Every finding on record at Avita Health and Rehab at Reeds Cove

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria.Findings included:- The initial kitchen tour of [NAME] house on 05/05/26 at 08:25 AM revealed a plate of food in the refrigerator with no date, ketchup and mustard which lacked an open date, a container of liquid eggs opened half of the container used with no open date. Freezer had an open bag of hotdogs open with no date and crystals on the hotdogs. In the pantry between the two kitchens, a container of molasses opened 01/03/26 had lines of syrup down the front and the back of the bottle causing the shelf to be sticky and the freezer and refrigerator logs only had documentation for 05/01/26 and 05/05/26 but lacked other documentation.During the initial tour of [NAME] House on 05/05/26 at 08:30 AM, temperature logs documented freezer and refrigerator temps obtained on 05/01/26, 05/02/26, and 05/03/26 in the PM; lunch and breakfast lacked temps on 05/04/26. The freezer had three packages of open hamburgers and/or sausage patties not labeled or dated. A jar of peanut butter located on top of the refrigerator had peanut butter on the outside of the container.The initial tour of Saghbene house on 05/05/26 at 08:54 AM revealed a bag of hotdogs left open and brussels sprouts open to air, located in the freezer with no date. The pantry had a bag of honey oats, which lacked a date, and a caramel dip, which was not sealed.During the initial tour of [NAME] house on 05/05/26 at 09:00 AM, the food temperature logs lacked temperatures on 4/30/26 for lunch, 05/03/26 lacked temps for dinner, and on 05/04/26 there were no food temps for lunch or dinner; 04/18/26 lacked temperature for sanitation and there was no log sheet for sanitation available.On 05/06/26 at 08:16 AM in an interview, Dietary Manager BB revealed she expected all items to be kept in a clean and sealed container with dates, expected all food items to be temp for safe food distribution, and stated there should be no holes regarding the temperature log.On 05/07/26 at 11:33 AM Administrative Staff A stated all food in the refrigerators should be closed or sealed and a date and the information required should be placed to maintain regulatory compliance.The facility's policy Food Preparation and Handling Policy, dated 12/7/23, documented the facility will store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Food that requires time/temperature control for safety to limit the growth of pathogens (bacterial or viral organisms capable of causing disease formation).

Based on interviews, observation, and record review, the facility failed to ensure adequate hand hygiene during dressing change and medication administration for Resident (R) 48. Additionally, the facility failed to properly transport clean personal linens.Findings included:1. 05/06/26 at 08:26 AM Licensed Nurse (LN) G removed soiled dressing from R48's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) site and discarded the dressing into the garbage. LN G started to open a dressing then removed her gloves with no hand hygiene performed. LN G applied new gloves and cleansed the G-tube site. LN G removed her gloves with no hand hygiene performed and applied a new pair of gloves. LN G applied a new dressing and labeled the tape with the date; she then removed her gloves with no hand hygiene performed and administered medications to R48 through the feeding tube. 2. 05/06/26 at 12:05 PM LN G entered R48's room picked up a cup and went to the bathroom and filled it with water; she then applied her personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) with no hand hygiene performed prior to applying PPE. On 05/06/26 at 12:22 PM LN G reported that she should have washed her hands when she removed her gloves each time and before applying new gloves.3. 05/06/26 at 02:26 PM Certified Nurse Aide (CNA) M exited the clean/laundry work room with a full basket of uncovered, clean personal laundry. CNA M reported that he had just taken it out of the dryer and was not sure what resident the linen belonged to and said that he generally covered the linen with a bag. CNA M transported the uncovered linen down the hallway to a resident's room. On 05/07/26 at 09:48 AM LN H reported the laundry that comes in and out of the soiled/clean laundry areas are required to be covered during transportation. On 05/07/26 at 10:17 AM Administrative Nurse E revealed she expected staff to perform hand hygiene before applying gloves and after gloves are removed. Administrative Nurse E was unsure whether clean linen required to be covered when transported to the residents' rooms.On 05/07/26 at10:55 AM Administrative Nurse E reported the laundry was to be covered in and out of the laundry rooms. The facility's policy Infection Control, dated 02/02/26, documented this facility will follow Standard Precautions for Infection Control and Prevention to protect residents, staff and visitors to ensure staff do not carry infectious pathogens on hands perform hand hygiene before and after contact with a resident and immediately after removing gloves.The facility's policy Laundry Protocols, dated 03/19/26, documented each piece of laundry will be handled, processed, stored, and transported in a manner designed to prevent transmission of infection. Laundered articles will be transported in enclosed, linen hampers with removable liners in enclosed carts or dollies or securely wrapped.

Based on interview, observation, and record review, the facility failed to address and resolve a grievance for Resident (R) 18 and failed to notify the resident of any actions or the status of the grievance. Findings included:- The Electronic Medical Record (EMR) for R18 documented a diagnosis of major depressive disorder (major mood disorder that causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R18's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. R18's MDS documented no behavior was noted. R18's Psychotropic Drug Use Care Area Assessment (CAA), dated 02/20/26, documented triggered secondary to use of psychotropic medication to manage illness and conditions. A licensed nurse would monitor side effects every shift, and the physician is to be notified for any abnormal findings.R18's Care Plan, dated 10/31/24, instructed staff to provide opportunities for expression of feelings related to situational stressors.On 05/06/26 at 04:00 PM, R18 was outside sitting in his scooter with staff and another resident enjoying the weather and watching a [NAME] in the water. R18 reported he was quite upset no one had come back and spoke to him about the grievance he filed the previous week, R18 reported the unknown Certified Nurse Aide (CNA) that he had a concern with did come back the next day to apologize to him though no one from management spoke to him about his grievance he filed. On 05/06/26 at 04:45 PM, Administrative Nurse D delivered the original grievance form R18 submitted on 04/24/26 which documented the resident was at the dinner table and requested CNA assistance for another resident as the table. R18 was concerned that the other resident may have been having difficulty with swallowing food and might have required assistance. R18 reported the CNA disregarded his request and did not check on the resident or notify the nurse. R18's Grievance/Complaint Report, date submitted 04/24/26, revealed the grievance section that asked if the resolution was resolved was checked off yes, however it lacked any documentation what the resolution was as the form stated describe the resolution. The form was signed by Administrative Nurse D with no date. On 05/06/26 at 04:54 PM, Administrative Nurse D reported that she did get back to R18 about his grievance the next day verbally. She reported she would give the resident a copy of the completed grievance form if they requested the form. Administrative Nurse D confirmed R18's 04/24/26 grievance form lacked documentation what the resolution was and the date she signed the form.On 05/07/26 at 09:17 AM, Administrative Staff A delivered a copy of R18's 04/24/26 grievance which documented a resolution that R18 was ok at that time and would notify Administrative Staff A and or Administrative Nurse D if he still had concerns after that day, dated 05/06/26 by Administrative Staff A. The facility's policy Grievance/Concern Policy, dated 01/07/26, documented the person(s) voicing the concern would be informed of any/all mechanisms of resolution within seven (7) days of filing the concern with the facility by the Administrator or designee.

Based on observation, interview, and record review, the facility failed to obtain a 14-day stop date or a specified duration with physician rationale for an as-needed (PRN) order for lorazepam (treatment of anxiety) medication for Resident (R) R66. Additionally failed to monitor antipsychotic medication for Resident (R) 18. Findings included:- R66's Physician Orders, dated 12/10/24, revealed the following diagnosis: cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R66's Annual Minimum Data Set (MDS), dated [DATE], Brief Interview for Mental Status (BIMS) score revealed severely cognitive impairment. The MDS noted behaviors towards others which occurred during the look back period one to three days. The behavior impacted or placed others at risk of physical injury. R66's Quarterly MDS revealed a BIMS score of three which indicated severely impaired cognition. There were no changes in behavior. R66's Care Area Assessment, dated 12/02/25, noted behaviors trigged secondary to the resident yelling out throwing cups and personal items. Risk factors included injuring self and increased anxiety. R66's Care Plan revision on 12/11/25 revealed R66's medications would be overseen and managed by nursing and the physician. R66 took medication with black box warnings including lorazepam. The plan directed staff to observe for psychosocial changes and report any changes in mental status caused by situation stressor to the physician. R66's orders included an order dated 04/30/26 for lorazepam oral tablet 0.5 mg (milligrams), one tablet by mouth every eight hours PRN for anxiety. The order lacked a stop date. On 5/07/26 at 08:20 AM Licensed Nurse (LN) H revealed the PRN lorazepam was started on 04/03/26 and verified the order did not have a stop date. LN H stated she would have to clarify the policy regarding stop dates. On 05/07/26 at 01:47 PM Administrative Nurse D said the psychotropic medication use should be monitored for side effects and PRN orders should have a 14-stop dated when obtained. The facility's policy Medication Administration all medication will be administered to every elder as ordered by a physician in a safe and sanitary manner. Psychotropic medications are prescribed only under the following parameters: PRN orders for psychotropic medication are limited to 14 days upon initial orders. At 14 days providers will evaluate and may extend beyond 14-day duration with a documented rationale for the extension. - The Electronic Medical Record (EMR) for R18 documented a diagnosis of major depressive disorder (major mood disorder that causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R18's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. R18's MDS documented no behaviors noted. R18's MDS documented he was administered antianxiety (a class of medications that calm and relax people), and antidepressant (a class of medications used to treat mood disorders) medications. R18's Psychotropic Drug Use Care Area Assessment (CAA), dated 02/20/26, documented triggered secondary to use of psychotropic medication to manage illness and conditions. A licensed nurse would monitor side effects every shift, and the physician is to be notified for any abnormal findings. R18's Care Plan, dated 10/31/24, instructed staff to administer medications as ordered and monitor/document for side effects and effectiveness. R18's Care Plan, dated 05/06/26, lacked documentation for Abilify (an antipsychotic medication used to treat major depressive disorder). R18's Physician Orders documented Abilify 2 milligrams (mg), give one tablet, by mouth daily for major depressive disorder date ordered, 04/15/26. R18's Electronic Medication Administration Record (EMAR), reviewed 04/15/26 through 05/06/26, lacked documentation of the number of episodes of identified target behaviors and/or side effects, actions taken, and effectiveness of interventions for Abilify. R18's Psych Provider Note, dated 04/08/26 at 04:00 PM, documented to discontinue Remeron (antidepressant) and start Abilify 2mg daily for adjunct depression. Continue all other medications as prescribed follow up in one month. R18's Progress Note, dated 04/14/2026 at 10:28 AM, documented R18 was seen by provider on 04/08/26 start Abilify 2mg daily for depression. On 05/06/26 at 04:00 PM R18 was outside sitting in his scooter with staff and another resident enjoying the weather and watching a [NAME] in the water. On 05/07/26 at 09:25 AM Licensed Nurse (LN) H reported that the EMAR would have a section for the nurse to complete monitoring and what nonpharmacological interventions were used for all psychoactive medications including antipsychotic medications. LN H reported that R18's Abilify was being used for depression, so they were monitoring Abilify like an antidepressant. On 05/07/26 at 09:47 AM Administrative Nurse D revealed she expected that the staff to monitor every psychoactive medication every shift. The facility's policy Medication Administration Policy, dated 03/19/26, documented monitoring the elder's response to medications is an important assessment activity for nurses, physicians, and pharmacists in particular, monitoring the eider's response to the first dose of a new medications is essential to the safety of the elder because any adverse reactions, including serious ones, are more unpredictable if the medication has never been used with the elder in the past. Clinical staff will monitor each eider's response to medication(s) by accounting for actual or potential adverse drug reactions and events.

Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 48's feeding tube (G-tube: tube surgically placed through an artificial opening into the stomach) was monitored for placement prior to administration of medications and enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). Findings included:- R48's Electronic Health Record (EHR) documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R48's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. R48's MDS documented he required total assistance with all activities of daily living and R48 had a feeding tube. R48's Feeding Tube Care Area Assessment (CAA), dated 07/21/25, documented the CAA triggered secondary to use of feeding tube for maintenance of nutritional/hydration status. Risk factors included complications related to use of feeding tube such as aspiration, weight changes, and fluid imbalance. R48's Care Plan, dated 07/21/21, instructed staff to check tube placement and gastric contents/residual volume per facility protocol and record.R48's Physician Orders directed staff to administer 50 milliliters (ml) bolus of water before and after each feed every six hours for enteral tube hydration date ordered 08/11/25.R48's Physician Orders directed staff to administer via feeding tube 60 ml water before and after meds every shift, date ordered 08/26/25.R48's Physician Orders, dated 05/06/26, lacked documentation to check for placement or residual of feeding tube. On 05/06/2026 at 08:05 AM R48 was in her bed, eyes closed. On 05/06/26 at 08:26 AM Licensed Nurse (LN) G flushed R48's feeding tube with 60 ml water and administered R48's medications through the feeding tube and flushed with 60 ml of water. LN G did not check placement of feeding tube prior to flushing the feeding tube with water. On 05/06/26 at 12:05 PM LN G removed R48's abdominal binder and connected the syringe to the feeding tube without checking for placement of the tube. LN G administered 50 ml of water and administered the enteral feed; LN G then flushed the tube with 50 ml of water after. On 05/06/26 at 12:22 PM LN G reported that she did not know she had to check placement on that type of feeding tube and verified she did not check for residual either. 05/06/26 at 12:28 PM Administrative Nurse D revealed she expected the nurse to verify placement of all feeding tubes prior to use. The facility's policy Enteral Tube Feeding Policy, dated 02/19/26, lacked documentation to check for placement of a feeding tube.The facility undated competency Procedure Tube Feeding documented to perform abdominal assessment by listening to bowel sounds in four quadrants check abdomen for firmness. Attach syringe to end of tube and inject 10 ml of air while auscultating stomach area with stethoscope, listening for whooshing sound when injected. Attach syringe to end of tube and aspirate all gastric contents of stomach with the syringe and measure to check for residual amount of feeding in stomach; visualize aspirated contents, check for color and consistency; return residual and proceed with feeding if amount of residual does not exceed limit indicated by ordering physician.

The facility identified a census of 66 residents, with 10 residents sampled. Based on observation, interview, and record review, the facility failed to prevent the development of facility-acquired pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on Resident (R)1's right and left buttock when staff failed to adequately monitor wounds after the initial development including measurements, presence of infection, drainage and effectiveness of treatments, failed to implement routine repositioning in the bed and the wheelchair until after the wounds progressed, and did not implement standard interventions such as low air loss mattress (a medical-grade mattress designed to prevent and treat pressure injuries by continuously circulating air to reduce moisture and heat buildup) until after the pressure ulcers worsened. The facility did not immediately implement nutritional interventions to address wound prevention or healing. As a result, R1 developed a facility-acquired Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure injury and placed the resident at risk for the development of new pressure ulcers, and delayed healing and worsening of existing ulcers. Findings included: - R1's Electronic Health Record (EHR) revealed diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), weakness, and urinary tract infection (UTI- an infection in any part of the urinary system). The 01/28/25 Admission Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required moderate assistance with activities of daily living (ADL) including transfers, bed mobility, and turning from side to side. The MDS documented R1 was at risk of developing pressure ulcers/injuries and was not on a turn and reposition schedule. The 02/04/25 Pressure Ulcer/Injury Care Area Assessment (CAA) triggered secondary to the potential for pressure ulcers. The CAA noted contributing factors included ADL impairment and incontinence and the risk factors included pain, development of pressure ulcers, skin conditions, and fluid deficit risk. The CAA noted a licensed nurse would assess R1's skin each week and place proper interventions in place to prevent skin breakdown; the skin was also assessed by caregivers with each bath and each time the resident was dressed. The CAA noted the physician would be notified of any abnormal findings and treatment orders are obtained and the dietitian was monitoring R1's food and fluid intake and implementing dietary interventions as necessary. R1's Braden Scale (a formal assessment used to predict pressure ulcer risk) dated 01/15/25 documented R1 was at low risk for pressure injuries with a score of 18. The scale dated 01/23/25 documented R1 had no risk with a score of 19. The scales dated 02/06/25 and 02/23/25 recorded R1 was at low risk for pressure injuries with a score of 18. R1s Care Plan documented R1 did not want to develop any pressure injuries and included interventions dated 02/11/25 that directed staff to assist with repositioning for comfort as necessary. Staff were to assist R1 with bed mobility and transfers as necessary. The plan noted R1 would use a one-quarter side rail attached to the bed to assist him with repositioning. The plan noted R1's skin would remain intact and without redness or breakdown throughout the next review period and staff would provide a pressure-reducing mattress and wheelchair cushion. The plan directed staff to assist R1 with repositioning as needed. The Licensed Nurse were to complete skin and Braden Scale (a tool used to assess a patient's risk for developing a pressure injury) assessments per facility protocol. R1's Care Plan was updated on 03/03/25 with an intervention that directed staff to reposition R1 every two to three hours while the resident was in bed and to reposition or change location to the bed as needed when R1 was uncomfortable in his wheelchair. R1's Tasks in the EHR lacked a turn and repositioning program. R1's EHR revealed a Weekly Skin Data Collection Tool, completed weekly from 01/15/25 through 02/28/25, all documented R1 had no skin issues present. R1's EHR recorded a Progress Note dated 02/26/25 noting R1's representative called and informed the nurse that R1 told them he had a wound on his coccyx (area at the base of the spine). The note documented the nurse informed R1's representative that no new wounds for R1 were reported to nursing and nursing would follow up. R1's Physician's Orders documented an order dated 02/26/25 that directed staff to clean the coccyx wound with normal saline, apple Skin-prep (liquid skin protectant), and cover with a sacral border foam dressing. The order noted to change the dressing Monday, Wednesday, and Friday or as needed (PRN) for soiling or dislodgement. The order was discontinued on 02/26/25. R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked evidence staff administered the treatment. R1's Physician's Orders documented an order dated 02/26/25 that directed staff to clean the coccyx wound with normal saline, cover with a sacral border foam dressing until healed, and change the dressing Monday, Wednesday, and Friday or as needed (PRN) for soiling or dislodgement. The order was discontinued on 02/27/25. R1's MAR/TAR lacked evidence that staff administered the treatment. A Progress Note dated 02/27/25 at 12:35 PM documented the nurse spoke to R1's representative and informed her that R1 did not have any new wounds. A Progress Note dated 02/28/25 at 05:46 AM recorded R1's skin was intact but also noted skin discolorations to the coccyx. R1's 03/01/25 Weekly Skin Data Collection Tool documented small open wounds to the scrotum and bilateral buttocks and noted there was a treatment in place. The tool lacked measurements of the open areas, assessment of the peri-wound (skin surrounding the wound) and presence of drainage or signs of infection. R1's Physician's Orders documented an order dated 03/01/25 which directed staff to apply silver sulfadiazine cream (used to prevent and treat wound infections) to the right buttock topically every shift for wound care. The order was discontinued on 03/02/25. R1's Physician's Orders documented an order dated 03/01/25 which directed staff to apply silver sulfadiazine cream to the inner buttocks topically every shift for wound care. The order was discontinued on 03/02/25. R1's Physician's Orders documented an order dated 03/02/25 which directed staff to apply silver sulfadiazine cream to the buttocks, scrotum, and sacrum (large triangular bone/area between the two hip bones) topically every shift for wound care and apply to buttocks, scrotum, sacrum topically as needed for wound, ordered 03/02/25. The order continued through 03/25/25 when it was discontinued. A Progress Note dated 03/05/25 at 05:01 PM documented R1's buttocks wound started to open starting to open and had some bloody drainage. The note lacked evidence of physician notification. The 03/07/25 Weekly Skin Data Collection Tool documented an open area to R1's buttocks, scrotum, and sacrum with a treatment in place. The tool lacked measurements of the open areas, assessment of the peri-wound, presence of drainage or signs of infection. A Progress Note dated 03/07/25 at 08:38 AM documented staff assessed R1's sacral wound that morning; it was the same area the resident had problems with. The note documented the area reopened that day and staff applied Silvadene (silver sulfadiazine) cream to the affected areas and R1's sacral area was off-loaded with a big blue pad. The note lacked evidence of physician notification. R1's Physician's Orders documented an order dated 03/11/25 for a liquid protein supplement, 30 milliliters by mouth, twice daily for supplement and wound healing. The 03/14/25 Weekly Skin Data Collection Tool documented R1 had open areas on his bilateral (both sides) buttocks, sacrum, and peri area with a treatment in place. The tool lacked measurements of the open areas, assessment of the peri-wound, presence of drainage, or signs of infection. The 03/17/25 Mid-Kansas Wound provider assessment documented wound one on R1's left buttock was a chronic Stage 3 pressure injury acquired on 03/10/25. The assessment noted the wound measured 4.5 centimeters(cm) by 2.5 cm by 0.1 cm and had an area of 11.25 square (sq) cm, and a volume of 1.125 cubic cm as well as a small amount of serosanguinous (semi-thick blood-tinged drainage) drainage with a mild odor. The assessment noted wound two on R1's right buttock was a chronic Stage 3 pressure ulcer acquired on 03/10/25 that measured 9.25 cm by 6.5 cm by 0.1 cm and had an area of 59.8 sq cm and a volume of 5.98 cubic cm; there was a small amount of serosanguinous drainage with a mild odor. The assessment noted both areas were debrided medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) by the provider. R1's Physician's Orders documented an order dated 03/19/25 that directed staff to cleanse the wounds with wound cleanser by applying to gauze and soaking the wound for five minutes with each dressing change; rinse with normal saline, then place alginate (dressing which forms a soft, gel that absorbs when it comes into contact with wound drainage) in the wound bed and cover with a bordered foam dressing one time a day on Monday, Wednesday, and Friday. A Progress Note dated 03/20/25 at 09:15 AM documented at approximately 09:00 AM that morning the Certified Nurse Aide (CNA) notified the nurse R1 had a large sore, skin spot on his bottom. The note documented the nurse looked at it and observed it looked like a large bruise spot, almost black. The note documented the nurse put a dressing over it in addition to the ordered cream and would notify the provider when the provider arrived. A Provider Note dated 03/21/25 documented that per staff, R1 had a worsening sacral wound; the wound nurse was contacted and given new wound orders. The note directed staff to follow up with the wound provider the following week. The 03/24/25 Mid-Kansas Wound wound provider assessment documented R1's wounds were measuring significantly larger. The assessment noted the left buttock chronic Stage 3 pressure injury acquired on 03/10/25 measured 8.5 cm by 3.5 cm by 0.1 cm and had an area of 29.75 sq cm and a volume of 2.975 cubic cm. with adipose (fat) tissue exposed and large amount of serosanguinous drainage with a mild odor. The assessment noted R1's right buttock chronic Stage 3 pressure ulcer acquired on 03/10/25 measured 13 cm by 6 cm by 0.1 cm and had an area of 78 sq cm and a volume of 7.8 cubic cm, with adipose tissue exposed and a small amount of serosanguinous drainage with a mild odor. A Provider Note dated 03/24/25 documented the provider saw R1 that day and the nurse reported R1 had a fever of 102.3 degrees Fahrenheit (F) (normal temperature is 98.6 degrees F), chills, and shaking. The note documented the wound provider saw R1 that morning and was concerned about the appearance and odor of the wound. The wound provider recommended sending R1 to the hospital with concerns of sepsis (a life-threatening systemic reaction that develops due to infections that causes inflammation throughout the entire body). R1 agreed and the staff contacted his representative. The note documented staff contacted Emergency Medical Services (EMS). The note also documented the provider suspected sepsis was secondary to the wound infection. R1's Physician's Orders documented an order dated 03/24/25 that directed staff to offload and rotate R1 every one-to-three hours for sacral wounds every shift. R1's Physician's Orders documented an order dated 03/24/25 that directed staff to admit R1 to the hospital for possible sepsis and wound debridement for wound care and change in condition. On 04/23/25, R1 remained in the hospital and was unavailable for observation. During an interview on 04/23/25 at 01:37 PM, CNA F reported she let the nurse know if a resident had a new skin issue. CNA F reported the nurse would let Administrative Nurse C know. CNA F reported a treatment would put in place right away and have seen the facility apply an air mattress right away on the resident's bed if there was a skin issue. During an interview on 04/23/25 at 03:30 PM, CNA G reported if a resident was on a turn and reposition schedule, it would be on the EHR for the staff to document that task. During an interview on 04/23/25 at 12:46 PM, Licensed Nurse (LN) E reported the nurse would assess any skin concerns, document it in her, and then notify the provider and get a treatment. LN E reported the nurse that provided the dressing change should measure the wound and document on the weekly skin tool. LN E said the wound care provider also completed measurements of a wound. During an interview on 04/23/25 at 01:55 PM, Administrative Nurse D reported the staff would report any skin concerns to the charge nurse and the CNAs also have a shower sheet and would document skin concerns on that sheet and report it back to the unit manager. Administrative Nurse D said the measurements of the wounds at the time when R1 was in the facility should have been completed by Administrative Nurse C. She reported that R1 did not have any open wounds when he was admitted and he was walking in the first unit he lived on, then R1 declined when he moved to the other unit. She could not recall when R1 received an air mattress. During an interview on 04/23/25 at 2:22 PM, Administrative Nurse C reported she had not completed wound assessments on R1 as the person who trained her did not correctly train her, so there was a gap of no wound assessments completed. Administrative Nurse C reported the first time she assessed R1's wounds was on 03/17/25 when Mid-Kansas Wound assessed the wounds. She reported the CNAs do not have a place to document on the EHR for the turn and reposition and said it was on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), and the nurses were responsible to make sure the CNAs were repositioning the residents that required assistance. During an interview on 04/24/25 at 10:40 AM, Administrative Nurse B reported R1 admitted on [DATE] with no open areas. She said she reviewed the Weekly Skin Data Collection Tools and reported she expected staff to communicate with the unit managers, interdisciplinary team, and the wound care team when a wound was identified. Administrative Nurse B said she expected the nurse to let the CNAs know what residents required to be turned and repositioned. Administrative Nurse B stated she expected nurses to measure wounds when documenting in the EHR. She reported the facility started working on a Performance Improvement Plan (PIP- a formal document outlining specific steps for an employee to improve their performance) around mid-March (2025) as the facility identified the tracking of wounds on the documents was not effective. During an interview on 04/24/25 at 12:06 PM, Physician Assistant H reported she assessed R1's wounds near the end of his stay. She said she expected the nurses would be documenting the wounds weekly including measurements and progression of the wounds. Physician Assistant H reported she relied on Mid-Kansas Wounds to handle the wounds and if there was a concern with any wounds, she would get involved. Physician Assistant H said she expected the facility to have applied an air mattress on R1's bed sooner than it was but she could not recall the exact date R1 received the air mattress. Physician Assistant H reported the facility had not placed preventative measures to prevent the pressure ulcers R1 acquired. The facility's policy Wound Management dated 01/10/25 documented the facility is committed to providing a comprehensive wound management program to minimize the development of in-house acquired pressure ulcers. Any resident with a wound receives treatment and services with the resident's goals of treatment.

The facility reported a census of 29 residents. The sample included three residents reviewed for medications. Based on observation, interview, and record review, the facility failed to prevent the significant medication error of cognitively impaired Resident (R) 1. On 10/11/24, Certified Medication Aide (CMA) R incorrectly administered R2's medications to R1, which included clopidogrel (antiplatelet medication) 75 mg (milligram), morphine (opioid medication used to treat severe pain) extended release (ER) 15 mg, as well as acetaminophen (analgesic) 650 mg. On 10/11/24 at 06:00 AM, during nursing shift report, Licensed Nurse (LN) G ensured that CMA R knew that R1 had a jejunostomy tube (J-Tube, a soft plastic tube surgically inserted into the small intestine to deliver food and medicine) and R1 could not receive any medications by mouth. CMA R drew a line through R1's medications and documented do not give medications. Later, LN G heard R2 coughing, assessed her oral cavity, and found four tablets in R2's mouth. LN G removed the four tablets to further prevent coughing or choking due to residents' history of aspiration pneumonia (a lung infection that occurs when food, liquid, or other substances are inhales into the lungs). Findings included: - R1's Physician Order Sheet (POS), dated 11/08/24, revealed R1 admitted on [DATE] with the following diagnoses; hereditary ataxia (a group of neurological disorders that cause a loss of balance and coordination due to faulty genes, multiple system atrophy (a rare, progressive neurodegenerative disease that affects the autonomic nervous system and other parts of the brain and nervous system), quadriplegia, (a condition that causes the complete or severe loss of motor function in all four limbs), basal ganglia dysfunction (a problem with the deep brain structures that help start and control movement), dysphagia (difficulty swallowing), and aphagia (the inability or refusal to swallow food, liquid, or saliva). The 05/03/24 Annual Minimum Data Set (MDS), documented the resident had short-term and long-term memory problems. R1 was dependent on nursing staff for Activities of Daily Living (ADLs). The resident required a peg-tube for nutrition and fluid intake and medication administration. The Nutrition Care Area Assessment (CAA), dated, 05/13/24, revealed the resident was dependent on a jejunostomy tube for nutrition and water flushes. The licensed nurse would continue to administer medications via the tube feeding as ordered for nutrition. R1's 08/02/24 Quarterly MDS documented the resident had short-term and long-term memory problems. R1 was dependent on nursing staff for ADL. The resident required a peg-tube for nutrition and fluid intake and medication administration. R1's Care Plan, revised on 07/10/24, documented R1's medications would be managed by the nursing and physician team during her stay. The care plan noted R1's medications were administered through the J-Tube. A Nursing Note, dated 10/11/24, revealed LN G reported to the Administrative Staff A, Licensed Nurse H, and the health care provider that R1 had been administered R2's medications. The health care provider ordered a chest X-ray, due to the resident's history of aspiration pneumonia (a lung infection that occurs when food, liquid, or other substances are inhaled into the lungs instead of swallowed), vitals signs to be obtained every four hours for 72 hours, and Augmentin (antibiotic) for ten days. A Health Care Provider (HCP) Encounter, dated 10/11/24, revealed the resident was assessed after nursing staff reported a medication error. R1 was administered R2's medications. R1 is NPO (nothing by mouth) and has a J-Tube for administration of medications. The HCP ordered a chest x-ray with no specific findings; however, the HCP did recommend Augmentin (antibiotic) for ten days and to monitor her vital signs every four hours for 72 hours. R1's Mobile Chest x-ray, dated 10/11/24, documented an increased airspace disease (a condition that occurs when the air in the lungs' alveoli is replaced by other substances, such as fluid, pus, blood, cells or fat) in the medial (middle or center) right lung base which may represent atelectasis (a partial or complete collapse of a lung that can cause shortness of breath), infection (occurs when a microorganism, like a virus, bacteria, or fungi, enters the body and causes harm), and/or aspiration (accidentally inhaling food or liquid through your vocal cord into your airway. CMA R's Witness Statement, dated 10/11/24, documented she walked into R1's room and administered R2's medications including clopidogrel 75 mg, morphine extended release (ER) 15 mg, as well as acetaminophen 650 mg to R1. R2's Electronic Medical Administration Records (EMAR) reflects the following orders: Plavix 75 mg tablet (clopidogrel Bisulfate) start date 03/17/22, administered by mouth in the morning for coronary artery disease. Morphine Sulfate ER Tablet Extended Release 15 mg, state date 08/08/24, administered one tablet my mouth every 12 hours for pain do not crush. Acetaminophen tablet 325 mg, start date 11/01/23, administer two tablets by mouth three times a day for pain. On 10/11/24 at 10:30 AM Licensed Nurse (LN) G reported she was walking past R1's room and heard R1 coughing. She entered R1's room and assessed her oral cavity to find four tablets in her mouth. LN G removed the four tablets from R1's mouth. While LN G was in R1's room, CMA R entered R1's room to advise her that she had walked out of R2's room and realized she administered R2's medications to R1. LN G verified on CMA R's report from earlier that morning and CMA R had appropriately identified R1 as do not give medications. LN G reported she educated CMA R the resident had a J-Tube and only a nurse could administer R1's medications. CMA R verbalized she understood. CMA R administered R2's medications which included clopidogrel 75 mg, Morphine Sulfate ER 15 mg, acetaminophen 650 mg 2 tablets. LN G notified the physician extended, who assessed the resident. The HCP ordered a chest x-ray due to R1's history of aspiration pneumonia, Augmentin (antibiotic) for ten days, and to monitor her vital signs every four hours for 72 hours. On 11/14/24 at 12:33 PM Consultant GG reported she was advised by LN G that CMA R had administered R2's medications to R1, that included clopidogrel 75 mg, Morphine Sulfate ER 15 mg, acetaminophen 650 mg. Consultant GG ordered a chest x-ray that indicated nonspecific findings related to the medications error. Consultant GG ordered R1's vital signs to be monitored four times a day for 72 hours and Augmentin for 10 days, as a precautionary, due to R1's history of aspiration pneumonia. The provider recommended a follow up chest x-ray in one month that indicated no concern. On 11/14/24 at 10:09 AM Administrative Staff A reported that LN G reported CMA R incorrectly administered R2's medications to R1. LN G reported to her that CMA R verbalized understanding and drew a line through R1's name with a note of do not administer medications. CMA R completed a witness statement and was asked to leave the building and put on a do not return (DNR) list for the facility. Administrative Staff A expected the CMAs to follow all medication orders and if the CMAs had questions, she expected them to ask the LN. On 11/14/24 at 2:16 PM the Administrative Nurse A was provided the IJ Template. The facility was notified they failed to prevent the significant medication error of dependent and cognitively impaired R1 on 10/11/24 when CMA R incorrectly administered R2's medications, orally to R1 who had a J-tube, placed R1 in immediate jeopardy. The immediately jeopardy was determined to first exist on 10/11/24 at 09:00 AM, when CMA R incorrectly administered R2's medications orally to NPO resident R1. The surveyor verified the facility identified the implemented corrective actions were completed prior to onsite survey on 11/14/24 when the facility completed the following: 1. On 10/11/24 at 09:00 AM the facility asked the CMA R to complete a witness statement, was escorted out of the facility, and placed the CMA on the Do Not Return (DNR) list. 2. Licensed Nurses (LN) and Certified Medications Aides (CMA) were provided education on 10/11/24 at 09:30 AM through 10/15/24 at 06:00 AM related to medications administration. 3. Licensed Nurses (LN) and Certified Medications Aides (CMA) completed a medication administration checkoff, observed by the Unit Managers on 10/11/24 at 09:30 AM through 10/15/24 at 06:00 AM. Due to corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 57 residents. The facility identified three kitchen/food service areas. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. This placed the affected residents at risk for decreased palatability of food and food-borne illness. Findings included: - Observation of the [NAME] House kitchen, on 08/12/24 at 12:50 PM, with Dietary Staff EE, revealed the following areas of concerns: 1. Dietary Staff EE was unable to locate the thermometers in the upright refrigerator and freezer. 2. In the stand-alone refrigerator; a large zipper style plastic bag of macaroni salad lacked a preparation date, an expirations date, or a label of contents. 3. In the stand-alone freezer; a container of breadsticks was open to air. 4. In the stand-alone freezer; a zipper style plastic bag that contained an unknown frozen clear liquid lacked a preparation date, expiration date, or label of contents. 5. In the stand-alone freezer; a box of sausage patties was open to air. In addition, walk-through corridor between [NAME] House and [NAME] House dry storage area with Dietary Staff EE, revealed the following concerns: 1. Contained a large bin with various pasta with a package of egg noodles and tortilla chips that both lacked open or expiration dates. An observation in Saghbene Kitchen 08/12/24 a 01:00 PM with Dietary Staff FF revealed the following areas of concern: 1. A refrigerator temperature of 46 degrees Fahrenheit (F). Dietary Staff FF stated the temperature should be 41 degrees or lower. 2. In the stand-alone freezer; a plastic bag with an unknown meat product that lacked an open date, expiration date, or label of contents. 3. In the stand-alone freezer; a box of hamburger patties and a box of breakfast biscuits that were open to air. 4. The stand-alone refrigerator; contained an unknown loaf of discolored luncheon meat that lacked an open date, an expiration date, or label of contents. On 08/12/24 at 01:13 PM, Administrative Nurse D reported that in the absence of the Certified Dietary Manager (CDM), she was in charge of the kitchen and was made aware of above concerns. On 08/13/24 at 07:32 AM, Dietary Staff P stated refrigerators should be at 41 degrees F or below and was made aware of above concerns and on follow-up tour, he stated that all the items had been corrected. The facility's Dietary Food Storage dated 03/13/24, documented the following: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items taken out of original packaging will be labeled and stored in air-tight containers. The label must include received by date and or open date. Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 degrees Fahrenheit or lower. Place hanging thermometer in the warmest part of the refrigerator. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility. This placed the residents at risk for unpalatable food and food-borne illness.

The facility reported a census of 57 residents with 17 residents sampled. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of residents that were dependent on staff assistance for eating when staff labeled the residents as feeders. This practice had the potential to lead to negative psychosocial effects related to dignity. Findings included: - On 08/15/24 at 12:40 PM, Certified Nurse Aide (CNA) GG was observed referring to residents who required feeding assistance as feeders. On 08/15/24 at 12:42 PM, CNA GG confirmed that she had referred to residents with a label and that it violated the dignity of the residents as there were other residents around her when she spoke it. On 08/15/24 at 01:58 PM, Licensed Nurse (LN) K stated that residents should be called by their names and not labels. On 08/15/24 at 02:05 PM, Administrative Nurse HH stated that residents should never be referred to with labels. On 08/15/24 at 02:24 PM, Administrative Nurse D stated that the use of labels to refer to residents is a dignity problem. The facility's Right to Dignity policy, dated 12/07/23 documented that the facility would care for the residents in a manner that maintains and enhances the resident's dignity and respect. Further, documented that staff would never call residents by terms or labels. The facility failed to protect the dignity of the residents of the facility that were dependent on the assistance of facility staff to eat, when staff labeled residents as feeders.

The facility reported a census of 57 residents which included 17 residents sampled, with four residents reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to provide four residents, Resident (R) 22, R3, R8 and R32 and/or their representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the residents transfers to the hospital. This deficient practice placed these residents at risk to not be allowed to return to their former rooms at the facility. Findings include: - Review of the Electronic Health Record (EHR) for R8 included the pertinent diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus type 2 (DM2 - a disease when the body cannot use glucose, not enough insulin [a hormone that lowers the level of glucose in the blood] is made or the body cannot respond to the insulin), and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest) with hypoxia (inadequate supply of oxygen). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The assessment documented that R8 received oxygen. The 06/11/24 Care Area Assessment (CAA) lacked documentation related to hospitalization s. The 08/13/24 Care Plan lacked documentation related to hospitalization s. The EHR census log for R8 documented a hospitalization from [DATE] to 08/09/24. The Progress Notes documented on 08/04/24 at 01:05 PM, R8 transferred to a hospital via ambulance and returned to the facility on [DATE] at 03:47 PM. Review of the EHR documents revealed Administrative Staff CC held a conversation with R8 via telephone on 08/06/24 at 04:03 PM. On 08/15/24 at 09:30 AM, Licensed Nurse (LN) K stated when a resident is transferred to the hospital, a bed hold is part of the paperwork that is included in the transfer packet that the resident or resident's representative received. On 08/15/24 at 11:50 AM, Social Services U and Social Services V stated Administrative Staff CC would complete any bed-hold paperwork after the resident or resident's responsible party was notified. On 08/15/24 at 12:10 PM, Administrative Nurse D stated that Social Services U and Social Services X and Administrative Staff CC work collaboratively to complete the bed hold process and that she expected staff to follow the policy. On 08/15/24 at 02:05 PM, Administrative Staff CC stated she would call the family or responsible party for a verbal consent for the bed-hold and chart it into the EHR and confirmed that she did not complete any form. On 08/19/24 at 11:20 AM, Administrative Staff A and Administrative Staff B stated that it was their expectation that the transferring nurse to complete the written bed hold if practicable, depending on the condition of the resident. The facility's Bed Hold Policy policy, dated 09/01/23 documented that the facility must provide written information to the resident or resident's representative that is sent with the appropriate paperwork in the transfer packet when a resident is sent to a hospital. The facility failed to provide a written bed-hold notice to R8 for a hospitalization on [DATE]. This deficient practice placed R8 at risk to not be allowed to return to their former rooms at the facility. - Review of the Electronic Health Record (EHR) for R32 included the pertinent diagnoses of diabetes mellitus type 2 (DM2 - a disease when the body cannot use glucose, not enough insulin [a hormone that lowers the level of glucose in the blood] is made or the body cannot respond to the insulin) and atherosclerotic heart disease (heart disease caused by narrowing of the vessels on the heart). The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The 12/22/23 Care Area Assessment (CAA) lacked documentation related to hospitalization s. The Quarterly MDS dated , 06/21/24 documented a BIMS of 15, which indicated intact cognition. The 08/13/24 Care Plan lacked documentation related to hospitalization s. The EHR census log for R32 documented a hospitalization from [DATE] to 02/17/24. The Progress Notes documented on 02/16/24, R32 was transferred to the hospital for a planned procedure with an overnight stay. Review of the EHR documents revealed Administrative Staff CC documented on 02/16/24 at 10:40 AM, documented that the family had always done a bed hold for the resident. The documentation lacked evidence of verbal or written contact with R32 or R32's representative. On 08/15/24 at 09:30 AM, Licensed Nurse (LN) K stated when a resident is transferred to the hospital, a bed hold is part of the paperwork that is included in the transfer packet that the resident or resident's representative received. On 08/15/24 at 11:50 AM, Social Services U and Social Services V stated Administrative Staff CC should complete any bed-hold paperwork after the resident or resident's responsible party notified. On 08/15/24 at 12:10 PM, Administrative Nurse D stated Social Services U, Social Services X, and Administrative Staff CC work collaboratively to complete the bed hold process and that she expected staff to follow the policy. On 08/15/24 at 02:05 PM, Administrative Staff CC stated she would call the family or responsible party for a verbal consent for the bed-hold and chart it into the EHR. She confirmed she did not complete any form. Further, Administrative Staff CC stated that she gave verbal notice to R32's representative when he was transferred to the hospital. On 08/19/24 at 11:20 AM, Administrative Staff A and Administrative Staff B stated it was their expectation that the transferring nurse complete the written bed hold if practicable, depending on the condition of the resident. The facility's Bed Hold Policy policy dated 09/01/23, documented the facility must provide written information to the resident or resident's representative that is sent with the appropriate paperwork in the transfer packet when a resident is sent to a hospital. The facility failed to provide a written bed-hold notice to R32 and/or their representative, specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to a hospital. 50659 - Resident (R) 3's Electronic Health Record (EHR) revealed diagnoses of schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and bipolar (major mental illness that caused people to have episodes of severe high and low moods). The 08/02/24 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R3 had a total mood severity score of 00, indicating no depression and there were no behaviors. She was independent with activities of daily living (ADLs), with toileting hygiene, dressing, personal hygiene, mobility, and transfers. R9 required supervision assistance with bathing. The 08/02/24 Functional Abilities Care Area Assessment (CAA) documented ADL function CAA triggered secondary for the need for assistance with ADL's. Contributing factors included depression, anxiety, medication usage, history of falls, and weakness. The 05/15/24 Quarterly MDS documented a BIMS score of seven, indicating moderately impaired cognition. R3 required maximal assistance with dressing, and toileting and set up for eating and oral care. Total severity score of two indicating minimal depression. Review of the Progress Notes from 01/01/24 to 08/13/24 revealed the following: On 05/12/24 at 03:28 PM, R3 had decreased appetite and stated the food was poisoned, she refused breakfast and lunch meal. R3's family member notified, and family member brought in food for R3; which she took two bites of hamburger and declined remainder of food and fluids. On 05/13/24 provider note after visit, revealed R3 lethargic (lacking energy or feeling sluggish), not eating and drinking well. Family member concerned R3 could have a urinary tract infection (UTI-an infection in any part of the urinary system). Provider recommended R3 to have intravenous (IV-administered directly into the bloodstream via a vein) fluids and labs (blood work) ordered. R3 understood and agreed. On 05/13/24 at 04:29 PM, the provider ordered IV fluids, normal saline to run at 100 milliliters per hour for one liter and labs were ordered. On 05/14/24 provider note after visit, revealed R3 received 1 liter of IV fluids, but continued to not eat. On 05/15/24 provider note after visit, revealed R3 continued to refuse eat or drink. Recommended to send R3 to hospital, family member agreed. On 05/15/24 at 17:03 PM, R3 admitted to a hospital for altered mental status and lethargy. The progress notes lacked documentation for a bed hold. On 06/05/24 at 04:10 PM, R3 readmitted to the facility. On 08/13/24 at 08:21 AM, R3 seated in the dining room, eating her breakfast, and smiled as staff walked by. On 08/13/24 at 11:45 AM, R3 ambulated out of her room independently to the dining room, seated herself down in a chair at the table. On 08/15/24 at 11:50 AM, Social Service Designee (SSD) U and SSD V stated no bed hold form was located in R3's EHR or in the progress notes. SSD U stated that administrative staff CC should complete the bed hold paperwork. On 08/15/24 at 12:10 PM, Administrative Nurse D stated she would have to check the bed hold policy. However, administrative staff CC and the SSD should work together to complete a bed hold. Administrative Nurse D expected a bed hold would be completed with every resident that transfers to the hospital and to follow the policy. On 08/15/24 at 12:40 PM, administrative staff CC reported she would call the family member or responsible party on the phone and have a verbal conversation about a bed hold, then chart the conversation in the EHR. Administrative staff CC stated that she did not complete any bed hold paperwork. 08/15/24 at 02:31 PM, Licensed nurse (LN) K stated when a resident is transferred to the hospital, the SSD was to complete the bed hold, and she stated that she did not know how to complete a bed hold. The facility's policy Bed Hold Policy dated 09/01/23 documented when a resident transfers to a hospital, the facility must provide written information to the resident, a responsible party or legal representative, the bed hold form, consisted of the bed hold price and what to do with resident's belongings. The facility failed to provide R3 and/or representatives with a bed hold. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. - Resident (R) 22's Electronic Health Record (EHR) revealed diagnoses of bipolar (major mental illness that caused people to have episodes of severe high and low moods) and dementia (progressive mental disorder characterized by failing memory, confusion). The 03/01/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R22 had a total mood severity score of 00, indicating no depression and there were no behaviors. She was independent with activities of daily living (ADLs), with toileting hygiene, dressing, personal hygiene, and transfers. R22 required supervision assistance with bathing and ambulation. The 03/01/24 Functional Abilities Care Area Assessment (CAA) documented ADL function CAA triggered for need for assistance ADL's. Contributing factors included dementia, weakness, and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The 05/31/24 Quarterly MDS documented a BIMS score of 12, indicating moderately impaired cognition. R22 remained independent with ADLs, except supervision for bathing. Review of the Progress Notes from 01/01/24 to 08/13/24 revealed the following: On 03/27/24 at 04:38 PM, provider note revealed R22 scheduled for left-sided nephrectomy (surgery to remove all or part of a kidney) on 03/28/24. The progress notes lacked documentation for a bed hold. On 04/01/24 at 04:00 PM, R22 readmitted to the facility. Review of the MDS tracker in EHR revealed 03/28/24 discharge return anticipated assessment completed and on 04/01/24 Entry assessment completed. On 08/15/24 at 11:50 AM, Social Service Designee (SSD) U and SSD V stated no bed hold form located in R22's EHR or in the progress notes. SSD U stated that Administrative Staff CC should complete the bed hold paperwork. On 08/15/24 at 12:10 PM, Administrative Nurse D stated she would have to check the bed hold policy. However, Administrative staff CC and the SSD should work together to complete a bed hold. Administrative Nurse D expected a bed hold would be completed with every resident that transfers to the hospital and to follow the policy. On 08/15/24 at 12:40 PM, Administrative staff CC stated she would call the family member or responsible party on the phone and have a verbal conversation about a bed hold, then chart it in the EHR. Administrative staff CC stated that she did not complete any bed hold paperwork. On 08/15/24 at 02:31 PM, Licensed Nurse (LN) K reported when a resident is transferred to the hospital, the SSD should complete the bed hold, and she stated that she did not know how to complete a bed hold. The facility's policy Bed Hold Policy dated 09/01/23 documented when a resident transfers to a hospital, the facility must provide written information to the resident, a responsible party or legal representative, the bed hold form, consisted of the bed hold price and what to do with resident's belongings. The facility failed to provide R22 with a bed hold. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

The facility reported a census of 57 residents and the facility identified five residents that had impaired cognition that were independently mobile. Based on observation, interview, and record review, the facility failed to provide a secure door to the maintenance shop area located in the main hallway that led to resident units. The maintenance shop contained multiple chemicals that documented to Keep out of Reach of Children and were harmful or fatal if ingested that included the following: Micro Kill disinfectant, neutral floor cleaner, goo gone, Mold [NAME] Rapid Cleaner, bleach, spray paint and insect cleaner. Furthermore, the facility failed to have a functional alarm on an unsecured door that led to the outside. Additionally, the facility failed to provide an environment that remained free from accident hazards for one resident when the facility failed to appropriately place an electric cord for Resident (R) 9's lamp. The approximately five-foot cord extended in front of resident's window on the carpeted floor between the resident's recliner and the dresser that could have the potential to result in an injury. Furthermore, R9 had a fall on 04/24/24 that resulted in a right hip fracture. Findings included: - On 08/14/24 at 08:38 AM, observation revealed the maintenance shop door was three quarters of the way opened. There was a keypad lock on the door. Upon entry into the maintenance shop, no staff observed in the maintenance shop area. Approximately ten seconds afterwards, at 08:39 AM, Dietary Staff P exited the open maintenance door that slowly closed. Dietary Staff P pushed the door back to open so he could exit, as he held a bag of cereal and stated that the door would close on its own. Dietary Staff P attempted to pull the door shut, it was resistant, and he stated it was hard to shut. Dietary Staff P walked away, and the door stayed opened for 15 seconds longer. At 08:46 AM, Dietary Staff P, and unknown dietary staff opened the maintenance shop door and walked back into the shop with an empty black cart. They both walked through the shop straight through an open door and turned to the left. It took forty seconds for the maintenance shop door to close. On 08/14/24 at 08:48 AM, Maintenance Staff O entered the maintenance shop door when he used the keypad entrance code. Maintenance Staff O stated he set the maintenance door to close slowly to make is easier to take equipment in and out of the shop. He stated that he set that door to slowly close about two years ago. Maintenance Staff O stated that there were chemicals stored in the maintenance shop that are on the shelf and in the cabinets that were not locked. He stated that he did not always wait for that door to close completely when he would exit the maintenance shop. On 08/14/24 at 08:50 AM, observation revealed chemicals labeled as harmful or fatal if ingested that included the following: Micro Kill disinfectant, neutral floor cleaner, goo gone, Mold [NAME] Rapid Cleaner, bleach, spray paint, toilet bowl cleaner and fly insect spray. These chemicals were located on a shelf that was open and directly to the left of the open door. On 08/14/24 at 08:58 AM, Environmental Supervisor N confirmed the above was a concern. On 08/14/24 at 09:12 AM, a tour of the maintenance area, with Environmental Supervisor N, revealed staff could enter the maintenance shop, and walk to the dietary section through an open door that faced an exit door. The exit door had a sensor, however no alarm sounded. The exit door faced the facility parking lot that was located approximately 850 feet south of a major four-lane roadway that services heavy traffic that included semi-trucks with a speed limit of 40 miles per hour (MPH). The facility was approximately 550 feet east of a major two-lane road with a speed limit of 40 miles per hour. Maintenance Staff O stated that no alarm would sound when the door opened and the sensor should send an alarm to his email, to the Environmental Supervisor N email, and to Administrative Staff A's email. He confirmed that no email received when the door opened. He stated that a red light should be on the sensor, however no red light observed. Maintenance Staff O stated that the battery must be dead, and he had no way to know the last time he had received an email for that door sensor. Maintenance Staff O stated that the exit door was not a door that he had on his log sheet when he completed alarm and sensor checks for exit doors. He stated that no resident should have access to the exit door. Environmental Supervisor N stated that the staff on the units should know to not let any of the residents exit off the unit without staff or family, however some of the residents do exit the unit by themselves. Review of the facility's policy Chemical Storage dated 01/13/23, documented the following: To provide a safe environment for all residents, staff, and visitors. All chemicals that are deemed hazardous to residents will be stored in a locked area. This is defined as any chemical that will cause harm, or states to keep away from children. Review of the facility policy Electronic Monitoring System for Exit Doors dated 04/02/24 documented the following: The electronic monitoring system for exit doors for facility will be operational so the elders who wander do not leave the facility without an appropriate escort. The environmental services team will ensure that each electronic door monitor is tested at least monthly. The facility failed to provide a secure door to the maintenance shop area located in the main hallway leading to resident units and failed to keep hazardous chemicals from the confused, self-mobile residents of the facility Furthermore, the facility failed to have a functional alarm on an unsecured door that led to the outside. This deficient practice could potentially result in resident injury. - The Electronic Health Records (EHR) documented Resident (R)9 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), fracture (broken bone) of right hip with routine healing after an open reduction (surgical procedure for reducing a fracture or dislocation by exposing the skeletal parts involved), abnormal gait, and muscle weakness. The 05/05/24 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R9 had a total mood severity score of 00, indicating no depression and there were no behaviors. Dependent assistance with activities of daily living (ADLs), with toileting hygiene, bathing, and transfers. R9 required maximal assistance with dressing and personal hygiene. R9 had a fall with major injury. The 05/05/24 Functional Abilities Care Area Assessment (CAA) documented R9 had a fall in the facility while in her room. Initial x-rays were negative for fracture, but follow-up x-ray revealed right valgus impacted femoral neck fracture (a type of hip fracture that occurs when the proximal fragment of the femur impacts the fracture site in a valgus configuration [a force that pushes toward the center of the body]). She was admitted to the hospital for the fracture. The 05/05/24 Falls CAA documented R9 had a recent fall, interventions in place to prevent further falls, R9 received Effexor (medication is used to treat depression) and would be monitored by the nurse and the physician. The 04/05/24 Quarterly MDS documented a BIMS score of 13. The resident had no falls. R9 was independent with ADL's except required set up assistance for eating and dressing. The 08/13/24 Care Plan documented interventions included Staff were instructed to provide R9 with bed mobility and transfers as necessary, date initiated 04/06/23. Nurses were instructed to monitor for side effects of medications that may increase fall risk and to notify the physician, date initiated 04/06/2023. Staff were to encourage R9 to use her call light for assistance when toileting, dated initiated 10/17/23. Staff were to provide stand pivot transfers and R9 was independent with wheelchair mobility in her room, date initiated 04/15/24. R9 was educated to slow down and take her time with ambulation and transfers, date initiated 04/26/24. The Physician Orders included Occupational therapy two times week, for 30 days, for exercise, self-care and wheelchair management, date ordered 08/07/24. Physical therapy, three times a week, for 30 days for exercise and gait training, ordered 08/09/24. Review of the Progress Notes from 01/01/24 to 08/13/24 revealed the following: On 04/26/24 at 11:15 PM, R9 had an unwitnessed fall when she stated she tripped and fell when she ambulated out of the bathroom. The resident complained of pain of the right side. Administrative Nurse D notified and instructed to contact the physician if pain intensified. On 04/27/24 at 06:45 AM, R9 stated right pain was more painful and requested an X-ray. The oncoming nurse notified to call the physician. On 04/28/24 at 06:00 AM, R9 remained in pain of right hip, pain medication administered all night. On 04/28/24 at 11:20 AM, R9 complained of right hip pain, pain medication administered. R9 in bed. On 04/28/24 at 04:51 PM, R9 complained of pain, swelling and warmth to medial (towards the middle) aspect of right knee Staff notified the physician. On 04/29/24 the provider visit note documented R9 had a fall over the weekend, on-call provider was contacted, right hip x-rays completed, and both showed no acute fracture. R9 reported pain persisted and had difficulty ambulating since fall. On 04/29/24 at 04:17 PM, the physician ordered another x-ray of the right femur, Norco (contains a combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication) 5/235 milligram, by mouth, twice a day, and Intravenous (IV-administered directly into the bloodstream via a vein) fluids of Normal Saline (NS- saline water solution for medical use) at 100 milliliter per hour, for one liter. Results from the x-ray showed a possible impacted fracture of right hip femoral head and neck junction (a closed fracture that occurs when the ends of a broken bone are jammed together by force). R9 transferred to the hospital. On 05/02/24 at 12:39 PM, hospital physical therapy note revealed R9 reported to the therapist that she would transfer and did not use a walker to assist with transfers, rather she furniture surfs. On 05/03/24 at 11:32 AM, R9 readmitted to facility. Reviewed fall investigation for 04/26/24 and it was determined R9 ambulated independently from her bathroom to the bed and tripped. On 08/13/24 at 10:05 AM, Observation of R9's room included an approximately five-foot cord extended in front of the resident's window on the carpeted floor, between the resident's recliner and the dresser. On 08/14/24 at 07:56 AM, cord remains on carpeted floor in front of window as noted on previous day. On 08/13/24 at 10:05 AM, R9 stated she had a lot of falls and broke her hip. She stated that she will furniture surf in her room to get to areas. She confirmed she would open her windows at times. Observation of R9's room included an approximately five-foot cord extended in front of the resident's window on the carpeted floor, between the resident's recliner and the dresser. On 08/13/24 at 11:10 AM, Certified Nurse Aide (CNA) Q stated R9's lamp cord has been in front of the window in her room for a long time, and R9 did not ambulate around in her room that much. On 08/15/24 at 08:18 AM, Therapy Director T confirmed that R9 would furniture surf in her room. R9 had therapy when she returned from the hospital and met her goals, but Therapy Director T stated resident restarted therapy last week as the weight bearing status was clarified as weight bearing as tolerated for R9's right hip. On 08/15/24 at 09:15 AM, Licensed Nurse (LN) R stated R9 was known to furniture surf and she would open her window at times by herself. LN R confirmed the cord on the floor in front of R9's window could be a tripping hazard and stated R9 might now allow staff to move her lamp in her room, as R9 liked to read in the recliner. Her room has been set up like it was for a long time. On 08/15/24 at 12:10 PM, Administrative Staff D confirmed the lamp cord was a tripping hazard and it should be removed. The facility's policy Fall Prevention Protocol dated 12/07/23 documented each elder residing at the facility will be provided services and care to ensure that the elder's environment remains as free from hazards as possible that included staff to be alert for anything that would be in the path of traffic which could create a walking hazard. The facility failed to provide an environment that remained free from accident hazards for one resident when the facility was aware the resident furniture surfed and failed to appropriately place an electric cord for Resident (R) 9's lamp where it would not be a fall hazard. The approximately five-foot cord extended in front of resident's window on the carpeted floor between the resident's recliner and the dresser that could have the potential to result in an injury.

The facility reported a census of 57 residents. The facility identified 20 residents that resided on the 400 hall on 07/21/24. Based on interview and record review, the facility failed to ensure 12 of the 20 residents (R) 30, R8, R11, R32, R42, R26, R39, R48, R13, R36, R4 and R29, received medications from 07/21/24 from 06:00 PM to 07/22/24 at 06:00 AM shift, when Licensed Nurse I failed to administer medications, as ordered by the physician. Findings included: - Review of the investigation report dated 07/23/24, revealed the facility employed a licensed nurse from a nursing agency to work from 07/21/24 from 06:00 PM to 07/22/24 06:00 AM shift in one of three houses for 20 residents. It was found that many medications were not administered to the residents during the shift and that the agency licensed nurse had weird behavior. Upon review of the resident Electronic Medication Administration records (EMAR) and Electronic Treatment Administration Record (EMAR) it was found medications were not given for a variety of reasons. Review of EMAR, ETAR, and progress notes initiated. The review found medication and treatment errors for 15 of the 20 residents residing in the house. R30 had a Brief Interview for Mental Status BIMS of 15, indicating intact cognition. Investigation of records indicated the following: On the order for his oxygen (O2) to be placed and titrated, Licensed Nurse I documented in the record upon assessment. CPAP worn at night. On order for Levaquin (antibiotic that fights bacteria in the body), LN I documented upon assessment medication administration not utilized. On order for Proventil HFA Inhalation Aerosol Solution (medication inhaler that relaxes airway muscles and prevents or treats bronchospasm), LN I documented upon assessment medication not given. On order for Senna (medication to treat constipation) tablet, LN I documented upon assessment medication administration not utilized. Medication not given. On order Ipratropium Albuterol Solution (medication used to open the airway in the lungs), LN I documented upon assessment patient. Medication administration not utilized. R8 with a BIMS of 13, indicating intact cognition. Review of the EHR revealed: On order for Atorvastatin Calcium (medication used for high cholesterol), LN I documented upon assessment patient. Medication unavailable. Regarding medication. Medication request utilization update as it relates to oncoming AM nurse. On 07/22/24 at 08:00 AM Administrative nurse D documented the medication was available to administer in the medication cart. R1 had a BIMS of 11, indicating moderately impaired cognition. Investigation of EHR revealed: Order for Donepezil HCL (medication to treat confusion related to Alzheimer's [progressive mental deterioration characterized by confusion and memory failure]), Mirtazapine (antidepressant [class of medication used to treat mood disorders]), Pepcid (medication to decrease stomach acid production and used to treat peptic ulcer disease), Zoloft (antidepressant), and Zyprexa (antipsychotic [class of medications used to treat major mental conditions which cause a break from reality]), LNI documented upon assessment patient. Medication unavailable. Regarding medication. Medication request utilization update as it relates to oncoming AM nurse. On 07/22/24 at 08:00 AM, administrative nurse D documented medication was available to administer in the medication cart. Order to assess for any signs and symptoms of anxiety, LN I documented upon assessment. Patient AAO (undetermined abbreviation), no complaints of pain of discomfort. Order to assess for any signs and symptoms of behaviors related to psychosis, LN I documented, upon assessment patient alert awake and oriented. Order to assess for signs and symptoms of depression, LN I documented upon assessment patient alert awake and oriented. No fluctuation in neuro status. R32 had a BIMS of 15, indicating intact cognition. Investigation of the EHR revealed: Order for Atorvastatin Calcium, Duloxetine, Famotidine (medication to relieve symptoms of acid reflux and heartburn), Latanoprost Eye Drop (medication to treat high pressure inside the eye due to glaucoma [abnormal pressure within an eye caused by obstruction to the outflow), Melatonin (medication used to treat sleeplessness), Brimonidine Tartrate Eye Drop (medication used to treat glaucoma), Dorzolamide HCL(used to treat glaucoma), Guaifenesin (medication used to treat cough/congestion), and Durezol Emulsion (medication for the eye used to treat eye pain and inflammation), LN I documented upon assessment patient. Medication unavailable. Regarding medication. Medication request utilization update as it relates to oncoming AM nurse. On 07/22/24 at 08:00 AM, administrative nurse D documented medication was available to administer in the medication cart. Order for routine Morphine Sulfate (extended release) (medication used to relieve moderate to severe pain, LN I documented upon assessment patient verbalized pain 2/10. Medication not given. On order for Basaglar (long-acting insulin), LN I documented upon blood glucose assessment blood glucose level 70 and documented that it was not given. On order for routine Percocet (pain medication), LN I documented upon assessment. Patient verbalized no complaints of pain or discomfort. On order for A&D Ointment, LN I documented upon assessment. Medication not given. Will follow up. On order for respiratory assessment, LN I documented upon assessment will follow up. R42 had a BIMS of 13, indicating intact cognition. Investigation of EHR revealed: On order for melatonin, TUMS (antacid), and ocean nasal spray, LN I documented upon assessment. Medication not given. Will follow up. Order for Nepro not documented. On order to cleanse bilateral (both) forearm skin tears LN I documented upon assessment. Not done. Will follow up. R26 had a BIMS of 13, indicating intact cognition. Investigation of the EHR revealed: On order for Otezla (medication used for treatment of certain types of psoriasis (chronic skin disorder characterized by red patches covered by thick, dry, silvery adherent scales) and psoriatic arthritis, LN I documented upon assessment. Medication not given. Medication unavailable. Medication request update to oncoming nurse. Will follow up. On 07/22/24 at 08:00 AM administrative nurse D documented medication was available to administer in the medication cart. Order for apply lotion to both lower extremities, LN I documented upon assessment. Not done. Will follow up. On order to complete Covid assessment, LN I documented upon assessment. Medication not given. Will follow up. Order for Lantus (insulin), LN I documented upon assessment. Medication not given. Will follow up. LN I documented a blood glucose of 93 in the record. Order for fluid restriction LN I documented upon assessment. Assess patient food intake per unspecified diastolic congestive heart failure order. Orders to monitor for signs and symptoms of acute anxiety and depression, LN I documented upon assessment acute anxiety and upon assessment, in regard to acute restlessness, as needed administered. During shift change narcotic count LN I documented on narcotic sheet that he administered two of the as needed (PRN) Ativan and Norco at 06:00 AM, one Zolpidem at 06:00 AM, and one Oxycontin at 06:00 AM on 7/22/2024. No documentation on 07/21/24 at 08:00 PM on the eMAR to reflect LN I administered the Oxycontin ER. R39 had a BIMS of 12, indicating moderate cognitive impairment. R39 reported he thought he did receive some medications but did not know what medications may have been administered. On order for fluid restriction monitoring, LN I stated upon assessment. Not done. Will follow up. On order for Respiratory assessment, he stated upon assessment. No complaints of shortness of breath. R48 had a BIMS of 13, indicating intact cognition. R48 reported LN I gave him some medications, but he tried to give him an additional dose of Keppra. R13 had a BIMS of 99, indicating severe cognitive impairment. The EHR revealed: Order to cleanse left gluteal cleft with skin prep and apply barrier cream with incontinent episodes, and Tubi grips to bilateral (both) arms for protection LN I documented upon assessment. Not done. Will follow up. R36 had a BIMS of 12 indicating moderate cognitive impairment. Investigation of the EHR revealed: Order for Percocet, Baclofen (medication used to treat muscle spasms), Colace (stool softener), Ativan (medication to treat anxiety), and sennosides (medication used to treat constipation, LN I documented upon assessment. Medication not given. Will follow up. R4 had a BIMS of 99. Investigation of the EHR records indicated that on routine orders he stated upon assessment. Not done. Will follow up. The investigation lacked the medications LN I failed to administer. R29 had a BIMS of 15. On orders for Insulin Glargine, Compression Wraps, and respiratory assessment, LN I documented upon assessment. Medication not given. Will follow up. Interview on 08/15/24 at 11:10 AM, R30 reported the nurse did not give him his medications he was supposed to. Interview on 08/15/24 at 11:15 AM, R26 reported she kept asking the nurse for her Ambien she received every night. He told her she could not have it now and he never gave her the medication. Interview on 08/15/24 at 11:22 AM, R36 reported she had a couple of medications due that night, but the nurse told her she did not need them. Interview on 08/15/24 at 11:30 AM, certified medication aide (CMA) J reported she was the Medication Aide on duty the night LN I came on shift. When he took the shift, the narcotic/ scheduled medication count was correct, but when she returned the next morning to count, pills had not been administered, not signed out, and the count was wrong. LN I just signed out the medications all at the same time, making it look like he gave the residents two narcotics at the same time. He kept quoting he was with state and that was how things were done. Interview on 08/15/24 at 11:45 AM, Licensed Nurse K reported she tried to give LN I report on the residents by going room to room to tell him a little bit about each one since he had not been there before. He told her he would assess the residents for himself to see if she was right and what they would need. She reported when she came in the next morning, she noticed the computer screen was yellow, indicating missed medications. When she asked him about it, he said these are the meds (medications) that he assessed and determined the residents did not need them and he did not give them. She reported to the director of nursing when she arrived, and they started reviewing each residents' medical records. Interview on 08/15/24 at 12:20 PM, Administrative nurse D said she was notified of the issue when she came in to work that morning. She rounded on the unit in question to speak with additional floor staff regarding agency LN I and his behavior. LN K, and CMA J, who received shift change report and reconciled the count of narcotic medications, informed administrative nurse D that it appeared as if some medications were not administered overnight and received reports that the night nurse was weird. It was difficult to see if any medications other than the medications not documented because their medication cards aren't set up by the day. The nurse would just punch the next one on the card. There were several medications not documented or would be charted as not given with a note in the nurses notes why he did not think the medication was necessary. She made several attempts to contact the nurse but had no response. The contracted agency was contacted and after report given, was issued a do not return to the facility notice. The agency reported they were unable to reach the nurse. On 08/15/24 at 03:30 PM, administrative staff L reported she would check all agency staff background prior to them entering the facility. There were no red flags on his record, and his license was active. She had gotten report the nurse was acting weird, but staff did not know he was not giving the scheduled medication. A statement by the physician assistant regarding the medication not being administered overnight on 07/22/24 revealed LN I failed to administer some of the medications for several of the residents. In addition, LN I failed to document in the EMAR of medications he may have administered. On the medications/treatments LN I failed to administer, LN I failed to notify the physician for hold order. Additionally, he failed to complete vital signs and document scheduled assessments for Covid and skin. The physician assistant reviewed orders and found that in her professional opinion, no significant harm done by the omittance of medications. She was able to substantiate that medications/treatments were not carried out per physician orders. Review of the facility policy for Medication Administration, dated 02/22 revealed all medications will be administered to every resident as ordered by a physician in a safe and sanitary manner. The facility failed to ensure 15 of the 20 residents received medications from 07/21/24 from 06:00 PM to 07/22/24 at 06:00 AM shift, when Licensed Nurse I failed to administer medications, as ordered by the physician.

The facility had a census of 57 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 6 reviewed during the medication administration pass, remained free of medication errors. Twenty-five medication opportunities were observed with twelve medication errors. This placed the resident at risk for adverse reactions from the medications and resulted in a medication error rate of 48%. Findings Included: - Resident 6's medical diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure) and heart failure (a condition with low heart output and the body becomes congested with fluid). The Electronic Health Record (EHR) revealed the following physician medications: Cholecalciferol (a dietary supplement prescribed for with vitamin D insufficiency or deficiency) tablet 1000-unit tablet, give one tablet, by mouth (po), daily for Vitamin D deficiency, ordered on 06/12/22. Aspirin (a medication that reduces pain, fever, inflammation, and blood clotting), tablet 81 milligram (mg), give one tablet by mouth, daily for atherosclerotic heart disease (a common condition that develops when a sticky substance called plaque builds up inside your artery), ordered on 06/12/22. Thera-M (Multiple Vitamins-Minerals) (a dietary supplement that contains a combination of vitamins and minerals, and sometimes other ingredients) tablet, give one tablet by mouth, daily, ordered on 06/12/22. Bupropion Extended Release (medication used to treat depression), 150 mg tablet, give one tablet by mouth daily, for depression, ordered on 07/22/22. Escitalopram (medication used to treat certain mental/mood disorders), 10 mg tablet, give one tablet by mouth daily, for depression, ordered on 04/13/23. Gabapentin (medicine used to treat partial seizures, nerve pain from shingles and restless leg syndrome), 300 mg capsule, give one capsule by mouth every 12 hours, for radiculopathy (a temporary condition that occurs when a nerve root in the spine is injured or compressed), ordered on 06/16/23. Acetaminophen (a medication that reduces pain and fever), 325 mg tablet, give two tablets by mouth, two times a day, for chronic pain, ordered on 11/01/23. Oxycodone (medication used to treat moderate to severe pain), five mg tablet, give one tablet by mouth, every 12 hours, for chronic pain ordered 04/12/24. Losartan Potassium (medication used to treat high blood pressure),100 mg tablet, give one tablet by mouth daily, hold if systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) is less than 110 or diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) is less than 60, for HTN, ordered on 04/16/24. Fluticasone Propionate Suspension (medication used to relieve seasonal and year-round allergic and non-allergic nasal symptoms), 50 mg per actuate (when you cause the inhaler to spray the medicine plus propellant), give two sprays into each nostril daily, for congestion, ordered on 04/30/24. Amlodipine (medication used to treat high blood pressure) five mg tablet, give, one tablet by mouth daily, hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60, for HTN, ordered on 05/01/24. Lasix (is a diuretic, also called a water pill, that is commonly used to reduce edema (fluid retention), 40 mg tablet, give one tablet by mouth, daily, for heart failure, ordered on 05/10/24. Potassium Chloride extended release (supplement used to prevent or to treat low blood levels of potassium), 10 milliequivalents tablet, give one tablet by mouth daily, ordered on 08/07/24. Guaifenesin liquid (is an expectorant that thins the mucus in the air passages to make it easier to cough up the mucus and clear the airways), 100 mg per five milliliters (ml), give ten ml by mouth as needed for cough, every four hours, ordered on 08/12/24. On 08/14/24 at 07:57 AM, Certified Medication Aide (CMA) II prepared medications for R6's morning medication administration. CMA II, hand hygiene with hand sanitizer on medication cart, then she verified all the medications as she prepared them. CMA II revealed R6's blood pressure was 108/58 and had hold order for Amlodipine five mg tablet and Losartan 100 mg tablet and those medications would not be administered. CMA II spilled the medication cup that contained all of R6's by mouth pills except for the Oxycodone. Six of the by mouth medications landed on the floor and four landed on the medication cart top. CMA II picked up all the medications that fell out and placed them back into the medication cup. She proceeded to remove the Oxycodone tablet from the blister pack, by popping into the medication cup with all the other pills. CMA II went to R6's table in the dining room and asked R6 if she would like her medications. R6 stated yes. CMA II took the cap off the Fluticasone Propionate nasal spray and sprayed one spray into R6's right nostril, which caused R6 to start coughing. CMA II waited for R6 to stop coughing and sprayed one spray into R6's left nostril, then repeated a second spray into each nostril and resident started to cough again. No gloves were worn by the CMA II when she administered the nasal spray. CMA II handed R6 the medication cup with the by mouth medications and R6 swallowed them with her juice. R6 requested cough medication. CMA II walked back to the medication cart; without hand hygiene performed. CMA II verified and prepared the as needed Guaifenesin liquid order and administered it to R6. CMA II walked back to the medication cart and started to prepare another residents medication and failed to perform hand hygiene. On 08/14/24 at 08:20 AM, CMA II confirmed that she should not have administered the medications that dropped out of the medication cup, she stated she should have started with all new medications. Additionally, CMA II stated she should have applied gloves before administering the nasal spray and did confirm that no hand hygiene occurred, she stated I know I should have washed my hands. On 08/14/24 at 08:25 AM, Administrative Nurse M confirmed that R6's medication should not have been administered after the pills fell out of the medication cup and landed on the cart and floor. She stated that CMA II should have washed her hands after giving medications and should have worn gloves when she administered the nasal spray. On 08/15/24 at 02:55 PM, Administrative Nurse D confirmed the above concerns, and expected all medications to be administered following infection control standards. The facility's policy Medication Administration Policy dated 04/24/24 documented the following: All medications will be administered to every resident as ordered by a physician in a safe and sanitary manner. The facility failed to ensure that R 6's medications were in a sanitary manner. Furthermore, the facility failed to ensure that the overall medication error rate was below 5%. These deficient practices had the potential to have a negative effect on the overall physical and psychosocial well-being of the residents in the facility.

The facility reported a census of 57 residents. The facility identified 20 residents that resided on the 400 hall on 07/21/24. Based on interview and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible for seven residents when Licensed Nurse I failed to document medications/ treatments/assessments from 07/21/24 at 06:00 PM to 07/22/24 at 06:00 AM. Findings included: - Review of the investigation report dated 07/23/24, revealed the facility employed a licensed nurse from a nursing agency to work from 07/21/24 from 06:00 PM to 07/22/24 06:00 AM shift in one of three houses for 20 residents. Upon review of the resident Electronic Medication Administration records (EMAR) and Electronic Treatment Administration Record (ETAR), multiple medications were not documented or given for a variety of reasons. The facility initiated a review of EMAR, ETAR, and progress notes of the 20 residents that LN I was in charge of medication administration and identified the following concerns: R30 had a Brief Interview for Mental Status BIMS of 15, indicating intact cognition. Investigation of records indicated the following: No vital signs documented in eMAR or progress notes. An order to place ASV (Adaptive servo-ventilation- a type of CPAP machine), off in AM and on at bedtime (HS), LN I failed to document. R42 had a BIMS of 13, indicating intact cognition. Investigation of EHR revealed: On order for melatonin, TUMS (antacid), and ocean nasal spray, LN I documented upon assessment. Medication not given. Will follow up. No documentation as to the reason the medications were not given. Order for Nepro not documented. On order to cleanse bilateral (both) forearm skin tears LN I documented upon assessment. Not done. Will follow up. No documentation as to the reason the treatment and assessment were not completed. R26 had a BIMS of 13, indicating intact cognition. Investigation of the EHR revealed: On order for Otezla (medication used for treatment of certain types of psoriasis (chronic skin disorder characterized by red patches covered by thick, dry, silvery adherent scales) and psoriatic arthritis, LN I documented upon assessment. Medication not given. Medication unavailable. Medication request update to oncoming nurse. Will follow up. No documentation as to the reason the medications were not given. On 07/22/24 at 08:00 AM administrative nurse D documented medication was available to administer in the medication cart. Order for apply lotion to both lower extremities, LN I documented upon assessment. Not done. Will follow up. No documentation why the treatment was not done as ordered. On order to complete Covid assessment, LN I documented upon assessment. assessment not completed. Will follow up. No documentation why the assessment was not done as ordered. Order for Lantus (insulin), LN I documented upon assessment. Medication not given. Will follow up. LN I documented a blood glucose of 93 in the record. No documentation or follow up documented. Order for fluid restriction LN I documented upon assessment. Assess patient food intake per unspecified diastolic congestive heart failure order. Fluid restriction not documented during the shift. During shift change narcotic count LN I documented on narcotic sheet that he administered two of the as needed (PRN) Ativan and Norco at 06:00 AM, one Zolpidem at 06:00 AM, and one Oxycontin at 06:00 AM on 7/22/2024. No documentation on 07/21/24 at 08:00 PM on the eMAR to reflect LN I administered the Oxycontin ER. R39 had a BIMS of 12, indicating moderate cognitive impairment. R39 reported he thought he did receive some medications but did not know what medications may have been administered. On order for fluid restriction monitoring, LN I stated upon assessment. Not done. Will follow up. On order for Respiratory assessment, he stated upon assessment. No complaints of shortness of breath. Review of the eMAR revealed no documentation of any medications given during the shift. R13 had a BIMS of 99, indicating severe cognitive impairment. The EHR revealed: Order to cleanse left gluteal cleft with skin prep and apply barrier cream with incontinent episodes, and Tubi grips to bilateral arms for protection LN I documented upon assessment. Not done. Will follow up. No documentation for the reason treatments were not completed as ordered. R4 had a BIMS of 99. Investigation of the EHR records indicated that on routine orders he stated upon assessment. Not done. Will follow up. The investigation lacked the medications LN I failed to administer. No follow up was documented in the eMAR and no reason to hold the medications. R29 had a BIMS of 15. On orders for Insulin Glargine, Compression Wraps, and respiratory assessment, LN I documented upon assessment. Medication not given. Will follow up. No follow up was documented in the eMAR and no reason to hold the medications. Interview on 08/15/24 at 11:30 AM, certified medication aide (CMA) J reported she was the Medication Aide on duty the night LN I came on shift. When he took the shift, the narcotic/ scheduled medication count was correct, but when she returned the next morning to count, pills had not been administered, not signed out, and the count was wrong. LN I just signed out the medications all at the same time, making it look like he gave the residents two narcotics at the same time. He kept quoting he was with state and that was how things were done. Interview on 08/15/24 at 11:45 AM, Licensed Nurse K reported she tried to give LN I report on the residents by going room to room to tell him a little bit about each one since he had not been there before. He told her he would assess the residents for himself to see if she was right and what they would need. She reported when she came in the next morning, she noticed the computer screen was yellow, indicating missed medications. When she asked him about it, he said these are the meds (medications) that he assessed and determined the residents did not need them and he did not give them. She reported to the director of nursing when she arrived, and they started reviewing each residents' medical records. Interview on 08/15/24 at 12:20 PM, Administrative nurse D reported it was difficult to see if any medications other than the medications not documented because their medication cards aren't set up by the day. The nurse would just punch the next one on the card. There were several medications not documented. She made several attempts to contact the nurse but had no response. The contracted agency was contacted and after report given, was issued a do not return to the facility notice. The agency reported they were unable to reach the nurse. A written statement by the physician assistant regarding the medication not being administered overnight on 07/22/24 revealed LN I failed to document in the EMAR of medications he may have administered. Additionally, he failed to complete vital signs and document scheduled assessments for Covid and skin. Review of the facility policy for Medication Administration, dated 02/22 revealed all medications will be administered to every resident as ordered by a physician in a safe and sanitary manner. The facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible for eight residents when Licensed Nurse I failed to document medications/ treatments/assessments from 07/21/24 at 06:00 PM to 07/22/24 at 06:00 AM.

The facility reported a census of 57 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to the sanitary manner medications administered and lacked proper hand hygiene during medication administration. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - On 08/14/24 at 07:57 AM, Certified Medication Aide (CMA) II prepared medications for R6's morning medication administration. CMA II performed hand hygiene with hand sanitizer located on the medication cart. CMA II spilled the medication cup that contained all R6's by mouth pills except for the Oxycodone (pain medication). Six of the by mouth medications landed on the floor and four landed on the top of the medication cart. CMA II picked up all the medications that fell out and placed them back into the medication cup. She removed the Oxycodone tablet from the blister pack, by popping into the medication cup with all the other pills. CMA II went to R6's table in the dining room and asked R6 if she would like her medications. R6 stated yes. CMA II took the cap off the Fluticasone Propionate nasal spray and sprayed one spray into R6's right nostril, which caused R6 to cough. CMA II waited for R6 to stop coughing and sprayed one spray into R6's left nostril, then repeated a second spray into each nostril and resident started to cough again. CMA II lacked gloves when she administered the nasal spray. CMA II handed R6 the medication cup with the by mouth medications and R6 swallowed them with her juice. R6 requested cough medication. CMA II walked back to the medication cart, and without hand hygiene, prepared the as needed Guaifenesin (medication used to treat cough) liquid order and administered it to R6. CMA II walked back to the medication cart and started to prepare another residents medication and again, failed to perform hand hygiene. On 08/14/24 at 08:20 AM, CMA II confirmed that she should not have administered the medications that dropped out of the medication cup, she stated she should have started with all new medications. Additionally, CMA II stated she should have applied gloves before administering the nasal spray and did confirm that no hand hygiene occurred, she stated I know I should have washed my hands. On 08/14/24 at 08:25 AM, Administrative Nurse M confirmed that R6's medication should not have been administered after the pills fell out of the medication cup and landed on the cart and floor. She stated that CMA II should have washed her hands after giving medications and should have worn gloves when she administered the nasal spray. On 08/15/24 at 02:55 PM, Administrative Nurse D confirmed the above concerns, and expected all medications to be administered following infection control standards. The facility's policy Medication Administration Policy dated 04/24/24 documented the following: All medications will be administered to every resident as ordered by a physician in a safe and sanitary manner. The facility's policy Infection Control dated 03/14/24 documented the following: The facility will facilitate safe care of all residents by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Hand hygiene refers to washing with plain or anti-microbial (something can inhibit, resist, or prevent the growth of microorganisms, such as bacteria, mold, viruses, fungi, and parasites) soap and water and use of alcohol gel. Perform hand hygiene before and after contact with a resident. The facility failed to ensure that R 6's medications were administered in a sanitary manner. These deficient practices had the potential to have a negative effect on the overall physical and psychosocial well-being of the residents in the facility.

The facility reported a census of 57 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to include Resident (R)21 for the development and continued planning of the resident's care plan quarterly. This deficient practice placed the residents at risk for impaired care and services. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs. Findings included: - Resident 21's medical diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of unspecified shoulder. The 10/30/23 Significant Change Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R21 had a total mood severity score of 02, indicating minimal depression and there were no behaviors. R21 required supervision assistance with activities of daily living (ADLs), with toileting hygiene, bathing, dressing, personal care, and transfers. R21 required total assistance for mobility. The 10/30/23 Functional Abilities Care Area Assessment (CAA) documented R9 required assist with ADLs. Staff will assist him as needed. The 07/06/24 Quarterly MDS documented a BIMS score of 15, indicating intact cognition. R21 required maximal assistance with ADL's, toileting, transfers, dressing, mobility, and personal hygiene. He required moderated assistance with bathing and was independent with eating. The 08/13/24 Care Plan documented R21 was to be invited to attend all care plan meetings with the facility team and family, date revised 11/10/2023. Review of the Progress Notes from 01/01/24 to 08/13/24 revealed the following: On 02/02/24 at 04:00 PM, Social Service progress note revealed the care plan scheduled for 02/08/24 at 01:30 PM, Social Service staff called family member and confirmed time, she will be attending. On 05/07/24 at 11:04 AM, Social Service progress note revealed the care plan scheduled for 05/09/24 at 02:00 PM, family member and hospice staff will be attending. On 08/13/24 at 09:31 AM, R21 is seated up right in his bed, reported that he has never been invited to a care plan meeting with staff. On 08/15/24 at 11:50 AM, Social service staff U reported that there is no attendance sign in sheet when care plan meetings completed. She confirmed there was no progress note on paper or in EHR that a care plan meeting occurred. On 08/15/24 at 11:50 AM, social service staff V confirmed she documented in the EHR, when a care plan meeting was scheduled, and did not document R21 being informed, she stated I thought that would be implied. Social service staff V reported that R21 had intact cognition and a good memory. On 08/15/24 at 12:10 PM, Administrative Nurse D reported residents should be invited to care plan meetings. The facility's Care Conferences Meeting policy dated 01/10/24 documented: Scheduling of care plan conferences would be conducted at least every 90 days and whenever there is a significant change in resident's condition. Participants included resident, family, or healthcare representative, as invited by the resident and the interdisciplinary team included, Nurse, Social Service Designee (SSD), Dietary, and any other relevant personnel. Document the details of the care plan conference, including attendees, discussion, decisions made, and any updates to the care plan. The facility failed to include Resident (R)21 to his care plan meetings. This deficient practice placed the residents at risk for inadequate care and services. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs.

The facility reported a census of 57 residents with 17 residents sampled. Based on observation, interview, and record review, the facility failed to verify Resident (R)8's advanced directives (a legal document in which a person specified what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether or not to withhold medical intervention in the event the resident's heart stops] order). Additionally, the facility failed to obtain proper authorization for a DNR for R3 when the facility allowed the resident's guardian to consent. These deficient practices had the potential to lead to uncommunicated needs specifically to end-of-life care. Findings included: - Review of the Electronic Health Record (EHR) for R8 included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus type 2 (DM2 - a disease when the body cannot use glucose, not enough insulin [a hormone that lowers the level of glucose in the blood] is made or the body cannot respond to the insulin) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest) with hypoxia (inadequate supply of oxygen). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The assessment documented that R8 received oxygen. The Care Area Assessment (CAA) lacked the resident's wishes regarding advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not speak). The [DATE] Care Plan documented on [DATE] that R8 was a full code and indicated that R8's advanced directives would be posted in the chart. Review of the Physician Orders revealed an order for full code (a term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest), dated [DATE]. Review of the resident's EHR home screen revealed R8 documented the code status (full code or DNR) as full code. Review of the scanned documents in the EHR revealed an un-rescinded DNR order signed by R8 on [DATE]. Review of the progress notes revealed a provider's progress note related to education of advanced directives that documented R8 had stated that R8 wished to be a full code and R8 understood the risks and benefits. On [DATE] at 02:15 PM, Certified Medication Aide (CMA) JJ stated the resident's code status should be documented in the orders in the EHR and in the chart. There were lanyards in the medication room which documented the resident's code status, but upon inspection were found to be empty. On [DATE] at 02:20 PM, Certified Nurse Aide (CNA) KK stated that in the event of a resident's cardiac arrest, the nurse would be notified and then look in the care plan book for the resident's current advanced directives, but upon inspection, CNA KK was unable to locate R8's advance directive wishes. CNA KK was able to locate code status on the EHR home screen. On [DATE] at 02:22 PM, Licensed Nurse (LN) R stated that a resident's advanced directive wishes should be documented in the EHR under the physician orders and in the scanned documents with a hard copy in the charts at the nurses' station. On [DATE] at 02:24 PM, Administrative Nurse D stated that if a discrepancy between the DNR order and the full code order was present, the expectation was for staff to honor the advanced directives that had the most recent date. The facility's policy for Advanced Directives, dated [DATE], documented the facility would assess each resident as to whether or not they had advanced directives and update the EHR with supporting documentation. The facility failed to verify R8's advanced directives and code status. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care. 50659 - Resident (R) 3's Electronic Health Record (EHR) revealed diagnoses of schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and bipolar (major mental illness that caused people to have episodes of severe high and low moods). The [DATE] Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R3 had a total mood severity score of 00, indicating no depression and there were no behaviors. She was independent with activities of daily living (ADLs), with toileting hygiene, dressing, personal hygiene, mobility, and transfers. R9 required supervision assistance with bathing. The [DATE] Functional Abilities Care Area Assessment (CAA) documented ADL function CAA triggered secondary for the need for assistance with ADL's. Contributing factors included depression, anxiety, medication usage, history of falls, and weakness. The [DATE] Quarterly MDS documented a BIMS score of seven, indicating moderately impaired cognition. R3 required maximal assistance with dressing, and toileting and set up for eating and oral care. Total severity score of two indicating minimal depression. The Care Plan dated [DATE] documented R3 had established an advance directive (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions) and had selected Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest). Check R3's advanced directives quarterly, as needed and with any significant change. The care plan lacked documentation that R3 had a guardian (someone who has the right and responsibility to make decisions about another person's health care, education, personal care, and other matters). The Physician's Order dated [DATE], documented a Do Not Resuscitate order. On [DATE] review of EHR an uploaded document dated [DATE], a DNR by verbal consent from R3's guardian, that was signed by a Licensed Nurse and Administrative Nurse D. On [DATE] review of EHR an uploaded document dated [DATE], a signed guardianship by a County District Court, however lacked direction of advanced directives. Interview on [DATE] at 02:24 PM, Administrative Nurse D stated that she was not aware a guardian could not sign a DNR. The facility's policy for Advanced Directives, dated [DATE], documented the facility would assess each resident as to whether or not they had advanced directives and update the EHR with supporting documentation. Additionally, a guardian is not allowed to make end of life decisions. The facility failed to obtain proper authorization for a DNR for R3 when the facility allowed the resident's guardian to consent. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care.

The facility reported a census of 57 residents with 17 residents sampled that included one resident reviewed for baseline care plan. Based on interviews, observations, and record review, the facility failed to develop a person-centered baseline care plan for one resident, Resident (R) 153. This deficient practice had the potential to lead to uncommunicated needs. Findings included: - The Electronic Health Record (EHR) for Resident (R)153, admitted to the facility on [DATE] with documented diagnoses that included acute pancreatitis (a condition characterized by inflammation of the pancreas that can be accompanied by severe pain with nausea and vomiting), chronic kidney disease (CKD - long term kidney disease with gradual decline in kidney function) and diabetes mellitus type 2 (DM2 - a disease when the body cannot use glucose, not enough insulin [a hormone that lowers the level of glucose in the blood] is made or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS) was incomplete and in progress. The Care Area Assessment (CAA) was incomplete and in progress. Review of the EHR lacked a baseline care plan that included instructions needed to provide effective and person-centered care of R153. The 08/13/24 Care Plan documented on 08/09/24 that R153 requested a mesh stop sign to be put on her door to deter other residents from entering her room, and staff provided R153 with a grabber. The care plan lacked any additional information or directions for cares. Review of the physical chart on 08/19/24 at 10:45 AM with Administrative Nurse D revealed that a baseline care plan document that was dated 08/04/24 was in the chart but incomplete. The baseline care plan document failed to address resident's initial goals, preferred name, representative name, communication (vision/hearing) risk, dietary preferences, dietary risks, dietary interventions, therapy/restorative services, functional interventions, social/psychosocial services, special treatments/procedures, alarms/restraints, skin concerns, other conditions/concerns, resident life history/daily routine preferences/cultural and ethnic preferences, discharge plans/goals, resident/caregiver education needs and/or hospice/outside coordination needs. Additionally, the baseline care plan was unsigned and undated by the interdisciplinary team (IDT - a team of healthcare professionals across all the available modalities of care which includes [but not limited to] nursing, dietary, physical/occupational therapy, social services). On 08/13/24 at 11:46 AM, R153 stated that she had not had a care plan meeting with the staff, nor had any staff asked her about her needs/wishes with regard to her care since she arrived in the facility. On 08/19/24 at 09:40 AM, Administrative Nurse D stated that her expectation is that staff to meet with all new residents and would have the document completed within the first 48 hours from a collaboration between the resident and staff, which included being signed and dated by the IDT team members and the resident or resident's representative. The facility's Care Planning policy, dated 11/12/18 documented that the facility's care planning and interdisciplinary team (IDT - a team of healthcare professionals across all the available modalities of care which includes [but not limited to] nursing, dietary, physical/occupational therapy, social services) was responsible to provide the residents and their representatives a summary of the baseline care plan within 48 hours of admission. The facility failed to complete a baseline care plan for one resident, R153. This deficient practice had the potential to lead to uncommunicated needs.

The facility identified a census of 57 residents which included 17 residents sampled and reviewed for care plan development. Based on interview, observations, and record review, the facility failed to develop a comprehensive person-centered care plan for one resident, Resident (R)30's, regarding oxygen delivery or nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication administration. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical well-being. Findings included: - R30's Electronic Health Record (EHR) included diagnoses of obstructive sleep apnea (OSA - a disorder of sleep characterized by periods without respirations due to anatomical obstructions in the airway) and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition and R30 did not receive oxygen. The Care Area Assessment (CAA), dated 11/03/23, lacked documentation related to oxygen use or nebulized medication. The 05/29/24 Care Plan lacked documentation related to oxygen use or nebulized medication. The Physician's Orders documented the following: Ipratropium (a long-acting medication used to open medium and large airways of the lungs) - albuterol (a short-acting medication used to open the airways of the lungs), 0.25-2.5 milligrams (mg) per milliliter (mL), 3 mL inhaled by mouth (orally) by nebulizer, every four hours as needed, for shortness of breath or wheezing, ordered 02/05/24. Ipratropium-albuterol, 0.2-2.5 mg/mL, inhaled by mouth by nebulizer, four times per day for cough/wheezing, and every four hours as needed for cough/wheezing, ordered 02/06/24. Oxygen at two liters per minute by nasal cannula, may titrate (adjust) to maintain oxygen saturation above 90 percent (%) or above as needed, every shift for shortness of breath and low oxygen saturation, ordered 07/08/24. Supplemental oxygen (O2) at two liters per minute, to maintain oxygen saturation above 90%, two times per day, for coughing and hypoxia (low oxygen saturation in the blood), ordered 08/09/24. On 08/14/24 at 09:04 AM, Certified Nurse Aide (CNA) LL identified R30 wore oxygen and stated that the tubing and nebulizers were to be changed every Wednesday, usually on night shift. On 08/19/24 at 05:53 AM, CNA F stated that cares are sometimes listed in the care plans in the care plan book, but not all residents are in the care plan book and it's not always accurate. CNA F further stated that if they questioned what cares that a resident should receive, they would ask the nurse. On 08/19/24 at 08:54 AM, Licensed Nurse (LN) K stated that all cares that a resident should get are listed in the care plan in the care plan book and in the EHR. On 08/19/24 at 10:33 AM, Administrative Nurse D confirmed that oxygen use and nebulized medication use was not on R30's care plan. Administrative Nurse D further stated that her expectation is that care plans should be accurate to reflect the cares that are administered to the residents. The facility's Care Planning policy, dated 11/12/18 documented that the facility's care planning and interdisciplinary team (IDT - a team of healthcare professionals across all the available modalities of care which includes [but not limited to] nursing, dietary, physical/occupational therapy, social services) was responsible to develop an individualized comprehensive care plan for each resident and that the care plan was current and revised whenever the resident's conditions changed. The facility failed to develop a comprehensive person-centered care plan for R30 related to oxygen use or nebulized medication use. This deficient practice had the potential to lead to uncommunicated needs that would negatively affect the physical well-being of R30.

The facility reported a census of 57 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately revise two residents care plans after Resident (R)22 and R9's had a fall. This placed the residents at risk for uncommunicated care needs. Findings included: - Resident (R) 22's Electronic Health Record (EHR) revealed diagnoses of bipolar (major mental illness that caused people to have episodes of severe high and low moods) and dementia (progressive mental disorder characterized by failing memory, confusion). The 03/01/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R22 had a total mood severity score of 00, indicating no depression and there were no behaviors. She was independent with activities of daily living (ADLs), with toileting hygiene, dressing, personal hygiene, and transfers. R22 required supervision assistance with bathing and ambulation. R22 had no falls. The 03/01/24 Functional Abilities Care Area Assessment (CAA) documented ADL function CAA triggered for need for assistance for ADL's. Contributing factors included dementia, weakness, and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The 03/01/24 Falls CAA documented R22 had a history of falls, weakness and physical performance limitations affecting gait, balance, and endurance. R22 received medications that placed her at a risk for falls. The 05/31/24 Quarterly MDS, documented a BIMS score of 12, indicating moderately impaired cognition. R22 remained independent with ADLs, except supervision for bathing. R22 had no falls. The 08/13/24 Care Plan documented interventions included staff were instructed to remove the clutter on R22's bed to give her more room to lay down and reposition self, dated 04/09/24. Staff educated R22 on the importance of locking her wheelchair when she would transfer to the wheelchair, dated 04/09/24. Review of the Progress Notes from 01/01/24 to 08/13/24 revealed the following: On 04/06/24 at 01:53 PM, R22 was conversing with another resident at the dining room table, staff overheard R22 state she rolled out of her bed. The (unidentified) Nurse spoke with R22, and she stated she fell out of bed, crawled back to wheelchair or bed, and assisted self-up. On 08/12/24 at 06:23 PM, Nurse documented in progress note, R22's family member told the facility nurse that R22 reported to them she had a fall sometime over the weekend. R22 had a yellow bruise on the middle of her back. R22 reported she fell on the concrete. Staff administered as needed Acetaminophen (a medication that reduces pain and fever) for pain. On 08/13/24 at 11:15 AM, R22 reported she fell out of her wheelchair the other day in her room and landed on concrete, as she pointed to an open area in her room in front of her window. She stated that the floor felt like concrete. She reported the staff knew she had a fall. On 08/15/24 at 12:02 PM, Administrative Nurse S reported care plans are updated as a team approach, but interdisciplinary staff members need to follow up to make sure the care plan has been updated. On 08/15/24 at 12:10 PM, Administrative Nurse D confirmed R22's care plan was not revised after her fall after family reported the fall on 08/12/24. Administrative Nurse D stated she had not been updated or aware of the progress note in R22's EHR. She expected the nurses would follow the falls protocol and update the care plan with an intervention the same day as the fall. On 08/15/24 at 02:31 PM, Licensed Nurse (LN) K reported witnessed, unwitnessed, or if a resident stated they had a fall, staff should assess the resident for pain, injury, and neurological exam (checks a person's mental status, coordination, ability to walk, and how well the muscles, sensory systems, and deep tendon reflexes work), complete a risk management in EHR, determine what caused the fall, notify Administrative Nurse D, Administrative Staff B, responsible party, and the physician. LN K stated she would document in the progress notes in EHR. The Administrative Nurse D and Administrative Nurse S should update the care plans. The facility's Care Plan Revision Policy dated 04/24/24 documented the following: The care planning process includes patient assessment, goal setting, intervention, referrals to other health care professionals, evaluation of patient response to treatment and revision of care and treatment in order to meet the patient's needs. Revisions of the care plan will be the responsibility of a Licensed Nurse, in collaboration with the elder, responsible party, direct care staff, and the entire interdisciplinary team and changes will be communicated with all staff on all shifts. The facility failed to revise R22's care plan after a fall to prevent possible further falls. This placed the residents at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. - The Electronic Health Records (EHR) documented Resident (R)9 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), fracture (broken bone) of right hip with routine healing after an open reduction (surgical procedure for reducing a fracture or dislocation by exposing the skeletal parts involved), abnormal gait, and muscle weakness. The 05/05/24 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R9 had a total mood severity score of 00, indicating no depression and there were no behaviors. R9 was dependent on staff assistance with activities of daily living (ADLs), with toileting hygiene, bathing, and transfers. R9 required maximal assistance with dressing and personal hygiene. R9 had a fall with major injury. The 05/05/24 Functional Abilities Care Area Assessment (CAA) documented R9 had a fall in the facility while in her room. Initial x-rays were negative for fracture, but follow-up x-ray revealed right valgus impacted femoral neck fracture (a type of hip fracture that occurs when the proximal fragment of the femur impacts the fracture site in a valgus configuration [a force that pushes toward the center of the body]). She admitted to the hospital for the fracture. The 05/05/24 Falls CAA documented R9 had a recent fall, interventions in place to prevent further falls and R9 received Effexor (medication is used to treat depression) and would be monitored by the nurse and the physician. The 04/05/24 Quarterly MDS documented a BIMS score of 13. The resident had no falls. R9 was independent with ADL's except required set up assistance for eating and dressing. The 08/13/24 Care Plan lacked any guidance or staff instructions regarding right hip fracture precautions for weight bearing status. The hospital discharge orders, dated 05/03/24 located in R9's EHR documented weight bearing status was touch toe weight bearing (TTWB a weight-bearing restriction that allows a person to stand or walk while only touching the floor with their toes for balance, without putting any weight on their leg) of her right lower extremity. The Physician Orders included weight bearing status of right lower extremity and non- weight bearing until x-ray results seen by surgeon, ordered 6/14/2024. Occupational therapy two times week, for 30 days, for exercise, self-care and wheelchair management, date ordered 08/07/24. Physical therapy, three times a week, for 30 days for exercise and gait training, ordered 08/09/24. Review of the Progress Notes from 01/01/24 to 08/13/24 revealed the following: On 04/26/24 at 11:15 PM, R9 had an unwitnessed fall when she stated she tripped and fell when she ambulated out of the bathroom. The resident complained of pain of the right side. Administrative Nurse D notified and instructed to contact the physician if pain intensified. On 04/29/24 at 04:17 PM, the physician ordered another x-ray of the right femur, Norco (contains a combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication) 5/235 milligram, by mouth, twice a day, and Intravenous (IV-administered directly into the bloodstream via a vein) fluids of Normal Saline (NS- saline water solution for medical use) at 100 milliliter per hour, for one liter. Results from the x-ray showed a possible impacted fracture of right hip femoral head and neck junction (a closed fracture that occurs when the ends of a broken bone are jammed together by force). R9 transferred to the hospital. On 05/02/24 at 12:39 PM, hospital physical therapy notes revealed R9's weight bearing status was touch toe weight bearing of her right lower extremity. On 05/03/24 at 11:32 AM, R9 readmitted to the facility. On 08/15/24 at 08:18 AM, reviewed the following therapy communication and team progress notes that were received from the Therapy Director T, and confirmed the communications were not in the care plan update book on the unit or in R9's paper chart or EHR. On 05/06/24, therapy to nursing communication form documented R9 was TTWB of her right lower extremity. On 05/21/24, a multidisciplinary therapy screen form documented R9 continued TTWB for her right lower extremity, follow up orthopedic (pertaining to bones) appointment in five weeks. On 08/05/24, a multidisciplinary therapy screen form documented R9's weight bearing status changed to weight bearing as tolerated per orthopedic physician. On 08/08/24, a therapy to nursing communication form documented staff instructed to provide a front wheeled walker and R9 required minimal assist with ADLs and was weight bearing as tolerated for right lower extremity. On 08/15/24 at 08:18 AM, Therapy Director T reported that R9 had therapy when she was readmitted in May,2024 and she reached her goals, as R9 was TTWB. Therapy Director T revealed provider ordered therapy on 08/09/24, as her weight bearing status upgraded to weight bearing as tolerated. Therapy Director revealed that she did not update the care plan in EHR, she would communicate with nursing on a therapy communication form. She stated the forms were not uploaded in the EHR, however, Administrative Nurse D, Administrative Nurse S, and to the nursing unit where the resident resided would be given a copy of the therapy communication form. On 08/15/24 at 08:46 AM, Licensed Nurse (LN) R reported Administrative Nurse D and Administrative Nurse S should update the care plans because the floor nurse does not update the care plan. LN R confirmed that therapy should deliver communication forms with recommendations for care plan changes and those forms were to be placed in the care plan book at the nurse's station. LN R revealed the only therapy communication form for R9 in the care plan book was dated 04/12/24 for transfer technique, stand pivot, R9 independent with wheelchair in her room only, and R9 was seen for neck pain. On 08/15/24 at 12:02 PM, Administrative Nurse S reported care plans are updated as a team approach, but interdisciplinary staff members need to follow up to make sure the care plan had been updated. Administrative Nurse S reported R9's care plan was not updated with her right hip fracture weight bearing status, and confirmed the therapy communication forms were not in the care plan book for R9. On 08/15/24 at 12:10 PM, Administrative Nurse D confirmed R9's care plan was not revised. Administrative Nurse D expected the nurses would update the care plan as needed. The facility's Care Plan Revision Policy dated 04/24/24 documented the following: The care planning process includes patient assessment, goal setting, intervention, referrals to other health care professionals, evaluation of patient response to treatment and revision of care and treatment in order to meet the patient's needs. Revisions of the care plan will be the responsibility of a Licensed Nurse, in collaboration with the elder, responsible party, direct care staff, and the entire interdisciplinary team and changes will be communicated with all staff on all shifts. The facility failed to revise R9's care plan after a fall with ordered weight bearing status. This placed the residents at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility.

The facility identified a census of 49 residents. The sample included 15 residents, with five residents reviewed for pressure ulcer (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 prevent the redevelopment of a pressure related injury for Resident (R) 33 and failed to ensure pressure reducing measures were in place for R9. This deficient practice placed R33 and R9 at increased risk of development or worsening of pressure related injuries. Findings included: - R33's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), atrial fibrillation (rapid, irregular heartbeat), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented that R33 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented R33 was at risk of development of pressure ulcers and did not have an unhealed pressure ulcer during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of nine, which indicated moderately impaired cognition. The MDS documented that R33 required limited assistance of one for ADL's. The MDS documented R33 did not have an unhealed pressure ulcer during the look back period. R33's Pressure Ulcer Care Area Assessment (CAA) dated 09/12/22 documented R33 was at risk of development of pressure ulcers related to limited mobility, weakness, and incontinence. The Licensed Nurse (LN) would complete weekly skin assessments as ordered and notify the physician of any skin related issues. R33's Care Plan dated 05/07/21 documented LN would complete skin and Braden scale ( a standardized tool to assess pressure ulcer risk) assessments per facility protocol. The Care Plan dated 06/08/21 documented Certified Nurses Aide (CNA) would make observations of R33's skin during bathing and report any changes or skin alterations to the LN. The Care Plan documented staff would assist R33 with bed mobility as needed. The Care Plan dated 04/27/22 documented a pressure reducing mattress and wheelchair cushion would be provided for R33 and treatment would be provided as ordered. The Care Plan with revision date of 11/03/22 documented staff would assist R33 with repositioning on rounds and as needed. Review of the EMR under Orders tab revealed a physician order for a Braden scale assessment every three months on night shift dated 06/18/21. Review of the EMR revealed a physician order for skin assessment every Thursday on day shift dated 06/23/22. The Weekly Skin Data Collection Tool dated 08/18/22 recorded the assessment was completed with no additional notes/information. The next Weekly Skin Data Collection Tool was completed on 09/05/22 and again on 09/08/22 with no additional notes/information. The medical record lacked documentation of the Weekly Skin Data Collection Tool until 9/29/22, which was 23 days later. A wound Visit Report dated 09/20/22 recorded Consultant HH assessed R33's right buttock was a chronic stage three pressure injury (full-thickness pressure injury with loss of skin that extends to the subcutaneous [under the skin] tissue) which had a status of not healed. The note recorded initial encounter as 1 centimeter (cm) length by 1.2 cm width by 0.1 cm depth, no tunneling or undermining present. There was scant amount of drainage and the wound bed had 76-100 percent (%) granulation (new tissue growth). The periwound (skin around the wound) had normal moisture; scarring and erythema (redness) were also noted on the periwound. The note recorded a wound order for right buttock pressure ulcer to apply collagen (protein infused dressing used to assist in wound healing) sheet 1 inch by 1 inch to wound every day for 30 days, apply hydrogel filler (define) to wound every day for 30 days. Cover wound with silicone dressing pad every day for 30 days. R33's clinical record lacked evidence this order was addressed. R33's clinical record lacked evidence the right buttock wound was measured, and the wound bed, drainage and periwound assessed after 09/20/22. The Wound Data Collection Tool dated 09/21/22 recorded there was an area of small, intact, non-blanchable erythema (redness) 2.5 cm distal to the lower right buttock wound edge . The tool recorded a treatment to cleanse with cleanser of choice, apply skin prep to periwound, apply hydrogel to moisten wound bed. Cover with a dry dressing and change daily. R33's EMR recorded an order dated 09/22/22 for the right buttock: cleanse the area with a wound cleanser of choice, apply skin prep skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to the peri-wound (is the tissue surrounding the wound), hydrogel (water-based gel which donates moisture and aides autolytic debridement) to the peri bed and cover with a dry dressing, change daily on day shift. This order was discontinued 9/25/22. R33's EMR recorded an order dated 09/25/22 for the right buttock: cleanse the area with a wound cleanser of choice, apply skin prep to the peri-wound, hydrogel to the peri bed and cover with a dry dressing for one time only for wound care. (Discontinued 10/05/22.) R33's EMR recorded an order dated 09/26/22 for right buttock: cleanse the area with a wound cleanser of choice, apply skin prep to the peri-wound, hydrogel to the peri bed, cover with a dry dressing, change daily on day shift. (Discontinued 10/05/22.) The Wound Data Collection Tool dated 09/28/22 documented the right buttock pressure ulcer wound showed good progress however the resident had moisture associated skin damage (MASD) on the intergluteal cleft (area between buttocks) The tool recorded barrier cream would be applied with each incontinent episode. The Weekly Skin Data Collection Tool dated 09/29/22 recorded the assessment was completed with no additional notes/information. The Wound Data Collection Tool dated 10/05/22 recorded the right buttock pressure wound was resolved. The tool directed to apply skin prep and cover with a dry dressing. The resident continued with MASD which showed good improvement. R33's EMR recorded an order dated 10/06/22 for right buttock: cleanse the area with a wound cleanser of choice, apply skin prep and cover with form dressing change every seven days and as needed in the morning. (Discontinued 10/11/22.) The Weekly Skin Data Collection Tool dated 10/06/22 recorded R33's skin was intact with old healing area to the coccyx (small triangular bone at the base of spine). There was a treatment in place. R33's EMR recorded an order dated 10/11/22 which directed to apply skin prep twice a day and cover with moisture barrier cream two times a day for wound healing. The Weekly Skin Data Collection Tool dated 10/27/22 documented a new skin issue was noted but lacked further information or assessment findings. The record lacked evidence of further weekly skin assessments until 11/17/22. A Nurses Note on 10/30/22 at 03:25 PM documented R33's right bottom was open and red; the area was cleansed with normal saline. R33 was to be in bed after meals to relieve pressure and staff to reposition every two hours. Family was notified. The Weekly Skin Data Collection Tool dated 11/17/22 recorded blanchable redness to the coccyx/sacrum area, the area was not open. Staff would continue to monitor. No further weekly skin assessments were completed as of review on 11/28/22. A Nurses Note on 11/21/22 at 02:42 PM documented R33 had skin breakdown on her coccyx that was bleeding; the area was cleaned with normal saline, staff applied barrier cream and covered with dry dressing. R33's EMR recorded an order dated 11/22/22 to cleanse wound with normal saline, apply collagen to wound bed, skin prep to peri-wound, and cover with dry dressing daily on day shift. R33's clinical record lacked further information including wound bed assessments, periwound assessments, drainage, and wound measurements . Observation of wound care for R33 on 11/30/22 at 11:41 AM Licensed Nurse (LN) J And LN I prepared to perform wound treatment. LN J explained the procedure to R33. LN I donned gloves, removed R33's soiled brief and provided peri-care. LN I doffed her soiled gloves, donned clean gloves without performing hand hygiene, and removed the saturated dressing from R33's coccyx area, LN I doffed the soiled gloves and without performing hand hygiene, donned clean gloves, and cleansed R33's coccyx area with normal saline. The skin was dark pink and blanchable. LN I measured and stated R33's coccyx wound was 13 cm by 10 cm, LN I then removed her gloves, but did not perform hand hygiene. LN J then donned clean gloves without performing hand hygiene after she had assisted with providing cares for R33. LN J than changed places with LN I, cleansed R33's coccyx area again with normal saline, donned her soiled gloves and without performing hand hygiene doffed clean gloves then applied skin prep to the peri-wound area. LN j then removed the soiled gloves and [NAME] clean gloves without performing hand hygiene. LN J touched her glasses, then cut a collagen dressing, applied hydrogel to the collagen dressing and applied the dressing to R33's coccyx area. On 11/30/22 at 11:29 AM Certified Nurse's Aide (CNA) P stated she would report any new skin related issues for any resident to the charge nurse. CNA P stated for R33, she would apply moisture barrier cream after every incontinent episode when she provided care for R33. CNA P stated she referred to the care plan to review if any changes for R33 had occurred. On 11/30/22 at 12:12 PM LN I stated R33's coccyx area reopens frequently from R33 scratching her skin. LN I stated the dressing was ordered to be changed daily. LN I stated she was not sure if any new interventions had been added to prevent R33's coccyx area from opening since the most recent occurrence of the pressure wound reopening. On 11/30/22 at 03:08 PM Administrative Nurse D stated R33's coccyx area had reopened, and she was unsure when the area had healed, and a dressing was applied for protection. Administrative Nurse D stated she would need to review R33's care plan to know what pressure reducing measure had been in place. The facility was unable to provide a policy related to prevention of pressure related injuries. The facility failed to prevent the redevelopment of a pressure related injury for R33 when they failed to consistently monitor the area, failed to identify and implement preventative measures, The facility further failed to ensure staff performed appropriate hand hygiene during dressing changes. - R9's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, reduced mobility, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and chronic pain. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R9 required limited assistance of one staff member for activities of daily living (ADLs). The MDS documented R9 was at risk of pressure ulcer development and would have a pressure reducing device on her bed and in her wheelchair. R9's Pressure Ulcer Care Area Assessment (CAA) dated 11/12/22 documented R9 was at risk related to bowel and bladder incontinence which required assistance with person al hygiene and mobility. Staff would monitor for skin breakdown during weekly skin assessments. R9's Care Plan dated 05/09/22 documented R9 was to have a special pressure reducing mattress on her bed and a cushion in her wheelchair. On 11/29/22 at 09:27 AM R9 laid on the bed. Her wheelchair was next to the bed with no wheelchair cushion noted. On 11/29/22 at 03:21 PM R9 sat at the dining room table; she participated in the afternoon activity. R9's wheelchair lacked a cushion. On 11/30/22 at 11:29 AM Certified Nurses Aide (CNA) P stated any resident that was in a wheelchair should have a wheelchair cushion to help prevent skin breakdown, CNA P stated she would notify the nurse if there was a resident without a cushion. On 11/30/22 at 12:12 PM Licensed Nurse (LN) I stated any resident that was at risk for skin breakdown and was in a wheelchair should have a cushion to help prevent pressure related injuries from occurring. On 11/30/22 at 03:08 PM Administrative Nurse D stated some residents refused to have a cushion in their wheelchairs, but resident that were at risk of development of pressure related breakdown should have a cushion in the its wheelchair. The facility was unable to provide a policy related to prevention of pressure related injury. The facility failed to ensure a pressure reducing cushion was in R9's wheelchair to help prevent and reduce the development of pressure related injury. This deficient practice placed R9 at an increased risk of development or worsening of pressure related injuries.

The facility census totaled 69 residents with 27 residents sampled, and 5 reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure staff followed the care plan for 1 of 5 residents to prevent a fall for resident # 22 which resulted in a fractured pelvis. Findings included: - Review of resident #22's physician order [REDACTED]. Review of the admission MDS (minimum data set, a required assessment) dated 2/4/14 revealed the resident had a BIMS (Brief interview for mental status) score of 14 (cognitively intact). The MDS also revealed the resident needed total assistance of 2 staff for bed mobility and transfers, and extensive assistance of 2 for toileting. The MDS identified the resident did not walk during the previous 7 days. According to the assessment the resident had a fall within the past month prior to the assessment, but none since admission to the facility. Review of the ADL CAA (care area assessment) dated 2/5/14 revealed the resident was admitted to the facility after being in the hospital for a UTI (urinary tract infection) and weakness. The resident needed extensive assistance of 2 staff for most ADLs (activities of daily living). The resident used a wheelchair and walker for transfers and short distance like from bed to wheelchair. The resident required extensive assistance of 1 staff to propel the wheelchair. The resident had weakness and required total assist with transfers and bed mobility of 2 staff. Review of the Fall CAA dated 2/5/14 identified the resident at risk for falls due to the resident unaware of safety needs, weakness, impaired mobility and pain. It revealed the resident had not fallen at the facility but did have an unsteady gait and history of falls at home. Review of the significant change MDS dated [DATE] revealed a BIMS score of 12 (moderate cognitive impairment), required extensive assist of 1 with transfers, bed mobility and toileting. The MDS revealed the resident did not walk during the past 7 days and did not have any falls since prior assessment. Review of resident #22's care plan reviewed on 3/7/14 revealed the resident was at risk for falls with actual falls. It directed staff to assess fall risk per facility policy and assist with wheelchair locomotion on and off unit. It also included hand written updates dated 3-6-14 included education provided to the resident, family, and therapy to wait for staff for help when walking or transferring, toileting after meals, and to remind the resident to wear appropriate foot wear when out of bed. It also indicated the resident was unable to walk and required extensive assistance of 1 staff for locomotion on and off the unit. The care plan lacked revision to indicate the resident was on a walk to dine program. Review of the care plan last reviewed on 5/12/15 identified the resident was at risk for falls and had a history of [REDACTED]. It directed staff to assist the resident with bed mobility, transfers, and locomotion on and off unit. It also revealed the resident required extensive assist of 1 staff to walk in room/corridor, total assist of 1 for locomotion on/off unit, and extensive assist of 1 for toilet use. The care plan lacked direction if staff needed to use a gait belt for walking. Review of the fall investigation dated 8/25/14 revealed the resident had a fall on 8/10/14 at 1:05 PM. Direct care staff Z assisted the resident to walk from the dining room back to his/her room. Staff Z reported he/she pushed the resident's wheelchair behind him/her while the resident walked pushing his/her front wheeled walker and wore a gait belt. Direct care staff Z stated he/she did not have hold of the gait belt to help stabilize the resident and could not get to the resident in time when the resident lost his/her balance. The resident was sent to the hospital for evaluation and the x-ray report revealed the resident had a pelvic fracture. During the investigation it was determined that the resident required extensive assistance from one staff with walking. On 5-26-14 therapy instructed staff to walk to dine (walk the resident back and forth to meals), using a gait belt and a front wheeled walker with 1 staff assistance. Review of the staff Z's witness statements revealed he/she assisted the resident back to his/her room. The resident walked pushing his/her front wheeled walker and wore the gait belt and staff Z followed behind the resident pushing the wheelchair in case the resident lost his/her balance. The resident took a couple of steps and lost his/her balance, fell to the floor and hit his/her head. Observation on 5/13/15 at 11:45 AM revealed resident #22 ambulated to the dining area for the noon meal with use of a walker and a staff member walking beside him/her holding onto the gait belt. The resident had a steady gait as he/she walked. Observation on 5/14/15 at 7:05 AM revealed direct care staff FF ambulated the resident with use of a gait belt and walker. The resident's gait was steady. When the resident reached the dining table the resident then sat in a wheelchair for the morning meal. During an interview on 5/14/15 at 8:00 AM direct care staff FF reported the resident was a walk to dine, but staff assisted him/her into the wheelchair so the resident could go to the bathroom right after he/she finished eating. During an interview on 5-14-15 at 5:10 PM Administrative staff A and Consultant staff BB stated based on the investigation direct care staff did not understand the meaning of stand by assistance when they walked the resident. They determined the facility needed to provide a facility wide education regarding stand by assistance and contact guard assistance. Staff BB stated the staff should have had hold of the gait belt while walking the resident. Review of the facilities transfer definitions revealed Stand By Assistance indicated the resident required a gait belt on, staff member next to the resident for safety and the staff needed to be ready to grab gait belt and assist if needed. The definition for Contact Guard the resident required a gait belt and staff holding gait belt for safety. The facility failed to ensure staff provided care as planned for resident #22 who had a fall with a pelvic fracture.

The facility census totaled 69 residents with 27 residents sampled with 4 residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to ensure staff provided nutritional supplements for 1 of 4 residents sampled for weight loss. Resident #107 experienced a severe weight loss. Findings included: - Review of resident #107's physician order [REDACTED]. Review of the significant change MDS (minimum data set, a required assessment) dated 11-26-14 revealed the resident had short and long term memory problems with moderately impaired decision making ability. The resident required total assistance of 1 staff with eating and had swallowing problems identified by coughing/choking during meals. The MDS also identified the resident had weight loss and was not on a prescribed weight loss regimen. Review of the ADL (activities of daily living) CAA (care area assessment) dated 12-8-14 indicated the resident had impaired function noted since his/her decline in status and was dependent on staff for eating. The Nutritional CAA revealed the resident had actual weight loss, received a mechanically altered diet with enhanced foods, and was dependent on staff for oral intake. The registered dietitian monitored the resident's weight loss and intake. Review of the quarterly MDS dated [DATE] revealed the resident had short and long term memory deficit with moderately impaired decision making ability. It also revealed the resident required extensive assistance of 1 with eating, had swallowing problems, had a significant weight loss and was not on a prescribed weight loss regimen. Review of resident #107's care plan last reviewed on 4-28-15 revealed the resident had a nutritional problem related to poor meal intake. The care plan included the following interventions: Cue to double swallow between bites and drinks, dependent on staff for oral intake, dietician to monitor and suggest intervention for continued weight loss, high calorie snacks between meals, Magic Cup as ordered, and med pass (a liquid nutritional supplement) as ordered. The care plan also directed staff to offer high caloric hot chocolate prepared with half and half at breakfast and PRN (as needed). The care plan directed staff to monitor intake and offer favorite foods such as pancakes when oral intake was poor and super cereal as ordered. Review of the care plan conference summary dated 4-28-15 identified the resident had current weight loss and staff reviewed the plan of care. Review of the physician's orders [REDACTED]. On 10-28-14 supercereal with breakfast ordered after a weight loss of 11 pounds (9.4%) in 19 days. On 11-11-14 magic cup three times a day with meals ordered after the resident continued to lose 6 more pounds. On 11-24-14 High calorie snacks between meals was ordered after the resident had gained 3 pounds. On 12-2-14 - Med pass 2.0 30 ml (millimeters) four times a day was ordered after the resident lost 2 more pounds for a total of 16 pounds or 14% loss in 2 months. On 4-20-15 Offer high calories hot chocolate prepared with half and half at breakfast and PRN (as needed) was ordered after the resident 3 pounds for a total of 19.9 pounds. Review of resident #107's weight records revealed the following weight loss: 10-2-14 the resident weighed 114.2# (pounds) and on 11-7-14 the resident weighted 99# which indicated a 13.35# weight loss in 1 month. On 4-2-15 the resident weighed 90.8#, a 20.4% loss in 6 months. On 5-5-15 the resident weighted 88.4# a severe weight loss of 25.8# in 7 months. Review of the dietitian progress notes revealed the following: The 10/12/2014 dietitian note revealed the resident received a mechanical soft, ground meat with gravy diet. It identified the resident liked turkey bacon, and pancakes, and received health shake twice a day between meals. On 10/23/2014 dietitian note revealed the resident had a diet with pureed texture, with nectar consistency fluids. It identified the resident did not like pureed texture foods. The staff assists as needed to help in feeding and cueing. Resident ate 50% or less of his/her meals. A dietary note dated 10/29/2014 revealed the resident's diet had been upgraded to mechanical soft with puree meats, and the resident may have regular pancakes. The 11/3/2014 dietitian notes revealed the resident received magic cup twice a day with lunch and supper. The resident refused super cereal at breakfast and liked pancakes with gravy. The dietitian requested staff to add half-and-half cream to the resident's pancakes. It revealed that staff would offer the resident pancakes for lunch and supper also. The resident continued to have poor meal intake and ate less than 25% of meals. The 12/1/2014 dietitian note revealed the resident had a significant weight loss in the past 3 months. The resident had a current diet of pureed foods with mechanical soft pleasure foods allowed (foods the resident liked); enhanced foods, magic cup three times a day with meals and between meals and high calorie snacks between meals. The resident received feeding assistance by staff and received medications ([MEDICATION NAME] and [MEDICATION NAME]) to stimulate his/her appetite. A dietary manager note on 12/7/2014 revealed the dietitian recommended on 12/1/14 to add med pass (a type of liquid supplement) 30 cc. four times a day. Dietitians note dated 12/15/2014 revealed staff reported breakfast was the resident's best meal but the resident still refused meals and alternates. The staff met with the resident's family and the decision not to place a feeding tube for nutrition was made. A dietary note dated 1/26/2015 revealed the resident's diet changed to regular texture per family. On 2/15/2015 a dietitian note revealed the dietitian observed the resident eat the noon meal on 2/14/15 and the resident fed him/herself using his/her fingers and did not want staff to help. A dietitian note dated 3/30/2015 revealed the resident weighed 93.2# on 3/26/15 which reflected a 15.4% significant weight loss in 6 months. On 4/3/2015 a dietitian note revealed the resident weighed 90.8#; and received a regular, mechanical soft pleasure food diet. The resident also received magic cup three times a day and [MEDICATION NAME] for an appetite stimulant. The resident weight loss revealed 18.7% in 6 months and weight loss of 8.1% in 3 months. On 4/27/2015 a dietitian note revealed the residents current weight of 90# reflected a significant loss of 12.9% in 6 months. A dietitian note dated 5/11/2015 revealed the residents current weight of 88.4# reflected a significant weight loss of 10.7% in 3 month and an 11.2% loss in 6 months. the resident received a regular, diet with the following supplements: High calorie hot chocolate at breakfast, High calorie snacks between meals, Med Pass 2.0 30 cc four times a day, Magic cup three times a day with meals, and enhanced pancakes when served. The resident continues to lose weight. Observation on 5/11/15 at 11:50 AM resident #107 sat at the raised table for lunch with a visitor. The resident had a piece of chicken in his/her right hand and was slowly eating it. At 12:23 PM the resident just sat in the chair with his/her eyes closed - staff was able to wake him/her up and he/she continued to eat. At 12:58 PM another visitor came and sat beside the resident and tried to cue the resident to eat the chicken. The direct care staff brought the resident a cup that had a shake/supplement and the visitor gave the resident a few drinks but the resident did not want any more. The resident did not get the magic cup as ordered. 5/12/2015 at 8:00 AM the resident sat at the breakfast table with his/her head in his/her hand and pancakes on the plate in front of him/her. At 8:25 AM a visitor came in to visit the resident and helped the resident eat the pancake, 25 minutes after staff served the resident. The resident ate 75% of the meal. Staff took the resident back to his/her room without providing the resident supercereal, magic cup, or hot chocolate with half and half as ordered. Observation on 5/13/15 at 8:30 AM revealed staff served the resident pancakes and bacon and a glass of orange juice. At 8:55 AM staff removed the resident's plate and the resident ate 75% of the pancakes and all of the bacon. At 9:20 AM staff took the resident back to his/her room without offering him/her the supercereal, magic cup, or the hot chocolate with half and half as ordered. Observation on 5/13/14 staff brought the resident to the table at 11:32 AM. At 12:33 PM, (1 hour and 1 minute later) staff served the resident a grilled cheese sandwich and a cup of water. At 12:49 PM direct care staff Q took the resident a piece of coconut cream pie and gave him/her a bite. At 1:46 PM direct care staff Q and P assisted the resident from the table and into his/her bed. The resident was taken from the table and did not receive the magic cup as ordered. Observation on 5/14/2015 at 8:18 AM staff served resident #107 a plate with pancakes and bacon and had a bowl of oatmeal. At 8:51 AM the resident ate 50% of his/her pancakes and started eating the supercereal. At 9:42 AM Dietary staff M gave the resident a magic cup, ice cream which he/she ate 100% and also ate 90% of his/her super cereal. The staff failed to serve the resident his/her hot chocolate shake made with half and half as ordered. 5/14/2015 at 10:15 AM observation of the electronic MAR (Medication Administration Record [REDACTED]. At 10:18 AM direct care staff Q administered the resident his/her medications. Staff Q did not take any med pass (liquid supplement) with him/her when he/she gave the resident the medications as ordered. At 10:20 AM the electronic MAR indicated [REDACTED]. An interview on 5/14/15 at 10:22 AM direct care staff Q stated he/she gave the med pass to the resident with his/her magic cup. (Observations revealed the dietary manager gave the resident the magic cup and staff Q did not add any med pass to it.) The staff Q then stated he/she put it in the chocolate drink he/she gave the resident and when informed the resident did not get a chocolate drink staff Q stated he/she would have to check on the med pass. During an interview on 05/14/2015 at 8:19 AM dietary staff V stated staff were supposed to serve the resident supercereal with breakfast every morning according to the dietary information. During an interview on 5/14/15 at 10:30 AM direct care staff P stated the amount of assistance the staff provided the resident varied each meal because the resident liked to do it him/herself if possible. Staff P stated that each of the direct care staff had to remind each other to give the resident his/her supercereal and shakes. He/she stated the resident had problems with weight loss in the past. During an interview on 5/14/15 at 2:45 PM dietary staff M stated the staff needed to give the resident the supercereal so that it was on the table and the resident could eat it if he/she wanted to. Staff M stated if the staff had not given the resident his/her supplements then weight loss would continue. During an interview on 5/14/15 at 11:22 AM licensed nursing staff R stated supplement administration showed up on the Medication Administration Record [REDACTED]. Staff R stated it was the nurse aide's responsibility to pass the supplements and make the shakes. During an interview on 5/14/15 at 11:34 AM administrative nursing staff T stated the direct care staff and dietary staff were supposed to offer the resident the supplements. Staff T stated if the documentation was not accurate he/she would not know, he/she did not have time to sit and watch a meal service. Staff T also stated he/she would expect the care plan to accurately reflect the needs of the resident, including his/her ability to feed self independently. The facility failed to provide nutritional supplements as ordered for resident #107 who experienced severe weight loss.

The facility had a census of 69 residents 27 selected for sample and 6 residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure 1 of 6 sampled residents remained free of significant medications errors. (#182) Findings included: -Resident #182's 10/24/15 admission physician orders [REDACTED]. Resident #182's 10/30/15 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 15, which indicated intact cognition. The assessment also indicated the resident required limited assistance of 1 person for transfers and toilet use. He/she required extensive assistance of 1 person for dressing and personal hygiene. The resident received scheduled and as needed pain medications for moderate pain that did not interfere with sleep or day to day activities. The assessment also revealed the resident received diuretic therapy (medications given to promote production of urine and decrease swelling) for 7 days of the assessment period. Resident #182's 10/30/14 CAAs (care area assessment) lacked an analysis of findings for the triggered care areas. The resident's 11/14/14 care plan directed staff to administer all medications as ordered. A progress note written by Nurse Practitioner C dated 10/29/14 stated the resident had CAD (coronary [MEDICAL CONDITION]) and recommended continuation of current medications. An 11/3/14 physician progress notes [REDACTED]. The note also documented the resident had hypertension (elevated blood pressure) and [MEDICAL CONDITION] (kidney disease) and noted the resident received [MEDICATION NAME], and [MEDICATION NAME] (all medications to lower the blood pressure). A physician progress notes [REDACTED]. The note indicated the resident received multiple blood pressure medications, including [MEDICATION NAME]. The resident's condition was stable and Nurse Practitioner C recommended he/she continue with the current medication regimen. Nurse Practitioner C's progress note dated 11/7/14 indicated the resident was short of breath with exertion and the resident stated it was no worse than usual. The resident wore continuous oxygen. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. A new order was given for an [MEDICATION NAME] breathing treatment three times a day. An 11/13/14 physician progress notes [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Nurses' notes dated 11/17/14 at 3:30 p.m. stated the resident went to an appointment with his/her cardiologist, who admitted the resident to a local hospital. Office notes from the visit with the cardiologist on 11/17/14 revealed the resident had [DIAGNOSES REDACTED]. treatment for [REDACTED]. According to the note the resident had 3+ [MEDICAL CONDITION] (rating scale for severity of swelling, indicating deep indention that remains for a short period of time and extremities look swollen). Resident #182's 11/17/14 admission history and physical from the local hospital identified the resident's chief complaint as shortness of breath and dyspnea. The resident complained of more shortness of breath that worsened in the past week prior to admission with increased leg [MEDICAL CONDITION]. The resident was in acute heart failure and required admission to the hospital for further evaluation and treatment. The list of home medications at the time admission included [MEDICATION NAME] 40 mg daily. The physical exam revealed the resident had decreased breath sounds at the bases and 3+ [MEDICAL CONDITION] in both extremities. The treatment plan included IV (intravenous) diuresis for the [MEDICAL CONDITION]. Review of resident #182's November 2014 MAR (medication administration record) revealed staff marked the following medications as 8 which indicated the medication was unavailable and not administered: *[MEDICATION NAME] for Gout (excess uric acid in joint) 11/9/14-11/17/14 (9 days) *[MEDICATION NAME] for diuresis (remove excess fluid) 11/10/14-11/17/14 (8 days, the week prior to admission to the hospital) *[MEDICATION NAME] ER for [MEDICAL CONDITION] (chest pain) 11/11/14-11/17/14 (7 days) *[MEDICATION NAME] for blood pressure 11/10/14-11/14/14 (5 days) *[MEDICATION NAME] for [MEDICAL CONDITION] 11/15/14-11/16/14 (2 days) *Tamsulosin for difficult urination 11/9/14-11/17/14 (9 days) *[MEDICATION NAME] for blood pressure 11/10/14-11/17/14 (unavailable 11 times, space blank 2 times, and administered once during this time frame) *[MEDICATION NAME] for shortness of breath 11/14/14-11/15/14 (2 days) Review of resident #182's clinical record lacked documentation in the nurses' notes that the resident did not receive the above ordered medications. Resident #182 no longer resided in the facility and was unavailable for observations. According to the facility's investigation, direct care staff U passed medications on 11/10/14, 11/11/14, 11/14/14, and 11/17/14. Staff U was aware the [MEDICATION NAME] for the resident was not in the medication cart on the days he/she worked. On 11/12/14,/11/13/14, 11/15/14, and 11/16/14, direct care staff W passed medications and was aware that the resident's [MEDICATION NAME] was not in the medication cart. The results of the facility investigation revealed the root cause of the reason for the medication omissions was due to the CMAs (certified medication aides, staff U and W) not reporting to the charge nurse when resident #182's medications were unavailable and also failed to follow the facility's policy for reordering medications. During an interview on 5/14/15 at 8:45 a.m., direct care staff X confirmed that if medications were unavailable, staff marked an 8 on the MAR. During an interview on 5/14/15 at 3:00 p.m., licensed nurse Y stated that if a medication was not available, he/she would first check the cart to ensure the medication was not misplaced. Then he/she would contact the pharmacy to verify they received the medication order or refill order. Nurse Y stated the pharmacy can review their records to see if they delivered the medication and who signed for it. Nurse Y also verified the facility's E-kit contained [MEDICATION NAME] and this could be used until the facility received the medication from the pharmacy to prevent the resident from missing a dose. An interview on 5/14/15 at 1:13 p.m. with Nurse Practitioner C revealed he/she monitored resident #182's condition during the week prior to his/her admission to the hospital. Nurse C stated he/she was unaware the resident did not receive all of his/her ordered medications. According to Nurse Practitioner C, the omission of the resident's [MEDICATION NAME] probably contributed to the exacerbation of his/her [MEDICAL CONDITION]. Nurse C thought the resident received the [MEDICATION NAME] during that time and confirmed his/her dyspnea gradually worsened. During an interview on 5/14/15 at 4:00 p.m., administrative nurse B confirmed resident #182 did not receive his/her medications as ordered, including the [MEDICATION NAME]. Nurse B stated he/she immediately investigated the incident for causative factors and suspended the staff involved pending the results of the investigation. The facility's revised 1/1/13 Medication Shortage/Unavailable Medication Policy directed staff to immediately initiate action to obtain medications when they identify an inadequate supply. If the discovery occurred during normal hours, the nurse should call the pharmacy to determine the status of the order. If the next available delivery causes delay or a missed dose in the resident's medication schedule, the nurse should obtain the medication from the emergency medication supply. Facility staff should notify the pharmacy and arrange for an emergency delivery. If discovered after normal pharmacy hours, the nurse should obtain the medication from the emergency medication supply and call the pharmacy emergency answering service. If an emergency delivery is unavailable, the nurse should contact the attending physician to obtain orders or directions. When a missed dose is unavoidable, the nurse should document the missed dose and an explanation for the missed dose on the MAR/TAR (treatment administration record) and in the nurses' notes. The facility failed to ensure resident #182 remained free from a significant medication error when facility staff failed to ensure the resident received his/her ordered medications. Facility staff failed to administer resident #182's [MEDICATION NAME] for 8 days. The resident required hospitalization for acute on chronic [MEDICAL CONDITION] that required intravenous diuretic therapy.

The facility census totaled 66 residents with 3 residents included in the sample reviewed for abuse. Based on observation, interview, and record review, the facility failed to immediately report an allegation of employee to resident sexual abuse and/or inappropriate touching involving 1 sampled resident #3 to the State survey and certification agency, failed to thoroughly investigate the allegation, failed to submit the results of the investigation to the State survey and certification agency within 5 working days, and failed to protect all residents from potential abuse during the investigation. Resident #3 made allegations of inappropriate touching by a non-Caucasian staff member of the opposite gender, who had the potential to work in all four houses of the facility. Resident #3 reported that he/she was afraid to go to sleep at night. This allegation was reported to Administrative staff immediately. Administrative staff failed to report, investigate, and protect other residents after learning of the allegation. This deficient practice placed all residents in the facility in immediate jeopardy. Findings included: - Review of resident #3's signed physician history and physical dated 4/17/14 revealed the following Diagnosis: [REDACTED]. Review of resident #3's significant change MDS dated [DATE] revealed the resident had a BIMS (brief interview for mental status) score of 11, indicating moderate cognitive impairment. The resident had inattention and disorganized thinking that was present and fluctuated. The resident felt tired or had little energy and had trouble falling or staying asleep, or slept too much for 2-6 days of the previous 14. The resident had a total mood severity score of 3, indicating minimal depression. The resident did not have hallucinations, delusions, or any behaviors. The resident required extensive assistance of one staff for toileting and personal hygiene and limited assistance of one staff for transfers, bed mobility, and walking in the room. The resident was always continent of bowel and occasionally incontinent of bladder. Review of resident #3's comprehensive care plan initiated on 2/26/14, revealed the resident was continent of bowel and bladder and requested staff assistance with toileting. On 7/18/14, staff added an intervention alerting staff the resident requested not to have caregivers of the opposite gender for personal cares. On 8/4/14, staff revised the intervention, but did not indicate what portion of the intervention was revised. Review of resident #3's OT (occupational therapy) daily progress note dated 7/23/14 revealed the resident stated he/she had a nurse of the opposite gender that worked at night and he/she was uncomfortable with that staff member being in his/her room. The resident hesitated and explained the staff member of the opposite gender would come in and touch him/her while he/she was in bed and facing the wall and would touch his/her buttocks. That nursing staff told the resident he/she was checking to see if his/her incontinence pad was dry, but the resident stated he/she did not think that was correct. The resident described other situations happening and the non-Caucasian nursing staff of the opposite gender (henceforth referred to as the alleged perpetrator, A.P.) would call it " therapy " and said it was good for him/her. The resident described the last holiday when most of the staff were gone, and the A.P. had him/her outside in the courtyard and was rough with him/her in the grass. The resident was afraid if he/she told anyone, he/she would be in trouble. The therapy staff then reassured the resident and the resident stated he/she was afraid to go to sleep at night. The resident told social services staff B he/she did not want a nursing staff member of the opposite gender with him/her in the shower and the social worker told the head nurse the resident requested nursing staff of the same gender only. The resident stated nothing happened the past few nights, but he/she saw the A.P. working out by the nurses station and when the resident got out of the restroom, the A.P. was gone. The resident believed the A.P. was scared because the resident's family member stayed the past Sunday night and that was why the A.P. had not returned to his/her room. The resident stated the A.P. came into his/her room on the night his/her family member stayed the night. The resident reported he/she feared the A.P. would retaliate against him/her if he/she said anything. Review of a notarized witness statement by therapy staff D dated 7/24/14 revealed resident #3 reported to staff there was a non-Caucasian nursing staff of the opposite gender that made him/her uncomfortable and touched him/her inappropriately on several occasions. The resident reported to staff D he/she told the social worker that he/she did not want nursing staff of the opposite gender in his/her room and the resident did not tell the social worker why at that time. The resident had seen the A.P. working since then and stated that nothing had happened the couple of nights prior to 7/23/14. The resident explained he/she was afraid of falling asleep at night in fear the A.P. would be coming in. Review of a notarized witness statement dated 7/31/14 revealed therapy staff D stated the resident gave administrative staff A a verbal report of resident #3's allegations of inappropriate touching and fear of the A. P. on 7/23/14. Staff D then went and discussed the situation with co-worker therapy staff C and then both of them went to administrative staff A and staff D verbally reported the conversation and concerns that the resident explained to him/her about inappropriate behavior. Staff D wrote he/she gave administrative staff A a written statement the following day on 7/24/14. Review of a notarized witness statement dated 7/31/14 from therapy staff C revealed he/she went with therapy staff D to administrative staff A's office on 7/23/14 to talk about what resident #3 reported as documented in OT daily progress note on 7/23/14. The resident told staff C his/her family member stayed the night on a Sunday night (July 20th) and that same staff member, the A.P., came into his/her room with his/her family member there. The resident told the A.P. he/she was not to be in his/her room and to get out. The resident said "I know if (gender) is not bothering me, (gender) is after someone else here." Review of the staff assignment sheets from 6/29/14-8/2/14 revealed direct care staff E, of the opposite gender, worked in resident #3's house on night shift on 7/4/14, 7/5/14, 7/6/14, 7/8/14, 7/9/14, 7/10/14, 7/11/14, 7/14/14, 7/15/14, 7/17/14, 7/18/14, 7/19/14, 7/20/14, 7/22/14, 7/23/14, 7/24/14, 7/25/14, 7/28/14, and 7/29/14. On 8/2/14, direct care staff E worked a double shift for 2nd (2 p.m. - 10 p.m.) and 3rd (10 p.m. - 6:00 a.m.) shift in a different house. Per facility report staff E worked on yet another house for 3rd shift on 8/1/14. For the week of 8/3/14-8/9/14, direct care staff E was scheduled to work in a different house than resident #3 lived in, on 8/3/14, and for double shifts (2nd and 3rd) on 8/8/14 and 8/9/14. Review of the August 2014 schedule, direct care staff E's assignment changed from resident #3's house to two separate houses for 2nd shift and 3rd shift. Interview on 7/31/14 at 12:00 p.m. with the resident's family member revealed the resident especially had a problem with nursing staff of the opposite gender. The resident ' s family member reported direct care staff E, the non-Caucasian staff member of the opposite gender (now referred to as the alleged perpetrator/A.P.), came in and reset the resident's fall alarm if it went off and he/she thought that bothered the resident. Resident #3 ' s family member revealed the resident did have a little bit of memory loss, but it had improved a lot recently and seemed to be the person he/she knew him/her to be. The family member reported the resident told him/her that on a weekend direct care staff E took the resident outside when there was no one around and rolled him/her on the ground. The resident reported the night the he/she stayed the night with the resident, staff E came in and may have been a little shocked to see him/her. The family member reported he/she knew the resident did not have as much confidence in going to sleep as he/she did before. At that time, the family member reported the facility had not talked to him/her about the incident all. The family member reported he/she had talked with licensed nurse F, and to social services staff B about the allegations of inappropriate touching by a staff member of the opposite gender and they told him/her they did not believe it was likely to have happened. The family member reported he/she had talked with the resident about it several times and the resident ' s story was always the same. During an interview with administrative staff A on 7/31/14 at 12:20 p.m. revealed the facility did not have any allegations of abuse that were not reported to the State complaint hotline because they always called them in. Interview on 7/31/14 at 12:59 p.m. with therapy staff D revealed resident #3 had some problems with his/her memory, but was not confused. Staff D reported the resident was very fearful to tell him/her about the abuse and reported he/she gave his/her written statement to administrative staff A the day following the resident ' s allegation. Interview with administrative staff A on 7/31/14 at 1:27 p.m. revealed he/she thought the therapist had a concern with the resident and a staff member on 7/23/14 or 7/24/14. Staff A reported he/she went to interview the resident that evening, and he/she was very confused. Staff A reported he/she liked the staff of the same gender and was not afraid to stay in the facility. Staff A reported the therapist's concern was that there was an opposite gender staff member that came and took the resident out into the courtyard and rolled him/her around in the grass and something else the therapist was concerned with. Staff A reported all of the night shift nursing staff of the opposite gender were non-Caucasian. Staff A reported the non-Caucasian direct care staff of the opposite gender had the possibility to work in any house depending on call-ins and staff A reported direct care staff E worked primarily in two houses, but if there was a call-in, staff E could work anywhere. Interview with therapy staff C on 7/31/14 at 2:19 p.m. revealed he/she was with therapy staff D on 7/23/14 when staff D told administrative staff A what the resident said and it did include the sexual nature of the allegation. Staff D since the allegation was reported to administrative staff A, the resident reported to him/her the A.P. tormented him/her by coming to the door, looking around and then leaving. On 7/31/14 at 2:56 p.m., interview with administrative staff A revealed he/she did not obtain written statements or document any of his/her investigation, but reported social services staff B had provided a written statement. Observation at that time, revealed an unsigned typed statement. Staff A reported he/she did not follow up with the therapist about the concern. Staff A reported the next day after the therapist told him/her about the allegation, the therapist came in and asked him/her what staff A had done about it and then provided a written statement. Staff A reported the resident had periods of confusion. Staff A reported whenever he/she received an allegation of abuse, neglect, or exploitation (ANE), if there was a clear A.P., he/she immediately suspended the A.P. Staff A reported the therapist told him/her the resident would be very willing to tell him/her about it. Staff A reported the allegation would have been considered ANE if the resident were able to corroborate the story the therapist told. Staff A reported he/she did not typically investigate an allegation and then report it to the State agency, but he/she did try to gather as much information as possible before calling something in to report it and because the resident would not or could not report anything to him/her about the allegation, so it was not reported. Staff A reported that rolling around in the grass and calling it therapy, did not sound plausible given some of the statements the resident talked about. Staff A reported if he/she truly thought someone had done something to a resident, he/she would take action and would do everything possible to protect the resident. Staff A reported he/she did not interview residents related to the allegation, but had interviewed several related to another investigation and none of those interviewed had concerns. Staff A reported during the time of the investigation, he/she had not suspended anyone because he/she did not have an A.P. to suspend because the resident could not pin it down to gender or even race. Interview with administrative staff A on 8/5/14 at 4:24 p.m. revealed the therapist reported the A.P. was a non-Caucasian nursing staff member of the opposite gender. Staff A reported since he/she could not provide a description of the A.P., he/she decided to suspend all non-Caucasian nursing staff of the opposite gender on 7/31/14, 8 days after therapy staff reported the allegation to him/her. Staff A reported there were maybe 3 non-Caucasian nursing staff members of the opposite gender that worked nights routinely. Staff A reported the staff completed resident interviews of every alert and oriented resident in the building and specifically asked if any non-Caucasian staff of the opposite gender had touched them inappropriately. Staff A reported the staff interviewed all non-Caucasian staff of the opposite gender and were unable to identify any evidence to keep the non-Caucasian staff of the opposite gender suspended. Staff A reported the resident reported the incident about rolling around in the grass happened during the day, which just was not feasible. Staff A reported the facility had originally suspended the 4 non-Caucasian staff of the opposite gender at the time the surveyor notified him/her of the immediate jeopardy on 7/31/14. Upon further questioning, he/she decided to suspend the 4 non-Caucasian staff for the night shift for 7/31/14. Staff A reported as part of the facility's plan of correction for the immediate jeopardy, every single employee participated in the in-services about abuse, neglect, and exploitation. Staff A reported he/she interviewed the suspended non-Caucasian nursing staff of the opposite gender and each of them had very consistent stories and knew the resident preferred nursing staff of the same gender and had not wanted opposite gender caregivers since 7/3/14. Staff A reported the resident had not had any personal cares provided by a staff member of the opposite gender since 7/3/14 that staff knew of. Staff A reported as an addendum to the correction plan would be that there would be no staff of certain gender working in the Saghbene house. Interview with consultant staff K on 8/5/14 at 4:48 p.m. revealed the facility had reviewed the surveillance videos of July 4th after they were notified of an immediate jeopardy situation and did not see staff in the courtyard with the resident. Staff K reported the facility reviewed the resident's bed alarm log, and could not find a pattern of the resident being more restless at night and the resident had a long standing history of [MEDICAL CONDITION]. Staff K reported all direct care staff were expected to go in and provide fluids for the resident and take out the trash. Staff K reported the resident had a bed alarm to alert staff he/she was getting up on his/her own because the resident lacked safety awareness. Staff K reported the resident was starting to become more independent, but had required incontinence care during the time he/she was very sick until about 7/15/14. Staff K reported the resident did have the bed sensor in place during the time he/she required incontinence care. Staff K reported when the facility completed the investigation regarding to allegation of abuse and could not substantiate the investigation. Staff K reported the facility had re-arranged the staff assignments so there were not any staff of the opposite gender working in the resident's house. Interview with administrative nursing staff A on 8/6/14 at 8:27 a.m. revealed the facility would report any allegations of ANE to the State and investigate them. Staff A reported to investigate, staff interviewed the resident if the resident was able to talk, interviewed the staff that worked directly with the resident close to the time frame of the injury or ANE allegedly occurred. Staff A reported staff assessed the resident and notified the physician. Staff A reported he/she tried to interview at least 3 alert and oriented residents about a situation close to what the allegation was. Staff A reported if there was an identified A.P., the individual was suspended immediately. Staff A reported the residents and families were informed on admission they could feel free to voice their concerns during the admission process and reminded during resident council of the Ombudsman (resident advocate program) number and complaint hotline. Staff A reported the residents were also told they could voice their concerns without fear of reprisal. For reporting, staff A reported the facility called in any allegations of ANE to the complaint hotline within 24 hours at the latest or as soon as the allegation was made and if there was reasonable suspicion of a crime, the facility contacted the police immediately. Staff A reported for corrective actions, it depended on the nature of the allegation. Staff A reported the facility conducted immediate corrective actions, then brought the issue to the Quality Assurance committee. Staff A reported they looked at the need for staff education, in-services, and trained all the staff if a need was identified. Observation during the interview, revealed staff A read from the facility policy to answer the questions. Interview on 8/6/14 at 8:33 a.m. revealed administrative staff A reported he/she could not explain why he/she did not call in the allegation of abuse against resident #3 to the complaint hotline. Staff A reported there was a lot going on in the facility that week. Staff A reported if he/she felt like the allegation would be substantiated, then he/she would have called it in. Staff A reported when he/she completed his/her preliminary investigation, it did not come together and he/she did not have a definite A.P. to suspend. Review of the undated facility policy for Abuse, Neglect and Exploitation, revealed all facility employees were educated that all alleged or suspected violations should be reported to the administrator IMMEDIATELY and the administrator or CEO (chief executive officer) would ensure all alleged or suspected violations involving mistreatment, neglect or abuse were investigated and reported immediately to the KDADS (Kansas Department of Aging and Disability Services) Complaint hotline within 24 hours of the incident. If there is enough evidence to suspect that an individual may have abused or neglected an elder, that individual will not be allowed to work in the facility or allowed access to the facility until the outcome of the investigation was known. The facility failed to complete a thorough investigation of abuse and exploitation after an allegation of employee to resident sexual abuse and/or inappropriate touching involving resident #3 to the State survey and certification agency, failed to thoroughly investigate the allegation, failed to protect all the residents during the investigation. The facility abated the immediate jeopardy on 8/5/14 at 5:00 p.m. when the facility completed their investigation, provided re-education on ANE to all employees on reporting allegations, suspended all non-Caucasian staff of the opposite gender that were in the building the time the immediate jeopardy was identified, then all non-Caucasian staff of the opposite gender until the facility ' s investigation was complete. The alleged perpetrator was also removed from the facility and was not expected to return. This deficient practice of failure to report, thoroughly investigate and report an allegation of abuse, exploitation, and protect residents during the investigation, remained at a scope and severity of an F.

The facility census totaled 66 residents with 3 residents included in the sample. Three residents were reviewed for abuse. Based on observation, interview, and record review, the facility failed to protect resident #3 from abuse and mental anguish. Findings included: - Review of resident #3's signed physician history and physical dated [DATE] revealed the following Diagnosis: [REDACTED]. Review of resident #3's profile page revealed the resident was originally admitted [DATE], and readmitted on [DATE] and [DATE]. Review of resident #3's significant change MDS (minimum data set) dated [DATE] revealed the resident had a short-term memory problem but his/her long-term memory was ok. The resident could identify staff names and faces and knew he/she was in a nursing home. The resident had moderately impaired cognitive skills for daily decision making. The resident had an acute mental status change from his/her normal status. The resident had inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION] that fluctuated. The resident had trouble falling or staying asleep, or slept too much and felt tired or had little energy ,[DATE] days of the previous 14 days. The resident had a total mood severity score of 6, indicating mild depression. The resident did not exhibit any behaviors. The resident required total dependence on two or more staff for toileting, personal hygiene, and bed mobility. The resident had an indwelling catheter and was frequently incontinent of bowel. Review of resident #3's Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) CAA (care area assessment) dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The resident was very lethargic and admitted to hospice services due to expected continued decline. The resident ' s communication was limited and staff often had difficulty understanding the resident due to [MEDICAL CONDITION] and dementia. Review of resident #3's Urinary Incontinence/Indwelling Foley Catheter CAA dated [DATE] revealed the resident was at risk for increased bowel incontinence due to requiring extensive assistance of two staff for toileting. The resident wore incontinent briefs for dignity and was dependent on staff for personal hygiene. The resident had an indwelling Foley catheter and depended on staff for catheter care. Review of resident #3's significant change MDS dated [DATE] revealed the resident had a BIMS (brief interview for mental status) score of 11, indicating moderate impairment. The resident had inattention and disorganized thinking that was present and fluctuated. The resident felt tired or had little energy and had trouble falling or staying asleep, or slept too much for ,[DATE] days of the previous 14. The resident had a total mood severity score of 3, indicating minimal depression. The resident did not have hallucinations, delusions, or any behaviors. The resident required extensive assistance of one staff for toileting and personal hygiene and limited assistance of one staff for transfers, bed mobility, and walking in the room. The resident was always continent of bowel and occasionally incontinent of bladder. Review of resident #3's Cognitive Loss/Dementia CAA dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The resident could make his/her needs known. The resident required staff assistance in decision making due to impaired cognition. The resident usually understood others and was usually understood by others. Review of resident #3's Urinary Incontinence/Indwelling Foley Catheter CAA dated [DATE] revealed the resident had occasional urinary incontinence and his/her urinary frequency and incontinence had increased with a recent UTI (urinary tract infection) which the resident received antibiotics for. The resident required extensive assistance with toileting and personal hygiene and wore incontinent briefs for dignity. Review of resident #3's comprehensive care plan initiated on [DATE], revealed the resident preferred to sleep in, and required extensive assistance of one staff with morning cares. On [DATE] and again on [DATE], staff revised the intervention to say the resident preferred to sleep in and required extensive assistance of one staff with morning cares. The resident had a current [DIAGNOSES REDACTED]. In the toileting schedule portion of the care plan, also initiated on [DATE], revealed the resident was continent of bowel and bladder and requested staff assistance with toileting. Staff revised the intervention on [DATE] to include for staff to assist the resident to the toilet for safety, monitor pericare, and provide assistance when needed. On [DATE], staff added an intervention alerting staff the resident was incontinent of bladder and continent of bowel and requested staff assistance for toileting for safety. It also directed staff to provide assistance when needed and alerted staff the resident requested not to have caregivers of the opposite gender for personal cares. On [DATE], staff revised the intervention, but did not indicate what portion of the intervention was revised. Review of a dietary note for resident #3 dated [DATE] revealed the resident sometimes skipped breakfast because he/she liked to sleep in per the nursing staff. Review of a nurses note dated [DATE] revealed resident #3 still had some confusion. Review of a nurses noted dated [DATE] at 2:19 a.m. revealed resident #3 was alert to person, place, and time, and could voice his/her needs. The resident was incontinent of bladder and continent of bowel. The resident required limited assistance of 1 person with ADLs (activities of daily living). The resident rested in his/her bed at that time. The note did not indicate the resident was sleeping. Review of a nurses note dated [DATE] at 6:05 p.m. revealed the resident ' s cognition continued to improve. Review of a nurses note for resident #3 dated [DATE] at 2:24 a.m. revealed the resident was alert and oriented to person, place, and time and could voice his/her needs. The resident had a bed alarm which staff utilized along with every 2 hour checks while the resident was in his/her room. The resident required extensive assistance of one person with ambulation with a front wheeled walker, toileting, and ADLs. The resident rested in his/her bed at that time. Review of a nurses note dated [DATE] at 12:50 a.m. revealed the resident was alert and oriented to person, place, and time and could voice his/her needs. The resident rested in his/her bed at that time. Review of a nurses note dated [DATE] at 11:51 p.m. revealed resident #3 was alert and oriented with confusion at times and the resident slept at that time. Review of resident #3 ' s behavior charting for [DATE] revealed the resident had 2 episodes of confusion from ,[DATE]-[DATE], both on [DATE] during the day shift. Review of a written statement from the former social services staff B dated [DATE] revealed several weeks prior, the resident had told him/her that he/she would prefer to receive showers from nursing staff of his/her same gender. The resident did not list anyone specific or complain about a staff member of the opposite gender. The resident was confused at times during the course of the conversation. The social worker let the charge nurse and administrator know of the resident's request to have a staff member of his/her same gender give him/her a shower. Review of an OT daily progress note dated [DATE] revealed the resident stated he/she had a nurse of the opposite gender that worked at night and he/she was uncomfortable with that staff member being in his/her room. The resident hesitated and explained the staff member of the opposite gender would come in and touch him/her while he/she was in bed and facing the wall and would touch his/her buttocks. That nursing staff told the resident he/she was checking to see if his/her incontinence pad was dry, but the resident stated he/she did not think that was correct. The resident described other situations happening and the non-Caucasian nursing staff of the opposite gender (henceforth referred to as the alleged perpetrator- A.P.) would call it " therapy " and said it was good for him/her. The resident described the last holiday when most of the staff were gone, and the A.P. had him/her outside in the courtyard and was rough with him/her in the grass. The resident was afraid if he/she told anyone, he/she would be in trouble. The therapy staff then reassured the resident and the resident stated he/she was afraid to go to sleep at night. The resident told the social services staff B he/she did not want a nursing staff member of the opposite gender with him/her in the shower and the social worker told the head nurse the resident had requested nursing staff of the same gender only. The resident stated nothing had happened the previous couple of nights before [DATE], but he/she saw the A.P. working out by the nurses station and when the resident got out of his/her restroom, the A.P. was gone. The resident believed the A.P. was scared because the resident's family member had stayed the night that past Sunday ([DATE]) and that is why the A.P. had not returned to his/her room. The resident stated the A.P. came into his/her room on the night his/her family member stayed the night. The resident reported he/she feared the A.P. would retaliate against him/her if he/she said anything. Review of a notarized witness statement by therapy staff D dated [DATE] revealed it contained the same information included in the OT therapy note from the day prior. Review of a notarized witness statement dated [DATE] revealed therapy staff D stated the resident gave administrative staff A a verbal report of abuse on [DATE]. Staff D then went and discussed the situation with co-worker therapy staff C and then both of them went to administrative staff A and staff D verbally reported the conversation and concerns that the resident explained to him/her about inappropriate behavior. Staff D wrote he/she gave administrative staff A a written statement the following day on [DATE]. Review of a notarized witness statement dated [DATE] from therapy staff C revealed he/she went with therapy staff D to administrative staff A ' s office on [DATE] to talk about what the resident had reported to staff D, as written in the OT daily progress note. Per the statement, staff A looked at the schedule and said the person the resident talked about worked all those nights, so he/she could not be the A.P. Staff C said to administrative staff A that the A.P. worked, but had stayed out of the resident ' s room, he/she thought because the resident ' s family member scared him/her off. Per the statement, staff A stated the resident was confused. Staff C and staff D both told staff A the resident had decreased memory but was alert and oriented to person, place, and time, and was not confused. Staff C wrote in the statement the things the resident had reported were higher level of functioning for thinking, as the resident said "I know if (gender) is not bothering me, (gender) is after someone else here." Review of the resident's notarized statement dated [DATE] revealed the resident had been having a rough time while at the facility and almost died because he/she got very sick. The resident ' s statement included there had been something bothering him/her and he/she reported it to a staff member. The statement indicated the resident did not want to cause any problems and he/she did not have any proof, but there had been someone abusing him/her. It had not happened for a while, but it had gone on for the last couple of months, since the spring. The statement indicated the abuser was a non-Caucasian of the opposite gender and told the resident he/she was a nurse. The resident ' s family member stayed all night not too long ago and the A.P. tried to come in then, but the resident thought it scared the A.P. away when he/she saw the resident ' s family member. Per the statement, for 3 days after that, the A.P. stayed away. The resident ' s statement indicated the A.P. always had an excuse that he/she was checking on something to be sure the resident did not fall. The resident reported in the statement he/she knew his/her memory was not very good, but he/she knew what had happened to him/her. According to the statement, the A.P. came into the resident ' s room late at night without knocking and said he/she was trying to see if the residents pants were wet and the A.P. would touch his/her bottom. The resident ' s statement indicated he/she did not make it sound as bad as it actually was. The resident ' s statement included the same incident reported to the therapist on [DATE]. The resident did not know what the A.P. was trying to do, but the resident hit the A.P. on the arms and it made the A.P. mad and he/she finally gave up. Per the statement, the A.P. had come back and tried to do it again, and the resident had fought him/her off. The resident ' s statement said he/she lay there every night scared the A.P. would come back. The A.P. told the resident it would make him/her feel good and it was " healthy " for him/her. The resident ' s statement indicated he/she hated to think what else the A.P. would have done if he/she had not fought him/her off. The resident did not go to bed until after 1:00 a.m. sometimes lying awake being afraid about it. The resident ' s statement reported nobody should be disturbed in their sleep as much as the resident was. The resident acknowledged his/her memory could be bad sometimes, but the resident knew he/she was not imagining anything or he/she would not lay there and worry about it all night. The resident ' s statement indicated the abuse had gone on for a couple of months and there were a lot of times the A.P. came in and " messed " with him/her. The resident reported in the statement he/she was very scared every time he/she saw the A.P. and had lost a lot of sleep over it. Review of an OT daily treatment note dated [DATE] revealed the resident stated he/she would rather die and go to heaven than put up what the non-Caucasian staff of the opposite gender did to him/her. Review of an OT daily treatment note dated [DATE] revealed the resident ate breakfast at 11:30 a.m. and the resident stated he/she was up until 1:00 a.m. because he/she was afraid to fall asleep in fear the A.P. would come into her/her room. Review of a social service progress note dated [DATE] revealed the social worker met with the resident in his/her room. The resident knew the date, month, year, and day of week. Review of the staff assignment sheets from [DATE]-[DATE] revealed direct care staff E worked in resident #3 ' s house on night shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], direct care staff E worked a double shift for 2nd (2 p.m. - 10 p.m.) and 3rd (10 p.m. - 6:00 a.m.) shift in a different house. Per facility report staff E worked on yet another house for 3rd shift on [DATE]. For the week of [DATE]-[DATE], direct care staff E was scheduled to work in a different house than resident #3 lived in, on [DATE], and for double shifts (2nd and 3rd) on [DATE] and [DATE]. Review of the 24 hour nurse report sheets for [DATE] revealed for resident #3: [DATE] day shift- The resident did not want any opposite gender aides. [DATE] day shift- Staff were to monitor for self-transfers and voiding on the floor. [DATE] night shift- The resident was up at 5:00 a.m. and unmade his/her bed without triggering the bed alarm. Observation on [DATE] at 8:50 a.m. revealed to get to the resident's room, staff had to walk from the hall into a foyer area in the corner and then go around another corner to the left. The resident's bed was located behind the door. The resident's room was not visible from the hallway. The resident's bed was also not visible from the foyer or the hallway. Interview on [DATE] at 12:00 p.m. with the resident's family member revealed the resident especially had a problem with nursing staff of the opposite gender. The resident ' s family member reported direct care staff E, the non-Caucasian staff member of the opposite gender, came in and reset the resident's fall alarm if it went off and he/she thought that bothered the resident. Resident #3 ' s family member revealed the resident did have a little bit of memory loss, but it had improved a lot and seemed to be the person he/she knew him/her to be. The family member reported the resident told him/her the same information included in the OT daily progress note dated [DATE]. The family member reported the night the he/she stayed with the resident, staff E came in and may have been a little shocked to see him/her. The family member reported he/she knew the resident did not have as much confidence in going to sleep as he/she did before. At that time, the family member reported the facility had not talked to him/her about the incident all. The family member reported he/she had talked with the licensed nurse F, and talked to social services staff B and they told him/her they did not believe it was likely to have happened. The family member reported there were only 2 staff that worked at night in the resident ' s house and he/she believed they helped cover other houses. The resident had reported to the family member he/she had asked staff E not to come into his/her room and had told other staff that. The family member reported he/she had talked with the resident about it several times and the resident ' s story was always the same regarding the incident reported on [DATE]. The family member reported he/she did not believe any of the resident ' s concerns were related to staff E ' s race as the resident had always taught them to love all people regardless of their differences. Interview on [DATE] at 3:47 p.m. with the resident's family member revealed the resident had not ever mentioned the non-Caucasian night shift staff of the opposite gender that he/she was afraid of by name, but the family member reported he/she knew it was direct care staff E because staff E worked in the resident's house a lot, more than any other staff member fitting that description. The family member confirmed the night he/she stayed, the non-Caucasian nursing staff of the opposite gender that came in was direct care staff E. The family member reported the resident had never been one to make things up. The family member reported he/she visited the resident at least twice a week every week. The family member reported the resident's cognition was very poor when he/she was sick and almost died , but it had improved a lot in the last month or so. The family member reported the resident had not had any confusion in the last ,[DATE] weeks. The family member reported he/she felt the resident would always be uncomfortable or afraid if direct care staff E continued working there and he/she hoped direct care staff E would not be working in the facility at night for sure. The family member reported he/she just wanted to be sure the resident could go to sleep peacefully at night. Interview with the resident on [DATE] at 4:10 p.m. revealed the non-Caucasian opposite gender staff member that worked at night that touched him/her inappropriately and made him/her scared was the same person that came in the during the night his/her family stayed. The resident reported he/she was certain of it. The resident had reported he/she had fought the staff member off 3 different times when they tried to touch him/her inappropriately. The resident reported there were a few nights during the previous week ([DATE]-[DATE]) the A.P. came very quietly in the night and he/she lay there awake and scared. The A.P. grabbed the resident ' s door and he/she saw the A.P ' s long fingers come around the edge of the door and the A.P. would just look in and smile, tormenting him/her. Interview with direct care staff G on [DATE] at 9:59 a.m. revealed when the resident readmitted to the facility, the resident had more confusion but at this time the resident was more with it and hardly ever had confusion. Staff G reported he/she had worked in the facility since February and worked the resident's house about once a month. Staff G reported the resident had not had any days of confusion in the last 3 months he/she had worked the house. Staff G reported he/she had not noticed any concerns with the resident's memory. Interview with on with direct care staff E [DATE] at 2:10 p.m. revealed the resident had not had any confusion on that day. Interview with direct care staff I on [DATE] at 4:52 p.m. revealed he/she regularly worked in resident #3 ' s house for the past 7 months. Staff I reported the resident was very independent at first, went home, came to the facility again, got really sick and was confused then, but had since gone off of hospice services. Staff I reported the resident had not had any confusion in the last couple of weeks. Interview with licensed nursing staff J on [DATE] at 5:48 p.m. revealed the resident did not like nursing staff of the opposite gender to work with him/her. Interview with licensed nursing staff J on [DATE] at 2:08 p.m. revealed he/she had worked with the resident since he/she was admitted . Staff J reported the resident came in after a fall at home and then got really sick with a bad UTI. Staff J reported the resident had occasional confusion, but not very often. Staff J reported the resident's confusion had gotten much better in the last couple of weeks. Interview with social services staff B on [DATE] at 6:15 p.m. revealed he/she confirmed his/her written statement from [DATE]. Staff B reported he/she did not question it because there were many residents that did want nursing staff of the opposite gender to provide personal cares. Staff B confirmed he/she did not document the conversation with the resident anywhere, but told the charge nurse. Interview on [DATE] at 12:59 p.m. and 1:56 p.m. with therapy staff D revealed the resident had some problems with his/her memory, but was not confused. Staff D reported the resident was very fearful to tell him/her about the abuse and reported he/she gave his/her written statement to administrative staff A the day following the resident ' s allegation. Staff D reported he/she gave administrative staff A a statement with a description of the occurrence for the resident, and later that day asked the administrator if he/she had talked to the resident. Staff D reported staff A told him/her that he/she had talked to the resident. Staff D reported he/she had not heard from staff A since that time. Interview with therapy staff C on [DATE] at 2:19 p.m. revealed he/she was with therapy staff D on [DATE] when staff D told administrative staff A what the resident said and included the sexual nature of the allegation. Staff D said since the allegation was reported to administrative staff A, the resident had reported to him/her that the A.P. had tormented him/her by coming to the door and looking around and then leaving. During an interview with administrative staff A on [DATE] at 12:20 p.m. revealed the facility did not have any allegations of abuse that were not called in because he/she always called them in. Interview with administrative staff A on [DATE] at 1:27 p.m. revealed he/she thought the therapist had a concern with the resident and a staff member on [DATE] or [DATE]. Staff A reported he/she went to interview the resident that evening the resident did not identify who was causing his/her problems. The resident talked about things that made him/her sound confused. Staff A reported he/she liked the staff of the same gender and was not afraid to stay in the facility. Staff A confirmed the therapist's concern as he/she had documented in the OT daily progress note. Staff A reported all of the night shift nursing staff of the opposite gender were non-Caucasian. Staff A reported the non-Caucasian direct care staff of the opposite gender had the possibility to work in any house depending on call-ins. Staff A reported if there were a call in, the direct care staff were moved around to help cover all of the houses. Staff A reported direct care staff E worked primarily in two of the four houses, but if there was a call-in, staff E might work anywhere. On [DATE] at 2:56 p.m., interview with administrative staff A revealed when the therapy staff told him/her about the allegation of abuse, he/she talked to the social worker and the staff members that worked in the resident ' s house. Staff A reported he/she asked the staff if the resident had complained about not liking a specific staff member, any complaints about staff in general, or anyone that he/she did not want going in his/her room. Staff A reported he/she spoke with licensed nursing staff L who told him/her the resident did not like opposite gender in his/her room since he/she had come back from the hospital but had not mentioned anyone specific. Staff A reported he/she did not obtain written statements or document any of his/her investigation, but reported the social services staff B had provided a written statement. Observation at that time, revealed an unsigned typed statement. Staff A reported he/she did not follow up with the therapist about the concern, but reported to the therapist the next day that he/she was taking care of it. Staff A reported the resident had periods of confusion. Staff A reported the resident had some times where he/she was lucid and times when the resident had odd statements mixed in with the lucid talk. Staff A reported whenever he/she received an allegation of abuse, neglect, or exploitation (ANE), if there was a clear A.P., he/she immediately suspended the A.P. Staff A reported the therapist told him/her the resident would be very willing to tell him/her about it. Staff A reported the allegation would have been considered ANE if the resident were able to corroborate the story the therapist told. Staff A reported he/she did not typically investigate an allegation and then report, but he/she did try to gather as much information as possible before calling something in to report it and because the resident would not or could not report anything to him/her about the allegation, it was not reported. Staff A reported that rolling around in the grass and calling it therapy, did not sound plausible given some of the statements the resident talked about. Staff A reported if he/she truly thought someone had done something to a resident, he/she would have taken action and would have done everything possible to protect the resident. Staff A reported he/she did not interview residents related to the allegation, but had interviewed several related to another investigation and none of those interviewed had concerns. Staff A reported during the time of the investigation, he/she had not suspended anyone because he/she did not have an A.P. to suspend because the resident could not pin it down to gender or even race. Interview with administrative staff A on [DATE] at 4:24 p.m. revealed the therapist reported the A.P. was a non-Caucasian nursing staff member of the opposite gender. Staff A reported since the resident could not provide a description of the A.P., he/she decided to suspend all non-Caucasian nursing staff of the opposite gender. Staff A reported there were maybe 3 non-Caucasian nursing staff members of the opposite gender that worked nights routinely. Staff A reported the staff completed resident interviews of every alert and oriented resident in the building and specifically asked if any non-Caucasian staff of the opposite gender had touched them inappropriately. Staff A reported the staff interviewed all non-Caucasian staff of the opposite gender and were unable to identify any evidence to keep the non-Caucasian staff of the opposite gender suspended. Staff A reported he/she visited with the resident ' s family member and reported he/she did not believe it to have happened and reported to him/her that all the night shift non-Caucasian staff of the opposite gender were great people. Staff A reported the resident reported the incident about rolling around in the grass happened during the day, which just was not feasible. Staff A reported the resident had a bed sensor, and if staff were providing cares, the alarm would be going off. Staff A did not know whether staff disabled the alarm while providing cares. Staff A reported the night shift charge nurses of the same gender were providing all the personal cares to the resident. Staff A reported the resident had not had any personal cares provided by a staff member of the opposite gender since [DATE] that staff knew of. Staff A reported as an addendum to the correction plan would be that there would be no staff of certain gender working in resident #3 ' s house. Interview with consultant staff K on [DATE] at 4:48 p.m. revealed the facility had reviewed the surveillance videos of [DATE]th and did not see staff in the courtyard with the resident. Staff K reported the facility had reviewed the resident ' s bed alarm log, and could not find a pattern of the resident being more restless at night and the resident had a long standing history of [MEDICAL CONDITION]. Staff K reported all direct care staff were expected to go in and provide fluids for the resident and take out the trash. Staff K reported the resident had a bed alarm to alert staff he/she was getting up on his/her own because the resident lacked safety awareness. Staff K reported the resident was starting to become more independent, but had required incontinence care during that time he/she was very sick until about [DATE]. Staff K reported the resident did have the bed sensor in place during the time he/she required incontinence care. Review of the undated facility policy for Abuse, Neglect and Exploitation, revealed all facility employees were educated that all alleged or suspected violations should be reported to the administrator IMMEDIATELY and the administrator or CEO (Chief Executive Officer) would ensure all alleged or suspected violations involving mistreatment, neglect or abuse were investigated and reported immediately to the KDADS (Kansas Department of Aging and Disability Services) Complaint hotline within 24 hours of the incident. If there was enough evidence to suspect that an individual may have abused or neglected an elder, that individual would not be allowed to work in the facility or allowed access to the facility until the outcome of the investigation was known. The facility failed to protect resident #3 from abuse and mental anguish after an allegation of abuse on [DATE] was reported to administrative staff A.