Every finding on record at Delmar Gardens of Overland Park

Based on observation, record review, and interview, the facility failed to ensure routine catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care was performed per professional standards of practice for Resident (R)1. Findings included:- R1'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).The admission / Medicare Minimum Data Set (MDS), dated 06/04/2026, for R1 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 required substantial to maximal assistance for upper body dressing, bed mobility, and transfers. The MDS documented R1 was dependent on staff for toileting hygiene, lower body dressing, and personal hygiene. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/04/2026, documented R1 had BPH and a Foley catheter. The CAA documented R1 had a decline in functional ability with Activities of Daily Living (ADL), toileting, catheter, incontinence care, and transfers.R1's 05/29/2026 Care Plan documented R1 had an indwelling catheter. The 05/29/2026 Care Plan included the following interventions for R1:05/29/2026 - directed staff to monitor for signs and symptoms of a urinary tract infection (UTI-an infection in any part of the urinary system)05/29/2026 - directed staff to provide catheter care every shift and as needed.R1's 05/29/2026 Care Plan documented R1 was at risk for contracting a multi-drug-resistant organism due to right wrist infection, Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics) and Foley catheter. A physician's order, with a start date of 05/29/2026, directed staff to perform catheter care per shift. The order frequency recorded care to be done every day, on day shift, evening shift, and night shift.Review of the Point of Care History, from 05/28/2026 through 06/30/2026, under the Indwelling Catheter Care section, revealed the following:No catheter cares documented, for any shift, on the following (11) days 05/29/2026, 05/30/2026, 05/31/2026, 06/01/2026, 06/03/2026, 06/04/2026, 06/05/2026, 06/08/2026, 06/10/2026, 06/11/2026, and 06/14/2026.Cather care documented as done one time a day on the following (6) days 06/02/2026, 06/06/2026, 06/07/2026, 06/09/2026, 06/12/2026, and 06/13/2026.Catheter care documented as done two times a day on the following (2) days 06/15/2026 and 06/16/2026.There were zero days during the look back period where catheter care was documented as being done on all three shifts as ordered. A Nursing note dated 06/17/2026 at 10:37 AM, documented staff noted dark red urine draining via Foley to gravity drain bag. The note recorded there was approximately 750 milliliters (mL) observed in the catheter bag. The note further recorded the nurse practitioner (NP) was contacted and made aware or red colored urine, that R1 denied pain, and was uncertain of other discomfort. The note recorded new orders were received to send R1 to the emergency department (ED) for evaluation.A Nursing note dated 06/17/2026 at 12:54 PM, documented a call was placed to Emergency Medical Services (EMS) per orders. The note recorded EMS arrived, report was provided, and resident was transported to the ED for evaluation.R1's EMR lacked evidence of any progress notes related to R1 receiving catheter care between 05/28/2026 through 06/17/2026 when R1 was sent to the ED.On 06/30/2026 at 04:18 PM, Licensed Nurse (LN) G stated when the nurses do patient care they were the ones that cleaned the catheter site, made sure the catheter had good flow, and had no blood or sediment. LN G stated catheter care was supposed to have been done on every shift. LN G stated if catheter care was not done regularly, it would put the resident at risk for infection. She stated a resident could become septic (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) from UTIs. She further stated sometimes the site around the catheter could become irritated or infected, and it was important for catheter care to have been completed on time, every day.On 06/30/2026 at 04:35 PM, Administrative Nurse D stated the nurses were the ones that did the cleaning of the catheter during catheter cares. She stated the Certified Nursing assistants (CNA) may have been documenting the catheter care as being done as they changed the resident's briefs more often and the order popped up under the CNA charting for them to document against. She stated the nurses had to check for signs of infection and perform the actual catheter care. Administrative Nurse D stated a lot of the times the nurses would put in a progress note, but if they cleaned the catheter, and there were no issues they may note have. Administrative Nurse D stated if the CNAs note anything, they report it to the nurse and to her. She stated the only way to know if the catheter care was done was through the CNA documentation on the Point of Care History under the Indwelling Catheter Care section in the EMR. She stated staff did notice the blood in R1's urine that day and had him transferred out via non-emergency transport to the hospital. She stated they ordered a UA, but he was sent out prior to it being collected. Administrative Nurse D stated R1 was on an antibiotic for his wrist infection the whole time he was in the facility. She stated she was surprised he would have a UTI. Administrative Nurse D stated the facility had not received an update on R1 after he was sent to the hospital. She stated she was not sure what had caused the blood in his urine.On 06/30/2026 at 05:06 PM, Consultant GG stated she worked as a nurse at the hospital. She reported she received report from the ED nurse that cared for R1 in the ED. She stated she also reviewed R1's medical records during his current hospital visit. Consultant GG stated R1 had a lot of blood in his urine when he arrived. Consultant GG stated R1 was diagnosed with a UTI at the hospital and was currently being treated for it.The facility's Catheter Care policy, with a revised date of 03/2021, documented purpose: to keep indwelling catheter free of discharge and or crusting which can cause infection. Catheter care should be given every shift and as needed.

The facility identified a census of 97 residents, with one kitchen and dining room. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food and equipment storage.Findings included:- On 01/26/25 at 09:05 AM, a walkthrough of the facility's kitchen was completed:An inspection of the steam table serving area revealed clean plates stored upward on the plate rack without a sanitary cover or barrier. An inspection of the dishwashing area revealed that clean plates were stored upward on the plate rack without a sanitary cover or barrier.An inspection of the walk-in freezer's air condenser unit revealed that it had leaked large amounts of fluid onto stored bags of servable ice and boxes of ice cream sandwiches stored below the leak.An inspection of the walk-in refrigerator revealed a 40-ounce package of Swiss cheese opened and undated on the top right rack of the unit. The cheese package was open and exposed.On 01/28/26 at 12:25 PM, Dietary Staff BB stated staff were expected to inspect the kitchen and storage areas each shift to ensure safe handling of the food. She stated staff were expected to store food and equipment with safe serving practices. She stated the leak was awaiting a part and was scheduled to be fixed on 01/29/26. She removed the boxes within the vicinity of the leak and stated staff would ensure the area remained clear until the leak was fixed.The facility's Storage Guidelines policy (undated) indicated the facility would ensure all food and supplies were stored appropriately to ensure quality and maximizes safety of the food.

The facility identified a census of 97 residents. The sample included 21 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 9.Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of heart failure, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Significant Change Minimum Data Set (MDS) dated 11/15/25 documented a Brief Interview for Mental Status (BIMS) score was not assessed and no information was documented during the observation period.R9's Dehydration Care Area Assessment (CAA) dated 01/04/26 documented staff would provide R9 with fluids and beverages to maintain his hydration. R9's Care Plan documented the following:07/02/25- Staff would encourage R9 to participation to the maximin independence.The plan of care lacked direction for monitoring weights and heart failure.R9's EMR under the Orders tab documented daily weights prior to breakfast. Notify the physician of a weight change of three pounds or greater in one day, dated 12/29/25.Review of R9's Medication Administration Record (MAR), Treatment Administration Record (TAR), and EMR from 12/30/25 to 01/26/26 (28 days) lacked evidence staff measured and recorded R9's weight on the following 12 dates: 12/30/25 weight was missed, 01/03/26 lacked documentation, 01/07/26 R9 was unavailable, 01/08/26 he had refused, 01/12/26 documented did not get the weight, 01/13/26 R9 was at an appointment, 01/14/26 Certified Nurse Aide (CNA) did not get the weight, 01/16/26 lacked documentation, 01/17/26 R9 refused, 01/18/26 R9 refused, 01/23/26 lacked documentation, and 01/24/26 R9 refused.The clinical record lacked documentation of physician's notification that the daily weight was not obtained.On 01/26/26 at 10:20 AM, R9 was asleep in the wheelchair in his room. R9 had a white dressing on his right forearm and wrist, and another white dressing on the top of his right hand. R9 stated he could not remember what had happened to his right arm.On 01/28/26 at 12:06 PM, CNA M stated the nurse would let the staff know who was to be a daily weight when needed. CNA M stated the staff would obtain the weight, or if the resident refused, the nurse would be notified.On 01/28/26 at 12:14 PM, Licensed Nurse (LN) G stated the nurse would notify the CNAs of which residents needed a weight that day. LN G stated if the resident refused, that would be documented in their EMR. LN G stated the physician should be notified and that would also be documented in the residents EMR under the progress note tab. LN G stated it was the nurse's responsibility to ensure the daily weight was charted or the physician was notified of their refusal.On 01/28/26 at 12:57 PM, Administrative Nurse D stated the nurse would notify the CNAs of the residents who needed a weight that day. Administrative Nurse D stated it was the nurse's responsibility to ensure the weight was obtained, or if the resident refused, the physician should be notified. Administrative Nurse D stated that it should be documented in the residents' EMR under the progress notes, which would be the best place for the documentation.The facility's Following Physician Orders policy, dated 06/29/21, documented it was the policy of the community to ensure that all Licensed Professional Nurses (RN/LPN/LVN) and other Healthcare Professionals followed Physician Orders in accordance with State and Federal regulations and their respective practice acts.

The facility identified a census of 97 residents. The sample included 21 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 4's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary manner.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), empyema (collection of pus in the pleural cavity related to bacterial pneumonia), open wound to left lower leg, and nicotine dependence.The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R4 was independent with eating and was dependent on staff assistance with toileting. The MDS documented R4 received oxygen therapy during the observation period.R4's Care Plan documented the following:05/21/25- R4 required oxygen therapy related to COPD, pneumothorax (abnormal collection of air between the lung and the chest wall), and respiratory distress. 05/21/25- Nursing staff would monitor oxygen saturation every shift and as needed.R4's plan of care lacked direction for the storage of R4's nebulizer mask.R4's EMR under the Orders tab revealed the following physician orders:Ipratropium-albuterol solution for nebulization: 0.5 milligrams (mg)-3 mg/3 milliliters (ml), give 3 ml inhalation (medication inhaled to open airways) for respiratory four times a day, dated 05/20/25.Change nebulizer tubing weekly and as needed on Fridays, dated 05/21/25.Albuterol inhalation solution for nebulization: 2.5/3.0 ml 2.5mg per give 2.5mg inhalation for shortness of breath four times a day as needed, dated 06/03/25.On 01/27/26 at 10:24 AM, R4 sat in his electric wheelchair in the commons area watching TV. R4 was wearing oxygen. R4's nebulizer laid on his bedside table. R4's nebulizer mask was not stored in a sanitary manner.On 01/27/26 at 02:22 PM, R4 sat in the commons room close to the TV. R4's nebulizer mask laid dangling over the bedside table. R4's nebulizer mask was not stored in a sanitary manner.On 01/27/26 at 12:05 PM, Certified Nurse's Aide (CNA) M stated respiratory equipment not in use should be put in a bag to keep the equipment clean. CNA M stated it was the nurse who gave the breathing treatment who put the mask into a bag.On 01/27/26 at 12:14 PM, Licensed Nurse (LN) G stated all respiratory equipment should be placed in a bag. She stated it was all the staff's responsibility to ensure the respiratory equipment was kept sanitary.On 01/27/26 at 12:58 PM, Administrative Nurse D stated all respiratory equipment should be placed in a mesh bag. Administrator D stated it was all the staff members' responsibility to ensure the respiratory equipment was not in use. She stated all staff should put the not-in-use equipment in the mesh bag.The facility's Nebulizing Cleaning policy, revised 05/2021, documented pulmonary equipment, including nebulizers, would be cleaned between uses and stored to prevent contamination and prevent the growth of microorganisms.

The facility identified a census of 97 residents. The sample included 21 residents, with one resident reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 6's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization.Findings included:- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of PTSD and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The admission Minimum Data Set (MDS) dated 12/24/25 documented the Brief Interview for Mental Status (BIMS) score was not assed or no information. The MDS documented R6 had the active diagnosis of PTSD. R6's Behavioral Symptoms Care Area Assessment (CAA) dated 01/09/26 documented she was not very interested in activities.R6's Care Plan documented the following:12/18/25- Staff would anticipate her needs.The plan of care lacked direction for her PTSD.R6's EMR under the Assessment tab lacked a trauma informed care assessment and the facility was unable to provide one upon request on 01/28/26 at 12:57 PM. On 01/28/26 at 07:15 AM, R6 sat in her wheelchair next to her bed. R6 propelled herself in the wheelchair down the hallway to the dining room. On 01/28/26 at 12:14 PM, Licensed Nurse (LN) G stated the social worker was responsible for completing the trauma-informed assessment.On 01/28/26 at 12:57 PM, Administrative Nurse D stated the MDS coordinator or the social service was responsible for completing the trauma-informed assessment. Administrative Nurse D stated she did not know if R6 had a trauma-informed assessment completed and would check for the assessment.The facility's Trauma Informed Care and Behavioral Health Management policy, revised 09/2019, documented it was the philosophy of the facility to treat all residents with love, care, and understanding. The Facility believes all behaviors have meaning and are often a way of communicating a need. 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. The facility provided Behavioral Health Services to residents who required such services in accordance with state and federal law. Within seventy-two (72) hours of admission, a review of the admission medical record would be completed by the social worker, and the residents would be asked, If they have experienced any trauma in their life that continues to upset them today.

The facility identified a census of 81 residents. Based on record review and interviews, the facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections. Findings included: - During the entrance conference Administrative Staff, A reported the facility did not have a certified Infection Preventionist and Administrative Nurse E was in the process of becoming certified. On 03/13/24 Administrative Nurse E was not available for the interview. On 03/13/24 at 04:02 PM Administrative Nurse D stated she was not certified as an Infection Preventionist, but had been tracking the immunizations, and doing the antibiotic stewardship. The facility was unable to provide an Infection Preventionist policy. The facility failed to ensure a staff member had the required qualification and certification as an Infection Preventionist to be responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections.

The facility reported a census of 81 residents. The sample included 21 residents. Five Certified Nurse Aides (CNA) were sampled for prevention of abuse, neglect, and exploitation training. Based on record review, and interviews the facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for the two of the five CNAs that were sampled. Findings included: - Employee record review of CNA PP revealed the facility failed to provide evidence that CNA PP received the required abuse, neglect, and exploitation training. Employee record review of CNA QQ revealed the facility failed to provide evidence that CNA QQ received the required abuse, neglect, and exploitation training. On 03/13/24 at approximately 01:00 PM facility staff had placed two white binders on a table for survey staff to review. The binders contained various education topics from 2023 with accompanied staff sign-in sheets. The binders were separated with blank tabs and the majority of topics lacked a duration or tracked time period for the education provided. The binders lacked any clear way that demonstrated education hours and topics were tracked. On 03/12/24 at 09:54 AM Administrative Staff A stated she could not show the required 12 hours of yearly in-service education. Administrative Staff A further stated the staff responsible for providing staff education didn't track hours and the facility did not have the staff education from the previous 12 months. Administrative Staff A stated the facility took steps to improve the education process and tracking at the facility and that a new educator was hired. Administrative Staff A further stated education was tracked under the new system since February 2024 and that the facility had a skills fair for the staff that counted as six hours of education, and included dementia, abuse, neglect, and exploitation training. Administrative Staff A stated new staff would have to complete an eight-hour orientation. On 03/12/24 at 10:03 AM Administrative Staff B stated administrative staff searched through all the records and that the facility had all the education except for the year 2023. Administrative Staff B stated the previous educator may have left with the education records for 2023. Administrative Staff B stated CNA PP only worked at the facility one day a week, and that CNA PP had done his education at another facility. Administrative Staff B stated the facility had a plan in place to provide education for CNA PP despite him working only one day a week. Administrative Staff B further stated CNA QQ had completed the education from the skills fair; however, CNA QQ had not returned the book, and it had not been graded. Administrative Staff B stated the education hours would not have been recorded until the education was graded. On 03/13/24 at 10:56 AM Administrative Staff A stated the Inservice Records for NA/CNAs was the form used to track staff education in their new system. Administrative Staff A stated the information documented on the forms was all the facility had for education and that any staff who did not have the skills fair documented on their Inservice Records for NA's/CNA's form must not have made it to the training. The facility provided Certified Nursing Assistants/Medication Aids (CNAs/CMAs) with a reviewed date of 06/21, documented all direct care staff are required to attend twelve hours of continuing education annually including but not limited to dementia and prevention of abuse, neglect and exploitation of residents and immediately reporting. The facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for two of the five CNAs that were sampled.

The facility had a census of 81 residents. The sample included 21 residents and five Certified Nurse Aides (CNAs) reviewed for required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education and two of the five CNA staff had the required in-service education for dementia (a progressive mental disorder characterized by failing memory, confusion) care. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's in-service records revealed the following: CNA LL, hired on 12/09/16, had eight hours of in-service in the past 12 months. CNA OO hired 09/29/09, had six hours of in-service in the past 12 months. CNA PP, hired on 10/26/21, had zero hours of in-service in the past 12 months, and CNA PP's records lacked evidence of the required education on the topic of dementia in the past 12 months. CNA QQ, hired on 01/03/18, had zero hours of in-service in the past 12 months, and CNA QQ's records lacked evidence of the required education on the topic of dementia in the past 12 months. CNA RR, hired on 02/14/18, had six hours of in-service in the past 12 months. On 03/13/24 at approximately 01:00 PM facility staff had placed two white binders on a table for survey staff to review. The binders contained various education topics from 2023 with accompanied staff sign-in sheets. The binders were separated with blank tabs and the majority of topics lacked a duration or tracked time period for the education provided. The binders lacked any clear way that demonstrated education hours and topics were tracked. On 03/12/24 at 09:54 AM Administrative Staff A stated she could not show the required 12 hours of yearly in-service education. Administrative Staff A further stated the staff responsible for providing staff education didn't track hours and the facility did not have the staff education from the previous 12 months. Administrative Staff A stated the facility took steps to improve the education process and tracking at the facility and that a new educator was hired. Administrative Staff A further stated education was tracked under the new system since February 2024 and that the facility had a skills fair for the staff that counted as six hours of education and new staff would have to complete an eight-hour orientation. On 03/12/24 at 10:03 AM Administrative Staff B stated administrative staff searched through all the records and that the facility had all the education except for the year 2023. Administrative Staff B stated the previous educator may have left with the education records for 2023. Administrative Staff B stated CNA PP only worked at the facility one day a week, and that CNA PP had done his education at another facility. Administrative Staff B stated the facility had a plan in place to provide education for CNA PP despite him working only one day a week. Administrative Staff B further stated CNA QQ had completed the education from the skills fair; however, CNA QQ had not returned the book, and it had not been graded. Administrative Staff B stated the education hours would not have been recorded until the education was graded. On 03/13/24 at 10:56 AM Administrative Staff A stated the Inservice Records for NAs/CNAs was the form used to track staff education in their new system. Administrative Staff A stated the information documented on the forms was all the facility had for education and that any staff who did not have the skills fair documented on their Inservice Records for NA's/CNA's form must not have made it to the training. The facility provided Certified Nursing Assistants/Medication Aids (CNAs/CMAs) documented all direct care staff are required to attend twelve hours of continuing education annually including but not limited to dementia and prevention of abuse, neglect and exploitation of residents and immediately reporting. The facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education and two of the five CNA staff had the required in-service education for care. This placed the residents at risk for inadequate care.

The facility reported a census of 81. Based on observations, record reviews, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial well-being and impaired quality of life. Findings Included: - A review of the Facility's Council Minutes from 03/2023 through 03/2024 indicated the council had recurring concerns with missing property and clothing, slow call light response and staff response time, staff cell phone use, lack of healthy snacks, specialized diets, and grievances not being resolved. The 03/2023 Resident Council Minutes documented recurring concerns related to call lights not being answered in the evening and missed showers for residents. The minutes indicated the council requested diabetic cookies be ordered for residents on special diets. The minutes lacked actions taken or outcomes for the repeat concerns. The 05/2023 Resident Council Minutes documented recurring concerns with missing property and slow call light response. The minutes indicated residents were encouraged to complete grievances to speed up the response time for missing items. The minutes lacked actions taken or outcomes for the repeat concerns. The minutes lacked actions taken or outcomes for the repeat concerns. The 06/2023 Resident Council Minutes documented ongoing concerns with call light response times. The minutes documented continued concerns about missing clothing. The minutes lacked actions taken or outcomes for the repeat concerns. The 07/2023 Resident Council Minutes documented ongoing concerns with slow call light response times. The minutes indicated concerns related to staff using phones and earbuds during shift making it difficult to hear call lights and calls for help. The minutes indicated staff re-education for the earbud usage. The 08/2023 Resident Council Minutes documented concerns that certain rooms were not being cleaned. The minutes indicated the usage of personal cellphones was out of control by staff. The council minutes indicated staff were still using earbuds. The council minutes request more low- low-carbohydrate-based foods. The council minutes requested fruits be always made available. The minutes lacked actions taken or outcomes for the repeat concerns. The 09/2023 Resident Council Minutes documented continued concerns with staff being on their cell phones during work. The council minutes noted ongoing concerns with lost laundry. The council minutes noted a resident's clothing was thrown in the trash instead of the laundry basket. The council minutes request the residents need more healthy snacks and fruits. The council minutes noted the facility ran out of snacks. The council reported some residents and staff may have been hoarding snacks. The minutes lacked actions taken or outcomes for the repeat concerns. The 10/2023 Resident Council Minutes noted old business noted continued concerns with staff cell phone usage, missing property, and aids throwing clothing in the trash instead of laundry baskets. The council minutes noted continued slow call light response on the night shift. The minutes indicated the need for more healthy snacks was still not resolved. The council minutes indicated continued concerns with a lack of nighttime snacks, healthy snacks, and special diet-based snacks. The 11/2023 Resident Council Minutes indicated continued staff cellphone usage and slow call light response were still not resolved. The council minutes noted concerns about missing laundry. The 01/2024 Resident Council Minutes indicated ongoing concerns related to slow call light response time. The council minutes noted some rooms were not being cleaned on certain days and continued concerns with staff using cell phones while on duty. The 02/2024 Resident Council Minutes indicated continued concerns with long call light responses, staff cellphone usage, and room cleanings. The minutes lacked actions taken or outcomes for the repeat concerns. The 03/2024 Resident Council Minutes indicated continued concerns with long call light responses, staff cellphone usage, and room cleanings. The minutes lacked actions taken or outcomes for the repeat concerns. On 03/12/24 at 02:00 PM, the Resident Council reported frustration with ongoing concerns about missing clothing, diabetic snacks, healthy snack choices, evening snacks, staff cell phones, and long call light wait times in the evening. The council reported concerns with the facility following up with reported concerns and not having the concerns resolved. On 03/13/24 at 09:12 AM Laundry Staff U stated resident's laundry was sent down labeled and washed separately from another resident. She stated the laundry was sent directly back up to the designated room. She stated that lost items may have occurred before being sent down. On 03/13/24 at 12:53 PM Activities staff Z stated she recorded the resident council minutes each month and was responsible for ensuring the concerns were given to the correct department head. She stated if council concerns were not addressed by the facility, she would return to the department head and ask why the identified concern was not resolved. She stated if an issue was outstanding or not resolved in a reasonable amount of the she would report it to the administrator. On 03/13/24 at 01:18 PM, Dietary BB stated that the facility always had snacks available. Dietary AA stated they tried to have a variety of chips, fruit, crackers, and at times made-up special snacks to be passed out to the residents in the evening. Dietary AA stated that in each dining area, there were snacks that were always out for the residents. Dietary AA stated if a resident preferred a snack other than what was on the cart the staff was able to get something else from the kitchen like sugar-free pudding or Jell-O. Dietary AA stated the chef was trying to order more of a variety of items and foods to suit the resident's preferences, but some food items were not always available. The facility did not provide a policy related to Resident Council as requested on 03/13/24. The facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial well-being and impaired quality of life.

The facility identified a census of 81 residents. The sample includes 21 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. The facility additionally failed to maintain the results of all grievances for the required three years. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included- - A review of the facility's Grievance Logs from March 2023 through March 2024 revealed the facility was missing logs from November 2023 through February 2024. The facility was unable to provide the missing documentation as requested on 03/13/24. On 03/12/24 at 08:00 AM an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 03/12/24 at 02:00 PM, the Resident Council members reported they were not aware if the facility provided a way to complete anonymous grievances. The council reported Social Services X was responsible for complaints and grievances. The council reported they had to get grievance forms from the front desk and then give them to staff to turn in to the appropriate person. On 03/13/24 at 12:25 PM, Social Service X stated the grievance forms were kept at the front desk and could be brought to the residents by staff. She stated a drop box was on the back wall of the administrative office, but she was not aware if the residents could turn the forms in themselves or anonymously. On 03/13/24 at 04:01 PM Administrative Staff A stated she was unable to locate the missing grievance logs due to recent changes in staffing. She stated the residents could file grievances using the facility's corporate grievance number but would not have paper records to show for it. The facility's provided Grievance policy revised 06/2021 indicated the facility would ensure each resident's right to file a grievance in writing, verbally, or anonymously. The policy indicated the facility would ensure the grievances were documented and ensure all written decisions included corrective actions and prompt resolution. The policy noted the grievance documentation will be kept for three years beyond the written decision. The facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously within the facility. The facility additionally failed to maintain grievance records. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances.

The facility identified a census of 81 residents. The sample included 21 residents. Based on record review and interviews, the facility failed to fully complete the comprehensive Minimum Data Set (MDS) assessment Section V, Care Area Assessment Summary (CAA) for Resident (R) 1, R3, R16, R17, R30, R3, R50, R52, R67, R80, R81, and R286 to include an analysis and rationale for care planning decisions. This placed these residents at risk for not accurately reflecting each resident's needs to develop an individualized comprehensive plan of care. Findings included: - R1's Annual MDS with assessment reference date (ARD) of 02/02/24 Section V Care Area Assessment (CAA) was not completed to include an analysis and rationale for care planning decisions. R3's Annual MDS with ARD of 10/10/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R16's Annual MDS with ARD of 12/23/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R17's Admission MDS with ARD of 03/02/24 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R30's Significant Change MDS with ARD of 10/20/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R31's Annual MDS with ARD of 01/25/24 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R50's Annual MDS with ARD of 11/13/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R52's Admission MDS with ARD of 02/29/24 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R67's Annual MDS with ARD of 10/16/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R80's Admission MDS with ARD of 02/29/24 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R81's Admission MDS with ARD of 02/20/24 Section V CAA was not completed to include an analysis and rationale for care planning decisions. R286's MDS with ARD of 12/28/23 Section V CAA was not completed to include an analysis and rationale for care planning decisions. On 03/13/24 at 12:35 PM Administrative Nurse D stated that she had completed the MDS and had completed the assessments for residents. Administrative Nurse D stated at the end of the assessments that had a section V, she was not able to close that section until she had validated it or finalized the section. Administrative Nurse D stated she did not realize that there was a separate page to go in to document the analysis data for information that needed to be added to the care plan. Administrative Nurse D stated after she had signed that page it would take her back to the original page with all the sections on it and at that allowed her to validate everything and finalize the section without completing the worksheets. The Resident Assessment Instrument Manual version 3.0 states, that the CAA process provides a framework for guiding the review of triggered areas and clarification of a resident's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. The assessment of the causes and contributing factors gives the interdisciplinary team (IDT) additional information to help them develop a comprehensive plan of care. Upon request, the facility did not provide a policy for Minimum Data Set Completion. The facility failed to complete comprehensive MDS Section V, CAA for R1, R3, R16, R17, R30, R31, R50, R52, R67, R80, R81, and R286 which placed these residents at risk for not accurately reflecting each resident's status and needs, to develop an individualized comprehensive plan of care.

The facility had a census of 81 residents. The sample included 21 residents with three residents reviewed for accident/fall prevention. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards when staff failed to secure chemicals in a safe, locked area, and out of reach of the thirteen cognitively impaired, independently mobile residents. The facility additionally failed to utilize safe assistive techniques related to Resident (R)61's wheelchair foot pedals and safe mechanical lift transfer techniques for R17 and R30. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 03/11/24 at 07:14 AM a walkthrough of the facility was completed. An inspection of an unlocked janitor closet on the 200 hallway revealed unsecured Diversify cleaning products including heavy-duty floor cleaners, bowl and bath cleaners, and general-purpose cleaners. The closet also contained two cans of Ajax powdered drain cleaner. All products identified contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. An inspection of the facility's first and second-floor spa rooms revealed unlocked cabinets containing chemical sanitizing wipes and chemical sanitizing spray bottles. All products identified contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 03/13/24 at 02:18 PM, Certified Nurses Aid (CNA) S stated cleaning products should be locked out of reach of the residents. She stated the cabinets and closets should always be locked. On 03/13/24 at 02:25 PM, Licensed Nurse (LN) K said staff should never leave the cleaning products out where the residents could access them. On 03/13/24 at 04:00 PM Administrative Nurse D stated staff were expected to ensure the areas containing hazardous chemicals remained locked and not accessible to the residents. The facility's provided Chemical Storage policy effective 06/2022 indicated all hazardous chemicals will be stored in a secured area, properly labeled, and out of reach from the residents. The facility failed to secure chemicals in a safe, locked area, and out of reach of the thirteen cognitively impaired, independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. - The Medical Diagnosis section within R61's Electronic Medical Records (EMR) included 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), and muscle weakness. R61's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated she required substantial to maximal assistance with dressing, transfers, and bathing. The MDS indicated she used a wheelchair and could ambulate herself under staff supervision. The MDS indicated she had a history of falls. R61's Falls Care Area Assessment (CAA) started on 03/12/24 indicated she was at risk for falls related to her dementia diagnosis. The CAA indicated she had a decline in functional status with problems of gait, impaired balance, and difficulty maintaining seated balance. R61's Care Plan initiated 07/09/23 indicated she had limits in her cognition that could impact her safety awareness and decision-making abilities. The plan encouraged staff to emphasize safe choices. The plan instructed staff to ensure she maintained a good position in her wheelchair. The plan indicated she required assistance with transfers, dressing, bed mobility, grooming, and bathing. On 03/11/24 at 08:30 AM Staff pushed R61 out of her room to the 200 hall dining area. She was positioned at a bedside table in front of the nurse's station. R61 wore shoes and her feet slid on the floor from her room to the dining area. Her wheelchair did not have foot pedals attached. On 03/12/24 at 07:45 AM R61 was wheeled to the dining area with her shoes sliding on the floor multiple times as she was pushed. Her wheelchair did not have foot pedals attached. On 03/13/24 at 02:18 PM, Certified Nurses Aid (CNA) S stated residents that who wheeled themselves around the facility would not have the pedals on their wheelchairs, but staff should never allow a resident's feet to drag on the ground while being pushed. She stated the residents could get hurt or fall. On 03/13/24 at 02:25 PM Licensed Nurse (LN) K stated the resident's feet should be propped up on foot pedals if they cannot hold their feet up during transport. On 03/13/24 at 04:00 PM Administrative Nurse D stated staff were expected to ensure foot pedals were used on residents that cannot hold their feet up. She stated the resident's feet should never touch the ground while in motion. The facility's provided Fall Risk/Prevention policy reviewed 04/2021 indicated staff will ensure safe practices and appropriate usage of transfer equipment including mechanical lifts, walkers, wheelchairs, and techniques to prevent accidents and falls. The facility failed to ensure an environment free from accident hazards when staff failed to use foot pedals when they propelled R61 in her wheelchair. This deficient practice placed R61 at risk for preventable accidents and injuries. 41037 - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, history of traumatic brain injury, hypertension (HTN-elevated blood pressure), chronic pain, myalgia (muscle pain), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented required partial to moderate assistance with personal hygiene during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented R30 required partial to moderate assistance with personal hygiene during the observation period. R30's undated Falls Care Area Assessment (CAA) lacked an analysis of her care areas triggered by the significant change MDS dated [DATE]. R30's Care Plan dated 09/18/22 documented she required the assistance of two staff members with the Hoyer (full body mechanical lift) lift for a safe transfer. R30's EMR under the Progress Notes tab revealed a Nursing Note at 02:44 PM dated 03/03/24 documented Certified Nurse Aide (CNA) notified the charge nurse that R30 was bumped on the forehead during a Hoyer lift transfer. A review of the undated facility investigation provided by the facility documented on 03/03/24, two CNAs reported to Licensed Nurse (LN) H that R30 was accidentally bumped in the head with the Hoyer lift bar during a transfer. LN H assessed R30 and found her to be without apparent injury. LN H educated CNA O and CNA P about being more careful and slowing down during transfers with residents who required a mechanical lift. LN H also interviewed R30 regarding the incident during the Hoyer lift transfer. LN H noted that R30 was upset because she stated this was the second time that this had happened. A facility-wide skills fair was conducted on 02/29/24 and 03/01/24, which included hands-on training for mechanical lifts. Ongoing training continued with return demonstration required, to ensure that staff were competent in providing safe transfers with mechanical lifts. A review of the sign-in sheets provided by the facility from the skills fair conducted from 02/29/24 through 03/01/24 lacked signatures from CNA O and CNA P that indicated they had received the Hoyer lift training. On 03/13/24 at 07:51 AM CNA N, CNA M, and Certified Medication Aide (CMA) R assisted R30 with a Hoyer lift transfer from her bed and into her wheelchair. CMA R operated the Hoyer lift controls, CNA M guided R30's Hoyer lift sling from the left side of the wheelchair, and CNA N assisted R30 from behind the wheelchair to prevent R30's head from hitting the Hoyer lift transfer bar. On 03/12/24 at 09:54 AM Administrative Staff A stated the staff responsible for providing staff education did not track hours and the facility did not have the staff education from the previous 12 months. Administrative Staff A stated the facility took steps to improve the education process and tracking at the facility and that a new educator was hired. Administrative Staff A further stated education was tracked under the new system since February 2024 and that the facility had a skills fair for the staff that counted as six hours of education, and included dementia, abuse, neglect, exploitation, and lift training. On 03/13/24 at 02:13 PM Certified Nurse Aide (CNA) N stated she received lift training during the facility's skills fair that was held from 02/29/24 through 03/01/24. 03/13/24 at 02:25 LN K stated he received Hoyer lift training approximately six months ago through the facility. On 03/13/24 at 04:03 PM Administrative Staff A stated lift training was offered during the skills fair that was held from 02/29/24 through 03/01/24. Administrative Staff A stated LN KK had received lift training during the skills fair before the incident. Administrative Staff A stated CNA O had received lift training after the second incident that involved a lift transfer. The facility did not provide a policy for safe resident transfers. The facility failed to ensure an environment free from preventable accidents when staff hit R30 in the head with the Hoyer lift bar during a transfer. This placed R30 at risk for preventable injuries. 41713 - The electronic medical record (EMR) for R17 documented diagnoses of hypertension (elevated blood pressure), and chronic kidney disease (CKD-a condition in which the kidneys are damaged and cannot filter blood as well as they should). R17's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R17 had impairment on one side of her lower extremities. R17 used a wheelchair for mobility. R17 required substantial assistance to total dependence on staff for activities of daily living (ADLs). R17 had a history of a fall with a fracture before admission. R17 was taking an antidepressant (a class of medications used to treat mood disorders), and an opioid (a class of medication used to reduce pain and could be addictive). R17 triggered the Care Area Assessment (CAA) but lacked analysis documentation. R17's Care Plan initiated on 02/20/24 directed staff to monitor for pain and edema (swelling). Staff was directed to administer medications and monitor and record effectiveness. Staff was directed to provide assistance with ADLs as indicated. Staff was to use a Hoyer lift (total body mechanical lift) with assistance from two persons for transfers. An Event Report for R17 documented an event that occurred on 03/07/24 at approximately 08:00 AM. R17 was struck in the head by the Hoyer lift bar during a transfer from her bed to her wheelchair. Licensed Nurse (LN) KK and Certified Nurse Aide (CNA) O were transferring R17 when her wheelchair wheel slipped making her hit the Hoyer lift on the front right side of her forehead. R17 was upset that she was intentionally hit. LN KK assessed the resident and found no visible injuries. R17 was reassured that the incident was an accident and not an intentional act. LN KK assessed R17's vital signs and neurological checks were initiated. R17's physician, nurse management, and emergency contact were notified. Administrative Staff A's undated summary of the event from 03/07/24 documented LN KK reported that R17 was accidentally bumped in the head with the Hoyer lift bar during a transfer. Administrative Staff A documented the two employees (LN KK and CNA O) did not have the resident facing the lift. R17 was instead seated perpendicular to the base of the lift. This caused the chair legs to become elevated once the lift was in place. As the staff were raising the lift with the resident's sling attached, the legs of the chair shifted and fell to the ground. The few inches of shift caused the resident to move suddenly. LN KK and CNA O could not tell if the resident fell into the lift with her head or if the lift swung into her head. Administrative Staff A educated both staff that any use of a modified lift was against facility policy and should not be used. Both LN KK and CNA O expressed concern that some residents have decreased flexibility that they feel may call for such modifications to the proper lift procedure. Administrative Staff A advised LN KK and CNA O that if they felt any resident was unsafe being transferred per policy to notify the assistant director of nursing (ADON) or herself immediately so the resident could be evaluated during policy-approved transfers. Administrative Staff A made it clear that no resident under any circumstances should have modifications to how they were positioned in the lift. Both LN KK and CNA O verbalized understanding. The facility was unable to provide evidence that CNA O had received an education, training, or competency assessment for transfers with a mechanical lift. A review of a Lift Inservice dated 02/2024 revealed LN KK received training on the use of lifts. A facility CNA Competency checklist for full body transfer with mechanical lift dated and signed 03/08/24 by CNA O and Administrative Nurse E. On 03/13/24 at 12:01 PM R17 sat in her wheelchair watching TV, the resident voiced no concerns. On 03/13/24 at 02:13 PM, CNA N stated they did not work the day of 03/07/24 when the incident happened but did know that two staff should always be present when transferring a resident using the Hoyer lift. CNA N stated the facility had provided transfer training and education about a month ago. On 03/13/24 at 12:35 PM Administrative Nurse D stated two staff were expected to use proper mechanical lift skills when transferring a resident using the Hoyer lift. CNA O had been re-educated and had to show competency for lift use after the incident on 03/07/24. On 03/13/24 at 04:28 PM Administrative Staff A stated that she had CNA O given reeducation and competency check for mechanical lift use by Administrative Nurse E on 03/08/24. Administrative Staff A stated CNA O was absent from the facility skills fair held in February 2024. Administrative Staff A stated the use of the Hoyer lift, required two qualified staff for all transfers. The facility did not provide a policy for safe resident transfers. The facility failed to ensure an environment free from preventable accidents when staff hit R17 in the head with the Hoyer lift bar during a transfer. This placed R17 at risk for preventable injuries.

The facility had a census of 81 residents. The sample included 21 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift on one cart. This placed the 16 residents with controlled substances on the cart at risk for misappropriation of medications. Findings included: - On 03/13/24 at 10:16 AM, observation on the lower-level Hall B medication cart Controlled Drug Record flow sheet lacked evidence the staff completed the narcotic reconciliation for night shifts on 02/01/24, 02/09/24, 02/10/24, ,02/11/24, 02/23/24, 02/29/24, 03/01/24, 03/03/24,03/09/24 and 03/10/24 02/23/24, 02/29/24, 03/01/24 and 03/03/24 for evening shift; 03/01/24 and 03/03/24 for day shift (sixteen times out of a possible 126 work shifts). On 03/13/24 at 10:25 AM, Licensed Nurse (LN) H stated nurses were expected to count the narcotics with another nurse each shift. LN H stated the nurse coming on duty and the nurse going off duty should ensure the narcotic count is correct. LN H stated all nurses and medication aides have been educated on narcotic counting. On 03/13/24 at 04:04 AM, Administrative Nurse D stated she expected the nurse coming on duty and the nurse leaving duty to count each card and ensure the narcotic count was correct. Administrative Nurse D said the two nurses together determined the count was correct. The Medication and Controlled Substance policy revised 02/2023 stated controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled medication should be reported to a supervisor and the pharmacy immediately. The facility failed to provide a consistent reconciliation of controlled drugs at the end of daily work shifts, placing the 16 residents with controlled substances on the cart at risk for misappropriation of medications by staff.

The facility identified a census of 81 residents. The facility had one main kitchen and three dining areas. Based on observation, record review, and interview, the facility failed to ensure food was appropriately labeled and dated during storage. The facility failed to ensure tableware was stored appropriately before meal service. The facility failed to ensure dining staff handled plates in a sanitary manner. This placed the residents at risk for foodborne illness. Findings included: - On 03/11/24 at 07:15 AM the initial tour of the main kitchen revealed the walk-in freezer had an open bag of tater tots that was not labeled or dated and was not in a sealed bag. There was an opened bag that contained four or five breaded chicken breasts that were not labeled or dated. There was an opened bag of donuts that was not labeled or dated in a sealed bag. There was an opened bag of mixed vegetables that was not in a sealed bag and lacked an open date. On 03/11/24 at 07:20 AM the walk-in refrigerator had two opened bags of whipped cream that had no open date on them. Observation of the temperature log for the dishwasher on 03/11/24 lacked evidence staff assessed the temperature on 03/06/24. Observation on 03/12/24 at 11:25 AM of the food temperature logs for March 2024 lacked evidence food temperatures for meals were assessed from 03/03/24 to 03/11/24. Observation on 03/12/24 at 11:45 AM revealed Dietary DD, Dietary EE, and Dietary FF prepared for the service of the lunch meal. The clean meal plates and bowls were face up on the serving table. The dietary staff donned clean gloves without performing hand hygiene first, and wore hairnets, as they stood near the steam table. Dietary FF began to scoop up food items onto a clean plate from the steam table. Dietary EE grabbed the plate from Dietary FF and walked out of the kitchen to serve to a resident out in the dining room. On 03/12/24 at 01:30 PM, Dietary BB all food should be in sealed containers/bags with the item and date opened on the bag. The temperature logs for food and the dishwashers should be obtained daily and at each meal. The Food Storage (Dry/Refrigerated/Frozen) policy dated 2014 documented that all foods would be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. The Storing Utensils, Tableware, and Equipment policy dated 2014 documented that cleaned and sanitized utensils and equipment would be stored at least six inches off the floor in a clean, dry location in a way that keeps them from contamination by splash, dust or other means. Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination. Spoons, knives, and forks should be touched only by their handles. Cups, glasses, bowls, plates, and similar items should be handled so as not to touch any surface that may come into contact with food or a resident's mouth. Glass and cups should be stored inverted. The facility lacked a policy regarding food service during mealtimes. The facility failed to ensure dietary staff appropriately stored, dated, and labeled food items after the original storage bag had been opened. The facility failed to ensure food temperatures and dishwasher temperature logs were assessed and monitored. This placed residents at risk of food-borne illnesses and cross-contamination.

The facility identified a census of 81 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the disinfecting of shared equipment and the sanitary storage of respiratory equipment. The facility failed to ensure the appropriate chemicals were used to clean a clostridium difficile (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements) isolation room and failed to post the correct type of isolation precautions for Resident (R) 236, who had a C-diff infection. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 03/11/24 at 07:26 AM revealed an enhanced barrier isolation sign was posted on Resident (R) 236's door with isolation bins that contained clean personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) in the hallway outside the door. Upon further investigation, staff verified that R236 was on isolation precautions for C-diff. On 03/11/24 at 07:46 AM R286's bilevel positive airway pressure (BiPAP-medical device which helps with breathing) mask was laid on the floor next to his bed and his mask used for breathing treatments laid on top of a nightstand table next to his bed. R286's BiPap and breathing treatment masks were not stored inside a bag. On 03/11/24 at 08:58 AM R9's oxygen tubing was coiled and rested on the seat of her wheelchair next to the bed. The coiled oxygen tubing lacked a plastic bag or container for storage when not in use. On 03/12/24 at 03:48 PM, R12's BiPAP mask was laid directly on the top of the BiPAP machine unbagged. On 03/13/24 at 07:51 AM Certified Nurse Aide (CNA) M pushed the Hoyer (total body mechanical lift) from R30's room following a Hoyer transfer to the shower room, CNA M then walked to the dining room area. CNA M did not sanitize the lift before ensuring the lift was disinfected. On 03/13/24 at 08:33 AM, R12's BiPAP mask remained unbagged on the top of his BiPAP machine. On 03/13/24 at 12:04 PM Housekeeping Staff V used the Oxivir Tb Diversify disinfectant to clean R236's room who had a diagnosis of C-diff. The Disinfectant Products Overview sheet provided by the facility revealed the disinfectant used was not approved to kill the C-diff virus. On 03/13/24 at 02:13 PM, Certified Nurse Aide (CNA) N stated the mechanical lifts should be disinfected between each resident. CNA N stated respiratory equipment should be stored in a plastic bag when not in use. CNA N stated staff would know what PPE was to be worn and precautions to be taken before entering an isolation room by the sign posted on that resident's door. On 03/13/24 at 02:25 PM, Licensed Nurse (LN) K stated shared equipment should be disinfected and cleaned between each use. LN K stated respiratory equipment should be stored in a plastic bag when not in use, not on the cushion of the wheelchair. LN G stated the nurse would post the isolation sign on a resident's door when a resident was placed in isolation. LN G stated a resident with C-diff should be placed in contact isolation not enhanced barrier isolation. On 03/13/24 at 04:025 PM, Administrative Nurse D stated respiratory equipment should be stored in a plastic bag when not in use. Administrative Nurse D stated shared equipment should be disinfected between each use. Administrative Nurse D stated a R236 should be on contact isolation, she was not aware that R236's room had an enhanced barrier isolation post on his door. The facility's Isolation Precautions policy dated 03/2020 documented: Contact Precautions: are used for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. Contact Precautions, for example, when a draining wound cannot be contained, when a resident exhibits noncompliant behavior with stool or other body fluids, or when a resident has very poor personal hygiene, etc. The above includes epidemiologically important organisms or other highly transmissible infections such as Clostridium difficile. Wash hands immediately with soap and water or alcohol-based hand rub unless the isolated organism was C-diff than soap and water are recommended. The facility failed to ensure proper infection control standards were followed related to the disinfecting of shared equipment and the sanitary storage of respiratory equipment. The facility failed to ensure the appropriate chemicals were used to clean a C-diff isolation room and failed to post the correct type of isolation precautions for R236 who had a C-diff infection. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 81 residents. The sample included 21 residents with two residents reviewed for dignity. Based on observation, record review, and interviews the facility failed to provide care in a respectful, dignified manner for Resident (R) 286 when staff failed to place R286's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) urine collection bag inside a dignity bag and failed to provide a dignified dining experience for R16 when staff stood beside R16 while assisting with a meal. This placed the residents at risk for impaired dignity and quality of life. Findings included: - On 03/12/24 at 07:32 AM an observation revealed R286's bedroom door was open, and he rested in his bed. R286's catheter urine collection bag hung from the side of his bed and had urine in it. A catheter dignity bag hung beside R286's urine collection bag. R286's catheter bag and urine were visible from the hallway outside of his room. On 03/12/24 at 08:25 AM Certified Nurse Aide (CNA) LL entered R286's room and left without placing R286's catheter bag inside the dignity bag. On 03/12/24 at 08:25 AM CNA MM entered R286's room and left without placing R286's catheter bag inside the dignity bag. On 03/13/24 at 02:13 PM, CNA N stated the catheter bags were hung on the side of the bed, below a resident's bladder, and placed inside a dignity bag. On 03/13/24 at 04:03 PM Administrative Nurse D stated if a resident was in bed, she expected staff to place the resident's catheter bag on the side of their bed, lower than their bladder, and that staff should have placed the catheter bag inside of a dignity bag. No policy related to dignity was provided by the facility. The facility failed to provide care in a respectful, dignified manner for R286 when staff failed to place R286's catheter bag inside a dignity bag. This placed R286 at risk for impaired dignity and quality of life. 41037 - R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of senile degeneration of the brain, dementia (a progressive mental disorder characterized by failing memory, and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and hypertension (HTN-elevated blood pressure). R16's Annual Minimum Data Set (MDS) dated [DATE] documented a staff assessment was completed and indicated moderately impaired cognition. The MDS documented R16 required set-up assistance of staff with eating during the observation period. R16 Quarterly MDS dated [DATE] documented she had moderately impaired cognition. The MDS documented that R16 required set-up assistance from staff with eating. R16's undated Nutritional Status Care Area Assessment (CAA) lacked a documented analysis of her care area triggered by the annual MDS dated [DATE]. R16's Care Plan dated 12/14/20 documented R16 was dependent on two staff members for assistance with eating. On 03/11/24 at 12:51 PM, R16 sat upright in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining room table. Licensed Nurse (LN) L stood on R16's left side and assisted her with a few bites of food before another staff member motioned to LN L to sit beside R16. LN L sat down and continued to assist R16 with lunch. On 03/13/24 at 02:13 PM, Certified Nurse Aide (CNA) N stated staff should always be sitting next to the resident they are assisting at mealtimes. On 03/13/24 at 02:45 PM, Licensed Nurse (LN) K stated staff should never stand next to a resident when they are assisting the resident with dining. LN K stated staff should always sit next to the resident and be at eye level. On 03/13/24 at 04:02 PM, Administrative Nurse D stated she expected staff to be seated next to the resident during mealtimes. Administrative Nurse D stated staff should engage the resident during the meal while they assisted the resident. The facility's undated Resident' Rights policy documented the residents' right to be treated with dignity and respect was the foundation on which all other resident rights and responsibilities are based. The facility failed to ensure R16 was treated with dignity during dining. This deficient practice placed R16 at risk for weight loss and impaired dignity.

The facility had a census of 81 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to include Resident (R) 12 in the development and planning of the resident's care plan, which placed R12 at risk of impaired care and autonomy. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute and chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (inadequate supply of oxygen), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), depressive disorder (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), anxiety (a feeling of fear, dread, and uneasiness), seasonal allergic rhinitis (allergic reaction that causes sneezing, congestion, itchy nose and watery eyes), morbid obesity(excessive body fat), and Covid- 19 (highly contagious respiratory virus). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R12 required total assistance with bathing and dressing. The Functional Abilities Care Area Assessment (CAA) dated 03/13/23 documented R12 required total assistance with his activities of daily living (ADLs). The Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 03/13/23, documented R12 required total assistance with ADL. R12 required total assistance with toileting. R12 used a Hoyer (full body mechanical lift) lift with assistance from two staff to get in and out of bed, and in and out of the wheelchair. R12's Care Plan revised 12/01/23, documented R12 has a diagnosis of obsessive-compulsive disorder, anxiety disorder, depression disorder, agitation, and periods of isolation. R12's Care Plan documented the last care conference was on 11/29/22. The EMR lacked further documentation of care conferences. On 03/12/24 at 09:23 AM R12 stated he had not had a care conference in a long time, he stated he desired to participate. On 03/13/24 at 04:04 PM, Administrative Nurse D stated she had been doing the care plans, and care plans were updated when there were any changes with the resident. The facility's Care Plan Conference policy, revised 05/21, documented the facility identifies resident needs and establishes obtainable goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for each resident. The facility failed to include R12 in the development and planning of the resident's care plan placing the resident at risk for impaired care and autonomy.

The facility identified a census of 81 residents. The sample included 21 residents with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)80's call light remained within his reach. The facility additionally failed to honor R12's preferences related to his bathing. This deficient practice left both residents vulnerable to impaired care and decreased autonomy. Findings Included: - The Medical Diagnosis section within R80's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), heart disease, anxiety disease, cognitive communication deficit muscle weakness, and gastroesophageal reflux disorder (GERD-backflow of stomach contents to the esophagus). R80's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he required substantial to maximal assistance with bed mobility. The MDS indicated he was at risk for the development of pressure ulcers. The MDS noted the use of pressure-reducing devices for his bed and chair. The MDS indicated he received hospice services (end-of-life comfort care). On 03/11/24 the Care Area Assessments (CAA) were not completed for R80. R80's Care Plan initiated 02/08/24 indicated he was at risk for pain, skin breakdown, pressure injuries, and decreased psychosocial wellbeing. The plan indicated he had a deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) on his coccyx (area of skin over the tailbone). The plan noted instructed staff to assess him for pain related to his pressure ulcer or its treatment. The plan noted for staff to turn and reposition him frequently. The plan indicated he used pressure-reducing devices on his bed and chair. On 03/11/24 at 07:28 AM R80 slept in his bed. His call light was on the floor underneath his bed. On 03/11/24 at 08:21 AM R80 slept in his bed. His call light was on the floor underneath his bed. At 08:50 AM R80 awoke and began yelling out help due to his call light being under his bed. Staff entered the room at 09:01 AM and gave him pain medication due to his pressure injuries. On 03/13/24 at 02:18 PM Certified Nurses Aid (CNA) S stated R80's call light should be placed within reach and staff should be checking its placement during each encounter. On 03/13/24 at 04:01 PM Administrative Nurse D stated staff were expected to ensure each resident's call light always remained within their reach. The facility's Call Light policy revised 01/2017 instructed staff to ensure the call lights were answered within a reasonable timeframe and remained within reach of the resident. The facility failed to ensure R80's call light remained within its reach. This deficient practice placed R80 at risk for preventable accidents and injuries. 49634 - R12's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of acute and chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (inadequate supply of oxygen), obstructive sleep apnea (a disorder of sleep characterized by periods without respirations), depressive disorder (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), anxiety (a feeling of fear, dread, and uneasiness), seasonal allergic rhinitis (allergic reaction that causes sneezing, congestion, itchy nose and watery eyes), morbid obesity (excessive body fat), and Covid- 19 (highly contagious respiratory virus). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R12 required total assistance with bathing and dressing. R12's Functional Abilities Care Area Assessment (CAA) dated 03/13/23 documented R12 required total assistance with his activities of daily living (ADLs). The Activity of Daily Living Care Area Assessment (CAA), dated 03/13/23, documented R12 required total assistance for all ADLs. R12's Care Plan revised 12/01/23, documented R12 has a diagnosis of obsessive-compulsive disorder, anxiety disorder, depression disorder, agitation, and periods of isolation. R12's Care Plan lacked documentation related to his bathing schedule and preferences. R12's EMR under the Orders tab revealed the following physician orders: Shower schedule: Tuesday, Thursday, and Saturday from 03:00-11:00 PM, staff to complete the shower sheet after each shower. A review of R12's EMR revealed no bathing opportunities occurred in March. A review of the bathing sheets revealed R12 did not receive his shower on Saturday, 03/09/23 per his preference. On 03/11/24 at 02:11 PM, R12 stated he did not get his shower on 03/09/24. R12 stated he asked the Certified Nursing Aide CNA) on the evening shift on 03/10/24 if he could have a shower, but he still did not get a shower. On 03/12/24 at 09:22 AM R12 stated he still had not had a shower. R12 stated the CNA the previous evening and the CNA suggested R12 could wait until his scheduled day. On 03/12/24 at 09:50 PM, CNA N stated all residents can ask for a shower on any day. She stated the CNA staff tried to provide a shower to all who asked for one. On 03/13/24 at 10:55 PM, Licensed Nurse (LN) H stated all residents can ask for a shower on a day they are not scheduled. LN H stated the resident may have to wait until later in the day, but the aides did try to get all the showers done. On 03/13/24 at 02:00 PM in an interview, Administrative Nurse D stated that all residents could ask for a shower even if it was not their scheduled shower day. Administrative Nurse D said the CNAs would attempt to fit in unscheduled showers as soon as they were able. Administrative Nurse D stated the facility scheduled residents' showers to ensure all residents received a shower. The facility policy Resident Rights last revised 07/29/2021 documented: The right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. To make sure surroundings are safe, clean, and comfortable; make it possible for you to keep and use your clothing and personal items to the extent space permits; provide safeguards against any kind of harsh or abusive treatment; avoid using restraints, unless they are necessary for medical reasons; and make it possible for you to share a room with your spouse. The facility failed to honor R12's preferences for bathing. This deficient practice left R12 vulnerable to impaired care and decreased autonomy.

The facility reported a census of 81 residents. The sample included 21 residents with two residents reviewed for personal property. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 81's right to private communications when R81's package was opened. This placed R81 at risk for impaired privacy and decreased autonomy. Findings included: - R81's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of lymphedema (swelling caused by the accumulation of lymph), cardiomyopathy (heart disease), congestive heart failure (a condition where the lower left chamber of the heart is not able to fill properly with blood during the diastolic phase, reducing the amount of blood pumped out to the body), and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) R81's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. A review of R81's MDS dated on 02/06/24 indicated no Care Area Assessments analysis were completed. R81's Care Plan revised on 02/05/24 indicated she was independent and self-directed in her activity choices. She enjoyed being creative in a variety of ways as well as participating in religious activities. A review of January 2024 and February 2024 Grievance Logs revealed no concerns related to R81's opened package and no resolution. On 03/12/24 at 07:20 AM, R81 sat in her room looking at the mail. R81's legs were wrapped with an ace wrap. She stated she would be leaving for breakfast soon. She said she had a package arrive sometime before the current month and went on to say the package had been opened, and the contents removed before the facility brought her the package. R81 stated she called her daughter and talked to Administrative Staff A. R81 stated the facility was still investigating. 03/13/24 at 04:01 PM, Administrative Staff A stated it was never the facility's intent for any resident mail to be opened. Administrate Staff A stated the facility investigated R81's package being opened, and the contents removed, but the facility could not determine what happened. The facility policy Resident Rights, documented the right to be treated with dignity and respect and, to make sure the surroundings were safe, clean, and comfortable. Provide safeguards against any kind of harsh or abusive treatment. The facility failed to ensure R81's right to private communications when R81's package was opened, and the contents were removed prior to R81 receiving the package. This placed R81 at risk for impaired privacy and decreased autonomy.

The facility identified a census of 81 with 21 residents included in the sample. The facility identified seven residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) for Resident (R) 12 and R 18. This failure placed the residents at risk for decreased autonomy and impaired decision-making. Findings included: - A review of R12's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 12/13/23 and ended on 01/05/24. R12 remained in the facility for custodial care. The facility was unable to provide evidence that staff issued the SNF ABN 10055. A review of R18's EMR documented the Medicare Part A episode began on 01/02/24 and ended on 01/23/24. R18 remained in the facility for custodial care. The facility was unable to provide evidence that staff issued the SNF ABN 10055. On 03/12/24 at 11:25 PM Administrative Staff A stated that she was unaware she needed to use form 10055 with an estimated cost for continued services. Administrative staff A stated she was the one doing the ABN, but going forward it would be social services. The facility did not provide an Advance Beneficiary Notices policy. The facility failed to ensure the forms provided at the end of skilled services contained the required information for the residents to make informed choices and appeal the non-coverage decisions. This failure placed the residents at risk for decreased autonomy and impaired decision-making.

The facility had a census of 100 residents. The sample included 21 residents with four reviewed for nutrition. Based on observation, record review, and interview, the facility failed to follow the registered dietitians' recommendations for one of four sampled residents. Resident (R) 24 had an 18.7% weight loss in one month (02/07/21-03/07/21) and 11.9% weight loss in 3 months (01/07/21-04/07/21). Findings included: - R24's undated Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE] documented the resident had moderately impaired cognition. R24 required extensive to total dependence of one to two staff members for bed mobility, and transfers and did not have any weight loss. R24 did not have any trouble with chewing or swallowing and required one staff assistance for eating. The Nutrition Care Area Assessment (CAA), dated 01/11/21, documented the resident received pureed diet with nectar thickened liquids. She required extensive assistance from staff to consume meals, weighed 99 pounds, and received physician ordered supplements. Resident to be weighed monthly or weekly per current orders. The Nutrition Care Plan, dated 03/30/21, documented the resident had the potential for weight loss and inadequate fluid/food consumption related to impaired cognition, dysphagia, and spinal cord injury due to a fall. The care plan directed staff to check weights as ordered and notify the doctor, registered dietitian, and family of significant weight loss greater than 5% over one month or 10% over 6 months. The Registered Dietician (RD) was to monitor weights, labs, intakes, and make recommendations as needed. The RD Review for weight loss, dated 03/11/21, documented an 18.7% weight loss in one month, a 16.2% weight loss for 3 months, and a 15.2% weight loss in 6 months. The RD asked nursing staff to notify the resident's family of the weight loss and ask if they would allow Mighty Shakes (a nutritional supplement with extra calories and protein) twice a day to be started. The dietitian also recommended for staff to weigh weekly. Review of the Electronic Medical Record revealed the following monthly weights in the Vitals tab revealed: 11/07/20 - 98.8 pounds 12/07/21 - 99.6 pounds 01/07/21 - 99.2 pounds 02/07/21 - 102.7 pounds 03/07/21 - 83.5 pounds 18.7% weight loss in one month from 02/07/21-03/07/21 04/07/21 - 87.4 pounds 11.9% weight loss in three months from 01/07/21-04/07/21 (The RD recommended weekly weights on 03/11/21. Review of the weights in the medical record lacked documentation of weekly weights as recommended.) The Nursing Progress Note, dated 04/02/21, recorded the resident had a 19 pound weight loss in one month, family refused supplements like Mighty Shakes, and staff called and left a voice message with a family member to inform her about weight loss. The Social Service Note, dated 04/05/21, recorded that social services spoke with the resident's family member about weight loss. The family member requested the facility continued to try and help her mother eat regular meals, but if she does not eat to try alternate items such as yogurt, Mighty Shakes, or milkshakes. The Electronic Medication Administration (EMAR) dated 04/14/21 recorded Mighty Shakes were implemented on 04/14/21 for three times a day. The two times the resident was recorded as taking the Mighty Shakes on 04/14/21 she drank 100%. On 04/13/21 at 12:21 PM, observation revealed staff served R24 ground Salisbury steak, mashed potatoes, pureed cream corn, pudding, water, and juice. CNA O sat down to assist her with her meal and the resident took one bite of meat, one drink of water, and pushed any further bites away. CNA O left the table and Administrative Nurse D then sat down next to the resident to assist her and the resident took several bites, pushed his hands away, and refused to take any more. A third staff, CNA P, sat down with the resident to assist her with her meal and the resident ate 50% of her meal and CNA P got her two Mighty Shakes because of her intake. The resident drank both Mighty Shakes. On 04/14/21 at 08:37 AM, observation revealed staff served R24 pureed sausage, pureed eggs, cream of rice cereal and a pureed pancake. She ate 100% of her meal with one staff assistance. On 04/13/21 at 12 :49 PM, CNA Q stated the resident did not like the food served here and her family used to bring her food into the facility, but they had not been here lately. CNA Q stated it was hard to get R24 to eat. On 04/14/21 at 12:48 PM, CNA P stated the resident needed one staff assistance for eating. She ate sometimes, but other times she pushed our hands away telling us she doesn't want anything. CNA P was unaware if R24 received any kind of supplements. On 04/13/21 at 12:44 PM, Administrative Nurse D stated the resident did not eat well and sometimes if staff let her rest a bit and then reapproached her, she would take a few more bites. Administrative Nurse D stated it was hit or miss with her on whether she would eat and was unsure if the resident received supplements. On 04/13/21 at 05:15 PM, Consultant HH stated the resident had not been placed on any supplements. She stated they had placed the resident on weekly weights in March to monitor her weights. She would expect her recommendations to be followed by nursing staff. The administrator and Director of Nursing (DON) meet with her monthly to talk about the residents who triggered for weight loss. On 04/13/21 at 05:15 PM, Administrative Nurse E also stated the family did not want the resident on nutritional supplements because they did not want to pay for them. The family thought the supplements cost extra. The supplements do not cost extra. I would expect nursing staff to carry out the Registered Dietitians' recommendations within a couple of days of receiving them. The Weight Monitoring policy, dated November 2018, stated any resident with a weight loss of 5 pound will be re-weighed in 24 hours. Resident's with unplanned weight loss will be weighed weekly or as ordered by the physician. The charge nurse should immediately notify the physician, registered dietitian and resident representative of the weight loss. The Registered Dietitian will periodically review and make recommendations for dietary adjustments and the adjustments will be made. The facility failed to follow the registered dieticians' recommendations for R24 who had an 18.7% weight loss in one month and 11.9% weight loss in three months, placing the resident at risk for increased weight loss and nutritional deficit.

The facility identified a census of 93 residents. Thirty-eight residents were included in the sample with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review, observation, and interviews, the facility failed to prevent a reoccurring stage three (full thickness pressure wound involving loss of tissue and fat but not involving bone, muscle or tendon) pressure ulcer for Resident (R) 59 by failing to implement preventative measures as instructed by wound care specialists and professional standards of care. These preventative measures included providing a wheelchair cushion, pressure redistribution mattress, and offloading with pillows. Findings included: - R59's electronic medical record (EMR) in the Continuity of Care Document (CCD) recorded [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] recorded a Brief Interview for mental Status (BIMS) score of 99 which indicated the interview could not be completed. Staff assessment of cognition revealed R59 had moderate cognitive impairment. The MDS documented that the resident was at risk for pressure ulcers per clinical assessment and formal evaluation tool. R59 did not have a pressure ulcer at that time. It further recorded pressure relieving devices were in use in her chair and bed. The quarterly MDS dated [DATE] documented that per staff assessment, R59 had severe cognitive impairment. She required extensive assistance of two people for bed mobility and transfers, and extensive assistance of one to two people for all other activities of daily living. The MDS recorded R59 was at risk for pressure ulcer and had one stage three pressure ulcer. It further recorded pressure relieving devices were in use in R59's chair and bed. The MDS documented R59 also had moisture associated skin damage (MASD). The Care Area Assessment (CAA) for pressure ulcers recorded R59 was at risk for skin breakdown due to decreased mobility and incontinence. The EMR contained a Braden (an assessment tool used to identify risk for development of pressure ulcers) assessment dated [DATE] which documented a score of 13 which indicated a moderate risk for pressure ulcer development. The EMR recorded another Braden assessment on 07/24/19 which documented a score of 13, also moderate risk. The EMR lacked evidence of additional Braden assessments. The EMR contained a Casual Risk Factor Assessment, related to pressure ulcers, dated 01/23/19 which recorded preventative and early intervention strategies utilized for R59. These included turning and repositioning. It listed there was a pressure redistribution device in use. The device named in the assessment was an air mattress. It further instructed to keep skin clean and dry, and listed an additional intervention of a Broda chair (specialized wheelchair with the ability to tilt and recline) cushion. The EMR recorded another Casual Risk Factor Assessment, related to pressure ulcers on 07/24/19. This assessment listed the preventative strategies used were pillows for positioning and offloading (a precaution in wound care that requires all weight off the extremity that has the ulcer). The care plan recorded an intervention on 01/14/19 which directed staff to assist her with turning and re-positioning while in bed and offloading while up in wheelchair. The care plan initiated on 01/23/19 recorded R59 had pressure injuries to the coccyx (small triangular bone at the base of the spine) due to deconditioning, impaired mobility, and incontinence of bowel and bladder. The care plan directed staff to keep R59's bony prominences from direct contact with one another using pillows. It directed staff to ensure skin was kept dry and clean. The care plan recorded additional interventions on 07/24/19 which included directions to turn and reposition the resident every 2 hours, provide incontinence care after every incontinent episode, and to apply barrier cream to the area after provision of incontinence care. It instructed staff to assess and measure the wound weekly. The EMR recorded a scanned History and Physical document from a wound care specialist dated 01/18/19. The document recorded R59 had a stage three pressure ulcer to her sacrum (large triangular bone between the two hip bones). The document recorded instructions to turn and offload frequently, pressure redistribution mattress, and wheelchair cushion per facility protocol. R59's EMR contained a scanned untitled document from the wound care specialists dated 04/23/19 which recorded R59's stage three coccyx pressure ulcer (PU) healed. R59's EMR contained a scanned untitled document from the wound care specialist dated 07/01/19. The document recorded R59 had two sacral pressure ulcers. It further recorded the resident developed two pressure ulcers documented as recurrent. The wound assessment recorded a stage three PU which measured 0.5 (centimeters (cm)) x 0.5 cm x 0.1 cm. A second PU recorded as a stage three PU measured 1 cm x 0.6 cm x 0.1 cm. The assessment and plan area documented to continue the treatment as listed on the assessment. It recorded wounds to an area of previous wounds. It documented to turn and offload frequently. It further ordered a pressure redistribution mattress and wheelchair cushion per facility protocol. R59's EMR contained a scanned untitled document from the wound care specialists dated 07/08/19 which documented R59 had upper and lower sacral stage three pressure ulcers. The wound assessment recorded a stage three PU (upper) which measured 0.7 cm x 0.5 cm x 0.1 cm. A second stage three PU (middle) measured 0.7 cm x 0.8 cm x 0.1 cm. A third stage three PU (lower) measured 0.6 cm x 0.5 cm x 0.1 cm. The assessment and plan area documented to change the current treatment to apply [MEDICATION NAME] (topical anti-infective medication) and cover with bordered foam. It ordered to offload frequently and provide good incontinence care. It further ordered a pressure redistribution mattress and wheelchair cushion per facility protocol. R59's EMR contained a scanned untitled document from the wound care specialists dated 07/15/19 which documented R59 had three stage three pressure ulcers. The wound assessment recorded a stage three PU which measured 0.7 cm x 0.6 cm x 0.1 cm. A second PU recorded as stage three measured 0.5 cm x 0.4 cm x 0.1 cm. A third PU recorded as a stage three healed. The assessment and plan area documented to continue the current treatment as listed on the assessment. It documented to turn and offload frequently. It further ordered a pressure redistribution mattress and wheelchair cushion per facility protocol. R59's EMR contained a scanned untitled document from the wound care physician dated 07/30/19. It recorded R59 had two sacral stage three pressure ulcers. The wound assessment recorded a stage three PU which measured 0.5 cm x 0.3 cm x 0.2 cm. A second PU recorded as stage three PU closed. It documented to turn and offload frequently. It further ordered a pressure redistribution mattress and wheelchair cushion per facility protocol. The physician's orders [REDACTED]. On 08/12/19 at 07:44 AM R59 sat upright in her high back wheelchair. There were no pillows for offloading observed. There was no wheelchair cushion. Continuous observation until 09:48 AM revealed R59 in her wheelchair, upright, with no pillows or wheelchair cushion. No repositioning or offloading occurred during that time. On 08/12/19 at 01:03 PM R59 sat upright in her wheelchair. No pillows or wheelchair cushion were observed in the chair. On 08/12/19 at 01:30 PM R59 was in bed with her eyes closed. The mattress on the bed was a perimeter mattress (specialty mattress with raised edges used to prevent falls) not a low air loss mattress (specialty pressure redistribution mattress used in the prevention and healing of pressure ulcers). On 08/13/19 at 07:29 AM R59 sat upright in her wheelchair at the nurses' station. The resident sat on a mechanical lift sling. No wheelchair cushion or pillows were observed. In an interview on 08/13/19 at 05:03 PM Licensed Nurse (LN) J stated the nurses do wound care daily. LN J stated in order to prevent and treat pressure ulcers staff should keep the residents dry, turn, and reposition every two hours. LN J stated the nurse should make sure the resident was not sitting for a long time. In an interview on 8/14/19 at 10:40 AM CNA L stated R59 has a wound on her coccyx. CNA L said staff tried to keep R59 clean and dry. They put barrier cream on after her cares and turn her every two hours. In an interview on 8/14/19 at 10:40 AM LN I stated R59 does have wounds on her coccyx. LN I said R59 had same wound before, it healed, and then reopened. LN I stated it may have reopened because she was in her chair more frequently. They try to lay her back, move her around, and change positions. LN I stated R59 had a Broda chair so LN I did not think R59 has any extra cushions. LN I stated staff placed some pillows sometimes to offload and when they lay R59 down, they reposition with pillows. LN I stated she was pretty sure R59's mattress was the kind that shifts around to help prevent pressure wounds. During an interview on 08/14/19 12:33 PM Administrative Nurse D stated R59 should be turned every two hours when in bed and her weight should be offloaded with pillows when up to her chair. R59 should be laying down after meals. Administrative Nurse D stated staff used a pillow or a rolled towel to help with positioning or offloading. She said R59 does not have a low air loss mattress or wheelchair cushion. She stated the physician would order those as needed. She stated R59 did not have a special pressure reducing mattress because the wound care nurse did not recommend it and they would only have a low air loss mattress if it was ordered by the physician. Administrative Nurse D stated they do not need a physician's orders [REDACTED]. She also said that though R59 can wiggle herself around in her wheelchair it would not be enough to offload or effectively reduce pressure. In an interview on 08/14/19 at 03:42 PM wound care specialist Consultant HH stated R59's wound was from pressure, but it also had a lot to do with her MASD. She stated a low air loss mattress, wheelchair cushion, and frequent repositioning would help in the healing and prevention of the wounds. Consultant HH said she was unaware R59 did not have a low air loss mattress or a wheelchair cushion and stated that since R59 was on hospice, hospice should provide those things. The undated facility policy Pressure Ulcer Prevention recorded staff would do a skin pressure risk assessment on admission, quarterly, and with a significant change of condition. It records that residents who are unable or require assistance with turning would be repositioned at a minimum of every two hours. It directed staff to change a resident's position frequently when sitting up in the chair and frail residents may need to be repositioned more frequently. It further directed staff to protect at risk areas by using pillows and special mattresses as indicated. The facility policy Pressure Ulcer Care of Documentation dated 12/2006 directed staff to use anti-pressure devices such as an air mattress to bed, specialty mattress to bed, and air cushion to the wheelchair. The facility failed to prevent a reoccurrence of a pressure ulcer to R59's coccyx by failing to implement preventative measures. The facility failed to reposition, offload with pillows, and provide pressure reducing devices meant to prevent pressure ulcer formation and to aid in healing. This deficient practice resulted in development of three stage three pressure ulcers for R59.

The facility reported a census of 93 residents. The sample included 3 residents. Based on observation, interview, and record review, the facility failed to ensure 1 (#1) of 3 sampled resident's rights in self-determination regarding his/her desire to have cardiopulmonary resuscitation (CPR) (full code, a life-saving medical procedure that consists of chest compressions to allow [MEDICATION NAME] blood to circulate to vital organs, such as the brain and heart, and artificial ventilation) were honored. Staff entered the resident's room and found the resident unresponsive, without respirations or a pulse. Staff failed to initiate CPR per the resident's wishes and the resident expired. The facility's failure to honor resident #1's desire for CPR placed the resident in immediate jeopardy. The facility further failed to ensure staff maintained current CPR certification for Healthcare Providers through a CPR provider whose training included hands-on practice and in-person skills assessment. Findings included: - The closed clinical record documented resident #1 admitted to the facility on [DATE] and was re-admitted on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The quarterly MDS, dated [DATE], documented a BIMS score of 8, which indicated moderately impaired cognition. The admission assessment completed by social services staff, dated [DATE], documented the resident was a full code. The care plan conference note, dated [DATE], documented the resident was a full code. The undated and unsigned physician's orders [REDACTED]. The care plan, dated [DATE], documented the resident was a full code per his/her wishes and directed staff, in the event of no pulse or respirations, to initiate CPR with the notification of emergency personnel. A progress note, dated [DATE] at 12:45 A.M., by licensed nursing staff G documented at 10:20 P.M., staff found the resident to be unresponsive. Direct care staff O notified licensed nursing staff G the resident vomited blood and was not responsive to his/her name. Licensed nursing staff G entered the resident's room and found the resident unresponsive with his/her chest and neck covered in bloody emesis (vomit). Licensed nursing staff H came into the resident's room and attempted to obtain the resident's vital signs (blood pressure, pulse, respirations) and turned the resident on his/her side. Licensed nursing staff G called for an ambulance. The paramedics arrived and performed CPR. CPR was unsuccessful and the resident's time of death was 11:07 P.M. Staff notified the Director of Nursing (DON), physician, and family. Direct care staff O last observed the resident at 8:00 P.M. and licensed nursing staff G observed the resident shortly after 8:30 P.M. The ambulance dispatch report, dated [DATE], documented facility staff notified emergency personnel at 10:31 P.M. the resident was unresponsive. The emergency medical services (EMS) staff were dispatched at 10:32 P.M., and arrived to the resident's bedside at 10:40 P.M. Upon arrival in the resident's room, EMS staff observed the resident lay in bed and was not breathing. Approximately six facility staff stood around the resident, but no staff had initiated CPR. The resident had a copious (a lot) amount of blood coming from his/her mouth. The resident did not have a pulse. The resident's body still had a warm core with pale skin, but EMS staff did not observe lividity or rigor (stiffness). Staff identified the resident as a full code. EMS staff initiated CPR at 10:41 P.M. and discontinued CPR at 11:07 P.M. On [DATE] at 11:05 A.M., administrative nursing staff D stated staff did not initiate CPR because licensed nursing staff G reported to him/her that the resident did not require CPR at the time direct care staff O found the resident unresponsive. Administrative nursing staff D stated when staff found a resident unresponsive or without a pulse and/or respirations, he/she expected staff to check the resident's code status, obtain the emergency cart, call the ambulance, and initiate CPR. On [DATE] at 1:00 P.M., direct care staff O stated on [DATE], he/she left the resident's room at approximately 8:00 P.M., after he/she assisted the resident to bed. During rounds at 10:20 P.M., direct care staff O entered the resident's room and observed blood dripping from the resident's mouth. He/she shook the resident's shoulder and called his/her name, then notified licensed nursing staff G the resident was unresponsive. He/she stated licensed nursing staff G entered the resident's room, shook the resident's shoulder, and called his/her name. Direct care staff O stated he/she thought licensed nursing staff H entered the resident's room and initiated CPR, but stated he/she could not remember what each staff did during the incident. On [DATE] at 2:45 P.M., licensed nursing staff H stated on [DATE] at approximately 10:30 P.M., licensed nursing staff G asked him/her to check the resident's blood sugar. When he/she entered the resident's room, the resident lay on his/her back in bed, his/her skin color appeared yellow, and he/she bled from the mouth. Licensed nursing staff H stated the resident did not have a pulse. Licensed nursing staff H did not have a stethoscope, so he/she placed his/her hand on the resident's chest, but did not feel the chest rise. Licensed nursing staff H stated he/she did not know the resident's code status, staff did not bring the emergency cart into the resident's room, and facility staff did not initiate CPR because it appeared that the resident had already died . On [DATE] at 3:15 P.M., licensed nursing staff G stated on [DATE], he/she was assigned to care for the resident. At approximately 10:20 P.M., direct care staff O notified him/her to come to the resident's room for an emergency. When he/she entered the resident's room, he/she observed blood all over the resident and the resident's hand laid on his/her chest. Licensed nursing staff G shook the resident's shoulder, called his/her name, but the resident was unresponsive and did not have a pulse. He/she confirmed he/she did not obtain the resident's vital signs. The resident's hand then fell off his/her chest and licensed nursing staff G thought the resident took a breath, but he/she did not listen for respirations. Licensed nursing staff G stated the resident was a full code, but he/she exited the resident's room and asked licensed nursing staff H to check the resident's blood sugar while he/she called the ambulance from the nurses' station. Licensed nursing staff G stated he/she did not initiate CPR because of the amount of blood, which poured from the resident's mouth. Licensed nursing staff G stated when he/she first checked the resident, his/her body was warm, he/she did not have a pulse, and his/her skin color was normal. Licensed nursing staff G stated emergency personnel instructed him/her over the phone to turn the resident on his/her side and emergency staff initiated CPR when they arrived to the facility. The facility's CPR Instructions policy, dated (MONTH) (YEAR), documented if CPR was indicated, CPR should be performed properly and promptly until advanced medical treatment could be obtained. CPR should continue until the resident responded with a pulse or breathing, EMS arrived, or an equally qualified person took over. The facility failed to honor this resident's rights and perform CPR for this cognitively impaired resident who was found unresponsive and without respirations or pulse. This deficient practice placed the resident in immediate jeopardy. - Review of licensed nursing staff H's personnel record revealed his/her CPR certification was completed from an online-only course and did not have an expiration date. On [DATE] at 4:05 P.M., administrative staff A stated the facility did not require staff to complete a specific type of CPR training. On [DATE] at 4:30 P.M., licensed nursing staff H confirmed he/she completed online training for his/her CPR training and he/she did not complete a hands-on practice and in-person skills assessment. The facility's CPR Instructions policy dated (MONTH) (YEAR) documented all licensed nurses were to be CPR certified by a qualified instructor. The facility failed to ensure staff maintained current CPR certification for Healthcare Providers through a CPR provider whose training included hands-on practice and in-person skills assessment. The facility abated the immediate jeopardy on [DATE] at 12:00 P.M., after implementing the following: 1. Immediate re-education of all staff regarding emergent situations 2. Re-education of nursing staff of the location of the code status on each resident 3. Re-education of nursing staff of CPR instructions 4. Re-education of non-nursing staff to include immediate notification to nursing staff if the resident appeared compromised in any manner 5. An audit of all resident charts to ensure the code status was clearly defined and accessible on the physician's orders [REDACTED].>6. Long-term monitoring would include review of the resident's code status upon admission, during the resident care plan meeting, on re-admission from a hospital stay, random chart audits to ensure code status accuracy, and information would be brought to the Quality Assurance and Performance Improvement committee. The deficient practice remained at a scope and severity of a G.

The facility identified a census of 97 residents. The sample included four residents for abuse. Based on record review, interview, and observation, the facility failed to provide an environment free from abuse when one resident (#1) touched five (opposite gender) residents (#2, #3, #4, #5, and #6). This deficient practice placed the five (opposite gender) residents of this facility in immediate jeopardy. Findings included: - Resident #1's physician order [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 9 which indicated moderately impaired cognition The resident required limited assistance of 1 person for transfers, required extensive assistance of one person for locomotion, had no range of motion impairment and used a wheelchair. The care plan for dementia dated 5/11/16 and revised 12/30/16 noted a new order for a psychiatric evaluation and treatment after the resident inappropriately touched a (opposite gender) resident. The care plan lacked identification of inappropriate behaviors displayed by the resident starting 11/14/16 or interventions for when the resident had these behaviors. The care plan lacked interventions and measures to provide safety for (opposite gender) residents after the incidents on 11/14/16, 12/20/16, 12/25/16, 12/27/16, and 12/29/16. The discharge MDS dated [DATE] documented the resident discharged to an acute hospital with return to the facility anticipated. The entry tracking MDS dated [DATE] document the resident returned to the facility. The admission nursing care plan dated 1/3/17 lacked interventions for sexual behaviors. The care plan revised 1/24/17 included an intervention of 1:1 (one staff with the resident at all times) for prevention of sexual behaviors/advances. The care plan revised 1/25/17 documented the staff referred the resident to a psychiatric physician for a follow-up related to a resident-to-resident incident. The care plan revised on 1/26/17 noted the resident was in long term care at the facility. His/her family was agreeable to refer to a same gender unit for possible placement for behaviors. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Psychiatry progress note dated 12/31/16, signed by consultant staff II, noted the resident's behavior for the past week as inappropriately touching and kissing {opposite gender} residents. The behavior had persisted even after he/she was confronted about the behavior. He/she denied touching and kissing (opposite gender) residents against their will. The note documented the resident's behavior was a result of his/her [MEDICAL CONDITION] complicated by [MEDICAL CONDITION] ([MEDICAL CONDITION], progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and all his/her other diagnoses. The note documented the resident as not competent, could control his/her behaviors, was not a danger physically, but could provoke others to hurt him/her. The Psychiatry progress note dated 1/27/17, signed by consultant staff II, noted the resident continued to violate the personal space of (opposite gender) residents and touched them inappropriately. The note documented a request to transfer the resident to a same gendered unit. The nurse's note dated 11/14/16 at 9:15 A.M. by licensed staff J documented resident #1 sat next to an unidentified (opposite gender) resident in the dining room, and kissed and caressed his/her back and face. The resident stated he/she should be allowed to do what he/she wanted. The nurse talked with the resident about his/her inappropriate behavior. The resident stated, I'm married but that situation can be changed. The nurse escorted the resident away from the {opposite gender} resident several times, as he/she kept going back. The nurse's note dated 12/10/16 at 6:00 P.M. by licensed staff K noted the resident went to an unidentified (opposite gender) resident's room. Staff stopped the resident, and advised him/her to stay away from that room. At 10:00 P.M., licensed staff K documented at around 8:00 P.M., he/she went into the same unidentified (opposite gender) resident's room and found resident #1 with his/her pants unzipped and the (opposite gender) resident laid at the edge of the bed with his/her chest exposed. The nurse advised resident #1 to leave the room. The nurse's note dated 12/25/16 at 12:00 P.M. by licensed staff L documented at 11:30 A.M. staff noted resident #1 was touching other residents inappropriately. Staff L observed resident #1 with his/her hand in a (opposite gender) resident's shirt touching his/her breast. Resident #1 was immediately redirected away from other residents and educated that he/she could not touch others without their consent. The nurse's note dated 12/25/16 at 1:30 P.M by licensed staff L documented this writer and CNA (certified nurse aide) observed resident #1 kiss an unidentified (opposite gender) resident in his/her room. Resident #1 had his/her hand in the (opposite gender) resident's pants while he/she kissed him/her. Staff redirected the resident and would continue to monitor the resident's behavior. The nurse's note dated 12/25/16 at 7:05 P.M. by licensed staff L documented staff observed the resident touch several (opposite gender) residents inappropriately. Staff redirected the resident to his/her room for the safety of others. The nurse's note dated 12/27/16 at 1:10 P.M. by licensed staff L documented the nurse and staff members observed the resident touch (opposite gender) residents against their will. The staff redirected the resident frequently. Staff observed the resident stare with his/her mouth opened wide in (opposite gender) residents' personal spaces. The nurse and other staff members witnessed the resident touch 2 unidentified (opposite gender) residents' breasts. The nurse's note dated 12/29/16 at 12:30 P.M. by licensed staff L documented various staff members observed the resident touch (opposite gender) residents inappropriately. The nurse's note dated 12/29/16 at 12:30 P.M. by administrative staff D documented he/she received a report the resident touched other residents inappropriately. The nurse's note dated 12/29/16 at 1:44 P.M. by licensed staff L documented around 12:30 P.M., staff observed the resident inappropriately touch an (opposite gender) resident without consent from the resident. The note lacked documentation of how staff monitored the resident after this event. The nurse's note dated 1/3/17 through 1/24/17 at 5:00 P.M. lacked documentation to ensure an environment free of abuse. The nurse's note dated 1/24/17 at 5:00 P.M. documented staff found the resident touching a (opposite gender) resident inappropriately twice. He/she was immediately removed from the (opposite gender} resident and put on 1:1 monitoring. The nurse received an order to send resident #1 immediately to the hospital for a psychiatric evaluation. On 1/30/17 at 8:25 A.M. record review of resident #1's medical chart lacked any social services notes. At 2:37 P.M. the medical record still lacked any social services notes. On 2/1/17 at 8:08 A.M. the resident's chart lacked any social services notes. On 1/30/17 at 5:07 P.M. social service staff Y delivered all of the social service notes dated 4/27/16 through 1/24/17. The notes lacked documentation about resident #1's inappropriate behaviors and about the resident's psychiatric evaluation from the hospital. On 2/1/17 at 8:39 A.M., the resident sat at a dining room table with one (same gender) resident. The staff member assigned to do 1:1 with the resident sat at a different table and assisted an unidentified resident with eating. On 1/30/17 at 9:11 A.M. resident #1 did not answer questions when asked, and looked at the floor when asked about the other residents, especially the (opposite gender) residents. On 1/30/17 at 9:04 A.M. direct care staff Q stated the resident was on 1:1 staff monitoring, but did not know the reason for the 1:1 monitoring. He/she stated resident #1 had behaviors of kissing (opposite gender) residents. Direct care staff Q was not sure when the inappropriate behaviors started, but stated it happened in December and last week. On 1/30/17 at 10:44 A.M. direct care staff R stated the resident had inappropriately touched other (opposite gender) residents and went into their rooms. He/she reported these incidents occurred for a couple of weeks. Staff R further stated staff separated resident #1 from (opposite gender) residents. On 1/30/17 at 8:31 A.M. licensed staff M stated the resident had behaviors of bothering other residents and inappropriately approaching (opposite gender) residents. On 1/30/17 at 8:37 A.M. resident 1's family member stated these behaviors started in December 2016, and it happened twice. Staff put him on 1:1 monitoring after the second time. The staff did not monitor the resident while the family member was with him/her. On 1/30/17 at 9:12 A.M. direct care staff T stated he/she was assigned to do 1:1 monitoring with the resident for behaviors. He/she reported the resident was inappropriate to other (opposite gender) residents. Staff T further stated he/she observed the resident attempt to enter other (opposite gender) residents rooms and he/she would stop him/her. Staff T stated the resident #1 moved around in the wheelchair independently. On 1/30/17 at 11:48 A.M. licensed staff J stated resident #1 tried to kiss resident #3, and inappropriately touched him/her. Staff J reported staff witnessed the resident walking in the hall, and stopped to inappropriately touch another (opposite gender) resident. The second episode occurred in the dining room when resident #1 touched resident #4. Staff J declined that staff put resident #1 on a 1:1 monitoring. On 1/30/17 at 4:03 P.M licensed staff H stated he/she did not observe anything happen to resident #4 from another resident. He/she said it would have been documented in the nurse's notes. Staff H confirmed the lack of a nurse's note in resident #4's medical record. He/she stated resident #1 had inappropriate behaviors last week when he/she kissed resident #3 and had his/her hand under the (opposite gender) resident's shirt. Staff redirected resident #1 and moved him/her to the area by the nurses desk. Licensed staff H placed a phone call. During the phone call, resident #1 returned to the resident #2 and inappropriately touched him/her. Staff H further stated resident #1 liked resident #3. The notarized witness statement dated 1/4/17 from licensed staff J documented on 12/29/16, direct care staff observed resident #1 in the dining room inappropriately touch resident #4. The facility's investigation dated 1/4/17 documented on 12/29/16 at about 12:30 P.M., resident #1 inappropriately touched resident #4. The notarized witness statement dated 1/30/17 from direct care staff O documented he/she witnessed resident #1 inappropriately touch (opposite gender) resident #2 while in the dining room. The notarized witness statement dated 1/27/17 from licensed staff H documented on or about 1/24/17 at approximately 4:00 P.M. licensed staff H observed resident #1 inappropriately touch resident #2 in the dining room. On 1/30/17 at 3:21 P.M. licensed staff I stated resident #3 was very friendly and told other residents and staff he/she loved them. Staff I stated resident #1 inappropriately touched resident #3. He/she reported resident #1 favored resident #3. Staff I stated resident #1 had behaviors of sitting close to other residents, kissing them, and inappropriately touching them. Licensed staff I stated he/she observed resident #1 (opposite gender) resident #3, resident #2, and resident #5. Staff I further stated he/she witnessed resident #1 sit very close to resident #5. Staff I reported staff redirected resident #1 over and over, but it didn't work. He/she said staff moved the resident to a different room several times. Staff I stated last week, the resident received 1:1 monitoring. Staff I further stated resident #1's inappropriate behaviors occurred during meals with several residents, but mostly (opposite gender) residents #3, #2, and #5. Review of resident #3's clinical chart revealed a quarterly MDS dated [DATE] noted he/she had a BIMS of 7, which indicated severely impaired cognition, required limited assistance of 1 person for locomotion and used a wheel chair. His/her care plan revised 1/16/17 lacked documentation of a consensual relationship with another resident or the resident was sexually active. The Report of Examination and Evaluation dated 7/20/16 signed by a physician documented resident #3 did not have the capacity to meet essential needs for physical health, safety or welfare, and was therefore, in his/her opinion, an adult with an impairment. Review of resident #2's clinical chart revealed a quarterly MDS dated [DATE] had a BIMS of 4 which indicated severe cognitive impairment, required extensive assistance of one staff for locomotion. The nurse's dated 1/24/17 at 10:00 P.M. documented resident #2 had been touched inappropriately by (opposite gender) resident twice on the early evening shift. This resident's family member and staff discussed the incident in great length. The family member reported he/she probably doesn't realize what he/she did, it's a disease and resident #2 doesn't even know his/her name most of the time. The notarized witness statement dated 1/30/17 from direct care staff O documented he/she witnessed resident #1 rubbing resident #2's breast and kissing him/her on the lips while in the dining room. Direct care staff O documented resident #2 appeared to be okay but he/she told the nurse. The nurse gave instructions to move resident #1 away from resident #2. He/she moved resident #1 to the nurses' station to be watched. The notarized witness statement dated 1/27/17 from licensed staff H documented on or about 1/24/17 at approximately 4:00 P.M. a direct care staff yelled out and licensed staff H observed resident #1 kissing and fondling resident #2's right breast in the dining room. Resident #1 was immediately removed from resident #2, placed at the nurse's station and a direct care staff was put 1:1 with resident #1. On 1/30/17 at 12:10 P.M. administrative nursing staff D stated resident #1's behaviors were caused by his/her dementia. Staff D instructed staff to put resident #1 on 1:1 monitoring in December. He/she said psychiatric services consulted with the resident, and he/she went to the hospital for an evaluation. Staff D further stated staff did not restart the 1:1 monitoring when resident #1 returned to the facility. After the incident on 1/24/17 with resident #2, staff started 1:1 monitoring with resident #1. Staff D further stated resident #3 and his/her family consented to the inappropriate touching from resident #1. Resident #1 started having the behaviors in December 2016. Administrative nursing staff D stated he/she called the state agency before completing the investigation. The second incident occurred with resident #4 in December when resident #1 inappropriately touched resident. The third incident occurred with resident #2 on 1/26/16 when resident #1 inappropriately touched resident #2. Resident #1 had a pattern of this type of behavior. On 2/1/17 at 12:11 P.M., direct care staff P stated no too long ago resident #1 had inappropriate behaviors with resident #3, then to residents #2 and #5. Resident #1 targeted the weaker (opposite gender) residents. Resident #3 could consent, but Staff P stated he/she observed resident #3 tell resident #1 to stop. Resident #1 thought the (opposite gender) residents liked the inappropriate touching. Direct care staff P stated he/she observed resident #1 inappropriately touch residents #2, #3, #5 and #6. With resident #6, who cannot talk at all or communicate, resident #1 inappropriately touched resident #6. Resident #5 cannot talk but flailed at resident #1 when he/she inappropriately touched him/her. The nurse instructed direct care staff P to take resident #1 downstairs to his/her family member. Not long after direct care staff P returned upstairs, the staff had taken resident #1 back upstairs, because he/she had already inappropriately touched another resident. When staff observed resident #1 attempting to inappropriately touch another resident, they redirected him/her. On 12/25/16, staff redirected resident #1 from inappropriately touching one resident, and he/she would do it to another resident. Staff P further stated resident #1 watched the staff for an opportunity to inappropriately touch the (opposite gender) residents again. Staff P stated the behaviors did not occur every day but several times a week. The behaviors started around the middle of November 2016. The quarterly Minimum (MDS) data set [DATE] for resident #6 documented staff reported the resident had short and long term memory problems, was severely impaired for cognitive skill for daily decision making, rarely/never understood others, required total dependence of 2 staff for transfers and total dependence of one person for locomotion, and used a wheelchair. Direct care staff R's witness statement on 1/30/17 documented he/she observed resident #1 inappropriately touch a (opposite gender) resident several times between the middle of December 2016 and the middle of January 2017. On 2/1/17 at 1:08 P.M. direct care staff Q stated he/she felt resident #1 had mental problems, along with resident #3. Resident #1 wandered around, and direct care staff Q observed resident #1 inappropriately touch resident #3 in the dining room and moved resident #1 to a different table. Direct care staff Q intervened and reported the incident to the nurse. Direct care staff talked to resident #1 about this and he/she didn't see anything wrong with kissing another (opposite gender) resident. Direct care staff Q thought resident #1's touching of resident #3 was inappropriate, and felt uncomfortable about the situation. Staff Q received training from the facility on abuse, including verbal and sexual, and to report it to the nurse. When a resident's cognitive ability does not function correctly, it was his/her responsibility to step in and protect them. Resident #3's cognitive ability was impaired, as he/she fired the staff and gave them raises, and didn't know what he/she was doing. On 1/30/17 at 4:26 P.M. social services staff Y stated he/she met with resident #1 on 11/14/16 to talk about sexual behaviors, and how the behavior affected other residents. The incident in December 2016 between resident #1 and #3 was not reported due to both residents consented. Social Service staff Y stated he/she met with resident #3's family after the incident and they did not have a concern. When resident #1 inappropriately touched resident #4 later in December, resident #4 could not make that choice. The facility sent resident #1 out for a psychiatric evaluation, but the resident returned to the facility without receiving the evaluation. The staff moved resident #1 off the same unit as resident #4 to determine if resident #1's behaviors were only directed to resident #4, as an attempt to protect resident #4. Social service staff Y did not know how staff protected other (opposite gender) residents from resident #1. On 1/30/17 at 4:46 P.M., licensed staff L stated resident #1 inappropriately touched other (opposite gender) residents. On 12/25/16, Staff L reported it was resident #3 who resident #1 touched inappropriately, as noted the his/her nursing notes. Resident #3 experienced confusion, and did not have a relationship with resident #1. Resident #3 allowed resident #1 to touch him/her. The care plans should reflect the resident's behaviors and have interventions for behaviors. On 1/30/17 at 3:35 P.M. administrative staff A stated he/she knew resident #1 inappropriately touched (opposite gender) residents #2, #3, and #4. Resident #1 and resident #3 had consented to the touching. On 2/1/17 at 1:30 P.M. consultant staff HH stated resident #1 had dementia and the last couple months started to have sexual behaviors. Resident #1 had one questionable consensual encounter of sexually inappropriate behaviors with a resident of the opposite sex. Within the last 3 weeks, the facility staff notified him/her of resident #1 having inappropriate behaviors towards a second (opposite gender) resident and resident #1 was put on 1:1 monitoring to protect the other residents, and then sent to the hospital for a psychiatric evaluation. The resident returned to the facility without a psychiatric evaluation, so last week, the resident received an in-house psychiatric evaluation. Consultant staff HH was not aware of several episodes when resident #1 had inappropriately touched other (opposite gender) residents. He/she stated he was always available for facility staff to contact at any time for residents with inappropriate behaviors. He/she did not know when the 1:1 monitoring started. Consultant staff H further stated the facility could have started 1:1 monitoring earlier to protect the other residents. The facility provided policy, revised September 2016, for Nursing Policy and Procedure Manual titled Abuse, Neglect and Exploitation noted the resident must not be subjected to abuse by anyone, including, but not limited to, staff or other residents. The policy's definition of sexual abuse included but not limited to, sexual harassment, sexual coercion or sexual assault. The policy failed to provide guidance for a resident-to-resident abuse. The facility failed to provide an environment free from abuse after resident #1 inappropriately touched 5 cognitively impaired (opposite gender) residents. This deficient practice placed the resident's in immediate jeopardy. The facility abated the immediate jeopardy on 2/1/17 at 11:30 P.M. by initiating the following: Provided one on one staff observation of resident #1 24 hours every day, re-educated nursing staff on 1:1 duties, updated the abuse, neglect, and exploitation policy with specific information regarding sexual behaviors, signs, and symptoms of possible abuse, all staff were in-serviced on the revised abuse, neglect and exploitation policy. This training will continue and be included in monthly in-services as well as new employee orientation. In the event of a sexually inappropriate incident the facility will report all incidents to the state and the facility will investigate and immediate interventions will be put in place to include removal from the community, a psychiatric evaluation, 1:1 monitoring. Audits of the residents charts for accurate charting, if discovered, staff would immediately be re-educated. The Director of Nursing or designee will monitor weekly for three months or until any possible issues are resolved, and monitored by the Quality Assurance process indefinitely. This deficient practice remained at the scope and severity of H.

The facility identified a census of 90 residents. The sample included 3 residents. Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one (#1) of three residents who required hospitalization for critically elevated blood glucose and sodium levels, and failed to coordinate services with hospice. The facility further failed to rotate administration sites of insulin for one (#3) of three residents reviewed for glucose monitoring. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. underlying tissue resulting from prolonged pressure on the skin) of the sacral region with unspecified staging. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented the resident had severely impaired cognition and required total staff assist for activities of daily living (ADL). The Quarterly MDS dated [DATE] documented the resident had severely impaired cognition and required total staff assist for ADLs. The Care Area Assessment for Cognitive Loss and Dementia dated 8/28/16 documented the resident was admitted to hospice services on 12/21/15 with a [DIAGNOSES REDACTED]. The resident was unable to make his/her needs known and staff were to anticipate all of his/her needs. The Care Plan dated 9/13/16 documented the resident depended on staff for all ADL needs and directed staff to provide extensive assistance with ADLs. The care plan also documented the resident was diabetic, at risk for [MEDICAL CONDITION] (elevated blood sugar level), directed staff to complete Accu-Checks (a blood glucose meter used to test the blood sugar level), administer insulin (a hormone made by the pancreas that allows the body to use sugar from carbohydrates in food for energy) as ordered, and to observe for indicators of [MEDICAL CONDITION] such as drowsiness, frequent urination, and excessive thirst. A physician's progress note dated 5/31/16 documented a visit by consultant staff II. The resident received hospice services. Consultant staff II reviewed the resident's blood sugar levels, and recommended staff to check the resident's blood sugar level only when he/she experienced symptoms. A nurse's progress note dated 5/31/16 at 6:30 P.M. documented the physician ordered to discontinue Accu-Checks, and to test the blood sugar only when symptomatic. A physician order [REDACTED]. A physician order [REDACTED]. Review of the clinical record from 8/01/16 through 1/24/17 lacked documentation of hospice visits after 8/09/16. Furthermore, the clinical record lacked documentation of discharge planning between the facility and hospice services. The clinical record lacked documentation the resident was seen by a physician or nurse practitioner in August 2016. Review of the Care Plan Conference note dated 9/13/16 by administrative staff B documented hospice services were discontinued on 8/16/16 due to an extended prognosis. The Care Plan Conference lacked documentation of discharge planning between the facility and hospice and lacked documentation the facility had discussed resuming monitoring of the resident's blood sugars. A physician's progress note dated 9/29/16 documented a visit by consultant staff HH. Consultant staff HH documented the resident was discharged from hospice services and ordered laboratory (lab) studies. The note documented for the management of the resident's diabetes, the resident had orders for Humalog sliding scale insulin with meals and [MEDICATION NAME] at bedtime. This physician's progress note conflicts with the physician order [REDACTED]. A nurse's progress note dated 9/29/16 at 7:00 P.M. documented the physician ordered lab work, which included a hemoglobin A1c (HbA1c) (a blood test that measures what percentage of hemoglobin (a protein the red blood cells that carries oxygen) is coated with sugar; the higher the HbA1c level, the poorer the blood sugar control which increases the risk of diabetes complications). Review of the lab studies dated 10/04/16 documented the HbA1c was 6.8%, which was elevated. The clinical record lacked documentation the resident was seen by a physician or nurse practitioner in November 2016. A nurse's progress note dated 11/04/16 at 9:00 P.M. documented a physician order [REDACTED]. This note conflicts with the physician order [REDACTED]. A physician's progress note dated 12/01/16 documented a visit by consultant staff HH and the resident did not receive medications for his/her diabetes. Review of the Care Plan Conference dated 1/17/17 by administrative staff B documented the resident received no scheduled medications and staff fed the resident in the dining room. A physician's progress note dated 1/18/17 at 6:10 P.M. documented a visit by consultant staff JJ. Nursing staff reported the resident had not eaten on 1/17/17 or 1/18/17, the resident was not like him/herself, was lethargic, and was not responding to his/her name. Consultant staff JJ ordered lab studies. A nurse's untimed progress note dated 1/18/17 documented staff propelled the resident to the nursing station from the dining room because he/she did not eat or speak, and was lethargic (sluggish). Consultant staff JJ examined the resident. A physician's orders [REDACTED]. Review of the clinical record lacked progress note documentation from 11/04/16 through 1/18/17 and lacked documentation the resident had a decrease in appetite and change in his/her level of consciousness. A nurse's progress note dated 1/18/17 at 11:30 P.M. by licensed nursing staff K documented the lab notified him/her about the resident's critically elevated sodium level of 169 millimoles per liter (mmol/L) (normal level is 135-146 mmol/L) and a critically elevated glucose level of 786 milligrams per deciliter (mg/DL) (normal level is 70-99 mg/DL). Staff K notified consultant staff JJ about the elevated lab results, and consultant JJ ordered staff to send the resident to the hospital. Review of the Resident Transfer Form dated 1/18/17 by licensed nursing staff K documented the resident was transferred to the hospital for critical laboratory results, had orders for a regular diet, required total assistance for ADLs, and was not able to make his/her needs known. The Resident Transfer Form lacked documentation the resident had a change in in his/her level of consciousness and failed to specify a timeframe in which the resident had not eaten or drank fluids. Review of the hospital forensic examination dated 1/19/17 documented the emergency room nurse spoke to a facility nurse who stated the resident's glucose was usually okay, so staff only checked it when they had time. Laboratory testing in the emergency room recorded a critically elevated sodium level of 172 mmol/L and a critically elevated glucose of 673 mg/DL. The hospital physician admitted the resident to the intensive care unit and he/she received insulin through his/her veins. Review of the clinical record from 5/01/16 through 1/24/17 lacked documentation the resident's blood sugar had been monitored. On 1/23/17 at 2:36 P.M., direct care staff O stated the resident had a great appetite and always ate and drank everything staff provided to him/her. Staff O stated he/she would notify the nurse if the resident did not eat or drink. On 1/23/17 at 2:47 P.M., licensed nursing staff J stated the resident's appetite started to decrease on 1/18/17 but maintained his/her fluids. Licensed nursing staff J stated when the resident admitted to the facility on [DATE], he/she received hospice services and blood sugars were monitored. Staff J further stated hospice services was discontinued in August 2016 but there was not a discussion about resuming blood sugar monitoring. Licensed nursing staff J stated if the resident had a change in the level of consciousness, staff would check a blood sugar level. Staff J further stated there was not a reason for this resident's blood sugars to be checked, because all insulin and Accu-Checks were discontinued 5/31/16. On 1/23/17 at 2:58 P.M., licensed nursing staff K stated he/she provided care on 1/18/17. He/she stated direct care staff brought the resident to the dining room to eat dinner but he/she was lethargic. The previous shift reported the resident had a decreased appetite, but had still eaten. Licensed nursing staff K stated consultant staff JJ was present on the unit, so he/she asked him/her to examine the resident. Lab studies were obtained and the resident was transferred to the hospital after the critically elevated glucose and sodium levels were reported. Licensed nursing staff K further stated the resident's orders for blood sugar monitoring and insulin had been discontinued. On 1/23/17 at 3:09 P.M., administrative nursing staff D stated he/she was not involved in any conversations with the family or the hospice company about resuming the resident's blood sugar monitoring. On 1/23/17 at 6:38 P.M., direct care staff P stated the resident normally ate and drank well. Direct care staff P stated on 1/18/17, he/she brought the resident to the dining room, but the resident would not eat, and his/her mouth hung open. Staff P further stated he/she reported these symptoms immediately to licensed nursing staff K. Direct care staff P stated he/she received a report the resident had not eaten well for breakfast or lunch on 1/18/17. On 1/24/17 at 838 A.M., consultant staff JJ stated he/she was present on the unit on 1/18/17 and was asked by nursing staff to examine the resident, because he/she was not the same as he/she normally was. Staff JJ stated upon examination, the resident was awake, but did not respond verbally, was lethargic, and stuporous (a level of consciousness wherein a person is almost entirely unresponsive). He/she ordered lab studies and once the results were reported, he/she had given an order to send the resident to the hospital for evaluation and treatment. Consultant staff JJ reviewed the clinical record and stated the resident had been on hospice, the decision was made to stop his/her Accu-Checks and medications with approval of the family. Staff JJ further stated when the hospice services were discontinued in August 2016, the documentation was unclear on the order sheet compared to the progress notes as to when things were discontinued, and why nothing was restarted after he/she discharged from hospice services. Consultant staff JJ stated the resident's HgA1c elevated HgA1c of 6.8% but did not know why the Accu-Checks and insulin orders were not resumed. On 1/24/17 at 1:40 P.M., direct care staff Q and R stated the facility staff did not monitor meal or fluid intake of residents. On 1/24/17 at 6:33 P.M., administrative staff B stated when the resident was discharged from hospice services in August 2016, the MDS nurse completed a Significant Change Assessment, and then he/she held a Care Plan Conference the next month. Administrative staff B stated he/she did not remember having a conversation about monitoring blood sugar levels or the need to resume previous orders once hospice was discontinued. Administrative staff B and administrative nursing staff D stated they were not aware of any discharge planning when a resident was removed from hospice services. On 1/24/17 at 4:58 P.M., the resident's family stated the resident was admitted to the hospital on [DATE] with dehydration and a critical glucose above 700. He/she stated he/she had a conversation with the hospice company and facility staff in May 2016 about decreasing the number of times a day the resident's blood sugar would be tested . The family member stated at the time, the resident received hospice services and his/her blood sugar was tested four times a day. Because the blood sugar levels and been stable, it was suggested to the family the resident be checked periodically, which he/she thought would mean once a day, every other day, or even just once a week. The family member stated he/she had no idea the facility had never checked it after May 2016. He/she stated when the resident was discharged from hospice services in August 2016, the facility did not discuss the resident's blood sugars or which physician's orders [REDACTED]. On 1/24/17 at 5:48 P.M., consultant staff HH stated he/she remembered ordering routine lab studies for the resident when he/she was discharged from hospice services. Consultant staff HH further stated he/she did not remember discussing monitoring the resident's blood sugars with anyone because the resident's prognosis had improved and he/she assumed the family did not want aggressive measures. On 1/26/17 at 12:50 P.M., consultant staff HH stated he/she reviewed the physician's progress notes, and physician's orders [REDACTED]. On 1/31/17 at 12:35 P.M., consultant staff GG stated when a resident no longer qualified for hospice services, their company met with the facility and the family for discharge planning. Consultant staff GG stated the hospice company could not instruct the facility on what orders to resume, as that would be a decision for the resident's physician. He/she stated hospice staff visited the resident on 8/11/16, 8/15/16, and 8/16/16 and the facility should have maintained copies of hospice documentation in the resident's clinical record. Review of the facility provided Abuse, Neglect, and Exploitation policy dated September 2016 documented the facility would maintain a living environment that was professional and free from neglect. The policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility lacked a requested policy regarding the monitoring of residents. The facility lacked a requested policy regarding coordination of care with hospice services. The facility failed to monitor the blood sugar as ordered by the physician and for signs of dehydration which resulted in a critically elevated glucose level and sodium level for this cognitively impaired and dependent resident who required hospitalization in intensive care. - The clinical record documented resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, and a [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented a BIMS score of 15, and a [DIAGNOSES REDACTED]. The Care Area Assessment for Nutritional Status dated 4/13/16 documented the resident was diabetic and able to make his/her own meal choices. The Care Plan dated 4/20/16 documented the resident was diabetic and directed staff to obtain Accu-Checks (a blood glucose meter used to test the blood sugar level) as ordered by the physician. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. On 1/23/17 at 5:07 P.M., licensed nursing staff I obtained the resident's blood sugar and injected the prescribed dosage of insulin into the resident's lower left abdominal quadrant. Review of the December 2016 Medication Administration Record (MAR) lacked documentation of the injection site for administration of [MEDICATION NAME] 16 units SQ for all three meals and for the sliding scale dosage. The MAR documented [MEDICATION NAME] 46 units SQ at bedtime was administered in the resident's abdomen for 8 shifts and lacked documentation of an injection site for 23 shifts. Review of the January 2017 MAR lacked documentation of the injection site for administration of [MEDICATION NAME] 16 units SQ for all three meals and for the sliding scale dosage. The MAR documented [MEDICATION NAME] 46 units SQ at bedtime was administered in the resident's abdomen for 12 shifts and lacked documentation of an injection site for 3 shifts. On 1/23/17 at 4:48 P.M., the resident stated nursing staff check his/her blood sugars before each meal and he takes [MEDICATION NAME] and [MEDICATION NAME]that the nurses usually inject in his/her abdomen. On 1/23/17 at 5:13 P.M., licensed nursing staff I stated he/she injected insulin wherever the resident told her to and he/she did not know where to find the injection site of a previous dose to determine if it had been rotated. On 1/24/17 at 11:25 A.M., licensed nursing staff H stated the injection site used for insulin should be documented on the MAR although some nurses did not document the injection site. Licensed nursing staff H stated if the resident preferred the same injection site, staff should rotate arms or quadrants in the abdomen with each injection. On 1/24/17 at 3:09 P.M., administrative nursing staff D stated he/she expected staff to rotate the site of insulin administration and document the administration and site on the MAR and the diabetic flowsheet. Review of the undated facility provided Subcutaneous Injection policy documented staff should select the site of administration and rotate sites to prevent unnecessary trauma and aid in absorption of the medication. The facility failed to rotate sites of insulin administration for this diabetic resident.

The facility identified a census of 90 residents. The sample included 3 residents. Based on observation, interview, and record review, the facility failed to develop and implement timely and effective interventions to prevent a pressure ulcer for 2 (#3, #1) of 3 residents reviewed for pressure ulcers. Findings included: - The clinical record documented resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 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 independent with bed mobility and transfers, at risk for pressure ulcers, and had a pressure reducing device in use on his/her bed and chair. The Quarterly MDS dated [DATE] documented a BIMS score of 15. The resident was independent with all activities of daily living (ADLs) and had a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed; some slough may be present; may include undermining and tunneling) that was not present on admission and measured 5.5 centimeters (cm) x 5.5 cm with [MEDICATION NAME] tissue (a type of tissue that lines the cavities and surfaces of blood vessels and organs throughout the body). The Care Area Assessment for Pressure Ulcers dated 4/13/16 documented the resident was able to change position on his/her own and did not have any current skin conditions. The Care Plan dated 4/20/16 documented the resident was at risk for skin breakdown due to diabetes, [MEDICAL CONDITION] (swelling caused by fluid retention), and [MEDICAL TREATMENT] (the clinical purification of blood by [MEDICAL TREATMENT], as a substitute for the normal function of the kidney) and directed staff to complete weekly body audits, report abnormal findings to the nurse, and provide a wheelchair cushion. A revision on 11/29/16 documented the resident wore a right heel boot as tolerated, and a revision on 1/09/17 documented the resident was started on an antibiotic for his/her right heel wound. The re-admission Care Plan dated 1/19/17 documented the resident had a pressure ulcer and directed staff to complete weekly skin and wound assessments, monitor nutrition and hydration, to float the resident's heels when in bed, to turn and reposition the resident every two hours, use a pressure reducing device in the bed and/or wheelchair, and to continue the right heel wound treatment as previously ordered. A physician order [REDACTED]. Review of the Braden Scale for Predicting Pressure Sore Risk with a patient admission sticker dated 5/20/16 documented a score of 21, which indicated the resident was a low risk. The form lacked a nurse signature, interventions, and a date of completion. Review of the Braden Scale for Predicting Pressure Sore Risk with a patient admission sticker dated 1/19/17 lacked documentation. The clinical record lacked evidence of further Braden assessments as ordered by the physician. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. An untimed physician's progress note dated 12/03/16 documented the resident had dry skin with a blood blister on the right inner heel. A physician's progress note dated 12/05/16 at 2:00 P.M. documented the resident had an Ankle-Brachil Indices ordered for the right heel wound and [MEDICAL CONDITION] scan of the right heel. Review of the clinical record from 4/02/16 through 1/24/17 lacked documentation of the results of a [MEDICAL CONDITION] scan of the right heel. A nurse's progress note dated 12/12/16 at 8:35 A.M. documented physician KK was notified the resident's right heel was not improving and a physician order [REDACTED]. A nurse's progress note dated 1/02/17 at 3:00 P.M. documented the weekly wound assessment of right heel measured 5.5 cm x 5.5 cm and was improving. A nurse's progress note dated 1/19/17 at 5:00 P.M. documented the resident was readmitted to the facility, his/her skin was assessed, and to continue with the [MEDICATION NAME] treatment to the right heel. Review of the progress notes from November 2016 through 1/24/17 lacked documentation of the development of a blood blister or open wound on the right heel. A Specialized Wound Management Note dated 1/09/17 documented the resident had developed a blister on his/her right heel that increased to a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough; it may also present as an intact or open/ruptured blister). The wound measured 6.0 cm x 5.5 cm. The clinical record lacked documentation of further notes from Specialized Wound Management. Review of the December 2016 Treatment Administration Record (TAR) lacked documentation of weekly skin assessments on 12/07/16, 12/14/16, 12/20/16, and 12/27/16, lacked documentation of the right heel dressing change on 12/10/16, 12/13/16, and 12/14/16, and lacked documentation each shift of the right heel boot being in place. Review of the January 2017 TAR lacked documentation of the right heel dressing change twice daily on 1/01/17, 1/07/17, 1/08/17, 1/09/17, 1/14/17, and 1/15/17. Review of the weekly body audit dated 11/16/16 documented the skin was normal. Review of the clinical record lacked documentation of a weekly body audit for December 2016 and January 2017, a total of 8 weekly assessments. A weekly wound assessment dated [DATE] documented a stage III pressure ulcer on the right heel that measured 4.5 cm x 4.0 cm x 0.1 cm and was unchanged. A weekly wound assessment dated [DATE] documented a stage III pressure ulcer on the right heel that measured 6.0 cm x 5.0 cm x 0.1 cm and was unchanged. This information conflicts with the previous wound measurement as it had increased in size. A weekly wound assessment dated [DATE] documented a stage III pressure ulcer on the right heel that measured 5.5 cm x 5.5 cm and wound improving. A weekly wound assessment dated [DATE] documented a stage III pressure ulcer on the right heel that measured 6.0 cm x 5.5 cm and wound improving. This information conflicts with the previous wound measurement as it had increased in size. Review of the clinical record lacked documentation of a weekly wound assessment for the week of 1/16/17 due to the resident being admitted to the hospital from 1/16/17 through 1/19/17 for an unrelated problem. On 1/24/17 at 11:10 A.M., licensed nursing staff H and administrative nursing staff D changed the dressing on the resident's right heel wound. The wound appeared pink, moist and was approximately 5.0 cm x 5.0 cm. On 1/23/17 at 4:48 P.M., resident #3 stated a blister developed on his/her right heel and opened when he/she bumped it on the edge of his/her motorized wheelchair. The resident stated the nursing staff should change it twice a day and wound care specialists saw him/her once a week to obtain measurements of the wound. On 1/23/17 at 5:13 P.M., licensed nursing staff I stated the resident had a diabetic ulcer on his/her right heel, the dressing was changed twice a day, and documented on the TAR. On 1/24/17 at 11:25 P.M., licensed nursing staff H stated the skin assessment was completed once a week during bath days and each charge nurse was responsible for completing the documentation on the weekly audit sheet and TAR. Licensed nursing staff H stated the wound care assessment with measurements was completed once a week. He/she stated the wound care nurse came to the facility every Monday but had missed seeing the resident and measuring his/her wound twice. On 1/24/17 at 3:09 P.M., administrative nursing staff D stated each nurse was responsible for completing the weekly skin assessment which was documented on the weekly body audit form and if the resident had a wound, staff would complete a weekly wound assessment until it was healed. Administrative nursing staff D stated the facility did not have a dedicated wound nurse but he/she oversaw the wounds and the facility would obtain a physician order [REDACTED]. On 1/24/17 at 4:09 P.M., administrative nursing staff D stated the resident's right heel wound was first identified on 12/09/16 and it was unstageable. Administrative nursing staff D confirmed the wound developed in the facility and had increased in size. On 1/24/17 at 6:33 P.M., administrative nursing staff D stated he/she and administrative nursing staff E conducted spot checks of the weekly body audits to ensure nursing staff were monitoring the resident's skin. Administrative nursing staff D confirmed the clinical record lacked documentation of weekly body audits. On 1/31/17 at 12:15 P.M., consultant staff KK stated he/she was aware of the wound on the resident's right heel. He/she stated the wound first developed as a blood blister and opened after the resident bumped it on his/her wheelchair. Review of the undated facility provided Skin Monitoring policy documented the Braden Scale was included as part of the admission process and quarterly with the MDS. Based on the assessed risk, preventative measures were to be initiated and documented in the plan of care. All wounds were assessed during dressing changes by nursing staff. The weekly wound rounds were completed by the Director of Nursing and wounds were to be measured, assessed for the appropriateness of the treatments, and their status documented on the weekly wound report. The facility failed to monitor the skin as ordered by the physician and implement timely and effective interventions to prevent the development of a stage III pressure ulcer for this at-risk resident. - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented the resident had severely impaired cognition and required total staff assist for activities of daily living (ADL). The resident was at risk for pressure ulcers, had no current skin conditions, and had a pressure reducing device in use on his/her bed and chair. The Quarterly MDS dated [DATE] documented the resident had severely impaired cognition, required total staff assist for ADLs, was always incontinent of bladder and bowel, had no current skin conditions, and had a pressure reducing device in use on his/her bed and chair. The Care Area Assessment for Pressure Ulcers dated 8/28/16 documented the resident was at risk for skin breakdown related to his/her incontinence and limited mobility. The resident had increased risk factors of advanced dementia and diabetes, intact skin, and a remote history of pressure ulcers. The Care Plan dated 9/13/16 documented the resident was at risk for skin breakdown due to incontinence, diabetes, limited mobility, and advanced dementia and directed staff to change his/her position frequently, complete skin/body audits per the facility guidelines, and the resident to wear heel lift boots at all times. Review of the Braden Scale for Predicting Pressure Sore Risk dated 8/23/16 documented a score of 14, which indicated moderate risk and interventions to consider heel elevators, a pressure reducing chair cushion, moisture barrier after each episode of incontinence, and to provide adequate fluid intake. A physician order [REDACTED]. A physician order [REDACTED]. A Care Plan Conference note by social service staff B dated 1/17/17 documented the resident had no skin issues and received no supplements. Review of the weekly body audit report dated November 2016 documented the resident's skin was normal. Review of the weekly body audit reports dated 12/12/16 and 12/26/16 documented the resident's skin was normal and lacked documentation for 12/05/16 and 12/19/16. Review of the clinical record lacked documentation of any weekly body audits for January 2017. Review of the December 2016 Treatment Administration Record (TAR) lacked documentation of weekly skin assessments on 12/05/16 and 12/19/16, and lacked documentation on 6 shifts of the heel boots being in place. Review of the January 2017 TAR lacked documentation of weekly skin assessments on 1/02/17, 1/09/17, and 1/16/17. Review of the physician's and nurse's progress notes from November 2016 through January 2017 lacked documentation of impaired skin. Review of the clinical record from May 2016 through 1/24/17 revealed the record lacked any documentation or evidence that the development of any wounds or skin impairment for this resident were clinically unavoidable. A physician order [REDACTED]. Review of the hospital forensic examination dated 1/19/17 at 5:21 A.M. documented the resident arrived to the emergency room with the following skin breakdown: a healing abrasion (an area damaged by scraping) on the left shoulder approximately 9 centimeters (cm) in length, multiple scattered round [MEDICAL CONDITION] (a region in an organ or tissue that has suffered damage through injury, such as a wound, ulcer, etc.) on the left breast and abdomen, an area on the right inner thigh approximately 3 inches in length, multiple scattered [MEDICAL CONDITION] on the left posterior upper arm, a linear area of redness on the left flank (the side of a person's body between the ribs and the hip) approximately 8 cm in length, a healing round sore about the size of a pencil eraser with surrounding redness below the left shoulder blade, and a pressure ulcer on the coccyx (the tailbone) approximately one inch in length. Review of the hospital wound care consult dated 1/19/17 at 12:38 P.M. documented the resident's right proximal (situated nearer to the center of the body) thigh had an area of shear injury that measured 3 cm x 2 cm x partial skin thickness with a red, moist wound bed, no active drainage, the right side of the sacrum (a strong bone that supports the weight of the upper body as it is spread across the pelvis and into the legs) with a stage II pressure injury (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough; it may also present as an intact or open/ruptured blister) presenting as a ruptured blister with the roof partially intact and a red, moist wound bed that measured 1.3 cm x 0.7 cm x partial skin thickness; on the left buttock was evidence of an old linear shaped pressure injury that was healed and measured 3.5 cm x 0.5 cm x 0 cm; the right posterior (further back in position) heel had a stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence) round 1 cm x 1 cm non-blanchable [DIAGNOSES REDACTED]tous (the ulcer appears as a defined area of persistent redness in lightly pigmented skin, and in darker skin tones may appear with persistent red, blue, or purple hues) pressure injury and an ecchymotic (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) deep tissue pressure injury that measured 4.2 cm x 1.3 cm. On 1/23/17 at 4:00 P.M., the resident was observed at the hospital lying in bed on his/her right side. Hospital staff removed the sacral dressing and a stage II pressure ulcer near the right side of the coccyx measuring approximately 1.5 cm x 1.0 cm was visualized with a red, moist wound base. On the right thigh, a shear injury (a strain in the structure of a substance produced by pressure, when its layers are laterally shifted in relation to each other) approximately 3 cm x 2 cm was visualized. Hospital staff removed the bilateral heel boots and the right heel had two unstageable suspected deep tissue wounds which presented as small round, dark purple areas. On 1/23/17 at 1:50 P.M., administrative staff A and administrative nursing staff D stated they spoke to the resident's family and he/she was upset about the resident's condition and his/her skin. Administrative nursing staff D stated he/she was unsure what the family was concerned about and he/she questioned whether the facility had missed something on the resident's skin. On 1/23/17 at 2:36 P.M., direct care staff O stated he/she did not remember seeing any open wounds on the resident but would report all changes in skin to the nurse. On 1/23/17 at 2:47 P.M., licensed nursing staff J stated when the resident first admitted to the facility, he/she had multiple open areas but those had healed and his/her skin was currently clear with no breakdown. Licensed nursing staff J stated the resident wore bilateral heel boots as a preventative measure. On 1/23/17 at 2:58 P.M., licensed nursing staff K stated when the resident first admitted to the facility, he/she had an open area on his/her left shoulder but it had healed and he/she expected direct care staff to report any open areas and to look at the skin when staff assisted with ADLs and showers. On 1/23/17 at 6:38 P.M., direct care staff P stated the resident's skin was clear and he/she did not remember if the resident had skin breakdown. On 1/24/17 at 8:38 A.M., consultant staff JJ stated he/she was not aware of any skin breakdown on the resident but he/she was at high risk based on his/her [DIAGNOSES REDACTED]. On 1/24/17 at 3:09 P.M., administrative nursing staff D stated he/she expected the nurse to complete the weekly skin assessment and document it on the weekly body audit form. If the resident had a wound, staff would complete a weekly wound assessment form until it was healed. Administrative nursing staff D further stated the facility did not have a dedicated wound nurse but he/she provided oversight for wound management. The facility obtained a physician order [REDACTED]. On 1/24/17 at 4:58 P.M., the resident's family stated he/she was very upset about the resident's condition and the emergency room staff found multiple open areas on his/her skin when they assessed him/her. On 1/26/17 at 6:16 P.M., administrative staff A stated wounds were discussed every month in the facility's Quality Assurance (QA) meeting and this resident did not trigger as needing further review or audit. Administrative staff A further stated the facility had documentation of when the resident did have wounds, those wounds had healed, and they had not received documentation from the hospital regarding the alleged skin issues. On 1/24/17 at 6:33 P.M., administrative nursing staff D stated he/she and administrative nursing staff E conducted spot checks of the weekly body audits to ensure nursing staff were monitoring the resident's skin. Review of the undated facility provided Skin Monitoring policy documented the Braden Scale was included as part of the admission process and quarterly with the MDS. Based on the assessed risk, preventative measures were to be initiated and documented in the plan of care. All wounds were assessed during dressing changes by nursing staff. The weekly wound rounds were completed by the Director of Nursing and wounds were to be measured, assessed for the appropriateness of the treatments, and their status documented on the weekly wound report. The facility failed to monitor the skin as ordered by the physician and implement timely and effective interventions to prevent the development of a stage II pressure ulcer for this high-risk and dependent resident.

The facility identified a census of 92 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to monitor the placement and side effects of pain medication ([MEDICATION NAME]) (a skin patch containing [MEDICATION NAME], narcotic pain medication) for 1 (#1) of 3 residents sampled for use of a [MEDICATION NAME] which resulted in the resident ' s hospitalization for narcotic overdose. Findings included: - Resident #1 May 2016 physician's orders [REDACTED]. emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) and constipation. Review of the annual minimum data set ((MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 3, which indicated severely impaired cognition. The resident received scheduled pain medication and staff observed facial expressions as an indicator of pain 1-2 days of the assessment. Review of the quarterly MDS dated [DATE] documented a BIMS of 4, which indicated severely impaired cognition. The resident received scheduled pain medication during the assessment. The Care Area Assessment (CAA) for pain dated 8/14/15 documented the resident was not able to rate his/her pain and had a [MEDICATION NAME] ordered by the physician. The care plan dated 8/20/15 indicated the resident had chronic pain related to [MEDICAL CONDITION] and [MEDICAL CONDITION] and directed staff to administer the [MEDICATION NAME] as ordered by the physician and to evaluate, record and report the effectiveness and any adverse side effects. A physician order [REDACTED]. A physician order [REDACTED]. The Black Box Warning (a black box warning issued by the FDA (US Food and Drug Administration) is a warning of serious or life-threatening risks located on the label of a prescription drug) Care Plan initiated 8/20/15 lacked documentation of a black box warning for [MEDICATION NAME]. According to www.fda.gov <http://www.fda.gov>, [MEDICATION NAME] had a black box warning of fatal overdose due to respiratory depression. Due to the mean elimination half-life of 17 hours of [MEDICATION NAME], patients who have had a serious adverse event, including overdose, would require monitoring and treatment for [REDACTED]. The May 2016 Aux-narc Flowsheet documented the administration of [MEDICATION NAME] 12-mcg per hour [MEDICATION NAME] on 5/1/16 on the right shoulder, 5/4/16, 5/7/16, 5/10/16, and 5/13/16 on the left chest. The flowsheet lacked documentation of the site of the patch on 5/4/16, 5/7/16, and 5/10/16. The flowsheet lacked documentation of monitoring placement of the [MEDICATION NAME] for 21 shifts from 5/1/16 through 5/15/16. The flowsheet lacked documentation of a second nurse witness for the removal and destruction of the [MEDICATION NAME] on 5/7/16 and 5/10/16. A progress note dated 5/15/16 at 8:45 A.M. documented the resident was in the dining room for breakfast and staff noted he/she did not look well. The resident was removed from the dining room for an assessment and was found to be non-responsive and diaphoretic (sweating heavily). Recorded vital signs at this time were a blood pressure of 93/57, a heart rate of 157, respirations of 28 and an oxygen saturation of 84% while receiving two liters of oxygen per minute. Nursing staff obtained a physician order [REDACTED]. A progress note dated 5/15/16 at 3:15 P.M. documented staff had called the hospital for report at 10:30 A.M. for a report on the resident ' s condition and was told the hospital physician had removed two [MEDICATION NAME]es from the resident and had administered [MEDICATION NAME] (a medication used to treat narcotic overdose in an emergency situation). Review of the hospital history and physical dated 5/15/16 documented the resident was admitted to the intensive care unit for altered mental status and a narcotic overdose from [MEDICATION NAME]. In the emergency room , the resident was found to have two [MEDICATION NAME]es on which were removed and he/she was given [MEDICATION NAME] in the emergency room . Review of the hospital progress note dated 5/16/16 documented constipation with fecal impaction and [MEDICAL CONDITION] with acute blood loss. The resident was unresponsive, had several bloody stools throughout the night. The facility ' s Medication Error Report dated 5/15/16 documented on 5/13/16 the [MEDICATION NAME] 12-mcg [MEDICATION NAME] was changed as prescribed but the [MEDICATION NAME] that was currently on the resident was not removed as ordered. The resident returned to the facility on [DATE] and was admitted to hospice services for end stage dementia. A progress note dated 6/9/16 at 9:00 P.M. documented the resident was found to have no vital signs at 4:35 P.M. and his/her body was released to the funeral home at 6:18 P.M. Observations were unavailable as the resident no longer resided at the facility. During an interview on 6/28/16 at 10:33 A.M., the resident ' s family member stated hospital staff found two patches on the resident ' s body, one dated 5/10/16 and one dated 5/13/16. The resident was unresponsive, required [MEDICATION NAME] for the narcotic overdose, and was sent to the intensive care unit to be monitored. During an interview on 7/13/16 at 4:17 P.M., direct care staff O stated he/she was unsure what to observe for with a resident who received too much pain medication. He/she said drowsiness might be a symptom of many different conditions and not just pain medication overdose. During an interview on 7/13/16 at 5:00 P.M., licensed nursing staff I stated all [MEDICATION NAME]es were to be placed at 8:00 in the morning and the removal and destruction of the patch should be witnesses by two licensed nursing staff. Licensed nursing staff I stated a licensed nurse must verify and document the location of the patch every shift. If the patch was missing, he/she would verify the placement with what had been charted and report the missing patch to the physician and the director of nursing. During an interview on 7/13/16 at 5:11 P.M., direct care staff P stated he/she would look for signs of sleeping through meals and anything out of the resident ' s normal routine as a possible concern with pain medication overdose. During an interview on 7/14/16 at 11:25 A.M., licensed nursing staff J stated the process for placing and removing a [MEDICATION NAME] was to verify the physician order, remove the old [MEDICATION NAME], place the new patch, and have a second licensed nurse document on the flowsheet that they had witnessed the destruction of the old patch. Licensed nursing staff J stated if a patch could not be found, staff should have another nurse help look for it on the resident and then notify the physician. He/she would monitor the resident for signs and symptoms of a narcotic patch overdose such as unusual behavior or lethargy. During an interview on 7/14/16 at 11:30 A.M., consultant staff JJ stated having multiple [MEDICATION NAME]es left on the resident ' s body would have contributed to a decrease in level of consciousness and a rapid decline in vital signs. Consultant staff JJ stated he/she was not aware the resident had received [MEDICATION NAME] while in the hospital. During an interview on 7/14/16 at 12:04 P.M., administrative nursing staff D stated two licensed nurses should be present to remove and replace a resident ' s [MEDICATION NAME]. During an interview on 7/14/16 at 12:56 P.M., licensed nursing staff K stated two nurses should document the removal of a [MEDICATION NAME] and should monitor the resident for signs and symptoms of a narcotic overdose such as lethargy, dizziness, and low blood pressure. The undated [MEDICATION NAME] Patches policy documented the nurse that administered the [MEDICATION NAME] needed to document where the new patch was placed and every shift thereafter would check for placement of the patch and document it in the treatment administration record. The facility failed to ensure this resident was free from a significant medication error when they failed to remove the [MEDICATION NAME] from the resident and placed a new patch on as ordered which caused the resident to become over sedated with a [DIAGNOSES REDACTED].

The facility identified a census of 88 residents. The sample included 3 residents sampled for falls. Based on observation, record review, and interview, the facility failed to provide care and services to prevent accidents for 2 of 3 residents sampled for falls. The facility failed to follow planned interventions which resulted in a fall and tibia/fibula (lower leg) fracture during an inappropriate transfer for one of three residents (#1), and failed to implement interventions per the assessment for one of three residents (#2), regarding high fall risk tag placement. Findings included: - Resident #1's April 2016 physician's orders [REDACTED]. The resident's annual Minimum Data Set ((MDS) dated [DATE] recorded the resident with short and long term memory problems and moderately impaired decision making skills. The resident displayed disorganized thinking, which fluctuated. The resident required limited assist of one staff with eating, extensive assist with one staff member with bed mobility, personal hygiene, locomotion, dressing and. and extensive assist of 2 plus staff with transfers, toilet use. The resident was not steady when moving from a seated to a standing position, moving on and off the toilet and surface to surface transfer. No range of motion limitations, the resident used a wheelchair for mobility; the resident was always incontinent of bowel and bladder. The resident had no falls since the previous assessment. The Care Area Assessment (CAA) for falls dated 1/22/16 recorded the resident had a remote history of falls. The resident was non-ambulatory and used a wheelchair as the primary source of locomotion. The resident had impaired cognition with poor safety awareness due to a [DIAGNOSES REDACTED]. Fall risk assessments dated 8/3/15 and 3/28/16 revealed the resident was a high fall risk. The care plan dated 1/22/16 included an intervention that the resident was currently an assist of 1-2 staff for transfers, using a gait belt. Staff added a care plan update on 3/28/16 for a 2 person assist with transfers, and another care plan update on 3/29/16 for a Hoyer lift (full body lift used for transfers). The facility's incident report recorded the resident had poor safety awareness and a history of falls, with moderately impaired daily decision making. On 3/28/16 at 4:30 PM, the Certified Nursing Assistant (CNA) transferred the resident from his/her bed to his/her wheelchair. During the transfer to his/her wheelchair, the resident's right leg shifted behind his/her left leg. The resident's legs became twisted and the direct care staff had to lower the resident to the floor. Staff then updated the care plan to transfer with two staff. On 3/29 resident had swelling to his/her right knee and bruising at the shin. The physician ordered an x-ray of right leg, which revealed tibia and fibula (bones of the lower leg) fractures. Upon return from the hospital, the facility changed transfer mode to Hoyer lift. The Post- Fall Assessment revealed a gait belt was not used during the transfer. Direct care staff A's witness statement revealed he/she swung the resident's legs around by grabbing one leg at a time, then began to reach under his/her armpits and grabbed his/her pants. Direct care staff A documented when he/she stood the resident up and started to turn, the resident's legs began to twist and his/her legs bent. It became difficult to move the resident with his/her leg twisted. Direct care staff A could not move the resident to the chair, so he/she sat him/her on the floor. Licensed nursing staff F's witness statement dated 3/28/16 revealed direct care staff A who was caring for the resident, informed him/her that he/she lowered the resident to the ground because his/her feet got tangled during a one person transfer. On 3/29/16 at 2:40 PM, the resident's physician ordered an x-ray of the right leg. The nurses note dated 3/30/16 at 7:30 AM recorded an x-ray was done and showed fractures of the tibia and fibula. The facility sent the resident out to the hospital by ambulance at 6 AM. Observations were unavailable as the resident no longer resided at the facility. During an interview on 5/13/16 at 9:49 AM, direct care staff B stated the resident required one person assist with a gait belt before the fall, and a Hoyer lift for transfers after the fall. During an interview on 5/13/16 at 3:00 PM licensed nursing staff G stated staff should use a gait belt with all transfers. During an interview on 5/16/16 at 9:20 PM direct care staff A stated he/she transferred the resident on 3/28/16 and lowered him/her to the floor. Direct care staff A confirmed he/she did not use a gait belt during the transfer, and stated it was the facility policy to use a gait belt with every resident transfer. During an interview on 5/17/16 at 12:55 PM, administrative nursing staff E stated his/her expectation was for staff to always use a gait belt with all transfers. Administrative nursing staff E confirmed that direct care staff A should have used a gait belt at the time of the resident's fall. The facility's gait belt use policy dated 7/1/15 documented the purpose was to provide control and balance of residents that required physical assistance for transfers and gait, and directed staff that gait belts should be used with all residents that required physical lifting assistance for transfers and/or ambulation. The facility failed to ensure safe transfers for this cognitively impaired, dependent resident who fell during a transfer without a gait belt which resulted in a tibia/fibula fracture. - Resident #2's May 2016 physician's orders [REDACTED]. (progressive mental deterioration characterized by confusion and memory failure). The admission MDS dated [DATE] recorded the resident with short term memory problems, intact long term memory and moderately impaired decision making skills. The resident required limited assist with one person for bed mobility, walking in room, locomotion on unit, personal hygiene, extensive assist of one person with transfers, walking in corridor, dressing an d toilet use; and total dependence of one person with locomotion off unit. The resident was not steady and was only able to stabilize with staff assist when moving from a seated to a standing position, moving on and off the toilet, and surface to surface transfer. The resident had functional limitation in range of motion on one side of the upper extremities. The resident used a walker and wheelchair for mobility. The resident was occasionally incontinent of bladder and always continent of bowel. The resident had a fall in the last month, and received physical and occupational therapies. The ADL (activities of daily living) CAA dated 2/21/16 revealed the resident lived with his/her family prior to admission for therapy services. The resident fell at a church activity and resulted in a right humerus fracture. He/she required extensive assist with dressing, transfers, and toileting. Fall risk assessments dated 3/4/16, 3/13/16, 3/25/16 and 4/19/16 documented the resident as high fall risk. The care plan listed fall prevention interventions, which included to complete a fall risk assessment and label all high fall risk residents with a red bag tag on their wheelchair or walker. Post fall assessments recorded the resident fell on [DATE], 4/14/16, 3/25/16, 3/13/16, and 3/4/16. Observation on 5/13/16 at 9:13 AM revealed the resident sat in his/her wheelchair in the dining room without a red tag on his/her wheelchair. Observation on 5/13/16 at 12:51 PM revealed the resident sat in his/her wheelchair at the dining room table and did not have a red tag on his/her wheelchair. During an interview on 5/13/16 at 12:58 PM, administrative nursing staff E confirmed the resident did not have a red tag on his/her wheelchair, but should have one. At this time, observation revealed administrative nursing staff E placed a red tag on the resident's wheelchair. During an interview on 5/13/16 at 2:57 PM, licensed nursing staff G stated the red tag meant the resident was a high fall risk. During an interview on 5/17/16 at 12:55 PM, administrative nursing staff E stated his/her expectation was that nurses were responsible to place the tags if needed when the completed a fall risk assessment. The facility's Fall Risk/Prevention Program Policy dated 8/1/15 recorded that residents who were at high risk for falls would have a red bag tag on their wheelchair or walker to remind everyone of the risk. The facility failed to provide planned fall prevention interventions for this cognitively impaired, dependent resident with a history of multiple falls.

The facility reported a census of 97 residents with 24 residents in the sample. Based on observation, interview, and record review the facility failed to protect the residents in the facility from potential abuse when they failed to investigate alleged verbal abuse for 1 of 1 residents reviewed (#61) and failed to report injury of unknown resident for 1 of 4 residents reviewed for accidents (#94). This facility placed the residents in immediate jeopardy. Findings Included: - Review of resident #61 admission MDS (Minimum Data Set) dated 4/11/2015 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she experienced no signs/symptoms of [MEDICAL CONDITION], hallucinations, delusions, physical or verbal aggression, and did not reject cares. He/she required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. He/she experienced functional limitation in range of motion to one lower extremity and used a wheelchair for mobility. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 4/16/2015 revealed the resident required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal cares, and bathing. He/she had a left [MEDICAL CONDITION]. Review of resident #61's 30 day MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she experienced no signs/symptoms of [MEDICAL CONDITION], hallucinations, delusions, physical or verbal aggression, and did not reject cares. The resident required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. He/she experienced functional limitation in range of motion to one lower extremity and used a wheelchair for mobility. Review of resident #61's plan dated 4/4/2015 revealed the care plan directed staff to remind the resident to use assistive devices as recommended by therapy for transfers and ambulation,. He/she required extensive assistive of one staff for toileting and transfers. Review of a nursing note written by licensed nursing staff K dated 4/25/2015 revealed the resident was upset with a CNA (certified nurses aide) for care he/she received. The resident stated the CNA did not return promptly to assist him/her off the toilet and the CNA slammed the door on his/her way out of the room. Staff K notified social services and removed the CNA from the hall and told him/her not to care for resident #61 again. The resident reported increased anxiety, was upset and staff called the physician. The physician ordered [MEDICATION NAME] (medication to treat anxiety) 0.5 mg(milligrams) every 4 hours for as needed for anxiety. Review of the May 2015 MAR (medication administration record) revealed staff administered [MEDICATION NAME] 0.5 mg (milligram) on 4/25/15 for a meltdown and on 4/26/15 for tense right upper extremity. The MAR indicated [REDACTED]. During an interview on 5/20/2015 at 11:47 A.M. the resident reported approximately 3 weeks ago he/she was left on the toilet for approximately 20 minutes by direct care staff R. The resident was upset when direct care staff R did not return in a timely manner. He/she reported staff R told him/her to shut up and stated he/she would not longer take care of the resident anymore. The resident stated he/she reported the incident to licensed nursing staff K the day of the incident and to administrative nursing staff D 2-3 days following the incident stating that was the first time he/she could locate staff D. He/she reporting telling staff K and D he/she felt verbally abused and neglected by staff R. The resident reported he/she was told by staff K and staff D they would speak with staff R and staff R would no longer be assigned to his/her hall. The resident reported being left on the toilet for a prolonged time caused increased pain due to his/her [MEDICAL CONDITION] and balance problems and also caused increased anxiety and crying. Staff R was not assigned to him/her again, however staff R continued to work at the facility. During an interview on 05/20/2015 at 2:35 P.M. the resident reported social service staff HH and administrative nursing staff E came in and spoke with him/her after the incident and prior to the resident reporting the incident to administrative nursing staff D. During an interview on 05/20/2015 at 12:21 P.M. licensed nursing staff K confirmed the resident reported neglect and abuse by direct care staff R and the resident cried the day of the incident. Staff K could not recall the specific date, however reported he/she made a progress note in the chart and spoke with social service staff HH who spoke with administrative nursing staff E on the day of the incident. Staff K reported he/she was told by staff E to ensure direct care staff R was not assigned to care for the resident again. During an interview on 05/21/2015 at 7:54 A.M. administrative nursing staff E reported he/she was aware of an incident and complaints involving the resident and direct care staff R. Staff E reported he/she was only a witness at the request of social worker staff HH and completed no documentation regarding the incident. Staff E reported he/she spoke to administrative nursing staff D and was not asked to complete any documentation. During an interview on 05/21/2015 at 8:03 A.M. social service staff HH reported he/she never saw an official grievance form. Staff HH reported the staff member who learns of the incident first was responsible for completing a grievance. Staff HH recalled he/she and administrative staff E met with the resident and discussed the incident. Staff HH stated the resident was upset about being left on the toilet for too long and by the time social service staff HH left the resident was okay. Staff HH stated he/she believed the incident was a nursing issue and thought staff E would follow up. Staff HH stated the incident should have been handled differently and a grievance filed. Stated the staff probably got busy and forgot. During an interview on 05/21/2015 at 5:49 P.M. Administrative nursing staff D reported he/she did not inform administrative nursing staff A of the incident and he/she was unaware the resident required [MEDICATION NAME] after the incident occurred and therefore was also unaware the effectiveness of [MEDICATION NAME] was not followed up on. Staff D reported staff R had answered the resident's call light once to his/her knowledge and the resident got upset. Staff D reported he/she explained to the resident that at times the aide would have to respond to his/her call light when no one else was available to make sure he/she was ok. Staff D reported direct care staff R had no other resident complaints, was a good employee, and felt the incident was a personality conflict. During an interview on 05/21/2015 at 1:43 P.M. administrative nursing staff A reported he/she was not informed of the incident regarding the resident on 4/25/2015. Staff A stated he/she would have expected a grievance be completed and an investigation initiated. During an interview on 05/21/2015 at 3:28 P.M. direct care staff R reported he/she assisted the resident with toileting on 4/25/2015 after answering his/her light. Staff R stated he/she left the room to put the resident's clothes in the hamper and told the resident he/she would be right back. Staff R stopped to assist another resident and then returned to the resident's room. Staff R reported the resident was hysterically crying. Staff R reported the resident asked him/ her what happened. Staff R then reported he/she told the resident he/she was going to step out of the room and closed the door behind him/her. Staff R went to licensed nursing staff K and reported the incident. Staff K stated administrative nursing staff E approached him/her and requested he/she write a statement of the incident. Staff R stated he/she did not complete a statement because he/she did not have time. Staff R revealed he/she had an evaluation last week and he/she brought up the incident to administrative nursing staff D and told her not to worry about it as long as you know we know. Staff R reported immediately following the incident licensed staff K advised him/her to avoid the resident as much as possible. He/she would go into the resident's room to care for the resident's roommate, but there was no communication between the resident and staff R. Staff R reported he/she was primarily assigned a different hall and would float as necessary. During an interview on 05/22/2015 at 1:50 P.M. physician II reported he/she could not recall being notified of the resident's report of neglect or verbal abuse. Review of the facility's policy on Abuse, Neglect, and Exploitation dated 12/2006 revealed any suspected, observed, or reported violation of the resident safety policy would be reported to the supervisor and the Administrator without fear of reprisal, the supervisor on duty would immediately report any allegations to the administrator or designee and the Administrator or designee would be responsible to ensure all alleged violations involving mistreatment, neglect, or abuse were reported immediately to other officials in accordance with state laws including the State Survey and Certification Agency. The Administrator or designee would assess the resident and assure proper documentation, supervisor would protect the resident's welfare and safety from harm during the investigation, an incident report would be completed, physician and family would be notified,any employee suspected of violation may be suspended pending investigation. The facility failed to protect the residents from potential abuse when they failed to investigate an allegation of abuse from resident #61. This placed all facility residents in immediate jeopardy. Additionally, the facility failed to report this allegation to the state survey agency. The facility abated the immediate jeopardy on 5/27/15 after the facility suspended direct care staff R, updated the facility policy on reporting and investigating allegations of abuse. All staff inservice was completed on the new policy on 5/27/15. The deficiency remains at the scope and severity of a F. - The signed physician's orders [REDACTED].#94 had [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment), was independent with transfers, required limited assistance of 1 staff for toilet use, had one non-injury fall since the prior assessment. The Care Area Assessment for falls dated 4/1/15 revealed the resident had potential for falls and fall related injuries. He/she had poor safety awareness and poor balance, required staff to stand-by or assist with transfers, and had a non-injury fall on 2/16/15. A handwritten entry dated 4/30/15 noted the care plan revealed the resident had an un-witnessed fall non-injury, staff increased frequent checks for safety, and monitored for injury change in level of conscious. A hand written entry on 5/10/15 revealed the resident had an un-witnessed fall in his/her room. Staff to monitor for any change in the level of conscious, injury, pain, x-ray for possible fracture. The nurse's note dated 5/10/15 at 9:30 P.M. revealed staff found the resident on the floor. He/she complained of a sore back. The physician's orders [REDACTED]. The x-ray results dated 5/11/15 revealed the resident had acute, non-displace left eighth and ninth rib fractures. The fall investigation lacked documentation the facility reported this injury of unknown origin to the state agency. On 5/20/2015 at 7:23 A.M. the resident sat in a recliner in his/her room. The call light was with in reach, table with personal items close, alarm to the bed, and the floor was free of clutter. On 5/22/15 at 11:35 A.M. administrative staff D stated the facility reported to the state agency all resident falls with significant injury, fractures, or those requiring hospitalization . He/she was not aware the resident had a fracture from the fall on 5/10/15. The facility's Abuse, Neglect and Exploitation policy dated December 2006 revealed the supervisor on duty should immediately report any alleged violations to the administrator or designee. If the supervisor was unable they should immediately contact the administrator, the director of nursing service or the registered nurse on call. The administrator or designee was responsible to ensure that all alleged violations involving injuries of unknown source were reported immediately to other officials in accordance with state law including to the state survey and certification agency. The facility failed to report to the state survey and certification agency injury of unknown source for this cognitively impaired resident.

The facility reported a census of 97 residents with 24 residents in the sample. Based on observation, interview, and record review the facility failed to protect the residents in the facility from potential abuse when they failed to report and investigate alleged verbal abuse for 1 of 1 residents reviewed. (#61) Findings Included: - Review of resident #61 admission MDS (Minimum Data Set) dated 4/11/2015 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she experienced no signs/symptoms of [MEDICAL CONDITION], hallucinations, delusions, physical or verbal aggression, and did not reject cares. He/she required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. He/she experienced functional limitation in range of motion to one lower extremity and used a wheelchair for mobility. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 4/16/2015 revealed the resident required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal cares, and bathing. He/she had a left [MEDICAL CONDITION]. Review of resident #61's 30 day MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she experienced no signs/symptoms of [MEDICAL CONDITION], hallucinations, delusions, physical or verbal aggression, and did not reject cares. The resident required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. He/she experienced functional limitation in range of motion to one lower extremity and used a wheelchair for mobility. Review of resident #61's plan dated 4/4/2015 revealed the care plan directed staff to remind the resident to use assistive devices as recommended by therapy for transfers and ambulation,. He/she required extensive assistive of one staff for toileting and transfers. Review of a nursing note written by licensed nursing staff K dated 4/25/2015 revealed the resident was upset with a CNA (certified nurse ' s aide) for care he/she received. The resident stated the CNA did not return promptly to assist him/her off the toilet and the CNA slammed the door on his/her way out of the room. Staff K notified social services and removed the CNA from the hall and told him/her not to care for resident #61 again. The resident reported increased anxiety, was upset and staff called the physician. The physician ordered [MEDICATION NAME] (medication to treat anxiety) 0.5 mg(milligrams) every 4 hours for as needed for anxiety. Review of the May 2015 MAR (medication administration record) revealed staff administered [MEDICATION NAME] 0.5 mg (milligram) on 4/25/15 for a meltdown and on 4/26/15 for tense right upper extremity. The MAR indicated [REDACTED]. During an interview on 5/20/2015 at 11:47 A.M. the resident reported approximately 3 weeks ago he/she was left on the toilet for approximately 20 minutes by direct care staff R. The resident was upset when direct care staff R did not return in a timely manner. He/she reported staff R told him/her to shut up and stated he/she would no longer take care of the resident anymore. The resident stated he/she reported the incident to licensed nursing staff K the day of the incident and to administrative nursing staff D 2-3 days following the incident stating that was the first time he/she could locate staff D. He/she reporting telling staff K and D he/she felt verbally abused and neglected by staff R. The resident reported he/she was told by staff K and staff D they would speak with staff R and staff R would no longer be assigned to his/her hall. The resident reported being left on the toilet for a prolonged time caused increased pain due to his/her [MEDICAL CONDITION] and balance problems and also caused increased anxiety and crying. Staff R was not assigned to him/her again, however staff R continued to work at the facility. During an interview on 05/20/2015 at 2:35 P.M. the resident reported social service staff HH and administrative nursing staff E came in and spoke with him/her after the incident and prior to the resident reporting the incident to administrative nursing staff D. During an interview on 05/20/2015 at 12:21 P.M. licensed nursing staff K confirmed the resident reported neglect and abuse by direct care staff R and the resident cried the day of the incident. Staff K could not recall the specific date, however reported he/she made a progress note in the chart and spoke with social service staff HH who spoke with administrative nursing staff E on the day of the incident. Staff K reported he/she was told by staff E to ensure direct care staff R was not assigned to care for the resident again. During an interview on 05/21/2015 at 7:54 A.M. administrative nursing staff E reported he/she was aware of an incident and complaints involving the resident and direct care staff R. Staff E reported he/she was only a witness at the request of social worker staff HH and completed no documentation regarding the incident. Staff E reported he/she spoke to administrative nursing staff D and was not asked to complete any documentation. During an interview on 05/21/2015 at 8:03 A.M. social service staff HH reported he/she never saw an official grievance form. Staff HH reported the staff member who learns of the incident first was responsible for completing a grievance. Staff HH recalled he/she and administrative staff E met with the resident and discussed the incident. Staff HH stated the resident was upset about being left on the toilet for too long and by the time social service staff HH left the resident was okay. Staff HH stated he/she believed the incident was a nursing issue and thought staff E would follow up. Staff HH stated the incident should have been handled differently and a grievance filed. Stated the staff probably got busy and forgot. During an interview on 05/21/2015 at 1:43 P.M. administrative nursing staff A reported he/she was not informed of the incident regarding the resident on 4/25/2015. Staff A stated he/she would have expected a grievance be completed and an investigation initiated. During an interview on 05/21/2015 at 3:28 P.M. direct care staff R reported he/she assisted the resident with toileting on 4/25/2015 after answering his/her light. Staff R stated he/she left the room to put the resident's clothes in the hamper and told the resident he/she would be right back. Staff R stopped to assist another resident and then returned to the resident's room. Staff R reported the resident was hysterically crying. Staff R reported the resident asked her/him what happened. Staff R then reported he/she told the resident he/she was going to step out of the room and closed the door behind him/her. Staff R went to licensed nursing staff K and reported the incident. Staff K stated administrative nursing staff E approached him/her and requested he/she write a statement of the incident. Staff R stated he/she did not complete a statement because he/she did not have time. Staff R revealed he/she had an evaluation last week and he/she brought up the incident to administrative nursing staff D and told her not to worry about it as long as you know we know. Staff R reported immediately following the incident licensed staff K advised him/her to avoid the resident as much as possible. He/she would go into the resident's room to care for the resident's roommate, but there was no communication between the resident and staff R. Staff R reported he/she was primarily assigned a different hall and would float as necessary. During an interview on 05/21/2015 at 5:49 P.M. Administrative nursing staff D reported he/she did not inform administrative nursing staff A of the incident and he/she was unaware the resident required [MEDICATION NAME] after the incident occurred and therefore was also unaware the effectiveness of [MEDICATION NAME] was not followed up on. Staff D reported staff R had answered the resident's call light once to his/her knowledge and the resident got upset. Staff D reported he/she explained to the resident that at times the aide would have to respond to his/her call light when no one else was available to make sure he/she was ok. Staff D reported direct care staff R had no other resident complaints, was a good employee, and felt the incident was a personality conflict. During an interview on 05/22/2015 at 1:50 P.M. physician II reported he/she could not recall being notified of the resident's report of neglect or verbal abuse. Review of the facility's policy on Abuse, Neglect, and Exploitation dated 12/2006 revealed the supervisor would do everything possible to protect the resident's welfare and safety from harm during the investigation and any employee suspected of violations may be suspended pending investigation. The facility failed to protect resident #61 from abuse .

The facility reported a census of 97 residents with 24 residents in the sample. Based on observation, interview, and record review the facility failed to protect the residents from potential abuse when they failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 1 reviewed for abuse allegation. (#61) Findings Included: - Review of resident #61 admission MDS (Minimum Data Set) dated 4/11/2015 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she experienced no signs/symptoms of delirium, hallucinations, delusions, physical or verbal aggression, and did not reject cares. He/she required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. He/she experienced functional limitation in range of motion to one lower extremity and used a wheelchair for mobility. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 4/16/2015 revealed the resident required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal cares, and bathing. He/she had a left below the knee amputation. Review of resident #61's 30 day MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she experienced no signs/symptoms of delirium, hallucinations, delusions, physical or verbal aggression, and did not reject cares. The resident required extensive one staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. He/she experienced functional limitation in range of motion to one lower extremity and used a wheelchair for mobility. Review of resident #61's plan dated 4/4/2015 revealed the care plan directed staff to remind the resident to use assistive devices as recommended by therapy for transfers and ambulation,. He/she required extensive assistive of one staff for toileting and transfers. Review of a nursing note written by licensed nursing staff K dated 4/25/2015 revealed the resident was upset with a CNA (certified nurses aide) for care he/she received. The resident stated the CNA did not return promptly to assist him/her off the toilet and the CNA slammed the door on his/her way out of the room. Staff K notified social services and removed the CNA from the hall and told him/her not to care for resident #61 again. The resident reported increased anxiety, was upset and staff called the physician. The physician ordered Ativan (medication to treat anxiety) 0.5 mg(milligrams) every 4 hours for as needed for anxiety. Review of the May 2015 MAR (medication administration record) revealed staff administered Ativan 0.5 mg (milligram) on 4/25/15 for a meltdown and on 4/26/15 for tense right upper extremity. The MAR lacked documentation of effectiveness for Ativan administered on 4/25/15 and staff documented the medication as effective on 4/26/2015. During an interview on 5/20/2015 at 11:47 A.M. the resident reported approximately 3 weeks ago he/she was left on the toilet for approximately 20 minutes by direct care staff R. The resident was upset when direct care staff R did not return in a timely manner. He/she reported staff R told him/her to shut up and stated he/she would not longer take care of the resident anymore. The resident stated he/she reported the incident to licensed nursing staff K the day of the incident and to administrative nursing staff D 2-3 days following the incident stating that was the first time he/she could locate staff D. He/she reporting telling staff K and D he/she felt verbally abused and neglected by staff R. The resident reported he/she was told by staff K and staff D they would speak with staff R and staff R would no longer be assigned to his/her hall. The resident reported being left on the toilet for a prolonged time caused increased pain due to his/her below the knee amputation and balance problems and also caused increased anxiety and crying. Staff R was not assigned to him/her again, however staff R continued to work at the facility. During an interview on 05/20/2015 at 2:35 P.M. the resident reported social service staff HH and administrative nursing staff E came in and spoke with him/her after the incident and prior to the resident reporting the incident to administrative nursing staff D. During an interview on 05/20/2015 at 12:21 P.M. licensed nursing staff K confirmed the resident reported neglect and abuse by direct care staff R and the resident cried the day of the incident. Staff K could not recall the specific date, however reported he/she made a progress note in the chart and spoke with social service staff HH who spoke with administrative nursing staff E on the day of the incident. Staff K reported staff E told him/her to ensure direct care staff R was not assigned to care for the resident again. During an interview on 05/21/2015 at 7:54 A.M. administrative nursing staff E reported he/she was aware of an incident and complaints involving the resident and direct care staff R. Staff E reported he/she was only a witness at the request of social worker staff HH and completed no documentation regarding the incident. Staff E reported he/she spoke to administrative nursing staff D and was not asked to complete any documentation. During an interview on 05/21/2015 at 8:03 A.M. social service staff HH reported he/she never saw an official grievance form. Staff HH reported the staff member who learned of the incident first was responsible for completing a grievance. Staff HH recalled he/she and administrative staff E met with the resident and discussed the incident. Staff HH stated the resident was upset about being left on the toilet for too long and by the time social service staff HH left the resident was okay. Staff HH stated he/she believed the incident was a nursing issue and thought staff E would follow up. Staff HH stated the incident should have been handled differently and a grievance filed. Stated the staff probably got busy and forgot. During an interview on 05/21/2015 at 5:49 P.M. Administrative nursing staff D reported he/she did not inform administrative nursing staff A of the incident and he/she was unaware the resident required Ativan after the incident occurred and therefore was also unaware the effectiveness of Ativan was not followed up on. Staff D reported staff R answered the resident's call light once to his/her knowledge and the resident got upset. Staff D reported he/she explained to the resident that at times the aide would need to respond to his/her call light when no one else was available to make sure he/she was ok. Staff D reported direct care staff R had no other resident complaints, was a good employee, and felt the incident was a personality conflict. During an interview on 05/21/2015 at 1:43 P.M. administrative nursing staff A reported he/she was not informed of the incident regarding the resident on 4/25/2015. Staff A stated he/she would expect staff to complete a grievance and an initial investigation. During an interview on 05/21/2015 at 3:28 P.M. direct care staff R reported he/she assisted the resident with toileting on 4/25/2015 after answering his/her light. Staff R stated he/she left the room to put the resident's clothes in the hamper and told the resident he/she would come right back. Staff R stopped to assist another resident and then returned to the resident's room. Staff R reported the resident was crying hysterically . Staff R reported the resident asked him/her what happened. Staff R then reported he/she told the resident he/she was going to step out of the room and closed the door behind him/her. Staff R went to licensed nursing staff K and reported the incident. Staff K stated administrative nursing staff E approached him/her and requested he/she write a statement of the incident. Staff R stated he/she did not complete a statement because he/she did not have time. Staff R revealed he/she had an evaluation last week and he/she brought up the incident to administrative nursing staff D and told her not to worry about it as long as you know we know. Staff R reported immediately following the incident licensed staff K advised him/her to avoid the resident as much as possible. He/she would go into the resident's room to care for the resident's roommate, but there was no communication between the resident and staff R. Staff R reported he/she was primarily assigned a different hall and would float as necessary. During an interview on 05/22/2015 at 1:50 P.M. physician II reported he/she could not recall the facility notifying him/her of the resident's report of neglect or verbal abuse. Review of the facility's policy on Abuse, Neglect, and Exploitation dated 12/2006 revealed any suspected, observed, or reported violation of the resident safety policy would be reported to the supervisor and the Administrator without fear of reprisal, the supervisor on duty would immediately report any allegations to the administrator or designee and the Administrator or designee would be responsible to ensure all alleged violations involving mistreatment, neglect, or abuse were reported immediately to other officials in accordance with state laws including the State Survey and Certification Agency. The Administrator or designee would assess the resident and assure proper documentation, supervisor would protect the resident's welfare and safety from harm during the investigation, an incident report would be completed, physician and family would be notified,any employee suspected of violation may be suspended pending investigation. The facility failed to address the abuse and meet psychosocial needs for this resident who suffered verbal abuse.

The facility identified a census of 97 residents. The sample included 24 residents. Based on observation, interview and record review the facility failed to complete a root cause analysis of the resident's falls and failed to develop and implement timely interventions to prevent future falls for 1 of 4 residents (#94) reviewed for falls who fell and sustained a laceration to the back of the head which required emergency room treatment and staples and rib fractures. Findings included: - The signed physician's orders [REDACTED].#94 had [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment), was independent with transfers, required limited assistance of 1 staff for toilet use, had one non-injury fall since the prior assessment. The Care Area Assessment for falls dated 4/1/15 revealed the resident had potential for falls and fall related injuries. He/she had poor safety awareness and poor balance, required staff to stand-by or assist with transfers, and had a non-injury fall on 2/16/15. The care plan reviewed 2/21/15 revealed staff reminded this cognitively impaired resident to wear proper footwear while ambulating, especially when ambulating to the toilet at night, and to ask for assistance. Staff increased frequent checks for safety, cued the resident to use the call light, and anticipated the resident ' s needs. A handwritten entry on 4/30/15 the care plan revealed the resident had an un-witnessed fall non-injury. Staff increased frequent checks for safety, and monitored for injury and a change in level of consciousness. A hand written entry on 5/10/15 revealed the resident had an un-witnessed fall in his/her room. Staff was to monitor for change in level of consciousness, injury, pain, and x-ray for possible fracture. The fall assessments dated: 11/8/13, 4/8/14, 4/10/14, 11/28/14, and 3/15/15 revealed the resident was at a high risk for falls. The nurse's note dated 4/8/14 2:30 p.m. revealed staff found the resident on the floor. The post fall assessment dated [DATE] revealed the resident had a non-injury fall in his/her room. The interventions taken immediately included range of motion of extremities assessment, and staff assisted the resident to the chair. It lacked root cause analysis of the fall and lacked appropriate interventions to prevent further falls. The nurse's note dated 4/18/14 at 7:45 A.M. revealed staff found the resident in bed with wet blood on the pillow originated from a laceration to the back of his/her head. A pool of blood was found on the floor by the resident ' s television stand. The resident was aroused but could not recall the time or location of the fall. At approximately 8:05 A.M. the resident ' s family took the resident to the emergency room . At 11:45 A.M. the resident returned with 5 staples closing the laceration on the back of his/her head. The fall meeting note dated 4/24/14 lacked root cause analysis of the fall and lacked appropriate interventions. The nurse's note dated 11/28/14 revealed staff found the resident on the floor in front of the resident's room at 12:40 A.M. The Post Fall assessment dated [DATE] revealed the resident had an un-witnessed injury fall. The resident received a 4 inch bruise to the right arm with a small abrasion. The resident could not recall how it happened. Intervention included reminding the resident to use his/her call light, and remind staff to do frequent checks on the resident. It lacked root cause analysis for the fall and lacked appropriate interventions. The post fall assessment dated [DATE] revealed the resident stated he/she had a fall out of the chair. It lacked root cause for the fall and lacked appropriate interventions. The nurse's note dated 4/30/15 at 4:50 A.M. revealed staff found the resident on the floor by the bathroom. The Post-fall assessment dated [DATE] lacked root cause analysis of the fall and lacked appropriate interventions. The nurse's note 5/10/15 at 9:30 P.M. revealed staff found the resident on the floor. He/she complained of a sore back. The physician order [REDACTED]. The nurse ' s note dated 5/10/15 at 11:40 P.M. indicated an x-ray to the left lower back due to the fall. The Bio Tech x-ray report dated 5/11/15 stated the resident had an acute, non-displaced left eighth and ninth rib fractures present. The fall investigation lacked root cause analysis of the fall and lacked appropriate interventions. On 5/20/2015 at 7:23 A.M. the resident sat in a recliner in his/her room. He/she had on shoes with soles, the call light was reachable, table with personal items close, bed had alarm on it, and the floor was free of clutter. On 5/20/2015 at 11:34 A.M. the resident took small steps to transfer him/her from the chair to the bed. On 5/21/15 at 4:39 P.M. direct care staff Q stated the resident was independent with ambulation and used a walker. Staff made sure the resident had shoes on when out of bed; no other fall interventions were in place because the resident was independent. On 5/21/15 at 4:45 P.M. licensed staff J stated the resident was independent with ambulation. Staff provided the cognitively impaired resident education on call light use. On 5/22/15 at 11:35 A.M. administrative staff D, stated he/she was not aware the resident had a fracture from the fall on 5/10/15. The staff updated the resident's care plan. The intervention was for the staff to remind this cognitively impaired resident to use the call light and was not an appropriate intervention. The facility's Fall Risk/Prevention Program dated June 2007 revealed the facility identified residents a risk for falls and implemented fall prevention to ensure appropriate and prompt follow up of resident falls. The facility failed to develop and implement appropriate and effective interventions to prevent falls for this cognitively impaired resident with a history of falls, who fell and sustained a laceration requiring staples to the head, and rib fractures.

The facility identified a census of 102 residents. The sample included 16 residents. Based on observation, interview, and record review the facility failed to develop and implement interventions to prevent the development of pressure ulcers for 3 of 3 residents reviewed for pressure ulcers. (#99, #137, #60) Findings included: - Resident #99's quarterly Minimum Data Set 3.0 Assessment ((MDS) dated [DATE], documented the resident's Brief Interview for Mental Status score (BIMS) was 15, which indicated the resident was cognitively intact. The resident required extensive assistance of staff with activities of daily living (ADLs) for bed mobility, transfers, dressing, and toilet use. The resident required limited assistance of staff with personal hygiene and was incontinent of bowel and bladder. The Pressure Ulcer Care Area Assessment (CAA) dated 8-12-13 documented the resident was at risk for pressure ulcers related to his/her poor sensory, moisture, and poor nutrition. The resident did not have any skin concerns at this time. the 10-17-13 Admission Nurses' Assessment documented the resident's skin was intact. The 10-24-13 care plan identified the resident at risk for the development of pressure ulcers and not able to reposition his/herself while in bed. The care plan directed staff to place the resident's feet in heel lift boots while in bed related to a necrotic (pertaining to the death of tissue in response to disease or injury) right heel, and apply skin prep (a liquid film forming dressing applied to skin to form a protective film). The care plan also included the following: Avoiding shearing with positioning. Provide a skin inspection twice weekly Encourage fluid intake. Provide the resident's diet as ordered by the physician. Prevent the resident's bony prominence's from direct contact with one another. Keep the resident off any area where the skin was compromised. Lotion the skin. Provide incontinence care after each incontinence episode. On 10-29-14 the facility added the following interventions: Application of a foot buddy (a device placed on the foot pedals of the wheelchair that prevented the feet from falling under the pedals). Turn and reposition the resident every 2 hours. Apply a moisture barrier product to the perineal area. Provide a pressure reducing cushion when in the chair. On 1-14-14 the care plan documented the resident with a wound on his/her coccyx (the bony area at the bottom of the spine) and referred to the Treatment Administration Record (TAR). On 1-21-14 the care plan documented a new intervention that directed staff to provide a multi vitamin, vitamin C, Juven (a nutritional supplement used for wound healing), and Prostat (a protein supplement used for wound healing) to the resident's treatment plan. On 1-28-14 the care plan documented a new intervention that directed staff to stand the resident up and shift his/her weight every one and a half hours while he/she was in the recliner and referred the resident to the wound nurse. The 10-17-13 admission nurses assessment documented the resident's skin intact. The 10-16-13 Braden Assessment (assessment tool used to determine a resident's risk for the development of a pressure ulcer) documented the resident's score of 18, which indicated the resident was at low risk for the development of a pressure ulcer. The 1-7-14 Braden Assessment documented the resident's score of 19, which indicated the resident was at low risk for the development of a pressure ulcer. Record review of the bi-weekly skin assessment on 12-27-13 documented the resident had redness on his/her coccyx area and referred to the wound book. The 12-29-13 skin assessment documented an area on the coccyx and referred to the wound book. Record review of the nurses' notes from 12-26-13 through 1-13-14 lacked documentation of any reference to the resident's red coccyx area. On 1-14-14 at 2:00 P.M. the nurse's note documented the resident with an open area on his/her coccyx that measured 1.7 centimeters (cm) length (L) X (by) 0.7 cm width (W) and 0 depth (D). Staff received an order from the physician to apply [MEDICATION NAME] foam (a wound healing dressing) to the wound and change the dressing every seven days or as needed (PRN). On 1-28-14 at 3:00 P.M. the nurse's note documented staff received an order from the physician to consult the wound nurse regarding the coccyx wound, turn and reposition the resident every 2 hours while in bed, stand and shift the resident every one and a half hours while in the reclining chair, discontinue the [MEDICATION NAME] treatment and cleanse the wound with wound cleanser, apply [MEDICATION NAME] (a [MEDICATION NAME] agent) to the wound bed, cover with [MEDICATION NAME] and change the dressing daily and PRN until healed. The 1-14-13 Wound Treatment Assessment documented the resident with a stage 3 pressure ulcer and measured 1.7 cm L X 0.7 cm W X 0 depth. The assessment documented the wound bed had 100 percent (%) tissue granulation (healing tissue) and the resident acquired the pressure ulcer on 1-14-14. The 1-22-14 Wound Treatment Assessment documented the pressure ulcer measured 1.8 cm L X 0.7 cm W X 0 D and 90% granulation and the wound was unchanged. observation on 1-28-14 at 12:56 P.M. revealed the resident's bathroom call light was on and staff responded to the call light. Observation on 1-28-14 at 1:10 P.M. revealed the resident sat in his/her recliner in an upright position with his/her feet on the floor and watched TV. At 1:39 P.M. licensed nurse L entered the resident's room and came back out. At 1:48 P.M. licensed nurse L entered the resident's room and closed the door. He/she came out of the resident's room at 1:53 P.M. and informed this writer he/she was going to change the resident's dressing. Observation on 1-28-14 at 2:17 P.M. licensed nurse L and direct care staff R entered the resident's room and explained to the resident his/her dressing needed changed. The resident sat in his/her recliner in an upright position with his/her feet on the floor. Direct care staff R placed a gait belt on the resident and assisted him/her to a standing position while licensed nurse L pulled the resident's pants and brief down and removed a dressing on the resident's upper coccyx area. The resident had an open area on his/her coccyx approximately 1.5 cm X 1 cm and the wound bed was covered with yellow slough (stringy dead tissue attached to the wound bed) and was unstageable. The resident's recliner did not have any type of pressure reducing cushion in the seat. Licensed nurse L cleansed the pressure ulcer with normal saline and applied an [MEDICATION NAME] dressing to the wound. Both staff pulled the resident's brief and pants up and assisted the resident back into the recliner. Observation on 1-29-14 at 6:54 A.M. revealed the resident laying on top of his/her fully made bed and was fully dressed. The resident did not have shoes on and his/her feet lay directly on the mattress and the resident was hollering out if someone could find out what time it was. Observation on 1-29-14 at 8:12 A.M. revealed the resident in his/her wheelchair in the hall. Licensed nurse J directed the resident to go to his/her room and he/she would be in the room shortly. The resident propelled him/herself with his/her feet to his/her room. On 1-28-14 at 7:55 A.M. during an interview with the resident, he/she stated he/she used a brief because staff did not get to him/her in time to use the bathroom. He/she stated he/she used his/her call light for cares and had a sore on his/her bottom. On 1-28-14 at 3:33 P.M. direct care staff R stated the resident was able to state his/her needs, used the call light for his/her needs. Direct care staff R stated staff placed the resident in his/her wheelchair after getting him/her up in the mornings and the resident was able to take him/herself to the bathroom and put the call light on when finished. He/she stated the resident was not able to transfer to the recliner independently and called staff when he/she wanted to sit in the recliner. On 1-28-14 at 4:27 P.M. direct care staff S stated the resident was able to tell staff if he/she was incontinent or if he/she was going to have a bowel movement. On 1-28-14 at 1:35 P.M. licensed nurse L stated the pressure ulcer started out as a very small area then opened up and was discovered on 1-14-14. On 1-29-14 at 8:50 A.M. licensed nurse J was not aware of any pressure ulcers on the resident's heels after he/she returned to the facility in October of last year. He/she stated today was the first day he/she was aware of a treatment for [REDACTED]. On 1-29-14 at 12:04 P.M. administrative licensed nurse E stated after review of the resident's record he/she did not have a necrotic heel and was an error of the nurse that recorded it. The 10/2009 facility provided Pressure Ulcer Policy and Procedure documented the facility identified residents at risk for the development of pressure ulcers and promoted an environment to promote the prevention of pressure ulcers. The facility failed to prevent the development of a stage 3 to unstageable pressure ulcer for this resident at risk and failed to implement timely interventions after staff identified redness on the resident's coccyx that developed into an unstageable pressure ulcer. - Resident #137's admission Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status score (BIMS) was 15, which indicated the resident was cognitively intact. The resident required extensive assistance of staff with activities of daily living (ADLs) for bed mobility transfers, locomotion and toilet use. The resident had occasional incontinence of his/her bladder and was continent of bowel. The resident was at risk for the development of pressure ulcers, did not have pressure ulcers upon admission and had venous and arterial ulcers present upon admission to the facility. The Pressure Ulcer Care Area Assessment (CAA) dated 9-9-13 documented the resident had [MEDICAL CONDITION] (skin infection caused by bacteria that is characterized by heat, redness and swelling) and an ulcer on his/her left second toe. The resident admitted to the facility from an acute care facility for treatment of [REDACTED]. Closed record review of the 8-27-13 care plan directed staff to reposition the resident every 2 hours, provide a pressure reducing device on the resident's bed and in his/her wheelchair, monitor his/her nutrition and hydration and float the resident's heels. second toe and left lateral leg. The care plan documented the resident had a wound on his/her The 8-27-13 wound care plan directed staff to initiate additional preventive measures to prevent further breakdown, assess the resident weekly, consult the dietician and/wound nurse if indicated and had wounds on his/her left lower extremity and toes. On 9-6-13 the care plan documented a new intervention to provide the resident with vitamin C, Prostat (a protein supplement to promote wound healing), and a multi vitamin for wound healing. The care plan documented the resident had a blister on his/her left heel and direct staff to lay the resident down for an hour after lunch daily. On 9-11-13 an new intervention directed staff to transfer the resident to and from his/her bed/wheelchair with a transfer lift. On 9-14-13 the care plan documented the resident had a left buttock wound. On 9-17-13 the care plan documented a new intervention that directed staff to provide the resident with a low air loss mattress. The 8-27-13 Braden Assessment (assessment tool used to determine a resident's risk for the development of a pressure ulcer) documented the resident's score of 20, which indicated the resident was at low risk for the development of a pressure ulcer. The Braden assessment documented the resident was slightly limited with mobility, had adequate nutrition and did not have a problem with friction or shearing of skin while in bed. The 8-27-13 Incontinence Assessment documented the resident had an impairment of his/her sensory perception, had mobility impairment and was not physically able to get to the bathroom in time. The 9-4-13 Wound Assessment sheet documented the resident admitted with a wound on his/her 2nd toe, and left calf area. On 9-14-13 the Wound Assessment sheet documented the resident had 2 wounds on his/her left buttock and the first one measured 1.0 centimeters (cm) length (L) by (X) 2.0 cm width (W) and 0 depth (D). The second wound measured 2.0 cm L X 2.0 cm W X 0 cm D. On 9-25-13 the Wound Assessment sheet documented the left buttock wounds were stage 2 and the first wound measured 1.5 cm L X 1.0 cm W X 0 D. The second measured 2.0 cm L X 0.5 cm W X 0 D. On 10-4-13 the Wound Assessment sheet documented the first stage 2 left buttock wound measured 1.5 cm L X 1.0 cm W X 0 D and the second wound measured 1.9 cm L X 0.5 cm W X 0 cm D. On 9-14-13 at 7:40 A.M. the nurse's note documented the resident had bleeding from his/her buttock and staff found 2 wounds on the resident's left buttock. The first wound measured 1.0 cm X 2.0 cm X 0 cm D and the second wound measured 2.0 cm L X 2.0 cm W X 0 cm D and were previous pressure sores that re-opened. On 1-29-14 at 8:50 A.M. licensed nurse J stated the resident admitted to the facility with multiple pressure ulcers that became gangrenous (death of tissue). He/she stated the resident had one toe that was completely necrotic and staff did not want to go into the resident's room because the smell was very overwhelming. He/she stated the resident was very weak, often tired and did not do very well with rehabilitation. He/she stated the resident had [MEDICAL CONDITION] and had fluid filled blisters on his/her lower legs. On 1-29-14 at 2:55 P.M. administrative nurse D stated the resident admitted to the facility and had a general decline, discharged to the hospital from the facility then went to a hospice house. He/she stated the resident developed pressure ulcers on his/her buttock because he/she did not want to get out of bed and did not like being bothered. He/she stated they had a low air loss mattress in place and staff repositioned the resident. The 10/2009 facility provided Pressure Ulcer Policy and Procedure documented the facility identified residents at risk for the development of pressure ulcers and promoted an environment to promote the prevention of pressure ulcers. The facility failed to prevent the development of two stage two pressure ulcers for this resident who entered the facility with wounds and was identified at risk for the development of pressure ulcers. - Resident #60's (a closed record review) identified the August 2013 physician's orders [REDACTED]. The 9/16/13 30 day Minimum Data Set 3.0 (MDS) assessment recorded the resident with a Brief Interview for Mental Status score of 13 which indicated the resident's cognition was intact. The MDS recorded the resident required extensive assistance of two staff with most activities of daily living (ADLs), was incontinent of bowel and bladder, ambulatory in a wheelchair with staff assist, weighed 265 pounds, and did not have pressure sores. This same MDS revealed the care area for pressure sores triggered for review and care plan consideration. The clinical record lacked documentation of the Care Area Assessment. Review of the Braden Scale (a numerical scale used to determine pressure sore potential) dated 11/19/13 revealed a score of 15 which placed the resident at a moderate risk for developing pressure sores. The 9/17/13 pressure sore care plan directed staff to avoid sheering the resident's skin, conduct a skin inspection twice weekly, perform incontinence care as needed, encourage fluids and nutrition, maintain his/her bed at the lowest possible elevation, turn and reposition and encourage the resident to make adjustments, use a lift device, moisture barrier products, and pillows as therapy recommended. This same care plan recorded the resident was full weight bearing. Review of the POS [REDACTED]'s groin area and buttocks daily. The POS recorded an order dated 8/29/13 to discontinue the [MEDICATION NAME] cream and begin the use of 3 in 1 cream (a moisture barrier cream). The weekly wound sheet dated 10/31/13 recorded the appearance and measured 3 centimeters (cm) by (x) 0.5 cm of an unstageable right buttock wound acquired on 10/28/13. Continued review of the clinical record revealed the following physicians orders: 10/30/13 - use draw sheet only when moving resident in bed, 10/30/13 - add zinc, vitamin C, air mattress, obtain air pull to assist with repositioning, apply ointment to scrotum and perineal area three times a day, and insert a Foley catheter as needed, 10/30/13 - clean left buttock with normal saline or wound cleanser, pat dry, and use skin prep, apply extra thin duoderm dressing to right buttock and change every three days. The nurses progress notes dated 10/28/13 lacked reference to any wound on the resident's buttocks. Review of the nurse's progress notes dated 11/1/13 revealed the resident vomited while in bed, had a temperature of 100.3 degrees Fahrenheit, had difficulty breathing and was transferred to an area hospital. The 11/1/13 hospital admission consult report documented the physician's assessment of [MEDICAL CONDITION] syndrome (a complex systemic [MEDICAL CONDITION] condition associated with infection) due to pneumonia - facility acquired pneumonia, aspiration pneumonia, urinary tract infection and present on admission a decubitus ulcer, stage 3 and staff to continue with wound care management. On 1/29/14 at 1:00 P.M. interview with administrative licensed nurse E remembered the resident was at an assisted living facility and came here for rehabilitation but was not able to go back due to the resident required maximum assist with his/her ADLs and then he/she got ill, was hospitalized , returned, and was on hospice care. He/she did have a pressure sore. The 10/2009 facility Wound Care Protocol policy recorded: "To prevent ulcers and/or prevent deterioration of existing pressure ulcers," and "documentation of the initial and weekly assessment findings should be noted on the Weekly Wound Assessment form". The facility failed to prevent the development of a stage 3 pressure sore for this dependent resident.

The facility identified a census of 102 residents. The sample included 16 residents. Based on observation, interview, and record review the facility failed to develop and implement interventions to prevent and monitor weight loss, resulting in significant weight loss for 1 (#57) of 3 residents reviewed for nutrition. Findings included: - The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] for resident #57 revealed a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. The resident required extensive assistance from 2 staff members for transfer, toilet use, and bathing. The resident received a therapeutic diet and had a weight loss without physician prescribed weight loss program. The 4/12/13 Care Area Assessment for nutrition revealed the resident was obese and had several food dislikes which put him/her at risk for poor nutrition. The 4/1/13 care plan regarding nutrition, with a revision date of 8/30/13, revealed the resident exceeded his/her ideal body weight limits. Staff transported the resident to and from the independent dining room on the upper level of the facility. Staff followed recommendations made by the registered dietitian, who reviewed the resident quarterly and as needed. Staff honored the resident's food preferences and provided alternatives for foods refused. The resident liked corn flakes but disliked clam chowder and fish and used light plastic cups at all meals. The 9/26/13 care plan regarding Activities of Daily Living (ADLs) revealed the resident ate meals in the independent dining room on the upper level of the facility and required transportation to and from meals from staff. Staff monitored the resident for any decline in ADL performance and intervened. The clinical record revealed the following weights: 5/1/13 = 187 pounds (#) 6/2/13 = 186 # 7/1/13 = 181 # 8/1/13 = 178 # 9/1/13 = 174 # 10/1/13 = 170 # 11/1/13 = 156 # 11/19/13 = 149 # Consisting of a 38 pound or 20.32 percent (%) weight loss in 6 months. The untimed nurse's note dated 8/7/13 revealed the resident continued to have confusion and paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), accusing staff of not helping him/her, refusing medications, and stated staff was trying to drug him/her to make him/her tired. The nurse's note dated 8/8/13 at 3:20 P.M. revealed a new order for [MEDICATION NAME] (a medication used for the treatment of [REDACTED]. The nurse's note dated 8/9/13 at 9:00 P.M. revealed the resident was noncompliant with going to the independent dining room. Staff offered him/her a room tray. The nurse's note dated 8/18/13 at 9:00 P.M. revealed the dietary staff in the independent dining room reported to the certified nursing assistant (CNA) the resident was not eating. Staff notified social services and the dietitian had the resident eat in the assisted dining room for close monitoring. The dietary note dated 9/17/13 revealed the resident had an 11 pound weight loss since admission. It was also noted the resident went through a period of time where he/she felt staff poisoned his/her food but then began eating better after the physician adjusted his/her medications. The dietitian recommended to liberalize the resident's diet. The dietary note dated 11/19/13 revealed the resident had a weight loss of 21 pounds or 12.3%. Staff moved the resident to the assisted dining room on the lower level of the facility for closer supervision with meals and placed the resident on weekly weights. The charge nurse also reported to the dietitian that the resident occasionally required assistance with feeding. The Treatment Administration Record (TAR) for 10/2013 and 11/2013 lacked evidence of meal percentage intake monitoring. Observation on 1/28/14 at 8:47 A.M. revealed the resident sat in a wheelchair at a table in the assisted dining room on the lower level of the facility and ate breakfast. Staff served the resident scrambled eggs (ate 75%), raisin toast (ate 100%), 2 sausage links (ate 100%), orange juice (drank 100%), and water (drank 100%). The resident fed him/herself without difficulty. Observation on 1/28/14 at 5:55 P.M. revealed the resident sat in a wheelchair at a table in the assisted dining room on the lower level of the facility and ate dinner. Staff served the resident 1 piece of fried fish, documented on the care plan that he/she did not like, (ate 10%), steamed broccoli (ate 50%), a baked potato (ate 50%), 1 piece of cherry pie (ate 90%), water (100%), coffee (drank 100%). The resident fed him/herself without difficulty. Interview on 1/28/14 at 2:06 P.M. with consultant dietitian EE revealed if a resident had weight loss, staff EE discussed it with nursing to rule out a fluid issue or if the resident was trying to lose weight. If not then staff would liberalize the resident's diet and monitor weekly weights. If the weight loss was desired then staff EE would discuss healthy options with the resident. Staff reviewed any weight changes and discussed them in the weight meetings on Tuesday mornings. Staff EE also reviewed meal percentage intake monitoring as needed. Staff EE reported it was identified in the past the weight monitoring was not accurate so the facility changed their method and had a designated restorative aid do all weekly weights to keep them consistent. Staff EE reported in September 2013 this resident's diet was changed from a no added salt diet to a regular diet, to liberalize it due to his/her weight loss. He/she also stated the resident went through a period of confusion, thinking the staff was poisoning his/her food and therefore would not eat well. The resident's physician adjusted his/her medication with good results. In November 2013 the facility placed the resident weekly weights and moved him/her to the assisted dining room for closer monitoring. Staff EE considered initiating a supplement if the weight loss continued but the resident's weight had somewhat stabilized. Interview on 1/29/14 at 10:25 A.M. with direct care staff NN revealed the resident changed from the independent dining to the lower level assisted dining room approximately 2 to 3 months ago. He/she stated staff monitored and documented meal percentage intake for all residents in the assisted dining rooms and acknowledged this resident's documentation for meals was inconsistent. Staff NN also reported at times the resident had tremors and required assistance from staff during meals. Interview on 1/29/14 at 11:14 A.M. with licensed nursing staff I revealed staff moved the resident from the independent dining room to the assisted dining room due to tremors and weight loss. At times the resident's tremors made it difficult for him/her to feed him/herself so staff assisted. Interview on 1/29/14 at 3:04 P.M. with direct care staff Q revealed the resident reported to him/her he/she was trying to lose weight. Staff Q expected this information to be included on the care plan. Staff Q stated staff monitored and documented meal percentage intake for all residents that ate meals in the assisted dining rooms of the facility. Interview on 1/29/14 at 3:15 P.M. with licensed nursing staff K revealed the resident required supervision with meals and was changed from the independent dining room to the assisted dining room approximately 2 months prior. He/she also reported staff documented meal percentage intake for all residents in assisted dining rooms and acknowledged there was inconsistency with documentation for this resident. Staff K also stated the resident told him/her that he/she desired to lose weight when he/she was admitted to the facility. Staff K did not think this desire was ever noted in the record and was unsure if it was included on the care plan. Interview on 1/29/14 at 3:55 P.M. with administrative nursing staff D revealed he/she expected the care plan to reflect the resident's change in dining rooms and the resident's desire to lose weight. Staff D acknowledged the resident's care plan lacked these changes in his/her nutritional status and care needs. Staff D also reported staff monitored and documented the meal percentage intake for all residents that ate meals in the assisted dining rooms. The 12/2009 policy provided by the facility regarding weight monitoring failed to address maintenance of nutritional status for residents at risk for weight loss. The facility failed to assess and provide timely interventions for the prevention of a significant weight loss for this resident.