Every finding on record at Baldwin Healthcare & Rehab Center, LLC

Based on observation, record review, and interviews, the facility failed to appropriately store medications and biologicals when staff set up 11 residents' medication early and placed them in medication cups in the medication cart, labeled with resident's initials but lacking the required information regarding each medication (prescription and dosing information).Findings included:- On 04/13/26 at 07:42 AM, the medication carts were placed outside the dining room. Inspection of the medication carts revealed 11 medication cups marked with initials that contained medications. The medication cups were stored in the top left-hand drawer of the medication cart. The cups did not have names of the medications contained, the dose, or administration instructions.On 04/13/26 at 07:46 AM, Certified Medication Aide (CMA) S stated the facility's policy was to pop medication from bubble packs, right before administration of the medication to the residents. She stated medication should not be popped out of medication cards and placed into medication cups before a resident is ready to take the medication.On 04/15/26 at 09:20 AM, Administrative Nurse D stated medications should not be set up early. She stated the staff had been educated to set up medications only when the resident was ready to take medication.The facility's Medication Storage dated 01/01/20 documented all medications housed in the facility would be stored in the medication carts or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, moisture control, segregation, and security.

Based on observation, record review, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) were in place for Resident (R) 7 who had a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer (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) to the sacral (tailbone) area and failed to ensure staff used the appropriate personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) while providing wound care to R7. Findings included:- On 04/15/26 at 08:54 AM, Administrative Nurse E entered R7's room and washed her hands (no EBP sign was noted in the room or on R7's door) but did not wear a gown. Certified Nurse Aide (CNA) M was already in R7's room and had gloved hands but did not wear a gown. R7's bedside table had a barrier placed on top of it with the supplies needed for R7's wound dressing change on top of the barrier. CNA M raised R7's bed and pulled down his pants, and untabbed his brief. At this time, it was asked by the NFS why EBP were not being followed and why the appropriate PPE was not put on. Administrative Nurse E removed R7's dressing from his sacral wound and threw the dressing in the trash, then she removed her gloves and went to the sink to wash her hands. Administrative Nurse E applied clean gloves and grabbed the med cup that had gauze pads soaked in normal saline (NS- saline water solution for medical use) that she wiped the wound area with. Administrative Nurse E placed the used gauze in the trash, removed her gloves, and went to the sink to wash her hands and put on clean gloves. Administrative Nurse E applied the Santyl (prescription ointment is used to remove damaged tissue from skin ulcers) to the wound area, then applied the collagen particles (a treatment used for wounds with minimal to moderate drainage) to the wound bed. Administrative Nurse E removed her gloves and discarded them in the trash, washed her hands at the sink, and applied clean gloves. She then placed the new dressing on the wound area. During the wound dressing change, Administrative Nurse E did not wear a gown. On 04/15/26 at 08:56 AM, Administrative Nurse E stated that R7's wound was new and not chronic, so he did not require to be on EBP and a gown did not need to be worn. On 04/15/26 at 10:40 AM, Administrative Nurse E stated that the facility went by the most recent CDC guidelines for EBP. Administrative Nurse E could not state for certain what the facility policy regarding EBP said. Administrative Nurse E stated it was always her understanding that the use of EBP was only needed for chronic wounds and not any wound. On 04/15/26 at 11:03 AM, Administrative Nurse D stated she did not misquote what the facility policy was regarding the use EBP, but it was her understanding that unless a wound was chronic that full EBP including wearing a gown was not needed. The facility's Enhanced Barrier Precautions policy dated 04/01/24 documented the facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) that is not currently targeted by the Centers for Disease Control and Prevention (CDC). An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO. The Implementation of Enhanced Barrier Precautions included making gowns and gloves available immediately near or outside of the resident's room.

Based on interviews, observation, and record review the facility failed to ensure Resident (R) 2's needs were met when staff failed to provide R2 with a call light in order to communicate her needs and wants to staff.Findings included:- R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and dysphagia (swallowing difficulty).The Quarterly Minimum Data Set (MDS) dated 11/25/25 documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R1 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) to her upper and lower extremities on one side of her body. The MDS documented R2 was dependent on staff assistance with toileting, dressing, bathing, personal hygiene, and bed mobility. R2's Falls Care Area Assessment (CAA), dated 08/27/25, documented she was dependent on staff for assistance with activities of daily living which placed her at risk for falls.R2's Care Plan documented the following interventions:05/07/25, staff would ensure the call light was within reach and encourage her to use it for assistance as needed.On 04/14/26 at 12:49 PM, R2 laid on her bed with her eyes closed. The head of her bed was elevated, and her blankets were pulled up to her chest. The call light laid on the floor behind her recliner and bedside stand at the head of bed out of reach. Unable to view R2 from doorway of room, the privacy curtain was pulled from the wall to the foot of her bed.On 04/15/26 at 08:08 AM, Unable to view R2 from the doorway of her room. R2 laid on her bed awake. The call light laid on the floor behind her recliner and bedside stand out of reach of R2.On 04/15/26 at 08:10 AM, Certified Medication Aide (CMA) R stated R2 should always have a call light in her reach. CMA R stated R2 had a push button call light. CMA R pulled the call light out from behind the recliner and bedside stand and placed the call light on R2's abdomen.On 04/15/26 at 09:10 AM, Administrative Nurse D stated she expected every resident to have their call light within their reach when in their rooms.The facility's Accommodation of Needs policy dated 12/01/25 documented the facility would treat each resident with respect and dignity and would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered.

Based on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).Findings included:- The PBJ Staffing Data Report CASPER Report 1705D provided by the Centers for Medicaid and Medicare (CMS) for Fiscal Year (FY) 2026 triggered during Quarter (Q) 1 for excessively low weekend staffing.On review of the facility's actual working schedule sheets from 10/01/25 to 01/01/26 revealed the facility maintained and had the same number of staff scheduled and worked as during the week: Two nurses for day and evening shift, and one nurse for night shift; four to five nurse aides both day and evening shift, three nurse aides on nights, and two medication aides on day and evening shiftsThe facility's Facility Assessment, revised on 11/11/25, documented the staffing needs and assignments were determined to promote continuity of care for residents within and across their assignments. Staffing needs and assignments vary based on the census and acuity level of the resident in the facility. The direct care staff was to have two licensed nurses for day and evening shift and one nurse for night shift, one medication aide on day and evenings, four to five nurse aids on days and evening shift, and three nurse aides on night shift.On 04/14/26 at 08:00 AM, Administrative Staff A stated she was unsure why the facility had triggered for low weekend staffing. She stated the New York office submits the PBJ from the hours the facility submits. Administrative Staff A stated she had reached out to the New York office. She stated there were as many staff working and scheduled on the weekend as there were on weekdays.The facility's Payroll Based Journal dated 02/05/25 documented it was the policy of the facility to electronically submit timey to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

The facility identified a census of 51 residents. The sample included four residents reviewed for dignity and resident rights. Based on record review, observation, and interview the facility failed to maintain an environment that treated Resident (R) 1 with respect and dignity and maintained or enhanced R1's quality of life. This placed R1 at risk for impaired dignity. Findings included: - The Electronic Medical Record (EMR) documented R1 was admitted to the facility on [DATE] following hospitalization for a cerebral vascular accident (CVA-stroke- a medical emergency that occurs when blood flow to the brain is blocked or reduced). The EMR further recorded diagnoses of rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle injury); bacteremia (presence of bacteria in the blood); urinary tract infection (infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra) and hypertension (elevated blood pressure). The Medicare 5-day Minimum Data Set (MDS) dated [DATE] documented R1 had short-term and long-term memory impairment, was rarely understood, and had moderately impaired decision-making skills. The MDS documented R1's functional limitations were under review and R1 was occasionally incontinent of bladder. R1's Nursing Admission/Readmission assessment dated [DATE] documented the resident was alert and cognizant of person, place, time, and situation. The evaluation noted R1 had expressive aphasia (a condition where a person understands speech but has difficulty speaking fluently). The assessment recorded R1 used bilateral hearing aids, was independent with eating and had one-sided limited mobility. R1's Care Plan initiated on 08/13/24 documented that R1 had a communication problem and directed staff to ensure and provide a safe environment; monitor and document for physical or nonverbal indicators of discomfort or distress and report any changes in R1's communication ability. R1's Care plan also documented R1's impaired cognition and advised approaching R1 in a gentle, friendly, and unhurried manner and to communicate to R1's family and caregivers R1's capabilities and needs. The plan further directed caregivers to address R1's emotional issues and teach her family members that due to the CVA, the resident may have emotional lability and depression. A Physician Progress Note dated 08/13/24 at 10:41 AM documented Consultant H assessed R1 for nursing due to a report of R1's altered mental state. The report recorded Consultant H was told R1 did awaken, ate breakfast, and was sleeping at this time. Consultant H's report did not note a significant change in RI's vital signs or symptoms. The assessment concluded with orders for laboratory tests and to monitor and follow R1 closely. A Nurse Progress Notes, dated 08/13/24 at 1:47 PM documented: that during Consultant H's assessment around 10:00 AM, R1 was less responsive but clenching her mouth tightly during the oral check and closing her eyes tightly during the eye check. At 11:00 AM, while attempting collection for a urinalysis, R1 clenched her legs tightly. At 01:00 PM the nurse received orders to send the resident to the hospital. Administrative Nurse E's Witness Statement dated 09/24/24 recorded that on 8/13/24 Administrative Nurse E observed Consultant H assess R1. Administrative Licensed Nurse E noted that R1 was not responding to verbal and tactile stimuli. At that time, Consultant H stated to Administrative Nurse E that he was not sure if [R1] was just playing opossum or not. The statement documented R1's family was in the room but did not respond to the comment. During a telephone interview on 09/24/24 at 03:10 PM, R1's representative stated while Consultant H was checking to see if R1 had thrush (a yeast infection that causes white, raised lesions on your tongue, cheeks, and other parts of your mouth) he stated maybe R1 was playing opossum since R1 would not open her mouth. R1's representative reported the statement made them uncomfortable and uncertain that R1 was being assessed appropriately. During a telephone interview on 09/24/24 at 03:10 PM, Consultant H acknowledged having commented that R1 might be playing opossum but said it was without any malicious intent. Consultant H stated he certainly did not mean it in a malicious or mean way and said he would not want to say anything mean to or about a resident. On 09/24/24 at 10:00 Administrative Staff A acknowledged staff reported Consultant H's comments and said that according to the staff present, R1's representative did not seem upset and did not indicate to staff they were upset. The facility's Promoting/Maintaining Resident Dignity Policy, revised January 1, 2020, recorded: that the practice of the facility is to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in and environment that maintains or enhances residents' quality of care by recognizing each resident individuality, Specifically the policy direct caregivers to Speak respectfully to residents, avoid discussion with Residents that may be overheard. The facility failed to maintain an environment that treated R1 with respect and dignity and maintained or enhanced R1's quality of life. This placed R1 at risk for impaired dignity.

The facility had a census of 53 residents. The sample included 16 residents with two reviewed for accidents. Based on observation, record review, and interview the facility failed to secure hazardous cleaning chemicals in a safe, locked area, and out of reach of the seven cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents. Findings Included: - On 06/10/24 at 07:10 AM an inspection of the facility's south hall revealed an unattended shower room with the entry door propped open. An inspection of an unlocked closet inside the shower room revealed a full-gallon bottle of bleach, purple disinfectant wipes, and several cleaning spray cans left on the shelf inside the closet. All the cleaning products identified contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. An unsecured closet had a sign with Door should be locked at all times on it. An unidentified staff member secured the closet door at 07:12 AM. On 06/12/24 at 12:04 PM Certified Nurses Aid (CNA) H indicated hazardous cleaning chemicals should always be supervised or locked up when not in use to prevent exposure to the residents. She stated cleaning products were stored in locked closets or the secured laundry room. On 06/12/24 at 12:15 PM Licensed Nurse H stated staff were to ensure the shower rooms were not left unsecured. She stated the cleaning closets should remain locked. On 06/12/24 at 12:31 PM Administrative Nurse D stated staff were expected to ensure areas with hazardous chemicals remained locked. She stated staff were expected to monitor the use of cleaning chemicals and keep them out of reach from the residents. The facility's Cleaning and Disinfection of Resident-Care Equipment dated 03/2020 indicated resident care equipment will be cleaned and sanitized in accordance with Centers for Disease Control (CDC) standards. The policy noted all approved cleaning materials will be utilized and stored in a safe manner to prevent chemical exposure to the residents and staff. The facility failed to secure chemicals in a safe, locked area, and out of reach of the seven cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents.

The facility identified a census of 53 residents. The facility identified 11 residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to enhanced barrier precautions, wound care, disinfection of mechanical lifts, and maintaining oxygen therapy equipment. These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 06/10/24 at 07:08 AM an inspection of Resident (R) 1's room revealed her supplemental oxygen tubing rested on the back of her wheelchair next to her canister. No clean bag or storage device was in the room to store the oxygen equipment when not in use. On 06/10/24 at 07:08 AM R7's oxygen tubing and nasal cannula lay under her bed. No clean bag or storage device was in the room to store the oxygen therapy equipment when not in use. On 06/10/24 at 07:08 AM R25's oxygen nasal cannula and tubing lay on the floor next to her room's recliner. No clean barrier bag was in the room to store the oxygen equipment when not in use. R25's room had no enhanced barrier precaution signage or personal protective equipment posted in or around her room for her wound care. On 06/10/24 at 07:15 AM an inspection of R204's room revealed no enhanced barrier precaution signage or personal protective equipment posted in or around his room related to his dialysis (a procedure where impurities or wastes were removed from the blood) care. R204's nebulizer mask (a device used to administer medication in the form of a mist inhaled into the lungs) sat directly on his room's recliner. No clean bag or storage device was in the room to store the oxygen equipment when not in use. On 06/10/24 at 07:21 AM an inspection of R49's room revealed no enhanced barrier precaution signage or personal protective equipment posted in or around his room for his wound care. On 06/10/24 at 09:10 AM R306's oxygen tubing and nasal cannula lay on his bed on top of a used incontinent pad. R306's oxygen nebulizer mask sat directly on the room's air conditioner unit. No clean bag or storage device was in the room to store the oxygen equipment when not in use. On 06/11/24 at 08:02 AM, an unidentified staff pushed the Hoyer lift (full-body mechanical lift) into R43's room and completed a transfer. Upon exiting the room staff did not sanitize the machine before parking it in the 100 Hallway. On 06/12/24 at 11:21 AM R306's nebulizer mask again sat on the room's air conditioning unit. No clean bag or storage device was in the room to store the oxygen therapy equipment when not in use. On 06/12/24 at 11:00 AM Administrative Nurse E prepped R10 for wound care. Administrative Nurse E placed the wound care supplies directly on the bedside table without a clean barrier. In the process of wound care to R10's penis, Administrative Nurse E did not perform gloves changes when switched between dirty-to-clean surfaces, placed her soiled glove in her pocket to retrieve a pen without changing gloves before continuing wound care, and did not complete hand hygiene after eventually changing her gloves. She stated mechanical lifts should be disinfected before and after use. On 06/12/24 at 12:15 PM Certified Nurses Aid (CNA) M stated oxygen therapy equipment should be stored in a clean plastic bag when not in use. She stated hand hygiene should be complete after removing gloves and when visibly soiled. She stated the mechanical lifts should be disinfected before and after use. On 06/12/24 at 12:15 PM Licensed Nurse H stated oxygen tubing and equipment needed to be placed in a bag when not in use. She stated each room should have a clean bag for each resident's equipment. She stated clean barriers should be placed before setting down supplies and equipment for wound care. She stated hand hygiene should be completed in between glove changes. On 06/12/24 at 12:31 PM Administrative Nurse D stated residents on enhanced barrier precautions should have signs posted either in their rooms or at the doorway. She stated staff were required to complete hand hygiene before entry. She stated staff were expected to wear gloves and protective gowns prior to providing high-risk care. She stated staff were expected to store the oxygen therapy equipment in a clean plastic bag when not in use. She stated clean barriers, frequent glove changes, and hand hygiene should have been completed during wound care. The facility's Enhanced Barrier Precautions policy implemented 04/2024 indicated the facility would train and provide the appropriate protective equipment. The policy indicated the facility would have discretion on how to communicate to staff which residents required enhanced barrier precautions. The facility's Infection Prevention and Control Program policy (undated) indicates the facility will ensure safe infection control practices are implemented and followed. The policy indicated shared equipment will be cleaned before and after use or when visibly soiled. The policy indicated staff will complete hand hygiene before during and after contact with residents or potentially soiled surfaces. The policy indicated therapy equipment will be stored in a manner that prevents contamination. The facility failed to follow sanitary infection control standards related to enhanced barrier precautions, sanitary wound care, disinfection of mechanical lifts, and maintaining oxygen therapy equipment. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 53 residents. The sample included 16 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure that resident (R)1 had foot pedals on her wheelchair while being pushed. This deficient practice left R1 vulnerable to preventable accidents and injuries due to unmet care needs. Findings included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), pain, hypertension (HTN-elevated blood pressure), functional urinary incontinence, dysphagia (swallowing difficulty), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS recorded R1 was dependent on staff for all activities of daily living (ADLs) except eating, for which she was independent. R1 required the assistance of one staff member for sit-to-stand and chair/bed-to-chair transfers. The MDS stated R1 was dependent on staff for wheelchair mobility. R1's Cognitive Loss Care Area Assessment (CAA) dated 08/05/23 documented R1 had short-term and long-term memory issues. R1 had impaired decision-making abilities. R1 was monitored for signs and symptoms of all medication. Staff was to speak to her using short, simple sentences to ensure an adequate understanding of what was being said to her. R1's family was encouraged to visit and decorate her room with familiar belongings. Activities are provided to keep her engaged in activities of her choice. R1 was to be redirected and tasks were broken down to ensure she was able to help with her activities of daily living (ADLs). R1's Care Plan dated 11/11/23 documented R1 needed assistance with ADLs related to CHF. The plan of care documented R1 required extensive assistance of two staff with a stand-up lift when moving between surfaces during care. The plan of care documented R1 was dependent on staff for wheelchair mobility. On 06/10/24 at 07:42 AM, an unidentified staff member pushed R1 in the wheelchair down the 100 halls. R1 did not have foot pedals. R1 had her left foot raised, and her, right foot was dragging on the floor. On 06/10/24 at 01:39 PM R1 was pushed without foot pedals in the 100 halls, she stated she was on her way to play bingo, in the dining room. R1 had her left foot raised and her right foot was dragging on the floor. On 06/12/24 at 12:02 PM Certified Nursing Aide (CNA) stated if a resident is being pushed by a staff member, their wheelchair pedals should be on their wheelchair. On 06/12/24 at 12:15 PM Licensed Nurse (LN) H stated all residents should have foot pedals if being pushed by staff. On 06/12/24 at 12:28 PM Administrative Nurse D stated residents should not be pushed by staff unless they have foot pedals on their wheelchairs. The facility policy Accommodation of Needs policy documented the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. The facility failed to provide foot pedals for R1's wheelchair. This deficient practice left R1 vulnerable to preventable accidents and injuries due to unmet care needs.

The facility identified a census of 53 residents. The sample included 16 residents with one resident reviewed for a baseline care plan. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 304 to include his hemodialysis (a procedure where impurities or wastes were removed from the blood) provider, days of the week, and time for dialysis. This deficient practice placed R304 at risk of impaired care related to uncommunicated care needs. Findings included: - R304's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic kidney disease, pulmonary edema (accumulation of extravascular fluid in the lung tissues), and heart failure. R304 was admitted on [DATE] and transferred to the hospital on 05/23/24. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R304 had received dialysis services during the observation period. R304's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/23/24 documented he was dependent on staff assistance for activities of daily living (ADL) and had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). R304's baseline Care Plan dated 05/15/24 documented the facility would monitor lab work and report to the physician as needed. The plan of care documented the nursing staff would monitor vital signs per facility protocol and notify the physician of significant abnormalities. The plan of care documented nursing staff would monitor, document, and report as needed any signs or symptoms of infection to access the site for redness, swelling, warmth, or drainage. The baseline care plan lacked the dialysis provider, days of the week, and times for dialysis. R304's EMR under the Orders tab revealed the following physician orders: R304's dialysis was provided on Monday, Wednesday, and Friday. Departure time at 12:40 PM and chair time 02:00 PM dated 05/15/24. Complete pre and post-dialysis communication form: Obtain weight and vital signs before and after dialysis. Notify the physician if systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries greater) (>) 190 millimeters of mercury (mmHg) or less (<) 80 mmHg, diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) >105mmHg or < 45mmHg, heart rate >110 or <45, temperature >100 degrees, and oxygen sats <88% in the evening every Monday, Wednesday, and Friday for post dialysis. Ensure that his binder was brought back, dated 05/15/24. Complete pre and post-dialysis communication form: Obtain weight and vital signs before and after dialysis. Notify the physician if SBP >190mmHg or < 80mmHg, DBP >105mmHg or <45mmHg, heart rate >110 or <45, temperature >100 degrees, and oxygen saturation <88% every Monday, Wednesday, and Friday for pre-dialysis to be completed prior to leaving for chair time of 02:00 PM. Assure this information was in the white dialysis binder for R304 and the binder was sent with R304 dated 05/15/24. Remove the dialysis dressing at bedtime every dialysis day. Notify the physician as indicated for bleeding or discomfort every night every Monday, Wednesday, and Friday dated 05/15/24. No blood pressure was obtained from the right arm. Monitor port site on right chest every shift. Notify the physician and director of nursing immediately of swelling, numbness, decreased temperature, increased pain, prolonged bleeding, redness, or fluid leakage. Insert a progress note of any changes to the port site on the left upper extremity dated 05/15/24. A review of R304's EMR under the Misc tab of the Dialysis Communication Form revealed two forms. The communication form dated 05/15/24 lacked a post-dialysis assessment documented. The communication form dated 05/20/24 lacked evidence of pre-dialysis assessment and the dialysis provider had documented under the post-dialysis section of the communication form. The dialysis communication sheet dated 05/20/24 had documented by the dialysis provider that R304's condition was poor, and his access site had bleeding. R304's clinical record lacked evidence of physician notification or post-assessment. The EMR lacked evidence of a dialysis communication sheet for 05/17/24. R304's EMR lacked evidence of communication with the dialysis provider. R304's May 2024 Medication Administration Record (MAR) and Treatment Administration record (TAR) lacked documentation of a pre-dialysis assessment dated [DATE]. On 06/12/24 at 12:02 PM, Certified Nurse Aide (CNA) M stated she did not have access to the resident's care plan. CNA M stated there was a resident information sheet at the nurse's desk. CNA M stated she was not sure how often the sheets were updated. CNA M stated she was not sure if the information sheets included dialysis information. On 06/12/24 at 12:15 PM, Licensed Nurse (LN) H stated she was not sure if the care plan included dialysis information. LN H stated some dialysis information was on the MAR and TARs. LN H stated if the dialysis provider was not listed on the MAR or TAR she would check the transportation log for that information. LN H stated she was not sure how an agency would know to check the transportation log for the dialysis provider. LN H stated Administrative Nurse E was responsible for initiating and completing the baseline care plan. On 06/12/24 at 12:28 PM, Administrative Nurse D stated she expected the baseline care plan to include dialysis information. Administrative Nurse D stated the baseline would include the dialysis provider's, phone number and address. Administrative Nurse D stated Administrative Nurse E would initiate and complete the care planning. Administrative Nurse D stated everyone had access to the care plan or Kardex (a nursing tool that gives a brief overview of the care needs of each resident). The facility's Baseline Care Plan policy dated 02/01/20 documented the facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The facility failed to develop a baseline care plan for R304 to include his physician orders for the hemodialysis provider, days of the week, and time for dialysis. This deficient practice placed R304 at risk of impaired care related to uncommunicated care needs.

The facility identified a census of 53 residents. The sample included 16 residents with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to obtain communication from the dialysis center and assess the pre-dialysis and post-dialysis status for Resident (R) 304. This deficient practice placed R304 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R304's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic kidney disease, pulmonary edema (accumulation of extravascular fluid in the lung tissues), and heart failure. R304 was admitted on [DATE] and transferred to the hospital on 05/23/24. The Admission 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 R304 had received dialysis services during the observation period. R304's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/23/24 documented he was dependent on staff assistance for activities of daily living (ADL) and had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). R304's Care Plan dated 05/15/24 documented the facility would monitor lab work and report to the physician as needed. The plan of care documented the nursing staff would monitor vital signs per facility protocol and notify the physician of significant abnormalities. The plan of care documented nursing staff would monitor, document, and report as needed any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage. The plan of care dated 05/21/24 documented that the facility would monitor the port site on the right upper chest. R304's EMR under the Orders tab revealed the following physician orders: R304's dialysis was provided on Monday, Wednesday, and Friday. Departure time at 12:40 PM and chair time 02:00 PM dated 05/15/24. Complete pre and post-dialysis communication form: Obtain weight and vital signs before and after dialysis. Notify the physician if systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries greater) (>) 190 millimeters of mercury (mmHg) or less (<) 80 mmHg, diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) >105mmHg or < 45mmHg, heart rate >110 or <45, temperature >100 degrees, and oxygen sats <88% in the evening every Monday, Wednesday, and Friday for post dialysis. Ensure that his binder was brought back, dated 05/15/24. Complete pre and post-dialysis communication form: Obtain weight and vital signs before and after dialysis. Notify the physician if SBP >190mmHg or < 80mmHg, DBP >105mmHg or <45mmHg, heart rate >110 or <45, temperature >100 degrees, and oxygen saturation <88% every Monday, Wednesday, and Friday for pre-dialysis to be completed prior to leaving for chair time of 02:00 PM. Assure this information was in the white dialysis binder for R304 and the binder was sent with R304 dated 05/15/24. Remove the dialysis dressing at bedtime every dialysis day. Notify the physician as indicated for bleeding or discomfort every night every Monday, Wednesday, and Friday dated 05/15/24. No blood pressure was obtained from the right arm. Monitor port site on right chest every shift. Notify the physician and director of nursing immediately of swelling, numbness, decreased temperature, increased pain, prolonged bleeding, redness, or fluid leakage. Insert a progress note of any changes to the port site on the left upper extremity dated 05/15/24. A review of R304's EMR under the Misc tab of the Dialysis Communication Form revealed two forms. The communication form dated 05/15/24 lacked a post-dialysis assessment documented. The communication form dated 05/20/24 lacked evidence of pre-dialysis assessment and the dialysis provider had documented under the post-dialysis section of the communication form. The dialysis communication sheet dated 05/20/24 had documented by the dialysis provider that R304's condition was poor, and his access site had bleeding. R304's clinical record lacked evidence of physician notification or post-assessment. The EMR lacked evidence of a dialysis communication sheet for 05/17/24. R304's EMR lacked evidence of communication with the dialysis provider. R304's May 2024 Medication Administration Record (MAR) and Treatment Administration record (TAR) lacked documentation of a pre-dialysis assessment dated [DATE]. On 06/12/24 at 07:58 AM, Administrative Staff A stated R304 had received dialysis services on 05/15/24, and 05/17/24, and only received about half of a dialysis session related to his access site had collapsed on 05/20/24. Administrative Staff, A stated confirmed R304's EMR lacked evidence of a post-dialysis assessment on 05/20/24. Administrative Staff A stated R304 had been transported to the dialysis provider on 05/22/24 and the provider had refused to treat R304. On 06/12/24 at 12:15 PM, Licensed Nurse (LN) H stated she would assess a resident's dialysis access site at least daily and document the assessment on the MAR. LN H stated the nurse would complete a pre-dialysis assessment and a post-dialysis assessment for a resident who received hemodialysis. LN H stated the assessment information was documented on the Dialysis Communication Form and sent with the resident to the dialysis provider. LN H stated the communication sheets were scanned into the resident's EMR. On 06/12/24 at 12:28 PM, Administrative Nurse D stated most of a resident's information related to dialysis was located on the MAR or TAR. Administrative Nurse D stated she would expect there to be communication between the facility and the dialysis provider. Administrative Nurse D stated she expected the nurse to call the dialysis provider and get a verbal report from the dialysis provider if the dialysis communication sheet was not returned or lacked documentation from the provider. The facility's Hemodialysis policy dated 01/01/20 documented that the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility failed to obtain communication from the dialysis center and assess the pre-dialysis and post-dialysis clinical status for R304. These deficient practices placed R304 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility reported a census of 53 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow orders related to medication monitoring when the facility administered Resident (R)50's anti-hypertensive beta-blocker (class of medication used to treat high blood pressure) medication on multiple occasions outside the physician ordered parameters without physician notification. This deficient practice placed R50 at increased risk for unnecessary medication and side effects. Findings included: - The Medical Diagnosis section within R50's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory, and confusion), restless leg syndrome, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R50's Admission Minimum Data Assessment (MDS) completed 04/06/24 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS indicated he was dependent on staff for transfers, bed mobility, bathing, dressing, and personal hygiene. R50's Dementia Care Area Assessment (CAA) completed 04/08/24 indicated he had poor short and long-term memory and impaired decision-making abilities. The CAA encourages staff to communicate with short and simple sentences to ensure adequate understanding. R50's Functional Abilities CAA completed 04/08/24 indicated he was dependent on staff for all care. The CAA indicated he had a history of falls and was at risk for skin impairment related to his limited mobility. The CAA noted his goal was to remain at his long-term care facility. R50's Care Plan initiated 03/31/24 indicated he required maximal to total dependence from staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The plan indicated he was at risk for altered cardiovascular status related to his hypertension. The plan encouraged staff to monitor him for shortness of breath, chest pain, and abnormalities related to his hypertension. R50's EMR under Physician's Orders revealed an order dated 03/30/24 to administer 50 milligrams (mg) of metoprolol (antihypertensive medication) by mouth twice daily for his hypertension. The order instructed staff to hold the medication if his systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg) or diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) was less than (<) 60mmHg. R50's EMR under Medication Administration Record (MAR) between 03/31/24 through 06/11/24 (72 days reviewed) indicated his metoprolol medication was given outside the ordered physician's parameters on 05/01/24 (morning), 05/01/24 (evening). 06/02/24 (morning dose), 06/02/24 (evening dose), 06/03/24 (morning dose), 06/03/24 (evening dose), 06/09/24 (evening dose). On 06/12/24 at 07:34 AM Licensed Nurse (LN) G assessed R50's blood pressure. His blood pressure was within the given parameters for his metoprolol. R50's metoprolol was administered. On 06/12/24 at 12:15 PM Licensed Nurse H stated that licensed staff should mark in the EMR that a medication was held due to the ordered parameters. She stated the physician would be notified of the held medication and a progress note would be completed. On 06/12/24 at 12:31 PM Administrative Nurse D stated staff were expected to follow the medication parameters per the physician's orders. She stated the MAR required staff to enter a specific reason the medication was held if out of parameters. The facility's Provisions of Physicians Ordered Services policy (undocumented) indicated the facility will ensure services, medications, and treatments ordered by the medical provider by accurately followed and the clinical provider be notified of changes or missed treatments. The facility failed to follow orders related to medication monitoring when the facility administered R50's anti-hypertensive beta-blocker medication on multiple occasions outside the physician-ordered parameters without physician notification. This deficient practice placed R50 at increased risk for unnecessary medication and side effects.

The facility had a census of 53 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure a gradual dose reduction (GDR) was attempted or addressed by the physician for Resident (R) 43's antipsychotic (class of medications used to treat a mental disorder characterized by a gross impairment testing) medication, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R43's Electronic Medical Record (EMR) documented the resident had diagnoses of dementia without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major depressive disorder (major mood disorder which causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (HTN-elevated blood pressure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly 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 R43 depended on staff assistance for activities of daily living (ADLs), except eating for which R43 was independent, after set up. The MDS documented R43 received antipsychotic medication and no GDR was attempted during the observation period. R43's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/10/23 documented R43 was admitted to hospice after COVID-19 (highly contagious respiratory virus). R43 required partial to moderate assistance with care, and she was frequently incontinent of bowel and bladder. R43 was a fall risk due to left-sided paralysis. R43 was at risk for impaired skin due to incontinence. R43 was currently receiving Risperidone (antipsychotic medication) for dementia with behaviors. R43's goal is to remain in long-term care with hospice. R43's Care Plan dated 02/15/23 documented R43 was prescribed psychotropic medication and was at risk for complications due to behavior psychosis. The plan of care directed staff to administer medications as ordered. R43's plan of care documented the facility should consult with the pharmacy and physician to consider a GDR when clinically appropriate, at least quarterly. R43's EMR under the Orders tab revealed the following physician's orders: Risperidone (antipsychotic) 0.5 milligrams (mg) give two tabs in the evening for major depressive disorder dated 12/15/22 (discontinued). Risperidone 0.5mg give two tabs in the evening for major depressive disorder with psychosis dated 11/17/23 (discontinued). Risperdal (risperidone) 0.5 mg by mouth, one tablet every morning, and two tablets by mouth every evening for major depression disorder with psychosis dated 02/26/24. The Monthly Medication Review (MMR), from June 2023 documented a recommendation to consider a GDR for the Risperdal. The physician marked no to the GDR and checked a dose reduction would impair the resident's function because the targeted behaviors were persistent and a dose reduction would cause psychiatric instability by exacerbating her psychiatric disorder. R43's Pharmacy Consult dated 09/20/23 and 05/15/24, documented the risperidone order was prescribed for a diagnosed condition and not being used for convenience or discipline, the physician documented yes, The risperidone order was clinically indicated to manage a resident's symptoms or condition where other cause have been ruled out, the physician documented yes. The signs, symptoms, or related causes are persistent or clinically significant enough to warrant the initiation or continuation of medication therapy, the physician documented yes. The indicated or actual benefit is sufficient to justify the potential risk or adverse consequences associated with the medication, dose, and duration, the physician documented yes. The behavior and physical symptoms targeted for the use of risperidone for this resident included psychosis and rejection of care. The Monthly Medication Review (MMR), from July 2023 through June 2024 did not identify attempts for a GDR for R1's antipsychotic medication and lacked evidence the physician documented a justification for not attempting a GDR. On 06/10/24 at 11:17 AM, observation revealed R43 sat in the dining room visiting with peers. On 06/12/24 at 12:28 PM Administrative Nurse D stated the facility relies on the pharmacist to let the physician know if a resident is due for a gradual reduction, or if the diagnosis is correctly indicated for antipsychotic medications. The facility's Gradual Dose Reduction of Psychotropic Drugs policy dated 01/01/20 documented that Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated, in an effect to discontinue these drugs. The facility failed to ensure a GDR was attempted for R43's antipsychotic medication, who had a diagnosis of dementia. This placed the resident at risk for unnecessary psychotropic medications and related complications.

The facility identified a census of 53 residents. The sample included 16 residents with one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R)40, R41, and R256. This deficient practice placed the residents at risk for impaired dignity and quality of life. Findings Included: - On 06/10/24 at 07:52 AM an inspection of the hallway behind the activity room revealed a clear file box attached to the wall. A grievance form completed by Resident (R)256's resident representative was placed in the clear box with the details of the grievance visibly displayed. On 06/10/24 at 12:19 AM R41 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room. R40's indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) tubing ran down the right side of his chair and hung in the lower back of his chair. R41's urinary collection bag lacked a privacy (dignity) cover. Urine was visible in the collection bag. On 06/11/24 at 07:21 AM R40 approached the nurse's station on his electric mobility scooter. R40's urinary catheter ran down the right side of his leg and his urine collection was attached to the handlebars of his electric scooter. R40's catheter bag had no privacy cover or dignity bag. Visible urine pooled in the tubing and collection bag as he sat at the nurse's station. On 06/11/24 at 01:05 PM Social Service Staff X stated R256's grievance form was accidentally placed in the wrong box by a new kitchen staff member. She stated the grievances should be placed in the locked grievance box in the main hallway. On 06/12/24 at 12:05 AM Certified Nurse's Aide (CNA) M stated all indwelling catheters should have a privacy bag to ensure the resident's dignity was maintained. She stated grievance forms should be confidential and turned directly in to the social service staff. On 06/12/24 at 12:15 PM Licensed Nurse (LN) H stated the indwelling catheter should be placed below the level of the bladder and with a dignity bag. On 06/12/24 at 12:35 PM Administrative Nurse D acknowledged staff placed R256's grievance form in the wrong box and had already re-educated the staff about the correct grievance process. She stated every resident with an indwelling catheter should be placed in a dignity bag when out in public areas. The facility's Promoting and Maintaining Resident Dignity 09/2020 indicated the facility would protect and promote each resident's rights and promote an environment that maintains or enhances dignity. The facility failed to provide a dignified care environment for R40, R41, and R256. This deficient practice placed the residents at risk for impaired dignity and quality of life.

The facility identified a census of 53 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 51's comprehensive care plan was updated to include staff direction on the collaboration between the dialysis (a procedure where impurities or wastes were removed from the blood) clinic and the facility. The facility failed to ensure the care plan was updated with interventions to direct staff on the days, times, location, and contact numbers of R51's dialysis treatment clinic. This placed R51 at risk for complications related to dialysis due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R51 documented diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R51's Admission Minimum Data Set (MDS) dated [DATE] documented R51 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R51 had impairment on both sides of his lower extremities and required the use of a walker and/or wheelchair to assist with mobility. R51 required partial/moderate to substantial/maximal assistance with his activities of daily living (ADLs) and functional abilities. R51 required dialysis treatment. R51's Functional Abilities Care Area Assessment (CAA) dated 05/29/24 documented R51 required substantial to maximal assistance with care and was occasionally incontinent of bowel and bladder and remained a fall risk due to weakness and discomfort. R51 received hemodialysis. R51's Care Plan initiated on 05/20/24 directed staff to not draw blood or take blood pressure in the arm with the graft. Staff was directed to monitor the fistula (abnormal passage from an internal organ to the body surface or between two internal organs) to the right forearm. Staff was directed to monitor R51's intake and output. Monitor labs and report to the doctor as needed. Staff was directed to monitor vital signs per facility protocol and notify the physician of significant abnormalities. Staff was to monitor, document, and report as needed any signs or symptoms of infection to access the site for redness, swelling, warmth, or drainage. R51's Care Plan lacked staff direction on the location, days, times, chair time, and contact number for the dialysis clinic. R51's Order Summary in the EMR documented the following orders and or treatments: Dialysis Center: Resident receives dialysis services on Monday, Wednesday, and Friday with a departure time of 10:00 AM and a chair time of 11:00 AM dated 05/21/2024. Dialysis: Print a new medication list/order summary to send to dialysis the first week of every month and put the medication list in a personalized dialysis binder every Monday, Wednesday, and Friday for Dialysis communication, dated 05/20/2024. Dialysis: Remove dialysis dressing at bedtime every dialysis day Monday, Wednesday, and Friday; notify physician as indicated for bleeding or discomfort for monitoring, dated 05/20/2024. A high-protein snack was to be provided every Monday, Wednesday, and Friday upon arrival from dialysis. Document on the Treatment Administration Report (TAR) an A for accepted or R for refused one time a day every Monday, Wednesday, and Friday, dated 05/24/2024. Monitor the fistula/graft site for signs/symptoms of infection, edema, and bleeding upon return from dialysis and notify the physician if any signs are noted. If the site was bleeding apply pressure for 15 minutes and notify the physician and if the bleeding did not stop, twice daily and as needed, dated 05/20/2024. No blood pressure was obtained from the right arm. Monitor the fistula site at specify location every shift. Assess thrill and bruit. Notify the physician immediately of left upper extremity swelling, numbness, decreased temperature, increased pain, prolonged bleeding, redness, distended fistula, or fluid leakage. Insert progress note of any changes to fistula site to right upper extremity every shift, dated 05/21/2024. Obtain daily weight everyday shift for weight management, dated 06/06/2024. On 06/12/24 at 08:03 AM R51 sat in his wheelchair as he propelled himself to the dining room for breakfast. On 06/12/24 at 12:02 Certified Nurse Aide (CNA) M said she did not have access to the care plan, but the aides did have access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) that had what amount of care each resident needed. CNA M stated she knew R51 was on dialysis and was to keep track of how much he ate and to let the nurse know of any changes to the arm the fistula was in. On 06/12/24 at 12:10 PM, Licensed Nurse (LN) H stated R51's care plan should be updated to include the location of the dialysis center, when he went, and how to get a hold of the clinic. LN H stated residents on dialysis each had dialysis books. LN H stated each time R51 went to dialysis a communication sheet was sent with him. LN H stated that Administrative Nurse E was responsible for updating the care plans. LN H stated the nurses could add interventions, but Administrative Nurse E was the primary person to make changes to the care plan. On 06/12/24 at 12:26 PM Administrative Nurse D stated Administrative Nurse E was the staff member responsible for creating the care plans and developing the comprehensive care plans after the MDS was completed. Administrative Nurse D stated R51's care plan should have been updated with all the information about when, where, what time, and the chair time for his dialysis so staff was aware of that information. Administrative Nurse D stated that typically the residents' main screen in the EMR should have special instructions documented regarding the dialysis. The facility policy Comprehensive Care Plans implemented 02/01/20 documented: that it was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. The comprehensive care plan would be developed within seven days after the completion of the comprehensive MDS assessment. The comprehensive care plan would describe at a minimum any specialized services that were to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure R51's comprehensive care plan was updated with interventions to direct staff on the days, time, and location and contact number of R51's dialysis treatment clinic. The facility failed to ensure R51's comprehensive care plan was updated to include staff direction on the collaboration between the dialysis This placed R51 at risk for complications related to dialysis due to uncommunicated care needs.

The facility identified a census of 53 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure nurse staffing data was posted daily. Findings included: - On 06/11/24 at approximately 07:15 AM, an initial tour of the facility revealed the posted daily nurse staffing hour data was dated 06/07/24. On 06/12/24 at 12:26 PM Administrative Nurse D stated that the staffing coordinator was responsible for posting the nurse staffing data daily and the charge nurse was responsible for posting on the weekends. Administrative Nurse D stated that the weekend staffing sheets were behind the sheet from 06/07/24. The facility policy Nurse Staffing Posting Information implemented on 12/01/19 documented it was the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. The facility would post the nurse staffing data at the beginning of each shift. The information would be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility failed to ensure daily nurse staffing data was posted as required.

The facility identified a census of 51 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to identify the increased level of risk and respond with appropriate interventions and adequate supervision, to prevent an elopement for Resident (R) 1, who was cognitively impaired, at risk for elopement, and had a recent history of aggressive exit seeking behaviors on 02/07/23 and 02/09/23. On 02/16/23 the facility placed a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1 and removed the resident from one-to-one supervision, though not all doors were connected to the Wanderguard system. On 03/08/23 at 03:36 AM, R1 exited the facility from the alarmed South door, not included in the Wander Guard system. Staff responded to the door alarm, looked outside, and then canceled the alarm. Staff searched for R1, and noted his bed was made in a way to appear as if he was in bed. Staff alerted Administrative Staff A, and then later called Law Enforcement (LE). The area surrounding the facility was searched but R1 was not found. Three and a half hours later, R1 was found in the ditch adjacent to the facility property. R1 was cold and wet, more confused than usual, and transferred to the local hospital for assessment. The facility failed to reassess R1 after his previous elopement/exit seeking attempts and implement preventative interventions, which included adequate supervision, to ensure R1 did not leave the facility without staff knowledge. The facility staff also failed to immediately conduct a thorough outside search when the South door alarmed. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnoses tab recorded diagnoses of hepatic encephalopathy (loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage), hepatic failure (a condition in which the liver is unable to perform its normal metabolic functions), and neuralgia and neuritis (a sever pain due to damaged nerves that causes severe burning pain). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R1 required limited assistance of one staff member for bed mobility, dressing, toilet use, and personal hygiene. R1 required supervision of one staff member with transfers, walk in room and corridor, locomotion on the unit, and eating. R1 only required supervision and set up help with locomotion off the unit. The MDS noted R1 had daily wandering behavior present that placed R1 at significant risk of getting into a potentially dangerous place. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 02/09/23 documented R1 had daily wandering behaviors and placed R1 at significant risk of getting to a potentially dangerous place. The Cognitive Loss CAA dated 02/09/23 documented R1 had long-term and short-term memory loss related to liver failure and received medications to aid in memory. R1 had impaired decision-making abilities. The Urinary Incontinence CAA dated 02/09/23 documented R1 was a fall risk related to weakness and poor safety awareness with a goal of possibly needing placement in a locked unit related to confusion. The Behavioral Symptoms CAA dated 02/09/23 documented R1 had behaviors of wandering around the facility, and the licensed Nurse (LN) tracked and documented those in the treatment administration record (TAR). The Care Plan dated 02/03/23 directed staff to encourage independence while R1 was in the building but ensure supervision while outside, observe for signs and symptoms of acute illness which may enhance confusion, and to redirect R1 when wandering around doors and/or exits. It directed staff to visualize R1's whereabouts, frequently. The care plan further recorded an intervention dated 02/13/23 which documented a history of refusing/resisting ADL cares and directed staff to keep R1 out of others' rooms and keep him from exiting the front doors. An intervention created on 02/13/23 directed staff to provide one-on-one assistance with one staff member, related to exiting. R1's Care Plan noted on 02/16/23 R1 had a Wander Guard placed on his left hand. The Wandering/Elopement Risk Scale assessment dated [DATE] documented a score of five, which indicated low risk for wandering/elopement but documented in the notes section that R1 had exhibited behaviors of wandering since admission and was observed wandering in and out of other residents' rooms. R1's clinical record lacked further elopement/wandering assessment until after the elopement on 03/08/23. The Orders - Administration Note dated 02/04/23 at 08:10 AM documented R1 was wandering. The Behavior Note dated 02/06/23 at 09:09 AM documented R1 had one-on-one care with exit seeking, aggressive behavior toward staff, and wandering. The Health Status Note dated 02/07/23 at 04:23 PM documented R1 continued with one-on-one monitoring and every 15-minute checks. R1 walked around the halls several times so far on that shift. The Alert Note dated 02/07/23 at 06:57 PM documented R1 headed toward the lobby and walked up to the front doors, turned off the button at the top of the doors, and tried to walk out of the facility. An unidentified Licensed Nurse (LN) tried to stop R1 from leaving and had to yell for assistance. An unidentified Certified Nurse Aide (CNA) responded and the LN was able to redirect R1 back inside. The LN reported the event to Administrative Nurse D. The note documented R1 was halfway out the second door and staff had to gently take R1 by the arm and turn R1 around to bring him back into the building. The note documented R1 tried to leave the facility on three separate occasions the previous night and staff had to constantly watch R1 all night. The Behavior Note dated 02/09/23 at 09:44 AM documented clarification that R1 was not aggressive towards staff but was aggressively exit seeking and consistently wandered. The Nurse's Note dated 02/11/23 at 10:07 PM documented R1 remained restless and confused. One-on-one nursing monitoring continued. R1's EMR, under the Orders tab, documented a Physician Order dated 02/16/2023 which directed staff to ensure R1 had a Wander Guard every shift. R1's clinical record lacked further documentation related to the Wander Guard placement. The Nurse's Note dated 02/20/23 at 05:09 AM documented R1 remained restless and walked around the facility. R1 voiced he had nausea and staff encouraged him to rest, but he refused. R1 had confusion and was going through the activity area closets. The Nurse's Note dated 03/08/23 at 11:01 AM documented at 03:30 AM the south hall door alarmed indicating that it was opened. LN G, CNA M, CNA N, and CNA O checked the door and outside the surrounding area but were unable to visualize anyone in the vicinity. The staff checked R1's room. The noted documented R1 was ambulatory and wore a Wander Guard. R1's bed had bunched up blankets underneath the covers in the general shape of a body laying in the bed. LN G, CNA M, CNA N, and CNA O then searched the facility and the property. Staff notified Administrative Staff A who then notified LE when R1 was not located on the property. LE arrived at the facility and assisted the additional staff on site with the search. R1 was located laying down outside at approximately 07:10 AM and then transferred to the hospital for evaluation. Review of the facilities Incident Report noted on 03/08/23 at approximately 03:35 AM, the alarm sounded, alerting staff that a door was opened. CNA M went to the control panel located behind the long-term care charge nurse station to see which door was opened. The report documented CNA M, along with CNA N and CNA O, went outside of the south hall door and surveyed the surrounding area without seeing any person. Upon entry back to the building, the CNA staff notified LN G and began a head count, starting in R1's room. When staff looked in R1's room, they found R1's bed had blankets and clothing items lumped under the bedding to make it look like the resident was still in bed. The report noted staff continued searching with the head count in the building then moved the search outside the building. The report documented the staff notified Administrative Staff A, who then notified LE at 03:40 AM. The report noted that local LE took over the search using heat signature [NAME] and foot officers at 04:15 AM. The report noted at approximately 07:05 AM Dietary BB reported to CNA P that Dietary BB saw a person laying in the grass ditch outside the building. CNA P notified Administrative Staff A who flagged an unidentified LE officer over while Administrative Staff A headed to the area. The report noted at 07:10 AM, R1 was located about 80 feet from the building, laying on trash bags, wearing a hoodie, sweatpants, shoes and socks and socks on his hands. He was covered by a blanket. The gate chain [from the facility fence] was on the ground next to R1. The temperature at that time was 45 degrees Fahrenheit (F). The report indicated the video footage recorded R1 left his room with a packed bag at approximately 03:35 AM. R1 removed his Wander Guard in the small breezeway that linked the middle and south hall and exited the building on the end of the south hall, which was directly by the gate, to get out of the garden. The report documented R1 admitted to the facility on [DATE] with a BIMS of three, noted he originally did not score as an elopement risk, however he did have behaviors and a history of wandering to exits. He was placed on one-to-one from the time of admission on 02/03/23 until 02/16/23 as the facility waited on the Wander Guard shipment to arrive. On 02/16/23 the staff placed the Wander Guard on R1, related to R1's increased wandering with exit seeking. The report noted the elopement system in place was completed correctly by the staff; the door alarm triggered, and staff immediately acted verifying which door alarmed. Staff went directly to the door to complete a search of the immediate area. When staff saw no residents at the door or the surrounding area, staff began searching inside and completing a head count. Staff identified R1 was missing and began searching inside and outside of the building. The hospital History and Physical (H&P) dated 03/08/23 documented R1 lived at the facility due to hepatic failure and encephalopathy. He was last seen in the nursing facility at 02:00 AM. The H&P recorded R1 was found in a ditch by the facility; he was wet, cold, and confused and admitted to the hospital by ambulance at 07:46 AM. His body temperature was recorded at 36.4 degrees Celsius (97.5 degrees Fahrenheit) and in no acute distress. In a notarized Witness Statement dated 03/14/23, CNA M stated the door alarm sounded around 03:30 AM. CNA M stated she saw it was the south hallway and went right to the door to check it but did not see anyone, so staff went to R1's bedroom. They noted R1 made his bed to appear someone was still in it. CNA M stated when staff observed R1's bed, each staff took a hallway and looked in every room, and then started searching outside. In a notarized Witness Statement dated 03/14/23, CNA N stated the nurse and two other CNA were at the nurse's station at approximately 03:30 AM, when the south hallway door alarm went off. The three CNAs went to check it out. CNA N stated staff did not see anything outside and went over to the hallway where R1's room was located. CNA N stated one CNA turned on R1's lights and staff saw R1's bed was stuffed. CNA N stated staff then split up and looked down every hallway and searched outside. CNA N stated she went with another CNA to the apartments [located near the facility] while another staff drove around the surrounding block. Staff came back to the facility and searched inside again and called the admins. In a notarized Witness Statement dated 03/14/23, CNA O stated the door alarm went off down the 100 hall and CNA O and CNA N rushed down to the door, looked outside no one was near. CNA O stated they went and checked R1's bed and noted the bed had been stuffed to look occupied. CNA O stated staff then searched outside, yelled R1's name, and searched the entire building. The LE Incident Report recorded a 911 call received at 04:02 AM on 03/08/23 from Administrative Staff A alerting LE that R1 had left the facility against medical advice. LE arrived at the facility and Administrative Staff A informed LE that R1 had been at the facility approximately 30 days and had health issues related to his liver disease. Administrative Staff A told LE that at approximately 03:40 AM one of the facility alarms went off, and when staff checked the facility, they found that R1 had placed blankets and pillows in his bed forming them to look like a person was sleeping, then went down the southeast hallway and out the south door. The report indicated LE officers began searching the area on foot and in patrol cars. LE notified local county LE and requested the use of a thermal imaging drone. Multiple deputies responded and assisted in the search. LE officers conducted a grid search, as well as a one-mile drone search to seek out heat sources. Officers conducted a foot search of the adjacent golf course as well. At 06:00 AM, after the search efforts were exhausted, the county officers were cleared from the call and local LE continued to search the area in patrol vehicles. The report noted at 07:00 AM, LE received notification from a caller who reported a man laying in the ditch at an intersection just north of the facility. LE arrived at the scene and visualized R1. The report indicated it appeared as if R1 slipped while returning to the property, R1 appeared uninjured but did not want to return to the facility. The report noted it was determined that R1 travelled north on foot after leaving the facility and went to the local general store to get a lighter and a drink. On 03/14/23 at varying times throughout the survey, observation revealed the facility was in an [NAME] area along a two-lane road with posted speed limits of 30 miles per hour (MPH). R1's exact route was unknown although the resident would have had to walk down an incline exiting the premises. The general store was located over a mile away, on a busy two-lane highway with posted speeds of 35 MPH. According to Wunderground.com, the weather outside on 03/08/23 between 03:35 AM and 07:05 AM was approximately 41 degrees F. On 03/14/23 at 12:25 PM Administrative Staff A stated that R1 had never actively tried to get out of the building. Administrative Staff A further stated the elopement was a new behavior for R1 and that R1 only tinkered with things which was why R1 received a Wander Guard, just for his safety. On 03/14/23 at 12:40 PM Administrative Nurse D stated that when there was a change in a resident's wandering or elopement behaviors from the previous wandering/elopement assessment, she expected the nurses to complete a new wandering/elopement assessment. On 03/14/23 at 12:45 PM R1 stated he tried and tried to get the facility's attention but the facility would not listen to him. R1 revealed he took a small blanket, plastic bags in case he needed to lay down, napkins for toilet paper because his bowels had not been good, and lastly a lighter in case he needed to make a fire. R1 further revealed that he wanted to walk back to the city which he formerly resided. R1 stated he went through the small hallway that connected the two halls and exited the doorway on the parallel hallway. Once outside, he turned right and went through the gate and then closed the gate and went left once outside of the gate. R1 said he went left again at the corner of the chain link fence down to the parking lot. R1 revealed the ground was slick from the rain and that it had started to rain on him again while he was out walking. R1 stated after leaving the parking lot he walked on the sidewalk and noted that he was tired. R1 stated at that time he laid out a plastic bag in the ditch so he could rest. R1 laid down and then covered himself with leaves to help keep him warm. R1 revealed he wanted the police called and thankfully the police helped find him. R1 stated he had not slipped but he was cold and wet when he was outside. He said he rubbed his hands together and would blow warm air into them to try to stay warm. R1 stated he felt like no one found him because of the color of his coat and he had pushed leaves up on himself. R1 held up a darker brown farming coat with a zipper and hood. On 03/14/23 at 02:10 PM CNA M stated when the alarm went off that night, she went to the door and looked outside. CNA M further stated she went outside and noted the gate was closed. CNA M revealed she had last seen R1 at approximately 02:00 AM when assisting R1's roommate. CNA M stated R1 laid in bed watching TV and appeared calm. CNA M stated she searched the back, bottom parking lot but did not go out on the grass at all. CNA M revealed that she performed R1's one-on-one the following day, 03/09/23, and asked R1 if R1 heard CNA M yell his name. R1 stated he had, and that CNA M yelled loudly. CNA M revealed that R1 wandered and tried to go outdoors, historically. CNA M further revealed R1 had been a one-on-one for a long time, but had eased up on exiting, so the facility eased up on the one-on-one with R1 and then, after a period, the constant monitoring was not continued. On 03/14/23 at 02:30 PM CNA N stated it took approximately three minutes to reach the door, and she did go out the door to look for a resident. CNA N noted the gate to the right had no chain on it and could be opened freely. CNA N revealed that upon coming back into the building she went immediately to R1's room because CNA N knew R1 had previously been on one-on-one, related to wandering. When R1 was not located in his room, staff then went outside to search, while CNA N started to check other resident rooms related to R1's history of going into other residents' rooms. CNA N reported R1 had previously been noted in his room during the 02:00 AM check and change. CNA N said the staff working looked in on R1 when a call light was answered down R1's hall, related to R1's history of wandering and attempting to get out. On 03/14/23 at 03:07 PM Administrative Nurse D stated R1 displayed behaviors of going to doors and that was why R1 had one-on-one. Administrative Nurse D reviewed R1's wandering/elopement assessment at that time and stated she should have known R1 was an elopement risk. She stated Administrative Nurse E handled the admission audits and Administrative Nurse E would have reviewed R1's wandering/elopement assessment. Administrative Nurse D revealed the clinical team was more focused on R1's behaviors and what was being observed at that moment, she said the clinical team was making sure staff were in place to monitor R1, before the Wander Guard arrived. On 03/14/23 at 03:08 PM Administrative Staff A stated R1 had one-on-one monitoring the moment he arrived and R1 was not attempting to leave the building. R1 received a Wander Guard. When asked about R1's progress notes on 02/07/23 Administrative Staff A revealed R1 had stepped outside the door, but staff got R1 back in the door. Administrative Staff A further revealed R1's behaviors had not changed, and the facility awaited the Wander Guard delivery. R1 had a cognition of three out of 15 and R1 was going to doors, and that was why the facility placed a Wander Guard on R1. On 03/14/23 at 03:55 PM LN H stated that R1 wandered and exit-sought frequently. LN H revealed that when R1 initially arrived that was not the case, but then R1 started to change and started to wander. LN H revealed that was when R1 was placed on one-on-ones. LN H stated that one-on -one happened for a while, then R1 received a Wander Guard. LN H stated that if a resident at the facility was noted to change and start to wander, LN H would complete a new wandering/elopement assessment and a change in condition assessment to show the change. LN H further revealed that the front door and the North door that led out to the smoking area were the only two doors connected to the Wander Guard system, since residents had historically either gone to the front door or the smoking door to get out. The facility's Elopement and Wandering Residents Policy, lacked a date, documented the facility would ensure that residents that exhibited wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility failed to identify the increased level of risk, and respond with appropriate preventative interventions and adequate supervision, to prevent an elopement for R1, who was cognitively impaired, at risk for elopement, and had a recent history of aggressive exit seeking behaviors when the facility failed to reassess R1 after his previous elopement/exit seeking attempts and implement preventative interventions, which included adequate supervision, to ensure R1 did not leave the facility without staff knowledge. The facility staff failed to immediately conduct a thorough outside search when the door alarmed. This deficient practice placed R1 in Immediate Jeopardy. On 03/09/23 the facility completed the following corrective actions: The facility conducted in-service training and education to staff with regards to elopement policy and procedure as well as wandering behaviors. Elopement drills and spot checks were completed over all shifts. The facility added an additional camera to view the south hall door and a camera in the dining room for the fire exit door on 03/09/23 which will have video surveillance for all exit doors within the building. Stop signs were ordered and placed on both middle and south doors as visual indicators. When R1 returned to the facility on [DATE] a one-to-one with staff was put in place and R1 set to be reassessed prior to being removed. R1's elopement assessment was updated and noted with a score of 12, which indicated he was at high risk for elopement and/or wandering. R1's plan of care was updated to include interventions which addressed his varying mentation and risk for elopement and/wandering. The above corrections were completed prior to the start of the onsite survey, so the deficient practice was cited as past-noncompliance.

The facility identified a census of 51 residents. The sample included three residents reviewed for neglect. Based on record review and interviews, the facility failed to prevent an instance of neglect on 09/26/22 at approximately 07:30 PM when Certified Nurse Aid (CNA) O attempted to transfer Resident (R)1 from a wheelchair to R1's bed using the full-body mechanical lift. CNA O knew R1's care plan directed R1 required two staff assistance with the lift. As a result of the deficient practice, R1 fell , hit her head on the floor, and sustained a laceration (cut) which required emergent treatment and a staple. R1 also had impaired psychosocial wellbeing evidenced by tearfulness and expressions of guilt related to the incident. Findings included: - The electronic medical record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (also known as an stroke: when blood flow to the brain is blocked), chronic obstructive pulmonary disease (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing), left sided hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and stage four chronic kidney disease (CKD- a disease that inhibits the kidneys ability to filter blood). The Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of ten, indicating moderately impaired cognition. The MDS recorded R1 required extensive to total assistance of one to two staff with most activities of daily living (ADL) such as toilet use and dressing. The MDS recorded R1 required two-person assistance for transfers. The ADL Care Area Assessment (CAA) dated 06/10/22 recorded the resident required extensive to total dependence with ADL; she was at risk for falls due to poor trunk control, and a care plan would be developed in those areas. R1's Care Plan dated 06/06/22 recorded R1 had an ADL self-care performance deficit and required assistance with care needs. R1 was totally dependent on two staff for transfers with use of a mechanical (Hoyer) lift. The Care Plan recorded on 09/26/22, R1 fell from a lift sling, new full body slings were ordered, and a teachable moment was initiated. The Care Plan documented R1 frequently moved while in the Hoyer lift, and directed one staff member must move the lift and the second staff member must help R1 keep focus and ensure correct positioning. A Nurses Progress Note located in R1's EMR dated 09/26/22 at 08:28 PM recorded staff notified Consultant GG that R1 had a fall with injury. R1 sustained a 1 by 1 [note did not indicate a unit of measure] weeping (producing a clear liquid, blood, or pus) lump to the back of R1's head. The facility transported R1 to the hospital via ambulance. A Nurses Progress Note dated 09/26/22 at 09:36 PM documented R1 fell during the shift, experienced quite a bit of bleeding, and went to the hospital for evaluation. A Nurses Progress Note dated 09/27/22 at 12:30 AM documented R1 returned from the hospital accompanied by Emergency Medical Services (EMS). R1 was alert with some confusion, which was normal for the resident. R1 had a laceration on the back of her head which was clean and dry, with staples intact. Review of the Hospital Emergency Reports dated 09/25/22 at 09:00 PM recorded R1 presented with a history of high blood pressure, COPD, CKD, and stroke with persistent left sided deficit. R1 was on Plavix (prevents blood cells from forming clots). R1 came from a long-term care facility secondary to a fall with a scalp laceration. R1 transitioned from bed to chair via a Hoyer lift when R1 fell , striking the left side of her scalp on the ceramic floor with a resultant head injury without loss of consciousness. R1 denied head, neck, or back pain. R1 had chronic left sided deficits, most notable in her arm greater than her leg. R1 reported a moderate intensity of pain, three out of 10 (on 0-10 scale with zero being no pain and 10 the worst pain imaginable). R1's bleeding was controlled, and she had no active bleeding. The report recorded R1 received a single staple to the laceration. She remained asymptomatic and returned to facility by EMS with an order to return in 5-7 days for staple removal. A Communication Note located in R1's EMR under Progress Notes dated 09/29/2022 at 09:34 AM documented R1's representative voiced concern about R1's fall. R1's representative wanted to know how the fall occurred and what was put in place to prevent it from happening again. Administrative staff spoke with R1's representative on the phone and explained how the fall occurred. Staff reassured R1's representative the incident would not happen again. The facility educated staff on the importance of always having two people for transfers; full body slings were ordered as well. The note further recorded R1 had a full body sling and would keep it until more slings arrived. R1 was crying and thought the fall was her fault. Staff comforted R1 reassured her the fall was not her fault. Staff would continue to monitor R1's tearfulness and inform social services, her physician, and representative if R1's emotions did not change or got worse. A Social Services Note located in R1's EMR dated 10/06/22 at 12:44 PM documented R1's representative requested a referral be sent to another facility. A Nurses Progress Note in R1's EMR dated 10/12/22 at 12:32 PM documented R1 discharged to another facility that day at approximately 12:30 PM. Review of the facility's Incident/Investigation/Reporting Review regarding R1's fall documented on 09/26/22 after 07:30 PM CNA O transferred R1 using a Hoyer lift. R1 raised her hand over her head which caused the sling to shift, and R1 fell to the floor. R1 landed with her head on the floor and her buttocks and legs still in the lift sling. Staff [unidentified] adjusted R1 to get R1's head off the floor and assisted R1 to bed. Certified Medication Assistant (CMA) R entered the room and stated she would get the nurse for evaluation. Licensed Nurse (LN) H assisted with getting R1 situated in her bed then assessed the bleeding area on R1's head, CMA R notified Administrative Nurse D and Administrative Nurse D went to the facility. Administrative Nurse D assessed R1, but was unable to locate the source of bleeding. Due to R1's use of Plavix, staff notified Consultant GG and activated EMS. The Incident/Investigation/Reporting Review included one staff statement from CNA O dated 09/26/22. CNA O documented the resident, while being transferred from her wheelchair to her bed, started moving. The lift moved sideways, and R1 slipped out. Review of CNA O's employee file revealed a Disciplinary Action which recorded on 09/26/22, CNA O transferred R1 alone, and the lift sling was in an inaccurate position, which caused R1's fall. On 10/20/22 at 01:00 PM and 10/24/22 at 09:30 AM, CMA R and LN H were unavailable for interview. On 10/24/22 at 10:02 AM, CNA O stated he knew the facility policy directed staff to use two persons for the lift. CNA O said he tried to call for help but could not get anybody. CNA said he regretted not waiting for help. CNA O said R1 was medium-sized lady and used a medium lift sling. He said the sling was in good repair and ther was nothing wrong with the lift. CNA O attributed the cause of the fall to R1 jerked her arm, leaned to one side, and that caused an unbalance, and that caused the fall. CNA O noted R1 had done that before, but there were two staff present so staff were able to get R1 in bed safely. On 10/24/22 at 10:17 AM, Social Services Designee (SSD) S stated R1 had no previous falls she was aware of and stated R1's representative was upset, but R1 moved to another facility to be closer to other family members. Interviewed on 10/24/22 at 10:17 AM, Administrative Nurse D stated there were no witness statements from LN H because she was an agency nurse and was unfamiliar with the investigation tools used. Administrative Nurse D stated she thought she had a statement from CMA R and she would look for it. Administrative Nurse D stated she determined what was reportable to the state agency by the severity of any injury and/or indication abuse and/or neglect occurred. Administrative Nurse D said when R1 fell , she came into the facility and assessed R1, but could not find any source of bleeding. Administrative Nurse D stated she was very shocked the hospital put a staple in. She further said, at that time, she did not feel the incident should be reported. Administrative Nurse D said R1 had a lump on R1's head and it was weeping; Administrative Nurse D contacted Consultant GG and he referred R1 the hospital. After assessing R1, Administrative Nurse D reeducated CNA O and went over the whole policy for lifts. Administrative Nurse D said CNA O reported his reason for using the lift alone as he just wanted to get R1 into to bed. The facility did not have a policy related to transfers with the use of a mechanical lift, but rather presented an undated Total (Hoyer) Lift Competency checklist. The facility's Abuse, Neglect and Exploitation policy titled The Elder Justice Act and reporting Suspected Crimes against Residents Policy and Procedure issued 2019 documented a purpose to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. The policy defined neglect as the failure of the facility, it's employees or service providers to provide good and services to a resident that are necessary to maintain health and safety of a resident and to avoid physical harm, pain, mental anguish, or emotional distress. The facility failed to ensure R1 remained free from neglect when facility staff disregarded R1's safety and transferred R1 with a mechanical lift using only one staff member despite R1's plan of care which directed two staff were required. As a result, R1 fell , hit her head, required emergency treatment to include staples to close the laceration, and further suffered impaired psychosocial wellbeing evidenced by tearfulness and feelings of guilt and/or shame.

The facility identified a census of 51 residents. The sample included three residents identified at risk for abuse, neglect, exploitation, and/or misappropriation of property. Based on record review, observations, and interviews, the facility failed ensure an environment free from misappropriation of resident property when facility staff took Resident (R)2's new laptop computer without R2's permission or knowledge. As a result of this action, R2 experienced mental anguish and an impaired sense of security. Findings included: - R2's Electronic Medical Record (EMR) revealed R2 admitted to the facility on [DATE]. R2's EMR, under the Diagnosis tab, listed diagnoses of malignant neoplasm of the bladder (bladder cancer), protein calorie malnutrition, depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and other medical problems. The Admission Minimum Data Set (MDS) dated [DATE] recorded R2 had a Brief Interview for Mental Status (BIMS) score if 15, which indicated no cognitive impairment. The MDS recorded R2 had moderately severe depression, and no behaviors. The MDS recorded taking care of R2's personal belongings were very important to R2 but having a locked place to keep his belongings was not very important. The MDS further recorded R2 felt it was very important to keep up with the news, have things to read, and listen to his favorite music. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R2 had a BIMS score of 13, which indicated intact cognition. The MDS documented R2 required limited assistance from staff with activities of daily living (ADL) and walked with the use of a rolling walker or cane. Review of R2's Care Plan dated 09/21/22 recorded R2 had a behavior problem with thoughts of despair and restlessness, major depressive disorder, and was at risk for falls related to impaired mobility. The care plan directed staff to keep R2's personal items within reach and promptly respond to R2's requests. Review of R2's Inventory of Personal Effects listed R2 had one jacket, one shirt, one pair of sweatpants, one pair of socks, glasses, and a cane. The inventory lacked record of further personal items. The inventory was signed on 04/01/22 by R2 and an illegible staff signature. The Resident/Family/Staff Concern/Grievance Form for R2 dated 10/06/22 at 11:30 AM recorded R2 reported his Mac computer missing, not sure when he last had it. The form indicated Administrative Staff A was informed and called the police and reported the item stolen. The form's Follow with resident/family/Staff Member section recorded on 10/14/22 R2 understood the facility would not replace the laptop. The police had an ongoing investigation. The box was checked, which indicated the concern and/or grievance was resolved and signed with an illegible signature on 10/14/22. Review of the facility's undated Investigation revealed on or about 10/07/22, Certified Nursing Assistant (CNA) MM reported she assisted R2 in cleaning R2's room and looking for R2's MacBook though they were unable to locate R2's device. CNA MM reported she used R2's phone to ping the MacBook and the ping showed a location in a nearby town. Upon review of the address, the facility identified the address was the listed home address for three current employees and one former employee. Administrative Nurse E notified Administrative Staff A, who then notified local law enforcement. The three current employees who lived at the address were placed on suspension. The report recorded two of the staff were cleared by the police investigation and two others, CNA Q and Housekeeping U, remained under suspicion. The facility terminated CNA Q the previous week for conduct issues and Housekeeping U was a contracted employee. The Witness Statement dated 10/07/22 from CNA MM recorded the resident reported to CNA MM that the resident's MacBook was missing. CNA MM helped the resident clean and organize his room, but the MacBook was nowhere to be found. CNA MM asked if she could assist R2 on his phone to use the locate device application nad R2 agreed. CNA MM stated the device was located at a local address in Ottawa, KS. An internet search for the address revealed the address belonged to a staff member where three other staff also stayed. CNA MM reported the information to Administrative Nurse E and Administrative Staff A. On 10/20/22 at 11:36 AM R2 ambulated with a rolling walker to the conference room. R2 stated he recalled he had used his laptop much; he had just purchased it and was familiarizing himself with it. R2 stated he thought the device was hidden well; it was underneath some things and not readily visible. R2 stated he did not think any of his other stuff was disturbed. R2 reported the thief did not take the charger and or the case that was with the MacBook. R2 said the police located the device once and talked to some people but could not find the laptop. R2 said the police stated they knew who took it and where it was but could not prove it. R2 stated the incident shattered his sense of security at the facility. R2 said he was frustrated and angry that the incident happened. R2 stated he felt the facility should replace the laptop, but every time R2 asked about this, the facility told him they had to wait until the police investigation was completed. R2 stated he felt very frustrated and angry at the situation. On 10/20/22 at 11:15 AM Licensed Nurse (LN) G stated he filled out the resident inventory when a resident admitted on his shift. LN G stated he encouraged residents and their families to confer with a nurse when new items needed to be added or removed from the list. On 10/20/22 at 01:30 PM Administrative Staff A explained the police were notified and were still investigating the incident. He said there was a ping emitted from the laptop and the laptop was located in a nearby town; police went and spoke to the occupants. Two of the occupants were agency contracted CNAs at the facility, and one was a direct facility employee. Administrative Staff A said the staff gave permission for the house to be searched, but the laptop was not found. Administrative Staff A revealed the two contracted employees then left the premises and police were trying to locate them. Administrative Staff A said he thought the computer must be turned off as it has not pinged again, but it would when turned on. On 10/24/22 at 11:55 AM CNA MM stated she worked at the facility for three years and could not recall there ever being a theft of such an expensive item. CNA MM stated she read the facility contract/policy and it did not say the facility would or would not replace the item. CNA MM stated that made her upset because while the facility might not know exactly who took R2's MacBook, the facility knows it was one of the facility staff. On 10/20/22 at 01:30 PM Administrative Staff A presented the facility's policy regarding Personal Property and Inventory. The policy directed residents to ask the nurse in charge to record any new personal items on the resident's inventory. The policy directed the facility could not update the resident inventory of personal items unless the residnet or the family provided the information. The policy did not address electronics specifically but advised items of value should not be left in the resident's room. The policy directed if the resident had something of value and wanted it safeguarded during the resident's stay, the residnet could store their valuables in the facility's secured area. The facility's Abuse, Neglect and Exploitation policy titled The Elder Justice Act and reporting Suspected Crimes against Residents Policy and Procedure issued 2019 documented a purpose to facilitate efforts to detect, prevent and treat intervene, in and prosecute elder abuse, neglect and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect and exploitation. The policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident belongings or money without the resident's consent. The facility failed to ensure an environment free from misappropriation for R2 when R2's new MacBook was taken from his room without his knowledge or permission and was later located in the home of facility staff. R2's MacBook remains missing. As a result, R2 feels unsafe and uncertain in the facility and expresses mental anguish regarding the incident and the lack of facility response in response to the missing item.

The facility identified a census of 51 residents. The sample included three residents reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to report to the State Agency (SA) an incident of resident neglect (Reference citation F600). This deficient practice placed the resident at risk for ongoing and/or unidentified abuse and neglect. Findings included: - The electronic medical record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (also known as an stroke: when blood flow to the brain is blocked), chronic obstructive pulmonary disease (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing), left sided hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and stage four chronic kidney disease (CKD- a disease that inhibits the kidneys ability to filter blood). The Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of ten, indicating moderately impaired cognition. The MDS recorded R1 required extensive to total assistance of one to two staff with most activities of daily living (ADL) such as toilet use and dressing. The MDS recorded R1 required two-person assistance for transfers. The ADL Care Area Assessment (CAA) dated 06/10/22 recorded the resident required extensive to total dependence with ADL; she was at risk for falls due to poor trunk control, and a care plan would be developed in those areas. R1's Care Plan dated 06/06/22 recorded R1 had an ADL self-care performance deficit and required assistance with care needs. R1 was totally dependent on two staff for transfers with use of a mechanical (Hoyer) lift. The Care Plan recorded on 09/26/22, R1 fell from a lift sling, new full body slings were ordered, and a teachable moment was initiated. The Care Plan documented R1 frequently moved while in the Hoyer lift, and directed one staff member must move the lift and the second staff member must help R1 keep focus and ensure correct positioning. A Nurses Progress Note located in R1's EMR dated 09/26/22 at 08:28 PM recorded staff notified Consultant GG that R1 had a fall with injury. R1 sustained a 1 by 1 [note did not indicate a unit of measure] weeping (producing a clear liquid, blood, or pus) lump to the back of R1's head. The facility transported R1 to the hospital via ambulance. A Nurses Progress Note dated 09/26/22 at 09:36 PM documented R1 fell during the shift, experienced quite a bit of bleeding, and went to the hospital for evaluation. A Nurses Progress Note dated 09/27/22 at 12:30 AM documented R1 returned from the hospital accompanied by Emergency Medical Services (EMS). R1 was alert with some confusion, which was normal for the resident. R1 had a laceration on the back of her head which was clean and dry, with staples intact. Review of the Hospital Emergency Reports dated 09/25/22 at 09:00 PM recorded R1 presented with a history of high blood pressure, COPD, CKD, and stroke with persistent left sided deficit. R1 was on Plavix (prevents blood cells from forming clots). R1 came from a long-term care facility secondary to a fall with a scalp laceration. R1 transitioned from bed to chair via a Hoyer lift when R1 fell , striking the left side of her scalp on the ceramic floor with a resultant head injury without loss of consciousness. R1 denied head, neck, or back pain. R1 had chronic left sided deficits, most notable in her arm greater than her leg. R1 reported a moderate intensity of pain, three out of 10 (on 0-10 scale with zero being no pain and 10 the worst pain imaginable). R1's bleeding was controlled, and she had no active bleeding. The report recorded R1 received a single staple to the laceration. She remained asymptomatic and returned to facility by EMS with an order to return in 5-7 days for staple removal. A Communication Note located in R1's EMR under Progress Notes dated 09/29/2022 at 09:34 AM documented R1's representative voiced concern about R1's fall. R1's representative wanted to know how the fall occurred and what was put in place to prevent it from happening again. Administrative staff spoke with R1's representative on the phone and explained how the fall occurred. Staff reassured R1's representative the incident would not happen again. The facility educated staff on the importance of always having two people for transfers; full body slings were ordered as well. The note further recorded R1 had a full body sling and would keep it until more slings arrived. R1 was crying and thought the fall was her fault. Staff comforted R1 reassured her the fall was not her fault. Staff would continue to monitor R1's tearfulness and inform social services, her physician, and representative if R1's emotions did not change or got worse. A Social Services Note located in R1's EMR dated 10/06/22 at 12:44 PM documented R1's representative requested a referral be sent to another facility. A Nurses Progress Note in R1's EMR dated 10/12/22 at 12:32 PM documented R1 discharged to another facility that day at approximately 12:30 PM. Review of the facility's Incident/Investigation/Reporting Review regarding R1's fall documented on 09/26/22 after 07:30 PM CNA O transferred R1 using a Hoyer lift. R1 raised her hand over her head which caused the sling to shift, and R1 fell to the floor. R1 landed with her head on the floor and her buttocks and legs still in the lift sling. Staff [unidentified] adjusted R1 to get R1's head off the floor and assisted R1 to bed. Certified Medication Assistant (CMA) R entered the room and stated she would get the nurse for evaluation. Licensed Nurse (LN) H assisted with getting R1 situated in her bed then assessed the bleeding area on R1's head, CMA R notified Administrative Nurse D and Administrative Nurse D went to the facility. Administrative Nurse D assessed R1, but was unable to locate the source of bleeding. Due to R1's use of Plavix, staff notified Consultant GG and activated EMS. The Incident/Investigation/Reporting Review included one staff statement from CNA O dated 09/26/22. CNA O documented the resident, while being transferred from her wheelchair to her bed, started moving. The lift moved sideways, and R1 slipped out. Review of CNA O's employee file revealed a Disciplinary Action which recorded on 09/26/22, CNA O transferred R1 alone, and the lift sling was in an inaccurate position, which caused R1's fall. Interviewed on 10/24/22 at 10:17 AM, Administrative Nurse D stated there were no witness statements from LN H because she was an agency nurse and was unfamiliar with the investigation tools used. Administrative Nurse D stated she thought she had a statement from CMA R and she would look for it. Administrative Nurse D stated she determined what was reportable to the state agency by the severity of any injury and/or indication abuse and/or neglect occurred. Administrative Nurse D said when R1 fell , she came into the facility and assessed R1, but could not find any source of bleeding. Administrative Nurse D stated she was very shocked the hospital put a staple in. She further said, at that time, she did not feel the incident should be reported. Administrative Nurse D said R1 had a lump on R1's head and it was weeping; Administrative Nurse D contacted Consultant GG and he referred R1 the hospital. Administrative Nurse D said CNA O reported his reason for using the lift alone as he just wanted to get R1 into to bed. The facility's Abuse, Neglect and Exploitation policy titled The Elder Justice Act and reporting Suspected Crimes against Residents Policy and Procedure issued 2019 documented a purpose to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. The policy defined neglect as the failure of the facility, it's employees or service providers to provide good and services to a resident that are necessary to maintain health and safety of a resident and to avoid physical harm, pain, mental anguish, or emotional distress. The policy further directed the facility had a duty to report all alleged violations of abuse , neglect, exploitation or mistreatment . The facility failed to report to the SA an incident of resident neglect. This deficient practice placed the resident at risk for ongoing and/or unidentified abuse and neglect.

The facility had a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 51 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to ensure clean and sanitary food prep and storage areas. This placed the 51 residents at risk for foodborne illness. Findings included: On 10/03/22 at 10:47 AM, observation in the kitchen revealed the following: Loose plaster located in the crack between sheet rock on the ceiling on both sides of the kitchen approximately six feet (ft) long and 2 inches (in) wide. Missing tiles located in the dishwashing area, under the ice machine approximately seven to eight ft long by four ft wide. Missing board on the frame located around the dishwasher entrance window. Missing floor tile, approximately six ft x six ft, located to the right of the dry storage entrance door, underneath the two rolling carts of six pound (lb) canned goods. The ice machine drainage tube laid directly on the floor by the floor drain, in standing water, approximately one-quarter inch deep by 18 in wide. On 10/03/22 at 10:47 AM, Dietary BB verified the above findings and stated she had reported the issues to the maintenance several times. On 10/03/22 at 02:03 PM, Maintenance U stated he was unaware there should be an air gap between the floor drain and the drainage tube from the ice machine, and he would see what he could he could do to fix it. The facility's Maintenance Inspection Policy, implemented on 10/25/19, documented the director of maintenance services would perform routine inspections of the physical plant using a Maintenance checklist. The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the 51 residents who resident in the facility and received their food from the facility kitchen. This placed the 51 residents at risk for foodborne illness.

The facility had a census of 55 residents. The sample included 20 residents. Based upon observation, record review and interview the facility failed to maintain a safe environment free from potential abuse for residents when staff refused to provide care for two residents (#12 #82) causing fear for the resident's to ask for assistance and required residents to wait for toileting causing incontinent episodes. The facility failed to protect the Resident #12 from physical abuse when there was an allegation of rough treatment and the resident sustained [REDACTED]. Findings included: - Resident #12's quarterly MDS dated [DATE] revealed the resident scored 9 (moderate impaired cognition) on the Brief Interview for Mental Status, did have delusions, hallucinations or behaviors, and was occasionally incontinent of urine. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/02/2014 revealed the resident had a [DIAGNOSES REDACTED]. The CAA included the resident was incontinence of urine throughout the day and would void appropriately at times when toileted. The resident's care dated 11/25/15 and revised 3/6/15 included staff approached the resident warmly and positively at all times and provided consistent caregivers to the extent possible. Review of a concern/grievance report dated 12/16/14 documented the resident stated that on the night shift 12/15/14 into 12/16/14, he/she turned on his/her call light because he/she needed to use the bathroom. Licensed nurse L answered the resident's call light and told the resident he/she would be right back. The resident waited about 30 minutes and then re-activated his/her call light. Licensed nurse L came back and still did not take the resident to the bathroom. Licensed nurse L told the resident that he/she did not need 2 pillows and licensed nurse L ripped the pillow out from under the resident and the pillow scraped the resident's forehead. Licensed nurse L left the room and the resident turned his/her call light back on because he/she still needed to use the restroom. The resident stated another nurse came into the room and stated he/she would inform licensed nurse L. The resident stated he/she ended up waiting so long that he/she was forced to pee in his/her pants. When licensed L reentered the resident's room, licensed nurse L made the resident stay in bed while he/she changed the resident and licensed nurse L was rough when turning the resident and the resident's right hip was hurt. The resident informed licensed nurse L his/her right hip hurt from him/her pushing on it and licensed told the resident he/she would have a nurse get him/her a pain pill. The form included the social service designee observed a small red scrape on the upper left side of the resident's forehead. Review of the facility's investigation dated 12/17/14 documented the resident stated licensed nurse L made him/her wait for 30 minutes and would not toilet him/her. Licensed nurse L ripped a pillow out from under the resident's head and the resident sustained [REDACTED]. When licensed nurse L changed the resident because he/she was soiled the resident stated licensed nurse L was rough with him/her while turning her and hurt his/her hip when he/she pushed on it. The investigation included administrative nursing staff E interviewed the resident and noted an abrasion on the left side of the resident's forehead approximately 4 centimeters in length. Administrative nursing staff E also noted three small fingertip size bruises on the resident's right hip. On 5/12/15 at 3:45 P.M. the resident sat in a chair in his/her room and related the incident to the surveyor. The resident became tearful when he/she spoke of soiling his/her pant. The resident stated during the incident he/she did not say anything to licensed nurse L because he/she feared it would make the situation worse. The resident showed the surveyor a picture of him/her with the abrasion sustained during the incident on night shift of 12/15/14 into 12/16/14. Observation revealed a prominent area on the resident's left forehead that appeared as a gash/abrasion that measured approximately 3 centimeters. On 5/13/15 at 9:20 A.M. administrative staff A stated the resident was upset by the incident and could still recall the incident. The facility failed to ensure Resident #12 had an environment free of abuse and fear when staff refused to assist the resident with care and caused resident to be fearful. - Resident #82's May 2015 Physician order [REDACTED]. A Minimum Data Set was not completed. The resident's temporary plan of care dated 5/5/15 included the resident required assistance of 2 staff for toileting and repositioning. The temporary care plan included the resident was always incontinent of urine. The care plan did not include a toileting program/schedule for the resident. On 5/11/15 at 11:41 A.M. during Stage 1 of the survey the resident stated staff did not treat him/her with dignity and respect. The resident stated his/her physician had told him/her to go to the bathroom every hour. The resident stated over the weekend he/she asked licensed nurse L to assist him/her to the bathroom and licensed nurse L stated never mind you just wait. The resident stated she also asked licensed nurse L to put powder on an area he/she had under his/her breast and licensed nurse stated he/she would do it when he/she got around to it. The resident stated he/she expressed the concern to administrative staff. On 5/12/15 at approximately 4:45 P.M. a staff stated the resident informed him/her on 5/11/15 that licensed nurse L refused to take him/her to the bathroom and also refused to place powder under his/her breast. The staff he/she related the concern to administration. On 5/13/15 at 9:15 A.M. administrative staff A stated he/she was aware of the concern. He/she also stated the facility had received other concerns in the past regarding licensed nurse L. Resident #82's May 2015 Physician order [REDACTED]. A Minimum Data Set was not completed. The resident's temporary plan of care dated 5/5/15 included the resident required assistance of 2 staff for toileting and repositioning. The temporary care plan included the resident was always incontinent of urine. The care plan did not include a toileting program/schedule for the resident. On 5/11/15 at 11:41 A.M. during Stage 1 of the survey the resident stated staff did not treat him/her with dignity and respect. The resident stated his/her physician had told him/her to go to the bathroom every hour. The resident stated over the weekend he/she asked licensed nurse L to assist him/her to the bathroom and licensed nurse L stated never mind you just wait. The resident stated she also asked licensed nurse L to put powder on an area he/she had under his/her breast and licensed nurse stated he/she would do it when he/she got around to it. The resident stated he/she expressed the concern to administrative staff. On 5/12/15 at approximately 4:45 P.M. a staff stated the resident informed him/her on 5/11/15 that licensed nurse L refused to take him/her to the bathroom and also refused to place powder under his/her breast. The staff he/she related the concern to administration. On 5/13/15 at 9:15 A.M. administrative staff A stated he/she was aware of the concern. He/she also stated the facility had received other concerns in the past regarding licensed nurse L. The facility failed to ensure Resident #82 had a safe environment free from abuse when staff refused to assist the resident with care making the Resident wait for toileting.

The facility had a census of 55 residents. The sample included 20 residents. Based upon observation, record review and interview the facility failed to develop and implement timely interventions to prevent the development and to promote healing of a pressure ulcer that worsened for 1 (#51) resident sampled for pressure ulcers. Findings included: - Resident #51's May 2015 Physician order [REDACTED]. The POS included the resident had received a multivitamin daily since 4/10/15, Zinc sulfate (dietary supplement) 220 milligrams (mg) daily, Vitamin C (dietary supplement) 500 mg twice a day (BID) and [MEDICATION NAME] ( a supplement used to aid in wound healing) daily for wound healing since 4/22/15. The resident's admission Minimum Data Set ((MDS) dated [DATE] identified the resident scored 13 (cognition intact), had no behaviors, required extensive staff assistance with bed mobility, dressing, transfers, toilet use and personal hygiene. The activity of walking in the room/corridor did not occur and the resident was totally dependent upon staff for locomotion on/off the unit. The MDS recorded the resident was always continent of urine, fell in the last 2 to 6 months prior to admission and sustained a fracture related to a fall in the 6 months prior to admission. The MDS identified the resident weighed 143 pounds and had not experienced a weight loss, was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, utilized a pressure relieving device in his/her chair and on his/her bed and was on a turning/repositioning program. The resident's 14 day Payment Prospective System (PPS) assessment dated [DATE] identified the resident had (1) Stage 3 pressure ulcer not present upon admission, the pressure ulcer measured 4.0 centimeters (cm) by 5.0 cm and identified slough (non-viable) as the most severe tissue type. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 4/20/15 documented the resident had impaired mobility and required extensive staff assistance with mobility, and ADL tasks. The resident had right side weakness and a flaccid right arm and required extensive staff assistance with dressing, toileting and personal cares. The resident's Nutritional CAA dated 4/20/15 included the resident received a mechanical soft diet. The resident's Pressure Ulcer CAA dated 4/20/15 documented the resident required staff assistance with bed mobility and repositioning. Staff repositioned the resident at least every 4 hours and as needed. The resident had Panacea (pressure reducing) mattress on his/her bed to help with pressure reduction. The resident had impaired mobility due to a recent surgery to repair his/her fractured right hip and the resident had a surgical wound. The resident was continent of urine and used a bed pan most of the time. The resident had [MEDICAL CONDITION], a [DIAGNOSES REDACTED]. The resident's Braden Scale (scale used to predict the development of pressure ulcers) dated 4/13/15 identified the resident scored 16 and was at a mild risk for the development of pressure ulcers. The resident's care plan dated 4/17/15 included the resident had pain related to a fracture with surgical repair, had a [DIAGNOSES REDACTED]. Staff monitored the resident for pedal [MEDICAL CONDITION] (swelling of the feet), monitored for numbness, coldness, tingling, skin breakdown, swelling or pain in his/her right leg and calf area. The resident was unable to transfer independently and utilized a mechanical lift for all transfers. The resident received a mechanical soft diet and the dietician evaluated the resident's nutritional status. The resident was at risk for the development of pressure ulcers related to impaired mobility and mild paralysis in his/her right arm. Staff repositioned the resident every 2 hours while awake and per resident request. Staff educated the resident on the risk factors for the development of pressure ulcers and required staff assistance with repositioning to avoid skin friction/shearing. Staff observed the resident's skin each day during routine care and notified the resident's physician/responsible party if the resident developed a pressure ulcer. All of the above interventions had an onset date of 4/17/15. Undated entries to the resident's care plan included the resident had a pressure ulcer on his/her right lower leg due to an immobilizer and the physician's orders [REDACTED]. The immobilizer was discontinued. The resident had a low air loss mattress and received Vitamin C 500 mg BID and Zinc 220 mg for 3 weeks. A hand written entry dated 4/15/15 included the resident received Keflex (antibiotic) 500 mg four times a day (QID) for 10 days. A hand written entry dated 4/24/15 included the resident utilized a pressure relief foam boot on his/her right foot when in bed or supine (lying on the back and the face up) to promote healing of the pressure ulcer. An entry dated 4/29/15 included the resident received [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (an antibiotic) every 24 hours for [MEDICAL CONDITION] (skin infection caused by bacteria characterized by heat, redness and swelling) of the wound. The resident's undated temporary care plan included the resident required assistance of 2 staff for transfers and required staff assistance with ADLs. The care plan included an entry dated 4/11/15 that the resident received physical therapy 5 times a week for 30 days. The temporary care plan did not include the resident was at risk for the development of pressure ulcer or interventions to minimize pressure. The resident's hospital transfer orders dated 4/10/15 included the resident had a right femur fracture, do not remove the immobilizer and to follow up with the orthopedic surgeon on 4/15/15. A nurse's note (NN) dated 4/16/15 timed 12:41 P.M. documented the resident had a small open blister area to the underside of his/her right lower extremity, staff cleansed the area and placed a dressing over the area. The note did not include any measurements of the wound or any description of the blister. Review of the nurse's notes for 4/17/15, 4/18/15, and 4/19/15 documented the resident had an ulcerated area on the back of his/her right lower extremity. The notes did not include measurements or description of the ulcerated area. A skin assessment dated [DATE] documented the dressing to the open blister was intact. There were no measurements or description included on the skin assessment regarding the blister. A skin assessment dated [DATE] documented the resident's right lower leg had an open area. No measurements or description of the area was included. A skin assessment dated [DATE] included staff performed a treatment on the resident's right lower calf. No measurements or description of the pressure ulcer was included. A skin assessment dated [DATE] documented the resident had a Stage 4 pressure ulcer on his/her right lower calf. A wound consultant report dated 4/20/15 included the resident had a cast and immobilizer and after removal the resident had a wound on the back of his/her right lower leg. The note included the wound was a Stage 3 pressure ulcer that measured 4.40 centimeters by 5.0 cm with a depth of 0.10 cm and 20% of the wound bed was yellow in color. A wound consultant report dated 4/27/15 included the Stage 3 pressure ulcer measured 4.5 cm by 5.8 cm with a depth of 0.10 cm. Twenty percent of the wound bed was yellow and 80% was black. A wound consultant report dated 5/4/15 included the Stage 3 pressure ulcer on the back of the resident's right lower leg measured 5.10 cm by 5.40 cm with a depth of 0.10 cm and 80% of the wound bed was yellow and 10% was black. A wound consultant report dated 5/11/15 documented the Stage 3 measured 4.60 cm by 5.80 with a depth of 0.10 and the wound bed was 80% yellow. An undated orthopedic surgeon progress note documented no more knee immobilizer; cover the wound with a dressing and to start the resident on Keflex 500 mg QID (four times a day) for 10 days and for the resident to follow up with the orthopedic surgeon on Monday. The orthopedic surgeon's progress note dated 4/22/15 documented the resident started on an antibiotic until the calf wound healed, range of motion to the resident knee, non-weight bearing and to follow up in 2 weeks. An undated orthopedic surgeon progress note documented the wound on the resident's right leg was worse, the resident needed to go to a wound center, needed to see an infectious disease physician and a plastic surgeon. The facility was to perform wet to dry treatment twice a day. The resident's primary care physician progress notes [REDACTED]. The resident's primary care physician's progress note dated 4/29/15 included the resident's upper right lower extremity wound had increased redness, heat and pain and the orthopedic surgeon started the resident on Keflex for possible surgical wound treatment. The pressure wound on the resident's lower right calf was a Stage 2. The resident's primary physician's progress note dated 5/7/15 documented the resident saw the orthopedic surgeon today and he/she was upset that the resident's lower extremity wound was worse than when he/she saw it 2 weeks ago. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. An Occupational Therapy (OT) note with a start of care (SOC) date of 4/13/15 and signed 4/27/15 documented the OT fabricated a pressure relief boot in order to allow a better option for off-loading pressure to the posterior/lateral (back/side away from the middle) aspect pressure ulcer on the resident's right ankle. An OT note with a date of service of 4/22/15 included the resident saw the orthopedic surgeon on 4/22/15 and nursing staff reported the resident had a Stage 3 pressure ulcer on the back of his/her right calf from the cast. OT provided the resident with a better fitting wheelchair and the resident reported increased comfort. A laboratory report dated 4/6/15 recorded the resident's total protein was at 5.9 grams/deciliter (g/dl) (normal reference range 6.5 to 8.2 g/dl and the resident's [MEDICATION NAME] was at 3.1 g/dl (normal reference range 3.5 to 4.8 g/dl). The resident's weight logs recorded the following weights: 04/10/15: 143 pounds 04/15/15: 137 pounds (6 pounds or 4.19 percent of his/her body weight) 04/22/15: 134 pounds (9 pounds or 6.29 percent of his/her body weight since 4/10/15) During this time frame the resident developed a pressure ulcer on the posterior aspect of his/her right leg and the pressure ulcer worsened. A Nutritional History/assessment dated [DATE] documented the resident weighed 134; the resident had a pressure ulcer on the posterior aspect of his/her right lower leg. The resident received [MEDICATION NAME] (a diuretic), a multivitamin, Vitamin C, Zinc, and [MEDICATION NAME]. The registered dietician (RD) did not make any recommendations. A RD progress note dated 5/8/15 documented the resident weighed 134 pounds, the resident's admission weight was 143 pounds and the resident had a 9 (6.2%) pound weight loss. The resident had [MEDICAL CONDITION] on admission and it was resolving. The resident had a pressure ulcer on his/her right lower leg. The RD spoke with the resident about supplements, the resident stated he/she had not tried 2 Cal, health shakes or fortified foods (nutritional supplements to increase calories and protein). The resident liked ice cream and the RD spoke with the charge nurse about implementing them. The RD recommended the resident receive a magic cup (high calorie dessert) at lunch each day and for staff to add fortified food to the resident's current diet. Review of the resident's clinical record lacked evidence the facility monitored the resident's right lower extremity from admission on 4/10/15 until 4/15/15. The clinical record also lacked evidence the facility measured, staged or thoroughly assessed the pressure ulcer from 4/15/15 until 4/20/15. The clinical record also lacked evidence the facility started nutritional interventions until 4/22/15 (7 days after staff were aware of the pressure ulcer). On 5/12/15 at 11:00 A.M. and 2:30 P.M., the resident sat in the recliner in his/her room. Observation revealed a dressing in place on the resident's right lower extremity, the resident had on slipper socks and no foam boot or other device was in place. Further observation revealed the posterior aspect of the resident right leg rested directly on the raised foot rest of the recliner. On 5/13/15 at 6:50 A.M. the resident laid in bed on his/her back. Observation revealed a foam boot and a blue positioning device with curved up edges on the floor in the resident's room. On 5/13/15 at approximately 8:45 A.M. licensed nurse H performed the treatment on he distal aspect of the resident's right lower leg. Observation revealed the resident had a Stage 3 pressure ulcer that measured approximately 4.5 cm by 6.0 cm and the wound bed contained approximately 80% yellow slough. On 5/13/15 at 10:30 A.M. the resident sat in the recliner in his/her room with a pillow under his/her legs. Observation revealed the pillow was not properly positioned and the distal aspect of the resident's right leg rested on the foot rest of the recliner. On 5/13/15 at 11:15 A.M. direct care staff R stated the resident had a pressure ulcer on the posterior aspect of his/her lower calf. He/she stated staff placed a pillow under the resident's legs when he/she sat in the recliner to keep the resident's leg off of the foot rest of the recliner. Direct care staff R stated resident wore the foam boot when he/she was in bed. He/she stated night shift staff reported during the middle of the night the resident asked staff to remove the boot. He/she confirmed the boot was not in place this A.M. when the resident was in bed. On 5/13/15 at 11:42 A.M. physician staff KK stated immobilizer shift during standing and transfers which caused friction on the extremity. Therefore, even though the admitting physician's orders [REDACTED]. He/she stated after the pressure ulcer was first observed the expectation would be that staff staged, measured and assessed the pressure ulcer. Physician staff KK stated the pressure ulcer worsened. On 5/13/15 at 12:31 P.M. licensed nurse H stated the immobilizer the resident wore prior to the development of the pressure ulcer was removable but the facility had strict physician's orders [REDACTED]. On 4/15/15 the orthopedic surgeon observed the pressure ulcer on the back of the resident right lower leg after he/she removed the immobilizer. Licensed nurse H stated he/she was not on duty that day, and that he/she documented on the pressure ulcer on 4/16/15. Licensed nurse H stated at that time the pressure ulcer looked like a sheared area and was probably a Stage 2. He/she stated after the development of the pressure ulcer, OT fabricated a boot for the resident to wear. The boot had a cut out in the bottom and staff placed a pillow under the resident's leg when he/she sat in the recliner to keep the area from resting on the foot rest of the recliner. Licensed nurse H stated the pressure ulcer worsened. He/she stated during that time the resident was not eating much which contributed to the healing of the wound. Licensed nurse H stated the facility implemented nutritional interventions after the development of the Stage 2 pressure ulcer. On 5/13/15 at 1:45 P.M. therapy consultant II stated he/she fabricated the foam boot after the development of the pressure ulcer. He/she stated the resident was to wear the foam boot when in bed and when in the supine position. Therapy consultant II stated staff was to place the blue curve up device under the resident's legs when he/she sat in the recliner. During interview on 5/13/15 at approximately 4:00 P.M. with administrative nursing staff D and E; administrative nursing staff D stated the admitting physician's orders [REDACTED]. He/she stated some physician's orders [REDACTED]. [REDACTED]. Administrative nursing staff D stated the wound consultant assessed the pressure ulcer on 4/20/15 and documented the pressure ulcer was a Stage 3. Administrative nursing staff D stated licensed nursing staff had assessed and documented on the pressure ulcer in the nurse's notes and on the skin assessment sheets since 4/16/15. The facility Pressure Ulcer Monitoring Policy and Procedure dated 4/04 included upon detection of a pressure ulcer and each week following licensed staff documented the location, size and depth, description, drainage, necrosis (dead tissue) of the ulcer. The policy and procedure did not include nutritional interventions. The facility failed to measure and adequately document on the pressure ulcer from 4/15/15 until 4/20/15. The facility failed to develop and implement timely interventions to prevent the development and promote healing of a pressure ulcer that worsened. The facility also failed to timely implement nutritional interventions after the development of the pressure ulcer.