Every finding on record at Clearwater Nursing & Rehabilitation Center

Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R)14, who the facility identified as at high risk for wandering. On 05/15/2026 at approximately 11:35 AM, R14 exited the unsecured smoking area in the facility parking lot after Certified Nurse Aide (CNA) M turned to assist another resident. At approximately 01:43 PM, Dietary Staff BB went to R14's room to pick up his lunch tray and identified that the resident was not in his room and had not eaten lunch. Dietary Staff BB notified other staff, and they began searching for R14 at 01:45 PM. At approximately 02:04 PM, staff located R14 approximately 0.8 miles from the facility and returned him to the facility without injuries. The weather outside at that time ranged from 82 degrees to 88 degrees Fahrenheit (F). While R14's actual route was unknown, the resident would have crossed multiple busy [NAME] streets and railroad tracks to reach his destination. The facility failed to ensure R14 received adequate supervision to prevent an elopement, which placed R14 in immediate jeopardy. Findings included:- R14's Electronic Medical Record (EMR) documented he had diagnoses of hallucinations (sensing things while awake that appear to be real, but the mind created), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R14's Quarterly Minimum Data Set (MDS) dated [DATE] documented R14 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The MDS documented R14 had no behaviors or wandering during the observation period. R14's Care Plan prior to the elopement noted R14 was able to ambulate in a wheelchair by self-propelling, and staff were to encourage use of the wheelchair due to R14's amputation (surgical removal) of his toes. Staff frequently observed R14 ambulating without his wheelchair, and his weight bearing status was unrestricted, initiated: 06/05/2025 and revised on 02/21/2026. R14's Care Plan noted R14 was an elopement risk/wanderer due to a history of attempts to leave the facility unattended, initiated and revised on 09/26/2025. The plan, dated 09/26/2025, instructed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. The section called Resident prefers: had nothing else listed. Another intervention, dated 09/26/2025, documented R14 had a WanderGuard applied to his wrist. R14's Elopement Care Plan, dated 05/22/2026, after the elopement, documented R14 was an elopement/risk due to history of attempts to leave the building. The care plan directed staff to distract R14 from wandering by offering pleasant diversions, structured activities, food, conversion, television, or books. The care plan documented R14 had a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) applied to his wrist. R14's Elopement Risk Assessment dated 03/26/26 documented a score of 18, indicating a high risk. A Communication with Family/NOK/POA note dated 05/15/26 documented the resident walked away from the facility while out on a smoke break with staff. Upon 14's return to the facility at 02:20 PM, staff performed a full head to toe assessment, and no trauma was noted. R14 had no complaints and denied any pain at the time. A 'Health Status Note dated 05/15/26 documented that upon R14's return to the facility, he was drinking a bottle of water. Staff performed a head-to-toe assessment, and no trauma was noted. The resident stated that he was hungry, and a sandwich and chips were given to him, along with a glass of water. The resident denied any pain. His face was red. The resident was taken into the dining room after he finished his sandwich and chips because he was still hungry. The resident ate some more food and then wanted to go to his room. Staff walked the resident to his room, where he laid down in his bed. The Facility Incident Report, documented on 05/15/26 at approximately 01:35 PM, CNA Q noted R14 was not at the nurse's station for a smoke break. CNA Q went to get R14, but he was not in his room. Around the same time, Certified Medication Aide (CMA) S went to give R14 his medication and noted he was not in his room. R14 usually received a room tray for lunch, and staff provided a room tray. Dietary Staff BB went to pick up R14's room tray at approximately 01:43 PM and noted the resident was not in his room and his food was untouched. Dietary Staff BB notified Administrative Nurse B at 01:43 PM, and staff initiated the Missing Resident Protocol. Administrative Nurse B notified Administrative Nurse D and Administrative Staff A. Multiple staff went to search outside at 01:45 PM. After searching (walking) the property, three staff members began driving around to look for R14. At the same time, Administrative Nurse D reviewed the cameras and noted that R14 went out for a smoke break with staff at approximately 11:35 AM. R14 was in the designated smoking area, which was in the parking lot, with other residents and CNA M. There were eight other residents in the smoking area during this time, and five of the eight residents needed supervision with smoking, while four other residents were independent with smoking. Two of the residents were cognitively impaired residents who required Wander Guards. R14 began walking towards the dietary door at 11:34 AM. CNA M turned her back to assist another resident and R14 continued walking through the parking lot towards the front door. He arrived at the front door at 11:35 AM and was seen on camera walking past the front door and heading west toward the church parking lot. At approximately 02:04 PM, he was located approximately 0.8 miles from the facility and transported back to the facility at approximately 02:10 PM. CNA M's Notarized Witness Statement, dated 05/15/26, documented that during a smoke break, R14 walked toward the door to be let inside, and CNA M pulled another resident backwards toward to the door. When CNA M got to the door, R14 was gone, and she thought someone had let him back inside. CNA M documented after staff realized R14 was not on the property, staff looked for him outside and eventually found him. CMA S's Notarized Witness Statement, dated 05/15/26, documented when she was passing medication around 01:35 PM, she went to R14's room to give him his medications, but he was not there. She asked the other aides where R14 might be and they responded, in his room. CMA S stated she informed them R14 was not in his room, and one of the other aides stated he might be down Hall 3 taking a nap. One of the CNA staff went down to look for him while another informed the charge nurse. CMA S documented the last time she observed R14 was around 10:30 to 11:00 AM at the smoke break before lunch. On 06/01/26 at 02:45 PM, observation revealed R14 ambulated down the 300 hall with a walker, dressed in street clothes to the activity room. Continued observation revealed R14 pushed on the exit door that led to the patio/gazabo area where the residents smoked (scheduled smoke break was scheduled for 03:00 PM). R14 pushed the door and after 15 seconds, the door lock released, and the door opened, which sounded an alarm. Staff responded and redirected R14 back inside, away from the door to wait until the 03:00 PM smoke break that was supervised by staff. On 06/01/26 at approximately 03:45 PM, observation of the area where R14 exited the facility revealed multiple busy [NAME] roads around and between the facility and the area where the resident was found had posted speeds up to 45 miles per hour (mph). Observation further revealed railroad tracks between the facility and the area where R14 was located. In an interview on 06/01/26 at 03:50 PM, CNA M stated she took the residents out for a smoke break, and when it was time to go in, she saw R14 walk toward the door to be let inside. She said she was pulling another resident backwards to the door, and when she got up to the door, R14 was gone and no longer outside. She said she thought he was let inside and went to lunch. In an interview on 06/01/26 at 03:45 PM, Dietary Staff CC said he was in his office eating his lunch when staff told him that they could not find R14. He said he did not have his truck, so his coworker gave him the keys to her car, and he went looking for him. Staff told him they saw on the camera R14 heading north. They went down one street with posted speeds of 35 mph, went over the railroad tracks, and saw R14 walking toward the local C0-op. He pulled down a little dirt driveway and asked R14 if he needed a ride, and R14 said he needed a ride to Wichita. Dietary Staff CC called other staff to where the resident was, and they loaded R14 into the car. Dietary Staff CC stated it was very hot outside, so when he got back, staff gave him fluids and food. On 06/01/26 at 01:45 PM, Administrative Nurse D stated the facility video camera footage revealed R14 was last seen on 05/15/26 at 11:34 AM outside in the parking lot /designated smoking area and was visualized on camera. She stated the camera revealed R14 exited from the unalarmed, unsecured smoking area. She said staff delivered a room tray to the resident's room at some point, but no one noticed the resident was missing until dietary staff went to pick up his room tray at 01:43 PM. Administrative Nurse D verified the resident was found at 02:04 PM and was transported back to the facility, with no injuries noted. Administrative Nurse D verified the resident had an elopement risk with cognitive impairment and should not have been unattended when he was outside. Administrative Nurse D verified the facility changed the location of the smoking area to the outdoor patio/gazabo area that was secured with a fence and exit doors that alarmed, and the resident continued to be monitored during smoke breaks. The facility's Wandering and Elopement policy, dated March 2025, documented the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. If an employee observes a resident leave the premises, he/she should. a. Attempt to prevent the residents from leaving in a courteous manner. b. get help from other staff members in the immediate vicinity, if necessary; and c. instructs another staff member to inform the charge nurse or director of nursing that a resident is attempting to leave. If a resident is missing, initiate the elopement/missing resident emergency procedure. a. Determine if the resident is out on an authorized leave or pass, b. If the resident was not authorized to leave, initiate a search of the building and premises; and c. If the resident is not located, notify the administrator, the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and as necessary, volunteer agencies like emergency management, rescue squads, etc.) When the resident returns to the facility, the director of nursing or charge nurse shall: a. Examine the resident for injuries. b. Contact the attending physician and report findings and conditions of the resident. c. Notify the resident's legal representative (sponsor). d. Notify the search teams that the resident has been located:e. Complete and file incident report; and f. Document relevant information in the resident's medical record. On 06/02/26 at 03:23 PM, Administrative Staff A and Administrative Nurse D received the Immediate Jeopardy [IJ] Template and were notified of the facility's failure to provide adequate supervision to prevent an elopement for R14 placed the resident in immediate jeopardy. The facility identified and implemented immediate corrective actions completed by 05/16/26, which included all staff in-service on meal protocols, smoking supervision and safety, and supervision of all residents. All residents had a new elopement assessment completed on 05/15/26. An elopement drill was conducted on 05/15/26 for the 06:00 PM- 06:00 AM, and 05/17/26 for the 06:00 AM-06:00 PM shift. The smoking area was moved to a secure courtyard on 05/15/26. All residents who smoked had an updated smoking assessment. All residents with Wander Guards were checked for functionality. Staff completed a trauma assessment for R14. Dietary began using the reconciliation form for each meal. Due to all corrective actions being completed before the onsite survey, the citation was deemed past noncompliance and existed at a J (isolated, immediate jeopardy) scope and severity.

Based on record review and interview, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Findings included:- Review of the Registered Nursing Staffing Schedule for March 2026, April 2026, and May 2026 revealed the facility lacked a Registered Nurse on the following dates:03/16/26,03/21/26 and 03/22/26.04/04/26 and 04/18/26.05/02/26, 05/03/26, 05/16/26, 05/23/26, 05/24/26 and 05/31/26. On 06/03/26 at 09:00 AM, Administrative Nurse D verified the facility did not have a Registered Nurse in the building for eight consecutive hours or working as a charge nurse for the above documented dates. The facility's Registered Nurse policy, dated January 2024, documented the facility would employ the services of an RN for at least eight consecutive hours a day, seven days a week. The facility would designate an RN to serve as the Director of Nursing (DON) on a full-time basis. The policy documented the DON may serve as a charge nurse only when the facility has an average daily census of 60 or fewer residents. The RN hours would be recorded and reported on staffing sheet and would be reported on the Payroll Based Journal (PBJ) reporting system. Per Facility Assessment, the facility may identify when the residents of the facility require the services of an RN for more than eight hours a day based on the acuity level of the resident population, The facility may choose a variety of hours of duty such as an eight hour or a twelve hour shift, but the facility would always ensure eight consecutive hours of RN service every day, seven days per week.

Based on record review and interview, the facility failed to provide regular in-service education based on the outcome of performance reviews and failed to ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk of impaired care. Findings Include:- The facility's employment records documented eleven nurse aides were employed at the facility for at least one year. The facility's in-service records documented that 5 of those nurses' aides reviewed had not completed the required 12 hours of in-service training in the past year.Certified Nurse Aide (CNA) N, hired 01/29/2024, lacked the required number of in-service hours and in-services based on performance evaluations. CNA O, hired 05/29/2025, lacked the required number of in-service hours and in-services based on performance evaluations.CNA P, hired 05/22/2025, lacked the required number of in-service hours and in-services based on performance evaluations.CNA Q, hired 02/24/2025, lacked the required number of in-service hours and in-services based on performance evaluations.Social Service Director (SSD) and CNA X, hired 10/13/2023, lacked the required number of in-service hours and in-service based on performance evaluations. On 06/03/25 at 09:30 AM, Administrative Nurse D stated she had been employed at the facility for approximately six weeks and was unable to find the documentation and failed to provide the hours needed by the nurse aide staff. The In-Service Training Program, Nurse Aide,, dated May 2021, documented all nurse aides would participate in regularly scheduled in-service training classes. The facility completes a performance review of nurse aides at least every 12 months. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses. Annual in-services:Ensure the continuing competencies of nurse aides.Are no less than 2 hours per employment year. Address areas of weakness as determined by the facility assessment.Addresses the special needs of the residents, as determined by the facility assessment.Include training that addresses the care of residents with cognitive impairment: and Include training in dementia management and abuse prevention. All in-service classes attended by the employee are entered on the prospective employee's Record of In-Service by the department supervisor or other persons as designated by the supervisor

Based on observation, interview, and record review, the facility failed to employ a full-time certified dietary manager for the 32 residents who resided in the facility and received meals from the facility kitchen. Findings included:- On 06/02/2026, a review of the noon meal consisted of pork loin, oven-roasted potatoes, carrots, and Jello parfait.On 06/02/2026 at 11:00 AM, observation revealed Dietary CC in the kitchen overseeing the preparation of the noon meal.On 06/01/2026 at 08:00 AM, Dietary CC stated he was not a Certified Dietary Manager (CDM) and had not been enrolled in any dietary certification classes.On 06/03/26 at 09:00 AM, Administrative Nurse D verified he was not certified and planned to enroll him in classes at the end of June.The facility's Food and Nutrition Services policy, dated 10/2021, documented the Food Services manager would be CDM certified or enrolled in an accredited CDM program and on pace for completion.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety, and failed to consistently document food temperatures, refrigerator and freezer temperatures, and the dish machine PPM (Parts Per Million-a unit of measure used to indicate the concentration of a chemical sanitizer in the wash or rinse water) sanitizer log. Findings included:- On 06/01/2026 at 08:00 AM, during the initial kitchen tour, the stove had dried food and a greasy substance down the side and front, and inside the oven door, layers of black, stuck-on crusty food substances. The burners on the stove had blackened food particles. The shelf with the pots and pans had dried food particles throughout the shelf. The walk-in freezer had several unbagged tater tot potatoes and other unknown food items on the floor. The microwave in the dining room was dirty on the inside, with dried orange colored substance stuck on the top and food particles on the bottom and sides. Under two of the sinks, a hand sink and a food preparation sink, were containers of dirty water from the pipes that had leaked.On 06/01/2026 at 08:15 AM, a review of the dining room refrigerator temperature log for May 2026 lacked documentation. The temperature was not taken during the following days:05/12/2026- Evening 05/20/2026- Evening05/21/2026- Morning and Evening05/22/2026- Morning and Evening05/23/2026- Evening 05/24/2026- Morning05/25/2026- Morning05/26/2026- Morning and Evening05/27/2026- Morning05/28/2026- Morning and Evening05/29/2026- Morning and Evening05/30/2026- Morning and Evening05/31/2026- Morning and EveningReview of the walk-in refrigerator temperature log for May 2026 lacked documentation. The temperature was not taken during the following days:05/14/2026- Evening 05/15/2026- Evening 05/16/2026- Morning and Evening05/172026- Morning and Evening05/18/2026- Morning and Evening05/19/2026- Evening 05/20/2026- Evening 05/21/5026- Evening 05/23/2026- Evening 05/24/2026- Morning and Evening05/25/2026- Morning05/27/2026- Evening 05/28/2026- Evening 05/29/2026- Morning and Evening05/30/2026- Morning and Evening05/31/2026- Morning and EveningReview of the walk-in freezer temperature log for May 2026 lacked documentation. The temperature was not taken during the following days:05/14/2026- Evening 05/15/2026- Morning and Evening05/16/2026- Morning and Evening05/172026- Morning and Evening05/18/2026- Morning and Evening05/19/2026- Evening 05/20/2026- Evening 05/21/5026- Evening 05/23/2026- Evening 05/24/2026- Morning and Evening05/25/2026- Morning05/27/2026- Evening 05/28/2026- Evening 05/29/2026- Morning and Evening05/30/2026- Morning and Evening05/31/2026- Morning and EveningOn 06/01/2026 at 08:15 AM, Dietary CC was asked for the daily meal temperature logs for May 2026. Dietary CC was unable to produce any of the logs except for five days in the month of May. Dietary CC was asked for the daily dish machine PPM sanitizer record log, and he was unable to provide any recent log. Dietary CC stated he had only been here for six weeks and had new staff. Dietary CC stated he was aware that the kitchen was not as clean as it should be. He stated it was everyone's responsibility to clean the kitchen. He stated he had talked with the administration to see if there was a day that they could cater in meals so that they could do a deep clean in the kitchen. Dietary CC further stated he would make sure staff were documenting temperatures for the food, refrigerators, and freezers.On 06/02/2026 at 11:30 AM, Dietary DD stated she used the precision chlorine test strips daily for the sanitizer. Observation revealed the test strips had expired in 05/2026.On 06/03/2026 at 09:33 AM, Maintenance U stated he was aware the pipes had leaked under the sink and had plans to fix them this week.The facility's Food Preparation and Service policy, dated 10/2021, documented that the temperatures of food held in steam tables are monitored throughout the meal by food and nutrition services staff. Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices.The facility's Refrigerator and Freezers policy, dated 10/2021, documented that the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and would observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers would be posted to record temperatures. Food Service Supervisors or designated employees would check the refrigerator and freezer temperatures daily upon first opening and at closing in the evening. Refrigerators and freezers would be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary.

Based on observation, record review, and interview, the facility failed to ensure their (QAA) Quality Assessment and Assurance Committee adequately identified deficient areas of practice and develop and implement appropriate plans of action to correct the deficient practices for the 68 residents residing in the facility. Findings included:- Based on observation, record review, and interview, the facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives of residents. Refer to F577. Based on observation, record review, and interview, the facility failed to provide a resident with written information regarding the facility's bed hold policy when they were transferred to the hospital. Refer to 628. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with instructions to staff on providing surgical wound cares for a resident. Refer to 656. Based on observation and record review, the facility failed to apply the standards of practice when staff intentionally documented that they had provided treatments to a resident though they had not actually provided the treatments. Refer to 658. Based on observation, record review and interview, the facility failed to apply the standards of practice as related to dependent edema when staff failed to wrap a resident's legs to decrease the edema (swelling resulting from an excessive accumulation of fluid in the body tissue) in his legs as ordered. Refer to 684. Based on observation, record review, and interview, the facility failed to provide adequate resident supervision for elopement. Refer to 689. Based on observation, record review, and interview, the facility failed to provide infection control practices with a resident who had a nebulizer and oxygen tubing that was left on the bed and not stored properly. Refer to 695. Based on observation, record review, and interview, the facility failed to ensure staff possessed the skills and competencies required when administering insulin to a resident. Refer to 726 Based on observation, record review, and interview, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Refer to 727 Based on observation, record review, and interview, the facility failed to provide regular in-service education based on the outcome of performance reviews and failed to ensure all nurse aides receive the required number of in-service training hours per year. Refer to 730. Based on observation, record review, and interview, the facility failed to label insulin when opened and when expired and failed to discard expired insulin pens. Refer to 761. Based on observation, record review, and interview, the facility failed to employ a certified Dietary Manager. Refer to 801. Based on observation, record review, and interview, the facility failed to consistently provide a nourishing evening snack. Refer to 809. Based on observation, record review, and interview, the facility failed to store, prepare and serve in the kitchen. Refer to 812. Based on observation, record review, and interview, the facility failed to follow the infection control program, lacked donning and doffing of personal protective equipment in an isolation room, and failed to properly clean an isolation room. Refer to 880. On [DATE] at 1:30 PM, Administrative Staff A stated the QAA meetings were held monthly and included the medical director. The facility's QAPI Plan, dated [DATE], documented the QAPI program would aim for safety and high quality with all clinical interventions and services delivered while emphasizing autonomy, choices, and quality of daily life for residents and family by ensuring the data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. The facility would utilize the best available evidence, national benchmarks, published best practices, and clinical guidelines to define and ensure the facility goals. The plan documented at least annually or as needed, the QAPI Self-Assessment would be conducted. The assessment would be completed with the input from the entire QAPI team and organizational leadership. The result of the assessment would direct the facility to areas that needed to be worked on in order to establish and improve QAPI programs and processes in the organization. The annual facility assessment would be conducted to identify gaps in care and service delivery in order to provide necessary services. The items would be considered in the development and implementation of the QAPI plan.

Based on interview, and record review, the facility failed to consistently provide a nourishing evening snack to the 33 residents, who resided in the facility, 11 of whom have diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). Findings included:- On 06/02/2026 at 11:00 AM, during the resident council meeting, Resident (R) 18 and R22, stated they were diabetic and did not always have snacks available at night. They stated that they used to have them at the nurse's station, but some residents were taking too many, and others would not receive one. Both residents stated there were no sandwiches available if they wanted one, just apples, bananas, fig bars, and cheese crackers.On 06/02/2026 at 1130 AM, Dietary CC stated that he was working on a better selection of snacks for the residents during the evening. Dietary CC stated that right now, he had Jell-O, pudding, and Cheetos that residents could have. He wanted to get a cabinet that they could lock up snacks that only staff could hand out. Dietary CC further stated that he planned to provide different sandwiches for the residents and verified that he had not consistently provided protein snacks for the residents with DM. He stated that residents can ask for sandwiches when dietary staff are in the building, and before dietary staff leave the building, the staff are given the evening snacks for the residents.On 06/02/2026 at 02:15 PM, Licensed Nurse (LN) G stated that dietary staff bring the evening snacks, which are kept in a container underneath the nurses' station and are given to residents if they ask.On 06/03/2026 at 09:00 AM, Administrative Nurse D stated there were residents who would take a bunch of the snacks, and it did not leave enough for other residents. Some residents had asked for grilled cheese sandwiches late at night, and the dietary staff was already gone for the night. Dietary CC was working on a plan to make sure there were enough sandwiches and snacks for all the residents, and they planned to put a lock on a cabinet and a lock on the refrigerator for the cold items, like different sandwiches.The facility's Food and Nutrition Services policy, dated 10/2021, documented nourishing snacks are available to the residents 24 hours a day. The residents may request snacks as desired, or snacks may be scheduled between meals to accommodate the residents' typical eating patterns.

Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to change gloves and wash hands during incontinence care for Resident (R) 42. Staff also failed to store R12's breathing treatment mask and tubing in a sanitary manner. Findings included:1. On 06/01/26 at 10:00 AM, observation revealed R42 rested in bed on his back. Certified Nurse Aide (CNA) N and CNA O donned a gown and applied gloves and entered R42's room. R42 reported to the CNAs that he needed incontinence care due to having a bowel movement. CNA O gathered supplies, while CNA N pulled down the resident's pants and instructed him to turn onto his left side. Further observation revealed CNA N pulled down the brief in the back to reveal a moderate amount of stool covering the backside and his wound dressing area. CNA N removed the brief and dressing and provided peri-care to R42's buttock area, then instructed R42 to turn on his back. Further observation revealed CNA O provided peri-care to the residents' front peri area (private area) with the same soiled gloves, and then wearing the same gloves, placed a new incontinent brief underneath the resident and fastened it. The CNAs then removed and discarded the gloves. Observation revealed that both CNAs applied new gloves and assisted R42 in pulling up his pants, then doffed their gowns with gloves, placed them in a plastic bag, CNA O tied the bag, and both CNAs left the resident's room without washing their hands or using hand sanitizer. On 06/01/26 at 10:20 AM, CNA N verified that she had not changed gloves or washed her hands after providing incontinent care for R42 and stated that she usually washes her hands when entering another resident's room to provide care. 2. On 06/02/26 at 10:14 AM, observation revealed R12's breathing machine mask and tubing lying on the floor by a recliner, on top of a blue cloth bag, uncovered. Licensed Nurse (LN) G verified the finding and asked R12 where the plastic bag was for the mask and tubing, and the resident did not answer. LN G laid the uncovered mask on top of an end table, stated she would get a bag and take care of the mask and tubing, and left the room. On 06/03/26 at 08:51 AM, Administrative Nurse D stated she expected staff to store a resident's breathing treatment, a mask, and tubing in a bag. Administrative Nurse D stated she would expect staff to change gloves when providing incontinent care after dirty, and before they place a new incontinent brief on, and staff should wash their hands before and after providing care. The facility's Administration of Oxygen Policy, undated, instructed staff to store equipment in a dated plastic bag and leave it at the bedside.The facility's Handwashing/Hand Hygiene Policy, undated, instructed staff to use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:Before and after coming on duty.B. Before and after direct contact with residents.Before preparing or handling medications.Before performing a non-surgical invasive procedure.Before performing a non-surgical invasive procedure.Before donning sterile gloves.Before handling clean or soiled dressings, gauze pads, etc.Before moving from a contaminated body site to a clean body site during resident care.After contact with a resident's intact skin.After contact with blood or bodily fluids.After handling used dressings, contaminated equipment, etc.After contact with objects (medical equipment) in the immediate vicinity of the resident.After removing gloves.Before and after entering isolation precautions settings

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with instructions to staff on providing surgical wound cares for Resident (R) 46. Findings included:- R34's Electronic Medical Record (EMR) documented he had a diagnosis of mastoiditis (serious bacterial infection of the skull just behind and below the ear). R34's admission Minimum Data Set (MDS), dated [DATE], documented R34 as a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented R34 required supervision with most activities of daily living (ADLs). The MDS documented that the resident had surgical wounds and received surgical wound care. The Care Area Assessment, CAA, dated 05/04/26, documented Resident triggered for potential skin breakdown d/t supervision needed to maintain ADL function. Surgical wound care and had a diagnosis of osteomyelitis (local or generalized infection of the bone and bone marrow)R34's Care Plan, revised 05/20/26, acknowledged information regarding the resident's surgical wounds. The plan lacked instructions to staff on how to care for R34's surgical wounds.On 06/03/26 at 02:00 PM, observation revealed R34 sat in a wheelchair in the therapy room with a dressing on the top of his head and behind his left ear.The Nurse's Note, dated 04/29/26, documented R34 admitted to the facility from the hospital. He had removal of squamous cell carcinoma (slow-growing type of cancer) a few months ago with flap and skin graft failure. R34 was then brought back to the hospital for debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) of the scalp wound and closure with split-thickness skin graft (part of skin implanted to cover areas where skin was lost through burns or injury) and muscular cutaneous flap (surgical reconstructive technique that transfers a block of tissue consisting of an underlying muscle, its overlying skin, and the fat between them. He had also developed osteomyelitis and mastoiditis. On 06/02/26 at 09:25 AM, Licensed Nurse (LN) G verified that the skin integrity section of the care plan lacked interventions or instructions for staff on how to care for his wounds. LN G stated she goes by R34's care instructions on the Treatment Administration Record (TAR). LN G stated that if an agency nurse worked at the facility, she could see how the nurse would not know how to care for R34's wounds by looking at his care plan.On 06/02/26 at 01:00 PM, Administrative Nurse E verified R34's verified R34's skin integrity section in his care plan lacked instructions to staff on how to care for his surgical wounds, and they should be on it.

Based on observation, interview, and record review, the facility failed to label Resident (R)6 insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired and failed to discard R43's insulin flex pen that had expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included:- On [DATE] at 08:30 AM, observation of the facility's treatment cart revealed the following:R6's Humalog (fast-acting insulin) FlexPen was not labeled with an open date or an expired date.R43's Lantus (long-acting insulin) flex pen was labeled with an opened date of [DATE] and an expired date of [DATE]. On [DATE] at 08:15 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and discard the expired insulin flex pens. Medlineplus.gov directs open, unrefrigerated Humalog and Lantus can be used within 28 days; after that time, they must be discarded. The facility's Administering Medications policy, dated [DATE], documented medications are administered in a safe and timely manner, and as prescribed. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi dose container, the date is recorded on the container. Insulin pens containing multi dose of insulin are for single-resident use only. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies the correct pen is used for that resident. The expiration beyond use date on the medication label is checked prior to administering. When opening a multi-use container, the date is recorded on the container.

Based on observation, record review, and interview, the facility failed to provide infection control practices for Resident (R)16, when staff left her nebulizer mouthpiece (a device that changes liquid medication into a mist easily inhaled into the lungs) on the bed and left her BIPAP (-Bilevel Positive Airway Pressure is a noninvasive ventilation device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) tubing, that was unattached from the oxygen concentrator (medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen), directly on the floor. Findings included:- R16's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and pleural effusion (abnormal accumulation of fluid in the lungs).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition. R16 was dependent upon staff for all activities of daily living. R16 had shortness of breath (SOB) with exertion, at rest, and when lying flat. R16 required the use of oxygen therapy and used a non-invasive mechanical ventilator daily.R16's 05/13/2026 Care Plan included the following interventions for R16:11/03/2025- Assist R16, family, and caregivers in learning signs of respiratory compromise, encourage sustained deep breaths, and ask her to yawn, maintain a clear airway by encouraging her to clear her own secretions with effective coughing. Monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor her breath patterns and report any abnormalities to the physician, position her with proper body alignment for optimal breathing patterns, and administer medication as ordered. R16's care plan directed staff to ensure her Bipap settings as ordered and was on continuous oxygen at 3 liters (L) per nasal cannula (a lightweight, flexible medical device used to deliver supplemental oxygen directly into the nostrils).The Physician's Order, dated 03/16/26, directed staff to administer 1 ipratropium-albuterol solution (a sterile inhalation solution), 0.5-2.5 (3) milligram (mg)/3 milliliter (ml) nebulizer treatment every four hours for SOB.On 06/01/2026 at 10:16 AM, R16's nebulizer mouthpiece was lying on the bed next to her. R16's BIPAP tubing was disconnected from the oxygen concentrator and was lying on the floor unbagged.On 06/02/2026 at 09:15 AM, R16's nebulizer mouthpiece was lying on the bed next to her. R16's BIPAP tubing was disconnected from the oxygen concentrator and was lying on the floor unbagged.On 06/03/2026 at 07:00 AM, R16's nebulizer mouthpiece was lying on the bed next to her. R16's BIPAP tubing was disconnected from the oxygen concentrator and was lying on the floor unbagged.On 06/02/2026 at 09:00 AM, Certified Medication Aide (CMA) R verified the tubing should be in the bags provided.On 06/03/2026 at 07:30 AM, Administrative Nurse D stated the tubing from the BiPAP should be placed in the bag that was on the oxygen concentrator. Administrative Nurse D further stated R16 liked to have the nebulizer mouthpiece lying next to her on the bed and stated she would make sure that R16's preferences were on the care plan.The facility's Administration of Oxygen undated policy, documented staff are to store all nebulizer masks and tubing in labeled and dated plastic bags.

Based on observation, record review, and interview, the facility failed to apply the standards of practice as related to dependent edema when staff failed to wrap Resident (R) 39's legs to decrease the edema (swelling resulting from an excessive accumulation of fluid in the body tissue) in his legs as ordered. Findings included:- R39's Electronic Medical Record (EMR) documented diagnoses of edema, heart failure (a condition with low heart output and the body becomes congested with fluid), and urinary retention (lack of ability to urinate and empty the bladder).R39's admission Minimum Data Set (MDS), dated [DATE], documented R39 had intact cognition. R39 was independent with toileting hygiene, personal hygiene, transfers, and mobility. The MDS further documented R39 had lower functional impairment on both sides and received diuretic (a medication to promote the formation and excretion of urine) medication daily.The Quarterly MDS, dated 03/19/2026, documented R39 had intact cognition. R39 was independent in toileting, personal hygiene, and mobility. The MDS further documented R39 had lower functional impairment on both sides, required supervision with transfers, and received diuretic medication daily.R39's 04/14/2026 Care Plan included the following interventions for R39:10/23/2025- Inspect R39's skin daily with cares, administer medications as ordered, monitor and report any pertinent laboratory results to the physician, monitor vital signs as ordered, and notify the physician of any abnormalities. Monitor, document, and report as needed any signs of dependent edema in the legs and feet. The care plan lacked direction to the staff regarding wrapping his legs with Ace wraps (a stretchable cloth wrap designed to provide localized pressure, reduce swelling, and support weak or injured muscles and joints) or that R39 refused the wraps.The Physician Order, dated 09/27/2025, directed staff to administer spironolactone (a diuretic medication), 50 milligrams (m), by mouth, daily for edema.The Physician Order, dated 12/08/2025, directed staff to apply Ace wraps up to mid-thigh (the section of the lower limb that extends between the hip and the knee) in the morning and remove at bedtime.The Treatment Administration Record, dated May 2025, documented that staff applied the Ace wraps on the following days:05/01/202605/06/202605/11/202605/20/202605/21/202605/25/2026The Nurse's Notes for the above dates documented that R39 did not have the wraps when they went to remove them or that R39 had refused them.The Treatment Administration Record, dated June 2026, documented that staff applied the Ace wraps on the following days:06/01/202606/02/2026On 06/01/26 at 10:21 AM, R39 had on gripper socks and did not have on the Ace wraps as ordered. R39 stated that he was to have his legs wrapped every day, but that it rarely happened unless he reminded them to do it.On 06/01/26 at 03:00 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered.On 06/02/26 at 01:50 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered.On 06/02/2026 at 02:13 PM, Licensed Nurse (LN) G stated that staff tried to get R39 to wear the wraps every day, but he would refuse. LN G stated that she had charted that she had applied the Ace write the last two days and verified that R39 had not had them on. LN G asked if she should go in and change the charting, then said she would go to R39 and offer to put on the Ace wraps.On 06/03/2026 at 09:00 AM, Administrative Nurse D stated that if R39 did not want the Ace wraps, staff are to document that he refused and should not document that they were applied when they weren't.The facility's Quality of Care policy, dated 10/2021, documented that the facility was committed to providing high-quality care and services to residents in a safe, respectful, and person-centered environment. The facility ensured all residents received the highest standard of care, promoting each resident's physical, emotional, social, and psychosocial well-being and aiding in fostering a culture of continuous improvement and helping guide staff to deliver exceptional care to all residents.

Based on observation, record review, and interview, the facility failed to apply the standards of practice when staff intentionally documented that they had provided treatments to Resident (R) 39, though they had not actually provided the treatments. Findings included:- R39's Electronic Medical Record (EMR) documented diagnoses of edema, heart failure (a condition with low heart output and the body becomes congested with fluid), and urinary retention (lack of ability to urinate and empty the bladder). The Quarterly MDS, dated 03/19/2026, documented R39 had intact cognition. R39 was independent in toileting, personal hygiene, and mobility. The MDS further documented R39 had lower functional impairment on both sides, required supervision with transfers, and received diuretic medication daily. R39's 04/14/2026 Care Plan included the following interventions for R39: 10/23/2025- Inspect R39's skin daily with cares, administer medications as ordered, monitor and report any pertinent laboratory results to the physician, monitor vital signs as ordered, and notify the physician of any abnormalities. Monitor, document, and report as needed any signs of dependent edema in the legs and feet. The care plan lacked direction to the staff regarding wrapping his legs with Ace wraps (a stretchable cloth wrap designed to provide localized pressure, reduce swelling, and support weak or injured muscles and joints) or that R39 refused the wraps. The Physician Order, dated 12/08/2025, directed staff to apply Ace wraps up to mid-thigh (the section of the lower limb that extends between the hip and the knee) in the morning and remove at bedtime. The Treatment Administration Record, dated June 2026, documented that staff applied the Ace wraps on the following days:06/01/202606/02/2026 On 06/01/2026 at 10:21 AM, R39 had on gripper socks and did not have on the Ace wraps as ordered. R39 stated that he was to have his legs wrapped every day, but that it rarely happened unless he reminded them to do it. On 06/01/2026 at 03:00 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered. On 06/02/2026 at 01:50 PM, R39 had on gripper socks and did not have on the Ace wraps as ordered. On 06/02/2026 at 02:13 PM, Licensed Nurse (LN) G stated that staff tried to get R39 to wear the wraps every day, but he would refuse. LN G stated that she had charted that she had applied the Ace write the last two days and verified that R39 had not had them on. LN G asked if she should go in and change the charting, then said she would go to R39 and offer to put on the Ace wraps. On 06/03/2026 at 09:00 AM, Administrative Nurse D stated that if R39 did not want the Ace wraps, staff are to document that he refused and should not document that they were applied when they were not. The facility's Quality of Care policy, dated 10/2021, documented that the facility was committed to providing high-quality care and services to residents in a safe, respectful, and person-centered environment. The facility staff members would be highly trained, qualified, and dedicated to providing compassionate care.

Based on observation, record review, and interview, the facility failed to provide Resident (R) 22, with written information regarding the facility's bed hold policy when they were transferred to the hospital. Findings included: - The Electronic Medical Record (EMR) for R22 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin,) 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,) chronic respiratory failure (a long-term condition where the respiratory system struggles to adequately exchange oxygen and carbon dioxide, leading to dangerous low oxygen or high carbon dioxide levels in the blood,) hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood,) and syncope (fainting or passing out). R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R22 was dependent upon staff assistance for toileting hygiene, personal hygiene, and to shower/bathe herself. R22's Care Plan, dated 06/03/25, directed staff to monitor and report any signs or symptoms of coronary artery disease, chest pain or pressure, especially with activity, heartburn, nausea and vomiting, shortness of breath, and excessive sweating due to R22's altered cardiovascular status. R22's Progress Notes dated 02/07/26 at 12:44 PM, documented R22 complained of chest pain and shortness of air. R22 was alert and oriented. Staff obtained vital signs, and her blood pressure was 147/98 millimeters (mm) of mercury (Hg) and her pulse was 111 beats per minute. Emergency Medical Services transported R22 to the hospital for further evaluation and treatment. R22's Progress Notes dated 02/07/26 at 04:46 PM, documented R22 was admitted to the hospital for observation. R22's clinical record lacked evidence that a copy of the bed hold policy was provided to the resident or representative when she was transferred to the hospital. On 06/01/26 at 11:10 AM, observation revealed R22 lying in bed. On 06/02/26 at 10:00 AM, Administrative Nurse D verified R22 did not have a bed hold in her records and stated they should have had a bed hold notice provided to R22 and her responsible party. The facility's Bed Hold policy undated, documented before the facility transfers a resident to the hospital the resident goes or therapeutic leave, the facility would provide written information to the resident and/or resident representative that specifies the duration of the state bed-hold policy during which the resident is permitted to return and resume residency in the facility. The reserve bed payment policy in the state plan; the facility's policies regarding bed-hold period, which are consistent with the law permitting the resident to return. All information provided to a resident and/or representative requires a signature of receipt of the policy by the resident and/or representative, including bed hold information provided at the time of admission and bed hold information provided at the time of discharge/transfer related to hospitalization and/or therapeutic leave.

Based on observation, record review, and interview, the facility failed to ensure staff possessed the skills and competencies required when Licensed Nurse (LN) G failed to prime a Humalog (rapid-acting hormone that lowers the level of glucose in your blood) Kwik Pen (a pre-filled, disposable insulin injection device). prior to administration to Resident (R)19. Findings included:- On 06/02/2026 at 10:13 AM, R19 ambulated in the hall with a walker. LN G asked R19 if she was ready to receive her insulin, and R19 replied yes and entered her room. LN G followed her in with a plastic container that held a Humalog, 100 UNIT/milliliter (ml) [NAME] Pen, LN G clicked up seven units of insulin in the pen, then, without priming the pen (a procedure which removes the air from the needle and cartridge that may collect during normal use, ensuring that the pen is working correctly), administered the insulin in R19's left arm. LN G verified she had not primed the insulin and stated she was unaware she was supposed to. Upon request, the facility was unable to provide LN G's nursing skills check sheet.Review of a blank nursing skills check: medication pass check sheet revealed a lack of competency assessment regarding priming an insulin Kwik Pen. The Insulin Kwik Pen Instructions Pamphlet instructed staff to prime an insulin Kwik Pen before each injection. Priming your pen means. the pamphlet documented to prime a pen, turn the dose knob to select 2 units, hold your pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, continue holding your pen with the needle pointing up, push the dose know in until it stops, and 0 is seen in the dose window. Hold the dose in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps no more than 4 times. If you still do not see insulin, change the needle and repeat priming steps 6 to 8 times. On 06/03/2026 at 08:51 AM, Administrative Nurse D stated she expected staff to prime the insulin pen with two units of insulin before administering it to a resident. Administrative Nurse D stated that upon hire, nurses had to perform a competency check-off on insulin. On 06/03/26 at 09:50 AM, Administrative Nurse D verified that the nursing skills check lacked a competency check regarding priming an insulin kwikpen. Administrative Nurse D stated she could not find LN G's nursing skills check sheet. The facility's Competency of Nursing Staff Policy, undated, documented that the facility and resident -specific competency evaluations would be conducted upon hire, annually, and deemed necessary based on the facility assessment. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.

Based on observation, record review, and interviews, the facility failed to post the results of the most recent surveys in a place readily accessible to residents, family members, and legal representatives of residents. Findings included:- On 06/01/26 and 06/02/26, observation revealed the facility lacked a readily accessible posting regarding where the most recent survey results could be found.On 06/02/26 at 12:20 PM, when asked where the most recent survey was, Nurse Consultant CC found the most recent survey in a black binder located on the front reception desk without a sign notifying residents, family members, and representatives where the results were located. Nurse Consultant CC stated the facility should have a sign to indicate where the survey results were located so residents, family members, or residents' representatives could view them.The facility's Survey Results, Examination of Policy, revised October 2021, documented copies of survey results are maintained in the administrative office. A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state-approved plans of correction of noted deficiencies, would be maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room.

The facility had a census of 40 residents. Based on observation, interview, and record review, the facility failed to provide supervision, treatment, services, and physical well-being for Resident (R) 2, who had dementia (a progressive mental disorder characterized by failing memory and confusion) with intrusive wandering behaviors by going into R6, R4, R3, and R5's rooms uninvited. Findings included:R2's Electronic Medical Record (EMR) documented diagnoses of dementia, hypertension (high blood pressure), and unspecified protein-calorie malnutrition. R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R2 had severe cognitive impairment, physical behavioral symptoms directed toward others, which occurred one to three days of the look back period, and wandered four to six days of the look back period. R2 used a wheelchair for mobility, was dependent with toileting, showering, and putting on and taking off footwear, required substantial/maximal assistance with upper and lower body dressing, lying to sitting on the side of the bed, chair/bed-to-chair transfers, and was dependent with sit-to -stand. Frequently incontinent of urine and always incontinent of bowel. The MDS further documented that R1 had a condition or chronic disease that may result in a life expectancy of less than six months, two or more noninjury falls, and was taking an antidepressant. The Behavioral Symptoms Care Area Assessment (CAA), dated 07/29/25, documented that R2 had a diagnosis of Alzheimer's disease, wandered, and had a wander guard in place. The CAA documented staff to redirect R1 as needed with cues and assistance. R2's Care Plan dated 01/16/26, documented that R2 had the potential to be physically aggressive related to dementia. The Care Plan directed staff to administer medications as ordered, monitor for side effects, assess and address contributing sensory deficits, assess the anticipated needs for food, thirst, toileting needs, comfort level, and body positioning. R2 tolerated small groups of people at a time and needed personal space when agitated. The Care Plan documented R2 triggers for physical aggression due to abrupt approaches and behaviors, which are de-escalated by distraction, redirection, and offering a snack. Document observed behavior and attempt intervention on the behavior log. When R2 becomes agitated, intervene before agitation escalates, guide away from the source of distress, and engage calmly in conversation. If the resident is aggressive, staff should walk calmly away and approach later. The Progress Note dated 02/15/26 at 02:50 PM, documented that the Registered Nurse (RN) was notified that R2 had been hit in the face by another resident. R2 was assessed for injuries. On 03/23/26 at 11:00 AM, R6 stated R2 had entered her room wearing only a diaper, and R6 had to tell him to get out. On 03/24/26 at 10:00 AM, R4 reported R2 would come into her room in a wheelchair, and she would get out of bed and push him out of the room to get R2 to leave. On 03/24/26 at 12:40 PM, R5 lay in bed with the bed in high position. R3 reported the bed in a high position so that R2 could not get into the bed, because R2 had tried to do so, and R2 does not always leave the room when told to leave. R5 also reported waking up at 05:00 AM, and R2 was touching her foot. On 03/24/26 at 09:00 AM, Certified Nurse Aide (CNA) M stated that when R2 went into another resident's room, staff assisted R2 out, directed R2 to follow staff out of the room, which was not R2's room, and provided fluids. On 03/24/26 at 09:04 AM, Licensed Nurse (LN) G reported R2 wandered, and usually stayed on one hall and the dining room, but when R2 went into another room, the staff would go in and take R2 out of the room. On 03/24/26 at 11:54 AM, R3 heard yelling for help. Therapy and other staff went to the room, and R2 was in the room. Staff redirected R2 out of the room. R3 stated she was all right, and R1 did not always leave when told to. On 03/24/26 at 11:54 AM, Certified Medication Aide (CMA) R reported trying to catch and redirect R2 when heading into other resident rooms. Staff offer snacks and soda. On 03/24/26 at 12:39 PM, Social Service X reported spending one-on-one time, talking, offering cookies, and having R2 assist with handing out papers. R2 would not stay at activities and on the go but could change from day to day. The facility's undated Dementia -Clinical Protocol policy documented that the staff and physicians will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes. The interdisciplinary team (IDT) will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. The IDT will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in the resident's family wishes, and other relevant factors.

The facility had a census of 40 residents. The sample included three residents reviewed for medications. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 1 who did not receive medications as ordered Additionally, the facility failed to notify the physician of the error. Findings included:- R1's Electronic Medical Records (EMR), documented diagnoses which included wound infection, osteomyelitis (local or generalized infection of the bone and bone marrow), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), renal failure (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R1's 02/24/26 Medicare -5 Day Minimum Data Set (MDS) documented R1 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R1 had an infection of the foot and a diabetic ulcer. R1 took an antibiotic and intravenous (IV- administered directly into the bloodstream via a vein) medications. R1 had a diagnosis of a wound infection. R1's Care Plan dated 93/23/26, documented R1 had Methicillin-resistant Staphylococcus aureus (MRSA- a type of bacteria resistant to many antibiotics) in his right heel wound. The care plan directed staff to give antibiotic therapy as ordered. The Discharge Instructions dated 02/18/26 documented an order for Daptomycin Intravenous Solution Reconstituted (IV antibiotic) 500 milligrams (mg) intravenously and directed to see an outpatient antibiotic order. The Discharge Instructions dated 02/18/26 documented an order for Piperacillin Sod-Tazobactam So (an antibiotic) Solution Reconstituted 4 grams (g)-0.5 g/100 milliliter (ml). See the outpatient antibiotic order. R1's Preliminary Report documented an Infectious Disease (ID) Outpatient Antibiotic Order dated 02/17/26 for Daptomycin Intravenous Solution Reconstituted 750 mg intravenously every 48 hours until 03/14/26. Piperacillin Sod-Tazobactam Solution (IV antibiotic) Reconstituted 4.5 g intravenously two times a day for infection until 03/14/26. The report also documented a diagnosis of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) likely due to a right heel wound, right heel necrotic (pertaining to the death of tissue in response to disease or injury) wound and palpable (a physical examination using touch) bone on a diabetic patient, and right leg wounds and cellulitis (skin infection caused by bacteria). The Preliminary Report documented an Infectious Disease (ID) Outpatient Antibiotic Order, which documented the antibiotic order above was for the first two weeks after dismissal from the hospital. Further antibiotic orders will be from ID clinic after the first appointment. R1's note from Infectious Disease Consultants, P.A dated 02/28/26 documented R1 went to an appointment on 02/28/26. At that time, the ID provider provided the staff the Final Report ID Outpatient Antibiotic Order dated 02/17/26. This order was different than the previous order, and the facility was directed to use the new order. Daptomycin Intravenous Solution Reconstituted 750 mg intravenously every 24 hours until 03/17/26. Piperacillin Sod-Tazobactam Solution Reconstituted 4.5 g intravenously every eight hours for infection until 03/17/26. R1's Electronic Medication Administration Record (EMAR) for February and March 2026 documented and ordered Piperacillin Sod-Tazobactam Solution Reconstituted 4.5 g intravenously two times a day for infection; started on 02/18/26. This order was not discontinued until 03/05/26 after R1 went to the hospital. R1's EMAR for February and March 2026 documented an order for Daptomycin Intravenous Solution Reconstituted 750 mg intravenously every 48 hours until for infection; started on 02/18/26. This order was not discontinued until 03/05/26 after R1 went to the hospital. R1's note from Infectious Disease Consultants, P.A documented he returned to the office for a follow-up visit on 03/05/26. At that time, the provider noted R1 did not receive the corrected medication frequency of either medication. The provider also noted the peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) line dressing, which was to be changed weekly, and when needed, was loose and had not been changed since 02/17/26. And the PICC line clave connector (sterilizable connector attached to the end of each lumen of a PICC line to allow for needle-free administration of fluids and medication. They are designed to prevent infection, often used with disinfecting caps, and typically changed weekly using sterile technique, involving clamping the lumen and scrubbing the hub.) The doctor was notified, and the PICC line was taken out because it had been exposed for an unknown amount of time, and the patient is at a high risk for developing a central line-associated bloodstream infection. R1 was sent to the hospital for worsening wounds and concern for blood infection. On 03/23/26 at 08:52 AM, R1 sat in his wheelchair beside his bed watching television. Licensed Nurse (LN) G entered the room and washed her hands. LN G donned her gloves and opened the flush. R1 wore a long-sleeved tight shirt, so the dressing could not be visualized. R1's sleeve could be pushed up to expose the end of the PICC lumen. LN G cleaned the Clave connector with an alcohol pad and flushed the port with normal saline. LN G obtained the IV line and attached it to the Clave. LN G checked the IV bag and programmed the IV pump to run for one hour. On 03/23/26 at 02:44 PM, LN G stated when a resident returned from an appointment, the nurse should look at the information from the provider and change the orders as needed. On 03/23/26 at 02:53 PM, Administrative Nurse D stated the charge nurse on duty should have updated the order when R1 returned from the appointment. Administrative Nurse D said she has reeducated the nurses that this is the expectation and started calling ID weekly to prevent any future problems. The facility's undated policy, Medication and Treatment Orders, documented medications will be consistent with principles of safe and effective order writing.

The facility reported a census of 40 residents. The sample of seven residents included three residents reviewed for social/medically related social services. Based on observation, interview, and record review, the facility failed to provide care in a respectful and dignified manner for a dependent, cognitively impaired Resident (R)7 when staff shaved his beard off. Findings included:- R7's Electronic Health Record (EHR) documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion) with psychotic (characterized by a gross impairment in reality and/or perception) disturbances, and failure to thrive. The 02/27/26 Entry Minimum Data Set (MDS) documented R7 admitted to the facility on [DATE]. R7's Discharge Return Anticipated MDS, dated 03/01/26, documented the resident was transferred to the hospital on [DATE]. R7's Baseline Care Plan, initiated on 02/27/28 and updated 02/28/26, informed staff that the resident had poor communication and comprehension. The plan did not address R7's preferences for maintaining and/or grooming his beard. R7's Progress Notes dated 02/27/26 at 07:16 PM, documented he arrived at the facility accompanied by his daughter, wife, and grandson. He was pleasantly confused and required total assistance from staff with hygiene care after having a bowel movement. A Progress Note dated 03/01/26 at 10:45 PM, documented the family spoke with a facility representative via phone regarding their desire to remove the resident from the facility related to the fall that occurred on 03/01/26. R7's family also voiced concerns and expressed that they were upset because facility staff shaved off R7's beard. The staff member informed R7's representative that the grievance would be addressed with the management team to follow up. The staff member documented notification the resident was being admitted to the hospital. Review of the facility Grievance Log revealed a grievance was filed on 03/10/26, nine days after the resident was sent to the hospital regarding the staff shaving R7's beard. The grievance report lacked an action plan and/or any follow-up with the family as of 03/24/26. On 03/24/26 at 11:26 AM, Certified Nurse Aide (CNA) N reported she did not recall the resident. The staff received training upon hire regarding resident rights and respecting resident/representatives' preferences. She stated she did not know who obtained the information, but would guess preferences should be obtained at admission from the resident and/or representative. CNA N said when a new resident admitted to the facility, the staff prepares the room and receives a report of the resident's needed and preferred care when they arrive. If a resident has dementia or is confused, then the family will usually give us information about what the resident likes and their routine prior to admission to make the resident's and family's transition easier. On 03/24/26 at 12:15 PM, Licensed Nurse (LN) G stated she did not recall the resident. She stated she was new and was not aware who obtained the information regarding preferences on admission, and said the facility should include the residents' and/or representative reports of the resident's past routines or preferences. On 03/24/26 at 03:35 PM, R7's representative stated R7's beard was part of his identity and all his friends and family knew him as having a beard. She stated his beard was rimmed and well-cared for. She stated when she arrived at the facility to visit her father, the facility had shaved his beard. She nearly walked past him because she did not even recognize him. Additionally, she stated her children, the resident's grandchildren, did not recognize their grandfather. She said R7 had dementia and would not even recognize himself when he looked in the mirror. She stated she felt her father was stripped of his dignity and identity. She asked the staff why they had shaved him and was told that he had food in his beard. She stated the staff said they tried to call, but the number was wrong. R7's representative further stated she had discussed his beard being shaved with the Administrator and has not heard back from the Administrator or facility staff since filing a grievance. On 03/24/26 at 04:54 PM, Social Service X stated the resident and/or resident representative usually gave the facility the preference information for activities of daily living (ADLs), which should include shaving preferences, and if a resident was admitted with a full beard, that would be a nursing function. Social Service X stated she does not ask that question and did not know if consent would be required.to shave a resident with a full beard. She stated that if a grievance was reported, then it should be included on the Grievance Log and followed up by the appropriate department. She confirmed a grievance had been filed on 03/10/26 regarding the staff shaving R7 without contacting the family or representative, and said she expected staff to contact the representative before shaving off an existing beard for a resident with dementia. On 03/24/26 at 05:19 PM, Administrative Staff A confirmed the above findings. He stated the residents and/or representatives should be interviewed regarding the history of individual needs and preferences of the residents. He stated he expected that the information should be included in the development of the residents' care plan, and especially agreed that a resident with confusion should have input from their representative regarding their likes and dislikes related to the care and maintenance of their beard. He confirmed that a man with a beard, who has had a beard for years, may not be recognized by friends and/or family and could be unrecognizable without a beard if that is part of their identity. Administrative Staff A confirmed he had been made aware of the grievance regarding R7's beard being shaved on 03/10/26, and he had not responded to the reporter of the grievance as of 03/24/26. On 03/24/26 at 05:30 PM, Consultant GG agreed the R7 should not have had his beard shaved without consulting the resident's representative. She stated shaving a resident with dementia and a full beard without contacting the representative was not acceptable and would be upsetting to those who knew him as only having a beard as part of his identity. She verified the change in R7's appearance could be upsetting to family and friends who only knew him as having a beard. The undated facility policy titled Dementia Care Protocol documentation included the interdisciplinary team (IDT) would adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.

The facility reported a census of 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from physical and sexual abuse. On 05/12/25 Resident (R) 1 admitted to the facility with a history of inappropriate behaviors. On 05/14/25, R1 grabbed and hit cognitively impaired R2 and staff placed R1 on one-to-one until he discharged to a behavioral health hospital on [DATE]. R1 returned to the facility on [DATE], and the facility did not implement interventions for R1 to prevent further resident abuse. On 06/01/25, R1 bit R2's finger, causing it to bleed. R1 went to a behavioral health unit on 06/05/25 and returned to the facility on [DATE]. On 06/21/25, R1 and R2 had an altercation where they slapped each other, and R1 grabbed R2's arm. On 06/28/25, R1 placed his hand on cognitively impaired R3's clothed genital area. The facility did not complete an investigation into the event or implement interventions to prevent further abuse. On 08/05/25, R1 grabbed R2's breast while R2 slept. Staff placed R1 on one-to-one for ten days, but failed to administer R1's physician-ordered medication to address his sexual behaviors. On 08/24/25, R1 put his hand inside cognitively impaired R4's brief while R4 slept in her bed. The facility's failure to implement effective interventions to prevent physical and sexual abuse placed R2, R3, and R4 in immediate jeopardy.Findings Included:- R1's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R1's 06/02/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. R1's MDS documented he had no depression and no behaviors. The MDS documented R1 required supervision assistance with transfers and was independent with wheelchair mobility. The MDS documented R1 received antidepressant (a class of medications used to treat mood disorders) and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications.R1's 06/05/25 Cognitive Loss/Dementia Care Area Assessment (CAA) triggered secondary to orientation, memory, and recall deficits noted during the BIMS interview. The CAA recorded contributing factors included dementia, change in mental status, and short-term/long-term memory loss; risk factors included self-care deficits, falls with injuries, incontinence, decreased socialization, skin breakdown, weight loss, and fluid imbalance. The CAA noted a care plan would be initiated and reviewed to improve and/or maintain current cognitive status, activities of daily living (ADL) status, continence status, mobility, as well as to encourage active participation in facility functions, maintain communication, decrease fall and pressure ulcer risk, and maintain dietary intake and hydration status.R1 did not trigger for Behavioral Symptoms CAA as R1's behaviors were not captured on the MDS.R1's Behavioral Symptoms Tasks in the EHR dated 05/07/25 through 06/02/25 documented R1 wandered on 05/29/25, and R1 was sexually inappropriate on 05/30/25.R1's 06/04/25 Quarterly MDS documented a BIMS score of seven, which indicated severely impaired cognition. The MDS recorded R1 had no depression or behaviors during the lookback period. The MDS documented R1 received antipsychotic and antidepressant medications.R1's Baseline Care Plan dated 05/12/25 lacked mention or interventions related to R1's history of behaviors.R1's Care Plan dated 06/06/25 documented R1 had a behavior problem, physical and verbal aggression, and sexually inappropriate verbalizations and actions. Staff were educated to monitor R1's agitation, intervene before agitation escalated, and guide away from the source of distress. The plan directed staff to engage R1 calmly in conversation, and if his response was aggressive, staff were to walk calmly away and approach him later. The plan directed staff to obtain behavioral health consults as needed.R1's Care Plan on 06/12/25 documented staff were educated to intervene as necessary to protect the rights and safety of others. Staff were instructed to approach R1 and speak in a calm manner; divert R1's attention and remove him from the situation; take him to an alternate location as needed. Staff were instructed to minimize the potential for R1's disruptive behaviors by offering tasks that divert attention, such as activities of interest.R1's Care Plan on 08/05/25 documented R1's Paxil (antianxiety medication) was increased related to behaviors. Staff were to ensure medication compliance for Depo-Provera (a medication primarily known as a contraceptive for women but used in males as a method to reduce sexual drive and manage sexually offensive behavior) intramuscular (given directly into a muscle) suspension prefilled syringe 150 milligrams (mg)/milliliter (ml). Staff were to provide one-to-one sessions related to behaviors until R1's medication review with possible changes.R1's Care Plan on 08/27/25 documented R1's Seroquel (antipsychotic medication) was increased to 25 mg three times a day per medication review related to R1's increased sexual behaviors.R1's EHR, under the Misc tab revealed a scanned document provided from R1's previous facility upon admission, which included a Progress Note dated 04/29/25 that noted R1 continued to try to grab female staff during cares and noted he tried to work his way into elder females' space; R1 required constant supervision when up from bed and 15 minute checks when he was in bed.R1's EHR recorded an order for Physician Order Behavior Monitoring that documented staff monitored the resident for behaviors including itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Staff would document: 'N' if monitored and none of the above was observed. Staff would document 'Y' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document progress note findings every day and night shift for psychotropic (alters mood or thought) medication use, date ordered 05/12/25.R1's Progress Note on 05/14/25 at 09:45 AM documented staff arrived at the nurses' station and reported R1 just hit and grabbed another resident; the residents were separated, and R1was placed on one-to-one supervision as an intervention.The facility's 05/14/25 Incident Report at 09:45 AM documented that staff intervened appropriately to separate the residents with close monitoring provided to R1to ensure safety for other residents until a physician-ordered intervention was obtained. This incident lacked further investigation details and outcomes.R1's Physician Order documented administer Depo-Provera intramuscular suspension prefilled syringe 150 mg/ml inject 2 ml intramuscularly in the morning every two weeks on Thursdays for behaviors, date ordered 05/15/25.R1's Progress Note on 05/27/25 at 05:25 PM documented R1 readmitted from a behavioral health unit on one-to-one.R1's Progress Note on 06/01/25 at 01:57 AM documented, at approximately 11:15 AM staff heard a female resident yelling Help in the dining room. All staff members ran to the dining room and observed a female resident [R2] standing in front of R1 with the female resident's finger in R1's mouth. R1 was biting down with his teeth, and there was blood dripping from the female resident's hand. The noted documented staff members intervened immediately and removed both residents from the dining room. Staff placed R1 on one-to-one observation.The facility's 06/01/25 Incident Report at 11:15 AM documented staff intervened appropriately to separate the residents, with close monitoring provided to R1 to ensure safety for other residents until a physician-ordered intervention was obtained.R1's Progress Note on 06/18/25 at 04:05 PM documented R1 returned to the facility around 02:10 PM via facility transport in a wheelchair.R1's Progress Note on 06/21/25 at 03:08 AM documented staff witnessed R1 in the dining room with a female resident [R2]. The noted recorded staff witnessed both residents slapping each other on the arms, R1 grabbed the female resident's arm, and staff immediately intervened and separated the residents.The facility could not provide an investigation related to the 06/21/25 incident.R1's Physician Note on 06/23/25 at 05:50 PM documented a physician saw R1 after admission to the behavioral health unit again. The note documented R1 had a recent admission twice for inappropriate physical and sexual behaviors. The note documented R1 was primarily redirectable and noted the physician would follow up for changes in mood.R1's Progress Note on 06/28/25 at 11:03 AM, documented staff notified R1's representative that staff observed R1 touching a female resident in the genital area and R1 would be monitored on a one-to-one basis. The note recorded R1's representative stated they did not know how staff would stop R1 from doing that.The facility could not provide an investigation related to the 06/28/25 incident.R1's Progress Note on 07/03/25 at 05:31 AM, documented R1 tried to grab at a staff member's private area three times that day.R1's Physician Note on 08/04/25 at 10:13 AM, documented the provider saw R1 on 07/28/25 and issued new orders to decrease R1's Seroquel to 25 mg twice a day to attempt a gradual dose reduction, and increase Paxil to 30 mg daily for mood-behaviors; continue all other medications as ordered.R1's Progress Note on 08/05/25 at 03:36 PM documented staff witnessed R1 inappropriately touching a female resident's [R2] right breast in the television room. The note recorded the female resident was asleep when staff observed R1 groping her and attempting to reach under her shirt. Staff immediately intervened and separated both residents.The facility's 08/05/25 Incident Report at 10:00 AM documented staff immediately separated both residents, completed skin assessments, and updated R1's family and provider. The report noted medication changes were made on 08/05/25 (decrease of Seroquel and increase of Paxil), and R1 was on one-to-one from 08/05/25.R1's E-Medication Administration Record (eMAR) on 08/07/25 at 11:20 AM documented staff could not administer R1's injection of Depo-Provera for behavioral reasons because the medication was not in stock; staff re-ordered medications. The August 2025 eMAR documented the 08/07/25 dose was never administered, and R1 did not receive the Depo-Provera until the next scheduled dose on 08/21/25 (14 days later).R1's EHR lacked evidence staff notified the physician R1's Depo-Provera was not administered on 08/07/25 as ordered.On 08/10/25, the EHR revealed R1's one-to-one supervision was discontinued.R1's Progress Note on 08/24/25 at 01:06 PM documented staff observed R1 in a female resident's [R4] room with his hand in her brief while the female resident lay in her bed. Staff initiated one-to-one monitoring.The facility's 08/24/25 Incident Report at 12:00 PM documented staff removed R1 from a female resident's [R4] room and initiated one-to-one for R1. The report noted staff monitored both residents closely for behavioral or psychological changes, and R1 remained one-to-one until 08/31/25.R1's Physician Note on 08/26/25 at 08:23 PM documented R1 continued with one-to-one with no behavior issues observed or reported during that shift.R1's Progress Note on 08/27/25 at 02:08 PM documented R1 continued with one-to-one for inappropriate sexual behaviors. The note recorded staff spoke with the provider for a medication review as R1 recently had a gradual dose reduction (GDR) for Seroquel; the GDR attempt failed, and staff received a new order to increase R1's Seroquel 25 mg to three times a day.During an observation on 09/16/25 at 12:15 PM, R1 sat in the dining room waiting for lunch. During an observation on 09/17/25 at 08:45 AM, staff pushed R1 in a wheelchair from the shower room to the dining room. R1 sat at a table alone and fed himself breakfast.During an interview on 09/16/25 at 03:04 PM, Social Service Designee (SSD) X reported R1 admitted from a facility after they received the referral. SSD X reported she was not sure who evaluated R1 for admission and said she was unaware that R1 had behaviors at the prior facility. SSD X reported R1's behaviors and interventions should have been documented on the baseline care plan with appropriate interventions and said nursing staff was responsible for completing the baseline care plan.During an interview on 09/16/25 at 12:29 PM, Licensed Nurse (LN) G reported R1's one-to-one was discontinued a couple of weeks ago, as R1 had an increase in the Seroquel medication, and that helped with R1's behaviors. LN G reported R1 had several inappropriate sexual behaviors towards other female residents and staff. LN G reported that when a resident was placed on a one-to-one, it would only be for a short period of time.During an interview on 09/16/25 at 03:19 PM, Administrative Nurse E reported she worked as a floor nurse when R1 admitted in May 2025. She reported the floor nurse would complete the baseline care plan upon admission after assessments and a review of documentation from the admitting facility was completed. Administrative Nurse E reported the floor staff would not see the referral paperwork and reported she was unaware R1 had a history of sexual behaviors when he admitted . Administrative Nurse E reported R1's behaviors and interventions should have been documented on his care plan. Administrative Nurse E reported the facility would generally keep a resident on a one-to-one for about three days after an incident and then review. She reported staff should have removed the one-to-one from R1's Care Plan when it was discontinued on 08/31/25.During an interview on 09/16/25 at 05:00 PM, LN G reported if a medication was not available for administration, the nurse would check the emergency medication kit to see if that medication was available, and if it was not, the staff would notify the pharmacy. LN G reported the pharmacy would deliver the medication if it were an emergency. LN G reported medication was ordered once or twice a month, and the physician should be notified when the medication is not available.During an interview on 09/17/25 at 08:10 AM, Certified Nurse Aide (CNA) M reported he did not know about any hyper-sexual behaviors towards female residents by R1. CNA M reported he knew about sexual behaviors towards female staff, and he was asked numerous times by female staff to bathe R1 because they felt uncomfortable around him. CNA M further reported he was unaware of the location for information about R1's previous resident-to-resident abuse incidents or where to find the interventions to utilize if the incidents reoccurred. During an interview on 09/17/25 at 08:20 AM, CNA N reported he witnessed R1 attempt to grab or grope a female resident, but he immediately intervened and redirected R1. CNA N reported R1's information and interventions should be listed on his care plan.During an interview on 09/17/25 at 09:50 AM, Administrative Staff E reported she was unaware R1 had missed a Depo-Provera shot in August 2025. Administrative Staff E reported the facility orders the medication, receive multiple doses with each delivery, and when the nurse administered the last dose, the nurse would re-order the medication. Administrative Staff E reported she expected the floor nurses to perform a follow-up with this type of situation, and to communicate with the pharmacy, notify the provider that the medication was missed, and to chart progress notes related to the situation and follow-ups.During an interview on 09/17/25 at 10:25 AM, Administrative Staff A stated he expected all reportable incidents to be thoroughly investigated and the completed investigation to be submitted in the time frame allowable. Administrative staff A was unable to provide the completed investigations and confirmed he was not working in the facility at the time of the previous events on 06/21/25 and 06/28/25.The facility's policy Abuse Prevention Program dated May 2025 documented the residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. The community had zero tolerance for abuse, and to protect residents from abuse by anyone, the facility would implement measures to address factors that may lead to abusive situations.On 09/17/25 at 02:00 PM, Administrative Staff A and Consultant Staff II received a copy of the Immediate Jeopardy [IJ] Template and were notified that the facility failed to ensure residents remained free from physical and sexual abuse. The facility's failure to implement effective interventions to prevent physical and sexual abuse placed R2, R3, and R4 in IJ.The facility submitted an acceptable plan for removal of the IJ on 09/17/25 at 04:55 PM, which included the following:1. Staff were in-serviced on the facility's ANE P&P and De-Escalation Tool completed by 09/17/25. Staff were not allowed to work until verification of the in-service training was obtained.2. R1 was accepted to another facility with an estimated discharge date of 11/01/25 or sooner.3. To ensure R1 received his Depo-Provera, the Director of Nursing added the administration date to her calendar as a reminder to ensure that the medication was on hand by the due date every two weeks.4. All staff were educated on 09/17/25 regarding R1's specific behaviors that indicate that R1 might be escalating and the appropriate actions to take in response.5. The facility had a recent change in Administrator and Director of Nursing staff, and the new staff were in-service on 09/17/25 to do a root cause analysis when a resident was placed on one-to-one monitoring, which included what led up to the incident, what behaviors led up to the incident, and what to look for after the resident was removed from one-to-one monitoring. The entire interdisciplinary Team (IDT) also received this in-service on 09/17/25.6. The facility and corporate entity modified the current one-to-one policy to create ongoing monitoring once residents were removed from the one-to-one oversight, with regional support to monitor the effectiveness of interventions placed.7. The facility conducted a Quality Assurance and Performance Improvement (QAPI) meeting on 09/17/25 to review. On 09/17/25 at 05:05 PM, the surveyors verified implementation of the above corrective actions to address the immediacy as listed on the template. The scope and severity remained at a G to represent the actual psychosocial harm, using the reasonable person concept, since R2, R3, and R4 were cognitively impaired and unable to effectively communicate impact of the physical and sexual abuse experienced.

The facility reported a census of 39 residents. The sample included three residents who required transportation in the facility van. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remain free from accidents when Certified Medication Aide (CMA) R did not utilize the safety belt for R1 before transporting in the facility van. On 12/11/24 at approximately 03:00 PM, Certified Medication Aide R failed to secure dependent R1 in her wheelchair with the wheelchair safety belt in the facility van, prior to transporting. CMA R entered a busy highway with a speed limit of 60 miles per hour (MPH) and had to slam on the brakes to avoid an accident, which caused the resident to slide forward out of her wheelchair onto the floor of the van due to the lack of the seatbelt use. R1 sustained multiple injuries including skin tears and a laceration. Findings include: - R1's undated Physician Order Sheet (POS) documented the resident admitted on [DATE] with the following diagnoses: cerebral infarction (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), abnormality of gait and balance (any unusual or unexpected patterns of movement or changes in the way an individual walks or moves), lack of coordination (difficulty performing physical movements smoothly, accurately, and efficiently), weakness (lack of physical or muscle strength), and unsteadiness of feet (pattern of walking that's unstable). The Baseline Care Plan, dated 12/11/24, instructed staff that the resident was alert, cognitive, her vision was intact, and hearing was adequate. She required partial/moderate assistance with sit to standing and transfers. She ambulated independent with cane and self-propelled with a walker. Review of the Admission Note, dated 12/11/24 at 07:32 PM by Licensed Nurse (LN) G, documented the resident arrived at the facility via the facility van accompanied by CMA R. The resident transferred from the acute care hospital with a diagnosis of cerebral infarction. The resident was alert and oriented to person, place, time, and situation. The resident presented with left-sided weakness to upper and lower extremities (arms and legs) and face. She ambulated with her wheelchair and used of a four-wheel walker with one person assistance. LN G documented R1 had a skin tear located on her left forearm and to the top of her right hand. LN G cleansed the skin tears and covered with a wound dressing. Review of the Admission Skin Assessment, dated 12/15/24, documented R1's skin had the following skin issues: Skin tear located on her left forearm: 1.3 centimeters (cm) in width, small amount of sanguineous (leakage of fresh blood from an open wound) exudate (fluid that leaks from blood vessels) and dressing saturation was minimal (less than 25%). Skin tear located on top of her right hand: 0.5 cm in width, small amount of sanguineous exudate and dressing saturation was minimal. Abrasion located on her left knee: 0.5 cm in width, small amount of sanguineous exudate and dressing saturation was minimal. Review of the Facility Investigation, dated 12/19/24, documented R1 admitted to the facility on [DATE] from the hospital. Certified Medication Aide (CMA) R was the transportation driver and Certified Nurse Aide (CNA) M rode along as a companion. CMA R reported that the passenger safety belt for a wheelchair passenger had not been functional since she began work in April 2024, so instead, she had been using a gait belt on this transport and she did not secure the resident in her chair. After leaving the hospital, CMA R reported a vehicle pulled out in front of her, and she had to slam on the brakes, and R1 fell out of her chair onto the floor which resulted in a skin tear to her right hand and an abrasion to her left knee. CMA R and CNA M both stated that they stopped the van and helped the resident back into the chair. When asked if they had taken measure to secure the resident in her chair after the incident, both CMA R and CNA M both stated that they used a gait belt that was in the van. Upon returning to the facility, Administrative Nurse E, Administrative Staff A, Consultant GG, and Durable Power of Attorney were notified of the event. Administrative Staff E assessed the resident for fall protocols. CMA R was interviewed by Administrative Staff A, and she stated she had never used the passenger safety belt in the facility van because she was told it had not been functional since she started in April 2024, and she had never been trained on the use of the safety belt. She did not recall who told her it was not functional. CMA R was asked if she had ever reported that the safety belt was not functional to anyone. She reported that she did not. She was asked if she knew if anyone else had reported that the safety belt was not functional. She reported that she did not know if anyone reported it. CMA R was then told she was suspended pending an investigation. CNA M reported she also regularly accompanied CMA R during transports and had not observed how CMA R secured residents during transports. Social Services X reported she always used the safety seatbelt when transporting residents and able to safely demonstrate how secure a resident safely with the seatbelt in the van. Social Services X reported the safety belt had not been malfunctioning. She reported that she regularly accompanied CMA R during transports and had not noticed how CMA R secured the residents during transports. After learning this, Social Services X and CNA M were suspended. During an interview on 01/13/25 at 03:00 PM, Administrative Nurse D reported she reviewed the Facility Report and CMA R notified Administrative A and Administrative Nurse E, who are no longer employed with the facility at the time of the incident. Administrative Nurse D reported she visited with Consultant GG while she was in the facility when the resident arrived and did not feel the resident needed to be evaluated at the Emergency Department (ED). CMA R failed to notify Administration when she began transporting in April 2024 when she was advised that the seatbelt was not working appropriately before transporting residents. Administrative Nurse D reported she contacted CMA R on 01/13/25, and CMA R verified she had declined to complete a witness statement on 12/11/24. Administrative Nurse D was unable to reach CNA M. During an interview on 01/13/24 at 08:08 PM, CMA R reported she transported R1 from the hospital to the facility on [DATE]. CMA R reported on 12/11/24 at approximately 03:00 PM, she was in a hurry due to the cold temperature. CMA R secured the resident into the facility van with the four-point straps but failed to secure the seatbelt across the resident's wheelchair. She used a gait belt to loop around each of the arm rests of the wheelchair. She had been advised by another staff member that the seatbelt in the facility van was not functioning properly. CMA R reported during transport at approximately 03:00 PM she entered a busy highway with a speed of 60 miles per hour (MPH) and had to slam on the brakes to avoid an accident, which caused the resident to slide forward out of her wheelchair onto the floor of the facility van. R1 sustained multiple injuries including skin tears and a laceration. CMA R said she contacted Administrative Staff A and Administrative Nurse E of the incident, who advised since there was no accident and the resident was not injured, other than skin tear and abrasion, to continue to the facility and Consultant GG would meet the resident at the facility. CMA R reported she declined to complete a witness statement, was suspended that evening, and later terminated from her position. During an interview on 01/13/25 at 04:33 PM, Maintenance Director U reported on 12/11/24 he was advised of the incident. He advised Administration to stop all transportation of both facility vans until he could inspect each of them on 12/12/24. He reported he completed an inspection on both facility vans on 12/12/24 and the seatbelts were working appropriately. During an interview on 01/14/25 at 11:45 AM, Consultant GG reported she was at the facility when R1 arrived. Consultant GG reported the resident did have a skin tear to the top of her right hand and a laceration to her left knee. Consultant GG did not feel the resident required an evaluation at the Emergency Department (ED). The Correct Procedures and Operation of the Transport Van, dated 12/11/24, included wheelchair straps, ramp operations, and seat belt to secure resident in a wheelchair for safety. On 01/13/25 at 12:43 PM, the IJ template was provided to Administrative Staff A and Administrative Nurse D and notified the facility failed to ensure R1 remained free from accidents when Certified Medication Aide R did not utilize the facility transportation van seatbelt for R1 before transporting. CMA R used a gait belt to loop around each of the arm rests of the wheelchair for R1. During transport, CMA R entered a busy highway with a posted speed of 60 miles per hour (MPH) and had to slam on the brakes to avoid an accident, which caused the resident to slide forward out of her wheelchair onto the floor of the facility van. R1 sustained multiple injuries including skin tears and a laceration. The immediate jeopardy was determined to first exist on 12/11/24 at 03:00 PM, when CMA R transported R1 without a seatbelt. The facility identified and implemented the following corrective actions, completed on 12/18/24: 1. On 12/11/24 at 05:00 PM, the facility suspended CMA R. She was terminated on 12/18/24. 2. On 12/11/24 at 05:00 PM, the facility suspended CNA M. She self-terminated on 12/17/24. 3. On 12/11/24 the facility van was immediately taken out of service until the van could be inspected. 4. On 12/12/24, the facility van was inspected, and it was discovered that the passenger safety belt was not in despair but rather working as was intended. 5. All staff members were trained in lock out/tag out for equipment that was out of order. 6. All staff members were trained on when to report equipment that was not functional and how to use the work order system to alert the administration. 7. Staff members who transported residents for passenger pick up were educated on van safety and asked to demonstrate how to use the safety equipment in the van. 8. All staff were educated that passenger safety was the responsibility of both the driver and transportation companion. The facility presented an acceptable plan for removal of the immediate jeopardy on 01/14/25 at 08:45 AM. The surveyor validated that the immediate jeopardy was removed on 01/14/25 at 01:45 PM following the implementation of the plan for removal of the immediate jeopardy. Due to the corrective actions the facility completed prior to the onsite survey, the deficient practice was deemed past non-compliance and remain as a scope and sevirty of a J.

The facility reported a census of 43 residents with 15 residents sampled, which included two residents reviewed for behaviors and resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse, when Resident (R)22, who had a history of hitting other residents, continued to hit residents in the facility on multiple occasions. On 12/20/22, R22 grabbed R195's sweatshirt by the collar and pushed her wheelchair backwards. R22 let go and then grabbed her nose between his index and middle finger. He continued to pull on her nose, which according to R195, caused pain. On 01/01/23, R22 hit R 196. On 02/06/23, R22, with a closed fist, hit R196 to the back of the head. On 06/04/23, R22 hit his spouse and then hit R30 which knocked R30 out of his chair. On 06/11/23, R22 swung a baby doll, and hit R13 twice on the face across her glasses. On 05/12/24, R22 punched R17 on the left side of R17's jaw. On 05/20/24, R22 raised his closed fist to R2 and made contact with R2's face. These continued incidents of resident-to-resident abuse and lack of supervision and interventions to prevent abuse, placed the residents in immediate jeopardy for continued abuse. In addition, on 01/19/24, R16 who had a history of sexual behaviors and physical aggression, hit an unknown resident after the unknown resident bumped R16's wheelchair. On 01/24/24, R16 grabbed the breast of R12 through her shirt. On 01/25/24, R16 masturbated in a public area. Findings Included: - Resident (R) 22's Electronic Health Record (EHR) revealed diagnoses included vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and senile degeneration of brain. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R22 had severely impaired cognition. R22 required total assistance with activities of daily living (ADL) cares such as oral care, toileting, footwear, and personal hygiene; required maximal assistance with dressing, eating, and bathing; and was independent with ambulation. R22 was always incontinent of bladder and bowel. The Quarterly MDS dated [DATE], documented R22 had severely impaired cognition. R22 had physical behavioral symptoms directed toward others. R22 was independent with ambulation. The Cognitive Loss/Dementia CAA dated 02/16/24, documented R22 had an actual problem of cognition loss related to dementia. The Behavioral CAA dated 02/16/24, documented R22 had an actual problem with behavioral symptoms related to wandering. The 05/28/24 Care Plan dated 05/26/23, revised on 12/29/23, documented R22 had impaired cognitive function, dementia, or impaired thought processes. Staff instructed to provide a homelike environment and noted R22 liked to carry a baby doll to bring comfort. The care plan lacked interventions for staff related to resident-to-resident altercations. The Physician's Order dated 05/28/24, included the following orders: Divalproex (medication used to treat bipolar disorder [major mental illness that caused people to have episodes of severe high and low moods]) use and staff were to monitor for tearfulness or crying, aggression, agitation as well as adverse effects every day and night. The staff were to note the number of episodes of target behavior and a redirection code: 0=did not occur; 1=easily altered; 2=difficult to redirect, ordered 12/24/22. Trazodone HCl (antidepressant medication), 50 milligrams (mg), give 1 tablet by mouth at bedtime, related to unspecified dementia, ordered 06/22/23. Divalproex Sodium Delayed Release Sprinkle, 125 mg, give 250 mg by mouth, three times a day, related to major depressive disorder, ordered 03/08/24. Ativan (antianxiety medication) use, and staff were to monitor the resident for anxiety and anger every day and night shift for behavior monitoring. The staff were to note the number of episodes of target behavior and a redirection code: 0=did not occur; 1=easily altered; 2=difficult to redirect, ordered 04/04/24. Ativan, 0.5 milligram (mg), give 0.5 mg by mouth, every four hours as needed, for anxiety/restlessness related to terminal diagnosis, end of life for six months, ordered 04/25/24. Review of the Progress Notes from 12/01/22 to 05/28/24 documented the following resident-to-resident concerns: Review of the Progress Notes revealed on 12/20/22 at 02:20 PM, R22 grabbed resident 195's sweatshirt by the collar and pushed her wheelchair backwards. R195 stated she did not react because she knows residents with dementia don't know any different. R22 let go and then grabbed her nose between his index and middle finger. He continued to pull on her nose, which R195 said caused her pain, and she told him to stop and pushed his hand away. Review of the Progress Notes revealed on 01/01/23 at 06:50 PM R22 hit R196 on the chest with a closed fist. Review of a Facility Reported Incident called into the state agency revealed on 02/06/23 R22, with his closed fist, hit R196 to the back of his head. The EHR for R22 lacked documentation of the 02/06/23 resident-to-resident physical abuse. Review of the Progress Notes revealed the following: On 06/04/23 at 06:42 PM, R22 hit his spouse and then hit R30, which knocked R30 out of his chair. [R30 had impaired cognition per the 05/22/23 MDS.] On 06/11/23 at 05:21 PM, R22 swung a baby doll, hitting R13 twice on the face across her glasses. [R13 had intact cognition per the 06/01/23 MDS.] On 06/13/23 at 06:00 AM, R22 transferred to a behavior unit. On 06/22/23 at 01:00 PM, R22 returned from a behavior unit. On 07/30/23 the CNA reported she asked the resident to stand up and go to the restroom and the resident slapped her in the face. The CNA walked away from the resident. The record lacked any other Progress Notes regarding resident-to-resident altercations between 07/30/23 and 03/04/24. Review of the 03/04/24 behavior note at 07:00 PM revealed the dayshift nurse reported R22 sat at the nurse's station and got up to go to his room and his roommate told him to stop and when R22 and the nurse aide walked by him, R22 grabbed his roommate's shoulder and pulled him back toward him. The residents were separated. Review of the Progress Notes revealed the following: On 05/12/24 at 04:45 PM, R22 punched R17 in the jaw. [R17 had impaired cognition per the 03/14/24 MDS.] On 05/20/24 at 03:38 PM, R22 raised his closed fist to R2 and made contact with R2's face. On 05/28/24 at 12:11 PM, R22's family member reported the resident had a resident-to-resident altercation on 05/20/24, and the family member stated the facility did not notify the family they placed R22 on one-on-one. [R2 had impaired cognition per the 02/23/24 MDS.] During an interview on 05/28/24 at 02:57 PM, Certified Nurse Aide (CNA) C stated R22 was aggressive and would hit other residents and staff. CNA C stated she redirected R22 away from others if R22 was in a bad mood. CNA C stated R22 would have a mad expression on his face. CNA C stated that she would report resident-to-resident abuse to the charge nurse or the Director of Nursing. During an interview on 05/28/24 at 03:00 PM, Licensed Nurse (LN) H stated she was told R22 could be agitated and had placed his hands on other residents. LN H reviewed how to report any type of abuse alleged or witnessed to the Director of Nursing, Administrator, provider, family member and hospice if needed. On 05/28/24 at 03:08 PM, LN D stated was not aware R22 struck R17. LN C stated R22 hit R2 on the side of R2's face in the dining room and staff were busy at the time of the incident. CNA J witnessed the incident and reported to LN D. LN D stated she did not know why R22 hit R2, she stated that she reported the incident to the Assistant Director of Nursing, Director of Nursing, provider, hospice, and family member. LN D stated a risk management completed in EHR. LN D agreed that a progress note was not completed on R2. On 05/28/24 at 03:13 PM, Administrative Staff B revealed that neither incident on 05/12/24 or 05/20/24 were reported to state agency or reported to law enforcement and stated there was no physical injury that occurred with either incident. On 05/28/24 at 03:15 PM, Administrative Staff A stated staff notified her of both incidents (05/12/24 and 05/20/24) the same date they occurred. The facility's policy for Abuse Investigation and Reporting, dated October 2021 documented all allegations of resident abuse (including physical, mental, emotional, verbal, and or sexual abuse). Any reasonable suspicion of a crime shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse. These continued incidents placed the residents in immediate jeopardy for continued abuse. On 05/28/24 at 04:50 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to provide to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse. The facility submitted an acceptable plan for removal of the immediate jeopardy on 05/29/24 at 05:15 PM which included the following: 1. Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure. (ANE) and would be completed by 05/28/24. Staff will not be allowed to work until signatures received. 2. Inter-Disciplinary Team was in-serviced on 05/28/2024 for ANE reporting. 3. Staff placed R22 on a one on one at 05:00 PM on 05/28/2024 and would remain a one on one until deemed no longer a threat or discharged from the facility. 4. Referrals would be sent to Behavior Units for temporary placement. 5. Hospice and Medical Director to complete a medication review. 6. Quality Assurance Performance Improvement (QAPI) meeting on 05/29/24. The surveyor verified the facility implemented the above corrective measures on-site on 05/29/24 at 05:15 PM. The deficient practice remained at a scope and severity level of an E, following the implementation of the removal plan. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse. These continued incidents place the residents in immediate jeopardy for continued abuse. - R16's Electronic Health Record (EHR) revealed diagnoses of Intermittent Explosive Disorder (an impulse disorder marked by frequent anger outbursts or aggression, which are out of proportion to the cause and create significant distress to the person. The anger episodes can be mild or severe and may involve hurting someone badly enough to require medical attention or even cause death [per the Cleveland Clinic website]), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), dementia (progressive mental disorder characterized by failing memory, confusion), and sexual dysfunction. The Significant Change Minimum Data Set (MDS) dated [DATE], documented staff completed an interview to determine the resident's cognition, which indicated he had moderately impaired cognition. No behaviors were noted on the assessment. R16 required extensive assistance with Activities of Daily Living (ADL - such as bed mobility, toileting, and hygiene) and was independent for eating. R16 was always incontinent of bladder. The Quarterly MDS dated [DATE], documented the resident had a BIMS of seven, which indicated severe cognitive impairment. The resident had no behaviors. R16 required maximal to total dependence with ADL and required set-up assistance for eating. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 06/27/23, documented the resident had an increased need for assistance with ADL. The Cognitive Loss/Dementia CAA dated 06/27/23, documented the resident had a BIMS score of less than 13. The 05/29/24 Care Plan with an intervention dated 03/22/21, revealed R16 had cognitive functions, and mood and behavior. Staff were instructed to provide R16 privacy in his room with the door shut and reminded R16 to sit down when masturbating. On 09/13/23, an intervention revealed R16 had a potential for behavioral problems and staff were to administer medications as ordered and monitored for effectiveness. Staff were instructed to intervene as needed to protect the rights and safety of others and to divert the resident's attention. Staff were to remove the resident from the situation and take him to an alternate location as needed. The Physician's Order dated 05/29/24, documented on 12/01/22, staff were to monitor the resident for targeted behaviors associated with Depakote ([Divalproex]an anticonvulsant drug that treats seizures, migraines, and bipolar disorder) as well as monitor for potential adverse effects, which included: being anxious, refusing cares, and being tearful/crying. The Physician Order also included the following: Divalproex Sodium Oral Capsule Delayed Release Sprinkle, 125 milligrams, 4 capsules by mouth, two times a day, related to bipolar disorder, ordered 01/24/24. Paxil (an anti-depressant to treat depression), 30 milligrams by mouth, one time a day, for sexual dysfunction, ordered 03/25/24. Review of the Progress Notes from 12/01/23 to 05/28/24 documented the following: On 01/19/2024 at 03:07 PM, the resident was seated in the doorway of the dining room when an unidentified resident in an electric wheelchair bumped into R16's wheelchair. The unidentified resident yelled at R16 to get out of the way. When the unidentified resident moved close to R16's side, R16 punched the unidentified resident in the arm and yelled at the unidentified resident. On 01/24/24 at 12:37 PM, Licensed Nurse (LN) D documented Certified Nurse Aide (CNA) G observed R16 grab the breast of R12 through her shirt. On 01/25/24 at 01:04 PM, LN D documented Activity Director K notified LN D that R16 was in the dining room with his penis out and masturbated in front of residents. R16 was told to stop and removed from the dining room. R16 was to see psychologist provider in two weeks. On 01/25/24 at 06:48 PM, Administrative Staff L documented the internal investigation completed regarding incidents involving R16 on 01/24/24 and 01/25/24 concluded and R16 had not intentionally touched R12's breast. R16 was provided one on one. Provider adjusted R16's medications. On 02/22/24 at 11:39 AM, documented R16 was overheard saying sexually inappropriate statements to staff. R16 stated staff made sexual comments to him. R16 was educated that the interaction was witnessed, and staff made no inappropriate comments and that he could not continue to talk to staff in that manner. On 05/30/24 at 08:28 AM, Licensed Nurse (LN) D stated that her progress notes charted in R16's EHR on 01/24/24 and 01/25/24 were accurate as to what was told to her by staff who reported what they had seen. LN D stated, Administrative Staff L investigated the two incidents that were documented and did not request a statement from her. LN D stated she did not know anything further about the investigation. LN D verified the initials in the progress note on 01/24/24 was identified as R12. LN D stated that she received Abuse, Neglect and Exploitation (ANE) education this week prior to working and last week at the facility skills fair. On 05/30/24 at 09:01 AM, CNA F stated R16 had a history of hitting others, but she has not witnessed that. CNA F stated R16 did masturbate when and where he wanted to, and that staff were to re-direct the resident to a private area. CNA F stated that ANE education was completed on 05/29/24 before work and last week at the skills fair. On 06/03/24 at 10:39 AM, Activity Staff K stated on 01/24/24, she did not know about the incident when R16 grabbed another resident. Activity Staff K stated on 01/25/24, staff was notified that R16 was in dining room and had masturbated in front of other residents. Administrative Staff L did not request for Activity Staff K to write a statement for Administrative Staff L for either of the dates in January of 2024. On 06/03/24 at 12:00 PM, Administrative Staff A and Administrative B were questioned about R16's incidents on 01/19/24 and 01/25/24 and she stated she would look for investigations and update when found. On 06/03/24 at 01:20 PM, Administrative Staff A provided a copy of the 01/24/24 facility investigation. Stated that it was not called into police or reported to the state agency. Administrative staff A was not able to locate any incident from 01/19/24 for R16. On 06/03/24 at 02:00 PM review of the facility's undated investigation provided by Administrative Staff L revealed a signature sheet with 22 staff members signatures, and an undated, non-witnessed complaint investigation witness statement of facts with a written statement from CNA G that documented R16 appeared to be touching another resident's breast. The undated investigation by Administrative Staff L further contained an undated Training: Abuse and Neglect form that documented the definition of abuse as: a willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Staff were instructed that each employee was responsible to report any signs of abuse to their direct supervisor or department director as soon as possible. If staff were unsure about the signs of abuse, they were to speak with the Director of Nursing or Administrator. When in doubt staff were instructed to report the potential abuse. Review of the Abuse Prevention Program dated 10/2021 documented: Our residents have the right to be free from abuse, neglect, neglect, misappropriation of property and exploitation. The facility would develop and implement policies and procedures to aid in preventing abuse and investigate and report any allegations of abuse within timeframes as required by federal requirements. The facility's policy for Abuse Investigation and Reporting, dated October 2021 documented all allegations of resident abuse (including physical, mental, emotional, verbal, and or sexual abuse). Any reasonable suspicion of a crime shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The role of the Administrator is to assign an investigation to an appropriate individual, to prevent any further abuse. The role of the Investigator is to review completed forms, medical records, witnesses, and review all events leading up to the alleged incident. The facility would notify the Ombudsmen and ensure reporting of all alleged violations involving abuse etc. to state licensing/certification agency. The facility would notify the Ombudsman, adult protective services, and law enforcement within 2 hours if the alleged violation involved serious bodily injury, or 24 hours if not resulted in a serious bodily injury. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse regarding R16.

The facility reported a census of 43 residents with 15 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure the timely reporting of alleged abuse to the State Agency (SA - a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required. The facility failed to report two allegations of resident-to-resident abuse, when on 05/12/24 at 04:45 PM, R22, who had a history of hitting others, punched R17 on the left side of R17's jaw. On 05/20/24, R22 raised his closed fist to R2 and made contact with R2's face. Both notes from the electronic records revealed the staff notified management, however niether of the instances were reported to the state agency, as required. These continued incidents of resident-to-resident abuse and lack of supervision and interventions to prevent abuse, and falls placed the residents in immediate jeopardy for continued abuse.Furthermore, on 01/19/24, R16, who had a history of sexual behaviors and physical aggression, hit an unknown resident after the unknown resident bumped R16's wheelchair. On 01/24/24, R16 grabbed the breast of R12 through her shirt. Findings Included: - Resident (R) 22's Electronic Health Record (EHR) revealed diagnoses included vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), major depressive disorder (major mood disorder which causes persistent feelings of sadness) and senile degeneration of brain. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R22 had severely impaired cognition. R22 required total assistance with activities of daily living (ADL) cares such as oral care, toileting, footwear and personal hygiene; required maximal assistance with dressing, eating, and bathing; and was independent with ambulation. R22 was always incontinent of bladder and bowel. The Quarterly MDS dated [DATE], documented R22 had severely impaired cognition. R22 had physical behavioral symptoms directed toward others. R22 was independent with ambulation. The Cognitive Loss/Dementia CAA dated 02/16/24, documented R22 had an actual problem of cognition loss related to dementia. The Behavioral CAA dated 02/16/24, documented R22 had an actual problem with behavioral symptoms related to wandering. The 05/28/24 Care Plan dated 05/26/23, revised on 12/29/23, documented R22 had impaired cognitive function, dementia, or impaired thought processes. Staff instructed to provide a homelike environment and noted R22 liked to carry a baby doll to bring comfort. The care plan lacked interventions for staff related to resident-to-resident altercations. The Physician's Order dated 05/28/24, included the following orders: Divalproex (medication used to treat bipolar disorder [major mental illness that caused people to have episodes of severe high and low moods]) use and staff were to monitor for tearfulness or crying, aggression, agitation as well as adverse effects every day and night. The staff were to note the number of episodes of target behavior and a redirection code: 0=did not occur; 1=easily altered; 2=difficult to redirect, ordered 12/24/22. Trazodone HCl (antidepressant medication), 50 milligrams (mg), give 1 tablet by mouth at bedtime, related to unspecified dementia, ordered 06/22/23. Divalproex Sodium Delayed Release Sprinkle, 125 mg, give 250 mg by mouth, three times a day, related to major depressive disorder, ordered 03/08/24. Ativan (antianxiety medication) use, and staff were to monitor the resident for anxiety and anger every day and night shift for behavior monitoring. The staff were to note the number of episodes of target behavior and a redirection code: 0=did not occur; 1=easily altered; 2=difficult to redirect, ordered 04/04/24. Ativan, 0.5 milligram (mg), give 0.5 mg by mouth, every four hours as needed, for anxiety/restlessness related to terminal diagnosis, end of life for six months, ordered 04/25/24. Review of the Progress Notes from 12/01/24 to 05/28/24 documented the following resident-to-resident concerns: Review of the 03/04/24 behavior note at 07:00 PM revealed the dayshift nurse reported R22 sat at the nurse's station and got up to go to his room and his roommate told him to stop and when R22 and the nurse aide walked by him, R22 grabbed his roommate's shoulder and pulled him back toward him. The residents were separated. Review of the Progress Notes revealed the following: On 05/12/24 at 04:45 PM, R22 punched R17 in the jaw. [R17 had impaired cognition per the 03/14/24 MDS.] On 05/20/24 at 03:38 PM, R22 raised his closed fist to R2 and made contact with their face. On 05/28/24 at 12:11 PM, R22's family member reported the resident had a resident-to-resident altercation on 05/20/24, and the family member stated the facility did not notify the family they placed R22 on one-on-one. [R2 had impaired cognition per the 02/23/24 MDS.] On 05/20/24 at 03:38 PM, R22 raised his closed fist to R2 and made contact with their face. On 05/28/24 at 12:11 PM, R22's family member reported the resident had a resident-to-resident altercation on 05/20/24, and the family member stated the facility did not notify the family they placed R22 on one-on-one. On 05/28/24 at 02:57 PM, Certified Nurse Aide (CNA) C stated R22 is aggressive and would hit other residents and staff. CNA C stated she redirected R22 away from others if R22 was in a bad mood. CNA C stated R22 would have a mad expression on his face. CNA C stated that she would report resident-to-resident abuse to the charge nurse or the Director of Nursing. On 05/28/24 at 03:00 PM, Licensed Nurse (LN) H stated she was told R22 could be agitated and had placed his hands on other residents. LN H reviewed how to report any type of abuse alleged or witnessed to the Director of Nursing, Administrator, provider, family member and hospice if needed. On 05/28/24 at 03:08 PM, LN D stated was not aware R22 struck R17. LN C stated R22 hit R2 on the side of R2's face in the dining room and staff were busy at the time of the incident. CNA J witnessed the incident and reported to LN D. LN D stated she did not know why R22 hit R2, she stated that she reported the incident to the Assistant Director of Nursing, Director of Nursing, provider, hospice and family member. LN D stated a risk management completed in EHR. LN D agreed that a progress note was not completed on R2. On 05/28/24 at 03:13 PM, Administrative Staff B revealed that neither incident on 05/12/24 or 05/20/24 were reported to state agency or reported to law enforcement and stated there was no physical injury that occurred with either incident. On 05/28/24 at 03:15 PM, Administrative Staff A stated staff notified her of both incidents (05/12/24 and 05/20/24) the same date they occurred. The facility's policy for Abuse Investigation and Reporting, dated October 2021 documented all allegations of resident abuse (including physical, mental, emotional, verbal, and or sexual abuse). Any reasonable suspicion of a crime shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. The facility failed to ensure staff reported the alleged abuse to the State Agency or local law enforcement, as required for resident-to-resident abuse. These continued incidents placed the residents in immediate jeopardy for continued abuse. On 05/28/24 at 04:50 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template and notified the facility failed to ensure the timely reporting of alleged abuse to the State Agency (SA - a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required for resident-to-resident abuse, which placed the residents in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 05/29/24 at 05:15 PM which included the following: 1. Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure. (ANE), and would be completed by 05/28/24. Staff will not be allowed to work until signatures received. 2. Inter-Disciplinary Team was in-serviced on 05/28/24 for ANE reporting. 3. Staff placed R22 on a one-on-one at 05:00 PM on 05/28/24 and would remain a one-on-one until deemed no longer a threat or discharged from the facility. 4. Referrals would be sent to Behavior Units for temporary placement. 5. Hospice and Medical Director to complete a medication review. 6. Quality Assurance Performance Improvement (QAPI) meeting on 05/29/24. The surveyor verified the facility implemented the above corrective measures on-site on 05/29/24 at 05:15 PM. The deficient practice remained at a scope and severity level of an F, following the implementation of the removal plan. - R16's Electronic Health Record (EHR) revealed diagnoses of intermittent explosive disorder, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), dementia (progressive mental disorder characterized by failing memory, confusion), and sexual dysfunction. The Significant Change Minimum Data Set (MDS) dated [DATE], documented staff completed an interview to determine the resident's cognition, which indicated he had moderately impaired cognition. No behaviors were noted on the assessment. R16 required extensive assistance with activities of daily living (ADLs - such as bed mobility, toileting, and hygiene) and was independent for eating. R16 was always incontinent of bladder. The Quarterly MDS dated [DATE], documented the resident had a BIMS of seven, which indicated severe cognitive impairment. The resident had no behaviors. R16 required maximal to total dependence with ADLs and required set-up assistance for eating. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 06/27/23, documented the resident had an increased need for assistance with ADLs. The Cognitive Loss/Dementia CAA dated 06/27/23, documented the resident had a BIMS score of less than 13. The 05/29/24 Care Plan with an intervention dated 03/22/21, revealed R16 had cognitive functions, and mood and behavior. Staff were instructed to provide R16 privacy in his room with the door shut and reminded R16 to sit down when masturbating. On 09/13/23, an intervention revealed R16 had a potential for behavioral problems and staff were to administer medications as ordered and monitored for effectiveness. Staff were instructed to intervene as needed to protect the rights and safety of others and to divert the resident's attention. Staff were to remove the resident from the situation and take him to an alternate location as needed. Review of the Progress Notes on 01/19/24 at 03:07 PM revealed the resident was seated in the doorway of the dining room when an unidentified resident in an electric wheelchair bumped into R16's wheelchair. The unidentified resident yelled at R16 to get out of the way. When the unidentified resident moved close to R16's side, R16 punched the unidentified resident in the arm and yelled at the unidentified resident. The facility did not notify the state agency regarding this resident-to-resident abuse incident. Review of the Progress Notes on 01/24/24 at 12:37 PM, Licensed Nurse (LN) D documented Certified Nurse Aide (CNA) G observed R16 grab the breast of R12 through her shirt. The facility did not notify the state agency regarding the resident-to-resident abuse. On 05/30/24 at 08:45 AM, R16 seated in wheelchair in dining room for breakfast. Did not want to talk to anyone. R16 did not react when R10 took his breakfast plate that was full of his food away. During an interview on 05/30/24 at 09:01 AM, CNA F stated R16 had a history of hitting others, but she had not witnessed that. During an interview on 06/03/24 at 10:39 AM, Activity Staff K stated on 01/24/24, she did not know about the incident when R16 grabbed another resident. During an interview on 06/03/24 at 01:20 PM, Administrative Staff A stated the incident was not called into police or reported to the state agency. Administrative Staff A was not able to locate any incident information from 01/19/24 for R16. The facility's policy for Abuse Investigation and Reporting, dated October 2021 documented all allegations of resident abuse (including physical, mental, emotional, verbal, and or sexual abuse). Any reasonable suspicion of a crime shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. The facility failed to report all allegations of abuse, to include resident-to-resident abuse regarding R16.

The facility reported a census of 43 residents with 15 residents sampled, which included two residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to investigate all allegations of resident-to-resident abuse to protect residents from further incidents of abuse. The facility failed to thoroughly investigate two abuse allegations regarding R22, who had a history of hitting other residents, and continued to hit residents in the facility on multiple occasions. On 12/20/22, R22 grabbed R195's sweatshirt by the collar and pushed her wheelchair backwards. R22 let go and then grabbed her nose between his index and middle finger. He continued to pull on her nose, which caused R195 pain. On 01/01/23, R22 hit R196. On 02/06/23, R22, with a closed fist, hit R196 to the back of the head. On 06/04/23, R22 hit his spouse and then hit R30 which knocked R30 out of his chair. On 06/11/23, R22 swung a baby doll, and hit R13 twice on the face across her glasses. On 05/12/24, R22 punched R17 on the left side of R17's jaw. On 05/20/24, R22 raised his closed fist to R2 and made contact with R2's face. The facility failure to investigate, implement effective interventions and/or provide appropriate supervision to prevent further resident-to-resident abuse, placed the residents in immediate jeopardy for lack of protection. Furthermore, on 01/19/24, Resident (R)16 who had a history of sexual behaviors and physical aggression, hit an unknown resident after the unknown resident bumped R16's wheelchair. On 01/24/24, R16 grabbed the breast of R12 through her shirt. On 01/25/24, R16 masturbated in a public area. The facility did not thoroughly investigate these abuse allegations which allowed continued resident-to-resident abuse incidents. Findings Included: - Resident (R) 22's Electronic Health Record (EHR) revealed diagnoses included vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and senile degeneration of brain. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R22 had severely impaired cognition. R22 required total assistance with activities of daily living (ADL) cares such as oral care, toileting, footwear and personal hygiene; required maximal assistance with dressing, eating, and bathing; and was independent with ambulation. R22 was always incontinent of bladder and bowel. The Quarterly MDS dated [DATE], documented R22 had severely impaired cognition. R22 had physical behavioral symptoms directed toward others. R22 was independent with ambulation. The Cognitive Loss/Dementia CAA dated 02/16/24, documented R22 had an actual problem of cognition loss related to dementia. The Behavioral CAA dated 02/16/24, documented R22 had an actual problem with behavioral symptoms related to wandering. The 05/28/24 Care Plan dated 05/26/23, revised on 12/29/23, documented R22 had impaired cognitive function, dementia, or impaired thought processes. Staff instructed to provide a homelike environment and noted R22 liked to carry a baby doll to bring comfort. The care plan lacked interventions for staff related to resident-to-resident altercations. The Physician's Order dated 05/28/24, included the following orders: Divalproex (medication used to treat bipolar disorder [major mental illness that caused people to have episodes of severe high and low moods]) use and staff were to monitor for tearfulness or crying, aggression, agitation as well as adverse effects every day and night. The staff were to note the number of episodes of target behavior and a redirection code: 0=did not occur; 1=easily altered; 2=difficult to redirect, ordered 12/24/22. Trazodone HCl (antidepressant medication), 50 milligrams (mg), give 1 tablet by mouth at bedtime, related to unspecified dementia, ordered 06/22/23. Divalproex Sodium Delayed Release Sprinkle, 125 mg, give 250 mg by mouth, three times a day, related to major depressive disorder, ordered 03/08/24. Ativan (antianxiety medication) use, and staff were to monitor the resident for anxiety and anger every day and night shift for behavior monitoring. The staff were to note the number of episodes of target behavior and a redirection code: 0=did not occur; 1=easily altered; 2=difficult to redirect, ordered 04/04/24. Ativan, 0.5 milligram (mg), give 0.5 mg by mouth, every four hours as needed, for anxiety/restlessness related to terminal diagnosis, end of life for six months, ordered 04/25/24. Review of the Progress Notes revealed on 12/20/22 at 02:20 PM, R22 grabbed resident 195's sweatshirt by the collar and pushed her wheelchair backwards. R195 stated she did not react because she knows residents with dementia don't know any different. R22 let go and then grabbed R195's nose between his index and middle finger. He continued to pull on her nose, which R195 said caused her pain, and she told him to stop and pushed his hand away. Review of the Progress Notes revealed on 01/01/23 at 06:50 PM R22 hit R196 on the chest with a closed fist. Review of a Facility Reported Incident called into the state agency revealed on 02/06/23 R22, with his closed fist, hit R196 to the back of his head. The EHR for R22 lacked documentation of the 02/06/23 resident-to-resident physical abuse. Review of the Progress Notes revealed the following: On 06/04/23 at 06:42 PM, R22 hit his spouse and then hit R30 which knocked R30 out of his chair. [R30 had impaired cognition per the 05/22/23 MDS.] On 06/11/23 at 05:21 PM, R22 swung a baby doll, hitting R13 twice on the face across her glasses. [R13 had intact cognition per the 06/01/23MDS.] On 06/13/23 at 06:00 AM, R22 transferred to a behavior unit. On 06/22/23 at 01:00PM, R22 returned from a behavior unit. On 07/30/23 the CNA reported she asked the resident to stand up and go to the restroom and the resident slapped her in the face. The CNA walked away from the resident. The record lacked any other Progress Notes regarding resident-to-resident altercations between 07/30/23 and 03/04/24. Review of the 03/04/24 behavior note at 07:00 PM revealed the dayshift nurse reported R22 sat at the nurse's station and got up to go to his room and his roommate told him to stop and when R22 and the nurse aide walked by him, R22 grabbed his roommate's shoulder and pulled him back toward him. The residents were separated. Review of the Progress Notes and EHR revealed the following: A Progress Note dated 05/12/24 at 04:45 PM, revealed R22 punched R17 in the jaw. The 03/14/24 MDS in R17's EHR revealed R17 had impaired cognition. The facility lacked an investigation into the resident-to-resident altercation on 05/12/24 regarding R22 and R17. R22's Care Plan further lacked an updated interventions to deter R22's resident-to-resident aggression. A Progress Note dated 05/20/24 at 03:38 PM, revealed R22 raised his closed fist to R2 and made contact with R2's face. The 02/23/24 MDS for R2 indicated R2 had impaired cognition. The facility lacked an investigation into the resident-to-resident altercation on 05/20/24 regarding R22 and R2. R22's Care Plan lacked an updated interventions to deter R22's resident-to-resident aggression. On 05/30/24 at 08:45 AM, R22 sat in the dining room for breakfast, with one-on-one observation by staff. During an interview on 05/28/24 at 12:11 PM, R22's family member reported the resident had a resident-to-resident altercation on 05/20/24, and the family member stated the facility did not notify the family they placed R22 on one-on-one. During an interview on 05/28/24 at 02:57 PM, Certified Nurse Aide (CNA) C stated R22 is aggressive and would hit other residents and staff. CNA C stated she redirected R22 away from others if R22 was in a bad mood. CNA C stated R22 would have a mad expression on his face. CNA C stated that she would report resident-to-resident abuse to the charge nurse or the Director of Nursing. During an interview on 05/28/24 at 03:00 PM, Licensed Nurse (LN) H stated she was told R22 could be agitated and had placed his hands on other residents. LN H reviewed how to report any type of abuse alleged or witnessed to the Director of Nursing, Administrator, provider, family member and hospice if needed. During an interview on 05/28/24 at 03:08 PM, LN D stated she was not aware R22 struck R17. LN C stated R22 hit R2 on the side of R2's face in the dining room and staff were busy at the time of the incident. CNA J witnessed the incident and reported to LN D. LN D stated she did not know why R22 hit R2, she stated that she reported the incident to the Assistant Director of Nursing, Director of Nursing, provider, hospice and family member. LN D stated a risk management completed in EHR. LN D agreed that a progress note was not completed on R2. During an interview on 05/28/24 at 03:13 PM, Administrative Staff B revealed that neither incident on 05/12/24 or 05/20/24 were reported to state agency or reported to law enforcement and stated there was no physical injury that occurred with either incident. During an interview on 05/28/24 at 03:15 PM, Administrative Staff A stated staff notified her of both incidents (05/12/24 and 05/20/24) the same date they occurred. The facility's policy for Abuse Investigation and Reporting, dated October 2021 documented all allegations of resident abuse (including physical, mental, emotional, verbal, and or sexual abuse). Any reasonable suspicion of a crime shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. On 05/28/24 at 04:50 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template and notified that the facility failure to investigate all allegations of abuse to include resident-to-resident abuse, and failure to provide interventions and/or supervision to protect residents from further resident-to-resident abuse, placed the residents in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 05/29/24 at 05:15 PM which included the following: 1. Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure. (ANE), and would be completed by 05/28/24. Staff will not be allowed to work until signatures received. 2. Inter-Disciplinary Team was in-serviced on 05/28/2024 for ANE reporting. 3. Staff placed R22 on a one on one at 05:00 PM on 05/28/2024 and would remain a one on one until deemed no longer a threat or discharged from the facility. 4. Referrals would be sent to Behavior Units for temporary placement. 5. Hospice and Medical Director to complete a medication review. 6. Quality Assurance Performance Improvement (QAPI) meeting on 05/29/24. The surveyor verified the facility implemented the above corrective measures on-site on 05/29/24 at 05:15 PM. The deficient practice remained at a scope and severity level of F, following the implementation of the removal plan. - R16's Electronic Health Record (EHR) revealed diagnoses of Intermittent Explosive Disorder (an impulse disorder marked by frequent anger outbursts or aggression, which are out of proportion to the cause and create significant distress to the person. The anger episodes can be mild or sever and may involve hurting someone badly enough to require medical attention or even cause death [per the Cleveland Clinic website]), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), dementia (progressive mental disorder characterized by failing memory, confusion), and sexual dysfunction. The Significant Change Minimum Data Set (MDS) dated [DATE], documented staff completed an interview to determine the resident's cognition, which indicated he had moderately impaired cognition. No behaviors were noted on the assessment. R16 required extensive assistance with activities of daily living (ADLs - such as bed mobility, toileting, and hygiene) and was independent for eating. R16 was always incontinent of bladder. The Quarterly MDS dated [DATE], documented the resident had a BIMS of seven, which indicated severe cognitive impairment. The resident had no behaviors. R16 required maximal to total dependence with ADLs and required set-up assistance for eating. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 06/27/23, documented the resident had an increased need for assistance with ADLs. The Cognitive Loss/Dementia CAA dated 06/27/23, documented the resident had a BIMS score of less than 13. The 05/29/24 Care Plan with an intervention dated 03/22/21, revealed R16 had cognitive functions, and mood and behavior. Staff were instructed to provide R16 privacy in his room with the door shut and reminded R16 to sit down when masturbating. The care plan lacked interventions for staff related to resident-to-resident altercations. On 09/13/23, an intervention revealed R16 had a potential for behavioral problems and staff were to administer medications as ordered and monitored for effectiveness. Staff were instructed to intervene as needed to protect the rights and safety of others and to divert the resident's attention. Staff were to remove the resident from the situation and take him to an alternate location as needed. Review of the Progress Notes from 12/01/23 to 05/28/24 documented the following: On 01/19/2024 at 03:07 PM, the resident was seated in the doorway of the dining room when an unidentified resident in an electric wheelchair bumped into R16's wheelchair. The unidentified resident yelled at R16 to get out of the way. When the unidentified resident moved close to R16's side, R16 punched the unidentified resident in the arm and yelled at the unidentified resident. On 01/24/24 at 12:37 PM, Licensed Nurse (LN) D documented Certified Nurse Aide (CNA) G observed R16 grab the breast of R12 through her shirt. On 01/25/24 at 01:04 PM, LN D documented Activity Director K notified LN D that R16 was in the dining room with his penis out and masturbated in front of residents. R16 was told to stop and removed from the dining room. R16 was to see psychologist provider in two weeks. On 01/25/24 at 06:48 PM, Administrative Staff L documented the internal investigation completed regarding incidents involving R16 on 01/24/24 and 01/25/24 concluded and R16 had not intentionally touched R12's breast. R16 was provided one on one. Provider adjusted R16's medications. On 02/22/24 at 11:39 AM, documented R16 was overheard saying sexually inappropriate statements to staff. R16 stated staff made sexual comments to him. R16 was educated that the interaction was witnessed, and staff made no inappropriate comments and that he could not continue to talk to staff in that manner. During an interview on 05/30/24 at 08:28 AM, Licensed Nurse (LN) D stated that her progress notes charted in R16's EHR on 01/24/24 and 01/25/24 were accurate as to what was told to her by staff who reported what they had seen. LN D stated, Administrative Staff L investigated the two incidents that were documented and did not request a statement from her. LN D stated she did not know anything further about the investigation. LN D verified the initials in the progress note on 01/24/24 was identified as R12. LN D stated that she received Abuse, Neglect and Exploitation (ANE) education this week prior to working and last week at the facility skills fair. During an interview on 05/30/24 at 09:01 AM, CNA F stated R16 had a history of hitting others, but she has not witnessed that. CNA F stated R16 did masturbate when and where he wanted to, and that staff were to re-direct the resident to a private area. CNA F stated that ANE education was completed on 05/29/24 before work and also last week at the skills fair. During an interview on 06/03/24 at 10:39 AM, Activity Staff K stated on 01/24/24, she did not know about the incident when R16 grabbed another resident. Activity Staff K stated on 01/25/24, staff was notified that R16 was in dining room and had masturbated in front of other residents. Administrative Staff L did not request for Activity Staff K to write a statement for Administrative Staff L for either of the dates in January of 2024. During an interview on 06/03/24 at 12:00 PM, Administrative Staff A and Administrative B were questioned about R16's incidents on 01/19/24 and 01/25/24 and she stated she would look for investigations and update when found. During an interview on 06/03/24 at 01:20 PM, Administrative Staff A provided a copy of the 01/24/24 facility investigation. Stated that it was not called into police or reported to the state agency. Administrative staff A was not able to locate any incident from 01/19/24 for R16. On 06/03/24 at 02:00 PM review of the facility's undated investigation provided by Administrative Staff L revealed a signature sheet with 22 staff members signatures, and an undated, non-witnessed complaint investigation witness statement of facts with a written statement from CNA G that R16 appeared to be touching another resident's breast. The undated investigation by Administrative Staff L further contained an undated Training: Abuse and Neglect form that documented the definition of abuse as: a willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Staff were instructed that each employee was responsible to report any signs of abuse to their direct supervisor or department director as soon as possible. If staff were unsure about the signs of abuse, they were to speak with the Director of Nursing or Administrator. When in doubt staff were instructed to report the potential abuse. Review of the Abuse Prevention Program dated 10/2021 documented: Our residents have the right to be free from abuse, neglect, neglect, misappropriation of property and exploitation. The facility would develop and implement policies and procedures to aid in preventing abuse and investigate and report any allegations of abuse within timeframes as required by federal requirements. The facility's policy for Abuse Investigation and Reporting, dated October 2021 documented all allegations of resident abuse (including physical, mental, emotional, verbal, and or sexual abuse). Any reasonable suspicion of a crime shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The role of the Administrator is to assign an investigation to an appropriate individual, to prevent any further abuse. The role of the Investigator is to review completed forms, medical records, witnesses, and review all events leading up to the alleged incident. The facility would notify the Ombudsmen and ensure reporting of all alleged violations involving abuse etc. to state licensing/certification agency. The facility would notify the Ombudsman, adult protective services, and law enforcement within 2 hours if the alleged violation involved serious bodily injury, or 24 hours if not resulted in a serious bodily injury. The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident abuse, regarding R16.

The facility reported a census of 43 residents, with 15 included in the sample. Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when the hot water in four resident rooms and a beauty shop measured at hazardous levels ranging between 138 and 157 degrees Fahrenheit (F). This failure affected six residents (Resident (R) 3, R15, R19, R22, R29, and R30) two of which were cognitively impaired and independently mobile, and any resident who received services in the beauty shop rinse sink. This failure placed the residents in immediate jeopardy to their health and safety and at risk for burns and injury related to hot water exposure. Furthermore, the facility failed to thoroughly document and place effective interventions for each of R24's 12 documented falls since 03/26/24 (approximately 2 months). The facility also failed to conduct thorough fall investigations and provide adequate supervision and effective fall interventions to prevent falls for cognitively impaired R30, who fell multiple times with not fall prevention interventions implemented. Two of the falls experienced by R30 resulted in major injury (one fall resulted in a broken right hip and within a month he fell and broke his left hip) which required emergency medical treatment and surgical repair. Findings included: - During the annual onsite survey on 05/28/24, several residents mentioned hot water concerns. Resident (R) 3 reported the water in their room was hot and the resident reported they told the aides about it several weeks ago. Another resident stated the hot water got really hot and they had to adjust it to keep from being burned. R19 reported they used the hot water in the bathroom about every other day and it got hot, and they had to turn it down. The surveyor observed concerns regarding hot water temperatures in the sinks in several resident rooms, which affected resident rooms at the end of the 200 hallway. The surveyor found the following hot water at hazardous temperatures: At 10:18 AM the water temperature at the sink in room [ROOM NUMBER] measured 157 degrees F. At 10:20 AM the water temperature at the sink in room [ROOM NUMBER] measured 144 degrees F. At 10:24 AM the water temperature at the sink in room [ROOM NUMBER] measured 152 degrees F. At 10:39 AM the water temperature at the sink in room [ROOM NUMBER] measured 140 degrees F. At 11:00 AM the beauty shop had a temp of 138 degrees F in the wash out sink. Maintenance Staff Q checked the hot water temperatures at the same time, using his thermometer, and verified the temperatures matched the temperatures taken by the State Surveyor. The likelihood for a serious adverse outcome exists, due to the hazardous water temperatures affecting the Beauty shop and four resident rooms. Two of the four residents residing in the resident rooms were cognitively impaired and independently mobile. A third-degree burn (penetrate the entire thickness of the skin and permanently destroys tissue) can occur after skin exposure to hazardous hot water temperatures of 155 degrees F in 1 second, 148 degrees F in 2 seconds, 140 degrees F in 5 seconds, and 133 degrees F in 15 seconds. This placed the elderly residents, who have decreased thermal skin barriers, at increased risk for severe burns and injury. During an interview on 05/28/24 at 12:05 PM Maintenance Staff Q reported the facility installed a new water heater on 03/27/24. The gauge on the tank was set for 120 degrees F and no higher. He stated he checked the water temps in some of the resident rooms one week and the other the following week. He recorded the temps in TELS (maintenance program) and would print those. Maintenance Staff Q said he did not know of the elevated water temperatures and had not run across any hot water temperatures above 120 degrees F. On 05/28/24 at 02:15 PM Maintenance Staff Q provided water temperature logs and explained he checked the water temperature on three different rooms, on each hall, and then averaged those for the hall temperature on the water logs. During an interview on 05/28/24 at 02:20 PM Maintenance Supervisor R reported it would take him until next week to go to Wichita to buy a temperature gauge and install it on the tank. Until that time, he would have Maintenance Staff Q check the water temperature of the four rooms and beauty shop. Maintenance Supervisor R reported the temperatures were within normal, now that they turned the tank down and drained it to start it over. The temperatures were now below 120 degrees F in all four rooms and the beauty shop. On 05/28/24 at 12:24 PM Maintenance Supervisor R reported there was a small hot water tank on the end of 200 hall in an employee restroom. He stated when he went to check the tank, something had been pushed up against the tank and turned the setting up, which caused the hot water at the end of that (200) hall and the beauty shop. He said he was not aware Maintenance Staff Q did not know of the water tank and had not been monitoring it. Maintenance Supervisor R stated it had been at least three months since the hot water tank had been checked. On 05/28/24 at 12:30 PM Administrative staff A reported she felt like the facility had a system in place to monitor the water temps and was unsure how the water heater on the 200-hall got turned up so high to heat the water as hot as it was. Review of the facility policy named Environment-Water Temperatures dated October 2021 revealed Management staff and Environmental Services will provide safe and comfortable water temperatures for resident use at a variation from 98 degrees Fahrenheit to a maximum of 120 degrees Fahrenheit. Environmental Service Staff will monitor water temperatures for proper temperatures by testing and documenting water temps on a weekly basis. Areas tested should include sinks closest to the water heating systems and furthest away. On 05/28/24 at 04:25 PM the surveyor provided the IJ Template to Administrative Staff A and Administrative Nurse B and notified the facility failure to ensure safe hot water temperatures for four resident rooms, affecting and a beauty shop, placed the residents in immediate jeopardy and at risk for severe burn and injury. The facility submitted an acceptable plan for removal of the immediacy on 05/28/24 at 06:18 PM, which included the following: 1. Staff in-serviced on facility Physical Environment - Water Temps Policy and Procedure (P&P), completed by 05/28/24. Staff would not be allowed to work until signatures were received. 2. The facility drained the hot water tank at the end of the 200 hall on 05/28/24. 3. The facility checked the temperature of all rooms after the tank was drained and all were below 120 degrees on 05/28/24. 4. The facility ordered a new temperature gauge for the hot water tank on 05/28/24. 5. The facility will check the water temperatures daily for 30 days for rooms 209, 210, 211, 212, and then resume weekly temperature checks per policy. 6. We will have a QAPI meeting 05/29/24 to review. The surveyor verified the facility implemented the corrective actions, while onsite 05/29/24 at 08:00 AM. The deficient practice remained at an E scope and severity, after removal of the immediacy. 46960 - R30's Electronic Health Record (EHR) included diagnoses of diabetes mellitus type 2 (DM2- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), dementia (a progressive mental disorder characterized by failing memory, confusion), repeated falls and need for assistance with personal care. The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. R30 required setup and supervision with all cares with the exception of oral care and bathing, which were dependent on staff for completion, and eating which was performed independently. The assessment documented that R30 had fallen since admission to the facility. The Medicare 5 Day MDS dated [DATE] documented a BIMS score of four, which indicated severely impaired cognition. R30 required substantial/maximal assistance or dependence on staff for all cares. The assessment documented R30 had a fall within the 30-day look-back period, a fracture related to a fall in the six-month look-back period, major surgery in the 100-day look-back period which required skilled nursing facility (SNF - a facility that provides inpatient skilled nursing care to those who need medical, nursing, or rehabilitative services) and a repair of fractures of the hip. The Falls Care Area Assessment (CAA) dated 02/15/24 documented R30 was a high risk of falls related to antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) and history of falls. The 05/29/24 Care Plan documented that on 03/15/22 R30 was a high risk for falls related to lower leg weakness and confusion and included the following interventions: On 03/29/22, staff were to educate the resident/family/caregivers about safety reminders and what to do if a fall occurred. On 03/29/22, staff were to ensure R30 wore appropriate footwear (shoes or non-slip socks) when ambulating (walking). On 03/29/22, staff were to follow the facility fall protocol and provide a safe environment free from spills or clutter with adequate glare-free light, and a working and reachable call light. Staff were to place the bed in the low position at night and place personal items within reach of the resident. On 05/26/24, staff were to be educated related to the placement of the bedside table when the fall mat was in use. Review of the Fall Risk Assessments in the EHR revealed the facility identified R30 as a high risk for falls on 10/18/23. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 09:45 AM revealed the resident had a fall during the day. Assistive devices were not being used appropriately at the time of the fall and the resident had a skin tear. The assessment lacked any other description of the fall. The Progress Notes documented on 02/03/24 at 09:45 AM, R30 was found on the floor with a skin tear to his left forearm. Review of the Fall Report revealed on 02/03/24, R30 fell and sustained a minor injury. The facility determined that the root cause was that R30 had weakness and fatigue from an infection. The fall report lacked an immediate intervention by staff on duty to mitigate the risk of falls or a care planned intervention to prevent future falls. The Fall Risk Assessment staff completed for R30 after his 02/03/24 fall, identified R30 as a low risk for falls. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 02:30 PM revealed the resident had a fall during the day. The resident had on grip socks at the time of the fall. The resident had a skin tear to the right elbow and possible hip fracture. The resident walked into the dining room from physical therapy, lost his balance, and fell on to his back, hitting his head on the parallel bars. The resident reported his pain was at an 8 on a scale of 10 to the right hip. The facility called an ambulance to transport the resident to the hospital for further assessment. The Progress Notes dated 04/04/24 at 02:45 PM, revealed R30 was sent to the hospital by ambulance for a possible right hip fracture, and lacked additional documentation related to the fall or any injuries. Review of the Fall Report revealed on 04/04/24, R30 fell and sustained skin tears to the right elbow and a right hip fracture that required hospitalization and surgical repair. The facility's fall report lacked identification of the causal factor of the fall, immediate interventions implemented by the staff on duty or care plan interventions to prevent future falls. The Fall Risk Assessment completed for R30 after his 04/04/24 fall, identified R30 as a high risk for falls. The Progress Notes dated 04/08/24 at 10:58 PM, revealed R30 readmitted to the facility from the hospital after surgical stabilization of a right hip fracture. The 04/09/24 readmission Fall Risk Assessment identified R30 as high risk for falls. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 05:00 PM revealed the resident had a fall during the day. The resident was found on the floor in the dining room. The assessment lacked any other description of the fall. The Progress Notes dated 04/14/24 at 05:00 PM, revealed R30 was found on the floor in the dining room with no documented injuries. Review of Fall Report revealed on 04/14/24, R30 fell without injury. The facility determined that the causal factor of the fall was old age and confusion with cancer diagnosis [Review of R30's EHR revealed no cancer diagnoses]. The fall report documented the immediate intervention implemented by staff on duty was visual checks every two hours, however the care plan lacked a permanent intervention to prevent future falls. The Fall Risk Assessment completed for R30 after his 04/14/24 fall, identified R30 as a high risk for falls. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 07:50 PM revealed the resident had a fall in the evening. Staff observed the resident laying on the floor next to his wheelchair in the dining room and the resident could not say exactly what happened to cause the fall. The Progress Notes dated 04/22/24 at 01:25 AM, revealed R30 was found on the floor in the dining room with no injuries. Review of Fall Report revealed on 04/21/24, R30 fell without injury. The facility's fall report lacked identification of the causal factor of the fall, immediate intervention implemented by staff on duty, or permanent care plan intervention to prevent future falls. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 04:00 PM revealed the resident had a fall during the day. The resident had a hip fracture, received narcotic pain medications, and wore grip socks. The resident was chronically confused. He was found on the floor in his room, lying in his back, and parallel to his bed. Review of Fall Report revealed on 04/22/24 R30 fell without injury. The facility's fall report lacked identification of the causal factor of the fall, immediate intervention implemented by staff on duty, or permanent care plan intervention to prevent future falls. The Fall Risk Assessment completed on 04/22/24 identified R30 as a high risk for falls. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 01:00 AM revealed the resident had a fall during the night. The resident had skin tears to bilateral elbows. The skin tears were cleansed, and staff applied bordered gauze and a Band-Aid. The Progress Notes dated 04/23/24 at 03:14 AM, revealed R30 was found on the floor by his bed with skin tears to both elbows. Review of Fall Report revealed on 04/23/24 R30 fell . The facility's fall report lacked documentation of whether or not the resident sustained an injury. Additionally, the fall report lacked a completed RCA, or permanent care plan intervention to prevent future falls. The fall report documented an immediate intervention from staff on duty to obtain a urinalysis (UA - laboratory analysis of the urine) order from the provider. The Fall Risk Assessment completed on 04/23/24 identified R30 as a high risk for falls. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 06:20 AM revealed the resident had a fall during the day. The resident had pain to his left leg and staff placed a call to emergency management services. The assessment lacked any other description of the fall. The Progress Notes dated 05/02/24 at 06:32 AM, revealed R30 was found seated on the floor in his room and cried out with pain when staff attempted to assist him off the floor. The resident complained of isolated pain to his left leg. Review of Fall Report revealed on 05/02/24 R30 fell . The facility's fall report lacked documentation of any injuries, identification of causal factor, or an identified care plan intervention to prevent future falls. The immediate intervention implemented by staff was for staff to perform more frequent visual checks after resident was laid down. The Progress Notes dated 05/02/24 at 07:04 AM, revealed R30 transferred to the hospital via ambulance for further assessment of the left hip. The Fall Risk Assessment completed on 05/02/24 identified R30 as a high risk for falls. The Progress Notes dated 05/06/24 at 03:06 PM, revealed R30 readmitted to the facility from the hospital with surgical incisions present on his left hip. The Fall Risk Assessment completed on 05/06/24 identified R30 as a high risk for falls. Review of the Interdisciplinary Team (IDT) Fall assessment dated [DATE] at 10:30 AM revealed the resident got out of bed on his own without using assistive devices. The resident had pain his left hip and skin tears to the right and left upper extremities. R30's provider ordered an x-ray of his left hip. The resident was found on the floor on his left hip after attempting to sit up on the side of the bed to eat his breakfast. The resident's fall mat was not in place next to the side of the bed because the bedside table was in the way. Staff were educated to keep the fall matt at the side of the bed at all times and attempt to have resident get out of bed to eat meals to attempt to prevent falls from occurring. The Progress Notes dated 05/26/24 at 12:09 PM, revealed R30 was found on the floor by another (unnamed) resident with skin tears on the right lower leg and left upper arm and the provider ordered an x-ray (an imaging study that takes pictures of bones and soft tissues) of the left hip. The Progress Notes dated 05/26/24 at 12:19 PM, revealed facility staff documented the results of the x-ray of a possible nondisplaced fracture, and the physician recommended follow-up appointment with surgeon who repaired the hip following the fall on 05/02/24. Review of the Fall Report revealed on 05/26/24 R30 fell . The facility's fall report lacked documentation of any injuries, or any immediate interventions implemented by staff on duty. The facility determined the causal factor of the fall was the mattress (fall mat) was moved away from the bed and the lack of help getting the resident up at breakfast. The Fall Risk Assessment completed on 05/26/24, identified R30 as a high risk of falls. Observation of R30 on 05/29/24 at 01:32 PM revealed the resident sat in a high back wheelchair in the common area across from the nurse's station. The resident had ace wraps noted to both lower legs/feet, with toes exposed. The resident sat quietly and with shoulders hunched forward a bit and an unshaven face. R30 did not display signs of pain or attempts to get out of his wheelchair. He sat in his wheelchair and watched people walking by the area. On 05/30/24 at 09:20 AM, Certified Nurse Aide (CNA) M stated in the event of a resident fall, one CNA should stay with the resident and make them as comfortable as possible without moving them, while another CNA or staff member alerted the nurse. Once the nurse completed their assessment, the CNAs would obtain the resident's vital signs and follow the nurse instructions. On 05/30/24 at 11:14 AM, Licensed Nurse (LN) D stated if a resident were to fall, a CNA would stay with the resident and alert other staff to notify the nurse. Then the nurse would go assess the resident and render aid as needed, then the staff collectively would assist the resident off of the floor safely if possible. After the fall crisis was over, the LN were to notify the physician, Administrative Staff A, Administrative Nurse B, and the resident's responsible party. The LN would then fill out the fall packet which included a root cause analysis (RCA) and initiate an immediate intervention for the rest of the shift and communicate that to the staff on duty. The fall packet was then placed in the folder for Administrative Nurse E for her to review and create a permanent intervention in the care plan to prevent future falls. On 05/30/24 at 09:50 AM, Administrative Nurse E stated that after the crisis of a fall was over, the LN on duty would complete the fall packet which included a root cause analysis and would develop an immediate intervention to put in place for the remainder of the shift or until the stand-up meeting on the following business day. Administrative Nurse E further stated that the nurses on the clinical floor had the ability to make additions to the care plan. If they were not able to develop a care plan intervention after a fall, they should write a note on the fall packet submitted to Administrative Nurse E and administration would implement a permanent care plan intervention. Administrative Nurse E stated when reviewing fall reports, if a fall with major injury was discovered, she would alert Administrative Nurse B that a report needed to be filed with the State Agency (SA). Further stated for R30's fall on 04/04/24, Administrative Nurse N was notified of the need to file a report with the SA due to fracture of the right hip that required hospitalization and surgical repair. Additionally stated that for R30's fall on 05/02/24, Administrative Nurse B was notified of the need to file a report with the SA due to a fracture of the left hip that required hospitalization and surgical repair. On 06/03/24 at 08:58 AM, Administrative Nurse B stated she expected all treatments and modalities of care provided to the residents to be documented on the care plan. Administrative Nurse B stated she was unable to give an explanation as to why the care plan was missing information. The facility's Falls and Fall Risk, Managing policy, dated 10/2021, documented staff would identify interventions related to the resident's specific risks and cause based on previous evaluations and current data, to prevent the resident from falling and try to minimize complications from falling. Staff would monitor and document each response to interventions intended to reduce falling and re-evaluate as needed. The facility's Accidents and Incidents - Investigating and Reporting policy, dated 10/2021 documented that all accidents or incidents shall be investigated and reported to administration and that accident reports would be reviewed by the safety committee or QAPI (quality assurance process improvement - a process through which facilities improve the quality of care and services delivered to residents) for trends related to accident or safety hazards in the facility and would analyze individual resident vulnerabilities. The facility failed to provide a policy about quality of life related to accident/safety hazards as requested on 06/03/24. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being for a cognitively impaired resident who was identified with a high risk for falls, R30. The facility failed to implement interventions after multiple falls experienced by R30. On 04/04/24 R30 fell which resulted in a fractured right hip (which required hospitalization and surgical repair), fell again on 04/14/24, 04/21/24, 04/22/24, 04/23/24, on 05/02/24 (resulted in a fractured left hip which also required hospitalization and surgical repair), and on 05/25/24. These cumulative failures of care plan revision and accidents regarding the numerous falls for R30, resulted in deficient practice for quality of life, and had a negative psychosocial outcome, related to the risk for further falls, further injury, pain, decreased range of motion, and delayed healing of surgical repairs. The facility failed to ensure appropriate and effective fall prevention interventions and thorough fall investigations for cognitively impaired R30, who was identified with a high risk for falls and had a fall history, to prevent repeated falls with major injury. The facility failed to implement fall prevention interventions after multiple falls experienced by R30. On 04/04/24, R30 fell which resulted in a fractured (broken bone) right hip and required hospitalization and surgical repair. R30 fell four additional times in April (04/14/24, 04/21/24, 04/22/24, and 04/23/24), resulting in skin tears and placing the resident at risk for further injury and delayed healing to the right hip healing fracture. Less than a month after R30's fall with a right hip fracture, R30 fell again on 05/02/24, which resulted in a fractured left hip which also required hospitalization and surgical repair. R30 fell again on 05/26/24, for the seventh time in two months. - Review of R24's Electronic Health Record (EHR) revealed the following diagnoses: senile degeneration of brain, muscle weakness (generalized), other abnormalities of gait and mobility, need for assistance with personal care, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness, essential (primary), right shoulder, pain in right shoulder, and impulse disorder. Review of the 01/23/24 Significant Change Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of three, which indicated significantly impaired cognition. The resident had inattention behavior present, which fluctuated. The resident rejected care and wandered one to three days of the lookback period. The resident's wandering put the resident at risk of getting into a potentially dangerous place and intruded on the privacy or activities of others. The resident had no falls since the last assessment. Review of the Falls Care Area assessment dated [DATE] revealed R24's care plan would reflect his high risk for falls and his goal of minimizing risks. Review of the 04/19/24 Quarterly MDS revealed the resident had a BIMS score of two, which indicated severe cognitive impairment. The resident had rejection of cares, which occurred one to three days of the lookback period. The resident had wandering behaviors, which occurred four to six days of the lookback period. The resident had a fall since entry or the prior assessment. The resident had two or more non-injury falls since admission or prior assessment. Review of the Care Plan started 04/02/24 with a completion date of 04/30/24 revealed the following interventions: On 08/18/20 the staff were to monitor the resident's vital signs per protocol and take the resident's blood pressure lying/sitting/standing one time within the first 24 hours after the fall. On 08/20/20 the staff were to know the resident required supervision of one staff for toilet use. On 08/20/20 the staff were to encourage the resident to participate to the fullest extent possible with each interaction. On 08/20/20 the staff were to encourage the resident to use the call light to call for assistance. On 08/20/20 the staff would monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. On 06/14/23, for no apparent acute injury, the staff were to determine and address causative factors of the fall. On 06/14/23, the staff were to monitor/document/report as needed for 72 hours to the resident's physician any signs/symptoms, which included: bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, and agitation. Review of the Fall Risk Assessments in the EHR from 01/02/24 to 05/27/24 revealed the resident had a high risk for falls. Review of the Interdisciplinary Team Post Fall assessment dated [DATE] at 09:00 PM revealed the resident appeared to be trying to sit at a table in the dining hall on a rolling chair that was located near the resident. Staff would ensure the rolling chairs were removed from the dining hall once the feeders were done eating. Review of the 03/27/24 Fall Report Charting revealed the resident was found on his back, on the floor in dining hall near a rolling chair. It appeared the resident tried to sit at the table on a rolling chair. The resident had no injuries noted at the time of the fall. Review of the resident's Care Plan lacked any interventions that corresponded to the 03/26/24 fall. Review of the Interdisciplinary Team Post Fall assessment dated [DATE] at 08:15 PM revealed the resident was already on fall charting, confused, and hard to re-direct at times. Review of the Nurse's Note dated 03/28/24 at 08:15 PM revealed the resident had a fall. The resident was in a wheelchair and an assessment completed with no injury noticed. The resident could not tell what happened but complained when asked specifically about pain, that his back hurts. Staff were to take the resident to the bathroom and lay him down after dinner. The note lacked any further description of the fall. Review of the resident's Care Plan lacked any interventions that corresponded to the 03/28/24 fall. Review of the Interdisciplinary Team Post Fall assessment dated [DATE] at 06:00 PM revealed the resident removed their socks and slippers. The resident was found on floor of their room during evening medication pass by a Certified Medication Aide (CMA). The resident laid on his back with his pants and brief removed. The resident was assisted into wheelchair and staff placed a new brief and pants on the resident. Review of the Nurse's Note dated 04/01/24 at 06:00 PM revealed the resident was found lying on the floor on his back during the evening medication pass by the CMA. The resident removed his brief and pants and voided on the floor. The floor was free of clutter, besides the blanket that the resident kept wrapped around him. Review of the resident's Care Plan revealed an intervention dated 04/02/24 for staff to toilet R24 every two hours. Review of the Interdisciplinary Team Post Fall assessment dated [DATE] revealed an incomplete assessment. Review of the Nurse's Note dated 04/12/24 at 02:34 PM revealed the nurse writer and the Social Service Designee (SSD) walked down the hallway and saw the resident laying on the floor next to his bed and covered in urine. Review of the resident's Care Plan lacked any interventions that corresponded to the 04/12/24 fall. Review of the Interdisciplinary Team Post Fall assessment dated [DATE] at 11:00 AM revealed the resident removed gripped socks. Review of the Nurse's Note dated 04/15/24 at 11:08 AM revealed staff found the resident in front of the door to his room with his back against his roommate's bed. The resident's legs were in front of him and straight. Staff were to provide more frequent checks to the resident when resting in his room between meals. Review of the resident's Care Plan lacked any interventions that corresponded to the 04/15/24 fall. Review of the Interdisciplinary Team Post Fall assessment dated [DATE] at 05:00 PM revealed the resident stood up and held hands with another resident who was in a wheelchair. The resident lost his balance and fell to the ground. Review of the Nurse's Note dated 04/25/24 at 10:24 AM revealed the resident remained on fall follow up for a witnessed fall. Review of the undated Certified Nurse Aide (CNA) Fall Investigation revealed staff last saw the resident in the dining room. The resident was having a hard time walking in the morning and during the day. The form asked the CNA what could be done to prevent further falls for the resident and they replied, Do like a balance test. When asked why the resident fell the CNA stated, he was holding hands with another resident and loss his balance The CNA further stated maybe staff could educate the resi [TRUNCATED]

The facility census totaled 43 with 15 in the sample and two residents reviewed for pressure injuries. Based on observation, interview, and record review the facility failed to place interventions to prevent pressure injuries (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) for Resident (R) 30, and R3 who developed preventable, facility acquired, stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure injuries at the facility, and for R26, related to stage 3 pressure injury. The facility further failed to place interventions on the resident's care plans to prevent worsening of the wounds. Findings included: - Review of R30's Electronic Health Record (EHR) revealed the resident had the following diagnoses: displaced intertrochanteric fracture of left femur (broken left hip), type 2 diabetes mellitus without complications (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), displaced intertrochanteric fracture of right femur (broken right hip), pain in left hip, and weakness. Review of the Annual Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Score of 07, which indicated moderately impaired cognition. The resident required set up or clean up assistance with toileting, personal hygiene, and lower body dressing. The resident was independent with rolling/turning in bed, lying to sitting, and sitting to standing. The resident was always had bladder incontinence and was frequently had bowel incontinence. The resident had no pressure injuries at the time of the assessment. The resident did not have a pressure reducing device for his chair, pressure reducing device for his bed, and was not on a turning/repositioning program. Review of the Pressure Ulcer/Injury Care Area assessment dated [DATE] revealed the resident had a risk for developing pressure injuries related to bowel and bladder incontinence. The resident's care plan would address his incontinence with a goal of avoiding complications. Review of the 5-Day MDS assessment dated [DATE] revealed the resident had a BIMS of 04, which indicated severely impaired cognition. The resident had functional limitation in range of motion on both sides. The resident was dependent on staff for toileting hygiene and lower body dressing. The resident required partial/moderate assistance to roll left and right, to go from sitting to lying, and lying to sitting. The resident required a formal assessment for pressure injury risk and a clinical assessment. The resident had a risk of developing pressure injuries and had no unhealed pressure injuries at the time of the assessment. The resident had surgical wounds and skin tears. He required a pressure reducing device for his chair and bed but was not on a turning/repositioning program. Review of the 04/09/24 and 05/06/24 Braden Scale for Predicting Pressure Ulcer Risk assessments revealed the resident had a risk for pressure ulcer development. Review of the R30's Care Plan revealed the following interventions: 04/11/24 - Staff were to know the resident had an activity of daily living self-care performance deficit related to dementia. 04/11/24 - Staff were to know the resident had bladder incontinence related to cognitive dysfunction. 04/12/22 - Staff were to know the resident could reposition himself independently in bed. The resident's care plan lacked an update to indicate he required partial/moderate assistance to roll in bed per the 05/10/24 MDS assessment. The resident's care plan lacked any intervention intended to prevent the development of pressure injuries, even though the resident was identified as at risk on 04/09/24 and 05/06/24 and after surgical repair of both left and right femur fractures. Review of Skin Only Evaluations lacked evidence staff performed a full body assessment of the resident's skin. The assessments identified actual wounds, but no other information or description of what areas were reviewed/assessed. Review of the 05/17/24 Skin Only Note lacked any specific assessment of the resident's buttocks. Review of the 05/19/24 at 02:36 PM Skin Only Note revealed the resident had a skin issue to the right buttock, which measured 2.0 centimeters (cm) length (l) by 0.5 cm width (w) by 0.1 cm depth. The resident further had a skin issue to the left buttock, which measured 3.0 cm l by 0.5 cm w by 0.1 cm d. The note lacked any further description of the wound and or notification of the resident's physician. The resident's care plan lacked any interventions related to pressure injuries when the resident developed actual pressure injuries to the left and right buttocks on 05/19/24. Review of the 05/22/24 at 02:31 PM Skin Only Note revealed the resident had a wound to the left buttock, which was identified as a stage 3, full thickness, pressure injury, which measured 1.1 cm l by 0.6 cm w by 0.1 cm depth. The wound had a moderate amount of drainage noted. The note identified wounds to the resident's right lower extremity and right forearm were resolved but lacked any further documentation of the wound to the resident's right buttock identified on 05/19/24. The resident's care plan lacked any interventions related to pressure injuries when the resident developed actual pressure injuries to the left and right buttocks on 05/19/24. Review of the resident's Physician's Orders revealed an order, which was active on 05/23/24 (one day after the wound to the resident's buttock was identified) for staff to cleanse the resident's left buttock with wound cleanser, apply calcium alginate (highly absorbent dressing) to the wound base (cut to fit inside wound edges), and cover with bordered foam dressing. Review of the resident's Physician's Orders lacked any orders for the resident's right buttock wound. Review of the 05/31/24 at 03:14 PM Skin Only Evaluation revealed the resident had a wound to the left buttock, which was identified with 85 percent slough (dead tissue, usually cream or yellow in color) and 15 percent epithelial (new skin growing in a superficial wound) tissue. The note identified the wound as a stage 3, full thickness, pressure injury, which measured 0.9 cm l by 0.9 cm w. The wound had moderate drainage present. The note lacked any further documentation of the wound to the resident's right buttock identified on 05/19/24. Review of the 05/31/24 Skin Only Evaluation at 11:31 PM lacked any documentation regarding the resident's wound to his buttocks. The resident's care plan lacked any interventions related to pressure injuries when the resident developed actual pressure injuries to the left and right buttocks on 05/19/24. Review of the Skin Observation Task documentation revealed staff marked none of the above present from 05/06/24 to 06/03/24 when asked if the resident had scratches, red areas, discoloration, skin tears, open areas, if the resident refused assessment, and if the resident was not available all but one time on 06/01/24 when the resident was identified with a skin tear. The documentation noted no skin conditions present even though the resident had two documented pressure injuries and multiple skin conditions related to recent falls. Observations on 06/03/24 revealed the following: At 07:35 AM the resident was in bed laying on his back with no pressure reducing measures in place to prevent worsening of his stage 3 pressure injury to the buttocks. At 07:50AM the resident remained in bed and on his buttocks. At 08:05 AM the resident remained on his back and on his buttocks. At 08:20 AM the resident was repositioned in bed and laying on his left side. Observation of Licensed Nurse (LN) H on 06/03/24 at 09:03 AM as she performed wound care revealed she cleansed the wound, placed calcium alginate on wound bed, secured the open area with bordered gauze dressing, and estimated the measurement the wound. At the time of the observation the wound was estimated to measure 3 cm by 0.1 cm by 0.0 cm. The resident's bed lacked an air mattress at the time of the observation. During an interview with Administrative Nurse E on 05/30/24 at 09:50 AM she confirmed the resident's pressure injury and associated interventions were not on the resident's care plan but should have been. During an interview on 05/30/24 at 01:00 PM with Administrative Nurse B she acknowledged the resident's care plan lacked crucial information regarding the resident condition and/or a plan to care to care for the resident. She expected the resident's care plan to be accurate to the resident's needs and updated as needed. The facility's Pressure Injuries Overview policy, dated 03/2020, documented the purpose of the procedure was to provide information regarding definitions and clinical features of pressure injuries but lacked guidance related to the actual care of pressure related injuries. The facility failed to place interventions to prevent pressure injuries for R30, who developed a preventable, facility acquired, stage 3 pressure injury. The facility further failed to place interventions on the resident's care plan to prevent worsening of the wound. 50659 - Resident (R) 3's Electronic Health Record (EHR) revealed diagnoses that included a pressure ulcer of the right heel stage three (full thickness pressure injury extending through the skin into the tissue below), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R3 required maximal assistance with activities of daily living (ADL's lower dressing). R3 required total dependence for transfers and toileting. Partial to moderate assistance with wheelchair mobility, bed mobility, personal hygiene, bathing, and upper body dressing. R3 was incontinent of bowel and bladder. R3 was at risk for potential problems of developing pressure ulcer/injuries. The Quarterly MDS dated [DATE], documented a BIMS of 15. No changes in ADL's. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/02/24, documented the resident required assistance with functional abilities related to acquired loss of the lower limb. The Pressure Ulcer CAA dated 01/02/24, documented the resident had a potential problem of developing pressure ulcer/injury related to incontinence and required maximal assist for transfers. R3's care plan would reflect her risk of pressure ulcer/injury as well as her goal of minimizing risks and avoiding complications. The review of the Care Plan reviewed on 05/29/24, lacked documentation and interventions related to pressure ulcer prevention and/or identifiecation of a facility acquired pressure ulcer on R3's right heel stage three. The Physician's Order dated 05/29/24, documented the following: Prevalon boots (have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure), ensure the heel is free of the surface of the bed by use of Prevalon boots, with pillows under the knees to prevent hyperextension. Apply every day and every night for wound care, ordered on 01/23/24. Right heel Felt pad, cut-to-fit peri wound (skin surrounding the wound) to offload pressure from the wound. Felt pad when ambulating with Physical therapy every 24 hours as needed for ambulating with physical therapy, ordered on 05/10/24. Right lateral heel to be cleansed with normal saline, apply hydrofera blue (a type of moist wound dressing which provides wound protection and addresses bacteria and yeast) to the wound bed, cut to fit, apply border foam, medipore tape every day shift every other day, for wound care. Assess pulse, if unable to palpate use doppler (ultrasonography used to evaluate the direction and pattern of blood flow) and every 24 hours as needed if soiled or dislodged, ordered on 05/21/24. Review of the Progress Notes from 12/26/23 to 05/28/24 documented the following: On 01/23/2024 at 10:30 AM, noted the right lateral (away from the mid-line) heel had a deep tissue pressure ulcer (DTI- purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear), non-blanchable (skin that does not turn white when pressed, indicating poor blood flow or damage), deep red, maroon or purple discoloration. On 02/02/2024 at 10:09 AM, R3's right lateral heel had a DTI non-blanchable, deep red, maroon or purple discoloration. The wound margin undefined. The wound bed has 76-100 percent (%) epithelialization (the process of becoming covered with or converted to epithelium). The wound had improved. On 04/19/24 at 01:20 PM, documentation revealed the right lateral heel pressure ulcer stage three, with full thickness skin loss. On 05/22/2024 at 12:03 PM, the right lateral heel pressure ulcer stage three, improved. On 05/28/24 at 10:02 AM, R3 stated that she acquired a pressure ulcer on her right heel after being admitted to the facility. R3 stated it appeared a couple of weeks after being admitted . R3 stated she was provided with a heel boot to wear in bed, a trapeze on the bed and an air mattress after she acquired the wound. She stated she had appointments at a wound clinic and at the facility by a wound nurse, they provided treatments for her left leg surgical site that she had when she admitted . On 05/30/24 at 10:10 AM, Administrative Nurse E stated R3 did not have a care plan for stage three pressure ulcer or any skin interventions on the care plan. Stated that the Director of Nursing completed the weekly skin rounds and assumed that she would add that to the care plan. Administrative Nurse E stated R3's care plan was incomplete as the ADL section did not have staff instructions on how to provide ADL and agreed care plan intervention section had the word specify in that area of care plan. Administrative Nurse E stated that she and other staff members received education by Consultant Staff S in April and May of 2024. Administrative Nurse E stated Consultant Staff S was not happy how the care plans looked and that everyone needed to complete their parts of the care plan. Administrative Nurse E agreed R3 had a care plan meeting she attended on 03/20/24 and did not notice the care plan was not completed. On 05/30/24 at 01:00 PM, Administrative Nurse B reported there needed to be more detail on care plans that were lacking crucial information regarding the resident condition and the plan to care for the resident. She expected the care plans to be accurate and updated as needed. The facility's Pressure Injuries Overview policy, dated 03/2020, documented the purpose of the procedure was to provide information regarding definitions and clinical features of pressure injuries but lacked guidance related to the actual care of pressure related injuries. The facility failed to place interventions to prevent pressure injuries for R3, who developed a preventable, facility acquired, stage 3 pressure injury. The facility further failed to place interventions on the resident's care plan to prevent worsening of the wound. 46960 - R26's Electronic Health Record (EHR) included diagnoses of diabetes mellitus type 2 (DM2- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), unsteadiness on feet, need for assistance with personal cares and hemiplegia (paralysis of one side of the body). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The assessment documented that R26 had an unstageable pressure ulcer/injury present on admission with pressure relieving devices on his bed and on his chair/wheelchair. The Care Area Assessment (CAA), dated 09/02/23, documented that R26 admitted to the facility with a wound on his bottom and was referred to wound team for evaluation and treatment. The Quarterly MDS, dated [DATE] documented a BIMS of 14, which indicated intact cognition. The assessment documented that R26 did not have a pressure ulcer/injury and was not assessed for risk of pressure ulcer/injury and did not have devices on his bed or chair/wheelchair. The 05/29/24 Care Plan lacked documentation related to pressure ulcer/injury prevention or interventions for wound healing, even though the resident was identified at risk for development of pressure ulcers. The 05/09/24 Braden Scale (tool used to predict pressure ulcer risk), revealed a score of 17, and R26 was at risk for development of pressure ulcers). The Physician's Orders documented the following: On 05/08/24 at 01:00 PM, nursing to cleanse the right buttock wound with hypochlorous acid, apply collagen powder, 1 gram (gm) to the base of the wound and cover with a bordered foam dressing every Tuesday, Thursday and Saturday and as needed (PRN) for wound healing. The 03/01/24 to 05/29/24 Medication Administration Record (MAR) and Treatment Administration Record (TAR) reviewed, and staff documented administration of medications, and cleaning of wounds as ordered. Review of the skin assessment, on 04/23/24, documented no skin issues. Review of the progress notes on 04/23/24 revealed the skin warm and dry, no current issues noted. Redness to bottom, barrier cream applied. The resident's care plan lacked any update regarding the resident's rednes to his bottom or any interventions to prevent further breakdown of the resident's skin. On 05/09/24, the Skin Assessment documentation revealed the resident's left buttock had 75 percent (%) granulation (new tissue formed during wound healing) and 25% slough (dead tissue, usually cream or yellow in color). The right buttock had 60% granulation, 20% sough, and 20% epithelial tissue (new skin growing in a superficial wound). The resident's care plan lacked any update regarding the injury to the resident's buttocks or any interventions to prevent further breakdown of the resident's skin. The 05/09/24 Progress Note documented the resident had a left buttock pressure ulcer/injury stage III, with full thickness skin loss and measured 5.6 by 2 by 0.1.(the documentation lacked whether the wound measured in centimeter) The right buttock was stage III, with full thickness skin loss and measured 4.7 by 1.9 by 0.1 (lacked type of measurement) and the right buttock had 60% granulation, 20% slough and 20% epithelial. The resident's care plan lacked any update regarding the injury to the resident's buttocks or any interventions to prevent further breakdown of the resident's skin. On 05/30/24 at 09:20 AM, Certified Nurse Aide (CNA) M stated R26 should be turned, and his brief checked every two hours. R26 would refuse to get out of his bed except for maybe one meal per day. R26 was not always compliant with allowing staff to turn him. Staff should report to the charge nurse if something odd is on someone's skin during cares or bathing. On 06/03/24 at 08:50 AM, Licensed Nurse (LN) H stated R26 had declined to allow surveyor to observe dressing change to his buttock, so she had already performed the task. On 06/03/24 at 08:50 AM Administrative Nurse E confirmed R26's care plan lacked instructions related pressure ulcer/injury prevention and wound care and these items needed to be added. On 06/03/24 at 08:58 AM, Administrative Nurse B stated that her expectation was that all treatments and modalities of care provided to the residents should be documented on the care plan. Administrative Nurse B was unable to give an explanation as to why the care plan was missing information. The facility's Pressure Injuries Overview policy, dated 03/2020, documented the purpose of the procedure was to provide information regarding definitions and clinical features of pressure injuries but lacked guidance related to the actual care of pressure related injuries. The facility failed to place interventions related to pressure injuries for R26 related to his stage 3 pressure injuries. The facility further failed to place interventions on the resident's care plan to prevent possible worsening of the wounds.

The facility reported a census of 44 residents, with 12 sampled, and one resident reviewed for nutrition. Based on observation, interview and record review, the facility failed to re-weigh or begin nutritional supplements as recommended by the registered dietician (RD), to prevent further weight loss for Resident (R)16. From 09/02/22 (156.8 lbs.) to 11/01/22 (141.2 lbs.) R16 lost 9.95% of her weight. Findings included: - The Electronic Health Record (EHR) documented R16's diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion), and Alzheimer's (progressive mental deterioration characterized by confusion and memory failure). The 10/18/21 Admission Minimum Data Set (MDS), documented a brief interview for mental status (BIMS) of 0, indicating severely impaired cognition. R16 required limited assistance of one staff with eating and identified areas of concern with chewing/swallowing. R16's height was 67 inches with a weight of 167 pounds (lbs.). The 10/18/21 Nutritional Status Care Area Assessment (CAA), documented R16 was on a mechanical soft diet (diet consisting of foods that are easy to chew and swallow) and needed assistance with all meals. The 07/19/22 Care Plan, documented the Registered Dietician (RD) would evaluate and make diet recommendations as needed (PRN). Instructed staff to also monitor/record/report to provider (physician) PRN any signs or symptoms of malnutrition, indicated by a weight loss greater than 5% in one month or greater than 7.5% in six months. The 10/17/22 RD Assessment requested R16 be reweighed due to 5% weight loss with documented intake of greater than 75% of meals. Recommended R16 receive the house supplement or fortified foods if R16 had lost 5% weight in one month, and directed staff to refer to the RD, PRN. On 09/02/22, the resident weighed 156.8 lbs. On 10/01/22, the resident weighed 148.4 pounds, which was a 5.36 % loss in weight. The 11/03/22 RD Assessment documented that, according to the weight records, R16's current weight was 141.2 lbs., which indicated a weight loss of 7.2 lbs. in one month. The food records documented R16 consumed greater than 75% of meals. R16 required 1600-1800 calories a day to maintain her current weight and 1950 calories a day to promote one to two lbs. weight gain a week. The RD recommended R16 have one or two nutritional supplements a day, to prevent further weight loss. The 11/09/22 EHR lacked documentation of a physician order for nutritional supplements for R16. (Six days after the RD's second recommendation) R16's monthly weights documented the following: On 08/03/22 R16 weighed 154.9 lbs. On 09/02/22 R16 weighed 156.8 lbs. On 10/01/22 R16 weighed 148.4 lbs. On 11/01/22 R16 weighed 141.2 lbs. which was a 15.6-pound loss, 9.95% loss, in the last 60 days. Observation on 11/03/22 at 08:49 AM, revealed R16 sat at the dining room table following the breakfast meal. R16's mechanical soft diet meal contained no added protein, the staff did not offer a nutritional supplement, and she ate approximately 50-60% of the meal on her own, after setting up by the staff. On 11/02/22 at 12:06 PM, Licensed Nurse (LN) H stated she did not receive or process the RD recommendations but believed the Director of Nurses (DON) did. She stated she did not re-weigh R16 because she had not been advised to. On 11/03/22 at 07:25 AM, Administrative Nurse D revealed she did not know how the staff processed the RD recommendations. The revised October 2021 Weight Assessment and Intervention documented the multidisciplinary team strived to prevent, monitor, and intervene for undesirable weight loss for the residents. Weights would be obtained by the 5th of the month, documented, and reported. Weight loss would be verified with re-weighing by the 10th of the month and the RD would review by the 15th of the month. Interventions for undesired weight loss should be considered at the resident preferences. The facility failed to follow the registered dietician's recommendations to obtain a reweight on the resident and to implement further interventions to ensure no further weight loss for R16, who lost 15.6 pounds in 60 days, with a 9.95% weight loss.

The facility reported a census of 40 residents with 15 residents included in the sample, and three residents reviewed for behavioral health. Based on observation, interview, and record review the facility failed to provide Resident (R) 21 with the treatment, services, and care plan interventions for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to address these behaviors resulted in the continued violent/aggressive outbursts within the facility, uncontrolled and unsupervised blood glucose (BG, amount of sugar in the blood) levels and insulin (hormone which regulates BG) administrations which led to incidents of severe [CONDITION(S)] (low BG), suspected illicit drug use, and required emergency treatment and transfers to acute care. These failures placed R21 and other resident in immediate jeopardy. The facility further failed to develop interventions to address addictive behaviors exhibited by R34. Findings included: - Review of R21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 11/21/20 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of zero, indicating no depression, and noted verbal behavioral symptoms directed towards others occurred one-to-three days in the review period. The MDS noted R21 was independent with all activities of daily living (ADLs) and noted the resident with almost constant pain. The resident received as needed (PRN) pain medications, daily insulin, and opioid medications. Review of the 02/18/21 Quarterly MDS documented R21 with a continued BIMS score of 15. Neither medications nor behaviors were noted in the MDS. Review of the 11/21/20 Behavioral Symptoms Care Area Assessment (CAA) documented the behavioral symptoms would be care planned and noted the staff would monitor and document behaviors per facility protocols. The staff would intervene to keep residents and others safe. The 12/10/20 Care Plan section regarding Mood and Behavior noted the following interventions: 12/10/20: Observe for signs and symptoms of increased depression (appetite change, tearfulness, isolation, increase in behaviors). 12/30/20: R21can become irate when he does not get his smoking breaks on time and when he cannot have extra smoking breaks. Staff to ensure consistent smoking breaks. R21 has episodes of anger outbursts toward staff, when staff attempt to assist with cares and educate on healthcare needs. [R21] becomes angry when you try to resolve situation prefers to be left alone. R21 states he is an expert with his blood sugars and prefers to be in control of insulin and blood glucose [BG] monitoring. Staff to follow [physician] orders. 02/02/21: R21 does display negative behaviors on a routine basis. He often yells at staff, curses at staff, exits through the 100-hallway door, and will not return his cigarettes and lighter to the nurse. [R21] will record staff with his cell phone and often threatens to either not eat, or to [NAME] the facility. R21 has been asked if he would prefer to move to a different facility. He declines that offer at this time. Staff will continue to encourage [R21] to make safe decisions but will honor his wishes if decides to make risky decisions. Staff will continue to educate [R21] on the facility smoking rules, the benefits of eating his ordered diet, and the importance of following the physician's prescribed insulin and blood sugar check orders. R21 has been offered services to be seen by and to talk to a therapist. He did agree to see Mental Health APRN [Advanced Practice Registered Nurse] R for psych needs on 01/11/21. He will be seen again in one month. Review of the 11/25/20 at 09:21 AM Behavior Note documented the resident went into the lobby area, cursing loudly, and complained he was being treated poorly and like a [expletive] child. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 11/27/20 at 04:35 PM Behavior Note revealed R21 started yelling and made remarks against the writer and threats to blow up the facility. The medical record lacked evidence the facility implanted new interventions to address R21's behavior, until new care plan interventions were added on 12/10/20. Review of the 12/20/20 at 07:25 PM Health Status Note revealed R21 was in the hallway, naked from the waist down. He had blood on his hands and his shirt, and a cut across the bridge of his nose. His face was swollen. R21 would not sit down, was mildly combative, and would not follow instructions. When staff asked the resident, what happened they noted his speech was incoherent and garbled. Staff checked R21's BG and it initially returned at 57 mg/dL. The resident refused to put his pants on, could not answer questions, and refused to take drinks of juice to help raise his blood sugar. The LN and direct care staff attempted to get the resident out of his bloody shirt, and he fought them and refused to change. EMS (Emergency Medical Services) came to evaluate R21 and determined a transport was not needed. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 12/24/20 at 07:41 AM Orders General Note from eRecord revealed R21's blood sugar dropped to 64 mg/dL and the staff found him on the floor, face down, convulsing and foaming at the mouth, and noted his nose was bloody. EMS came in and evaluated the situation, provided care, and helped stabilize him. R21 refused to leave the facility and go to the hospital. EMS left after stabilizing the resident. Per EMS please monitor sugar levels, hold insulin, and provide a protein breakfast. The dietary manager took breakfast to R21 and per the dietary manager R21 became hostile, and made rude remarks, and stated everyone was trying to fight him. R21 was very upset when he noticed his sweater had been ripped by EMS and he came out to the nurses station stating what the [expletive] am I supposed to do with this? as he waved his ripped sleeves in the air. Staff explained to him that EMS had to cut through the clothing to access a vein to provide him with some [MEDICATION(S)] (form of sugar given in an emergency). R21 became angry and stated, This is the only [expletive] I have, how am I going to go out and smoke?! Staff apologized to him and stated that EMS was in control and needed to cut them [the clothing] to help stabilize him. The resident stormed off, tried to tip over the hand sanitizer stand, and slammed the door to his room. Report was given to on coming nurse. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 12/29/20 at 12:50 PM Behavior Note noted R21 was at the nurse's desk cussing and saying that it is [expletive] that he is not allowed to control his insulin dosages. R21 then stated if his blood sugar was high that he will get violent and hurt people if he cannot manage his blood sugars the way that he wants to. He stated he was kind of an expert at managing it on his own because he has been a diabetic for [AGE] years. The note revealed R21's BG was currently 508 mg/dL after refusing 2 units of insulin when his reading was 179 mg/dL at 11:00 AM. Review of the 12/29/20 at 01:30 PM Behavior Note revealed R21 stated I am going to lose it and that the next [expletive] that does not speak right to me I am going to punch in the face. Review of the 12/29/20 at 01:40 PM Behavior Note revealed R21 pacing the halls and threatening to 'break stuff and go [expletive] because his blood sugar was high. The medical record lacked evidence the facility implanted new interventions to address R21's behavior, until new care plan interventions were added on 12/30/20. Review of the 12/31/20 at 08:30 AM Behavior Note revealed R21 continued to talk and curse under his breath. R21 then told the LN writer she did not know how to do her [expletive] job. After R21 administered his requested additional insulin, the LN writer documented she asked R21 to hand her the used syringe and he said no, not until you listen to what I have to say! The LN documented R21 threw the capped used syringe at the LN and noted it went into the hallway and landed on the floor. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/01/21 at 02:26 PM Behavior Note revealed at 07:15 AM R21 became angry and threatened to pull the fire alarm if the staff did not take him out to smoke immediately. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/04/21 at 01:00 PM physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented R21 became furious, threw his hands down on the table, and stood up quickly yelling at APRN Q. She stepped back toward the door as R21 came toward her and she told R21 he could not talk that way, but he continued to yell. R21 rushed over to his dresser, pulled out an insulin syringe, and stated, If I wanted to kill myself, I could inject myself with insulin, but I have not. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/07/21 at 12:55 PM Behavior Note noted a new rule supposed to go into effect that morning where the nurses were to draw the insulin and administer to R21. When staff let R21 know of this information, he immediately got agitated and told the LN writer he was not [expletive] doing that! The DON reiterated the new rules and R21 continued to get agitated and began cursing. He then went to the nurse's desk and tried to get into the locked treatment cart and began banging on the walls. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/11/21 at 04:47 PM Administrator's Note revealed the administrator visited with R21 and noted he had gone into the kitchen to make is own meal. Administrative staff writer told R21 he could not go back to the kitchen and R21 stated that if he was hungry, he was going to do what he wanted, which included turning on the grill to cook chicken. The administrative staff writer told him that was against state regulations and could put other residents in harm's way. R21 replied he did not care. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/11/21 at 07:20 PM Incident Note revealed R21 wanted to go out to smoke and the staff were busy at the moment but would take the resident out when staff got a moment. R21 responded with I can just take us out and the LN writer told R21 that was not allowed. The LN writer heard the door alarms going off, another resident yelling about not being able to go outside and noted R21 had opened the door and let himself, and a couple other residents, outside to smoke without staff present. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/14/21 at 02:46 PM Behavior Note revealed a late entry regarding an incident on 01/12/21 at approximately 01:40 PM. The note revealed R21 walked down the hall and threw all of his glucometer trash on the floor with blood noted on it. R21 then hit the wall with his fist and walked out the west side door independently, due to anger over his new insulin orders. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/18/21 at 12:27 PM physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R21 started to become more aggressive and called names using foul language. The Administrator took R21 for a walk to calm him down. R21 returned and kept walking by the nurse's desk calling APRN Q a different name every time he walked past her. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/18/21 at 03:04 PM Administrator's Note revealed the administrator went to the nurse's station today and noticed R21 was very agitated and yelling at APRN Q. The note documented R21 started raising his voice and he started to call APRN Q names. The administrator attempted to remove R21 from the situation and offered to take him out for a cigarette. As R21 walked away he stated, I should throat punch you, you [expletive][expletive]. He got to his room and threw his used and uncovered insulin syringe. The administrator picked it up and disposed of it. As R21 walked by the nurse's station, he called APRN Q an inappropriate name using foul language. The administrator got R21 out to the smoking area, and upon coming back in, noted R21 continued to call APRN Q names. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/20/21 at 02:51 PM Incident Note revealed at 12:30 PM the Administrative Nurse B observed R21 draw up his insulin and took it without letting the AN B writer verify the amount. R21 gave Administrative Nurse B the used syringe but held onto the insulin medication (which he later returned). At approximately 02:15 PM, after a request by R21 for insulin, AN B stated she could not give him any insulin, per sliding scale orders. R21 then turned and punched the bedside table sitting next to the nurse's station, cussing, and went towards his room. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/21/21 at 04:06 AM physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Several staff reported smelling marijuana covered with cologne, near his room several different times. R21 received [MEDICATION(S)] (narcotic pain medication) 7.5 mg. Due to the safety of R21, a drug UA would be ordered due to concerns reported to APRN Q about possible other drugs. Will have to discuss options with administration about ensuring there was no additional insulin in his room. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/22/21 at 12:47 AM physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . LN DD reported R21 made her nervous, therefore they would discontinue the [MEDICATION(S)] in the morning, when there is more staff around to assist with any behaviors due to safety concerns of the staff. Review of the 01/22/21 at 01:12 AM Health Status Note revealed at approximately 08:50 PM staff were called to R21's room and noted the resident seizing. BG obtained and noted to be 43 mg/dL and staff administered [MEDICATION(S)]. At 09:10 PM staff rechecked R21's BG and noted it at 119 mg/dL. The note revealed at approximately 10:00 PM, staff reported to the LN another resident was in R21's room and the room smelled like marijuana. The LN writer called APRN Q and reported to her what had happened and spoke to her about the other resident going in the room may have been slipping him pills, since some (pills) had been found in her room. APRN Q stated they would be discontinuing the [MEDICATION(S)] but would wait until morning. The LN writer thought that would be appropriate due to him already making staff nervous tonight with his actions. Resident was on 15-minute checks as per DON (Director of Nursing) orders. Review of the 01/22/21 at 07:16 AM Behavior Note revealed R21 came out demanding to know why they provider discontinued his [MEDICATION(S)]. The LN writer explained he needed a drug UA in order to take them off hold. R21 became angry and told the LN that he could not [expletive] pee [expletive] and he then stomped through the halls slamming doors and cussing, saying he was going to go smoke in his room and people need to do their [expletive] jobs and take us out to [expletive] smoke. The note revealed the new resident across the hall started crying because she was startled. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 01/31/21 at 03:04 AM Behavior Note revealed R21 came up to the nurse's station and complained the new resident opened his door three different times and staff were not paying attention to what's going around us. The note revealed R21 stated, I am about to go off on some staff! and noted R21 continually walked to his room and then walked to the nurse's station constantly rechecking his blood sugar. Review of the 01/31/21 at 01:01 PM Behavior Note revealed the LN had a pink basket at the desk with a glucometer, strips, test needles, insulin, and syringe in it. R21 grabbed the pink basket from over the counter and ran to his room with it. The LN writer noted she then went to R21's room where R21 refused to give the basket and supplies back. The resident got up from his bed, shoved his bedside table against the LN, went into the bathroom, and as the LN attempted to ask for the basket, R21 shut the door on the LN's arm and hand as he attempted to slam the door, twice. R21 refused to give the insulin and syringe to the LN once again, per her request. Resident yelled I'll [expletive] overdose on it, or maybe better, stab you. The LN stated she was calling the physician and went to the front desk. While the LN was on phone, the resident brought the basket back up front, yelling in the background as the nurse talked on the phone. The LN revealed R21 did return all the supplies and insulin, but not the syringe/needle. R21 then went to his room and as the LN was ready to hang up, R21 yelled at a dementia resident get you [expletive] in your room, you can't be out here! The LN noted the dementia resident appeared highly upset and confused. The LN writer spoke to Administrative Nurse B and APRN Q whom stated to call Physician W directly as she was not included in this resident's case, due to R21 threatened her as well. Spoke with Physician AA, whom stated to tell the resident if he continued and did not calm down, staff would send R21 by ambulance for psychiatric assessment at the local hospital. The medical record lacked evidence the facility implanted new interventions to address R21's behavior until 02/02/21, when new care plan interventions were added. Review of the 02/03/21 at 11:13 PM Behavior Note revealed R21 got into the facility kitchen at approximately 08:40 PM and spewed milk all over the floor, took one container of cereal. Counseled by staff, resident just walked off. An unidentified male CNA stated R21 and a female resident went into a quarantined resident's room and the CNA observed all three residents in the room vaping (the action or practice of inhaling and exhaling vapor containing [MEDICATION(S)] and flavoring produced by a device designed for this purpose). The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/04/21 at 08:20 PM Orders Administration Note revealed R21 refused to tell the LN staff the BG results from 08:00 PM. Administrative Nurse B looked on the BG machine and the reading was 251 mg/dL. The resident drew up 7 units of Novolog, showed to this nurse, whom stated to the resident it should be 2 units, not 7 units. The resident refused to speak to either nurse and proceeded to give himself the 7 units of Novolog. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/05/21 at 11:13 PM Health Status Note revealed at 11:10 PM R21 requested to take his blood sugar, which returned at 202 mg/dL. R21 drew up 6 units of Novolog, the LN writer responded that sliding scale indicated only 1 unit of insulin be administered. R21 proceeded to give himself 6 units of Novolog. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/10/21 at 01:31 AM Behavioral Note revealed R21 walked out of the nurse's office upset and went to his room slamming the door. Review of the 02/10/21 at 11:50 AM Behavioral Note revealed R21 in his room, putting cups of water out in the hall on the floor, throwing things, and yelling in his room. When staff asked him a question, R21 ignored them. Review of the 02/10/21 at 11:51 AM Behavioral Note revealed at approximately 11:00 AM R21 started yelling at this nurse stating his blood sugar was over 600 mg/dL. When the nurse asked if she could give his Endocrinologist (a physician that specializes in DM) a call R21 yelled no [expletive] that, I want my [expletive] insulin now. The note continued to document R21 either placed his drinks in the hallway and someone knocked them over or R21 threw his drink in the hallway. The LN writer noted R21 went to his room, banged on the walls and doors, and he upset another resident next to his room. R21 then yelled at staff with foul language and slammed his door again. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/20/21 at 01:51 PM Health Status Note revealed staff notified R21 he was to be quarantined after leaving the building that afternoon. R21 was upset about the idea and said he was not going to follow it. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/24/21 at 08:00 PM Orders Administration Note regarding behaviors noted R21 cussed at staff who were behind the nurse's station. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/25/21 at 08:15 PM Incident Note revealed R21 argued with R34 and he yelled at her. The LN heard the commotion down the hallway and told R21 and R34 it was inappropriate, and they needed to stop yelling at each other and to separate. The LN returned to the nurse's station and the two residents started to argue again. R21 began advancing toward R34 and a CNA stepped in between the two residents. The LN heard R21 telling the CNA to get out of his way. When the CNA did not, R21 shoved the CNA in the chest at least twice. The LN writer called down the hallway and said stop that right now and R21 did stop his behavior. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/26/21 at 11:14 AM Administrator's Note regarding a yelling altercation involving another resident that lead to this resident being physical with an employee that stepped between the two residents. Noted a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The note revealed R21 was put on continuous staff monitoring and would remain on continuous staff monitoring for the remainder of his stay in the building. The note continued, R21's PCP contacted and would be in the building to put a note in that he did not feel our interventions were enough to prevent further incidents similar with staff and or residents. The facility failed to implement the continuous staff monitoring as stated in the 02/26/21 Administrator's Note and the medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 02/26/21 at 12:52 PM physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The provider noted he felt the facility cannot provide proper interventions to prevent further altercations with staff or other residents and noted it was Ok to discharge R21 to a local men's shelter. Review of the 02/27/21 at 12:04 AM Health Status Note revealed R21 transferred to a behavioral health unit after [CONDITION(S)]. Review of the 02/27/21 at 05:05 AM Health Status Note revealed R21 returned to the facility at approximately 05:00 AM. Review of the 02/27/21 at 06:43 PM Behavioral Note revealed R21 came to this nurse at the nurse's station and started talking about when he was in the hospital prior to coming here and talked about being in a coma. R21 talked of how the doctor put him on suicide watch at the hospital because when he woke up from the coma he said I don't want to live like this. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 03/13/21 at 01:56 PM Behavioral Note revealed an unidentified CNA was in her car when she smelled weed/marijuana and saw R21 up against a car outside smoking something. Review of the 03/14/21 at 12:02 PM Behavioral Note revealed the LN writer knocked on R21's door and waited for him to answer. He gave permission to open his door and upon entrance he stated I told you I'd tell you in a minute. I'm trying to calm myself down, leave me alone, leave me alone. The LN stated if he needed anything to let her know and shut the door, but it did not latch and R21 got up and slammed it shut. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 03/19/21 at 10:17 AM Health Status Note revealed the LN writer noted R21 is slurring his words. Falling asleep during conversation and difficulty following any conversation. Noted R21 was having difficulty sitting up on the side of the bed and noted the nurse suspected R21 could be under the influence. The medical record lacked evidence the facility implanted new interventions to address R21's behavior. Review of the 03/22/21 at 11:28 PM Health Status Note revealed R21 was extremely confused and disoriented was in another resident's bed and when asked questions only stated ok. The LN suspected [CONDITION(S)] (less than normal amount of sugar in the blood), but BG checked and noted at 116 mg/dL. The staff rechecked to confirm and noted it at 130 mg/dL. The resident only saying it hurts so bad. Blood pressure is 267 systolic (the pressure of the blood in the arteries when the heart pumps; the top number of a blood pressure reading) over 88 diastolic (minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) with pulse of 58. Review of the 03/22/21 at 11:15 PM Health Status Note revealed EMS transported R21 to local hospital ER and admitted R21. Review of the 03/23/21 at 09:53 AM Social Services Progress Note revealed the writer called the local hospital for a medical update on R21. The ED nurse told the writer R21 would be admitted , he was still in an altered mental status, 4-point harness, and on a blood pressure drip. The ED Nurse stated R21 tested positive for marijuana and was having the same drug reactions similar to those who have taken K2 (synthetic marijuana). Review of the 03/26/21 at 05:29 PM Health Status Note revealed Mental Health APRN R visited while R21 was here for follow-up with psych. Observation on 03/29/21 at 08:30AM revealed R21 wore a mask and had a pleasant and cooperative demeanor. R21 displayed no temper or aggression toward the surveyors. The resident played a few videos (from his cell phone) for the surveyors about food he was served and conversations with staff about getting insulin. The resident could be heard cussing at staff and slamming a door, on the video. An observation on 03/30/21 at 01:25 PM revealed R21 at the nurses' station complaining about his medications, stating he was not getting his insulin like he thought he should. Observation on 04/01/21 at 3:00 PM revealed Administrative Staff D stood at the end of hall 300 and loud music could be heard playing from down the hall. Administrative Staff D reported R21 was upset at staff and refused to turn his music down. At approximately 03:05 PM R21 forcefully pushed his lunch tray to the middle of the hallway with some of the items coming off the tray and landed on the floor in the hallway (napkin, empty glass, empty bowl). Interview with R21 on 03/29/21 at 08:36AM revealed he knew he needed assistance and needed to be in the facility. He said his blood sugar has been low. The resident said he had fallen out of bed and busted his head due to diabetic shock and that a staff member tricked him into smoking weed from his vape pen 3-4 weeks ago. The resident stated after [CONDITION(S)] on Monday and he came back here and ended up in the hospital. He said he apparently was in another room and he did not remember any of it. R21 said the facility called the cops on him because he was out of it and the police put him in handcuffs. R21 said they said I had blood all over my room and vomit everywhere . These people really hate me because I stand up for what is right .It is a very stressful and hostile environment . Staff woke me up one morning (in March, I think 3 weeks ago, Thursday) and said that they were immediately evicting me and sending me to a homeless shelter. And then called the cops on me because they said I wasn't leaving, but I had no idea what I was doing. The cops showed up and asked if I wanted to go to the behavioral health unit [BHU] like I had an option. So, I went to the BHU for like an hour and they said I had no reason to be there, so they sent me back here. They threaten me and tell all of us, all the time, that if we don't do what they want, they will take away our smoking privilege. Staff said we had to stay in our rooms, and I used the call light to get medication and no one would come. So, I went to the nurse's station and they refused to give me meds because I left my room. Staff uses the medication to hold over my head and it happens all the time .they don't wake me up at night to check on me or check my BG. I don't want to end up in the hospital again because of my sugar. I feel like it is my job to care for other residents and they check up on me too. Staff never check up on us, so we must check on each other. I need more education on my insulin pump before I use it, because I have no idea how it works . Interview with resident on 03/31/21 at 01:00PM revealed They gave me my pain meds this morning, but I was sleeping and when I woke up, the pill was underneath me and sweaty. And I asked for a new pill since I didn't swallow it, but they won't give me a new one. And they said they have to call the doctor and that's not ok. I am in pain all the time and need my meds. Interview with CNA Mentor P on 03/30/21 at 10:15 AM revealed Sometimes [R21] is nice and sometimes he bites my head off. He has never physically put hands on me or anyone else, but he has been verbally assaulting towards other staff and residents. Sometimes [R21's] blood sugar is too low or high and he will find the nurse to get medication. We cannot please him [R21]. We try so hard to care for him and it is never enough. [R21] goes to smoke on his own now and is supposed to check in and out when he smokes. [R21] told me once that CNA BB provided him drugs. I have seen [R21] leave the facility and come back and then go into R34's room. And then [R21] leaves R34's room and R34 is out of it. The other day, R34 and R21 were not out smoking yet, an[TRUNCATED]

The facility census totaled 40 residents, with 15 residents included in the sample, and five residents reviewed for falls. Based on observation, interview, and record review, the facility failed to identify causal factors related to falls experienced by Resident (R) 24, R33, and R9 and failed to implement fall interventions to prevent future falls. R24 experienced a fall in her room when she attempted to toilet independently, which resulted in a fracture of her arm. R9 fell when staff toileted her without a gait belt and she fell backward, resulting in a laceration and suture/staples to the back of her head. Findings included: - Review of R9's 02/03/21 Physicians Orders Diagnosis tab in the electronic medical record (EMR) revealed diagnoses of alcoholic [CONDITION(S)] (chronic [CONDITION(S)] disease of the liver) of the liver with ascites (build-up of fluid in abdomen) and muscle weakness. Review of the 01/20/21 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of five, indicating severely impaired cognition with no behaviors noted. The resident required supervision of one-person for transfers and toileting. The resident used a walker for mobility and the MDS noted no falls. Review of the 02/11/21 Discharge Assessment Return Anticipated MDS revealed a staff assessment for mental status which noted memory problems with moderately impaired decision making. She required cues and supervision with extensive staff assistance for transfers and toileting. She experienced one fall with injury since the last assessment. The 01/20/21 Cognitive Loss/Dementia Care Area Assessment (CAA), Activities of Daily Living (ADL) CAA, and Falls CAA all revealed R9's diagnosis included [CONDITION(S)] of the liver, which could result in confusion. She required staff assistance with ADLs due to weakness and suffered falls at home before admission to the facility. Review of R9's Medical Record from 01/07/21 to 03/31/21 lacked completion of any Fall Risk Assessment. Review of the 02/02/21 Care Plan revealed R9's cognitive function as oriented to person and required one staff assistance for ADLs, which included ambulation. R9 was at risk for falls related to the disease process ([CONDITION(S)]) and decline in ADLs, and she wanted to remain free from injury related to falls over the next review period. The staff would ensure the call light was within reach and non-skid socks were in place when she did not wear shoes. R9 was continent of bowel/bladder, and staff assisted with toileting as needed. Review of 02/11/21 at 11:55 AM Fall Investigation revealed R9 experienced a witnessed fall in her room, while being assisted to the bathroom, without a gait belt. The resident fell backward, striking and lacerating her head. The Certified Nurse Aide (CNA) II turned their back for a second, and the resident lost her balance and fell . Staff trained for the importance of a gait belt for transfers and assisting residents during transfers. Review of 02/11/21 at 10:40 AM Inter-Disciplinary Team (IDT) Post Fall Assessment revealed a contusion (bruise) and skin tear to the resident's posterior head after an aide assisted the resident to the bathroom without a gait belt and the resident fell backward striking her head. The Care Plan lacked revision to prevent future falls for R9, as related to her fall from 02/11/21. Review of 02/19/21 at 01:21 PM Skin/Wound Note revealed a wound to occiput (back of head) that measured approximately 2.5 centimeters (cm) in length by 2.5 cm in width with four staples found in her hair. The resident had one staple left intact. The resident's record lacked documentation on re-admission (02/15/21) about staples placed in the residents head or any description of wound. Observation of the resident on 03/29/21 at 10:08 AM revealed R9 rested in bed, in her room with eyes closed. Shoes noted beside the bed, side table next to bed, and wheelchair. Non-skid strips noted on the floor next to the bed and noted the call light was in reach. Interview with R9 on 03/24/21 at 01:37 PM revealed a month ago she fell ambulating to the bathroom and split her head open in the back, which required sutures/staples. The aide assisted her out of bed, with her walker, and she did not use a gait belt. She stated, she only needed the assistance of one staff, sometimes two. Interview with R9 on 03/29/21 at 10:10 AM revealed the physical therapists used the gait belt for transfers/walking, but the aides did not. The only intervention after her fall included staff assisted her with a gait belt and stayed with her for ambulating and transfers. Interview on 03/29/21 at 02:48 PM with CNA O revealed R9 experienced one fall while ambulating to the restroom with her walker, and the CNA did not use a gait belt or stay near the resident for the transfer/ambulation. The resident lost her balance and hit her head on the floor and required hospitalization and staples to her head. She stated, the CNA should have been right beside her, and [R9] would not have been hurt that bad. Interview on 03/30/21 at 10:49 AM with CNA P revealed before R9 fell , she required one to two staff assistance with a gait belt and her walker. She stated, she always stayed with any resident when ambulating with a gait belt to the bathroom. Interview on 03/29/21 at 01:55 PM with Licensed Nurse (LN) H revealed she received no update on what caused R9 to fall. R9 received a cut to the back of her head as a result of the fall. She required one staff assistance with transfers and toileting with a gait belt, and staff stayed with the resident while they ambulated. When a resident experienced a fall, staff obtained vital signs, assessed for injuries/range of motion (ROM), neurological checks completed if resident not cognitive, and if cognitive, then staff completed one set of neurological checks. The nurses filled out the fall risk assessment. She stated, she tried to put in interventions from the root cause of resident falls, and then the interventions were reviewed by the director of nursing and the administrator to see if appropriate. Interview with LN J on 03/30/21 at 12:19 PM revealed R9 required two staff assistance at the time of her fall, and she used a walker. The CNAs should always use a gait belt and stay with the resident until seated in the restroom. She required staples or sutures to the back of her head due to the fall. Interview on 03/30/21 at 08:57 AM with Administrative Nurse B revealed R9 received stitches/staples to her head due to that fall., The aide should have used a gait belt and stayed with the resident until seated on the toilet and therapy retrained the staff after that incident. Review of the revised 12/2007 Falls and Fall Risk, Managing policy stated The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Review of the revised 10/2010 Assessing Falls and Their Causes policy stated After a fall .nursing staff will record vital signs, record in the resident's medical record the assessment data and appropriate interventions taken to prevent future falls. The facility failed to use a gait belt and remain within reach of resident to prevent a fall which resulted in a laceration to the head which required staples. The facility also failed to implement a fall prevention strategy/interventions to prevent future falls. - Review of R24's 01/08/21Physician's Orders Diagnoses in the electronic medical record (EMR) revealed a fracture (broken bone) to the shaft of the humerus (bone of the upper arm) right arm, [CONDITION(S)] (fainting/passing out), hypertension (elevated blood pressure), muscle weakness, difficulty in walking, and need for assistance with personal care. Review of the 12/18/20 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15, indicated intact cognition with no behaviors noted. The resident required limited one-person assistance for transfers, walking, and toileting, with an impairment to one side of the upper extremity (arm) noted. She used a cane or crutch and a wheelchair for mobility with no falls. Review of the 02/26/21 Quarterly MDS revealed a BIMS of 13, indicating intact cognition with no behaviors noted. The resident required one staff assistance with toilet use and was independent with transfers and walking. The MDS noted no impairment to extremities (limbs) and she used a cane, crutch, or wheelchair for mobility. She experienced one non-injury fall since the last assessment. Review of the 12/18/20 Activities of Daily Living (ADL) Care Area Assessment (CAA), Urinary CAA, and the Fall CAA all revealed R24 admitted to the facility with a right humerus fracture, weakness, and required limited assistance with ADLs due to declining and inability to use her right arm. Intact cognition noted with a BIMS of 15. R24 was continent of bowel/bladder. She experienced several falls at home, and the last one resulted in a fracture. She suffered from pain in the right arm due to the fracture and was on scheduled pain medication. She walked the majority of the time, but used a wheelchair when she wanted, due to weakness. Review of R24's Medical Record from 12/11/20 to 03/29/21 lacked evidence of completion of Fall Risk Assessments. A review of the 12/14/20 Care Plan revealed a Functional Status problem with ambulation and transfer and no indication of the type or amount of assistance she needed for ADLs. The Falls portion of the care plan indicated staff would ensure the call light was within reach and non-skid socks were in place when she did not wear shoes. The Care Plan lacked any additional fall interventions. Review of 01/07/21 Therapy Notes revealed, the resident was a little more confused and unsteady today, reported to nursing. Review of 01/21/21 at 04:40 AM Fall Investigation revealed R24 experienced an unwitnessed fall in her room. Staff found her seated on the floor next to her bed after she ambulated back from the restroom. Staff noted the resident as alert/confused, ambulatory without assistance, no injury noted, weakness, and notified the director of nursing and physician. Per the notes, the resident required supervision for toileting, but did not like to call for assistance, her right arm noted in sling and unsteady on feet, fall does not appear to be result of neglect or abuse. The Fall Investigation lacked documentation about post-fall assessment, lacked identification of causal factors, and lacked interventions to prevent further falls. Review of 01/21/21 at 04:40 AM Interdisciplinary Team (IDT) Post-Fall Assessment revealed R24 had a history of falls and noted R24 as alert and she toileted independently. The staff reminded her to call for assistance. Review of 01/21/21 04:40AM Incident Note - Late Entry revealed the resident's roommate called staff to R24's room and found her seated on the floor next to the bed. She stated she tried to go to the bathroom but did not call for assistance to go to the bathroom. Staff documented R24 denied pain. Review of 01/22/21 at 12:53 PM Progress Note revealed R24 required minimal assistance for all tasks due to having an unsteady balance and her non-weight-bearing status to the right upper extremity. She currently used a cane during walking. R24 experienced a decreased medical status with nausea and increased pain in her arm (after the fall the previous day). Review of 02/08/21 Therapy Notes revealed R24 with increased pain and decreased range of motion (ROM) with swelling/bruising noted to the right arm. Reported to the physician, director of nursing, and the charge nurse, scheduled R24 for orthopedic appointment, and x-ray obtained. Review of Physician Orders dated 02/08/21 for a stat (immediate) right Humerus x-ray one time for new injury with pain noted for one day. Review of 02/08/21 X-Ray Findings revealed a [MEDICATION(S)] fracture (broken bone where the break is at a right angle to the long plane of the bone; most often occurred as the result of a strong force applied perpendicular to the long axis of a bone) of the right proximal (nearer to the center of the body or the point of attachment) humerus at the surgical neck (portion just below the head of the bone) with shortening and anterior (front) angulation (wrong direction) of the distal fracture fragment (piece). This finding indicated a new fracture of the right humerus. Observation of R24 on 03/29/21 at 10:33 AM revealed the resident was in her room with a sling to her right arm seated on her bed. The resident then ambulated without assistance using a walker to walk to the bathroom. Her call light was in place and activated for an unknown length of time. Interview on 03/24/21 at 02:08 PM with R24 revealed she fell and broke her arm again trying to get back in bed from the bathroom by herself because she believed staff did not answer her call light timely. Interview with R24 on 03/30/21 at 10:00 AM revealed on 01/21/21, when she fell , she and her roommate turned on their call lights and waited about 15 minutes for assistance because she required one staff assistance for toileting. She could not wait any longer and got up and went to the bathroom on her own, and on the way back to her bed, she fell . She stated that when she fell , she attempted to catch herself with her right arm. She also stated, a few days after the first fall, she fell again due to the same circumstances, but fell on to her bed, and she told the nurses. She experienced increased pain after that, and an x-ray found that she refractured her right humerus. She then stated, when staff asked about her pain, she told them her pain was bad and she developed nausea. She stated, the staff waited for me to call to use the bathroom, and she did, but waiting so long for assistance when you have to go is hard. Interview with Certified Nurse Aide (CNA) G on 03/29/21 at 02:48 PM revealed R24 experienced no falls, and CNA G stated she has no interventions for falls. R24 used the call light when she needed the toilet, but did self-toilet if she needed to go, and required one-person assistance for toileting. Interview with CNA P on 03/30/21 at 10:49 AM revealed if a resident fell she would obtain assistance from the nurse. CNA P stated she heard a lot of residents say their call lights are not answered quickly, but [R24] needed no assistance with toileting. She completed that independently. She then stated, she would have to look at the care plans, she only looked at the care plan when a resident admitted to the facility to see what assistance the resident required, but she considered [R24] independent. She did not know if R24 had specific intervention placed after her fall other than moving rooms closer to the nurse's station. Interview with Licensed Nurse (LN) H on 03/29/21 at 01:18 PM revealed R24 admitted to the facility with a right humerus fracture from a fall at home and experienced no falls since she arrived at the facility. When asked about the fall on 01/21/21, LN H indicated no knowledge of the fall. R24 required one staff assistance for toileting, and she used a small cane/step stool for walking. She stated, R24 called for help when she needed something or toileting, and she did not know if R24 had any implemented interventions for the fall. Interview with LN J on 03/30/21 at 12:05 PM revealed R24 required one staff assistance to the bathroom with her walker, especially since she required her right arm sling. When staff assisted R24 to the bathroom, staff used a gait belt, but she observed staff assisting residents without a gait belt at times. After she fell on [DATE], there were no new fall interventions placed. LN J stated, the nurse who completed the fall investigation places an appropriate intervention and updates the care plan with help from the Administrative Nurse C. Fall follow-up included 72-hour charting if an unwitnessed fall or the resident hit their head, along with neurological checks (mental/physical assessment). Interview with Administrative Nurse C on 03/31/21 at 09:12 AM revealed she received notification from therapy, R24 had increased pain during the week the fall occurred and indicated she notified the physician about increased pain. Interview on 03/30/21 at 08:57 AM with Administrative Nurse B revealed the falls were reviewed in risk management, and she had asked Administrative staff D about what information the fall investigations required. She stated the facility was supposed to have weekly risk meetings and the meetings had not occurred and had fallen through the cracks; those meetings were where the falls were discussed, and interventions implemented. Her expectations for fall investigations included that the weekly risk meetings occurred weekly to go over the fall interventions and update the care plans. She knew R24 worked with therapy, and the nurses completed pain scales every shift. She then stated, when R24 required the x-ray to her humerus for pain, it came out of nowhere, and she did not complete an investigation. She talked to R24 about her fall, and she said that she activated her call light, and no staff answered for a while, so she self-toileted. Her expectation for fall investigations required vital signs, assessment of injuries and pain, assessment of how the fall occurred, noting any change in cognition, and 72-hour fall follow-up documentation. The post-fall assessment must be completed along with the fall investigation and risk management reviews and completes. She stated, the description of the fall and anything not addressed in the click boxes on the investigation must be placed in the notes section. Neurological checks are completed for unwitnessed falls and scanned in under documents in the resident's chart. She did not know why R24 had not completed a voiding diary, but that the intervention appropriate for her after this fall would be prompted toileting every two hours to keep her safe and get the aides to answer the call lights better, the facility worked on that. Interview with Advanced Practice Registered Nurse (APRN) Q on 04/01/21 at 12:00 PM revealed her expectation for resident care included the staff notified her of any change in condition. Staff notified her of R24's fall, and she stated the resident experienced pain the day before the fall. When therapy worked with her the week leading up to the fall, she experienced muscle tightness and increased pain, and therapy noted bruising and swelling to the right arm. She then stated that R24 had a fall in December 2020 as well, and an x-ray obtained due to increased/new pain, but she could not recall if staff notified her of the fall or any secondary fall after the one on 01/21/21. Her expectation included that after any fall, staff notified her. A review of the revised 10/2010 Falls-Clinical Protocol policy stated, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Review of the revised 12/2007 Falls and Fall Risk, Managing policy stated, The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Review of the revised 10/2010 Assessing Falls and Their Causes policy stated After a fall .nursing staff will record vital signs and evaluate for possible injuries .Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record .[Identifying Causes of a Fall or Fall Risk] Staff will evaluate chains of events or circumstances preceding a recent fall, including whether there is a pattern of falls for this resident .When a resident falls, the following information should be recorded in the resident's medical record: assessment data, including vital signs and appropriate interventions taken to prevent future falls. The facility failed to provide the appropriate assistance to R24 for toileting resulting a fall, then failed to complete the fall investigation including fall risk assessments, follow-up assessments, vital signs, and intervention(s) after the fall. - Review of R33 pertinent diagnoses from 03/23/21 Physician's Order in the electronic medical records (EMR) documented the following: fracture of neck of right femur (thigh bone), right artificial hip joint, muscle wasting and atrophy (muscle weakness), [CONDITION(S)] (sudden severe confusion, disorientation and restlessness), anxiety disorder, restlessness and agitation, delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue). Review of the 09/17/20 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of nine, indicating moderately impaired cognition. R33 required one-person physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene and required setup only for eating. R33 received antipsychotics (mood stabilizers) seven out of seven-day review period . R33 did not have any falls prior to admission. Review of the 03/03/21 Quarterly MDS documented a BIMS of seven, indicating severely impaired cognition . R33 required supervision for bed mobility, transfers, dressing, toileting and personal hygiene and required setup only for eating. R33 required the use of a walker with ADLs. R33 had one fall with no injury and one fall with injury (skin tear). Review of the 09/17/20 Activities of Daily Living (ADL) Functional/Rehabilitation Potential (CAA) documented R33 could make her needs known, used the call light, and was limited to supervision depending on time of day. Review of the 09/17/20 Falls (CAA) documented R33 had no recent falls. Review of Fall Risk Assessments documented two completed assessments with a score of 11, indicating high risk for fall, on both 09/11/20 and on 01/16/21. Review of 09/14/20 Care Plan documented an initiation date of 03/25/21 for the following: R33 admitted with a right hip fracture and replacement with complaints of pain. The staff were to monitor for pain and offer non-pharmacological (non-medication) interventions and pain medication as needed (PRN). R33 was at risk for falls and staff were to encourage the use of a walker and the call light. R33 required extensive assistance from staff with ambulation and transferring using a walker. Review of the Electronic Health Records (EHR) Physician Orders documented an order for [MEDICATION(S)] (mood stabilizer) tablet, one milligram (mg), one tablet by mouth two times a day for dementia, started on 03/23/21. R33 was full weight bearing (placing full weight) on right leg, started on 03/23/21. R33 was to work with physical therapy (PT) five times a week for 100 days due to a fall with right hip fracture, started on 03/24/21. R33 was to work with occupational therapy (OT) five times a week for 30 days to address deficits (loss) with activities of daily living (ADL) performance, due to fall with hip fracture, started on 03/25/21. Review of the Fall Investigation from 12/27/20, revealed the nurse aide assisted R33 to the floor in the doorway, with no injuries noted. Interdisciplinary Team (IDT) Post Fall Assessment noted R33 was normally independent with ambulation. Facility documented this fall does not appear to be the result of neglect or abuse. No post fall interventions were completed or updated in the care plan and the investigation lacked identification of causal factors to prevent further falls. There were no vital signs documented in R33's chart related to the fall. Review of the Fall Investigation from 01/16/21 revealed an unwitnessed fall for R33 in her room, where she hit the bedside table and landed on her knees, with no other injuries noted. The facility documented this fall does not appear to be the result of neglect or abuse. No post fall interventions were completed or updated in the care plan the investigation lacked identification of causal factors to prevent further falls. The investigation lacked initiation of neurological (physical and mental function) checks . Review of the Fall Investigation from 01/28/21 revealed an unwitnessed fall for R33 on the toilet, where she slipped off and hit only her elbow. R33 was confused and was being treated for a urinary tract infection. Facility documented this fall does not appear to be the result of neglect or abuse. No vital signs or neurological checks documented, the investigation lacked identification of causal factors to prevent further falls, and no fall interventions completed or updated in the care plan. Review of the Fall Investigation from 03/18/21 revealed an unwitnessed fall for R33 with injury to her right hip in the dining room. IDT Post Fall Assessment stated R33 was ambulating in dining room without her walker and fell on to her right hip, which fractured. The facility sent R33 to the hospital and she received a hip replacement. No vital signs or neurological checks documented, the investigation lacked identification of causal factors to prevent further falls, and no fall interventions were completed or updated in the care plan. Observation on 03/29/21 at 01:24 PM of R33 revealed she laid in bed, with non-slip socks on her feet. R33 requested assistance with getting out of bed and the call light was noted within reach. Observation revealed her walker was located at the end of the bed. Administrative Nurse C and Certified Nurse Aide (CNA) O came in to assist R33 with getting up. Staff placed a gait belt (belt used to help transfer a person from one place to another) on R33 and placed the walker in front of R33. Bed was in the lowest position and door closed for privacy. R33 stood with staff assistance and staff provided toileting care to R33 with no issues noted and her right hip dressing noted intact. Observation on 03/30/21 at 4:00 PM revealed R33 sat in a wheelchair with a lunch tray on the bedside table. R33 was eating a sandwich. R33 complained of hip pain but stated it was a lot better than it was. R33 was alert and carried on a conversation. The resident had non-skid socks on both feet. Interview on 03/29/21 at 01:24 PM with R33 revealed I had a fall at this place and spun around and broke my hip. I went to the hospital for a little bit and got a new hip in my right side. The girls are pretty good about coming to help me when I push the button. I do not fall often. Interview on 03/29/21 at 03:30PM with CNA T revealed she falls occasionally. I was not here when she fell last and went to the hospital, but I was told she had an injury. Before going to the hospital, she was a one assist but would always refuse assistance. She was very unstable and did not really use her call light. Interview with CNA Mentor P on 03/30/21 at 09:59 AM revealed with her hip, she is a two-person, extensive assist. Prior to the hospitalization , she was independent and sometimes needed supervision. I was not here when she fell and went to the hospital . I have not heard of any interventions for fall prevention. Looking at the Kardex, there are not fall preventions listed, but it would be listed on here. I found out she was a two person assist by asking other staff how she is cared for and was told she is a two assist and light weight bearing. She has been in a lot of pain and has been letting staff assist her getting up. Interview with Licensed Nurse (LN) J on 03/30/21 at 10:53 AM revealed I do not believe I was ever present when she had falls in the past. There was a time when she was placed with a walker and had strips on the floor in front of the toilet. She was independent and became a times one assist and started to slowly decline. She is now a two person assist to get up. When a resident falls, we put them on neuro checks automatically, do a full assessment, call the family, fill out the fall packet and chart it. If a resident has a suspected injury, we notify the provider and call 911 with an order from the physician. There have been times when we must send a resident to the hospital without calling the provider first, but this has never been an issue. After a fall, we chart the assessment in the computer, and I believe the Assistant Director of Nursing (ADON) decides what will be the proper response and updates the care plans. Interview on 03/30/21 at 08:57 AM with Administrative Nurse B revealed we are supposed to have weekly risk meetings and those have not happened, it has fallen through the cracks. Those are the meetings we talk about the interventions. The expectation would be that the weekly risk meetings would be held to go over the fall interventions and update the care plans. With falls or any change in the resident's condition, the nurses are to call the DON, the physician, and the family based on what's going on. The expectation for documentation is that the staff document meds, progress notes, calls to physician, etc. We should be documenting all cares, refusals, basically any communication and cares. Review of the revised 12/2007 Falls and Fall Risk, Managing policy stated The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The facility failed to complete thorough fall investigations, to include identification of causal factors and care plan interventions to prevent further falls, which resulted in a fall with hip fracture and total replacement for R33.

The facility reported a census of 40 residents, with 15 residents included in the sample. Based on observation, interview, and record review the facility failed to further assess R21 for his safety concerning self-administration of insulin (hormone used to regulate blood sugar) medication. R21 displayed unsafe practices in self-administration and medication management when he drew up too much insulin, administered too much insulin, refused to tell staff his blood sugar level, had multiple episodes of severely low blood sugars which required emergency medical interventions and treatment. Findings included: - Review of R21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 11/21/20 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. R21 was independent with activities of daily living (ADL). R21 had almost constant pain and was receiving as needed (PRN) medications. R21 received insulin and opioid medications daily in the seven-day review period. R21 did not receive any antipsychotics. Review of the 11/21/20 Cognitive Loss/Dementia and Behavioral Care Area Assessments (CAA) documented R21 could make his needs known. Staff were to monitor R21 for behavioral changes and intervene to keep R21 safe. Review of the 12/02/20 Care Plan documented R21 had a goal to return to the community and live on his own, after receiving nursing assistance to stabilize his DM-1 and [CONDITION(S)] with [CONDITION(S)]. R21 was able to verbalize his understand of DM-1 treatment and that he needed assistance. R21 would have negative behavior directed toward staff when his blood sugar (BG) was low. Staff was to check his BG when a behavior occurred. Staff were to continue to encourage R21 to make safe decision but would honor [R21's] wishes if he decided to make risky decisions. Staff were to continue to educate R21 on the importance of following the prescribed insulin regimen and monitor his BG. R21 would become angry when staff tried to assist with any cares. R21 stated he is an expert with his BG and prefers to be in control of his insulin and BG monitoring, but staff were to follow physician orders. R21 enjoyed drinking orange juice and eating candy, neither of which were not allowed on his diet. Staff were to monitor R21 for signs of [CONDITION(S)] (low BG; confusion, heart palpitations (feelings of having a fast beating, fluttering or pounding heart), shakiness, and anxiety). R21's BG were to be managed by his Endocrinologist (physician that specializes in DM). Review of the Electronic Medical Records (EMR) Physician Orders for R21 documented the following: [MEDICATION(S)] Insulin (hormone medication to lower BG, 18 units subcutaneous (SQ; injected into belly fat) daily for DM-1 Novolog Insulin (hormone medication to lower BG), 1 unit for every 10 grams of carbohydrates eaten, plus 1 unit for every 40 deciliter (dL) over 140 dL BG based on pre-meal BG, three times daily (TID) for DM-1 Give glucose tabs or honey packets as alternative for low glucose. NO orange juice or other increased K products to treat low glucose. Test BG for symptoms of high or low blood glucose as needed related to DM-1 BG check before meals and HS Review of the 12/09/20 Medication Self-Administration Safety Screen documented that R21 was completely capable of administering insulin to himself. R21 agreed to the terms and policy for self-administration, but no physician order was completed. This screening was not completed a second time. Review of the 12/17/20 at 11:04 AM Incident Note revealed at approximately 10:30 AM, staff notified the nurse R21 was in trouble out at smoke shack east of the building. The LN writer noted they found R21, with the Administrator at his side, in a state unable to swallow or communicate, seizing and drooling at the mouth. The staff administered honey sublingual (SL) per a spoon and placed R21 in position to which he could not choke on his own saliva. Administrative Nurse B acquired his BG and noted it was 31 mg/dL (normal BG level for person with DM type 1 between 80-130 mg/dL) and a nurse administered [MEDICATION(S)] (medication used to treat very low blood sugar) and Glucogel (sugary gel used to treat very low blood sugar) from the E-Kit (emergency medication kit). Review of the 12/20/20 at 07:25 PM Health Status Note revealed R21 was in the hallway, naked from the waist down. He had blood on his hands and his shirt, and a cut across the bridge of his nose. His face was swollen. R21 would not sit down, was mildly combative, and would not follow instructions. When staff asked the resident, what happened they noted his speech was incoherent and garbled. Staff checked R21's BG and it initially returned at 57 mg/dL. The resident refused to put his pants on, could not answer questions, and refused to take drinks of juice to help raise his blood sugar. The LN and direct care staff attempted to get the resident out of his bloody shirt, and he fought them and refused to change. EMS (Emergency Medical Services) came to evaluate R21 and determined a transport was not needed. Review of the 12/24/20 at 07:41 AM Orders General Note from eRecord revealed R21's blood sugar dropped to 64 mg/dL and the staff found him on the floor, face down, convulsing and foaming at the mouth, and noted his nose was bloody. EMS came in and evaluated the situation, provided care, and helped stabilize him. R21 refused to leave the facility and go to the hospital. EMS left after stabilizing the resident. Per EMS please monitor sugar levels, hold insulin, and provide a protein breakfast. The dietary manager took breakfast to R21 and per the dietary manager R21 became hostile, made rude remarks, and stated everyone was trying to fight him. Review of the 12/25/20 at 06:30 AM Health Status Note noted the staff found the resident face down in his room at 06:30 AM with a BG of 73 mg/dL. The staff noted blood on floor and recliner in his room, and a large cut and contusion with swelling to his left eye. The staff called EMS. R21 was unresponsive with [CONDITION(S)]-like activity noted to bilateral arms and foaming at the mouth. Staff administered [MEDICATION(S)] and after EMS arrived the resident came around and fought with EMS telling them he did not want to go. The staff encouraged R21 to go with EMS as he had a large cut above his eye and swelling. The note revealed R21 transferred to the local hospital. Review of the 12/29/20 at 12:50 PM Behavior Note noted R21 was at the nurse's desk cussing and saying that it is [expletive] that he is not allowed to control his insulin dosages. R21 then stated if his blood sugar was high that he will get violent and hurt people if he cannot manage his blood sugars the way that he wants to. He stated he was kind of an expert at managing it on his own because he has been a diabetic for [AGE] years. The note revealed R21's BG was currently 508 mg/dL after refusing 2 units of insulin when his reading was 179 mg/dL at 11:00 AM. Review of the 01/10/21 at 02:55 PM Incident Note revealed the staff were called to R21's room and noted items knocked onto the floor and noted blood on the floor. R21 was in bed with blood on the left side of his face from an area above the eye that was cut on previous falls. The LN staff could not locate the continuous BG monitoring systems control. The LN writer used the facility glucometer, checked R21's BG to be at 59 mg/dL, noted the resident did wake up to loud voice and documented he displayed some confusion. Review of the 01/20/21 at 10:40 PM Health Status Note revealed another resident called the LN writer to R21's room. R21 was not responding and displayed jerking motions with his arms. R21 last checked his blood sugar at the desk and it was 66 mg/dL. He said he was going to eat, but he had not eaten anything since he returned from [CONDITION(S)]. The LN staff administered [MEDICATION(S)] and the BG came up to 54 mg/dL. Review of the 01/22/21 at 01:12 AM Health Status Note revealed at approximately 08:50 PM staff were called to R21's room and noted the resident seizing. BG obtained and noted to be 43 mg/dL and staff administered [MEDICATION(S)]. At 09:10 PM staff rechecked R21's BG and noted it at 119 mg/dL. The note revealed at approximately 10:00 PM, staff reported to the LN another resident was in R21's room and the room smelled like marijuana. The LN writer called Provider Q and reported to her what had happened and spoke to her about the other resident going in the room may have been slipping him pills, since some (pills) had been found in her room. APRN Q noted they would be discontinuing the [MEDICATION(S)] but would wait till morning. The LN writer thought that would be appropriate due to him already making staff nervous tonight with his actions. Resident was on 15-minute checks as per DON (Director of Nursing) orders. Review of the 01/31/21 at 01:01 PM Behavior Note revealed the LN had a pink basket at the desk with a glucometer, strips, test needles, insulin, and syringe in it. R21 grabbed the pink basket from over the counter and ran to his room with it. The LN writer noted she then went to R21's room where R21 refused to give the basket and supplies back. The resident got up from his bed, shoved his bedside table against the LN, went into the bathroom, and as the LN attempted to ask for the basket, R21 shut the door on the LN's arm and hand as he attempted to slam the door, twice. R21 refused to give the insulin and syringe to the LN once again, per her request. Resident yelled I'll [expletive] overdose on it, or maybe better, stab you. The LN stated she was calling the physician and went to the front desk. While the LN was on phone, the resident brought the basket back up front, yelling in the background as the nurse talked on the phone. The LN revealed R21 did return all the supplies and insulin, but not the syringe/needle. Review of the 02/04/21 at 08:20 PM Orders Administration Note revealed R21 refused to tell the LN staff the BG results from 08:00 PM. Administrative Nurse B looked on the BG machine and the reading was 251 mg/dL. The resident drew up 7 units of Novolog, showed to this nurse, whom stated to the resident it should be 2 units, not 7 units. The resident refused to speak to either nurse, and proceeded to give himself the 7 units of Novolog. Review of the 02/05/21 at 11:13 PM Health Status Note revealed at 11:10 PM R21 requested to take his blood sugar, which returned at 202 mg/dL. R21 drew up 6 units of Novolog, the LN writer responded that sliding scale indicated only 1 unit of insulin be administered. R21 proceeded to give himself 6 units of Novolog. Review of the 02/06/21 at 05:15 AM Health Status Note revealed R21 was nonresponsive upon CNAs check at 04:40 AM. The CNA summoned the LN writer who noted the resident as diaphoretic, bed completely wet, non-responsive, eyes fixed, started convulsing, then had almost continual grand mal seizures. The staff checked his BG which was 37 mg/dL. The staff administered intramuscular (IM) [MEDICATION(S)] into R21's left thigh. The staff rechecked his BG which was 55 mg/dL. Provider Q ordered to send R21 to the ER per EMS and the resident refused to go to the ER, after they arrived. Review of the 02/07/21 at 01:30 PM Health Status Note revealed at 01:20 PM the staff reported to this nurse that resident was seizing like when his blood sugar was low. The LN ran down the hall and staff checked his BG which was 39 mg/dL. R21 laid in bed twitching and moaning and drenched in sweat. The LN administered [MEDICATION(S)] shot, and glucose gel started to be administered by mouth, but R21 spit some of it out and swished the rest. The LN noted by 01:30 PM R21 was relaxing the twitching had subsided and was coming back to his normal self. Review of the 02/20/21 at 04:30 PM Health Status Note revealed the LN writer went into resident's room at 04:30 PM and noted R21 on the floor mumbling and not responding to the LN's voice. Noted there was a water bottle spilt all over the floor and things from his table were scattered on the floor. The LN checked his BG and noted it was 38 mg/dL. After the LN administered the [MEDICATION(S)] and applied glucose gel in R21's mouth and rubbed it on his gums, about 10 minutes later R21 was starting to scoot and tense up. The LN protected his head as he slowly scooted towards the nightstand, blood sugar rechecked and noted at 62 mg/dL. The LN writer noted he started coming to, but could tell his BG was still low, as he was slurring his speech at first and repeated himself asking about his sugar. Review of the 03/13/21 at 05:21 PM Health Status Note revealed this nurse noted R21 BG was low and entered room. R21 was noticeably sweaty, having jerking movements, and not responding to staff. The LN writer noted R21's BG was 41 mg/dL. The LN administered glucose gel and rechecked shortly after and his BG was 44 mg/dL. The LN went to get him a washcloth to wipe his head and upon re-entering his room he was now mumbling and jerking more, and the LN administered [MEDICATION(S)] injection and noted she would keep monitoring the BG until he was alert. An observation on 03/30/21 at 01:25 PM revealed R21 at the nurses' station complaining about his medications, stating he was not getting his insulin like he thought he should. During an interview on 03/29/21 at 08:36AM, R21 reported that his Endocrinologist got his insulin corrected and that his insulin was based on carb intake. R21 stated that Advanced Practice Registered Nurse (APRN) Q lied to his Endocrinologist saying R21 does not follow the correct meal plan and refuses to eat. R21 stated I have fallen out of bed and busted my head due to diabetic shock. I have a lot of videos with recorded conversations. I didn't get back from [CONDITION(S)] until like 730-8PM, and my BG was 498 and the [Administrative Nurse B] refused to give me insulin. [Administrative Nurse B] said that my endocrinologist changed the meds, but I talked to my endocrinologist and she said that they never talked to each other. I woke up in the morning and it was over 500. R21 stated that staff do not wake him up at night to check his BG and that he does not want to end up in the hospital again. An interview on 03/31/21 at 02:34PM with Regional Nurse E revealed that she believed R21 was intentionally overdosing on his insulin and would choose not to eat so that he would have a low BG. In an interview with APRN Q on 04/01/21 at 12:57PM, it was reported that she called the Endocrinologist and discussed the insulin regimen as R21 was not reporting how much he ate and therefore the dosage of insulin was incorrect. I put in an order that he was not allowed to draw up his own insulin because he would draw up more than he was supposed to and bottom out. I would try to enforce orders and for some reason it didn't happen. I tried making the order for nursing to draw up the order instead of him, but that was not being followed. I could not justify him drawing up the order, so I changed it. The medical record lacked the order for R21's to no longer self-administer insulin. A review of the revised April 2007 Medication Therapy policy stated the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication. The facility shall review medication-related issues as part of its Quality Assurance Committee and activities. The facility failed to provide a policy regarding self-administration of medication. The facility failed to further assess R21 for his safety, concerning self-administration of medication when it became clear R21 could not safely and properly self-dose his insulin.

The facility had a census of 53 residents with 10 residents selected for sample. The facility identified 5 residents with facility acquired pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and the sample included 4 of those residents. Based on observation, interview and record review, the facility failed to have processes in place to prevent pressure ulcer development and, once residents acquired pressure ulcers, have processes in place to promote healing of existing ulcers, prevent infection and prevent new ulcers from developing for 4 of 4 sampled residents. Residents #7 entered the facility without a pressure ulcer and then developed an unstageable ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar/dead tissue) to the heel. Resident #9 entered the facility without pressure ulcers and then developed a Stage 2 ulcer (partial thickness loss of skin presenting as a shallow open area with a red pink wound bed) and a Stage 3 (full thickness loss of skin) ulcer between his/her toes. Both resident's wounds were advanced by the time staff discovered them, in part due to facility failure to complete weekly skin assessments as directed by the care plans and facility policy. Resident #10 was admitted to the facility with a pressure ulcer which staff failed to assess/measure routinely and failed to implement preventative measures to prevent additional skin breakdown. The facility also failed to complete weekly skin assessments and implement preventative measures to prevent skin breakdown for resident #8. Findings included: - Resident #7's medical record included a [DIAGNOSES REDACTED]. The 1/23/19 quarter minimum data set (MDS) identified the resident with long and short term memory problems, severely impaired decision making abilities, the need for extensive assistance of 1 staff for bed mobility and transfers, the need for extensive assistance of two staff for ambulation, a risk for 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) development, no current pressure ulcers, use of pressure reduction devices for the chair and bed, and a turning/repositioning program. The 11/16/16 care plan identified the resident as independent with ambulation, transfers and bed repositioning. According to the care plan, the resident had a pressure reduction mattress on the bed. The care plan included the intervention a licensed nurse to complete a full body skin assessment weekly. The care plan lacked goals/interventions related to the presence of a current pressure ulcer. The 2/1/19 skin risk assessment identified resident #7 as mild risk for skin breakdown. The clinical record lacked evidence of weekly skin assessments as directed by the care plan in the time period from 1/1/19 - 4/10/19. A 3/19/19 Wound Assessment identified the presence of an unstageable pressure ulcer (a pressure ulcer whose severity cannot be determined with visual exam due to substances covering the wound bed/base) to the right heel which measured 4.0 centimeters (cm) by 5.0 cm. The Wound Assessment lacked other descriptions of the wound and/or surrounding tissues. According to the assessment, staff should offload (relieve pressure) the resident's heels at all times while in bed. The clinical record lacked evidence of a thorough assessment of the right heel pressure ulcer including measurements in the time period from 3/19/19 - 4/10/19. During an observation on 4/10/19 at 10:50 a.m., resident #7 had black eschar (dead tissue) covering the entire right heel. The resident required assistance of 2 staff to transfer from the wheelchair to the bed. Once in bed, staff placed a boot on the resident's right foot and offloaded pressure by placing the feet on a pillow. During an interview on 4/10/19 at 10:50 a.m., licensed nursing staff H reported the resident acquired the right heel pressure ulcer at the facility. According to staff H, the resident previously walked within the facility without staff assistance, but declined over the past few months and now lacked the ability to ambulate. Staff H could not verbalize any interventions in place to prevent skin breakdown of the heels prior to development of the heel pressure ulcer. Staff H reported staff started offloading the heel and applying a boot after the development of the pressure ulcer. During an interview on 4/10/19 at 3:00 p.m. administrative nursing staff B confirmed the resident #7's right heel pressure ulcer was facility acquired. Staff B also reported awareness staff failed to complete the weekly skin assessments for resident #7 prior to the development of the pressure ulcer, and when staff first noticed the skin breakdown to the right heel, the area was already considered unstageable. Attempts to contact Midlevel Practitioner F, the provider responsible for resident #7's care in the facility, were unsuccessful on 4/13/19 at 11:10 a.m., 4/23/19 at 8:30 a.m. and 4/23/19 at 1:00 p.m. The facility's undated Skin System Policy and Procedure included, Residents who enter the facility without a pressure sore will not develop a pressure sore unless the individual's clinical condition demonstrates it was unavoidable .A skin assessment will be completed on admission/readmission, with any fall and weekly thereafter .The Care Area Assessment for Pressure Ulcer and Care Plan will be reviewed and updated each week until the wound has healed .Staging and measuring will be done by the assigned nurse to maintain continuity in documentation of progression of wound healing using the NPUAP (National Pressure Ulcer Advisory Panel) current guidelines .The assigned nurse manager will provide oversight of the resident's skin/wound care in collaboration with the nurse, nurse assessment coordinator, physician and report changes to the Skin Committee on a weekly basis. Prevalence of wounds/skin impairment will be tracked and trended using the Electronic Health Record Wound Care Module and reviewed by the Skin Committee on a weekly and monthly basis . The facility failed to have processes in place to prevent the development of an avoidable, unstageable pressure ulcer on resident #7's heel, including weekly skin assessments, implementation of appropriate interventions based on the resident's risk for skin breakdown, and timely identification of skin breakdown. The facility also failed to provide resident #7 with the appropriate treatment to promote healing of a pressure ulcer when staff failed to complete thorough assessments of the wound weekly, including measurements. - Resident #9's clinical record included a [DIAGNOSES REDACTED]. The 2/1/19 quarterly minimum data set (MDS) lacked assessment information related to the resident's cognition. According to the assessment, the resident required total dependence on staff for bed mobility and transfers and lacked the ability to ambulate. The resident weighed 96 pounds and experienced weight loss without a physician prescribed weight loss plan. The resident was at risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) but lacked current pressure ulcers. The resident received Hospice services. The 8/26/15 care plan directed a licensed nurse to complete a full body skin assessment for the resident weekly. The 11/26/18 skin risk assessment identified the resident as mild risk for skin breakdown. The clinical record lacked evidence of completion of a skin risk assessment since 11/26/18, a time period of 4 1/2 months. The clinical record lacked evidence of weekly skin assessments as directed by the care plan in the time period from 1/1/19 - 4/10/19. The nurse's notes dated 2/14/19 at 6:26 a.m. described a Hospice order for skin prep between toes on both feet daily for unstageable ulcers (a pressure ulcer whose severity cannot be determined with visual exam due to substances covering the wound bed/base). Review of the nurse's notes/progress notes revealed no mention of the skin condition between the toes in the weeks prior to this note. A nurse's note dated 3/17/19 included, Continues with PU (pressure ulcers) to the right 3rd and 4th toes and noted the areas appeared to be smaller. The note revealed it was very difficult to obtain measurements due to location of the wounds and noted a small amount of drainage noted to the old duoderm (wound dressing) with no odor noted. The resident continued with an unstageable to the right 3rd inner toe and a stage 2 (partial thickness loss of skin presenting as a shallow open area with a red pink wound bed) to the right 4th toe. The clinical record lacked any documentation about the pressure ulcers on the resident's toes in the 24-day time period from 3/17/19 - 4/10/19. Additionally, the record lacked evidence of thorough assessments of the pressure ulcers to the toes, including measurements, in the time period from 2/14/19 - 4/10/19. During an observation on 4/10/19 at 1:30 p.m., licensed nursing staff K removed the dressings from between the resident's toes on the right foot. Per staff K, the resident developed the pressure ulcers while a resident at the facility. Staff K described the pressure ulcer to the 3rd inner toe as a Stage 3 (full thickness loss of skin). During an interview on 4/10/19 at 1:30 p.m., licensed nursing staff J described resident #9's pressure ulcers as facility acquired and reported the resident lacked the ability to move/reposition without staff assistance. Nurse J could not verbalize any interventions in place to prevent skin breakdown to the resident's feet prior to the development of the right toe pressure ulcers. After development of the pressure ulcers, staff were directed to place foam boots on both of the resident's feet when the resident was in bed. During an interview on 4/10/19 at 3:00 p.m. administrative nursing staff B confirmed resident #9's right toe pressure ulcers were facility acquired. Nurse B also reported awareness staff failed to complete weekly skin assessments for resident #9 prior to the development of the pressure ulcer, and when staff first noticed the skin breakdown to the toes, the pressure ulcers were already considered unstageable. Attempts to contact Midlevel Practitioner F, the provider responsible for resident #5's care in the facility, were unsuccessful on 4/13/19 at 11:10 a.m., 4/23/19 at 8:30 a.m. and 4/23/19 at 1:00 p.m. The facility's undated Skin System Policy and Procedure included, Residents who enter the facility without a pressure sore will not develop a pressure sore unless the individual's clinical condition demonstrates it was unavoidable .A skin assessment will be completed on admission/readmission, with any fall and weekly thereafter .The Care Area Assessment for Pressure Ulcer and Care Plan will be reviewed and updated each week until the wound has healed .Staging and measuring will be done by the assigned nurse to maintain continuity in documentation of progression of wound healing using the NPUAP (National Pressure Ulcer Advisory Panel) current guidelines .The assigned nurse manager will provide oversight of the resident's skin/wound care in collaboration with the nurse, nurse assessment coordinator, physician and report changes to the Skin Committee on a weekly basis. Prevalence of wounds/skin impairment will be tracked and trended using the Electronic Health Record Wound Care Module and reviewed by the Skin Committee on a weekly and monthly basis . The facility failed to have processes in place to prevent development of two avoidable pressure ulcers, Stage 2 and Stage 3 located between the resident's toes, for resident #9, including weekly skin assessments, implementation of appropriate interventions based on the resident's risk for skin breakdown, and timely identification of skin breakdown. The facility also failed to provide resident #9 with the appropriate treatment to promote healing of a pressure ulcer when staff failed to complete thorough assessments of the wound weekly, including measurements. - Resident #10's clinical record included a [DIAGNOSES REDACTED]. The 3/13/19 Medicare 5-day minimum data set (MDS) identified the resident with no current pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The 3/28/19 significant change MDS identified the resident with long and short term memory problems, the need for extensive assistance of two staff for bed mobility, an inability to ambulate, functional limitations in range of motion on both sides of the lower extremities, occasional bladder incontinence, always incontinent of bowel, at risk for pressure ulcers, the presence of one Stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow open area with a red pink wound bed) that was not present on admission and one unstageable pressure ulcer (a pressure ulcer whose severity cannot be determined with visual exam due to substances covering the wound bed/base) that was not present on admission. According to the MDS, the resident used pressure reduction devices for the bed and chair, participated in a turning and repositioning program, received pressure ulcer care and application of nonsurgical dressings. The 7/29/17 care plan directed licensed nurses to complete a full body skin assessment on the resident weekly. According to the care plan, the resident required assistance of 2 staff for repositioning. As of 4/9/19, the resident's care plan lacked any interventions related to preventative measures taken to prevent skin breakdown on the feet. The care plan also lacked measurable goals and individualized interventions related to the presence of current pressure ulcers and/or treatments for those wounds. An 11/9/18 skin risk assessment identified the resident as minimal risk for skin breakdown. The next skin risk assessment dated [DATE] identified the resident as moderate risk for breakdown. The clinical record lacked evidence of completion of skin risk assessments in the 4-month time period between 11/9/18 and 3/8/19. The clinical record lacked evidence of weekly skin assessments as directed by the care plan in the time period from 1/1/19 - 4/10/19. Review of the nurse's note dated 3/8/19 at 4:21 p.m. described the resident's readmission following hospitalization . According to the note, the resident has two Stage 2 pressure ulcers on (his/her) buttock which measured 2 centimeters (cm) by 0.5 cm and 2.5 cm by 1.2 cm. The clinical record lacked evidence of wound assessments, including measurements, in the 10-day time period from 3/8/19 - 3/18/19. Then, on 3/18/19 at 6:22 a.m., a nurse's note described deterioration/worsening of the wounds. According to the nurses note, the resident had a Stage 2 wound to the sacrum (large triangular bone between the two hip bones)/coccyx (small triangular bone at the base of the spine) that measured 3 cm by 0.2 cm. The note also described an unstageable pressure ulcer to the right buttock that measured 3.5 cm by 2.5 cm with a depth of 0.3 cm with a dark area: to the wound bed. The clinical record lacked evidence of wound assessments, including measurements, from 3/18/19 - 4/10/19, a time period of 23 days. During an observation on 4/10/19 at 9:40 a.m., Licensed Nurses J and L prepared to complete a dressing change to resident #10's pressure ulcers. The resident had a foam dressing in place to the coccyx area with an open area noted below the dressing that was not covered with a dressing. Licensed Nurse J removed the undated foam dressing from the coccyx and found no areas of skin breakdown beneath the dressing. According to Licensed Nurse J, someone put the dressing in the wrong place. According to Nurse J, the open area to the left buttock is a Stage 2. At the time of this observation, the resident lay in bed with no heel protectors in place. Assessment of the resident's feet revealed the presence of a quarter sized non-blanchable area to the left heel as well as the entire left great toe which was red and non-blanchable. Upon palpation, Licensed Nurse J reported the right heel also feels boggy. During an interview on 4/10/19 at 10:00 a.m., Licensed Nurse J reported the resident lacked the ability to move without assistance in bed and the resident never got out of bed. Nurse J could not verbalize any interventions put into place to protect the resident's feet from breakdown prior to 4/10/19. During the afternoon hours of 4/10/19, staff reported they placed soft booties on the resident's feet to address the skin integrity issues of both feet as identified during the 4/10/19 observation at 9:40 a.m. Additionally, Licensed Nurse J reported he/she checked the MAR (medication administration record) and found the dressing that was placed in error on the resident's coccyx rather than over the left buttock pressure ulcer and was applied on 4/8/19, two days earlier. During an interview on 4/10/19 at 3:00 p.m. Administrative Nurse B reported awareness staff failed to complete weekly skin assessments for resident #10 as directed by the care plan. The facility's undated Skin System Policy and Procedure included, Residents who enter the facility without a pressure sore will not develop a pressure sore unless the individual's clinical condition demonstrates it was unavoidable .A skin assessment will be completed on admission/readmission, with any fall and weekly thereafter .The Care Area Assessment for Pressure Ulcer and Care Plan will be reviewed and updated each week until the wound has healed .Staging and measuring will be done by the assigned nurse to maintain continuity in documentation of progression of wound healing using the NPUAP (National Pressure Ulcer Advisory Panel) current guidelines .The assigned nurse manager will provide oversight of the resident's skin/wound care in collaboration with the nurse, nurse assessment coordinator, physician and report changes to the Skin Committee on a weekly basis. Prevalence of wounds/skin impairment will be tracked and trended using the Electronic Health Record Wound Care Module and reviewed by the Skin Committee on a weekly and monthly basis . The facility failed to have processes in place to promote healing of an existing pressure ulcer and to prevent development of new pressure ulcers for resident #10. Staff failed to complete weekly skin assessments as directed by the care plan, failed to thoroughly assess existing pressure ulcers in a timely manner, failed to apply dressings to a pressure ulcer as ordered by the physician and failed to initiate preventative interventions to avoid further skin breakdown to the resident's feet. - Resident #8's clinical record included a [DIAGNOSES REDACTED]. The 3/19/19 quarterly minimum data set (MDS) identified the resident with long and short-term memory problems, severely impaired decision-making abilities, always incontinent of bowel and bladder, total dependence on two staff for bed mobility and transfers, at risk for pressure ulcers , (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) the presence of a current pressure ulcer considered a Stage 2 (partial thickness loss of skin presenting as a shallow open area with a red pink wound bed), and use of pressure reduction devices for the bed and chair. The 11/4/11 care plan directed licensed nurses to complete a full body skin assessment for the resident weekly. The care plan lacked measurable goals and interventions related to the presence of a pressure ulcer as identified on the 3/19/19 MDS. A 12/7/18 skin risk assessment identified the resident as moderate risk for skin breakdown. A 3/15/19 skin risk assessment identified the resident as high risk for skin breakdown. The clinical record lacked evidence of weekly skin assessments as directed by the care plan in the time period from 1/1/19 - 4/10/19. A nurse's note dated 3/6/19 described an open area on the resident's right side. The entry lacked assessment of the wound, including measurements and staging. A nurse's note date 3/17/18 described the open area to the right hip/side area which measured 2.5 centimeters (cm) by 1.5 cm with 100% slough (dead tissue, usually yellow or cream in color) to the wound base. The clinical record lacked evidence of nursing assessments of the existing wound, including measurements, in the 24-day time period from 3/17/19 - 4/10/19. During an observation on 4/10/19 at 2:00 p.m., licensed nurse L removed a dressing from a wound located on the residents right upper thigh/hip area. The area of breakdown was not located over a pressure point. According to licensed nurse L, the facility considered the wound a pressure ulcer even though it was not located over a pressure point. Nurse L examined all other pressure points and found the resident's left heel reddened and non-blanchable with a white center. The non-blanchable area measured 7 cm by 4.5 cm. The resident did not wear heel protectors or have the heels positioned in a manner to prevent pressure at the time of the observation. During an interview on 4/10/19 at 2:15 p.m., licensed nurse L could not verbalize interventions put into place to prevent skin breakdown on the resident's heels prior to the observation of the non-blanchable area on 4/10/19. During an interview on 4/10/19 at 2:00 p.m., administrative nursing staff B reported awareness the staff failed to complete weekly skin assessments for resident #8. Administrative nurse B could not provide evidence of preventative interventions implemented to prevent the skin breakdown on the resident's heels. The facility's undated Skin System Policy and Procedure included, Residents who enter the facility without a pressure sore will not develop a pressure sore unless the individual's clinical condition demonstrates it was unavoidable .A skin assessment will be completed on admission/readmission, with any fall and weekly thereafter .The Care Area Assessment for Pressure Ulcer and Care Plan will be reviewed and updated each week until the wound has healed .Staging and measuring will be done by the assigned nurse to maintain continuity in documentation of progression of wound healing using the NPUAP (National Pressure Ulcer Advisory Panel) current guidelines .The assigned nurse manager will provide oversight of the resident's skin/wound care in collaboration with the nurse, nurse assessment coordinator, physician and report changes to the Skin Committee on a weekly basis. Prevalence of wounds/skin impairment will be tracked and trended using the Electronic Health Record Wound Care Module and reviewed by the Skin Committee on a weekly and monthly basis . The facility failed to have systems in place to assess resident #8's skin weekly as directed by the care plan and failed to develop/implement appropriate preventative interventions to reduce the risk of skin breakdown.

The facility had a census of 53 residents with 10 residents selected for sample. Based on observation, interview and record review, the facility failed to provide 2 of 3 residents reviewed for falls (Residents #4, #5) with adequate supervision to prevent falls when staff failed to assess for causal factors after each fall and failed to develop/implement appropriate fall prevention strategies based on causal factors to prevent additional falls. Resident #5 fell twice, and staff failed to assess for causal factors and implement appropriate interventions based on causal factors. When resident #5 fell the third time, he/she sustained fractures of two ribs. Findings included: - Resident #5's clinical record included an undated [DIAGNOSES REDACTED]. The 2/3/19 quarterly minimum data set (MDS) identified the resident with long and short-term memory problems, moderately impaired decision-making abilities, the need for extensive assistance of one staff for transfers and toileting, impaired balance and only able to stabilize with staff assistance, use of a walker and a wheelchair, frequent incontinence of bladder, and no falls since the prior assessment. The 3/17/17 care plan noted the resident's dependence on one staff for assistance with repositioning and transfers. The care plan also identified the resident as a fall risk and directed staff to complete fall risk assessments quarterly and with changes or falls. The 2/24/18 fall risk assessment identified the resident as low risk for falls. The next fall risk completed by staff was on 3/23/19 and identified the resident as high risk for falls. The facility provided fall investigation as follows: An 11/12/18 Fall Investigation Worksheet referred to a fall which occurred on 11/9/18 when the resident attempted to toilet independently. The fall investigation lacked evidence of attempts to determine causal factors/root cause analysis of the fall and then development/implementation of fall interventions based on the causal factors. According to the worksheet, staff implemented an intervention to check on resident over night to make sure resident wears pull up as a new fall prevention strategy. A 12/26/18 Fall Investigation Worksheet referred to a fall which occurred on 12/24/19 when the resident again attempted to toilet independently. The fall investigation lacked evidence of attempts to determine causal factors/root cause analysis of the fall and then development/implementation of fall interventions based on the causal factors. According to the worksheet, staff implemented the intervention resident educated to call for help and wait as a new fall prevention strategy. A 3/23/19 Fall Investigation Worksheet referred to a fall which occurred on 3/23/19 when the resident attempted to stand without assistance of another person. The fall investigation lacked evidence of attempts to determine causal factors/root cause analysis of the fall and then development/implementation of fall interventions based on the causal factors. The section of the form entitled, Recommendations to Prevent Further Falls remained blank. A nurse's note dated 3/24/19 described resident #5's fall on 3/23/19 and the resident's complaints of pain to the right mid and lower back immediately after the fall. A nurse's note dated 3/26/19 at 4:46 a.m. described injuries sustained by resident #5 as a result of the 3/23/19 fall as nondisplaced (bones remain in alignment) fracture (break) of the lateral (pertaining to the side - away from the middle) aspect of the 7th and 8th ribs on the right side. During an interview on 4/10/19 at 3:00 p.m., administrative nursing staff B confirmed the fall investigations submitted for review were the only investigative documents completed by staff. According to Nurse B, the resident was failing physically at the time of the 3/23/19 fall and was more unsteady and weak than in previous days. Attempts to contact Midlevel Practitioner F, the provider responsible for resident #5's care in the facility, were unsuccessful on 4/13/19 at 11:10 a.m., 4/23/19 at 8:30 a.m. and 4/23/19 at 1:00 p.m. The facility's undated Incident and Accident Process directed staff to assess and investigate accidents in a systematic manner to identify hazards and risk, evaluate and analyze hazards and risks, implement interventions to reduce hazards and risk and monitor for effectiveness and modify interventions when necessary. The document lacked direction related to assessment for causal factors/root cause analyses after each fall with development/implementation of new interventions based on the root cause of each fall. The facility failed to provide resident #5 with adequate supervision to prevent falls when staff failed to thoroughly investigate falls on 11/9/18 and 12/24/18, including assessment of causal factors, and then develop/implement fall prevention strategies based on causal factors in an attempt to prevent additional falls. Resident #5 fell a third time on 3/23/19 and sustained two fractured ribs as a result of the fall. - Resident 4's clinical record included a [DIAGNOSES REDACTED]. The 3/8/19 quarterly minimum data set (MDS) lacked assessments of the resident's cognitive status. According to the assessment, the resident required assistance of one staff for bed mobility and transfers and extensive assistance of one staff to walk in the room. The resident also had impaired balance and was only able to stabilize with staff assistance. The residents had not experienced falls since the prior assessment. The 11/18/17 care plan noted the resident used a walker for ambulation. According to the care plan, the resident was at risk for falls. The fall risk assessment completed on 10/13/18 identified the resident as low risk for falls. The fall risk assessments completed on 3/15/19 and 3/21/19 identified the resident as a high risk for falls. Review of the Nurses Notes dated 3/15/19 at 6:55 a.m. described an unwitnessed fall. Staff found the resident sitting on the floor near the door leading into the corridor. Staff also found a dry brief in the trashcan near the sink. The resident was described as confused with more weakness and forgetful. The resident did not sustain an injury as a result of the fall. The 3/20/19 Fall Investigation of the 3/15/19 fall included the following immediate intervention to prevent further falls: Resident is independent with toileting. Going to request blood lab or UA (urinalysis) with culture to rule out, confused lately. Review of the nurse's note dated 3/22/19 at 8:08 p.m. described an unwitnessed fall. Staff found the resident on the floor in his/her room with a boomerang shaped gash on the left side of the forehead which measured 3 centimeters (cm) by 5 cm by 1.2 cm. According to the note, the resident had blood on his/her hands, face, shoulder and hair as well as the floor and furniture as a result of the gash to the head. After contacting the physician, staff sent the resident to the emergency room (ER) and the resident received sutures/staples to the forehead. The 3/25/19 fall investigation of the 3/22/19 fall lacked evidence of assessment for causal factors of the fall and lacked evidence of development and implementation of fall prevention strategies based on causal factors of the fall. The immediate intervention to prevent further falls recorded on the fall investigation form was resident sent to ER. During an observation on 4/10/19 at 1:10 p.m., direct care staff M assisted resident #4 to ambulate in the hallway. The resident used a walker to assist with ambulation. The resident had extensive facial bruising on the left side of the face under the eye and in the cheekbone area. The resident also had a fresh scar on the forehead above the left eye from the laceration sustained in the 3/22/19 fall. During an interview on 4/11/19 at 9:00 a.m., administrative nursing staff B reported the resident had signs/symptoms of a urinary tract infection prior to the 3/15/19 fall and therefore it seemed appropriate to obtain lab tests to determine if an infection contributed to the fall. Although requested, Nurse B could not provide evidence of assessment of causal factors after the 3/22/19 fall. The facility failed to provide resident #4 with adequate supervision to prevent accidents when staff failed to assess for causal factors after each fall and then develop/implement appropriate fall prevention strategies based on causal factors.

The facility census totaled 54 residents with 18 in the sample. Based on observation, interview and record review the facility failed to ensure 1 resident sampled for accidents received appropriate assistance with the use of an assistive device (gait belt) in order to prevent accidents (#25). This failure allowed the resident to fall on 5/15/16 and he/she sustained an impacted fracture of the left hip. Findings included: - Review of the signed April 2016 physician's orders [REDACTED].#25 revealed the following Diagnoses: [REDACTED]. The annual minimum data set ((MDS) dated [DATE] identified the resident with a brief interview for mental status (BIMS) score of 12 indicating moderately impaired cognition. The resident required extensive assistance of 1 staff with bed mobility, transfers, walking (in/out of the room), dressing, and toilet use. He/she received an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) daily during the 7 day observation period and no falls since last assessment. Review of the cognition care area assessment (CAA) dated 4/28/16 revealed the resident had mild cognitive impairment during the MDS interview but mostly lacked interest in participating. He/she had a [DIAGNOSES REDACTED]. Review of the activities of daily living (ADL) CAA dated 4/28/16 revealed the resident continued to ambulate with a walker and staff assistance. He/she dragged his/her feet when walking and required 1 person assist. Review of the fall CAA dated 4/28/16 revealed the resident had no recent falls and remained at risk for falls related to the dragging of his/her feet while walking, he/she received medications which increase the fall risk and he/she laid in bed for prolonged periods of time. The significant change MDS dated [DATE] identified the resident as severely impaired cognition, required extensive assistance of 2 staff for bed mobility, dressing, toilet use and total dependence on 2 staff for transfers. Review of the ADL care plan with a start date of 8/18/15 revealed the facility planned for the resident to have limited assistance by 1 staff with dressing, toileting and transfers. Staff were to ensure the call light was in place in the resident's reach while he/she was in the room. The care plan dated 4/27/16 revealed the resident had a bruise to his/her left wrist and right hand with directions for staff to monitor the resident's extremities during transfers. On 5/13/16 staff updated the care plan to reflect a skin tear to the resident's right hand between thumb and index finger as a result of the resident losing his/her balance and staff grabbed his/her hand to prevent a fall. Review of the at risk for falls care plan dated 8/18/15 revealed the resident was at risk for falls related to muscle weakness and medications. The interventions included the use of a rolling walker at all times for ambulation with staff provision of reminders. The resident exhibited poor safety awareness and staff were to allow him/her to verbalize frustrations, assist him/her in redirecting to avoid unsafe choices. The care plan had no updates or changes until 5/15/16 (after the fall). On 5/15/16 staff updated the care plan with resident was non-weight bearing on the lower left extremity due to fracture of the left hip and directed to use 2 staff for assistance with ADLs. Nurses' notes on 5/13/16 at 12:14 PM revealed a nurse aide reported to the nurse while the resident ambulated in the dining room he/she started to lose his/her balance and the nurse aide grabbed the resident's right hand to keep him/her from falling. On 5/16/16 at 5:09 AM a nurses made a late entry regarding an incident on 5/15/16 at 9:00 PM when a nurse aide reported the resident was on the floor. The nurse entered the room and saw the resident on the floor with his/her back under the sink. A nurse aide assisted the resident to the bathroom and back to bed with the walker. On the way back from the bathroom the resident lost his/her balance and began to fall. The nurse aide did not have contact with the resident at this time as he/she was straightening the blankets on the bed. The nurse aide assisted the resident during the fall to keep him/her from hitting his/her head but the resident landed on his/her buttocks. At 4:00 AM the nurse and 2 nurse aides stood the resident and asked him/her to use the walker to walk to the bathroom. The resident would not take any steps and did not want to bear weight on the left leg. The resident would not pivot to sit down on the walker seat, denied pain but did cry out when staff assisted the resident to a standing position. Staff called the doctor on call and received orders to obtain an X-ray of the left hip due to complaint of pain and unwillingness to bear weight. On 5/16/16 at 10:56 AM a nurse recorded he/she received the X-ray report at 9:25 AM and called the report to the physician's assistant. At 10:30 AM the nurse received an order to send the resident to the emergency room for evaluation and treatment. Review of the facility's investigation revealed on 5/15/16 at 9:00 PM direct care staff JJ assisted the resident to the bathroom, he/she let go of the resident to pull the covers back on the bed and the resident stumbled backwards. The resident landed on his/her bottom on the floor. The licensed nurse assessed the resident and had 2 staff assist the resident to stand when the resident would not walk and staff assisted him/her to bed. The resident complained of pain in left knee and hip, was unable to move the leg away from the midline of the body and staff called the physician. The investigation indicated the resident was alert and oriented with a BIMS score of 12 (moderately impaired cognition) and needed assistance of 1 staff with most ADLs and transfers and ambulation with a rolling walker. Review of the X-ray report dated 5/16/16 revealed a left femoral neck (hip) fracture. Review of the notarized statement by direct care staff JJ dated 5/17/16 revealed staff JJ walked the resident to the bathroom on 5/15/16 at 9:00 PM. While he/she assisted the resident back from the bathroom with the walker (no mention of a gait belt) he/she let go of the resident to pull back the blankets and the resident stumbled backwards. Interview on 2/21/17 at 4:04 PM with direct care staff FF revealed the resident required 1 staff assistance with ADLs and he/she used the call light. The resident needed a gait belt and staff to hold on to the gait belt during transfers and ambulation. Interview on 2/21/17 at 3:59 PM with licensed nurse W reported the resident came to the facility due to an overall decline and required staff assistance of 1 with transfers and walking. On 2/22/17 at 3:38 PM administrative nurse J and licensed nurse W said anytime a resident is care planned to need assistance of 1 or more staff it meant hands on with a gait belt or it would read stand by assist. Both nurses reported an expectation for staff to keep their hands on the gait belt throughout the care when a resident required assistance of 1 staff. Nurse W reviewed the facility's investigation and confirmed staff failed to follow the care plan regarding the assistance with transfers and walking. Review of the facility's policy for use of a gait belt dated 2014 revealed it is the policy of the facility for staff to use gait belts with residents who cannot independently ambulate or transfer for the purpose of safety. Interview on 2/22/17 at 3:54 PM with physician extender GG confirmed the report on the fracture read as an acute, impacted fracture of the left hip. He/she said impacted would be indicative of the fall causing the fracture and the report did not show the fracture as pathological (bone fracture caused by disease). The facility failed to provide appropriate assistance with the use of a gait belt for resident #25, who fell when staff failed to use a gait belt and let go of the resident. The resident sustained [REDACTED].