0.1 cm, no amount of exudate or odor, moist, periwound red warm +1 [MEDICAL CONDITION], cleanse with wound cleaner or normal saline, apply 4x4 every 3 days, dress with sacro-adhesive [MEDICATION NAME] foam (a sterile dressing used to cover acute and chronic wounds) every 3 days and improved stage. The Admission/new onset/ weekly wound analysis dated on 1/28/16 documented #6 wound (left buttocks) identified 1/28/16, pressure ulcer, initial and deepest stage 2, 1.0 cm length, 1.0 cm width, depth less than 0.1 cm, no exudate or odor, moist, edges even and pink, peiwound red, temperature normal, no [MEDICAL CONDITION], and cleanse with normal saline or wound cleanser every 3 days. The resident had a Roho cushion for wheelchair, and staff repositioned every 2 hours. Treatment administration record ordered 1/28/16 documented the resident had a sacrum and buttocks ulcer, and staff were to cleanse open areas with normal saline or wound cleaner, pat dry, and apply sacro-adhesive advanced foam. Change every other day and as needed. Treatment administration record ordered 1/28/16 directed staff to place a foam wedge under the resident's left leg every hour of sleep. During an observation on 01/28/2016 at 8:27 A.M. the resident sat at breakfast table. Staff served the resident eggs, sausage, toast and oatmeal and he/she fed self and ate 100% of the meal. He/she drank 50% of chocolate milk and 25% water. During an observation on 01/28/2016 at 12:36 P.M. staff served the resident a roll, beef, baked potatoes and peas. The resident independently ate 75% of the potatoes and peas, 25% brownie, 50% beef, and bite of the roll. During an observation on 01/28/2016 at 1:48 P.M. licensed staff MM changed the wound dressing to the resident's buttocks. The resident turned to his/her side with staff assistance. An open skin area of 0.7 centimeters (cm) length, 0.7 right width at a Stage II. Staff cleaned the wound with wound cleanser and gauze pad. A second open area found at this time by licensed staff MM measured 1 cm width and 1 cm length. Staff cleaned with Skin integrity wound cleanser and applied a dressing to cover both wounds and placed pillows under the resident's feet. During an observation 02/01/2016 at 9:19 A.M. the resident sat in the television area sleeping in his/her wheelchair. The resident had no heel protection cushion in place at this time. During observations on 02/01/2016 at 9:47 A.M., 10:03 A.M., 10:19 A.M., 10:41 A.M. the resident was sat in the television area in his/her wheelchair. During an observation on 02/01/2016 at 10:45 A.M. staff took the resident to an activity. The resident sat in his/her wheelchair with no position change offered at 11:00 A.M., and 11:16 A.M. During an observation on 02/01/2016 at 11:28 A.M. the staff took the resident to his/her room to check his/her brief before going to lunch, but staff had to wait for another staff member and the hoyer availability of the hoyer lift. At 11:49 A.M. staff retrieved the lift, and the resident was still seated in wheelchair. During an observation on 02/01/2016 at 11:53 A.M. direct care staff FFF entered the room with another staff member to transfer the resident. Staff placed the resident was placed in the hoyer lift and transferred him/her to bed for a brief change. The resident was not repositioned for 2 hours and 6 minutes. During an observation on 02/01/2016 at 4:06 P.M. licensed staff MM performed wound cleaning and dressing change on the left malleous wound and the left heel. The heel had a hard black skin covering. The resident had no heel covering, and the resident wore non-slip footwear. During an observation on 02/02/2016 at 7:30 A.M. no pillows or cushions were under the resident's feet or legs when he/she rested in bed. The resident attempted to turn to one side but was unable. During an observation on 02/02/2016 at 8:01 A.M., 8:15 A.M., 8:37 A.M., 8:49 A.M., 9:05 A.M. the resident sat at the table for breakfast. The resident voiced his/her back hurt and attempted to reposition self, but was unable. During an observation on 02/02/2016 at 9:25 A.M. the staff wheeled the resident down the hall to go to his/her room. The resident sat in his/her room sleeping with no position change at 9:37 A.M., 9:50 A.M., 9:50 A.M., 10:04 A.M., 10:18 A.M., and 10:31 A.M. Staff did not reposition the resident for 2 hours and 30 minutes. During an observation on 02/02/2016 at 1:48 P.M. the resident slept in bed with no pillows or heel bench under his/her feet. During an interview on 01/28/2016 at 2:18 P.M. the resident's family member stated staff did not talk to him/her about treatments for the multiple pressure ulcers, and he/she did not know if staff used any pillows or a heel bench at night. He/she stated the resident was able to turn him/herself in bed but needed extensive assistance. During an interview on 01/28/2016 at 2:30 P.M. licensed staff NN stated the resident had a wheelchair cushion that was pressure relieving, but it caused the resident to slide out of the seat. They changed to an anti-thrust cushion to help with the sliding, but would need to reevaluate the cushion due to the resident's pressure ulcers on the buttocks. During an interview on 02/01/2016 at 10:51 A.M. direct care staff U stated the resident required help with transfers, extensive assistance with ADLs, was incontinent and staff should reposition him/her every two hours. They often used barrier cream to help with wounds. During an interview on 02/01/2016 at 1:58 P.M. direct care staff FFF stated they used barrier cream on any reddened skin areas the resident had to help prevent wounds. He/she stated the resident did not like to lay down so they may need to have the resident stand up from wheelchair and then sit back down to relieve pressure. He/she stated the resident was able to answer questions about needing to go to the bathroom, and could turn in bed by his/herself at times. He/she stated the staff repositioned the resident every two hours, and used pillows under the heels at night when in bed. During an interview on 02/02/2016 at 10:57 A.M. licensed staff J stated therapy was trying to get a different cushion for the wheelchair. The resident was on a habit toileting plan, meaning before and after meals and at hour of sleep. Staff should reposition every two hours. He/she expected the aides to reposition him/her on that schedule. He/she recalled the physician spoke with the family about a wedge to put under the feet for heel elevation when in bed. During an interview on 02/02/2016 at 1:21 P.M. licensed staff MM stated that he/she felt the wheelchair cushion may have caused of the buttock ulcers. He/she was not sure if the heel ulcer developed from lack of positioning or from having his/her heel resting on the foot rest for long periods of time. During an interview on 02/01/2016 at 3:32 P.M. physician HHH stated that avoiding shear stress and constant pressure points, as well as repositioning would help with prevention and treatment of [REDACTED]. Physician HHH was not sure about the resident wearing a heel protector or boot because he/she was moved around so much and was not sure if it would stay in the correct place. During an interview on 02/02/2016 1:58 P.M. administrative nursing staff D stated when a resident was at risk for pressure ulcers, they implemented a toileting schedule, protected the skin with moisture barrier cream, provided therapy, used a wheelchair cushion, and performed a bed service assessment to see if the resident required more then the normal pressure reduction mattress. Staff discussed the resident's wounds in daily meetings and notified dietary, nursing, the family, therapy, and the doctor. He/she stated that if the resident was on a plan for every two hour repositioning, then he/she expected that staff performed that regularly. He/she stated the resident was able to shift in the wheelchair on his/her own and did not stay in bed to lay down. He/she expected that staff stood him/her up using the rails in the hallways to relieve pressure. Therapy recently had the resident on a wheelchair cushion that prevented sliding but was evaluating him/her for a different one. He/she felt that pillows under the feet would not be as effective due to the resident's restlessness. The Pressure Ulcer Policy dated 1/1/07 documented that staff would monitor wounds on an ongoing basis and alter the treatment plan as indicated. The facility failed to implement interventions to prevent pressure ulcer development and prevent the progression for three pressure ulcers for this cognitively impaired, dependent resident. - Review of resident #55's clinical record documented the resident had the following Diagnoses: [REDACTED]. Review of a quarterly MDS (Minimum Data Set) dated 10/23/2015 documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident did not resist care or exhibit any behaviors. The resident required extensive assistance from staff for bed mobility, transfers, and toileting; was dependent on staff for locomotion on and off the unit and dressing; and ate independently with set up assistance. The resident had 2 stage 2 pressure ulcers and moisture associated skin damage. Staff provided the resident a pressure relieving device for his/her wheelchair and bed, nutrition and hydration to manage skin problems, and received pressure ulcer care. The resident was not on a turning and repositioning program. Review of the annual MDS dated [DATE] documented a BIMS score of 13, which indicated intact cognition. He/she did not exhibit behaviors or resist care. The resident required extensive assistance of 2 or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; dependent on 2 or more staff with bathing; and dependent on one staff with locomotion on and off the unit. The resident had 3 stage two pressure ulcers and 1 unstageable pressure ulcer with suspected deep tissue injury. Staff provided the resident with a pressure reducing device for his/her bed and chair, nutrition or hydration to manage skin problems, provided pressure ulcer care, and applied nonsurgical dressings to an area other than his/her feet. The resident was not on a turning and repositioning schedule. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 1/14/2016 documented the resident required assistance with toileting and mobility and had a pressure ulcer to his/her left buttock. Review of a Pressure Ulcer CAA dated 1/14/2016 documented the resident had several pressure ulcers and was at risk for complications and the development of new pressure ulcers. The resident refused several times to obtain specialized wound care and/or to allow the facility wound nurse to complete daily wound care. He/she refused to lay down for periodic pressure reduction, use a broda chair (a specialized wheelchair for comfort) to assist with positioning, and he/she was incontinent of bowel and bladder. Review of the care plan dated 1/18/2016 documented the resident had pressure ulcers to both heels and directed staff to apply soft heel lift boots when up in chair and the resident was not to wear diabetic shoes until the wounds healed. The Braden Skin Assessments dated 1/22/16 revealed a score of 14, which indicated the resident was at moderate risk for the development of pressure ulcers. Review of physician orders [REDACTED]. The resident to wear a decubitus (ulcer) boot to both feet. Keep left heel blister intact and if broken follow the facility skin care protocol, effective 10/29/2015 Apply skin prep to the left heel every shift for pressure, effective 11/18/2015 Apply offloading boot to left foot when up in wheelchair and do not wear shoes to the left foot, effective 11/23/2015 Apply skin prep to both heels twice daily and offloading boots at all times, effective 1/12/2016 Cleanse the right heel ulcer with normal saline/wound cleanser and apply [MEDICATION NAME] (a medicated dressing) foam dressing every 3 days. Discontinue skin prep, effective 1/15/2016 Review of wound treatment records included the following: On 12/3/2015 staff documented the resident had a suspected deep tissue injury to left heel, which measured 1.0 cm (centimeters) x (by) 1.0 cm and was first identified on 11/18/2015. The resident wore diabetic shoes, and had a heel bench when in bed to offload his/her heels. On 1/16/2016 staff documented the resident had a stage 2 pressure ulcer to his/her right heel, first identified on 1/12/2016. The wound measured 3.2 cm x 2.5 cm x 0.1 cm, and was an opened blister. Interventions included; the resident was not to wear shoes and was to wear soft heel lift boots when in his/her chair. Review of the medical record documented the resident refused to go to the wound center for non-healing pressure ulcers on 1/25/2016. During an observation on 1/26/2016 at 1:23 P.M. the resident leaned to his/her right side in a wheelchair with pillows and cushions used for support. He/she wore heel protectors to both feet. During an observation on 1/28/2016 at 8:36 A.M. the resident had a wedge pillow in place but leaned to his/her right in a wheelchair. On 1/28/2016 at 11:00 A.M. observation revealed a padded area of a dressing in the resident's sock of his/her right foot but it was not positioned over the area of the resident's wound. During an observation on 2/1/2016 at 2:43 P.M. licensed nursing staff MM and direct care staff GGG assisted the resident with repositioning. The resident wore a heel protector boot to his/her right foot and no protector on the left foot. The resident had no dressing to his/her right heel. The left heel had a dime sized thick dark blackened area and the right heel had a quarter sized blackened area. There was no dressing on the right heel as ordered. Staff MM applied skin prep to both heels. This was not the current wound order. During an interview on 2/1/2016 at 11:21 A.M. the resident said the nurse changed his/her dressings. During an interview on 2/2/2016 at 2:30 P.M. direct care staff SS stated staff made sure the resident wore his/her orthotic boots because he/she had an area on his/her heels that were sore from rubbing. During an interview on 2/2/2016 at 2:15 P.M. licensed nurse L stated the wound care nurse did wound dressing changes on the unit for all residents with skin treatments. Nurse L stated if a dressing came off and/or became soiled and needed replaced, the nurse on the floor did the treatment. During an interview on 2/2/2016 at 2:30 P.M. administrative licensed nurse MM stated the resident's heel wounds began as a blister and progressed to an unstageable wound. Nurse MM stated he/she thought the wounds occurred (in house) as a result of the resident wearing diabetic shoes. During an interview on 2/2/2016 at 3:00 P.M. administrative licensed nurse D stated shower aides, direct care staff, and nursing all participated in the identification of skin issues with bath skin reports and they informed nurses and fill out assessments and forward to wound care. Administrative licensed nurse D sated resident #53 was often not receptive (non-compliant) with repositioning and use of protective equipment to prevent development of his/her pressure sores. The facility Pressure Ulcer policy revised 12/19/13 recorded: the facility would promote healing and enhance the resident's quality of life by the identification of new wounds, communication, and development of treatment plans, and ongoing monitoring. The facility failed to implement physician orders [REDACTED].

The facility reported a census of 93 residents and the sample size was 3. Based on observation, record review, and interview the facility failed to implement fall prevention interventions as planned for one sampled resident (#1) who fell and sustained a hip fracture. Findings included: - Resident #1's Minimum Data Set (MDS) 3.0 dated 4/1/13 recorded the resident with a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The MDS recorded the resident required extensive assistance with all Activities of Daily Living (ADLs) except needed limited assistance with eating. The MDS also noted the resident could not balance without staff assistance. On the admission care plan dated 3/18/13 fall interventions were initiated due to the fall risk assessment which scored the resident at high risk for falls. The interventions included the resident's bed in a low position, a landing mat on the floor next to the bed, and bed and chair alarms applied. The care plan dated 4/29/13 documented the resident needed encouragement to use the call light. The added intervention at this time was a one to one sitter at all times. Review of the nurses notes reported the resident fell on [DATE] at 4:12 A.M. while he/she attempted to take him/herself to the bathroom. The bed alarm did not sound when the resident got up from the bed. The bed alarm cord was detached from the alarm box, which was found on top of the dresser. The bed was in the low position, and a floor mat was in place. The facility sent the resident to the hospital and the resident admitted with a fracture to the right hip. In an untimed, signed statement dated 4/13/13 licensed nurse D stated at the time of the fall, the alarm pad was on the bed and the alarm box was on the dresser next to the closet. In an untimed, signed statement dated 4/15/13 direct care staff F stated the bed alarm did not sound when the resident fell out of bed. Every night staff F worked he/she noted the alarm was never plugged in. In an untimed, signed statement dated 4/16/13, direct care staff G stated when the resident fell , the alarm box on the dresser was disconnected from the mat on the bed. In an untimed, signed statement dated 4/16/13 therapy staff H stated on 4/12/13 staff H assisted with the transfer of the resident from his/her bed to the wheelchair, and no bed alarm sounded. Observation of the resident on 5/7/13 at 11:11 A.M. revealed the resident laid in bed asleep. The bed alarm was in place. Observation of the resident on 5/7/13 at 12:15 P.M. revealed the resident laid in bed with his/her eyes open. The bed alarm remained in place. The resident refused to get out of bed for lunch. Resident interview on 5/7/13 at 1:16 P.M. stated he/she wanted to stay in bed and be left alone. Interview on 5/7/13 at 1:18 P.M. direct care staff E stated the resident refused to eat lunch and now he/she refused to get out of bed for a shower. At the beginning of the shift, staff check to see if the bed alarm works, keep the bed in the lowest position and place a mat at his/her bedside. There was one staff assigned one on one for the resident. Licensed staff C interview on 5/7/13 at 4:02 P.M. stated the resident had one on one care and would continue this until he/she was deemed safe. Interview on 5/7/13 at 4:15 P.M. with administrative licensed staff A stated the facility admitted the resident with a broken left arm. The staff identified him/her as a fall risk and had interventions in place. The resident just walked for the first time with therapy earlier in the day that he/she fell . There was a bed alarm ordered for the resident's bed, but at the time of the fall the cord was not connected to the alarm box. The facility policy dated 3/25/09 documented one or more individuals were assigned to routinely monitor for proper function of the alarms. The facility failed to maintain the resident's environment free from accident hazards, failed to properly implement fall prevention interventions as planned for this resident who required extensive assistance from staff for transfers.