Every finding on record at Diversicare of Haysville

Based on observation, record review, and interview, the facility failed to accurately identify risks and provide interventions and adequate supervision to prevent an elopement for Resident (R) 1. On 05/16/2026, staff assessed R1's elopement risk during a Health Status Evaluation and inaccurately assessed R1 with the inability to leave the facility unattended therefore no risk was identified. On 05/28/2026 at around 01:50 PM, residents alerted Licensed Nurse (LN) G that R1 was outside on the East side of the building. LN G brought R1 back inside and assisted R1 into dry clothes. The facility was on [NAME] roads with posted speeds up to 35 miles per hour. The area also included other hazards such as a leaning fence with loose boards and nails on the ground. There was densely wooded tree line to the south and west of the facility. The weather at the time was approximately 72 degrees Fahrenheit (F.) with winds up to 15 miles per hour; it was raining at the time. The facility's failure to accurately identify risks and provide adequate supervision placed R1 in immediate jeopardy. Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of dementia, muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination, repeated falls, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R1's Annual Minimum Data Set (MDS), dated 05/20/2026, documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. R1 used a walker for ambulation, was independent with toileting hygiene, and required partial to moderate assistance for bathing. The MDS documented that R1 had two or more falls since admission, re-entry or since the prior assessment; at least one fall resulted in injury. R1's Care Plan, revised on 01/16/2025, documented that she was at risk for falls. The revised intervention dated 09/08/2025 informed staff that R1 ambulated independently with her walker. The intervention dated 01/26/2026 instructed staff to offer R1 assistance with ambulation and to encourage her to use her walker. R1's Care Plan, dated 05/29/2024 and revised 06/08/2026, documented that she had impaired cognitive function/dementia or impaired thought process related to dementia. The related intervention, dated 05/29/2024, instructed staff to monitor, document, and report, as needed, any changes in R1's cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing herself, difficulty understanding others, level of consciousness, and mental status. R1's Care Plan lacked interventions related to R1's wandering or elopement risk. The General Note on 02/24/2026 at 02:03 AM documented R1 was having increased confusion at night and wandered the hall in a shirt and incontinent brief. She had to be redirected and assisted back to her room. The Clinical Health Status Evaluation 1.0-V4-V5, dated 05/16/2026, under Elopement was marked no and therefore the rest of the remaining questions were disregarded. The Weekly Nurse's Note on 05/23/2026 at 01:31 AM documented that R1 had increased confusion at night, she wandered the hallway and required redirection and assistance back to bed. The General Note on 05/28/2026 at 05:05 AM documented that R1 continued to be weak and needed assistance to the bathroom. The General Note on 05/28/2026 at 03:11 PM documented that at approximately 01:20 PM staff observed R1 sitting at a table drinking coffee and watching the rain. At approximately 01:50 PM R1 was observed walking outside with her walker. Staff assisted her to her room and assisted her with changing into dry clothes. Staff assessed her at that time. Staff received a physician's order and a Wanderguard (a bracelet that helps monitor residents who are at risk of wandering) was placed on R1. The Weekly Nursing Note on 05/31/2026 at 06:02 AM documented that R1 was an elopement risk and the Wanderguard was in place. R1 continued to require assistance and her walker due to an unsteady gait. The facility investigation, dated 06/05/2026, documented the elopement protocol was followed when the resident was found, all residents were accounted for, and all Wanderguards were tested. All staff were then re-educated on elopement with a drill. The elopement books were updated with R1's information and each door was checked for functionality. The report also documented that the WanderGaurd system was functioning appropriately, but the front door was found to not be fully latching. A staff member was posted at the door continuously from 02:00 PM until the door was found to be functioning appropriately at 09:49 AM on 05/29/2026. R1 was seen by the provider on 05/29/2026 and determined to have a urinary tract infection. The facility In- Service Training Record, dated 05/28/2026, and completed 05/28/2026, documented staff were trained on the elopement policy and mandatory frequent checks on all residents. The third-party vendor invoice, dated 06/02/2026 with a service date of 05/29/2026, documented that a service technician installed a doorbell system on the front lobby door and everything tested and worked properly. CNA M's undated Facility Witness Statement documented that R1 was walking out of hall four. CNA M stopped R1 and noticed she had her purse. CNA M asked R1 where she was going and R1 said to her car. CNA M told R1 to sit in the recliner before lunch. Once lunch was being served, CNA M walked R1 to the seat, pushed her in and gave her lunch. R1 was eating lunch the last time CNA M saw her. Consultant GG's undated Facility Witness Statement documented that the resident attempted to exit the main door at 01:20 PM. Consultant GG distracted the resident and seated her with a cup of coffee. The resident was not agitated and agreed not to go out due to the rain; she was content to relax and watch the rain. Consultant GG was called away from the conversation to help another resident. LN G's undated Facility Witness Statement documented at approximately 01:20, R1 was sitting at the table in front of the windows drinking a cup of coffee. R1 seemed content to look out the window at the rain. Administrative Staff A's undated Facility Witness Statement documented she held the door open for another resident at 01:15 PM as he returned inside the building. She discussed the weather with him and about letting a family member visit. It was documented that since the door had been held open for too long the alarm sounded. She followed the resident and family member in, and the door latched appropriately. Administrative Staff A stated she then left for lunch and at that time, R1 sat at a nearby table, drank a cup of coffee, and the door functioned appropriately. Observed on 06/15/2026 at 12:35 PM, R1 sat in the dining room drinking liquid and eating lunch with other residents. She had a WanderGuard loosely in place on her right ankle. Observed on 06/15/2026 at 01:30 PM, while exiting the main door, the inner door that goes into the facility had to be forcibly pushed shut as it remained slightly open and did not fully close itself and lock shut. Observed on 06/15/2026 at 01:40 PM, the facility was located one block east of the main thoroughfare that runs north and south through the town with a speed limit of 35 miles-per-hour (mph). The main road, that butted up to the north edge of the facility property had a 20-mph speed limit. The street that ran east and west on the south side of the facility campus and turned intersecting with another street on the east side of the facility had no posted speed limit. There was a privacy fence that separated the facility's front parking lot and an apartment parking lot that was leaning, had several missing boards throughout and there were several loose boards with nails scattered amongst the ground next to the fence. On 06/15/2026 at 12:22 PM, CNA M said residents were identified as wandering if their routines were different from baseline. She said on the day R1 eloped, R1 was down another hall wandering, said her car was in the shop, and she needed to get it. CNA M said she tried to calm her down and told her she had a reservation for lunch. This was at 12:45 PM and she was very focused and insistent about her car. CNA M said the nurse on duty was right there when she was redirecting R1 and she sat R1 down in the common area with the nurse and another nurse. She said the nurse gave her the ok and thumbs up. On 06/15/2026 at 12:27 PM, CNA N said residents were identified as wanderers if they went from room to room, different hall to different hall, if they were confused and if they said they wanted to go home. CNA N said that she was not sure how long R1 had been outside, but she seemed a little off after she was brought back inside. She also said that R1 had been more confused recently. On 06/15/2026 at 12:22 PM, LN G said R1 had been sitting by the main window drinking coffee and watching the rain. About 20 minutes later, other residents said they saw R1 wandering around outside with her walker. She said that R1 had not required any more assistance that day than previous days, and she would often get confused and lost but had been easily redirectable and content. LN G said that it had not been reported to her that R1 was showing any wandering or elopement behavior. It was not noticed until after she was found outside that the main door was not functioning correctly. LN G said she went out and brought her back inside, she found her on the backside of the facility, which is on the east side of the building, she was unsure how long she had been outside, she was wet as it was raining that day, she was fully clothed. On 06/15/2026 at 12:55 PM, Administrative Staff A said that around 01:15 PM on 05/28/2026 she had held the main door open for an extended period time while talking with and assisting another resident and the door did alarm as she held it open, but she could not recall where R1 was at that time. Approximately five minutes later Administrative Staff A went out the main door and R1 was sitting at a table, and she watched the rain. She said she personally checked the main door, and it closed and locked at that time. Administrative Staff A said that once R1 was found outside she was immediately assessed and staff put dry clothes on her. The full elopement protocol was put into place, and all the residents were accounted for. Training was then performed related to elopement for all shifts. On 06/16/2026 at 11:15 AM, Maintenance U said that he was notified that the main entrance door was not closing properly and when he arrived, he adjusted it and filed the top of the door frame where it was catching and then it closed and latched properly. He also said a third-party vendor was contacted to develop an estimate to remove the old privacy fence and install a new one. The facility's Elopement policy dated 04/2017 documented the purpose of the policy was to establish a process that identifies risks and establishes interventions to mitigate the occurrence of elopements. When a newly identified elopement risk is identified, the Risk of Elopement evaluation is completed to determine interventions, and an individualized plan is established and implemented to mitigate that risk. On 06/15/2026 at 05:05 PM, Administrative Nurse D received a copy of the Immediate Jeopardy [IJ] Template' and was informed of the facility's failure to accurately identify risk and provide adequate supervision for R1 placed R1 in IJ. On 06/15/2026 at 10:57 PM, the facility submitted an acceptable removal plan which listed the following corrective actions:All residents with WanderGuard bracelets were checked for functionality and positioning with all in place noted on 5/28/2026 at 01:50 PM. All WanderGuard bracelets were in place and functioning properly. All residents at risk of wandering had their care plan and elopement book reviewed on 5/28/2026 with pictures and current care plans in place.Administrative Staff A began an investigation and Root Cause Analysis to determine how the resident went outside; [NAME] Side front door was not locking, and employee was placed at the door to monitor and ensure no resident enters or exits center through door. An employee remained at door through 2-10 shift and a second was assigned for 10-6. A third was observing door from 06:00 AM, until door demonstrated proper locking function at 09:49 AM. by Maintenance Director (MAINT). An employee monitored the door starting at 05:00 PM. on 06/15/2026 until the door was verified to be functioning correctly at 08:00 PM.Nursing staff completed elopement assessments on 100% of residents on 06/15/2026. Initiated nurses' education on completing elopement assessments accurately by 06/16/2026. The facility immediately initiated an in-service with all staff regarding our elopement policy guideline (including nursing, maintenance, office personnel, dietary, housekeeping, therapy, and any volunteers) on 05/28/2026 for all three shifts and again confirmed on 06/15/2026. Any staff member that was not educated at that time will be educated prior to working.Then facility conducted an elopement drill on all three shifts beginning 05/28/2026 and then occur monthly on all three shifts for three months.Licensed Nursing Staff checked for proper function and placement of Wander Guard bracelets every shift beginning 05/28/2026, with documentation on the Treatment Administration Record (TAR).Doors were monitored by a staff member 24/7 until door function repaired and verified by Regional Maintenance Director beginning 06/15/2026.Door checks will be conducted daily to ensure proper function beginning 06/15/2026. Implementation of the corrective actions was verified onsite on 06/16/2026, The noncompliance remained at the scope and severity of a D (isolated risk, no actual harm).

Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1, R2, R3, R4, R5, R6, R7, R8, and R9 remained free from misappropriation when facility staff diverted 187 hydrocodone, Oxycodone, and/or Percocet (potent semi-synthetic opioid analgesics and antitussive used to treat severe pain) between 02/01/2025 to 10/30/2025. Findings included:- Review of the Electronic Medical Record (EMR) revealed the following: 1. The EMR for R1 documented diagnoses of central cord syndrome (an incomplete spinal cord injury characterized by disproportionately more weakness in the arms and hands than in the legs), sprain of ligaments of cervical spine, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), fusion of spine, and chronic pain. R1's EMR had a Physician Order dated 08/21/2025 for Hydrocodone, 5 milligrams (MG) 1.5 tablet by mouth every four hours as needed for severe pain, with a stop date of 09/08/2025. R1's Medication Administration Record (MAR) for August and September 2025 documented that pain was assessed, and the pain medication had been provided. 2. The EMR for R2 documented diagnoses of fracture of the lower end of right radius, motorcycle driver injured in collision with car, pick-up truck or van in traffic accident, and gout (inflammation of the joints). R2's EMR had a Physician Order dated 08/21/2025, with a stop date of 08/21/2025, for Oxycodone, 15 mg, one tablet by mouth every four hours as needed for pain; another order, with a start date of 08/21/2025 and stop date of 08/29/2025, was for Oxycodone, 15 mg, one tablet every four hours as needed for pain and one tablet by mouth one time daily for pain. R2's MAR for August 2025 documented that pain was assessed, and the pain medication had been provided. 3. The EMR for R3 documented diagnoses of chronic pain. R3's EMR had a Physician Order dated 09/12/2025, with a stop date of 10/01/2025, for Hydrocodone-Acetaminophen, 5-325 mg, one tablet by mouth every four hours as needed for pain. Another order, dated 10/01/2025 with a stop date of 11/11/2025, was for Hydrocodone-Acetaminophen, 5-325 mg, one tablet by mouth every four hours as needed for pain and one tablet by mouth twice daily for pain. R3's MAR for August 2025 documented that pain was assessed, and the pain medication had been provided. 4. The EMR for R4 documented diagnoses of pain in left shoulder, polyneuropathy (a neurological condition characterized by the simultaneous damage to multiple peripheral nerves throughout the body), chronic pain, pain in left knee, and fracture of upper end of left humerus. R4's EMR had a Physician Order dated 05/27/2025, with a stop date of 09/26/2025, for Hydrocodone-Acetaminophen 7.5-325 mg, one tablet by mouth four times daily for chronic pain. Another order, dated 09/30/2025 with a stop date of 10/30/2025, was for Hydrocodone-Acetaminophen 7.5-325 mg, one tablet by mouth four times daily for pain. R4's MAR for August-September-October 2025 documented that pain was assessed, and the pain medication had been provided. 5. The EMR for R5 documented diagnoses of chronic pain, and chest pain. R5's EMR had a Physician Order dated 09/16/2025, with a stop date of 09/17/2025, for Hydrocodone-Acetaminophen 5-325 mg, one tablet by mouth every four hours as needed for pain. Another order, dated 09/17/2025 with a stop date of 10/07/2025, was for Hydrocodone-Acetaminophen 5-325 mg, one tablet by mouth every four hours as needed for pain, not to exceed 3 grams (GM) acetaminophen from all sources in 24 hours. R5's MAR for September-October 2025 documented that pain was assessed, and the pain medication had been provided. 6. The EMR for R6 documented diagnoses of spinal stenosis, neurogenic claudication (pain, numbness, tingling, or weakness in the lower back, buttocks, and legs that are triggered by standing or walking and relieved by sitting or leaning forward), chronic pain, polyneuropathy, rheumatoid arthritis (chronic inflammatory disease that affects joints and other organ systems). R6's EMR had a Physician Order dated 06/20/2025, with a stop date of 10/10/2025, for Percocet 5-325 mg, one tablet by mouth every six hours as needed for chronic pain, and one tablet daily for chronic pain. Another order, dated 10/10/2025 with a stop date of 12/13/2025, was for Percocet 5-325 mg, one tablet by mouth every four hours as needed for chronic pain, and one tablet daily for chronic pain. R6's MAR for August-September-October 2025 documented that pain was assessed, and the pain medication had been provided. 7. The EMR for R7 documented diagnoses of gout, and chronic pain. R7's EMR had a Physician Order dated 11/20/2024 for Hydrocodone-Acetaminophen 7.5-325 mg, one tablet by mouth every six hours as needed for pain. R7's MAR for August-September-October 2025 documented that pain was assessed, and the pain medication had been provided. 8. The EMR for R8 documented diagnoses of chronic pain, polyneuropathy, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R8's EMR had a Physician Order dated 04/15/2025, with a stop date of 05/26/2026, for Hydrocodone-Acetaminophen 7.5-325 mg, one tablet by mouth every six hours as needed for pain. R8's MAR for August-September-October 2025 documented that pain was assessed, and the pain medication had been provided. LN I's Notarized Witness Statement, dated 10/2025, documented that she had taken the narcotics paper for R8 and placed it in the back of the narcotics book and left it there for another nurse to verify and remove it. She left the previous night around 11:38 PM and did not remove the paper or have another nurse review it because her shift had ended at 10:00 PM and she was in hurry to get her kids back to the hotel and sleep because they had school the next day, 10/27/2025. On 10/27/2025 she was told the paper was nowhere to be found. LN I cleaned out the drawers at the nurse's station, her office, and by the fax machine on hall five and the paper was not found by her or the other nurses that helped her look. LN H's Notarized Witness Statement, dated 10/29/2026, documented that she did not remember co-signing R8's 10/10/2025 narcotic sheet for LN I. LN J's Notarized Witness Statement, dated 10/27/2025, documented when she and another staff were counting R9 asked for pain medication. R9 was given medication and when LN J did the count she noticed R9 had a card with five Hydrocodone and a card with 27 hydrocodone, the next morning another staff could not find the narcotic sheet for R9 that was removed by LN I at 11:00 PM on 10/26/2025. LN K's Notarized Witness Statement, dated 10/29/2025, documented that she did not remember co-signing the controlled substance reconciliation record as witness for the nurse she was asked about. LN K also documented that she did not recognize the handwriting of the initials she was asked if were her's, and she did not work some of the dates she was asked about. The facility's investigation, dated 11/04/2025, documented on 10/27/2025 one narcotic sheet and one narcotic card were removed from the medication cart on hall five which was signed out by LN I. No narcotic record was turned into medical records for that date. The facility completed an audit from 02/01/2025 to 10/30/2025 and they found 187 opioid tablets missing from 08/22/2025 to 10/27/2025, and LN I was working for the time periods that showed the narcotics missing. The investigation also documented that document falsification also occurred with team member initials on the reconciliation logs when the narcotic logs were removed; three narcotic cards were removed from the reconciliation log without documentation. The investigation documented that LN I had been responsible for the missing narcotics from hall five by falsifying staff initials and removing a narcotic card that was not empty when a new card arrived from the pharmacy. The facility filed a report with the police department on 10/28/2025. The facility then implemented that the empty narcotic card would remain on the cart until medical records or a designee would remove them. They also had the pharmacy send a report of all narcotics that were ordered each week, and the facility cross referenced it. All nurses and medication aides were re-educated on the documentation of recording correctly on the medication log, and the Abuse, Neglect, Misappropriation, Exploitation policy was reviewed with all staff. The facility also contacted the human resource department and initiated appropriate action and drug screen against the staff member in question and suspend the staff member on 10/27/2025. They then began the reimbursement process to all residents that were affected. The director of nursing, or designee, then performed narcotic audits three times a week for two weeks, then weekly for four weeks, and then monthly for three months. The results of the on-going audits were then shared at the monthly Quality Assurance and Performance (QAPI) meetings. Observed on 06/16/2026 at 08:28 AM, CMA R went through the hall five medication cart narcotics drawer and counted the narcotics. The narcotics logbook was checked for accuracy for the month of June 2026. the June 2026 Controlled Substance Shift Count Sheet showed a missing signature for the off-going shift on 06/14/2026 at 06:00 AM. oncoming shift, dated 06/15/2026 at 10:00 PM, and off-going shift, dated 06/16/2026 at 06:00 AM. Observed on 06/16/2026 at 09:30 AM, LN H went through the medication room and at that time there were no narcotic drugs in the room. On 06/16/2026 at 08:28 AM, CMA R said that two staff counted the controlled medications every time they changed shifts, and both signed the shift count sheet for verification. She also said that now they leave the empty narcotic card in the cart until the medical records pulled it out with a witness and verified the count. CMA R also said anytime a medication was discontinued, Administrative Nurse D would pull it and the count sheet out and both staff members would sign the sheet. On 06/16/2026 at 08:36 AM, R8 reported she had no uncontrolled pain, staff gave her something any time she needed it for pain. On 06/16/2026 at 09:30 AM, LN H said the CMA left the empty cards in the cart until administrative staff retrieved them. She also said that any discontinued narcotics stayed in the cart and were counted by Administrative Nurse D, and then Administrative Nurse D and the pharmacist destroyed them. On 06/16/2026 at 09:48 AM, R9 reported that her pain level varied and sometimes she would hurt worse than other times. When she asked for a pain pill, staff always got her one right away,. On 06/16/2026 11:03 AM, Administrative Nurse D reported that prior to the diversion, the nurses would remove the empty cards and give the count sheets to medical records. Administrative Nurse D stated she worked day shift in October 2025, one day the CMA had to leave early, so they were counting the narcotics and R9 requested a narcotic. Administrative Nurse D said she popped the narcotic from the card and signed it out, as they counted, Administrative Nurse D realized she signed the wrong sheet and then fixed it. The next morning when Administrative Nurse D was counting the narcotics she noticed that the narcotic sheet she had signed out the medication on the previous day was missing. Administrative Nurse D said she alerted the director of nursing, and they went back and looked at the previous 90 days. She said he nurse that worked the previous night had, several times, not have someone sign with her that a card was empty. Administrative Nurse D said the facility changed the process. On 06/16/2026 at 12:15 PM, Administrative Staff A said that when the diversion occurred the facility immediately began an investigation and once it was completed, the facility contacted the Kansas State Board of Nursing (KSBN) and turned LN I in. The facility policy Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, documented that the purpose was to prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. All corrective actions were completed by 11/03/2025, prior to the onsite survey therefore the deficient practice was deemed past noncompliance.

Based on observation, record review, and interview, the facility failed to ensure an accurate reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed. Findings included:- A facility reported incident, dated 10/27/2025, documented that one narcotic sheet was missing from the hall five medication cart. The facility then performed a medication audit that covered 02/01/2025 through 10/30/2025. The facility discovered that from 08/22/2025 to 10/27/2025 a total of 187 opioid tablets was missing from the hall five medication cart. The facility immediately implemented corrective actions that included the empty card and control sheet would remain on the cart until medical records or a designee removed them, and all licensed nurses (LN) and certified medication aides (CMA) were re-educated on documentation of recording correctly on the medication log. On 06/16/2026 at 11:30 AM, a review of the June 2026 Controlled Substance Shift Count Sheet showed a missing signature for the off-going shift on 06/14/2026 at 06:00 AM. oncoming shift, dated 06/15/2026 at 10:00 PM, and off-going shift, dated 06/16/2026 at 06:00 AM. On 06/16/2026 at 08:28 AM, CMA R said that two staff counted the controlled medications every time they changed shifts, and both signed the shift count sheet for verification. On 06/16/2026 at 12:16 PM, Administrative Nurse D said she received the email on 06/15/2026 about the staff not signing the count sheet on 06/14/2026. She said she thought it had been taken care of, so she had done nothing about it. Administrative Nurse D then said she had received an email on 06/16/2026 about the off-going nurse's signature missing on 06/14/2026 at 06:00 AM, and the oncoming nurse for 06/15/2026 at 10:00 PM, and off going nurse on 06/16/26 at 06:00 AM. She then said that when this occurred, she would notify the nurse that they needed to come back and verify the count and sign the sheet. The facility policy Controlled Substance Guideline: Chapter 4 Change of shift reconciliation documented that two licensed nurses (or one licensed nurse and one certified medication technician or two certified medication technicians - where allowed by law) - typically the nurse/medication tech arriving on duty and the nurse/medication tech departing from duty; are required to conduct the reconciliation (i.e. Change of Shift Count) of patient specific controlled substances and sign a signature log attesting to the completion and accuracy of the count.

The facility identified a census of 84 residents which included four residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program that included 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) and failed to implement adequate infection control and hand hygiene measures during wound care for one resident in the facility, Resident (R) 1. This deficient practice placed R1 at risk for wound infection and related complications. Findings Included: - During an observation on 05/20/25 at 11:20 AM, Licensed Nurse (LN) G entered R1's room to perform wound care. LN G performed hand hygiene and donned clean gloves but did not don a gown. LN G removed the old dressing from R1's leg wound. LN G then doffed the gloves, performed hand hygiene, and applied new gloves. LN G then cleansed R1's coccyx (small triangular bone at the base of the spine) wound with wound cleanser. LN G removed the gloves, performed hand hygiene, and then donned new gloves. LN G then placed Skin-prep (liquid skin protectant) along the borders of R1's coccyx wound and placed Derma Blue (a highly absorbent vertically wicking foam primary dressing embedded with three proven antimicrobials) into the coccyx wound bed. LN G then removed the gloves and donned new gloves without performing hand hygiene. LN G then placed a boarder-gauze dressing and ABD pad (a large pad to absorb drainage) on the coccyx wound. LN G then placed Triad cream (a topical cream used to assist in the healing of superficial wounds) on R1's leg wound and covered the wound with an ABD pad. LN G then doffed her gloves and performed hand hygiene. During an interview on 05/20/25 at 11:25 AM, LN G said that hand hygiene only needed to be performed between glove changes when transitioning between the dirty and clean phases of wound care or when transitioning between different wounds. Additionally, LN G confirmed that she failed to wear a gown to complete the requirements for EBP during wound care. LN G stated that wound care should be completed from start to finish on one wound before transitioning between wounds. LN G confirmed that she initiated treatment on R1's leg wound before transitioning to R1's coccyx wound, completed wound care on R1's coccyx wound, then transitioned back to R1's leg wound and completed care of the leg wound. During an interview on 05/20/25 at 12:32 PM, Administrative Nurse E stated that from an infection control perspective, wound care should be performed while wearing EBP and said wound care should be completed on one wound before moving on to any additional wounds and hand hygiene should be performed with each glove change. During an interview on 05/20/25 at 01:07 PM, Administrative Nurse D revealed the facility's expectation is that EBP would be used for all dressing changes and wound care would be completed for one wound before initiating wound care on any additional wounds. Administrative Nurse D said staff should follow the order of operation listed on the Clean Dressing Change Audit form. Administrative Nurse D said hand hygiene would be performed between each glove change. The facility's Policies and Practices - Infection Control policy dated 11/01/17 documented that the facility's infection control policies and practices were intended to maintain a safe and sanitary environment to prevent and manage the transmission of infections. All team members would be trained on hire and periodically thereafter. EBP included the use of a gown and gloves which would be used for residents with wounds.

The facility identified a census of 81 residents. The sample included 21 residents. Based on observations, interviews, and record reviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to safely handle, store, and administer resident medications. This deficient practice placed the residents at risk for potential medication errors and side effects. Findings included: - A Complaint Investigation Witness Statement completed 01/28/25 revealed the facility was unable to locate Resident (R) 35's prescribed five-milligram oxycodone (controlled substance pain medication with a high potential for abuse and dependency) pill card. The report indicated the pill card contained 30 individually packed and numbered for use. The report indicated the facility received the medication pill card on 01/09/25 and was placed in the narcotic lock box. The report indicated the narcotic count was updated to include the new card. The report indicated the missing count sheet and pill card were identified as missing on 01/28/25. The report indicated the facility was unable to identify when the card was last verified or seen by staff since being placed in the narcotic lock box. The report indicated that 11 other medication cards went missing from the designated medication destruction/disposal box. The report's Root-Cause Analysis indicated the facility would start a process for each controlled substance to be accounted for each shift change, use controlled substances tracking sheets, and follow the controlled substances per the disposal guidelines. On 03/10/25 at 07:04 AM, an initial walkthrough of the facility revealed a treatment cart in the 300 Hall was left unlocked and unattended by nursing staff. The cart contained prescription medications and ointments. (Refer to F761) On 03/10/25 at 07:59 AM, an inspection of the 300 Hall revealed an unlocked medication cart with the keys in the lock left unattended outside by R9's room. The cart contained medications and prescribed ointments. (Refer to F761) On 03/10/25 at 08:49 AM, an inspection of R22's room revealed her morning medications were left unattended on her bedside table as R22 slept in her bed. (Refer to F554) On 03/10/25 at 09:20 AM, an inspection of the 300 Hall's Quiet Room revealed an unlocked medication cart. The cart contained medicated creams and ointments. (Refer to F761) On 03/11/25 at 09:48 AM, R22's medications were again left on her bedside table unattended as she slept in her bed. (Refer to F554) On 03/12/25 at 12:16 AM, Certified Medication Aide (CMA) R stated the medication carts were to be locked when not in use or unsupervised. She stated nurses and medication aides have been educated not to leave the carts unlocked. She stated medication should never be left unsupervised in the resident's rooms. She stated staff should complete narcotics counts at each shift change to verify all medications were present. On 03/12/25 at 12:35 PM, Licensed Nurse (LN) G stated staff were expected to lock the med carts when they walked away from them. She stated nursing staff were expected to complete and sign off on narcotic medications at the beginning of each shift with two nurses signing. She stated staff should never leave medications in the resident's rooms unsupervised. On 03/12/25 at 01:24 PM, Administrative Nurse D stated staff were expected to check the medication carts to ensure they were secured before leaving them. She stated the nurses were expected to count and verify narcotic cards each shift as a correction plan for the loss of medications. She stated medications were expected to be destroyed with two nurses witnessing and signing off. The facility was unable to provide a policy related to competent staffing as requested on 03/13/25. The facility failed to ensure staff possessed the appropriate skills and knowledge to safely handle, store, and administer resident medications. This deficient practice placed the residents at risk for potential medication errors and side effects.

The facility reported a census of 81 residents. The sample included 21 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - A review of the facility's submitted PBJ data from 10/01/24 through 12/31/24 indicated the facility triggered for excessively low weekend staffing for Fiscal Year (FY) Quarter One 2025. On 03/12/25 at 10:00 AM, the facility's Resident Council reported staffing on the weekends consistently changed due to call-offs. The council indicated the weekend manager would come in to fill shifts and help fill in the gaps. A review of the facility's working schedule, time sheets/punches, and posted staffing hours indicated no gaps or loss of hours. An inspection of the working schedule revealed weekend call-offs documented with administrative nurse coverage. On 03/12/25 at 11:34 AM, Certified Medication Aide (CMA) R stated the facility had call-offs at times but would often have weekend managers to come in and either find replacements or work. On 03/12/25 at 01:30 PM, Administrative Nurse D stated the facility did have a lot of call-offs recently due to the influenza (contagious viral infection) outbreak. She stated the nurse managers came in to work and their time was not added to the PBJ submission. The facility was unable to provide a policy related to staffing or PBJ reporting as requested on 03/12/25. The facility failed to ensure accurate staffing hour information was submitted to the federal regulatory agency through PBJ when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility identified a census of 81 residents. The sample included 21 residents, with five residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R) 9, R14, R27, and R130. This deficient practice placed the residents at risk for impaired dignity and quality of life. Findings Included: - On 03/10/24 at 09:10 AM, R9 (a severely cognitively impaired resident) was assisted by an unidentified staff member in her room. R9 sat on the side of her bed in her room. R9's bedside table was positioned in front of her with her breakfast. R9 had only underwear on her lower half. R9 fell asleep as she sat on the side of her bed with her head against the wall. Her leg and groin area were left exposed. On 03/10/25 at 10:17 AM, R14 (a severely cognitively impaired resident) sat in his bed with his door fully open. R14 only had a sheet covering his groin area as staff and other residents passed his room. On 03/11/25 at 09:08 AM, R27 (a severely cognitively impaired resident) sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the window table in the dining room. R27 recevied feeding assistance for her breakfast meal. The staff member stood the entire time while feeding her breakfast. On 03/11/25 at 09:32 AM, R130 (a physically and cognitively impaired resident dependent on all assistance) lay in her bed facing the door. R130 wore a gown but her entire upper right side up to her chest was exposed while her bed faced the door. On 03/12/25 at 12:38 PM, Certified Medication Aide (CMA) R stated staff were expected to cover up the residents to prevent exposure and possible embarrassment. She stated staff were expected to sit next to the residents while providing feeding assistance. On 03/12/25 at 01:04 PM, Licensed Nurse G stated some residents would prefer not to wear pants or clothing, but the facility was responsible for ensuring the residents were dressed and preventing possible exposure to themselves or others. She stated staff should never stand while providing feeding assistance to the residents. On 03/12/24 at 01:30 PM, Administrative Nurse D stated staff were expected to provide dignified care to each resident. She stated staff were to sit next to residents while assistance was provided. She stated staff were expected to monitor each resident to prevent the resident from being exposed. The facility's Resident Rights and Quality of Life policy revised 05/2012 indicated the facility was to ensure a dignified existence for all residents. The policy noted the facility would ensure a clean, comfortable, and safe environment for each resident. The facility failed to provide a dignified care environment for R9, R14, R27, and R130. This deficient practice placed the residents at risk for impaired dignity and quality of life.

The facility had a census of 81 residents. The sample included 21 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure the safe storage of medications, pressurized oxygen cylinders, and chemical agents from eleven cognitively impaired independently mobile residents. The facility additionally failed to ensure Resident (R) 130's bed remained at a safe height per her care-planned interventions. This deficient practice placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 03/10/25 at 07:04 AM, an initial walkthrough of the facility was completed: An inspection of the supplemental oxygen storage closet revealed that the entry door was unlocked. The closet contained 79 fully compressed oxygen cylinder tanks stored in floor racks. At 07:10 AM, Licensed Nurse (LN) H inspected the door and found it was unlocked because the manual latch was not turned on the handle. LN H stated that the closet and oxygen rooms should remain locked. An inspection of the 100-Hall revealed the shower room was propped open. An inspection of the shower room revealed an unsecured bottle of multi-surface disinfectant. The bottle contained the warning, Keep out of reach from children. An inspection of the treatment cart positioned at the entrance of the 300 Hall revealed the cart was left unlocked and unattended. The cart revealed unsecured medication and prescription ointments. (Refer to F761) On 03/10/25 at 07:59 AM, an inspection of the 300 Hall revealed an unlocked medication cart with the keys in the lock left unattended outside by R9's room. The cart contained medications and prescribed ointments. (Refer to F761) On 03/10/25 at 08:49 AM, an inspection of R22's room revealed her morning medications were left unattended on her bedside table as R22 slept in her bed. (Refer to F554) On 03/10/25 at 09:20 AM, an inspection of the 300 Hall's Quiet Room revealed an unlocked medication cart. The cart contained medicated creams and ointments. (Refer to F761) On 03/11/25 at 09:48 AM R22's medications were again left on her bedside table unattended as she slept in her bed. (Refer to F554) On 03/12/25 at 12:16 AM, Certified Medication Aide (CMA) stated the oxygen storage rooms and medication carts were to be locked when not in use or unsupervised. She stated nurses and medication aides have been educated not to leave the carts unlocked. On 03/12/25 at 01:24 PM, Administrative Nurse D stated staff were expected to check the oxygen rooms and medication cart to ensure they were secured before leaving them. The facility's Medication Storage policy dated 04/2020 indicated the facility will ensure the safe storage of medications and biologicals in a secure area per the manufacturer's recommendation. The facility failed to ensure the safe storage of medications, pressurized oxygen cylinders, and chemical agents from eleven cognitively impaired independently mobile residents. This deficient practice placed the affected residents at risk for preventable accidents and injuries. 41037 - R130's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and 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) affecting her dominant right side. The Significant Change Minimum Data Set (MDS) dated [DATE] documented she had severely impaired cognition. The MDS documented R130 had an impaired range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) on one side of her upper and lower extremities. The MDS documented R130 was dependent on staff assistance for all activities of daily living (ADL). R130's Falls Care Area Assessment (CAA) dated 02/14/25 documented she required total assistance with transfers and mobility. R130's Care Plan last revised on 03/10/25 directed the staff to keep her bed in a low position while she was in bed for safety. On 03/10/25 at 07:40 AM, R130 laid on her back in the bed. R130's bed was elevated four feet off the floor. On 03/11/25 at 08:20 AM, R130 laid on the left side of the bed facing the open door. R130's bed was elevated three feet off the floor and her right shoulder was exposed to the hallway. On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R stated fall interventions could be found on the Kardex (nursing tool that gives a brief overview of the care needs of each resident). CMA R stated if a bed was to be in the low position that information would be included on the Kardex. On 03/12/25 at 12:42 PM, Licensed Nurse (LN) G stated the interventions for falls were listed on the care plan and Kardex. LN G stated R130's bed should be in the lowest position. LN G stated it was the charge nurse's responsibility to ensure fall interventions were in place. On 03/12/25 at 01:29 PM, Administrative Nurse D stated the fall interventions could be found on the resident's care plan or the Kardex. Administrative Nurse D stated she would expect everyone to ensure a resident's fall interventions were in place at all times. The facility's Fall Prevention policy documented the facility was to identify risks and establish interventions to mitigate the occurrence of falls. The facility would provide a comprehensive care plan to include the preventative interventions that would be initiated and placed on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) for all team members to review. The identified interventions would be communicated to all team members by the fall prevention team. The facility failed to ensure R130's bed was kept in the lowest position when she was in the bed for safety. This deficient practice placed R130 at further risk for injuries related to falls.

The facility identified a census of 81 residents. The sample included 21 residents, five medication carts and three medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in three of the five medication carts. The facility also failed to label medication in one of the five medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - During initial tour on 03/10/25 at 07:10 AM a medication cart on the 300 hallway was unlocked and unattended in the hallway. The unattended medication cart contained five opened, undated insulin (hormone that lowers the level of glucose in the blood) pens. On 03/10/25 at 07:59 AM on hall 300 a medication cart with scheduled medication, scheduled narcotics, nasal sprays, was left unlocked with the medication keys and narcotic keys left in the cart. On 03/10/25 at 09:20 AM a medication cart in the resident's quiet room was unlocked and unattended. The medication cart contained eye drops, skin creams, enemas and pain relieve cream. On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R stated the medication cart should never be left unlocked and unattended. CMA R stated the keys should never be left in the lock on the medication cart and left unattended. On 03/12/25 at 12:42 PM, Licensed Nurse (LN) G stated the medication carts should not be left unlocked and unattended. LN G stated the keys should never be left in the lock of the medication unattended. LN G stated an insulin pen should be labeled at the time of the first administration. On 03/12/25 at 01:29 PM, Administrative Nurse D stated she expected all medication carts to be locked when unattended. Administrative Nurse D stated the keys should never be left in the lock of the medication cart and then left unattended. Administrative Nurse D stated she expected insulin pens to be label and dated. The facility was unable to provide a policy related medication storage. The facility failed to properly to store and label medications. This deficient practice could potentially cause adverse consequences or ineffective treatment to the affected residents.

The facility identified a census of 81 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care) and one person on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record reviews, observations, and interviews, the facility failed to ensure to Resident (R) 130's Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) tubing was off the floor. The facility additionally failed to store R38 respiratory equipment in a sanitary manner. The facility further failed to sanitize a shared Hoyer (total body mechanical lift) between residents and failed to ensure the clean linen was covered in a sanitary manner when going through residents' halls. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 03/10/25 at 07:04 AM a walkthrough of the facility was completed. An inspection of R38's room revealed a nasal oxygen tubing wrapped around the back wheelchair handle, R38's nasal tubing was not stored in a sanitary manner. On 03/10/25 at 09:32 AM after transferring R38 with Hoyer lift Certified Nurse's Aide (CNA) M pushed the Hoyer to the residents quit room and walked away, CNA M did not sanitize the Hoyer lift after R38's transfer. On 03/11/25 at 09:28 AM a laundry personal pushed clean linen down hall 100, and then down 200 halls, the laundry cart had clean towels, the laundry cart was not covered in a sanitary manner. On 03/11/25 at 11:38 AM R130's Foley catheter tubing laid directly on the floor. R130's urinary bag was coved with a privacy bag and laid directly on the floor. On 03/12/24 at 12:17 PM, Certified Medication Aide (CMA) R stated all oxygen tubing and equipment should be stored in a clean plastic bag to prevent contamination and respiratory infections. She stated Hoyer should be wiped down, and wipes were stored in the medication room. CMA R stated clean linen should be covered when going down hallways. She stated the Foley catheter and tubing should be off the floor. On 03/12/25 at 12:41 PM, Licensed Nurse (LN) G stated all shared equipment should be sanitized between residents. She stated residents have bags to place all respiratory equipment in when not in use. LNG stated linen should always be covered, and the Foley catheter bag and tubing should be off the floor. On 03/12/25 at 01:30 PM, Administrative Nurse D stated linens should be covered when going through hallways, and the Hoyer should be sanitized between resident use. Foley catheters bags and tubing should never be on the floor, and all residents have bags in their rooms or hanging from there canisters to place oxygen tubing when not in use. The facility's Infection Control policy dated 11/01/17 documented The facility's infection control polices and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The facility failed to ensure to R130's Foley catheter and tubing was off the floor. The facility additionally failed to store R38 respiratory equipment in a sanitary manner. The facility further failed to sanitize a shared Hoyer between residents and failed to ensure the clean linen was covered in a sanitary manner when going through residents' halls. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 81 residents. The sample included 21 residents, with one resident reviewed for self-administration of medication. Based on observation, record review, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 22. This deficient practice placed R22 at risk for unnecessary medication side effects and self-administration errors. Findings included: - R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of blindness in one eye, paraparesis (partial paralysis, usually affecting only the lower extremities), need for assistance with personal care, muscle weakness, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R22 was dependent on staff assistance for transfers. The MDS documented R22 had received antidepressant (a class of medications used to treat mood disorders) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R22 required substantial to maximum assistance with upper body dressing and was dependent on staff assistance with bed mobility. R22's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 06/08/24 documented she required assistance with all daily cares and most tasks required the assistance of two staff members. R22's Care Plan dated 09/05/24 documented staff would administer her medications as ordered. Review of R22's EMR under the Orders tab lacked any order for the self-administration of medication. Review of R22's EMR lacked an assessment related to the self-administration of medication. On 03/10/25 at 08:49 AM, R22 laid on her bed with the head of her bed elevated and her bedside table over the bed. R22 stated she was waiting for breakfast and a paper medication cup with multiple pills sat on top of her water pitcher on the bedside table. On 03/11/25 at 09:48 AM, R22 laid asleep with her bedside table across the bed in front of her. On R22's water pitcher sat a paper medication cup with multiple medications in the cup. On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R stated a resident would require a physician order for self-medication administration after the nurse had performed an assessment to ensure they were safe to administer their own medications, On 03/12/25 at 12:42 PM, Licensed Nurse (LN) G stated that R22 did not have an order to self-administer her medications and the medication should not be left on her bedside table. On 03/12/25 at 01:29 PM, Administrative Nurse D stated that R22 did not have an assessment or a physician order to self-administer her own medications. Administrative Nurse D stated her medication should not be left on her bedside table. The facility was unable to provide a policy related to resident self-medication administration. The facility failed to ensure safe and appropriate self-administration of medications for R22. This deficient practice had the risk of unnecessary medication side effects and self-administration errors for R22.

The facility reported a census of 81 residents. The sample included 21 residents, with four reviewed for accommodation of needs. Based on interviews, observations, and record review, the facility failed to ensure Resident (R) 3 and R66 had the appropriate call light or other method to communicate their needs. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - The Medical Diagnosis section within R3's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), muscle weakness, need for assistance with care, intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), and obesity (severely overweight). R3's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted she used a wheelchair for mobility. The MDS noted she required partial to moderate assistance with bed mobility, transfers, dressing, bathing, personal hygiene, and toileting. The MDS noted she had upper extremity impairment to one side. R3's Functional Abilities Care Area Assessment (CAA) completed 01/11/24 indicated she was admitted to the facility with impaired speech. The CAA noted that screeching is the only sound she can make due to her intellectual disability. The CAA noted she required staff assistance with all activities of daily living (ADL). R3's Care Plan initiated on 09/04/18 noted she was admitted to the facility with severe cognitive loss, impaired speech, and poor memory. The plan noted staff were to ask her simple yes or no questions. The plan noted staff were to monitor her body language and facial expressions to further determine her needs. The plan noted staff were to ensure her call light remained within her reach when in her room. The plan noted she used a touchpad call light. The plan noted she was at risk for falls due to her impaired communication and cognition. On 03/10/25 at 07:10 AM, an inspection of R3's bed revealed her room had a push button call light in place. An inspection of the room revealed no soft-touch call light. On 03/12/25 at 07:20 AM, R3 rested in her bed. R3 had difficulty holding the small push-button call light when asked if she could operate it. On 03/12/25 at 12:16 PM, Certified Medication Aide (CMA) R stated the soft-touch call lights were meant for residents who could not hold or activate the push-button call lights. She stated that R3 should have a touch call light due to her difficulty holding the button. On 03/12/25 at 01:30 PM, Administrative Nurse D stated that R3's call light was just replaced with a touch light before the interview. She stated staff were expected to monitor the residents' care environments to ensure the correct care interventions and equipment were in place. The facility failed to provide a policy related to accommodation of needs or call lights as requested on 03/12/25. The facility failed to ensure R3 had the appropriate call light or other method to communicate their needs. This deficient practice placed the residents at risk for preventable accidents and injuries. 49634 - R66's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, need for assistance with personal care, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), hyperlipidemia (condition of elevated blood lipid levels), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R66 was independent with all activities of daily living (ADL) except bathing and required touching and cueing. The Admission MDS dated [DATE] documented a BIMS score of four which indicated severely impaired cognition. The MDS documented R66 was independent with eating and oral hygiene and needed partial to moderate assistance of staff from staff for bathing and upper and lower body dressing. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 08/19/24 documented R66 was admitted to the center post-hospital stay for therapy with diagnoses of hypertension and dementia. R66 was alert and orientated, able to voice her needs. Staff were to assist with toileting tasks as needed, R66 had occasional incontinence of the bladder. R66's Care Plan dated 08/27/24 documented staff would anticipate and meet R66's needs. R66's plan of care documented staff would ensure R66's call light was within her reach and encourage her to use the light for assistance, her plan of care documented R66 needed prompt responses to all requests for assistance, and staff would follow the facility's falls protocol. On 03/10/25 at 08:41 AM, R66 laid on her bed. R66's call light was wrapped with another call light. The call light dangled on the floor in the middle of R66's room. R66's call light was not in her reach. On 03/11/25 at 08:41 AM, R66 laid on her bed. R66's call light was wrapped with another call light. The call light dangled on the floor in the middle of R66's room. R66's call light was not in her reach. On 03/12/25 at 11:22 AM, Certified Medication Aide (CMA) R stated all residents should have access to their call light. She stated call lights should be within the resident's reach. On 03/12/25 at 12:41 PM, Licensed Nurse (LN) G stated it was all staff's responsibility to ensure residents have their call light within the resident's reach. On 03/12/25 at 01:30 PM, Administrative Nurse D stated the resident's call light was to be placed within the resident's reach. The facility failed to provide an accommodation of needs policy about call lights. The facility failed to ensure R66's call light was within her reach. This deficient practice left R66 vulnerable to unmet care needs due to the inability to call for staff assistance.

The facility identified a census of 81 residents. The sample includes 21 residents, with five residents reviewed for resident funds. Based on observation, record review, and interviews, the facility failed to provide and or ensure resident funds accounts were accessible 24 hours a day seven days a week. This deficient practice placed residents at risk for decreased psychosocial well-being. Findings Included: - On [DATE] at 10:13 AM, Resident Council members Resident (R) 19, R53, and R65 reported the only way residents could access their money in their trust accounts was through Administrative Staff B. They reported that they were only aware that money withdrawals occurred Monday through Friday from 11:00 AM to 12:00 PM during the day. She stated we set a time because residents would be in my office all day long. On [DATE] at 11:431AM, Certified Medication Aide (CMA) R stated residents can get money on the weekends, she stated there was money in an envelope on the 300-hall cart. CMA R stated residents could ask for money on the weekends. On [DATE] at 12:17 PM, Licensed Nurse (LN) G stated residents could get money Monday through Friday. LN G stated residents could also get a small amount of money on the weekend from the nurse working hall 300. On [DATE] at 01:07 PM, Administrative Staff B stated the money was given out Monday-Friday from 11:,d+[DATE]:00 during the day. She stated there was a small amount of cash kept in the cart in the hall 300 residents had access to. She stated we set a time because residents would be in my office all day long. On [DATE] at 01:30 PM, Administrative Staff D reported the residents were informed on admission when they could get money. She stated residents were able to get cash Monday through Friday from 11:00 AM through 12:00 PM. Administrative D stated the money was kept in the business office, and residents' funds were distributed by the Activities Director. She stated residents could get cash on the weekends from the nurse working the 300 halls, cash was kept on her cart. The facility's Residents Trust policy documented the facility shall have standardized policies for the handling of resident trust accounts both active residents' funds and funds of deceased residents. Monitoring systems shall be in place to ensure funds were handled according to applicable state regulations. The facility would maintain at least $200.00 in petty cash, used specifically for withdrawals of cash for residents daily. All petty cash funds would be held on in cash in the facility Administrator's name and funds would be replenished upon recording residents spending into the resident trust system. The facility failed to ensure resident funds accounts were accessible 24 hours a day seven days a week. This deficient practice placed residents at risk for decreased psychosocial well.

The facility identified a census of 81 residents. The sample included 21 residents, with one reviewed for abuse and/or neglect. Based on record review and interview, the facility failed to ensure Resident (R) 35 was free from abuse when R35's medication was misappropriated from the facility medication cart. This placed the residents at risk for both physical and psychosocial negative outcomes. Findings included: - R35's Electronic Medical Record (EMR) under the Diagnosis tab recorded diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) of the left nondominant side, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of ten which indicated moderately impaired cognition. The MDS documented R35 received opioids (a class of controlled drugs used to treat pain) during the observation period. Review of R35's physician orders revealed R35 was receiving Oxycodone (pain medication) HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 24 hours as needed for pain -Order start date 12/27/24 -discontinue (D/C) date 01/31/25. Review of the Complaint Investigation Witness Statement dated 01/28/25 documented when the Director of Clinical Operations arrived at the facility to help with locating the missing narcotic card, Administrative Nurse F looked in the count binder and confirmed the shift count sheet was present and complete. On 01/09/25 the receiving nurse of the narcotics did not log the medication into the narcotic inventory count. Review of the Complaint Concern log dated 01/28/25 documented when the Assistant Director of Nursing was notified of missing narcotics she immediately verified the medication book was on the medication cart, and the narcotic count sheet was present in the book. The ADON verified the current count was reconciled and correct. Review of the Custom Concern log dated 01/30/25 recorded an unknown resident was missing medication/ narcotics in a bubble pack and confirmed reimbursement of the cost of medication. Review of the Manual Check Request log documented a reimbursement for medication was given for missing medication for R35 in the amount of $13.43. The facility's Investigation Template dated 01/30/25 documented a process was established where all controlled substances would be accounted for at each shift change to ensure accuracy and prevent discrepancies. Every controlled substance would be traced using Controlled Substances Count Sheets to ensure a detailed log was maintained. Any unused controlled substances would be disposed of following the Disposal of Controlled Substances guidelines. The facility would be doing regular audits of narcotic documentation three times per week for eight weeks to ensure compliance. Medication destruction audits would also take place monthly, in partnership with a pharmacy consultant. The facility was unable to determine an alleged perpetrator. The facility's process for controlled substance delivery and accountability had been modified to prevent future discrepancies. All nursing staff would undergo mandatory training on narcotic management and controlled substance accountability to ensure comprehensive understanding and adherence to new protocols. To maintain accountability an ensure the implemented interventions are effective, the results of ongoing audits would be shared at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. All residents were evaluated to ensure proper pain management and to confirm no residents had missed any doses of prescribed medications. The police were called to ensure any potential criminal activity could be investigated. A review of staff training on 07/22/24 documented all staff were given Abuse and Neglect training. On 03/12/25 at 10:47 AM, Administrative Nurse D stated that Licensed Nurse (LN) G had received a controlled substance the previous day 01/09/25, and that LN G failed to sign the narcotic card into the narcotic count. Administrative nurse D stated the ADON was notified on 01/28/25. Administrative Nurse D stated the Administrator was notified immediately. Administrative Nurse D stated while investigating the missing bubble pack, other controlled cards were determined to be missing from the medication box to be destroyed. She stated the facility started training to ensure all cards were counted, and education on the medication destroy box. Administrative Nurse D stated the facility had not called the State because the facility did not feel there was abuse involved. She stated the facility figured out what happened to the medication but was unsure who the alleged perpetrator was. She stated the facility figured out the cards were taken. Administrative Nurse D stated she does not have documentation of ongoing audits, she walks by the carts and ensures the count was correct. She stated the facility reimbursed R35 for the medication, and he never missed a dose of pain medication. Administrative Nurse D stated the Abuse and Neglect training was started with all staff members. On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R stated all narcotics were counted by the oncoming staff and outgoing staff on each shift. She stated she did not know what the process would be because she had never had anyone not count narcotics with her. On 03/12/25 at 12:41 PM, LN G stated it was the facility's policy to count narcotics with the oncoming and outgoing nurse each shift. She stated it was also the policy of the facility to document narcotic cards added to the narcotic count each shift. The facility's Abuse, Neglect and Exploitation dated 01/2019 documented the facility Administrator would oversee the implementation of corrective actions to protect all residents. The Administrator or designee would conduct an internal investigation against any violation/alleged violation of abuse, neglect, exploitation, injury of unknown source misappropriation of resident property, or involuntary seclusion and report the results of the investigation to the enforcement agency in accordance with state law including the state survey and certification agency within five working days of the incident or according to state law. The facility failed to ensure R35 was free from abuse when R35's medication was misappropriated from the facility medication cart. This placed the residents at risk for both physical and psychosocial negative outcomes.

The facility identified a census of 81 residents. The sample included 21 residents, with one reviewed for abuse and/or neglect. Based on record review and interview, the facility failed to submit a full investigation of a reportable occurrence for Resident (R) 35 to the appropriate state agency within twenty-four hours as required for misappropriation of R35's missing controlled substance. This placed the residents at risk for unidentified and ongoing abuse and /or neglect. Findings included: - R35's Electronic Medical Record (EMR) under the Diagnosis tab recorded diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) of the left nondominant side, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of ten which indicated moderately impaired cognition. The MDS documented R35 received opioids (a class of controlled drugs used to treat pain) during the observation period. Review of R35's physician orders revealed R35 was receiving Oxycodone (pain medication) HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 24 hours as needed for pain -Order start date 12/27/24 -discontinue (D/C) date 01/31/25. Review of the pharmacy delivery sheet documented 30 oxycodone tablets were delivered on 01/09/25. Review of the Complaint Investigation Witness Statement dated 01/28/25 documented when the Director of Clinical Operations arrived at the facility to help with locating the missing narcotic card, Administrative Nurse F looked in the count binder and confirmed the shift count sheet was present and completed. On 01/09/25 the receiving nurse of the narcotics did not log the medication into the narcotic inventory count. Review of the Complaint Concern log dated 01/28/25 documented when the Assistant Director of Nursing was notified of missing narcotics, she immediately verified the medication book was on the medication cart, and the narcotic count sheet was present in the book. The ADON verified the current count was reconciled and correct. Review of the Custom Concern log dated 01/30/25 recorded an unknown resident was missing medication/ narcotics in bubble packs and confirmed reimbursement of the cost of medication. Review of the Manual Check Request log documented a reimbursement for medication was given for missing medication for R35 in the amount of $13.43. The facility's Investigation Template dated 01/30/25 documented a process was established where all controlled substances would be accounted for at each shift change to ensure accuracy and prevent discrepancies. Every controlled substance would be traced using Controlled Substances Count Sheets to ensure a detailed log was maintained. Any unused controlled substances would be disposed of following the Disposal of Controlled Substances guidelines. The facility would be doing regular audits of narcotic documentation three times per week for eight weeks to ensure compliance. Medication destruction audits would also take place monthly, in partnership with a pharmacy consultant. The facility was unable to determine an alleged perpetrator. The facility's process for controlled substance delivery and accountability has been modified to prevent future discrepancies. All nursing staff would undergo mandatory training on narcotic management and controlled substance accountability to ensure comprehensive understanding and adherence to new protocols. To maintain accountability and ensure the implemented interventions are effective, the results of ongoing audits would be shared at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. All residents were evaluated to ensure proper pain management and to confirm no residents had missed any doses of prescribed medications. The police were called to ensure any potential criminal activity could be investigated. A review of staff training on 07/22/24 documented all staff were given Abuse and Neglect training. On 03/12/25 at 10:47 AM, Administrative Nurse D stated that Licensed Nurse (LN) G had received A controlled substance the previous day 01/09/25, the LN G failed to sign the narcotic card into the narcotic count. Administrative nurse D stated the ADON was notified on 01/28/25. Administrative Nurse D stated the Administrator was notified immediately. Administrative Nurse D stated while investigating the missing bubble pack, other controlled cards were determined to be missing from the medication box to be destroyed. She stated the facility started training to ensure all cards were counted, and education on the medication destroy box. Administrative Nurse D stated the facility had not called the State because the facility did not feel there was abuse involved. She stated the facility figured out what happened to the medication but was unsure who the alleged perpetrator was. She stated the facility figured out the cards were taken. Administrative Nurse Stated she does not have documentation of ongoing audits; she walks by the carts and ensures the count was correct. She stated the facility reimbursed R35 for the medication, and he never missed a dose of pain medication. Administrative Nurse D stated the Abuse and Neglect training was started with all staff members. On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R stated all narcotics were counted by the oncoming staff and outgoing staff on each shift. She stated she did not know what the process would be because she had never had anyone not count narcotics with her. On 03/12/25 at 12:41 PM, LN G stated it was the facility's policy to count narcotics with the oncoming and outgoing nurse each shift. She stated it was also the policy of the facility to document narcotic cards added to the narcotic count each shift. The facility's Abuse, Neglect and Exploitation dated 01/2019 documented the facility Administrator would oversee the implementation of corrective actions to protect all residents. The Administrator or designee would conduct an internal investigation against any violation/alleged violation of abuse, neglect, exploitation, injury of unknown source misappropriation of resident property, or involuntary seclusion and report the results of the investigation to the enforcement agency in accordance with state law including the state survey and certification agency within five working days of the incident or according to state law. The facility failed to submit a full investigation of a reportable occurrence for R35 to the appropriate state agency within twenty-four hours as required, for misappropriation of R35's missing controlled substance. This placed the residents at risk for unidentified and ongoing abuse and /or neglect.

The facility identified a census of 81 residents. The sample included 21 residents, with three sampled residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 14 and R54 and their representative received written notification of transfer, as soon as practicable to R14 and R54 or their representative for their facility-initiated transfer. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R14 and R54. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and fracture of left tibia (broken bone of the lower leg). R14's Discharge MDS dated 09/13/24, documented an unplanned discharge to a short-term acute hospital with an anticipated return. R14's Entry MDS dated 09/16/24, documented a re-entry to the facility from a short-term acute hospital. R14's Discharge MDS dated 10/19/24, documented he had an unplanned discharge to a short-term acute hospital with an anticipated return. R14's Entry MDS dated 10/22/24, documented a re-entry to the facility from a short-term acute hospital. R14's Significant Change Minimum Data Set (MDS) dated 11/02/24, documented he had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R14 required substantial assistance to dependent on staff for functional abilities and activities of daily living (ADL). R14 required the use of a wheelchair for mobility. R14's goal for discharge was to remain in the facility. R14's Discharge MDS dated 12/24/24, documented he had an unplanned discharge to a short-term acute hospital with an anticipated return. R14's Entry MDS dated 12/31/24, documented a re-entry to the facility from a short-term acute hospital. R14's Functional Abilities Care Area Assessment (CAA) dated 11/04/24, documented that he was alert, had some confusion and was able to voice his needs for assistance. R14 needed assistance for ADLs, and can be self-limiting, and may refuse care. R14 was participating in therapy but had a history of refusing. R14 will remain at the long-term care center. R14's Care Plan revised on 02/12/25, documented he planned on living at the facility permanently due to his diminished functioning. The care plan directed staff to evaluate his physical, mental, and cognitive needs quarterly, annually, and as needed to ensure appropriate interventions were in place. Staff were directed that R14 only wanted to be asked about discharging annually and upon significant change. A General Notes in the Progress Notes tab of the EMR dated 09/13/24 at 12:13 PM for R14 documented the resident was sent to the emergency room to be evaluated and treated due to altered mental status. A bed hold policy was sent with R14, and his daughter was made aware. The facility provided an EINTERACT Transfer Form in the EMR dated 09/13/24 at 12:26 PM, documenting that R14 was transferred due to an unplanned altered mental status. The facility did provide written notification of transfer for R14's 12/24/24 as it had not been completed for the transfer. On 03/11/25 at 09:18 AM, R14 laid on his back on his bed. R14's head of the bed was elevated, and the call light was within reach. On 03/11/25 at 02:29 PM, Administrative Nurse D stated that when a resident was sent out to the hospital Notice of Bed Hold Policy and the Notice of Transfer or Discharge were sent with the resident. Administrative Nurse D stated the forms were not completed for R14's 10/19/24 discharge to the hospital. Licensed Nurse (LN) H was out on leave with his daughter. Administrative Nurse D stated for R14's 12/24/24 discharge, a bed hold and written notification were not provided to the resident and his representative. The facility policy Transfer & Discharge effective 01/01/16 documented before the facility transfers or discharges a resident, it shall notify the resident and the resident's representative of the basis for the transfer or discharge in a language and manner they understand; they would also notify the state long-term care ombudsman. The notice of transfer shall include the information required under the law, including the resident's appeals rights, and shall be provided at least 30 days before the proposed date of the transfer or discharge unless sooner notice was permitted. Notice may be made as soon as practicable before a transfer or discharge when an immediate transfer was required due to urgent medical needs. The facility failed to provide a written notice of transfer as soon as practicable to R14 or their representative for their facility-initiated transfer. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R14. - R54's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R54's admission Minimum Data Set (MDS) dated 10/07/24, documented she had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R54 required moderate assistance from staff for oral hygiene, upper body dressing, and personal hygiene. R54 was dependent on staff assistance with all other functional abilities and activities of daily living (ADL). R54 used a wheelchair to assist with mobility. R54's goal for discharge was to discharge back to the community. Active discharge planning was occurring for the resident to return to the community. R54's Discharge MDS dated 12/09/24, documented an unplanned discharge to a short-term acute hospital with an anticipated return. R54's Entry MDS dated 12/11/24, documented a re-entry to the facility from a short-term acute hospital. R54's Discharge MDS dated 02/11/25, documented he had an unplanned discharge to a short-term acute hospital with an anticipated return. R54's Entry MDS dated 02/24/25, documented a re-entry to the facility from a short-term acute hospital. R54's Quarterly MDS dated 02/28/25 documented she had both short and long-term memory problems. R54 required moderate to maximal staff assistance with her functional abilities. R54 required the use of a wheelchair for mobility. R54's Functional Abilities Care Area Assessment (CAA) dated 10/08/24, documented she was alert, orientated, and able to voice her needs. R54 required assistance from staff for all daily cares. R54 minimally participated in therapy. R54's overall goal for discharge was to remain in the facility. R54's Care Plan initiated on 03/10/25, documented that she planned on living at the facility permanently due to his diminished functioning. The care plan directed staff to evaluate her physical, mental, and cognitive needs quarterly, annually, and as needed to ensure appropriate interventions was in place. Staff were directed that R54 only wanted to be asked about discharging annually and upon significant change. R54's written notification of transfer or discharge was requested for her facility-initiated discharge to the hospital on [DATE] and 02/11/25. The facility provided a printout of R54's 12/09/24 at 08:29 AM EINTERACT Transfer Form in the Progress Notes tab of the EMR. The note documented R54 was transferred due to being unresponsive. A General Notes note in the Progress Notes tab of the EMR dated 12/09/24 at 08:47 AM documented R54 was sent to the emergency room (ER) to be evaluated and treated due to unresponsiveness. The aides went to get her ready for breakfast but R54 was unable to respond to them. The nurse assessed R54, and she was hard to arouse, was mumbling a little bit, and responded to sternal rub by moaning. The nurse practitioner was notified, and an order was received to send her to the ER for evaluation and treatment. R54's daughter was made aware. R54's daughter arrived at the facility as emergency medical services (EMS) arrived. A bed hold policy was sent with R54 to the hospital. The facility was unable to provide evidence a Notice of Transfer or Discharge was completed and provided to R54 for her facility-initiated transfers on 12/09/24 and 02/11/25. The facility failed to provide evidence that a copy of the Notice of Transfer or Discharge was sent by mail within a reasonable time frame to R54's representative for the transfers. On 03/11/25 at 12:05 PM, R54 was propelled by staff from her room to the dining room for lunch. On 03/11/25 at 02:29 PM, Administrative Nurse D stated that when a resident was sent out to the hospital Notice of Bed Hold Policy and the Notice of Transfer or Discharge were sent with the resident. Administrative Nurse D stated the forms were not completed for R54's 02/11/25 discharge to the hospital. Administrative Nurse D stated the representative was typically notified by the nurse when being transferred and no written notification was mailed to them. The facility policy Transfer & Discharge effective 01/01/16 documented before the facility transfers or discharges a resident, it shall notify the resident and the resident's representative of the basis for the transfer or discharge in a language and manner they understand; they will also notify the state long-term care ombudsman. The notice of transfer shall include the information required under the law, including the resident's appeals rights, and shall be provided at least 30 days before the proposed date of the transfer or discharge unless sooner notice was permitted. Notice may be made as soon as practicable before a transfer or discharge when an immediate transfer was required due to urgent medical needs. The facility failed to provide a written notice of transfer as soon as practicable to R54 or their representative for their facility-initiated transfer. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R54.

The facility identified a census of 81 residents. The sample included 21 residents, with three sampled residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a bed hold policy to Resident (R) 14 and R54 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability for R14 and R54 to return to the facility and their previous rooms. Findings included: - R14's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and fracture of left tibia (broken bone of the lower leg). R14's Discharge MDS dated 09/13/24, documented an unplanned discharge to a short-term acute hospital with an anticipated return. R14's Entry MDS dated 09/16/24, documented a re-entry to the facility from a short-term acute hospital. R14's Discharge MDS dated 10/19/24, documented he had an unplanned discharge to a short-term acute hospital with an anticipated return. R14's Entry MDS dated 10/22/24, documented a re-entry to the facility from a short-term acute hospital. R14's Significant Change Minimum Data Set (MDS) dated 11/02/24, documented he had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R14 required substantial to dependent assistance from staff for functional abilities and activities of daily living (ADL). R14 required the use of a wheelchair for mobility. R14's goal for discharge was to remain in the facility. R14's Discharge MDS dated 12/24/24, documented he had an unplanned discharge to a short-term acute hospital with an anticipated return. R14's Entry MDS dated 12/31/24, documented a re-entry to the facility from a short-term acute hospital. R14's Functional Abilities Care Area Assessment (CAA) dated 11/04/24, documented that he was alert, had some confusion and was able to voice his needs for assistance. R14 needed assistance for ADLs, and can be self-limiting, and may refuse care. R14 was participating in therapy but had a history of refusing. R14 will remain at the long-term care center. R14's Care Plan revised on 02/12/25, documented he planned on living at the facility permanently due to his diminished functioning. The care plan directed staff to evaluate his physical, mental, and cognitive needs quarterly, annually, and as needed to ensure appropriate interventions were in place. Staff were directed that R14 only wanted to be asked about discharging annually and upon significant change. A General Notes in the Progress Notes tab of the EMR dated 09/13/24 at 12:13 PM for R14 documented the resident was sent to the emergency room to be evaluated and treated due to altered mental status. A bed hold policy was sent with R14, and his daughter was made aware. The facility provided an EINTERACT Transfer Form in the EMR dated 09/13/24 at 12:26 PM, documenting that R14 was transferred due to an unplanned altered mental status. The facility had not provided a written notification of transfer for R14's 12/24/24 discharge as it had not been completed for the transfer. On 03/11/25 at 09:18 AM, R14 laid on his back on his bed. R14's head of the bed was elevated, and the call light was within reach. On 03/11/25 at 02:29 PM, Administrative Nurse D stated that when a resident was sent out to the hospital Notice of Bed Hold Policy and the Notice of Transfer or Discharge was sent with the resident. Administrative Nurse D stated the forms were not completed for R14's 10/19/24 discharge to the hospital. H was out on leave with his daughter. Administrative Nurse D stated for R14's 12/24/24 discharge, a bed hold and written notification were not provided to the resident and his representative. The Bed Hold Policy dated 11/01/16 documented the facility would, in accordance with federal and state regulations, hold a resident's bed during a temporary hospitalization or therapeutic leave. Before the facility transfers a resident to a hospital or the resident goes on therapeutic leave, the facility would provide the resident or his or her representative the bed hold policy. If the resident required a transfer to a hospital or went on temporary therapeutic leave, the facility would hold the resident's bed for the duration required under state law, and law and allow the resident to return to the facility subject to the terms of this bed hold policy. The facility failed to provide a bed hold policy to R14 or their representatives when they transferred to the hospital. This deficient practice had the risk of impairing the ability of R4 to return to the facility and to his previous room. - R54's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R54's admission Minimum Data Set (MDS) dated 10/07/24, documented she had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R54 required moderate assistance from staff for oral hygiene, upper body dressing, and personal hygiene. R54 was dependent on staff assistance with all other functional abilities and activities of daily living (ADL). R54 used a wheelchair to assist with mobility. R54's goal for discharge was to discharge back to the community. Active discharge planning was occurring for the resident to return to the community. R54's Discharge MDS dated 12/09/24, documented an unplanned discharge to a short-term acute hospital with an anticipated return. R54's Entry MDS dated 12/11/24, documented a re-entry to the facility from a short-term acute hospital. R54's Discharge MDS dated 02/11/25, documented he had an unplanned discharge to a short-term acute hospital with an anticipated return. R54's Entry MDS dated 02/24/25, documented a re-entry to the facility from a short-term acute hospital. R54's Quarterly MDS dated 02/28/25 documented she had both short and long-term memory problems. R54 required moderate to maximal staff assistance with her functional abilities. R54 required the use of a wheelchair for mobility. R54's Functional Abilities Care Area Assessment (CAA) dated 10/08/24, documented she was alert, orientated, and able to voice her needs. R54 required assistance from staff for all daily care. R54 minimally participated in therapy. R54's overall goal for discharge was to remain in the facility. R54's Care Plan initiated on 03/10/25, documented that she planned on living at the facility permanently due to his diminished functioning. The care plan directed staff to evaluate her physical, mental, and cognitive needs quarterly, annually, and as needed to ensure appropriate interventions were in place. Staff were directed that R54 only wanted to be asked about discharging annually and upon significant change. R54's written notification of transfer or discharge was requested for her facility-initiated discharge to the hospital on [DATE] and 02/11/25. The facility provided a printout of R54's 12/09/24 at 08:29 AM EINTERACT Transfer Form in the Progress Notes tab of the EMR. The noted documented R54 was transferred due to being unresponsive. A General Notes note in the Progress Notes tab of the EMR dated 12/09/24 at 08:47 AM documented R54 was sent to the emergency room (ER) to be evaluated and treated due to unresponsiveness. The aides went to get her ready for breakfast but R54 was unable to respond to them. The nurse assessed R54, and she was hard to arouse, was mumbling a little bit, and responded to sternal rub by moaning. The nurse practitioner was notified, and an order was received to send her to the ER for evaluation and treatment. R54's daughter was made aware. R54's daughter arrived at the facility as emergency medical services (EMS) arrived. A bed hold policy was sent with R54 to the hospital. The facility was unable to provide evidence a Notice of Transfer or Discharge was completed and provided to R54 for her facility-initiated transfers on 12/09/24 and 02/11/25. The facility failed to provide evidence that a copy of the Notice of Transfer or Discharge was sent by mail within a reasonable time frame to R54's representative for the transfers. On 03/11/25 at 12:05 PM, staff propelled R54 from her room to the dining room for lunch. On 03/11/25 at 02:29 PM, Administrative Nurse D stated that when a resident was sent out to the hospital Notice of Bed Hold Policy and the Notice of Transfer or Discharge were sent with the resident. Administrative Nurse D stated the forms were not completed for R54's 02/11/25 discharge to the hospital. Administrative Nurse D stated the representative was typically notified by the nurse by phone when being transferred, and the bed hold was sent with the resident. The Bed Hold Policy, dated 11/01/16, documented the facility would, in accordance with federal and state regulations, hold a resident's bed during a temporary hospitalization or therapeutic leave. Before the facility transfers a resident to a hospital or the resident goes on therapeutic leave, the facility shall provide the resident or his or her representative the bed hold policy. If the resident required a transfer to a hospital or went on temporary therapeutic leave, the facility would hold the resident's bed for the duration required under state law and allow the resident to return to the facility subject to the terms of this bed hold policy. The facility failed to provide a bed hold policy to R54 or their representatives when they transferred to the hospital. This deficient practice had the risk of the impaired ability for R54 to return to the facility and to her previous room.

The facility identified a census of 81 residents. The sample included 21 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities on Sundays to promote socialization. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings included: - A review of the facility's Activity Calendar for January, February, and March 2025 was completed. The Activity Calendar for January 2025 recorded each Sunday listed church services at 02:00 PM. The Activity Calendar for February 2025 recorded each Sunday listed church services at 2:00 PM, Sunday 02/02/25 at 06:30 PM listed resident movie night, 02/09/25 at 06:30 PM listed game night, 02/16/25 at 06:30 listed resident chooses game night, and 02/23/25 at 06:30 listed resident movie night. The Activities Calendar for March 2025 recorded each Sunday listed church services at 02:00 PM, Sunday 03/02/25 at 06:30 PM listed residents choose a game to play, on 03/09/25 at 06:30 PM card games, on 03/16/25 at 0:6:30 PM board game, and on 03/23/25 listed movie time. On 03/11/25 at 10:00 AM, Resident Council members reported on Sundays, there were not many activities. The council reported they could go to church services. The Resident Council stated there were no consistent activities on Sundays, and residents stayed in their rooms and watched TV. The Resident Council stated the weekends get very long. The Resident council stated there are activities on the calendar for Sundays, these activities are supposed to be led by staff, they stated the staff are very busy and do not have time. On 03/12/25 at 01:05 PM, Activities Staff Z worked Monday through Friday, and the facility had church on Sundays, and either volunteers or staff-led activities on the weekends. On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R, stated the resident could go to church on Sundays, and there were staff-led activities or volunteers on the weekends. On 03/12/25 at 01:20 PM, Administrative D stated the facility had volunteers on Sundays, and the nursing staff did Sunday activities in the evening. She stated the facility did one-to-one with residents who were unable to attend the Sunday activity. The facility's Activities policy dated 04/22 documented it was the policy of the center to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Center-sponsored group, individual, and independent activities would be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities would encourage both independence and interactions within the community. The facility failed to provide consistent weekend activities for the residents to promote socialization. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation.

The facility identified a census of 81 residents. The sample included 21 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) for Resident (R) 2. This deficient practice placed R2 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), CHF, and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R2 was dependent on staff assistance with transfers. The MDS documented R2 had received diuretic medication (a medication to promote the formation and excretion of urine) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 12 which indicated moderately impaired cognition. The MDS documented that R2 was dependent on staff assistance with transfers. The MDS documented R2 had received diuretic medication during the observation period. R2's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/16/24 documented he required assistance with activities of daily living. R2's Care Plan dated 01/24/25 documented nursing staff would monitor his weight as ordered. R2's EMR under the Orders tab revealed the following physician orders: Daily weights using the same modality each time (Hoyer lift- total body mechanical lift) one time a day for CHF dated 09/02/24. Bumex (diuretic) oral tablet give two milligrams (mg) by mouth two times a day for CHF dated 09/09/24. Review of R2's Medication Administration Record (MAR) from 02/01/25 to 03/10/25 (37 days) lacked evidence staff measured and recorded R2's weight) on following three dates 02/20/25, 02/28/25, and 03/02/25. The MAR documented R2 had refused on the following two dates 02/10/25 and 02/14/25. The MAR documented R2 was asleep on 02/13/25. The MAR documented R2's weight was on hold the five dates 02/03/25, 02/04/25, 02/05/25, 02/08/25, and 02/11/25. The MAR documented other/see progress notes on the following two dates 02/02/25 and 02/09/25. The clinical record lacked documentation of physician notification of daily weight was not obtained. On 03/11/25 at 09:51 AM, R2 was asleep on his back on the bed. R2's side rails were up and locked on both sides of the bed. R2's pressure relieving devices were in place on his lower extremities. On 03/12/25 at 12:17 PM, Certified Medication Aide (CMA) R stated everyone would assist in obtaining the daily weights. CMA R stated the charge nurse would enter the weights into the resident's EMR. On 03/12/25 at 12:42 PM, Licensed Nurse (LN) G stated everyone was responsible for obtaining the daily weights. LN G stated the nurse would enter the daily weights in the resident's MAR. LN G stated the physician should be notified of any daily weights that were not obtained and the notifications would be documented in the resident's progress notes. On 03/12/25 at 01:29 PM, Administrative Nurse D stated she expected the charge nurse to ensure the daily weights were obtained and recorded. Administrative Nurse D stated the physician should be notified of any daily weights not obtained and a progress note written with the physician's response. The facility failed to provide a policy related to quality of care. The facility failed to follow a physician's order for daily weights related to R2's CHF. This deficient practice placed R2 at risk of adverse side effects from unnecessary medication or complications related to fluid overload.

The facility identified a census of 81 residents. The sample included 21 residents, with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 12 to promote the resident's highest practicable level of well-being. This deficient practice placed R12 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), insomnia (difficulty sleeping), and need for assistance with personal cares. R12's Annual Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted she used a wheelchair for mobility. The MDS noted she required partial to moderate assistance with bed mobility, transfers, dressing, bathing, personal hygiene, and toileting. The MDS noted no recent falls. R12's Functional Abilities Care Area Assessment (CAA) completed 02/16/25 indicated she was alert with some confusion. The CAA noted she may or may not voice her needs for assistance and had poor safety awareness. The CAA instructed staff to assist her with her daily care. R12's Care Plan initiated 06/03/24 indicated she had a self-care deficit related to her impaired cognition and dementia. The plan noted she required the assistance of one staff for transfers, dressing, bathing, bed mobility, grooming, and toileting. The plan instructed staff to provide hair, nail, and oral care daily and as needed. The plan lacked indication or interventions related to her dementia-related behaviors or refusal of care. R12's EMR under Progress Notes completed on 03/10/25 documented R12 transferred herself from her wheelchair to the nurse's station chair and began grabbing items off the nurse's desk. The note revealed staff were unable to redirect her and she remained at the station for four to five hours. The note indicated she eventually agreed to go to bed. R12's EMR under Progress Notes completed on 11/20/24 documented R12 was confused and asked to call a cab to go home. The note reported that R12 informed staff she had no money and didn't want to stay. The note indicated staff offered pudding but R12 refused to eat it. R12's EMR under Progress Notes completed on 09/29/24 documented R12 was educated not to eat roommates' food or drinks. The note indicated she was educated to keep her hands to herself. R12's EMR under Progress Notes revealed a note completed on 09/20/24 documented indicated R12 became agitated at staff and threw a water pitcher while staff attempted a check and change. The note indicated she then threw feces at staff. The note indicated staff were unable to redirect R12. No other interventions were noted. R12's EMR under Documentation Survey Report from 01/01/2025 to 03/12/25 (70 days reviewed) revealed she received bathing on 10 occasions: 01/02/25, 01/06/25, 01/20/25, 01/23/25, 01/30/25, 02/03/25, 02/17/25, 03/03/25, 03/06/25, and 03/10/25. The report noted she refused on nine occasions in the reviewed period. R12's EMR revealed no rationale or interventions offered for the refused bathing occurrences. On 03/10/25 at 07:40 AM, R12 sat in the dining area. R12's hair was greasy and uncombed. She reported she was not sure when her last bathing occurrence was and if staff offered to comb her hair. On 03/11/25 at 12:30 PM, R12 sat in her wheelchair in the dining room. Her hair was uncombed. On 03/12/25 at 11:30 AM, Certified Medication Aide (CNA) R stated that R12 had a history of refusing care and bathing. She stated staff would often ask to provide bathing assistance and report to the nurse if she refused. She stated that R12 would also refuse to allow staff to assist with grooming and activities. She stated staff would allow time for R12 to calm down and reoffer the care. On 03/12/25 at 11:45 AM, Licensed Nurse (LN) G stated that R12 refused bathing and care frequently. She stated staff should offer alternative care if she did not want bathing or showers. She stated R12 sometimes had confusion but rarely was aggressive or not redirectable. She stated offering R12 a snack was often effective. She stated the care plan should identify her behaviors and provide interventions to help staff understand how to calm her down. On 03/12/25 at 01:30 PM, Administrative Nurse D stated that R12 was often redirectable and loved sugary snacks. She stated staff were expected to be patient and allow her time to process what was asked. She stated staff were expected to provide options and alternatives to R14 if she refused her daily care. She stated staff were expected to chart refusals and note what interventions were attempted. The facility's Dementia Care revised 01/2016 noted the facility was to ensure care was provided in a consistent and dignified manner. The policy noted staff were to re-approach residents after refusals and respond to any behaviors of distress to ensure all unmet needs were addressed. The facility failed to provide dementia-related care services for R12 to promote the resident's highest practicable level of well-being. This deficient practice placed R12 at risk for decreased quality of life, isolation, and impaired dignity.

The facility reported a census of 88 residents with 13 selected for review including two residents reviewed for sexual abuse, Resident (R)4 and R5. Based on observation, interview, and record review, the facility failed to prevent sexual abuse on 09/26/23 at approximately 07:00 PM when Dietary Staff (DS) BB failed to immediately separate R4 away from R5, after DS BB saw R4 lift R5's dress. After witnessing the incident, DS BB went into the kitchen and told DS CC, which left R4 and R5 unsupervised, as no other staff were in the dining room at that time. DS CC stated when she walked out of the kitchen, she saw R4 had R5's dress pulled up with one hand and R4's other hand was on R5's thigh, and R5 seemed flustered and irritated. DS CC went to get the nurse on R5's hall, which again left R4 and R5 unsupervised. DS CC told CNA M that R4 had R5's dress pulled up exposing her, and his hand was on her thigh. CNA M stated when she entered the dining room, R4 was facing R5 with his arm up her dress and CNA M could not see where his hand was. CNA M's witness statement stated R4's hand was up R5's dress, rubbing her breast area, and he stopped and removed his hand when approached. CNA M stated R5 was teary eyed and had stated she kept telling him to stop and he wouldn't. This deficient practice allowed R4 to continue to sexually abuseR5 and placed her in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R4 included a diagnosis of major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R4 with a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, used a wheelchair for mobility, required supervision and setup for locomotion on and off the unit, and had no impairment of range of motion to his upper or lower extremities. The Annual MDS dated [DATE] for R4 assessed him with a BIMS score of 12, indicating moderate cognitive impairment. There were no changes to his locomotion on and off the unit, range or motion, or devices used for mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/30/23 revealed R4's BIMS score of 12 out of 15 indicated moderately impaired cognition. The Activities of Daily Living [ADL] CAA dated 08/30/23 revealed R4 was alert and oriented and able to voice his need for assistance and noted he was impulsive at times. The Care Plan dated 09/05/23 included an intervention dated 11/05/22, which revealed R4 seemed to be a social person, but lacked healthy boundaries with others. The facility revised R4's care plan on 09/29/23 to include a history of sexual urges. R4 acted on sexual urges on 09/26/23, required one to one monitoring continuously, and required medication changes on 09/27/23. The Medical Diagnosis tab for R5 included diagnoses of major depressive disorder, mild neurocognitive disorder without behavioral disturbance, need for assistance with personal care, muscle weakness, lack of coordination, cognitive communication deficit, and aphasia (condition with disordered or absent language function). The Admission MDS dated [DATE] for R5 assessed her with a BIMS score of five, indicating severe cognitive impairment, she had clear speech, and could make herself understood. She required extensive assistance of one staff for locomotion on and off the unit, used a wheelchair for mobility, and had impairment to her upper and lower extremity range of motion on one side. The Significant Change in Status Assessment MDS dated [DATE] assessed R5 with a BIMS score of seven, indicating severe cognitive impairment, had clear speech, could make herself understood. She required assistance of two or more for locomotion on and off the unit and had no changes to her range of motion. The Cognitive Loss/Dementia CAA dated 09/12/23 revealed R5's BIMS score of seven out of 15 indicated severely impaired cognition. The ADL Functional/Rehabilitation Potential CAA dated 09/12/23 revealed R5 was alert with some confusion, would voice her needs for assistance, and required extensive assistance of two staff for most daily cares. The Care Plan dated 09/20/23 revealed R5 was able to effectively communicate with others. The facility revised her care plan on 09/29/23 to include she was at risk for negative impact of trauma on physical and mental health related to her exposure to a sexual abuse experience. The Progress Notes dated 09/26/23 at 07:45 PM for R5 revealed at approximately 07:00 PM staff notified Licensed Nurse (LN) G of an incident that occurred in the dining room involving a male resident who put his hands up R5's dress and touched her inappropriately. R5 was tearful and LN G offered therapeutic communication and reassured her she was staff. Staff assisted R5 to her room and then to bed and performed a skin assessment. The Progress Notes for R4 lacked an entry regarding the incident until 09/27/23 at 04:18 PM by Consultant Staff Nurse Practitioner GG. The note revealed R4 had inappropriate sexual behaviors. The note revealed last night at dinner R4 put his hand up another resident's skirt and she began screaming and alerting the staff. According to Administrative Nurse G R4 admitted to what he had done. The facility investigation lacked any witness statements with the dietary staff regarding the incident on 09/26/23. The undated Witness Statement by Certified Nurse Aide (CNA) M stated at approximately 07:00 PM she entered the dining room and saw R4 with his hand up R5's dress and he was rubbing her breast area. CNA M stated when she approached, R4 stopped and removed his hand from R5. R5 stated to CNA M I told him to stop but he wouldn't. The undated Witness Statement , for the incident on 09/26/23 by LN G revealed when she asked R5 what happened she was tearful and stated, I kept telling him to stop and get away and he wouldn't. On 10/09/23 at 02:36 PM R5 was laying on his bed with his eyes closed and CNA P was in the room providing one to one supervision. On 10/10/23 at 04:50 PM CNA N stated on 09/26/23 around 06:30 PM after every tray served in the dining room, he saw R4 sitting in the dining room in his wheelchair by the front table, which was not his typical place where he would sit. CNA N stated R4 was not eating at that time and was watching him. CNA N stated he went to get something for another resident from the kitchen and R4 was several feet away from R5 at the time with his hands to himself. CNA N stated he exited the dining room to help assist residents to their rooms. On 10/11/23 at 09:13 AM CNA O stated she was on duty from 04:00 PM to 10:00 PM on 09/26/23. CNA O stated she had seen R4 earlier in the evening eating dinner about a table away from R5, R4 was sitting with a couple of male residents. CNA O stated she was not in the dining room when the incident occurred, however she took care of R5 that evening and she was pretty distraught at first and as time went on, she seemed like she did not quite remember it. CNA O stated that R5 told her she asked R4 to stop but she did not say what he did. On 10/11/23 at 09:55 AM CNA M stated she entered the dining room after DS CC came and got her, R4 was facing R5 with his arm up her dress, and she was not sure where R4 was touching R5. CNA M stated Dietary Staff (DS) CC came and got her because of what was going on. CNA M stated she was on her way to the dining room and was the first staff member DS CC saw. CNA M stated when she came up from behind R5, R5 stated I told you to stop. CNA M stated she had to ask R4 to stop and removed R5 away from him. CNA M stated at the time R5 was teary eyed and she told CNA M she kept telling him to stop and he would not. On 10/11/23 at 10:36 AM DS BB stated on 09/26/23 while cleaning off the tables in the dining room, she saw R4 talk to R5, and then later she saw R4 close to R5, R4 lifted up R5's dress or shirt up, and R5 stated what are you doing? DS BB stated went into the kitchen and told DS CC what R4 did. DS BB stated at that time there was not any other staff in the dining room. DS BB stated she did not hear R5 say anything else and did not see R4 do anything with the hand that was not lifting up R5's clothing. DS BB stated that was her first time she had been in that situation and did not know what to do. DS BB stated she stayed in the kitchen after telling DS CC R4 had lifted up R5's dress. On 10/11/23 at 10:54 AM Administrative Staff A stated if a resident touched another resident inappropriately, the staff should separate them immediately and isolate and remain with the perpetrator. On 10/11/23 at 11:05 AM DS CC stated on 09/26/23 DS BB had entered the kitchen and told her R4 was talking to R5 and R5 seemed irritated. DS CC stated then DS BB entered the kitchen a second time and said R4 had R5's dress pulled up, and that is when she was when she went out to the dining room as she knew that was not okay. DS CC stated when she walked out of the kitchen R4 had R5's dress pulled up with one hand and his other hand was on her thigh. DS CC stated R5 was not saying anything at that time and seemed flustered and irritated. DS CC stated she knew what hall R5 was on, so she exited the dining room to get the nurse, and approximately 30 seconds later she seen CNA M and told her R4 had R5's dress pulled up with his hand on her thigh and was exposing her. DS CC confirmed when she went to get the nurse there were not any other staff in the dining room. On 10/11/23 at 11:16 AM Administrative Nurse D stated she expected the staff to separate R4 and R5 immediately. The facility policy Abuse, Neglect, Misappropriation, Exploitation dated January 2019 defined sexual abuse as nonconsensual sexual contact of any type with a resident/patient. If actual violation or alleged violation occurs the resident will immediately be removed from any potential harm. The facility failed to separate R4 form R5 after witnessing unwanted touching, the staff twice left R4 and R5 unsupervised in the dining room, after observing R4 lifting R5's dress, and then again observing R4 lift R5's dress and place his hand on her thigh. This failure allowed R4 to continue to sexually abuse R5, which caused her to be tearful and reported to staff she had told him to stop, and he would not. On 10/11/23 at 03:20 PM Administrative Staff A was provided a copy of the Immediate Jeopardy Template and notified of the facility's failure to prevent sexual abuse with the failure to separate R4 from R5 on 09/26/23 at approximately 07:00 PM. The immediate jeopardy was determined to first exist on 09/26/23 and the surveyor verified the removal of the immediate jeopardy occurred on 09/27/23 at 11:57 PM, prior to the surveyor entrance, which deemed the deficient practice as past non-compliance when they completed the following: 1. On 09/26/23 at 07:05 PM R4 and R5 separated and R4 placed on one-to-one supervision. 2. On 09/26/23 at 07:10 PM emotional supportive care and safety reassurance provided. 3. On 09/26/23 at 07:15 PM interviewed R5. 4. On 09/26/23 at 07:27 PM assessment completed of R4 and R5. 5. On 09/26/23 at 07:30 PM resident responsible party and physician notified. 6. On 09/26/23 at 09:00 PM Kansas Department for Aging and Disability (KDADS) and police notified. 7. On 09/27/23 at 08:00 AM both residents referred to consulting Licensed Clinical Social Worker for emotional support. 8. On 09/27/23 at 11:30 AM alert and oriented interviews completed, and team member interviews completed. 9. On 09/27/23 at 11:57 PM completion to all team members educated or prior to working on Abuse policy, Elder Justice Act, and Trauma Informed Care. The deficient practice existed at a J scope and severity following the removal of the immediate jeopardy.

The facility reported a census of 86 residents, with three residents included in the sample and reviewed for wandering. Based on observation, interview, and record review the facility failed to ensure a safe, secure environment for cognitively impaired and independently mobile Resident (R)1, identified at high risk for elopement and who made exit seeking remarks. On 06/16/23 prior to 08:48 PM, R1 left the facility without staff knowledge. The facility staff last saw R1 at 07:30 PM and did not know R1 was missing until the local fire department called to ask about the found person and the facility then conducted a head count and identified R1 was missing. Upon investigation the facility discovered R1 exited the facility's [NAME] door without staff knowledge and/or supervision, and without the door alarming. R1 ambulated down the street approximately one block, unattended on an uneven sidewalk next to a road with a posted speed limit of 30 miles per hour, until a local community member picked R1 up and brought R1 to the local fire department. R1 fell while exiting the car at the fire department, which caused cause facial abrasions and a fractured left wrist. This failure placed R1 in immediate jeopardy. Findings included: - R1's 06/01/23 signed Physician's Orders revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). The 10/28/23 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The 05/18/23 Quarterly MDS indicated a BIMS score of four, indicating severe cognitive impairment. The 06/01/23 Care Plan revealed R1 was an elopement risk related to R1's comments I am leaving, going home with wandering and staying by the exit doors at times. The Nurse Notes dated 06/16/23 at 09:22 PM documented the facility received a phone call from the local fire department asking if R1 lived at the nursing home. The local fire department informed the staff the resident was presently with them and did sustain minor injuries. The fire department notified Emergency Medical Services to take R1 to the hospital, to which R1 declined. EMS arrived with R1 at 08:05 PM to the facility and R1 appeared alert, confused, and unable to recall what happened. R1 also had minor scrapes to his bilateral knees. Staff checked all exits and entrance doors for proper functioning and placed a new Wander Guard bracelet ( a device used to keep elderly people with dementia from wandering) to R1's left wrist. The Nurse Notes dated 06/16/23 at 08:50 PM revealed staff completed a skin assessment of R1 and noted abrasions on his forehead and bridge of nose, and scrapes to his bilateral knees. The note included R1 had bruising to his left hand to the lateral outer hand area. R1 declined to go to the hospital. Staff initiated neuro checks, administered routine medication, and placed a new Wander Guard to his left wrist. Review of the facility Investigation regarding the elopement of R1 on 06/16/23 at approximately 08:40 PM revealed the facility received a call from the local fire department that R1 was found by community member and brought R1 to the local fire station. As R1 got out of the car, R1 tripped, causing abrasions to his forehead, nose, and a fracture of his left wrist. All doors tested for proper functioning by charge nurse, and it was determined the west entrance Wander Guard was not alerting when the bracelets were in range. The doorway was then locked to prevent entrance and keypad placed out of order to prevent exit out of the door, until the Wander Guard system was evaluated and properly functioning. The company came out at noon the next day and the technician found a loose wire in the power board that kept the Wander Guard from alerting. The wire was fixed and the facility placed the door back into service at approximately 01:00 PM on 06/17/23. An x-ray report, dated 06/17/23, for R1's left wrist revealed the x-ray completed due to pain and a fall by the resident. The results documented the resident sustained an acute nondisplaced intra-articular fracture through the left radial syloid (left wrist). Observation on 06/22/23 at 03:00 PM, revealed R1 sat in a chair behind the nurse's desk with abrasions to his forehead, cheeks, and nose, presumed from the fall R1 had while out of the facility no bruising/swelling noted on his left wrist. Observation on 06/26/23 03:00 PM, revealed the street was approximately one block from the facility, with an uneven sidewalk next to a street. The street held a posted speed limit sign of 30 miles per hour. During an interview on 06/26/23 at 10:25 AM, Certified Medication Aide (CMA) R reported they did not know R1 went through the exit door. CMA R said it was not until the nurse received the phone call that the facility staff conducted a resident head count. CMA R stated after R1 returned the staff placed him on one-on-one observation and the staff received education on elopement. During an interview on 06/26/23 at 10:29 AM, CMA S reported the last time she saw R1 was when he tried to follow her through the double doors to go into the back part of the facility, on 06/16/23 and the wander guard alarm sounded. At that time CMS S redirected R1 away from the doors and then reset the alarm. During an interview on 06/27/23 at 08:20 AM, Licensed Nurse (LN) G revealed she was not working when R1 exited the facility. LN G stated the facility provided training on elopement to the staff to check the Wander Guard on each shift. LN G said there was an elopement book at the nurse's station that covered everything that needed to be completed with any possible elopement. LN G said if the Wander Guard alarm sounded, the staff were to check all the doors and complete a head count to verify all residents were in the facility. During an interview on 06/26/23 at 11:00 AM, Administrative Nurse D said the facility expected the staff to follow the elopement policy, check the Wander Guards every shift, redirect residents away from the doors, and if the alarm went off, to see if anyone was outside and initiate a head count. The 04/2017 facility Elopement policy revealed the facility would identify risk and establish interventions to mitigate the occurrence of elopement. Door alarm protocol team members knew how to respond to all door/exit alarms. Once door/exit alarms were activated a resident search was completed, ensuring there was no missing resident. The facility failed to ensure a safe/secure environment for cognitively impaired and independently mobile R1, identified by the facility to be a high risk for elopement, who made prior exit seeking remarks, and who exited the facility through a [NAME] door, which the Wander Guard alarm did not alert, on 06/16/23. The facility did not know R1 eloped until the local fire department called the facility regarding a found person and R1 fell while outside, sustaining abrasions to his face, nose, and a fractured left wrist. The facility immediately following the resident's return, identified and implemented the following corrective actions, which were completed on 06/18/23 at 05:51 PM: 1. The [NAME] door to the parking lot remained closed until the wander guard system had completed repairs on 06/17/23 at 01:00 PM. 2. All residents with Wander Guard bracelets were checked for functionality and positioning. 3. All resident at risk for wandering had care plan and elopement book updated. 4. All doors were checked for proper function and operation. 5. Wander Guard repaired by outside vendor, completed on 06/17/23 at 01:00 PM. 6. Reassessment completed for each resident for potential risk for elopement. 7. Verified team members to check proper placement every shift and functioning of Wander Guard bracelets was in the Electronic Medical Record. 8. Conducted an elopement drill with all staff educated on all three shifts beginning 06/16/23. 9. Elopement training with all staff started on 06/16/23 upon the resident's return to the facility and completed on 06/18/23 at 05:51 PM. The surveyor verified the completed corrective actions while onsite on 06/27/23. Due to the corrective measures identified and completed prior to the surveyor's initial entrance on 06/22/23, this deemed the deficient practice as past noncompliance at a J scope and severity level.

The facility reported a census of 87 residents, with 18 residents sampled, including five residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to provide adequate nutritional interventions for Resident (R)3, to maintain her body weight, and prevent a significant weight loss of 6.85% (percent) in less than one month. Findings included: - Review of Resident (R)3's electronic medical record (EMR) revealed a diagnosis of Crohn's disease (chronic inflammation of the bowel). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She required supervision with setup help for eating. Her height was 63 inches and she weighed 166 pounds (lbs.), with no or unknown weight loss or weight gain. The Nutritional Status Care Area Assessment (CAA), dated 04/18/23, documented to refer to the dietary notes. The Care Plan, dated 04/12/23, lacked staff instruction regarding nutrition or eating assistance for R3. Review of the resident's EMR revealed an admission weight of 166.4 lbs. on 04/07/23. Review of the resident's EMR revealed a Clinical Health Status Evaluation dated 04/07/23, which included the resident had no known chewing problems and the resident did not require adaptive equipment for meals. Her oral intake was a regular diet and liquids. Review of the resident's EMR revealed a Nutritional Screening, dated 04/17/23, which included the resident had no weight loss or gain on her regular diet with thin liquids. The resident had a swallowing disorder with a reported choking episode, per the progress notes. Review of the resident's EMR revealed a Registered Dietician (RD) Nutritional Assessment, dated 04/17/23, which documented the resident required a total of 1890-2100 calories, 61-76 grams (g) protein, and 1890-2280 cubic centimeters (cc), to meet her estimated nutritional needs. The resident could feed herself. The nutritional goal was for the resident to maintain her weight and consume greater than (>) 50-75% of all meals. Her nutritional intervention was for speech therapy (ST) to evaluate and treat. The resident's EMR documented a weight of 155 lbs. on 05/02/23, which revealed a weight loss of 6.85% (percent), in less than 30 days, from the 04/07/23 admission weight of 166.4 lbs. No other documented weights were available. The resident's EMR lacked physician notification of the weight loss until 05/02/23. Review of the resident's EMR revealed a Physician's Order for a house supplement twice daily (BID), and weekly weights for four weeks on Mondays, dated 05/08/23-- six days after the obtained weight with the significant decline on 05/02/23 Review of the resident's EMR, from 04/17/23 through 05/16/23, revealed the resident consumed 51-100% of meals and required setup help only for meals. On 05/17/23 at 09:27 AM, Certified Nurse Aide (CNA) C sat the resident up in bed and served her breakfast, which consisted of two pancakes, uncut, and ground sausage with gravy. CNA C then left the room. On 05/17/23 at 09:40 AM, the resident remained upright in bed with her eyes closed. Her untouched breakfast remained on the over the bed table. On 05/17/23 at 10:30 AM, the resident remained upright in bed with her eyes closed. Her untouched breakfast remained on the over the bed table. On 05/16/23 at 09:10 AM, CNA D stated the resident could usually feed herself. CNA D said the resident did not receive snacks or shakes during the day shift. On 05/16/23 at 02:50 PM, CNA G stated the resident could feed herself. CNA G stated the resident went to the dining room at times for the evening meal, but ate in her room at times, also. CNA G said the resident did not need assistance with meals. On 05/17/23 at 10:48 AM, CNA C stated the resident ate a couple bites of pancake and confirmed she had not reheated the resident's breakfast, which sat in her room for a long time before the resident was fed. On 05/16/23 at 11:08 AM, Licensed Nurse (LN) E stated all residents were weighed at least monthly unless otherwise ordered by the physician. If a resident had weight loss the staff would usually do weekly weights. LN E did not know the resident had a weight loss. On 05/17/23 at 08:06 AM, Dietary Staff O stated when a resident admitted to the facility staff obtained daily weights for three days. Dietary Staff O stated staff documented all weights in the computer system and weights were reviewed during morning stand up meetings. Dietary Staff O did not know of the resident's weight loss. On 05/17/23 at 12:08 PM, Dietary Staff K stated she expected the facility to notify her of any resident who had a weight loss so that she could review the resident and make recommendations. Dietary Staff K did not know when or if the facility notified her of the resident having a significant weight loss. On 05/17/23 at 08:14 AM, Administrative Nurse B stated weights were reviewed and discussed during the morning meetings. Administrative Nurse B said the computer sent an alert for residents who were showing a weight loss and for some reason the computer did not send an alert to show R3's weight loss. Administrative Nurse B stated the resident weights fell through the cracks. The facility policy for Weight and Height of Resident, effective 03/21/21, included residents with a recent unplanned weight loss and/or a history of weight loss will be weighed weekly. The resident will immediately be reweighed if there is a three pound greater/or less than the previous weight. A weight loss of 5 percent (%) in one month is significant; greater than 5% is severe. Review the resident's care plan to assess for any special needs of the resident. The facility failed to provide adequate nutritional interventions for R3 to maintain her body weight and prevent a significant weight loss of 6. 85% in less than one month.

The facility census totaled 96 with 23 residents included in the sample. Based on observation, interview, and record review the facility failed to thoroughly/consistently assess Resident (R)75 for signs of injury after a fall on 05/30/19. The facility further failed to notify the resident's physician after he repeatedly complained of pain from the fall for four days. The resident had an x-ray on 06/03/19 (four days after the fall), which identified the resident with a left femur and left shoulder fracture. Findings included: - Review of resident R75's Electronic Medical Record dated 06/07/19 revealed the following Diagnoses: [REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. R75 required two staff members for bed mobility, toilet use, and required total dependence on staff for transfers. The resident had a fall with major injury in the prior six months. Review of the falls Care Area Assessment (CAA) dated 06/14/19 revealed the resident fell on [DATE] and fractured his left clavicle and left hip. He was in the hospital on [DATE] for surgical repair of the left hip and had non-weight bearing restrictions for the left upper extremity (fractured clavicle). Review of Care Plan dated 10/22/19 revealed R75 had limited mobility, left sided weakness, and required two staff members for cares. The care plan documented a history of falls and identified the resident as at risk for future falls due to 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 one-sided weakness. Review of the Nursing Progress Note dated 05/30/19 at 07:59 AM revealed the resident complained of left side discomfort from the fall, which occurred at 06:59 AM. The facility initiated a standing order for [MEDICATION NAME] (pain medication). The facility notified the resident's representative via the telephone at the time of the note. Review of the Nursing Progress Note dated 05/30/19 at 08:18 AM revealed Nursing staff walked by R75's room and saw the resident lying on his left side on the floor. The nurse writer noted blood on a t-shirt by the resident. Staff assisted the resident back to bed with full body lift and two Certified Nurse Aides (CNAs). Staff assessed the resident for injuries and noted blood coming from R75's nose with no other injury noted. The writer further assessed redness to the resident's left arm, side, hip and ankle and the resident complained of pain to the left side of his body. The resident stated, it hurts more than normal. Review of the Fall Report regarding a fall dated 05/30/19 at 06:59 AM revealed R75 fell in his room when he attempted to sit up in bed, and staff assessed he had redness to left arm, side, hip, and ankle. Review of the Nursing Progress Note dated 05/31/19 at 10:52 PM revealed a new physician order for [REDACTED]. Review of the Nursing Progress Note dated 06/01/19 (two days after the fall) at 03:05 PM revealed R75's left foot swollen and painful. Staff would continue to monitor the resident. The note lacked any further assessment of the resident's injuries from the fall dated 05/30/19. Review of the Nursing Progress Note dated 06/02/19 (three days after the fall) at 03:01 PM revealed R75 complained of left hip pain and he refused to get up for meals. The note lacked any further assessment or follow up from the resident's complaint of pain or injuries from the fall three days prior. Review of the Nursing Progress Note dated 06/03/19 (four days after the fall) at 01:39 PM revealed the resident continued to report pain and discomfort related to his recent fall. Staff noted the resident's left eye bruised and left leg presented with [MEDICAL CONDITION]. The facility notified the physician extender and received an order for [REDACTED].>Review of the Physician's Order dated 06/03/19 revealed an order for [REDACTED]. Review of the Nursing Progress Note dated 06/03/19 at 07:03 PM revealed R75 had a fracture to his left shoulder and left femur/hip. Review of the Nursing Progress Note dated 06/03/19 at 10:15 PM revealed staff transferred R75 to the hospital for evaluation and treatment of [REDACTED]. Review of the Nursing Progress Note dated 06/09/19 at 12:46 AM revealed R75 had left hip surgery while in the hospital. An observation on 10/28/19 at 09:06 AM revealed R75 sat upright in a high-back wheelchair in his room with the door open. R75's upper body leaned to the far left of the wheelchair, his left arm appeared flaccid (limp), and his right hip was seated on the far-right side of the seat of his wheelchair. His head hung down, eyes were closed, and he appeared to be sleeping. R75's call light was not within his reach. During an interview on 10/24/19 at 10:35 AM R75 stated he fell out of bed and broke his hip and thought he broke his left shoulder. The resident reported his left shoulder hurt badly. An interview on 10/30/19 at 11:52 AM with Licensed Nurse (LN) W stated she would notify the physician immediately regarding post-fall pain and would not wait for swelling or further evidence to appear before she requested an order for [REDACTED]. An interview on 10/30/19 at 12:22 PM with Administrative Nurse B stated she expected nursing staff to notify the physician in a timely manner regarding post-fall pain or increased pain after a fall. If the resident had a history of [REDACTED]. A phone interview on 10/31/19 at 02:55 PM with Physician Extender J stated the facility reported R75 had left ankle pain after the fall and ordered an x-ray of the left ankle. Physician Extender J confirmed the facility did not notify the physician of R75's left hip and left shoulder pain until Monday on 06/03/19 (four days after the fall) when he/she ordered x-rays of the left hip and left shoulder. Review of the facility policy titled, Falls, revised (MONTH) (YEAR) revealed the following: To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. A fall is an unintentional change in position coming to rest on the ground, floor, or next lower surface either unassisted or assisted. The policy lacked information and/or instruction for notifying the physician about post-fall pain/injury, and duration and frequency of post-fall nursing/physical assessments. The facility failed to thoroughly/consistently assess Resident (R)75 for signs of injury after a fall on 05/30/19. The facility further failed to notify the resident's physician after he repeatedly complained of pain from the fall for four days. The resident had an x-ray on 06/03/19 (four days after the fall), which identified the resident with a left femur and left shoulder fracture.

The facility census totaled 96 residents with 23 residents in the sample and three residents reviewed for urinary catheters (tube placed in the bladder to drain urine into a collection bag). Based on observation, interview, and record review the facility failed to ensure the facility staff followed physician orders [REDACTED]. the skin). Findings included: - Review of R82's Electronic Medical Records (EMR) dated 10/08/19 revealed the following Diagnoses: [REDACTED]. or injury of the central nervous system or peripheral nerves involved in the control of urination). Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of 12, indicating moderately impaired cognition. The resident required extensive one person assistance for toilet use and personal hygiene, and the resident had an indwelling catheter. Review of the significant change MDS dated [DATE] revealed a BIMS of 12, indicating moderately impaired cognition. The resident required extensive assistance of two staff for toilet use and personal hygiene. The resident had an indwelling catheter. Review of the 10/10/19 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) revealed the resident had a new supra-pubic catheter and required extensive two person assistance for toileting needs. R82 had a urinary catheter with a penile tear and the hospital placed a supra-pubic catheter. Review of Care Plan dated 08/23/18 revealed the following: 09/19/19 - R82 had pain from his catheter (his urethra had torn) and catheter movement aggravated R82's pain. Staff would ensure the [MEDICATION NAME] was in place. 09/19/19 - Staff were to monitor/record/report to the nurse any signs or symptoms of non-verbal pain. 09/19/19 - Staff were to perform catheter care per facility protocol and check tubing for kinks every shift. R82 pulled on his catheter and staff encouraged him not to. 10/14/19 - The resident had an indwelling catheter with skin breakdown/wounds. R82 had bladder incontinence and he readmitted to the facility with a supra pubic catheter. Review of Physician order [REDACTED].>08/30/19 - Staff to apply petroleum jelly to the resident's urethral opening two times a day (BID) for his urethral tear until 09/16/19. 09/01/19 - Apply [MEDICATION NAME] to patient's thigh and replace every 7 days. Staff to secure catheter tubing in the [MEDICATION NAME] at all times and provide slack for the resident. Review of Weekly Skin assessment dated [DATE] revealed no skin issues to R82's penis. Review of Weekly Skin assessment dated [DATE] revealed R82's penis was split. Review of Situation, Background, Assessment and Recommendation (SBAR) - Change of Condition Situation note dated 08/28/2019 at 07:28 PM revealed the resident's penis was split and had been so according to the unidentified Certified Nurse Aide (CNA) since Monday 08/26/18 (two days prior). The note revealed the CNA stated she reported the tear to the nurse on duty that night. Review of physician progress notes [REDACTED]. to tear. The physician ordered a [MEDICATION NAME] instead of the leg-strap, which would be changed weekly. The physician encouraged the facility to teach good catheter/peri-care to staff and ordered the staff to complete the cares every shift. The physician noted the penile tear looked nearly healed, with just a small slit opening. Staff to apply petroleum jelly twice a day and monitor closely. Review of SBAR - Change of Condition Situation note dated 09/01/19 at 02:27 PM revealed the resident complained of pain to his penis and requested as needed (PRN) pain medications. The resident was resistive to care at times, due to pain. R82 penis was split from the catheter. Review of physician progress notes [REDACTED]. The physician ordered narcotic pain medication ([MEDICATION NAME]) and ordered staff to monitor the injury closely. Review of physician progress notes [REDACTED]. The resident was tearful and complained of pain at a 10/10 (a pain scale used to identify a resident's pain with one indicating no pain and ten indicating worst pain) after taking two [MEDICATION NAME] 7.5 milligram (mg) tablets. The nurse reported the resident's penis split open and the resident stated his penis hurts badly. The resident had a significant urethral tear to the left side penile head which appeared worsened since the last visit (09/03/19). The flimsy Velcro leg strap was still in place that was discontinued on 08/30/19 when she ordered the [MEDICATION NAME] as a replacement. The resident would be sent to emergency room (ER) for treatment of [REDACTED]. Review of General Note dated 09/05/19 at 02:37 PM revealed the facility sent the resident to the emergency room (ER) for evaluation of his urethral tear and hematuria. Review of hospital documentation dated 10/03/19 revealed the ER nursing staff called the facility, who reported the urethral tear happened on (MONTH) 26th or (MONTH) 3rd. Review of physician progress notes [REDACTED]. Observation of R82 on 10/28/19 at 10:03 AM revealed the resident in his room watching television with a catheter in place and a [MEDICATION NAME] noted to his left leg. Interview with CNA P on 10/30/19 at 11:34 AM revealed the urethral tear for R82 started a week to two weeks before he went to the hospital. CNA P said she was not told to change the Velcro strap that held the catheter or to do anything different other than watch the catheter closely each shift. She let the nurse know about his condition each shift so she could chart the state of his urethral tear. Interview with CNA O on 10/30/19 at 12:24 PM revealed two days before the resident went to the hospital, he complained of his genital area hurting. CNA O told Licensed Nurse (LN) N and about 30-45 minutes later, LN N checked on him, cleaned the area, asked him about his pain. CNA O reported R82 had a Velcro strap to hold his catheter which gave it a little slack but remained tight enough to hold it in place. The catheter could move around, but not a lot. R82 pulled on his catheter because he was having pain, but he had never pulled on it before that. An attempt to interview LN N on 10/30/19 could not be completed as she refused to speak with the surveyor (no longer employed by the facility). Interview with LN F on 10/28/19 at 10:17 AM revealed on 09/05/19 at 2:00 PM, the CNA informed her R82's penis was torn and bleeding. LN F went into the resident's room and found R82's penis torn and bleeding. LN F called the doctor and sent R82 to the ER. LN F did not think R82 had a strap holding his catheter and thought she had to go find a strap so that the catheter did not get pulled on and would be held in place. LN F thought the catheter had been pulled on or something because if catheters get pulled on, they will cause an injury, but she also said she never saw the resident pull on his catheter. Interview with Administrative Nurse B on 10/28/19 at 03:06 PM revealed she expected the staff to change the Velcro strap to the [MEDICATION NAME] when it was ordered on [DATE]. Interview with Administrative Staff A on 10/28/19 at 03:14 PM revealed she expected the staff to change the Velcro strap out to the [MEDICATION NAME] and said the staff should have followed the physician orders. Interview with Physician Extender J on 10/28/19 at 11:00 AM revealed she talked with the facility nurse about changing out the Velcro strap to a [MEDICATION NAME], to give proper slack and not pull on R82's catheter the way the Velcro strap did. Physician Extender J stated she discontinued the Velcro strap and put the [MEDICATION NAME] order in. After the weekend her work partner saw the resident and asked her about it and said the urethral tear was worse. Physician Extender J asked if staff changed the Velcro strap to the [MEDICATION NAME] and her work partner said it was still the Velcro strap. The next day, she saw the resident and he had bright red blood in his catheter tube and bag. Physician Extender J said R82's penis looked much worse than it had been the last week, and she noted the Velcro strap was still in place. Physician Extender J stated she had no knowledge the resident pulled on his catheter before he went to the ER. Review of Clinical Nursing Skills and Techniques (reference book for evidenced based nursing clinical skills) used by the facility regarding catheters dated 2014 revealed there should be a device to secure the resident's catheter. Staff would secure an indwelling catheter with a catheter strap or other securement device. Staff would leave enough slack to allow for leg movement. Securing the catheter reduced the risk of urethral erosion. The facility failed to ensure the facility staff followed physician orders [REDACTED].

The facility had a census of 107 residents. The facility identified 18 residents at risk for elopement. The sample included 3 residents at risk for elopement. Based on observation, interview and record review, the facility failed to provide 1 of 3 residents with adequate supervision to prevent elopements when staff failed to respond appropriately to a sounding door alarm at approximately 2:00 a.m., failed to conduct a thorough search of the area outside the building in response to the door alarm, and failed to ensure all facility residents were present and accounted for after the door alarm sounded. Resident #1, a resident with a [DIAGNOSES REDACTED]. Failure of staff to provide adequate supervision to prevent elopement placed Resident #1 in immediate jeopardy. Findings included: - Resident #1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 4/26/19 quarterly minimum data set (MDS) identified the resident with moderate cognitive impairment with a brief interview for mental status (BIMS) score of 8, no wandering behaviors, independence with transfers and ambulation and no balance impairments. The 4/30/19 care plan noted the resident's risk for elopement as well as a history of wandering prior to admission to the facility. According to the care plan, the resident was at risk for elopement due to confusion and dementia. The care plan also described the resident's confusion and lack of awareness of the current month of the year, or day of the week. The care plan noted the resident's risk for falls related to balance/gait issues. A 5/2/19 intervention described the use of a Wanderguard alarm (bracelet that sets off an alarm when residents wearing the bracelet attempt to exit the building without an escort). On 5/3/19 a note on the care plan described the resident's elopement from the facility which occurred when the resident went to look for his/her spouse because he/she failed to answer the phone. The facility reviewed/revised the care plan following the elopement to include multiple interventions to prevent further elopements. An elopement risk assessment completed on 3/9/19 identified the residents as at risk for elopement and noted the use of a Wanderguard. Progress Notes included: 1/17/19: An admission note described the resident's [DIAGNOSES REDACTED]. 1/30/19 at 1:23 a.m.: The entry described the resident's pacing behaviors throughout the night shift and placement of the resident on every 30-minute visual checks. 1/30/19 at 11:59 p.m.: The entry described increased attempts to pack personal items and leave the facility. According to the note, the resident continued to wander throughout the facility during the nighttime hours and remained on 30-minute visual checks. The note described use of a Wanderguard bracelet. 2/1/19 at 3:00 a.m.: The note described the resident's repeated attempts to exit facility doors as well as continued wandering throughout the facility the entire night. 2/2/19 at 2:56 a.m.: The note described placement of the resident on 15-minute visual checks due to increased elopement risk. 2/3/19 at 5:02 a.m.: The note described continuation of 15-minute visual checks due to his/her elopement risk and wandering behaviors. 2/3/19 at 10:26 a.m.: The entry described placement of the resident on 30-minute visual checks due to his/her elopement risk. According to the note, the resident repeatedly tried to walk out the front door. 2/4/19 at 7:05 a.m.: The note described the resident's threat to walk home. 2/17/19 at 6:52 a.m.: The entry described the resident as exit seeking and noted an attempt by the resident to open a fire escape door to exit the building. 2/17/19 at 7:31 a.m.: The note described the resident's verbal threats directed at staff related to staff who attempted to stop him/her from leaving the building. 2/17/19 at 3:51 p.m.: The entry described the resident's constant attempts to open doors to leave the facility to go to a relative's house. According to the note, staff completed visual checks of the resident every 15 minutes. 3/1/19 at 9:02 p.m.: The entry described continuation of the 15-minute visual checks due to his/her elopement risk. 3/13/19 at 7:43 a.m.: The note described continuation of the 15-minute visual checks. 5/3/19 at 1:42 p.m.: The note described the resident as very restless and wandering down the hallways. Review of the progress notes lacked additional mention of resident #1's elopement from the facility on 5/3/19 at approximately 2:00 a.m. The facility investigation of resident #1's elopement described the sounding of a door alarm on the Hall 2 service hall on 5/3/19 at approximately 2:00 a.m. According to the investigation, Licensed Nurses C and D immediately responded to the door alarm. The nurses looked around the area directly outside of the door as well as in the nearby smoke shack and did not see anyone. One of the nurses saw two people standing in the parking lot of a nearby apartment complex but did not identify either person as a facility resident. As the nurses watched, the two people in the parking lot began to walk farther away. Licensed Nurses C and D then went back inside the building and accounted for the residents on the halls to which they were assigned which included 4 of 5 hallways within the facility. At approximately 3:30 a.m., 1 1/2 hours after the door alarm sounded at 2:00 a.m., the resident presented himself/herself to the front door of the facility and wanted to enter. The resident did not wear a Wanderguard bracelet at the time of his/her return. The resident experienced no injury as a result of the elopement. A 5/7/19 notarized statement from Licensed Nurse C described the 5/3/19 sounding of the Hall 2 door alarm at approximately 2:00 a.m Licensed Nurse C reported he/she saw 2 people standing in the nearby apartment complex parking lot but did not identify either person as a facility resident. Nurse C reported he/she then went back inside the facility and completed rounds on Hall 1. At approximately 3:30 a.m., staff heard a knock on the front door and discovered resident #1 and an occupant of the apartment complex standing outside the door. The apartment occupant told staff he/she and resident #1 just walked around and visited the entire time the resident was outside. A 5/7/19 notarized statement from Licensed Nurse D described the sounding of an alarm on 5/3/19 at approximately 1:45 a.m. - 2:00 a.m Upon arrival at the Hall 2 door, Nurse D reported the red alarm on the door was not sounding. Another nurse looked outside and did not see anyone outside the door. According to Licensed Nurse D, he/she then went outside to look in the smoke shack and surrounding area. Nurse D saw 2 people in the parking lot of the apartment complex and wondered if they had tried to gain access to the facility and that was why the alarm sounded. Nurse D watched as the two people in the parking lot walked off together. Nurse D and the other nurse then returned inside the facility and ensured the residents on their hallways were accounted for. At approximately 3:30 a.m., a person brought Resident #1 to the front door of the facility and asked if he/she was a facility resident. A 5/7/19 notarized statement from Licensed Nurse E described his/her assignment to Hall 5 on the night of 5/3/19, the hall on which resident #1 lived. According to the statement, resident #1 was not sleepy and had spent time in the Hall 5 lobby until returning to his/her room at approximately 1:30 a.m. Licensed Nurse E reported he/she heard a faint alarm sound at approximately 1:45 a.m. and thought it might be an IV (intravenous) pump alarm so he/she checked all the IV pumps. Nurse E reported he/she also checked all the doors on Hall 5 to ensure they weren't the source of the sounding alarm. Nurse E then went to the West side of the facility and heard 2 nurses talking about an alarm. The West side nurses did not advise Nurse E of any concerns related to an alarm or residents, so Nurse E returned to Hall 5. Licensed Nurse E then described resident #1's return to the facility at a later time. The facility staff provided notes related to an interview with resident #1 on 5/3/19. At that time, the resident reported he/she left the building with the intention of going home to see his/her spouse. The resident described the door he/she used to exit the building. According to the statement, when the resident got outside, he/she saw a person with a dog standing in a parking lot. The resident then approached the person and they visited for a while and walked the dog. The resident then returned to the facility. During an observation on 5/7/19 at 3:00 p.m., the facility was located in a residential/business neighborhood with a swimming pool and city building located directly across the street. An apartment complex was located to the left of the north end of the facility. A creek with running water was located approximately 100 - 150 yards from the facility to the west and curving around to the south side of the facility. A street and expanse of grass separated the facility from the creek. During an observation on 5/7/19 at 5:00 p.m., resident #1 wore a Wanderguard bracelet on his/her left wrist. During an interview on 5/7/19 at 5:00 p.m., direct care staff F reported the resident used a Wanderguard bracelet since admission to the facility but had the ability to remove the bracelet. Staff F reported the resident sometimes chews off the bracelet to remove it. During an interview on 5/7/19 at 5:05 p.m., licensed nurse G reported resident #1 removed the Wanderguard bracelet at least 5 times in the past 30 days. According to nurse G, the resident used nail clippers, a butter knife and who knows what else to remove the bracelet. Nurse G reported staff attempted to keep the Wanderguard in place by placing it in different locations on the resident's body, but the resident still managed to remove the Wanderguard. Nurse G was unable to verbalize other interventions used to prevent elopement once staff knew the resident could remove the Wanderguard bracelet. During an interview on 5/9/19 at 9:56 a.m., administrative nurse B reported resident #1 lived nearby prior to admission, which added to the resident's desire to go home. Nurse B reported the staff determined a need for every 15 minute or every 30-minute visual checks based on their nursing judgement and then communicated the information to other staff via communication reports and/or word of mouth. When discussing resident #1's elopement on 5/3/19, nurse B reported nurses who worked that night failed to follow facility policy to check on the whereabouts of all residents after the staff heard the sounding alarm and could not locate any residents outside. Nurse B reported the nurses on the West side also failed to communicate with the Hall 5 nurse about the sounding alarm and therefore that nurse failed to account for all of his/her residents on his/her hall as well. The facility's (MONTH) 2019 Elopement policy included, Team members know how to respond to all door/exit alarms. Once doors/exit alarm are activated a resident search is completed ensuring there is no missing resident The facility failed to provide resident #1 with adequate supervision to prevent elopements when the staff failed to respond appropriately to a sounding door alarm at approximately 2:00 a.m., failed to conduct a thorough search of the area outside the building in response to the door alarm, and failed to ensure all facility residents were present and accounted for after the door alarm sounded. Resident #1, a resident with a [DIAGNOSES REDACTED]. Failure of staff to provide adequate supervision to prevent elopement placed resident #1 in immediate jeopardy. The facility implemented immediate corrective action to prevent elopements and to ensure safety of all facility residents on 5/3/19 by completing the following: Placed resident #1 on 1:1 staffing immediately upon his/her return to the facility on [DATE] to continue for 24 hours with re-evaluation at the end of that 24-hour time period Completed a new elopement risk assessment for resident #1 on 5/3/19. Checked the 18 residents who used Wanderguards for placement and function on 5/3/19. Checked all exit door alarms and Wanderguard alarms for functionality on 5/3/19. Changed the key pad codes on the doors on 5/3/19. Changed the batteries on all battery-operated door alarms on 5/3/19. Ensured the Elopement Books contained identifying information and pictures for all residents determined to be at risk for elopement. Initiated staff training on the facility elopement policy immediately after the elopement on 5/3/19. The staff education was completed with all facility staff (90-100 total) except 2 staff who were not available. The facility had developed a plan to ensure those 2 staff receive training prior to their next assigned shift. Initiated elopement drills on all 3 shifts on 5/3/19 by doing specific scenarios to ensure staff responded appropriately to alarms, completed follow up head counts, and properly initiated searches for missing residents. Conducted an immediate QAPI (Quality Assurance Performance Improvement) discussion on 5/3/19 with required members to address the elopement and prevent additional elopements. Based on the facility's development and implementation of immediate interventions to address the elopement prior to onsite investigation by the State Survey and Certification agency, the incident was considered to be past noncompliance.

The facility census totaled 107 residents with 15 residents included in the sample and 4 sampled for accidents. Based on observation, interview and record review, the facility failed to provide supervision, assistive devices and investigate for causal factors to develop interventions to prevent future falls for 2 of 4 sampled residents (#4 and #8). Cognitively impaired resident # 4 had a history of [REDACTED]. The resident fell on [DATE] with facility staff re-education of the resident to use the call light to call for staff assistance with getting into the wheelchair, bathroom or ambulating. The cognitively impaired resident fell again on 8/11/17 at 1:55 AM and staff failed to implement effective interventions and investigate for causal factors and indicated they re-educated the resident to use the call light. The resident fell again on 8/11/17 at 3:52 AM and later that day went to the emergency room and was diagnosed with [REDACTED]. Findings included: - Review of the interagency transfer (IAT) form dated 7/10/17 revealed the following [DIAGNOSES REDACTED]. The History and Physical dated 6/10/17 included [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE] did not include an assessment for mental status. The resident exhibited physical behaviors towards others on 1-3 days of the 7 day observation period with no rejection of cares. He/she required extensive assistance from 1 staff for bed mobility, transfers, dressing and toileting use and walking activity did not occur. The resident was occasionally incontinent of bladder, had no routine or as needed (PRN) pain medications and did not report a presence of pain. He/she had a history of [REDACTED]. The Medicare 14-day MDS dated [DATE] included a brief interview for mental status (BIMS) score of 11, indicating moderately impaired cognition. He/she knew the year and the month but not the day of the week and could only recall test items with cueing. He/she had no behaviors and required limited assistance of 1 staff for bed mobility, transfers, toileting and walking with 1 staff assistance on 1 or 2 days of the 7 day observation period. The resident did not receive routine or PRN pain medications and denied the presence of pain. He/she fell on ce since the 7/17/17 MDS which resulted in a non-major injury (skin tear, abrasion, superficial bruises and such). The admission health status dated 7/11/17 identified the resident as oriented to person and place with memory problems, hearing impaired and needed assistance of 1 staff for bed mobility/transfers/dressing/toileting. Fall risk identified factors of impaired gait/balance and history of falls with fractured and impaired lower extremity strength and medications that increased his/her risk of falling. The cognition and communication care plan with an onset date of 7/10/17 directed staff to listen to the resident's concerns and wishes and inform his/her guardian as needed. Allow resident to make daily decisions about what to wear and activity to participate in and preference for what to eat. His/her guardian would make all medical and placement/life decisions. Observe the resident for changes in cognitive status. The activities of daily living (ADLs) care plan with an onset date of 7/10/17 directed staff to assist the resident as needed with toileting. The at risk for falls care plan with onset date of 7/13/17 directed staff to provide the resident with stand-by-assist for all ambulation and assist with 1 staff member for all ADLs. Staff should keep the resident's walker within reach at all times, remind him/her to ask for assist with ambulation, keep bed in lowest position and keep call light in reach. Staff should refer the resident to physical therapy for evaluation as needed (PRN). On 7/23/17 staff updated the care plan when the resident fell and broke his/her hip and was at the facility for therapy and directed staff to assist the resident with 1 staff member for all ambulation. Staff educated the resident to always ask for assistance with ambulation on 7/23/17 (repeated intervention from 7/13/17). Staff should observe for changes in his/her condition which could warrant increased supervision/assistance and notify the physician. Referral to restorative/rehabilitative nursing program PRN , keep the bed in the lowest position, he/she had a touch pad call light, staff should keep room/area free of clutter and the resident could be weight bearing as tolerated (WBAT) with hip precautions (do not cross legs or ankles when sitting, standing or lying down. Do not bend too far forward from the waist or pull leg up past the waist). Review of the Inter Agency Transfer (IAT) signed 7/10/17 revealed orders for skilled services including physical and occupational therapy, wound care and WBAT with hip precautions for the left lower extremity. Review of a Doppler study results for the left lower extremity dated 7/27/17 revealed no acute illness with the left lower extremity or deep vein thrombosis (a blood clot within a deep vein, typically in the thigh or leg). Review of the physician's orders [REDACTED]. Review of the Post fall/trauma assessment dated [DATE] revealed staff found the resident on the floor at 4:00 PM. The resident had walked in his/her bathroom without staff assistance, toileted and while walking back to the bed he/she slipped and fell . The resident wore gripper socks but the socks were worn out. He/she received a skin tear and had received an anticoagulant (blood thinner medication) in the past 24 hours. Interventions to prevent future falls included non-skid socks and encouraged the resident to ask for assistance with transferring and walking. Review of the nursing notes between 8/2/17 and 8/10/17 revealed the following: On 8/2/17 staff made an MDS completion note which indicated the resident had a BIMS of 11 out of 15, mild dementia and could communicate effectively with others. None of the Nursing notes between 8/2/17 and 8/10/17 lacked documentation of any left leg swelling or abnormalities. On 8/11/17 at 7:13 AM licensed nurse A recorded the resident had confusion, and observed ambulating down the hall with his/her wheelchair independently looking for his/her sweater. Nurse A walked with the resident to his/her room doorway and met with direct care staff B who finished assisting the resident into the room. The resident fell on his/her hands and knees after he/she turned with the wheelchair at 1:55 AM. He/she did not hit his/her head and range of motion (ROM) remained within normal limits except for the left lower extremity (LLE) which had abnormal ROM and the resident voiced no complaints of discomfort related to fall. On 8/11/17 at 8:01 AM licensed nurse A made an addendum to the previous note and recorded he/she also observed the resident seated on the floor on his/her buttocks with the chair flipped on its back and the small wheels in the air at 3:52 AM. The resident denied pain related to the fall,. The nurse noted the resident with abnormal ROM in the left lower extremity. The nurse indicated he/she started Neurological checks on the resident and the neurological checks were within normal limits. On 8/11/17 at 2:19 PM licensed nurse C documented after receiving report from licensed nurse A he/she checked the resident's left leg and it appeared twice the size of his/her right leg from the knee to the hip. Nurse C notified the on-call physician group (IPC The Hospitalists Company) and received orders for mobile X-ray of the left leg/hip 3 views. The Nurse practitioner arrived before mobile X-ray and after his/her assessment, canceled the X-ray and wrote orders to send the resident to the emergency room by emergency medical services which arrived and transported around 8:30 AM. On 8/11/17 at 3:07 PM a nurse recorded he/she received an update on resident #4. The ER assessment revealed a new fracture of the left femur just below the previous repaired hip fracture. The ER stated the resident was scheduled on 8/12/17 for surgical repair of the new fracture. Review of the Post fall/trauma assessment dated [DATE] at 1:55 AM revealed the resident was seen walking in the hallway with his/her wheelchair independently while looking for his/her sweater (information the same as the nursing note above). The resident had LLE limited ROM, a skin tear to right outer forearm. Under the section for physical assessment the nurse recorded the resident had signs and symptoms of a urinary tract infection and left thigh swelling with abnormal ROM. Interventions included education to the resident the importance of using the call light for assist, explained he/she needed help with transfers and he/she agreed to use the call light for assist. The assessment lacked documentation of increased supervision or frequent visual checks as an intervention implemented after the fall on 8/11/17 at 1:55 AM. Review of the Post fall/trauma assessment dated at 3:52 AM revealed staff observed the resident seated on the floor on his/her buttocks with the wheelchair flipped on its back and the small wheels in the air. The resident denied pain related to the fall and had abnormal ROM to the left lower extremity and neurological checks were initiated and were within normal limits. Staff assisted the resident to bed and properly positioned the resident in bed and monitored him/her closely. The report listed the same injuries as noted in the 1:55 AM fall. Interventions included education of the resident on standing, walking and transferring without assist, educated to use call light for assist and monitored closely. Provide diversional activities or one-on-one supervision if the resident continued to stand without assist. Review of the neurological evaluation flowsheet dated 8/11/17 starting at 4:00 AM revealed licensed nurse A assessed the resident's left leg stimulus with a Pa (alternate stimulus squeezing of the trapezius muscle which is located in the shoulder so not indicative of a leg impairment) and marked with an asterisk symbol (licensed nurse A said on 8/15/17 at 2:07 PM the asterisk meant it was abnormal). He/she confirmed the record lacked any documentation defining what the abnormality of the neurological assessment which he/she marked with an asterisk. The left leg response was marked with N meaning no response. Interview on 8/14/17 at 3:40 PM with direct care staff B revealed after he/she received shift to shift report around 10:00 PM on 8/10/17, he/she started the usual routine of passing ice water, clean towels and checking on residents as well as answering call lights. He/she confirmed being assigned to care for the resident on 8/10/17 into 8/11/17 (overnight shift). He/she said the resident normally slept all night and he/she would check the resident every 2 hours to see if the resident needed to use the bathroom and normally the resident would not get up for the bathroom. Staff B said on the night he/she did nothing different and had not received any information in report to indicate any changes in the resident. He/she went in to check on the resident around 1:30 AM and asked if the resident needed the bathroom which he/she did not. At 1:55 AM he/she saw the resident walking in the hallway towards the nursing station by the laundry barrels. The nurse approached the resident and helped him/her to walk back to his/her room. Direct care staff B exited another resident's room and approached the nurse and the resident. Once at the room door the nurse turned as he/she walked out of the room. He/she was in the doorway with his/her back towards the resident. Staff B visualized the resident standing in the room with his/her wheelchair and saw the wheelchair start to move but could not get to the resident before he/she fell . The nurse also turned around but could not stop the fall and the resident landed on his/her hands and knees. Direct care staff B reported the nurse checked the resident for injuries and he/she did not have any pain. Direct care staff B and licensed nurse A used a gait belt to help the resident to stand and transferred him/her into the wheelchair. Staff B said he/she could see the resident's legs and nothing was swollen or rotated it looked normal. Then he/she moved the resident in the wheelchair next to the bed and staff B and nurse A stood the resident and did a pivot transfer to get him/her into the bed. He/she reported this event occurred around 2:00 AM on 8/11/17. He/she then resumed duties of answering call lights, taking vital signs and other assigned duties. At about 4:00 AM direct care staff B observed a call light on across the hall from the resident and went to answer the call light. As staff B approached the room with the call light activated he/she saw resident #4 seated on the floor and alerted the nurse. He/she said the resident's left leg from about 3 inches above the knee to the hip was swollen, his/her left foot turned inward and the knee outward and he/she could not lift the leg but never complained of pain. Staff B said he/she asked nurse A if he/she would send the resident to the hospital and the nurse said, No, he/she did not have time to send the resident because he/she needed to finish the first fall report and pass medications and call the doctor. Direct care staff B said after the 3:52 AM fall he/she checked the resident every 15 minutes taking vital signs and making sure the resident remained comfortable and every time he/she would look at the resident's leg and noted it to be the same. Interview on 8/15/17 at 2:07 PM with licensed nurse A revealed he/she worked on an as needed basis and had not cared for the resident more than a few times. He/she reported finding the resident walking in the hallway at 1:55 AM with his/her walker and no staff assistance. Nurse A reported he/she walked with the resident back to his/her room. He/she encountered direct care staff B along the way and direct care staff B took over assisting the resident. He/she reported direct care staff B was about 1 step away from him/her and the resident when he/she turned and walked back towards the nursing station. He/she was 2-3 doors down the hall when the aide called out about the fall. Nurse A reported the intervention was to educate the resident to call for assistance and to use the call light. He/she did not start one-on-one supervision or 15 minute visual checks and when asked about the education being the same as previous interventions nurse A reported he/she did not implement any new intervention to prevent future falls. When asked about abnormal ROM of the left leg he/she reported doing a chart review and saw the resident's leg was swollen before and had a Doppler done and saw the results were negative. He/she reported the resident already had abnormal ROM to the left leg from his/her previous fracture and repair. The nurse indicated the resident could adduct (move in towards the body) and abduct (move away from the body) the leg and lift the leg after the 1:55 AM fall but not after the 3:52 AM fall. He/she said the abnormality was the swelling. Nurse A said he/she directed the direct care staff to monitor the resident more closely but he/she did not know if the staff actually checked on the resident more frequently or not. He/she said the facility had a 15 minute check form but he/she did not have the staff do one that night. He/she reported recording the 1:55 AM fall in the IPC doctor's book so the physician or nurse practitioner would know late in the morning of the fall. He/she confirmed direct care staff B asked about sending the resident into the hospital and he/she told staff B he/she would assess the resident first. He/she said the neurological checks did not change and the swelling did not increase until the last check around 5:45 AM when he/she asked licensed nurse C to assess it also. Interview on 8/14/17 at 4:29 PM with administrative nurse E revealed an expectation for the nurse to call the director of nursing or the nurse on-call and the medical director to report falls with injuries. He/she identified an expectation for the physician to be called with the documentation of swelling and abnormal ROM. Interview with physician D on 8/14/17 at 3:15 PM confirmed neither physician D nor the on-call service received a call from the facility on 8/10/17 or 8/11/17. He/she said if the nurse noted anything out of the ordinary for the resident then the nurse should call because falls with the elderly could be fatal. He/she reported pain was not a good indicator of injury and he/she had seen many patients with fractures who did not have pain. The swelling and inability to complete ROM indicated potential of an injury and nursing staff should have notified the physician on call. Review of the facility's policy for a falls dated 4/2017 revealed directions to staff of what to do post fall: patient was physically assessed for injuries and medical attention is rendered as needed. The physician and resident's representative are notified of the fall, a fall Huddle was called to help in investigation circumstances around the fall and help determine immediate interventions. The post fall evaluation was completed to assist in developing and implementing interventions to prevent future falls. IPC Hospitalist Company standing order for skilled and Long Term Care (LTC) units dated 5/1/14 directed staff for falls: nursing to complete a thorough assessment. If no apparent injury, continue routine vital signs and assessments per facility protocol and notify the provider the next business day. Call provider for injury falls. The facility's Neurological Observations policy and procedure dated 8/1/12 directed staff to check the movement of all extremities and communicate changes to the responsible physician. The facility failed to provide supervision and thoroughly investigate for causal factors with each fall and use those results to develop effective interventions to prevent future falls for this cognitively impaired resident with a history of falls, hip fracture and inability to remember to call for help. The resident fell on [DATE] at 4:00 PM with no new interventions and repeated to remind the resident to call for help. The resident fell again at 3:52 AM on 8/11/17, which resulted in a fractured femur (leg bone) and transfer to the hospital for surgical intervention.

The facility reported a census of 115 residents. Based on observation, interview and record review, the facility failed to implement appropriate, effective interventions to prevent falls for 1 of 3 residents (#3) reviewed for falls. The resident 's care plan directed staff to ensure the resident wore non-skid socks, though per staff report the resident frequently removed them. The resident fell three times while in the facility and at the time of each fall did not have non-skid socks on. The resident sustained [REDACTED]. Findings included: - Review of resident #3 's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 10/4/16 revealed a BIMS (brief interview for mental status) score 9, indicating moderately impaired cognition. The resident had behavioral symptoms and rejected cares 1-3 days during 7 days prior to assessment. The resident needed extensive assistance of 1 staff for bed mobility and dressing. Staff provided weight bearing support for transfers; supervision, guidance and limited assistance for walking. The resident was not steady but able to stabilize with staff assistance. The resident had 1 fall in the last 2-6 months prior to admission/entry or reentry, used a wheelchair, was frequently incontinent and had a urinary toileting program. Review of the CAAs (care area assessment) dated 10/4/16 revealed: Cognitive Loss: The resident had daily episodes of confusion, frustration and combativeness. Falls: The resident had a history of [REDACTED]. The resident fell on ce without injury during the review period. His/her dementia was active at night and increased his/her fall risk. ADL (activities of daily living) Functional: The resident came to the facility for therapy after a hospital stay for placement of a pacemaker (an electric apparatus used to increase heart rate by electronically stimulating the heart muscle; implanted device to regulate the beating of the heart) and required extensive assistance for most ADLs. The resident was alert with confusion that occurred mostly at night. Urinary incontinence: The resident was frequently incontinent of bladder, occasionally incontinent of bowel, and required extensive staff assistance with toileting tasks. The resident received Bumex diuretic (a medication to promote the formation and excretion of urine). Review of the resident 's Admission Clinical Health Status assessment revealed the resident had the following risk factors indicating he/she had a risk for falls: Impairment in gait or balance Impairment in lower extremity strength Diminished awareness of safety Medications included psychoactive (medications that can alter the consciousness, mood, and thoughts of those who use them), diuretics (medication to promote the formation and excretion of urine), benzodiazepines (medications used to treat anxiety and convulsions and can produce sedation and muscle relaxation). Displays restlessness, lethargy, wandering, or resistive to care Review of the resident 's care plan reviewed 11/30/16 revealed the resident had a history of [REDACTED]. (9/23/16) Assist/encourage the resident to wear non-skid shoes/socks when out of bed. (9/26/16) Observe for changes in cognitive status. Report to primary care practitioner. Offer/monitor to assist with ambulation due to impulsiveness. Observe for changes in condition that could warrant increased supervision/assistance and notify the physician. Keep the bed in the lowest position. Keep the call light in reach. Side rails positioned per protocol. Keep the room/area free of clutter. Send to the emergency room for evaluation and treatment. (10/28/16) (11/3/16) Administer pain medications as ordered, assist with diversional activities; give Tylenol as ordered/needed. (11/23/16) Stay with the resident if he/she wandered. Observe for and document behavior. (12/1/16) Physical Therapy to screen (a brief initial examination to evaluate the need for additional physical therapy assessment and services). Physical therapy to work with the resident on transfers and ambulation as needed. Occupational Therapist to work with the resident on ADL re-training as needed. Review of the nurse 's notes dated 9/24/16 - 2:02 AM revealed the resident had a non-injury fall. The Fall Analysis worksheet dated 9/23/16 completed by the facility revealed the resident did not have his/her gripper socks on. The facility determined the root cause of the fall was the resident 's increased confusion and an extra chair in the resident 's room. Review of the undated Fall Analysis worksheet (attached to Post Fall/Trauma record dated 10/28/16) revealed the resident fell in his/her room and stated he/she was packing clothes in his/her carriage (wheelchair) to take to the basement. The facility determined the root cause of the fall was the resident 's increased confusion and the resident did not have his/her gripper socks on. Interventions to prevent recurrence of a fall included staff should assist the resident with his/her gripper socks and remind him/her to put gripper socks on. This was the second fall the resident experienced while walking without his/her gripper socks. Review of post fall/trauma record dated 10/28/16 revealed the resident expressed discomfort in area of injury and discomfort with range of motion. The resident did not have gripper socks on and voiced he/she had pain in his/her back. The resident would not allow range of motion on his/her right leg. He/she sneezed and verbalized he/she had pain in his/her hip. The facility recommended interventions post fall to keep the resident ' s call light in reach, put a sign up in the resident 's room that instructed the resident to please use call light to request help , and frequently remind the resident to use his/her call light. Review of the nurse's notes revealed on 10/28/16 at 7:39 AM the resident fell at 4:15 AM and complained of pain in his/her back, hip, and right leg. The resident went to the hospital for evaluation and treatment. Review of the Resident Incident Report dated 10/28/16 revealed the resident walked in his/her room and fell , called for help and laid on the floor in front of his/her closet. The resident did not have his/her gripper socks on and did not appear to be injured but voiced he/she had pain. The resident went to the hospital by EMS (emergency medical services) on 10/28/16 at 5:30 AM. Review of the resident 's hospital X-Ray report dated 10/28/16 revealed a right femoral neck fracture (broken bone at the neck of the femur (thighbone) at the point where the neck of the femur joins the head (highest part of the thigh bone)). Review of the nurse's notes dated 12/2/16 at 8:34 AM revealed the resident had a fall without injury Review of the Fall Analysis worksheet dated 12/1/16 at 6:20 AM revealed the resident fell in his/her room when trying to get to his/her wheelchair. The resident did not have his/her gripper socks on. This was the third fall the resident experienced while walking without his/her gripper socks. The facility determined the root cause of the fall was the resident attempted to transfer him/herself. The facility recommended interventions post fall to place the resident's wheelchair locked and next to his/her bed. An observation on12/13/16 at 5:04 PM revealed the resident attempted to get up out of his/her wheelchair and a family member who was visiting grabbed his/her arm and told him/her to sit back down. An observation on 12/14/16 at 8:32 AM revealed direct care staff J placed a gait belt around the resident's waist, secured it then put non-skid socks on the resident's feet, then helped the resident to stand up then pivoted him/her around and the resident sat in his/her wheelchair. During an interview on 12/13/16 at 5:08 PM the resident reported he/she could walk and did not need help. The resident's family member reported the resident had confusion and had fallen recently. During an interview on 12/14/16 at 7:43 AM direct care staff B reported the resident woke up at night and would try to get out of his/her bed. During an interview on 12/14/16 at 8:42 AM direct care staff C reported the resident could toilet him/herself but staff needed to stand by and supervise because he/she could fall. During an interview on 12/14/16 at 2:23 AM direct care staff D reported the resident sometimes slept with his/her gripper socks on and he/she should have his/her gripper socks on when he/she was out of bed. At night the resident would try to get up without using his/her call light so therapy services had put a sign up to remind the resident about using his/her call light. The sign was in the resident's room when he/she was on the skilled services unit but staff D did not know what had happened to the sign after the resident moved to the long term care unit. During an interview on 12/14/16 at 11:31 AM licensed nursing staff E reported staff needed to answer the resident's call light right away, check on him/her every hour and toilet him/her every 2 hours. Staff E stated the resident would probably pay attention to a sign in his/her room about using his/her call light because he/she could read and follow directions. During an interview on 12/14/16 at 1:34 PM licensed nursing staff E reported the resident could put his/her gripper socks on but staff needed to stand by when he/she put the socks on to make sure the resident put them on correctly and the resident should have his/her gripper socks on when he/she lay in bed because he/she tried to get up by him/herself. Staff E stated the resident either took his/her gripper socks off by him/herself or whoever put the resident to bed took them off when he/she put the resident to bed. Sometimes the resident took his/her gripper socks off and sometimes he/she forgot to put the gripper socks on. Staff E stated the staff needed to remind the resident to keep his/her gripper socks on. During an interview on 12/14/16 at 1:45 PM Therapy staff F reported the resident was receiving therapy services at the time he/she fell and broke his/her hip then was discharged from therapy services before he/she moved to the long term care unit. Staff F did not know why the resident's sign to use his/her call light was not in his/her room in the long term care unit but gripper socks were available in the resident's room and the resident should use them. During an interview on 12/14/16 at 2:10 PM administrative nursing staff A reported gripper socks were not an effective intervention unless they were used but the resident did not like to wear the socks and took them off him/herself then hid them under his/her pillows. Staff A stated staff should check the resident more frequently to make sure he/she had his/her gripper socks on and staff needed to be with the resident when the resident got up to make sure he/she had the gripper socks on because the gripper socks would have prevented him/her from falling. Staff A stated the resident's gripper socks should have been on when he/she fell and got hurt on 10/28/16. Staff A stated the sign instructing the resident to use his/her call light to request help should be posted in the resident's room. Staff A directed administrative nursing staff L to check the resident's room for the sign. Administrative staff L checked the resident's room and reported the sign for the resident to use his/her call light fell down between the bed mattress and the wall and was not visible. Review of the undated facility policy Care System Guideline - Falls revealed the fall event and interventions to prevent future falls should be recorded on the care plan. If a resident was cognitively impaired, use appropriate footwear. If there were multiple falls, keep the resident in view during high risk times if possible. The facility failed to develop and implement appropriate effective interventions to prevent falls for the cognitively impaired resident. The facility also failed to ensure the resident wore his/her non-skid socks when out of bed. The resident fell three times while in the facility and was not wearing his/her non-skid socks as care planned. After one of these falls, the resident sustained [REDACTED].

The facility census totaled 102 residents. Based on observation, interview, and record review, the facility failed to immediately report to the State Agency, an incident of sexual abuse by resident #4 to resident #1 on 7/19/15. The facility also failed to protect all other residents of the opposite gender of resident #4 from sexual abuse by resident #4, and also failed to thoroughly investigate 3 incidents of sexual abuse by resident #4 to resident #1. This allegation was reported to Administrative staff immediately. Administrative staff failed to report, investigate, and protect other residents after learning of the allegation. This deficient practice placed all residents of the opposite gender of resident #4 in the facility in immediate jeopardy. The facility also failed to investigate an incident of resident-to-resident abuse by resident #8 to resident #2. This had the potential to affect all 64 residents of the opposite gender of resident #4. Findings included: - Review of resident #1's signed physician orders dated 9/22/15 revealed the following Diagnoses: [REDACTED]. fear), and delusional disorder (disorder characterized by untrue persistent belief or perception held by a person although evidence shows it was untrue). Review of resident #1 ' s quarterly MDS (minimum data set) dated 7/3/15 revealed resident #1's cognitive skills for daily decision-making were severely impaired (he/she never/rarely made decisions). The resident could not remember the current season, location of his/her room, or that he/she lived in a nursing home. The resident had short and long-term memory problems, but no signs of [MEDICAL CONDITION]. The resident required extensive assistance of one staff for transfers, and for locomotion on and off the unit. The resident used a wheelchair for locomotion. Review of resident #1's annual MDS dated [DATE] revealed no change in his/her cognition. The resident could not remember the current season, location of his/her room, staff names/faces, or that he/she was in a nursing home. The resident required extensive assist of one staff for transfers, and had total dependence of one staff for locomotion on and off the unit. The resident used a wheelchair for locomotion. Review of resident #1 ' s Cognitive Loss/Dementia CAA (care area assessment) dated 9/16/15 revealed the resident had [MEDICAL CONDITION] and dementia (progressive mental disorder characterized by failing memory and confusion), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The resident did not re-direct with reorientation. The resident's family member was very involved in his/her cares and the resident had a DPOA (durable power of attorney- a person designated to make healthcare and other important decisions when a person could not make them for themselves) in place as the resident could not make decisions related to healthcare. It included direction to staff to keep resident #1's DPOA involved and informed so he/she could make decisions. Review of resident #1 ' s Psychosocial Well-being CAA dated 9/16/15 revealed the area triggered for further review but staff did not complete the further assessment. Review of resident #1 ' s Behavioral Symptoms dated 9/16/15 revealed the resident liked to wander around the facility in his/her wheelchair and was not an elopement risk. The resident had poor safety awareness. He/she enjoyed seeing other residents and people. He/she might yell at staff or reject cares at times. Review of resident #1's care plan, updated 10/5/15 revealed interventions directed staff to: · Monitor the resident's whereabouts when in the dining room. Review of resident #1's care plan update sheet revealed staff made the following updates to resident #1's update sheet: · 8/18/15- resident to resident encounter. Educate staff to ensure separation. · 10/16/15- resident to resident encounter. Keep this resident away from another resident. The care plan did not mention any incidents involving inappropriate touching by resident #4. Review of resident #4 ' s Quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and moderately impaired cognitive skills for daily decision making. The resident could normally recall the location of his/her own room and staff names and faces. The resident required extensive assistance of one staff for transfers and supervision of one staff for locomotion on the unit. Review of resident #4 ' s Annual MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident could normally remember the location of his/her own room and that he/she lived in a nursing home. The resident did not exhibit any behaviors. The resident required limited assistance of one person for transfers and locomotion on the unit. Review of resident #4's care plan, initiated 8/18/15 revealed the resident had a history of [REDACTED]. Interventions included: · Administer Depo-[MEDICATION NAME] (a birth control medication). · Please keep resident #4 separate from the resident of the opposite gender he/she had a history of [REDACTED]. · Administer [MEDICATION NAME] (a mood stabilizer medication). · Provide psychiatric services as ordered. · Ensure during activities, in the dining room, or around the building staff kept resident #4 separate from the resident of the opposite gender he/she had a history of [REDACTED].#4 had the potential to inappropriately touch. (Review of the care plan on 11/2/15 revealed this intervention not in place on the care plan at that time.) · Please encourage resident #4 ' s spouse to visit and provide affectionate spousal support. · Staff were educated to keep resident #4 away from the resident of the opposite gender that he/she had a history of [REDACTED]. · An addition made dated 11/2/15-11/3/15 at 2 PM revealed the resident would have one-on-one monitoring for behaviors. Review of resident #4's care plan update sheet revealed staff made the following updates to resident #4's update sheet: · 8/18/15- resident to resident encounter . Educated staff to ensure separation. · 8/31/15- inappropriate sexual behavior. Administer Depo-[MEDICATION NAME]. · 10/16/15- resident to resident. Plan to keep away from resident. · 10/16/15- resident to resident/sexual behaviors. Administer [MEDICATION NAME]. Upon request on 11/2/15 at 5:20 PM, administrative staff J provided a folder with the following 3 pieces of information when asked for investigations for any incidents between resident #4 and resident #1: · Review of a complaint investigation witness statement, signed and dated by direct care staff N on 7/19/15 read: 7/19/15 Kitchen staff alerted me to a situation that was occurring (sic) in the front dinning (sic) room area at 1630 (4:30 p.m.). Upon entering the dinning (sic) room I observed (resident #4) with (his/her) hand down (resident #1's) depends. I approach (resident #4) and (resident #1) telling (resident #4) no no no to get (gender) attention. (Resident #4) then yells at me and tells me (gender) knows what (gender) is doing. I started to remove (resident #1) from the situation and (resident #4) tells me to go to hell. I reported the incident to 2 LPN (Licensed Practical Nurse) (licensed nurse E) and (licensed nurse O). I then reported the Incident to (administrative nurse F) via telephone . · Review of a complaint investigation witness statement, signed by dietary staff G, read in part: I was employed as Cook at Diversicare of Haysville in Haysville, Kansas. On or about July 19 in the year 2015 I was investigated/witnessed the following incident (describe below) involving (resident #1) and (resident #4) .I walked into the dining room around 4:30 pm. I saw (resident #4) next to (resident #1). (Resident #4) had (resident #1's) shirt slightly up and was putting (gender) right hand into (resident #1's) pants and working (gender) way down. I immediately turned and got (direct care staff N). (Staff N) told (Resident #4) (gender) can not do that and removed (resident #1) from the Dining Room. · Review of undated record signed by licensed nurse P read: Resident: (Resident #4) I took resident from the dinning (sic) room to (gender) room. (Gender) was very cooperative by then. When we went to (gender) room. I started asking (gender) questions. (1) First asked (gender) whether (gender) knows where (gender) is at that moment and (gender) told me (gender) was at Diversicare Health Center (Haysville). I asked (gender) full names and (gender) told me that (gender) is (resident #4). I finally asked (gender) whether (gender) knows the month of the year and (gender) told me, (gender) can't remember. And I don't care. - ) I asked (resident #4) whether (gender) knows (resident #1) and (gender) said, (gender) does not know (resident #1). - ) I asked (gender) whether (gender) touched a (person of the opposite gender) by the name (resident #1) inappropriately like putting hands in (gender) pants. (Resident #4) loudly responded by saying that (gender) can't do something like that I have a (spouse) and a (child) and I can't touch anybody. - ) (Resident #4) became very agitated with me and said I don't want any more questions. Somebody is accusing me falsely. Get out of my room right now. I couldn't ask (gender) more questions. · All of the documentation from the sexual abuse incident by resident #4 to resident #1 lacked a plan to protect other residents from sexual abuse by resident #4. Review of the nurse's notes from 4/1/15- 8/15/15 revealed no notes regarding inappropriate touching or other resident-to-resident incidents. The nurse's notes lacked any documentation about the incident of sexual abuse by resident #4 to resident #1. As of 11/3/15 at 8:50 AM the facility had not reported the 7/19/15 allegations to the State Agency complaint hotline. When requested on 11/3/15 and 11/10/15, the facility failed to provide any additional investigation of the sexual abuse by resident #4 to resident #1 on 7/19/15. Review of a notarized witness statement, signed by direct care staff N on 11/5/15, revealed the same information as his/her statement dated 7/19/15, with the addition that he/she reported the incident to administrative staff F via telephone, who started laughing. I told (staff F) he/she needed to take the incident more seriously. Staff F then proceeded to tell him/her to wait before he/she wrote the incident in writing, but Staff N proceeded to write his/her statement anyway. Thirty minutes later, staff F called him/her back and told him/her to go ahead and fill out a statement. Review of a notarized witness statement written by licensed nurse O, signed and dated 11/4/15 revealed he/she was consulted by direct care staff N on 7/19/15 regarding an alleged sexual abuse against resident #1 by resident #4. Staff N claimed he/she witnessed resident #4 touching resident #1 inappropriately in public and that his/her hands were found underneath resident #1's brief. Staff N sought information on how to report the incident. Staff O encouraged and advised staff N to write a statement, call administrative nurse F and the administrator, and to notify his/her charge nurse of the ongoing matter and ensure that resident #1 had been removed from the geopardy (sic). I followed up with the charge nurse to ensure all parties had been informed: abuse coordinator, social worker, family, and PCP (primary care physician). This follow-up occurred on the said date. (7/19/15) Review of resident #1's nurse's note dated 8/15/15 revealed at approximately 1:55 PM another resident of the opposite gender touched this resident in his/her private area over his/her clothes in the bridge/dining room. Both residents were in their wheelchairs at that time. Staff separated the residents with no apparent injury. Staff were to monitor the resident and keep him/her away from that resident of the opposite gender. The facility failed to provide an investigation, as requested on 11/2/15 and 11/10/15, of the 8/15/15 incident of sexual abuse by resident #4 to resident #1. The facility also failed to protect other residents from sexual abuse by resident #4. Review of the e-mail that the facility indicated was their investigation, to the State Complaint hotline from the facility revealed on 10/16/15 at approximately 11:15 AM activity staff Q walked through the dining room towards resident #4 and resident #1 when he/she saw resident #4 reach over and touch resident #1's left breast. Staff Q then intervened and removed resident #1 from the situation. Resident #4 was alert with confusion at times and resident #1 was alert to person only. Staff completed a head-to-toe assessment on resident #1 and no injuries or complaints of pain or discomfort noted from resident #1. The doctor and family were notified. The physician extender was in the facility at the time of the incident and wrote new orders for resident #4 for [MEDICATION NAME] (a mood stabilizer) 125 mg (milligrams) two times per day. Staff were aware of the incident and would keep them separate and monitor. The facility failed to provide an investigation, as requested on 11/2/15 and 11/10/15, of the 10/16/15 incident of sexual abuse by resident #4 to resident #1. The facility also failed to protect other residents from sexual abuse by resident #4. Observation on 11/3/15 at 11:17 AM revealed resident #1 self-propelled his/her wheelchair through the dining room. Resident #4 was not in the area. Interview with resident #4 on 11/4/15 at 5:35 PM revealed he/she got married June 25, 1960 to (spouse ' s name) and he/she reported his/her wife came up every now and then to visit him/her. The resident spoke as he/she self-propelled his/her wheelchair down the hall from the dining room into his/her room. Once in his/her room, the resident reported he/she was not sure what town he/she was in, but did know his/her birthdate, even reporting the hospital he/she was delivered in and the doctor. The resident stated he/she love the people here. Don't have any trouble with people as long as they were decent. The resident reported he/she thought the month was October, he/she knew he/she had a height of 5 foot 9 inches, and stated he/she wore glasses most of the time and had artificial teeth. To allow for anonymity of staff members, specific dates and times have been omitted from the interviews with direct care staff and licensed nursing staff. All interviews took place between 11/2/15 and 11/10/15. Interview with social services staff C revealed there was a period of time that resident #1 and resident #4 were very affectionate with each other. Staff C reported staff talked to the spouse of resident #4 and resident #1's family member at the time and they were both okay with it. For a couple of weeks, staff C reported staff were running to watch out for them and making sure they were not touching each other for a while. Staff C reported the first incident of inappropriate touching of resident #1 by resident #4 happened within the week before the 8/3/15 note. Staff C reported when there were incidents of inappropriate touching, he/she would visit with the residents or the families and talked with them to establish a plan. Staff C reported the plan was to keep them separated. Staff C reported resident #4 kind of self-contained as part of his/her daily routines, but resident #1 was everywhere wandering, so he/she was not readily available for resident #4 to have access to. The incidents of inappropriate touching by resident #4 to resident #1 occurred in the dining room, so staff C thought everyone was able to keep an eye on both residents. Interview with direct care staff A revealed he/she had been told by nursing staff to keep resident #1 away from resident #4 as resident #4 had touched resident #1 inappropriately. Interview with direct care staff B revealed he/she normally worked the hall resident #4 lived on and worked first and second shifts. Staff B reported the facility had a huge nursing meeting about 2 months ago and during it went over all the ANE (abuse, neglect, and exploitation) policies and reporting. Staff B reported he/she had to watch out for resident #4 because he/she was not allowed to be near resident #1 because staff caught resident #4 touching resident #1 inappropriately so they were not allowed to be alone together. During an interview with former dietary staff G regarding an inappropriate touching incident by resident #4 to resident #1 that happened in July 19, 2015, revealed he/she remembered he/she had just come around the corner from the hall into the dining room when he/she saw resident #4 with resident #1's pants pulled away from him/her and resident #4 was pushing his/her hands down resident #1's brief. Staff G reported he/she did not know what to do, so he/she found a nurse at the nurse's desk and told him/her there was inappropriate behavior going on and he/she needed to come immediately. Staff G reported immediately, the nurse got resident #1 away from resident #4 and the nurse told resident #4 his/her behavior was inappropriate. Resident #4 got very upset and mad and asked the nurse what right did he/she have to tell him/her what to do. Staff G reported resident #1 was not capable of making those kinds of decisions. Staff G reported he/she based his/her view of resident #1's cognition on the fact that he/she never heard resident #1 talk, only babble and giggle a lot. Interview with direct care staff H revealed staff sent resident #4 to the behavioral health unit on 11/9/15 because a staff member had been watching him/her all the time, but resident #4 did not know it and he/she tried to go towards resident #1 and staff had to intervene before resident #4 got to resident #1. Interview with licensed nursing staff D revealed resident #4 had inappropriately touched resident #1. Staff D reported staff kept the two residents separated during activities and resident #1 wandered around, not knowing resident #4 could be in the area, so staff just redirected resident #1 to a different area away from resident #4. Interview with licensed nurse I revealed he/she knew of more than 3 incidents of inappropriate touching between resident #4 and resident #1 but did not know the exact dates. Staff I said he/she reported the incidents to administrative nurse F and administrative staff J when they happened and then trusted they would take care of reporting the incidents and investigating them. Staff I stated, I think that once they (administrative staff) realized they were not isolated incidents and (resident #4) was not going to stop, they decided they needed to start reporting them (the incidents). Staff I stated with emphasis the administrative staff told him/her resident #1 was a consenting adult, so there was nothing they could do. (Resident #1) was not a consenting adult. Staff I reported resident #1 didn't have the mental capacity to consent. During an interview with licensed nurse E revealed he/she knew of one time when resident #4 had his/her hand in resident #1's pants and another time resident #4 touched resident #1's breast. Staff E reported when the first incident happened, he/she called administrative nurse F, and then tried to keep the two residents separated. Staff E reported staff were told to let social services handle the incidents. Staff E reported resident #4 watched resident #1 and preyed on him/her. Staff E reported there could have been more incidents involving inappropriate touching, but he/she did not know for sure. Staff E reported at times there were not enough staff because there needed to be someone to supervise resident #4 a lot more, but there were not enough staff to keep resident #4 away from resident #1. Interview with administrative staff J on 11/2/15 at 4:21 PM revealed resident #4 really only went to resident #1 when he/she touched inappropriately, staff believed because resident #1 looked like resident #4's spouse. Staff J reported staffs ' initial thought when the inappropriate touching occurred was to determine if resident #4 had touched any other resident. Staff J reported the situation was hard because staff felt both residents were with it enough and were cognitive and oriented enough to have a relationship. Resident #1 did not try to pull away from sexual touching by resident #4. Staff J reported staff had to try to determine if resident #1 was cognitive enough to know whether or not he/she liked the sexual touching or had the cognitive ability to say whether or not he/she actually wanted it. Staff J reported after the incidents happened, the facility trained and oriented staff to keep resident #1 and resident #4 separate. Staff J reported resident #4 took two medications to try to curb his/her sexual drive. Staff J reported staff had put initial 15 minute checks in place after the first incident, but there was not any documentation of that intervention. At 5:35 PM staff J revealed the facility struggled with what to do in the situation between resident #1 and resident #4 because there seemed to be some gray area. Staff J reported both residents were cognitively impaired, and resident #1 did not seem to be bothered when resident #4 touched him/her in his/her private areas. Resident #1's family member reported to him/her that resident #1 might enjoy the sexual touching, but staff just did not feel like resident #1 had the mental capacity to realize he/she could say no or pull away when resident #4 touched him/her, even if he/she enjoyed it. Staff J confirmed the plan to keep resident #1 safe was for staff to frequently observe both residents and keep them separated. Staff J confirmed frequently could mean different things to different people. Staff J also confirmed the care plan was not specific as to who staff were supposed to separate from whom. Interview with administrative nurse F on 11/2/15 at 5:40 PM revealed the facility was in a hybrid phase with the care plans where some of it was on paper and some of it was in the electronic care plan. Staff F reported updates were made to the update sheet in the paper care plan each time the residents had a change. Staff F reported he/she knew the care plans were updated for resident #4 and resident #1 after each of the incidents of inappropriate touching. Staff F also reported all of the incidents of inappropriate touching were reported to the State agency. Interview with administrative nurse F and administrative staff J on 11/4/15 at 1:55 PM revealed after the first incident of sexual touching in July 2015 by resident #4 to resident #1, staff were educated to keep the two residents separate. Staff J acknowledged there was no plan to protect other residents of the opposite gender from inappropriate sexual touching by resident #4 and there was poor documentation of the incidents. Staff F and staff J reported after the incident in August 2015 and again in October 2015, staff were educated to keep the two residents apart without any further interventions to protect resident #1 or any other residents of the opposite gender or resident #4. Review of the facility policy for Abuse, last revised 3/1/14, revealed the policy of the facility was to take appropriate steps to prevent the occurrence of abuse and neglect and to ensure all violations which involved mistreatment, neglect, or abuse were reported immediately to the administrator of the center. The violations would also be reported to the state agencies in accordance with existing state laws. The administrator would direct a thorough investigation of each alleged violation. The administrator was responsible to report the results of all investigations to the state agencies as required by state and federal law. Employees were required to report incidents of suspected abuse or neglect. Reporting of suspected alleged violations to the Administrator/Director of Nursing were required by every employee. Incidents of alleged violations would be reviewed by QAPI (quality assessment/process improvement) for detection of patterns and trends. If the circumstances required it, the administrator or DON would remove a resident suspected of being the subject of an alleged violation to a place where the residents could safely be protected. If the suspected perpetrator was another resident, the administrator or DNS, staff would separate the residents so they did not have access to each other until the circumstances of the alleged incident could be determined. All alleged violations involving mistreatment, neglect, or abuse, were reported immediately to the administrator and to other officials in accordance with State law. The policy did not include protection of other residents at risk for abuse during a resident-to-resident abuse situation. The facility failed to report, investigate, and protect residents regarding resident-to-resident incidences of abuse when administrative staff did not immediately report to the State survey and certification agency an incident involving sexual abuse by resident #4 to resident #1 that occurred on 7/19/15, failed to thoroughly investigate the incident of sexual abuse as well as 2 other instances of sexual abuse/inappropriate touching, and failed to protect all the residents of the opposite gender of resident #4 during the investigation. This placed the (gender) residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 11/6/15 when the facility provided re-education on ANE to all employees on reporting allegations, revised the facility policy regarding ANE to include the protection of any residents at risk for abuse, and revised resident #4's care plan to include protection of all residents of the opposite gender of resident #4. This deficient practice remained at a scope and severity of an E. - The facility provided a list of resident-to-resident altercations as requested on 11/2/15 for August 2015-October 2015. Review of that list revealed an incident between resident #9 and resident #2. When the surveyor requested an investigation on 11/3/15 into the resident-to-resident incident between resident #9 and resident #2, administrative nurse J provided a folder that contained a single e-mail to the State complaint hotline, which included: At approximately 1:10 PM on 10/1/15, resident #9 wheeled past resident #2 and started yelling at resident #2 because of the placement of resident #2's cloth napkin. Resident #9, then hit resident #2 with an open hand on his/her left shoulder. Staff witnessed the interaction and redirected resident #9, who continued to yell about the placement of the cloth napkin. Staff planned to keep residents separated and care plan accordingly. Review of the facility policy for Abuse, last revised 3/1/14, revealed the policy of the facility was to take appropriate steps to prevent the occurrence of abuse and neglect and to ensure all violations which involved mistreatment, neglect, or abuse were reported immediately to the administrator of the center. The violations would also be reported to the state agencies in accordance with existing state laws. The administrator would direct a thorough investigation of each alleged violation. The administrator was responsible to report the results of all investigations to the state agencies as required by state and federal law. Employees were required to report incidents of suspected abuse or neglect. Reporting of suspected alleged violations to the Administrator/Director of Nursing were required by every employee. Incidents of alleged violations would be reviewed by QAPI (quality assessment/process improvement) for detection of patterns and trends. If the circumstances required it, the administrator or DON would remove a resident suspected of being the subject of an alleged violation to a place where the residents could safely be protected. If the suspected perpetrator was another resident, the administrator or DNS, staff would separate the residents so they did not have access to each other until the circumstances of the alleged incident could be determined. All alleged violations involving mistreatment, neglect, or abuse, were reported immediately to the administrator and to other officials in accordance with State law. The policy did not include protection of other residents at risk for abuse during a resident-to-resident abuse situation. The facility failed to investigate an incident of resident-to-resident abuse by resident #9 to resident #2.

The facility had a census of 107 residents with 3 residents sampled for nutritional parameters. Based on interview, record review, and observations, the facility failed to initiate adequate nutritional interventions to maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed (#62). The resident suffered a severe weight loss of 50 pounds or 26.5% of his/her body weight in less than 4 months. Findings included: -Review of resident #62 ' s admission MDS (minimum data set) dated 1/28/15 revealed the resident had a BIMS (brief interview for mental status) score of 13 indicating the resident was cognitively intact. The MDS revealed the resident had no swallowing disorders, was on a therapeutic diet, and weighed 177 pounds. The resident also had no teeth or teeth fragments. He/she required set up assistance only, for eating. Review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating the resident was cognitively intact. The resident required set up assistance only, for eating. He/she weighed 146 pounds and was on a therapeutic diet. Review of the clinical record dated 1/28/15 for ADL (activities of daily living) CAA (care area assessment) revealed the resident had decreased strength and balance, was able to voice concerns, and staff needed to assist and reassure the resident. Review of the Nutritional CAA dated 1/28/15 revealed the resident required a therapeutic diet for MI ([MEDICAL CONDITION] infarction or [MEDICAL CONDITION]), The care plan dated 2/9/15 revealed the resident was sometimes forgetful, but his/her memory was intact. He/she had no natural teeth and didn't wear the dentures. His/her chewing was fine without them. The staff was encouraged to offer and record snacks offered three times a day. He/she had a diet as ordered per the physician and staff was to record the amount eaten. He/she had a bad appetite, but usually ate well and liked a variety of foods. He/she required a low fat, low cholesterol, no salt added diet with regular texture. He/she weighed around 170 pounds at home. The staff was to weigh the resident as ordered, provide medications and supplements as ordered, and provide any texture modifications as requested per the resident. Review of the nutritional assessment dated [DATE] signed by the registered dietician revealed the resident had no changes in weight, no [MEDICAL CONDITION] (swelling), preferred to eat in his/her room, had no teeth and wore dentures, and had no swallowing problems. Review of the dietary note by the registered dietician dated 3/19/15 revealed the resident was followed for weight loss, was having difficulty swallowing over the last two weeks and had been sick causing poor appetite. The resident had stopped smoking and drank diet pop. He/she required a low fat, low cholesterol, no added salt diet with regular texture. The resident had weighed 185 pounds and was currently at 171 which was a 14 pound decrease over 7 days due to fluid changes in the body. The registered dietician recommended weekly weights, house shakes with dinner, and Promod (a nutritional protein supplement). The dietician would continue to monitor. Review of the dietary note by the registered dietician dated 5/8/15 revealed the resident had a quarterly assessment done. He/she required house shakes with dinner. The resident's weight had dropped from 176 pounds to 164 pounds which was an 11% decrease in one month. The resident had open sores on his/her toes that were now healed. The registered dietician would continue to follow up routinely or if weight loss continued. Review of the dietary note by the registered dietician dated 5/20/15 revealed the resident's current weight was 143 pounds. Review of the dietary note by the registered dietician dated 6/10/15 revealed the resident ' s weight remained stable. He/she continued house shakes three times a day, no new labs were ordered, and the registered dietician would continue to follow monthly until weight stabilized for six months. Review of the resident's weights: 1/21/2015 the resident weighed 177 pounds 2/6/15 188 pounds 3/5/15 185 pounds 4/2/15 161 pounds 5/7/15 144 pounds 5/28/15 143 pounds 6/25/15 138 pounds The resident had a severe weight loss of % from 2/6/15-6/25/15(less than 4 months). Review of the 3/20/15 physician orders [REDACTED]. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) revealed a lack of documentation of the Promod being given by staff. The MAR and TARs also lacked documentation of the percentage of snacks taken or eaten. Review of the physician telephone orders revealed on 6/10/15 the physician wrote an order for [REDACTED]. The MAR did show documentation from 5/26/15 until 6/26/15 when the mighty shakes were discontinued. The resident consumed 100% on most days. Review of the March 2015 medication administration record revealed the resident received 20 milligrams of [MEDICATION NAME] (a water pill) for 3 days on 3/26/15 to 3/29/15. An observation on 6/24/15 at 8:45 a.m. revealed the resident was in his/her room and had a bowl of hot cereal and a banana on the bed side table. The cereal was covered in plastic wrap. He/she had two glasses of soda with a straw on the table as well. The resident sat in the recliner in his/her room and took 1 minute to open the banana and get the plastic off the bowl. Direct care staff entered the room to assist the resident ' s roommate. The resident asked for sugar for his/her cereal. The direct care staff went and got the sugar and assisted the resident to put sugar packs in the bowl of hot cereal. At 9:06 a.m. direct care staff entered the room to assist him/her to the bathroom. The resident had one half of the banana drop on the floor and he/she consumed 10% of the cereal by 9:12 a.m. The resident reported the cereal was cold and didn't want any more. He/she went outside to smoke. Review of the meal and snack intake, completed by the nurse aides for 6/24/15 revealed the resident consumed 100% of his/ her breakfast. An observation on 6/24/15 at 12:09 p.m. revealed the resident had a room tray delivered. He/she had a hamburger, chips, French fries, cake, and soda. The resident sat in the recliner and ate his/her lunch. The resident showed no signs of chewing or swallowing problems. The resident consumed 50% of the hamburger, a few French fries, and drank part of the soda. By 12:24 p.m. the resident was sleeping in the recliner. Review of the meal and snack intake for 6/24/15 revealed the resident consumed 25% of the lunch. An observation on 6/25/15 at 8:02 a.m. revealed the resident sat in the recliner when his/her breakfast was delivered. The direct care staff Z left it covered per the resident ' s directions and the resident went back to sleep and was snoring. At 8:12 a.m. direct care staff re-entered the room and woke the resident to see if he/she wanted to eat his/her breakfast. The resident stated he/she would like assistance with the meal because he/she had a rough night sleeping and was very tired. Direct care staff assisted the resident and he/she consumed 100% of his/her eggs, toast, bacon, and drank soda. The resident finished eating at 8:45 a.m. Per surveyor request on 6/25/15 at 9:44 a.m. direct care staff Y weighed the resident. He/she weighed 138 pounds. The resident stood with a steady gait and used the rail on the scale for balance. The resident had a 23.33% weight loss from 1/22/15-6/25/15 (a 5 month time period). An observation on 6/25/15 at 9:53 a.m. revealed the resident in his/her wheelchair in the hallway, nursing staff W stopped and gave the resident a Mighty Shake. He/she consumed 100% of the shake. An interview with the resident on 6/25/15 at 8:48 a.m. revealed the resident stated today was the first day anyone had offered or assisted him/her in eating. He/she also reported he/she wanted to get back into therapy and get stronger. He/she wanted to be weighed and had not been in several weeks. An interview on 6/24/15 with direct care staff X revealed the resident was independent for the most part but had been declining and needed more assistance. The resident had vomited twice yesterday. He/she reported the resident usually ate 50% of the meals, would drink soda throughout the day, and wasn't aware of him/her having any shakes. An interview on 6/25/15 at 9:45 a.m. with direct care staff Y revealed the resident weighed 138 pounds today and he/she stood to be weighed. The last time the resident was weighed was on 5/28/15. He/she also reported the restorative department didn ' t assist the resident with eating and would report the weight change to the charge nurse on his/her hall who should report to the DON (director of nursing), the physician, and the registered dietician. An interview on 6/25/15 at 2:06 p.m. with direct care staff Z revealed the resident drank soda throughout the day and was on a regular diet. He/she reported today was the first day staff had assisted the resident with his/her meal. The resident had declined over the past months and was alert and oriented to call for assistance. He/she reported the resident usually ate well. An interview on 6/25/15 at 4:16 p.m. with licensed nurse AA revealed the resident required house shakes for weight loss. He/she reported the resident did not eat much and today the resident required assistance with his/her meal. He/she also reported the resident required monitoring of how much food he/she took, house shakes, and to offer snacks for interventions with his/her weight loss. The resident was weighed last on 5/28/15 and nurse AA was not sure who weighed the resident or how often. An interview on 6/25/15 at 3:25 p.m. with administrative nurse A revealed the resident came in the building at 177 pounds in January of 2015. The resident had a trend in weight loss and required house shakes three times a day and Promod for a protein supplement. He/she reported the resident's weight was stable and was unaware the staff were not weighing the resident weekly. He/she would expect weekly if not daily weights on the resident. Nurse A also reported the facility did not identify or place any other interventions in place except the Promod that was discontinued due to the resident did not like it and the house shakes were increased to three times a day for weight loss. Nurse A was unable to find or provide documentation the physician was aware of the resident ' s weight loss or if the resident was recommended for fortified food or any other intervention for weight loss. The facility failed to identify the resident continued to lose weight and notify the physician of the 39 pound weight loss between 1/21/15 and 6/25/15. An interview on 6/25/15 at 2:15 p.m. with Registered Dietician F revealed the resident had weighed 177 pounds on admission and had a trend in weight loss. He/she reported the facility identified the weight loss and put house shakes in place along with Promod for a supplement in March. He/she documented the initial assessment for the resident's nutrition in January 2015. He/she reported no changes were in place for the resident from March to April and could not find any documented notes regarding the resident's decline in weight. He/she didn't recommend any changes in interventions for the resident or add any fortified foods to his/her diet. Staff F recommended on June 10, 2015 to discontinue the Promod due to the resident did not like it and increase the house shakes to three times a day for more calories. He/she reported the resident took the Mighty Shakes and usually consumed them 100%. He/she did not request any new labs. Staff F reported the resident had an order for [REDACTED]. Staff F also reported the resident was a part of the high risk for weight loss charting and he/she was working on better documentation for the resident. He/she was not aware the resident had lost another 5 pounds over the last month. Staff F reported he/she is in the building daily and worked full time for the facility. He/she failed to identify the resident continued to lose weight, did not order any fortified foods for the resident, and failed to notify the physician of the weight loss. Interview on 6/29/15 at 1:13 p.m. with the physician KK revealed he/she was unaware the resident continued to lose an extreme amount of weight over the past 6 months and was not notified. The facility communicated with him/her through a therapeutic nutritional note. Consultant KK would expect the resident to be weighed weekly and for staff to correctly identify the amount the resident consumed with each meal. He/she reported the resident was on a diuretic for [MEDICAL CONDITION] (swelling) in March but no longer took it. Consultant KK also reported he/she would recommend an evaluation from therapy and to start another supplement or fortified foods immediately. Review of the facility weight monitoring policy dated 3/1/13 revealed if a resident's weight loss was noted the facility would monitor the resident's weight weekly for 4 weeks. Dietary staff would put the weight into the computer weekly and if a change from previous weights, alert nursing management to ensure the 3 day reweighs were completed. The residents would require increased observation, cueing, and may need an alternative offered. The facility would document physician awareness and or notification in nurse's notes related to weight loss. The facility failed to identify and implement adequate nutritional interventions to maintain acceptable parameters of nutritional status and to notify the physician when the resident suffered a severe loss of 26.5% of his/her body weight between 2-6-15 to 6-25-15.

The facility census totaled 120 residents with 15 included in the sample. The sample included the review of 3 residents with pressure ulcers. Based on observation, record review and interview, the facility failed to adequately assess, develop and implement interventions to prevent the development of pressure sores for a resident with a history of pressure sores and failed to provide the necessary treatment and services to promote healing and prevent infection in a resident with a pressure ulcer. (#1 and #3) Resident #1 entered the facility without pressure ulcers, developed a pressure ulcer that the facility healed, then developed another pressure ulcer in the same area which deteriorated over several weeks and required surgical intervention for healing. Findings included: - Review of resident #1's closed electronic record revealed under the [DIAGNOSES REDACTED]. to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on 2/21/13 and 9/21/13, general muscle weakness and abnormal posture. Review of the annual MDS (Minimum Data Set 3.0-a required assessment) dated 12/23/13 identified the resident with a BIMS (Brief Interview for Mental Status) score of 4/15, which indicated the resident had severely impaired cognition, exhibited no behaviors, did not reject care, required the extensive assistance from 2 staff with bed mobility, transfers, toileting, required the extensive assistance from one staff with personal hygiene. The assessment also identified the resident was always incontinent of bladder and occasionally incontinent of bowel, had a steady weight at 200 pounds, was at risk for the development of pressure ulcers, did not have a pressure ulcer at that time, identified the resident had one Stage 2 (open) pressure ulcer on the prior assessment that had healed, received a pressure relieving device for the chair and bed, was on a turning/repositioning program and received a nutrition or hydration intervention program to manage skin problems. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 1/6/14, identified the resident had a healed pressure ulcer to the coccyx with a preventative dressing in place. It also identified the resident required assistance with repositioning, assistance with eating and directed the readers to review the formal skin assessment, the Braden Scale. Review of the quarterly MDS dated [DATE] identified the resident had severely impaired cognition with both short and long-term memory problems, no behaviors, required extensive assistance from two staff with transfers, dressing, toileting, required extensive assistance from one staff with bed mobility, eating and personal hygiene. The assessment also identified the resident was always incontinent of bladder and bowel, had a steady weight of 198 pounds, remained at risk for the development of pressure ulcers, had one Stage 2 pressure ulcer that developed on 2/6/14, used a pressure reducing device for the chair, bed, staff utilized a turning/repositioning program, received a nutrition/hydration program to manage skin problems, and the resident received pressure ulcer care. Review of the care plan, dated 8/1/13 and in place at the time of a development of a pressure ulcer on 9/21/13 and 2/7/14, revealed the resident had skin in pretty good shape, that the resident wore heel protectors while in bed and a splint during the night. The care plan also identified the resident's feet became swollen at times. The care plan directed staff to ensure the resident had heel protectors on at bed time, assist the resident with repositioning and bed mobility as needed, assist the resident with repositioning every 2 hours and as needed, ensure the resident had the splint on at bedtime and off in the morning and that a pressure relieving cushion was in place in the wheelchair. The care plan did not address the development of pressure ulcers on 9/21/13 or 2/7/14, or how the facility revised the interventions to help the areas to heal. Review of the current care plan, dated 4/7/14, revealed the resident had an area on his/her bottom that the staff were treating and the resident went to the wound clinic. The resident had an air mattress, took a supplement to assist with wound healing, and was on an antibiotic due to infection in the wound. The resident also wore heel protectors while in bed. The resident wore a left hand splint that staff put on at bedtime and removed in the morning. The resident required help with repositioning. Staff were to ensure the resident had heel protectors on at bed time, assist the resident with repositioning every two hours and as needed, ensure the resident had the splint on at bedtime and off in the morning, and ensure pressure relieving cushions were in place to the resident's wheelchair. Staff were also to ensure the resident had an air mattress in place with a fitted sheet on at all times, ensure the resident had treatments in place as ordered/needed, and the resident received aspirin as ordered/needed. Staff were to monitor the resident for excessive bleeding and bruising and notify the doctor as needed, assist the resident with laying down after meals and as requested, assist the resident with repositioning and bed mobility every 2 hours and as needed and ensure the resident received nutritional juices three times daily with meals. According to the NPUAP (National Pressure Ulcer Advisory Panel) general guidelines, 2009, best practices limited the amount of linen placed on the mattress and to keep the resident off the pressure ulcer if at all possible. The care plan directed staff to keep a fitted sheet on the air mattress and failed to direct staff to keep the resident off the coccyx. Review of the wound assessments in the resident's electronic record revealed the following: 9/21/13: Staff identified the resident developed a new wound on the sacrum (large triangular bone between the two hip bones). The assessment identified the area as a Stage I (reddened skin, but closed), length 0.8 cm (centimeters) x 0.4 cm. The family and physician had been notified. As for treatments, staff documented "Pending treatment orders". 9/23/13: Weekly update: Stage 2 (now open) pressure ulcer on sacrum-improved. Measured 0.6 cm x 0.2 cm x 0.1 cm in depth. Staff documented the physician gave new orders: 1. Discontinue the [MEDICATION NAME] (barrier cream). 2. Clean with normal saline and apply DuoDerm (a type of [MEDICATION NAME] dressing) to coccyx (small triangular bone at the base of the spine--forms a point together with the sacrum) change every 3 days and whenever needed. Will continue to monitor. 9/30/13: Weekly update: Pressure ulcer on Sacrum-improved. Stage 2, 0.2 cm x 0.2 cm in size. No change in treatment. Nurses note: 10/7/13 at 9:12 a.m.: Area to resident's coccyx (previously identified as sacrum) is resolved. No open area noted. Will continue DuoDerm at this time for prevention. Dietician's note: 10/9/13 at 12:30 p.m. Resident's Stage II pressure wound to his/her coccyx (also documented as sacrum) had healed as of (10/7). The resident had been receiving nutritional juices twice a day for wound healing and had consumed ~79% in AM and ~93% afternoon supplement. The resident really enjoyed the nutritious juices, so the dietician recommended to continue nutritional juices for 1-2 weeks for preventative nutritional support for recent altered skin integrity and then will recommend to discontinue. According to the nurse's notes, the resident experienced a decline in condition. Review of the nurse's notes revealed the following: On 1/20/14 at 2:27 a.m., staff documented the resident usually slept good through the night with the bed in a low position, and aroused easily. Staff checked the resident routinely throughout night and provided pericare as needed. The resident would look at staff while the staff provided care but seldom talked anymore. Staff had started to use a mechanical lift for transfers due to the resident not standing any longer. On 1/20/14 at 11:13 a.m. staff documented the physician gave new orders: 1) Discontinue DuoDerm to coccyx. Area has been resolved for a while now. 2) moisture barrier to buttocks per facility protocol. Review of the care plan revealed staff did not conduct a further assessment of the resident's skin to ensure the intervention for repositioning every 2 hours was sufficient to maintain the resident's skin integrity without the added protection of the [MEDICATION NAME] dressing. On 1/27/14 at 1:24 a.m. staff documented the resident slept good with bed in low position, alarms in place and activated. The resident usually aroused easily, but hardly ever spoke anymore--but would watch what staff was doing. The resident did not show signs of pain or discomfort, was incontinent of bowel and bladder, and required extensive assist with ADLs (Activities of Daily Living). On 2/7/14 at 2:25 a.m. 18 days after staff stopped using the [MEDICATION NAME] dressing for protection and without assessing the tolerance of the new tissue from the healed pressure ulcer, staff documented the resident rested in bed, and that it was reported by the previous shift the resident had an open area on his/her coccyx/bottom. Thin DuoDerm in place. Will pass on for treatment nurse to assess. Review of the electronic wound assessments revealed the following: 2/7/14: New pressure ulcer on coccyx identified on 2/6/14. Stage 2, 1.0 cm x 0.2 cm. Physician and responsible party notified on 2/7/14. Treatments: (2/7/14) Cleanse open area to coccyx with normal saline, apply skin prep, then cover with thick DuoDerm. Change every three days and as needed. (2/7/14) Monitor placement of DuoDerm to coccyx every shift. Change if needed. Review of a nurses note dated 2/7/14 at 2:46 p.m. revealed staff documented the resident had an open area noted to his/her coccyx that was a Stage 2 pressure area. Staff identified the resident was already on an air mattress and wheelchair cushion. Staff obtained a new physician's orders [REDACTED]. Change every 3 days and PRN (as needed). Monitor every shift for placement. Will continue to monitor. Electronic wound assessment dated [DATE]: Weekly update: Pressure ulcer on coccyx deteriorated. Stage 2- 0.9 x 0.4 cm, wound bed covered 90% in slough (dead tissue, usually cream or yellow in color), no change in treatment. NPUAP 2009 guidelines identify to respond immediately in deteriorations in pressure ulcers. Staff did not ask the physician for a change in treatment, or re-evaluate the interventions in place at that time. Review of the dietitian's note dated 2/10/14 revealed the resident had a Stage 2 pressure ulcer on the coccyx. Reviewed recent laboratory results from 2/5/14 which were within normal limits. Recorded intakes over the past 7 days averaged 89% at breakfast, 71% at lunch and 100% at dinner. The resident received calcium with vitamin D for supplementation. The dietitian recommend starting nutritional juices as supplement for additional calories and protein and to give the juices with meals due to insulin action for maximum blood sugar control. Recommend multi vitamin to ensure micronutrients are being met. Electronic wound assessment dated [DATE] revealed: Weekly update. Pressure Ulcer on coccyx improved. Stage 2. 0.9 x 0.3 cm. Granulation tissue (newly healing tissue) 30%, slough 70%. No change in treatments. The resident started to have some issues with maintaining body alignment, so staff had Occupational and Physical Therapy (OT/PT) review the resident. Review of the nurses notes revealed the following: On 2/21/14 at 1:32 a.m. staff documented the resident was on Part B (type of Medicare payment) for therapy for positioning. Slepts on an air mattress, staff checked the resident routinely for incontinence. The resident was able to position self at night, but staff repositioned as needed. The resident did not display any discomfort. On 2/21/14 at 6:51 p.m. staff documented the resident remained on Part B services for positioning and was followed by PT/OT. Staff identified the resident as alert and oriented to self only, not able to verbalize needs. Staff had observed the resident leaning to left side once that evening and repositioned with maximum assist of two staff, minimal assist of one provided with feeding. Total assist provided with other ADLs. The resident was incontinent of bowel and bladder, used a mechanical lift for transfer. Pleasant and cooperative with care. Half side rail in place for safety and bed mobility. Denied any discomfort. Review of the electronic wound assessments revealed the following: 2/24/14: Weekly update: Pressure Ulcer on coccyx improved. Stage 2, 0.9 cm x 0.7 cm. Granulation tissue 100%. No change in treatments. 3/3/14: Weekly update : Pressure ulcer on the coccyx status is unchanged. Stage 2, 0.9 x 0.7 cm: Granulation tissue 100%. No change in treatments. Review of a nurse's note dated 3/3/14 at 12:44 a.m. revealed the resident continued to receive therapy for positioning, the resident was able to reposition self in bed but staff repositioned the resident as well. Continued review of the electronic wound assessments: 3/10/14: Weekly update: pressure ulcer on coccyx is improved. Stage 2, 1.0 x 0.6 cm. Granulation tissue 100%. No change in treatment. 3/17/14: Weekly update: Pressure ulcer to coccyx is improved. Stage 2, 0.9 cm x 0.6 cm, Granulation tissue 100%. No change in treatment. 3/24/14: Weekly update: Pressure Ulcer to coccyx is deteriorated. Stage 2, 2.0 cm x 1.0 cm, Granulation tissue 100%. No change in treatment. Staff failed to follow the NPUAP's guidelines and immediately respond to a deterioration in the pressure ulcer. 3/31/14: Weekly update: Pressure ulcer to coccyx is deteriorated. Stage 2, 2.0 cm x 1.0 cm, Granulation tissue 70%, slough 30%. No change in treatment. Staff failed to follow the NPUAP's guidelines and immediately respond to a deterioration in the pressure ulcer. 4/7/14: Weekly update: Pressure ulcer to coccyx is deteriorated. Stage 2, 3.5 cm x 3.0 cm x 0.5 cm. Wound showed signs and symptoms of infection including increased, malodorous or purulent drainage. Staff conducted a culture of the drainage and the physician started the resident on antibiotic treatment. Slough 30%, Eschar 70%, Physician and responsible party notified of change on 4/7/14. The physician also changed the treatment to: 1) Cleanse coccyx wound with normal saline. Pack with [MEDICATION NAME] AG (silver). Cover with water proof dressing. Change every 3 days and PRN (as needed). 4/14/14: Weekly update: Pressure ulcer on coccyx has deteriorated. Unstageable due to eschar/slough. 5.0 cm x 9.0 cm x 1.0 cm. Increased drainage. Malodorous or purulent drainage. Moderate mount of serous drainage. Slough 30%, Eschar 70%. Doctor and responsible party notified on 4/14/14. Notes: During wound rounds noted resident's wound to be much larger than Friday. Call to doctor's office and received new order. 1) Transport to Wesley emergency room for evaluation and treatment of [REDACTED]. According to the nurse's note on 4/14/14, the resident was admitted to the hospital with [REDACTED]. On 6/9/14 at 1:20 p.m., Administrative nurse A, stated that the facility followed their policies on treatments of all pressure ulcers. On 6/12/14 at 12:38 p.m., Physician B, stated that after the resident admitted to the hospital, the wound nurse assessed the resident's wound and determined that the wound was deep enough that bone was present. As a result of that assessment, the resident was diagnosed with [REDACTED]. Physician B stated the resident was not admitted to hospital with the [DIAGNOSES REDACTED]. Physician B identified the resident arrived in a fairly stable clinical state, other than the wound. Physician B also stated the resident currently had a surgical repair to the wound and because of that, the hospital staff repositioned the resident from side to side only in an effort to keep all pressure off the resident's wound. Review of the facility's Wound Care Manual, dated 3/1/13, identified the observation of skin redness or the presence of a wound is a visible sign that tissue destruction has occurred. The stage of tissue destruction will guide the team's discussions in developing the most appropriate intervention plan. Initially, the interdisciplinary care planning team will establish an individualized positioning, transfer, range of motion, sitting, and/or turning schedule. If the patient/resident is admitted with an open wound or develops a wound after admission, the plan will then expand to include the use of an appropriate debridement and dressing regimen and the consideration for the use of modalities for wound healing. The facility used the following guidelines to treat pressure ulcers: For Assessment of wounds, the recommendations included: Reassess the individual if the ulcer does not show signs of healing as expected despite adequate local wound care, pressure redistribution, and nutrition. Expect some signs of healing in most individuals within 2 weeks. Adjust expectations in the presence of multiple factors (particularly unmodifiable factors) that impair wound healing (e.g., persistent undernutrition, poor perfusion, and co-morbidities known to impair wound healing). Use pressure ulcer assessment findings to plan interventions that will best promote healing. The treatment needs of a pressure ulcer change over time, in terms of both healing and deterioration. Treatment strategies should be continuously re-evaluated based on the current status of the ulcer. For Monitoring the healing of a pressure ulcer: Signs of deterioration should be addressed immediately General Recommendations: Choose positioning devices and incontinence pads that are compatible with the support surface. Limit the amount of linen and pads placed on the bed. For Positioning: Do not position an individual directly on a pressure ulcer If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer. The facility failed to adequately assess the tissue tolerance for a resident with a history of a healed pressure ulcer over the coccyx to ensure every 2 hours of repositioning was sufficient to prevent skin breakdown. The resident developed another pressure ulcer over the coccyx. The facility failed to develop and implement sufficient interventions, including responding immediately when the pressure ulcer showed signs of deterioration. The pressure ulcer became infected, rapidly deteriorated and the resident was hospitalized as a result. - Review of resident #3's [DIAGNOSES REDACTED]. to function for an unknown cause). Review of the significant change in status MDS (Minimum Data Set 3.0, a required assessment) dated 4/24/14, identified the resident with a BIMS (Brief Interview for Mental Status) score of 10/15, which indicated the resident had moderately impaired cognition, exhibited verbal behavioral symptoms directed toward others 1-3 days during a 7 day observation, the resident did not refuse care, required extensive assistance from 2 staff with bed mobility, transfers, toilet use, required extensive assistance from 1 staff with personal hygiene, the resident had an indwelling urinary catheter, and was always incontinent of bowel. The assessment also identified the resident at risk for the development of pressure ulcers, did not have any unhealed pressure ulcers, and that staff provided a pressure reducing device for the chair and bed, a turning/repositioning program, nutrition/hydration interventions to manage skin problems, and applied ointments/medications and nonsurgical dressing to places other than to the feet. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 5/1/14,identified the resident had a skin tear and abrasion noted to the back of bilateral (both) legs. The areas had continued to deteriorate due to the resident's noncompliance. The resident wanted to be repositioned every 4 hours at night, refused to be turned off of his/her back and lay down after meals. Staff had provided education to the resident regarding the risk versus benefits on repositioning, but the resident continued to refuse. The resident continued to go to the wound clinic as ordered. The treatments remained in place as ordered. The patient had a Foley (brand of indwelling urinary catheter) catheter in place to assist with wound healing. The resident also continued to receive nutritional supplements to assist with wound healing. Review of the ADL (Activities of Daily Living) CAA dated 5/1/14 revealed the resident required extensive assistance with ADLs and transfers. The resident required a sit to stand lift with transfers. The resident had a restorative program in place but refused to work with restorative aides. The resident had a [DIAGNOSES REDACTED]. The resident was noncompliant at times with repositioning noted. Review of the Behavioral CAA dated 5/1/14 revealed the resident became easily frustrated by others when not allowed time to finish his/her thought processes. The CAA also identified that the resident had a recent episode of threatening to harm others. The resident later apologized for this threat. The resident stated that he/she had "just lost it for a moment." Review of a discharge assessment dated [DATE] identified the resident discharged to an acute hospital on [DATE]. At the time of the discharge, the assessment identified the resident did not have any pressure ulcers. Review of the care plan, dated 5/8/14, revealed the resident had a indwelling urinary catheter due to wounds, was incontinent of bowel at times, wore briefs, and was recently in the hospital where the hospital staff "cleaned out my wounds". The care plan also identified the resident used a [DEVICE] to help with healing. The care plan identified the resident frequently refused to lay down or be repositioned, only wanted to awakened every 4 hours for repositioning. The care plan directed staff to ensure the resident was the last one up and the first one to lie down due to the pressure ulcers, but the resident did not always want that. The care plan also directed staff that during the night time, staff were only to check the resident for incontinence every 4 hours, apply a moisture barrier cream after each incontinent episode and as needed, provide perineal care after each incontinent episode and as needed, apply a [MEDICATION NAME] powder (medicated powder used for specific rashes), check and change the resident every couple of hours throughout the day and as needed, assist with catheter care at least every shift, keep the catheter anchored down and below the bladder during transfers. The care plan also directed staff to ensure the air mattress was in place and working properly at all times, assist the resident with repositioning every couple of hours and as needed except during the night. Remind the resident of the importance of repositioning for healing of the wounds, ensure the resident had a wheelchair cushion in place at all times, educate and remind the resident of the importance of repositioning and getting off his/her bottom, and encourage the resident to drink plenty of fluids. Review of the wound assessments, located in the electronic record, revealed the following: On 4/3/14, review of a wound clinic progress note identified the resident had pressure ulcers to the right ischium. The orders identified that staff were to not remove the [MEDICATION NAME] (type of dressing) on the right buttock, and were to obtain an air loss mattress for the patient and keep him/her off the buttocks. On 4/24/14, the wound clinic physician wrote a progress note that identified the resident was to be on strict bedrest, up for meals only, last up for mealtime, first down, staff were to turn the resident every 2 hours and PRN (as needed), pack the right ischial wound with normal saline guaze and change daily, do not allow the right ischial wound to get wet, a surgical consult was needed. According to the nurse's notes, the resident was hosptalized on [DATE]. The resident returned to the facility on [DATE]. Review of the wound assessments revealed on 5/14/14: Right buttock; buttock/upper thigh. Date wound identified 5/14/14. Re-assessment. Resident out of the facility through 5/14. Stage 3 (full thickness tissue loss-fat may be visible, but not bone, muscle or tendon) 2.2 x 3.6 x 4.6 cm. Physician and family notified. Tx: (5/15/14) Wound vac (vacuum) to right buttocks - change every Tuesday, Thursday and Saturday -Wound Vac @ 120 mmHg (strength of suction) 5/20/14: Weekly update: Right buttock; buttock/upper thigh Pressure ulcer. Stage 3. Unchanged- 2.0 x 4.5 x 5.5 cm Physician and responsible party notified. Tx (5/15/14) Wound Vac to Rt buttocks - change every Tues, Thurs and Sat - Wound Vac @ 120 mmHg. Review of the wound clinic progress note, dated 5/22/14 identified requests from staff to send supplies, both wound vac and incontinent, with resident on his/her appointments, as well as an order for [REDACTED]. Place on left side for sleep. 5/28/14: Weekly update: Right buttock Ischium stage 3 deteriorated 2.5 x 4.0 x 6.5 cm. Physician and responsible party notified. Notes: Measurements taken at wound clinic. Tx (5/27/14): Wound vac to rt buttocks - change every Monday and Friday by nursing home and Wednesday by wound clinic. Wound vac @ 120 mmHg. Review of the wound clinic progress note, dated 5/28/14, identified the physician documented the ulcer was getting deeper. The note directed staff to continue the previous orders and that the physician had a long discussion with the resident regarding getting out of the chair if he/she was expecting to heal the wound or accept the wound and have some mobility. 6/2/14: Weekly update: Right buttock; ischium, Stage 3, improved. 2.0 x 4.0 x 6.0 cm physician and responsible party notified. Tx (5/27/14) Wound vac to Rt buttocks - change every Monday and Friday by nursing home and Wednesday by wound clinic. Wound Vac @ 120 mmHg. On 6/4/14 at 7:18 a.m., observation revealed the resident lay in bed on his/her back in his/her room. The overhead light was off in the room, but the television was on. The resident laid on an air mattress that ran and filled the mattress with air. On 6/4/14 at 7:32 a.m., observation revealed the resident continueed to lay in bed on his/her back in the room. The overhead light remained off. However, the resident was talking to the room mate, and he/she asked the room mate "have you had breakfast yet?" and the room mate said "no". Observation revealed staff had already passed out 7 room trays to residents down the same hall the resident lived on and those residents were already eating. No staff entered the room to encourage the resident to reposition. On 6/4/14 at 7:45 a.m., observation revealed the resident continued to lay on his/her back in bed. The overhead light was off and the television remained on in the resident's room. On 6/4/14 at 8:00 a.m. No change noted in the resident-continues to lay in bed on his/her back in bed. On 6/4/14 at 8:12 a.m., observation revealed direct care staff C and assisted the resident's room mate up from bed and into a wheelchair. The staff did not assist or encourage the resident to reposition in bed and the resident remained on his/her back. Once up in a wheelchair, the room mate asked the resident if he/she was getting up for breakfast and direct care staff C told the room mate "He/she does not get up for breakfast." The room mate said "oh" and staff C then took him/her out of the room. Direct care staff D then went and got the menu options for breakfast and came back and obtained the resident's order for breakfast. On 6/4/14 at 8:23 a.m., the staff had not brought the resident a room tray of food yet for breakfast. The resident continued to lie on his/her back in bed. On 6/4/14 at 8:39 a.m., staff delivered a room tray to the resident. The resident received a bowl of mini wheats, scrambled eggs, pancakes with syrup, an 8 oz (ounce) glass of thickened milk, an 8 oz glass of thickened water, and two 8 oz glasses of thickened juice. The aide elevated the resident's head of the bed to at least 75 degree angle, then put the fork in the resident's hand, made sure the resident could reach the plate, and left. The resident started to eat independently. On 6/4/14 at 8:55 a.m., the resident continued to eat in his/her room independently. Remained on his/her back in bed with the head of the bed (HOB) elevated. On 6/4/14 at 9:10 a.m., No change-remained on his/her back with HOB elevated and eating. On 6/4/14 at 9:17 a.m., the resident was no longer eating, but remained in bed with the head of the bed elevated. Ate well. No staff observed in hallway to remove tray. On 6/4/14 at 9:30 a.m., the resident was done eating and had eaten >75% of his/her food on the plate. The resident drank all of the juice and milk, but did not drink the water. No change in position. On 6/4/14 at 9:42 a.m., remained in bed on his/her back, but the head of the bed was back down to about 40 degrees. The resident remained without a position change, or staff encouraging the resident to reposition, for over 2 hours. On 6/4/14 at 11:45 a.m., observation revealed the resident continued to lie on his/her back in bed. He/she said that staff had started to give him/her a bed bath and that they had done the front half, but they were waiting to do the back half when the wound nurse came back because the wound nurse had to change the dressing for his his/her wound vac, and while they had him/her turned over they were going to wash his/her back half so he/she did not have to turn as much. The resident said that he/she hated lying on his/her side, he/she has had both shoulders crushed and he/she can't lay on either side for very long before it starts to hurt and he/she can't stand it. On 6/4/14 11:52 a.m., the resident continued to lie in bed on his/her back, waiting on staff to bring him/her the noon meal. On 6/4/14 at 12:05 p.m., observation revealed the resident continued to lie in bed on his/her back in the room. Staff had not served lunch to him/her yet. On 6/4/14 at 12:14 p.m., observation revealed direct care staff C and D entered the resident's room. The resident was anxious, saying he/she wanted up. The staff said that they were waiting on the wound nurse, that they thought he/she had gone to get more equipment to change the resident's dressing on his/her pressure ulcer. The resident said "I have not ordered (lunch) yet." Staff told him/her that they would go find out where the wound nurse was. On 6/4/14 at 12:18 p.m., the staff returned and told the resident the wound nurse had left for his/her lunch break and would not be back for 30 minutes. So they asked

The facility census totaled 94 residents with 5 reviewed for weight loss. Based on observation, interview, and record review, the facility failed to ensure 1 of 5 sampled residents (#25) maintained acceptable parameters of nutrtional status, such as body weight, unless the resident's clinical condition demonstrated that was not possible. The facility staff failed to encourage eating and provide dietary supplements as planned. The resident's weight went from 134 pounds to 113 pounds in 3 months, for a loss of 21 pounds (16%), a significant amount of weight loss. Findings included: - Review of the 6/24/11 physician's review of orders identified resident #25 experienced the following Diagnoses: [REDACTED]. Review of the significant change in status MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 5/23/11 identified the resident with little cognitive impairment, required extensive assistance from staff with bed mobility, transfers, dressing, eating, toilet use and personal hygiene, with a weight loss of 5% in the last month or 10% or more in the last 6 months, on a mechanically altered diet and with a weight of 124 pounds. Review of the Nutritional Status CAA (Care Area Assessment) dated 5/27/11 identified the resident requested snacks, received a mechanical soft diet with magic cups (dietary supplement) with meals, average meal intake totaled 42% and fluid intake ranged from 0-420cc (cubic centimeters) at meals. "Feeds self in main dining room. Current weight 124 pounds, weight down 8.15% in 1 month and down 9.62% in 180 days. Snacks & magic cups (three times a day) provided." Review of the care plan, dated 6/2/11, identified the resident without much of an appetite "lately since I have been so ill." It further identified that staff help get what the resident wanted to eat and then helped the resident to eat it. It directed staff to ensure the resident received a mechanical soft consistency diet as ordered, to weigh the resident as needed, encourage the resident to drink plenty of fluids, and ensure the resident received the magic cups as ordered. The CNAs (certified nurse aides) carried sheets that described the type of assistance the residents required. According to these sheets, entitled "ADL (Activities of Daily Living) Information Sheets" and last reviewed/updated on 7/15/11 the resident received a regular diet, and directed staff to encourage the resident to take small sips, small bites and to assist the resident. It failed to mention the needed encouragement or administration of supplements. Review of the resident's weights, revealed the following: 1/28/11 135.6 2/25/11 136.4 3/25/11 127.5 4/15/11 134.2 5/4/11 125.5 6/17/11 116.0 7/15/11 112.5 The resident experienced a weight loss of 21.7 pounds from 4/15/11 to 7/15/11. This represented a weight loss of 16% in 3 months, a significant weight loss. Review of a dietary assessment, completed by Registered Dietitian A and dated 5/24/11 revealed the resident's diet order included a mechanical soft diet and magic cups with meals and med pass 30cc (another dietary supplement) three times a day. It also identified the resident received a bedtime snack "per snack menu." The dietitian also documented the resident's weight declined 8.15% in 1 month and 9.62% in 180 days. The dietitian recommended staff to encourage po (by mouth) intake, and identified they planned to continue to follow the resident's condition. Review of the Dietitian A's progress notes revealed that on 6/6/11 they identified the resident continued on the same diet (mechanical soft diet with magic cups with meals and snacks three times a day), with a weight of 121.5 pounds that indicated a weight loss of 9.67% in 1 month and 11.44% in 180 days. "Significant weight loss." The notes concluded with "no recommended changes at this time." Review of the dietitian's progress note dated 6/27/11 identified the resident continued on the same diet, with a weight of 116 pounds that indicated a weight loss of 6.45% in 1 month and 15.45% in 180days. The note also identified the resident had identified they did not care for the magic cups but liked the health shakes, so the dietitian recommended staff start health shakes three times a day rather than the magic cups for added calories/protein. Observation on 7/18/11 at 1:08 p.m. revealed the resident sat in a wheelchair in the dining room, eating the noon meal. Staff served the resident ground Salisbury steak, mashed potatoes, green peas, a container of ice cream, a dessert of pumpkin praline, plus a roll. The resident ate independently, without staff nearby for encouragement. Observation at 1:20 p.m. revealed the resident now propelled their wheelchair away from the dining room table. The resident ate less than 10%, and no staff stopped the resident to encourage the resident to eat more or to ask if the resident wanted anything else to eat. Staff failed to encourage the resident to eat. Observation on 7/19/11 at 8:43 a.m. revealed staff served the resident a breakfast of super cereal (hot cereal with added calories that included butter and brown sugar), a cheese omelet, and ground sausage. The resident did not attempt to eat any breakfast. Several staff walked by as they served other residents, but did not encourage the resident to eat or drink. At 8:56 a.m. observation revealed the resident took 1-2 bites of the omelet, but nothing else. Nurse B, who passed medicines to the resident that sat across the table from the resident, sat at the table to wait for the tablemate to take their medicine. Nurse B spoke to resident #25, but did not encourage the resident to eat or drink. At 9:05 a.m., the resident mixed all of the sausage and omelet into the cereal bowl and did not eat. At 9:07 a.m. Nurse C stopped at the table and administered medicines to the resident, then assisted the resident away from the table and towards the resident's room without encouraging the resident to eat or offering anything else. At 10:40 a.m. on 7/19/11, observation revealed nurse aides D and E weighed the resident with a sling and a mechanical lift with a scale. Staff E identified the resident's weight as 110.5 pounds, a loss of an additional 2 pounds in 4 days. Observation on 7/19/11 at 1:04 p.m. revealed staff served the resident a noon meal of lasagna, a bowl of broccoli and cheese sauce, a slice of garlic bread, and a piece of chocolate cake. The resident took a few bites of lasagna, but failed to eat anything else, and staff did not encourage the resident to eat anything else. Staff failed to encourage the resident to eat. Review of the staff documentation of the administration or offering of supplements and dietary intake records for the first 19 days of July 2011 revealed staff were to offer supplements to the residents between meals at 10 a.m., 3 p.m., and at bedtime (HS). Review of the documentation revealed the following: - At the 10 a.m. time, staff documented the resident refused the supplement once, took 50% one other time, and the other 17 times staff failed to document the administration of the supplement. - At the 3 p.m. time, staff documented the resident accepted 100% of the supplement 8 times, took 50% once, refused once, and for the other 9 times, staff failed to document the administration of the supplement. - At the HS time, staff failed to document the administration of a supplement all 19 times. Staff failed to document they followed the plan and offered or administered a supplement 3 times a day between meals. On 7/19/11 at 6:48 p.m., when asked what type of assistance the resident required and how they helped the resident, nurse aide J stated that the resident ate independently, and that staff cut up some of the resident's food, but otherwise they didn't have to do anything for the resident. On 7/20/11 at 10:30 a.m., Dietitian A stated that the resident had been steadily losing weight due to the resident's loss of an appetite. Staff A stated staff have tried snacks between meals, as well as magic cups, but the resident said they didn't really like the magic cups, so staff "are now trying the mighty shakes between meals." On 7/20/11 at 10:50 a.m., Advanced Registered Nurse Practitioner P identified that the facility notified them of the resident's weight loss and they saw the resident yesterday. Staff P said they reviewed the facility's documentation and noticed a lot of holes where staff failed to document either a meal or a supplement intake, and Staff P stated they circled those holes on the documentation to make staff aware. Staff P also said they mentioned to the evening staff to please encourage the resident to take a supplement if the resident did not eat well, and if the resident happened to be asleep when they passed the supplements, to please wake the resident up and encourage the consumption of the supplement. Staff P agreed that it was hard to know if staff administered the supplements as planned if they failed to document. The facility failed to encourage a resident to eat and failed to administer a supplement 3 times a day as planned to a resident who failed to maintain an acceptable parameter of nutritional status. The resident experienced a weight loss of over 21 pounds, or 16% in 3 months, a significant amount. The failure to administer the supplements and encourage eating as planned made the weight loss avoidable.

The facility reported a census of 106 residents, with 9 residents included in the sample. Of the 9 residents, 3 residents were reviewed for weight loss. Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as body weight and protein levels for 1 of 3 sampled residents (#1001), by the failure to provide dining interventions as planned, reassess the status of a resident with identified weight loss, and put interventions in place to prevent further weight loss. Findings included: - Review of the Active [DIAGNOSES REDACTED].#1001 with the following Diagnoses: [REDACTED]. Review of the resident's Admission MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 7/6/11 identified the resident with a BIMS (Brief Interview for Mental Status) score of 10 (8-12 indicated moderate impairment). It also identified the resident required limited assist of one staff member for eating, had no or unknown weight loss noted, the resident received a therapeutic diet, had a height of 70 inches, weighed 243 lbs., and had no dental issues. Review of the CAA (Care Area Assessment) signed on 7/13/11, identified Nutritional Status triggered for a further assessment. Review of the CAA revealed, "Food is good. My appetite is "normal". Sometimes I'm hungry, sometimes I'm not. I drink coffee every morning. " It also noted, "CHO (controlled carbohydrate) - low sodium diet (NAS (No added salt)). " It identified the resident's oral intake averaged 25% per meal, had calorie needs of 1688-2064 calories per day, and needed encouragement/assistance with meals. The assessment also identfied the resident received Ensure (a protein supplement) twice daily between meals, ate in the back dining area, required cueing and assistance at meal times, and for staff to monitor weight as the physician preferred. Review of a signed physician's orders [REDACTED]. Review of a signed 7/11/11 physician's orders [REDACTED]. On 7/21/11, another signed physician's orders [REDACTED]. Review of a Dietary Progress Note dated 8/2/11 revealed, "Res (resident) is on consistent carbohydrate, no added salt diet, Res is now taking meals in back dining room with assistance as needed. Receives Ensure BID (twice daily) for added calories/protein. Res is now to receive food in bowls. PO (by mouth) intake avg (average) 36% at meals. Fluid intake 120-600ml (milliliters) at meals. PO intake increased from 29% avg on 7/21/11 RD (Registered Dietician) Note. Documented 63% intake of Ensure in last week. Current wt (weight) 222.4#, wt down 8.48 percent in 1 month (significant). Continue Ensure, food in bowls, and back dining room seating for assistance as needed at meals." Review of the Care Plan last signed on 9/6/11 revealed, "I just don't have much of an appetite. I don't feel like I am moving around as much here and I don't work up as much of an appetite. I don't have any food allergies [REDACTED]. I love to have a fresh cup of coffee every morning. It helps me wake up" and identified the resident's food likes and dislikes. The care plan directed staff to provide the resident with his/her food in bowls, ensure the resident received Ensure as ordered and document the percent taken, ensure the resident received iron and Vitamin C as ordered, to weigh the resident as his/her doctor preferred, and also directed staff to assist the resident as needed in the back dining room for meals. Observation at 12:46 P.M. on 9/20/11 in the main dining room revealed the resident sat at a table with other residents in the independent dining area. The resident received a bowl of ham and beans, a plate of greens and macaroni and cheese, and a small bowl of cobbler. The resident moved his/her plate and bowls around into the preferred setting, then began to eat. After the resident ate approximately 50% of his/her meal, he/she pushed away from the table and propelled from the dining room. A staff member asked if the resident had finished eating, the resident stated, "yes" and propelled independently back to their room. Staff failed to provide all of the resident's foods in bowls as planned, and failed to encourage the resident to finish eating. Observation at 8:28 A.M. on 9/21/11 revealed the resident again sat in the independent dining area. The resident began to eat a bowl of cereal with pieces of banana added. Observation at 8:54 A.M. revealed the resident ate less than 50 % of their meal, then pushed away from the table, and started to propel from the table. Observation revealed Direct care staff D assisted the resident to the resident's hall. Staff failed to encourage the resident during the meal, or ask if the resident wanted anything other than the food served. During an interview on 9/20/11 at 3:48 P.M., Direct Care staff E confirmed he/she worked on the hall where the resident lived, and confirmed working in the dining room during meals. Staff E reported he/she did not know if the resident had experienced any weight loss. When asked about needed assistance or encouragement, Staff E stated, "(Gender) feeds (gender's self). That's all I know." At 12:18 P.M. on 9/21/11, Direct Care staff C reported he/she did not need to encourage the resident to when the resident ate in the dining room. Staff C also reported he/she did not know if the resident had any weight loss, or if the resident had anything specific the staff had to monitor for or be aware of at meals. Staff C reported the resident as "pretty independent." During an interview at 8:56 A.M. on 9/21/11 Dietary staff I reported he/she followed the recommendations from the dietician, and reported the dietician reviewed the weights to look for weight loss. Staff I confirmed the resident's foods needed to be in bowls. When asked the reason for the bowls, Staff I stated, "I think that was a request from family," but wasn't sure. During an interview on 9/21/11 at 10:03 A.M., Licensed Nursing staff G confirmed the resident needed encouragement to eat at meals. When asked about the resident receiving food in bowls during meal time, Staff G stated, "I don't think it's a dexterity issue" and confirmed the care plan didn't specify why the resident needed food served to him/her in bowls. Staff G also confirmed the resident no longer sat in the back/assisted dining. Staff G reported the resident used to sit in the back/assisted dining area because "(gender) was not wanting to eat, and to provide encouragement." Staff G reported he/she wanted to ask Administrative Nursing staff A about the issues Review of the Weight Log revealed the following weight history: 8/19/11 223.2 pounds 8/22/11 223.6 pounds 8/26/11 221.2 pounds 9/5/11 217.2 pounds 9/10/11 217.8 pounds 9/12/11 215 pounds 9/14/11 216.6 pounds 9/16/11 216.4 pounds 9/20/11 214.6 pounds At 8:04 A.M. on 9/21/11 Direct Care staff D assisted the resident to the scale. The scale read, and Staff D confirmed a weight of 214.2 pounds, a 4% weight loss from 8/19/11. Consultant H on 9/21/11 at 9:06 A.M. reported he/she looked at weight loss weekly, and if a resident experienced weight loss, made interventions then reevaluated as needed. Consultant H reported he/she did not consider the resident as having had significant weight loss at that time, and reported he/she waited until a resident's weight loss triggered as significant prior to reassessing the resident. Consultant H also reported the resident had Ensure in place to provide extra calories and protein, and received food in bowls because the resident ate better. Consultant H reported the resident sat in the back dining area for increased assistance, but then reported he/she did not know why the resident currently ate in the independent dining area. On 9/21/11 at 11:27 A.M. Administrative Nursing staff A confirmed the dietician looked at the weights weekly, and monitored for weight loss. If the dietician identified a weight loss, he/she communicated it to the multidisciplinary team, and placed a notation in the chart that the resident had a pending significant change, even if the resident started to drop weight and did not trigger for significant loss. Staff a confirmed Consultant H identified the resident with a significant weight loss on 8/2/11. Staff A reported the resident currently sat in independent dining because of issues with other residents in the back dining area, and reported he/she felt the resident didn't need much assistance, but still needed to be served his/her meals in bowls. Also, Staff A reported the facility's QA (Quality Assurance) program focused on who had supplements, and supplement documentation, but confirmed the QA team didn't focus on identifying residents with weight loss. On 9/21/11 at 9:48 A.M., Administrative Nursing Staff B reported consultant H confirmed they expected staff to identify and put interventions into place prior to weight loss becoming significant. Staff B reported a signficant weight loss was a weight loss or gain of 5% in 1 month, 7.5% in 3 month, and 10% in 6 months. The facility failed to provide dining interventions as planned, reassess the status of resident #1001 with identified weight loss, and put interventions in place to prevent further weight loss.

The facility census totaled 94 residents, with 2 residents reviewed for the facility's provision of fluids. Based on observation, interview, and record review, the facility failed to ensure the sufficient fluid intake to maintain proper hydration and health for 1 of 2 sampled residents. (#25) The facility staff failed to offer and encourage the resident to drink, and the resident failed to consume adequate fluids to maintain hydration and required the administration of infused fluids through the subcutaneous tissue in the abdomen. Findings included: - Review of the 6/24/11 physician's review of orders identified resident #25 experienced the following Diagnoses: [REDACTED]. Review of the significant change in status MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 5/23/11 identified the resident with little cognitive impairment, required extensive assistance from staff with bed mobility, transfers, dressing, eating, toilet use and personal hygiene, and on a mechanically altered diet. Review of the Nutritional Status CAA (Care Area Assessment) dated 5/27/11 identified the resident's fluid intake ranged from 0-420cc (cubic centimeters) at meals. "Feeds self in main dining room." Review of the care plan, dated 6/2/11, identified the resident liked coffee for breakfast and supper and iced tea for lunch. It directed staff to encourage the resident to drink plenty of fluids. The CNAs (certified nurse aides) carried sheets that described the type of assistance the residents required. According to these sheets, entitled "ADL (Activities of Daily Living) Information Sheets" and last reviewed/updated on 7/15/11 directed staff to encourage the resident to take small sips, small bites and to assist the resident. It failed to mention the need for encouragement of fluids. Review of a Dietary assessment dated [DATE] identified the resident required 1680-1960cc (cubic centimeters) of fluids per day to maintain adequate health and hydration. Review of the documentation of fluid intake for the month of July 2011 revealed the resident consumed the following daily fluid amounts: 7/01/11 - 160cc 7/02/11 - 660cc 7/03/11 - 600cc 7/04/11 - 460cc 7/05/11 - 600cc 7/06/11 - 240cc 7/07/11 - 300cc 7/08/11 - 320cc 7/09/11 - 240cc 7/10/11 - 240cc 7/11/11 - 360cc 7/12/11 - 180cc 7/13/11 - 400cc 7/14/11 - 480cc 7/15/11 - 660cc 7/16/11 - 360cc 7/17/11 - 300cc 7/18/11 - 240cc 7/19/11 - 720cc The documentation revealed staff failed to ensure the resident consumed sufficient fluids. Observation on 7/18/11 at 1:08 p.m. revealed staff served the resident a noon meal which included three 8oz (ounces) glasses of fluid, one each of milk, iced tea and water, for a total of 720cc (cubic centimeters). The resident ate independently. At 1:20 p.m., the resident independently propelled their wheelchair away from the table. Observation revealed the resident did not drink any of the fluids, nor did staff stop to encourage the resident to drink. Observation on 7/18/11 at 1:43 p.m. revealed nurse aides T and U assisted the resident with a transfer from the wheelchair and into bed. Once in bed, they removed the resident's incontinent brief. Nurse aide U then stated "I hope (the resident) is wet. (The resident) did not go at all the other day." Nurse aide T said "I know (the resident) hasn't been going much lately." Once they checked the brief, the aides identified it as dry. The aides failed to offer/encourage the resident a drink of water before leaving the room. Observation on 7/19/11 at 8:20 a.m. revealed nurse aide U assisted the resident into the dining room. Once there, staff U poured the resident a glass of ice water (8oz) and put a straw in it for the resident to drink. At 8:43 a.m., staff served the resident their breakfast, which included a 6oz cup of coffee. The resident sat looking at their breakfast, but failed to start eating or drinking. Several staff walked by as they served other residents, but did not encourage the resident to eat or drink. Observation revealed at 8:56 a.m., nurse B administered medications to a tablemate. Nurse B talked with resident #25, but failed to encourage the resident to eat or drink. At 9:07 a.m., Nurse C administered medications to the resident and gave the resident a 4oz cup half full of water to take them with. The resident took the medicine and the water, and then Nurse C propelled the resident away from the table and to the resident's room. Nurse C did not encourage the resident to drink anything more, either at the table, or once in the resident's room. Staff failed to encourage the resident to drink as planned. On 7/19/11 at 6:50 a.m., nurse W identified that the staff "really have to encourage (the resident) to drink because (the resident) doesn't drink much at all on (their) own." On 7/20/11 at 10:50 a.m., Advanced Registered Nurse Practitioner P stated they reviewed the resident's care the day before and talked with the resident, who stated they did not feel well. While reviewing staff documentation of the resident's fluid intake, staff P noted that the documentation revealed the resident consumed less than 750cc of fluid per day, so staff P thought the resident had dehydration which might be part of why the resident did not feel well, so they ordered staff to infuse 2000ml (milliliters) of fluid. On 7/20/11 at 2:15 p.m., when asked about the order for the infusion of fluids, Administrative Nurse Q confirmed staff were administering the fluids at that moment. Nurse Q stated that the resident had received infusions of fluid previously and had "no veins" so they administered the fluids in the subcutaneous tissue (fatty tissue below the skin), so that is where the staff administered the current order for fluids. The facility failed to encourage and provide sufficient fluids to maintain proper hydration and health for a resident with a history of poor oral intake. The resident required 2 liters of infused fluids through the subcutaneous tissue of the abdomen.