Every finding on record at Diversicare of Council Grove

Based on interviews, observation, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high-contact care) while providing direct care to a Resident (R) 5 with open wounds to her left heel and left gluteal (buttock) fold. Additionally, the facility failed to ensure adequate hand hygiene during a wound measurement for R1. The facility failed to properly transport clean linen and personal linens in a sanitary manner to prevent cross contamination.Findings included:1. On 07/06/2026 at 09:45 AM, Certified Nurse Aide (CNA) M was observed to have several uncovered washcloths and towels held up against her uniform that she carried in the 100 hallways.On 07/07/2026 at 08:58 AM, CNA M reported that she should have covered the pile of washcloths and towels she carried down the hallways and not have them up against her uniform. 2. On 07/06/2026 at 12:00 PM, Laundry Staff W delivered personal linens with a covered cart. As Laundry Staff W removed the personal clothes from the cart, she held the clothes up against her uniform as she entered several of the residents' rooms in A unit hallway. Laundry Staff W performed no hand hygiene in between residents' rooms as she opened closets and removed hangers.On 07/06/2026 at 12:09 PM, Laundry Staff W reported she was told by her supervisor she did not need to wash her hands in between rooms, as she is only touching the closet handle, and she reported that she did realize she held the clothes and blankets against her uniform, as sometimes it was a heavy load to grab. On 07/08/2026 at 09:31 AM, Housekeeping Supervisor V expected the staff to wash hands between residents' rooms as the staff needed to open drawers and closets. She also expected the staff to never hold the linen or personal clothes up against their uniforms. 3. On 07/07/2026 at 02:12 PM, CNA M and CNA P transferred R5 with a mechanical lift. CNA M and CNA P did not have a gown on and only used gloves. R5 had an EBP sign on her door with personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) hung on the door. R5 has an open area on her left heel and her left gluteal fold. CNA M and CNA P provided peri care to R5 while only wearing gloves for the care provided. The CNAs confirmed they did not wear a gown as part of required PPE on inquiry.On 07/08/2026 at 07:44 AM, Administrative Nurse D and Administrative Nurse E were in R1's room taking photographs of her wounds. Neither of the nurses had their PPE gowns tied, and their gowns kept falling off their shoulders while completing the wound measurements when assisting R1 to reposition in bed and when the disc marker (to help align the image for accurate measurement and documentation) was applied near each open wound for the photograph. Administrative Nurse E took a picture of R1's right buttock open wound, removed the disc marker sticker, and then removed one glove from her right hand and kept the other glove on her left hand. No hand hygiene was performed; she then applied a clean glove on her right hand. Administrative Nurse E took a photo of the left buttock wound, removed the disc marker, removed her right glove, no hand hygiene was performed, and applied a new glove to her right hand. Observed several open areas on buttocks, sacrum, and back of thighs; small amount of serosanguineous (semi-thick blood-tinged drainage) drainage noted on the brief.On 07/08/26 at 12:45 PM, Administrative Nurse D reported she expected the staff to wear the PPE correctly and reported that the tie on her gown had broken and she should have changed the gown. Administrative Nurse E reported it depended on what the staff was doing to make it acceptable to only remove one glove and apply another glove. Administrative Nurse E reported she did not want to contaminate her camera. Administrative Nurse D reported she expected the staff to remove both gloves and perform hand hygiene before new gloves were applied. Administrative Nurse D expected the staff to wear gowns when residents were on EBP when completing hands-on care. Administrative Nurse D reported she expected the laundry to not be touching the uniforms, to be covered, and expected the staff to wash hands in between rooms when passing linen.The facility's policy Infection Control Guide, dated 2025, documented enhanced barrier precautions refers to the expanded use of PPE and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multiple drug-resistant organisms (MDROs- common bacteria that have developed resistance to multiple types of antibiotics) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. Hand Hygiene before and after patient/resident contact, including after gloves are removed. Handling of clean linen was not addressed in infection control.

Based on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP).Findings included:- On 07/08/2026 at 12:45 PM, Administrative Nurse E (Interim) revealed she could not locate her IP certificate. She reported that when she accepted the interim position, an IP certification was not mentioned, and she reported that she really had not completed much of the IP duties at the facility. Administrative Nurse E reported that she was enrolled at this time and taking courses for IP.On 07/08/2026 at 12:50 PM, Administrative Nurse E produced the antibiotic/infection control log binder. There was a Completion for Nursing Home Infection Preventionist Training Course dated 07/07/2026 for Administrative Staff A. On 07/08/26 at 01:00 PM, Administrative Staff A reported that she thought Administrative Nurse E had a current IP certificate and expected the facility to have a designated certified IP employed at the facility. The facility did not provide a policy for an Infection Preventionist.

Five Certified Nurse Aide (CNA) staff who worked in the facility for more than 12 months were reviewed for the required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff with the required topics and no less than 12 hours per year. Findings included:- Review of CNA personnel files revealed the following:CNA N, hired on 04/04/2007, lacked the total hours calculated for the 12 hours required.Certified Medication Aide (CMA) T, hired on 12/20/2012, lacked the total hours calculated for the 12 hours required. Additionally, CMA T lacked the required education on abuse, neglect, exploitation, and dementia education. CNA MM, hired on 03/25/2023, lacked the total hours calculated for the 12 hours required. Additionally, CNA MM lacked the required dementia training. CNA M, hired on 03/07/2024, lacked the required dementia training.CNA O, hired on 02/12/2025, lacked the total hours calculated for the 12 hours required. Additionally, CNA O lacked the required dementia training.On 07/08/2026 at 10:00 AM, Administrative Staff A reported that she expected the CNAs to have the required 12 hours and the required training completed. The facility did not provide a policy for staff training.

Based on observation, interview, and record review, the facility failed to complete the Care Area Assessment (CAA- analysis of findings), related to a Comprehensive Minimum Data Set (MDS), for seven Residents (R)2, R3, R4, R7, R25, R48, and R52, to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs.Findings included:- Review of resident's most recent Comprehensive Minimum Data Set (MDS) documentation revealed the triggered Care Area Assessment (CAA) lacked completion as follows:1. R2's Annual MDS, dated 02/18/2026, lacked completion of CAAs dated 02/18/2026 for Communication, Functional Abilities (Self-Care and Mobility), Psychosocial Well-Being, Behavioral Symptoms, Activities, Falls, Nutritional Status, Dehydration/fluid Maintenance, Pressure Ulcer/Injury, and Psychotropic Drug Use.2. R3's admission MDS, dated 02/12/2026, lacked completion of CAAs dated 03/03/2026 for Pain, Cognitive Loss/Delirium, Functional Abilities (Self-Care and Mobility), Behavioral, Urinary Incontinence/Indwelling Catheter, Activities, Dehydration, Psychosocial well-being, Falls Communication, NS, Pressure Ulcer/Injury well-being'3. R4's Annual MDS, dated 03/05/2026, lacked completion of CAAs dated 03/19/2026 for Functional Abilities (Self-Care and Mobility), Cognitive Loss/Delirium, Urinary Incontinence/Indwelling Catheter, Activities, Psychosocial well-being, Dental, Pain, Communication, Nutritional Status, and Psychosocial well-being.4. R7's admission MDS, dated [DATE], lacked completion of CAAs dated 12/09/2025 for Functional Abilities (Self-Care and Mobility), Urinary Incontinence/indwelling Catheter, Falls, Nutritional Status, Dehydration/Fluid Maintenance, Pressure Ulcer/Injury, and Psychotropic Drug use.5. R25's Significant Change in Status MDS, dated 11/28/2025, lacked completion of CAAs dated 12/05/2025 for Cognitive Loss/Dementia, Urinary Incontinence, Psychosocial Well-being, Falls, Pressure Ulcer/ Injury, and Communication.6. R48's Annual MDS dated 10/15/2025 lacked completion of CAAs dated 10/27/2025 for Functional Abilities (Self-Care and Mobility), Urinary Incontinence, Visual Function, Falls, Psychotropic Drug Use, and Nutritional Status. 7. R49's Annual MDS, dated 09/17/2025, lacked completed CAAs dated 09/25/2025, for Cognitive Loss/Dementia, Communication, Functional Abilities (Self-Care and Mobility), Urinary Incontinence and Indwelling Catheter, Nutritional Status, Falls, Dehydration/Fluid Maintenance, Pressure Ulcer/Injury, Dental Care, and Psychotropic Drug Use.8. R52's Annual MDS, dated [DATE], lacked completed CAAs dated 9/18/2025 for Functional Abilities (Self-Care and Mobility), Falls, Psychotropic Drug Use, Nutritional Status, and Pressure Ulcer/Injury.On 07/08/2026 at 08:30 AM, Administrative Nurse E stated she was not aware of a nurse at the facility who completed the MDS assessments and referred the inquiry to Administrative Nurse D.On 07/08/2026 at 08:45 AM, Administrative Nurse D reported she thought the MDS assessments were completed offsite and referred the inquiry to Consultant II.On 07/08/2026 at 08:59 AM, Consultant II confirmed the facility's MDS Comprehensive assessments were completed off-site by a Registered Nurse who was responsible for the accuracy and completion of the MDSs, including the comprehensive assessment with the analysis of findings/CAAs. She referred the inquiry to Consultant KK via telephone. Consultant KK reported the facility used the Resident Assessment Manual (RAI) October 2025 for guidance to complete the MDS and CAAs for comprehensive assessments. She confirmed the CAA completion should include the location of the information and resource materials that lead to the individualized analysis for the triggered areas of the CAA to develop the care plan. She verified the CAA documentation for the above-named residents lacked source documentation of information to indicate the analysis of the data collected, other than the narrative for the location of the data that triggered the CAA initially, and lacked analysis keeping with the guidance provided in the RAI Manual.The Resident Assessment Instrument (R.A.I.) Manual, titled The Care Area Assessment (CAA) Process and Care Plan Completion documentation, dated 2025, included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's care plans that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based Trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of this manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments.

Based on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent when two errors were identified, resulting in a medication error rate of 7.41 percent. Finding included:- R22's Physician Orders recorded an order for acetaminophen (a medication to treat mild-to-moderate pain and fevers), tablet, 325 milligrams (mg), give 2 tablets by mouth three times a day related to chronic pain at 07:00 AM, 11:00 AM, and 05:00 PM, date ordered 04/16/24.R22's Physician Orders recorded an order for Refresh Tears ophthalmic solution (fast-acting, original-strength lubricating eye drops designed to soothe mild, occasionally dry eyes), instill 1 drop in both eyes three.times a day related to dry eye syndrome at 07:00 AM, 01:00 PM, and 08:00 PM, date ordered 03/09/25. On 07/07/2026 at 09:03 AM, Certified Medication Aide (CMA) R prepared R22's medications; she reported that she administered R22's 07:00 AM medications with all her other AM medications, as she has always done that. CMA R administered artificial tears, one drop in each eye, and administered the acetaminophen at this time; both medications were ordered for 07:00 AM. CMA R reported that she had not told a Licensed Nurse (LN) that she administered R22's medications late. On 07/07/2026 at 10:03 AM, CMA R reported that R22 had always used artificial tears and did not have Refresh eye drops; she reviewed the order in the EMR and reviewed the label on the artificial tears and reported that it was not the same ingredients as the Refresh eye drops. On 07/06/2026 at 10:15 AM, a medication substitution formulary was requested, and the facility did not provide one. On 07/07/2026 at 10:29 AM, Consultant Staff JJ (Pharmacist) reported that Refresh eye drops and the artificial tears R22 were administered and were not the same medication. Consultant Staff JJ reported that if a medication was scheduled at a specific time, the staff have an hour before or after to administer the medication. On 07/07/2026 at 01:39 PM, Consultant Staff II (Regional RN) reported she expected the medications to be passed one hour before or after a medication was scheduled. On 07/07/2026 at 06:00 PM, Consultant Staff II reported she believed the refresh eye drops were on back order and the artificial tears were on the substation formulary. Consultant Staff II was reminded that the formulary was requested and not received and that Consultant Staff JJ reported the eye drops were not the same medication. Consultant Staff II shook her head yes when she answered that if a different medication was being used, the physician order would be changed then. The facility's policy Medication Administration, dated 2026, documented that medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure that rights of medication administration are followed: right drug and right time.

Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus) for Resident (R) 5, R44, R8, R48, and R49. Findings included:1. R5's Electronic Medical Record (EMR) lacked documentation of a COVID-19 vaccine being offered since 2021.2. R44's EMR lacked documentation of a COVID-19 vaccine being offered since 2024. 3. R8's EMR lacked documentation of a COVID-19 vaccine being offered since 2023.4. R48's EMR lacked documentation of a COVID-19 vaccine being offered since 2024.5. R49's EMR lacked documentation of a COVID-19 vaccine being offered since 2024.On 07/08/2026 at 12:10 PM, Administrative Staff A provided information for COVID-19 vaccines; she reported she did not have current consents/declinations for the residents. On 07/08/2026 at 01:50 PM, Administrative Staff A reported she was unsure if the facility offered the COVID-19 vaccine education to the staff. Consultant Staff HH (Regional VP Administrator) reported that when an employee was hired, Administrative Staff B provided education for the COVID-19 vaccine, and staff were offered to go to their own provider to receive a vaccine, and if they cannot receive a COVID-19 vaccine, the facility would provide them with one. On 07/08/2026 at 02:20 PM, Consultant Staff HH provided a copy of the PowerPoint slide that is used for the COVID education that was reviewed when a new hire was in orientation. The COVID-19 education PowerPoint educated on what COVID was, the symptoms, and to wear a mask or stay home. The PowerPoint lacked education about the COVID-19 vaccine and how to obtain one. Consultant Staff HH reported that it was completed verbally during the education. The facility's policy COVID-19 Vaccination dated 05/21/2021 documented the COVID vaccine offered to patients/residents and team members may be provided directly by the center or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. All patients/residents and team members must be educated on the vaccine-specific COVID-19 Vaccine they are offered.

Based on observation, interview, and record review, the facility failed to notify the Long-Term Care Ombudsman in writing of Resident (R) 53's discharge from the facility. The facility failed to complete a discharge summary which included recapitulation of R6's stay and/or reconciliation of his medications following discharge.Findings included:1. Resident (R) 53's Entry Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE].R53's Discharge Return not Anticipated MDS, dated 05/07/2026, documented the resident's discharge from the facility to the community on 05/07/2026.R53's Electronic Medical Record (EMR) Social Service Progress Note documentation, dated 05/07/2026 at 01:30 PM, included that the resident does not want to stay at the facility. She left the facility against medical advice. Her EMR lacked documentation for notification of the Ombudsman of the resident's discharge from the facility. The facility was unable to provide the documentation upon request.On 07/07/2026 at 12:03 PM, Administrative Staff B reported she did not notify the Ombudsman of resident discharges from the facility.On 07/07/2026 at 02:00 PM, Social Service Staff X reported she was not responsible for notification of residents' discharges to the Ombudsman.On 07/08/2026 at 12:22 PM, Administrative Staff A confirmed the above and stated the facility had not notified the Ombudsman of residents' discharges from the facility prior to the survey.2. R6's admission MDS documentation, dated 05/05/2026, included the resident admitted to the facility on [DATE]R6's Electronic Medical Record (EMR) Progress Note (PN), dated 06/29/2026 at 01:53 PM, included orders received for discharge on [DATE].R6's EMR lacked a discharge summary which included recapitulation of R6's stay and /or reconciliation of his medications on discharge.On 07/07/2026 at 11:25 AM, Licensed Staff (LN) H reported that when residents were discharged from the facility to the community, the nurse should ensure the resident has discharge orders, complete a discharge assessment to recap the resident's stay and reconcile their medications, and document the disposition of the medications.On 07/07/2026 at 11:45 AM, Administrative Staff D reported Social Service Staff (SSD) X should open the discharge evaluation and set up a discharge plan for the residents. Upon review of R6's EMR, Administrative Nurse D confirmed the resident lacked a discharge summary to include a recap of her stay and/or reconciliation of R6's medications. The facility lacked a policy related to completion of a discharge summary to include the recapitulation of the resident's stay, reconciliation of medications, and/or notification of the ombudsman when residents are discharged to the community.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for activities of daily living (ADLs) for Resident (R) 8, who was not showered for two weeks, and R25 had dirty fingernails.Findings included:- Review of the Electronic Health Record (EHR) revealed that R8 's diagnoses included left femur fracture/displacement (a traumatic bone break where two ends of the bone separate out of their normal position), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), diabetes mellitus type II (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dysphagia (swallowing difficulty), and polyneuropathy (a neurological condition characterized by damage to multiple peripheral nerves simultaneously). R8's Significant Change Minimum Data Set (MDS), dated 04/29/2026, documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognitive impairment. The Functional Abilities Care Area Assessment (CAA), dated 04/29/2026, documented R8 required substantial/moderate assistance with eating, showering, and shower room transfers. The CAA noted R8 fell on [DATE], resulting in a left hip fracture that required surgical intervention. R8's Care Plan for ADLs, dated 12/05/2024, instructed staff to provide substantial to moderate assistance with eating, showering, and shower transfers. The shower book at the nurses' station contained blank forms, and completed shower sheets had a shower schedule in the front of the book verifying R8's bath/shower days were scheduled for Tuesday AM and Friday PM. This shower book had completed shower sheets for 07/01/2026 – 07/06/2026. There were no completed shower sheets for R8. R8's EHR, under the bathing Tasks tab, did not have documented evidence that R8 received a bath or shower for the period between 06/19/2026 and 07/03/2026. Observation on 07/06/2026 at 11:46 AM revealed R8 sat in an open room watching television with other residents present. He wore a very worn navy sweatshirt and navy sweatpants with dirty white socks. His sweatshirt had an excess of tiny white skin flakes, and his hair appeared messy and uncombed. R8 had notable stubble on cheeks and chin. In an interview on 07/06/2026 at 03:05 PM, R8 said showers were scheduled for Tuesdays and Fridays. R8 stated he had not received a shower for almost two weeks. R8 stated there are times he refused his showers, but he did not receive a bath or shower at all the previous week. R8 also stated he likes to be clean-shaven, as he rubbed his chin and cheeks. On 07/08/2026 at 04:05 PM, an interview with Administrative Nurse D stated she expected that all residents receive at least two showers per week. She stated if nursing or other staff bring to her attention that a resident is refusing and/or not getting their showers, she will personally speak with the resident to discuss why this might be happening. During an interview with Consultant II on 07/08/2026 at 04:10 PM, Consultant II stated that shower sheets are not an appropriate form of documentation and that the Tasks in Point Click Care should be utilized as the exclusive tool for reference. - R25's Electronic Medical Record (EMR) revealed diagnoses of parkinsonism (a slowly progressive neurologic disorder characterized by resting tremors, shuffling gait, muscle rigidity, and weakness) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R25's 11/28/2025 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status could not be completed as R25 was rarely/never understood) Staff interview completed, and R25's MDS documented she had severely impaired cognition. R25's MDS documented that she required supervision assistance for personal hygiene. R25's 12/05/2025 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) lacked a documented CAA note. R25's 05/06/2026 Quarterly MDS documented a BIMS score of four, indicating severely impaired cognition. R25's MDS documented that she required maximal assistance for personal hygiene. R25's Care Plan, dated 05/11/2026, documented that staff were instructed to provide maximal assistance to R25 for her personal hygiene. On 07/06/2026 at 10:33 AM, R25 was seated in her wheelchair with closed eyes; R25's nails had a brown substance under them. R25 would not answer any questions. On 07/06/2026 at 02:15 PM, R25 was eating some vanilla wafers while sitting in her wheelchair in the television lounge. R25's fingernails had a brown substance under her nails. On 07/07/2026 at 08:01 AM, R25 was seated in the dining room in her wheelchair; R25's fingernails had a brown substance under her nails. On 07/08/2026 at 07:38 AM, R25 was seated in her wheelchair in the dining room with her eyes closed, and her fingernails had a brown substance under the nails. On 07/08/2026 at 09:03 AM, Certified Nurse Aide (CNA) N stated that if the staff noticed a resident had dirty, unclipped nails, staff would take care of the nails on their shower day, and the staff should check the resident's nails every morning. CNA N reported that R25 does not refuse care. On 07/08/2026 at 12:01 PM, Licensed Staff (LN) G reported that the residents should have their nails cleaned when they are seen dirty and especially on shower day. On 07/08/2026 at 03:36 PM, Administrative Nurse D expected staff to clean nails as needed and on scheduled shower days. The facility did not provide a policy for activities of daily living for a dependent resident.

Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 25 when staff failed to respond to R25's requests for help and failed to provide foot pedals when staff propelled the wheelchair. Findings included:- R25's Electronic Medical Record (EMR) revealed diagnoses of parkinsonism (a slowly progressive neurologic disorder characterized by resting tremors, shuffling gait, muscle rigidity, and weakness) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R25's 11/28/2025 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status could not be completed as R25 was rarely/never understood) Staff interview completed, and R25's MDS documented she had severely impaired cognition. R25's MDS documented she had one non-injury fall, and she required total staff assistance with wheelchair mobility. R25's 12/05/2025 Falls Care Area Assessment (CAA) lacked a documented CAA. R25's 05/06/26 Quarterly MDS documented a BIMS score of four, indicating severely impaired cognition. R25's MDS documented she had one non-injury fall, and she was independent with wheelchair mobility.R25's Care Plan, dated 05/11/2026, instructed staff that R25 was independent with locomotion in her manual wheelchair. R25's Care Plan, dated 07/07/2026, lacked documentation regarding foot pedals. R25's Fall Risk Screen, dated 01/09/2026, documented she was at high risk for falls with a score of 20.0. R25's Weekly Nurses Note, on 07/08/2026 at 02:15 AM, documented R25 propels self in wheelchair throughout the facility. On 07/06/2026 at 10:24 AM, R25 was propelled out of the restroom by Certified Nurse Aide (CNA) Q near the nurse station; no foot pedals were on her wheelchair, and her socked foot hit the floor one time when pushed to the television lounge. On 07/07/2026 at 11:25 AM, R25 was seated in her wheelchair holding onto the back of a blue recliner chair, pulling her buttocks forward on the wheelchair seat, calling out for help. CNA Q walked by the resident. On 07/07/2026 at 11:33 AM, CNA Q propelled R25 down the hallway from the television lounge to the dining room. No foot pedals were noted on R25's wheelchair; at one time, CNA Q pushed the chair and let it go and skipped towards R25's wheelchair. On 07/08/2026 at 11:16 AM, CNA Q reported that R25 was able to propel herself in the wheelchair and that she should not push her in the wheelchair without foot pedals. CNA Q reported she was just trying to get R25 to her meals. On 07/08/2026 at 12:01 PM, Licensed Staff (LN) G reported that the residents should always have foot pedals on when the staff is pushing them. On 07/08/2026 at 03:36 PM, Administrative Nurse D expected staff to use foot pedals when transferring a resident. The facility did not provide a policy regarding foot pedals.

Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the influenza vaccine (vaccine designed to prevent highly contagious viral infection) form to Resident (R) 5, and R8. Findings included:1. R5's Electronic Medical Record (EMR) documented that no education was provided when she received the influenza vaccine on 11/07/2025. Consent was documented as confirmed. 2. R8's EMR documented no education was provided when he declined the influenza vaccine on 10/31/2025. The facility was unable to provide a signed declined Patient/Resident Declination/Authorization Form (Flu).On 07/08/2026 at 12:10 PM, Administrative Staff A provided information for influenza vaccine of a list of handwritten residents' names, a copy of the sticker of the influenza vaccine lot number, expiration date, and site the vaccine was administered. Administrative Staff A reported she had no current signed consents or declinations for the resident's influenza vaccines. On 07/08/2026 at 01:00 PM, Administrative Staff A reviewed the EMR for the resident's influenza vaccines that were documented when given or declined and reported that the nurse should have documented yes for education when administering the vaccine or when the resident refused. The facility policy Influenza Vaccination Policy dated 11/01/2016, documented the facility would obtain and document consent or declination for the influenza vaccine using the Patient/Resident Declination/Authorization Form. The facility would discuss with the resident and/or responsible party information regarding influenza and influenza vaccine as noted on the Patient/Resident Declination/Authorization Form.

The facility reported a census of 47 residents, with two residents reviewed for wounds. Based on observation, interview, and record review, the facility failed to provide adequate wound care for Resident (R)1 to prevent the wound from being contaminated with maggots (fly larvae). This deficient practice led to R1's right lower leg wound becoming contaminated with maggots, which caused physical and psychosocial discomfort.Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic veinous hypertension (high blood pressure in the legs) with inflammation of an unspecified lower extremity, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), an open right lower leg wound, and need for assistance with personal care.R1's 03/26/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R1 required substantial/maximal assistance with application of footwear and lower body dressing, and partial/moderate assistance for shower/bathing. The assessment documented no venous or arterial ulcers or lesions; R1 had surgical wound(s) that received surgical wound care and received application of non-surgical dressings and ointments/medications to areas other than the feet.The 03/26/25 Care Area Assessments (CAA) did not address R1's right lower leg wound.The 06/23/25 Quarterly MDS documented a BIMS score of 15. The assessment documented R1 required substantial/maximal assistance with application of footwear, partial/moderate assistance with lower body dressing, and supervision/touching assistance with shower/bathing. The assessment documented R1 had no venous or arterial ulcers/lesions or surgical wounds. R1 received surgical wound care and application of ointments and medications to areas other than the feet.R1's 03/17/25 Care Plan reviewed on 07/08/25 documented R1 had an old surgical wound, non-healing wound(s) to lower extremities with a risk for development of further wound(s) due to long-term open wound management and chronic edema. The care plan documented R1's wound would be free of signs and symptoms of infection and included the following interventions:Staff would administer medications and obtain labs as ordered, dated 04/03/25.Staff would wrap both legs with Unna boots (a compressive dressing to aid in circulation and wound healing) every three days, dated 04/03/25.The Orders tab of the EHR documented the following orders:Cleanse legs with Hibiclens (a topical antiseptic) daily and apply a clean dressing everyday shift, dated 06/25/25 at 06:00 AM.Mupirocin (a topical antibiotic) ointment 2 percent (%), apply to both legs topically twice per day, related to skin graft infection, venous hypertension, and open wound right lower leg, dated 04/26/25 at 07:00 AM.Apply calcium alginate (highly absorbent dressing) with antibacterial silver to wounds on both lower extremities. Cover with Hydralock (highly absorbent dressing with waterproof backing), then wrap with Kerlix (stretchy gauze bandage) and secure. Change every three days related to an open wound on the right lower leg, dated 05/24/25 at 07:00 AM.Eucerin (skin lotion), apply to both lower legs, topically, two times per day. Apply after Bactroban (a topical antibiotic), then apply absorbent dressing, wrap with Kerlix, and then Coban (self-adherent elastic wrap used to provide compression and secure dressings), dated 04/28/25 at 03:00 PM.The Progress Notes documented the following:On 06/23/25 at 10:24 AM, R1 received a shower at 09:40 AM. Her dressings were removed from both lower legs, and maggots were observed crawling on the skin of both ankles and heels. Staff left a message with R1's primary care physician (PCP) and were awaiting a call back.On 06/23/25 at 03:11 PM, R1's PCP returned the call and gave a telephone order to cleanse R1's legs daily with Hibiclens and apply clean dressings. R1's PCP requested a report back on 06/27/25 and further stated the maggots were probably good for the wounds.R1's June 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented Administrative Nurse D updated R1's PCP about the wound on 06/27/25 at 12:38 PM.During an observation on 07/09/25 at 10:05 AM, R1 sat in her wheelchair with loose dressings on both lower legs. Both dressings appeared saturated with an unknown yellow liquid. Multiple flies were observed in R1's room and around R1. R1 was able to put her hands between the dressings and her legs.During an observation on 07/09/25 at 01:30 PM, Licensed Nurse (LN) G performed a dressing change on R1's lower extremity wounds. LN G noted both dressings appeared saturated and were falling off R1's legs. During the dressing change, both the surveyor and LN G observed maggots on R1's right lower extremity wound. LN G removed maggots from the wound while performing wound care.On 07/08/25 at 10:05 AM, R1 acknowledged she did have maggots in both lower extremity wounds and said she sometimes pushed the dressing down to scratch the wounds and would get maggot pieces on her fingers. R1 demonstrated this, but no maggot debris was observed on R1's fingers. R1 said she could feel the maggots crawling in and out of her skin, and this caused her physical discomfort from itching, which she stated caused her to feel restless at times. R1 stated that the thought of the maggots bothered her a bit occasionally, but mainly it was just itchy.On 07/08/25 at 01:30 PM, LN G revealed that the dressings to R1's lower extremities used to be changed every three days, but after maggots were discovered in the right lower leg wound, the orders were changed to include Hibiclens, and the dressing changes are performed daily now.On 07/08/25 at 02:10 PM, Administrative Nurse D said R1's dressing changes used to be performed three times per week, but the order was recently changed to daily. Administrative Nurse D was unaware of the continued presence of maggots in R1's wound and said wounds should not have maggots in them. Administrative Nurse D further stated the flies in the facility were a concern for a while but could not provide a definitive length of time.On 07/08/25 at 05:00 PM, Administrative Staff A stated she was not aware of the continued presence of maggots in R1's right lower extremity wound.On 07/10/25 at 09:00 AM, during an interview, Physician HH revealed she was unaware of the continued existence of maggots in the wound on R1's right lower leg. She reported the facility does have a fly problem that has been present for the last few weeks and stated that, in her professional opinion, maggots in the wound are not harming the wound or impeding the wound's healing process.Per the Maggot Infestation: Various Treatment Modalities article from the National Institute of Health National Library of Medicine website revealed The invasion of the skin and subcutaneous tissue by the larvae (Maggot) is known as Maggot infestation. Per the Centers for Disease Control (CDC) website About Myiasis [myiasis is a parasitic infection of fly larva (maggots) in human tissue]. people who have untreated or open wounds have a higher risk for getting myiasis . certain species' larvae will move deeper in the body and can cause severe damage.The facility did not have a policy related to wound care and dressing changes and stated that the facility followed the professional standards of care.

The facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment in the common living area for the residents of the facility. This placed the affected residents at risk for decreased quality of life.Findings included:- Observation on 07/08/25 at 10:38 AM revealed a strong odor of urine upon entering the facility from the east doors to the A-Hall unit.Observation on 07/08/25 at 10:42 AM, R3 sat in a reclining chair in the common area. R3's pants were wet on the front between the legs, and the seat of the chair was saturated. There was a strong odor of urine.Observation on 07/08/25 at 10:54 AM, Certified Nurse Aide (CNA) M and CNA N brought a sit-to-stand lift to assist R3 out of the recliner. As they lifted R3, they could see that the recliner and R3 were saturated. CNA M did not clean the chair, but requested that someone call housekeeping to clean the chair. On 07/08/25 at 11:16 AM, the recliner remained uncleaned. CNA M again requested that a staff member call housekeeping. Observation on 07/08/25 at 11:21 AM, Housekeeping Staff U brought a shampooer into the living area. She shampooed the seat of the recliner.Observation on 07/08/25 at 04:26 PM, the recliner remained wet with a wet floor sign in it. The recliner had multiple stains on the armrest, seat, footrest, and back of the chair where the head rests.On 07/08/25 at 12:15 PM, R3's representative reported that the smell in the facility was very bad. She remarked that the smell was worse on her family member's wing. On 07/08/25 at 12:52 PM, R3's husband said the facility was dirtier over the last six to eight months, and the smell of urine had gotten worse. On 07/08/25 at 2:40 PM, CNA O stated she did notice the strong urine smell. CNA O said that at times, staff used Bye-Bye Odor spray for the strong urine smell.On 07/08/25 at 04:56 PM, Administrative Staff A reported that she talked to the regional managers of the contracted housekeeping employees who will provide training and instruction for better cleaning and removal of unpleasant odors. The facility did not provide a policy related to creating and maintaining a clean, safe, and comfortable home-like environment for the residents of the facility.

The facility reported a census of 46 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to inadequate hand hygiene during wound care and inadequate cleaning of furniture. This deficient practice had the potential to spread possible infections to the residents in the facility.Findings included:- Resident (R)3's Electronic Medical Record (EMR) revealed diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness) due to cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and a history of urinary tract infections (UTI-an infection in any part of the urinary system). R3's 04/27/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. R3 was always incontinent of urine and bowel, and she required substantial to maximum assistance with toileting. R3's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R3 required increased assistance with all areas of daily living. R3's EMR under Tasks documented R3 was continent one time in the last 30 days. R3's Care Plan dated 09/13/23 documented R3 was incontinent of bladder related to confusion, impaired mobility, and a history of UTIs. An intervention dated 09/17/24 directed staff to offer toileting assistance before and after meals, bedtime, and as needed at night. Observation on 07/08/25 at 10:42 AM, R3 sat in a reclining chair in the common area. R3's pants were showing wetness on the front of her pants between the legs, and the seat of the chair was saturated. There was a strong odor of urine. Observation on 07/08/25 at 10:54 AM, Certified Nurse Aide (CNA) M and CNA N brought a sit-to-stand lift. They told R3 that they were taking her to the bathroom, then to lunch. CNA M and CNA N attached R3 properly to the lift and lifted her to a standing position. As they lifted R3, they could see that she was wet from her knees to her mid-back above her waist. CNA M and CNA N assisted R3 from the fabric-covered recliner to the wheelchair and took her to the shower room to change and toilet her. CNA M did not clean the chair but requested that someone call housekeeping to clean the chair. CNA M and CNA N cleaned and changed R3's clothing. On 07/08/25 at 11:16 AM, the recliner remained uncleaned. CNA M again requested that a staff member call housekeeping. Observation on 07/08/25 at 11:21 AM, Housekeeping Staff U brought a shampooer into the living area. She shampooed the seat of the recliner. Observation on 07/08/25 at 04:26 PM, the recliner remained wet with a wet floor sign in it. The recliner had multiple stains on the armrest, seat, footrest, and back of the chair where the head rests. On 07/08/25 at 11:25 AM, Housekeeping Staff U said the housekeeping staff use hot water to clean urine off the chairs, and that is all that was in the shampooer. Housekeeper Staff U said the housekeeping staff did not use any chemicals for cleaning the chair. On 07/08/25 at 11:46 AM, Consultant GG stated nursing staff cleaned up bodily fluids like urine, and then housekeeping disinfected the surface. Consultant GG stated that each building had its own cleaning supplies, so which chemicals were used was dependent on what products the facility had. Consultant GG acknowledged that hot water alone was not a disinfectant. On 07/08/25 at 12:59 PM, Administrative Nurse D stated that if the soiled chair was cloth, it must be discarded, and if it was not cloth, nursing staff should immediately wipe the chair with a germicide wipe, then get housekeeping to clean the chair. Administrative Nurse D stated she expected chairs to be disinfected with a disinfectant, not just hot water. On 07/08/25 at 04:20 PM, Administrative Nurse D said 24 out of the 47 residents could transfer to the recliners with or without assistance and had the potential to be affected by this deficient practice. On 07/08/25 at 04:56 PM, Administrative Staff A reported that she talked to the regional managers of the contracted housekeeping employees who will provide training and instruction. The facility's Infection Control policy dated 11/01/17, documented that the center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. - Observation on 07/08/25 at 12:00 PM, Licensed Nurse (LN) G entered Resident (R)2's room and donned gloves and gown without performing hand hygiene. LN G removed the wound dressing from R2's left leg. LN G cleansed the wound with water, Hibiclens wash (an antibacterial and antimicrobial skin cleanser), and gauze. Without washing her hands or changing gloves, LN G applied a clean Telfa (nonstick gauze) and Kerlix (stretchy gauze bandage) to the wound on R2's left leg. LN G changed her gloves but did not perform hand hygiene. LN G removed the dressing from the right leg and cleansed the wound with water, Hibiclens, and gauze. LN G changed her gloves without performing hand hygiene. LN G then applied a clean Telfa and Kerlix to the wound on the right leg. LN G doffed her gown, then her gloves. On 07/08/25 at 12:25 PM, LN G confirmed she should have washed her hands when entering the room. She should have performed hand hygiene and changed gloves after cleaning the wound and before applying clean gloves. LN G stated the correct order in doffing is gloves, then gown. On 07/08/25 at 02:10 PM, Administrative Nurse D confirmed she expected hand hygiene to be completed when a staff member goes into a room and out of a room, and when applying and reapplying gloves. Administrative Nurse D said staff should perform hand hygiene after touching a dirty area, prior to touching a clean dressing. Administrative Nurse D stated that when doffing gown and gloves, the gloves were to be removed first, hand hygiene performed, then remove the gown with hand hygiene again. The facility's Infection Control policy, dated 11/01/17, documented that the center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

The facility had a census of 46 residents. Based on observation, interview, and record review, the facility failed to ensure effective pest control in the facility. This deficient practice placed the affected residents of the facility at risk for decreased health and wellness. (Refer to F684) Findings included: - On 07/08/25 at 08:05 AM, 10:20 AM, and 12:00 PM, observation of R2's room revealed a lot of flies in the room. Further observation revealed a fly paper strip hanging from the ceiling in R2's room next to the closet. On 07/08/25 at 10:05 AM, 01:30 PM, and 03:05 PM, observation of R1's room revealed a lot of flies in R1's room. R1's room did not show any evidence of any fly mitigation attempts. On 07/08/25 at 01:30 PM, observation of wound care on R1's right lower leg revealed live maggots (fly larvae) on R1's right lower leg wound.On 07/08/25 at 02:10 PM, Administrative Nurse D revealed that the facility had been concerned about flies for a while, and Administrative Staff A had been implementing fly mitigation strategies. On 07/08/25 at 05:00 PM, Administrative Staff A revealed the facility had identified R1's room, R2's room, and some other unidentified residents' rooms as problem areas related to flies. The facility had installed fly paper strips, but this was ineffective. The facility had ordered fly bags (a liquid-filled bag with a one-way valve used to trap and eliminate flies), and they had arrived but had not been installed. Administrative Staff A revealed that the cause of the flies was due to the mostly rural area and the prevalence of cattle in the area. The facility did not provide a policy related to pest management.

The facility reported a census of 46 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to treat residents in a dignified manner when Resident (R)2 received personal care without privacy. This deficient practice placed the resident at risk for decreased psychosocial well-being and embarrassment.Findings included:- R2's Electronic Medical Record (EMR) revealed a diagnosis of a local infection of the skin and unspecified adult personality disorder.R2's 06/30/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.Observation on 07/08/25 at 12:00 PM, Licensed Nurse (LN) G entered R2's room without shutting the door. LN G did not close the curtain to provide privacy. LN G proceeded to perform a dressing change on both of the resident's legs with the door and privacy curtain open, leaving the resident visible from the hall.On 07/08/25 at 12:25 PM, LN G confirmed she should have provided privacy for R2 when she provided his dressing change.On 07/08/25 at 02:10 PM, Administrative Nurse D confirmed she expected staff to treat all residents with respect and dignity by providing privacy with care.The facility's Clean Dressing Change Care Audit documented that staff were to inform the resident what the nurse was going to do and provide privacy by shutting the door and pulling the privacy curtain.

The facility identified a census of 52 residents. The sample included one resident reviewed for involuntary discharge. Based on observation, record review, and interview, the facility initiated a 30-day involuntary discharge for Resident (R)1 though R1's clinical record did not contain evidence to validate the reason for the involuntary discharge. This deficient practice placed R1 at risk for impaired health and well-being and involuntary discharge from the facility. Findings included: - R1's Electronic Health Record (EHR), under the Diagnosis tab, recorded diagnoses of schizoaffective disorder bipolar type (characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diabetes mellitus type two (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), heart failure (chronic inability of the heart to pump blood sufficiently which results in shortness of breath), visual loss [to] both eyes, personality and behavioral disorders, alcohol abuse with alcohol-induced mood disorders, a need for assistance with personal cares, and difficulty in walking. R1's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The assessment documented R1 had verbal behavioral symptoms towards others four to six days and rejection of care one to three days, during the seven-day observation period. R1's Quarterly MDS dated 03/25/25 documented a BIMS score of 15. The assessment documented R1 had verbal behavioral symptoms towards others and other behavioral symptoms not directed towards others one to three days during the seven-day observation period. R1's Care Plan reviewed on 06/12/25 revealed no discharge planning care plan interventions before 02/07/25. R1's Care Plan documented on 07/08/24 R1 sometimes had behaviors that included cursing, shouting/yelling during care, and refusing care. The plan instructed staff to administer medications as ordered, assist the resident to avoid situations or people who were upsetting, offer diversions, report to the provider if behaviors interfered with daily living, ensure the resident was not in pain or discomfort, inform R1 what staff would do before beginning and speak to him in an unhurried manner and calm voice. A review of R1's EHR under the Progress Notes revealed the following notes: A note dated 01/03/25 at 09:28 PM, documented R1 would display a tantrum if R1's wishes were not immediately addressed. The note documented R1's behaviors included screaming expletives at staff, slamming his hand on a wall or table and kicking furniture; R1 attempted to bully staff to provide skin treatments and medications that were not ordered in the EHR. R1's EHR lacked evidence of interventions attempted to address the documented behaviors. A physician note dated 01/08/25 at 04:56 PM documented R1 had mixed complaints as well as argumentative and defiant behaviors. The physician documented R1 did not display good judgment or insight into reality. A note dated 01/12/25 at 05:08 PM documented R1 had good days and bad days and described that R1 accused staff and other residents of stealing his drinks and cigarettes. R1 displayed a tantrum at times when he didn't get his way and attempted to loudly bully staff when angry or if he had to wait. The note lacked evidence of interventions attempted to address the documented behaviors. A note dated 01/19/25 at 10:59 AM documented R1 was well-behaved for periods of time. R1 refused to accept he had smoked his cigarettes and accused others of stealing his cigarettes. The note lacked evidence of interventions attempted to address the documented behaviors. A note dated 01/21/25 at 05:55 AM documented R1 became angry when an (unnamed) Certified Nurse Aide (CNA) staff asked R1 to repeat himself because they could not hear R1's request. R1 swore at the staff and threw his shoe at staff. The note lacked evidence of interventions attempted to address the documented behaviors. A note dated 01/30/25 at 10:47 AM documented R1 was verbally abusive to staff and another resident. Staff documented behaviors that included R1 yelled at staff due to R1 not getting his breakfast fast enough. The entry lacked documentation of verbal statements made to any other residents and lacked evidence of interventions attempted to address the documented behaviors. A note dated 02/02/25 at 02:22 AM documented R1 yelled at staff and set off the door alarms; it took approximately three hours for staff to calm R1. A note dated 02/02/25 at 11:10 AM documented R1 accused R2 of being in his room, taking R1's cigarettes, and moving R1's bedding and furniture. The note recorded staff had not observed R2 in R1's room. R1 accused R2 of walking around with his genitals exposed and stated he did not want to be around R2. Staff documented calling Administrative Nurse D who advised staff to move R2 to a different room. A note dated 02/02/25 at 01:52 AM documented staff assisted R1 to the dining area where he began yelling and asked where the man who walked around with his genitals exposed was. Staff asked R1 to leave the dining area due to disruptive behaviors. R1 refused and rolled his wheelchair into staff and began swearing at staff. A note dated 02/02/25 at 03:41 PM documented R1 called staff expletive names. Staff described R1 as belligerent though the note evidence of interventions attempted to address the documented behaviors. A note dated 02/07/25 at 09:39 AM documented R1 sat in his wheelchair near the nurse's station and when staff approached, R1 rolled his wheelchair forward and struck a staff member on the legs with his wheelchair. R1 laughed and reported to the staff that he could not see her then requested a urinal so he could urinate in the common area. Staff assisted R1 to his room and handed him his urinal. Staff documented R1 then yelled and stated he did not want to use the urinal in his room. R1's EHR lacked documentation from a physician that R1's needs could not be met at the facility, or that R1 had placed other residents in danger warranting involuntary discharge. The facility was unable to provide evidence of investigative reports or incident reports regarding the alleged inappropriate behaviors of R1 towards other residents or behavioral interventions that were attempted but were unsuccessful. A review of documents provided by Administrative Staff A revealed a letter sent by Administrative Staff A to R1 on 02/07/25 which stated RE: Notice of Transfer or Discharge that documented R1 would be discharged from the facility on 03/10/25 because the transfer or discharge is necessary because the health of other individuals may be at risk if R1 remained in the facility. A review of documents provided by the Long-Term Care Ombudsman (LTCO) revealed a letter that formally requested to withdraw the involuntary discharge letter to R1 due to a change in circumstances, postmarked 04/12/25. During an observation on 06/12/25 at 11:40 AM, R1 rested in bed with his eyes closed. During an interview on 06/12/25 at 01:05 PM, Administrative Staff A reported R1 was scheduled to be discharged to home under the care of his daughter, and the family was involved with the planning process. Administrative Staff A reported that for an unknown reason, R1's family was not agreeable to his discharge home under the care of his representative. Administrative Staff A said R1's representative refused to acknowledge R1's behavior which included sexual aggression and violence towards staff. Administrative Staff A stated R1 had bragged about being evicted from multiple other facilities for behaviors that included fondling another resident at a different facility. During an interview on 06/12/25 at 02:05 PM, Administrative Nurse D revealed R1 refused care approximately 70 percent (%) of the time and then accused staff of neglect. Administrative Nurse D said R1 frequently instigated confrontations with staff to elicit a negative response and/or to get his demands met and R1 chose to be discharged from the facility to live with his representative. Administrative Nurse D reported that the facility had no reportable incidents, including no resident-to-resident altercations involving R1, during the survey review period of 01/01/25 to 06/12/25. During an interview on 06/12/25 at 04:10 PM, Certified Medication Aide (CMA) R reported R1 had his good days and bad days and denied any known physical or verbal aggression towards other residents. CMA verified all of R1's behaviors were directed at staff. During an interview on 06/12/25 at 04:15 PM, CNA M revealed R1 had yelling behaviors toward staff, but she denied knowledge of any physical behaviors R1 had towards other residents or staff. During an interview on 06/12/25 at 04:18 PM, Administrative Nurse E reported that R1 would moan and grumble whenever he had to wait for staff assistance. Administrative Nurse E denied R1 had any physical altercations with other residents and stated that there were multiple occasions in which R1 was verbally inappropriate and aggressive towards other residents. Administrative Nurse E went on to say R1 was irritable, impatient, and had threatened other residents. Administrative Nurse E reported when staff assisted other residents around R1, they attempted to be greater than an arm's length away. During an interview on 06/12/25 at 04:37 PM, Administrative Staff A stated on 02/02/25 during the verbal exchange between R1 and R2, R1 threatened to kill R2. Administrative Staff A confirmed that no reportable incident report existed because she did not recognize it as resident-to-resident abuse and therefore did not report the incident to the State Agency (SA). The facility did not provide a policy related to involuntary discharge.

The facility reported a census of 43 residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS on the Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report weekend staffing for Quarter 3 of 2023 (April 1-June 3), Quarter 4 of 2023 (July 1-September 30), Quarter 1 of 2024 (October 1-December 31) and Quarter 2 of 2024 (January 1-March 31). Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 3 2023 (April 1-June 3), Quarter 4 (July 1-September 30), Quarter 1 2024 (October 1-December 31) and Quarter 2 (January 1-March 31), revealed excessively low weekend staffing. Review of the facility's daily staffing sheets revealed the facility's weekend staffing to be the same as the staffing on weekdays. On 08/28/24 at 09:37 AM, Administrative Staff A stated that Administrative Nurse D worked most weekends. Since Administrative Nurse D was a salaried employee, her hours were not shown on the facility timesheet hours. Administrative Staff A stated the facility would send their hours to their corporate office and the corporate office was responsible for turning the time into Centers for Medicare and Medicaid Services (CMS). The facility lacked a policy regarding the completion of the PBJ. The facility failed to accurately report weekend staffing on the PBJ for four quarters.

The facility reported a census of 43 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to review and revise the care plans for four or the sampled residents, Resident (R) 18 and R8 for scabies (a contagious skin infection caused by mites) infections, R41 for use of urine collection leg bag device, and R19 for self-removal of anchoring device, and alternative catheter stabilizing devices. Findings included: - Review of R8's medical record, revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), and vision loss. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognition. The resident was dependent on staff for activities of daily living (ADLs). The Cognitive Loss/Dementia Care Area Assessment (CAA) revealed the resident required extensive/total assistance with all ADLs. The Care Plan reviewed 06/07/24, instructed staff the resident had altered skin integrity due to psoriasis (a chronic skin disease that causes thick scaley inflamed skin), staff were to provide treatments as ordered, and conduct weekly skin assessments. The care plan lacked an update for suspicion of scabies (a contagious skin infection caused by mites) infection. A Nurse Note dated 06/04/24, documented the staff noticed the resident scratching and digging at her stomach and chest, and noted pruritic (itching) bumps. A Physician's Order dated 06/06/24, instructed staff to apply Permethrin (a medicated cream used to treat mites) 5% cream to the resident's body at bedtime, one time, and then shower the resident and change all linens in the morning for scabies. A Nurse Note dated 08/03/24, documented the staff noticed a clustered itchy rash to the resident's trunk. A Physician's Order dated 08/03/24, instructed staff to apply Permethrin 5% cream R18's body at bedtime, and then shower resident and change all linens in the morning for scabies at bedtime for seven days for recurrent scabies. Interview, on 08/28/24 at 01:00 PM, with Administrative Nurse D, revealed the resident had suspected scabies infection, and had two rounds of Permethrin treatment. Administrative Nurse D stated the incidents were not added to the care plan. The facility policy Care Plans effective June 2027, instructed to revise the care plan as needed according to the resident status. The facility failed to review and revise the resident's care plan to include the R8's initial and recurrent infection with scabies. - Review of Resident (R) 19's medical record revealed diagnoses that included cerebral vascular accident (CVA stroke sudden death of brain cells due to lack of oxygen), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), chronic obstructive pulmonary disease (COPD a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The resident required substantial to maximal assistance for transfers and utilized a wheelchair for mobility. The resident had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 01/29/24, was not developed. The Falls CAA dated 01/29/24, assessed the resident as unsteady on her feet and noted she did not remember to call for assistance. The resident had multiple diagnoses that affected her balance and had a recent decline in her ability to transfer, ambulate, and make herself understood. The resident had a urinary catheter placed for urinary retention. The Quarterly MDS dated [DATE] revealed the resident had a BIMS score of three, which indicated severe cognitive impairment. The resident required supervision/touching assistance for transfers and utilized a wheelchair for mobility. The resident had one non-injury fall during the look back period. The resident had an indwelling urinary catheter. The Care Plan reviewed 08/21/24, instructed staff to provide catheter care with soap and water every shift. A Physician's Order dated 07/24/24, instructed staff to maintain a number 18 French (a size of tubing that is inserted directly into the bladder) urinary catheter to dependent drainage. Observation, on 08/26/24 at 11:39 AM, revealed the resident seated in her wheelchair in the dining room. Approximately six inches of the urine collection tubing lay directly on floor. Observation, on 08/27/24 at 08:00 AM, revealed the resident seated in the common dining area. The resident lacked a lap robe to cover her exposed thighs. The actual urinary catheter was visible and hanging down between the resident's open legs. Approximately eight inches of the urine collection tubing lay directly on the floor. Observation, on 08/27/24 at 08:17 AM, revealed the Certified Nurse Aide (CNA) P transported the resident in her wheelchair to her room. Approximately eight inches of the catheter tubing lay directly on the floor during the transport. Upon transfer into the bed the catheter became placed under the resident's right thigh and lacked an anchoring device. CNA P stated the resident should have an anchoring device, but she usually took them off. Search for an anchoring device in the bed or on the floor failed to find the device. Interview, on 08/28/24 at 08:08 AM, with Administrative Nurse D, revealed she would expect staff to provide an anchoring device, but the resident did frequently remove the device herself and would need to explore options for catheter anchoring and include measures on the care plan. The facility policy Care Plans effective June 2027, instructed to revise the care plan as needed according to the resident status. The facility failed to review and revise the care plan to include R19's care plan to include alternatives for the urinary catheter device and R19's behavior of removing the anchoring device to ensure the catheter remained sanitary and in proper position. 34056 - Review of Resident (R)41's Electronic Medical Record (EMR) revealed a diagnosis of obstructive and reflux uropathy (when urine flow is blocked [partially or completely] through the ureter [the duct by which urine passes from the kidney to the bladder], bladder, or urethra [the duct by which urine is conveyed out of the body from the bladder] due to an obstruction and when urine flows backward from the bladder into the kidneys). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. He had an indwelling catheter (a catheter that is inserted into the bladder and left in place for many days or weeks) and required substantial to maximal staff assistance with toileting. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 03/27/24, documented the resident had a urinary catheter due to urinary retention and obstruction. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of six, indicating severe cognitive impairment. He had an indwelling catheter and required substantial to maximal staff assistance with toileting. The indwelling urinary catheter Care Plan, revised 06/27/24, lacked staff instruction regarding the use of a leg bag for the resident's catheter and lacked staff instruction regarding the need for a dignity cover for the leg bag. Review of the resident's EMR revealed the following physician's order: Indwelling urinary catheter 16 French (fr--the measurement of the external diameter of the catheter tube), 10 centimeters (cm--the length of the urinary tubing), to dependent drainage, ordered 05/07/24. On 08/27/24 at 07:47 AM, the resident sat in the dining room awaiting breakfast. His urinary catheter leg bag was attached at the right ankle and lacked a dignity cover, making the collection bag containing urine, visible to all in the dining room. On 08/27/24 at 10:45 AM, the resident sat in the common's area watching TV. His urinary catheter leg bag was attached at the right ankle and lacked a dignity cover, making the collection bag containing urine, visible to all in the common's area. On 08/27/24 at 10:53 AM, the resident sat in the dining room awaiting lunch. His urinary catheter leg bag was attached at the right ankle and lacked a dignity cover, making the collection bag containing urine, visible to all in the dining room. On 08/27/24 at 10:55 AM, the resident stated he would prefer others not be able to see his catheter bag. On 08/27/24 at 01:13 PM, Certified Nurse Aide (CNA) N stated the staff attach the leg bag to the resident's ankle. CNA N stated they did not have a dignity bag to place over the leg bag. On 08/27/24 at 01:13 PM, CNA M stated the facility did not have bags to place the catheter leg bags in, to hide them. They only had covers for the normal sized catheter bags. On 08/28/24 at 08:03 AM, Administrative Nurse D stated the leg bag and dignity bag should be included on the resident's care plan. The facility policy for Care Plans, revised June 2017, included: Care plans will be developed for all residents based upon the Resident Assessment Instrument (RAI) guidelines. Care plans are developed by the interdisciplinary team (IDT) and revised as needed according to resident status or change. The facility failed to review and revise this dependent resident's care plan to include the leg bag for his urinary catheter and the need for a dignity bag. 36881 - Review of Resident (R) 18's Physician Orders, dated 08/18/24, included diagnoses muscular dystrophy (MD-group of inherited disorders that involve muscle weakness and loss of muscle tissue, and worsen over time), contracture (abnormal permanent fixation of a joint or muscle) of the right and left ankles, immobility syndrome (paraplegic) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and scabies infestation (contagious infestation of the skin by burrowing mites). The Modified Annual Minimum Data Set (MDS), dated [DATE] documentation included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. He required staff assistance for activities of daily living (ADL). The resident had functional limitation with range of motion of his upper and lower extremities and used a wheelchair for a mobility device. He reported it was very important to have his family or a close friend involved in discussions about his care. R18 lacked any noted skin conditions or treatments. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 10/19/23 revealed the resident was dependent for most ADLs due to his Muscular Dystrophy. He was cognitively intact with a BIMS of 15 and independently mobile once in his motorized wheelchair. The Care Plan dated 08/01/24, failed to address the resident's change of condition and treatment for a scabies infestation. R18's Physician Orders, dated 08/18/24, documentation included an order for Permethrin External Cream 5 % (Permethrin-lotion used to treat scabies infestation). Staff were to apply the cream to from neck down, topically, one time a day for rash for seven days at night and shower it off in the morning. Review of Progress Notes dated 08/21/24 lacked documentation of the resident's representative/1st emergency contact, or responsible party were notified of the resident's change in condition and/or new order for treatment. The Weekly Nurses Note, dated 08/24/24 at 10:17 AM documentation included the resident was treated for a scabies type rash. Observation on 08/27/24 at 09:54 AM, revealed the resident in the shower room and Certified Nurse Aide (CNA) R answered the call light and entered the shower room to assist the resident with dressing after shower. CNA R confirmed the resident had a rash and received lotion for treatment of scabies infestations. On 08/27/24 at 10:03 AM the resident exited the shower room. He sat in his electric wheelchair maneuvering it independently. The resident controlled it with his right hand and maneuvered through the doorway without difficulty. The resident reported no discomfort or itching. On 08/27/24 at 03:31 PM, Administrative Nurse D stated the resident's care plan should have been updated to provide guidance to the staff related to the treatment of R18's scabies infestation when ordered by the physician. She confirmed the resident's care plan had not been updated to direct the staff's care of R18. The facility Policy Notification of Change in Patient/Resident Health Status dated 06/2027 documentation included a treatment plan should be developed to ensure patient's/resident's change in health status to address an acute change in condition/treatment (intervention). The facility failed to review and revise R18's care plan to reflect a new acute diagnosis of scabies infestation and its prescribed treatment for the resident.

The facility reported a census of 43 residents with 14 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to two Residents (R)19, by failing to cover the resident's bare lap, which left the silicone portion of an indwelling urinary catheter (a catheter that is inserted into the bladder and left in place for many days or weeks) visible to others while in the dining room and R41 for failure to utilize a dignity cover for the collection leg bag of the resident's indwelling urinary catheter while in the dining room and common's area. Findings included: - Review of Resident (R)41's electronic medical record (EMR) revealed a diagnosis of obstructive and reflux uropathy (when urine flow is blocked (partially or completely) through the ureter (the duct by which urine passes from the kidney to the bladder), bladder, or urethra (the duct by which urine is conveyed out of the body from the bladder) due to an obstruction and when urine flows backward from the bladder into the kidneys). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. He had an indwelling catheter (a catheter that is inserted into the bladder and left in place for many days or weeks) and required substantial to maximal staff assistance with toileting. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 03/27/24, documented the resident had a urinary catheter due to urinary retention and obstruction. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of six, indicating severe cognitive impairment. He had an indwelling catheter and required substantial to maximal staff assistance with toileting. The indwelling urinary catheter care plan, revised 06/27/24, lacked staff instruction regarding the use of a dignity cover for the resident's leg collection bag. Review of the resident's EMR revealed the following physician's order: Indwelling urinary catheter 16 French (fr--the measurement of the external diameter of the catheter tube), 10 centimeters (cc--the length of the urinary tubing), to dependent drainage, ordered 05/07/24. On 08/27/24 at 07:47 AM, the resident sat in the dining room awaiting breakfast. His urinary catheter leg bag was attached at the right ankle and lacked a dignity cover, making the collection bag containing urine, visible to all in the dining room. On 08/27/24 at 10:45 AM, the resident sat in the common's area watching TV. His urinary catheter leg bag was attached at the right ankle and lacked a dignity cover, making the collection bag containing urine, visible to all in the common's area. On 08/27/24 at 10:53 AM, the resident sat in the dining room awaiting lunch. His urinary catheter leg bag was attached at the right ankle and lacked a dignity cover, making the collection bag containing urine, visible to all in the dining room. On 08/27/24 at 10:55 AM, the resident stated he would prefer others not be able to see his catheter bag. On 08/27/24 at 01:13 PM, Certified Nurse Aide (CNA) N stated the staff attach the leg bag to the resident's ankle. CNA N stated they did not have a dignity bag to place over the leg bag. On 08/27/24 at 01:13 PM, CNA M stated the facility did not have bags to place the catheter leg bags in to hide them. They only had covers for the normal sized catheter bags. On 08/28/24 at 08:03 AM, Administrative Nurse D stated it was the expectation for staff to use a cover of some type for all catheter bags. The facility policy for Rights of Nursing Facility Residents, dated May 2012, included: Every resident has the right to be treated with dignity, respect, and consideration. The facility failed to utilize a dignity cover for this dependent resident's catheter bag, making the bag, containing urine, visible to others in the dining room and common areas of the facility. 28560 - Review of Resident (R) 19's medical record revealed diagnoses that included cerebral vascular accident (CVA - stroke sudden death of brain cells due to lack of oxygen), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), chronic obstructive pulmonary disease (COPD a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The resident required substantial to maximal assistance for transfers and utilized a wheelchair for mobility. The resident had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter (CAA), dated 01/29/24, was not developed. The Falls CAA dated 01/29/24, assessed the resident as unsteady on her feet and did not remember to call. The resident had multiple diagnoses that affected her balance and had a recent decline in her ability to transfer, ambulate, and make her elf understood. The resident had urinary catheter placed for urinary retention. The Quarterly MDS dated [DATE] revealed the resident had a BIMS score of three, which indicated severe cognitive impairment. The resident required supervision/touching assistance for transfers and utilized a wheelchair for mobility. The resident had one non-injury fall during the look back period. The resident had an indwelling urinary catheter. The Care Plan reviewed 08/21/24, instructed staff to provide catheter care with soap and water every shift. A Physician's Order dated 07/24/24, instructed staff to maintain a number 18 French (a size of tubing that is inserted directly into the bladder) urinary catheter to dependent drainage. Observation, on 08/26/24 at 11:39 AM, revealed the resident seated in her wheelchair in the dining room with approximately six inches of the urine collection tubing lay directly on floor. Observation, on 08/27/24 at 08:00 AM, revealed the resident seated in the common dining area without a lap robe to cover her exposed thighs. The actual urinary catheter was visible and hanging down between the resident's open legs. Approximately eight inches of the urine collection tubing lay directly on the floor. Observation, on 08/27/24 at 08:17 AM, revealed the Certified Nurse Aide (CNA) P transported the resident in her wheelchair to her room. Approximately eight inches of the catheter tubing lay directly on the floor during the transport. Upon transfer into the bed the catheter moved under the resident's right thigh and lacked an anchoring device. CNA P stated the resident should have an anchoring device, but she usually took them off. Search for an anchoring device in the bed or on the floor failed to find the device. Interview, on 08/28/24 at 08:08 AM, with Administrative Nurse D, revealed she would expect staff to provide an anchoring device, but the resident did frequently remove the device herself and would need to explore options for catheter anchoring to keep the device secure and protected. Administrative Nurse D stated she would expect to be diligent in ensuring the resident unknowingly exposed herself and catheter in public places. The facility policy for Rights of Nursing Facility Residents, dated May 2012, included: Every resident has the right to be treated with dignity, respect, and consideration. The facility failed to ensure staff maintained the R19's dignity when she unknowingly exposed herself and the urinary catheter in common living areas.

The facility reported a census 43 residents with 14 residents sampled, which included Resident (R)18 reviewed for reasonable accommodation. Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of R18's needs when the facility failed to follow up on recommendations for a different wheelchair, which would meet the resident's physical needs and preference to maintain his independence. Findings included: - Review of Resident (R)18's Physician Orders, dated 08/18/24, included diagnoses muscular dystrophy (MD - group of inherited disorders that involve muscle weakness and loss of muscle tissue, and worsen over time), contracture (abnormal permanent fixation of a joint or muscle) of the right and left ankles, immobility syndrome (paraplegic-paralysis characterized by motor or sensory loss in the lower limbs and trunk) and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Modified Annual Minimum Data Set (MDS), dated [DATE] documentation included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. He required staff assistance for activities of daily living (ADLs). The resident had functional limitation with range of motion of his upper and lower extremities and had no behaviors. He reported it was very important to have his family or a close friend involved in discussion about his care. R18 lacked any noted skin conditions or treatments. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 10/19/23 revealed the resident was dependent with most activities of daily living (ADLs) due to his MD. The resident was independently mobile once he is in his motorized wheelchair. The Care Plan dated 08/01/24, directed the staff to know the resident had an activities of daily living (ADL) deficit, he was non weight bearing, and used electric wheelchair for locomotion. Review of the Occupational Therapy (OT) Evaluation & Plan of Treatment dated 03/03/23 (17 months prior) documentation included the resident and clinician were to participate in a seating and positioning assessment to determine the resident's wheelchair needs to maximize his upright posture and decrease the risk of further skin breakdown/contracture's as the resident's disease process continued. His current electric wheelchair was donated to him years ago. The note stated the resident's knees were increasingly flexed and he had poor positioning of ankles/feet, which lead to worsening the risk of contracture's to the resident's lower extremities. The Weekly Nurses Note, dated 07/21/24 at 08:57 AM, included R18 had muscular dystrophy which was slowly advancing. The resident worried about his diagnosis and any subtle changes in his body or routine were very upsetting to him. The Physician Progress Note, in the electronic medical record (EMR), dated 08/21/24 at 03:51 PM, included the resident's muscular dystrophy, which was slowly progressing was causing weakness and disabilities. The note lacked documentation noting the resident's representative/1st emergency contact or responsible party were contacted regarding an evaluation or assessment for a new electric wheelchair or follow-up related to his changing condition. Review of R18's Electronic Medical Record dated 03/23/23 through 08/23/24 (17 months,) lacked documentation or follow-up regarding the assessment recommendation for R 18's specific wheelchair to meet his needs for seating and positioning related to maintain his functioning identified by therapy on 03/03/23, as noted above. On 08/27/24 at 09:54 AM, revealed the resident in the shower room and Certified Nurse Aide (CNA) R answered the call light and entered the shower room to assist the resident with dressing after his shower. CNA R confirmed the resident was dependent on the staff for transfers to the wheelchair and then operated his electric wheelchair independently. Observation on 08/27/24 at 10:03 AM the resident exited the shower room as he sat in his electric wheelchair maneuvering it independently. The resident controlled the wheelchair with his right hand maneuvered through the doorway without difficulty. R18 reported his wheelchair was on its last leg due to the wheels going flat and the last maintenance man and his brother had to patch and pumped the wheels up. He stated his brothers were talking with the nursing home administrator (NHA) about possibility of getting another wheelchair, but he did not know what the status was with his wheelchair. On 08/27/24 at 12:26 PM, R18's designated representative reported he made multiple attempts to contact the facility administrator and left messages with the staff of the facility regarding the resident obtaining a electric wheelchair to meet R18's needs. The representative expressed his displeasure with the facility's lack of communication, which included the failure to return phone calls and/or response to messages regarding the resident's need for a different wheelchair to prevent further decline and maintain his functioning. He stated he called and left messages with the facility as recent as 06/07/24 and 07/11/24. The administrator had not called him back at the time of the interview. R18's representative stated it should not be so difficult to get a timely response from the facility so he would have information on how to meet his family member's needs. On 08/28/24 at 09:45 AM, Administrative Staff A stated a year or so ago therapy staff recommended the resident receive an evaluation for a new electric wheelchair. The provider assessed the resident and made recommendations. The recommendations were forwarded to the facility's corporate office for determination on how to proceed. On inquiry Administrative Staff A confirmed the resident's medical record lacked documentation of the assessment, recommendations, and/or corporate determination/directive how to proceed with meeting the identified need related to the resident's assessment and resulting recommendation. Additionally, Administrative Staff A verified the resident's electronic medical record lacked documentation of follow-up regarding the recommendations with the resident's representative, and he did not recall talking with the resident's representative regarding the providers recommendation or corporate decision regarding the provision of the needed device. On 08/28/24 at 11:12 AM, R18 reported the therapist recommended a new wheelchair that would fit him better than the current one. He reported the current electric wheelchair was on its last leg and he did not know the status regarding obtaining a wheelchair that met his identified need for positioning R18 reported he thought the facility administrator was discussing the wheelchair with his chosen representative. He stated his representative informed him that he had trouble getting in touch with the administrator, although he had tried multiple times. R18 confirmed he expected the facility to communicate with his chosen representative regarding health care decisions because he forgot things sometimes. On 08/28/24 at 11:50 AM, Therapy Consultant HH stated she tried to get R18 a new wheelchair in March of 2023. She reported she felt a new wheelchair fitted to the resident would be beneficial to maximize the resident's upright posture and decrease the risk of skin breakdown and contracture's as the resident's disease progressed. The company that assessed the resident was specialized in seating and positioning. Consultant HH reported the resident exhibited tightening of his bilateral leg muscles related to his diagnosis. She felt the current electric wheelchair would contribute to further decline and it was her opinion that a power tilt chair would benefit the resident and enhance his independence. The company assessed the resident and recommended the resident to have a power tilt wheelchair. The recommendation was then submitted to the administrator who informed her the recommendation was forwarded to the facility's corporate office. Consultant HH stated she was not aware of the follow up or final determination regarding the resident getting the recommended electric wheelchair. The facility lacked a policy to address reasonable accommodation of identified needs for a resident. The facility failed to ensure reasonable accommodation of R18's needs when the facility failed to follow up on recommendations for a different wheelchair, which would meet the resident's physical needs and preference to maintain his independence.

The facility identified a census of 57 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to ensure that 1 resident (#1) received adequate supervision to prevent an elopement when the resident expressed the desire to exit the facility through a window on 8/13/16, attempted to exit the facility through a window on 8/27/16, 8/29/16, and 8/30/16, and successfully exited the facility through a window on 10/29/16 without staff knowledge and remained outside for approximately 25 minutes. The resident ambulated independently using a walker and walked 651 feet (ft.) in the dark at approximately 7:45 PM. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 included a [DIAGNOSES REDACTED]. It documented an order dated 7/11/16 every shift to check the function of the Wander guard device (bracelet that sets off an alarm when a resident wearing one attempted to exit the building without an escort) which the resident wore. The Admission Minimum Data Set ((MDS) dated [DATE] documented the resident had short term and long term memory problems, and had moderately impaired decision making skills. He/she did not wander. The resident required extensive assistance from staff for locomotion on the unit and used a walker. The Quarterly MDS dated [DATE] documented the resident suffered from short term and long term memory problems, and had moderately impaired decision making skills. The resident wandered and required limited assistance from staff for locomotion on the unit and used a walker. The Care Area Assessment (CAA) dated 5/26/16 for cognitive loss documented the resident needed cues to complete tasks. The CAA for Activities of Daily Living (ADLs) documented the resident required staff assistance for ADL tasks. The CAAs did not record the resident's wandering behaviors or related interventions. The care plan dated 11/10/16 documented the resident exhibited exit-seeking behavior and attempted to break out windows in order to leave the facility. Staff redirected the resident to an activity when this behavior occurred. The care plan lacked interventions related to the use of a Wander guard device, the monitoring required for it, and 30 minute checks. The care plan also lacked new interventions to prevent an elopement after the resident expressed the desire to exit the facility through a window on 8/13/16, attempted to exit the facility through a window on 8/27/16, 8/29/16, and 8/30/16, and successfully exited the facility through a window on 10/29/16 without staff knowledge. The elopement assessment dated [DATE] documented the confused resident required the use of a Wander guard device. The elopement assessment dated [DATE] documented the resident was not at risk for an elopement as he/she did not exhibit exit-seeking behavior. It did not document whether or not the resident wore a Wander guard bracelet. Review of the nurse's note dated 8/13/16 at 1:58 PM documented the resident attempted to open windows and stated he/she was going home even if he/she had to break the window out. The resident said he/she would walk to the golf course and find a ride home. Review of the nurse's note dated 8/27/16 at 9:37 AM documented the resident attempted to exit the facility through his/her bedroom window. Review of the nurse's note dated 8/29/16 at 1:10 PM documented the resident attempted several times to break out the windows in the facility. He/she climbed onto a bed and tried to break out a window. Review of the nurse's note dated 8/30/16 at 11:28 AM documented the resident opened the window in a resident's room (not his/her room) and had partially climbed out of the window. The clinical record lacked new elopement assessments and/or interventions implemented after the above incidents. Review of the nurse's note dated 10/29/16 at 11:30 PM documented a community member found the resident outside of the facility at 7:55 PM. Staff were unware the resident was outside. According to wunderground.com, the temperature was 69.1 degrees on 10/29/16 at 7:53 PM. According to Google maps.com, the resident traveled 651 ft. On 11/15/16 at 5:22 PM, the resident walked with a walker in the hall without staff assistance. He/she wore a Wander guard device on his/her left ankle. On 11/15/16 at 5:30 PM, administrative staff A stated after staff brought the resident back to the facility on [DATE], he/she went to the resident's room to look around. Staff A stated the bed that was normally in front of the windows had been moved out from the wall. He/she said the windows were closed, but noted 2 of the 4 screens on the windows were raised. Staff A further stated the resident's roommate reported the resident went out of the window, and he/she closed the window after the resident exited. Staff A said the resident recounted he/she went out of the window and down the golf cart path to the house with the light on. Staff A further stated the resident traveled 635 ft. according to a contractor's measuring device. On 11/16/16 at 8:07 AM, administrative nursing staff E stated the resident previously exhibited exit seeking behavior by trying to open the windows. Staff E further said staff ensured all the windows in the facility were locked. Staff also moved the vacant bed in the resident's room away from the windows to deter the resident from eloping out the window. On 11/16/16 at 9:34 AM, community member KK stated he/she found the resident outside of the facility on 10/29/16 at 7:55 PM in the driveway of a house across from the facility, and notified the facility at that time. Community member KK stated the resident asked for a ride home, and named a city. He/she said the resident wore a long sleeved shirt, pants, jacket, socks and shoes. Community member KK stated the resident had a pillow, blanket, and a walker with him/her. On 11/16/16 at 4:05 PM, the confused resident did not recall leaving the facility on 10/29/16. On 11/16/16 at 5:12 PM, licensed nursing staff H stated the resident wandered around the facility. He/she said the resident voiced on multiple occasions he/she wanted to leave the facility. Staff H further stated staff checked on the resident every 30 minutes. On 11/16/16 at 5:27 PM, direct care staff O stated the resident was at risk for elopement and he/she checked on the resident every 30 minutes. Staff O checked on the resident at 7:30 PM on 10/29/16. The resident sat on the bed at that time in his/her room. The facility's policy, Elopement, undated, documented staff were to assess the resident for a risk of elopement, and develop an appropriate plan of care to prevent an elopement. The facility failed to ensure this severely cognitively impaired resident, with a history of exit seeking behavior through a window, received adequate supervision to prevent an elopement. This deficient practice placed this resident in immediate jeopardy. The facility abated the immediate jeopardy on 11/18/16 at 8:00 PM by initiating the following: All windows in the facility were locked and the window stays (devices to prevent a window from opening completely) were engaged throughout the facility; resident Wander guard transmitters and exit door alarms were checked for proper functioning; all window stays were secured in the out position by installing metal screws; review of the elopement policy; nursing staff in-service on 11/2/16 and all other staff in-service by 11/18/16 at 8:00 PM; updated elopement risk assessments and care plan revisions; window audits to ensure windows remained secure; elopement drills weekly for a month then monthly, and continual monitoring of staff knowledge of elopement. The scope and severity remained at a D.