Every finding on record at Diversicare of Sedgwick

The facility had a census of 48 residents. The sample included six residents with one resident reviewed for involuntary discharge. Based on interviews and record review, the facility failed to ensure Resident (R) 1's Electronic Health Record (EHR) contained physician documentation of the rationale for the involuntary immediate discharge. This placed the resident at risk for impaired rights and inappropriate discharge. Findings included: - R1's EHR documented diagnoses that included Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), history of suicidal behavior and major depressive disorder (MDD - a major mood disorder that causes persistent feelings of sadness).R1's Census log documented Discharge Paid dated 06/26/25, and Stop [NAME] dated 06/27/25.R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented, per staff interview, R1 had moderately impaired cognition. The assessment documented verbal behaviors towards others and behaviors not towards others occurred one to three days during the look-back period. The assessment documented these behaviors put the resident at risk for physical illness and/or injury and interfered with care. R1 was dependent on staff for personal hygiene, shower/bathing, toileting hygiene, and oral hygiene. R1 required substantial/maximal assistance for application of footwear, and upper and lower body dressing. R1 required supervision/touching assistance for eating. R1 required substantial/maximal assistance for all transfers and was always incontinent of bowel and bladder.R1's Behavioral Symptoms Care Area Assessment (CAA) dated 05/29/25, documented R1 had physical harm to himself related to hitting his head against the wall and placing himself on the floor.R1's Discharge - Return Anticipated Minimum Data Set (MDS) dated [DATE] documented R1 had an unplanned discharge from the facility to an inpatient psychiatric facility. The assessment documented a Brief Interview of Mental Status interview could not be completed, though per staff assessment, R1 had severely impaired cognition. The assessment documented physical, verbal, and other behaviors towards himself and others, with rejection of care, which occurred one to three days during the look-back period.R1's EHR Physician Orders documented an order to transfer/discharge R1 to an Emergency Department (ED) due to acute psychosis (any major mental disorder characterized by a gross impairment in reality perception) with a suicide attempt, dated 06/26/25, from Physician Extender EE. The order was entered by Administrative Nurse D.R1's EHR Progress Notes documented the following notes:On 06/09/25 at 08:17 AM, staff documented R1 was restless, anxious, and agitated. Non-medicinal interventions were attempted but unsuccessful, and R1 became physically violent with staff. As-needed (PRN) medications were given, and 1:1 observation continued.On 06/14/25 at 02:45 PM, staff documented that at approximately 02:00 PM, R1 was verbally aggressive and threatened physical violence to staff. PRN medications were administered along with non-medicinal interventionsOn 06/21/25 at 10:52 AM, staff documented R1 had increased restlessness, anxiety, and aggression with physical violence and verbal aggression towards staff. PRN medications were administered with non-medicinal interventions in place.On 06/25/25 at 12:15 AM, staff documented R1 suddenly became physically and verbally aggressive towards staff, which included expletives and insults. R1 placed himself on the floor and started banging his head on the floor. Staff unsuccessfully attempted to redirect R1, and PRN medications were administered.On 06/25/25 at 04:18 PM, Physician DD documented an exam of R1, which noted R1 had a sitter for 1:1 observation due to recent behaviors. Physician DD documented staff reported increased behaviors and noted R1 had been seen by a psychiatric provider who was no longer at the facility; a new psychiatric provider had been located, but R1 had not been evaluated by the new psychiatric provider. Physician DD documented R1 was very hard to redirect with his behaviors.On 06/25/25 at 08:40 PM, staff documented a Weekly Nurses Note that documented R1 continued with 1:1 staff supervision related to the history of suicide attempts and suicidal ideations (thoughts or ideas about dying by suicide). R1 continued to have episodes of aggression and anxiety with verbal and physical abuse towards self and others.On 06/26/25 at 04:22 PM, staff documented at approximately 01:50 PM, R1 suddenly got up and forcefully removed the blinds from the window and stated he wanted to kill himself. He then placed himself on the ground and began hitting his head against the floor. Staff attempted redirection and placed cushions around him to prevent injury. R1 refused to surrender the window blinds to staff or allow staff to assist him off the floor. At approximately 02:00 PM, the Licensed Nurse (LN) provided PRN medications to help calm R1, but the medications were ineffective. At approximately 02:05 PM, Administrative Nurse D was notified of the situation. At approximately 02:10 PM, R1 began to wrap the window blinds around his neck and continued to express a desire to kill himself. When staff intervened, R1 became physically aggressive and was violent towards staff. At approximately 02:42 PM, Emergency Medical Services (EMS) was called. Staff were able to safely place R1 in his bed prior to EMS arrival. When EMS arrived, R1 verbalized he was willing to be transported to a local hospital for evaluation and additional treatment. EMS left with R1 at approximately 03:20 - 03:25 PM. R1's physician was notified at approximately 03:30 PM.On 06/26/25 at 06:16 PM, staff documented R1's representative was notified by telephone at 06:00 PM and left a message when R1's representative did not answer the telephone.On 06/26/25 at 09:15 PM, staff documented R1 had an unplanned transfer to a hospital on [DATE] at 03:25 PM due to behavioral symptoms that included agitation and psychosis.On 06/26/25 at 09:24 PM, staff documented the facility called the hospital to verify R1's status. Hospital staff revealed R1 was admitted to a medical floor.On 06/30/25 at 04:48 PM, staff documented Social Services Designee (SSD) X emailed R1's representative with an emergency notice of transfer/discharge. Staff documented R1's needs could no longer be met by the facility, and R1 presented a safety risk to other residents. Staff documented R1 had chosen to be discharged from the facility. SSD X notified hospital staff and provided information related to alternate locations that might accept R1.On 07/01/25 at 06:27 PM, staff documented SSD X called the significant other of R1's representative since R1's representative had not responded to the facility's message left on 06/30/25. The significant other of R1's representative verbalized understanding that the facility could no longer meet R1's needs.R1's EHR Resident Documents contained a scanned letter, dated 06/26/25, to discharge R1 to a hospital on [DATE]. The letter documented the reasons for the discharge were: the discharge was necessary as the resident's needs could no longer be met by the facility; the discharge was necessary due to a safety risk to other individuals at the facility; the resident had chosen to be discharged from the facility. The letter was signed by Administrative Staff A.R1's EHR, reviewed 04/16/25 to 07/01/25, did not contain physician documentation of specific services the facility was unable to provide to R1 or that R1 posed a risk to the safety of the other residents of the facility.On 09/09/25, Administrative Staff A and Administrative Nurse D were unavailable for interview.During an interview on 09/09/25 at 02:25 PM, Administrative Staff B revealed R1's discharge was not planned. Prior to his discharge, R1 had been sent multiple times to a hospital for his behaviors and attempts at self-harm; however, the hospital would only medicate R1 and discharge him back to the facility when no behaviors or attempts at self-harm were observed. R1 had attempted self-harm with anything he could find, so staff had removed potentially harmful objects from his room and placed padding on the walls and floor to prevent him from banging his head against the walls and/or floor. The facility had even attempted to refer R1 to a facility with a special unit for individuals with Huntington's disease, but the receiving facility declined to take R1 due to his history of attempts at self-harm. On the date R1 was discharged , he had attempted to strangle himself by wrapping the power cord for the television and the cords for the window blinds around his neck; it took three staff members to pry his fingers away and remove the cords from around his neck. Law Enforcement Officers (LEO) and EMS were called, and R1 was transported to a different hospital for psychiatric help.During an interview on 09/09/25 at 03:05 PM, Administrative Staff B stated the facility expected to be cited for the discharge of R1. The facility had exhausted all known resources and understood that R1 could not remain at the facility due to ongoing safety concerns for staff and other residents.The facility's 11/01/16 Transfer & Discharge policy documented the facility would permit each resident to remain and not transfer or discharge the resident except in accordance with Federal and State laws. The facility could transfer a resident if the resident's welfare and needs could not be met by the facility, or the safety of other individuals was endangered due to the resident. If the basis of the transfer or discharge was due to the safety or welfare of others, physician documentation would support the transfer.

The facility reported a census of 42 residents. The sample included 15 residents, which included three residents selected for closed record review. Based on interviews and record review the facility failed to provide the necessary care and service needed to manage symptoms when staff failed to promptly identify and react to a change in condition for Resident (R) 29, who had diabetes mellitus. On 05/04/25 R29 refused all his morning medication including his diabetic medications; R29's blood glucose was 388 milligrams (mg) per deciliter (dL) at 05:45 AM that morning. Staff did not notify R29's physician of the medication refusal or the abnormally high blood glucose level. On the evening of 05/04/25, R29 refused all his medications again and had a blood glucose of 513 mg/dL at 09:00 PM but staff did not notify the provider of the dangerously high blood glucose or the medication refusals. On the morning of 05/05/25, staff entered an order for a one-time dose of Humalog (fast-acting insulin) at 06:13 AM but the insulin was not administered as R29 was unresponsive and sent by ambulance to the hospital at 07:40 AM. The facility's failure to identify and respond to changes in R29's medical condition and immediately involve the physician placed R29 in immediate jeopardy. Findings included: - R29's Electronic Medical Record (EMR) documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anorexia (lack or loss of appetite), type 2 diabetes mellitus with diabetic neuropathy (DM-a long-term complication of type 2 diabetes where nerve damage occurs, primarily due to chronically elevated blood sugar levels), and acute osteomyelitis of left ankle and foot (an infection of the bone that develops fast). The Significant Change Minimum Data Set (MDS) dated 03/24/25 documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment documented R29 required supervision or touching assistance activities of daily living (ADL) such as oral and personal hygiene, and partial to moderate assistance with bathing. The MDS noted R29 received insulin injections for all seven days in the observation period. R29's Care Plan dated 12/14/23 and revised on 11/18/24 documented R29 had an alteration in blood glucose due to being insulin-dependent with a diagnosis of diabetes mellitus. Interventions included the administration of medications and insulin as ordered. The plan directed staff to observe R29 for high blood sugar symptoms and report to the nursing/physician any changes in vision, decreased mental function, poorly healing wounds, dizziness, dehydration, vomiting, cardiac symptoms, or renal dysfunction. R29's Care Plan dated 08/01/24 documented R29 was at risk for decreased mood related to a history of depression, use of medication for management, and refusal to eat. Interventions included the administration of medications as ordered and informing the physician if symptoms were not improving. R29's Care Plan dated 01/21/25 documented R29 was at risk for impaired cardiovascular status related to congestive heart failure, coronary artery disease (heart disease), and peripheral vascular disease. Interventions included giving medications as ordered by the physician, observing and reporting any signs of chest pain, edema (swelling), shortness of breath, abnormal pedal (foot) pulses, restlessness, and fatigue; staff were to observe for any changes in condition. R29's Care Plan dated 04/07/25 documented R29 had the potential for alteration in hydration related to diabetes mellitus with an active infection. Staff were directed to notify the physician of signs or symptoms of excess fluid. The plan directed staff to observe R29 for mental status changes and changes in mood or behavior. R29's EMR under the Orders tab listed an order for a fasting and evening blood glucose level two times daily for DM, dated 08/26/24. The order lacked instructions regarding notification parameters. R29's May 2025 Medication Administration Record/ Treatment Administration Record (MAR/TAR) revealed on 05/04/25 documented a 2 indicating R29 refused all his morning (AM) scheduled medication including aspirin, liquid protein supplement, metoprolol tartrate ( a medication used to treat high blood pressure and cardiac issues), Reglan (medication used to treat digestive issues), amoxicillin (antibiotic), thiamine HCl (supplement), cholecalciferol (supplement), clopidogrel bisulfate (used to prevent blood clots), ferrous sulfate (iron supplement), folic acid (supplement), Megace (appetite stimulant), mirtazapine (medication used to treat depression), pantoprazole sodium (medication used to treat digestive disorders), rosuvastatin (medication used to lower cholesterol), and Sertraline HCl (medication used to treat depression). The MAR/TAR also listed R29 refused his empagliflozin (medication used to treat diabetes mellitus) and Tradjenta (injectable medication to treat high blood glucose). R29's EMR and MAR/TAR lacked evidence the staff notified R29's physician regarding the medication refusals. R29's May 2025 MAR/TAR recorded the 05:30 AM fasting blood glucose was 388 mg/dL (normal fasting glucose is between 80-120 mg/dL). R29's EMR lacked evidence the staff notified the physician regarding the abnormally high fasting blood glucose level. R29's May 2025 MAR/TAR documented a 2 to indicate the resident refused his evening (HS) medications which included mirtazapine (medication used to treat depression), melatonin (supplement used to promote sleep), tamsulosin HCl (medication used to treat prostate disorders), amoxicillin, liquid protein supplement, metoprolol tartrate, and Reglan (scheduled at 05:00 PM). R29's EMR and MAR/TAR lacked evidence the staff notified R29's physician regarding the evening medication refusals. R29's May 2025 MAR/TAR recorded R29's 08:00 PM blood glucose was 513 mg/dL. R29's EMR lacked evidence the staff notified the physician regarding the abnormally high blood glucose level. R29's May 2025 MAR/TAR recorded no as-needed medication was administered on 05/04/25. R29's May 2025 MAR/TAR recorded an order dated 05/05/25 at 06:13 AM for Humalog, inject 10 units one time only, for elevated blood sugar; recheck blood sugar 30 minutes after administration. The order was documented at 4 indicating the medication was not administered because the resident was hospitalized . R29's EMR lacked any notes under the Notes tab for 05/03/25 and 05/04/25. R29's EMR recorded a Progress Note dated 05/05/25 at 06:18 AM which documented the above Humalog order. R29's EMR recovered a late entry note dated 05/05/25 at 03:17 PM which noted the resident was sent to the hospital at 07:40 AM due to the resident was unresponsive. A review of the facility's TEAM Health Standing Orders or Skilled and Long-Term Care Units dated 08/29/23 directed staff to notify the physician of blood glucose over 350 mg/dL unless otherwise specified. A review of the facility's investigation provided by the facility revealed LN G worked with R29 on 05/03/25 and 05/04/25 revealed the facility verified LN G did not perform her duties on 05/04/25 in regard to medication and charting issues. During an interview on 05/13/25 at 01:30 PM, Licensed Nurse (LN) I reported that the facility provider should be notified if a resident's blood glucose is 350 mg/dL or higher or 60 mg/dL and below. During an interview on 05/13/25 at 01:46 PM, Administrative Nurse C verified there were no progress notes in the EMR for R29 on 05/04/25. During an interview on 05/13/25 at 02:55 PM, LN I reported he charted by exception and did not chart anything on 05/04/25 due to R29 being lucid and responding appropriately. LN I reported he had previously contacted the provider and informed her that he believed R29 was giving up and reported the provider agreed. During an interview on 05/13/25 at 03:12 PM, Administrative Nurse C reported the facility charted by exception unless the resident was a new admit or had a change in status. During an interview on 05/14/25 at 08:59 AM, LN F stated the facility had standing orders to notify the provider if a resident had a blood glucose of 350 mg/dL or above or 60 mg/dL and below. LN F also reported that she had been instructed during orientation to notify the provider if a resident had refused medication during a shift. During an interview on 05/14/25 at 09:10 AM, Administrative Nurse C reported that facility protocol was to notify the provider if a resident had refused medications. The Notification of Patient/Resident Change Policy, dated 11/01/16, indicated that the facility would notify the resident's provider and notify the resident's legal representative or interested family member whenever there is an acute illness or a significant change in the resident's physical, mental, or psychosocial status or whenever a there was a need to significantly alter treatment. On 05/14/25 at 01:00 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R29. On 05/14/25 at 05:00 PM, the facility submitted an acceptable removal plan which included the following corrective actions: 1. R29 was assessed on 05/05/25 at 06:45 AM. Staff contacted Emergency Medical Services for assessment and transport to the hospital. 2. Staff notified R29's physician and representative on 05/05/25 at 07:05 AM. 3. The facility initiated an investigation of the event on 05/05/25. LN G was placed on administrative leave pending the results of the investigation; LN G was terminated on 05/08/25. 4. An audit of all residents with a diagnosis of diabetes mellitus was completed to evaluate for change of condition and physician notifications were made as appropriate on 05/14/25 5. The Director of Nursing (DON) and Designee provided re-education to all licensed nursing staff on 05/14/25 and/or prior to working on immediate physician notification for blood glucose levels exceeding 350 mg/dL or per resident-ordered parameters and documentation protocols for refusals and physician notifications. 6. A full clinical review of all diabetic residents was conducted by DON on 05/14/25. No other residents were identified to be at immediate risk due to medication refusal or lack of provider notification. 7. The facility conducted a Quality Assurance and Performance Improvement (QAPI) meeting addressing the incident on 05/14/25 with the attendance of the Administrator, DNS, and Medical Director by phone. Removal of the immediacy was verified by the onsite survey team on 05/15/25. The deficient practice remained at a scope and severity of G to represent the actual harm to R29.

The facility reported a census of 42 residents. Five Ceritifed Nurse Aide (CNA) were reviewed with three reviewed for annual performance evaluations. Based on interview and record review, the facility failed to complete annual performance reviews for two of the three CNA staff that were employed for a year or more. This placed the residents at risk for inadequate care. Findings included: - Per review of employee records, Certified Medication Aide (CMA) M was hired on 02/12/21. CMA M's annual Performance Evaluation, dated 02/13/25, was not completed with the employee's signature indicating it had been reviewed with the staff member. CMA N's employee records noted she was hired 05/08/20. CMA N's most recent Performance Evaluation, was completed on 02/27/24. On 05/14/25 at 09:21 AM, Administrative Nurse C verified the above findings and confirmed that direct care staff should receive an annual evaluation to include identified weaknesses and actions to address weaknesses to ensure the residents receive adequate care. The facility did not provide a policy related to annual performance evaluation.

The facility reported a census of 42 residents. The sample included 15 residents. Based on interviews, record reviews, and observation, the facility failed to ensure a safe environment in all areas of the facility including the laundry area. This deficient practice created the risk for contaminated laundry and fires. Findings included: - During an observation on 05/13/25 at 09:30 AM, the fluorescent light fixtures above the washers and the dryers had no covers over the bulbs. There were several light fixtures that had exposed rust on the metal housings. During an observation on 05/13/25 at 09:35 AM, the ceilings above the washers and dryers had cracked and peeling paint. During an observation on 05/13/25 at 09:40 AM, it was observed that there was an open grate drain with standing water that the washing machines drained into in front of the washing machines. During an observation on 05/13/25 at 09:45 AM, the washing machine detergent hoses were fed through an open hole in the wall with an exposed dry wall just below a vent covered in lint and dust. During an observation on 05/13/25 at 09:50 AM, the wall behind the dryers was covered in dryer lint. There were several electrical boxed on this wall. During an interview on 05/13/25 at 10:05 AM, Maintenance Staff QQ reported that he had recently crawled behind the dryers and re-taped the metal dryer vent lines because they had been blowing lint on the floor and wall. The facility did not have a policy that addressed maintenance requirements related to the laundry service areas.

The facility reported a census of 42 residents. The sample included 15 residents. Based on interviews, record reviews, and observation, the facility failed to implement professional standards of care related to infection control practices during direct care and laundry services. This deficient practice placed the residents at risk for infections. Findings included: - R21's Electronic Medical Record (EMR) revealed a diagnosis of a persistent vegetative state (state of wakefulness accompanied by a complete lack of cognitive function), tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted), and Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). The 03/07/25 Annual Minimum Data Set (MDS) documented R21 was in a vegetative state. R21 was dependent on staff for her care. The MDS noted R21 required a tracheostomy and supplemental oxygen. The MDS recorded R21 had a feeding tube and received her nutrition from it. It documented R21 had had a Foley catheter. The 03/07/25 Feeding Tube CAA triggered secondary to use of a feeding tube for maintenance of nutritional and hydration status. The CAA noted contributing factors included a vegetative state and a care plan would be developed and maintained to improve and maintain nutritional and hydration status, monitor labs and weights. R21's Care Plan dated 05/27/21 documented R21 was a risk for infection related to a surgical site for a tracheostomy. R21's Care Plan dated 05/19/21 documented R21 had a Foley catheter and directed staff to keep the drainage bag of the catheter below the level of the bladder and off the floor. During an observation on 05/13/25 at 12:30 PM, Certified Nurse Aide (CNA) T and Certified Medication Aide (CMA) N entered the room to change R21. They wore a gown and gloves per the policy. CMA N pulled some personal hygiene wipes out and began to wipe R21. CMA N folded the soiled wipe over and wiped again from the front to the back wiping past the catheter. She obtained more wipes out of the package and wiped again several more times. CMA N touched R21's neck pillow with her soiled glove to adjust it and then obtained a clean brief with her soiled gloved hands and placed it under the resident while CNA T rolled R21. CMA N removed her gloves and applied fresh gloves without performing hand hygiene. CNA T opened a bag and CMA N placed the soiled sheets in it. CMA N spread a clean gown over R21, and CNA T rolled her to the side. CNA T then removed the soiled brief and cleaned R21's buttocks. R21's pillow fell to the floor. CNA T picked up the pillow and placed it on the bed over R21's right shoulder and tracheostomy. Then CNA T obtained a pillowcase and changed it. During an observation at 05/14/25 on 10:40 AM CNA U and CNA T transferred R21 from the bathchair to the bed. CNA T attached the catheter bag to the straps of the lift sling at shoulder height. CNA U said they were unaware that the catheter bag had to be below the bladder during transfers. During an interview on 05/13/25 at 12:30 PM, CNA T and CMA N stated they were unaware of the need to get a fresh wipe out once the wipe was soiled. They said they understood that hand hygiene needed to be completed after removing soiled gloves prior to putting on new gloves, and when gloves are soiled, they should not touch anything clean. CNA T and CMA N reported they knew the pillowcase was dirty when it went to the floor and said she should not have put it on the bed when she picked it up. During an interview on 05/14/25 at 11:04 AM, Licensed Nurse (LN) KK stated that staff were expected to use good infection control including hand hygiene after removing soiled gloves, keeping the catheter bag below the level of the bladder, not using the same wipe numerous times, and not placing items that touched the floor on the bed or resident. During an interview on 05/15/25 at 05:21 PM, Administrative Nurse C stated she expected the staff to follow infection control practices including hand hygiene after removing soiled gloves, not touching clean items with soiled gloves, and keeping the catheter bag below the level of the bladder. Administrative Nurse C stated staff should avoid using the wipes for several swipes, and should not place items from the floor on the bed or resident. The facility's Infection Control policy dated 11/01/17, documented the facility's infection control policies are intended to maintain a safe, sanitary, and comfortable environment. - During an observation on 05/13/25 at 09:40 AM, there was an open grate drain with standing water that the washing machines drained directly into in front of the washing machines. During an observation on 05/13/25 at 10:00 AM, the clean clothes folding room was shared by the dietary manager as an office and housed the time clock. The clean clothes folding table was next to the time clock and had several non-laundry items on it. During an interview on 05/13/25 at 10:00 AM, Maintenance Staff QQ reported that the clean laundry was stored and folded in a room that doubled as the dietary office. The facility's policy titled Policies and Practices - Infection Control, dated 11/01/17, did not address the storage and management of resident linen during the laundry process to prevent contamination or infection.

The facility identified a census of 42 residents. The sample included 15 residents with one reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 21, a resident in a persistent vegetative state (state of wakefulness accompanied by a complete lack of cognitive function) received adequate restorative care, including the application of splints, to minimize further decline. This deficient practice placed R21 at risk for increased pain and contractures (abnormal fixation of joints or muscles). Findings included: - A review of R21's Electronic Medical Record (EMR) revealed a diagnosis of a persistent vegetative state. The 03/07/25 Annual Minimum Data Set (MDS) documented R21 was in a vegetative state; R21 was dependent on staff for her care. The MDS noted R21 received no range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) exercise during the assessment period. The 03/07/25 Care Area Assessment (CAA) did not trigger for R21 for ADLs. R21's Care Plan dated 04/10/25 documented that she was dependent on staff for all of her care due to a persistent vegetated status with arm and foot contractures. The plan noted an intervention dated 05/17/21 which directed that heel boots should be worn. R21's Care Plan dated 04/10/25 directed to maintain proper positioning by using stuffed animals to preserve R21's skin integrity related to contractures. The care plan lacked interventions related to wrist braces. During an observation on 05/14/25 at 10:40 AM, Certified Nurse Aide (CNA) T transferred R21 with the assistance of another CNA. They positioned R21 in bed. There were two papers on the wall just above the resident's head with a picture of a wrist brace on it labeled left and right. CNA T reported that R21 was supposed to wear the wrist splints, but she did not know where the splints were. CNA T said the facility did not have restorative aides, and the CNAs did not do ROM or any restorative programs. During an observation on 05/15/25 at 08:52 AM, R21 lay in bed with no boots or hand braces. R21's arms were propped on a stuffed animal and her wrist dangled in a flexed position. R21 tightened and flexed further. R21's feet were contracted in a foot drop (inability or difficulty in moving the ankle and toes upward) position. During an interview on 05/14/25 at 12:34 PM, Licensed Nurse (LN) KK stated that R21's splints had a broken strap, so staff sent it to therapy. During an interview on 05/15/25 at 08:59 AM, Therapy Staff LL stated he found the splints buried in a drawer in R21's room. Therapy LL said therapy worked with some residents repeatedly because the facility did not have a restorative program. Therapy LL said the facility was aware of the problem and was implementing a plan to start a restorative program. Therapy LL provided a list of residents who would benefit from a restorative program to Administrative Nurse E. During an interview on 05/15/25 at 11:22 AM, Administrative Nurse E stated the facility had not had a restorative program for a long time. Administrative Nurse E stated the facility had taken steps to initiate a restorative program and identified residents who needed restorative services. Administrative Nurse E stated the facility had not completed any restorative assessments or evaluations yet, because they did not have any staff that have had training. Administrative Nurse E said the facility needed to get the CNAs trained before the CNAs could proceed. Administrative Nurse E said the nurse did get an order to get R21 therapy services to evaluate for hand splints and positioning and then took the sign down for the hand splints. During an interview on 05/15/25 at 12:13 PM, Administrative Nurse C stated the facility did not have a restorative program and has not for a long time. She was unsure how long. They have identified it as a concern and they are working on initiating a restorative program. The facility's Restorative Guideline dated 2024, documented each resident will be screened or evaluated for inclusion in the appropriate restorative program when the need is identified.

The facility identified a census of 42 residents. The sample included 15 residents with one reviewed for enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 21, a resident fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding when staff failed to monitor R21's weight routinely and/or as ordered. This placed the resident at risk for continued weight loss and malnutrition. Findings included: - A review of R21's Electronic Medical Record (EMR) revealed a diagnosis of a persistent vegetative state (state of wakefulness accompanied by a complete lack of cognitive function). The 03/07/25 Annual Minimum Data Set (MDS) documented R21 was in a vegetative state; R21 was dependent on staff for her care. The MDS noted R21 weighed 145 pounds and she had no weight loss or gain since the last MDS. The MDS recorded R21 had a feeding tube and received her nutrition from it. R21's 03/07/25 Nutritional Care Area Assessment (CAA) triggered secondary to swallowing issues, enteral diet, and the presence of a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer on her left buttock. The CAA noted R21's risk factors included weight instability and a care plan would be developed to improve and maintain dietary and hydration status and monitor weights. The 03/07/25 Feeding Tube CAA triggered secondary to use of a feeding tube for maintenance of nutritional and hydration status. The CAA noted contributing factors included a vegetative state and a care plan would be developed and maintained to improve and maintain nutritional and hydration status, monitor labs and weights. R21's Care Plan dated 03/20/23 documented R21 had a a potential for alteration in hydration related to enteral feeding and directed staff to monitor R21's weights per physician order. R21's Care Plan dated 02/17/25 documented R21 was at nutritional risk related to a persistent vegetative state; she was dependent on staff for tube feedings to provide all nutritional and fluid needs. The plan directed staff to monitor weights. R21's EMR revealed the following physician's order: Weekly weight on shower day, every Wednesday, ordered on 04/09/24. R21's Registered Dietitian's Progress Note on 05/12/25 at 03:05 PM, documented R21 had no intake by mouth and had weekly weights. R21's EMR documented the following: Staff did not weigh R21 on 02/05/25. On 02/12/25, 02/19/25, and 02/26/25 the nurse documented R21 was weighed, but no documentation was recorded of R21's actual weight. On 03/05/25 and 03/19/25 staff did not weigh R21. On 03/12/25 and 03/25/25 the nurse documented that R21 was weighed, but no documentation was recorded of R21's actual weight. On 04/23/25 the nurse documented that R21 was weighed, but no documentation was recorded of R21's actual weight. On 04/16/25 and 04/30/25 the order was not documented as completed nor was a weight recorded. On 05/07/25 and 05/14/25 the nurse documented that R21 was weighed, but no documentation was recorded of R21's actual weight. R21's EMR, Under the weights section, documented a gradual decrease since 09/05/25. On 09/05/25 R21's weight was 153.3 pounds and on 04/04/25 R21's weight was 144.6 pounds. During an observation on 05/14/25 at 11:04 AM, Licensed Nurse (LN) KK wore a gown and gloves and administered medications to R21 via the feeding tube. LN KK flushed the tube before and after administering the medications. During an interview on 05/14/25 at 11:04 AM, LN KK stated that staff weighed R21 every Sunday and on her bath day. LN KK said the nurses would enter the weight in the computer after the staff obtained it. During an interview on 05/15/25 at 12:13 PM, Administrative Nurse C stated that when a resident receives enteral feedings, staff should be obtaining weights at least weekly. The facility's competency for Administering Eternal Feedings documented that staff should weigh the resident daily or three times a week as appropriate.

The facility reported a census of 42 residents. There were 15 residents in the sample, with one resident reviewed for trauma-informed care. Based on observation, interview, and record review the facility failed to develop and implement approaches to care that were both clinically appropriate and person-centered for Resident(R) 12, who had a history of personal trauma and substance abuse. This placed the resident at risk for decreased quality of life and re-traumatization. Findings included: - R12's Electronic Health Record (EHR) revealed diagnoses that included major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 99, and noted R12 refused to answer any questions regarding mood as well. The MDS noted R12 used a manual wheelchair and walker and required supervision/touching assistance for transfers. The MDS recorded R12 had active diagnoses of anxiety, depression, and PTSD. The Delirium Care Area Assessment (CAA) dated 03/02/25 indicated R12 had symptoms of delirium (sudden severe confusion, disorientation, and restlessness) due to the presence of an acute mental status change and/or the presence of inattention, disorganized thinking or altered mental status. The End of PPS Part A Minimum Data Set (MDS) dated [DATE], documented a BIMS score of 15, indicating intact cognition. The MDS noted R12 answered yes to having little interest or pleasure in doing things, trouble falling asleep and/or staying asleep or sleeping too much; R12 felt tired or had little energy. The MDS noted R12 required supervision/touching assistance with transfers and walking 10 feet or more. R12's Care Plan interventions, dated 03/19/21 and revised 03/14/25 noted PTSD but did not address any triggers identified and did not address R12's history of illicit drug use. The care plan did not include interventions to address the resident's adjustment difficulties and/or history of trauma. The care plan lacked any description of the resident's indications of distress and/or interventions intended to assist the resident. R12's Progress Notes from 01/01/25 to 05/15/25 lacked any documentation of past trauma. A review of R12's Physician Encounter dated 07/19/22, 10/17/23, 08/26/24, and 05/06/25 listed past marijuana use and PTSD was listed as a diagnosis. The current facility assessment dated [DATE] under the common diagnosis section, special treatments, and conditions, sub-section mental, active, and current substance use disorder listed the current resident number as zero. During an interview on 05/14/25 at 11:44 AM, Social Services Staff FF stated the facility used an evaluation, Social Service admission Evaluation, to identify PTSD. Social Services Staff FF reported that R12 did not have PTSD, she stated that R12 would make up false things to her. Social Services Staff FF further reported that the facility currently did not have any residents with a substance abuse history. During an interview on 05/14/25 at 12:42 PM, Administrative Staff A reported that the provider was who determined the PTSD diagnosis and said there would have been coordination between the provider and the social services designee once that diagnosis had been made. Administrative Staff A said the PTSD would have then been discussed at the Interdisciplinary (IDT) meetings in the morning, and then worked into the care plan to help drive the care for the resident. The current facility assessment dated [DATE] under the common diagnosis section, special treatments, and conditions, sub-section mental, active, and current substance use disorder listed the current resident number as zero. The facility did not provide a policy on trauma-informed care.

The facility reported a census of 40 residents. Based on interview and record review, the facility failed to ensure sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Findings included: - Review of the Facility Assessment, updated 04/28/23, documented the facility would base the staffing plan on resident population and the needs of residents' care and support. The facility would require three to four licensed nurses (LN) providing direct resident care and seven to 12 Certified Nurse Aides (CNA) and/or Certified Medication Aides (CMA), every day, depending on the census and acuity (the level of care a resident requires) of the residents. Review of the facility's daily staff postings, from 06/01/23 through 07/16/23, revealed the facility staffed the nursing department with one to three LNs and four to seven CNA/CMAs per day. On 07/17/23 at 11:07 AM, R 22 stated the evening and night shift did not have enough staff available. On 07/17/23 at 12:49 PM, R 13's family member stated his mother had told him there was not enough staff during the night and on weekends. On 07/17/23 at 01:29 PM, Resident (R)21 stated there was not enough staff on the night shift. R 21 stated his roommate had to wait a long time for his call light to be answered. On 07/17/23 at 08:05 AM, CNA, P stated the facility will staff the night shift, 06:00 AM through 06:00 PM, with one CNA, one CMA and one nurse. CNA P stated that was not enough staff to get everything done. Several residents require two staff for cares. On 07/18/23 at 06:17 PM, CNA Q stated the facility usually only had one CNA, one CMA and one nurse on the night shift. CNA Q stated there are several residents in the facility who require two staff to complete cares. CNA Q stated staff were not able to get all cares, such as bathing, done. On 07/18/23 at 06:46 PM, Licensed Nurse (LN) L stated the night shift had one CNA, one CMA and one LN. LN L stated they were not able to answer call lights quickly. Some of the call lights would remain on for quite a while without being answered. On 07/19/23 at 10:35 AM, Administrator Nurse D stated the facility had always had three staff members on the night shift and Administrator Nurse D felt that was adequate staffing, at this time. The facility lacked a policy for sufficient staffing. The facility failed to ensure there was sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being.

The facility reported a census of 40 residents. Based on interview and record review the facility failed to complete annual competency performance reviews at least once every 12 months for five of the five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA) reviewed, CNA N, CNA NN, CNA OO and CMA T and CMA S, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included: - Review of five employee personnel files, revealed employment by the facility for greater than one year, revealed the following areas of concern: 1. Certified Medication Aide (CMA) S, hired 03/14/22, lacked an annual performance review in her personnel file. 2. Certified Nurse Aide (CNA) N, hired 12/18/14, lacked an annual performance review in her personnel file. 3. CNA NN, hired 05/24/17, lacked an annual performance review in her personnel file. 4. CNA OO, hired 06/27/22, lacked an annual performance review in her personnel file. 5. CMA T, hired 05/17/22, lacked an annual performance review in her personnel file. On 07/19/23 at 02:30 PM, Administrative Staff B stated the annual staff evaluations had not been completed due to the high turnover in the administrative nurse position. The facility policy for Performance Management, dated 2022, included: Performance reviews provide both managers and team members the opportunity to discuss job tasks, identify and correct weaknesses, encourage, and recognize strengths and discuss positive, purposeful approaches for meeting goals. Team members will have their performance appraisal at least one time per year, on or around their anniversary date. The facility failed to complete annual staff competency evaluations for five of the five CNA/CMAs, to ensure adequate appropriate cares and services provided to the residents of the facility.

The facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to store, prepare, serve food to the residents in a sanitary [NAME] to prevent the outbreak of foodborne illness, regarding the failure of wearing hairnets, dirty reach-in freezers, and reach-in refrigerators and six plastic drawers which contained cooking utensils. Findings included: - During an initial tour of the kitchen on 07/17/23 at 11:12 AM revealed the following areas of concern: 1. Former dietary staff CC entered the kitchen and stood next to a food preparation table where staff were preparing food, on 07/17/23 at 11:18 AM. Former dietary staff CC did not wear a hairnet while she was in the kitchen where staff were preparing food for the residents. 2. The bottom of two reach-in refrigerators had a heavy build-up of food debris on the bottom shelf as well as a heavy build-up of food debris in the rubber door gasket seal around the reach-in doors. 3. The bottom of two reach-in freezers had a heavy build-up of food debris on the bottom shell as well as a heavy build-up of food debris in the rubber door gasket seal around the reach-in doors. 4. Two three-drawer rolling plastic carts had a sticky build-up on the front and handles of the drawers and a build-up of a sticky substance on the inside of all six drawers which contained cooking utensils used in the preparation of meals. On 07/19/23 at 08:05 AM, Dietary staff BB stated it was the expectation for anyone who entered the kitchen to wear a hairnet at all times, in the kitchen. Dietary staff BB confirmed staff had not cleaned the bottom shelves of the reach-in freezers and reach-in refrigerators, the rubber door gasket seal of the reach-in freezers and reach-in refrigerators and the six plastic drawers which contained kitchen utensils used in the preparation of meals. The facility lacked a policy for kitchen cleanliness. The facility failed to follow proper sanitation to prevent the outbreak of foodborne illness for the residents of the facility. 28560 - Observation, on 07/18/23 at 02:00 PM, with Maintenance Staff U, revealed a medication room contained a resident snack refrigerator with three jars of an unknown food substance unlabeled and undated. Interview, on 07/18/23 at 02:15 PM, with Licensed Nurse (LN) G, revealed the jars belonged to a resident but he did not know what was in them or when they were brought in. LN G stated the jars should have the resident's name on them and a date of expiration. The facility policy Use and Storage of Food from Outside Sources, effective November 1, 2016, instructed staff to label with the resident's name and dated. All cooked or prepared food brought in for a resident and stored in the unit's pantry refrigerator will be dated when accepted for storage and discarded after 24 hours. The facility failed to store this resident's personal food items in a sanitary manner to prevent food borne illness.

The facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified resident care issues to enhance the residents' quality of life, failed to implement appropriate and effective action plans for environmental issues and resident care issues. Findings included: - Interview, on 07/19/23 at 2:30 PM, with Administrative Staff A, revealed he was in the administrative position since March 2023. Staff A explained the facility Quality Assurance Performance Improvement (QAPI) utilized data from the electronic medical record reports and staff input. The Quality Assurance Committee met on 12/21/22, 03/01/23, 05/31/23 and 06/28/23. During the facility survey from 07/17-19/23, the following several concerns were identified and in need of corrective actions by the facility. Refer to F584, the facility failed to ensure a safe, sanitary, and homelike environment for the residents in seven resident rooms of the facility. Refer to F657, the facility failed to review and revise the care plan for one resident (R)10 for urinary catheter and pain management, one resident R13 for behavioral interventions, two residents R24 and R7 for foot pedal use when in wheelchair, one resident R8 for individualized toileting plan and positioning safety, and one resident R34 for suicide ideations. Refer to F 677, the facility failed to provide facial grooming for two Residents (R)10 and R 7, failed to ensure one R 4 changed into clean clothing and failed to get one R 34 out of bed and dressed for the entirety of a day. Refer to F689,the facility failed to ensure two Residents (R)24 and 7 of the four residents had pedals on their wheelchairs when staff provide propulsion assistance, failed to ensure staff provided one resident R8, of the four residents with upper extremity safety when positioned in her wheelchair and staff provided propulsion, and failed to ensure staff provided safe transfer of one resident R34 of the four residents reviewed for accidents. Refer to F690, the facility failed to toilet one dependent Resident (R)8 timely and failed to complete a 72-hour voiding diary to assist the staff in the development of an individualized toileting program to assist R 30 improve or maintain his bladder continence. Refer to F695, the facility failed to ensure the resident's oxygen concentrator had a humidifier bottle. Refer to F697 the facility failed to provide adequate pain relief for this dependent Resident (R)10 to remain free from pain. Refer to F725, the facility failed to always ensure sufficient qualified nursing staff available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. Refer to F730, the facility failed to complete annual competency performance reviews at least once every 12 months for five of the five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA) reviewed, CNA N, CNA NN, CNA OO and CMA T and CMA S, to ensure adequate appropriate cares and services provided to the residents of the facility. Refer to F756 the facility failed to follow up on pharmacy recommendations for two Residents (R) 34 and R 4 of the five residents reviewed for unnecessary medications. Refer to F757, the facility failed to ensure Resident (R)4 was kept free from unnecessary medications, by failing to notify the physician of blood sugars (BS) outside of ordered parameters. Refer to F758, the facility failed to ensure two Residents (R)34 and R36, of the five residents had Abnormal Involuntary Movement Scale (AIMS) assessments and one resident, R4 of the five residents had a gradual dose reduction of antipsychotic (class of medication used to treat psychosis and other mental emotional conditions) medication as recommended from the pharmacy consultant. Refer to F812, the facility failed to store, prepare, serve food to the residents in a sanitary manner to prevent the outbreak of foodborne illness, regarding the failure of wearing hairnets, dirty reach-in freezers, and reach-in refrigerators and six plastic drawers which contained cooking utensils. Refer to F887, the facility failed to offer residents COVID-19 vaccinations per the CDC (Center for Disease Control) guidelines. The facility policy Diversicare of [NAME]-QAPI Center Plan, undated, instructed staff the scope of QAPI encompasses all types and segments of care and services that impact clinical care, quality of life and resident choice. The facility QA (Quality Assurance) program failed to develop and implement appropriate and effective action plans to timely identify, correct infractions of the residents' environment, and care issue to ensure optimum well-being for the residents of the facility.

The facility reported a census of 40 residents. Based on observation, interview, and record review the facility failed to ensure an effective infection control program in the facility with the failure to maintain accurate tracking and trending of infections in the facility, failure to store supplies in a sanitary manner, and failure to ensure housekeeping staff were knowledgeable on the effective use of cleaning chemicals. Findings included: - Review of the Infection Prevention and Control Tracking Logs for 2023, revealed the lack of logs for January, February, and March 2023. Interview, on 07/19/23 at 11:30 AM, with Administrative Nurse D confirmed the missing infection control tracking logs. The facility policy Surveillance and Communicable Diseases Reporting Guideline, revised November 1, 2017, instructed staff to collect accurate and relevant surveillance data, evaluate and compare calculate rates of various infections, evaluate compare the data and report the data to team members. The facility failed to maintain an effective infection control program with the failure to complete infection tracking and trending logs to assess the infections amongst the residents to determine the impact of infections on the residents and to ensure appropriate interventions were in place in response to the infections. - Observation, on 07/18/23 at 01:40 PM, with Maintenance Staff U, revealed two clean utility rooms each contained two boxes of personal protective equipment which sat directly on the floor. Interview, on 07/18/23 at 02:00 PM, with maintenance staff U, confirmed staff should store all supplies off the floor. The facility policy Infection Control, dated November 1, 2017, instructed staff to maintain a safe, sanitary, and comfortable environment to prevent the transmission of diseases and infections. The facility failed to store these boxes of personal protective equipment in a sanitary manner to prevent the spread of infection. - Observation, on 07/18/23 at 09:15 AM, revealed housekeeping staff V cleaning a resident room. Interview at that time revealed housekeeping staff V thought the dwell time (time that the cleaning product must remain on the surface to effectively sanitize) was one minute. The product label instructed staff the dwell time as 10 minutes. Observation, on 07/18/23 at 09:30 AM, revealed housekeeping staff W cleaning a resident room. Interview with housekeeping staff W revealed she thought the cleaning product did not need to sit for any length of time and could be wiped with a cloth. The sprayed cleaning product label instructed staff the dwell time as 10 minutes for effective sanitation. Interview, on 07/18/23 at 03:18 PM, with maintenance staff U, revealed the housekeeping staff was from a contracted agency and he would expect the staff to know the instructions for the cleaning chemicals used to ensure a sanitary environment for the residents' areas. The Healthcare Services Group 5 Step Daily Room Cleaning, undated, instructed staff to refer to the manufacturers recommended dwell time (also referred to as contact time which is how long a chemical needed to be in contact with the surface to effectively sanitize or disinfect) when cleaning a room. The facility failed to ensure staff followed manufacturer's instructions for dwell time of cleaning products to ensure effective sanitation of surfaces to prevent the spread of infection amongst the residents.

The facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to ensure a safe, sanitary, and homelike environment for the residents residing in seven resident rooms of the facility. Findings included: - Observation, on 07/18/23 at 01:40 PM, with Maintenance Staff U revealed the following areas of concern: 1. Two resident rooms had large areas of missing paint. 2. One resident room with five cracked broken floor tiles at the entrance to their room. 3. One resident room contained two completely loose floor tiles beside the resident's bed. 4. One resident room contained a privacy curtain between the two resident's bed with a black substance along approximately one third of the lower edge. 5. One resident room contained a closet with blankets directly on the floor and a box of shredded wheat directly on the floor. 6. One resident room contained a bed frame without a mattress. Interview, on 07/18/23 at 02:30 PM, with Maintenance Staff U, confirmed the above. The facility lacked a policy for maintenance of resident rooms. The facility policy Food Storage: Dry Goods, revised 09/2017, instructed staff to store all items on shelves at least six inches above the floor. The facility policy Use and Storage of Food from Outside Sources, effective November 1,2016, instructed staff to educate the resident of food handling and storage techniques as needed. The facility failed to provide a safe, sanitary, and homelike environment for the seven residents of the facility in these resident rooms.

The facility reported a census of 40 residents with 16 residents sampled, including four residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to provide facial grooming for two Residents (R)10 and R 7, failed to ensure one R 4 changed into clean clothing and failed to get one R 34 out of bed and dressed for the entirety of a day. Findings included: - The Physician Order Sheet (POS), dated 06/29/23, for Resident (R)4, documented the resident had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required no setup assistance or staff assistance with dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/17/22, documented the resident had inattention and disorganized thinking. The resident had a diagnosis of dementia and had a self-care deficit. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA, dated 10/17/22, documented the resident required staff assistance with ADLs due to generalized weakness. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of six, indicating severe cognitive impairment. He required no setup assistance with dressing. The care plan for physical functioning, updated 05/08/23, instructed staff the resident was independent with dressing. Review of the resident's EMR, from 06/19/23 through 07/17/23, documented the resident was independent with dressing. On 07/17/23 at 09:45 AM, the resident sat in his recliner in his room. The resident wore a blue shirt and black pants which contained dried food debris on the front side. On 07/18/23 at 08:00 AM, the resident sat in his recliner and wore the same clothes with food debris from the day before. On 07/18/23 at 08:23 AM, Certified Medication Aide (CMA) R entered the resident's room to remove his breakfast tray. CMA R failed to prompt the resident to change into clean clothing. On 07/18/23 at 08:52 AM, Licensed Nurse (LN) J entered the resident's room to administer his morning medications. LN J failed to prompt the resident to change into clean clothing. On 07/18/23 at 10:27 AM, CMA T entered the resident's room to change his bed linens. CMA T failed to prompt the resident to change into clean clothing. On 07/18/23 at 11:00 AM, LN J entered the resident's room to administer his insulin. LN J failed to prompt the resident to change into clean clothing. On 07/19/23 at 08:47 AM, the resident ambulated in the hallway. The resident continued to wear the blue shirt and black pants which contained the same dried food debris. On 07/17/23 at 03:05 PM, the resident's family member stated the staff do not offer to assist the resident with changing his clothing. At times his clothing was dirty, and she would like for him to always have on clean clothing. On 07/18/23 at 08:17 AM, CMA T stated the resident was able to dress himself and did not require assistance with changing clothes. On 07/18/23 at 06:17 PM, Certified Nurse Aide (CNA) Q stated the resident will refuse cares at times and does not want female staff to assist him with changing clothes. CNA Q stated she had never prompted the resident to change his clothing, even when they were dirty. On 07/18/23 at 06:31 PM, Licensed Nurse (LN) K stated the resident did not like female staff to assist him. LN K stated she had never prompted the resident to change his clothing. On 07/18/23 at 06:46 PM, LN L stated the resident will allow him to assist with his cares as he was a male. LN L stated he had not offered to assist the resident to change his clothing. On 07/19/23 at 10:35 AM, Administrative Nurse D stated she would expect staff to ensure all residents be dressed in clean clothing. The facility policy for Resident's Rights and Quality of Life, effective May 2012, included: All residents will have the right to a dignified existence. The facility failed to ensure this resident wore clean clothing. - Review of Resident (R)10's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. He required extensive assistance of one staff for personal hygiene. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/16/23, documented the resident required staff assistance with ADLs. The care plan for ADLs, dated 06/16/23, instructed staff the resident required extensive assistance of one staff for completion of personal hygiene cares. Review of the resident's EMR, from 06/20/23 through 07/18/23, revealed the resident required limited to total assistance of one staff for personal hygiene, including shaving. On 07/17/23 at 09:52 AM, the resident sat in the recliner with his feet elevated. The resident's face was unshaven, and his hair was uncombed. On 07/18/23 at 08:00 AM, the resident sat in the recliner in his room. The resident remained unshaven and his hair was uncombed. On 07/18/23 at 12:34 PM, the resident sat in the recliner in his room. The resident remained unshaven and his hair was uncombed. On 07/18/23 at 02:46 PM, the resident sat in the recliner in his room. The resident remained unshaven and his hair was uncombed. On 07/17/23 at 09:57 AM, the resident stated he always had a clean-shaven face and kept his hair combed. On 07/18/23 at 08:57 AM, Certified Nurse Aide (CNA) MM stated residents were shaven on their shower days and hospice would give the resident his showers. CNA MM stated she had not offered to shave the resident and had not combed his hair. On 07/18/23 at 11:05 AM, Certified Medication Aide (CMA) T stated residents were shaven on their shower days. CMA T stated she had not offered to comb the resident's hair. On 07/18/23 at 02:59 PM, CMA R stated she was unsure of when the resident should be shaven. CMA R stated she had not offered to comb the resident's hair. On 07/18/23 at 03:01 PM, Licensed Nurse (LN) J stated she did not know when residents were shaven. On 07/19/23 at 10:00 AM, LN I stated residents were shaven on their shower days. Residents should have their hair combed whenever it became messy. On 07/19/23 at 10:35 AM, Administrative Nurse D stated it was the expectation for resident's hair to be come and for staff to shave facial hair if the resident wanted a clean-shaven face. The facility policy for Resident's Rights and Quality of Life, effective May 2012, included: All residents will have the right to a dignified existence. The facility failed to provide facial grooming and hair care for this dependent resident. 28560 - Review of Resident (R)7's Physician Order Sheet, dated 06/29/23, revealed diagnoses included history of malignant neoplasm (cancerous tumor) of the brain, polyneuropathy, schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment. The resident required extensive assistance for personal hygiene. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/07/22, assessed the resident required assistance with ADL due to generalize weakness. The Quarterly MDS, dated [DATE], assessed the resident with severe cognitive impairment and required extensive assistance for ADLs. The Care Plan, reviewed 07/12/23, instructed staff the resident required extensive assistance for personal hygiene and oral care. Observation, on 07/17/23 at 10:30 AM, revealed the resident seated in his wheelchair in his room. The resident's uneven mustache extended over his bottom lip. The resident's beard was of varying lengths and untrimmed. Observation, on 07/18/23 at 08/17 AM, revealed the resident seated in his wheelchair coming from the dining room. The resident's uneven mustache extended over his bottom lip. The resident's beard was untrimmed. Interview on 07/18/23 at 11:46 AM, with Certified Nurse Aide (CAN) M, revealed the resident required staff assistance for personal hygiene and confirmed the resident's mustache extended over his bottom lip and appeared uneven. CAN M proceeded to trim the resident's mustache with scissors. Interview, on 07/18/23 at 12:00 PM, with Licensed Nurse G, revealed the resident required assistance with ADLs and staff should provide shaving and trimming of facial hair as needed. Interview, on 07/19/23 at 11:30 AM, with Administrative Nurse D, revealed she would expect staff to groom residents according to their preferences. The 'Care Combing and Shaving Policy, undated, instructed staff that the resident's appearance and sense of wellbeing are affected by how their hair looks and feels. Dependent resident with beards or mustaches needs help keeping facial hair clean. The facility failed to ensure this dependent resident received assistance to maintain his mustache and facial hair in a groomed manner as a normal person would expect to maintain a sense of wellbeing. Review of Resident (R)34's Physician Order Sheet, dated 06/29/23, revealed diagnoses included cerebral infarction (stroke which is the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), left hemiplegia (paralysis and weakness of one side of the body muscular of one half of the body), hemiparesis (muscular weakness of one side of the body), and major depressive disorder (major mood disorder). The Significant Change Minimum Data Set (MDS) dated [DATE] assessed the resident with normal cognitive function. The resident required extensive assistance for transfer and dressing. The resident required supervision with eating. The resident had functional impairment in range of motion on one side of her upper and lower extremity. The (Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/03/23, assessed the resident required assistance with ADLs due to functional impairment. The Quarterly MDS, dated [DATE], assessed the resident with normal cognitive function and required extensive assistance with dressing. And had impairment in range of motion on one side of her upper and lower extremity. The Care Plan, reviewed 07/07/23, instructed staff the resident required extensive assistance with dressing. Observation, on 07/17/23 at 09:00 AM revealed the resident in bed, dressed in a hospital gown, eating breakfast. Observation, on 07/17/23 at 03:11 PM, revealed the resident remained in bed, dressed in a hospital gown. Interview, at that time, with the resident, revealed the resident preferred to get dressed and out of bed but staff did not always have time to assist her. Interview, on 07/17/23 at 04:00 PM, with Licensed Nurse (LN) G revealed he did not know why staff did not get the resident dressed or out of bed. Observation, on 07/18/23 at 01:23 PM, revealed the resident dressed, and positioned in bed with her overbed table containing her noon meal on a tray. The resident's head of bed was elevated approximately 45 degrees (not in an upright seated position). The resident attempted to see the food on the plate and use her fork to feed herself. Certified Nurse Aide (CNA) O came into the room and stated she did not know who delivered the resident's tray to her. The resident requested CNA O to raise her head up. Afterward, the resident stated this made eating much easier and more comfortable. Interview, on 07/19/23 at 11:30 AM, with Administrative Nurse D revealed she would expect staff to provide ADLs to residents per their preferences. The facility policy Resident Rights and Quality of Life, effective 05/01/2012, instructed staff the resident has the right to a dignified existence. The facility failed to provide this dependent resident assistance with activities of daily living which included dressing, assistance out of bed, and positioning during a meal to ensure optimal sense of wellbeing.

The facility reported a census of 40 residents with 16 selected for review which included four residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure two Residents (R)24 and 7 of the four residents had pedals on their wheelchairs when staff provide propulsion assistance, failed to ensure staff provided one resident R8, of the four residents with upper extremity safety when positioned in her wheelchair and staff provided propulsion, and failed to ensure staff provided safe transfer of one resident R34 of the four residents reviewed for accidents. Findings included: - Review of Resident (R)8's Physician Order Sheet, dated 06/29/23, revealed diagnoses included Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), weakness, and dysphagia (swallowing difficulty). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with moderately impaired cognitive function. The resident had impairment in functional range of motion in both sides of her upper and lower extremities and was dependent on staff for locomotion. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/25/23, assessed the resident required assistance with ADLS with contributing factors of weakness and Huntington's disease. The Falls CAA, dated 04/25/23, assessed the resident at risk for injury due to falls with contributing factors in strength, endurance, and mobility. The Quarterly MDS, dated [DATE], assessed the resident with moderate cognitive impairment, dependent on staff for transfers, and impairment in functional range of motion on both sides of upper and lower extremities. The Care Plan, reviewed 05/23/23, instructed staff to observe for the need of padding to siderails or wheelchairs. The resident was a high risk for falls due to diagnosis of Huntington's disease. Observation, on 07/17/23 at 11:26 AM, revealed the resident seated in her wheelchair in the common living area leaning to the left with her left arm over the edge of the armrest and resting on the wheel of the wheelchair. The wheelchair contained positioning devices bilaterally and a small pillow under her left axilla (armpit), but her left elbow and upper arm continued to rest directly on the wheel of the wheelchair. Licensed Nurse (LN) G propelled the resident to her room for medication administration and noted her left arm resting on the wheel. The nurse attempted to reposition the resident. LN G stated therapy works with her to place positioning devices in her chair, but she continues to lean. Observation, on 07/17/23 at 01:41 PM, revealed the resident in the common living area, continuing with leaning to the left with left arm axilla positioned on the small pillow but her elbow flexed, and her upper arm rested directly against the wheel of the wheelchair. Interview, on 07/17/23 at 01:41 PM, with a family member, revealed the current positioning devices and wheelchair, were ineffective for posturing and the family worried about nerve entrapment due to leaning over the arm of the wheelchair. The family member obtained a stuffed animal and placed in beneath the resident's left axilla. Observation, on 07/18/23 at 02:09 PM, revealed the resident seated in her wheelchair with no additional support beneath her left axilla, and the resident leaning to the left with her elbow and upper arm resting directly on the wheel. Observation and interview, on 07/18/23 at 03:21 PM, revealed Certified Nurse Aide (CMA) R and CNA M provided peri care to the resident. Upon return to the wheelchair, the resident continued to lean to the left. CMA R placed a stuffed animal under the resident's left axilla, but the resident became distressed, so CMA R removed the stuffed animal. CNA M stated the resident prefers a pink stuffed animal as a positioning devise, but she did not know where it was. CNA M propelled the resident back out to the common living area, with her arm positioned directly touching on the wheel. 0bservation, on 07/18/23 at 04:30 PM, revealed the resident in the common dining room, leaning to the left. A friend of the resident identified that the resident required repositioning and the friend attempted to do this. Interview, on 07/19/23 at 08:43 AM, with therapy staff HH, revealed therapy staff did work with the resident for positioning, and confirmed the resident continues to lean to the left with her left arm near the wheelchair wheel. Interview, on 07/19/23 at 11:20 AM, with Administrative Nurse D confirmed the resident leaned to the left and the arm did come near the wheelchair wheel. She stated therapy staff should provide devices to prevent potential entrapment or skin issues from the wheel when staff propel her. The facility policy Lift 4 Care-Safe 4 All, dated February 2023, instructed all staff members to train on resident positioning and safety. The facility failed to ensure staff provided safe positioning of this resident's left arm when in her wheelchair and/or propelling the resident to prevent injury. - Review of Resident (R)7's Physician Order Sheet, dated 06/29/23, revealed diagnoses included history of malignant neoplasm (cancerous tumor) of the brain, polyneuropathy, schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment. The resident required extensive assistance for locomotion and was dependent on staff for transfers. The resident had no impairment in his upper extremities but had impairment in both lower extremities and use a wheelchair for mobility. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/07/22, assessed the resident required assistance with ADL due to generalize weakness. The Quarterly MDS, dated [DATE], assessed the resident with severe cognitive impairment, required extensive assistance for locomotion. The Care Plan, reviewed 07/12/23, instructed staff the resident required extensive assistance for ADLs. Staff instructed to encourage the resident to self-propel his wheelchair rather than push him to and from all meals. A Health Narrative Note, dated 07/09/23, assessed the resident required two people transfer with the mechanical lift due to generalized body weakness. The resident self-propelled himself with the help of upper extremity muscles. Observation, on 07/17/23 at 10:30 AM, revealed the resident seated in his wheelchair in his room. The resident's feet were flexed at his ankles and beneath his wheelchair. Observation, on 07/18/23 at 08:17 AM, revealed the resident seated in his wheelchair coming from the dining room. The resident's left foot sat flexed beneath the wheelchair and his right foot was flexed and lay directly on the floor as he attempted to propel himself using his hands on the wheels of the wheelchair. The resident attempted to use his left foot at times but did not extend his leg or place his foot in proper anatomical alignment to assist in propulsion. Observation, on 07/18/23 at 11:55 AM, revealed Certified Nurse Aide (CNA) M propelled the resident in his wheelchair to the dining room The resident did not lift his legs and his feet skimmed along on the floor. The resident could not hold his feet off the floor. CNA M stated she thought the resident could stretch his legs out and hold his fee up but chose not to. Observation, on 07/18/23 at 04:23 PM, revealed CNA M propelling the resident in his wheelchair. The resident moved his left foot, but unable to lift his right foot. Both feet were flexed beneath his wheelchair and skimmed along on the floor. Interview, on 07/18/23 at 12:00 PM, with Licensed Nurse G, revealed the resident propelled himself in his wheelchair using his hands on the wheels and thought he could use his feet when he wanted to. Interview, on 07/19/23 at 08:43 AM, with therapy staff HH, revealed staff should apply foot pedals when propelling residents in their wheelchairs to prevent injury. Interview, on 07/19/23 at 11:30 AM, with Administrative Nurse D revealed she would expect staff to use foot pedals for resident safety when propelling residents in their wheelchairs. The facility policy Transporting Patients within the Facility, undated, instructed staff to ensure the leg rests are in place when appropriate. The facility failed to determine this resident's ability to place his feet in proper anatomical position when self-propelling himself and failed to ensure this resident's feet were protected from injury when staff propelled him in his wheelchair without foot rests in place on the wheelchair. - Review of Resident (R)34's Physician Order Sheet, dated 06/29/23, revealed diagnoses included cerebral infarction (stroke which is the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), left hemiplegia (paralysis and weakness of one side of the body muscular of one half of the body), hemiparesis (muscular weakness of one side of the body), and major depressive disorder (major mood disorder). The Significant Change Minimum Data Set (MDS) dated [DATE] assessed the resident with normal cognitive function. The resident required extensive assistance for transfer and dressing. The resident required supervision with eating. The resident had functional impairment in range of motion on one side of her upper and lower extremity. The (Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/03/23, assessed the resident required assistance with ADLs due to functional impairment. The Quarterly MDS, dated [DATE], assessed the resident with normal cognitive function and required extensive assistance of one staff for bed mobility and transfer. The resident has impairment in functional range of motion on one side of her upper and lower extremity. The Care Plan, reviewed 07/07/23, instructed staff the resident required extensive assistance of two staff with stand/pivot transfer technique. Observation, on 07/18/23 at 10:14 AM, revealed the resident seated in her wheelchair in her room, with foam heel protective boots on both feet. Licensed Nurse (LN) G requested a gait belt and looked about the room for one. Certified Nurse Aide (CNA) M instructed the resident to place her arms on her shoulders without placing a gait belt on the resident or removing the foam boots, which did not have antiskid surface on the bottom and then assisted/lifted the resident to stand and then pivoted the resident onto the side of her bed. Interview, on 07/18/23 at 10:30 AM, with LN G, revealed CNA M should use a gait belt and remove the resident's foam boots before transfer to ensure a safe transfer and prevent injury for both resident and herself. Interview, on 07/19/23 at 11:30 AM, with Administrative Nurse D revealed she would expect staff to provide safe transfer techniques with use of a gait belt. The facility policy Lift 4 Care Safe 4 All dated February 2023, instructed staff the transfer belt should be used for residents that can ambulate but require support for maintaining balance are able to bear weight on one or both legs and are able to turn and pivot to transfer. The facility failed to ensure staff provided safe transfers for this resident who required extensive assistance of two staff for transfers and a gait belt to prevent injury. 34056 - Review of Resident (R)24's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) and weakness. The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required extensive assistance of one for locomotion on the unit and had impairment on one side of her lower extremity. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/20/22, did not trigger. The Cognitive Loss/Dementia CAA, dated 12/20/22, documented the resident had a diagnosis of dementia. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. She required supervision with setup help for locomotion on the unit. The care plan for physical functioning, revised 06/05/23, instructed staff the resident utilized a front wheeled walker and a wheelchair and required supervision of one for locomotion. Review of the resident's EMR, from 06/19/23 through 07/17/23, documented the resident required total assistance of one staff for locomotion on the unit with her wheelchair. On 07/18/23 at 09:00 AM, Certified Medication Aide (CMA) T propelled the resident from the dining room to her room in her wheelchair. The resident's feet with shoes came into direct contact with the hallway carpet on multiple occasions. The wheelchair lacked foot pedals. On 07/18/23 at 01:19 PM, CMA R propelled the resident from her room to the living room in her wheelchair. The resident's feet with shoes came into direct contact with the hallway carpet on multiple occasions. The wheelchair lacked foot pedals. On 07/18/23 at 11:15 AM, CMA T stated the resident did not use foot pedals on her wheelchair as she will propel herself around in the wheelchair at times. On 07/18/23 at 01:19 PM, CMA R stated the resident did not have foot pedals for her wheelchair. On 07/18/23 at 06:17 PM, Certified Nurse Aide (CNA) Q stated staff did not use foot pedals for the resident's wheelchair because she would propel herself in the wheelchair at times. On 07/19/23 at 08:43 AM, Consultant staff HH stated there should be foot pedals on wheelchairs when staff propel residents. On 07/18/23 at 03:33 PM, Licensed Nurse (LN) J stated she did not know if the resident had foot pedals for her wheelchair or not. On 07/19/23 at 10:00 AM, LN I stated the resident would propel herself in her wheelchair at times, so she did not have foot pedals. On 07/19/23 at 10:35 AM, Administrative Nurse D stated staff should ensure foot pedals are on the wheelchair when they propel residents. The facility policy for Transporting Patients Within the Facility, created May 2020, included: To ensure the safety of residents the staff shall follow the procedure related to safely transporting residents within the facility. Staff shall ensure leg rests are in place to resident's wheelchair when appropriate. The facility failed to safely transport this dependent resident in her wheelchair by failing to have foot pedals to ensure the resident did not receive an injury.

The facility reported a census of 40 residents with five residents reviewed for immunizations. Based on interview and record review. The facility failed to offer residents COVID-19 vaccinations per the CDC (Center for Disease Control) guidelines. Findings included: - Review of the resident immunizations in the electronic medical record revealed the following: Resident (R)14, admitted to the facility 04/11/19, received three doses of COVID-19 vaccine with the last immunization administered on 01/7/22. R8 admitted to the facility 07/06/15 received three doses of COVID-19 vaccine with the last Immunization administered on 01/17/22. R9 admitted to the facility 01/06/22 and historically received three doses of COVID-19 with last immunization administered on 12/28/21. R 4 admitted to the facility 10/10/22 and historically received three doses of COVID-19 with last dose received 11/10/21. R7 admitted to the facility 02/02/18 and received three doses of COVID-19 with the last dose received 01/17/22. The CDC recommended a fourth COVID-19 booster in May 2022 and approved and recommended the bivalent (a COVID-19 vaccine designed for the most current strains of COVID) booster available 09/02/22. Interview, on 07/19/23 at 10:30 AM, with consulting staff II confirmed the lack of COVID-19 immunizations since 01/17/22 to the residents of the facility. The facility policy COVID-19 Vaccination (COVAX) Policy (Patients/Residents and Team Members,) effective 05/21/21, instructed staff to administers the COVAX in accordance with the CDC Advisory Committee on Immunization Practices, manufacturer guidelines and Food and Drug Administration recommendations. The facility failed to offer residents the COVID-19 immunizations as required to prevent the spread of infection amongst the compromised residents of the facility.

The facility reported a census of 40 residents, with 16 sampled for review. Based on observation, interview, and record review the facility failed to review and revise the plan of care for two sampled residents including Resident (R)13 with psychotrophic medications and )13 for foot pedals on the wheelchair. Findings included: - Review of Resident (R)13's electronic medical record (EMR) revealed diagnoses of major depressive disorder (major mood disorder) and anxiety (feeling of worry, nervousness, or unease). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received an antidepressant medication (medication used to treat the symptoms of depression) seven days of the seven day assessment period. The Behavioral Symptoms Care Area Assessment (CAA), dated 12/02/22, did not trigger. The Psychosocial Well-Being CAA, dated 12/02/22, did not trigger. The Mood State CAA, dated 12/02/22, did not trigger. The Psychotropic Drug Use CAA, dated 12/02/22, documented the resident took psychotropic medication (medication capable of affecting the mind, emotions, and behavior) to manage her psychiatric illness (mental illness or its treatment). The licensed nurse (LN) was to monitor for side effects of the psychotropic medications every shift and notify the resident's physician of any abnormal findings. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 14, indicating intact cognition. She received an antidepressant medication seven days of the seven day assessment period. The care plan lacked staff instruction for interventions related to the resident's sad, depressed mood. Review of the resident's Treatment Administration Record (TAR), from 07/11/23 through 07/17/23, revealed the resident had sadness/crying documented on six days, the resident was withdrawn for five days and the resident had a flat affect (near or total absence of typical emotional responses). Documentation from 06/01/23 through 07/10/23, had no behavioral symptoms documented. On 07/17/23 at 12:47 PM, the resident stated she felt sad and hopeless. On 07/18/23 at 12:59 PM, the resident's family member stated he had noticed a decrease in the resident's mood over the past two to three weeks. The resident's family member stated his mother was not joking with her family or the staff anymore. On 07/18/23 at 08:57 AM, Certified Nurse Aide (CNA) MM stated the resident had been more sad and withdrawn that usual lately. On 07/18/23 at 10:29 AM, Certified Medication Aide (CMA) T stated the resident started acting depressed a couple of weeks ago. CMA T stated she was not sure what to do for the resident when she felt sad. On 07/18/23 at 06:17 PM, CNA Q stated she would tell the resident everything was going to be OK when she acted sad. On 07/19/23 at 06:42 AM, Social Service staff X stated the resident's depressive symptoms had begun in late June or early July. Social Service staff X confirmed the care plan lacked staff instruction for interventions related to the resident's sad, depressed mood, as it should. On 07/19/23 at 10:35 AM, Administrative Nurse D stated the expectation was for the care plans to be reviewed and revised to include staff instruction on how to assist this resident with a sad, depressed mood. The facility policy for Care Plans, revised October 2021, included: Care plans are developed by the interdisciplinary (ID) team and revised as needed according to resident status or change. The facility failed to review and revise this resident's care plan to include staff instruction on interventions to assist the resident when she had a sad and depressed mood. - Review of Resident (R)24's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) and weakness. The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required extensive assistance of one for locomotion on the unit and had impairment on one side of her lower extremity. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/20/22, did not trigger. The Cognitive Loss/Dementia CAA, dated 12/20/22, documented the resident had a diagnosis of dementia. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. She required supervision with setup help for locomotion on the unit. The care plan, revised 06/05/23, lacked staff instruction for foot pedals on the wheelchair while staff propelled the resident, to prevent her feet from coming into contact with the floor. Review of the resident's EMR, from 06/19/23 through 07/17/23, documented the resident required total assistance of one staff for locomotion on the unit with her wheelchair. On 07/18/23 at 09:00 AM, Certified Medication Aide (CMA) T propelled the resident from the dining room to her room in her wheelchair. The resident's feet with shoes came into direct contact with the hallway carpet on multiple occasions. The wheelchair lacked foot pedals. On 07/18/23 at 01:19 PM, CMA R propelled the resident from her room to the living room in her wheelchair. The resident's feet with shoes came into direct contact with the hallway carpet on multiple occasions. The wheelchair lacked foot pedals. On 07/18/23 at 11:15 AM, CMA T stated the resident did not use foot pedals on her wheelchair as she will propel herself around in the wheelchair at times. On 07/18/23 at 01:19 PM, CMA R stated the resident did not have foot pedals for her wheelchair. On 07/18/23 at 06:17 PM, Certified Nurse Aide (CNA) Q stated staff did not use foot pedals for the resident's wheelchair because she would propel herself in the wheelchair at times. On 07/19/23 at 08:43 AM, Consultant staff HH stated there should be foot pedals on wheelchairs when staff propel residents. On 07/19/23 at 10:35 AM, Administrative Nurse D stated the expectation was for the care plans to be reviewed and revised to include staff instruction to use foot pedals while staff propel this dependent resident in her wheelchair. The facility policy for Care Plans, revised October 2021, included: Care plans are developed by the interdisciplinary (ID) team and revised as needed according to resident status or change. The facility failed to review and revise this resident's care plan to include staff instruction for foot pedals on this dependent resident's wheelchair.

The facility reported a census of 40 residents with 16 residents sampled, including three residents reviewed for bowel and bladder. Based on observation, interview and record review, the facility failed to toilet one dependent Resident (R)8 timely and failed to complete a 72-hour voiding diary to assist the staff in the development of an individualized toileting program to assist R 30 improve or maintain his bladder continence. Findings included: - Review of Resident (R)30's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He required limited assistance of one staff for toileting and was frequently incontinent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 10/18/22, documented the resident required assistance with toileting due to actual incontinent episodes. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. He required limited assistance of one staff for toileting and was always incontinent of bladder and occasionally incontinent of bowel. The care plan for bowel and bladder, revised 04/24/23, instructed staff to check and change the resident every two to three hours and as needed (PRN). Staff were to cue the resident to toilet upon awakening, before and after meals, at bedtime and PRN. The resident required limited assistance of one staff for toileting. The resident's EMR lacked a current 72-hour voiding diary to assist the staff in the development of an individualized toileting program for the resident. Review of the resident's EMR revealed from 06/20/23 through 07/18/23, the resident required limited assistance of one staff for toileting and was mostly incontinent of urine. On 07/17/23 at 01:20 PM, Certified Medication Aide (CMA) N entered the resident's room to assist the resident to toilet. The resident was incontinent of urine in his brief. CMA assisted the resident with peri-care (cleansing of genitals) and a clean brief was put on the resident. On 07/18/23 at 09:03 AM, Certified Nurse Aide (CNA) MM assisted the resident to toilet following breakfast. The resident's brief was saturated with urine. The CNA assisted the resident with peri-care and a clean brief was put on the resident. On 07/17/23 at 02:15 PM, CMA N stated she was unsure of what the resident's toileting program was. CMA N stated she would go and toilet the resident whenever he would use the call light and request assistance with toileting. On 07/18/23 at 09:04 AM, CNA MM stated the resident required assistance with toileting because he could be incontinent of urine. Staff were to offer to toilet the resident every two hours or so, however CNA MM confirmed she failed to toilet the resident before breakfast. The resident was able to be continent of urine if toileted often enough. On 07/18/23 at 10:03 AM, Licensed Nurse (LN) J stated she was unsure of when staff were to toilet the resident. On 07/19/23 at 10:35 AM, Administrative Nurse D stated she was unsure if the resident had an individualized toileting program. The staff lacked a policy for bowel and bladder incontinence. The facility failed to complete a 72-hour voiding diary to assist the staff in the development of an individualized toileting program to assist the resident in improving or maintaining bladder continence. 28560 - Review of Resident (R)8's Physician Order Sheet, dated 06/29/23, revealed diagnoses included Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), weakness, and dysphagia (swallowing difficulty). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with moderately impaired cognitive function. The resident had impairment in functional range of motion in both sides of her upper and lower extremities and was dependent on staff for toileting and personal hygiene. The resident was always incontinent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 04/25/23, assessed the resident was incontinent of bladder and bowel. The resident was dependent on staff for incontinence care and required check and change for incontinent episodes for reduction of pressure ulcer, fall risk and to reduce the risk for urinary tract infections. The Quarterly MDS, dated [DATE], assessed the resident with moderate cognitive impairment, dependent on staff for transfers and toileting. The resident had impairment in functional range of motion on both sides of upper and lower extremities. The resident was always incontinent of bowel and bladder. The Care Plan, reviewed 05/23/23, instructed staff to observe for incontinence and provide incontinence care as needed with the use of brief/pads for protection and barrier cream. The resident was at high risk for pressure ulcers related to incontinence and friction form Huntington's movements. Needed padding to siderails or wheelchairs. The resident was a high risk for falls due to diagnosis of Huntington's disease. The resident required assistance of one to two for check and change. The resident used blue disposable briefs to preserve her dignity, and staff instructed to change the resident frequently and as needed. Observation, on 07/18/23 at 10:54 AM, revealed the resident dressed and seated in her wheelchair in the common living area. Observations continued every 15 minutes. Observation, on 07/18/23 at 03:21 PM, revealed the resident seated in her wheelchair in the common living area. Certified Nurse Aide (CNA) M and CMA R stated they did not know when the resident had last been checked for incontinence. Observation, on 07/18/23 at 03:21 PM, approximately four and one-half hours after being dressed and transferred into her wheelchair, CNA M and CMA R transferred the resident into her bed and found the resident saturated her brief with urine. The resident's shorts were wet as well as the seat of the wheelchair. The resident urine had a foul odor and peri care revealed redness to the perineal area. CNA M provided peri care and applied barrier cream. Interview, on 07/18/23 at 04:00 PM, with Licensed Nurse G, revealed staff should check and change the resident every two hours. Interview, on 07/19/23, at 11:30 AM, with Administrative Nurse D, revealed she would expect staff to follow the care plan and confirmed the care plan did not indicate an individualized care plan other than check and change. The facility policy Helping a Resident with Toileting Needs, undated, instructed staff to assist residents with toileting needs to maintain a resident's dignity and hygiene. The facility failed to provide timely toileting for this dependent incontinent resident to prevent infection, skin breakdown and maintain a sense of well-being.

The facility reported a census of 40 residents with 16 residents sampled, including three residents reviewed for respiratory care. Based on observation, interview and record review, the facility failed to ensure one of the three sampled resident's (R)10 oxygen concentrator had a humidifier bottle. Findings included: - The Physician Order Sheet (POS), dated 06/29/23, for Resident (R)10, documented a diagnosis of Chronic Obstructive Pulmonary Disease (COPD)- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. He used oxygen while a resident. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/16/23, documented the resident had impaired cognition. The care plan for respiratory status, dated 06/16/23, instructed staff the resident used oxygen at 7 liters (L) per nasal cannula (NC), continuously for a diagnosis of COPD. Review of the resident's EMR, revealed the follow physician's orders: Oxygen 7 L via NC, continuous, to maintain oxygen levels above 90%, ordered 06/17/23. Change humidifier water bottle when empty, 06/17/23. On 07/18/23 at 08:00 AM, the resident sat in the recliner in his room with oxygen on at 7 L via NC. The humidifier bottle on the oxygen concentrator was dry. On 07/18/23 at 11:05 AM, 02:46 PM and 03:21 PM, the resident continued to wear his oxygen at 7 L via NC and the humidifier bottle remained dry. On 07/19/23 at 10:35 AM, Administrative Nurse D stated the humidifier bottle should be replaced when they are low of water. She would expect staff to not allow the humidifier bottles to run completely dry. The facility policy for Oxygen Guideline, effective January 2022, included: Oxygen is a drug and therefore it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice. The facility failed to ensure the humidifier water bottle on this dependent resident's oxygen concentrator which dispensed at 7 L, did not run dry.

The facility census totaled 39 residents, with five residents reviewed for skin issues. Based on observation, interview, and record review the facility failed to order and provide four days (11/01/21-11/04/21) of continued intravenous antibiotic treatment as ordered for Resident (R)7, who was continuing post-surgical recovery for [CONDITION(S)] and gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) treatment to his left foot. On 11/01/21 R7's Infectious Disease Provider prescribed [MEDICATION(S)] (antibiotic) intravenously (IV, through the vein) three times a day for an additional two weeks. The interruption in the IV antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore the facility failed to ensure necessary treatment and care, in accordance with professional standards of practice, for Resident (R) 4, who had multiple wounds. Findings included: - Review of R7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/13/21 Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R7 had a surgical wound with foot infection and received antibiotics for seven days out of the seven-day observation period. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 10/13/21, documented R7 was at risk for skin breakdown with a surgical wound to the left foot measuring 19.9 centimeters (cm) by 4.5 cm by 6.2 cm. The 10/20/21 Care Plan directed staff to administer IV medication and antibiotics per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/06/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/10/21 Wound Assessment documented Nurse Practitioner (NP) KK ordered the IV antibiotic for R7's [CONDITION(S)] infection. The IV antibiotic was to be given for two weeks and then reevaluated. The 10/17/21 Wound Note lacked documentation of the left foot surgical site measurements. The chart lacked the next scheduled wound care assessment note (per order) on 10/24/21. The 10/2021 through 11/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/01/21 Infectious Disease Consultants IV Order signed by NP KK documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/02/21 Wound Assessment documented completion of the IV antibiotic and noted the resident had a tele-med (virtual appointment using the computer or handheld device) visit with Physician HH on 11/01/21. (The assessment lacked mention of the 11/01/21 re-ordered [MEDICATION(S)]) The Wound Note dated 11/02/21 documented the left foot surgical wound measured 3.9 cm long by 1.7 cm wide by 5.9 cm deep. The 11/02/21 picture of R7's left foot wound revealed the partial amputation with a scabbed area that ran across the end of the residual foot. The skin around the scab looked light pink and non-edematous, the incision scab looked healing as it was intact, dark, and dry. The 11/04/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse D stated NP KK wanted to continue the IV antibiotic due to the persistence of the wound infection. NP GG documented that no staff placed the IV antibiotic order into R7's chart and Administrative Nurse D was to follow up with the Infectious Disease Team to determine continued antibiotic treatment. The MAR/TAR lacked documentation of the administration of [MEDICATION(S)] from 11/01/21 through 11/04/21 (a total of 4 days). The 11/05/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Infectious Disease Consultants IV Order dated 11/08/21 signed by NP KK documented [MEDICATION(S)] 4.5 GM IV every eight hours for one week to end on 11/15/21. The 11/08/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician discontinued (stopped) the order on 11/16/21. The 11/08/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/09/21 wound picture revealed R7's left foot incisional wound revealed the partial amputation with a scabbed area that ran across the end of the residual foot. The skin around the top side of the scabbed incision looked pink and very edematous. The residual foot area looked over twice the size (due to tissue swelling) from the 11/02/21 picture. The bottom side of the foot near the outer areas of the incision was very reddened and the skin was pulling away from the scabbed area. The outer area of the scabbed incisional wound was cracked open across the incision, revealing beefy red tissue underneath. The top area around the incisional wound near the inside top of the foot revealed a round darkened area. The 11/09/21 Wound Assessment documented R7 received IV antibiotics per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Note dated 11/09/21 documented the left foot surgical wound measured 5.4 cm long by 3.0 cm wide by 3.7 cm deep. The Wound Note dated 11/14/21 documented the left foot surgical wound measures 5.6 cm long by 2.7 cm wide by 4.9 cm deep. (During this time, the antibiotic was being given.) Observation on 01/04/22 at 02:00 PM of R7 revealed Licensed Nurse J completed a dressing change of the resident's surgical amputation wound on the midfoot area. The skin was pink and intact with one open area where his toes would have been. Observation on 01/05/22 at 01:36 PM revealed R7 lying in bed, with his left foot wrapped up with a dressing labeled 01/04/22, when the staff last changed the dressing. Observation revealed a small amount of dried blood at the area where R7's big toe would have been. Interview on 01/05/22 at 01:35 PM with R7 revealed he had an amputation of his toes on his left foot and received IV antibiotics for about a month. R7 stated he received the IV antibiotics multiple times a day but could not remember if there were problems with receiving the antibiotic. Interview on 01/05/22 at 06:00 PM with NP GG revealed R7 had a tele-med visit on 11/01/21 with Physician HH. Administrative Nurse D received a verbal order from NP KK during the tele-med visit to extend the [MEDICATION(S)] 4.5 GM IV three times a day and a fax of the order would be sent to the facility. On 11/04/21, NP GG visited R7 and noted R7 had a PICC line, but it was not being used. NP GG called Administrative Nurse D and found the [MEDICATION(S)] order from 11/01/21 was never placed into R7's chart and was not given to R7 for a total of four days. NP GG restarted the [MEDICATION(S)] order for 11/05/21 and notified Administrative Nurse D that Physician HH needed to be notified of the medication error and to have Administrative Nurse D ask for clarification of the [MEDICATION(S)] order continuing. NP GG stated that during her visitations with R7, the appearance of R7's wound from 11/04/21 to 11/08/21 became worse (more gangrenous and needing debridement; medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). Interview on 01/06/22 at 02:19 PM with Consultant Pharmacist LL revealed [MEDICATION(S)] must be given for the ordered duration from the Physician. Having an interruption in the medication would not be ideal and could cause the gangrene or other bacteria to come back within the four days the [MEDICATION(S)] was not given to R7. By giving the [MEDICATION(S)] properly the bacteria would be prevented from re-growing and the expected result would be to see the wound decrease and ultimately heal. Interview on 01/10/22 at 02:15 PM with Licensed Nurse (LN) G revealed she completed the weekly assessment of R7's foot and tracked the progress of the wound healing. R7 received IV antibiotics for his gangrenous foot wound, that was ordered by the Infectious Disease Team. LN G stated the ID team had concerns about the way R7's wound looked, and the Infectious Disease Team chose to continue the IV antibiotic using the PICC line. LN G stated the antibiotic order was never placed into R7's chart and was ultimately noted to be missing from the chart by NP GG. From what LN G remembered, Administrative Nurse D should have placed the IV antibiotic order into R7's chart as the tele-med order was given to Administrative Nurse D. Interview on 01/10/22 at 07:00 PM with LN H revealed Administrative Nurse D received a verbal order from the Infectious Disease Team to continue the IV antibiotic. She did not place the order into R7's chart but told LN H to place the order once the faxed orders arrived from the Infectious Disease Team. LN H stated that because Administrative Nurse D received the verbal order, Administrative Nurse D should have placed the order in the resident's chart. LN H did not feel comfortable placing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 01/10/22 at 08:00 PM with LN I revealed R7 received IV antibiotics for a left foot wound. LN I stated there was a mix up with the IV antibiotic order and staff never placed it in the chart. She stated that R7's foot looked worse during that time and was covered with eschar. Interview on 01/11/22 at 08:43 AM with Administrative Nurse D revealed R7 admitted to the facility receiving IV antibiotics per Physician HH's order. R7 was on [MEDICATION(S)] for about a month after admission and was eventually switched to the PO (by mouth) version. Administrative Nurse D stated the Infectious Disease Team was to fax an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/05/21 Administrative Nurse D stated she discovered the [MEDICATION(S)] order was never placed into R7's chart, so she notified the Infectious Disease Team via telephone of the issue. Administrative Nurse D stated the Infectious Disease Team decided to switch R7 to the PO form of antibiotic at that time. An interview on 01/13/21 at 02:30 PM with NP KK revealed she documented a note stating on 11/01/21 she wanted R7's [MEDICATION(S)] continued for two weeks. NP KK stated the Infectious Disease Team had no documentation of R7 missing doses of the [MEDICATION(S)] until 11/10/21. NP KK stated she gave verbal orders during the tele-med appointment and then faxed all orders to the facility. She stated she expected the nurse would place the order into the resident chart with the verification of the faxed order(s). NP KK did not remember which nurse was present during the 11/01/21 tele-med visit but stated that Administrative Nurse D had taken charge of the tele-med visits. The facility, undated Physician's Telephone Orders policy stated the physician's verbal and telephone orders would be entered into the resident chart by the licensed nurse accepting the order, and would document the date, time, physician name, and order provided. The order would then be validated for accuracy by the licensed nurse and the order would be printed, signed, and placed into the resident's paper chart under the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to provide the ordered antibiotic treatment to R7 for four days and the resident's surgical wound revealed worsening with decline. - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE], documented R4 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and required extensive assistance with bed mobility, limited assistance with transfer, and total dependence on the staff for toileting. The resident had a non-pressure chronic ulcer of buttock with fat layer exposed and received surgical wound care and application of non-surgical dressings. The Pressure Ulcer/Injury Care Area Assessment, (CAA), dated 07/08/21, indicated the resident had stage three or higher pressure ulcers. The Activities of Daily Living Functional/Rehabilitation CAA, dated 07/08/21, indicated the resident had impaired mobility due to a double lower extremity amputation. The Quarterly MDS, dated [DATE], documented R4 with a BIMS score of 15, indicating intact cognition and required supervision with bed mobility, limited assistance with transfer, and extensive assistance of two staff members with toileting. The resident had a non-pressure chronic ulcer of the buttock with fat layer exposed and a surgical wound. He received surgical wound care and applications of non-surgical dressings. The Care Plan, revised 12/14/20, documented the resident had altered skin integrity, non-pressure, related to a surgical wound to left ischial tuberosity, left buttock, ulcer superior to former rectum, ulcer to former rectum tunnel, and coccyx. The staff were to provide treatments as ordered and weekly wound assessments. The resident also had actual impairment to skin integrity of the buttocks and required daily dressing changes until healed as ordered. A PO, dated 12/14/21, documented instructions to the staff to cleanse the resident's right upper back with normal saline/wound cleanser, dry, apply alginate to wound bed, cover with ABD, and secure with [MEDICATION(S)] to keep intact. Change daily and PRN. Hospice will perform wound care during their visits. Every day shift for wound. Review of the December 2021 Treatment Administration Record (TAR) revealed it lacked documentation to identify the staff provided the ordered wound care as above on December 15th, 18th, 19th and 23rd, indicating the nurse did not provide treatment as ordered by the physician. The facility lacked evidence that the hospice nurse provided treatment on those dates. A PO, dated 10/18/21, documented cleanse all open areas to surgical wound (distal) with wound cleanser, dry, apply gauze moistened with petroleum barrier directly to wound bed, Optilock foam, and cover with ABD. Change daily. Hospice performs treatments Monday through Friday. Every day shift for chronic wounds. Review of the December 2021 TAR revealed lack of documentation of wound care for above order on December 7th, 15th, 18th, 19th and 23rd, indicating the nurse did not provide treatment as ordered by the physician. The facility lacked evidence that the hospice nurse provided treatment on those dates. A PO, dated 10/18/21, documented ulcer - fistula right lateral inferior buttock: remove old dressing and cleanse with Pure and Clean. Use [MEDICATION(S)] blue as packing, then cover with an ABD as secondary dressing. Treat daily and as needed every day shift for chronic wound. Review of the December 2021 TAR revealed lack of documentation of wound care for above order on December 7th, 15th, 18th, 19th and 23rd, indicating the nurse did not provide treatment as ordered by the physician. The facility lacked evidence that the hospice nurse provided treatment on those dates. Review of weekly Skin and Wound Evaluations revealed for the months of November and December 2021, the nursing staff did not assess or monitor for the healing of the left buttock from 11/20/21 through 12/06/21 (15 days), the next evaluation was eight days later on 12/14. Nine days later the wound was evaluated on 12/23/21. There were no other wound evaluations available after 12/23/21. Review of weekly Skin and Wound Evaluations revealed for the month of December 2021, the nursing staff did not assess or monitor for the healing of the right illiac crest from 12/06/21 through 12/14/21 (eight days), the next evaluation was nine days later on 12/123. There were no other wound evaluations available after 12/23/21. The facility policy Skin Care Guideline, dated July 2018, documented .Process .DNS or designee will be responsible to implement and monitor the skin integrity program .Key Elements .Weekly skin evaluations are completed and documented . Interview, on 12/29/21 at 08:19 AM, with Administrative Staff A, revealed the Director of Nursing (DON) was responsible for the resident's wound care at that point and time and it hadn't been timely. The facility had a wound care nurse who helped once a week, but she had a falling out with the DON. Daily wound care was the responsibility of all the nurses in the facility and they should be documenting accordingly. The DON should be performing the weekly monitoring when nurses aren't available. Interview, on 01/11/22 at 10:45 AM, with Administrative Nurse D, revealed the wound evaluations were to be performed every week, but they haven't been done consistently. The wound care nurse was no longer with the facility and some of the nurses here have helped out with the weekly wound monitoring. Administrative Nurse D stated she did not assess this resident's wounds or perform any evaluations. The facility put a nurse on administrative leave due to not performing her duties which included dressing changes. Wound care not documented on the treatment administration record (TAR), was not done. The facility failed to provide necessary treatment and care to ensure proper monitoring and promote healing for this resident with multiple wounds.

The facility reported a census of 49 residents, which included four residents selected for review. The sample included two residents sampled for abuse. Based on interview, observation, and record review, the facility failed to provide adequate supervision and one to one, as care planned to prevent physical abuse, which placed R3 in immediate jeopardy for physical abuse from R4. R4, who had a history of [REDACTED]. Findings included: - R4's signed Physician Orders, dated 10/22/2020, documented the resident admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. R4's Admission Minimum Data Set, ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severely impaired cognition. The resident had difficulty focusing attention and disorganized thinking. R4 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at other). This occurred one to three days of the look back period. The resident used a manual wheelchair for mobility. The [MEDICAL CONDITION] Care Area Assessment (CAA), dated 09/29/20 revealed the resident had difficulty following directions and he was difficult to redirect at times. The Psychosocial Well-Being CAA, dated 09/29/20, revealed the resident had a [DIAGNOSES REDACTED]. He was difficult to redirect at times, and often required one to one support, especially when hallucinating (sensing things while awake that appear to be real, the mind created). The Care Plan, reviewed on 11/02/20, documented the resident had the potential to be verbally aggressive due to hallucinations related to mental/emotional illness, cognitive deficit, and [MEDICAL CONDITION]. The facility staff were to administer medications as ordered and give the resident as many choices as possible about his care and activities. Monitor behaviors such as agitation, screaming, spitting, and swinging arms. Staff to document observed behavior and attempted interventions. When the resident would become agitated, staff should intervene before agitation escalated. Guide away from the source of his distress, engage calmly in conversation, if response was aggressive, staff should walk calmly away, and approach him later. Staff should provide one to one care. Provide psychiatric/psychogeriatric consult as indicated. R4's electronic medical record lacked documentation related to the allegation of abuse on 11/27/20, however, the electronic medical records revealed the resident had a history of [REDACTED]. On 11/19/20 at 03:50 PM, Provider's Extender GG observed the resident self-propelling his wheelchair approximately a foot behind (an unidentified) female resident who was ambulatory with a front wheeled walker. She had her back to R4. R4 reached his right arm outstretched in front of him with a fist and attempted to hit the female resident and missed striking the unsampled resident. The provider called out R4's name, and attempted to get to R4, however R4 was able to strike the resident's buttocks and twist his fist into her buttocks vigorously. Staff separated the residents. LN G notified the Director of Nursing. On 11/20/20 at 11:26 PM, the resident displayed agitation and physical behaviors. Staff provided one to one supervision for safety related to the resident was a threat to himself and others. Staff administered [MEDICATION NAME] (an antipsychotic medication used to treat certain mental/mood disorders) intramuscularly (medication given by injection). On 11/22/20 at 02:15 PM, the resident had behaviors of yelling, throwing dining room tables and chairs, puzzles, and games. He became physically and verbally aggressive towards staff and required an injection of [MEDICATION NAME]. On 11/23/20 at 04:00 PM, the resident became very agitated and threw himself on the floor. Staff attempted to assist him back to his wheelchair and he became physically and verbally aggressive with staff. All attempts at redirection were unsuccessful, and staff administered PRN (as needed) [MEDICATION NAME]. The facility's Investigation Template, dated 11/27/2020, was incomplete and lacked staff witness statements, resident interviews, and a root cause analysis of the incident. Observation on 12/01/20 at 03:44 PM, R4 was in his bed with his eyes closed. He was holding his baby doll. There was no staff present to provide one to one care. Observation on 12/01/20 at 05:35 PM, R4 sat in the commons area at the table. R3 sat near R4, however there was no staff member providing one to one with the resident. Observation on 12/01/20 at 06:06 PM revealed R3 sat at a table in the common sitting area, feeding herself supper. R4 sat in his wheelchair at the same table, adjacent to her, eating his supper. Staff was not present to provide one to one supervision with the resident. Observation on 12/01/20 at 06:10 PM, the resident requested to go to bed. After staff transferred the resident to bed, staff left the resident's room, and the resident lacked one to one supervision. Interview on 12/01/20 at 4:00 PM with alert resident R5 revealed he witnessed R4 pull on R3's oxygen hose while she was standing, causing her to fall to the floor. R5 stated he witnessed R4 strike R3. R5 stated he often found the resident in his room, going through his belongings. Interview on 12/01/20 at 04:38 PM with Licensed Nurse G revealed R4's behaviors were unpredictable. The facility did not provide a designated staff member every shift to provide one to one care for R4. Interview on 12/01/20 at 03:55 PM with CNA MM revealed R4 required one on one monitoring, and usually a staff member at the desk kept an eye on him when other staff answered call lights and assisted the other residents on the unit. CNA MM verified the resident had behaviors of throwing things and he would hit residents as well as staff. Interview on 12/02/20 at 09:45 AM with Licensed Nurse H revealed he did not witness the events on 11/27/20 between 05:30AM and 06:00 AM. LN H stated Certified Nursing Staff M, reported to him R4 struck R3 on the side of the head. LN H stated when he got to the unit, R3 was standing next to a chair. LN H stated he reported the incident to Administrative Nurse D. LN H reported he failed to document the incident, however, he thought Administrative Nurse D would notify the provider, responsible party, and complete an incident report. Interview on 12/02/20 at 01:18 PM with Administrative Nurse D revealed R4 did have behavior problems and verified the resident would hit at the other residents. Administrative Nurse D stated she began an investigation after staff informed her of R4 striking R3 in the head. Administrative Nurse D confirmed staff should monitor the resident on a one on one, however one staff member stepped away from view of the resident when the incident occurred. She verified staff should have maintained a one to one supervision with the resident, for the safety of himself and other residents. In addition, Administrative Nurse D stated R4 became agitated, and R3 attempted to comfort him, came up behind him, startled him, and he flipped his hand backwards, and the resident hit the left side of R3's face. In addition, Administrative Nurse D verified staff failed to monitor R3's neurological assessments, after being struck in the face by R4. Interview on 12/02/20 at 04:30 PM with CNA M revealed she witnessed the altercation between R4 and R3, but was not within physically touching distance to prevent R4 from striking R3 in the left temple area with his fist. CNA M stated R3 started to sway, and she was able to lower R3 to the floor. CNA M stated the resident was Out for approximately three to five minutes. CNA M stated she informed LN H of the incident, and he told her to obtain vital signs, which she did and reported to him. Interview on 12/03/20 at 08:45 AM with Provider's Extender GG, revealed the facility did not notify her that R4 had behaviors on 11/27/20. Staff notified Consulting Staff GG on 12/02/20 at 07:45 AM, however the facility failed to notify her that R3 was struck in the head by R4. Consulting Staff GG stated she would expect the facility to notify her immediately of the incident, monitor the resident's neurological status, and possible send the resident (R3) for a computerize tomography scan (CAT) to rule out injuries. The facility policy, Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/2019, revealed the purpose was to prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations to in accordance with Federal and State Laws. First and fore most the resident/patient will be immediately assessed and removed from any potential harm. The facility failed to take immediate actions to ensure R4 who had a history of [REDACTED]. R4 struck R3 in the head. The facility provided an acceptable plan of removal of the immediate jeopardy on 12/03/2020 at 05:45 PM. The plan included: A focused Quality Assurance Performance Improvement (QAPI) initiated and completed on 12/03/20 at 04:30 PM with the Administrator, Director of Nursing Services, and the Medical Director at 04:30 PM. All staff education on one-on-one expectations while the resident resided in the facility, completed on 12/03/2020 at 05:45 PM, which included one staff member to remain with the resident to accommodate one to one with R4. Staff would complete a one to one requirement every shift to ensure the resident separated from other residents, on 12/03/2020 at 05:45 PM. The survey team validated the immediate jeopardy was removed on 12/03/2020 at 05:45 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of an G level following the removal of the immediate jeopardy.

The facility reported a census of 49 residents, which included four residents selected for review. The sample included two residents sampled for abuse. Based on interview, observation, and record review, the facility failed to ensure the 48 residents remained free from the risk of physical abuse, when R4, who had a history of [REDACTED]. The facility failed to provide adequate supervision and one to one, as care planned to prevent physical abuse, which placed R3 and the other residents who resided at the facility in immediate jeopardy for physical abuse from R3. Findings included: - R4's signed Physician Orders, dated 10/22/20, documented the resident admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. The resident's Admission Minimum Data Set, ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severely impaired cognition. The resident had difficulty focusing attention and disorganized thinking. R4 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at other). This occurred one to three days of the look back period. The resident used a manual wheelchair for mobility. The [MEDICAL CONDITION] Care Area Assessment (CAA), dated 09/29/20 revealed the resident had difficulty following directions and he was difficult to redirect at times. The Psychosocial Well-Being CAA, dated 09/29/20 revealed the resident had a [DIAGNOSES REDACTED]. He was difficult to redirect at times, and often required one to one support, especially when hallucinating (sensing things while awake that appear to be real, the mind created). The Care Plan, reviewed on 11/02/20, documented the resident had the potential to be verbally aggressive due to hallucinations related to mental/emotional illness, cognitive deficit, and [MEDICAL CONDITION]. The facility staff were to administer medications as ordered and give the resident as many choices as possible about his care and activities. Monitor behaviors such as agitation, screaming, spitting, and swinging arms. Staff to document observed behavior and attempted interventions. When the resident would become agitated, intervene before agitation escalated. Guide away from the source of his distress, engage calmly in conversation, if response was aggressive, staff should walk calmly away, and approach him later. Staff should provide one to one care. Psychiatric/psychogeriatric consult as indicated. R4's electronic medical record lacked documentation related to the allegation of abuse on 11/27/20, however the electronic medical records revealed the resident had a history of [REDACTED]. On 11/19/20 at 03:50 PM, the Provider's Extender GG, observed the resident self-propelling his wheelchair approximately a foot behind (an unidentified) female resident who was ambulatory with a front wheeled walker. She had her back to R4. R4 reached his right arm outstretched in front of him with a fist and attempted to hit the female resident and missed striking the unsampled resident. The provider called out R4's name, and attempted to get to R4, however R4 was able to strike the resident's buttocks and twist his fist into her buttocks vigorously. Staff separated the residents. LN G notified the Director of Nursing. On 11/20/20 at 11:26 PM, the resident displayed agitation and physical behaviors. Staff provided one to one supervision for safety related to the resident was a threat to himself and others. Staff administered [MEDICATION NAME] (an antipsychotic medication used to treat certain mental/mood disorders) intramuscularly (medication given by injection). On 11/22/20 at 02:15 PM, the resident had behaviors of yelling, throwing dining room tables and chairs, puzzles, and games. He became physically and verbally aggressive towards staff and required an injection of [MEDICATION NAME]. On 11/23/20 at 04:00 PM, the resident became very agitated and threw himself on the floor. Staff attempted to assist him back to his wheelchair and he became physically and verbally aggressive with staff. All attempts at redirection were unsuccessful, and staff administered PRN (as needed) [MEDICATION NAME]. The Investigation Template dated 11/27/20 was incomplete and lacked staff witness statements, resident interviews, and a root cause analysis. Observation on 12/01/20 at 03:44 PM, R4 was in his bed with his eyes closed. He was holding his baby doll. There was no staff present to provide one to one care. Observation on 12/01/20 at 05:35 PM, R4 sat in the commons area at the table. R3 sat near R4, however there was no staff member providing one to one with the resident. Observation on 12/01/20 at 06:06 PM revealed R3 sat at a table in the common sitting area, feeding herself supper. R4 sat in his wheelchair at the same table, adjacent to her, eating his supper. Staff was not present to provide one to one supervision with the resident. Observation on 12/01/20 at 06:10 PM, the resident requested to go to bed. After staff transferred the resident to bed, staff left the resident's room, and the resident lacked one to one supervision. Interview on 12/01/20 at 4:00 PM with alert resident R5 revealed he witnessed R4 pull on R3's oxygen hose while she was standing, causing her to fall to the floor. R5 stated he witnessed R4 strike R3. R5 stated he often found the resident in his room, going through his belongings. Interview on 12/01/20 at 04:38 PM with Licensed Nurse G revealed R4's behaviors were unpredictable. The facility did not provide a designated staff member every shift to provide one to one care for R4. Interview on 12/01/20 at 03:55 PM with CNA MM revealed R4 required one on one monitoring, and usually a staff member at the desk kept an eye on him when other staff answered call lights and assisted the other residents on the unit. CNA MM verified the resident had behaviors of throwing things and he would hit residents as well as staff. Interview on 12/02/20 at 09:45 AM with Licensed Nurse H revealed he did not witness the events on 11/27/20 between 05:30AM and 06:00 AM. LN H stated Certified Nursing Staff M, reported to him R4 struck R3 on the side of the head. LN H stated when he got to the unit, R3 was standing next to a chair. LN H stated he reported the incident to Administrative Nurse D. LN H reported he failed to document the incident, however, he thought Administrative Nurse D would notify the provider, responsible party, and complete an incident report. Interview on 12/02/20 at 01:18 PM with Administrative Nurse D revealed R4 did have behavior problems and verified the resident would hit at the other residents. Administrative Nurse D stated she began an investigation after staff informed her of R4 striking R3 in the head. Administrative Nurse D confirmed staff should monitor the resident on a one on one plan, however one staff member stepped away from view of the resident when the incident occurred. She verified staff should have maintained a one to one supervision with the resident, for the safety of himself and other residents. In addition, Administrative Nurse D stated R4 became agitated, and R3 attempted to comfort him, came up behind him, startled him, and he flipped his hand backwards, and the resident hit the left side of R3's face. In addition, Administrative Nurse D verified staff failed to monitor R3's neurological assessments, after being struck in the face by R4 . Interview on 12/02/20 at 04:30 PM with CNA M revealed she witnessed the altercation between R4 and R3, but was not within physical touching distance to prevent R4 from striking R3 in the left temple area with his fist. CNA M stated R3 started to sway, and she was able to lower R3 to the floor. CNA M stated the resident was Out for approximately three to five minutes. CNA M stated she informed LN H of the incident, and he told her to obtain vital signs, which she did and reported to him. Interview on 12/03/20 at 08:45 AM, with Physician Extender GG revealed the facility did not notify her R4 had behaviors on 11/27/20. Staff notified her on 12/02/20 at 07:45 AM, however the facility failed to notify her that R3 was struck in the head by R4. Physician Extender GG stated she would expect the facility to notify her immediately of the incident, monitor the resident's neurological status, and possible send the resident (R3) for a computerize tomography scan (CAT) to rule out injuries. The facility policy, Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/2019, revealed the purpose was to prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations to in accordance with Federal and State Laws. First and fore most the resident/patient will be immediately assessed and removed from any potential harm. The facility failed to protect the 48 residents residing in the facility when staff failed to provide one on one supervision to R4, who had physically aggressive behaviors and hit R3 in the head. The facility also failed to thoroughly investigate an incident of resident to resident abuse. The facility provided an acceptable plan of removal of the immediate jeopardy on 12/03/2020 at 05:45 PM. The plan included: A focused Quality Assurance Performance Improvement (QAPI) initiated and completed on 12/03/20 at 04:30 PM with the Administrator, Director of Nursing Services, and the Medical Director at 04:30 PM. All staff education on one-on-one expectations while the resident resided in the facility, completed on 12/03/2020 at 05:45 PM, which included one staff member to remain with the resident to accommodate one to one with R4., Staff would complete a one to one requirement every shift to ensure the resident separated from other residents, on 12/03/2020 at 05:45 PM The survey team validated the immediate jeopardy was removed on 12/03/2020 at 05:45 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of an F level following the removal of the immediate jeopardy.

The facility reported a census of 50 residents with three residents, Resident (R) 19, R45, and R250 sampled for abuse. Based on observation, interview, and record review the facility failed to ensure 26 female residents remained free from the risk of sexual abuse when R19 engaged in inappropriate sexual behavior with R250 in a public area of the facility on 10/04/2020 and then inappropriately touched R45 on 10/15/2020. The facility failed to provide adequate supervision to prevent sexual abuse, which placed R250, R45, and the other 24 female residents in immediate jeopardy for sexual abuse from R19. Findings included: - R19's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. Staff assessed the resident as having delusions and wandering in the facility during the seven day lookback period. The resident required supervision from staff when ambulatory. The Admission MDS, dated [DATE], documented the resident had short term and long term memory problems and moderately impaired cognitive skills for daily decision making. The Care Area Assessment (CAA), dated 05/22/2020, for Cognitive Loss/Dementia, documented the resident had a cognitive deficit as evidenced by memory problems and altered mental status. The CAA for [MEDICAL CONDITION] Drug Use documented the resident received an antipsychotic related to altered mental status. The care plan, updated 10/29/2020, documented the resident demonstrated sexually inappropriate behaviors on 05/2020 exhibited by masturbation in public. The staff were to help the resident avoid situations or people that tend to trigger those behaviors and provide a diversion from those behaviors. The care plan also directed the staff to observe for wandering behaviors in relation to [MEDICAL CONDITION] (an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech). The care plan lacked interventions and did not define who the people were or the situations that caused the inappropriate contact with female residents in the facility. Review of a General Note, dated 05/14/2020, documented the staff explained to the resident that he could talk to female residents, but not touch them. At that point he had put his arm around a female resident and rubbed her arm and shoulder. He was told that it was not appropriate. Facility staff failed to review and revise the plan of care to address the resident's inappropriate behavior. Review of a General Note, dated 09/08/2020, documented the resident took off his clothes and was naked on the East side of the facility. The nurse took him back to the West side of the facility to help him put his clothes back on. On 10/4/2020, the facility's internal investigation for Sexual Relations documented R19 and R250 were seen sitting together on a couch supervised by staff. The CNA stepped away to help a resident and when she returned R250 had her pants off and R19 was in his underwear and engaged in sexual activity. They were immediately separated, told it was inappropriate, assisted back in to their clothes, and to their rooms. They were both placed on 1:1 with staff. The residents reported their desire to have relations with each other. Both were able to recall the events that occurred and verbalized consent for a relationship. Social Services staff X reached out to the nurse consultant for guidance and advised to get a BIMS score for both residents. She was also advised to reach out to Consultant JJ who advised the facility not to contact the family due to privacy concerns and both the residents were their own person. Consultant JJ told staff X they had a right to a consensual sexual relationship. The BIMS score was provided to Consultant JJ who advised the facility to provide a safe place for the residents to engage in sexual activities if that was their wish. The facility determined there was no suspicion of abuse as the relationship was consensual by both parties. Both parties were able to express their wishes. Consultant JJ concurred with this finding. Review of the BIMS Interview for MDS 3.0, dated 10/04/2020, documented R19's BIMS score of seven (severely cognitively impaired) and R250's BIMS score of 11 (moderately cognitively impaired). Review of a ONE-ON-ONE Observation Book, dated 10/04/2020 through 10/05/2020 for R19 documented staff were to monitor the resident to keep him away from other female residents to avoid inappropriate touching/behaviors. Started on 10/04/2020 at 12:45 PM and ended at 01:45 PM on 10/05/2020, then discontinued. The facility failed to put any further interventions in place to monitor the resident's behaviors. Review of a General Note, dated 10/13/2020 (11 days after the incident), documented the staff received an order for [REDACTED]. Review of a Behavior Charting Note, dated 10/15/2020 at 08:30 PM, documented the resident was found on the floor in front of a female resident with his head in her lap. The female resident had begun to cry. A few minutes prior to that situation, another female resident told the resident to stop touching her. Review of a Behavior Charting Note, dated 10/15/2020 at 08:46 PM, documented upon further investigation, it was found that the female resident was not crying, but was trying to get the staff's attention. Review of facility investigation for Confused Resident, dated 10/16/2020, documented on 10/15/2020, R19 got out of his wheelchair and kneeled down in front of R45. He then hugged her waist and rubbed her legs thinking she was his wife. When staff separated them, R19 was confused and upset stating that is my wife. R45 was not injured and nodded she was ok. R19 did not touch R45 inappropriately. This was not reported to the state agency due to R19 had a poor BIMS. The residents were immediately separated. The staff placed R19 on 1:1 with staff. Review of the ONE-ON-ONE Book documented from 10/15/2020 at 08:45 PM through 10/21/2020 at 11:30 PM revealed incomplete monitoring documentation. There was missing documentation from 07:00 PM through 09:45 PM and 08:15 PM through 10:45 PM on 10/17/2020. On 10/18/2020 there was missing documentation from 12:00 AM through 05:45 AM. Review of a General Note, dated 10/16/2020 at 08:44 AM, documented an order to hold [MEDICATION NAME] for 2 days and give [MEDICATION NAME] (antipsychotic) twice daily for the next two days due to behaviors that required 1:1 staff supervision. Review of a General Note, dated 10/16/2020 at 10:21 AM, documented staff called a Senior Behavior Health Hospital to request placement of the resident due to increased sexual behaviors. The behavior hospital denied admission due to oxygen use. Review of a General Note, dated 10/19/2020, documented staff made calls to a medical center to see if they would accept R19 in the behavioral health unit for his inappropriate behaviors with other residents. Staff also spoke to his family about completing guardianship paperwork as the facility needed it as soon as possible. Until they had guardianship or documentation that showed R19 as a danger to self or others, they would not be able to place him. Review of a General Note, dated 10/21/2020 at 11:27 AM, documented R19 transferred to a hospital emergency room for respiratory distress. He left the facility with emergency medical services at 11:25 AM. Review of a General Note, dated 10/22/2020, documented the staff called the hospital's emergency room for update on the resident. All labs and tests came back normal, but due to behaviors, he was being sent to a behavioral health unit for admission. On 10/22/2020 at 03:14 PM, Administrative Nurse D revealed the 1:1s were done to keep the female residents safe. R19 was then kept 1:1 until he left to go to the hospital on [DATE]. Administrative Nurse D was unsure of why there were blank spots on the 1:1 sheets. She stated that staff should have been with R19 at all times. She did not consider R19 safe to make decisions. When sitting and talking with him, he became really confused. He was not on 1:1 monitoring after 01:45 PM on 10/05/2020 and was placed back on 1:1 monitoring on 10/15/2020 after the incident with R45 occurred. Administrative Nurse D spoke with R250 and R250 told her that R19 asked her out on a date. Administrative Nurse D was unsure if a BIMS score of 11 would affect R250's decisions about a sexual relationship. Administrative Nurse D also stated that R19 was specifically after R250. R250 went to the hospital soon after the incident and R19 had no other behaviors after the fact. He was monitored as before the incident and checked on frequently. The incident between R19 and R45 was inappropriate and she did not know if it had been reported to her family. The facility should have reported it to the state. On 10/27/2020 at 15:57 PM, Consultant JJ stated the facility reached out to her about consent and she sent them several resources about consent through the email. She did not instruct the facility on how to handle the situation, only sent resources for guidance. The facility sent her the BIMS scores, but she did not ask for them. This was a consultation to the facility. She did not open a complaint investigation and didn't get into much detail. Because she was not able to see or talk with the residents, those were not decisions that she could make. What she tried to do was to give the facility information and resources to help them decide if the residents were cognitively able to make decisions. She told the staff that the next step was to use the resources to determine consent. On 10/28/2020 at 12:36 PM, Certified Medication Aide (CMA) RR revealed when R19 had a room on the East side he liked to stay up all night and sit by the nurse's station in a chair. He would sit and talk with the staff. When he moved to the West side he started having behaviors. He was angrier. R250 lived on the other side and at night R19 would walk back and forth talking to people in the facility. Before R19 and R250 got together that morning, R19 was laying down in his room and R250 was on a rampage and saying delusional things. The nurse redirected her to calm her down. R19 got up and went to sit in a chair on the East side. Later, R19 and R250 were sitting together on a couch in the bird room. About halfway into the shift R19 and R250 were trying to go into other resident rooms on the West side. At the time she wasn't sure why, but she had to redirect them out of those rooms. After helping another resident, she checked on them again and found them in the bird room. R19 was on his knees with his pants down. R250 had her pants off, but was wearing her shirt. CMA SS went in with her and stopped what the residents were doing. R250 said it's up to you (R19). They got the residents dressed and R250 went back to her room. R19 went to sit by the fireplace on the other side of the facility. He was calm and quiet. We reported the incident to the charge nurse. The nurse sat with R19 until dayshift started. CMA RR finished rounds while the dayshift staff sat with him. We did 1:1 every day up until he was sent to the hospital recently. We were doing 1:1 even though it wasn't being documented. On 10/28/2020 at 02:20 PM, Certified Medication Aide (CMA) SS revealed she remembered at the beginning of the shift R250 came from her room, which was on the other side of the building away from R19's room and started talking to R19. CMA RR and CMA SS checked to make sure she was okay. CMA RR asked her to watch them because R19 thought R250 was his wife. The residents sat on the couch and talked in the East living room by the bird aviary. She went to help another resident and when she looked in on them afterwards, they had no pants on and R19 was on his knees in front of R250. The aides went in and separated the residents. They got them re-dressed and they were both put on 1:1 monitoring. Staff reported the incident to the charge nurse. R250 was upset that they had been interrupted. R250 said R19 was her husband and to leave them alone. They redirected her. R250 went to her room and they had no more issues from her. R250 experienced delusions later so the staff tried to redirect her with a snack, and sat and talked with her. The CMAs helped R19 to the restroom in his room. They kept a close eye on both of them. They both had confusion, but staff SS thought they were consenting to each other. They were acting and talking like they were husband and wife. We started 1:1 documentation that morning. R250 was later sent to the hospital for behaviors. They stopped the 1:1 documentation after R250 left the facility. They continued to keep a close eye on R19 to keep him away from the other residents. They received abuse education right after the incident. On 10/29/2020 at 01:10 PM, Social Services Staff X verified the information in the investigation and that she consulted with Consultant JJ for guidance. She stated that she did put R19 and R250 on 1:1 monitoring with staff and kept them separate until she talked to Consultant JJ for guidance. She stated the incident should have been reported to the State. R19 believed R250 to be his wife, had increased confusion, and scored a 7 on the BIMS assessment after it happened. R19 and R250 were not competent to make decisions regarding a sexual relationship with others. R19 was kept on 1:1 monitoring until R250 admitted to a behavioral health unit a couple of days later. She did not know how staff monitored him after that. She stated R250 had moments of lucidity and delusions. R250 told staff X R19 was her boyfriend. After the incident she was delusional and staff X spent some time doing 1:1 monitoring with her. R250 thought staff X was going to kill her. R250 experienced some escalating behaviors and was sent to the hospital. When she found out about the incident between R19 and R45, she discussed it with their regional team, researched what happened, and talked to the staff involved. She understood that R19 kneeled on the floor in front of R45, but did not touch her. She spoke with R45 afterwards and she was able to tell her she was ok. Witnesses stated she wasn't upset or afraid at the time of the incident. R45 was not afraid of R19. R19 was put on 1:1 monitoring with the staff directly after the incident and was in that status until he admitted to the hospital on [DATE]. On 11/01/2020 at 09:12 PM, Licensed Nurse (LN) L revealed R19 had poor cognition. Sometimes he would take all his clothes off and walk down the hallway in the facility. He refused care from staff and would seek attention from women. He wasn't physically aggressive or verbally abusive, but at times was sexually inappropriate with women and staff. One time he wheeled his chair up to R45 and got on his knees and hugged her around the waist. LN L tried to get him up while R19 kept stating this woman is my wife. LN L attempted to redirect him and remind him that R45 was not his wife. She was sitting in her wheelchair and just looking down at R19. She looked up at LN L and showed no signs of fear. She wasn't upset. She never screamed or cried when she saw him. R19 was put on 1:1 monitoring right after that, so staff were always with him and directed him away from the other residents. The 1:1 staff were assigned to stay with the resident at all times. LN L reported the incident between R45 and R19 to the DON and she took it from there. There was an internal investigation and he made a statement about the incident. There was no other contact with R250 after she returned from the hospital. LN L did know that they were both very angry that they were separated and R19 was angry for a couple of days after that. R19 was taken off 1:1 after R250 went to the hospital. LN L believed the residents knew what they were doing because both of them were very angry when the staff separated them. On 11/02/2020 at 04:10 PM, Administrative Nurse E revealed R19's cognition went up and down. He would get confused at times during conversations, but he was able to express his needs. His behaviors were appropriate most of the time. R19 and R250 struck up a friendship and they would visit together in the dining room. Other times they would seek each other out. They seemed to have a mutual interest in each other. As far as what occurred between them, obviously cognitively questionable, but she felt they were capable of expressing their wishes and desires. Several hours after the incident, R250 tried to look for him and R19 wanted to find her, actually until the next afternoon. R19 was able to recall the event. R250 made some delusional remarks before the incident happened. Administrative Nurse E had not ever seen R250 be physically aggressive or threaten anyone. She did not know R19 and R250 were trying to find a room to be alone in until after the fact. R19 recognized his wife when she visited and when they talked on the phone. He had put himself on the floor to fix things possibly hallucinating. A score of 7 on the BIMS assessment was definitely a cognition impairment. R250's cognition was also impaired. Administrative Nurse E stated that it wasn't a good decision on their part having sexual activity in a place where they would get caught. She thought it was questionable about their ability to consent. She did not determine whether it was appropriate to call the incident to the state. The social worker called the Ombudsman and the decision was made to not report the incident. Any suspicion of abuse should be reported. The residents were on 1:1 monitoring to protect the other residents while she investigated the incident. After all that happened, the contact between R250 and R19 stopped. Between the contact with R250 and contact with R45, Consultant HH ordered [MEDICATION NAME] after Administrative Nurse E talked with her about the sexual concerns R19 expressed and he showed some signs of depression. Administrative Nurse E found out about the event between R19 and R45 after it happened. She understood he put his head in R45's lap. She was not sure if he touched her inappropriately with his hands. She received conflicting reports from the staff. R19 called R45 his wife when the incident happened. The staff were right there, immediately intervened, and separated them. She talked with R45 and R45 denied feeling violated and was ok. She never acted afraid or screamed when she saw R19. On 11/03/2020 at 01:06 PM, Consultant HH stated the cognition varied throughout the day for both patients. She did not recall the location of the incident within the facility. R250 was sent to inpatient behavioral health hospital where she rounded routinely. When she saw her for a follow up at the hospital, R250 had no recollection of the event. Cognition varied for both parties, the BIMS scores provide a general assessment, the level of competence in decision making at the time could vary from the BIMS score. The facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, documented, Purpose: To prohibit and prevent abuse, neglect, exploitation . in accordance with Federal and State Laws .Sexual Abuse: Nonconsensual sexual contact of any type with a resident/patient . A resident to resident altercation will be reviewed as a potential situation of abuse .Ongoing assessment of residents with behaviors will be addressed with care planning and appropriate interventions .sexually aggressive behaviors such as saying sexual things, inappropriate touching/grabbing .wandering into other's rooms/space .The Administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of abuse. The facility failed to provide adequate supervision to ensure R250 and R45 remained free from sexual abuse when R19 engaged in inappropriate sexual behavior with R250 in a public area of the facility on 10/04/2020 and then inappropriately touched R45 on 10/15/2020. This failure placed R250 and R45 and the other 24 female residents in immediate jeopardy for sexual abuse from R19. The facility removed the immediate jeopardy on 10/27/2020 at 4:05 PM after completion of the following: 1. R19 sent to Behavioral Unit on 10/21/2020 at 11:25 am. 2. Male resident care planned on 10/27/2020 at 1:00 pm to remain on one on one if he returns from the hospital. 3. A focused QAPI meeting addressing the finding was held with Administrator, Director of Nursing, and Medical Director in attendance on 10/27/2020 at 1:00 pm. 4. Education of staff regarding reporting of incidents of Abuse, Neglect, and Exploitation to Administrative staff immediately was completed on 10/27/2020 at 4:05 pm. The deficient practice remained at a scope and severity of an E.

The facility reported a census of 50 residents with 21 residents sampled, including three residents reviewed for nutrition. Based on observation, record review, and interview, the facility failed to follow recommendations by the registered dietitian, to prevent significant weight loss for Resident (R)30, who experienced a significant weight loss of 21.5 pounds (lb), a 16 percent loss in 10 days from 09/12/20 to 10/01/20. Findings included: - The Physician order [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. He required supervision of one staff for eating. His weight was 134 lbs and he'd had a significant weight loss of 5% or more in the past month or a loss of 10% or more in the past 6 months and was not on a physician prescribed weight-loss program. He received 51% or more of his total calories through a feeding tube during the look back period. The Nutritional Status Care Area Assessment (CAA), dated 09/18/20, documented that due to the resident being on a PEG (Percutaneous endoscopic gastronomy--procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding) tube feeding, his weight could fluctuate. The Nutritional Care Plan, dated 09/24/20, instructed staff the resident had an unplanned/unexpected weight loss related to an acute illness, the wrong formula for his tube feeding, and a recent hospitalization . If his weight loss persisted, staff were to contact his physician and the dietician immediately. Review of the resident's electronic medical record EMR, revealed the following Physician Orders: Daily weight while NPO (nothing by mouth), in the morning. Report weight loss greater than 3 pounds to his physician, ordered 09/12/20 . This order was discontinued (DC'd), 10/20/20. Staff did not complete the daily weights for this resident, as ordered. Weight weekly on Wednesdays, report weight loss to the physician, ordered 10/20/20. Review of the resident's weights in the hospital records in the EMR, revealed the following including weights prior to from the resident's hospital stay before admission to the facility: 09/10/20=138 lb 09/11/20=134 lb Further review of the resident's EMS, revealed the following weights: 09/12/20 (admission weight)-134.1 lb 10/01/20-112.6 lb--loss of 21.5 pounds (lbs) and 16 % from 09/12/20, a period of 20 days Discharge Orders , dated 09/12/20, from the hospital included enteral feeding every (Q) shift, Glucerna (a nutritional formula), 1.2 cal at 40 milliliters (ml) per hour (1152 calories/24 hours), and free water 150 ml every four hours, ordered 09/12/20. This order was DC'd on 10/06/20. This number of calories was below the Registered Dieticians recommendation, dated 09/28/2020. A new Physician order [REDACTED]. Staff were to obtain daily weights. This order was DC'd on 10/08/20. A new Physician order [REDACTED]. Staff were to unhook and flush with 30 ml of water and clamp tubing for four hours each day for gut rest. Review of the Treatment Administration Record (TAR), for September, October, and November, revealed the feedings were given, as ordered. Review of the Registered Dietician's (RD) Nutritional Assessment, dated 09/28/20, (#16 days after admission) revealed the following information: The total caloric needs for the resident were 1828-2132 calories, 60-73 grams (gm) of protein and 2132 cc of fluid, per day. With the current enteral feeding orders the resident was receiving 1152 calories, 57.6 gms of protein and 773 cc's of free fluids + 900 cc's of water flush, per day. The RD recommended increasing the resident's enteral feeding to Glucerna 1.2 80 cc's per hour for 20 hours and to continue the 150 cc's free water every 4 hours. The resident's feeding was not increased until 10/06/20 - 8 days after the RD's assessment. The RD's evaluation summary documented the resident's enteral feeding and flushes were not adequate to meet the resident's nutritional needs. On 10/21/20 at 10:26 AM, the resident sat in the TV room. The enteral feeding ran at 100 cc's per hour. On 10/26/20 at 12:06 PM, the resident sat in the recliner with his enteral feeding running at 100 cc's per hour. On 10/29/20 at 10:53 AM, Certified Nurse Aide (CNA) O, took the resident in his wheelchair to the dining room to obtain his weight. Staff O weighed the resident in the wheelchair and got a weight of 167 lbs. Staff O then transferred the resident from his wheelchair to a dining chair and weighed the wheelchair and got a weight of 51.4 lbs. The resident's actual weight at that time was 115.6 lbs. On 10/29/20 at 10:53 AM, CNA O stated, the resident had recently lost weight. Staff O was unsure of how much weight the resident had lost and was unsure of how often staff were to weigh the resident. On 10/28/20 at 08:30 AM, Licensed Nurse G stated, staff weigh the resident weekly due to him having an enteral feeding. He had recently lost weight. Nurse G was unsure of how often staff weighed the resident. The Certified Dietary Manager (CDM) would tell them when a resident needed to be weighed. On 10/29/20 at 09:50 AM, Dietary Staff CC stated, she would review the weights frequently throughout the week and remind staff to obtain the monthly weights. One day a week in the morning meeting, the department heads reviewed the weights. They were aware the resident had a weight loss, but thought the weights were inaccurate. Staff CC stated she did not believe the admission weight was accurate. Residents who receive their nutrition through enteral feedings were to be weighed weekly. The resident had missing weights. When the RD makes recommendations on residents, they will be submitted to the doctor for an order. On 10/29/20 at 10:24 AM, Administrative Nurse E stated, the RD will send her recommendations to Dietary Staff CC and Administrative Nurse D upon completion. The recommendations will be reviewed and then sent to the doctor or the nurse practitioner for an order. Staff E stated she did not believe the resident's admission weight was accurate, but it was the weight staff entered. Staff E stated new admissions were to be weighed daily for three days and then weekly for four weeks. She was unsure as to why the 09/28/20 recommendation was not implemented until 10/07/20. On 11/02/20 at 11:23 AM, Dietary Consultant staff BB , stated the facility will send her a list of residents who need to be evaluated monthly. She did not receive the list from the facility until 09/15/20 and was unaware the resident had a tube feeding. She sent her recommendations on 09/28/20 to Administrative Nurse E, Dietary Staff CC and Administrative staff A. At that time, Administrative Nurse D was new to the facility and Dietary Consultant staff BB did not have her e-mail, but did ask for the recommendation to be given to Dietary Consultant staff BB. Staff BB stated she noticed the resisdent had a weight loss and made a recommendation to increase his enteral feeding. The feedings he was receiving at that time were not adequate to meet his nutritional needs and the resident had a weight loss. Staff BB confirmed staff had not acted upon the 09/28/20 recommendation timely. On 10/29/20 at 01:43 PM, Administrative Nurse D stated, the RD recommendations are sent to the nurse practitioner for approval before being made an order. Currently the facility did not have a timeline on how long it should take for the RD to make her recommendations on new admissions. New admissions should be weighed daily for three days and then weekly. The weights are documented in the resident's EMR. When Dietary Staff CC noticed a weight loss, she would notify the RD. Weights are not reviewed during morning meetings. Nurse D stated she was not aware of the facility's weight loss policy, at this time. A resident with enteral feedings should be weighed weekly. On 11/02/20 at 11:43 AM, Nurse D stated, she had been aware of a recommendation for the resident, but had not seen the recommendation. She believed the recommendation had been put into the system, so she did not ask what the recommendations had been. On 10/29/20 at 01:43 PM, Administrative staff A stated, the EMR would alert when a resident had a significant weight loss. These residents with weight loss would be reviewed in the morning meetings. On 11/02/20 at 07:06 PM and 11/03/20 at 06:42 PM, Consultant staff GG, stated in his opinion the resident's weights were inconsistent. He stated he did not feel the resident would lose that much weight without being [MEDICATION NAME] , which he wasn't. The normal protocol was for the resident to be identified as as losing weight, then the RD would make recommendations for the physician to approve. The facility policy for Weight Loss Interventions, effective 08/01/2012, included: Residents will be weighed weekly for four weeks to evaluate the effectiveness of interventions. Weight loss will be entered into the MDS/Care Plan as a problem. The facility failed to follow recommendations from the Registered Dietician for this dependent resident with an enteral feeding who experienced a significant weight loss of 16 percent loss in 10 days from 09/12/20 to 10/01/20., and a further 5 percent weight loss in two days from 10/16/20 to 10/18/20.

A complaint survey was conducted by the Kansas Department for Aging and Disability Services (KDADS), on behalf of the Centers for Medicare and Medicaid Services (CMS) on [DATE]. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. On [DATE] at 5:00 P.M., the facility administrator was provided a copy of the IJ template and informed of the I[NAME] The facility reported a census of 56 residents and identified 5 with hospice services. Of the 56 residents the facility also identified 40 residents with a full code status, leaving 16 residents with a Do Not Resuscitate (DNR) code status. Based on interview and record review the facility had 4 hospice residents with DNR codes and 1 Resident (R) 1 with a full code status. The staff failed to provide CPR (cardiopulmonary resuscitation) to R1 when he was found unresponsive and without vital signs present. Findings included: - The electronic medical record (EMR) for Resident (R) 1 revealed the facility readmitted the resident on [DATE] following a hospital stay. The readmission physician orders [REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified the resident with a Brief Interview for Mental Status score of ,[DATE], indicating cognition intact. The resident required extensive assistance with all activities of daily living except eating. The Care Area Assessment (CAA) dated [DATE] for Activities of Daily Living (ADLs) included the resident required one staff member for assistance with ADLs, except eating. The Care Plan, dated [DATE], included the resident's need for extensive assistance of one staff member for all ADLs, except eating. The care plan included, on [DATE] that the resident had a full code status. R1's Physician order [REDACTED]. The EMR lacked a change in code status. The Facility Investigation verified, on [DATE] at 04:30 AM, certified nurse aide (CNA) [NAME] entered R1's room to answer the roommate's call light. While in the room the CNA assisted the roommate. When finished the CNA pulled the privacy curtain open between the residents at approximately 4:40 AM and noted R1 was without pulse or respirations. After R1 failed to respond to a tap on the shoulder, CNA [NAME] called for Licensed Nurse (LN) C. Then LN C assessed the resident and provided sternal rub with no response. LN C notified hospice but failed to perform any Cardiopulmonary Resuscitation CPR to the resident when found without pulse or respirations. In a notarized statement, written on [DATE], LN C documented she assumed since the resident was in end [MEDICAL CONDITION] and on hospice, he had a DNR (do not resuscitate) order. At that time (approximately 5:00 AM) she made no attempt to verify the resident's code status, but later noted in the record the resident had a full code status. On [DATE] at 9:20 [NAME]M., Administrative Staff A reported the facility suspended licensed nurse C on [DATE], reported the incident to the State complaint report hot line, and investigated the lack of CPR provided to the resident with a full code. On [DATE] at 2:00 PM, Social Service Designee (SSD) D verified meeting with R1 and the resident's sister after the resident decided to sign onto hospice services for end of life care, on [DATE]. During the meeting, R1 appointed his sister as his Durable Power of Attorney (DPOA). The sister then realized [MEDICAL CONDITION] had spread and she became very upset and cried. The resident commented to SSD D that due to his sister's reaction he would not consider putting a DNR in place which would upset her more. On [DATE], interviews with four licensed nurses on duty, including LN F at 9:40 AM, LN G at 10:10 AM, LN H at 2:15 PM and LN I at 3:40 PM, all reported that the residents' code status were identified on their report sheets, as well as in the paper and electronic charts. On [DATE] at 2:20 PM, Administrative Licensed Staff B verified the facility always had at least one staff member with a current CPR certification on duty on each shift. On [DATE], interviews with seven CNA/CMA (Certified medication Aide) staff members including CNA J at 9:45 AM, CMA K at 10:20 AM, CNA L at 10:30 AM, CMA M at 10:40 AM, CNA N at 1:50 AM, CMA O at 2:00 PM and CNA P at 2:30 PM, all reported they carried the code status of each resident on their pocket care records. On [DATE] at 5:00 PM, Administrative Staff A and Administrative Licensed Staff B were informed that the facility was in immediate jeopardy, past non-compliance after they completed the following prior to surveyor entrance on [DATE] at 9:15 [NAME]M.: a). Special Quality Assurance and Performance Improvement meeting held on [DATE] at 2:30 P.M., with plans to correct the incident. b). All staff re-education related to CPR and the facility policy completed on [DATE] at 3:30 P.M. c). All resident charts reviewed for code status and orders verified to assure accuracy for the total census of 56 residents. d). Code drills completed on all shifts on [DATE] and [DATE] . e). The facility plan included to continue to provide CPR training for all employees. The facility policy effective and last reviewed in ,[DATE] included: CPR will be initiated when [MEDICAL CONDITION] occurs for residents who have requested CPR in their advanced directives, or who do not have valid DNR order signed by a physician. The facility staff failed to check code status and provide CPR to the resident who was a full code, when staff found the resident without pulse or respirations. This placed the resident in immediate jeopardy.

The facility reported a census of 56 residents, with 3 sampled for review of elopement. Based on observation, interview and record review, the facility failed to provide adequate supervision and/or assistive devices to prevent accidents to 1 (#01) of the 3 sampled residents, did not exit the facility without staff knowledge. The resident exited the facility main entrance door on 9/4/18 around 1:00 A.M., in a w/c (wheelchair) on the sidewalk into the residential surrounding area, got his/her w/c tuck in a sidewalk crack and fell out of the w/c. The facility staff noted the resident missing from the facility, at approximately 1:15 A.M The nursing staff notified 911 and the police called the facility approximately 20 minutes later when they found the resident, 4 blocks from the facility on the sidewalk. Facility nursing staff returned the resident to the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #01's electronic medical record revealed the resident admitted on [DATE], with [DIAGNOSES REDACTED]. The annual MDS (minimum data set) assessment, dated 6/22/18, documented the BIMS (brief interview for mental status) at 14, which indicated the resident with cognition intact. The resident did not walk and required extensive assistance with transfers. The resident was not a wanderer. The care plan, dated 7/15/18 failed to include any mention the resident being allowed time outside by himself/herself. It also lacked any mention of the resident's use of a wanderguard on the wheelchair to notify the staff of his/her exiting the building. Per administrative staff A, on 9/5/18 at 10:00 A.M., the resident was not identified as an elopement risk and staff allowed the resident to spend short periods of time outside on the front porch, with staff knowledge. Prior to this incident, the facility staff placed a wanderguard bracelet on his/her wheelchair to notify the staff he/she was exiting the building. Per interview, on 9/6/18 at 10:00 AM, administrative staff A and administrative nursing staff B, explained the incident, on 9/4/18. Licensed nursing staff C assisted the resident outside to the front porch on 9/4/18 after midnight, staff did not identify the wonderguard alarm at the door, did not sound. The resident let themselves back into the facility around 12:45 A.M. Then the resident went to the dining room to get something to drink before going to his/her room. Licensed nursing staff C, during routine bed check at 1:20 A.M., failed to see the resident in his/her room. Staff checked the front porch and noted the resident's water glass on the patio table. Staff initiated a full search of the center and property surroundings. With the staff unable to find the resident, the staff notified the police department with a 911 call at approximately 1:35 A.M. Per documentation in the resident's medical record, the police notified the facility at 1:45 A.M., (approximately 1 hour since the resident was last seen in the facility) they located the resident about 4 blocks from the facility laying on the sidewalk. Two staff members returned the resident to the facility. Licensed nursing staff C completed a physical assessment of the resident and found only a small abrasion to his/her left knee. The resident fell from the wheelchair onto the sidewalk when the wheels got caught in a sidewalk crack. Administrative staff A, on 9/5/18 at 10:00 A.M., reported the wanderguard bracelet on the resident's wheelchair functioned properly, when brought back into the facility and tested with a tester. However, it did not function when brought back in through the door. The staff checked the front and back doors with a wandreguard bracelet and found the alarms to be temporarily disabled due to an electrical disturbance. (A storm went through the area earlier.) The facility placed a staff member at each of the doors until the door alarm vendor verified the doors' functioning appropriately on 9/5/18. The vendor determined the night storm, previous to the resident's leaving the facility, disabled the wanderguard function, on the facility front and back doors. The doors then later reset themselves. The facility's obtained notarized statement, from licensed nursing staff C, (who was unable to be reached for interview), which explained on the night of the resident's elopement, on 9/4/18 around midnight, the staff assisted the resident out the front door to the front patio/porch. At that time the front door wanderguard alarm failed to sound. (The staff were aware of the door alarm failure.) Later, the resident exited the front door by his/herself and left the property in his/her wheelchair, without staff knowledge. The resident was found by the city police, approximately 1 hour, after last seen in the facility, (1:45 A.M.) four blocks from the facility and laying on the sidewalk. The resident sustained [REDACTED]. On 9/5/18 at 11:10 A.M., the exit doors checked with administrative staff A, revealed the door alarms to be in appropriate working condition. The facility had three wanderguard alarmed doors, the front, the back and one exit from inside the kitchen. The facility's other 4 exit doors without wanderguard alarms, also functioned properly. Observations, on 9/5/18 at 11:40 A.M., revealed the resident self-propelling his/her wheelchair, in the hallway without need of assistance. At 1:20 P.M., the resident reported he/she left the facility that night to go to a store that was open all night (not realistic as it is several miles away). He/she said there was enough light to wheel the chair on the sidewalk until it got caught in a crack. He/she commented he/she was not hurt, only a little scrap to the knee. The resident under stood he/she was to let the staff know when he/she wanted to go outside. The facility policy and procedure for Elopement, dated 4/2017, included the following key elements: An elopement risk is evaluated upon admission and when a new elopement risk is identified. When an elopement risk is identified an individualized care plan intervention is established and implemented. There is a system with a central repository kept current identifying all those as elopement risk including photographs. When an elopement occurs searching and notification is completed timely. The facility failed to provide adequate supervision and/or assistive devices to prevent accidents. The resident left the facility without staff knowledge, was missing for at least an hour, and was found turned over in his/her wheelchair on a city sidewalk four blocks from the facility. This deficient practice placed the resident in immediate jeopardy. This deficient practice was cited as past-noncompliance as of 9/4/18 at 11:00 PM, when the facility completed the following: 1.) The facility provided a full body assessment, provided treatment to the resident's left knee, and notified the physician and family members. 2.) The facility placed staff at the exit doors until the door alarms were properly functioning. The facility notified the code alert company for immediate check of the system. Doors are now routinely checked on each shift. 3.) The facility staff completed updates of care plans and the elopement book, for all of the residents at risk for wandering. The facility staff checked for functionality and positioning of all residents with code alert bracelets (Wanderguard). The facility staff completed reassessments on all residents for potential risk of elopement. 4.) The facility staff immediately initiated an in-service with all staff regarding the facility elopement procedures. In-service and drills were done, on 9/4/18 for 48 staff members. 13 staff members, who were unable to attend in-service on 9/4/18, were notified they would not be able to clock into work until completion of training. 5.) The facility held a risk management/QA (quality assurance) meeting with staff members, on 9/4/18 at 1:00 P.M. The facility staff contacted the medical director and corporate representatives by phone. The staff reviewed the elopement and procedures put in place, as well as the corrections and staff education.

The facility reported a census of 56 residents with a sample of 3 residents selected. Based on observation, interview, and record review, 2 of 3 residents (#2 and 3) reviewed for abuse, were found to be subjected to sexual abuse by another resident. The facility failed to provide adequate supervision to a mobile resident (#1) who was found sexually abusing resident #2 (a cognitively impaired resident), then left unsupervised and was found sexually abusing resident #3 (a cognitively impaired resident), which placed all residents in the facility in immediate jeopardy. Findings included: - Signed physician orders, dated 6/1/16, for resident #1, documented the facility readmitted the resident on 5/24/16, with [DIAGNOSES REDACTED]. Feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The undated face sheet indicated the facility admitted the resident 2/22/13, and most recently readmitted the resident on 5/24/16. The annual MDS (minimum data set), dated 12/8/15, revealed the resident had long and short term memory impairment with moderately impaired decision making skills. The assessment lacked identification of sexually inappropriate behaviors, and indicated the resident needed extensive assistance of staff for locomotion. The quarterly MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 3/15, indicating severely impaired cognition, and lacked indicators of sexual behaviors. Additionally, the assessment indicated the resident required extensive assistance for locomotion. The CAA (care area assessment), dated 12/8/15, included for cognition the resident had a [DIAGNOSES REDACTED]. The care plan, last reviewed on 4/9/16, per administrative nursing staff B on 6/8/16 at 4:40 PM, indicated the resident had behaviors, including sexually inappropriate behaviors, such as reaching out and grabbing or touching a female staff. Interventions included: 1. Please remind me to stop and keep my hands to myself. 2. Received medications for sexually inappropriate behavior. 3. Added on 5/16/16 to send the resident to a behavioral health unit for evaluation and treatment. 4. Monitor for increased sexual behaviors, due to a recent increase in inappropriate behaviors especially those sexual in nature. Please monitor me frequently and ensure I am not near vulnerable residents, unsupervised. This was added on 5/16/16. 5. Increase the resident ' s participation in supervised activity and encourage the resident to attend. 6. Monitor behaviors with the use of [MEDICATION NAME] to assist with managing my inappropriate behaviors. Monitor the effectiveness of the medication. Review of the nursing documentation/notes, lacked information regarding the resident ' s sexual actions on 5/14/16. Review of the resident ' s signed physician orders, dated 6/1/16 included: [MEDICATION NAME], 10 mg (milligrams), once daily, for inappropriate sexual behaviors, started 1/29/15 On 5/14/16 at approximately 6:45 PM, per interview with direct care staff D, on 6/1/16 at 12:35 PM, this resident was seated at a table in the East hall lobby area, along with 2 other residents (one of opposite gender). Per direct care staff D ' s interview, each sat at one side of the square table, each in his/her wheelchair, following the supper meal. During one observation, direct care staff D reported he/she observed resident #1, moved him/her self in the chair closer to resident #2 (of the opposite gender) and was holding resident #2 ' s hand. The staff did not intervene at that time, because resident #1 never displayed inappropriate sexual abuse towards residents, so they were not concerned, believing resident #1 was just comforting resident #2. Upon the next observation, approximately 10-15 minutes later, the staff noted the resident had his/her hand inside the resident ' s undergarment, having loosened the adult brief. Direct care staff D then removed resident #2 promptly, instructing resident #1, of being inappropriate. Staff D took resident #2 to the nursing desk, where licensed nursing staff G was sitting. Staff D informed staff G of the occurrence, then removed resident #2 to his/her room to assist the resident into bed. Upon return to the living area, staff D observed resident #1 moved his/her wheelchair nearer resident #3 (of the same gender), seated at the table and had his/her hands in resident #3 ' s lap. Upon closer inspection staff D noted resident #1 had his/her hand rubbing resident #3 ' s private area, through the resident ' s clothing. Staff D then removed resident #1 from the lobby area and moved the resident into the bird room, which was vacant of any other residents. Staff D then returned and took resident #3 to his/her room to assist into bed, leaving resident #1 in the bird room, unsupervised. Staff E assisted resident #3 to bed, again notifying licensed nurse G of the incident between resident #1 and #3. Based on further interview and record review, licensed nursing staff G verified he/she failed to intervene following the second incident, thereby placing all other residents of the facility at risk of sexual abuse, by resident #1. On 6/1/16 at 11:45 AM, resident #1 sat in the dining room awaiting lunch. Multiple staff members approached the resident and offered various fluids/foods. There were two table mates seated at the table with the resident. Resident #1 had no interaction with the table mates. At that same time, resident #2 sat at a dining table, with his/her adult child present. The resident looked at, making eye contact with the adult child, however, did not speak. Resident #3 sat in the dining room at a table across from another resident. The resident did not speak during the meal, however, was able to feed him/her self, without difficulty. All three residents sat in wheelchairs throughout the meal. On 6/1/16 at 2:10 PM, the staff assisted the resident with lying down on the bed. The resident was cooperative and made no sexual advances made to the staff member. Intermittent observations identified the resident rested in bed until 4:00 PM. On 6/1/16 at 11:00 AM, administrative staff A reported the facility investigated the incident, which occurred on 5/14/16 but was not reported to the administrator or the director of nursing until 5/16/16, revealed the staff monitored the resident approximately every 15 minutes, but not one on one supervision, during the 5/14/16 to 5/16/16 time period, until the resident was sent out to the hospital behavioral health unit. The administrator felt the staff adequately protected the residents of the facility, however, confirmed a second incident closely followed the first contact, even though the staff provided frequent monitoring of the resident. On 6/1/16 at 12:35 PM, direct care staff D reported he/she was present the evening resident #1 became sexual with the 2 residents, seated at the table. Staff D reported it was common for resident #1 to be overly friendly with the female staff, but he/she was not known to be sexual in nature to other residents. The staff member further reported all 3 residents were confused with resident #2 and #3 mostly non-verbal. On 6/1/16 at 2:15 PM, direct care staff E reported usually the resident did not move about a lot on his/her own, but was able to do so when he/she wanted to. The staff reported they were on duty the evening of the incident where the resident touched other residents inappropriately. After the incident occurred, the staff reported they monitored resident #1 frequently, but not continuously, and assisted the resident to bed. On 6/1/16 at 2:20 PM, direct care staff F, reported they were aware, at the time of the incident, that the resident often touched staff inappropriately, however, was not aware the resident ever touched other residents inappropriately. The staff further reported they were not aware of the incident until after the fact, as the nurse prior to the shift did not give that information in shift to shift report. On 6/1/16 at 2:35 PM, licensed nursing staff G reported they were on duty the evening of the incident with the residents, and the direct care staff notified him/her of the events, however, the nurse reported he/she were not sure if they passed the information onto the oncoming shift. Staff G further reported the shift was very hectic, and he/she forgot to document on the sexual abuse concerns. Staff G further reported he/she believed that monitoring the resident was appropriate for the resident who touched the residents inappropriately. Staff G further reported he/she assessed the residents and did not find any marks of any kind on the residents after the incident. The staff verified he/she failed to notify the DON (director of nursing) or the Administrator of the incident. On 6/2/16 at 2:42 PM, administrative staff A verified the facility failed to protect the residents of the facility when the resident sexually abused a second resident on the evening of 5/14/16, following an observed initial incident of inappropriate sexual contact with another resident. The facility policy, dated 3/1/14, titled Abuse Policy, included under Protection, if the circumstances required it, the administrator/DNS (director of nursing services) or designee shall remove a resident suspected of being the subject of an alleged violation to an environment where the resident ' s safety can be protected. If the suspected perpetrator is another resident, the DNS or administrator or designee shall separate the residents so they do not have access to each other and the suspected perpetrator does not have access to any other residents until the circumstances of the alleged incident can be determined. The facility failed to protect the residents of the facility, or provide adequate supervision for resident #1, who displayed behaviors of inappropriate touching in a sexual manner to residents # 2 and 3, and failed to protect the remaining residents of the facility, therefore placing all of the residents in immediate jeopardy. The facility abated the immediate jeopardy on 5/17/16 at 4:15 PM, after completion of training of all staff regarding the protection of residents after inappropriate touching in a sexual manner by a resident and implemented one to one supervision of resident #1 on 5/17/16. The training also included the importance of following the abuse policy, regarding reporting and protection of residents. The facility furthermore sought in-patient behavioral health services for resident #1. This deficiency is cited as past non-compliance.

The facility reported a census of 56 residents with a sample of 3 residents selected. Based on observation, interview, and record review, 2 of 3 residents (#2 and 3) reviewed for abuse, were found to be subjected to sexual abuse by another resident. The facility failed to provide adequate supervision to a mobile resident (#1) who was found sexually abusing resident #2 (a cognitive impaired dependent resident), then left unsupervised and was found sexually abusing resident #3 (cognitive impaired dependent resident), which placed all the residents in immediate jeopardy. The facility also failed to thoroughly investigate the incidents of sexual abuse in a timely manner. The licensed nursing staff failed to report the sexual abuse incidents to the administrator and/or the director of nursing, or designee from 5/14/16 at approximately 7 PM to 5/16/16 at approximately noon, a total of approximately 41 hours. Findings included: - Signed physician orders, dated 6/1/16, for resident #1, documented the facility admitted the resident on 5/24/16, with [DIAGNOSES REDACTED]. Feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The undated face sheet indicated the facility admitted the resident on 2/22/13, and most recently readmitted the resident on 5/24/16. The annual MDS (minimum data set), dated 12/8/15, revealed the resident with long and short term memory impairment with moderately impaired decision making skills. The assessment lacked identification of sexually inappropriate behaviors, and indicated the resident needed extensive assistance of staff for locomotion. The quarterly MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 3/15, which indicated severely impaired cognition, and lacked indicators of sexual behaviors. Additionally, the assessment indicated the resident required extensive assistance for locomotion. The CAA (care area assessment), dated 12/8/15, included for cognition the resident had a [DIAGNOSES REDACTED]. The care plan, last reviewed on 4/9/16, per administrative nursing staff B on 6/8/16 at 4:40 PM, indicated the resident had behaviors, including sexually inappropriate behaviors, such as reaching out and grabbing or touching a female staff. Interventions included to: 1. Please remind me to stop and keep my hands to myself. 2. Received medications for sexually inappropriate behavior. 3. Added on 5/16/16 to send the resident to a behavioral health unit for evaluation and treatment. 4. Monitor for increased sexual behaviors, due to a recent increase in inappropriate behaviors especially those sexual in nature. Please monitor me frequently and ensure I am not near vulnerable residents, unsupervised. This was added on 5/16/16. 5. Increase the resident ' s participation in supervised activity, encouraging the resident to attend. 6. Monitor behaviors with the use of [MEDICATION NAME] to assist with managing my inappropriate behaviors. Monitor the effectiveness of the medication. Review of the resident's behavioral unit stay, from 5/16/16 to 5/24/16, discharge summary, identified the resident initially had some sexually inappropriate behaviors, with the staff, during personal cares. The resident ' s medications were adjusted and the physician noted the resident mostly stopped having inappropriate sexual behaviors, during the stay. Review of the nursing documentation/notes, lacked information regarding the resident ' s sexual actions on 5/14/16. Review of the resident ' s signed physician orders, dated 6/1/16 included: [MEDICATION NAME], 10 mg (milligrams), once daily, for inappropriate sexual behaviors, started 1/29/15 [MEDICATION NAME], 20 mg, daily for major [MEDICAL CONDITION], started during the resident ' s geri-psych of 5/16/16 to 5/24/16 hospitalization and continued in the facility. Per the investigation conducted on 6/1/16, including witness statements and interviews, on 5/14/16 at approximately 6:45 PM, this resident sat at a table in the East hall lobby area, along with 2 other residents (one of opposite gender). Per direct care staff D ' s interview on 6/1/16 at 12:35 PM, the staff placed each resident at one side of the square table, each in his/her wheelchair, following the supper meal. During one observation, direct care staff D reported they observed resident #1, whom had moved him/her self in the chair closer to resident #2 (of the opposite gender) and was holding resident #2 ' s hand. The staff did not intervene at that time, because resident #1 had never displayed inappropriate sexual abuse towards residents, so they were not concerned, believing resident #1 was just comforting resident #2. Upon the next observation, approximately 10-15 minutes later, the staff noted the resident had his/her hand inside the resident ' s undergarment, having loosened the adult brief. Direct care staff D then removed resident #2 promptly, instructing resident #1, of being inappropriate. Staff D took resident #2 to the nursing desk, where licensed nursing staff G was sitting. Staff D informed staff G of the occurrence, then removed resident #2 to his/her room to assist the resident into bed. Upon return to the living area, staff D observed resident #1 had moved his/her wheelchair nearer resident #3 (of the same gender), seated at the table and had his/her hands in resident #3 ' s lap. Upon closer inspection staff D noted resident #1 had his/her hand rubbing resident #3 ' s private area, through the resident ' s clothing. Staff D then removed resident #1 from the lobby area and moved the resident into the bird room, which was vacant of any other residents. Staff D then returned and took resident #3 to his/her room to assist into bed, leaving resident #1 in the bird room, unsupervised. Staff E assisted resident #3 to bed, again notifying licensed nurse G of the incident between resident #1 and #3. Based on further interview and record review, licensed nursing staff G verified he/she failed to intervene following the second incident, thereby placing all other residents of the facility at risk of sexual abuse, by resident #1. On 6/1/16 at 11:45 AM, resident #1 sat in the dining room awaiting lunch. Multiple staff members approached the resident and offered various fluids/foods. There were two table mates seated at the table with the resident. Resident #1 had no interaction with the table mates. On 6/1/16 at 2:10 PM, the staff assisted the resident to lie down on the bed. The resident was cooperative and made no sexual advances to the staff member. Intermittent observations identified the resident rested in bed until 4:00 PM. On 6/1/16 at 11:00 AM, administrative staff A reported the facility investigated the incident, which occurred on 5/14/16 but was not reported to the administrator or the director of nursing until 5/16/16. The facility investigation revealed the staff monitored the resident approximately every 15 minutes, but not one on one supervision, during the 5/14/16 to 5/16/16 time period, until the resident was sent out to the hospital behavioral health unit. The administrator stated the staff protected the residents of the facility, however, confirmed a second incident closely followed the first contact, even though the staff provided frequent monitoring of the resident. On 6/1/16 at 12:45 PM, direct care staff D reported he/she was present on the evening resident #1 became sexual with the 2 residents, seated at the table. Staff D reported it was common for resident #1 to be overly friendly with the female staff, but he/she was not known to be sexual in nature to other residents. On 6/1/16 at 2:15 PM, direct care staff E reported usually the resident did not move about a lot on his/her own, but was able to do so when he/she wanted to. The staff reported they were on duty the evening of the incident where the resident touched other residents inappropriately. After the incident occurred, the staff reported they monitored resident #1 frequently, but not continuously, and staff did assist the resident to bed. On 6/1/16 at 2:20 PM, direct care staff F, reported they were aware, at the time of the incident, that the resident often touched staff inappropriately, however, was not aware the resident ever touched other residents inappropriately. The staff further reported they were not aware of the incident until after the fact, as the nurse prior to the shift did not give that information in shift to shift report. On 6/1/16 at 2:35 PM, licensed nursing staff G reported he/she was on duty the evening of the incident with the residents, and direct care staff notified the nurse of the events. However, staff G reported he/she was not sure if he/she passed the information onto the oncoming shift. Staff reported the shift was very hectic, and he/she forgot to document on the sexual abuse concerns. Staff G further reported he/she believed that monitoring the resident was appropriate for the resident who touched the residents inappropriately. Staff G further reported he/she assessed the residents and did not find any marks of any kind on the residents after the incidents. The staff verified they failed to notify the DON (director of nursing) or the Administrator of the incident. On 6/2/16 at 2:42 PM, administrative staff A verified the facility failed to protect the residents of the facility when the resident sexually abused a second resident on the evening of 5/14/16, following an observed initial incident of inappropriate sexual contact with another resident. The facility policy, dated 3/1/14, titled Abuse Policy, included under Protection, if the circumstances required it, the administrator/DNS (director of nursing services) or designee shall remove a resident suspected of being the subject of an alleged violation to an environment where the resident ' s safety can be protected. If the suspected perpetrator is another resident, the DNS or administrator or designee shall separate the residents so they do not have access to each other and the suspected perpetrator does not have access to any other residents until the circumstances of the alleged incident can be determined. The facility failed to protect the residents of the facility, or provide adequate supervision for resident #1, who displayed behaviors of inappropriate touching in a sexual manner to residents # 2 and 3, and failed to protect the remaining residents of the facility from unwelcomed sexual advances, which placed all of the residents of the facility in immediate jeopardy. The facility abated the immediate jeopardy on 5/17/16 at 4:15 PM, when: 1) The facility implemented one to one supervision for resident #1 on 5/17/16. 2) Completed training of all staff regarding the protection of residents after inappropriate touching in a sexual manner by a resident, on 5/17/16. The training also included the importance of following the abuse policy, regarding reporting and protection of residents. 3) The facility sought in-patient behavioral health services for resident #1. This deficiency is cited as past non-compliance.

The facility had a census of 59 residents, with 3 residents reviewed for accidents. Based on observation, interviews, and record reviews, the facility failed to ensure 2 of these sampled residents (#1 & #2) received adequate supervision and assistive devices to prevent accidents. Resident #2 sustained a fractured hip from a fall. Resident #1 left the facility, unattended by staff, on 3 different occasions on the same evening. Findings included: - Review of resident #2's closed clinical record revealed staff admitted the resident to the facility on on [DATE], with [DIAGNOSES REDACTED]. Staff recorded on the resident's admission [DATE] MDS (Minimum Data Set) the resident had a fall in the past month prior to admission. Staff recorded on the resident's [DATE] CAAS (Care Area Assessment Summary) for cognitive loss/dementia, the resident alert to self, unable to state month, year or the president. Staff recorded the resident did not initiate conversation and had altered thought processes. Under the triggered area of falls, staff recorded the resident fell prior to admission to the facility and had not experienced any falls since admission to the facility. Staff recorded in the [DATE] nursing notes, at 4:55 PM, staff found the resident on the floor, on the resident's right side. Upon assessment, staff identified a hematoma on the resident side of the resident's head, a reddened area to the right shoulder with no swelling noted, and a small skin tear on the resident's right hand. Staff recorded in the [DATE] nursing notes at 2 PM, another resident notified staff the resident had fallen in their room. Upon assessment, staff found the resident lying on the resident's right side and a small abrasion to the resident's right knuckle. On [DATE], staff identified the resident with a score of 9 points (,[DATE] points indicates moderate risk - implement moderate risk interventions) on the resident's fall risk assessment form. On [DATE], staff identified the resident with a score of 9 points (,[DATE] points indicates moderate risk - implement moderate risk interventions) on the resident's fall risk assessment form. Staff recorded in the [DATE] nursing notes at 7:30 AM, the resident had remained on the toilet since 6:45 AM and denied being done. Staff recorded resident as a high fall risk. Staff recorded in the [DATE] nursing notes at 9:30 AM, the resident not oriented to place, person and time and able to ambulate to the bathroom with assistance of 2 staff using gait belts. Staff recorded on the resident's quarterly [DATE] MDS the resident with a BIMS (Brief Interview for Mental Status) score of 3 (a score of ,[DATE] indicated severe cognitive impairment), no indicators of delirium, the resident's mood interview revealed the resident with little interest ,[DATE] days, trouble falling asleep, feeling tired 2- 6 days, no wandering behaviors, bed mobility and transfers required extensive assistance of 2 staff, walking in the room required extensive assistance of 1 staff, walking in the corridor did not occur, locomotion on and off the unit required extensive assistance of 1 staff, toilet use required extensive assistance of 2 staff, balance during transitions and walking which included moving from a seated to a standing position, moving on and off the toilet, surface-to-surface transfer not steady, only able to stabilize with human assistance, used a wheelchair, and with one fall coded since admission or a prior assessment. On [DATE], staff identified the resident with a score of 7 points (,[DATE] points indicates moderate risk - implement moderate risk interventions) on the fall risk assessment form. The resident's [DATE] care plan recorded the following: Mobility and safety - Required assistance of 1 for transfers; had a personal alarm to alert staff if the attempted to stand unattended. Staff to keep on non-skid socks on the resident's feet, no shoes, to reduce the risk of falling. Staff to sure the call light in reach when the resident sat in the recliner. Staff to encourage the resident to use the call light. Reposition the resident when the resident sat in the recliner or lying in the bed to avoid the resident from attempting to stand and fall. The care plan had an intervention, dated [DATE], to change the heel protectors to the podus boots, special boots which had a hard, plastic surface on the bottom of the boots, to the resident's feet at all times. Staff recorded in the [DATE] nursing notes at 7 AM, staff notified a nurse staff found the resident sitting on the floor after being left alone to use the toilet. Upon assessment, staff identified a skin tear to the resident's right fore arm which measured 7 cm (centimeters) by 2.0 cm, a skin tear to the right elbow which measured 3 cm by 2 cm. Staff recorded the resident complained of right hip pain. Staff initiated neurological checks, and notified the physician. At 9:30 AM, staff obtained an order for [REDACTED]. Staff cleansed and treated the resident's skin tears and administered the resident pain medication. At 3 PM, staff obtained the x-ray results which revealed a fracture of the resident's right hip. Staff notified the resident's physician and transferred the resident to a local hospital by ambulance at 3:30 PM. On [DATE], staff identified the resident with a score of 11 points (11+ points indicates high or very high risk - implement high-risk interventions) on the resident's fall assessment form. On [DATE] at 10:30 AM, licensed administrative staff B stated, "(The resident) had a fall. At first (the resident) didn't complain of pain. (The resident) went to breakfast and then complained of pain. (The resident's) doctor was called...The medical director's nurse practitioner was here. The resident's doctor wanted (the resident) to come to (the doctor's)office for an x-ray, but the nurse practitioner ordered a portable x-ray done. After we received the x-rays results, we sent (the resident) to the hospital...(The resident) had an alarm in bed. Not sure about an alarm in the chair. (Direct care staff D) put (the resident) on the toilet, went to weigh the wheelchair, came back, and (the resident) was on the floor. (The resident) tried to get up by self." On [DATE] at 1:35 PM, direct care staff D stated, "(The resident) wore an alarm. (The alarm) was on all the time. (The resident) did have a fall. (The resident) was in the shared residents' bathroom. When (the resident) got up, (the resident) took a couple of steps and fell between the bathroom doorway and the hall doorway. I put (the resident) on the toilet around 6:15 AM. I had recently come over to this side to work. I was not that familiar with (the resident). I told (the resident) to stay put. I would be right back. I went to weigh (the resident's) wheelchair, came back in about 2 minutes, and found (the resident) on the floor. I weighed the wheelchair in the wheelchair room on the opposite side of the building. (The resident) said, 'Oh, my gosh.' (The resident) did not say (the resident) was in pain. I lifted (the resident) into the wheelchair instead of telling the nurse. Then I told the nurse. The nurse came and assessed him. As the morning progressed, (the resident) had more pain in the right hip. (The resident) was sent out." On [DATE] at 2:29 PM, licensed staff C reported, "...(The resident) was difficult to keep down. We had an alarm on (the resident) all the time. Staff were supposed to stay with (the resident) while (the resident) was on the toilet. Not sure if that was care planned." On [DATE] at 4:35 PM, licensed staff E stated, "(The resident) was an assist of 1 staff with transfers on and off the toilet. I was told by (direct care staff D) that (direct care staff D) had put (the resident) on the toilet and left to go weigh the wheelchair. Wheelchairs are weighed on the east side of the building. It takes about 3 to 5 minutes to walk that distance. When (direct care staff D) came back into the room, the resident was on the floor and (direct care staff D) put the resident back in the wheelchair. (Direct care staff D) told me on the way into the dining room about the fall...Another aide took (the resident) out of the dining room, put (the resident) to bed, and told me (the resident) was complaining of right hip pain. I went and assessed (the resident) in bed. There was no swelling or bruising and no hurting with range of motion to the hip..." This licensed staff reported the resident received a portable x-ray of the right hip around noon. This licensed staff added, "Between 1 PM or 2 PM, x-ray called back with results of a fracture of the right hip. The doctor said to send (the resident) to (local hospital). Around 2 or 2:30 PM, (I) called EMS (emergency medical services) and (the resident) went to the hospital. The care plan was not specific about an alarm on the toilet..." On [DATE] at 4:55 PM, direct care staff F stated, "...(The resident) was a 1 person transfer with a gait belt. (The resident) had a sensor pad in (the resident's) wheelchair. (The resident) had an alarm attached to the bathroom wall. You could not leave (the resident) safely alone on the the toilet. (The resident) was a fall risk..." On [DATE] at 11:20 AM, direct care staff D verified the resident wore the podus boots on the resident's feet while the resident sat on the toilet. Also, this direct care staff verified the resident lacked an alarm in place while on the toilet. On [DATE] at 11:22 AM, licensed staff E verified the resident wore the podus boots on the resident's feet while the resident sat on the toilet. This licensed staff stated, "Staff needed to put an alarm on the resident when (the resident) sat a long time on the toilet. Otherwise, staff needed to stay with (the resident). I did not hear any alarm going off. I did not know anything about his fall until (direct care staff D) told me (the resident) had fallen...". On [DATE] at 12:42 PM, direct care staff G stated, "...(The resident) was a fall risk. (The resident) had a body alarm in the chair, on at all times, and an alarm under the bed sheet. When (the resident) was on the toilet, we put an alarm on (the resident). There was velcro attached to the wall in the bathroom where we could attach the alarm box..." On [DATE] at 1:55 PM, licensed administrative staff B verified staff needed to place an alarm on the resident when staff left the resident unattended on the toilet for a long time. This staff member added, "The resident didn't normally try to get up and walk when (the resident) was on the toilet." On [DATE] at 1:30 PM, administrative staff A reported the facility followed resident centered care and implemented interventions depending upon the resident's fall assessments. This administrative staff reported the facility lacked any policy and/or procedures which addressed generalized interventions for residents identified as a fall risk. The facility failed to provide adequate supervision and assistive devices to prevent accidents. Facility staff left this resident, identified with mental confusion, unattended on the toilet. The resident stood up from the toilet and walked into the resident's room, wearing podus boots which had a hard, plastic surface on the bottom of the boots. The resident sustained [REDACTED]. - Staff admitted resident #1 to the facility on [DATE], with [DIAGNOSES REDACTED]. which is often nonspecific or unknown to the individual), and urinary incontinence (the inability to control urination). Staff recorded on the resident's [DATE] MDS (Minimum Data Set) the resident with a BIMS (Brief Interview for Mental Status) score of 3 (a score of ,[DATE] indicated severe cognitive impairment), the resident mood interview revealed the resident felt tired ,[DATE] days, wandering behavior not exhibited, supervision and set up help with bed mobility, transfers, independent with walking in the room and corridor independent and locomotion on and off the unit independent, and no mobility devices coded. Staff recorded on the resident [DATE] elopement risk assessment form, the resident identified at risk for elopement. Narrative on back of the assessment, dated [DATE], recorded a wanderguard placed to right ankle at this time. The resident's [DATE] care plan had an intervention, dated [DATE], for staff to provide one on one staff ration if the resident attempted to leave the facility unattended until the staff notify the on call RN (Registered Nurse). On [DATE], staff added a new intervention to monitor for increased agitation, and the resident g wanting to go home following family visits or telephone calls. The resident's (child) to let staff know when (the child) left the building. Staff recorded on the resident's [DATE] MDS (Minimum Data Set) the resident with a BIMS (Brief Interview for Mental Status) score of 3 (a score of ,[DATE] indicated severe cognitive impairment), bed mobility and transfers required extensive assistance of 1 staff, walking independently in the room and corridor, independent with locomotion on and off the unit, no mobility devices used, and with behaviors of wandering occurred ,[DATE] days. Staff recorded in the [DATE] CAAS (Care Area Assessment Summary) for cognitive loss/dementia the resident oriented to self and some days the resident oriented to place. The resident had impaired memory and frequently desired to go home. The resident frequently asked the location of the resident's room daily. For behavioral symptoms, staff recorded the resident had a history of [REDACTED]. For falls, staff recorded the resident had a fall when the resident left the facility unattended, with temperatures outside in excess of 100 degrees Fahrenheit. The resident was on the ground with abrasions to the face, knees and contusions to the ribs. Staff will check the resident's wanderguard each shift to ensure proper working order of the wanderguard. The resident's [DATE] care plan informed staff the resident ambulated without the use the use of any assistive devices and a moderate fall risk. The resident liked going outside, but often forgot that the resident needed staff to escort the resident. The resident wore a wanderguard on the right ankle as staff identified the resident at risk for elopement. Nursing staff to test the wanderguards to reduce the chance of elopement. The resident's wanderguard expired on ,[DATE]. If weather permitted, ask the resident if the resident wanted to walk around the building. Review of the resident's nursing notes revealed the following: Staff recorded in the [DATE] nursing notes at 11:00 PM, the resident complaining, unable to sleep due to roommate being loud. Staff placed the roommate at the nurses' station for closer monitoring. The resident's clinical record lacked any additional nursing notes until the following entry: On [DATE] at 6:15 PM, staff recorded the resident found wandering outside. Staff brought the resident into the building. The alarm (wander) sounded as (the resident)entered. The resident saying (the resident) was going home. Staff sat the resident in the bird room with other residents, with the television on. On [DATE] at 7 PM, staff recorded the resident left the building. CMA (Certified Medication Aide) brought (the resident) back in. Staff took the resident to the resident's room to lay down. Staff recorded the resident's wander alarm working. On [DATE] at 7:30 PM, staff recorded the local EMS (Emergency Medical Services) transported the resident to the hospital. EMS reported the resident found laying on the ground outside. At 7:50 PM, staff called the resident's (child) and informed (the child) the resident transferred to the hospital. At 11:15 PM, the resident returned to the facility. Staff recorded the resident with abrasions on the nose, under the nose, on the left cheek, and on the left knee. The resident complained of soreness at the left ribs. Staff assisted the resident to bed. Staff recorded the resident alert and oriented to self. The resident's [DATE] emergency room after care report recorded the following [DIAGNOSES REDACTED]. The report recorded a fall with contusions to the head, knees, left shoulder, and face. On [DATE] at 10:30 AM, administrative licensed staff B stated, "(The resident) is alert and oriented with confusion. (The resident) varies with orientation. (The resident) has delusional thought process, more so in the evening. Has sundowners. (The resident) is more restless in the afternoon...(The resident) got out the front door. (The resident) said (the resident) read the code. (The resident's) bracelet (wanderguard) was on (the resident's) ankle. The (wanderguard) sensitivity didn't pick up (the resident's) bracelet. (Administrative staff A) had the company come out and adjust the sensitivity. (The resident) told us (the resident) read the code and got out. (The resident) has some scrapes, not a significant injury." On [DATE] at 11:20 AM, administrative staff A reported, "The wander guard system was installed incorrectly. I had 2 separate contractors come out and tested the system. "(The resident was approximately 100 yards from the facility. EMS found him on the service road behind the base ball field. EMS took him to (local hospital). EMS did not make out a report. It was after 7 PM and the temperature was around 85 degrees. (The resident) usually wears a shirt, jeans, tennis shoes and socks. No hat. There was no indication of dehydration at the hospital." At 1:21 PM, this staff member stated, "The first elopement, (the resident) was walking around the south part of the property on the facility's walking path. A neighbor saw (the resident) and (a staff member) brought (the resident) back inside to the east nurses' desk..(The resident) was on 15 minute checks. (The resident) got out a second time. Found (the resident) during the 15 minute checks, out front and (the resident) was starting to go around the building. At 7 PM, (a staff member) couldn't find (the resident) and found (the resident) walking on the side walk. Five minute checks is what we did after the second elopement. Then (the resident) got out the third time. That is when (the resident) went by the baseball field, west of the facility. The third time was between 7:10 PM and 7:15 PM. When I talked to the EMS during my investigation, they said they received the call around 7:20 PM and that it takes up to ,[DATE] minutes for dispatch to make the call to them after dispatch receives a call. The wanderguard sensor on the door frame was on the hinge side of the door frame, and we found during our investigation that sometimes the sensor would not pick the bracelet. Since then I have had 2 different companies come out. The sensor was moved to the exit side of the door frame instead of on the hinge side of the door frame." On [DATE] at 12:10 PM, observation revealed the resident in the dining room in a regular dining room chair eating lunch. Observation revealed a wander guard bracelet in place on the resident's right ankle area. On [DATE] at 2:29 PM, licensed staff C stated, "We have a box we use to check the wanderguards with. We check all doors every shift. Check the expiration dates on the wander guard bracelets. Chart on a sheet at the nurses desk. Most residents would go to a door and the alarm would go off. If a door alarm goes off and we don't see a resident, we have to go outside to check. I was the charge nurse on the evening (the resident) got out. (Staff member) said just got (the resident) back from outside. I don't know where (staff member) found (the resident). (Staff member) brought the resident in the back door and put (the resident) in the bird room. We had CNA students that evening. Had a lot of students as some of the aides had 2 students assigned to them. We thought maybe one of them let (the resident) out. I took the CNA instructor aside to have (the instructor) tell the students to not let any resident out. While I was in there talking to (the instructor (the resident) got out again. (The resident) was right by the desk when we came out of that office. I did not here an alarm go off. (Staff member) was doing 15 minute checks and couldn't find (the resident). (The resident) went outside on the front side walk. I think the alarm went off when (the resident) came back in the second time. (Staff member) put (the resident) to bed. (The resident) said (the resident) was tired. Nothing new was added at that time. One aide saw (the resident) standing by (the resident's) doorway a little later. The third time, I don't know what door (the resident) went out, most likely the front door. A neighbor called EMS. EMS came to the facility and said the resident was on the way to the hospital. I don't know exactly know where (the resident) was when the EMS found (the resident). (The resident) had an abrasion on (the resident's) left cheek, below (the resident's) nose, and on (the resident's) knee. (The resident) said (the resident) pushed the button. The alarm at that point must not have been working. Upon (the resident's) return, (the resident) just wanted to lie down. I don't remember what (the resident) was wearing. It was hot outside..." On [DATE] at 4:31 PM, observation the resident walking into the west shower room with an aide. On [DATE] at 5 PM, observation revealed the resident standing in the doorway of the resident's room. On [DATE] at 12 noon, observation revealed the resident in a regular dining room chair eating lunch. On [DATE] at 1:55 PM, licensed administrative staff B stated, "...(Licensed staff C) did not call any administrative staff until after the third incident...The first intervention after the first elopement was that staff sat (the resident) in the bird room on the east side of the building. There are usually nurses down there. The windows were also checked at that time to make sure (the resident) had not gotten out through a window. The second elopement was when (licensed charge nurse C) talked to the student aides nursing instructor. We had student aides in the building that evening. After the third elopement, (administrative staff A) and (administrative licensed staff H) were called at 8:45 PM and implemented every 5 minute checks on all the other residents at risk for elopement starting at 8:45 PM on [DATE]. The every 5 minute checks were done through the night and until 7 AM on [DATE]." On [DATE] at 1:30 PM, administrative staff A reported the facility followed resident centered care and implemented interventions depending upon the resident's elopement risk assessments. This administrative staff reported the facility lacked any policy and/or procedures which addressed generalized interventions for residents identified as an elopement risk. The Quality Controlled Local Climatological Data from Kansas State University recorded the following temperatures in the area: On [DATE] at 5:54 PM, the temperature was 100 degrees, Fahrenheit. On [DATE] at 6:54 PM, the temperature was 97 degrees, Fahrenheit. On [DATE] at 7:54 PM, the temperature was 93 degrees, Fahrenheit. The facility failed to provide adequate supervision and assistive devices to prevent accidents. The resident, identified as an elopement risk, left the facility, unattended by staff on 3 different ocassions during one evening.