Every finding on record at Delmar Gardens of Lenexa

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan in consideration with R1 and his Durable Power of Attorney (DPOA). The facility failed to ensure R1 safely discharged , including notifying his DPOA that he discharged and providing her with post-discharge instructions for R1. Findings included:- R1 admitted to the facility on [DATE] and discharged home to live independently on 05/22/2026. R1's Electronic Medical Record (EMR) documented diagnoses of acute kidney failure (inability of the kidneys to excrete waste, concentrate urine, and conserve electrolytes), dementia (a progressive mental disorder characterized by failing memory and confusion), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R1's admission Minimum Data Set (MDS) dated 04/24/2026, documented he had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. R1 was dependent on staff for toileting hygiene, showering, dressing, and transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/30/2026, documented R1 had a BIMS score of nine, which indicated moderate cognitive impairment. R1 had a diagnosis of dementia and was able to make his needs known. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 04/30/2026, documented needed staff assistance with both mobility and completion of ADLs. R1 was non-ambulatory and required staff assistance with two staff for safe transferring using the Hoyer lift. R1's goal was to return home, but therapy recommended long-term care at that time. R1's 04/30/2026 Care Plan documented R1 had problems with temporal orientation and short-term memory due to a diagnosis of dementia. The plan documented the following interventions:04/30/2026- Staff always told R1 what they were going to do before they initiated care.04/30/2026- Staff anticipated R1's needs and helped with them, such as toileting, meals, and grooming.04/30/2026- R1 needed simple choices to allow him to make decisions with his care, such as clothes to wear, activities to attend, and food choices at meals.04/30/2026- R1 needed his call light within reach to call for assistance if he remembered.04/30/2026- Staff provided cueing and prompting for decisions and participation in his care as needed. R1's Care Plan did not address his ADL assistance requirements or his discharge goals and plan. R1's medical record revealed the following: A Nursing note on 04/21/2026 at 02:32 PM, documented R1 admitted around 01:40 PM via facility transportation and R1 required a Hoyer lift. A Nursing note on 05/04/2026 at 04:04 PM, documented R1 was non-compliant with care and he appeared less motivated to complete ADLs. The nurse updated R1's DPOA on lab results and new orders. R1's DPOA expressed concerns with how therapy was going and she was transferred to the therapy department for an update. R1's DPOA stated she would try to go to the facility the next week to see if R1 wanted to go on hospice or do more therapy and be compliant with cares. R1's medical record lacked documentation of discharge planning from 04/21/2026 to 05/07/2026. A Care Conference Report on 05/08/2026, documented the facility held an initial care plan meeting in the social services office. Social Services X, Administrative Nurse D, and Therapy GG present with R1's DPOA on the phone. R1 did not wish to be present for the care plan meeting. Therapy GG gave an update on R1's progress with therapy and stated R1 sometimes participated, but also asked therapy to come back later or stated he did not want therapy that day. R1 was not very motivated, would sometimes get up in his wheelchair, but preferred to stay in bed. R1 was unable to ambulate and required substantial/maximal assistance for mobility and ADLs. Therapy GG indicated that R1's cognition was a barrier. The interdisciplinary team (IDT) indicated to R1's DPOA that R1 may need a higher level of care upon discharge. Administrative Nurse D indicated R1 needed 24-hour care at that time. R1's DPOA stated R1 did not have Medicaid, and he would do what he wanted which was probably go back home. She asked how to get Medicaid for R1 and Social Services X indicated R1 needed to provide R1's DPOA with bank statements. R1's DPOA stated she had not been to visit R1 yet but planned to the following week to have the hard conversation with R1 regarding discharge and the Medicaid application. R1's DPOA stated R1 lived at home alone and handled his own bills. Social Services X asked R1's DPOA to give her a call once she spoke with R1 and let her know what the plan was, so Social Services X could send any referrals needed. R1's DPOA stated she would and indicated she felt overwhelmed because she was all R1 had, and she was busy with work. R1's DPOA stated she would talk to R1 and give Social Services X a call the following week. IDT indicated that it was a good plan, and they would reconvene once they had more information. R1's medical record lacked evidence of follow-up for R1's discharge plans from 05/09/2026 to 05/18/2026. A Social Services note on 05/19/2026 at 03:05 PM, documented the facility issued a Notice of Medicare Non-Coverage (NOMNC) with a last day of coverage date of 05/21/2026 and an anticipated discharge from skilled rehabilitation on 05/22/2026. The facility presented the NOMNC to R1 and he voiced an understanding of the coverage date, discharge date , and his right to appeal. R1 indicated he was not ready to return to his prior living environment because he could not walk. R1 requested the appeal contact to be written in large number so he could appeal. R1's medical record lacked evidence the facility attempted to call R1's DPOA related to his discharge plans from 05/09/2026 to 05/20/2026. A Social Services note on 05/21/2026 at 03:18 PM, documented Social Services X visited R1 to clarify his discharge plan. R1's DPOA had not spoken with IDT since the care plan meeting and she had not returned calls. R1 indicated he did not appeal the NOMNC and the facility never received a notice of appeal. Social Services X presented R1 with a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and R1 indicated he did not want skilled rehab services to continue as he did not have resources to continue skilled rehab services out-of-pocket. R1 stated he planned to discharge to his previous living environment and needed assistance with discharge transportation. R1 stated he was open to home health transitional services and he did not have a provider preference. The facility sent a referral to a home health service. R1's DPOA called and discussed R1's discharge plan with Social Services X. R1's DPOA requested referral packets be sent to LTC facilities. Social Services X compiled referral packet to be sent to appropriate facilities. R1's DPOA spoke with Administrative Staff A who clarified that R1 was not accepted for in-house long-term care. A Physical Therapy (PT) PT Discharge Summary dated 05/21/2026, documented R1 made improvement over the course of treatment but was limited, likely due to lack of R1's full participation in PT sessions. R1's bed mobility improved from total assistance to supervision and his transfers improved from total assistance to moderate assistance. R1 refused to participate in standing tolerance training or gait training. R1's insurance denied further skilled stay. R1 did not have a discharge plan in place at that time. Therapy documented a discharge home alone for R1 was not recommended. A Nursing note on 05/22/2026 at 10:30 AM, documented R1 discharged from the facility at 10:30 AM. The facility sent R1's personal belongings and his medications with him. On 06/11/2026 at 01:01 PM, R1's representative stated she was R1's DPOA and the facility had a care plan meeting a couple weeks prior to his discharge. She stated therapy discussed how R1 was not progressing and that he would need long-term care to which she agreed. R1's DPOA stated in the care plan meeting, she said she and R1 needed to apply for R1 to get Medicaid, and she asked the facility for referrals. She stated they did not get a discharge plan in place because the facility said she needed to get R1 on Medicaid before they would send referrals. R1's DPOA stated she visited R1 on 05/21/2026 and he was very upset because the facility told him had to leave because his insurance ran out. She stated she immediately went to the front desk to talk to Social Services X, but she was gone. She stated she talked to Administrative Staff A and told her she wanted referrals sent out to places that would accept him as Medicaid pending. She stated the facility did not contact her about the NOMNC and R1's right to appeal because she would have appealed it if she received the NOMNC. R1's DPOA stated after the care plan meeting, the facility never contacted her about further healthcare decisions except for new orders and results. She stated the facility did not start discharge planning with her and R1 when he admitted . She stated the facility discharged him to his former independent living apartment and left him there. The independent living contact called her and told her R1 was at his apartment, and it was not safe. She stated that was how she found out R1 had been discharged from the facility. R1's DPOA stated she called the facility and asked what they did with R1 when they had discussed sending referrals to nursing homes and the facility did not really have an answer as to why they discharged him in that way. She stated the facility never called her to tell her R1 was being discharged that day, nor did they go over any post-discharge instructions with her. On 06/08/2026 at 01:31 PM, Social Services X stated skilled resident discharge planning started on admission and the facility liked to have at least one care plan meeting before the resident discharged . She stated when she presented a resident with a NOMNC 48-hours prior to discharge from skilled and she met with the resident to talk to them about their discharge plan. She stated the resident's care plan documented whether the resident planned to stay in the facility or discharge. She stated when she presented R1 with the NOMNC, he was concerned about returning to his prior living environment and intended to appeal but did not end up appealing. Social Services X stated R1's DPOA indicated his prior living environment was not good and she wanted R1 to go somewhere else. She stated when the facility discussed what R1's options were with R1's DPOA, R1's DPOA had no knowledge about his resources and Social Services X requested she had a conversation with R1 about his resources and what he wanted to do. Social Services X stated she had not tried to call R1's DPOA when she issued the NOMNC to R1. On 06/08/2026 at 01:50 PM, Administrative Nurse D stated when a resident admitted , the facility tried to have a care conference within 48 to 72 hours depending on the situation and family. She stated the care plan had the resident's discharge plan and she tried to get the care plan in as soon as she completed the MDS and whenever something came up. On 06/08/2026 at 02:22 PM, Administrative Staff A stated the facility had a care plan meeting to assess and figure out the resident's goals and review the resident's progress with the family as they went along. She stated the facility tried to prepare the resident as much as possible before they had to issue a NOMNC. Administrative Staff A stated the facility went over the resident's discharge planning as much as they could in the care plan meeting. On 06/08/2026 at 02:29 PM, Administrative Nurse E stated that usually Social Services helped a resident with discharge planning and discharge planning started as soon as a resident admitted to the facility. She stated every resident had a care plan meeting to go over discharge goals and plans and if they felt safe going home. The facility's Discharge Planning Process policy, effective November 2017, directed a discharge plan was consistent with the discharge rights and included the following:1. The discharge needs of each resident were identified and resulted in the development of a discharge plan for each resident.2. The facility regularly re-evaluated residents to identify changes that required modification of the discharge plan and the facility updated the discharge plan as needed to reflect those changes.3. The facility involved the IDT in the ongoing process of developing the discharge plan.4. The facility considered the resident's caregiver/support person's availability and the resident or caregiver/support person's capacity and capability to perform required care, as part of the discharge needs.5. The facility involved the residents and their representatives in the development of the discharge plan and informed the residents and their representatives of the final plan.6. The facility addressed the resident's goals of care and treatment preferences.7. The facility documented that the resident had been asked about their interest in receiving information regarding their return to the community.

Based on record review and interviews, the facility failed to provide R1's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) with the Medicare Liability Notice, CMS 101123- Notice of Medicare Non-Coverage (NOMNC) prior to the last day of skilled coverage on 05/21/2026. Findings included:- R1 admitted to the facility on [DATE] and discharged home to his independent living apartment on 05/22/2026. R1's Electronic Medical Record (EMR) documented diagnoses of acute kidney failure (inability of the kidneys to excrete waste, concentrate urine, and conserve electrolytes), dementia (a progressive mental disorder characterized by failing memory and confusion), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R1's admission Minimum Data Set (MDS) dated 04/24/2026 documented he had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/30/2026 documented R1 had a BIMS score of nine, which indicated moderate cognitive impairment. R1 had a diagnosis of dementia and was able to make his needs known. R1's 04/30/2026 Care Plan documented R1 had problems with temporal orientation and short-term memory due to a diagnosis of dementia. The Care Plan documented the following interventions:04/30/2026- Staff always told R1 what they were going to do before they initiated care.04/30/2026- Staff anticipated R1's needs and helped with them, such as toileting, meals, and grooming.04/30/2026- R1 needed simple choices to allow him to make decisions with his care, such as clothes to wear, activities to attend, and food choices at meals.04/30/2026- R1 needed his call light within reach to call for assistance if he remembered.04/30/2026- Staff provided cueing and prompting for decisions and participation in his care as needed. R1's medical record revealed the following: A Nursing note on 04/21/2026 at 02:32 PM, documented R1 admitted around 01:40 PM via facility transportation and R1 required a Hoyer lift. R1's Notice of Medicare Non-Coverage documented his skilled services coverage would end on 05/21/2026. R1 and Social Services X signed and dated the notice on 05/19/2026. A Social Services note on 05/19/2026 at 03:05 PM, documented the facility issued a NOMNC with a last day of coverage date of 05/21/2026 and an anticipated discharge from skilled rehabilitation on 05/22/2026. The facility presented the NOMNC to R1 and he voiced an understanding of the coverage date, discharge date , and his right to appeal. R1 indicated he was not ready to return to his prior living environment because he could not walk. R1 requested the appeal contact to be written in large numbers so he could appeal. R1's medical record lacked evidence that the facility sent R1's DPOA the NOMNC or attempted to call R1's DPOA to discuss the NOMNC and R1's right to appeal. A Social Services note on 05/21/2026 at 03:18 PM, documented Social Services X visited R1 to clarify his discharge plan. R1's DPOA had not spoken with IDT since the care plan meeting and she had not returned calls. R1 indicated he did not appeal the NOMNC, and the facility never received a notice of appeal. Social Services X presented R1 with a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and R1 indicated he did not want skilled rehab services to continue as he did not have resources to continue skilled rehab services out-of-pocket. R1 stated he planned to discharge to his previous living environment and needed assistance with discharge transportation. R1 stated he was open to home health transitional services and he did not have a provider preference. The facility sent a referral to a home health service. R1's DPOA called and discussed R1's discharge plan with Social Services X. R1's DPOA requested referral packets be sent to LTC facilities. Social Services X compiled a referral packet to be sent to appropriate facilities. R1's DPOA spoke with Administrative Staff A, who clarified that R1 was not accepted for in-house long-term care. A Physical Therapy (PT) PT Discharge Summary dated 05/21/2026, documented R1 made improvement over the course of treatment but was limited, likely due to lack of R1's full participation in PT sessions. R1's bed mobility improved from total assistance to supervision, and his transfers improved from total assistance to moderate assistance. R1 refused to participate in standing tolerance training or gait training. R1's insurance denied further skilled stay. R1 did not have a discharge plan in place at that time. Therapy documented a discharge home alone for R1 was not recommended. A Nursing note on 05/22/2026 at 10:30 AM, documented R1 discharged from the facility at 10:30 AM. The facility sent R1's personal belongings and his medications with him. On 06/11/2026 at 01:01 PM, R1's representative stated she was R1's DPOA and the facility had a care plan meeting a couple weeks prior to his discharge. She stated therapy discussed how R1 was not progressing and that he would need long-term care, to which she agreed. R1's DPOA stated she visited R1 on 05/21/2026 and he was very upset because the facility told him had to leave because his insurance ran out. She stated she immediately went to the front desk to talk to Social Services X, but she was gone. She stated the facility did not contact her about the NOMNC and R1's right to appeal and she would have appealed it if she received the NOMNC. R1's DPOA stated after the care plan meeting, the facility never contacted her about further healthcare decisions except for new orders and results. On 06/08/2026 at 01:31 PM, Social Services X stated she presented a resident with a NOMNC 48-hours prior to discharge from skilled services, and she met with the resident to talk to them about their discharge plan. She stated if a resident had a DPOA in place, she contacted the DPOA. She stated when she presented R1 with the NOMNC, he was concerned about returning to his prior living environment and intended to appeal but did not end up appealing. Social Services X stated R1's DPOA was not present when she issued the NOMNC, and she did not try to call R1's DPOA when she issued the NOMNC to R1. She stated she presented R1 with the NOMNC because she could not get ahold of R1's DPOA previously. She confirmed there was no documentation that noted the facility could not get ahold of R1's DPOA prior to the note on 05/21/2026. Social Services X stated if a resident had a BIMS score lower than 12 then their DPOA should be contacted. On 06/08/2026 at 02:22 PM, Administrative Staff A stated the Social Services X delivered the NOMNC to the resident and their family. She stated it depended on the resident's cognition on who received the NOMNC but a lot of times the facility issued it to the resident unless they knew their DPOA was active. The facility did not provide a policy on beneficiary notice.

The facility reported a census of 162 residents, with 32 residents sampled. Based on observation, interview, and record review, the facility failed to ensure three of six medication carts observed were locked while unattended.This deficiency had the potential to affect 19 residents located on the 500 hallways and 29 residents located on the 600 hallways. Findings included:- On 03/16/2026 at 08:16 AM, an observation of an unlocked and unattended medication cart was in the 600 hallways for three minutes unattended; Licensed Nurse (LN) CC walked by and locked the medication cart and walked away. On 03/16/2026 at 08:53 AM, an observation of an unlocked unattended medication cart in the 600 hallways. At 08:55 AM, Certified Medication Aide (CMA) S returned to the unlocked medication cart checked on the computer and walked away from the unlocked medication cart and into a resident's room. CMA S returned to the unlocked medication cart two minutes later to prepare medications. On 03/16/26 at 11:37 AM, an observation of an unlocked and unattended medication cart in the 500 hallways for three minutes. LN L was in R96's room, the medication cart drawer was opened without LN L noticing.On 03/16/26 at 08:20 AM, LN CC 08:20 AM reported that the nurse medication cart stored the residents' insulins and treatment supplies, and LN CC reported the cart should always be locked when not in use or in eyesight. On 03/17/26 at 08:57 AM, CMA S reported the medication cart should always be locked when not in use. On 03/16/26 at 11:40 AM, LN L exited R96's room and reported that she should have locked the medication cart. On 03/17/26 at 01:38 PM, Administrative Nurse D reported that she expected the staff to always lock all the medication carts when not in use and unattended. The facility's policy Medication Administration dated January 2021 documented keeping the cart in visible range or locking all items prior to going into the resident's room.

The facility reported a census of 162 residents. Twenty-six medication administrations were observed. Based on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent when five errors were identified, resulting in a medication error rate of 19.23 percent. Finding included:- R47's Physician Orders recorded an order for ferrous sulfate tablet (an iron supplement), administer 325 milligrams (mg) tablet by gastric tube (G-tube: tube surgically placed through an artificial opening into the stomach), once a day for anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), date ordered 03/10/26 R47's Physician Orders recorded an order for sennosides-docusate (used to prevent occasional constipation).Administer 1 tablet: 8.6-50 mg by gastric tube, twice a day, the order lacked a diagnosis, date ordered 03/10/26.R47's Physician Orders recorded an order for tamsulosin capsule (used to relieve symptoms such as difficulty urinating, weak stream, and urgency). Administer 1 capsule 0.4 mg crushed by gastric tube, once a day for malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the bladder, date ordered 03/10/26.During an observation on 03/17/26 at 09:01 AM, Licensed Nurse (LN) I prepared R47's medications and reported that she was not going to administer the tamsulosin capsule as the order documented daily and the medications administration record documented daily, however, the tamsulosin medication card dated 03/02/26 documented to be administered at bedtime. LN I reported she would need to clarify the order before she administered the tamsulosin. During an observation on 03/17/26 at 09:12 AM, LN I crushed R47's ferrous sulfate 325 mg tablet and sennosides-docusate 8.6-50 mg and administered the medications via R47's gastric tube. - R134's Physician Orders recorded an order for docusate sodium (used to prevent occasional constipation) 100 milligrams (mg) capsule, administer 2 capsules by mouth, one time a day for constipation, date ordered 06/12/25. R134's Physician Orders recorded an order for trazodone (an antidepressant, a class of medications used to treat mood disorders), 50 mg tablet, administered 1 tablet twice a day for a psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), date ordered 10/25/25. An observation on 03/17/26 at 11:15 AM, LN G crushed R134's trazodone 50 mg tablet, and 2 docusate sodium 100 mg capsules, and administered the medications by mouth to R134 mixed in pudding. On 03/17/26 at 12:58 PM, LN I reported that she had not administered the tamsulosin at that time and reported she had to contact the provider for clarification. LN I reported that the pharmacy would be delivering the correctly labeled tamsulosin card soon for R47. LN I reported she was unsure if the ferrous sulfate tablet and the senna plus tab could not be crushed and reported there was no direction on the order to not crush the medications. On 03/17/26 at 01:38 PM, Administrative Nurse D reported that R47's medications were going to be changed to a different form as the ferrous sulfate and sennosides-docusate should not have been crushed. On 03/17/26 at 04:05 PM, Consultant Staff HH Pharmacist revealed completed a medication review on 03/10/26 when R47 was readmitted and followed the orders from the hospital. She reported she had not requested a change of medication form for the sennosides-docusate and ferrous sulfate tablets. Consultant Staff HH reported the sennosides-docusate and ferrous sulfate tablets should not have been crushed when administered. On 03/18/26 at 08:00 AM, Administrative Nurse D reported that R134's docusate sodium and trazodone tablets should not have been crushed. The facility's policy Medication Administration dated January 2021 documented do not crush medications when it was contraindicated on a caution label or in the Physicians' Desk Reference (PDR, now known as the Prescribers' Digital Reference, is a primary, authoritative resource for Food and Drug Administration -approved drug information, including dosage, side effects, and interactions).

The facility reported a census of 162 residents. The sample included 32 residents. Based on interview, observation and record review, the facility failed to protect the privacy of Resident (R) 10 and R96's personal and medical records. Findings included:- On 03/16/26 at 08:53 AM, observed an unattended medication cart in the 600 hallways. The computer screen was open with Personal Health Information (PHI) of R10's medication administration record displayed for four minutes. On 03/16/26 at 11:37 AM, observed a medication cart in 500 hallways unattended with PHI of R96, treatment orders displayed on the computer screen for over three minutes. On 03/16/26 at 08:57 AM, Certified Medication Aide (CMA) S reported that he should have closed the computer screen so no one could see R10's information. On 03/16/26 at 11:41 AM, Licensed Nurse (LN) L reported she should have closed the computer screen to maintain confidentiality of residents' medical information.On 03/17/26 at 01:38 PM, Administrative Nurse D expected that all resident information on the computer should be protected by closing the computer screen when the cart was unattended. The facility's undated Residents' Rights policy documented your right to privacy and confidentiality is as important to you as it is to any other person. You have the right of confidentiality for your personal and clinical records.

The facility had a census of 162 residents. The sample included 34 residents, with two reviewed for abuse. Based on observation, record review, and interview, the facility staff failed to identify a resident to resident altercation as potential abuse and report to the facility's Administrator as required. Findings included: - R62's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behaviors, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) major depressive disorder (major mood disorder that causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear.) R62's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R62 had severely impaired cognitive function. The MDS recorded R62 required extensive assistance with transfers, activities of daily living (ADL), and propelled in a wheelchair. The MDS documented the residents receiving Hospice services. The MDS documented that the resident had no behavior and received antianxiety (a class of medications that calm and relax people), antidepressants (a class of medications used to treat mood disorders), and hypnotics (a class of medications used to induce sleep). R62's Activities of Daily Living (ADL) Care Plan, dated 02/26/26, recorded R62 required staff assistance with most ADL care. R62's Care Plan documented she used her legs and feet to maneuver her wheelchair. R62's Behaviors Care Plan, dated 02/26/26, recorded she had behaviors that were disruptive to herself and others, and she would become combative and resist cares. The care plan documented R62 could be physically aggressive with other residents and staff.R62's care plan directed staff to attempt non pharmacological interventions before staff administered as needed medications to calm her, assess for pain, unmet needs, toileting needs, hunger, offer a snack, activity of interest, quite time, leave the resident for 5-10 minutes, offer a back rub, hug, hold her hand, or obtain a dip stick urinalysis if indicated. The care plan directed staff to administer medication as ordered and review her behavior at least quarterly and as needed by the care plan team. The Nurses Notes dated 09/04/25 at 02:26 PM documented R62 was involved in a resident-to-resident altercation. R62 was observed grabbing another resident's arm and covering her mouth. The Nurses Notes documented R62 required redirection and physical moving of hands. R62 was removed from the area and placed at the window with 1 on 1 interaction with the nurse to calm down. The note documented that staff would continue to monitor for safety due to the residents' poor safety awareness. The facility lacked an investigation related to the event and was unable to provide evidence the incident was reported to the SA. On 03/17/26 at 08:25 AM, hospice aide pushed R62 from her room to the dining room in a wheelchair, dressed in street clothes. Staff served R62 her breakfast and she was able to eat independently. On 03/17/26 at 02:45 PM, Administrative Staff B stated the nurse's notes on 09/04/25 at 02:26 PM documented R62 was in an altercation with R134. After an interview with the nurse involved Administrative Staff B stated the nurse was a new nurse, and it was her first day on the job, and she documented what the trainer nurse told her however, it was not documented correctly. Administrative Staff B verified the nurse told her after interview on 03/17/26, it should have been documented R62 grabbed R134's sweater, and she was unsure what the nurse meant when she documented the resident covered her mouth. Administrative Staff B stated they were going to have the nurse put in an additional progress note stating R134's arm was not grabbed, and documented R62 grabbed R134's sweater. Administrative Staff B verified they did not have a witness statement from the nurse who wrote the note, but they would obtain one today. Administrative Nurse B verified they would have the nurse put in a note today, a late entry describing the incident that was described to the administrative staff when the nurse was interviewed today. Administrative Staff B verified it was the facility policy to have staff report an incident of this nature immediately and the facility would investigate and determine what further action would need to be taken. On 03/18/26 at 08:05 AM, Administrative Nurse D stated the nurse who documented the entry was a brand new nurse and had a staff nurse who trained her that day, and the new nurse apparently did not document the incident correctly so the staff nurse did not feel it was abuse and felt she did not have to report the incident to administration. Administrative Nurse D verified an incident of abuse should be reported immediately to the administration and they would investigate, gather witness statements and report to the State agency as indicated. The facility's Abuse, Neglect, and Exploitation policy, dated September 2022, documented the facility maintains a work and living environment that is professional, and residents are free from threat or occurrence of harassment, abuse to include verbal, physical, mental or sexual, neglect corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. The policy documented to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including the State Survey Agency, within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. The policy documented each individual shall report allegations or suspicions of abuse, neglect, or exploitation to the Administrator or supervisor. The Administrator, or designee, shall report to the State agency and one or more law enforcement entities for the political subdivision in which the facility is located, and reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Each individual shall report immediately, but not later than two hours after forming the suspicion, if the events that caused the suspicion result in serious bodily injury, or not, later than 24 hours if the events that caused the suspicion do not result in serious bodily injury. The policy documented the Administrator or designee on duty would assess the resident, including the size and location of any injury, and assure proper documentation of the date, time, and location of the reported or suspected incident. An incident report would be completed, and the physician and family would be notified as soon as possible. The Administrator or Director of Nursing is responsible for notifying the Regional Nursing Supervisor to report alleged violations of the resident safety policy to ensure prompt investigation and corrective actions are in place. The Administrator or designee would interview the residents as well as any nursing, housekeeping, laundry, dietary, social service staff, any visitors, volunteers or others who may have knowledge of the occurrence or who may have been in the vicinity at the time of the incident. The Administrator or designee on duty would prepare a written summary of each interview.

The facility had a census of 162 residents. The sample included 34 residents, with two reviewed for abuse. Based on observation, record review, and interview, the facility failed to identify a resident to resident altercation as potential abuse and initiate an investigation. Findings included:- R62's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behaviors, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) major depressive disorder (major mood disorder that causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear.) R62's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R62 had severely impaired cognitive function. The MDS recorded R62 required extensive assistance with transfers, activities of daily living (ADL), and propelled in a wheelchair. The MDS documented the residents receiving Hospice services. The MDS documented that the resident had no behavior and received antianxiety (a class of medications that calm and relax people), antidepressants (a class of medications used to treat mood disorders), and hypnotic (a class of medications used to induce sleep). R62's Activities of Daily Living (ADL) Care Plan, dated 02/26/26, recorded R62 required staff assistance with most ADL care. R62's Care Plan documented R62 used her legs and feet to maneuver her wheelchair. R62's Behaviors Care Plan, dated 02/26/26, recorded R62 had behaviors that were disruptive to herself and others, and she would become combative and resist cares. The care plan documented R62 could be physically aggressive with other residents and staff.R62's care plan directed staff to attempt non pharmacological interventions before staff administered as needed medications to calm her, assess for pain, unmet needs, toileting needs, hunger, offer a snack, activity of interest, quite time, leave the resident for 5-10 minutes, offer a back rub, hug, hold her hand, or obtain a dip stick urinalysis if indicated. The care plan directed staff to administer medication as ordered and review her behavior at least quarterly and as needed by the care plan team. The Nurses Notes dated 09/04/25 at 02:26 PM documented R62 was involved in a resident-to-resident altercation. R62 was observed grabbing another resident's arm and covering her mouth. Th Nurses Notes documented R62 required redirection and physical moving of hands. R62 was removed from the area and placed at the window with 1 on 1 interaction with the nurse to calm down. The note documented that staff would continue to monitor for safety due to the residents' poor safety awareness. The facility was unable to provide evidence a thorough investigation was conducted related to the resident to resident altercation. On 03/17/26 at 08:25 AM, hospice aide pushed R62 from her room to the dining room in a wheelchair, dressed in street clothes. Staff served R62 her breakfast and she was able to eat independently. On 03/17/26 at 02:45 PM, Administrative Staff B stated the nurse's notes on 09/04/25 at 02:26 PM documented R62 was in an altercation with R134 after interview with the nurse involved stated the nurse was a new nurse, and it was her first day on the job and she documented what the Trainer nurse told her however, it was not documented correctly. Administrative Staff B verified the nurse told her after interview on 03/17/26 it should have been documented R62 grabbed R134's sweater, and she was unsure what the nurse meant when she documented the resident covered her mouth. Administrative Staff B stated they were going to have the nurse put in an additional progress note stating R134's arm was not grabbed, and documented R62 grabbed R134's sweater. Administrative Staff B verified they did not have a witness statement from the nurse who wrote the note, but they would obtain one today. Administrative Nurse B verified they would have the nurse put in a note today, late entry describing the incident that was described to the administrative staff when the nurse was interviewed today. Administrative Staff B verified it was the facility policy to have staff report an incident of this nature immediately and the facility would investigate and determine what further action would need to be taken. On 03/18/26 at 08:05 AM, Administrative Nurse D stated the nurse that documented the entry was a brand new nurse and had a staff nurse that trained her that day, and the new nurse apparently did not document the incident correctly and so the staff nurse did not feel it was abuse and felt she did not have to report the incident to administration. Administrative Nurse D verified an incident of abuse should be reported immediately to the administration and they would investigate, gather witness statements and report to the State agency as indicated. The facility's Abuse, Neglect, and Exploitation policy, dated September 2022, documented the facility maintains a work and living environment that is professional, and residents are free from threat or occurrence of harassment, abuse to include verbal, physical, mental or sexual, neglect corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends or other individuals. The policy documented to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including the State Survey Agency, within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. The policy documented each individual shall report allegations or suspicions of abuse, neglect, or exploitation to the Administrator or supervisor. The Administrator, or designee, shall report to the State agency and one or more law enforcement entities for the political subdivision in which the facility is located, and reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Each individual shall report immediately, but not later than two hours after forming the suspicion, if the events that caused the suspicion result in serious bodily injury, or not, later than 24 hours if the events that caused the suspicion do not result in serious bodily injury. The policy documented the Administrator or designee on duty would assess the resident, including the size and location of any injury, and assure proper documentation of the date, time, and location of the reported or suspected incident. An incident report would be completed, and the physician and family would be notified as soon as possible. The Administrator or Director of Nursing is responsible for notifying the Regional Nursing Supervisor to report alleged violations of the resident safety policy to ensure prompt investigation and corrective actions are in place. The Administrator or designee would interview the residents as well as any nursing, housekeeping, laundry, dietary, social service staff, any visitors, volunteers, or others who may have knowledge of the occurrence or who may have been in the vicinity at the time of the incident. The Administrator or designee on duty would prepare a written summary of each interview.

The facility reported a census of 162 residents; the sample included 32 residents with one resident reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 47s head of bed was elevated as his enteral feed formula was administered through R47's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) by a feeding pump. Additionally, the facility failed to administer R47's enteral feed by the physician's order. Findings included: - R47's Electronic Medical Record (EMR) documented diagnoses which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and dysphagia (swallowing difficulty). R47's Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R47's MDS documented he required total assistance with all activities of daily living. R47's Nutritional Status Care Area Assessment (CAA) dated 02/20/26, documented that R47 had a significant change had occurred and R47 had elected to receive hospice services. The CAA triggered due to R47's body mass index (BMI is a measure of body fat based on height and weight that applies to adult men and women), which was below the recommended range for his age and gender. R47 received a pureed diet due to his dysphagia. R47's Care Plan dated 03/11/26 revealed staff instructed to keep the head of bed elevated to prevent aspiration (inhaling liquid or food into the lungs).R47's Care Plan dated 03/11/26 revealed staff instructed to look in treatment administration record for current feedings and flush orders, as these would change frequently. R47's Physician Orders dated 03/09/26 revealed enteral feeding, elevate the head of bed 30 degrees continuously. R47's Physician Orders dated 03/16/26 revealed enteral feeding formula Glucerna 1.5 flow rate 50 milliliters (ml) per hour every shift.R47's Physician Orders dated 03/16/26 revealed stop tube feeding for two hours daily for gut rest from 04:30 AM to 06:30 am once a day. R47's Physician History and Physical Note dated 03/11/26 revealed R47 was admitted to the hospital with urinary tract infection, acute kidney injury, and hyponatremia. R47 was treated for all the above problems in Additionally, placement of a G-tube with the tube feeding.R47's readmission Nutrition assessment dated [DATE] at 12:39 PM revealed R47 was readmitted to the community on hospice and had peg placement. Recommended product change to Glucerna 1.5 in an effort to promote weight gain as well as provide gut rest for two hours per day. Recommended to keep rate of Glucerna 1.5 at 50ml/hour for 22 hours per day (off from 4:30 am-6:30 am), which may also allow R47 to be hungry for breakfast. Continue with 150ml water flush q 4hrs. On 03/16/2026 at 11:51 AM, observation of R47 laid in his bed that was flat. R47 had an enteral feeding running via a feeding pump at 50ml/hour. The enteral feeding bag was labeled 03/16/26 at 04:00 AM, 50ml/hour and 150 ml/hour of water every four hours. The label lacked what type of enteral feed was in the bag. On 03/17/2026 07:35 AM, observed R47 was in his bed, eyes closed. The head of bed was elevated to 30 degrees. The enteral feeding pump was not on, and the enteral feeding tubing was not connected to R47's G-tube. The enteral feeding bag was labeled dated 03/17/26 at 03:30 AM, Glucerna 1.5 rate of 50ml/hr, and 150 ml of water every four hours. On 03/17/2026 at 08:19 AM, observed R47 was awake in bed he laid on his back with head of bed elevated at 3 degrees, the tube feeding remained off and not connected to R47. On 03/17/26 at 09:45 AM observed Licensed Nurse (LN) I turned R47's feeding pump on after she completed medications. LN I connected R47's G-tube to the enteral feeding line. When the feeding pump was turned on the screen displayed R47 had 48 ml of enteral feed infused and 39 ml of water infused after the feeding was changed at 03:30 AM 03/17/26. LN I positioned R47 on his left side in bed, lowered his bed and R47's head of bed remained elevated at 30 degrees. On 03/17/2026 at 10:34 AM, observed R47 laid on his right side in bed, his eyes were closed, and the head of his bed was elevated at 10 degrees. R47's enteral feeding was on and running at 50 ml/hour. On 03/16/2026 at 12:09 PM, LN J entered R47's room and Certified Nurse Aide (CNA) MM was in R47's room washing his hands. CNA MM reported he had not provided care for R47 he reported he was just in the room to wash his hands and walked out. LN J did not notice that R47's bed was flat until she was asked if R47's enteral feeding was running. LN J reported that R47's head of bed should be elevated and was unsure of how high the head of bed should be elevated, as she asked how it should be. LN J then elevated R47's head of bed to 30 degrees and reported she would let R47's nurse be aware. On 03/16/26 at 12:15 PM, CNA P reported that he had taken care of R47 around 11:00 AM today and thought he had elevated the head of bed to 30 degrees and then reported that CNA MM was also assigned to R47's hallway, so maybe he did it. On 03/17/2026 at 10:36 AM, CNA M reported she had repositioned R47 a few minutes ago. CNA M reported R47's head of bed should be elevated to 180 degrees. CNA M reported she thought she raised R47's head of bed. CNA M reported R47 would not be able to lower the head of bed as the controller was not in reach. On 03/17/26 at 12:58 PM, LN I reported R47s tube feeding had not been turned back on until 09:45 AM after medication administered. LN I reported the night nurse reported to her during AM report that R47's feeding tube was shut off late this morning. LN I reported she was unsure what time the tube feeding was shut off as she did not write that information down on her report sheet. LN I reported she believed that the night nurse told her at 05:00 AM. LN I reviewed R47's enteral feeding orders and reported could not locate an order for the tube feeding to be stopped at 04:30 AM for two hours and start the tube feeding at 06:30 AM. LN I reviewed the Consultant Staff GG Registered Dietician's documented note in EMR from 03/16/25. LN I reported she would not receive the Consultant Staff GG recommendations. LN I reported that R47s head of bed should be always elevated at least 30 to 45 degrees. On 03/17/26 at 01:10 PM, Consultant Staff GG reported that she made the recommendation on 03/16/26 to shut off the R47's enteral feed for two hours in the morning and she delivered the recommendations to interdisciplinary team members on 03/16/26. Consultant Staff GG reported that Administrative Nurse F or Certified Medication Aide (CMA) E who completed medical records would receive the orders from the provider and place the order in the EMR. Consultant Staff GG reviewed R47's orders in EMR and confirmed R47 had the order placed 03/16/26 to shut off the enteral feeding for two hours from 04:30 AM to 06:30 AM every day. Consultant Staff GG reported she expected the LNs to follow the providers' orders. On 03/17/2026 at 01:38 PM, Administrative Nurse D reported that she expected the staff to keep R47's head of bed always elevated when the tube feeding was running. Administrative Nurse D reported she expected the LNs to follow the physician orders for his enteral feed. The facility's policy Gastrostomy Tube Care dated 06/2021 lacked documentation of the head of bed elevated for enteral feedings. The facility's policy Physician Orders, Following dated 06/2021 documented it was the policy of the community to ensure that all Licensed Professional Nurses (RN/LPN /LVN) and other Healthcare Professionals follow Physician Orders in accordance with State, Federal regulations, and their respective practice acts.

The facility identified a census of 132 residents. The sample included 32 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9s as needed diphenhydramine (an antihistamine used to treat allergy symptoms, hay fever, the common cold, insomnia, and motion sickness) medication order had a diagnosis or reason to administer medication. Findings included: - The Electronic Medical Record (EMR) for R9 documented a diagnosis of insomnia (inability to sleep) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R9's Annual Minimum Data Set (MDS) dated 01/11/26 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R9's MDS revealed she had no skin issues, and she was independent with her activities of daily living.R9's Psychotropic Drug Use Care Area Assessment (CAA) documented that R9 triggered CAA due to being prescribed psychotropic medications for anxiety that may increase the risk of adverse consequences. R9 would be closely monitored. R9's Care Plan, 03/16/26, lacked documentation for diphenhydramine. R9's 11/12/25 Physician Orders documented diphenhydramine, give 50 milligrams (mg), by mouth three times a day as needed. The order lacked a reason/diagnosis. R9's EMR reviewed from 11/12/25 through 03/17/26; the EMR lacked documentation of the diphenhydramine order in progress notes, provider notes, dermatology notes, pharmacy notes, and psych notes. On 03/16/26 at 11:30 AM, R9 was up in her room putting her sandals on. R9 reported she does not know all of her medications. On 03/17/2026 at 07:43 AM, R9 was in her bed with her eyes closed. On 03/18/2026 at 08:45 AM, R9 ambulated independently with a walker at the front of the facility. She reported she was going out with activities. She reported that if she needed any medication, she would let the nurse know, and reported she had a lot to choose from. On 03/17/26 at 04:05 PM, Consultant Staff GG Pharmacist reviewed R9's EMR and reported that R9 did not have a reason or diagnosis for her as needed diphenhydramine order. Consultant Staff GG reported she missed that on her last medication review. Consultant Staff GG reported all medications are required to have a diagnosis code and or reason. On 03/18/26 at 07:42 AM, Certified Medication Aide (CMA) S reported all as needed medications need to have a reason to give the medications. CMA S reported the nurse instructed the CMAs when to administer an as needed medication to a resident. On 03/18/26 at 07:58 AM, Licensed Nurse (LN) K reported that all medications required a diagnosis or a reason why a medication was ordered. On 03/18/2026 at 12:18 PM, Administrative Nurse D reported that R9's diphenhydramine order since 11/12/25 should have had a reason why the medication was needed. Administrative Nurse D reported that all medications required a diagnosis and reason. The facility did not provide a policy on as needed medications orders.

The facility identified a census of 162 residents. The sample included three residents reviewed for beneficiary notifications. Based on interviews and record review, the facility failed to use the appropriate Advance Beneficiary Notice of Non-Coverage (ABN) Form CMS-10055 for resident (R) 194.Findings included:-The facility provided documentation noted R195's Medicare Part A last covered day was 10/31/25. The resident remained in the facility. Form CMS-20052 (11/2017) was provided instead of Form CMS-10055. During an interview with Administrative Staff A on 03/18/26 at 09:46 AM, she stated the correct ABN form was not provided for R195. During an interview on 03/18/26 at 09:52 AM with Social Services X stated ABN Form CMS-10055 was not provided to R195. The undated Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055 (2024) policy was provided.

The facility reported a census of 162 residents. The sample included 32 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 3 with a coccyx (distal tip of the spine/tail-bone) wound and while providing direct care to R 120 and R 101 with open and scabbed wounds. Additionally, the facility failed to ensure adequate hand hygiene before and after personal care for R 3, and while passing ice between residents. Furthermore, the facility failed to sanitize the mechanical lift between residents' use and maintain R6's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) tubing laid directly on the floor.Findings included:- On 03/16/26 at 09:40. Certified Nurse Aide (CNA) H brought a sit-to-stand/mechanical lift from one room directly to room [ROOM NUMBER] without sanitizing the lift prior to using the mechanical lift to transfer R6, with an indwelling catheter. On 03/17/2026 at 09:48 AM, observed R6 sat on the edge of his bed with his clothes off, his indwelling urine collection drainage bag laid directly on the floor. CNA P entered R6's room, sanitized their hands and applied gloves. CNA O and CNA P failed to apply a gown when providing direct care to R 6 with Enhanced Barrier Precautions (EBP) as required with a resident with an indwelling catheter to prevent the spread of infection and cross contamination. CNA O and CNA P assisted R6 to the restroom with the unsantized sit to stand lift. R6's catheter bag was placed under the wheelchair (w/c) by CNAs O and P upon his transfer from the bed to the W/C. The resident's urine drainage collection bag and tubing dragging directly on the floor when the resident rolled to the restroom. CNA O and CNA P transferred the resident to the toilet with the unsanitized sit to stand lift. CNA P removed his gloves and failed to sanitize his hands before exiting R 6's room. On 03/16/26 at 09:51 AM, CNA stated he should have worn a gown while providing direct high contact care to a resident with EBP. He confirmed the signage on the resident's door indicated the resident with EBP and indicated Personal Protective Equipment (PPE), including gloves, gowns, and hand sanitizing due to his catheter. On 03/16/26 at 09:54 AM, CNA O should have worn a gown, gloves, and sanitized their hands. Before applying gloves and after removal of gloves. Both CNAs state they usually wipe down the sit to stand mechanical lift, but they were in a hurry to get residents up for breakfast. On 03/17/2026 at 07:48 AM, CNA M passed ice out to the residents in hallway 500. He left the ice scoop in the ice cooler and failed to close the lid to the cooler, which he left unattended when he entered the resident's rooms. On 03/17/2026 at 07:50 AM, CNA M closed the lid While the another CNA N went to two resident's rooms down the hallway and brought two drinking cups out and filled the cups and let the ice scoop in the cooler and the lid open while leaving the left the scoop in the ice left the lid open and took two cups back to the resident's room and returned to the ice cooler any proceeded down the hall retrieved two more cups from the resident room and returned to the ice cooler and filled drinking cups and return them to the residents room. She came out quickly and without sanitizing her hands throughout the ice water pass in 500 halls. On 03/17/2026 at 07:52 AM, CNA M closed the ice cooler again and reported that the scoop should not be left in the ice as there is a holder, and the ice cooler should remain closed. 03/17/2026 7:53 AM, CNA N reported on inquiry, she normally closes the lid and keeps the scoop out of the ice and in the holder, and confirmed she did not wash her hands in-between residents' cups as she should to prevent cross contamination and the spread of infection. On 3/17/2026 at 09:10 AM, Licensed Nurse (LN) I reported that the ice coolers should be closed when not is use and the ice scoop should not be left in the ice cooler but placed in the holder. LN I reported that the staff should wash their hands in between residents. 03/17/2026 at 10:22 AM, Resident 3 was lying on his bed. Observed door signage on his door indicating the resident required EBP, which included PPE of gowns, gloves, and hand hygiene when providing direct care to the resident. The PPE setup was present for staff accessibility to the required PPE. Upon inquiry, the resident stated he did not know why he was on EBP and did not know what that meant. He did not have an indwelling device such as a catheter, no obvious signs of wound concerns, or what that meant. He was well groomed, raised his arms on verbal cues, and stated sometimes he itches under his elbow; no redness or skin integrity issues noted. On 03/17/2026 at 10:25 AM, CNA Q entered R 3's room, sanitized and put on gloves and gown. He provided incontinence care to the resident and placed the sling for the mechanical lift under the resident. CNA Q removed his gloves and gown after positioning the sling, removed his gloves, and sanitized his hands between dirty and clean during incontinence care and positioning the sling. He left the room and stated he needed help to transfer the resident. On 03/17/2026 at 10:33 AM, CNA, MM returned to resident's room accompanied by CNA Q to help with mechanical lift transfer. Neither CNAs applied gowns during transfer for resident's transfers. On 03/17/2026 at 10:43 AM, CNA Q verified resident required EBP, which included PPE of gowns when giving direct care. Stated understanding of EHBP was to wear a gown when providing direct care, such as incontinent care, but since he provided incontinent care earlier, he wore a gown, but he was not sure why, and that EBP precautions were initiated due to that. On 03/17/26 at 01:34 PM, Administrative Nurse E reported she expected the staff to wear the PPE for residents that have EBP, have indwelling catheter urine collection bags always covered and off the floor. Staff should wash their hands when they remove their gloves before applying new gloves. On 03/18/2026 at 08:38 AM, Administrative Nurse E reported that she expected the staff to close the ice cooler when not in use, and she expected the staff to place the scoop in holder and perform hand hygiene between residents and only do one cup at a time. 03/16/2026 3:30 PM, observed R120 with blood spots over his white T-shirt on arms and open areas on skin on bilateral arms and legs. Resident with rash red raised over the body, the areas on his arms and legs with some scabbing present. The resident was scratching his arms and legs, blood was noted on his leg coverings no bandages were present. Visible open areas on his legs, some wounds with scabs. On inquiry, he said the areas itch, but he does not like the cream they put all over him, he would just like something on the open areas and something for the itching. R201 reported the areas were an issue for a couple of months. Additionally, he raised his white T-shirt to reveal a red raised rash covering his chest and torso and across his shoulders. The residents' door lacked signage for EBP to include specific PPE use due to wounds, set up for PPE was not present for staff accessibility. On 03/17/2026 at 11:18 AM, R120 was in bed, with bright red blood noted on his pillowcases and bedding. His socks were crumpled below his mid leg with red staining throughout. Open areas were pronounced on his arms and legs. Review of the resident's electronic medical record Skin Condition Report lacked a detailed assessment of the resident's skin, open areas, and rash as follows: On 03/17/2026 at 12:16 PM, LN MM, Administrative Nurse E, and LN J conducted a skin assessment for R120, revealing the resident with 13 wounds which included:Left upper arm 0.5centimeters (cm) x 0.8 cm by Unable to determine (UTD)due 100% scabbedLeft forearm 0.6 cm by 0.5 cm by 0.1 cm, open area, no scabbing present, red wound bed with blood presentLeft lateral arm 0.3 cm by 0.3 cm by 0.1 cm, no scabbing present, red wound bed with blood presentLeft Wrist 0.1cm by 0.5 cm by 0.1cm, open area with bright red wound bed, blood presentLeft medial wrist 1.0 cm by 0.5 cm by 1 red wound bed with blood present, 100% scabbedLeft wrist superior 0.5 cm by 0.7 cm by 0.1UTD scabbed raised arealeft hand 0.5 cm by 0.5cm by UTD due to fully scabbed On 03/17/2026 at 12:16 PM, LN MM, Administrative Nurse E, and LN J confirmed the above findings, stated the open wounds had bled on the president's personal clothing and linen. He used his w/c to move around his room, and he refused personal care on occasion. Staff changed his linen and clothing, which were blood stained. The housekeeping staff clean his room. Open wounds should indicate the resident should have enhanced barrier precautions to include signage, PPE set up and use of gloves, gowns and hand hygiene when giving care. Staff verified EBP had not been implemented for this resident. Additionally, dressing should be applied to open areas with bleeding to prevent cross contamination and the potential for the spread of infection. The facility policy titled Infection Prevention and Control Surveillance, dated 02/25/26, documented all skin lesions must be covered, and dressing must be dry. The facility will require staff to perform hand hygiene when necessary. The facility will provide infection prevention and control training regarding hand hygiene, standard precautions, proper cleaning and disinfecting of equipment, and other infection prevention and control topics as determined by program needs.

The facility had a census of 162 residents. The sample included 32 residents with one resident reviewed for accommodation of needs related to call lights. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 98 call light was within her reach.Findings Included: - R98's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (elevated blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R98 was dependent on staff for all activities of daily living (ADLs).The Falls Care Area Assessment (CAA) dated 08/20/25 documented the fall CAA triggered related to R98 had one minor-injury fall during the lookback period. The CAA documented fall precautions were in place, and R98 was closely monitored.R98's Care Plan documented the following:12/27/22 Keep R98's call light within her reach and answer promptly.08/15/25 R98 had a minor injury witnessed fall, R98 was being wheeled in a wheelchair without foot pedals and put her feet down. R98 was to have foot pedals on wheelchair.09/07/25 R98 had a fall with injury, intervention was R98 was not left alone in her wheelchair chair while awake.05/19/26 R98 was at risk for falls due to a history of falls from poor safety awareness and impulsiveness.On 03/17/26 at 02:01 PM, R98 laid in her bed on her back with her eyes open and covered with her blankets. R98 was yelling out. R98's call light laid behind the headboard of her bed. R98's call light was not within her reach.On 03/17/26 at 02:05 PM, Certified Medication Aid (CMA) R stated residents should always have their call light within their reach. CMA R reached behind R98's bed and placed R98's pancake light on her abdomen.On 03/18/26, Licensed Nurse (LN)H at 08:14 AM stated residents should have their call lights next to them, or anywhere the resident could reach the call light.On 03/18/26 at 09:58 AM, Administrative Nurse D stated all residents should have their call lights where the call light was reachable by the resident.The facility's Call Light Answering policy dated 06/21 documented staff to go to the resident as soon as he/she calls. Staff were to answer call light within 15 minutes. Emergency lights should be responded to immediately to prevent injury. Check to see that the call light was within the resident's reach.

The facility had a census of 151 residents. The sample included 31 residents. The facility had six medication carts. Based on observation, interview, and record review, the facility failed to date Resident (R)53's insulin (a hormone which allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R15 and R346's insulin flex pen and R01's insulin vial when outdated. The facility further failed to discard expired stock medications. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:15 AM, observation of the facility's 500 Nurse medication cart revealed the following: R53's Lantus (long-acting insulin) flex pen lacked an open date and discard date. R15 s Lantus flex pen opened date of [DATE] and discard date of [DATE]. On [DATE] at 08:20 AM, observation of the facility's 600 Nurse medication cart revealed the following: R346's Levemir (long-acting insulin) flex pen lacked an open and discard date. R01's Lantus vial had an opened date of [DATE], and a discard date of [DATE]. On [DATE] at 08:25 AM, observation of the facility's 600 medication cart revealed the following: [NAME]-Tussin DM (cold and cough medication) 16 fluid ounces expired [DATE]. On [DATE] at 10:30 AM, Administrative Nurse E verified the nurses were to date the insulin when opened and discard the outdated insulin, Administrative Nurse E said staff were to discard expired stock medications. Medlineplus.gov directs open, unrefrigerated Levemir vials and pens that can be used within 42 days, but after that time they must be discarded. Unrefrigerated vials or pens of Lantus can be used within 28 days but after that time they must be discarded. The facility's Insulin Administration policy dated [DATE], documented the staff would administer insulin via pen device according to the physician's orders and the facility's policy and procedures. Insulin pens should be clearly labeled with the person's name. The label on the pen and make sure it is the correct ordered insulin for the resident, check the expiration date, if the pen is being used for the first time, date the on the label. Refer to the chart for pen expiration dates. Verify the insulin is being given at the correct time in relation to meals. The facility's Storage of Drugs policy, dated [DATE], documented the facility would store in the original container in which they were received. The refrigerator, freezer, and control room would be available in the pharmacy medications requiring specific storage. No discontinued, outdated, or deteriorated drugs or medications are stored in the facility over thirty (30) days. The facility failed to date R53's flex pen insulin with the date opened and discard date, and failed to discard R01's, R15's, and R346's outdated insulin vial. The facility also failed to discard expired stock medications placing the residents at risk for ineffective medication.

The facility had a census of 151 residents. The sample included 31 residents with one reviewed for dignity. Based on observation, record review, and interview the facility failed to treat Resident (R) 115 with dignity in one of five dining rooms, during the noon meal when staff stood over R115 while assisting him to eat. This placed the resident at risk for an undignified experience. Findings included: - On 03/25/24 at 11:39 AM, observation in the 300-hall dining room revealed Certified Nurse Aide (CNA) M served R115 a plate of food. CNA M stood over R115 and gave the resident bites of food. CNA M left the table several times during the noon meal to do other tasks and then returned to R115's table, stood over him, and gave him bites of food. On 03/25/24 at 12:05 PM, Certified Dietary Manager (CDM) BB stated staff should sit in a chair next to R115 when assisting him with eating, not stand over him. On 03/26/24 at 04:30 PM, Administrative Nurse D stated she expected staff to sit by the resident face to face when assisting the resident to eat. Administrative Nurse D stated staff should try to converse with the resident and that staff should not leave the table to go do other tasks until the resident was finished eating. The facility's Resident Rights Policy, undated, documented the right to be treated with dignity and respect was the foundation on which all other resident rights and responsibilities were based. The facility failed to treat R115 with dignity when staff stood over him at the 300-hall dining room table during assisted dining. This placed the resident at risk for an undignified experience.

The facility had a census of 151 residents. The sample included 31 residents with four reviewed for hospitalization . Based on observation, record review, and interview, the facility failed to provide written notice for facility-initiated transfer to Resident (R) 68, R347, and R75 or their representatives, when they were transferred to the hospital. This placed the residents at risk for uninformed care choices. Findings included: - R68's Electronic Medical Record (EMR) documented R68 had a diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) R68's Admission Minimum Data Set (MDS), dated [DATE], documented R68 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required substantial to maximal staff assistance with toileting and personal hygiene. The Urinary Incontinence Care Area Assessment (CAA), dated 10/18/23, documented R68 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and instructed staff to monitor R68 for urinary tract infections (UTI-an infection in any part of the urinary system). R68's Care Plan, revised 10/18/23, documented R68 had an indwelling catheter and instructed staff to provide catheter care as needed (PRN) and encourage R68 to drink fluids to reduce UTI risks. The Progress Note, dated 03/04/2024 at 05:10 PM, documented R68 was admitted to the hospital. A review of R68's clinical record lacked evidence the resident or representative was provided written notice when he was transferred to the hospital. On 03/25/24 at 04:22 PM, observation revealed R68 sat quietly in a wheelchair in his room. His indwelling foley catheter was in a privacy bag hooked on the wheelchair and the urine in the tubing had clear yellow urine. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R68 or his representative was provided written notice when the resident was transferred to the hospital. Administrative Staff B stated nursing was responsible for sending the bed hold policy with transfer papers to the hospital and she did not follow up on obtaining the signed notice. On 03/26/24 at 10:45 AM, Administrative Nurse D stated verified the facility lacked documentation R68, or their representative was provided a written notice when the resident was transferred to the hospital. Upon request, the facility failed to provide a policy regarding facility-initiated transfers to the hospital. The facility failed to provide R68 or his representative written notice regarding R68's facility-initiated transfer to the hospital. This placed the resident and/or her representative at risk of uninformed care choices. - R347's Electronic Medical Record (EMR) documented R347 had a diagnosis of disorders of the lungs, R347's Admission Minimum Data Set (MDS), dated [DATE], documented R347 had a Brief Interview of Mental Status score of 15, which indicated intact cognition. The MDS documented R347 was dependent on staff for toileting, showering, lower body dressing, putting on and taking off footwear, and transfers. R347 required partial to moderate staff assistance with oral care and personal hygiene; R347 required substantial to maximal staff assistance with upper body dressing and bed mobility. R347's Care Plan, revised 01/05/24, instructed staff to change the oxygen tubing and water reservoir per facility protocol and administer oxygen as the physician ordered. Staff monitored R347's oxygen saturation as the physician ordered and notified the physician of abnormal readings. The care plan instructed staff to monitor R347 for shortness of breath during activity participation. The Progress Note, dated 03/08/24 at 07:12 AM, documented R347 was admitted to the hospital. A review of R347 's clinical record lacked evidence the resident or representative was provided written notice when R347 was transferred to the hospital. On 03/25/24 at 03:46 PM, observation revealed R347 sat in bed with oxygen on per nasal cannula. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R347 or his representative was provided written notice of the transfer to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D verified the facility lacked documentation R347, or the representative was provided a written notice when R347 was transferred to the hospital. Upon request, the facility failed to provide a policy for facility-initiated transfer to the hospital. The facility failed to provide R347 or his representative written notice regarding R347's facility-initiated transfer to the hospital. This placed the resident and/or her representative at risk of uninformed care choices. 32360 - R75's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), and iron deficiency (too little iron in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R75 had severely impaired cognition and required substantial/maximum assistance for dressing, transfer, toileting, and partial/moderate assistance for personal hygiene. R75's Care Plan, dated 03/12/24 and initiated on 04/12/23, documented R75 had a potential for cardiovascular problems and directed staff to administer medications as ordered, monitor vital signs as ordered, and notify the physician of any abnormal readings. The Nurse's Note, dated 08/21/23 at 09:39 PM, documented R75 was admitted to the hospital on 08/16/23. A review of R75's clinical record lacked evidence the resident or representative was provided written notice when she was transferred to the hospital. On 03/26/24 at 08:55 AM, observation revealed R75 sat in her wheelchair and talked on the telephone in her room. On 03/26/24 at 10:45 AM, Licensed Nurse (LN) G stated the nurse sent the bed hold policy with the resident when they went to the hospital. LN G said the staff called the resident's representative but would not send a written notice. On 03/26/24 at 10:39 AM, Administrative Staff B stated the nurse sent the bed hold policy with transfer papers to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D stated the nurse sent a bed hold with residents when they were transferred to the hospital; medical records were responsible for receiving it back. Administrative Nurse D verified the facility did not notify the resident's representative in writing regarding transfers to the hospital and the reason for the transfer. The facility's Bed Hold policy, undated, documented the facility notified the resident and/or representative of the bed hold policy in writing at the time of admission when transferred to the hospital or during therapeutic leave, as well as the intent for readmission according to state and federal regulations. The facility failed to provide R75 or her representative written notice regarding R75's facility-initiated transfer to the hospital. This placed the resident and/or her representative at risk for uninformed care choices.

The facility had a census of 151 residents. The sample included 31 residents. Based on observation, interview, and record review the facility failed to ensure Residents (R) 87, R68, and R110 received a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) to identify potential care needs related to a mental disorder (MD) or intellectual disability (ID). This placed the residents at risk for unidentified needs and inadequate care. Findings included: - R87's Electronic Medical Record (EMR) documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), asthma (a disorder of narrowed airways that caused wheezing and shortness of breath), and bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R87 had no mood or behaviors during the observation period. R87 required set up for eating, verbal cues for bathing, and dressing, and moderate assistance for toileting, and transfers. R87's Care Plan, dated 3/16/24, stated he preferred to stay in his room and was most comfortable when around familiar people. He would occasionally attend the group setting although he tended to leave early related to emotional comfort as big groups made him anxious. R87's clinical record lacked evidence a PASRR was completed. On 03/26/24 at 07:40 AM, observation revealed R87 independently ate hot cereal while holding the bowl in his lap. On 3/26/24 at 08:20 AM, Administrative Staff A stated the resident was admitted from the Veteran's Administration (VA) and the VA did not perform a PASRR. Upon request, the facility did not provide a policy. The facility failed to ensure a PASRR was completed for R87 before admission. This placed the residents at risk for unidentified needs and inadequate care. 32358 - R68's Electronic Medical Record (EMR) documented diagnoses of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R68's Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R68 had no mood or behaviors during the observation period. The MDS documented R68 required substantial to maximal staff assistance with activities of daily living (ADLs). R68's Care Plan, revised 09/12/23, documented R68 preferred privacy when staff provided care as well as when discussing personal issues and instructed staff to provide care in a calm, patient, non-judgmental manner. Staff were to explain what task was to be done before beginning the task. R68's clinical record lacked evidence a PASRR was completed. On 03/25/24 at 04:22 PM, observation revealed R68 sat quietly in a wheelchair in his room. On 3/26/24 at 08:20 AM, Administrative Staff A stated the resident was admitted from the Veteran's Administration (VA) and the VA did not perform a PASRR. Upon request, the facility did not provide a policy. The facility failed to ensure a PASRR was completed for R68 before admission. This placed the residents at risk for unidentified needs and inadequate care. 27168 - R110 was admitted to the facility on [DATE]. R110's Electronic Health Record (EHR), recorded the diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress,) and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear.) R110's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, with intact cognition. The MDS documented the resident had verbal behaviors directed towards others. R110's Care Plan, dated 03/21/24, indicated R110 had a history of behavioral symptoms and had a history of being manipulative, making statements that were exaggerated or false about events, care, and medications, and often wanting to manipulate staff's time. R110's EHR lacked evidence a PASRR assessment was completed as required. The facility was unable to provide a PASRR screening for R110 upon request. On 03/25/24 at 02:10 PM, observation revealed R110 sat in a recliner in his room watching TV. On 03/26/24 at 08:20 AM, Administrative Staff A verified R110 lacked a PASRR assessment before admission to the facility. Administrative Nurse D stated the resident was from the Veterans Hospital (VA) and the VA did not assess for PASRR upon admission. Upon request, the facility did not provide a policy. The facility failed to adequately assess the resident for placement in the facility by obtaining a PASRR screening as required. This placed R110 at risk for inadequate facility care and unidentified needs.

The facility had a census of 151 residents. The sample included 31 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with trauma triggers and coping strategies for Resident (R)50 who had post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) which placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - Resident (R) 50's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (a language disorder that affects ability to communicate), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), major depressive disorder (major mood disorder which causes persistent feelings of sadness), Wernicke's encephalopathy (impaired coordination movement and eye dilated veins). R50's Quarterly Minimum Data Set (MDS), dated [DATE], documented that staff assessed R50's cognition as moderately impaired. R50 rejected care one to three days of the look-back period. R50 received an antidepressant (medication used to treat mood disorders) and was independent with most activities of daily living. The Behavioral Symptoms Care Area Assessment (CAA), dated 08/21/23, documented R50 had multiple episodes of refusing care such as showers. R50's family was very involved and encouraged R50 to participate. R50's Care Plan, dated 02/27/24, documented R50 had problems with short-term memory due to the diagnosis of dementia. The care plan directed staff always to tell R50 what staff were going to do before initiating nursing care and to encourage R50 to talk about her life, past experiences, career, and family. R50's admission information documented R50 had a 70 percent (%) disability through the Veteran Administration (VA). The facility's Social Service Quarterly Long-Term Observation, dated 11/17/22, documented a trauma screening which recorded R50 answered No when asked about a history of traumatic events. The Progress Note dated 12/27/23 at 01:49 PM, documented R50's family called the facility regarding R50 being upset. R50 indicated that someone had spoken mean to her, and she wanted someone to pick her up from the facility. The note further documented R50's roommate had been using profanities toward staff and R50's family inquired about a private room. On 03/26/24 at 08:17 AM, observation revealed R50 remained in bed, covered with several blankets. She had a breakfast tray sitting on her overbed table. On 03/26/24 at 02:20 PM, Social Service X stated most of the facility's residents were admitted from Veteran Administration (VA) referrals and usually had PTSD. Social Service X had not assessed or gathered information related to R50's triggers of past trauma nor had she spoken to R50's family about possible triggers to prevent re-traumatization. On 03/26/24 at 02:20 PM, Administrative Staff Nurse E verified that R50's Care Plan had behaviors of obsessive cleaning noted but did not specifically address R50's trauma issues. On 03/26/24 at 04:29 PM, Administrative Nurse D stated residents with a diagnosis of PTSD were not assessed for triggers on admission, only when the residents showed some sort of symptoms such as depression, flashbacks, or anxiety. Administrative Nurse D said if those symptoms occurred, she expected her staff to conduct a PTSD assessment. The facility's Trauma Informed Care and Behavioral Health Management policy, dated 09/2019, documented it is the philosophy of the facility to assist in the early identification of residents' past traumatic events/behaviors and to develop and implement interventions to manage or de-escalate those behaviors. Any actual or potential areas of concern identified by the social worker based on the interview will be documented and communicated with the nurse, nursing administration, behavior management committee, and care planned. Care Plans will be communicated to all direct caregivers to avoid triggers for the residents and promote their mental and psychological well-being. The facility failed to identify and implement interventions for R50's diagnosed PTSD, which placed the resident at risk of uncommunicated care needs.

The facility had a census of 151 residents. The sample included 31 residents, of which one was reviewed for mobility and positioning. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 53 received appropriate treatment and services to maintain and prevent a decline in mobility and ambulation. This placed the resident at risk for a decline in mobility and impaired independence. Findings included: - R53's Electronic Health Record (EHR), recorded the diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R53's Admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment revealed the resident required partial to moderate assistance with activities of daily living (ADLs) and supervision to walk 50 to 150 feet. R53's Care Plan, dated 12/07/23, directed staff to assist the resident with dressing but lacked any direction for therapy or restorative assistance. R53's Restorative Therapy Plan of Care, dated 03/09/24, documented the restorative aide would assist the resident to walk two to three times a week using the platform walker in the therapy gym with a gait belt for 100 feet, twice with stand-by assistance. A review of the Restorative Flowsheet documentation revealed the resident refused to walk on 03/26/24 and lacked documentation the resident was provided or asked to participate in ambulation from 03/09/24 until 03/26/24. On 03/25/24 at 11:00 AM, observation revealed the resident sat in a recliner in her room. She was dressed in street clothes and had her feet elevated. On 03/26/24 at 07:30 AM, Physical Therapist (PT) HH stated the resident received physical therapy from admission 12/05/23 until 03/09/24. PT HH stated the therapists developed a restorative program for R53 on 03/09/24 and the restorative aide would continue the resident's restorative program 2-3 times a week. PT HH stated the facility had one restorative aide to complete restorative on all the residents in the facility who required restorative services. On 03/26/24 at 02:10 PM, Administrative Nurse E verified the physical therapists completed the resident's therapy and then the therapist developed a restorative program. Administrative Nurse E stated the restorative aide would document the restorative services in the EHR. Administrative Nurse E verified the resident had not received any of the directed restorative services since 03/09/24 when the therapist developed the restorative program for the resident. The facility's Restorative Therapy Program policy, dated May 2021, documented the facility would assist each resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance with State and Federal regulations. Each resident would be screened and evaluated by the nurse or therapist designated to oversee the restorative nursing process for inclusion into the appropriate facility restorative nursing program when it has been identified by the interdisciplinary team that the resident is in need or may benefit from such program. The facility's restorative nursing program would include, but not be limited to hygiene, mobility including ambulation, dining, and communication. The restorative program would be documented on the facility-designated restorative care form and tools in the resident's electronic medical record. The designated nurse would be responsible for obtaining orders for the resident's restorative program and documentation every month. The therapist would be responsible for initiating and updating restorative care plans and the designated nurse or therapist would continue to monitor the resident's progress. The designated nurse would evaluate the restorative documentation monthly to determine if there are any changes needed to the existing program and make a monthly progress note, in the resident's electronic medical record. The policy documented some residents may not wish to participate in restorative care programming which will be respected as an election of choice and documented accordingly. The facility failed to ensure R53 received appropriate restorative treatment and services to increase or prevent further deterioration for the resident. This placed the resident at risk for a decline in mobility and impaired independence.

The facility had a census of 151 residents. The sample included 31 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 68, R347, and R75 or their representative with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the residents at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R68's Electronic Medical Record (EMR) documented R68 had a diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) R68's Admission Minimum Data Set (MDS), dated [DATE], documented R68 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented the resident required substantial to maximal staff assistance with toileting and personal hygiene. The Urinary Incontinence Care Area Assessment (CAA), dated 10/18/23, documented R68 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and instructed staff to monitor R68 for urinary tract infections (UTI-an infection in any part of the urinary system). R68's Care Plan, revised 10/18/23, documented R68 had an indwelling catheter and instructed staff to provide catheter care as needed (PRN) and encourage R68 to drink fluids to reduce UTI risks. The Progress Note, dated 03/04/2024 at 05:10 PM, documented R68 was admitted to the hospital. A review of R68's clinical record lacked evidence the resident or representative was provided the bed hold policy when he was transferred to the hospital. On 03/25/24 at 04:22 PM, observation revealed R68 sat quietly in a wheelchair in his room. His indwelling foley catheter was in a privacy bag hooked on the wheelchair and the urine in the tubing had clear yellow urine. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R68, or his representative was provided the bed hold policy when R68 was transferred to the hospital. Administrative Staff B stated nursing was responsible for sending the bed hold policy with transfer papers to the hospital and she did not follow up on obtaining the signed notice. On 03/26/24 at 10:45 AM, Administrative Nurse D verified the facility lacked documentation R68, or their representative was provided the bed hold policy when the resident was transferred to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility failed to provide R68 or his representative with the bed hold policy when R68 was transferred to the hospital. This placed the resident and/or her representative at risk of uninformed care choices. - R347's Electronic Medical Record (EMR) documented R347 had a diagnosis of disorders of the lungs. R347's Admission Minimum Data Set (MDS), dated [DATE], documented R347 had a Brief Interview of Mental Status score of 15, which indicated intact cognition. The MDS documented R347 was dependent on staff for toileting, showering, lower body dressing, putting on and taking off footwear, and transfers. R347 required partial to moderate staff assistance with oral care and personal hygiene; R347 required substantial to maximal staff assistance with upper body dressing and bed mobility. R347's Care Plan, revised 01/05/24, instructed staff to change the oxygen tubing and water reservoir per facility protocol and administer oxygen as the physician ordered. Staff monitored R347's oxygen saturation as the physician ordered and notified the physician of abnormal readings. The care plan instructed staff to monitor R347 for shortness of breath during activity participation. The Progress Note, dated 03/08/24 at 07:12 AM, documented R347 was admitted to the hospital. A review of R347s clinical record lacked evidence the resident or representative was provided the bed hold policy when R347 was transferred to the hospital. On 03/25/24 at 03:46 PM, observation revealed R347 sat in bed with oxygen on per nasal cannula. On 03/26/24 at 10:39 AM, Administrative Staff B verified the facility lacked documentation R347, or his representative was provided the bed hold policy when R347 was transferred to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D verified the facility lacked documentation R347, or the representative was provided the bed hold policy when R347 was transferred to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility failed to provide R347 or his representative with the bed hold policy when R347 was transferred to the hospital. This placed the resident and/or her representative at risk of uninformed care choices. 32360 - R75's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), and iron deficiency (too little iron in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R75 had severely impaired cognition and required substantial/maximum assistance for dressing, transfer, toileting, and partial/moderate assistance for personal hygiene. R75's Care Plan, dated 03/12/24 and initiated on 04/12/23, documented R75 had a potential for cardiovascular problems and directed staff to administer medications as ordered, monitor vital signs as ordered, and notify the physician of any abnormal readings. The Nurse's Note, dated 08/21/23 at 09:39 PM, documented R75 was admitted to the hospital on 08/16/23. A review of R75's clinical record lacked evidence the resident or representative was provided the facility's bed hold policy when R75 went to the hospital. On 03/26/24 at 08:55 AM, observation revealed R75 sat in her wheelchair and talked on the telephone in her room. On 03/26/24 at 10:45 AM, Licensed Nurse (LN) G stated the nurse sent the bed hold policy with the resident when they went to the hospital. LN G said the staff called the resident's representative but would not send a written notice. On 03/26/24 at 10:39 AM, Administrative Staff B stated the nurse sent the bed hold policy with transfer papers to the hospital. On 03/26/24 at 10:45 AM, Administrative Nurse D stated the nurse sent a bed hold with residents when they were transferred to the hospital; medical records were responsible for receiving it back. Administrative Nurse D verified the facility did not notify the resident's representative in writing regarding transfers to the hospital and the reason for the transfer. The facility's Bed Hold policy, undated, documented the facility permits residents to return to the facility after they are hospitalized or placed on therapeutic leave and if a resident who was hospitalized exceeds the bed-hold period under the State plan, may return to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility and was eligible for Medicare/Managed Care skilled nursing services or Medicaid. The facility failed to provide R75 or his representatives with the bed hold policy when they were transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

- R70's Electronic Medical Record, (EMR) documented the resident had a diagnosis of [CONDITION(S)] (greater than normal amount of potassium in the blood). R70's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The MDS documented R70 required staff supervision with activities of daily living (ADLs). R70's Medication Care Plan, revised 10/02/22, instructed staff to administer her medications as the physician ordered. R70's EMR documented her potassium level was out of normal range (3.5-5.1millimoles per liter (mmol/L) of blood) on the following dates: 04/22/22-6.2 mmol/L 05/31/22-5.4 mmol/L The Physician Order, dated 06/09/2022, instructed staff to administer to R70 [MEDICATION(S)] (medication used to treat high levels of potassium in the blood) 5 gram (g) packet, daily. The Nurse's Note, dated 09/19/2022 at 01:50 PM, documented R70 did not receive the physician ordered [MEDICATION(S)], 5g daily, for the last two days related to the pharmacy failed to deliver it. On 10/24/22 at 8:00 AM, observation revealed R70 sat in a wheelchair at the nurse's station. On 10/24/22 at 12:19 PM, Licensed Nurse (LN) G stated she reordered residents' medication seven to 10 days before it ran out. LN G stated if a resident was out of a medication, she called the pharmacy and asked the pharmacy to send it stat (right away). LN G stated the facility had been having trouble with the pharmacy failing to send residents medications on time; the medications were often sent to a sister facility or not sent at all. On 10/24/22 at 01:29 PM, Administrative Nurse D stated if a resident was out of a medication, she expected staff to call the physician, family and pharmacy. If the medication continued to be unavailable, she expected staff to keep calling the physician and pharmacy. Administrative Staff D stated the facility had been having trouble with the pharmacy delivering R70's [MEDICATION(S)]; first it was trouble with insurance, then they were not stocking it. The undated Pharmacy Services Policy, documented the facility would provide routine and emergency medications and biologicals (medications developed from blood, proteins, viruses, or living organisms) to its residents through an agreement with United Scripts Pharmacy. The facility failed to ensure availability of physician ordered medications for R70, which placed the resident at risk for ineffective medication management. The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to ensure consistent reconciliation of controlled drugs at the end of daily worked shifts for two of six medication carts and failed to ensure availability of physician ordered medication for two days for Resident (R) 70, which placed residents at risk for misappropriation of medications by staff and unmet therapeutic medication regimen. Findings included: - On 10/18/22 at 10:26 AM, observation on the 200-hall medication cart revealed a lack of staff signatures on the Controlled Drug Record at the beginning of the day shift 10/04/22 through 10/07/22 (four days). Certified Medication Aide (CMA) S verified the lack of signatures and stated the Controlled Drug Record should have been signed to indicate the reconciliation was completed. On 10/18/22 at 04:11 PM, observation on the 700-hall medication cart lacked staff signatures on the Controlled Drug Record on day shift 10/02/22, 10/10/22, 10/16/22 and evening shift 10/07/22, 10/11/22, and 10/17/22. CMA R verified lack of signatures the Controlled Drug Record. On 10/18/22 at 04:20 PM, Administrative Nurse D verified staff should complete a reconciliations and sign the Controlled Drug Record at the end of each shift to show the count was completed. The facility's Medications, Controlled Drugs policy, dated 06/2021, documented when controlled keys change hands during a shift, controlled drugs are recounted and the counted record is signed by nurse/certified medication aide. Monitoring of accuracy will be completed routinely by Nursing Administration and Pharmacy. The facility failed to ensure consistent reconciliation of controlled drugs for two of six medication carts which placed residents at risk for misappropriation of medications by staff.

The facility identified a census of 189 residents, with one resident (#1) sampled for abuse. Based on observation, interview, and record review, the facility failed to protect opposite gender residents from potential sexual abuse. Staff observed resident #1, who had a history of [REDACTED]. This deficient practice placed 14 opposite gender residents on the unit in immediate jeopardy. Findings included: - The clinical record documented the facility admitted resident #1 on 6/22/17 with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The resident required supervision with locomotion on the unit. The quarterly MDS, dated [DATE], documented a BIMS score of 3, which indicated severely impaired cognition. The Care Area Assessment, dated 7/3/17, for Activities of Daily Living documented the resident was confused, but very independent. The resident walked independently, required redirection, and nursing staff were to closely monitor him/her because he/she wandered. The care plan, dated 10/3/17, documented staff found the resident in the room of opposite gender resident #2 with his/her hands inside resident #2's brief. Staff immediately separated the resident and placed him/her on one-to-one monitoring (1:1 - one staff with one resident). A revision, dated 1/10/18, documented staff discontinued the 1:1 monitoring. A revision, dated 1/18/18, documented staff placed the resident back on 1:1 monitoring secondary to an incident with another opposite gender resident (#3). A progress note, dated 1/15/18 at 1:00 P.M., documented administrative nursing staff E instructed nursing staff the resident was not to have any contact with resident #2 and staff was to closely monitor the resident. A progress note, dated 1/18/18 at 7:00 A.M., documented staff observed the resident sit on the edge of resident #3's bed. Staff reported the incident to management at 10:00 A.M. and placed the resident on 15-minute checks. A progress note, dated 1/18/18 at 5:35 P.M., documented staff notified the family the resident would be on 1:1 staff monitoring when staff was available. Review of the 1:1 monitoring sheets from 1/18/18 through 1/31/18 lacked complete documentation for all shifts that staff had performed 1:1 monitoring. On 1/31/18 at 7:45 A.M., the resident sat in his/her room without 1:1 staff monitoring. Direct care staff O assisted a resident in the dining room. Direct care staff P passed medications to residents in the dining room. Direct care staff R poured juice for residents in the dining room. Another staff assisted a resident in his/her room at the opposite end of the hallway from resident #1's room. Direct care staff Q arrived on the secured unit at 8:10 A.M. to provide 1:1 monitoring for the resident. On 1/31/18 at 8:20 A.M., direct care staff O stated on 1/18/18, resident #1 sat on opposite gender resident #3's bedside without his/her shirt on and resident #3 laid in bed without his/her pants on. Direct care staff O stated after this incident, staff placed the resident on 1:1 staff monitoring. He/she stated there were days when they did not have enough staff to do the 1:1 monitoring, so staff took turns checking on resident #1 every 15 minutes. Staff O stated he/she was not assigned to do the 1:1 staff monitoring that shift. On 1/31/18 at 8:30 A.M., direct care staff P stated the resident had 1:1 staff supervision, but he/she was not responsible for the 1:1 monitoring at this time. On 1/31/18 at 8:40 A.M., direct care staff Q stated the staff did not perform 1:1 staff monitoring this morning until management instructed him/her to provide 1:1 staff monitoring for resident #1. On 1/31/18 at 9:30 A.M., administrative nursing staff D stated on 1/18/18, staff placed the resident on 1:1 staff monitoring when staff was available, otherwise he/she expected staff on the unit to keep an eye on him/her throughout the shift. On 1/31/08 at 5:35 P.M., direct care staff R stated administrative nursing staff instructed staff to keep a close watch on the resident. He/she stated staff kept close observation on all of the residents in that unit. Staff R further stated he/she did not keep closer observation on resident #1 than he/she did for any other resident in the unit. Staff R stated he/she received only instructions to keep close observation of the resident, and not provide 1:1 staff monitoring. The facility lacked a requested policy regarding 1:1 monitoring. The facility's Freedom from Abuse, Neglect, and Exploitation policy, dated (MONTH) (YEAR), documented adjustments to staffing levels were based on the average census of each unit as well as the individual needs of the residents. Staff were assigned to the units based on residents needs. It was the responsibility of supervisors to ensure that needed care was provided in accordance with the plan of care. The facility failed to protect opposite gender residents from potential sexual abuse from this cognitively impaired resident with a history of sexual abuse. This deficient practice placed 14 opposite gender residents on the secured unit in immediate jeopardy. The facility abated the immediate jeopardy on 1/31/18 at 8:04 P.M., after implementing the following: 1. Staff for subsequent shifts assigned to the 1:1 monitoring would be in-serviced on proper 1:1 monitoring. Staff in-servicing for 1/31/18 would be completed on 1/31/18 by 9:00 P.M. 2. All staff who performed 1:1 monitoring would document the monitoring completed, including a visual 1:1 resident monitoring log. 3. To verify the resident had continuous 1:1 coverage for the ensuing 24 hours, the Director of Nursing (DON) or designee would verify staff scheduling for 1:1 monitoring in the morning to ensure staff were scheduled to 1:1 monitoring for the next 24 hours. 4. Ongoing, the DON or designee would monitor the completion of 1:1 care during daily rounds. The deficient practice remained at a scope and severity of an E.

The facility reported a census of 190 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to provide an environment free from verbal intimidation and physical abuse from direct care staff O when he/she spoke inappropriately to resident #1 on 7/6/17, and from direct care staff Q when he/she sexually and emotionally abused resident #2 on 7/5/17. This deficient practice placed residents #1 and #2 in immediate jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The quarterly MDS dated [DATE] documented a BIMS score of 9, which indicated moderately impaired cognition. The Care Area assessment dated [DATE] for Cognitive Loss and Dementia documented the resident had severe to moderate cognitive impairment and a [DIAGNOSES REDACTED]. The care plan revised 7/7/17 documented the resident had cognitive loss and impaired memory and directed staff to tell the resident what they were going to do prior to providing nursing care. Review of the facility's investigation dated 7/7/17 documented on 7/6/17, direct care staff P witnessed direct care staff O slap resident #1 in the face. Direct care staff P stated he/she heard direct care staff O ask the resident if he/she wanted to fight him/her. Direct care staff P witnessed direct care staff O slap the resident in the face, and the resident raised his/her hands in a defensive pose. Direct care staff P reported the witnessed abuse on 7/7/17 at 9:30 A.M. and direct care staff O was suspended. A typed interview with resident #1 by social service staff F dated 7/7/17 documented the resident stated he/she was in pain and staff slapped him/her. The notarized witness statement dated 7/7/17 by direct care staff P documented on 7/6/17, he/she entered resident #1's room to look for the mechanical lift. Direct care staff P heard direct care staff O ask the resident in a stern voice if he/she wanted to fight. Direct care staff P observed direct care staff O slap the resident in the face. The resident appeared terrified and put his/her hands up in defense. The notarized witness statement dated 7/7/17 by licensed nursing staff C documented direct care staff P reported on 7/7/17 he/she observed direct care staff O slap resident #1 in the face on 7/6/17, and the resident appeared frightened and startled. Licensed nursing staff C reported the incident to administrative staff B. The notarized witness statement dated 7/10/17 by direct care staff O documented he/she liked to play with the resident and make him/her laugh. Direct care staff O stated he/she was playing with the resident and nothing else happened. Direct care staff O's timesheet documented he/she worked in the facility on 7/6/17 from 6:30 A.M. until 3:00 P.M., and on 7/7/17 from 6:30 A.M. until 9:45 A.M. On 7/10/17 at 5:00 P.M., the resident sat in his/her wheelchair and watched television. On 7/10/17 at 3:10 P.M., direct care staff P stated on 7/6/17 at approximately 2:00 P.M., he/she entered the resident's room to look for the mechanical lift. He/she heard direct care staff O ask the resident if he/she wanted to fight, and he/she observed direct care staff O slap the resident across the face. Staff P further stated the resident raised his/her hands in a defensive motion. Direct care staff P stated what he/she witnessed shocked him/her, he/she immediately left the resident's room and thought he/she had 24 hours to report the incident. Direct care staff P stated he/she reported the witnessed abuse on 7/7/17 at approximately 8:00 A.M. to licensed nursing staff C. On 7/10/17 at 4:40 P.M., licensed nursing staff C stated on 7/7/17 at approximately 9:00 A.M., direct care staff P reported he/she witnessed direct care staff O physically abuse the resident on 7/6/17 at approximately 2:00 P.M. Licensed nursing staff C immediately reported the incident to administrative staff B. He/she stated all allegations or witnessed abuse should be reported within two hours to the director of nursing (DON) or the administrator. On 7/10/17 at 5:00 P.M., resident #1 stated a staff member hurt him/her and slapped him/her. On 7/10/17 at 5:07 P.M., administrative nursing staff D stated he/she expected staff to immediately protect the resident after an abuse allegation and immediately report all incidents of abuse to their charge nurse and administrative staff. On 7/11/17 at 7:45 A.M., licensed nursing staff J stated he/she had no knowledge of the incident between direct care staff O and resident #1 until 7/7/17 when the assistant administrator escorted direct care staff O out of the facility. Licensed nursing staff J stated allegations or witnessed abuse should be reported to the administrator and DON immediately or within two hours. On 7/11/17 at 7:50 A.M., administrative staff B stated licensed nursing staff C informed him/her of the incident between direct care staff O and resident #1 on 7/7/17 at approximately 9:00 A.M. He/she stated licensed nursing staff C reported to him/her that direct care staff P witnessed direct care staff O slap the resident in the face. Administrative staff B stated he/she immediately suspended direct care staff O during the investigation and he/she expected staff to immediately report witnessed abuse or allegations. Review of the facility provided Freedom from Abuse, Neglect, and Exploitation policy dated November 2016 documented the Centers for Medicare and Medicaid Services (CMS) believed reporting immediately meant not later than two hours after the allegation was made if the events that caused the allegation involved abuse. The policy further documented any observed or reported violation of the resident safety policy should be reported immediately to the supervisor and administrator without fear of reprisal. The facility failed to provide an environment free from physical abuse for this cognitively impaired resident. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G. - The clinical record documented the facility admitted resident #2 on 2/12/17 with the [DIAGNOSES REDACTED]. response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent for toileting. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent with toileting. The Care Area Assessment (CAA) dated 2/23/17 for incontinence (loss of bladder control) documented the resident was continent (able to control the bladder) of bladder and had a [MEDICAL CONDITION] bag which staff and the resident managed. The care plan revised on 4/17/17 for incontinence documented the resident had a [MEDICAL CONDITION] and needed help with its management. The care plan directed staff to empty the [MEDICAL CONDITION] bag as needed and to change the bag as ordered and as needed. The clinical record lacked evidence of documentation of appropriate interventions to protect the resident from sexual abuse and mental anguish after the resident shared his/her concerns with staff on 7/5/17, 7/6/17, and 7/7/17. Direct care staff Q's timesheet documented he/she worked in the facility on one unit until 7/7/17 at 6:15 P.M. On 7/11/17 at 10:09 A.M., resident #2 stated direct care staff Q harassed him/her for months. The resident stated staff Q frequently entered his/her bathroom without knocking, when he/she was in the restroom with his/her body parts exposed. The resident stated staff Q stood and stared at him/her for some time, and then pretended it had not happened. The resident stated staff Q made him/her feel very uncomfortable. The resident denied he/she required staff assistance with toileting. The resident further stated staff Q took away his/her privacy and dignity, and made him/her feel violated by repeatedly entering the bathroom when he/she was in there. The resident stated this happened multiple times over several months and he/she decided to tell licensed nursing staff H, because he/she could not stand it any longer. The resident stated he/she had concerns about the well-being of other residents that were less independent. On 7/11/17 at 10:20 A.M., resident #3 (resident #2's roommate) stated direct care staff Q acted rude and unprofessional. He/she stated staff Q was a bully and had instructed him/her not to use the call light when he/she needed assistance. On 7/11/17 at 12:15 P.M. licensed nursing staff H confirmed resident #2 informed him/her on 7/5/17 that direct care staff Q watched him/her in the bathroom and it made him/her uncomfortable, because he/she was undressed. Staff H stated he/she then informed administrative nursing staff I about the situation. Staff I instructed staff H not to allow staff Q to enter resident #2's room anymore. Staff H further stated resident #2 then reported again to him/her on the following day (7/6/17) that staff Q entered his/her room again the night before. Staff H stated resident #2 made it very clear he/she did not want staff Q anywhere near him/her. Staff H stated he/she then reported to administrative nursing staff C. Staff H then stated on the following day (7/7/17) resident #2 observed staff Q again on the unit, and that was when resident #2 became extremely upset and threatened to report the facility to the state agency. On 7/11/17 at 1:05 P.M., administrative nursing staff G stated resident #2 reported to administrative nursing staff F on 7/7/17 that he/she wanted something done about direct care staff Q. He/she added he/she then interviewed several residents about staff Q. On 7/11/17 at 2:01 P.M., administrative nursing staff C stated he/she remembered first hearing about the situation with staff Q and resident #2 in an email the week before. He/she stated administrative nursing staff I and D were both aware of the situation before Friday 7/7/17. He/she stated administrative staff chose to have staff Q change assignments and then units (which potentially exposed a different group of residents to staff Q's abusive behavior) however, he/she stated the information was never passed on during shift change. Staff C further stated he/she was unaware if administrative staff B was aware of the situation. On 7/11/17 at 2:21 P.M., administrative nursing staff E stated there was to be a change in staff Q's assignment at the end of last week 7/6/17, but the information was not relayed by the nurses during shift change report, so staff Q continued to provide care for resident #2. Staff E further stated the situation heightened on Friday afternoon, 7/7/17, when resident #2 became very upset. He/she stated together with administrative nursing staff F and administrative staff B, they decided to send staff Q home. Staff Q was suspended and left the building on 7/7/17 at 6:15 P.M. (2 days after resident #2 first told a staff member he/she was uncomfortable with and harassed by staff Q). On 7/11/17 at 2:50 P.M., administrative nursing staff F stated he/she was unaware of the situation until 7/7/17 at 4:45 P.M. when resident #2 approached him/her and informed him/her about staff Q watching him/her in the bathroom. Staff F stated the resident removed all of his/her clothing when he/she performed his/her [MEDICAL CONDITION] care, because he/she didn't want to risk getting his/her clothing soiled. When he/she was naked in the bathroom, staff Q would come in, unannounced, and linger, while he/she stared at the resident's body. The resident stated it felt like he/she was being raped. Staff F offered for resident #2 to call local law enforcement, which then occurred. Staff F stated after the police left, administrative staff B suspended staff Q. On 7/11/17 at 3:20 P.M., administrative staff B stated he/she was unaware of any problems between resident #2 and staff Q before the afternoon of 7/7/17. He/she stated he/she expected administrative nursing staff I and administrative nursing staff D to inform himself/herself of potential problems related to staff Q and resident #2. The facility's Abuse, Neglect, and Exploitation, Freedom From Policy, revised November 2016, documented residents had the right to be free from inappropriate or unusual behavior with the following examples to be considered sexual, and to be reported to a supervisor and/or administrator immediately: not allowing privacy to dress or undress, not providing a gown or draping unless emergent situation, any behavior, gestures, or expression that may reasonably be interpreted as seductive or sexual, sexually demeaning behavior, including but not limited to, any verbal or physical contact which may reasonably be interpreted as demeaning, humiliating, embarrassing, threatening, or harmful. The facility failed to provide an environment free from sexual abuse for resident #2 from direct care staff Q when the resident told staff he/she was uncomfortable with Staff Q providing care, he/she felt harassed and raped by Staff Q while performing self-care in the bathroom in Staff Q's presence. This deficient practice placed resident #2 in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G.

The facility reported a census of 190 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to protect 24 residents on one unit from verbal intimidation and physical abuse when direct care staff O spoke inappropriately and physically abused resident #1 on 7/6/17. Direct care staff P witnessed the abuse and failed to immediately report the incident to administrative staff. Direct care staff O continued to work, providing care for the remainder of the shift on 7/6/17, and returned to work on 7/7/17, providing care until 9:45 A.M. Furthermore, the facility failed to protect an additional 24 residents on another unit from sexual abuse and mental anguish when direct care staff Q violated resident #2's privacy while he/she was nude. Licensed nursing staff H, C, and I had knowledge of the allegation and failed to immediately report it to administrative staff. Direct care staff Q continued to work, providing care until 7/7/17 at 6:15 P.M. This deficient practice placed 48 residents on 2 of 9 halls in immediate jeopardy. The facility also failed to provide evidence of registry verification and criminal background check for five staff prior to allowing the staff to work in the facility. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The quarterly MDS dated [DATE] documented a BIMS score of 9, which indicated moderately impaired cognition. The Care Area assessment dated [DATE] for Cognitive Loss and Dementia documented the resident had severe to moderate cognitive impairment and a [DIAGNOSES REDACTED]. The care plan revised 7/7/17 documented the resident had cognitive loss and impaired memory and directed staff to tell the resident what they were going to do prior to providing nursing care. Review of the facility's investigation dated 7/7/17 documented on 7/6/17, direct care staff P witnessed direct care staff O slap resident #1 in the face. Direct care staff P stated he/she heard direct care staff O ask the resident if he/she wanted to fight him/her. Direct care staff P witnessed direct care staff O slap the resident in the face, and the resident raised his/her hands in a defensive pose. Direct care staff P reported the witnessed abuse on 7/7/17 at 9:30 A.M. and direct care staff O was suspended. A typed interview with resident #1 by social service staff F dated 7/7/17 documented the resident stated he/she was in pain and staff slapped him/her. The notarized witness statement dated 7/7/17 by direct care staff P documented on 7/6/17, he/she entered resident #1's room to look for the mechanical lift. Direct care staff P heard direct care staff O ask the resident in a stern voice if he/she wanted to fight. Direct care staff P observed direct care staff O slap the resident in the face. The resident appeared terrified and put his/her hands up in defense. The notarized witness statement dated 7/7/17 by licensed nursing staff C documented direct care staff P reported on 7/7/17 he/she observed direct care staff O slap resident #1 in the face on 7/6/17, and the resident appeared frightened and startled. Licensed nursing staff C reported the incident to administrative staff B. The notarized witness statement dated 7/10/17 by direct care staff O documented he/she liked to play with the resident and make him/her laugh. Direct care staff O stated he/she was playing with the resident and nothing else happened. Direct care staff O's timesheet documented he/she worked in the facility on 7/6/17 from 6:30 A.M. until 3:00 P.M., and on 7/7/17 from 6:30 A.M. until 9:45 A.M. The staffing schedule documented direct care staff O was assigned to a unit where 24 residents resided. On 7/10/17 at 5:00 P.M., the resident sat in his/her wheelchair and watched television. On 7/10/17 at 3:10 P.M., direct care staff P stated on 7/6/17 at approximately 2:00 P.M., he/she entered the resident's room to look for the mechanical lift. He/she heard direct care staff O ask the resident if he/she wanted to fight, and he/she observed direct care staff O slap the resident across the face. Staff P further stated the resident raised his/her hands in a defensive motion. Direct care staff P stated what he/she witnessed shocked him/her, he/she immediately left the resident's room and thought he/she had 24 hours to report the incident. Direct care staff P stated he/she reported the witnessed abuse on 7/7/17 at approximately 8:00 A.M. to licensed nursing staff C. On 7/10/17 at 4:40 P.M., licensed nursing staff C stated on 7/7/17 at approximately 9:00 A.M., direct care staff P reported he/she witnessed direct care staff O physically abuse the resident on 7/6/17 at approximately 2:00 P.M. Licensed nursing staff C immediately reported the incident to administrative staff B. He/she stated all allegations or witnessed abuse should be reported within two hours to the director of nursing (DON) or the administrator. On 7/10/17 at 5:00 P.M., resident #1 stated a staff member hurt him/her and slapped him/her. On 7/10/17 at 5:07 P.M., administrative nursing staff D stated he/she expected staff to immediately protect the resident after an abuse allegation and immediately report all incidents of abuse to their charge nurse and administrative staff. On 7/11/17 at 7:45 A.M., licensed nursing staff J stated he/she had no knowledge of the incident between direct care staff O and resident #1 until 7/7/17 when the assistant administrator escorted direct care staff O out of the facility. Licensed nursing staff J stated allegations or witnessed abuse should be reported to the administrator and DON immediately or within two hours. On 7/11/17 at 7:50 A.M., administrative staff B stated licensed nursing staff C informed him/her of the incident between direct care staff O and resident #1 on 7/7/17 at approximately 9:00 A.M. He/she stated licensed nursing staff C reported to him/her that direct care staff P witnessed direct care staff O slap the resident in the face. Administrative staff B stated he/she immediately suspended direct care staff O during the investigation and he/she expected staff to immediately report witnessed abuse or allegations. Review of the facility provided Freedom from Abuse, Neglect, and Exploitation policy dated November 2016 documented the Centers for Medicare and Medicaid Services (CMS) believed reporting immediately meant not later than two hours after the allegation was made if the events that caused the allegation involved abuse. The policy further documented any observed or reported violation of the resident safety policy should be reported immediately to the supervisor and administrator without fear of reprisal. The facility failed to protect this cognitively impaired resident from verbal and physical abuse, allowed direct care staff O to continue to provide care to residents on the unit, and did not immediately report the witnessed abuse to administrative staff. This deficient practice placed 24 residents on one unit in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G. - The clinical record documented the facility admitted resident #2 on 2/12/17 with the [DIAGNOSES REDACTED]. response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent for toileting. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent with toileting. The Care Area Assessment (CAA) dated 2/23/17 for incontinence (loss of bladder control) documented the resident was continent (able to control the bladder) of bladder and had a [MEDICAL CONDITION] bag which staff and the resident managed. The care plan revised on 4/17/17 for incontinence documented the resident had a [MEDICAL CONDITION] and needed help with its management. The care plan directed staff to empty the [MEDICAL CONDITION] bag as needed and to change the bag as ordered and as needed. The clinical record lacked evidence of documentation of appropriate interventions to protect the resident from sexual abuse and mental anguish after the resident shared his/her concerns with staff on 7/5/17, 7/6/17, and 7/7/17. Direct care staff Q's timesheet documented he/she worked in the facility on one unit where 24 residents resided until 7/7/17 at 6:15 P.M. On 7/11/17 at 10:09 A.M., resident #2 stated direct care staff Q harassed him/her for months. The resident stated staff Q frequently entered his/her bathroom without knocking, when he/she was in the restroom with his/her body parts exposed. The resident stated staff Q stood and stared at him/her for some time, and then pretended it had not happened. The resident stated staff Q made him/her feel very uncomfortable. The resident denied he/she required staff assistance with toileting. The resident further stated staff Q took away his/her privacy and dignity, and made him/her feel violated by repeatedly entering the bathroom when he/she was in there. The resident stated this happened multiple times over several months and he/she decided to tell licensed nursing staff H, because he/she could not stand it any longer. The resident stated he/she had concerns about the well-being of other residents that were less independent. On 7/11/17 at 10:20 A.M., resident #3 (resident #2's roommate) stated direct care staff Q acted rude and unprofessional. He/she stated staff Q was a bully and had instructed him/her not to use the call light when he/she needed assistance. On 7/11/17 at 12:15 P.M. licensed nursing staff H confirmed resident #2 informed him/her on 7/5/17 that direct care staff Q watched him/her in the bathroom and it made him/her uncomfortable, because he/she was undressed. Staff H stated he/she then informed administrative nursing staff I about the situation. Staff I instructed staff H not to allow staff Q to enter resident #2's room anymore. Staff H further stated resident #2 then reported again to him/her on the following day (7/6/17) that staff Q entered his/her room again the night before. Staff H stated resident #2 made it very clear he/she did not want staff Q anywhere near him/her. Staff H stated he/she then reported to administrative nursing staff C. Staff H then stated on the following day (7/7/17) resident 2 observed staff Q again on the unit, and that was when resident #2 became extremely upset and threatened to report the facility to the state agency. On 7/11/17 at 1:05 P.M., administrative nursing staff G stated resident #2 reported to administrative nursing staff F on 7/7/17 that he/she wanted something done about direct care staff Q. He/she added he/she then interviewed several residents about staff Q. On 7/11/17 at 2:01 P.M., administrative nursing staff C stated he/she remembered first hearing about the situation with staff Q and resident #2 in an email the week before. He/she stated administrative nursing staff I and D were both aware of the situation before Friday 7/7/17. He/she stated administrative staff chose to have staff Q change assignments and then units (which potentially exposed a different group of residents to staff Q's abusive behavior) however, he/she stated the information was never passed on during shift change. Staff C further stated he/she was unaware if administrative staff B was aware of the situation. On 7/11/17 at 2:21 P.M., administrative nursing staff E stated there was to be a change in staff Q's assignment at the end of last week 7/6/17, but the information was not relayed by the nurses during shift change report, so staff Q continued to provide care for resident #2. Staff E further stated the situation heightened on Friday afternoon, 7/7/17, when resident #2 became very upset. He/she stated together with administrative nursing staff F and administrative staff B, they decided to send staff Q home. Staff Q was suspended and left the building on 7/7/17 at 6:15 P.M. (2 days after resident #2 first told a staff member he/she was uncomfortable with and harassed by staff Q). On 7/11/17 at 2:50 P.M., administrative nursing staff F stated he/she was unaware of the situation until 7/7/17 at 4:45 P.M. when resident #2 approached him/her and informed him/her about staff Q watching him/her in the bathroom. Staff F stated the resident removed all of his/her clothing when he/she performed his/her [MEDICAL CONDITION] care, because he/she didn't want to risk getting his/her clothing soiled. When he/she was naked in the bathroom, staff Q would come in, unannounced, and linger, while he/she stared at the resident's body. The resident stated it felt like he/she was being raped. Staff F offered for resident #2 to call local law enforcement, which then occurred. Staff F stated after the police left, administrative staff B suspended staff Q. On 7/11/17 at 3:20 P.M., administrative staff B stated he/she was unaware of any problems between resident #2 and staff Q before the afternoon of 7/7/17. He/she stated he/she expected administrative nursing staff I and administrative nursing staff D to inform himself/herself of potential problems related to staff Q and resident #2. The facility's Abuse, Neglect, and Exploitation, Freedom From Policy, revised November 2016, documented residents had the right to be free from inappropriate or unusual behavior with the following examples to be considered sexual, and to be reported to a supervisor and/or administrator immediately: not allowing privacy to dress or undress, not providing a gown or draping unless emergent situation, any behavior, gestures, or expression that may reasonably be interpreted as seductive or sexual, sexually demeaning behavior, including but not limited to, any verbal or physical contact which may reasonably be interpreted as demeaning, humiliating, embarrassing, threatening, or harmful. The facility failed to protect 24 residents from sexual abuse from direct care staff Q and immediately report the allegations when resident #2 told staff he/she was uncomfortable with Staff Q providing care and felt harassed and raped by Staff Q while performing self-care in the bathroom in Staff Q's presence. This deficient practice placed 24 residents on one unit in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G. - Review of direct care staff R's personnel file documented the facility hired him/her on 11/18/14 and submitted the criminal background check request on 11/25/14. The facility lacked evidence of registry verification prior to 2/3/16. Review of direct care staff O's personnel file documented the facility hired him/her on 12/27/2001. The facility lacked evidence of registry verification prior to 2/3/2008 and the criminal background check was undated. Review of housekeeping staff S's personnel file documented the facility hired him/her on 4/18/17 and submitted the criminal background check request on 6/2/17. Review of dietary staff T's personnel file documented the facility hired him/her on 2/21/17. The facility lacked evidence of a criminal background check. Review of direct care staff U's personnel file documented the facility hired him/her on 4/25/17 and submitted the criminal background check request on 6/2/17. On 7/12/17 at 1:45 P.M., administrative staff K confirmed he/she did not submit the criminal background check on staff until after they completed orientation because there was a lot of employee turnover. Administrative staff K verified the personnel file for direct care staff R and O lacked documentation of a registry verification. He/she stated all direct care staff should have registry verification and all licensed nursing staff should have license verification prior to their hire date. The facility-provided Freedom from Abuse, Neglect, and Exploitation policy, dated November 2016, documented all new employees would receive a reference check, criminal background check, and registry verification would be verified. The facility failed to ensure five employees had registry verification and a criminal background check prior to allowing them to work with residents.

The facility identified a census of 190 residents. Based on record review and interview, the facility failed to implement their written policies and procedures for the screening and training of employees, protection of residents, and for the prevention, identification, and reporting of abuse. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The quarterly MDS dated [DATE] documented a BIMS score of 9, which indicated moderately impaired cognition. The Care Area assessment dated [DATE] for Cognitive Loss and Dementia documented the resident had severe to moderate cognitive impairment and a [DIAGNOSES REDACTED]. The care plan revised 7/7/17 documented the resident had cognitive loss and impaired memory and directed staff to tell the resident what they were going to do prior to providing nursing care. Review of the facility's investigation dated 7/7/17 documented on 7/6/17, direct care staff P witnessed direct care staff O slap resident #1 in the face. Direct care staff P stated he/she heard direct care staff O ask the resident if he/she wanted to fight him/her. Direct care staff P witnessed direct care staff O slap the resident in the face, and the resident raised his/her hands in a defensive pose. Direct care staff P reported the witnessed abuse on 7/7/17 at 9:30 A.M. and direct care staff O was suspended. A typed interview with resident #1 by social service staff F dated 7/7/17 documented the resident stated he/she was in pain and staff slapped him/her. The notarized witness statement dated 7/7/17 by direct care staff P documented on 7/6/17, he/she entered resident #1's room to look for the mechanical lift. Direct care staff P heard direct care staff O ask the resident in a stern voice if he/she wanted to fight. Direct care staff P observed direct care staff O slap the resident in the face. The resident appeared terrified and put his/her hands up in defense. The notarized witness statement dated 7/7/17 by licensed nursing staff C documented direct care staff P reported on 7/7/17 he/she observed direct care staff O slap resident #1 in the face on 7/6/17, and the resident appeared frightened and startled. Licensed nursing staff C reported the incident to administrative staff B. The notarized witness statement dated 7/10/17 by direct care staff O documented he/she liked to play with the resident and make him/her laugh. Direct care staff O stated he/she was playing with the resident and nothing else happened. Direct care staff O's timesheet documented he/she worked in the facility on 7/6/17 from 6:30 A.M. until 3:00 P.M., and on 7/7/17 from 6:30 A.M. until 9:45 A.M. On 7/10/17 at 5:00 P.M., the resident sat in his/her wheelchair and watched television. On 7/10/17 at 3:10 P.M., direct care staff P stated on 7/6/17 at approximately 2:00 P.M., he/she entered the resident's room to look for the mechanical lift. He/she heard direct care staff O ask the resident if he/she wanted to fight, and he/she observed direct care staff O slap the resident across the face. Staff P further stated the resident raised his/her hands in a defensive motion. Direct care staff P stated what he/she witnessed shocked him/her, he/she immediately left the resident's room and thought he/she had 24 hours to report the incident. Direct care staff P stated he/she reported the witnessed abuse on 7/7/17 at approximately 8:00 A.M. to licensed nursing staff C. On 7/10/17 at 4:40 P.M., licensed nursing staff C stated on 7/7/17 at approximately 9:00 A.M., direct care staff P reported he/she witnessed direct care staff O physically abuse the resident on 7/6/17 at approximately 2:00 P.M. Licensed nursing staff C immediately reported the incident to administrative staff B. He/she stated all allegations or witnessed abuse should be reported within two hours to the director of nursing (DON) or the administrator. On 7/10/17 at 5:00 P.M., resident #1 stated a staff member hurt him/her and slapped him/her. On 7/10/17 at 5:07 P.M., administrative nursing staff D stated he/she expected staff to immediately protect the resident after an abuse allegation and immediately report all incidents of abuse to their charge nurse and administrative staff. On 7/11/17 at 7:45 A.M., licensed nursing staff J stated he/she had no knowledge of the incident between direct care staff O and resident #1 until 7/7/17 when the assistant administrator escorted direct care staff O out of the facility. Licensed nursing staff J stated allegations or witnessed abuse should be reported to the administrator and DON immediately or within two hours. On 7/11/17 at 7:50 A.M., administrative staff B stated licensed nursing staff C informed him/her of the incident between direct care staff O and resident #1 on 7/7/17 at approximately 9:00 A.M. He/she stated licensed nursing staff C reported to him/her that direct care staff P witnessed direct care staff O slap the resident in the face. Administrative staff B stated he/she immediately suspended direct care staff O during the investigation and he/she expected staff to immediately report witnessed abuse or allegations. Review of the facility-provided Freedom from Abuse, Neglect, and Exploitation policy, dated November 2016, documented the Centers for Medicare and Medicaid Services (CMS) believed reporting immediately meant not later than two hours after the allegation was made if the events that caused the allegation involved abuse. The policy further documented any observed or reported violation of the resident safety policy should be reported immediately to the supervisor and administrator without fear of reprisal. The facility failed to implement their written policy regarding reporting allegations of abuse for the protection of the residents and prevention of abuse. - Review of direct care staff R's personnel file documented the facility hired him/her on 11/18/14 and submitted the criminal background check request on 11/25/14. The facility lacked evidence of registry verification prior to 2/3/16. Review of direct care staff O's personnel file documented the facility hired him/her on 12/27/2001. The facility lacked evidence of registry verification prior to 2/3/2008 and the criminal background check was undated. Review of housekeeping staff S's personnel file documented the facility hired him/her on 4/18/17 and submitted the criminal background check request on 6/2/17. Review of dietary staff T's personnel file documented the facility hired him/her on 2/21/17. The facility lacked evidence of a criminal background check. Review of direct care staff U's personnel file documented the facility hired him/her on 4/25/17 and submitted the criminal background check request on 6/2/17. On 7/12/17 at 1:45 P.M., administrative staff K confirmed he/she did not submit the criminal background check on staff until after they had completed orientation because there was a lot of employee turnover. Administrative staff K verified the personnel file for direct care staff R and O lacked documentation of a registry verification. He/she stated all direct care staff should have registry verification and all licensed nursing staff should have license verification prior to their hire date. The facility-provided Freedom from Abuse, Neglect, and Exploitation policy, dated November 2016, documented all new employees would receive a reference check, criminal background check, and registry verification would be verified. The facility failed to implement their written policy regarding screening of employees.

The facility reported a census of 190 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to provide an environment free from verbal intimidation and physical abuse from direct care staff O when he/she spoke inappropriately to resident #1 on 7/6/17, and from direct care staff Q when he/she sexually and emotionally abused resident #2 on 7/5/17. This deficient practice placed residents #1 and #2 in immediate jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The quarterly MDS dated [DATE] documented a BIMS score of 9, which indicated moderately impaired cognition. The Care Area assessment dated [DATE] for Cognitive Loss and Dementia documented the resident had severe to moderate cognitive impairment and a [DIAGNOSES REDACTED]. The care plan revised 7/7/17 documented the resident had cognitive loss and impaired memory and directed staff to tell the resident what they were going to do prior to providing nursing care. Review of the facility's investigation dated 7/7/17 documented on 7/6/17, direct care staff P witnessed direct care staff O slap resident #1 in the face. Direct care staff P stated he/she heard direct care staff O ask the resident if he/she wanted to fight him/her. Direct care staff P witnessed direct care staff O slap the resident in the face, and the resident raised his/her hands in a defensive pose. Direct care staff P reported the witnessed abuse on 7/7/17 at 9:30 A.M. and direct care staff O was suspended. A typed interview with resident #1 by social service staff F dated 7/7/17 documented the resident stated he/she was in pain and staff slapped him/her. The notarized witness statement dated 7/7/17 by direct care staff P documented on 7/6/17, he/she entered resident #1's room to look for the mechanical lift. Direct care staff P heard direct care staff O ask the resident in a stern voice if he/she wanted to fight. Direct care staff P observed direct care staff O slap the resident in the face. The resident appeared terrified and put his/her hands up in defense. The notarized witness statement dated 7/7/17 by licensed nursing staff C documented direct care staff P reported on 7/7/17 he/she observed direct care staff O slap resident #1 in the face on 7/6/17, and the resident appeared frightened and startled. Licensed nursing staff C reported the incident to administrative staff B. The notarized witness statement dated 7/10/17 by direct care staff O documented he/she liked to play with the resident and make him/her laugh. Direct care staff O stated he/she was playing with the resident and nothing else happened. Direct care staff O's timesheet documented he/she worked in the facility on 7/6/17 from 6:30 A.M. until 3:00 P.M., and on 7/7/17 from 6:30 A.M. until 9:45 A.M. On 7/10/17 at 5:00 P.M., the resident sat in his/her wheelchair and watched television. On 7/10/17 at 3:10 P.M., direct care staff P stated on 7/6/17 at approximately 2:00 P.M., he/she entered the resident's room to look for the mechanical lift. He/she heard direct care staff O ask the resident if he/she wanted to fight, and he/she observed direct care staff O slap the resident across the face. Staff P further stated the resident raised his/her hands in a defensive motion. Direct care staff P stated what he/she witnessed shocked him/her, he/she immediately left the resident's room and thought he/she had 24 hours to report the incident. Direct care staff P stated he/she reported the witnessed abuse on 7/7/17 at approximately 8:00 A.M. to licensed nursing staff C. On 7/10/17 at 4:40 P.M., licensed nursing staff C stated on 7/7/17 at approximately 9:00 A.M., direct care staff P reported he/she witnessed direct care staff O physically abuse the resident on 7/6/17 at approximately 2:00 P.M. Licensed nursing staff C immediately reported the incident to administrative staff B. He/she stated all allegations or witnessed abuse should be reported within two hours to the director of nursing (DON) or the administrator. On 7/10/17 at 5:00 P.M., resident #1 stated a staff member hurt him/her and slapped him/her. On 7/10/17 at 5:07 P.M., administrative nursing staff D stated he/she expected staff to immediately protect the resident after an abuse allegation and immediately report all incidents of abuse to their charge nurse and administrative staff. On 7/11/17 at 7:45 A.M., licensed nursing staff J stated he/she had no knowledge of the incident between direct care staff O and resident #1 until 7/7/17 when the assistant administrator escorted direct care staff O out of the facility. Licensed nursing staff J stated allegations or witnessed abuse should be reported to the administrator and DON immediately or within two hours. On 7/11/17 at 7:50 A.M., administrative staff B stated licensed nursing staff C informed him/her of the incident between direct care staff O and resident #1 on 7/7/17 at approximately 9:00 A.M. He/she stated licensed nursing staff C reported to him/her that direct care staff P witnessed direct care staff O slap the resident in the face. Administrative staff B stated he/she immediately suspended direct care staff O during the investigation and he/she expected staff to immediately report witnessed abuse or allegations. Review of the facility provided Freedom from Abuse, Neglect, and Exploitation policy dated November 2016 documented the Centers for Medicare and Medicaid Services (CMS) believed reporting immediately meant not later than two hours after the allegation was made if the events that caused the allegation involved abuse. The policy further documented any observed or reported violation of the resident safety policy should be reported immediately to the supervisor and administrator without fear of reprisal. The facility failed to provide an environment free from physical abuse for this cognitively impaired resident. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G. - The clinical record documented the facility admitted resident #2 on 2/12/17 with the [DIAGNOSES REDACTED]. response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent for toileting. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent with toileting. The Care Area Assessment (CAA) dated 2/23/17 for incontinence (loss of bladder control) documented the resident was continent (able to control the bladder) of bladder and had a [MEDICAL CONDITION] bag which staff and the resident managed. The care plan revised on 4/17/17 for incontinence documented the resident had a [MEDICAL CONDITION] and needed help with its management. The care plan directed staff to empty the [MEDICAL CONDITION] bag as needed and to change the bag as ordered and as needed. The clinical record lacked evidence of documentation of appropriate interventions to protect the resident from sexual abuse and mental anguish after the resident shared his/her concerns with staff on 7/5/17, 7/6/17, and 7/7/17. Direct care staff Q's timesheet documented he/she worked in the facility on one unit until 7/7/17 at 6:15 P.M. On 7/11/17 at 10:09 A.M., resident #2 stated direct care staff Q harassed him/her for months. The resident stated staff Q frequently entered his/her bathroom without knocking, when he/she was in the restroom with his/her body parts exposed. The resident stated staff Q stood and stared at him/her for some time, and then pretended it had not happened. The resident stated staff Q made him/her feel very uncomfortable. The resident denied he/she required staff assistance with toileting. The resident further stated staff Q took away his/her privacy and dignity, and made him/her feel violated by repeatedly entering the bathroom when he/she was in there. The resident stated this happened multiple times over several months and he/she decided to tell licensed nursing staff H, because he/she could not stand it any longer. The resident stated he/she had concerns about the well-being of other residents that were less independent. On 7/11/17 at 10:20 A.M., resident #3 (resident #2's roommate) stated direct care staff Q acted rude and unprofessional. He/she stated staff Q was a bully and had instructed him/her not to use the call light when he/she needed assistance. On 7/11/17 at 12:15 P.M. licensed nursing staff H confirmed resident #2 informed him/her on 7/5/17 that direct care staff Q watched him/her in the bathroom and it made him/her uncomfortable, because he/she was undressed. Staff H stated he/she then informed administrative nursing staff I about the situation. Staff I instructed staff H not to allow staff Q to enter resident #2's room anymore. Staff H further stated resident #2 then reported again to him/her on the following day (7/6/17) that staff Q entered his/her room again the night before. Staff H stated resident #2 made it very clear he/she did not want staff Q anywhere near him/her. Staff H stated he/she then reported to administrative nursing staff C. Staff H then stated on the following day (7/7/17) resident #2 observed staff Q again on the unit, and that was when resident #2 became extremely upset and threatened to report the facility to the state agency. On 7/11/17 at 1:05 P.M., administrative nursing staff G stated resident #2 reported to administrative nursing staff F on 7/7/17 that he/she wanted something done about direct care staff Q. He/she added he/she then interviewed several residents about staff Q. On 7/11/17 at 2:01 P.M., administrative nursing staff C stated he/she remembered first hearing about the situation with staff Q and resident #2 in an email the week before. He/she stated administrative nursing staff I and D were both aware of the situation before Friday 7/7/17. He/she stated administrative staff chose to have staff Q change assignments and then units (which potentially exposed a different group of residents to staff Q's abusive behavior) however, he/she stated the information was never passed on during shift change. Staff C further stated he/she was unaware if administrative staff B was aware of the situation. On 7/11/17 at 2:21 P.M., administrative nursing staff E stated there was to be a change in staff Q's assignment at the end of last week 7/6/17, but the information was not relayed by the nurses during shift change report, so staff Q continued to provide care for resident #2. Staff E further stated the situation heightened on Friday afternoon, 7/7/17, when resident #2 became very upset. He/she stated together with administrative nursing staff F and administrative staff B, they decided to send staff Q home. Staff Q was suspended and left the building on 7/7/17 at 6:15 P.M. (2 days after resident #2 first told a staff member he/she was uncomfortable with and harassed by staff Q). On 7/11/17 at 2:50 P.M., administrative nursing staff F stated he/she was unaware of the situation until 7/7/17 at 4:45 P.M. when resident #2 approached him/her and informed him/her about staff Q watching him/her in the bathroom. Staff F stated the resident removed all of his/her clothing when he/she performed his/her [MEDICAL CONDITION] care, because he/she didn't want to risk getting his/her clothing soiled. When he/she was naked in the bathroom, staff Q would come in, unannounced, and linger, while he/she stared at the resident's body. The resident stated it felt like he/she was being raped. Staff F offered for resident #2 to call local law enforcement, which then occurred. Staff F stated after the police left, administrative staff B suspended staff Q. On 7/11/17 at 3:20 P.M., administrative staff B stated he/she was unaware of any problems between resident #2 and staff Q before the afternoon of 7/7/17. He/she stated he/she expected administrative nursing staff I and administrative nursing staff D to inform himself/herself of potential problems related to staff Q and resident #2. The facility's Abuse, Neglect, and Exploitation, Freedom From Policy, revised November 2016, documented residents had the right to be free from inappropriate or unusual behavior with the following examples to be considered sexual, and to be reported to a supervisor and/or administrator immediately: not allowing privacy to dress or undress, not providing a gown or draping unless emergent situation, any behavior, gestures, or expression that may reasonably be interpreted as seductive or sexual, sexually demeaning behavior, including but not limited to, any verbal or physical contact which may reasonably be interpreted as demeaning, humiliating, embarrassing, threatening, or harmful. The facility failed to provide an environment free from sexual abuse for resident #2 from direct care staff Q when the resident told staff he/she was uncomfortable with Staff Q providing care, he/she felt harassed and raped by Staff Q while performing self-care in the bathroom in Staff Q's presence. This deficient practice placed resident #2 in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G.

The facility reported a census of 190 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to protect 24 residents on one unit from verbal intimidation and physical abuse when direct care staff O spoke inappropriately and physically abused resident #1 on 7/6/17. Direct care staff P witnessed the abuse and failed to immediately report the incident to administrative staff. Direct care staff O continued to work, providing care for the remainder of the shift on 7/6/17, and returned to work on 7/7/17, providing care until 9:45 A.M. Furthermore, the facility failed to protect an additional 24 residents on another unit from sexual abuse and mental anguish when direct care staff Q violated resident #2's privacy while he/she was nude. Licensed nursing staff H, C, and I had knowledge of the allegation and failed to immediately report it to administrative staff. Direct care staff Q continued to work, providing care until 7/7/17 at 6:15 P.M. This deficient practice placed 48 residents on 2 of 9 halls in immediate jeopardy. The facility also failed to provide evidence of registry verification and criminal background check for five staff prior to allowing the staff to work in the facility. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The quarterly MDS dated [DATE] documented a BIMS score of 9, which indicated moderately impaired cognition. The Care Area assessment dated [DATE] for Cognitive Loss and Dementia documented the resident had severe to moderate cognitive impairment and a [DIAGNOSES REDACTED]. The care plan revised 7/7/17 documented the resident had cognitive loss and impaired memory and directed staff to tell the resident what they were going to do prior to providing nursing care. Review of the facility's investigation dated 7/7/17 documented on 7/6/17, direct care staff P witnessed direct care staff O slap resident #1 in the face. Direct care staff P stated he/she heard direct care staff O ask the resident if he/she wanted to fight him/her. Direct care staff P witnessed direct care staff O slap the resident in the face, and the resident raised his/her hands in a defensive pose. Direct care staff P reported the witnessed abuse on 7/7/17 at 9:30 A.M. and direct care staff O was suspended. A typed interview with resident #1 by social service staff F dated 7/7/17 documented the resident stated he/she was in pain and staff slapped him/her. The notarized witness statement dated 7/7/17 by direct care staff P documented on 7/6/17, he/she entered resident #1's room to look for the mechanical lift. Direct care staff P heard direct care staff O ask the resident in a stern voice if he/she wanted to fight. Direct care staff P observed direct care staff O slap the resident in the face. The resident appeared terrified and put his/her hands up in defense. The notarized witness statement dated 7/7/17 by licensed nursing staff C documented direct care staff P reported on 7/7/17 he/she observed direct care staff O slap resident #1 in the face on 7/6/17, and the resident appeared frightened and startled. Licensed nursing staff C reported the incident to administrative staff B. The notarized witness statement dated 7/10/17 by direct care staff O documented he/she liked to play with the resident and make him/her laugh. Direct care staff O stated he/she was playing with the resident and nothing else happened. Direct care staff O's timesheet documented he/she worked in the facility on 7/6/17 from 6:30 A.M. until 3:00 P.M., and on 7/7/17 from 6:30 A.M. until 9:45 A.M. The staffing schedule documented direct care staff O was assigned to a unit where 24 residents resided. On 7/10/17 at 5:00 P.M., the resident sat in his/her wheelchair and watched television. On 7/10/17 at 3:10 P.M., direct care staff P stated on 7/6/17 at approximately 2:00 P.M., he/she entered the resident's room to look for the mechanical lift. He/she heard direct care staff O ask the resident if he/she wanted to fight, and he/she observed direct care staff O slap the resident across the face. Staff P further stated the resident raised his/her hands in a defensive motion. Direct care staff P stated what he/she witnessed shocked him/her, he/she immediately left the resident's room and thought he/she had 24 hours to report the incident. Direct care staff P stated he/she reported the witnessed abuse on 7/7/17 at approximately 8:00 A.M. to licensed nursing staff C. On 7/10/17 at 4:40 P.M., licensed nursing staff C stated on 7/7/17 at approximately 9:00 A.M., direct care staff P reported he/she witnessed direct care staff O physically abuse the resident on 7/6/17 at approximately 2:00 P.M. Licensed nursing staff C immediately reported the incident to administrative staff B. He/she stated all allegations or witnessed abuse should be reported within two hours to the director of nursing (DON) or the administrator. On 7/10/17 at 5:00 P.M., resident #1 stated a staff member hurt him/her and slapped him/her. On 7/10/17 at 5:07 P.M., administrative nursing staff D stated he/she expected staff to immediately protect the resident after an abuse allegation and immediately report all incidents of abuse to their charge nurse and administrative staff. On 7/11/17 at 7:45 A.M., licensed nursing staff J stated he/she had no knowledge of the incident between direct care staff O and resident #1 until 7/7/17 when the assistant administrator escorted direct care staff O out of the facility. Licensed nursing staff J stated allegations or witnessed abuse should be reported to the administrator and DON immediately or within two hours. On 7/11/17 at 7:50 A.M., administrative staff B stated licensed nursing staff C informed him/her of the incident between direct care staff O and resident #1 on 7/7/17 at approximately 9:00 A.M. He/she stated licensed nursing staff C reported to him/her that direct care staff P witnessed direct care staff O slap the resident in the face. Administrative staff B stated he/she immediately suspended direct care staff O during the investigation and he/she expected staff to immediately report witnessed abuse or allegations. Review of the facility provided Freedom from Abuse, Neglect, and Exploitation policy dated November 2016 documented the Centers for Medicare and Medicaid Services (CMS) believed reporting immediately meant not later than two hours after the allegation was made if the events that caused the allegation involved abuse. The policy further documented any observed or reported violation of the resident safety policy should be reported immediately to the supervisor and administrator without fear of reprisal. The facility failed to protect this cognitively impaired resident from verbal and physical abuse, allowed direct care staff O to continue to provide care to residents on the unit, and did not immediately report the witnessed abuse to administrative staff. This deficient practice placed 24 residents on one unit in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G. - The clinical record documented the facility admitted resident #2 on 2/12/17 with the [DIAGNOSES REDACTED]. response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent for toileting. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident was able make himself/herself understood and was completely independent with toileting. The Care Area Assessment (CAA) dated 2/23/17 for incontinence (loss of bladder control) documented the resident was continent (able to control the bladder) of bladder and had a [MEDICAL CONDITION] bag which staff and the resident managed. The care plan revised on 4/17/17 for incontinence documented the resident had a [MEDICAL CONDITION] and needed help with its management. The care plan directed staff to empty the [MEDICAL CONDITION] bag as needed and to change the bag as ordered and as needed. The clinical record lacked evidence of documentation of appropriate interventions to protect the resident from sexual abuse and mental anguish after the resident shared his/her concerns with staff on 7/5/17, 7/6/17, and 7/7/17. Direct care staff Q's timesheet documented he/she worked in the facility on one unit where 24 residents resided until 7/7/17 at 6:15 P.M. On 7/11/17 at 10:09 A.M., resident #2 stated direct care staff Q harassed him/her for months. The resident stated staff Q frequently entered his/her bathroom without knocking, when he/she was in the restroom with his/her body parts exposed. The resident stated staff Q stood and stared at him/her for some time, and then pretended it had not happened. The resident stated staff Q made him/her feel very uncomfortable. The resident denied he/she required staff assistance with toileting. The resident further stated staff Q took away his/her privacy and dignity, and made him/her feel violated by repeatedly entering the bathroom when he/she was in there. The resident stated this happened multiple times over several months and he/she decided to tell licensed nursing staff H, because he/she could not stand it any longer. The resident stated he/she had concerns about the well-being of other residents that were less independent. On 7/11/17 at 10:20 A.M., resident #3 (resident #2's roommate) stated direct care staff Q acted rude and unprofessional. He/she stated staff Q was a bully and had instructed him/her not to use the call light when he/she needed assistance. On 7/11/17 at 12:15 P.M. licensed nursing staff H confirmed resident #2 informed him/her on 7/5/17 that direct care staff Q watched him/her in the bathroom and it made him/her uncomfortable, because he/she was undressed. Staff H stated he/she then informed administrative nursing staff I about the situation. Staff I instructed staff H not to allow staff Q to enter resident #2's room anymore. Staff H further stated resident #2 then reported again to him/her on the following day (7/6/17) that staff Q entered his/her room again the night before. Staff H stated resident #2 made it very clear he/she did not want staff Q anywhere near him/her. Staff H stated he/she then reported to administrative nursing staff C. Staff H then stated on the following day (7/7/17) resident 2 observed staff Q again on the unit, and that was when resident #2 became extremely upset and threatened to report the facility to the state agency. On 7/11/17 at 1:05 P.M., administrative nursing staff G stated resident #2 reported to administrative nursing staff F on 7/7/17 that he/she wanted something done about direct care staff Q. He/she added he/she then interviewed several residents about staff Q. On 7/11/17 at 2:01 P.M., administrative nursing staff C stated he/she remembered first hearing about the situation with staff Q and resident #2 in an email the week before. He/she stated administrative nursing staff I and D were both aware of the situation before Friday 7/7/17. He/she stated administrative staff chose to have staff Q change assignments and then units (which potentially exposed a different group of residents to staff Q's abusive behavior) however, he/she stated the information was never passed on during shift change. Staff C further stated he/she was unaware if administrative staff B was aware of the situation. On 7/11/17 at 2:21 P.M., administrative nursing staff E stated there was to be a change in staff Q's assignment at the end of last week 7/6/17, but the information was not relayed by the nurses during shift change report, so staff Q continued to provide care for resident #2. Staff E further stated the situation heightened on Friday afternoon, 7/7/17, when resident #2 became very upset. He/she stated together with administrative nursing staff F and administrative staff B, they decided to send staff Q home. Staff Q was suspended and left the building on 7/7/17 at 6:15 P.M. (2 days after resident #2 first told a staff member he/she was uncomfortable with and harassed by staff Q). On 7/11/17 at 2:50 P.M., administrative nursing staff F stated he/she was unaware of the situation until 7/7/17 at 4:45 P.M. when resident #2 approached him/her and informed him/her about staff Q watching him/her in the bathroom. Staff F stated the resident removed all of his/her clothing when he/she performed his/her [MEDICAL CONDITION] care, because he/she didn't want to risk getting his/her clothing soiled. When he/she was naked in the bathroom, staff Q would come in, unannounced, and linger, while he/she stared at the resident's body. The resident stated it felt like he/she was being raped. Staff F offered for resident #2 to call local law enforcement, which then occurred. Staff F stated after the police left, administrative staff B suspended staff Q. On 7/11/17 at 3:20 P.M., administrative staff B stated he/she was unaware of any problems between resident #2 and staff Q before the afternoon of 7/7/17. He/she stated he/she expected administrative nursing staff I and administrative nursing staff D to inform himself/herself of potential problems related to staff Q and resident #2. The facility's Abuse, Neglect, and Exploitation, Freedom From Policy, revised November 2016, documented residents had the right to be free from inappropriate or unusual behavior with the following examples to be considered sexual, and to be reported to a supervisor and/or administrator immediately: not allowing privacy to dress or undress, not providing a gown or draping unless emergent situation, any behavior, gestures, or expression that may reasonably be interpreted as seductive or sexual, sexually demeaning behavior, including but not limited to, any verbal or physical contact which may reasonably be interpreted as demeaning, humiliating, embarrassing, threatening, or harmful. The facility failed to protect 24 residents from sexual abuse from direct care staff Q and immediately report the allegations when resident #2 told staff he/she was uncomfortable with Staff Q providing care and felt harassed and raped by Staff Q while performing self-care in the bathroom in Staff Q's presence. This deficient practice placed 24 residents on one unit in immediate jeopardy. The facility abated the immediate jeopardy on 7/12/17 at 5:00 P.M. by initiating the following: direct care staff O and direct care staff Q were immediately suspended pending the facility investigation. All personnel would be in-serviced by 7/13/17 at 5:00 P.M. on the Policy and Procedure titled Abuse Neglect and Exploitation with an emphasis of timely reporting. Ongoing, the above policy would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would be in-serviced prior to returning to work. The community would continue thorough background checks on new hires. The community would continue to call on reference checks prior to hiring new staff. The community had posted signs throughout the building on the importance of timely reporting. The nurse educator would monitor the staff completion of compliance training on the community policy and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months, then as indicated by the QAPI Committee. The social services staff would interview 5 residents monthly and report findings to the QAPI Committee monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of G. - Review of direct care staff R's personnel file documented the facility hired him/her on 11/18/14 and submitted the criminal background check request on 11/25/14. The facility lacked evidence of registry verification prior to 2/3/16. Review of direct care staff O's personnel file documented the facility hired him/her on 12/27/2001. The facility lacked evidence of registry verification prior to 2/3/2008 and the criminal background check was undated. Review of housekeeping staff S's personnel file documented the facility hired him/her on 4/18/17 and submitted the criminal background check request on 6/2/17. Review of dietary staff T's personnel file documented the facility hired him/her on 2/21/17. The facility lacked evidence of a criminal background check. Review of direct care staff U's personnel file documented the facility hired him/her on 4/25/17 and submitted the criminal background check request on 6/2/17. On 7/12/17 at 1:45 P.M., administrative staff K confirmed he/she did not submit the criminal background check on staff until after they completed orientation because there was a lot of employee turnover. Administrative staff K verified the personnel file for direct care staff R and O lacked documentation of a registry verification. He/she stated all direct care staff should have registry verification and all licensed nursing staff should have license verification prior to their hire date. The facility-provided Freedom from Abuse, Neglect, and Exploitation policy, dated November 2016, documented all new employees would receive a reference check, criminal background check, and registry verification would be verified. The facility failed to ensure five employees had registry verification and a criminal background check prior to allowing them to work with residents.

The facility identified a census of 190 residents. Based on record review and interview, the facility failed to implement their written policies and procedures for the screening and training of employees, protection of residents, and for the prevention, identification, and reporting of abuse. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The quarterly MDS dated [DATE] documented a BIMS score of 9, which indicated moderately impaired cognition. The Care Area assessment dated [DATE] for Cognitive Loss and Dementia documented the resident had severe to moderate cognitive impairment and a [DIAGNOSES REDACTED]. The care plan revised 7/7/17 documented the resident had cognitive loss and impaired memory and directed staff to tell the resident what they were going to do prior to providing nursing care. Review of the facility's investigation dated 7/7/17 documented on 7/6/17, direct care staff P witnessed direct care staff O slap resident #1 in the face. Direct care staff P stated he/she heard direct care staff O ask the resident if he/she wanted to fight him/her. Direct care staff P witnessed direct care staff O slap the resident in the face, and the resident raised his/her hands in a defensive pose. Direct care staff P reported the witnessed abuse on 7/7/17 at 9:30 A.M. and direct care staff O was suspended. A typed interview with resident #1 by social service staff F dated 7/7/17 documented the resident stated he/she was in pain and staff slapped him/her. The notarized witness statement dated 7/7/17 by direct care staff P documented on 7/6/17, he/she entered resident #1's room to look for the mechanical lift. Direct care staff P heard direct care staff O ask the resident in a stern voice if he/she wanted to fight. Direct care staff P observed direct care staff O slap the resident in the face. The resident appeared terrified and put his/her hands up in defense. The notarized witness statement dated 7/7/17 by licensed nursing staff C documented direct care staff P reported on 7/7/17 he/she observed direct care staff O slap resident #1 in the face on 7/6/17, and the resident appeared frightened and startled. Licensed nursing staff C reported the incident to administrative staff B. The notarized witness statement dated 7/10/17 by direct care staff O documented he/she liked to play with the resident and make him/her laugh. Direct care staff O stated he/she was playing with the resident and nothing else happened. Direct care staff O's timesheet documented he/she worked in the facility on 7/6/17 from 6:30 A.M. until 3:00 P.M., and on 7/7/17 from 6:30 A.M. until 9:45 A.M. On 7/10/17 at 5:00 P.M., the resident sat in his/her wheelchair and watched television. On 7/10/17 at 3:10 P.M., direct care staff P stated on 7/6/17 at approximately 2:00 P.M., he/she entered the resident's room to look for the mechanical lift. He/she heard direct care staff O ask the resident if he/she wanted to fight, and he/she observed direct care staff O slap the resident across the face. Staff P further stated the resident raised his/her hands in a defensive motion. Direct care staff P stated what he/she witnessed shocked him/her, he/she immediately left the resident's room and thought he/she had 24 hours to report the incident. Direct care staff P stated he/she reported the witnessed abuse on 7/7/17 at approximately 8:00 A.M. to licensed nursing staff C. On 7/10/17 at 4:40 P.M., licensed nursing staff C stated on 7/7/17 at approximately 9:00 A.M., direct care staff P reported he/she witnessed direct care staff O physically abuse the resident on 7/6/17 at approximately 2:00 P.M. Licensed nursing staff C immediately reported the incident to administrative staff B. He/she stated all allegations or witnessed abuse should be reported within two hours to the director of nursing (DON) or the administrator. On 7/10/17 at 5:00 P.M., resident #1 stated a staff member hurt him/her and slapped him/her. On 7/10/17 at 5:07 P.M., administrative nursing staff D stated he/she expected staff to immediately protect the resident after an abuse allegation and immediately report all incidents of abuse to their charge nurse and administrative staff. On 7/11/17 at 7:45 A.M., licensed nursing staff J stated he/she had no knowledge of the incident between direct care staff O and resident #1 until 7/7/17 when the assistant administrator escorted direct care staff O out of the facility. Licensed nursing staff J stated allegations or witnessed abuse should be reported to the administrator and DON immediately or within two hours. On 7/11/17 at 7:50 A.M., administrative staff B stated licensed nursing staff C informed him/her of the incident between direct care staff O and resident #1 on 7/7/17 at approximately 9:00 A.M. He/she stated licensed nursing staff C reported to him/her that direct care staff P witnessed direct care staff O slap the resident in the face. Administrative staff B stated he/she immediately suspended direct care staff O during the investigation and he/she expected staff to immediately report witnessed abuse or allegations. Review of the facility-provided Freedom from Abuse, Neglect, and Exploitation policy, dated November 2016, documented the Centers for Medicare and Medicaid Services (CMS) believed reporting immediately meant not later than two hours after the allegation was made if the events that caused the allegation involved abuse. The policy further documented any observed or reported violation of the resident safety policy should be reported immediately to the supervisor and administrator without fear of reprisal. The facility failed to implement their written policy regarding reporting allegations of abuse for the protection of the residents and prevention of abuse. - Review of direct care staff R's personnel file documented the facility hired him/her on 11/18/14 and submitted the criminal background check request on 11/25/14. The facility lacked evidence of registry verification prior to 2/3/16. Review of direct care staff O's personnel file documented the facility hired him/her on 12/27/2001. The facility lacked evidence of registry verification prior to 2/3/2008 and the criminal background check was undated. Review of housekeeping staff S's personnel file documented the facility hired him/her on 4/18/17 and submitted the criminal background check request on 6/2/17. Review of dietary staff T's personnel file documented the facility hired him/her on 2/21/17. The facility lacked evidence of a criminal background check. Review of direct care staff U's personnel file documented the facility hired him/her on 4/25/17 and submitted the criminal background check request on 6/2/17. On 7/12/17 at 1:45 P.M., administrative staff K confirmed he/she did not submit the criminal background check on staff until after they had completed orientation because there was a lot of employee turnover. Administrative staff K verified the personnel file for direct care staff R and O lacked documentation of a registry verification. He/she stated all direct care staff should have registry verification and all licensed nursing staff should have license verification prior to their hire date. The facility-provided Freedom from Abuse, Neglect, and Exploitation policy, dated November 2016, documented all new employees would receive a reference check, criminal background check, and registry verification would be verified. The facility failed to implement their written policy regarding screening of employees.

The facility identified a census of 200 residents. The sample included three residents for elopement risk. Based on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (#1). The resident eloped from the facility on 2/17/17, was found and picked up by police approximately 1/2 mile from the facility. This deficient practice placed cognitively impaired resident #1 in immediate jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with a history of transient ischemic attack (TIA) (a brief stroke-like attack that includes weakness on one side of the body, vision problems, and slurred speech that is transient and usually resolves within 24 hours). Review of the physician progress notes [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The resident ambulated independently without a mobility device and had wandering behavior that occurred for 1 to 3 days of the look back period, which placed him/her at significant risk of getting to a potentially dangerous place. The Quarterly MDS dated [DATE] documented a BIMS score of 10, which indicated moderately impaired cognition. The resident ambulated independently without a mobility device and did not exhibit wandering behavior. The Care Area Assessment (CAA) dated 3/26/16 for Cognitive Loss and Dementia documented the resident was alert and oriented but had mild cognitive impairment and memory loss. The resident had a tendency to wander because he/she enjoyed walking outside but had a history of [REDACTED]. The resident did not remember staff at times, wore a Wanderguard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort), and staff accompanied him/her on walks. A physician order [REDACTED]. The care plan dated 3/25/16 lacked interventions regarding the resident's wandering and risk of elopement. A handwritten revision on the care plan dated 5/11/16 directed staff to discontinue the Wanderguard and initiate 30-minute checks. A handwritten revision on the care plan dated 7/15/16 documented the resident refused to wear the Wanderguard, had a BIMS score of 10, which indicated moderately impaired cognition, stated he/she wanted to go to Texas, had not shown exit seeking behavior, and liked to go outside and walk around the building. A handwritten revision on the care plan dated 7/20/16 documented the resident agreed to use the sign-out sheet when he/she wanted to go outside to walk the property and he/she was okay to walk outside the building without supervision. A handwritten revision on the care plan dated 8/05/16 documented the resident walked around the building and would notify staff when he/she would go to the bar next-door to have a beer. The care plan revised 9/20/16 documented the resident was at risk for wandering and elopement and made statements of wanting to go to Texas, but had not acted upon leaving the building. The resident liked to take walks outside the facility, wore a Wanderguard on his/her wrist, and directed staff to complete 15-minute checks to ensure his/her safety when he/she did not sign out and was seen walking around outside the building. The care plan further documented the resident had agreed to sign out when he/she wanted to go outside and walk the property. He/she could walk outside the building without supervision, and his/her picture was in the elopement book due his/her high risk of elopement. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. and elopement risk. A physician order [REDACTED]. A physician order [REDACTED]. The clinical record lacked documentation of a physician order [REDACTED]. Review of the Elopement Risk assessment dated [DATE] documented the resident was considered to be an elopement risk. Review of the Elopement Risk assessment dated [DATE] documented the resident was not an elopement risk. Review of the Elopement Risk assessment dated [DATE] documented the resident was considered to be an elopement risk. The clinical record lacked documentation of an Elopement Risk Assessment between 7/16/16 through 2/17/17 and lacked documentation of an elopement assessment in October 2016, after the resident had a TIA. A typed paper in the clinical record dated 7/20/16 documented the resident liked to walk outside the perimeter of the building and staff should be on alert if he/she was gone for an extended amount of time. The resident had a sign-out book at the nursing station and had agreed to sign him/herself out if he/she left the building. Review of the sign-out log at the nursing station lacked documentation the resident had signed him/herself out of the building after 9/30/16. Review of the sign-out log at the reception desk at the front entrance of the building lacked documentation prior to 2/26/17. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. A psychiatry progress note dated 2/20/17 documented that since admission, staff documented the resident went into other resident's rooms and took things belonging to other residents. The resident became agitated with redirection from staff. The resident was recently found by police wandering and had stated to police he/she was going to town. The psychiatry note further documented the resident had vascular dementia with behavioral disturbance, was not confused unless he/she had a TIA or seizure, and therefore had safety awareness. A physician progress notes [REDACTED]. The resident had cognitive impairment, suspected vascular dementia, and he/she recommended to continue the Wanderguard for patient safety, provide supervised outdoor walks, and for psychiatry to re-evaluate the resident. A nurse's note dated 3/14/16 at 4:45 P.M. documented the resident stated he/she did not want to be at the facility, had a Wanderguard in place, made statements he/she would cut the Wanderguard off, and paced continuously throughout the evening. A nurse's note dated 3/15/16 at 12:30 A.M. documented the resident removed the Wanderguard and agreed to keep it in his/her pocket. An untimed nurse's note dated 3/15/16 documented the resident continued to attempt to exit the facility, refused the placement of a Wanderguard, continued to request information on how to leave the facility, and staff notified the MDS coordinator of his/her severe elopement risk. A nurses note dated 3/15/16 at 3:00 P.M. documented the resident was directed to the social worker regarding verbalization about leaving the facility and per the assistant administrator, he/she had been going outside with staff members. A nurse's note dated 3/21/16 at 8:00 P.M. documented the resident had removed the Wanderguard and stated he/she threw it away. At 9:30 P.M., staff replaced the Wanderguard on the resident's wrist. Review of the nurse's notes from 5/12/16 through 6/08/16 documented the resident had no exit seeking behaviors, kept the Wanderguard in place, and was his/her own responsible party. A nurse's note dated 7/08/16 at 6:00 P.M. documented the nurse spoke to the resident regarding his/her walks outside in the heat and that the resident was outside without permission. The nurse encouraged the resident to wear the Wanderguard for his/her safety to alert staff when he/she would like to go outside. The resident became agitated and staff placed the resident on 15-minute checks. A nurse's note dated 7/20/16 at 4:50 P.M. documented the physician and admission coordinator spoke with the resident regarding a new order that he/she was safe to walk outside the building. The resident liked to walk the perimeter of the building outside, refused to wear the Wanderguard, denied he/she would leave the property, agreed to sign him/herself out when he/she went outside and would alert staff when he/she was out of the building. Staff informed the resident that he/she would not have to wear the Wanderguard and he/she had freedom. A nurse's note dated 9/08/16 at 9:30 P.M. documented the resident told the nurse he/she was going to the bar. The nurse instructed the resident it was not a good idea. Another staff member allowed the resident to exit the facility at 9:35 P.M. At 9:55 P.M., staff was alerted the resident was not back and the grounds were searched by several staff. The nurse drove to the bar and observed the resident seated at the bar drinking a beer. The resident returned to the facility with three staff members and the director of nursing was notified. An untimed nurse's note dated 1/13/17 documented staff observed the resident pacing between hallways. He/she entered other resident rooms, took the other resident's belongings, and became agitated when staff returned the items. A nurse's note dated 2/17/17 at 4:00 P.M. documented the resident walked outside the perimeter of the building with the assistant director of nursing. The resident was cognitively aware of his/her surroundings and remained on the sidewalk. A nurse's note dated 2/17/17 at 6:20 P.M. documented the receptionist informed the nurse that the resident was ambulating outside independently. The nurse picked the resident up at the front desk and brought him/her back to the nurse's station. The resident was alert and oriented with confusion. Staff placed a Wanderguard on the wrist for the resident's safety. Staff advised the resident not to go outside the building unsupervised, and staff notified a supervisor. The police report dated 2/19/17 documented on 2/17/17 at 5:44 P.M., officers were dispatched to check on the welfare of a person who seemed confused. The police officers arrived at the location of the resident at 5:52 P.M. The resident told the reporting party that he/she was going downtown to look at rental property. Officers approached the resident at an intersection approximately half a mile from the facility. The resident was confused and told police he/she was trying to walk downtown because he/she had a friend who lived by a big church. At one point during their conversation, the resident thought he/she was in Texas. The officers contacted the facility and staff stated the resident lived there and had walked away during dinner. The police officer returned the resident to the facility at 6:00 P.M., and two staff members escorted the resident inside. The clinical record lacked documentation the police found the resident on 2/17/17 approximately half a mile from the facility walking in the dark and that the resident was returned to the facility by the police. On 2/28/17 at 2:12 P.M., the resident ambulated independently with a steady gait in the hallway. Direct care staff O stopped the resident and instructed him/her that his/her shoes were on the wrong feet and he/she should switch them so he/she did not fall. The resident was compliant with the redirection. On 3/1/17 at 1:00 P.M., the resident ambulated independently through the main dining room and stopped at an exit door, looked out of the window on the door, then sat in a chair a nearby table for approximately 1 to 2 minutes before he/she stood and ambulated through the dining room. On 3/1/17 at 2:00 P.M., the resident was asked about the Wanderguard on his/her wrist. The resident stated he/she had to wear it because he/she was picked up by the police. The resident stated he/she did not know where he/she was at or how far away he/she had walked from the facility. On 2/28/17 at 2:10 P.M., licensed nursing staff F stated this resident was at risk for elopement, wore a Wanderguard, and was not allowed outside unless staff was with him/her. On 2/28/17 at 2:12 P.M., direct care staff O stated the resident was a high fall and elopement risk. Because of his/her impaired cognition, he/she was not supposed to be outside without a staff escort. Direct care staff O stated he/she was told in report on the next shift he/she worked after 2/17/17, that the resident had left the faciity on [DATE] and was brought back to the property by police. On 2/28/17 at 2:43 P.M., administrative nursing staff D stated staff identified the resident as an elopement risk on admission but the physician had reviewed his/her history and allowed the resident to wear a Wanderguard and walk independently outside as long as he/she signed out and told staff so they could enter a code at the door for him/her to exit. Staff had been instructed they had to make sure the resident was back inside within 15 minutes, otherwise staff would enact the missing persons elopement policy. Administrative nursing staff D stated he/she was aware of the incident on 9/8/16 when the resident went to the bar. He/she stated the bar was not on the facility's property, but the resident was his/her own responsible party and could go to the bar if he/she wanted to. The physician was involved in the decision that the resident was safe to walk around unattended and could go to the bar. Administrative nursing staff D stated he/she was not in the facility on 2/17/17, was not told the resident had left the building until 2/20/17, and did not know if the police were involved in his/her return to the facility. He/she stated staff removed the resident's Wanderguard in December 2016 because staff knew he/she would not go outside in the cold weather. Administrative nursing staff D then stated he/she thought the police may have been involved in the resident's return because a pedestrian had called the facility to ask about whether a resident was outside but there was no police report filed, and the facility did not conduct an investigation or report this incident from 2/17/17 to the state agency. On 2/28/17 at 3:00 P.M., administrative nursing staff E stated he/she walked outside around the facility with the resident on 2/17/17 at 4:00 P.M. At 8:00 P.M., he/she received a phone call from a nurse that the resident had left the building again and staff reported the resident was on the corner of the property, police had stopped to ask if he/she was okay to be outside, brought the resident back into the facility, and no police report was filed. Administrative nursing staff E stated the resident was allowed to be outside as long as he/she told staff. Staff should monitor him/her every 15 minutes but they did not have to be outside with him/her because the receptionist would call the nurse as soon as he/she was out of eyesight from the front door of the facility. On 2/28/17 at 3:21 P.M., staff L stated an elopement book was kept in the workroom and contained a face sheet and picture of all residents at risk for elopement. Staff L stated the resident was allowed to walk around the perimeter of the building, but if he/she could not see the resident or 15 minutes had passed, he/she would alert the nurse. On 2/28/17 at 5:45 P.M., licensed nursing staff G stated the resident had an order that he/she could walk outside and was supposed to sign out, but because the resident was his/her own person, he/she did not have to sign out. Licensed nursing staff G stated staff completed 15-minute checks on the resident throughout the day because of his/her confusion and staff did not always accompany him/her outside. On 2/28/17 at 6:00 P.M., staff M stated the resident was confused at times, considered an elopement risk, and sometimes had a Wanderguard in place. Staff M stated he/she was supposed to check on the resident every 15 minutes while he/she was outside and if he/she did not see the resident, he/she should call the nurse. On 3/1/17 at 8:58 A.M., consultant physician JJ reviewed the resident's medical record and stated he/she examined the resident on 2/9/17 and based on his/her notes, the resident was not considered safe to walk outside the building alone and was an elopement risk. Consultant staff JJ stated the psychiatrist's note had conflicting information by documenting the resident had vascular dementia but also had safety awareness. On 3/01/17 at 9:45 A.M., consultant physician JJ stated he/she did not feel comfortable allowing the resident to walk around outside unsupervised by staff and stated the resident should not leave the facility grounds without staff or family present. On 3/01/17 at 11:00 A.M., administrative staff A and administrative nursing staff D stated on 2/17/17 after 6:00 P.M., the resident was walking around the facility and the receptionist was aware he/she was outside. The police drove by and called the reception desk to see if he/she was okay to be outside, the receptionist went out to check on the resident, and the resident willingly came back inside. Administrative staff A and administrative nursing staff D stated they were not aware of the resident being off of the property or of police escorting him/her back into the building. Administrative nursing staff D reviewed the clinical record at this time and verified consultant physician KK wrote the order dated 7/20/16 that the patient is safe to walk outside the building. He/she stated that decision was supported by a physician progress notes [REDACTED]. The clinical record lacked documentation of the history and physical dated 7/20/16. On 3/1/17 at 11:15 A.M., administrative staff A and administrative nursing staff D stated the receptionist kept a communication log at the front desk of which residents went outside and the times they left and returned to the facility. The communication log was not considered a part of the clinical record and administrative staff A shredded the log after a page was filled with documentation. Administrative staff A stated if the receptionist did not see the resident within 15 minutes of him/her exiting the building, he/she would call nursing staff and the nursing staff could complete 15-minute checks on the resident per their judgment. On 3/1/17 at 11:30 A.M., administrative staff A stated the only reason why the Wanderguard was on the resident was to alert staff of his/her whereabouts, he/she was his/her own responsible party and could go outside. Administrative staff A stated the facility had the documentation to support that staff monitored the resident, had intact cognition when outside, and had safe decision-making. Administrative staff A stated the only reason the order dated 12/29/16 was written to discontinue his/her ability to walk outside was because of cold weather. Administrative staff A acknowledged the physician order [REDACTED]. Administrative staff A stated he/she would ask consultant physician KK to fax his/her history and physical dated 7/20/16 to support the order. On 3/1/17 at 3:30 P.M., a physician progress notes [REDACTED]. Patient had been admitted to the facility earlier this year and had been going out of facility to enjoy the outdoors. Concerns about his/her safety and cognition were raised. (The) patient's condition is stable, cognition is not impaired, will allow him/her to be outside the facility. This physician progress notes [REDACTED]. On 3/1/17 at 3:27 P.M., social services staff J stated since admission the resident had been fixated on leaving the facility and had impaired cognition. Staff J stated the resident had entered his/her office earlier in the day and asked for help getting to someone's house. Staff J stated the resident was unable to tell him/her whose house he/she wanted to visit and stated he/she was not oriented to place and time. On 3/1/17 at 3:50 P.M., direct care staff P stated the resident was confused and considered to be an elopement risk. Direct care staff P directed the resident toward the main dining room on 2/17/17 but did not know the resident was brought back to the facility by police until dinner was over at approximately 6:15 P.M. He/she stated the resident had a Wanderguard in place after he/she returned to the facility. On 3/1/17 at 3:55 P.M., direct care staff Q stated the resident did not always wear the Wanderguard but was confused and considered an elopement risk. On 3/1/17 at 4:13 P.M., social services staff K stated the resident was confused but is street smart and could adapt well to make it appear like he/she was more oriented than he/she really was. Staff K stated he/she was informed by the director of nursing on 2/20/17 during a morning meeting that the resident had exited the facility after dinner on 2/17/17 and was brought back by police. Staff K stated he/she did not know if the resident was on or off the property. On 3/1/17 at 6:34 P.M., staff N emailed a statement to administrative staff A about the events on 2/17/17, which documented the resident spoke to staff N and then exited the front door of the facility at approximately 5:35 P.M. Staff N documented approximately 10 minutes later, around 5:45 P.M., he/she received a phone call regarding the resident. The resident arrived less than 5 minutes later in a squad car and was greeted by licensed nursing staff H and I. On 3/1/17 at 7:05 P.M., licensed nursing staff H stated he/she served the resident coffee in the main dining room on 2/17/17 at approximately 5:30 P.M. He/she was not aware the resident had left the building until licensed nursing staff I approached him/her at approximately 6:00 P.M. and stated the receptionist had called licensed nursing staff I to say the police called the facility and had picked the resident up outside of the facility property. The police told licensed nursing staff H and I that the resident was found near an intersection approximately half a mile away from the facility. Licensed nursing staff I applied the Wanderguard and notified administrative nursing staff C of the incident since he/she was present in the facility. Licensed nursing staff H stated the resident was a high elopement risk because of his/her confusion, recent stroke, history of falls, and his/her ability to walk around the facility independently. He/she stated all residents identified as an elopement risk should have a Wanderguard in place. On 3/1/17 at 7:40 P.M., licensed nursing staff I stated the resident was confused and needed redirection. The resident was allowed to go outside and walk around the building but was supposed to remain on the facility property. Licensed nursing staff I stated the resident was supposed to sign out with the receptionist and he/she would notify the nurse if the resident was not seen for 15 minutes. Licensed nursing staff I stated at approximately 6:00 P.M., he/she received a phone call from the receptionist who reported the police had found the resident walking outside. He/she asked licensed nursing staff H to help escort the resident back into the building. The police told licensed nursing staff I and H that the resident was found at an intersection approximately half a mile from the facility. Licensed nursing staff I stated the resident was confused that evening and staff placed a Wanderguard on the resident. Staff reported the incident to administrative nursing staff C, who was present in the facility. Administrative staff C instructed staff to complete 15-minute checks on the resident and then later decided to place the resident on a 1:1 observation. Licensed nursing staff I stated he/she did not know where staff documented the 1:1 observation in the clinical record. He/she stated the resident had a Wanderguard on in the past but then had done much better so it was removed. When he/she became confused again, staff placed the Wanderguard back on the resident but the resident kept taking it off. On 3/1/17 at 9:10 P.M., administrative nursing staff C stated he/she was in the facility on 2/17/17 when licensed nursing staff I informed him/her that the resident had been dropped off by the police. The resident was found near an intersection approximately half a mile away from the facility. Administrative nursing staff C stated he/she notified the administrator and director of nursing on 2/17/17 and administrative staff A instructed staff to place the resident on 1:1 observation. Administrative nursing staff C stated he/she did not document the incident in the clinical record. On 3/1/17 at 9:15 P.M., administrative staff A reviewed the clinical record and confirmed it lacked documentation of the 1:1 observation. On 3/2/17 at 11:13 A.M., administrative staff A provided an email from consultant physician KK dated 3/2/17 at 9:20 A.M., which documented clarification - the order for this resident was that he/she could leave the property of the facility. This clarification was regarding the order written on 7/20/16. Review of the undated facility provided Residents at Risk for Elopement policy documented all residents identified as an elopement risk would receive a Wanderguard. The risk of elopement would be assessed on admission, quarterly, and with significant change. If a resident developed wandering behavior, risk precautions would be initiated, the behavior would be documented, the care plan would be updated, and the Wanderguard would be placed on the resident. Residents with repeated elopement attempts would be reported to the director of nursing and the physician would be notified for other interventions or alternative placement. The facility failed to provide supervision to this cognitively impaired resident who eloped from the facility on 2/17/17 and was found by police approximately half a mile away from the facility. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 3/2/17 at 5:00 P.M. by initiating the following: the facility would continue to ensure that the resident environment remained as free of accidents and hazards as possible. Each resident received adequate supervision and assistant devices to prevent hazards. The resident in question would not be allowed outside the facility unsupervised until further assessment could be completed. The MDS and care plan for the resident in question would be reviewed and updated to reflect his/her current status. The Interdisciplinary Team (IDT) would review all current residents at risk for elopement and interventions and care plans would be modified if deemed necessary. The IDT would continue to review current residents ongoing and upon admission, quarterly, and with significant change in condition during care plan meetings to identify residents at risk for elopement and update care plans as indicated. All personnel would be immediately in-serviced on the policies and the policies would be reviewed with newly hired staff in their initial orientation and training. All staff currently on vacation or leave of absence would not be allowed to resume work until in-servicing was complete. The director of nursing or designee would report compliance findings to the Quality Assurance and Performance Improvement Committee (QAPI) monthly for 12 months and then as indicated by the QAPI Committee. The deficient practice remained at a scope and severity of D.

The facility identified a census of 190 residents. The sample included 1 resident for privacy/mental abuse. Based on observation, record review and interview, the facility failed to ensure 1 of 1 sampled resident (#1) remained free from abuse. Direct care staff T took a video, including him/herself and direct care staff Q, of the resident while using the toilet and posted the video to a social media site. This deficient practice placed the resident in immediate jeopardy. Findings included: -Resident #1's [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set ((MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The resident required limited assistance of staff with bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, personal hygiene, and supervision with eating. The resident used a wheelchair for mobility. The resident was frequently incontinent of urine and occasionally incontinent of bowel. The Care Area assessments dated 9/6/16 revealed: Cognitive loss/dementia: admitted with short and long term memory impairment, staff and family anticipate the resident's needs. ADLs (activities of daily living): required limited assist with ADLs and transfers, wheelchair for mobility long and short distances, and worked with therapy services. Urinary incontinence: incontinent of bowel and bladder, wore briefs for skin protection, and staff were to assist with hygiene. The resident's care plan dated 9/22/16 recorded the resident was incontinent of bladder due to the [DIAGNOSES REDACTED]. Untimed documentation of interviews on 9/23/16 conducted by administrative staff A revealed the following: Direct care staff T admitted to taking the video of a resident, but stated he/she could not remember the resident or the date of the incident, and direct care staff Q stated he/she was unaware of the video being taken. Observation of the untimed and undated video revealed it appeared that resident #1 sat on a shower chair after using the toilet. Direct care staff T was in front of the camera recording him/her self and taking the video and direct care staff Q in the video standing by the resident. The resident had dog ears, nose, and tongue graphics on his/her face, and laughing smiley faces and a peace sign graphics later in the video, as well as a written as 95 {year} old {person} wipe {his/her} a__ . Observation on 10/11/16 at 1:07 PM revealed resident #1 in his/her room lying in bed. The resident was cognitively impaired and non-interviewable. During a complaint intake on 9/13/16, an anonymous complainant stated he/she saw a video on a social media site on 9/12/16 of the resident and two staff members. During an interview on 9/23/16 at 4:15 PM, resident #3 stated he/she saw staff using their cell phones. During an interview on 9/23/16 at 4:30 PM, resident #2 stated he/she saw staff using their cell phones. During an interview on 10/11/16 at 1:23 PM, administrative staff A stated the facility suspended direct care staff Q and T the day the incident was brought to the facility's attention by the state agency. The facility conducted in-service training regarding photographs/videos and social media with some facility staff, however direct care staff T had not attended the training prior to this incident. Facility staff were not allowed to use their cell phones in resident care areas. If a phone was visible and staff saw it, the staff were automatically written up. During phone interview on 9/23/16, direct care staff T admitted to taking the video and posting it to a social media site. Administrative staff A stated the local Police Department was investigating the incident. On 10/11/16 at 1:39 PM, administrative nursing staff E stated the facility policy was that staff was not supposed to have cell phones out in resident care areas. If they did, they would be written up. The August 2016 policy titled Unauthorized Photographs and/or Audio/visual Recordings of Residents revealed the purpose was to protect resident privacy and confidentiality and prohibit resident abuse with relation to the use of photographs and audio/video recordings by the nursing home staff. The policy recorded taking unauthorized audio/video recordings of the resident while personal care was being provided no matter what state of dressing or undressing was a violation of the resident's right to privacy and confidentiality. All residents have the right to privacy and confidentiality no matter what their cognitive, physical, psychological and intellectual needs may be. Each resident had the right to be free from all types of abuse, including mental abuse. Mental abuse includes abuse that was facilitated or caused by nursing home staff taking or using photographs or recordings in a manner that would demean or humiliate the resident. If a photograph or recording of a resident, or the manner that it was used, demeans or humiliates a resident, it will be considered mental abuse. This would include photographs and recordings of resident that contain nudity, toileting, labeling residents pictures and/or providing comments in a demeaning manner. The facility failed to ensure resident #1 remained free from mental abuse. Staff posted a video of resident#1 on a social media site while the resident sat on the toilet and included demeaning graphics and a demeaning statement about the resident. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 9/23/16 when all staff received education on abuse, neglect and exploitation including photographs/video/social media, and direct care staff T and Q were terminated. This deficiency remains at the scope and severity of a G.

The facility identified a census of 185 residents. The facility identified 8 residents located the unsecured hallway were cognitively impaired and independently mobile. The sample included a review of 3 residents at risk wandering/risk for elopement. Based on interview and record review the facility failed to provide adequate supervision for 1of 3 (#1) cognitively impaired and independently mobile resident who had a history of [REDACTED]. Resident #1 exited the facility unattended, found by an unidentified motorist on a highway 2.5 miles from the facility and taken to an activity center 5 miles from the facility. This deficient practice placed resident #1 in immediate jeopardy. Findings Included: - A review of resident #1 ' s physician order [REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. He/she had delirium (sudden severe confusion, disorientation and restlessness) and wandered daily. The Cognitive Loss Care Area Assessment (CAA ' s) dated 05/03/2016 documented the resident had a BIMS of 3 due to the progression of his/her Alzheimer ' s Disease and staff monitored for further decline. The care plan dated 11/25/15 identified the resident had a history of [REDACTED]. Staff were directed to assist the resident with the calendar or clock as needed to keep him/her oriented and offer him/her cues and reminders for activities and events as they occurred. Review of a nursing note dated 7/7/16 at 11:15 A.M. documented the resident transferred from 100 hall (a secured locked unit) to the 500 hall (an unsecured unit). Staff made the resident aware of smoke breaks and placed a roam alert device (a device used to alert staff if a resident exited an alarmed door) on for safety. Review of a nursing note dated 7/8/2016 at 2:00 P.M. documented the resident complained of money and his/her home being gone due to family and felt he/she was better off dead. Review of a nursing note dated 7/9/2016 at 6:00 A.M. documented staff reported to the nurse the resident was not in his/her room. Review of licensed nursing staff H ' s notarized witness statement dated 07/08/2016 at 4:00 P.M. documented staff H opened the patio door, took the resident into the courtyard for a short time, returned the resident to his/her room, closed the screen door and left the patio door open as the resident wanted to enjoy the breeze. The resident laid down on his/her bed and never attempted to go outside. Staff H closed the patio door at 8:30 P.M. when the resident went to the bathroom. The patio door alarm in the resident ' s room sounded at 4:00 A.M. on 07/09/2016 and staff placed the resident on 15-minute visual supervised checks. At 6:00 A.M. direct care staff O reported to nurse H the resident was not in his/her room and staff last saw the resident at 5:45 A.M. when direct care staff P made rounds. Staff H alerted facility staff and looked for the resident in the building and on the grounds. Staff was unable to locate the resident and notified the police, the administrator, director of nursing and the resident ' s family. Review of a nursing note dated 07/09/2016 at 7: 30 A.M. documented the police informed the facility the resident was located at a Community Center 5 miles from the facility and the resident refused to allow them to return him/her to the facility. Administrative nursing staff D escorted the resident back to the facility at that time and placed the resident on the secured unit. According to Wunderground.com (a site used to determine weather conditions on a specific date and time) the recorded weather on 07/09/2016 at 6:00 A.M. was 72 degrees and fair. During an interview on 7/14/16 at 12:11 P.M. licensed nursing staff I said the resident had increased anxiety when he/she transferred from the secured unit to the unsecured unit. During an interview with administrative nursing staff D on 07/14/2016 at 11:54 A.M. he/she stated the roam alarm device did not work when going through the patio door because it was not on the wander guard system, but there was an alarm on the patio door, which did not sound when the resident left the building. Staff D stated the courtyard gate also had an alarm and he/she expected staff to make rounds every 2 hours on the night shift and more frequently if indicated. During a telephone interview on 7/14/2016 at 4:38 P.M. community center staff II stated he/she worked on the morning of 7/9/2016 when the resident came to the facility at 7:00 A.M. with an unknown male who reported he/she had picked up the resident on highway 69. During an interview on 07/14/2016 at 6:13 P.M. maintenance staff X stated the sensor pad that alarmed the courtyard gate outside the resident ' s room did not work and he/she replaced the sensor pad after the resident eloped. Staff X stated he/she had also replaced other patio door alarms. During a telephone interview on 7/14/2016 at 3:37 P.M. physician consultant AA said the facility did not involve him/her in the decision to move the resident off the secured unit. Staff AA said due to the resident ' s cognition and behaviors he/she felt it was not a good decision. It was determined through investigation the distance from the facility to highway 69 was 2.5 miles, distance from facility to community center was 5 miles and the speed limit on highway 69 was 60 miles per hour (mph). An undated Facility Policy titled Elopement/Missing Resident documented a elopement occurred with a resident left the facility without the knowledge of staff or a resident who had impaired decision making ability, was oblivious to his/her own safety needs and those at risk for injury outside the confines of the facility. The facility failed to provide adequate supervision to prevent an elopement for this cognitively impaired and independently mobile resident who exited the facility unattended, crossed a highway with a speed limit of 60 mph and to an activity center located 5 miles from the facility. The facility abated the Immediate Jeopardy (IJ) on 7/15/2016 at 4:45 P.M. The facility ' s IJ response included all staff understood the critical nature of assuring sliding doors in resident rooms and courtyard gates were secured and alarmed where residents at risk for elopement resided and the facility provided proof of in-service for all new and current employees. The in-service included the Elopement Policy and Procedures, Resident ' s at Risk for Elopement, Missing Persons and Securing the Building with Locks and Alarms. The deficient practice remained at the scope and severity of a D.

The facility reported a census of 204 residents. The sample included 16 residents. Based on observation, record review and interview the facility failed to develop and implement timely and effective interventions to prevent falls for 2 (#42, #167) of 3 residents reviewed for falls. Resident #42's fall resulted in a fracture. The facility also failed to prevent resident accessibility to hazardous chemicals for 48 cognitively impaired, independently mobile residents 1 of 5 days onsite of the survey. Findings included: - The physician's orders [REDACTED]. The discharge Minimum Data Sheet (MDS) 3.0 dated 12/18/13 revealed the resident had impaired short term memory and the resident had moderate cognitive impairment. The resident required extensive assist of one person for bed mobility, transfers, toileting and dressing. The resident was totally dependent for personal hygiene. The resident was not steady and was able to stabilize with staff assist to turn around and moving on and off the toilet. No behaviors were exhibited. The resident was inattentive and had disorganized thinking. Review of the fall assessment tool dated 9/6/13 rated 12 (ten or greater meant the resident was at a high risk for falls), 9/12/13 rated 16, 11/2/13 rated 18, 12/18/13 rated 15, and on 1/19/14 rated 21. The Care Area Assessment (CAA) dated 6/27/13 for falls revealed the resident required assistance to transfer. The fall risk assessment score of 17 indicated a high fall risk, and staff implemented high fall precautions. The CAA dated 6/27/13 for cognition revealed the resident had memory impairment with poor decision making. The resident had some limitations due to language barrier and mostly answered yes/no questions correctly. A child was able to interpret as needed. Review of the care plan initiated 7/9/12 revealed the resident was a high risk for falls due to history of cerebral vascular accident (the sudden death of brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain). The staff were to assess for an unsteady gait, assist to the dining room and activities as needed, assist with all activities of daily living and transfers, and to evaluate the cause of all falls. The care plan updated 10/18/13 the staff were to provide the resident with a hi-lo bed. Review of the readmission Care Plan dated 5/24/13 revealed the staff should have the call light in reach of the resident and staff were to answer promptly. Review of the comprehensive care plan dated 6/27/13 revealed the staff were to assist with all activities of daily living and transfers, assist the resident to the dining room and activities as needed, to evaluate cause of falls, and nursing performed a fall risk assessment on admission, quarterly, after falls or significant change, and as necessary. The resident should have high fall risk precautions per fall guidelines, the call light in reach at all times and answered promptly, restorative aide program as ordered, therapy screen as needed, and a carpeted floor. Review of the individual fall documentation dated 1/4/13 at 9:30 A.M. revealed the staff found the resident on the floor outside his/her room, with the new intervention of staff to provide a perimeter mattress and hourly checks. Review of the individual fall documentation dated 1/31/13 at 7:30 A.M. the staff found the resident on the floor next to his/her bed and staff did not add a new intervention. Review of the individual fall documentation dated 4/10/13 at 11:15 A.M. the staff found the resident on the floor of his/her room, with the new intervention, staff were not to leave the resident alone in his/her wheelchair. Review of the interdisciplinary fall review dated 4/12/13 for the 4/10/13 fall listed the intervention, staff to have the resident's family counsel the cognitively impaired resident on call light use for assistance and general safety. The individual fall documentation dated 5/6/13 at 4:00 P.M. revealed the staff found the resident on the floor next to his/her bed. The staff did not implement new interventions for the prevention of falls. The individual fall documentation dated 7/30/13 at 6:00 A.M. the staff found the resident on the floor next to his/her bed. The staff were to check on the resident every hour to reposition and toilet on night shift. Review of the fall investigation dated 7/30/13 at 6:00 A.M. revealed the staff observed the resident on the floor next to his/her bed with no apparent injury. The investigation lacked the causative factors for the fall. The individual fall documentation dated 9/4/13, no time indicated, revealed staff observed the resident on the floor in his/her room with his/her right arm behind his/her back. The intervention was for the staff to not leave the resident alone in his/her room and to assist the resident to bed for naps. The resident was to have a pommel seat cushion (a cushion with a raised area between his/her thighs) and for the wheelchair to have leg rests. Review of the fall investigation dated 9/4/13 at 11:15 AM revealed the staff observed the resident on the floor in his/her room on his/her right side with his/her arm and wrist behind them. The staff assisted the resident into the wheelchair with a gait belt and the resident had pain and swelling of the right wrist. An x-ray of the wrist was completed at 12:18 P.M. and the resident was transferred to the emergency room for further evaluation. The resident returned to the facility at approximately 6:00 P.M. with a right wrist splint. The investigation lacked the causative factors for the fall. Review of the nurse's note dated 9/4/13 revealed the x-ray reported the fracture of the radial and ulna (the bones in the forearm) in the right wrist. The individual fall documentation dated 12/18/13 at 6:40 P.M. revealed the staff found the resident on the television room floor with a skin tear on his/her forehead with the intervention for the staff to toilet the resident immediately after dinner, prior to assisting the resident to the television room. The fall investigation dated 12-18-13 at 6:40 P.M. revealed the staff observed the resident sleeping on the floor in the television room. The staff assisted the resident into the wheelchair and noted a skin tear on the resident's forehead. The investigation lacked the causative factors for the fall. On 2/10/14 at 2:30 P.M. direct care staff U transferred the resident to the toilet and back to the wheelchair with the use of a gait belt and the resident had non skid socks on. The staff assisted the resident to bed and placed the bed in the low position. Observation on 2/10/13 at 4:30 P.M. direct care staff V transferred the resident from the bed to the wheelchair with use of a gait belt and the resident wore non skid socks. Interview on 2/10/14 at 2:30 P.M. direct care staff U stated the staff should not leave the resident alone in his/her room in his wheelchair. Interview on 2/10/14 at 4:30 P.M. direct care staff V stated the staff were to transfer the resident with the use of a gait belt and the staff were not to leave the resident alone in the bathroom or room. Interview on 2/11/14 at 11:15 A.M. licensed staff M stated the resident had a low bed and a perimeter mattress but the resident did not fall out of bed, he/she fell from his/her wheelchair. Staff were not to leave the resident alone in his/her room, and if in the wheelchair the staff were to place the resident in an observable area such as the television room, dining room, or with his/her family. On 2/12/14 at 12:30 P.M. administrative nursing staff D stated staff investigated to determine the cause of the fall and staff should implement interventions to prevent it from happening again. He/she expected the new interventions to be effective. The fall risk/prevention policy provided by the facility dated 11/12 documented if the resident had a score greater than 5 the nursing staff referred to the Falls Protocol Intervention Guidelines, to complete a care plan and address the resident's risk for falling. The High Risk for Falls Guidelines policy provided by the facility documented the staff were to arrange the furniture in the room to decrease the risk (phone, water, urinal, etcetera within reach). The staff were to assist the resident with all transfers, toilet the resident frequently while awake, reposition the resident in bed and reorient to the environment frequently. The resident should not be left alone on the toilet and attempt to keep the resident in common areas. The staff were to complete a fall risk assessment every 90 days. The facility failed to provide timely and effective interventions for the prevention of falls that resulted in a fracture for this cognitively impaired, dependent resident. - The January 2014 physician's orders [REDACTED]. The Annual Minimum Data Set 3.0 dated 11/12/13 documented a Brief Interview for Mental Status (BIMS) score of 4 (less than 7 indicated severely impaired cognition). It noted the resident had 2 non-injury falls since the previous assessment. The Care Area Assessment (CAA) dated 11/12/13 for cognition noted the resident was alert and pleasant, and spent most of the time in his/her room. The CAA dated 11/12/13 for falls documented the resident fell several times. The care plan dated 11/20/13 for falls noted staff ensured assistive devices were available and in good condition, ensured the resident's areas were free of hazards, and staff redirected the resident when he/she entered unsafe areas. A nurse's note dated 6/17/13 documented staff found the resident sitting on the floor. The staff encourage, the severely cognitive impaired resident, to use the call light. A nurse's note dated 7/16/13 documented the resident began to transfer himself/herself from the bed to the wheelchair and lowered himself/herself to the ground. The staff educated the severely cognitive impaired resident to use the call light. A nurse's note dated 8/3/13 documented staff found the resident on the floor in his/her room. Staff again re-educated the resident on using the call light and to wait for staff assistance. A nurse's note dated 9/19/13, untimed, documented the resident was in bed, and attempted to transfer himself/herself to the wheelchair and fell . Staff found the resident on the floor mat. Staff again encouraged and reminded the severely cognitively impaired resident to use the call light. A nurse's note dated 12/3/13, untimed, revealed staff observed the resident on the floor seated on the floor mat. No new interventions were attempted. A nurse's note dated 2/1/14 revealed staff found the resident sitting on the bathroom floor. No new interventions were attempted. Observation on 2/10/14 at 1:25 P.M. staff transferred the resident from the wheelchair to the toilet. Observation on 2/11/14 at 3:20 P.M. staff transferred the resident from the wheelchair to the bed. Interview on 2/12/14 at 11:00 A.M. licensed nursing staff L stated he/she encouraged the resident to use the transfer poles and the call light. He/she said the resident had a floor mat. He/she toileted the resident frequently, and ensured the resident was seated properly in the wheelchair. Interview on 2/12/14 at 11:10 A.M. direct care staff T stated he/she kept the wheelchair out of the resident's reach to discourage self-transfers, kept the resident's personal items within reach, and reminded the resident frequently to use the call light. Interview on 2/12/14 at 12:30 P.M. administrative nursing staff D stated staff were expected to implement effective interventions after each fall. The facility's policy "Post-Fall Assessment", undated, revealed staff were to develop interventions to reduce falls. The facility failed to develop and implement effective interventions to prevent additional falls for this cognitively impaired resident with a history of falls. - During the initial tour of the facility on 2/3/14 at 3:30 P.M. revealed an unlocked housekeeping closet located on the 300 unit and contained the following chemicals: Glance NA glass and multipurpose cleaner concentrate, Triad disinfectant cleaner concentrate, Breakdown XC odor eliminator concentrate, Virex II 256 disinfectant and cleaner and deodorizer concentrate, and a mop bucket with UHF 1500+ floor stripper in it. The warning labels on these products stated "keep out of the reach of children" and "harmful if swallowed". Interview on 2/3/14 at 4:55 P.M. housekeeping staff Z stated staff should keep the closet locked. He/she said the locking mechanism no longer worked and stated the chemicals would be removed. Observation on 2/3/14 at 5:50 P.M. the mop bucket was removed, but the above chemicals remained in the closet. Interview on 2/3/14 at 6:10 P.M. administrative staff stated all chemicals were removed from the closet and the door was locked. Observation on 2/11/14 at 3:45 P.M. revealed the closet was locked. The facility failed to provide an environment free of chemical hazards.

The facility reported a census of 203 residents with the sample of 3 residents. Based on observation, record review, and interview the facility failed to prevent the development of avoidable pressure sores for 1(#1) of 3 residents sampled for pressure sores. Findings included: - Resident #1's 60 day Minimum Data Set (MDS) 3.0 dated 4/20/13 recorded the resident with a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident was severely cognitively impaired. The MDS recorded the resident required limited assistance with bed mobility, transfer, toileting and personal hygiene, and had one stage 3 pressure ulcer. The care plan dated 3/11/13 documented the resident needed assistance with all Activities of Daily Living (ADLs) due to weakness. The care plan also documented a stage 3 pressure ulcer on the resident's left hip and the nurse to monitor the resident's skin during biweekly showers, and report to the doctor any signs or symptoms of skin breakdown. This care plan lacked information about the resident's head which leaned to one side or the care of the skin for this area. A Braden skin assessment on 3/6/13 reported a score of 17 which indicated the resident was at risk for pressure ulcers. The history and physical on admitted d 2/20/13 documented the resident was found in his/her home lying on his/her left side and laid there for an undetermined amount of time. Admission assessment dated [DATE] documented a pressure ulcer on the resident's left hip. An untimed nurses note on 2/27/13 recorded the wound was unstageable with yellow slough. Skin audits on 3/5/13, 3/12/13, 3/19/13, and 4/22/13 documented a left hip pressure ulcer. Bath sheets dated 4/16/13, 4/18/13, 4/22/13, and 4/25/13 indicated the resident refused a shower. Nurses' notes from 2/28/13 to 4/27/13 failed to reveal information concerning skin issues on the resident's neck. An untimed occupational therapy note dated 2/25/13 documented the resident had cervical joint limitations. An untimed nurses note on 4/27/13 reported the facility sent the resident to the hospital due to unresponsiveness. The emergency room admitting physician on 4/27/13 documented ulcerations to the resident's right chest, right chin and left hip with infection and decreased tissue perfusion. An untimed nurses note dated 4/27/13 reported the hospital admitted the resident to Intensive Care Unit (ICU) and the admitting nurse documented on 4/27/13 at 11:00 P.M. a pressure ulcer to the right chest measured 3.5 centimeters (cm) by (x) 2.0 cm x (by) 1 cm, the right lateral chin measured 0.3 cm x 2 cm, and there were no measurements for the left hip. The wound assessment at the hospital dated 4/29/13 at 9:00 A.M. documented measurements of right upper chest wall at 2.4 cm x 3.3 cm x 0.2 cm, stage 3; the right lateral chin measured 0.8 cm x 2.2 cm x 0.5 cm, unstageable; and the left hip measured 5 cm x 3 cm x 1.2 cm x 4.7 cm, stage 4. Observation of the resident at the hospital on [DATE] at 3:50 P.M. revealed the resident laid on the bed with his/her eyes open, head leaned on the right chest. The resident was intubated and not able to communicate. Interview with hospital licensed staff K on 5/14/13 at 4:02 P.M. stated the hospital admitted the resident with wounds on his/her neck that did not have a dressing on them. The resident's head rested on his/her chest from an unsuccessful neck surgery 3 or 4 years ago. The hospital started the resident on antibiotic therapy. Interview with hospital licensed staff L on 5/14/13 at 4:04 P.M. stated the resident's wounds were bad on admission. The resident had one under his/her chin, one where his/her chin laid on his/her chest, and one on his/her hip. Interview with direct care staff F on 5/15/13 at 11:51 A.M. stated the resident preferred female care. The resident's head was always down and his/her head rested on his/her chest. Interview with licensed staff C on 5/15/13 at 12:12 P.M. stated the resident's wound on his/her hip was unstageable when he/she first came in but it was looking better before he/she went to the hospital. I do not remember ever doing a skin assessment on him/her. The staff were not instructed to do anything special for the resident's neck, he/she had a padded head rest, and were to keep an eye on him/her. Interview with occupational therapy staff I on 5/15/13 at 12:22 P.M. stated the resident received therapy to increase his/her shoulder range of motion without progress. There was an attempt to try a cervical collar and the resident refused. Interview with administrative licensed staff A on 5/15/13 at 12:55 P.M. stated when the facility admitted the resident he/she held his/her head to one side and had a open area on his/her hip. His/her expectation was for therapy to guide us on what the staff should do for the resident's neck. Staff should bathe the resident on his/her shower day, skin assessments done weekly and staff to notify him/her of any changes. Interview with consulting wound nurse J on 5/15/13 at 1:41 P.M. stated he/she assessed and treated the wound on the resident's left great trochanter. He/she said he/she did not do a full body assessment but would look at other pressure points on the resident's body. Interview with direct care staff E on 5/15/13 at 2:33 P.M. stated when the facility first admitted the resident, he/she was able to do a lot by him/herself but slowly declined. Staff stated when the resident wanted a shower he/she received it in the evening. If the resident refused the scheduled shower, then he/she did not receive a bath until it was offered on the next scheduled day. Interview with licensed staff D on 5/15/13 at 3:09 P.M. stated the resident had a very poor appetite and staff tried everything to get him/her to eat. Staff D stated he/she assessed the resident's skin when he/she was in bed and charted on the body audit sheets. The resident held his/her head on his/her right shoulder, it was very hard to get the resident to move his/her head. The resident refused to wear any kind of support for his/her neck. The undated facility policy on skin monitoring documented, to identify residents who were at risk for skin breakdown and to initiate immediate treatment when skin breakdown occurred. The facility failed to provide timely assessments and interventions for the prevention of an avoidable stage 3 pressure ulcer and an unstageable pressure ulcer for this cognitively impaired resident with a history of pressure ulcers.

The facility census totaled 209 residents with 3 residents sampled. Based on observation, interview and record review, the facility failed to provide treatment/services for 1 of 3 sampled residents (#1) with urinary catheter. Findings included: - Resident #1's Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident's BIMS (Brief Interview for Mental Status) score of 9 which revealed the resident with moderately impaired cognition. The MDS documented the resident required supervision with set up help only for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. The MDS further documented the resident required an indwelling catheter. The Care Area Assessment (CAA) dated 12/16/11 documentation related to urinary status revealed the resident with a history of [MEDICAL CONDITION] and a Foley catheter in place. The resident's skin would be monitored during cares, showers, and as needed. The care plan reviewed on 5/29/12 documented a potential for urinary tract infection due to Foley catheter. The care plan instructed the nursing staff to provide Foley catheter care on every shift. The nursing staff instructed to avoid pulling on the catheter tubing. The nursing staff should observe for signs/symptoms of urinary tract infection (fever, hematuria, sedimentation). The Monthly Nursing Summary dated 3/31/12 under the elimination section checked an indwelling catheter in place with no other documentation. Review of the medical record revealed the resident seen by urology physician on 4/26/12. The physician documented the resident first seen on December 15, 2011 related to [MEDICAL CONDITION]. The physical examination revealed no genital abnormalities including no signs of traumatic [DIAGNOSES REDACTED] (urethra opens on the under surface of the genitalia). The physical examination on 4/26/12 revealed a Foley catheter draining clear yellow urine. The catheter was under significant tension. The resident's genitalia revealed a traumatic [DIAGNOSES REDACTED]. The 4/1/12 at 4:00 A.M. nurses notes documented the Foley catheter changed per order. The catheter removed without difficulty. The nurse noted the widened urethral opening at posterior underside. The nurse reinserted a 14 French Foley catheter without difficulty with return clear straw colored urine with no odor. The resident tolerated the aseptic technique without difficulty and no acute distress noted. On 5/8/12 at 9:55 A.M. observed licensed nursing staff A provide catheter care for the resident. Licensed nursing staff A washed his/her hands, applied gloves and proceeded to clean the genitalia area and then cleansed the Foley catheter tubing. The Foley catheter tubing was anchored to the leg with tape. The resident's genitalia noted to have a healed [DIAGNOSES REDACTED] opening. Licensed nurse revealed that the [DIAGNOSES REDACTED] had been there for a while but not sure how long. On 5/8/12 at 11:25 A.M. administrative nursing staff A revealed the skin issue was not passed on after found on the 1st of April and the weekly skin assessments just show redness in groin areas;. The undated facility policy "Catheter Guidelines, Foley" instructed the charge nurse to write a narrative summary concerning the Foley catheter on the monthly summary or as needed. The charge nurse would be responsible for monitoring and documenting the routine catheter was completed The charge nurse would be responsible for observing the residents during daily rounds. The undated facility policy "Catheter (Indwelling), Insertion and Removal of" instructed the nursing staff to secure the catheter to the resident's leg with a catheter strap. The revised October 2008 facility policy "Catheter Care" instructed the nursing staff to observe and report any irritation around the catheter. The facility failed to report to the physician the traumatic skin issue from the indwelling catheter. The facility failed to ensure that the catheter was secured to prevent tension on the resident's genitalia which caused traumatic [DIAGNOSES REDACTED] to this catheter dependent resident.

The facility reported a census of 195 residents, with 25 sample residents selected for review. Based on record review, observation and interview, the facility failed to prevent the development of pressure ulcer for 1 of 1 sampled resident #113 for pressure ulcers. Findings include; - The medical record of resident #113, documented admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial admission resident assessment, dated 2/1/11, documented the resident without open areas, with bruising noted. The residents initial Braden Scale for Predicting Pressure Score Risk, dated 2/1/11, documented the resident with a score of 15, at high risk above a score of 10. The admission MDS (Minimum Data Set), dated 2/11/11, documented the resident with the following. "Able to communicate needs, a BIMS (Brief Interview of Mental Status), score of 15, indicating cognition intact. The resident required total assistance of 2 staff for bed mobility, transfers and bathing. Functional limitation in range of motion documented the upper extremity with impairment on one side, and the lower extremity with impairment on both sides. Mobility per wheelchair, with staff assistance of 1. Always incontinent of urine and frequently incontinent of bowel. No unhealed pressure area. A pressure reducing device for the chair and bed, turn and repositioning program. The resident's weight is 208 pounds." The Care Plan, dated 2/21/11, documented the potential for alteration in skin integrity related to decreased mobility with bowel and bladder incontinence. Interventions as follow: The resident required total dependence on staff assistance with routine turning and repositioning. The resident is unable to sit on the toilet due to positioning. Staff to check and change at least every 2 hours and prn (as needed). Briefs/pads provided along with peri-care after incontinent episodes. Monitor nutritional and hydration status. Monitor skin during daily cares, with biweekly showers and weekly body audits by nurse. Nursing to perform Braden Scale upon admission, quarterly and prn. Pressure reducing mattress for bed and pad for wheelchair. The plan of care failed to instruct staff how often the resident required repositioning. Further more, the plan of care failed to address off loading of the residents heels. 4/19/11, Pressure Ulcer, left heel. 4.5 cm (centimeter) in length and 5 cm in width. Stage 2. Current treatment skin prep to left heel twice daily. Blue boots on at all times. Float heel while in bed. The record review of the residents weekly left heel wound assessment indicated pressure ulcer development on 4/19/11, with continued assessments as follows; 4/19/11, 4.5 cm (centimeter) length and 5 cm width. Stage 2. Current treatment skin prep to left heel twice daily. Blue boots on at all times. Float heel while in bed. On 4/27/11. 4.5 cm length and 5 cm width, blister. On 5/12/11, 4.0 cm length and 4.2 cm width, stage 2. On 6/15/11, 1.5 cm length and 2.5 cm width. On 6/30/11, 4 cm length and 4 cm width, shape irregular and unstageable, further documentation of blister, hardened scar tissue. On 7/1/11, 3 cm length and 2.3 cm width, unable to determine depth, unstageable, exudate with scant amount and color serous (thin, watery, clear). Surrounding skin is dry with 0.7 to 1.0 mushy periwound, 10 o'clock to 6 o'clock, edges not attached. Necrotic tissue present, yellow slough, black, soft, hard (slough at edges, from 10 o'clock to 6 o'clock, eschar cap has been lifted). Percentage of wound necrotic, 100%. The tissue bed without granulation tissue, moist edges. The status deteriorating, notified 7/1/11 doctor's office, treatment changed to Santyl. On 7/15/11, 2.5 cm length and 2.3 cm width, unstageable. No change in exudate. necrotic tissue (eschar) present 100% of the wound, improved. Current treatment, cleanse, Santyl to edges and under cap, zinc oxide to peri wound, petroleum gauze, wrap. On 7/27/11, 1.2 cm length and 1.5 cm width, with 0.3 cm depth, stage 3. The wound with moderate serosanguineous (thin watery blood) drainage. The surrounding skin dry but [MEDICAL CONDITION], necrotic tissue is present, yellow slough, soft, in 25% of the wound. The tissue bed with 60-70% of granulation tissue present and moist. The wound nurse completed sharp debridement. On 8/10/11, 0.9 cm length by 0.7 cm width and 0.2 cm depth, stage 3. The exudate scant, purulent, opaque in consistency. Surrounding skin, discolor, edges attached, necrotic tissue not present. Granulation of tissue bed 100%, and moist. The wound healing and improved. The physician's orders [REDACTED]. The record review of weekly wound assessments for the upper coccyx pressure area indicated pressure ulcer development on 5/12/11, with continued assessments as follows: On 5/12/11, 0.5 cm length and 0.7 cm width and 0.1 cm depth. The shape is oval, stage 2. The current treatment, cleanse with normal saline, skin prep area, place Versive dressing, change every 3 days and prn until healed. In the margin documented compromised tissue from old wounds. On 6/15/11, 1.1 cm length and 0.8 cm width, with 0.2 cm depth, stage 2. The area is deteriorating, no change in treatment. On 6/27/11, 0.9 length and 0.8 cm width, with 0.2 cm depth, stage 2. The area improved, current treatment, cleanse, sensi care cream three times a day and prn. On 7/21/11, 1.2 cm length, 0.8 cm width, stage 2. The wound deteriorating, current treatment, cleanse, sensicare each time soiled. The record review of weekly wound assessments for the lower coccyx pressure area indicated pressure ulcer development on 6/18/11, with continued assessments as follows: On 6/18/11, 0.5 cm in length, 0.5 cm in width, and 0.1 cm in depth. The current treatment is cleanse, thin [MEDICATION NAME]. On 6/27/11, 0.5 cm length, and 0.5 cm width and 0.1 cm depth, stage 2. The current treatment is cleanse, sensi care cream three times a day and prn, to lay down after each meal. On 7/27/11, 0.5 cm length, 0.3 cm width and 0.1 cm depth, stage 2. The resident with scant amount of serous exudate. The current treatment is unchanged. On 8/2/11 documented the pressure area healed. The physician's orders [REDACTED]. The physician's orders [REDACTED]. On 8/10/11, at 7:15 AM, observation revealed, the resident in a high back wheelchair, with a pressure relieving cushion to seat and positioning device for foot/ankle in place. However the pair of blue protective boots lay on the low air loss mattress of the. The resident with a low air loss mattress in place. Observations documented every 15 minutes from 7:15 AM through 9:34 AM, revealed the facility staff failed to apply the blue protective boots without protective blue boots in place. The interview on 8/10/11, at 9:55 AM, with certified nursing staff T, reported the resident is repositioned every 2 hours or as needed, could be every 1-1/2 hour. We are to provide perineal care and apply Sensicare to the residents bottom, coccyx area. For the residents left heel we are to use the blue boots when she in in bed and the blue off load boots to be on when in the wheelchair. The wheelchair has a cushion device for her heels/feet to keep them in place. The facility failed to promote the prevention of pressure ulcer development and promote the healing of pressure ulcers that are present.

The facility identified a census of 198 residents. The sample included 23 residents. Based on interview and record review, the facility failed to develop and implement appropriate interventions to prevent the development of pressure ulcers for one of three residents sampled for pressure ulcers. (#1014) Findings included: - According to the closed record, resident #1014 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The Physician order [REDACTED]. The initial 5 day Minimum Data Set 3.0 (MDS) Assessment documented the resident with a BIMS (Basic Interview of Mental Status) score of 7 which indicated the resident with poor cognitive ability. The MDS recorded the resident required extensive assistance of 1 to 2 staff members with most activities of daily living (ADLs), i.e. bed mobility, transfer, dressing, walking and toilet use. This same assessment recorded the resident continent of bowel, occasionally incontinent of bladder, used antianxiety, antibiotic and diuretic medications, without pressure sores. Review of the initial nursing data assessment dated [DATE], documented the resident as alert and oriented, full weight bearing, and required 2 person physical assistance which contraindicated the MDS assessment. This same assessment however, lacked information regarding the presence or treatment of [REDACTED]. The initial nutrition assessment dated [DATE] recorded the resident ' s height at 5 feet 8 inches, weight of 218 pounds, no pressure sores and no recent [MEDICATION NAME] levels (measure of blood protein stores). The POS recorded the resident received a regular diet, underwent blood sugar checks four times a day and received scheduled and as needed insulin. This same POS revealed an undated physician's orders [REDACTED]. The clinical record however, lacked documentation of any skin audits performed for the month of September 2011. Review of the 8/29/11 Braden scale (a numerical scale used for assessing the potential of developing pressure scores) recorded a value of 20 which placed the resident at low risk for development of pressure sores. The admission nursing care plan dated 8-29-11, lacked documentation regarding any current or healed pressure sores and/or skin disruptions. This same preprinted care plan lacked documentation of interventions for wound treatments. Review of the nurse ' s progress notes dated , 9-11-11 (untimed) revealed "pressure ulcers noted on bilateral heels, wound assessment completed, new order for skin prep and blue boots at all times. " Review of the Weekly Wound Assessments dated 9-12-11, documented the resident acquired a pressure ulcer to the left heel, which measured 1.1 cm (centimeters) x 4.3 cm x 0 cm without tunneling and no exudate (drainage) surrounding skin intact, necrotic (dead) tissue present- black, fifty percent of the wound was necrotic, no pain, new wound, current treatment: blue boots, skin prep. This same assessment (dated 9/12/11) recorded the resident acquired a pressure ulcer to the right heel , which measured l.6 cm x 5.1 cm x 0 cm, no undermining or tunneling, surrounding skin intact, necrotic tissue present, black, 50% of wound with necrotic tissue, granulation tissue not present, new wound, current treatment: blue boots and skin prep. Continued Review of the POS skin prep to bilateral heels every day, off load heels with blue boots while in bed and chair." Review of the Treatment Assessment Record (TAR) also documented the physician orders [REDACTED]." Continued review of the nurse's progress notes dated 9/17/11 at 5:25 A.M., revealed resident hospitalized for [REDACTED]. On 10/13/11 at 1:30 P.M. administrative nursing staff A, acknowledged the lack of interventions to prevent pressure ulcers for the resident and the blank skin sheets for September 2011. Administrative nursing staff A added that, "he/she expected staff to complete weekly skin audits as ordered." On 10/13/11 at 1:45 P.M. direct care K staff stated, "the resident could stand for assistance with dressing; assist with changing (incontinent products). Had spots between his/her legs on admission, I think we had to turn him/her every 2 hours, but then he/she got to the point to where he/she could turn self, he/she had an air mattress, and when he/she got here his/her heels were bad. He/she had the blue boots that he/she wore in bed and kept them on in the wheelchair." On 10/13/11 at 2:10 P.M. administrative nursing staff B stated, "All I have is the weekly wound assessment for when they initially found it (pressure sores) on 9-12-11, "and added from, "looking at the care plan it looked like nothing was in place to prevent the resident from developing pressure ulcers " Administrative nursing staff B added, "the care plan should have been updated when the resident developed the pressure ulcer." Administrative nursing staff B, "acknowledged discrepancies between the resident's Braden score and level of assistance needed per the assessment and nurse s notes." Also, administrative nursing staff B stated, "the standard to maintain skin integrity sheet was an additional tool for staff to fill out and they usually fill it out however, it wasn't filled out for this resident," and "the weekly skin assessments were blank and should have been done by the nurses. " The facility policy entitled Pressure Ulcer Care and Documentation revised 12/06 recorded the need for accurate assessment and use of preventative pressure reducing measures, i. e. wheelchair cushions and bed air mattress. The facility failed to ensure this dependent resident who entered the facility without pressure sores received appropriate services to prevent the development of two unstageable pressure ulcers.