Every finding on record at Curtis Home St Elizabeth Center, The

Based on observations, review of clinical records, facility documentation, facility policies, and interviews for 1 of 4 residents (Resident #47) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall with injury and failed to follow the fall care plan interventions for injury prevention; and for the only sampled resident (Resident #36) reviewed for smoking, the facility failed to ensure a container being used for smoking materials was safe from potential fire hazard. The findings include: 1. Resident #47 was admitted to the facility in March 2024. Resident #47's diagnoses included dementia with behavioral disturbances, mood disturbance, anxiety, and large right cerebellar infarcts (stroke). The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required assistance of 1 for bed mobility, personal hygiene, and was a full mechanical lift for transfers. The Resident Care Plan dated 4/10/24 identified falls as an area of concern. Interventions included using a low bed with bilateral floor mats on each side of the bed, monitor for attempts to self-transfer, poor safety awareness in the environment, and potential hazards, assistance of 1 with care, and full mechanical lift for transfers. The Resident Care Plan was updated on 6/10/24 with a new intervention to have Resident #47's current low bed replaced with a floor bed (a bed that can be raised but could be lowered all the way to the floor) and high floor mats. A. The physician orders dated 6/12/24 directed to administer Eliquis (blood thinner) 2.5 milligrams (mg) twice a day, transfer via mechanical lift with assist of 2 staff, and assist of 1 staff with activities of daily living including self-feeding. An interim physician order dated 6/13/24 directed to change the low bed to a floor bed with floor mats on both sides of the bed. A review of nursing notes from 3/1/24 through 3/4/25 identified that Resident #47 had 4 falls from his/her bed on 3/25/24, 6/9/24, 6/24/24, and 1/16/25. A review of an RN assessment form completed by RN #5 on 6/24/24 at 4:30 AM following Resident #47's fall on 6/24/24 identified that NA #2 provided incontinent care to Resident #47 and reached for towels/washcloths at the end of the bed. Resident #47 was noted to have rolled off the bed between the bed and floor mat and hit his/her head. A laceration was noted to the left side of forehead, pressure was applied to area, and no change in level of consciousness was noted. The physician was notified and ordered to send Resident #47 to the emergency room (ER) to evaluate the head injury. The responsible party was made aware of the injury and the resident's transfer to the ER. A review of the Accident and Incident Report completed by RN #5 dated 6/24/24 at 4:30 AM indicated that Resident #47's fall was witnessed by NA #2. NA #2 was unable to stop the fall or catch the resident. Resident #47 was unable to provide a statement due to his/her cognitive status. A written statement by NA #2 dated 6/24/24 at 4:30 AM indicated that NA #2 saw Resident #47 at 2:45AM and 4:30AM. Incontinent care was provided to Resident #47 at 2:45 AM with no agitation or restless behavior. NA #2 indicated at 4:30 AM she raised the bed with the mats still in place and went to grab towels and wash clothes at the end of the bed. Resident #47 rolled off the bed landing between the bed and the floor mat. NA #2 indicated she was unable to catch Resident #47 to prevent him/her from hitting the floor and immediately called the supervisor to come to Resident #47's room as he/she was bleeding from the head. A review of The Reportable Event Form submitted to the state agency by the DNS on 6/24/24 at 7:45 PM indicated that Resident #47 rolled off the bed while receiving care and sustained a laceration to his/her forehead. NA #2 raised Resident #47's bed in preparation to provide incontinent care. When NA #2 reached for wash clothes located at the foot of bed, Resident #47 quickly rolled over and fell out of bed between the bed and floor mats. Resident #47 sustained a laceration to the forehead, was sent to the ER, received 5 sutures, and returned to the facility. A review of Resident #47's ER discharge summary dated 6/24/24 at 8:54 AM identified that Resident #47 had an unwitnessed fall with a head strike. A CT scan was performed on the head that was negative for any bleeding. The laceration to the resident's forehead was repaired with 5 sutures. Interview with NA #2, (not currently employed at the facility) on 3/5/25 at 9:00 AM identified when Resident #47 fell on [DATE] it was her first time working the overnight shift, she normally worked second shift, and she had not received any orientation to the night shift routine. NA #2 stated in preparation for incontinent care she raised Resident #47's bed and went into the bathroom for water. While in the bathroom, waiting for the water to warm up, she heard a loud thud, saw the resident on the floor between the bed and floor mat, and noted Resident #47 was bleeding from his/her head. She indicated she immediately called for the nurse from the doorway who came to the room to assess Resident #47. NA #2 indicated that she was unaware she should not have left Resident #47 alone after raising the bed. NA #2 recalled writing a statement and possibly speaking to the DNS after the incident but was unable to identify why her current verbal statement differed from the statement she had written when Resident #47 fell on [DATE]. Although the facility documentation indicated that NA #2 had witnessed Resident #47's fall, her recollection was that she was in the bathroom when Resident #47 fell . Interview with the DNS on 3/5/25 at 11:00 AM indicated she spoke to NA #2 after Resident #47's fall. NA #2 wrote a statement regarding the incident and the DNS recalled that NA #2 indicated that she was at the foot of the bed when Resident #47 rolled out of bed onto the floor. Additionally, the DNS indicated that Resident #47 had a history of rolling out of bed suddenly and it was surprising how quickly he/she could move out of bed. Interview with RN #5 on 3/5/25 at 1:30 PM she identified that Resident #47 had to be sent to hospital because of bleeding from the head. RN #5 stated that NA #2 indicated she was at the foot of the bed gathering supplies when Resident #47 rolled out of bed striking his/her head. RN #5 stated she was aware that Resident #47 was in a high/low bed but did not recall the position of the bed at the time of the incident stating that NA #2 was nervous and upset following the incident. Re-interview with NA #2 on 3/6/25 at 1:15 PM identified that she was aware her verbal statement given on 3/5/25 differed from her original written statement dated 6/24/24. NA #2 could not recall what she had written in her statement but again denied being at the end of the bed and reiterated she did not see Resident #47 fall. Interview with PT #1 on 3/10/25 at 10:11 AM identified that she was aware of Resident #47's fall on 6/24/24. She indicated that Resident #47 had a high/low bed and if a staff member was giving or preparing for care with the bed in high position, as long as staff remained at the bedside, it would have been appropriate for staff to be at the foot of the bed. PT #1 further indicated it would not be appropriate to raise the resident's bed then step away as Resident #47 was a high risk for falls and had a history of falling out of bed. PT #1 stated that Resident #47 was screened after the fall on 6/24/24 but was not appropriate for therapy and remained at his/her baseline. B. An observation on 3/10/25 at 10:20 AM, identified that Resident #47's bed was by the window, the door to room was closed, and the divider curtain was pulled between residents. Resident #47's bed was in a high position, noted to be at the height of the windowsill, mats were noted on the floor at the bedside, and the over bed table was next to and to the right side of his/her bed. At the time of observation, no staff were in the room. At 10:20 AM NA #5 entered the room, and she proceeded to lower Resident #47's bed to the lowest position. Interview with NA #5 at 10:35 AM identified she was the NA assigned to Resident #47. NA #5 stated that when she went in to assist Resident #47 with breakfast around 8:45 AM, the bed was in a high position when she entered. After breakfast, she left the room without lowering the resident's bed stating she had planned to return and provide care at 10:30 AM. NA #5 further indicated that she should have put the bed in a low position. A review of the Fall Prevention Policy dated 6/2/14 directed, in part, that the facility will provide education on fall prevention to caregivers, patients and families and if a fall occurs, the facility will investigate the factors contributing to the fall and develop a plan of action to minimize further falls. In addition, the nurse will document the fall risk measures that have been instituted in the Resident Care Plan and nurse aide assignment. 2. Resident #36's diagnoses included dementia, schizoaffective disorder, and metabolic encephalopathy. The annual Minimum Data Set assessment dated [DATE] identified Resident #36 was severely cognitively impaired, had serious mental illness, currently used tobacco, was dependent with toileting, and required partial/moderate assistance with bed mobility and transfers. The Resident Care Plan dated 1/10/25 identified Resident #36 smoked. Interventions included smoking was allowed according to the supervised smoking schedule, smoke only in the designated smoking area with supervision, and ensure a smoking apron was used. A significant change Smoking Evaluation for Resident #36 dated 1/10/25 indicated the resident needed staff to light his/her smoking material and that he/she could independently and safely extinguish smoking materials. Observation and Interview with NA #3 on 3/6/25 at 11:10 AM in the resident smoking area identified Resident #36 seated in his/her wheelchair. NA #3 applied Resident #36's smoking apron and lit his/her cigarette. Two receptacles were noted in the area, 1 gooseneck self-extinguishing device and 1 short metal can with a wide opening at the top labeled 'wastepaper container'. The wastepaper container was noted to have a large number of cigarette butts along with other waste including several paper packs of cigarette containers, a few clear plastic cups, and clear plastic packaging/bags. According to NA #3, the wastepaper container had been in place for several months, residents used both receptacles to extinguish their still lit cigarettes, and she had made the Administrator aware of the fire hazard yesterday, who indicated to her that he would correct the issue, but had not as yet. An interview with the Administrator on 3/6/25 at 1:30 PM identified he was aware that there was a tall ashtray and a short metal can in use at the facility's resident smoking area. The Administrator indicated that although he was recently out at the facility's resident smoking area and saw the short metal can, he did not look inside of it or remove it from the area. The Administrator identified that the short metal can was not a self-extinguishing device and that it should not have been utilized by residents to dispose of their still-lit cigarettes. The Administrator indicated that he would have the short metal receptacle removed from the facility's resident smoking area. Subsequent to surveyor inquiry an observation on 3/10/25 at 11:04 AM identified the wastepaper can had been removed from the facility's resident smoking area. Review of the facility policy, Smoking/Residents, dated 8/21/17, directed that the facility would ensure a safe smoking environment and maintain safe smoking practices. The policy further directed that residents may smoke only in the designated area at the designated times under the supervision of a staff member. 51756

Based on facility documentation and staff interview regarding Payroll Based Journal (PBJ) submission, the facility failed to submit accurate PBJ staffing data for the 3rd quarter of 2024 (April 1, 2024, through June 30, 2024). The findings include: The PBJ 3rd quarter submission report for April 1, 2024, through June 30, 2024, triggered as having no Registered Nurse (RN) coverage for 8 consecutive hours a day, low weekend staffing, and no licensed nurses 24 hours a day. Interview with the Business Office Manager on 3/11/25 at 12:42 PM identified that she inadvertently submitted the incorrect data. She indicated that she reviewed the staff payroll list for the skilled nursing center and the Residential Care Home (RCH). She indicated that she unclicked (removed) the skilled nursing staff in error instead of the RCH nursing staff from the payroll list. She then submitted the data for PBJ that was for RCH nursing staffing and not the skilled nursing home staffing. She stated she realized that she unintentionally submitted the wrong data. Review of the mandatory submission of staffing information based on payroll data in a uniform format. The facility must submit direct care staffing information on the schedule specified by CMS, but no less than quarterly.

Based on interviews, observations, clinical record review, and facility policies for 1 of 5 sampled residents (Resident #8) reviewed for abuse, and for 2 of 2 residents (Resident #11 and Resident #45) reviewed for choices, the facility failed to ensure the resident right to choose was honored. The findings include: 1.Resident #8's diagnoses included anxiety, hypothyroidism, and asthma. The quarterly Minimum Set (MDS) assessment dated [DATE] identified Resident #8 as cognitively intact, independent with transfers, dressing, and personal hygiene. The Resident Care Plan dated 12/10/24 identified behavior/refusal of care issues. Interventions directed to provide emotional support as needed, explain potential negative outcomes, and provide positive reinforcement. Review of the nurse's note dated 12/16/24 identified that Resident #8's window had been screwed shut, Resident #8 verbalized being upset to staff, and he/she was anxious. Interview and observation with Resident #8 on 3/3/25 at 12:00 PM identified the window in his/her room had been screwed shut, a fan was not adequate, and he/she was upset due to his/her inability to open the window for fresh air. Resident #8 indicated that he/she had informed staff of his/her desire to independently open the window whenever he/she chose. An interview on 3/6/25 at 9:48 AM with Social Worker #1 identified that she was aware Resident #8's window had been screwed shut since 12/16/24. Re-interview with Resident #8 on 3/6/25 at 11:46 AM identified that he/she woke up sweating at night and wanted some fresh air, but his/her window had been screwed shut for over a month. Resident #8 complained that he/she was the only resident in the facility who was not allowed to open their window, and this was upsetting to him/her. An interview with the Director of Nursing on 3/6/25 at 1:39 PM identified that she was aware Resident #8's window had been screwed shut for the past couple of months. An interview with the Administrator on 3/10/25 at 2:08 PM identified he had screwed Resident #8's window shut on 12/16/24 because the resident was leaving the window open on cold days making the room too cold for the roommate. The Administrator indicated Resident #8's window would remain screwed shut until the weather was warmer. Although Resident #8 had been upset by this action, the Administrator stated he failed to see he had done anything wrong by screwing the window shut, and that the resident had been educated. 2. Resident #11's diagnoses included coronary artery disease, congestive heart disease, and post-traumatic stress disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had moderate cognitive impairment, was dependent for upper and lower body dressing, was independent in utilizing a manual wheelchair for mobility, and required moderate assistance for chair to bed and bed to chair transfers. The Resident Care Plan (RCP) dated 1/9/25 identified Resident #11 was at risk for changes in mood and behavior. Interventions included encouraging independence to the extent possible and encourage and allow open expression of feelings and/or needs. A nursing progress note dated 1/25/25 at 2:45 PM identified that Resident #11 had an altercation with another resident who entered his/her room without permission. The note further identified that Resident #11 was heard yelling at the other resident to leave his/her room and noted the intervention for the altercation was administering 25 milligrams (mg) of Trazadone to Resident #11 every 6 hours for the next 30 days. A Physician order dated 1/25/25 directed 25 mg of Trazadone by mouth to be administered every 6 hours as needed for agitation. An interview with Resident #11 on 3/3/25 at 1:58 PM identified that he/she did not like other residents entering his/her room and would like to keep his/her door shut. Resident #11 further identified that staff have informed him/her that the door to the room had to remain open. An interview with Licensed Practical Nurse (LPN) #5 on 3/5/25 at 7:31 AM identified that it was her preference that Resident #11's door was to stay open and that a stop sign was placed on his/her door to deter a wandering resident from entering the room. An interview with the Director of Nursing Services (DNS) on 3/6/25 at 10:47 AM identified she was unaware that Resident #11 would like his/her door shut and would inform staff that 15 minute checks could be provided to honor the Resident's choice to have his/her door shut. 3. Resident #45's diagnoses included hypersomnia (sleep disorder), Mitochondrial Encephalopathy, Lactic Acidosis, Stroke-like episodes (MELAS) Syndrome (a genetic stroke like disorder), and malignant neoplasm of the brain. The baseline Resident Care Plan (RCP) dated 3/1/24 identified Resident #45 was at risk for depression. Interventions included encouraging independence to the extent possible, if care was refused leave safely and reapproach at a later time and explain potential consequences/negative outcomes. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #45 had intact cognition, required set-up assistance with eating, used a manual wheelchair for mobility and required moderate assistance with chair to bed and bed to chair transfers. An interview with Resident #45 on 3/4/25 at 10:23 AM identified that facility staff got him/her up too early. Resident #45 indicated that when he/she had made his wishes known to staff on multiple occasions, staff denied his/her request and got him/her out of bed anyway. Interview and review of the Resident Care Card with Nurse Aide (NA) #4 on 3/6/25 at 12:05 PM identified she had been notified by Resident #45 on multiple occasions that he/she did not want to get out of bed and wanted to keep sleeping. NA #4 indicated that due to aspiration precautions, Resident #45 had to be taken out of bed despite his/her wishes. She further identified the shift started at 7:00 AM and there was an expectation to have all her assigned residents up for breakfast by 8:00 AM. NA #4 noted if Resident #45 wanted to go back to bed after he/she ate, she would assist him/her back in bed. Further, although the Resident Care Card indicated for Residet #45 to be out of bed for meals, it failed to indicate that aspiration precautions were in effect. A re-interview with NA #4 on 3/6/25 at 2:16 PM identified that she had incorrectly identified Resident #45 was on aspiration precautions and that Resident #45 could have stayed in bed per his/her request. An interview with Registered Nurse (RN) #2 on 3/6/25 at 2:38 PM identified the facility practice was to honor the resident's wishes, allow the resident to remain in bed, notify the RN, and reapproach the resident later. Although RN#2 indicated that the facility practice was to honor the resident's wishes, she could not honor Resident #45's request to stay in bed because he/she needed to get up to eat. An interview with the Director of Nursing Services (DNS) on 3/6/25 at 2:47 PM identified that she was aware of Resident #45's request to stay in bed past 7:00 AM. Although the DNS noted that he/she has the right to make the choice to stay in bed, she indicated it was better for his/her mental health to get out of bed. The Facility's Resident's [NAME] of Rights identified that a Resident has the right to treat living quarters as his/her home with no fewer rights than any other resident of the facility, has the right to make choices about aspects of his/her life that are significant to him/her, and has the right to refuse any visitor that he/she does not want to see. 51182

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident #28 and Resident #58) reviewed for edema and with diagnoses of Congestive Heart Failure (CHF), the facility failed to consistently obtain and document daily weights per the physician's order, for Resident #58, the Registered Nurse (RN) staff and Advanced Practice Registered Nurse (APRN) failed to ensure documentation of an assessment when a significant weight gain occurred, and for 1 of 3 sampled residents (Resident #45), reviewed for nutrition the facility failed to obtain weekly weights on admission per the facility policy and monthly weights per the physician orders. The findings include: 1. Resident #28's diagnoses included chronic systolic CHF, non-rheumatic tricuspid valve insufficiency, and paroxysmal atrial fibrillation (irregular heartbeat). The admission Minimum Data Set assessment dated [DATE] identified Resident #28 was cognitively intact, required substantial/maximal assistance for bed mobility, and was dependent with toileting and transfers. The Resident Care Plan dated 1/21/25 identified CHF relative to cardiac, nutrition, and hydration status. Interventions included monitoring body weight and completing weights as ordered. A physician's order dated 2/10/25 directed to weigh Resident #28 daily and notify the physician or the Advanced Practice Registered Nurse (APRN) if the resident's weight changed by 2 pounds or greater in 1 day or 5 pounds in 1 week. Review of Resident #28's Nurse Aide (NA) care card failed to indicate daily weights. Interview and clinical record review with Licensed Practical Nurse (LPN) #3 on 3/10/25 at 10:00 AM failed to identify documentation of daily weights in the clinical record or in the Medication Administration Record (MAR) for 3/7/25, 3/8/25 and 3/9/25. LPN #3 was unable to explain why daily weights were not completed. Additionally, LPN #3 indicated the charge nurse should have communicated the need for the weights with the NA and ensured the weight was obtained. LPN #3 indicated that she would have the NA obtain Resident #28's weight with the mechanical lift today. Registered Nurse (RN) #4's nurses note dated 3/10/25 at 10:50 AM identified the APRN was notified that Resident #28 had not been weighed on 3/7/25, 3/8/25 and 3/9/25. An interview with the nursing supervisor (RN #4) on 3/10/25 at 10:58 AM identified she did not know the reason Resident #28's daily weights were not completed on 3/7/25, 3/8/25 and 3/9/25, but that Resident #28's weight was just completed on 3/10/25 via the mechanical lift. RN #4 indicated that the weights should have been done daily per the physician's order and the charge nurse was responsible to have communicated with the NA and made sure the weights were obtained and documented daily. An interview and clinical record review with the DNS on 3/10/25 at 12:20 PM identified she was not aware that Resident #28 did not have daily weights completed and documented in the Medication Administration Record (MAR) on 3/7/25, 3/8/25 and 3/9/25. The DNS indicated that, although she was unsure or the reason Resident #28's weights were not completed and documented for those dates, the resident's weights should have been completed and documented daily in the MAR per the physician's order. The DNS indicated the charge nurse on 3/7/25, 3/8/25 and 3/9/25 on the 7:00 AM to 3:00 PM shift should have confirmed Resident #28's weight was taken by the NA and then documented the resident's weight in the MAR. Additionally, the DNS identified she planned to make a list for the nursing supervisors of all of the residents with daily weights ordered to ensure the weights were obtained and documented going forward. Interview with LPN #6 on 3/11/25 at 11:20 AM identified she was the charge nurse for Resident #28 on the 7:00 AM to 3:00 PM shift on 3/8/25. LPN #6 indicated that although she was aware that Resident #28 was a daily weight in the AM, the resident did not have his/her weight done on 3/8/25 because she and the NA's were too busy, and it was too difficult to get Resident #28's weight completed. LPN #6 identified that it would have been her responsibility to communicate with the NA to ensure the resident's weight was obtained, but that she failed to do so on 3/8/25. LPN #6 further indicated that she did not let anyone know that Resident #28's weight was not obtained as ordered by the physician on 3/8/25. 2. Resident #45's diagnoses included a terminal condition, moderate protein-calorie malnutrition, and irritable bowel syndrome (IBS). The baseline Resident Care Plan (RCP) dated 3/1/24 identified Resident #45 was at risk for nutritional deficits related to a terminal condition, IBS, and diabetes. Interventions included monitoring body weight, dietician consults as needed, and offering alternative choices with dislikes. An Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 had intact cognition, required set-up assistance with eating, used a manual wheelchair for mobility, and required moderate assistance with chair to bed and bed to chair transfers. a. A review of Resident #45's weight information identified an admission weight was taken on 3/3/24 and was 227.2 pounds (lbs.) but failed to identify weekly weights were taken thereafter per the facility policy. Additionally, Resident #45's weights were not documented monthly for August 2024 or September 2024. An interview with Registered Nurse (RN) #2 on 3/5/25 at 10:54 AM identified weights for Resident #45 were recorded on a weight documentation sheet when completed. She was unable to identify additional weekly weights that had been taken for 4 weeks in March 2024 or that weights had been taken for the months of August 2024 and September 2024. RN #2 was unable to explain the reason for the missing for Resident #45. b. A physician order dated 2/29/24 directed Resident #45 to be weighed monthly on shower day. A review of Resident #45's weights identified an admission weight of 227.2 pounds (lbs.) on 3/3/24, Resident #45 weighed 272 lbs. in April 2024 (a 44.8 lb./a 19/7% gain in one month from 3/3/24), weighed 266 lbs. in May 2024 (a 6 lb. weight loss from April 2024), 266 lbs. in June 2024, 264.8 lbs. in July 2024, 228.0 lbs. in October 2024 (a 36 lb./a 13.5% weight loss from July 2024), 226.6 lbs. in November 2024, 215 lbs. in December 2024 (a 11 lb./a 5.1% weight loss from November 2024), 214.4 lbs. in January 2025, and 206.4 lbs. in February 2025 (a 8 lb./a 3.7% weight loss from January 2025). One reweight in May 2024 was noted in Resident #45's weight record (272 lbs. initial and 266 lbs. reweight) identifying the facility failed to identify 5 of 6 opportunities to obtain a reweight for a weight change of 3 lbs. over/under the previous weight. An interview on 3/5/25 at 10:54 AM with Registered Nurse (RN) #2 identified she was not aware that reweights for Resident #45's weight gains/losses were not being completed and noted it was the expectation of Nurse Aides (NAs) to obtain reweights if there was a weight increase or decrease. RN #2 was unable to identify the reason that Resident #45's reweights were not completed per the facility policy. An interview on 3/6/25 at 2:57 PM with the DNS identified if a weight taken was suspected to be an incorrect weight, a reweight should be taken. 3. Resident #58 was admitted to the facility in April 2023 with diagnoses that included congestive heart failure, atrial defibrillation, type 2 diabetes and coronary bypass surgery. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #58 was cognitively intact and was independent with bed mobility, toilet transfers, and transfers from the wheelchair to a chair. The Resident Care Plan dated 12/17/24 identified a potential for respiratory distress/respiratory failure. Interventions included observing for signs and symptoms of increasing distress, increased respiration rate, dyspnea (difficulty breathing), tachycardia (rapid pulse), restlessness, anxiety or changes in mental status. Additional interventions included performing a respiratory assessment every shift. An Advanced Practice Registered Nurse (APRN) #1's progress note dated 1/21/25 identified Resident #58 had right arm swelling, mild shortness of breath, weakness and a heart rate of 48 to 52 beats per minute. Additionally, no respiratory distress was noted and APRN #1 directed to hold Resident #58's Metoprolol (a medication to treat hypertension and atrial fibrillation) for a heart rate of less than 60 beats per minute, complete a physical/occupational therapy screen, and complete daily weights for 7 days. The order failed to specify parameters for weight gains or losses or when the physician/APRN should be notified. The Resident Care Plan dated 1/21/25 identified Resident #58 was at risk for alteration in skin integrity, weight gain, and changes in respiratory status related to generalized edema, with right hand prominent edema and increased weakness. Interventions included performing a respiratory assessment every shift, assistance of 2 staff with transfers, oxygen as directed and monitor vital signs and oxygen saturations every shift and as needed (PRN). Review of the Medication Administration Record, Treatment Administration Record and nursing notes from 1/21/25 through 1/28/25 identified on 1/22/25 Resident #58 weighed 205.6 pounds (lbs.). On 1/23/25, Resident #58 weighed 206.2 lbs. Resident #58 was not weighed on 1/24/25, and on 1/25/25 he/she weighed 212.0 lbs. (a 5.8 lb. gain) in 2 days. On 1/26/25, Resident #58 weighed 208.5 lbs., the APRN was notified on 1/26/25 and directed to hold Resident #58's Amiodarone (a medication used to treat abnormal heart rhythms) and call the Cardiologist on 1/27/25 to update and discuss the episodes of bradycardia (slow heart rate). On 1/27/2025 Resident #58 weighed 218.5 lbs. (a 10 lb. weight gain in one day with no further re-weight to verify accuracy). Nursing notes failed to reflect a nursing assessment was completed on 1/27/25 when Resident #58 had a 10 lb. weight gain. APRN #1's order dated 1/27/25 directed to administer Lasix (a diuretic) 40 mg by mouth once. Interview with APRN #1 on 3/11/25 at 10:44 AM identified that although she saw Resident #58 on 1/27/25, she could not recall what was documented (there was no assessment documented in the clinical record). Interview with the DNS on 3/11/25 at 9:40 AM indicated that with a change in condition, a fall, or resident being sent to the hospital, an RN should have completed an assessment and subsequent nursing note. Review of the undated facility Weight Policy directed that weights will be completed as ordered and the charge nurse on each unit will be responsible for monitoring and tracking the weights as they are completed, weekly weight will be taken for 4 weeks following admission and then monthly, For any weight change of 3 lbs. over or under the last weight, the Nurse Aid (NA) must alert the charge nurse and the reweight must be completed with the NA and charge nurse. Further, the policy indicates, any resident with a significant weight loss of 5% in one month, or 10% in 3 months, will be reported to the attending physician, the responsible party, and the dietician. 51182 51867

Based on the tour of the Dietary Department/Nourishment Rooms, staff interviews, and review of the facility policies, the facility failed to ensure food items were sealed, labeled and dated when opened and the only nourishment refrigerator/freezer temperatures were documented. The findings included: 1. Tour of the Dietary Department on 3/3/25 at 10:40 AM during the initial walk through with the Dietary Director identified the following: a. 3 bags (16 ounce) each Penne pasta bag #1 was 3/4/ full, bag #2 was 1/2 full, bag #3 1/4 full were opened and failed to include the date opened. b. An opened 5 pound bag of heart shaped pasta that was 1/4 full failed to include the date opened. c. An opened 5 pound bag of elbow pasta that was 1/2 full failed to include the date opened. d. A 32-ounce opened bag of powdered sugar that was 1/2 full failed to include the date opened. e. An opened 5 pound bag of sugar that was 3/4 full failed to include the date opened. f. A package containing 2 frozen fish cakes was opened and failed to include the date opened. g. A 1 bag of romaine lettuce was opened, not sealed and failed to include the date opened. Interview on 3/3/25 at 11:00 AM with the Dietary Director identified that all items that were opened should be labeled with the date they were opened. Facility policy for Food Storage identified that all food items that are open will be clearly labeled with the month, date and year. 2. Tour of the only Nourishment Room on 3/5/25 at 10:45 AM identified that monitored freezer temperatures for February 2025 were documented for 2 of 28 days. Additionally, 16 of 28 days, freezer temperatures were identified with a check mark and lacked the actual temperatures obtained, and for 10 days there were no temperatures taken or documented. An interview with the Dietary Director on 3/5/25 at 11:00 AM identified that the dietary staff were responsible for monitoring the nourishment room freezer temperatures every evening and that the staff member who was monitoring and keeping a record was doing the logs incorrectly. Further, the Dietary Director indicated that she was unsure of the policy for monitoring the temperatures of the refrigerator/freezer. Review of the facility policy for Refrigerator & Freezer Temperatures identified that the evening shift for dietary staff was responsible for monitoring the freezer temperature on the logs accurately.

Based on interviews, review of the clinical record, and facility policy for 1 of 3 residents (Resident #45), reviewed for nutrition, the facility failed to notify the dietician and responsible party of a significant weight gain and significant weight loss. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the brain, moderate protein-calorie malnutrition, and Irritable Bowel Syndrome (IBS). The baseline Resident Care Plan (RCP) dated 3/1/24 identified Resident #45 was at risk for nutritional deficits related to cancer, IBS, and diabetes. Interventions included monitoring body weight, dietician consults as needed, and offering alternative choices with dislikes. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 had intact cognition, required set-up assistance with eating, used a manual wheelchair for mobility, and required moderate assistance with chair to bed and bed to chair transfers. A physician order dated 2/29/24 directed Resident #45 to be weighed monthly on his/her shower day. A review of Resident #45's weight record indicated the following: an admission weight in March 2024 of 227.2 pounds (lbs.), in April 2024 a weight of 272 lbs., a weight gain of 44.8 lbs. (16.5%) in 1 month; in May 2024 a weight of 266 lbs., in June 2024 a weight of 266 lbs., in July 2024 a weight of 264.8lbs., (missing weights in August and September), in October 2024 a weight of 228.0 lbs., a weight loss of 36.8 lbs. (14%) in 3 months, in November 2024 a weight of 226.6 lbs., in December 2024 a weight of 215 lbs. in January 2025 a weight of 214.4 lbs., and in February 2025 a weight of 206.4 lbs. a weight loss of 20.2 lbs. (9%) in 3 months. Review of nursing progress notes, Dietician progress notes, and the Dietician Communication Log failed to identify the Dietician or responsible party was notified regarding Resident #45's weight gains or losses. Interview and review of the clinical record with RN #2 on 3/5/25 at 10:54 AM identified that nursing staff does not track a resident's weight over time and that the dietician was independently responsible to review all resident's weight tracking. Although RN #2 indicated that nursing would notify the dietician if the resident had a significant weight loss or gain from the previous month, she was unable to explain why the dietician wasn't notified when Resident #45 was noted to have a significant weight gain from March 2024 to April 2024 (44.8 lbs. or 16.5% in 1 month). An interview on 3/6/25 at 2:16 PM with the Dietician identified the facility had hired her in November 2024 so she could not comment on any of Resident #45's weight issues prior to her hire date. She indicated she was not aware of the 5.1% weight loss in 1 month from November 2024 when the resident weighed 226.6 lbs. to December 2024 when the resident weighed 215 lbs. Although she was the dietician at the time, she was not aware of the 3 month weight loss from November 2024 when the resident weighed 226.6 lbs. to February 2025 when Resident #45 weighed 206.4 lbs. a 8.9% weight loss. She indicated that if she had been aware of the weight loss after November 2024, she would not have done anything different as she could not trust the accuracy of any weights taken before she was hired. The Dietician stated that the facility practice was to notify her of a weight gain or weight loss greater than 5% but she had not been notified of Resident #45's weight changes. An interview on 3/6/25 at 2:57 PM with the Director of Nursing Services (DNS) identified if a weight was taken on a resident was suspected to be incorrect then a reweight should have been taken. A review of the Facility's Weight Policy identified that any Resident with a significant weight loss of 5% in one month or 10% in 3 months would be reported to the attending physician, the responsible party, and the Dietician.

Based on review of clinical records, facility documentation, interviews, and facility policy for 2 of 5 sampled residents reviewed for abuse (Resident #15 and Resident #29) the facility failed to report allegations of abuse to the state agency in a timely manner. The findings include: 1. Resident #15's diagnoses included mild cognitive impairment, multiple sclerosis, and abnormalities of gait and mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #15 was moderately cognitively impaired and required moderate assistance of 1 staff to transfer from the bed to the wheelchair, from lying to sitting on the side of bed, and for toilet transfers. Physician's orders dated 6/4/24 directed the assistance of 1 staff for transfers from the wheelchair and for activities of daily living. The Resident Care Plan dated 6/5/24 indicated mobility impairment was a concern. Interventions included transferring the resident per the physician's order to a custom wheelchair and administer pain medications as needed. 2. Resident #29's diagnoses included Post Traumatic Stress Disorder (PTSD), history of alcohol abuse, depression, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #29 had short term and long-term memory deficits but was able to recall the current season, location of room, staff names and faces, and that he/she resided in a nursing home. Resident #29 was independent with dressing, toileting, eating, and required set up for personal hygiene. The Resident Care Plan dated 2/11/25 identified that Resident #29 frequently refused care from staff, could become easily agitated, was accusatory toward staff, administered his/her own medications, and was able to leave the facility independently to go shopping and for appointments. Physician's orders dated 3/1/25 identified that Resident #29 could self-administer medications and could go out on leave of absence independently. Interview with Resident #29 on 3/3/25 at 2:45 PM, identified that he/she witnessed NA #3 being rough and that the NA had thrown Resident #15 into his/her wheelchair during a transfer. Resident #29 indicated that he/she reported NA #3 to the DNS and Administrator at that time. According to Resident #29, NA #3, following being reported, was later confronted by Resident #29 about the way she treated Resident #15, and NA #3 stated to Resident #29 to shut the F*** up. Resident #29 indicated the incident happened several months ago and both incidents had been reported to the DNS and the Administrator at the time of the occurrences. During an interview with the DNS on 3/3/25 at 3:00 PM she was informed by the surveyor that Resident #29 had reported he/she witnessed NA #3 throw Resident #15 into his/her wheelchair during a transfer from the bed to the wheelchair and that NA #3 had used profane language toward Resident #29. The DNS was further informed that Resident #29 indicated he/she had reported the incident to the DNS and Administrator. Although the DNS indicated Resident #29 frequently discussed concerns with her, she was unable to recall the incident and denied having a reportable event or grievance related to the allegations of abuse for either resident. The DNS indicated that Resident #29 had accusatory behaviors and tended to fixate on certain staff he/she did not like and would verbally confront those staff members. An interview with Resident #15 on 3/4/25 at 2:00 PM identified he/she had no recollection of any incidents of a nurse aide being rough. An interview with Social Worker (SW) #1 on 3/4/25 at 3:15 PM identified that she was not aware of any grievances from Resident #15 or Resident #29. There were no allegations of abuse or mistreatment for either resident. Re-interview (7 days after the initial interview) with the DNS on 3/10/25 at 1:25 PM identified that Resident #29's allegation of NA abuse towards Resident #15 had not been reported to the state agency following her interview with the surveyor on 3/3/25. The DNS stated she must have misunderstood that the allegations were allegations of mistreatment, and that even if a resident had a history of accusatory behaviors, the facility would still follow the protocols for reporting to the state agency for allegations of abuse. The DNS indicated that it was her responsibility to ensure allegations were reported. Subsequent to surveyor inquiry, Resident #15's allegation of physical mistreatment was reported to the state agency on 3/10/25, 7 days after the facility was made aware of the allegation. Resident #29's allegation of verbal mistreatment was reported to the state agency on 3/11/25, 8 days after the facility was made aware of the allegation. A review of the facility Abuse Policy directed in part, the Administrator and/or DNS ensure that alleged or suspected violations involving mistreatment, neglect, abuse, exploitation, misappropriation of property and injuries of unknown origin are investigated and reported. Alleged allegations involving abuse or injuries of unknow origin causing serious injury are reported to the state agency within 2 hours. Allegations of neglect, mistreatment, misappropriation that do not result in serious harm are reported within 24 hours.

Based on review of clinical records, facility documentation, interviews, and facility policy for 2 of 5 sampled residents (Resident #15 and Resident #29) reviewed for abuse, the facility failed to investigate an allegation of abuse in a timely manner. The findings include: 1. Resident #15's diagnoses included mild cognitive impairment, multiple sclerosis, and abnormalities of gait and mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #15 was moderately cognitively impaired and required moderate assistance of 1 staff to transfer from bed to wheelchair, from lying to sitting on the side of the bed, and for toilet transfers. Physician's orders dated 6/4/24 directed the assistance of 1 staff for transfers from the wheelchair for activities of daily living. The Resident Care Plan dated 6/5/24 indicated that mobility impairment was an area of concern. Interventions included transfer resident per physician order to a custom wheelchair and administer pain medications as needed. 2. Resident #29's diagnoses included Post Traumatic Stress Disorder (PTSD), history of alcohol abuse, depression, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #29 had short term and long-term memory deficits but was able to recall the current season, location of his/her room, staff names and faces, and that he/she resided in a nursing home. Resident #29 was independent with dressing, toileting, eating, and required set-up assistance for personal hygiene. The Resident Care Plan dated 2/11/25 identified that Resident #29 frequently refused care from staff, could become easily agitated and accusatory of staff, administered his/her own medications and could leave the facility independently to go shopping and for appointments. Physician's orders dated 3/1/25 identified that resident could self-administer medications and could go out on leave of absence independently. Interview with Resident #29 on 3/3/25 at 2:45 PM, identified that he/she witnessed NA #3 being rough and that the NA #3 had thrown Resident #15 into his/her wheelchair during a transfer. Resident #29 indicated that he/she reported NA #3 to the DNS and Administrator at that time. According to Resident #29, NA #3, following being reported, was later confronted by Resident #29 about the way she treated Resident #15, and NA #3 stated to Resident #29 to shut the F*** up. Resident #29 indicated the incident happened several months ago and both incidents had been reported to the DNS and the Administrator at the time of occurrences. During an interview with the DNS on 3/3/25 at 3:00 PM she was informed by the surveyor that Resident #29 had reported he/she witnessed NA #3 throw Resident #15 into his/her wheelchair during a transfer from the bed to the wheelchair and that NA #3 had used profane language toward Resident #29. The DNS was further informed that Resident #29 indicated he/she had reported the incidents to the DNS and Administrator. Although the DNS indicated Resident #29 frequently discussed concerns with her, she was unable to recall the incident and denied having a reportable event or grievance related to the allegation of abuse for either resident. The DNS indicated that Resident #29 had accusatory behaviors and tended to fixate on certain staff he/she did not like and would verbally confront those staff members. An interview with Social Worker (SW) #1 on 3/4/25 at 3:15 PM identified that she was not aware of any grievances from Resident #15 or Resident #29. There were no allegations of abuse or mistreatment for either resident. Re-interview with the DNS on 3/10/25 at 1:25 PM identified that although Resident #29's allegations of abuse towards Resident #15 and Resident #29 by NA #3 had been reported to her on 3/3/25 by the surveyor, she indicated that investigations had not yet been started. The DNS stated she must have misunderstood that the allegations were allegations of mistreatment, and that even if a resident had a history of accusatory behaviors, the facility would still follow their policy and procedure for investigating the allegations. The DNS indicated that it was her responsibility to ensure allegations were investigated. Subsequent to surveyor inquiry, an investigation was initiated for Resident #15's allegation, 7 days after the facility was made aware, and an investigation was initiated for Resident # 29's allegation, 8 days after the facility was made aware. A review of the facility Abuse Policy directed in part, the administrator and/or DNS ensure that all alleged or suspected violations involving mistreatment, neglect, abuse, exploitation, misappropriation of property and injuries of unknow origin are investigated and reported. Alleged allegations involving abuse or injuries of unknow origin causing serious injury are reported to the state agency within 2 hours. Allegations of neglect, mistreatment, misappropriation that do not result in serious harm are reported within 24 hours. An investigation will be documented in accordance with state law.

Based on interviews and review of the clinical record for the only sampled resident (Resident #58) reviewed for hospitalization , the facility failed to implement interventions in the Resident Care Plan (RCP) for the completion of a respiratory assessment, each shift, for resident with Congestive Heart Failure (CHF). The findings include: Resident #58's diagnoses included congestive heart failure, atrial defibrillation, type 2 diabetes and coronary bypass surgery. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #58 had intact cognition and was independent with bed mobility, toilet transfers, and transfers from the chair to the bed and bed to the chair. The RCP dated 12/17/24 identified a potential for respiratory distress/respiratory failure. Interventions included observation for signs and symptoms of increasing distress, increase in respiration rate, dyspnea, tachycardia, restlessness, anxiety or change in mental status. Additional interventions included performing a respiratory assessment every shift. The RCP dated 1/21/25 identified Resident #58 was at risk for alteration in skin integrity, weight gain, and changes in respiratory status related to generalized edema, with right hand prominent edema and increased weakness. Interventions included performing a respiratory assessment every shift, assistance of 2 with transfers, oxygen as directed and monitor vital signs and oxygen saturations every shift and as needed (PRN). Review of the Medication and Treatment Administration Records dated December 2024 and January 2025 failed to identify a respiratory assessment that had been completed every shift per the RCP. Review of nursing notes from 12/19/24 through 1/28/25 identified on 1/20/25 at 6:00 PM Resident #58 complained of his/her legs feeling weak and sniffles, lungs were clear, no cough, and no abnormal temperature were noted. A weekly note dated 1/25/25 (illegible time written) indicated Resident #58's lungs were clear with 2 plus bilateral lower extremity edema but failed to identify further each shift respiratory assessments. Interview and record review with the DNS on 3/11/25 at 9:40 AM identified the RCP indicated a respiratory assessment was to be completed each shift for Resident #58. She indicated that there was not a specific form for a respiratory assessment, this should be done by the registered nurse, and the assessment would be documented in the nurse's note section of the clinical record. The DNS reviewed the nursing notes but failed to identify that a respiratory assessment had been completed for Resident #58 from December 2024 and January 2025.

Based on observations, interviews, and clinical record review for 1 of 3 residents (Resident #19), reviewed for activities of daily living, the facility failed to provide podiatry services to a diabetic resident. The findings included: Resident # 19's diagnoses included diabetes mellitus type 2 with neuropathy, gout, and Parkinson's disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was cognitively intact, required substantial/maximal assistance from staff for personal hygiene, and was dependent on staff for lower body dressing and transfers. The Resident Care Plan dated 1/7/25 identified Resident #19 was at risk for alteration in the metabolic process secondary to diabetes. Interventions included good foot care daily, proper footwear, podiatry care as needed, and podiatry to cut toenails. A physician's order dated 12/24/24 and currently in effect, allowed Resident #19 to be seen and treated by podiatry. The Wound/Ostomy Advanced Practice Registered Nurse (APRN) consultations dated 12/20/24 and 1/7/25 recommended a podiatry consult for toenail dystrophy (abnormal structure and appearance). The Wound/Ostomy APRN consultations dated 1/21/25 and 2/4/25 identified nail dystrophy. An e-mail dated 1/23/25 at 1:30 PM, with attachments, identified a correspondence between the podiatry service provider and the DNS related to podiatry enrollment requirements and which needed to be completed prior to Resident #19 receiving services. The e-mail instructed the DNS to send a copy to the Administrator of the Long Term Care (LTC) facility. Additionally, along with the completed form, the e-mail should specify that Attached are Veterans Affairs (VA) enrollments for podiatry. The facility will assume financial responsibility for podiatry care. An e-mail correspondence dated 1/24/25 at 11:38 AM identified the podiatry providers receipt of Resident #19's signed consent (dated 1/15/25) and face sheet as well as an intent to add Resident #19 to the podiatry service list. An e-mail correspondence from the podiatry service provider dated 2/20/25 at 2:04 PM identified Resident #19 was still not scheduled for podiatry services and a request from the podiatry service Account Manager requesting the Processing Department schedule Resident #19 for podiatry services was included. An e-mail dated 3/7/25 at 10:42 AM from the podiatry service provider to the DNS identified the podiatrist was at the facility on 12/9/24, 2/10/25 and 2/16/25. Additionally, the e-mail identified Resident #19 was signed up for podiatry services on 1/20/25, but was placed on a do not treat list pending verification of VA-covered services to be billed to the facility, and Resident #19 was removed from the do not treat list on 2/20/25. Observation on 3/3/25 at 11:13 AM identified Resident #19 with toenails that were thick and excessively long (curling over). Interview and chart review with Registered Nurse (RN) #2 on 3/5/25 at 9:28 AM identified the facility policy directed Nurse Aids (NAs) to clip toenails, but if a resident was diabetic or presented with thick nails, the resident would be seen by the podiatrist who comes to the facility monthly. If the resident was a veteran, they would go out to the VA for podiatry services. RN #2 identified Resident #19 was on the list to see podiatry but could not produce a copy of the list, proof of when Resident #19 was on the list to be seen, or a date of when the podiatrist was due to return to the facility. A chart review with RN #2 failed to identify a signed consent for podiatry, at which point she stated Resident #19 was a veteran with 100% service-connected disability and would not have a consent with the in house podiatrist but rather goes to the Veterans Affairs (VA) for services. RN #2 could not identify when Resident #19's podiatry appointment was scheduled or if an appointment had been scheduled with the VA. Follow up interview with RN #2 on 3/5/25 at 9:56 AM identified she spoke with the VA, Resident #19 was overdue since it's been almost a year since his/her last appointment, clarifying that since he/she has been at the facility no podiatry services were provided or offered. Interview with Resident #19 on 3/5/25 at 10:53 AM identified he/she could not recall if podiatry services were offered upon admission to the facility but was told by the facility that he/she missed their scheduled appointment and would have to be rescheduled with the possibility of seeing the in-house podiatrist. Interview and contract review with the Director of Finance on 3/5/25 at 11:47 AM identified that the facility pays for all resident podiatry services, including veterans. Per the Department of Veterans Affairs contract that was effective 10/1/24, all rates include an additional $.50 per day for podiatry services so that veterans can receive their services in-house at the LTC facility. Subsequent to surveyor inquiry, an e-mail dated 3/7/25 at 10:50 AM from the podiatry service provider identified the next scheduled podiatry visit would be 4/18/25, since visits occurred every 60 days, including a request from the DNS for Resident #19 to be seen earlier. Interview with the DNS on 3/10/25 at 10:03 AM identified that every resident was referred to the in-house service for podiatry unless they were a short-term resident that was expected to be discharged within 2 weeks. The DNS identified Resident #19 was initially in the facility for short term rehabilitation and about 3 weeks after his/her admission it was determined that his/her stay would be extended. On 1/15/25 Resident #19 signed a podiatry consent, and all the paperwork was emailed to the podiatry provider. Somewhere along the line requirements from the podiatrist changed requiring that the Administrator be copied on the e-mail. The DNS stated she was unaware of the requirement, which prolonged Resident #19 receiving services. The DNS identified that all staff were aware that all residents receive in- house podiatry services, unless the admission was a short-term rehabilitation resident who had their own podiatrist in the community. Further, consents were signed upon admission and the resident was then put on the podiatry list by the admitting nurse, including veterans. Interview with the podiatry service customer care and billing representative on 3/11/25 at 10:03 AM identified that facilities receive a packet with information regarding policy details including what information was needed for a resident to be seen, and comprised of a request for services form, resident face sheet including Power of Attorney (POA) information, insurance information, and physician orders. The Administrator notification was not a requirement of service on the podiatry service end but might be the cause of delay in treatment due to other factors on the facility end. Subsequent to surveyor inquiry, Resident #19 was seen by the podiatrist on 3/12/25, and received manual reduction, trimming of nails from 4/5 millimeters (mm) to 2 mm. Although requested, a facility policy for podiatry was not provided.

Based on observations, interviews, and clinical record reviews for 1 of 2 residents, (Resident #4), reviewed for pressure ulcers, the facility failed to follow infection control standards to identify and provide precautions for a resident with wounds, and for the only sampled resident (Resident #36) reviewed for blood glucose monitoring. The facility failed to clean and disinfect the glucose meter after use. The findings included: 1. Resident #4's diagnoses included a pressure ulcer of the sacral region, rheumatoid arthritis, and urge urinary incontinence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was severely cognitively impaired, and dependent on staff for hygiene, dressing, and transfers. The Resident Care Plan dated 2/18/25 identified Resident #4 had a stage 2 pressure area to her/his sacrum. Interventions included providing treatment as ordered, observing the area for good wound healing, and observing for signs and symptoms of infection. The Pressure Ulcer Progress Report initiated 2/20/25 identified a 0.8 centimeter (cm) x 0.8 cm stage 2 pressure ulcer on the sacrum. On 2/26/25 the stage 2 pressure ulcer on the sacrum measured 2.0 cm x 2.0 cm, and on 3/7/25 the stage 2 pressure ulcer on the sacrum measured 2.5 cm x 3.5 cm x 0.2 cm. (A stage 2 pressure ulcer was defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough). The physician's orders dated 2/25/25 failed to identify an order for Enhanced Barrier Precautions (EBP). Review of the EBP resident list dated 2/26/25 failed to include Resident #4. Observations of Resident #4's room on 3/3/25 at 11:11 AM, 3/4/25 at 11:30 AM and 3/5/25 at 10:35 AM failed to identify an EBP sign posted outside the resident's room. Additionally, although there were precaution carts outside all the other resident rooms who had EBP signage, observation outside Resident #4's room failed to identify a precaution cart containing Personal Protective Equipment (PPE). Observation of LPN #2 on 3/5/35 at 10:35 AM identified she was performing a dressing change to Resident #4's sacral area without the benefit of a gown. Interview with Infection Preventionist Registered Nurse (RN) #3 on 3/5/25 at 1:35 PM identified the facility policy to institute EBP for residents with a history of Multi Drug Resistant Organism (MDRO), indwelling devices and large wounds. RN #3 defined a large wound as a measurement of 2.0 cm x 2.0 cm or greater. Resident #4 was not put on EBP when the wound was first identified on 2/20/25 because it measured 0.8 x 0.8 cm, and RN #3 would not expect Resident #4 to have been put on EBP because the last measurement of the sacral wound taken on 2/26/25 was 2.0 cm x 2.0 cm, which she considered borderline. Interview and record review with the DNS on 3/5/25 at 1:55 PM identified it was the facility policy to institute EBP for residents who had an MDRO, indwelling medical devices such as intravenous therapy, an indwelling catheter, or a large wound. She further identified that she defined large wounds to measure 2 cm or greater. Upon review of Resident #4's Pressure Ulcer Progress Report dated 2/26/25 which identified a stage 2 sacral wound measuring 2.0 cm x 2.0 cm, the DNS identified she would have expected the nursing staff to implement the policy and place Resident #4 on EBP. A follow up interview and record review with RN #3 on 3/10/25 at 10:48 AM identified she was using guidance for EBP criteria pertaining to large wounds measuring 2.0 cm x 2.0 cm from APIC (Association for Professionals in Infection Control and Epidemiology). Additionally, RN #3 identified that the residents sacral wound was measured on 3/7/25 and showed an increase in size to 2.5 cm x 3.5 cm x 0.2 cm, and that is when and why Resident #4 was placed on EBP's. RN #3 stated she would have to have to look to see exactly where in APIC this guidance was referenced. A follow up interview with RN #3 on 3/11/25 at 10:14 AM identified she could not produce a copy of the APIC guidance, and subsequent to surveyor inquiry, the facility policy on EBP would be amended to reflect wounds (previously written as large wounds). Review of the Infection Control- Enhanced Barrier Precautions Policy dated 7/19/22, directed, in part, that Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities. Nursing home residents with (the word large handwritten) wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with Multi Drug Resistant Organisms. Review of the updated Infection Control- Enhanced Barrier Precautions Policy dated 7/19/22 and revised 3/11/25, identified that the facility had no changed the policy from the original policy dated 7/19/25, but they had removed the handwritten word large. According to CDC documentation dated 6/28/24, Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection, and regardless of whether others in the facility are known to have MDRO colonization. 2. Resident #36's diagnoses included diabetes with other diabetic kidney complications, hyperglycemia, and metabolic encephalopathy. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was severely cognitively impaired, required moderate assistance from staff for washing, dressing, toilet use, and required supervision for meals. The Resident Care Plan dated 1/10/25 identified diabetes as an area of concern. Interventions included monitoring any signs and symptoms of hyper/hypoglycemia, monitor blood glucose and provide insulin as ordered, and administer insulin and medications as directed. Physician's orders dated 3/5/25 directed to obtain a fasting blood sugar daily at 6:30 AM and call the physician if the glucose level was greater than 350, administer an injection of Lantus 18 units at 9 AM, and Ozempic injections 0.5 milligrams (mg) once a week on Monday mornings. Observations on 3/5/25 at 5:45AM of Registered Nurse (RN) #1 obtaining a blood glucose level for Resident #36 identified she cleaned the glucose meter prior to entering Resident #36's room. RN #1obtained a blood glucose level for Resident #36 at the bedside. RN #1 then proceeded back to medication cart in the hallway. RN #1 placed the meter on top of the medication cart without the benefit of cleaning or disinfecting prior to placing. Further observation identified RN #1 continued with her medication pass, and at 5:55 AM, RN #1 was observed placing the glucose meter in the top drawer of the medication cart without the benefit of cleaning the meter. Interview with DNS on 3/5/25 at 6:30AM identified that the blood glucose meters got wiped down with purple top disinfect wipes after each use and then are stored in the medication carts. Medication carts are supplied with 2 glucose meters. The DNS indicated that it was not the practice of the facility to put blood glucose meters back in the medication cart after use without first disinfecting the meter per the manufacturer's guideline. Interview with RN #1 on 3/5/25 at 6:45AM identified that blood glucose meters. are supposed to be cleaned before and after each use, but she had not cleaned the glucose meter after obtaining Resident #36's blood glucose level and prior to placing it back in the medication cart. RN #1 stated, after realizing she had forgotten to clean the glucose meter, she removed it from the cart and appropriately cleaned it prior to using it for another resident. RN #1 indicated that she just forgot and knew that the glucose meter could potentially be contaminated after use, and she should not have stored it in the medication cart prior to cleaning it first. Review of the facility Blood Glucose Monitoring policy directed, in part, to disinfect blood glucose meters per manufacturer guidelines using approved germicidal wipes to wipe down the meter after each use. 51756

Based on interviews, review of the clinical record, and review of facility policy for 2 of 3 residents (Resident #8 and Resident #45), reviewed for nutrition, the facility failed to accurately code the Minimum Data Set (MDS) assessment for significant weight changes. The findings include: 1. Resident #8's diagnoses included anxiety, hypothyroidism, and asthma. a. A quarterly MDS assessment dated [DATE] identified Resident #8 had intact cognition, was independent with oral hygiene, dressing and transfers. Additionally, the MDS identified Resident #8 required set up assistance with eating, weighed 153 pounds (lbs.), and had no significant weight loss or gain. The Yearly Weight Record identified Resident #8 weighed 156.2 lbs. in February 2024, 161.7 lbs. in March 2024, and weighed 148.6 lbs. in April 2024 which was 13.1 lbs., a 8.1 percent (%) loss in one month. A Resident Care Plan dated 4/27/24 identified Resident #8 was at risk for nutritional deficits related to weight loss. Interventions included providing a diet as ordered, dietician consults as needed, Lactaid ice cream at lunchtime, monitor body weight (no specific frequency identified) and provide Glucerna supplement 8 ounces twice daily. An annual MDS assessment dated [DATE] identified Resident #8 had intact cognition, was independent with oral hygiene, dressing and transfers. Additionally, the MDS identified Resident #8 required set up assistance with eating and weighed 149 pounds (lbs.). The MDS failed to identify a significant weight loss of 13.1 lbs., 8.1% from March 2024 to April 2024. b. The Yearly Weight Record document identified Resident #8 weighed 139.8 lbs. in August 2024, and in February 2024 weighed 156.2 lbs. which was a 16.4 lb., 10.49% weight loss in 6 months. The quarterly MDS assessment dated [DATE] identified Resident #8 had intact cognition, was independent with oral hygiene, dressing, and transfers. Additionally, the MDS identified Resident #8 required set-up assistance with eating, and weighed 140 lbs. The MDS failed to identify a significant weight loss of 16.4 lbs., a 10.49% loss from February 2024 to August 2024/6 months. Interview and review of the Yearly Weight Record with Registered Nurse (RN) #6, the MDS Coordinator, on 3/10/25 at 10:04 AM identified Resident #8's MDS was coded incorrectly and should have been coded to reflect the significant weight loss. RN #6 indicated that it was the facility practice and responsibility of the dietician to document weight and whether there was a significant weight loss or gain in section K of the MDS. 2. Resident #45's diagnoses included malignant neoplasm of the brain, moderate protein-calorie malnutrition, and Irritable Bowel Syndrome (IBS). The baseline Resident Care Plan (RCP) dated 3/1/24 identified Resident #45 was at risk for nutritional deficits related to cancer, IBS, and diabetes. Interventions included monitoring body weight, dietician consults as needed, and offering alternative choices with dislikes. An admission MDS assessment dated [DATE] identified Resident #45 had intact cognition, required set up assistance with eating, required moderate assistance with chair to bed and bed to chair transfers, and he/she had not had any significant weight changes. Physician's order in effect from 2/2024 through 2/2025 directed Resident #45 to be weighed monthly on shower days. A review of Resident #45's weight record indicated the following: in March 2024 a weight of 227.2 pounds (lbs.), in April 2024 a weight of 272 lbs., in May 2024 a weight of 266 lbs., in June 2024 a weight of 266 lbs., in July 2024 a weight of 264.8lbs., (missing weight in August and September) in October 2024 a weight of 228.0 lbs., in November 2024 a weight of 226.6 lbs., in December 2024 a weight of 215 lbs. in January 2025 a weight of 214.4 lbs., and in February 2025 a weight of 206.4 lbs. Review of the quarterly MDS assessment dated [DATE] identified Resident #45 weighed 266 lbs The MDS failed to note Resident #45 had a weight gain of 38.8 lbs., a 17.1% change in 3 months (227.2 lbs. on 3/3/24, 266 lbs. in May 2024). Review of the quarterly MDS assessment dated [DATE] identified Resident #45 weighed 227 lbs. The MDS failed to note Resident #45 had a 39.4 lb. weight loss, a 14.8% change in 6 months (266 lbs. in June 2024 and 226.6 lbs. in November 2024). Interview and review of the clinical record with RN #2 on 3/5/25 at 10:54 AM identified the Dietician was responsible to ensure weights and reweights were obtained, and that the dietician was solely responsible for weight tracking, not reliant on nurses to notify her unless there was a big 1 month change. An interview with the Dietician on 3/6/25 at 2:16 PM identified that she did not perform weight loss/gain calculations for Resident #45 for the 6/9/24 MDS because she was not working at the facility at that time. She further identified she did not perform weight loss/gain calculations for Resident #45 for the 12/6/24 MDS because she was not certain that weights taken before her hiring were correct. An interview with MDS Coordinator, Registered Nurse (RN) #6 on 3/11/25 at 10:07 AM identified that although she knew how to perform weight loss/gain calculations, she had not performed the calculations to code Resident #45's MDS weight change section for the 6/9/24 or 12/6/24 assessment. She further indicated she used the dietician's information to input data into Section K (the section on weights) of the MDS and was only responsible for the data entry, not accuracy. Although RN #6 indicated that she had used information provided by the Dietician to complete Resident #45's MDS's, she was unable to provide the Dietician's documentation. Review of the Resident Assessment Instrument (RAI) instruction manual (used to direct MDS processes) dated October 2023 directed, in part that a weight gain or loss of 5% in 30 days or 10% in 180 days should be coded accordingly as a significant weight loss or gain. 51182

Based on review of employee files and interviews for 2 of 4 Nurse Aides (NA) (NA #3 and NA #5) the facility failed to ensure annual employee performance evaluations were completed. The findings include: Review of NA #3 and NA #5 employee files and interview with the Human Resource Coordinator on 3/11/25 at 10:30 AM failed to identify performance evaluations in the employee files. NA #3 was hired by the facility on 9/11/11 and is a current full-time employee. NA #5 was hired by the facility on 4/30/20 and is a current per diem employee. The Human Resource Coordinator stated that if evaluations had been completed, they would be located in the employee file or might be with DNS. The Human Resource Coordinator indicated that she could not recall the last time she received an employee evaluation from the Nursing Department. Interview with the DNS on 3/11/25 at 11:30 AM identified that she had not completed any NA evaluations on any NA employed at the facility. The DNS stated she has worked for the facility for [AGE] years and had never completed any nursing staff evaluations. The DNS indicated that she has just not had enough time to complete nursing staff evaluations, however, she stated that she had discussed the issue with the new administrator, and they recognized this was an issue. The facility is starting to work on a Quality Assessment Performance Improvement (QAPI) plan for annual nursing staff evaluations.

Based on observations and interviews, the facility failed to ensure the medication room was clean and sanitary. The findings include: In an interview and observation with RN #2 on 3/6/25 at 11:10 AM, identified that the medication room floor was dirty with a brown substance and littered with paper. The medication room counter was cluttered with brown boxes and papers. RN #2 identified that it was the responsibility of the housekeeping staff to keep the floor clean of the observed substances. Additionally, RN #2 stated that it is the responsibility of the nurses who access the medication room to ensure that it is free of clutter. In an interview and observation with Housekeeper # 1 on 3/6/25 at 11:31 AM, it was identified that it is the responsibility of housekeeping to keep the medication room clean. After bringing Housekeeper #1 to the medication room, it was identified that it was not her responsibility to clean the medication room and that it was the responsibility of the housekeeper on A-wing to complete. In an interview and observation with Housekeeper # 2 on 03/06/25 at 11:34 AM, it identified that it is the responsibility of housekeeping to keep the medication room clean. After bringing Housekeeper #2 to the medication room, it was identified that it was not her responsibility to clean the medication room. Additionally, she stated that she never enters that room and is only responsible for cleaning the nursing station, not the medication room. In an interview and observation with the Administrator on 3/6/25 at 11:50 AM, it identified that it is the responsibility of housekeeping to keep the medication room clean and that it should be done daily. After bringing the Administrator to the medication room, it was identified that the floors were dirty and needed to be cleaned and that the counters were also cluttered and dirty, needing to be organized and wiped down. Subsequent to surveyor inquiry, the Administrator stated that he would notify housekeeping to have the medication room cleaned. Although requested from the Administrator, a facility policy for housekeeping was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 Residents (Resident #10) reviewed for abuse, the facility failed to notify the State Agency of the allegation according to established timeframes. According to Appendix PP at S483.12(c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The findings include: Resident #10 was admitted [DATE] and readmitted [DATE] with diagnosis that included schizophreniform disorder, violent behavior, dementia, and ataxic gait (inability to walk in a straight line). The quarterly MDS dated [DATE] identified Resident #10 had impaired cognition, was totally dependent for care and utilized a wheelchair. The care plan dated 3/8/23 identified a focus of combativeness with interventions that included staff supervision and provision of interaction with resident especially when resident appears anxious or restless late afternoon. A reportable event form dated 1/17/22 at 10:30 AM identified Resident #10 hit another resident in the face. This was reported to State Agency on 1/18/22 at 2:11 PM, over 24 hours later. A reportable event form dated 2/27/22 at 10:30 AM Resident #10 hit another resident in the face. This was reported to State Agency on 2/28/22 at 10:25 AM, over 23 hours later. A reportable event form dated 5/1/22 at 9:45 AM identified Resident #10 was punched by another resident. This was reported to State Agency on 5/2/22 at 10:34 AM, over 24 hours later. A reportable event form dated 5/2/23 at 7:50 PM identified Resident #10 grabbed the neck of another resident. Reported to State Agency 5/3/23 12:57 PM, over 17 hours later. Interview with the DNS on 8/1/23 at 10:45 AM failed to reflect that the abuse incidents involving Resident #10 on 1/17/22 at 10:30 AM, 2/27/22 at 10:30 AM, 5/1/22 at 9:45 AM and 5/2/23 at 7:50 PM had been reported to the State Agency within the 2-hour required timeframe. The DNS indicated she made phone calls, however failed to provide times or dates.

Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #32) reviewed for PASARR, the facility failed to ensure a Level II PASARR was completed. The findings include: A PASARR Level 1 screen dated 2/12/15 indicated Resident #32 met the conditions for an exempted hospital discharge to a nursing facility, and a physician had certified that he/she would likely require fewer than 30 days in the nursing facility. Accordingly, if the nursing facility thought more than 30 days in the facility would be required, a nursing facility representative must update the Level I screen by or before the 30th day after admission. At that time, a full PASARR Level II evaluation must be performed. No PASARR Level II evaluation was completed for Resident #32. Resident #32 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia and Bipolar Disorder. The annual MDS dated [DATE] identified Resident #32 had intact cognition and received antipsychotic medications during the last 7 days. The care plan dated 6/14/23 identified Resident #32 was receiving psychotropic medications related to diagnoses of Paranoid Schizophrenia and Bipolar Disorder. Interventions included recording target behaviors, observing mood for changes, and follow-up with mental health team. Interview with SW #1 on 8/1/23 at 7:16 AM identified that that Resident #32 was admitted from another facility with a Level I PASARR, after having been there for 5 years and was receiving services with the VA. SW #1 indicated that a Level I rescreen or a Level II PASARR evaluation was not completed upon Resident #32's admission, because of her misunderstanding of the guidance. Subsequent to surveyor inquiry, SW #1 scheduled a PASARR Level II evaluation for Resident #32 on 8/3/23. Interview with the DNS on 8/1/23 at 11:42 AM identified that SW #1 submitted a request for the Level II PASARR to be completed, subsequent to surveyor inquiry. The DNS further indicated that the website that provides an overview of PASARR statuses failed to identify that there was an outstanding evaluation due. The DNS identified that she would have expected SW #1 to complete a PASARR re-screen on admission for Resident #32. The DNS identified that SW #1 will do an audit of all positive PASARR's in-house and rescreen, as necessary. Review of the facility's PASARR follow-up guidance, directed a level of care only needs to be updated if the payer source is Medicaid or a Level II evaluation is warranted if there is serious mental illness, or a time limit is concluded.

Based on review of the clinical record, facility policy, and interviews for 10 residents (2, 5, 7, 9, 11, 21, 24, 40, 48 and 255) who wore their call bell on a lanyard, the facility failed to complete an assessment of each resident prior to application of the lanyard, and for 1 of 5 residents (Resident #11) reviewed for unnecessary meds, the facility failed to ensure the licensed staff accurately edited the monthly physician's orders and monthly medication administration record and for the only sampled resident (Resident #48) reviewed for tube feeding, the facility failed to ensure weights were monitored and orthostatic blood pressures were completed, per the physician's order. The findings include: 1. Intermittent observations on 7/30/23 and 7/31/23 identified Resident's #2, 5, 7, 9, 11, 21, 24, 40, 48 and 255 wore a lanyard with a call bell around their neck. Interview with the DNS and Administrator on 7/31/23 at 1:00 PM identified that the call system for Resident's #2, 5, 7, 9, 11, 21, 24, 40, 48 and 255 was broken prior to him becoming the Administrator (over a year ago), and that the lanyards with the call bells that the residents wore had been in place since his hire. The Administrator identified that he has secured permission and funding to have the entire call system replaced. The DNS identified that none of the resident's had been assessed for the use of the lanyards as a call bell and subsequent to surveyor inquiry, the lanyards were removed, education was provided to the residents and staff, and hand bells were provided to the residents. Although a call light policy identified all facility personnel must be aware of call lights at all times and to answer all call light promptly whether or not you are assigned to the resident, the policy did not address measures related to residents who were wearing the lanyards with call bells. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, COPD, and atrial fibrillation. A physician's order dated 12/16/22 directed to admit Resident #11 to hospice services, administer 5mg Morphine Sulfate sublingually every 3 hours, as needed for pain or shortness of breath, administer 0.125mg Hyoscyamine sublingually every 4 hours, as needed for increased secretions, and administer 0.5mg Lorazepam sublingually every 6 hours, as needed for restlessness times 14 days and re-evaluate. A physician's order dated 4/11/23 directed to administer 0.5mg Lorazepam Concentrate sublingually every 6 hours, as needed for restlessness or anxiety, times 30 days. Review of the MAR dated April 2023 identified the new physician's order dated 4/11/23, for 0.5mg Lorazepam Concentrate for 30 days was not added to the MAR as written. The MAR reflected a revision was created on the reoccurring order (with a start date of 12/16/22), the 12/16/23 date was crossed out and the new start date of 4/11/23 was added, additionally, a 30-day end date was edited onto the original order. A physician's order dated 5/9/23 directed the administration of 0.5mg Lorazepam Concentrate sublingually every 6 hours, as needed for restlessness or anxiety, times 30 days. Review of the MAR dated May 2023 identified the new physician's order for 0.5mg Lorazepam Concentrate sublingually for 30 days was not added to the MAR as written. The MAR reflected a revision was created on the reoccurring order (with a start date of 12/16/22), the 12/16/23 date was crossed out and the new start date of 5/9/23 was added, additionally a 30-day end date was edited onto the original order. The quarterly MDS dated [DATE] identified Resident #11 had severely impaired cognition and was receiving hospice care. The care plan dated 6/27/23 identified Resident #11's COP had chosen hospice care for the resident. Interventions included admitting Resident #11 to hospice services and administering Morphine Sulfate, Hyoscyamine, and Lorazepam as directed. Review of the MAR's dated December 2022 through July 2023, 8 months, identified the order for 0.5mg Lorazepam sublingually every 6 hours, as needed for restlessness had a start date of 12/16/22, and had never been discontinued. Interview and review of the clinical record with the DNS on 8/1/23 at 11:24 AM identified that the facility nurse transcribing the new April and May Lorazepam orders should have discontinued the December 2022 order and written in a new order on the MAR, rather than editing the old order. The DNS further identified that it is the responsibility of the facility nurses or the monthly editing nurse to have old orders discontinued. The DNS indicated an in-service will be provided to licensed staff. Although attempted, an interview with the Medical Director was not obtained. Review of the facility's Editing Guidelines for Monthly physician's orders and Kardexe policy directed that with medications that were discontinued, to cross out the medication/prescription with a single line and put down the discontinued date. If a medication/treatment has been ordered recently and is not on the new order sheet, do the following: + mm/dd/yy, medication dose, route, frequency, and duration. 3. Resident #48 was admitted to the facility on [DATE] with diagnoses that included [NAME]-Lemil-[NAME] syndrome, Tetralogy of Fallot, abnormal weight loss, and Gastrostomy status. A physician's order dated 7/12/23 directed body weights to be completed on admission, weekly times 4 weeks, and then monthly, and administer 2mg Risperidone 1mg/1ml oral solution to be three times per day via G-tube. A physician's order dated 7/14/23 directed orthostatic blood pressures to be completed weekly times 4 weeks, then monthly on Tuesday's during the evening shift (3:00 PM - 11:00 PM). The nurse's notes dated 7/12/23 through 8/1/23 failed to identify a body weight or orthostatic blood pressure had been obtained. The 2023 weight record and the TAR dated 7/12/23 through 7/31/23 identified that an admission weight was obtained on 7/12/23. The records failed to identify weekly weights were obtained for the weeks of 7/18/23 and 7/25/23. Review of the MAR's dated 7/12/23 through 7/31/23 indicated although an order directed orthostatic blood pressures to be obtained daily times 72 hours (if on antipsychotic) and weekly times 4 weeks, the MAR identified one orthostatic blood pressure was documented on 7/13/23 but no other orthostatic blood pressures were obtained on 7/14, 7/15, or during the weeks of 7/18 and 7/25/23. The care plan dated 7/17/23 identified Resident #48 was at risk for dehydration, nutritional deficits, falls, and alteration in cardio/respiratory conditions. Interventions included monitoring body weights, as ordered, and monitor orthostatic blood pressures. The admission MDS dated [DATE] identified Resident #48 had severely impaired cognition, received feedings via a Gastrostomy (G tube), and had received an antipsychotic medication during the last 7 days. Interview and review of the clinical record with RN #2 on 8/1/23 at 9:50 AM failed to identify body weights and orthostatic blood pressures were obtained on Resident #48, as directed by the physician. RN #2 indicated that she would expect to see body weights and orthostatic blood pressures completed, as ordered, and it is the responsibility of the nurse, assigned to the resident at the time the assessment is due, to complete the order. If the weight or orthostatic blood pressure was unable to be obtained or if the resident refused care, then a progress note documenting the reason for refusal should be written and follow-up notifications to the physician, family, and conservator should be made. RN #2 further indicated that she recently completed a continuing education in-service on 7/19/23 addressing resident care, documentation, I&O's, and orthostatic blood pressures. Subsequent to surveyor inquiry, RN #2 completed a body weight and orthostatic blood pressure on Resident #48. Interview and review of the clinical record with the DNS on 8/1/23 at 11:36 AM failed to identify that Resident #48's weights and orthostatic blood pressures were completed as ordered. The DNS indicated that the nurse working at the time the assessment was due would be responsible for completing the order. The DNS further identified that if there was a refusal of care, the refusal should be documented on the back of the Kardex and in a nursing progress note. The DNS indicated that there would be additional staff education on obtaining resident weights and orthostatic blood pressures, and that she and RN #2 would audit the resident's MAR and TAR to ensure tasks and assessments were completed and documented. Review of the facility's Weight Policy directed weights to be completed upon admission/readmission to the facility, weekly times four weeks, then monthly. Weekly weights may be instituted for brief periods for those residents who require closer monitoring. Review of the facility's Orthostatic Blood Pressures policy directed orthostatic blood pressures will be taken on all residents who receive an antipsychotic medication, and orthostatic blood pressures will be taken on admission or initiation of the antipsychotic medication, orthostatic blood pressure will be taken weekly for 4 weeks then monthly. 47457

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #21) reviewed for pressure ulcers, the facility failed to implement a pressure relieving device on the resident's bed when the resident was readmitted to the facility with a stage II pressure ulcer. The findings include: Resident #21 was admitted to the facility in March 2023 with diagnoses that included atrial fibrillation, congestive heart failure, and post-traumatic stress disorder. Review of the RN assessment form dated 3/8/23 identified Resident #21's skin was intact except for slightly reddened Moisture-Associated Skin Damage (MASD) to the groin. The care plan dated 3/13/23 identified Resident #21 had a skin rash MASD to groin area. Interventions included to apply treatment as ordered. Assist with incontinent care every two hours. The admission MDS dated [DATE] identified Resident #21 had intact cognition, required extensive assistance with bed mobility and toilet use. Resident #21 had frequent incontinent of bowel and bladder. A physician's order dated 3/20/23 directed to send Resident #21 to the hospital for evaluation post fall and complaints of left hip pain. The nurse's note dated 3/20/23 at 9:00 PM identified Resident #21 was admitted to the hospital with diagnoses of femoral neck fracture and plans for a hemiarthroplasty. Review of the census form identified Resident #21 was transferred and admitted to the hospital on 3/20/23. Review of the hospital inter-agency patient referral report (W-10) documentation dated 3/27/23 at 2:44 PM identified Resident #21 was discharged back to the facility with a stage II coccyx pressure ulcer. Review of the census form identified Resident #21 was readmitted from the hospital to the facility on [DATE]. Review of the RN assessment form dated 3/27/23 identified Resident #21 was readmitted to the facility with a diagnoses of left hip hemiarthroplasty with intact dressing to be on until follow up with physician. Additionally, the resident assessment data collection identified Resident #21 had a stage II coccyx pressure ulcer measuring 1.0 cm x 1.0 cm x 0 cm. Review of the pressure ulcer progress report dated 3/27/23 identified Resident #21 was readmitted from the hospital with stage II coccyx pressure ulcer, measuring length 1.0 cm x width 1.0 cm x depth 0 cm, reddened at base of wound, no drainage, cleanse with Normal Saline followed by Hydrocolloid everyday times 14 days and re-evaluate. The Braden Scale dated 3/27/23 (score of 18) identified the resident was at mild risk for skin breakdown. A physician's order dated 3/27/23 directed to complete a body audit every week on shower day (Wednesday on the 3:00 PM - 11:00 PM shift). Further, the orders directed to cleanse the stage II coccyx with Normal Saline pat dry, followed by Foam Dressing daily times 14 days and re-evaluate. Review of the physician's orders failed to reflect documentation for a Low Air Loss mattress (LAL). Review of the Treatment Administration Record (TAR) and nurse's notes dated 3/27/23 through 3/31/23 failed to reflect documentation of a Low Air Loss mattress (LAL). The revised care plan dated 3/28/23 identified Resident #21 was readmitted from the hospital with a stage II pressure ulcer to the coccyx. Interventions included to cleanse coccyx with Normal Saline, pat dry, followed by Foam Dressing everyday times 14 days and re-evaluate. Assist with turning and repositioning every 2 hours. Keep urinal within reach. Assist with toileting every 2 - 3 hours. The revised care plan dated 3/28/23 failed to reflect documentation of a Low Air Mattress (LAL). Review of the physician's order, TAR and nurse's notes dated 4/1/23 through 5/17/23 failed to reflect documentation of a Low Air Loss mattress (LAL). A nurse's note dated 5/17/23 at 9:00 AM identified Resident #21 went to an appointment at the hospital at 8:50 AM. A nurse's note dated 5/17/23 at 12:00 PM identified Resident #21 was admitted to the hospital secondary to left arm edema. Review of the census form identified Resident #21 was admitted to the hospital on 5/17/23. Review of the census form identified Resident #21 was readmitted from the hospital to the facility on [DATE]. Review of the RN assessment form dated 5/22/23 identified Resident #21 was readmitted to the facility with a diagnoses of volume overload, heart failure, progressive weight gain, and bilateral lower extremities edema. Additionally, coccyx open area measuring 1.5 cm x 0.2 cm x 0 cm. Left buttock open area measuring 1.5 cm x 1.0 cm x 0 cm. Cleanse with Normal Saline followed by Foam Dressing, change every 3 days, and as needed. Follow up evaluation of wounds by the wound nurse. Review of the readmission physician's orders and TAR dated 5/22/23 through 5/31/23 failed to reflect documentation of a Low Air Loss mattress (LAL). A nurse's note dated 5/27/23 at 3:00 PM identified Resident #21 can possibly benefit from an air mattress. Message left for the DNS and wound nurse for consideration due to ongoing skin issues. Resident #21 remained in bed, turn and positioning every two hours to keep pressure off coccyx. Review of the nurse's notes, and physician's orders dated 6/1/23 through 6/18/23 failed to reflect documentation of a Low Air Loss mattress (LAL). A physician's order dated 6/19/23 directed to apply a Low Air Loss (LAL) mattress, check for placement, and condition every shift. Further, the orders directed to cleansed coccyx wound with [NAME] Saline, apply Medi-honey followed by Xeroform Gauze twice daily with no cover dressing. The revised care plan dated 6/19/23 directed to apply a Low Air Mattress (LAL). Review of the TAR dated 6/19/23 through 6/30/23 identified Low Air Loss mattress (LAL) check for placement and condition every shift on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, 11:00 PM - 7:00 AM. Interview and review of the clinical record with RN #1 on 7/31/23 at 9:00 AM failed to provide documentation that Resident #21 had a LAL mattress prior to 6/19/23. RN #1 indicated she was aware that Resident #21 was readmitted with a stage II coccyx pressure ulcer but indicated she was not aware that Resident #21 did not have a LAL mattress. RN #1 indicated her expectation was for the admission nurse to obtain an order for the LAL mattress upon readmission with a pressure ulcer. RN #1 indicated Resident #21 should have had a LAL mattress upon readmission on 3/27/23 with a stage II coccyx pressure ulcer to help in the healing process. RN #1 indicated she realized that Resident #21 did not have a LAL mattress on 6/19/23 and she notified the physician and obtained an order for the LAL mattress on 6/19/23. RN #1 indicated Resident #21 received the LAL mattress on 6/19/23. Interview and review of the clinical record with the DNS on 8/1/23 at 10:21 AM identified she was not aware of Resident #21 did not have a LAL mattress on until 6/19/23. The DNS indicated Resident #21 should have had an order for the LAL mattress upon readmission with a stage II coccyx pressure ulcer. The DNS indicated all licensed staff will be in-service. Although attempted, an interview with MD #1 was not obtained. Review of the facility pressure ulcer prevention protocol policy identified to develop a plan of care including prevention and wound treatments. Obtain any needed orders for wound care treatment. Investigate advanced directives to determine if there are any implications for treatment. Assure that resident and family expectations are compatible with the prognosis established. Perform daily observation of the skin. Encourage frequent repositioning/weight shifting. Utilize pressure redistributing surface (reduction or relief). Pressure reduction/relief mattress and chair cushion.

Based on observations, review of the clinical record, facility documentation, facility policy and interview for 1 of 4 residents (Resident #22) reviewed for accidents, the facility failed to ensure that 1:1 supervision with meals was provided to a resident with an identified aspiration risk and for 1 of 5 residents (Resident #28) reviewed for smoking, the facility failed to supervise smoking while escorting a resident from the smoking area into the facility. The findings include. 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included advanced dementia, end stage renal disease without dialysis, and multiple myeloma. The quarterly MDS dated [DATE] identified Resident #22 had severely impaired cognition, was always incontinent of bowel and bladder and required the assistance of one staff member with eating, dressing, and toileting. The care plan dated 5/11/23 identified Resident #22 had a potential risk for aspiration due to pocketing food. Interventions included 1:1 supervision with meals. The resident care conference note dated 5/11/23 identified Resident #22 required frequent cues and supervision with meals to swallow due to holding food in his/her mouth. The physician's order dated 5/29/23 identified Resident #22 required 1:1 supervision with meals and aspiration precautions which included eating at a slow rate, small bites and sips. An initial observation on 7/30/23 at 8:08 AM identified Resident #22 eating his/her breakfast unsupervised while seated in an area directly to the right of the nurses' station. No facility staff were observed with Resident #22. The breakfast included hot cereal and custard. A subsequent observation on 7/30/23 at 9:05 AM also identified Resident #22 continuing to eat his/her breakfast unsupervised. Interview with RN #3 (nursing supervisor) on 7/30/23 at 9:26 AM identified Resident #22 was supposed to have 1:1 observation with meals. RN #3 was unable to identify why there was no facility staff providing supervision to Resident #22 during his/her meal. An observation on 7/30/23 at 12:12 PM identified Resident #22 eating his/her lunch, which included pureed squash, potatoes, apple sauce, vanilla ice cream, ginger ale, and coffee. Again, the resident was unsupervised in the area directly to the right of the nurse's station. Resident #22 had consumed nearly 100% of his/her meal. Interview with the DNS on 8/1/23 at 10:30 AM identified that Resident #22 should have 1:1 supervision with meals due to pocketing food. The DNS identified that Resident #22 had not had any issues with choking or aspiration with meals but did require verbal prompts to swallow his/her food, which was why the 1:1 supervision order was in place. The DNS further identified Resident #22 was able to self-feed, but was slow to eat meals, sometimes over an hour to complete his/her meal. The DNS identified that the amount of time for Resident #22 to finish meals impacted the ability to provide 1:1 supervision for meals, and that was why Resident #22 was positioned next to the nurses' station. The facility policy on close observation and monitoring directed close monitoring was initiated for residents who had risk behaviors. The policy further directed that the purpose of the policy was to ensure the resident's physical well-being and safety. 2. Resident #28 was admitted [DATE] with diagnosis that include schizoaffective disorder, abnormal posture, and dementia. The quarterly MDS dated [DATE] identified Resident #28 had severely impaired cognition, was independent with eating, had Parkinson's disease and was wheelchair bound. The care plan dated 5/10/23 identified a focus for safe smoking practices with interventions that include smoking blanket to be brought outside with the resident at all times, and a smoking apron is placed on Resident #28 prior to smoking due to Parkinson's disease for safety. Observation on 7/30/23 at 9:00 AM identified Resident #28 was smoking with 4 other residents (Resident #3, 20, 36, and 44) in the outdoor, designated, supervised smoking area. When Resident #28 finished his/her cigarette, he/she expressed a desire to go back into the resident area inside the facility. NA #1 wheeled Resident #28 through the exterior door, punched the code for the interior door allowing Resident # 28 re-entry to the facility while the other 4 smokers continued to smoke. NA #1's back was turned to the 4 remaining smokers while she escorted Resident #28. Interview with NA #1 at the time of the observation identified she was told to monitor smoking and not turn her back to the residents. NA #1 further identified she had to assist Resident #28 back to the door and indicated she could not see the other 4 residents when she brought Resident #28 inside. Further, NA #1 identified she was never trained on the use of the flame-retardant blanket. Observation on 7/30/23 at 11:00 AM identified 5 residents smoking (Resident #3, 20, 28, 36, and 44), and NA #2 supervising. Resident #28 expressed an interest to return to the indoors and NA #2 advised Resident #28 to wait until the 4 remaining smokers were done and then she could escort him/her into the facility at that time. NA #2 waited until all smokers had finished their cigarettes and escorted them all safely back into the facility. NA #2 identified the flame-retardant blanket is to be placed upon the resident during a fire, as the blanket will quickly extinguish the fire. Observation on 7/31/23 at 9:00 AM identified NA #3 took the flame-retardant blanket to the smoking area, and supervised 4 residents (Resident #3, 20, 36, and 44). NA #3 identified the blanket is used to quickly extinguish a fire on a resident should there be a fire. Interview with the DNS on 8/1/23 at 10:45 AM identified every smoke monitor was trained on every aspect of expectations including the purpose and use of the flame-retardant blanket. The DNS further indicated it is her expectation that smoking is supervised. The policy for smoking-residents indicates all residents smoking at the facility are supervised and the observer must be in the direct area of the smokers and be able to respond to emergency situations. The staff members will be aware of the individuals with specific interventions necessary to maintain safe smoking practices. 46040

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #21) reviewed for pressure ulcers, the facility failed to ensure the dietitian evaluated a resident in a timely manner who was readmitted with a pressure ulcer, and for 1 resident (Resident #50), who was on fluid restriction, the facility failed to monitor and document fluid Intake and Output (I&O). The findings include. 1. Resident #21 was admitted to the facility in March 2023 with diagnoses that included atrial fibrillation, congestive heart failure, post-traumatic stress disorder, and vitamin B-12 deficiency anemia. Review of the RN assessment form dated 3/8/23 identified Resident #21 skin was intact except for slightly reddened Moisture-Associated Skin Damage (MASD) to the groin. The nutritional admission assessment dated [DATE] identified Resident #21's diet order was regular, and the resident was at risk for weight fluctuation related to diuretic use. The care plan dated 3/13/23 identified Resident #21 had a skin rash/MASD to the groin area. Interventions included to apply treatment has ordered and assist with incontinent care every two hours. The admission MDS dated [DATE] identified Resident #21 had intact cognition and was independent with eating. A physician's order dated 3/20/23 directed to send Resident #21 to the hospital for evaluation post fall and complaints of left hip pain. The nurse's note dated 3/20/23 at 9:00 PM identified Resident #21 was admitted to the hospital with diagnoses of a femoral neck fracture. Review of the hospital inter-agency patient referral report (W-10) documentations dated 3/27/23 at 2:44 PM identified Resident #21 was discharged back to the facility with a stage II coccyx pressure ulcer. Review of the RN assessment form dated 3/27/23 identified Resident #21 was readmitted to the facility with diagnoses of left hip hemiarthroplasty. Additionally, the resident assessment data collection identified Resident #21 had a stage II coccyx pressure ulcer measuring 1.0 cm x 1.0 cm x 0 cm. Review of the pressure ulcer progress report dated 3/27/23 identified Resident #21 was readmitted from the hospital with stage II coccyx pressure ulcer, measuring length 1.0 cm x width 1.0 cm x depth 0 cm, reddened at base of wound, no drainage, cleanse with Normal Saline followed by Hydrocolloid everyday times 14 days and re-evaluate. A physician's order dated 3/27/23 directed to provide low sodium diet, regular consistency with thin liquids. The revised care plan dated 3/28/23 identified Resident #21 was readmitted from the hospital with a stage II pressure ulcer to the coccyx. Interventions included to cleanse coccyx with Normal Saline, pat dry, followed by foam dressing everyday times 14 days and re-evaluate. Assist with turning and repositioning every 2 hours. Keep urinal within reach. Assist with toileting every 2 - 3 hours. Further, the revised care plan identified Resident #21 was at risk for nutritional deficits related to readmission with a stage II open area to coccyx. Interventions included to provide diet as ordered and tolerated. Monitor labs as ordered. Review of the clinical record from 3/27/23 through 3/31/23 failed to reflect that the Dietitian assessed Resident #21 after readmission to the facility with a stage II coccyx pressure ulcer. A physician's order dated 4/15/23 directed to administer Liquid Protein 30 ml by mouth twice a day times 30 days for wound healing. Review of the APRN wound note dated 4/25/23 identified Resident #21 has a community acquired stage II coccyx pressure ulcer measuring 0.5cm x 0.3cm, color pink, with scant serous drainage and no odor. Continue with same wound care but decrease wound care to twice a week and as needed. Review of the clinical record from 4/1/23 through 5/17/23 failed to reflect that the Dietitian assessed Resident #21 after readmission (on 3/27/23) to the facility with a stage II coccyx pressure ulcer. The nurse's note dated 5/17/23 at 9:00 AM identified Resident #21 went to an appointment at the hospital at 8:50 AM. The nurse's note dated 5/17/23 at 12:00 PM identified Resident #21 was admitted to the hospital secondary to left arm edema. Review of the census form identified Resident #21 was readmitted to the facility on [DATE]. Review of the RN assessment form dated 5/22/23 identified Resident #21 was readmitted to the facility with a diagnoses of volume overload, heart failure, progressive weight gain, and bilateral lower extremities edema. Additionally, coccyx open area measuring 1.5 cm x 0.2 cm x 0 cm. Left buttock open area measuring 1.5 cm x 1.0 cm x 0 cm. A physician's order dated 5/22/23 directed to administer low sodium diet, regular consistency with thin liquid diet, and house supplement 120 ml by mouth twice a day and document percentage taken. Review of the clinical record from 5/22/23 through 6/30/23 failed to reflect that the Dietitian assessed Resident #21 after two readmissions (on 3/27/23 and 5/22/23) to the facility with a stage II coccyx pressure ulcer. Review of the APRN wound progress note dated 7/25/23 identified Resident #21 has a community acquired stage II pressure ulcer to coccyx and right heel improving slowly. Measurement of stage II coccyx pressure ulcer 1.0cm x 0.4cm x 0.1cm, drainage, no odor with intact peri wound. Stage II to right heel 2.0cm x 1.0cm beefy red in color, clean with mild serous drainage, no odor, and peri wound unremarkable. Review of the clinical record from 7/1/23 through 7/30/23 failed to reflect that the Dietitian assessed Resident #21 after two readmissions (on 3/27/23 and 5/22/23) to the facility, a stage II coccyx pressure ulcer and a stage II to right heel. Interview and review of the clinical record with RN #1 on 7/31/23 at 9:00 AM identified she was aware that Resident #21 was readmitted with a stage II coccyx pressure ulcer. RN #1 indicated she was not aware that Resident #21 was not receiving supplements to help in the healing process of the pressure ulcer until 4/15/23. RN #1 indicated the license nurses could have notified the physician and obtain an order for supplements upon readmission on 3/27/23. Further, RN #1 failed to provide documentation that the Dietitian had assessed Resident #21 after multiple readmissions (3/27/23 and 5/22/23), and a stage II coccyx pressure ulcer. RN #1 indicated she was aware that the Dietitian had not assessed Resident #21 regarding the pressure ulcer. RN #1 indicated the facility was going through a hard time finding a Dietitian at that time. RN #1 indicated the facility has hired a new Dietitian recently. Subsequent to surveyor inquiry a dietary progress note dated 7/31/23 identified Resident #21 is on a low sodium regular diet with thin liquids. Resident #21 is at nutritional and dehydration risk due to stage 3 on coccyx and stage 2 to right heel. Resident #21 is on Liquid Protein 30 ml twice a day. Providing additional 30 gm protein a day, and extra 200 calories a day for wound healing. Continue with diet and supplement. Interview and review of the clinical record with the DNS on 8/1/23 at 10:23 AM identified she was aware the facility did not have a routine Dietitian at that time. The DNS indicated the facility has just hired a new Dietitian. Although attempted, an interview with MD #1 was not obtained. Review of the facility consultant dietitian functional position description form identified job responsibilities involved: Assessing the nutritional needs of the residents. Developing therapeutic diets. Developing regular diets to meet the specialized needs of the residents. Will attend the medical staff meetings when available. Writes all therapeutic diets and approved menus. Participating in nutritional care plans for each resident. Review of the facility pressure ulcer prevention protocol policy identified to develop a plan of care including prevention and wound treatments. Obtain any needed orders for wound care treatment. Investigate advanced directives to determine if there are any implications for treatment. Assure that resident and family expectations are compatible with the prognosis established. Perform daily observation of the skin. Encourage frequent repositioning/weight shifting. Utilize pressure redistributing surface (reduction or relief). Pressure reduction/relief mattress and chair cushion. 2. Resident #50 was admitted to the facility on [DATE] with diagnosis that include end stage renal disease, anxiety disorder, and pleural effusion. The admission MDS dated [DATE] identified Resident #50 is cognitively intact, has end stage renal disease requiring dialysis, thyroid disorder, and hypotension. The care plan dated 5/25/23 had a focus of risk of dehydration with interventions to monitor vital signs, and intake and output and labs as ordered. Physician's order dated 5/23/23 directed a fluid restriction on 1200 ml per 24 hours. Review of the Intake and Output (I&O) records dated 5/23/23 - 7/31/23 identified I&O had not been documented 5/23/23 - 6/18/23 and 7/17/23 - 7/31/23. Review of the clinical record with RN #2 (staff development) on 8/1/23 at 11:06 AM identified although Resident #50 is on 1200ml/day fluid restriction, she was unable to show that I&O's had been monitored consistently since 5/23/23. RN #2 identified the nurse aides document the I&O's on the fluid intake sheet, and nursing evaluates the intake daily to determine if fluid goals are met. Interview with the DNS on 8/1/23 at 10:45 AM identified that when a resident is on a fluid restriction, it is her expectation that fluid I&O's are monitored and documented. Although requested, a facility policy for monitoring I&O's was not provided. 43032

Based on clinical record review, facility documentation and staff interview for 1 of 2 sampled residents (Resident #2) reviewed for a resident to resident altercation, the facility neglected to ensure emergency first aid was provided after a resident was assaulted with a wheelchair leg rest. The findings include: Resident # 2's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident with moderately impaired cognition, without behaviors and extensive assistance with ADL's. The RCP dated 7/26/17 identified a new roommate. Interventions included monitor mood and behavior for changes. Facility documentation dated 8/22/17 at 4:15 AM identified that Resident # 1 was found standing at Resident # 2's bedside holding a wheelchair foot pedal over Resident # 2's head. The documentation identified Resident # 2's head was bloody with multiple lacerations to the head, face and scalp. The documentation identified that Resident # 1 was standing over Resident # 2 repeatedly striking the residents head and face with the wheelchair foot pedal. Review of the Prehospital Care report Summary dated 8/22/17 at 4:18 AM identified the patient with an approximate 1.5 inch deep avulsion to the left side of head, skull is visible, a 3/4 inch laceration noted on the right side of the head and copious amounts of blood are noted around the residents head. The resident was transported at 4:33 AM to the hospital. Nurse's notes dated 8/22/17 at 5:45AM identified a noise heard in resident's room, found Resident # 1 standing at Resident# 2's bedside with a wheelchair foot pedal in hand. The note identified blood was observed all over Resident # 2's head, and that vital signs were unable to be obtained secondary to pool of blood all over the resident. Review of the hospital discharge summary dated 8/22/17 identified the resident sustained [REDACTED]. Review of the Skin Tear Assessment Sheets dated 8/22/17 identified the following: a 2.0cm by 0.1cm laceration to the left Occipital/Parietal region with 2 staples, a second 2cm by 0.1cm laceration to the left Occipital/Parietal region with 2 staples, a 3.2cm by 0.1cm laceration to the left side of the face with 6 sutures, a 4.7cm by 0.1cm linear laceration on the mid forehead with 7 staples, a 3.8cm by 0.1cm laceration to the left side of face, a 1.4cm by 0.1cm laceration to the right temple with 2 sutures, a 1.3cm by 0.1cm laceration to the right temple with 2 sutures, a 2cm by 0.1cm laceration to the right parietal frontal region with 4 staples, a 2.3 cm by 0.1cm laceration to the right parietal frontal region of the head with 4 staples, a 1.2cm by 0.1cm laceration to the right parietal frontal region of the head with 4 staples, the left temporal post ear region with multiple skin tears, a 1cm by 0.1cm left lateral wrist laceration, a 1.3cm by 0.1cm left parietal region laceration with 3 staples, a 1.3cm by 0.1 cm laceration to the right temple with 2 sutures, a 2cm by 0.1cm laceration to the left earlobe with 2 sutures, a 2.5cm by 3cm laceration to the left parietal region of the head with 7 staples and a 7.5cm by 0.1cm laceration to the left parietal region of the head with 10 staples. Interview with NA # 1 on 8/28/17 at 11:38AM stated that when she went into the resident room she saw Resident # 2 lying in bed, holding his/her head that was bleeding profusely. NA # 1 stated that the RN Supervisor left the room and that she did not see the nurse provide any care to the resident. Interview with NA # 2 on 8/29/17 at 8:30AM stated that she was called into the room and saw Resident # 2 lying in bed and saw blood all over the walls, floor sheets and the residents head. NA # 2 stated that she did not see either the LPN or RN Supervisor provide any care to the residents head before they left the room. Interview with LPN # 1 on 8/29/17 at 8:05AM stated that he did not provide any type of assessment or care to Resident # 2's head wounds and did not see if the RN Supervisor had. Interview with the RN Supervisor on 8/28/17 at 12:05PM stated that although Resident # 1 was bleeding profusely from the head, and she saw the resident had blood from his/her waist to head she did not assess the residents head and/ or provide direct pressure to stop the bleeding because she just couldn't believe this happened and was shocked. The RN Supervisor stated that she saw the resident move so she knew he/she was alive. Interview with the DON on 8/28/17 at 12:00PM stated that the expectation is that the RN remain with the resident, assess the area and apply pressure to the bleeding. The DON stated that the nurse should not have left the resident until the paramedics arrived. The DON stated that the RN should have attempted to make an assessment of the resident so it could be told to the Paramedics upon arrival. Additionally, the DON stated that they facility did not have a policy regarding providing first aide to a resident in an emergency situation.

Based on clinical record review, facility documentation and staff interviews for 1 of 2 sampled residents (Resident #2) reviewed for abuse, the facility failed to ensure emergency first aid was provided after a resident was assaulted with a wheelchair leg rest resulting in a significant head injury. The findings include: Resident # 2's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident with moderately impaired cognition, without behaviors and extensive assistance with ADL's. The RCP dated 7/26/17 identified a new roommate. Interventions included monitor mood and behavior for changes. Facility documentation dated 8/22/17 at 4:15 AM identified that Resident # 1 was found standing at Resident # 2's bedside holding a wheelchair foot pedal over Resident # 2's head. The documentation identified Resident # 2's head was bloody with multiple lacerations to the head, face and scalp. The documentation identified that Resident # 1 was standing over Resident # 2 repeatedly striking the residents head and face with the wheelchair foot pedal. Additionally, the documentation noted that the residents were separated and Resident # 2 was seated on resident # 1's foot of bed. Review of the Prehospital Care report Summary dated 8/22/17 at 4:18 AM identified the patient with an approximate 1.5 inch deep avulsion to the left side of head, skull is visible, a 3/4 inch laceration noted on the right side of the head and copious amounts of blood are noted around the residents head. The resident was transported at 4:33 AM to the hospital. Nurse's notes dated 8/22/17 at 5:45AM identified a noise heard in resident's room, found Resident # 1 standing at Resident# 2's bedside with a wheelchair foot pedal in hand. The note identified blood was observed all over Resident # 2's head, and that vital signs were unable to be obtained secondary to pool of blood all over the resident. Review of the hospital discharge summary dated 8/22/17 identified the resident sustained [REDACTED]. Review of the Skin Tear Assessment Sheets dated 8/22/17 identified the following: a 2.0cm by 0.1cm laceration to the left Occipital/Parietal region with 2 staples, a second 2cm by 0.1cm laceration to the left Occipital/Parietal region with 2 staples, a 3.2cm by 0.1cm laceration to the left side of the face with 6 sutures, a 4.7cm by 0.1cm linear laceration on the mid forehead with 7 staples, a 3.8cm by 0.1cm laceration to the left side of face, a 1.4cm by 0.1cm laceration to the right temple with 2 sutures, a 1.3cm by 0.1cm laceration to the right temple with 2 sutures, a 2cm by 0.1cm laceration to the right parietal frontal region with 4 staples, a 2.3 cm by 0.1cm laceration to the right parietal frontal region of the head with 4 staples, a 1.2cm by 0.1cm laceration to the right parietal frontal region of the head with 4 staples, the left temporal post ear region with multiple skin tears, a 1cm by 0.1cm left lateral wrist laceration, a 1.3cm by 0.1cm left parietal region laceration with 3 staples, a 1.3cm by 0.1 cm laceration to the right temple with 2 sutures, a 2cm by 0.1cm laceration to the left earlobe with 2 sutures, a 2.5cm by 3cm laceration to the left parietal region of the head with 7 staples and a 7.5cm by 0.1cm laceration to the left parietal region of the head with 10 staples. Interview with NA # 1 on 8/28/17 at 11:38 AM stated that when she went into the resident room she saw Resident # 2 lying in bed, holding his/her head that was bleeding profusely. NA # 1 stated that the RN Supervisor left the room and that she did not see the nurse provide any care to the resident. Interview with NA # 2 on 8/29/17 at 8:30 AM stated that she was called into the room and saw Resident # 2 lying in bed and saw blood all over the walls, floor, sheets and the residents head. NA # 2 stated that she did not see either the LPN or RN Supervisor provide any care to the residents head before they left the room. Interview with LPN # 1 on 8/29/17 at 8:05 AM stated that he did not provide any type of assessment or care to Resident # 2's head wounds and did not see if the RN Supervisor had. Interview with the RN Supervisor on 8/28/17 at 12:05 PM stated that although the resident was bleeding profusely from the head, and she saw the resident had blood from his/her waist to head she did not assess the resident's head and/ or provide direct pressure to stop the bleeding because she just couldn't believe this happened and was shocked. The RN Supervisor stated that she saw the resident move so she knew he/she was alive. Interview with the DON on 8/28/17 at 12:00 PM stated that the expectation is that the RN remain with the resident, assess the area and apply pressure to the bleeding. The DON stated that the nurse should not have left the resident until the paramedics arrived. The DON stated that the RN should have attempted to make an assessment of the resident so it could be told to the Paramedics upon arrival. Additionally, the DON stated that they facility did not have a policy regarding providing first aide to a resident in an emergency situation. According to the Fundamental Nursing Care Second Edition (2008), trauma to the head can result in intracranial bleeding, intracranial pressure and [MEDICAL CONDITION]. Death may occur if the client is not treated immediately. Assessment of the mechanism of injury is of utmost importance in determining how sever the injury is. with head trauma, careful continuous monitoring of the level of consciousness is essential. Review of facility policy and procedure for change in condition identified if a significant change in resident status occurs a comprehensive assessment will be completed.

Based on clinical record review, facility documentation and staff interview for 1 of 2 sampled residents (Resident #2) reviewed for a resident to resident altercation, the facility failed to ensure emergency first aid was provided after resident was assaulted with a wheelchair leg rest. The findings include: Resident # 2's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident with moderately impaired cognition, without behaviors and extensive assistance with ADL's. The RCP dated 7/26/17 identified a new roommate. Interventions included monitor mood and behavior for changes. Facility documentation dated 8/22/17 at 4:15 AM identified that Resident # 1 was found standing at Resident # 2's bedside holding a wheelchair foot pedal over Resident # 2's head. The documentation identified Resident # 2's head was bloody with multiple lacerations to the head, face and scalp. The documentation identified that Resident # 1 was standing over Resident # 2 repeatedly striking the residents head and face with the wheelchair foot pedal. Review of the Prehospital Care report Summary dated 8/22/17 at 4:18 AM identified the patient with an approximate 1.5 inch deep avulsion to the left side of head, skull is visible, a 3/4 inch laceration noted on the right side of the head and copious amounts of blood are noted around the residents head. The resident was transported at 4:33 AM to the hospital. Nurse's notes dated 8/22/17 at 5:45AM identified a noise heard in resident's room, found Resident # 1 standing at Resident# 2's bedside with a wheelchair foot pedal in hand. The note identified blood was observed all over Resident # 2's head, and that vital signs were unable to be obtained secondary to pool of blood all over the resident. Review of the hospital discharge summary dated 8/22/17 identified the resident sustained [REDACTED]. Review of the Skin Tear Assessment Sheets dated 8/22/17 identified the following: a 2.0cm by 0.1cm laceration to the left Occipital/Parietal region with 2 staples, a second 2cm by 0.1cm laceration to the left Occipital/Parietal region with 2 staples, a 3.2cm by 0.1cm laceration to the left side of the face with 6 sutures, a 4.7cm by 0.1cm linear laceration on the mid forehead with 7 staples, a 3.8cm by 0.1cm laceration to the left side of face, a 1.4cm by 0.1cm laceration to the right temple with 2 sutures, a 1.3cm by 0.1cm laceration to the right temple with 2 sutures, a 2cm by 0.1cm laceration to the right parietal frontal region with 4 staples, a 2.3 cm by 0.1cm laceration to the right parietal frontal region of the head with 4 staples, a 1.2cm by 0.1cm laceration to the right parietal frontal region of the head with 4 staples, the left temporal post ear region with multiple skin tears, a 1cm by 0.1cm left lateral wrist laceration, a 1.3cm by 0.1cm left parietal region laceration with 3 staples, a 1.3cm by 0.1 cm laceration to the right temple with 2 sutures, a 2cm by 0.1cm laceration to the left earlobe with 2 sutures, a 2.5cm by 3cm laceration to the left parietal region of the head with 7 staples and a 7.5cm by 0.1cm laceration to the left parietal region of the head with 10 staples. Interview with NA # 1 on 8/28/17 at 11:38AM stated that when she went into the resident room she saw Resident # 2 lying in bed, holding his/her head that was bleeding profusely. NA # 1 stated that the RN Supervisor left the room and that she did not see the nurse provide any care to the resident. Interview with NA # 2 on 8/29/17 at 8:30AM stated that she was called into the room and saw Resident # 2 lying in bed and saw blood all over the walls, floor sheets and the residents head. NA # 2 stated that she did not see either the LPN or RN Supervisor provide any care to the residents head before they left the room. Interview with LPN # 1 on 8/29/17 at 8:05AM stated that he did not provide any type of assessment or care to Resident # 2's head wounds and did not see if the RN Supervisor had. Interview with the RN Supervisor on 8/28/17 at 12:05PM stated that although Resident # 1 was bleeding profusely from the head, and she saw the resident had blood from his/her waist to head she did not assess the residents head and/ or provide direct pressure to stop the bleeding because she just couldn't believe this happened and was shocked. The RN Supervisor stated that she saw the resident move so she knew he/she was alive. Interview with the DON on 8/28/17 at 12:00PM stated that the expectation is that the RN remain with the resident, assess the area and apply pressure to the bleeding. The DON stated that the nurse should not have left the resident until the paramedics arrived. The DON stated that the RN should have attempted to make an assessment of the resident so it could be told to the Paramedics upon arrival. Additionally, the DON stated that they facility did not have a policy regarding providing first aide to a resident in an emergency situation. Review of facility policy and procedure for change in condition identified if a significant change in resident status occurs a comprehensive assessment will be completed.

Based on clinical record review, facility documentation and staff interview for 1 of 2 sampled residents (Resident # 2) reviewed for resident to resident abuse, the RN Supervisor failed to request additional assistance to ensure resident safety after Resident #2 was assaulted with a wheelchair legrest. The findings include: Resident # 2's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident with moderately impaired cognition, without behaviors and extensive assistance with ADL's. The RCP dated 7/26/17 identified a new roommate. Interventions included monitor mood and behavior for changes. Facility documentation dated 8/22/17 at 4:15 AM identified that Resident # 1 was found standing at Resident # 2's bedside holding a wheelchair foot pedal over Resident # 2's head. The documentation identified Resident # 2's head was bloody with multiple lacerations to the head, face and scalp. Blood was noted on the walls, floor bed and linens. The documentation identified that Resident # 1 was standing over Resident # 2 repeatedly striking the residents head and face with the wheelchair foot pedal. Additionally, the documentation noted that Resident # 1 was seated on Resident # 2's foot of the bed. Review of the Prehospital Care report Summary dated 8/22/17 identified the paramedics on scene and at the resident's bedside at 4:18AM. The patient with an approximate 1.5 inch deep avulsion to the left side of head, skull is visible, a 3/4 inch laceration noted on the right side of the head and copious amounts of blood are noted around the residents head. Additionally, staff was noted standing by the window. The resident was transported at 4:33 AM to the hospital. Review of the hospital discharge summary dated 8/22/17 identified the resident sustained [REDACTED]. Interview with NA # 1 on 8/28/17 at 11:38 AM stated that she was called into the resident's room and saw Resident # 1 was bleeding profusely from the head. NA # 1 stated she saw Resident # 1 half on and half off resident # 2's bed holding onto the side rails. NA # 1 stated she was told by the RN Supervisor to stay in the room with the residents, but did not instruct her with what to do if Resident # 1 became agitated again. Interview with NA # 2 on 8/29/17 at 8:30 AM stated that the RN Supervisor yelled for help and upon entering the resident's room she saw Resident # 1 lying atop Resident # 2's legs at the foot of the bed. NA # 2 stated that she saw blood on the walls, floor, and bed and that Resident # 2's head and face was all bloody. NA # 2 stated that the RN Supervisor instructed her and NA # 1 not to touch anything and to stay in the room but did not tell them what to do if the resident became agitated again. Interview with the RN Supervisor on 8/28/17 at 12:05 PM stated that she was at the nurse's station and heard a tapping noise and when she went down the hall she saw Resident # 1 standing over Resident # 2 with a wheelchair foot pedal over Resident # 2's head. The RN Supervisor stated she yelled for help and to call 911, and took the foot pedal out of the resident's hand. RN Supervisor stated that she moved Resident # 1 and sat him/her at the bottom of Resident # 2's bed. The RN Supervisor further stated that Resident # 1's eyes were close, he/she's body was stiff and was not speaking. The RN Supervisor stated that although she told the NA's to stay with the residents and keep an eye on them, she failed to direct them in what to do if the resident's behavior escalated again because she was shocked at what happened and wasn't thinking clearly. The RN Supervisor stated that she did not separate the residents because Resident # 1 was holding onto the side rails and his/her body was stiff. She further stated that she did not ask the other nurse for assistance on separating the residents because she thought the NA's could keep an eye on the residents. Interview with the DON on 8/28/17 at 12:00PM stated that the nurse should have removed Resident # 1 from any residents until the paramedics arrived to ensure the safety of all residents.

Based on clinical record review and staff interview for three of six residents in the survey sample reviewed for accidents (R#18, R # 66, R # 29), the facility failed to provide adequate supervision and assistance to prevent an accident, and/or failed to implement the care plan resulting in a fall, and/or failed to ensure a resident was transferred safely resulting in an injury. The findings include: 1. Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital neurology consult dated 4/13/14 (conducted prior to admission) indicated the resident had suffered a fall 5-7 days prior to hospital admission and had numerous falls in the past. An admission nursing assessment dated [DATE] indicated the resident was alert and disoriented with red spots and light bruises noted on the resident's left knee. A fall risk assessment dated [DATE] indicated the resident was high risk for falls. physician's orders [REDACTED]. A physician's orders [REDACTED]. An undated care plan identified a potential for falls/injury. Interventions included bed sensor alarm in bed, tab alarm in bed, mats at bedside, and offer nap after lunch daily. a. Review of a nurse's note dated 4/16/14 at 11:00 pm indicated the resident had a witnessed fall. The chair alarm went off and an attempt was made to break the fall, but was unsuccessful. The supervisor was notified at that time. The resident had a small abrasion on the left eye brow and a cut on the inside upper lip. The resident's extremities were within normal limits with a strong grasp. Pupils were equal and reactive to light. The Physician was made aware. At 11:25 PM person # 1 came into the facility and requested the resident be sent to the emergency room for evaluation. Resident # 66 was sent to the emergency room at 11:45 PM. A reportable event form and investigation dated 4/16/14 indicated R # 66 tried to get out of the chair and lost his/her balance. The resident was sent to the hospital for evaluation. A review of the clinical record and interview on 3/4/15 at 3:10 PM with LPN # 1 indicated prior to R # 66's fall on 4/16/14 the resident had been very restless and attempting to get out of the bed the entire evening. At approximately 10:30 PM the resident was assisted out of bed into a wheelchair with the chair alarm in place. LPN # 1 indicated he/she brought the resident near him/her as s/he charted for the evening. His/her back was to the resident and when he/she heard the alarm sound he/she attempted to assist the resident who was standing, but was unsuccessful and the resident fell . LPN # 1 indicated he/she did not recall if he/she had notified RN #2 (supervisor) of the resident's restlessness and unsafe behaviors prior to the fall, but he/she would have documented the notification if he/she had. LPN #1 was unable to provide documentation at that time that RN # 2 (supervisor) was notified. An interview on 3/4/15 at 4:15 PM with RN # 2 indicated he/she did not recall being notified of R #66's restlessness and unsafe behaviors prior to his/her fall on 4/16/14. If he/she had been notified he/she would have assessed the resident and would have documented the assessment in the clinical record. Although RN # 2 was unable to indicate what interventions he/she would have been in place, he/she indicated it would have been based on his/her assessment. No assessment was noted in the clinical record at that time. The resident was admitted to the hospital with [REDACTED]. b. Resident # 66 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] indicated R # 66 was disoriented and had healing ecchymotic areas to the face. A fall risk assessment dated [DATE] indicated the resident was high risk. A care plan dated 4/18/14 identified a potential for fall/injury. An intervention included scoop mattress in bed. A nurse's note dated 4/19/14 indicated R # 66 fell in the bathroom while being toileted. The resident was complaining of back pain. The resident was sent to the hospital for evaluation. A reportable event and investigation dated 4/19/14 at 10:15 AM indicated R # 66 was left on the toilet alone and fell to the floor. An interview on 3/4/15 at 1:00 PM with NA # 3 indicated he/she and NA #4 assisted R # 66 to the toilet. Nurse aide # 4 left the room after the transfer and NA#3 he/she decided to wash the resident while he/she was in the bathroom. He/she left the bathroom (near the door) and went to the resident's bed (near the far window) to get a washcloth and towel. He/she heard a noise and went back to the bathroom and found the resident on the floor. Nurse aide # 3 indicated he/she was aware the resident should not have been left alone on the toilet, but because he/she was only going to be gone for a brief time he/she thought the resident would O.K. A review of a facility policy on fall risk indicated no resident is to be left in the bathroom unless they have been assessed as being safe to do so. 2. Resident # 29's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had short and long-term memory problems, had severely impaired decision-making, required extensive assist with bed mobility and transfer, did not walk and was always incontinent of bladder. A resident care plan dated 11/5/14 identified a potential for falls and injury. Interventions included assist of 2 for transfers, cue resident for safe acts, and side rails as ordered. A Physician order [REDACTED]. A nurse's note dated 11/16/14 at 7:15 PM indicated resident's knees buckled during transfer. The resident was caught on the side rail and sustained a laceration on his/her buttock. The resident was lowered to the floor and sent to the emergency room for evaluation at 7:30 PM. A hospital history and physical dated 11/16/14 indicated R # 29 presented in the emergency room with a laceration to the left buttock cheek. The resident underwent [REDACTED]. A reportable event and investigation dated 11/16/14 indicated R # 29 was assisted to a standing position with a rolling walker and the assistance of NA # 1 and NA # 2. While the resident was standing, perineal care was performed by NA # 1. Nurse aide #2 supported the resident under the armpits without the benefit of a gait belt during this time. After the resident was cleaned, he/she was instructed to turn so his/her back was against the bed. The resident was positioned against the side rail which was located at the head of the bed. The resident's knees buckled and the resident slid from the edge of the bed while lacerating his/her buttock on the side rail. Nurse aide # 1 and # 2 were suspended pending further investigation. Facility staff were re-educated on the use of a gait belt for transfers, positioning the resident in the middle of the bed before transfer, and providing care in bed (not while standing). An additional note dated 11/21/4 indicated NA # 1 and NA # 2 were terminated. Attempts to notify NA # 1 and NA # 2 were unsuccessful. An interview on 3/5/15 at 3:15 PM with LPN # 2 indicated residents should be provided care in bed and not while standing for safety as well as for dignified care. He/she further indicated gait belts should be used for all resident transfers. Review of facility policy on gait belts indicated gait belts will be used for resident transfers and gait/ambulation training. 3. Resident #18's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with moderately impaired cognition requiring extensive assistance with personal hygiene, and limited assistance with transfers and ambulation. physician's orders [REDACTED]. The Resident Care Plan dated 1/9/15 identified the resident was at risk for falls. Interventions directed the staff to ensure the tabs alarm is clipped out of the resident's reach. Facility Documentation identified the resident had 7 falls between 1/4/14 to 7/22/14 Nurse's Notes dated 2/22/15 at 7:30 AM identified the resident was found on the floor. No apparent injury was noted. The physician was notified and directed the use of an alarm pad while in bed in place of a tab alarm. Interview on 3/4/15 at 1:00 PM with NA# 3 identified she/he entered the resident's room and found the resident on the floor. The alarm was not sounding. Interview and review of the clinical record on 3/4/15 at 1:00 PM with RN# 1, who assessed the resident after the fall, identified that although the supervisor checks the placement and function of resident's alarms on every shift, the resident would often unclip the tabs alarm before attempting to get up without assistance. The clip should be secured out of the residents reach. Subsequent to the fall, the physician was notified and directed the use of an alarm pad while in bed in place of a tab alarm.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who was reviewed for elopement, the facility failed to provide adequate supervision when a resident had expressed a desire to leave the facility and/or for one of three sampled residents (Resident #4) who had was at risk for falls, the facility failed to provide the appropriate number of staff assistance when transferring the resident as outlined in the plan of care and/or the physician's orders [REDACTED]. The findings include: 1,. Resident #4's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The readmission MDS assessment dated [DATE] identified Resident #4 had severe cognitive impairments, no behavioral symptoms and required two person extensive assistance for transfers and toilet use and the resident's balance during transition moving on and off the toilet and surface to surface transfer was not steady and the resident was only able to stabilize with staff assistance. The care plan dated 9/17/13 indicated the resident was at risk for falls and/or potential for injury. Interventions directed a tab alarm at all times, floor mats on both sides of bed, and re-enforce use of call bell. Review of the nurse's note and Reportable Event Form dated 9/22/13 at 7:40 PM identified Resident #4 was lowered to the floor while being provided peri-care. The investigation identified that Nurse Aide (NA) #1 had transferred the resident from the toilet to standing position so she could provide perineal care. Although Licensed Practical Nurse (LPN) #1 assisted NA #1 with transferring Resident #4 from the wheelchair to the toilet, NA #1 transferred the resident from the toilet to a standing position without the benefit of a second staff person to assist. Subsequent to physician notification an x-ray of the left femur and hip was obtained. Although the radiology report dated 9/22/13 identified a left hip x-ray with diffuse osteopenia and age indeterminate fractures involving the superior and inferior pubic rami, Resident #4 refused to be transferred to the hospital until 9/23/13 and was admitted . The hospital discharge summary dated 9/25/13 identified that Resident #4 was treated for [REDACTED]. Interview with the DON on 12/5/13 at 9:15 AM identified that NA #1 was terminated on 9/24/13 for not following the care plan. NA #1 was not available for interview. 2. Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessments dated 8/1/13 and 10/24/13 identified that Resident #1 had no memory or cognitive deficits, exhibited physical and verbal behaviors, no wandering behavior, was independent with ambulating, the resident's balance with transitions from different levels and walking was not steady but was able to stabilize without staff assistance, utilized a walker and/or wheelchair for mobility, and was incontinent of bowel and bladder. The care plan dated 9/12/13 identified that the resident had a potential for mood and behavior changes. Interventions directed to monitor the specific behaviors as ordered, psychiatric consultation as ordered and a history of a wanderguard code alert that was initiated on 7/5/13 when Resident #1 was found leaving the building on 7/5/13 at 12:00 AM and the wanderguard was discontinued on 7/25/13. The nurse's note dated 10/27/13 at approximately 11:20 PM identified that Resident #1 had wheeled him/herself to the nurse's station, dialed the phone and was overheard saying that if he/she "didn't get out of this place, he/she would kill themselves." The social service note dated 10/28/13 indicated that the resident denied further suicidal ideation and that Resident #1 had reported "not wanting to be here" and stated "this was not the place for me." Review of the nurse's notes and the Reportable Event Form dated 11/18/13 identified that the facility received a telephone call from the local police department at 2:00 AM informing the facility that Resident #1 had been found self-propelling the wheelchair on another street in the neighborhood approximately 0.4 miles away from the facility. The facility sent Nurse Aide (NA) #2 on foot to return the resident to the facility. Subsequent to the incident, Resident #1 was moved to another room closer to the nurse's station and a wanderguard bracelet was initiated again. Review of the Social Service note dated 11/18/13 identified when Resident #1 was questioned, the resident indicated "they had already checked my room and I didn't see anyone in the hall. I saw an opportunity and I took it." The facility Elopement policy directs, in part, to ensure residents are safe a wanderguard was to be used to enable the staff to know the whereabouts of residents who are a potential for wandering. Observations on 12/4/13 of resident's previous room identified that the room was located in close proximity to the elevator. Interview with NA #3 identified that the weather was cold and rainy and Resident #1 was calm, laughing and had remarked that he/she had almost accomplished his/her goal of reaching home. Interview with NA #2 on 12/4/13 at 2:12 PM identified that the last time she had seen Resident #1 was at 1:00 AM in bed. NA #2 indicated that the facility doors have keypads except for the front door and that the resident must have gone out that one. Review of the clinical record and interview with the Director of Nursing (DON) on 12/4/13 at 2:30 PM identified that although on 10/28/13 Resident #1 had expressed "not wanting to be here" no new measures had been implemented to ensure the resident was not a risk for elopement.

Based on clinical record review, review of facility investigative summaries, policies and procedures, and interviews for one sampled resident reviewed for an injury of unknown origin, (R#1), the facility failed to provide adequate supervision to prevent an accident. The findings include: Resident (R) #1's [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified impaired cognition, moderately impaired decision-making, wandered daily, assist of one to two staff for all activities of daily living (ADLs) and mobility activities, fell in the past thirty days and thirty-one to one hundred and eighty days, and daily antipsychotic and antidepressant medications. A Fall Risk assessment dated [DATE] identified a score of 12 and, on 06/15/10, a score of 14 with a total score above 10 representing a high risk to fall. Review of a Resident Care Plan for falls reviewed and revised on 06/15/10 identified a re-admission with a plan to continue same plan of care that included low bed, out of bed for breakfast, assist with activities of daily living (ADL), encourage participation in ADL's, transfer and ambulation with assist of one. Review of a facility investigation dated 06/16/10 at 11:20 AM identified that R#1 was found on his/her knees, on the floor between the bed and the bedside chair. A bed and chair alarm were in place and functioning. New interventions included the use of gripper socks when in bed, x-rays of the left hip and left knee, and rehabilitation evaluation. A portable x-ray report dated 06/16/10 reported to the facility at 3:21 PM identified mild osteoarthritis of the left knee with no fracture and left hip joint in alignment, but narrowing of the joint space due to modest degenerative changes, modest degenerative spurring involving the acetabular border and femoral head and neck junction with no fracture or dislocation. A physical therapy assessment dated [DATE] at 9:15 AM identified that nursing should provide assistance of two staff for transfers and ambulation for safety. Interview with the Physical Therapy Assistant (PTA) and review of the treatment log dated 06/17/10 on 01/05/10 at 3:00 PM identified that R#1 had been evaluated in the morning and then treated later in the afternoon, at which time, he/she exhibited a more steady gait and improved balance and, further, that R#1 had a history of [REDACTED]. A physician's orders [REDACTED]. Review of a facility investigation dated 06/18/10 at 8:00 AM identified that Nurse Aide (NA) #1 was providing morning care to R #1 in the bathroom when R #1 lost his/her balance. NA #1 grasped R #1 from behind to prevent a fall, and placed the resident on the toilet. R #1 hit his/her left forehead on the sink during the transfer and sustained a lump and abrasion above the left eyebrow. A nursing assessment included a neurological assessment with a sitting blood pressure of 98/60, pulse of 60, respiratory rate of 20, pupils that were equal, round, and reactive to light, no vertigo, no vomiting, equal and strong bilateral hand grasps, alert, with scant amount of bleeding from the abrasion and no complaints of blurred vision. R #1 had no complaints of pain and full range of motion in all extremities. A neurological assessment was completed every one half hour until 9:30 AM when R #1 stood up to ambulate, while attending a recreational activity, and was assisted by the recreation staff who observed the resident twitch and his/her knees start to buckle. R #1 did not respond to the staff or make eye contact. R #1 was assisted to sit in a chair and was immediately assessed by RN #1. The MD #3 was notified and directed to transfer R #1 to Acute Care Hospital #1 for an evaluation and treatment. Review of the nursing progress notes dated 06/18/10 identified that the facility was notified at 4:00 PM that R #1 had been admitted to Acute Care Hospital #1 with a [DIAGNOSES REDACTED]. Review of documentation of a second interview conducted by the Director of Nursing (DNS) with NA #1 on 06/21/10 identified that he/she had stood R #1 up to provide care, as R #1 held on to the towel bar, then, left the bathroom to get a shirt from the closet in the bedroom. NA #1 heard R #1 cry out, and turned to see the resident starting to fall, grasped R #1 from the back and transferred the resident to the toilet. A facility policy for Fall Risk identified that no resident was to be left unattended in the bathroom unless they had been assessed as being safe to do so. Observation of R#1's bathroom and review of NA #1's statement with the Director of Nursing (DNS) on 01/05/11 at 1:10 PM identified that the DNS had brought NA #1 to R #1's bathroom on 06/21/10 to demonstrate how the accident occurred and, at that time, NA #1 identified that he/she had left R #1 unattended, holding on to the towel rack, and went to get a shirt from the closet, four to five steps away. The DNS identified that NA #1's second version of the sequence of events did not seem consistent with the degree of injury sustained. Interview with NA #1 on 01/05/11 at 2:00 PM identified that he/she had walked the resident into the bathroom for AM care, as usual, had R #1 hold onto the towel bar and he/she left the bathroom and went to the closet briefly, to get a shirt. NA #1 heard NA #1 cry out and turned from the closet to see R #1 start to fall and observed the resident hit his/her forehead on the sink as he/she grabbed the resident's waist and slid/pushed R #1 to the toilet to prevent the resident from hitting the floor. The resident did not cry out or seem to be in pain. NA #1 immediately called RN #1, who completed the assessment with R #1 sitting on the toilet, and when the assessment was complete, walked the resident to the nursing station so he/she could be observed during breakfast. R #1 did not complain of pain during ambulation. Interview with MD #3 on 01/21/11 at 2:20 PM identified that R #1 was severely debilitated with a long history of steroid use for treatment of [REDACTED]. R #1 sustained an impacted femoral neck fracture with a varus deformity which would not be indicative of a spontaneous and/or pathological fracture even in a patient with osteoporosis. The fracture would require some type of trauma or torsion and the associated pain might not be readily identified by a patient with dementia, but would be exacerbated by ambulation. NA #1 failed to follow the facility policy for provision of adequate supervision of a resident identified as a high risk to fall which resulted in the resident sustaining a left femoral neck fracture. There will be a referral to the Practitioner's Unit for their action deemed necessary relative to NA # 1's failure to follow facility policy.