Every finding on record at Easton Health Care Center

The facility identified a census of 39 residents. The sample included 12 residents, with one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to prevent the development of an avoidable stage three (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer on Resident (R) 25's left heel.Findings included:- R25's Electronic Medical Record (EMR) documented diagnoses of embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and thrombosis (a clot that develops within a blood vessel) of the vein, polyneuropathy, and pressure ulcer of the left heel stage three.R25's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R25 had impairment in both lower extremities. R25 was dependent on staff for his cares. R25 was at risk for pressure ulcers but currently had no unhealed pressure wounds. R25 had no skin or ulcer/injury treatments in place.R25's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 11/05/25 documented R25 was at risk for development of pressure injuries due to decreased mobility and prolonged periods in his bed or chair. Contributing factors may include impaired sensory perception, friction/shear, and/or incontinence. Skin assessments revealed no open areas at this time; however, his skin was fragile and required close monitoring. R25's nutrition and hydration status were monitored as these are essential to skin integrity and healing.R25's Care Plan, revised on 02/24/25, documented R25 had a pressure-reducing mattress and a cushion in his wheelchair. R25 was able to offload while up in his recliner. R25 was able to assist with turning and repositioning while in bed with the use of bed canes. The Care Plan directed staff to complete a Braden Scale quarterly and as needed to identify the risk for skin issues. The Care Plan directed staff that nursing would complete a weekly skin assessment, and staff would monitor his skin with all cares. The initial Care Plan lacked interventions to reduce pressure to the heels and elbows. The Care Plan lacked staff direction on treatment and cares in place for R25's Stage three pressure ulcer on his left heel.R25's EMR Orders tab documented a physician's order dated 01/27/25 to clean the left heel with wound cleanser and pat dry, cut AquaRite (a highly absorbent, non-woven wound dressing made from sodium carboxymethyl cellulose and cellulose fibers, used for moderately to heavily exuding wounds like ulcers) to fit the wound, and apply it to the wound, then cover with a dry dressing.R25's EMR Orders tab documented a physician's order dated 02/22/25 to clean left heel with wound cleanser and pat dry, apply gentamycin (medicated cream used for bacterial infections) and Santyl (prescription medication used to remove dead or damaged tissue from chronic skin ulcers and severe burns), cut calcium alginate (highly absorbent dressing) to fit wound and apply to wound, cover with a dry dressing every shift and as needed for pressure ulcer and deep tissue injury to left heel. This order was discontinued on 05/07/25.R25's EMR Orders tab documented a physician's order 05/07/25 to clean the open area on the left heel with hypochlorous acid wound cleanser (a natural disinfectant used in skin care for wound healing), pat dry, cut Prisma collagen (wound treatment used to absorb fluid and provide an antibacterial barrier) to fit the wound bed, and apply. Cover with an abdominal (ABD) pad, secure with kerlix (gauze bandage) and tape every day shift and as needed for pressure ulcer of the left heel. This order was discontinued on 08/21/25.R25's Braden Scale for Predicting Pressure Sore Risk (evidence-based assessment tool used widely to predict the risk of developing pressure injuries) at admission dated 09/06/24 documented a score of 21, which indicated low risk.R25's Weekly Skin Evaluation dated 01/15/25 at 12:15 AM documented discoloration noted on all extremities; left lateral leg bruising. Edema (swelling) in the bilateral lower extremities.R25's Weekly Skin Evaluation dated 01/27/25 at 08:04 AM documented new open areas to the left heel- a deep tissue injury measuring 6 centimeters (cm) by 4.5 cm and a Stage three pressure ulcer measuring 5 cm in length by 4 cm in width by 0.2 cm in depth. A treatment order was received from the physician.R25's Weekly Pressure Injury Skin Report dated 01/27/25 at 10:08 PM, documented a Stage three pressure wound to the left heel that measured 5 cm in length, 4 cm in width, and 0.2 cm in depth. The wound had moderate serosanguineous (semi-thick blood-tinged drainage) exudate (a fluid that leaks out of body vessels and tissues), with maceration (softening and breaking down of skin because of prolonged exposure to moisture, such as sweat, urine, or feces) and discoloration to the surrounding skin. Interventions put in place were for wound treatments and a positioning device. The wound treatment was to clean the left heel with wound cleanser and pat dry, cut AquaRite to fit the wound, and then apply it to the wound bed, then cover with a dry dressing, change daily and as needed for soiling. There was a deep tissue injury to the left heel that measured 6 cm in length and 4.5 cm in width.R25's Misc tab had a scanned physician's visit documentation from 02/24/25 documenting the resident seen and examined for a regulatory visit. R25 was lying in bed. It was almost 09:00 AM, and R25 was asked if he was eating breakfast. R25 stated no, that he was not hungry, but he planned on getting up right now. R25 was asked about his mood, and he stated it was great. R25 has a wheelchair for ambulation. The pharmacy recommended a reduction in his trazodone (medication used to treat depression), and it would be done. R25 followed commands appropriately and was in no apparent distress. The residents' medications were reviewed. The case was discussed with the staff, and R25 would continue to be monitored. The physician's visit did not mention anything regarding R25's left heel wound.The Skin Check progress note dated 08/21/25 at 06:48 PM documented R25's Skin was warm and dry, skin color within normal limits (WNL), and turgor was normal. R25's foot evaluation was completed, and the pressure ulcer/injury was resolved, wound healed, and or closed.Review of R25's EMR revealed that a nurse assessment of R25's skin was documented weekly from 08/21/25 to 12/06/25.R25's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documented a score of 15, which indicated he was at risk of pressure sore development.The Skin Check progress note dated 12/06/25 at 06:20 AM documented: Skin: Skin warm & dry, skin color WNL, and turgor is normal. R25 did not have an external device, and the left heel had a scabbed area wound acquired in-house.The Skin Check progress note dated 12/11/25 at 02:47 PM documented the skin issue had not been evaluated. The left heel has a scabbed area, a wound acquired in-house. R25 had a new skin issue to left heel with a pressure ulcer/injury. Progress: new wound. Pressure ulcer staging: Stage three Pressure ulcer/injury - full-thickness skin loss, a wound acquired in-house with the exact date of 12/11/25. No signs and symptoms of infection, not painful. Measurements: 1.55 cm in length by 1.48 cm in width by 0.3 cm in depth. There was no undermining, no tunneling, the area was normal in color, and no swelling or edema.R25's Order Summary Report documented a physician's order dated 12/16/25 to clean the left heel with wound cleanser and pat dry, apply a nickel-thick layer to the wound bed, cut calcium alginate (highly absorbent wound dressing used for wound healing) to fit the wound bed, and apply, cover with a dry dressing. Every day shift related to pressure ulcer of the left heel, Stage three.On 01/12/26 at 11:15 AM, R25 sat in his wheelchair in the hallway and was self-propelling to the dining room.On 01/13/26 at 11:40 AM, Licensed Nurse (LN) G stated she only worked occasionally and really did not update the care plans, but she would expect R25's care plan to address or have interventions in place for wound prevention. LN G stated most residents should have all the normal interventions in place, like the barrier cream used and floating the heels.On 01/13/26 at 09:30 AM Administrative Nurse D stated she did her best to make sure treatments and skin care interventions had been updated in the care plans. Administrative Nurse D stated she had done the weekly skin assessments on him but looking at his care plan, she clearly dropped the ball on getting his treatment and wound information from the previous heel wound or the current wound put on his care plan.The facility's Pressure Injury Prevention Interventions Policy policy dated 05/18/24 documented the purpose of pressure injury interventions was to prevent the formation of avoidable pressure Injuries and to promote healing of existing pressure injuries. It is the policy of this facility to implement evidence-based Interventions for all residents who are assessed at risk or who have a pressure Injury present. Individualized interventions would address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment. Preventive Skin Care included: inspecting skin while providing care, paying close attention to bony prominences. Inspect the skin underneath medical devices at least twice [NAME]. Keep the skin clean and dry underneath. Adjust devices as needed for proper fit. Avoid positioning the resident on an area of redness whenever possible. Keep the skin clean and dry. Manage incontinence with absorptive products. Check every two hours, and provide perineal care as needed after incontinent episodes. Protect skin from exposure to excessive moisture with barrier products. Moisturize dry skin. Use positioning devices or folded linens to keep body surfaces from rubbing against one another. Consider use of prophylactic dressings for prevention of sacral and heel pressure injuries. Avoid vigorous massage over bony prominences.The Wound Treatment Management Policy dated 05/03/24, documented the purpose of wound treatments was to promote wound healing of various types of wounds, It Is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and. physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatments will be documented on the Treatment Administration Record or in the electronic health record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: Lack of progression towards healing; Changes in the characteristics of the wound; Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

The facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and glove use during high contact care) were used for Resident (R) 4, who had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder), failed to handle and transport soiled linen in a safe and sanitary manner, failed to ensure R4's catheter bag did not drag on the floor while in his wheelchair and bed. The facility failed to ensure staff performed appropriate glove changing and hand hygiene while performing personal care for R4 and failed to disinfect a mattress after changing soiled linens.Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of retention of urine (the inability to completely empty the bladder), urinary tract infection (UTI- an infection in any part of the urinary system), and benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow).R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition. R4 was dependent upon staff assistance for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene. R4 further required partial staff assistance with mobility. The MDS documented R4 had a urinary catheter and had a UTI during the lookback period.R4's 10/19/25 Care Plan included the following interventions:10/26/25 - Encourage the resident to use the bell to call for assistance; he required moderate to maximum assistance from one staff member for personal hygiene.11/08/25 - R4 had an indwelling suprapubic catheter and positioned the catheter bag and tubing below the level of the bladder. R4 frequently placed his catheter bag on the floor and had been educated on the risk associated with doing this. Monitor and document output as per facility policy, monitor for signs and symptoms of discomfort, urination, and frequency. Monitor and document for pain or discomfort due to the catheter, monitor, document, and record signs and symptoms of a UTI.The care plan lacked documentation and direction to staff on the use of personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) to be worn while cares were provided.On 01/11/26 at 09:20 AM, R4 sat on the side of the bed. He wore a shirt and an incontinence brief. R4's bottom sheet was very soiled with bowel movement. R4 stated that he had sat in the bowel for a while and had asked staff to clean him up. R4 stated he was told that they would clean him up after breakfast when they got him up and into his wheelchair, so he tried to clean himself up. R4 stated that he had a catheter and lifted the apron of his belly (a fold of excess skin that hangs from the lower abdomen). Observation revealed a reddened catheter insertion site with yellow drainage. There was a wadded-up, soiled 4x4 gauze (a woven or non-woven fabric used in wound care for absorbing fluids) dressing between the folds of his abdomen. Continued observation revealed Certified Nurse Aide (CNA) M came into the room and stated they were getting ready to get him up. When asked if he was aware of the soiled linens, he stated, No, he was just helping the other CNA. CNA M left to go get clean linens and came back into the room with CNA M. CNA M pushed the full mechanical lift into the room; she wore a gown and gloves, but CNA M only had on gloves and did not shut R4's room door. The CNAs assisted R4 to lie down in the bed. CNA N bent down to empty the catheter bag, and when she was done, laid the bag on the floor. While CNA N drained the catheter bag, CNA M started to take off the bed linens. R4 rolled to the left side, and CNA M opened the incontinent brief and used wipes to clean the bowel off the resident and stated, You are having another bowel movement. And continued to clean the resident. CNA M had R4 roll onto his back, and she wiped under his abdomen apron and did not change her gloves. CNA N had R4 roll to the right side, and there was bright red blood on the sheet and brief. When asked where the blood came from, CNA M stated, He has hemorrhoids (swollen, inflamed veins in the lower rectum or around the anus). CNA M removed the rest of the soiled sheets from the bed and threw them onto the floor. R4 rolled onto his back, and the clean brief was secured. CNA N placed the catheter bag on the bed and started to assist R4 with a clean pair of sweatpants. R4 rolled to his left side, and CNA M put the mechanical lift sling under him, with the same soiled gloves. They attached the sling to the lift, transferred him into his wheelchair, and hooked the catheter bag under his wheelchair. CNA M picked up the soiled sheets from the floor and carried them unbagged down the hall. CNA N took off R4's shirt and set it on the bed, then assisted him with a clean shirt. CNA M came back into the room and took the shirt and wiped off R4's mattress, laid the dirty shirt on his bedside table, and put new linens on the bed with the same soiled gloves. When asked why CNA N had on a gown, and CNA M didn't, she stated it was personal preference and did not know that CNA M was supposed to wear a gown. R4 asked the CNAs for soapy water and a rag to wash his hands, and they did not get him any. CNA M took R4 down to the dining room. On 01/12/26 at 03:00 PM, Licensed Nurse (LN) G went into R4's room, took off his socks, used wound cleanser to wash his legs, and applied A & D ointment to his legs and feet. LN G did not have a gown on, just gloves. LN G stated she had forgotten to put one on. R4's shirt was stained at the area of the catheter site. LN G lifted his shirt and his abdomen, and there was thick, yellow, stringy discharge at the site. LN G stated she would have staff lay R4 into bed, and she would look at the site. Further observation revealed four gowned and gloved CNAs in R4's room to assist with the transfer from his wheelchair and into his bed. The mechanical lift's battery was dead, so they had to go get a charged battery. R4 was transferred into his bed, and his sweatpants were removed. CNA M had R4 roll to his left side. She opened the brief and provided incontinence care. CNA N had him roll onto his back and cleaned the insertion site. CNA M rolled R4 to his right side, and there was bright red blood on the brief. CNA N and CNA M continued to clean R4 and put the clean brief on and covered him up. Further observation revealed LN G and LN H came into the room and looked at R4's catheter insertion site, and R4 stated, it's been oozing pus (a thick yellowish or greenish opaque liquid produced in infected tissue consisting of white blood cells and bacteria with tissue debris). LN G stated, it looked fine. LN H opened up R4's brief to see where the blood was coming from, and they were able to see that he had 2 areas on his scrotum (the sac of skin and muscle located outside the lower body that holds and protects the testicles). LN H stated it looked like it was from being pinched. LN H measured the superior open area at 8.2 centimeters (cm) by 0.7 cm and the inferior open area at 0.9 cm by 0.6 cm. LN H stated she would contact the physician about the areas and his catheter insertion site.On 01/12/26 at 03:30 PM, Administrative Nurse D stated, she would contact the physician about the concerns and get a treatment order. Administrative Nurse D stated staff are to wear the gown and gloves when providing cares for R4.On 01/13/25 at 03:40 PM, Administrative Nurse D stated R4 has a history of noncompliance with cares and would lay his catheter bag on the floor. She stated staff should have changed their gloves after cares and before getting him dressed. The CNA should have bagged the linens and taken them to the laundry room and should not have used his clothing to wipe off the bed. She stated she had already started education regarding the PPE and would also do infection control education.The facility's Handling Clean and Dirty Linen Policy, dated 06/24/26, documented that all linen should be handled using standard precautions and treated as potentially contaminated. Linens may require special handling is visibly soiled with blood and large amounts of bodily fluids. Used or soiled linen shall be collected at the bedside and placed in a linen bag or designated lined receptacle. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. If linen is heavily soiled, wet and/or presents a risk of leakage or soaking through, the linen shall be double bagged.The facility's Enhanced Barrier Precautions (EBP) policy, dated 05/18/24, documented EBP must be used for high contact resident care activities or residents with indwelling medical devices including, but not limited to, central line, urinary catheters, and feeding tubes.The facility's Standard Precautions-Infection Control policy, dated 05/14/24, documented all staff were to assume that all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to standard precautions to prevent the spread of infection to residents, staff and visitors. Staff shall perform hand hygiene after contact with contaminated objects.

The facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to prevent two superficial open areas on Resident (R) 4's scrotum (the sac of skin and muscle located outside the lower body that holds and protects the testicles).Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of chronic osteomyelitis (local or generalized infection of the bone and bone marrow), venous insufficiency (slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin) type two.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented R4 had intact cognition. R4 was dependent upon staff assistance for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene. R4 further required partial staff assistance with mobility. The MDS documented R4 was at risk for breakdown, received nonsterile dressings, and ointments.R4's 10/19/25 Care Plan included the following interventions:10/26/25 - Directed nursing staff to assess, record, and monitor wound healing. Measure length, width, and depth where possible. Assess and document the status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. Educate the resident/family/caregivers as to causes of skin breakdown, including transfer, positioning requirements, the importance of taking care during ambulation, mobility, good nutrition, and frequent repositioning. Follow facility policies/protocols for the prevention/treatment of skin breakdown. If the resident refuses treatment, confer with the resident, team, and family to determine why and try alternative methods to gain compliance. Document alternative methods.On 01/11/26 at 09:20 AM, during incontinence care Certified Nurse Aide (CNA) N had R4 roll to the right side and there was bright red blood on the sheet and brief. When asked where the blood came from, CNA M stated, He has hemorrhoids (swollen, inflamed veins in the lower rectum or around the anus). R4 rolled onto his back and the clean brief was secured.On 01/12/25 at 03:00 PM, during incontinence care, CNA M rolled R4 to his right side and there was bright red blood on the brief. CNA P left the room to get a nurse. CNA N and CNA M continued to clean R4 and put the clean brief on and covered him up. Further observation revealed LN G and LN H came into the room to assess R4. LN H opened up R4's brief to see where the blood was coming from, and they were able to see that R4 had two areas on his scrotum (the sac of skin and muscle located outside the lower body that holds and protects the testicles). LN H stated it looked like it was from being pinched. LN H measured the superior open area at 8.2 centimeters (cm) by 0.7 cm and the inferior open area at 0.9 cm by 0.6 cm. LN H stated she would contact the physician about the areas and would see if they needed to provide larger incontinence briefs for R4.On 01/12/26 at 03:30 PM, Administrative Nurse D stated she would contact the physician about the concerns and get a treatment order. Administrative Nurse D stated she would try to figure out how to ensure his skin was protected so that he was not getting pinched.The facility's Wound Treatment Management Policy, dated 05/03/24, documented the facility provided evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatment decisions would be based on pressure, surgical, incidental, and atypical. Due to the unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. The facility would follow specific physician orders for providing wound care.

The facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to promote dignity and respect for one resident, Resident (R) 4, when staff did not close the door to his room before providing personal cares.Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of retention of urine (the inability to completely empty the bladder), urinary tract infection (UTI- an infection in any part of the urinary system), and benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow).R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented R4 had a Brief Interview for Mental Status Score (BIMS) of 15, which indicated intact cognition. R4 was dependent upon staff assistance for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene. R4 further required partial staff assistance with mobility. The MDS documented R4 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) and had a UTI during the lookback period.R4's 10/19/25 Care Plan included the following interventions:10/26/25 - Directed staff to encourage the resident to use the bell to call for assistance. R4 required moderate-to-maximum assistance from one staff member for personal hygiene.11/08/25 - Documented R4 had an indwelling suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) and positioned the catheter bag and tubing below the level of the bladder. R4 frequently placed his catheter bag on the floor and had been educated on the risk associated with doing this. Monitor and document output as per facility policy, monitor for signs and symptoms of discomfort, urination, and frequency. Monitor and document for pain or discomfort due to the catheter, monitor, document, and record signs and symptoms of a UTI.R4's Care Plan lacked documentation and direction to staff on the use of personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) to be worn while cares were provided. On 01/11/26 at 09:20 AM, R4 sat on the side of the bed. He wore a shirt and an incontinence brief. R4's bottom sheet was very soiled with bowel movement. R4 stated that he had sat in the bowel for a while and had asked staff to Clean him up. R4 stated he was told that they would clean him up after breakfast when they got him up and into his wheelchair, so he tried to clean himself up. Continued observation revealed Certified Nurse Aide (CNA) M came into the room and stated they were getting ready to get him up. CNA M left to get clean linens and came back into the room with CNA N. CNA N pushed the full mechanical lift into the room, and did not shut R4's room door. The CNAs assisted R4 to lie down in the bed. CNA N bent down to empty the catheter bag, and when she was done, laid the bag on the floor. While CNA N drained the catheter bag, CNA M started taking off the bed linens. R4 rolled to the left side, and CNA M opened the incontinent brief and used wipes to clean the bowel off the resident and stated, You are having another bowel movement. And continued to clean the resident. CNA M removed the rest of the soiled sheets from the bed and threw them onto the floor. R4 rolled onto his back, and the clean brief was secured. CNA N placed the catheter bag on the bed and started to assist R4 with a clean pair of sweatpants. R4 rolled to his left side, and CNA M put the mechanical lift sling under him. They attached the sling to the lift and transferred him into his wheelchair, then hooked the catheter bag under his wheelchair. CNA N took off R4's shirt, set it on the bed, then assisted him with a clean shirt. On 01/13/25 at 02:30 PM, Administrative Nurse D stated staff should have shut the resident's door before providing cares and any resident in a shared room, staff were to pull the privacy curtain.The facility's Promoting/Maintaining Resident Dignity policy, dated 09/21/25, documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity, as well as care for each resident in a manner and in an environment that maintained or enhanced the resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and resident rights. Staff are to maintain resident privacy.

The facility identified a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure R4's care plan had been revised to include enhanced barrier precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact cares) that needed to be worn during staff cares of his supra pubic catheter (urinary bladder catheter inserted through the abdomen into the bladder).Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of retention of urine (the inability to completely empty the bladder), urinary tract infection (UTI- an infection in any part of the urinary system), and benign prostatic hyperplasia (BPH -non-cancerous enlargement of the prostate which can lead to interference with urine flow).R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented R4 had a Brief Interview for Mental Status Score (BIMS) of 15, which signified intact cognition. R4 was dependent upon staff assistance for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene. R4 further required partial staff assistance with mobility. The MDS documented R4 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) and had a UTI during the lookback period.R4's 10/19/25 Care Plan included the following interventions:10/26/25 - Encourage the resident to use the bell to call for assistance; he required moderate-to-maximum assistance from one staff member for personal hygiene.11/08/25 - R4 had an indwelling suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) and positioned the catheter bag and tubing below the level of the bladder. R4 frequently placed his catheter bag on the floor and had been educated on the risk associated with doing this. Monitor and document output as per facility policy, monitor for signs and symptoms of discomfort, urination, and frequency. Monitor and document for pain or discomfort due to the catheter, monitor, document, and record signs and symptoms of a UTI. R4's Care Plan lacked documentation and direction to staff on the use of personal protective equipment (PPE-gowns, face shields, and/or eyeglasses/goggles, and gloves) to be worn while cares were provided.On 01/11/26 at 09:20 AM, R4 sat on the side of the bed. He wore a shirt and an incontinence brief. R4's bottom sheet was very soiled with bowel movement. R4 stated that he had sat in the bowel for a while and had asked staff to clean him up. R4 stated he was told that they would clean him up after breakfast when they got him up and into his wheelchair, so he tried to clean himself up. R4 stated that he had a catheter and lifted the apron of his belly (a fold of excess skin that hangs from the lower abdomen). Observation revealed a reddened catheter insertion site with yellow drainage. There was a wadded-up, soiled 4x4 gauze (a woven or non-woven fabric used in wound care for absorbing fluids) dressing between the folds of his abdomen. Continued observation revealed Certified Nurse Aide (CNA) M came into the room and stated they were getting ready to get him up. When asked if he was aware of the soiled linens, he stated, No, he was just helping the other CNA. CNA M left to go get clean linens and came back into the room with CNA M. CNA M pushed the full mechanical lift into the room; she wore a gown and gloves, but CNA M only had on gloves and did not shut R4's room door. The CNAs assisted R4 to lie down in the bed. CNA N bent down to empty the catheter bag, and when she was done, laid the bag on the floor. While CNA N drained the catheter bag, CNA M started to take off the bed linens. R4 rolled to the left side, and CNA M opened the incontinent brief and used wipes to clean the bowel off the resident and stated, You are having another bowel movement. And continued to clean the resident. CNA M had R4 roll onto his back, and she wiped under his abdomen apron and did not change her gloves. CNA N had R4 roll to the right side, and there was bright red blood on the sheet and brief. When asked where the blood came from, CNA M stated, He has hemorrhoids (swollen, inflamed veins in the lower rectum or around the anus). CNA M removed the rest of the soiled sheets from the bed and threw them onto the floor. R4 rolled onto his back, and the clean brief was secured. CNA N placed the catheter bag on the bed and started to assist R4 with a clean pair of sweatpants. R4 rolled to his left side, and CNA M put the mechanical lift sling under him, with the same soiled gloves. They attached the sling to the lift, transferred him into his wheelchair, and hooked the catheter bag under his wheelchair. CNA M picked up the soiled sheets from the floor and carried them unbagged down the hall. CNA N took off R4's shirt and set it on the bed, then assisted him with a clean shirt. CNA M came back into the room and took the shirt, wiped off R4's mattress, laid the dirty shirt on his bedside table, and put new linens on the bed with the same soiled gloves. When asked why CNA N had on a gown, and CNA M didn't, she stated it was personal preference and did not know that CNA M was supposed to wear a gown. R4 asked the CNAs for soapy water and a rag to wash his hands, and they did not get him any. CNA M took R4 down to the dining room. On 01/13/25 at 02:30 PM, Administrative Nurse D stated R4's EBP status should be on the care plan, and she would make sure it was updated.The facility's Comprehensive Care Plan policy, dated 10/31/24, documented that the facility develops and implement comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment.

The facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide services consistent with the standard of care for one resident, Resident (R) 4, reviewed for urinary catheter (a tube inserted into the bladder to drain urine) or urinary tract infection (UTI- an infection in any part of the urinary system).Findings included:- The Electronic Medical Record (EMR) for R4 documented diagnoses of retention of urine (the inability to completely empty the bladder), UTI, and benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow).R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented R4 had intact cognition. R4 was dependent upon staff assistance for toileting hygiene, lower body dressing, and substantial assistance with personal hygiene. R4 further required partial staff assistance with mobility. The MDS documented R4 had a urinary catheter and had a UTI during the lookback period.R4's 10/19/25 Care Plan included the following interventions:10/26/25 - Encourage the resident to use the bell to call for assistance; he required moderate-to-maximum assistance from one staff member for personal hygiene.11/08/25 - R4 had an indwelling suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) and positioned the catheter bag and tubing below the level of the bladder. R4 frequently placed his catheter bag on the floor and had been educated on the risk associated with doing this. Monitor and document output as per facility policy, monitor for signs and symptoms of discomfort, urination, and frequency. Monitor and document for pain or discomfort due to the catheter, monitor, document, and record signs and symptoms of a UTI.A review of R4's clinical record revealed the R4 had a positive UTI on 11/06/25 and 12/31/25.The Physician's Order dated 11/26/25 directed staff to administer meropenem (a powerful, broad-spectrum antibiotic used to treat serious bacterial infections), 1 gram (gm), intravenously, every eight hours for seven days.The Physician's Order dated 12/31/25 directed staff to administer Macrobid (antibiotic to treat UTIs), 100 milligrams (mg), by mouth, twice a day for ten days.The Physician's Order dated 10/19/25 directed staff to change the suprapubic catheter anchor every night shift, every seven days.The Physician's Order dated 10/19/25 directed staff to cleanse the suprapubic catheter with soap and water every day and night.The Physician's Order dated 10/26/25 directed staff to change the suprapubic catheter collection bag every night shift, every seven days, for the diagnosis of retention of urine.The Physician's Order dated 11/25/25 directed staff to change the suprapubic catheter, size 18 French with 30 milliliter (ml) balloon every 28 days for the diagnosis of retention of urine.On 01/11/26 at 09:20 AM, R4 sat on the side of the bed. He wore a shirt and an incontinence brief. R4 stated that he had a catheter and lifted the apron of his belly (a fold of excess skin and at that hangs from the lower abdomen). Observation revealed a reddened catheter insertion site with yellow drainage. There was a wadded-up, soiled 4x4 gauze (a woven or non-woven fabric used in wound care for absorbing fluids) dressing between the folds of his abdomen. The Certified Nurse Aide (CNA') assisted R4 to lie down in the bed. CNA N bent down to empty the catheter bag and did not clean the drainage valve. When she was done, laid the bag on the floor and did not change her gloves. R4 rolled to the left side, and CNA M opened the incontinent brief and used wipes to clean the bowel off the resident, and stated, You are having another bowel movement, and continued to clean the resident. CNA M had R4 roll onto his back, and she wiped under his abdomen apron, with soiled gloves. R4 rolled onto his back and the clean brief was secured. CNA N placed the catheter bag on the bed and started to assist R4 with a clean pair of sweatpants. R4 rolled to his left side and CNA M put the mechanical lift sling under him, with same soiled gloves. They attached the sling to the lift and transferred him into his wheelchair and hooked the catheter bag under his wheelchair. CNA M took R4 down to the dining room. On 01/12/26 at 03:00 PM, Licensed Nurse (LN) G went into R4's room, took off his socks, used wound cleanser to wash his legs, and applied A & D ointment to his legs and feet. LN G did not have a gown on, just gloves. LN G stated she had forgotten to put one on. R4's shirt was stained at the area of the catheter site. LN G lifted his shirt and his abdomen and there was thick, yellow, stringy discharge at the site. LN G stated, she would have staff lay R4 into bed and she would look at the site. Further observation revealed four gowned and gloved CNA's in R4's room to assist with the transfer from his wheelchair and into his bed. The mechanical lift's battery was dead, so they had to go get a charged battery. R4 was transferred into his bed, and his sweatpants removed. CNA M had R4 roll to his left side, she opened the brief and provided incontinence care. CNA N had him roll onto his back and cleaned the insertion site. CNA N and CNA M continued to clean R4 and put the clean brief on and covered him up. Further observation revealed LN G and LN H came into the room and looked at R4's catheter insertion site and R4 stated, it's been oozing pus (a thick yellowish or greenish opaque liquid produced in infected tissue consisting of white blood cells and bacteria with tissue debris). LN H stated she would contact the physician for treatment.On 01/11/26 at 09:30 AM, CNA N stated she should have changed her gloves before she helped him put on clean clothes.On 01/12/25 at 03:00 PM, LN H stated R4 had a habit of scratching everywhere and then touches his catheter site. The catheter site was cleaned every time they checked and changed his incontinence brief.On 01/12/25 at 02:30 PM, Administrative Nurse D stated R4 had a history of urinary tract infections and would put his catheter bag on the floor sometimes, but should not drag it on the floor. Administrative Nurse D further stated that she would contact the physician to get a treatment order for his catheter insertion site. Administrative Nurse D further stated staff should change their gloves when going from dirty to clean.The facility's Catheter Care policy, dated 06/26/24, documented the facility ensured that residents with indwelling catheters received appropriate catheter care and maintained their dignity when indwelling catheters were in use. Ensure the drainage bag was located below the level of the bladder to discourage backflow of urine. Perform hand hygiene when done.

The facility had a census of 39 residents. The sample included 12 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required.Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2025 Quarter (Q) 1, Q2, Q3, and Q4 indicated excessively low weekend staffing.Review of the facility's Nursing Staff scheduled for the above quarters revealed adequate staffing on duty was provided.On 01/12/26 at 02:15 PM, Administrative Staff A stated the information for the PBJ was pulled in the corporate office from the time clock. Administrative Staff A stated they have not been short on the weekends and do not use agency. The Director of Nursing and herself do the schedule. They have gone through several different payroll programs so that may be what has caused this issue. The facility does weekend [NAME] staffing which means staff who work both Saturday and Sunday, 12 hours earn an extra eight hours on their check for working both days; however, if they call in, then they are not rewarded the eight hours. They also allow the full-time staff to pick their preferred days and utilize part-time or as-needed staff to fill in the gaps.The facility's Sufficient Staff Policy, dated 05/18/24, documented the facility provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity, and diagnosis of the resident population would be considered based on the facility assessment. The facility was responsible for submitting timely and accurate staffing data through the CMS PBJ system

The facility identified a census of 34 residents with three residents reviewed for falls and accidents. Based on record review and interview, the facility failed to ensure Resident (R) 1's safety during a transfer when Certified Nurse Aide (CNA) M and Licensed Nurse (LN) G used a Hoyer lift (total body mechanical lift) to transfer R1 from her bed to her wheelchair. During the transfer, the lift tipped, and R1 hit the back of her head on a dresser. As a result, R1 sustained a laceration to the back of her head that required staples and sutures to close. This deficient practice also placed R1 at risk for pain and other avoidable injuries. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of generalized muscle weakness, Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dependence on wheelchair, unspecified lack of coordination, and aphasia (condition with disordered or absent language function). The Annual Minimum Data Set (MDS), dated [DATE], for R1 documented the Brief Interview for Mental Status (BIMS) assessment could not be completed. The MDS documented R1 had problems with recall ability, short-term, and long-term memory. The MDS further documented R1 had severely impaired decision making and never or rarely made decisions. The MDS documented R1 used a wheelchair and was dependent on staff for all activities of daily living (ADL) including locomotion on the unit and transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/07/24, documented R1 was alert and oriented to herself only, was unable to complete the BIMS, and required total assistance with ADLs. R1's Care Plan, with an initiated date of 11/17/17, documented R1 had a stroke, was weak, and fatigued easily. An intervention initiated on 01/02/18, documented R1 was not able to stand and required use of a Hoyer lift, with two staff assistance, for all transfers. A Fall Note dated 07/12/24, documented at 04:00 PM CNA M and LN G used the Hoyer lift to transfer R1 from the bed to her wheelchair and the Hoyer lift tipped in the middle of the transfer. The note documented CNA M and LN G lowered R1 to the floor and on the way down, the back of R1's head hit the corner of a dresser. The note further documented that R1 suffered a laceration to the back of her head related to the fall, and was transported to the emergency room . A Nurse Note dated 07/12/24, documented the facility received report from the emergency room about R1's condition. The note further documented R1 required seven staples and three sutures to the back of her head. CNA M's Complaint Investigation Witness Statement dated 07/12/24, documented CNA M asked LN G to help transfer R1 from her bed to her Broda chair (specialized wheelchair with the ability to tilt and recline) and the lift tipped in the middle of the transfer. The statement documented CNA M and LN G lowered R1 to the floor and R1 hit the back of her head on the corner of a dresser. An undated Entity Reports and Complaint Data Collection form documented on 07/12/24 at 04:00 PM, LN G and CNA M transferred R1 via Hoyer lift from her bed to her wheelchair when the lift tipped in the middle of the transfer. The report documented staff attempted to lower R1 to the floor and the back of R1's head hit the corner of the dresser. The reported documented 911 was called and R1 was transported to an emergency room . The report documented the Hoyer lift was removed from use in the facility until a mechanical and physical evaluation was completed and the maintenance director was notified. Review of the CCI Monthly Lift Safety Maintenance Checklist for April 2024 to July 2024 revealed the facility had three lifts that were inspected. The checklists lacked evidence there were any issues with the lifts. R1 was unavailable for observation. On 07/16/24 at 12:50 PM Administrative Nurse D stated she was unsure if staff completed Hoyer lift training prior to R1's fall from the lift. Administrative Nurse D stated CNA M and LN G were hired before her and the previous person responsible for staff education no longer worked at the facility. Administrative Nurse D looked for the education files and stated there were no records of the LN completing Hoyer lift training at the facility. Administrative Nurse D stated the lift training for CNA M was filled out by the previous employee, that provided education for staff; however, it was not signed by CNA M to show it was complete. Administrative Nurse D stated she had lift training scheduled on 07/25/24. She stated some training was completed after R1's fall; however, she wanted to have additional training to go though everything more in depth with staff. Administrative Nurse D stated lift training would be added to the facility's yearly education as part of staff yearly competencies in October going forward. On 07/16/24 at 01:14 PM LN G stated she was not sure what caused the lift to tip to the right and said it happened fast. LN G stated R1 did not have a hard landing on the floor as her and CNA M were able to get a hold of R1; however, she stated they were not able to move R1 over enough to clear the corner of the dresser during the fall which resulted in R1 hitting her head. LN G stated the legs of the lift were open while she transferred R1, and they appeared to be open all the way. She stated the legs should be open to provide a wide base and stated she was not sure why it tipped. LN G stated there was nothing that indicated the lift was not working correctly, and if she had noticed an issue with the lift, she would have stopped with the transfer and switched lifts. LN G stated she received lift training when she hired on about 14 to 15 months ago. LN G stated she was unsure who would have provided the training previously as so many people have changed positions. On 07/16/24 at 01:30 PM CNA N stated she worked at the facility for about four months and had been a CNA for nine years. CNA N stated she had not received lift training at the facility but had received lift training at a previous facility. CNA N stated the facility asked if she had prior training and knew how to operate a Hoyer lift when she hired on, but she was not asked to demonstrate that she knew how to properly use one. CNA N stated she had not noticed any issue with any of the Hoyer lifts in the facility other than the occasional dead battery from not being charged. CNA N stated if there was an issue with one of the lifts it would have been taken out of service, so no one used it, and placed in the maintenance book. CNA N stated she moved the Hoyer lift with the legs strait while placing the lift under the bed, as there was no room to open the legs due to the structure of the bed. She stated after the resident was raised in the lift, she pulled the lift straight out and turned the lift while the legs were straight. She stated she opened the legs once the wheelchair was in place. On 07/16/24 at 03:03 PM Administrative Nurse D stated she worked on more education for staff that day. Administrative Nurse D stated she went over the lift user guide and the Food and Drug Administration (FDA) patient lift safety guide with the staff today. She stated she had one staff member left to provide training for. Administrative Nurse D stated she trained staff to keep the legs out, and not together, while moving a resident in the lift. The undated, facility provided Safe Resident Handling/Transfers policy documented it is the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with the current standard and guidelines. The facility failed to ensure R1's safety during a transfer when CNA M and LN G used a Hoyer lift to transfer R1 from her bed to her wheelchair. During the transfer, the lift tipped, and R1 hit the back of her head on a dresser. As a result, R1 sustained a laceration to the back of her head that required staples and sutures to close. This deficient practice also placed R1 at risk for pain and other avoidable injuries.

The facility identified a census of 33 residents and 23 active resident trust fund accounts. The sample included five residents. Based on record review and interview, the facility failed to distribute quarterly statements to all residents that held trust fund accounts in the facility. This placed the residents at risk for uninformed decisions regarding their trust fund and misappropriation. Findings included: - Review of the Trial Balance as of 08/22/24 revealed 23 total accounts with a balance of $16,931.18. The Trial Balance documented Resident (R) 2 had a current trust fund balance of $681.35. On 08/23/24 at 03:17 PM, R2's representative and responsible financial party stated he had not received a quarterly stated regarding R2's trust account at all this year. He stated that he had called and attempted to talk with the new person in charge of the trust accounts but had not been able to get ahold of anyone. On 08/26/24 at 02:40 PM Administrative Staff B confirmed she has never sent out any quarterly statements for any of the trust accounts at the facility. She stated she had not yet received training regarding quarterly statements. The undated facility policy Transactions Involving Resident Funds documented quarterly statements would be provided in writing to the resident, or the residents representative, within 30 days after the end of the quarter and upon request. The facility failed to distribute quarterly statements to all residents that held trust fund accounts in the facility. This placed the residents at risk for uninformed decisions regarding their trust fund and misappropriation.

The facility identified a census of 33 residents and 23 active resident trust fund accounts. The sample included five residents. Based on record review and interview, the facility failed to distribute quarterly statements to all residents that held trust fund accounts in the facility. This placed the residents at risk for uninformed decisions regarding their trust fund and misappropriation. Findings included: - Review of the Trial Balance as of 08/22/24 revealed 23 total accounts with a balance of $16,931.18. The Trial Balance documented Resident (R) 2 had a current trust fund balance of $681.35. On 08/23/24 at 03:17 PM, R2's representative and responsible financial party stated he had not received a quarterly stated regarding R2's trust account at all this year. He stated that he had called and attempted to talk with the new person in charge of the trust accounts but had not been able to get ahold of anyone. On 08/26/24 at 02:40 PM Administrative Staff B confirmed she has never sent out any quarterly statements for any of the trust accounts at the facility. She stated she had not yet received training regarding quarterly statements. The undated facility policy Transactions Involving Resident Funds documented quarterly statements would be provided in writing to the resident, or the residents representative, within 30 days after the end of the quarter and upon request. The facility failed to distribute quarterly statements to all residents that held trust fund accounts in the facility. This placed the residents at risk for uninformed decisions regarding their trust fund and misappropriation.

The facility identified a census of 33 residents which included 23 residents with active trust accounts, held by the facility. Based on interviews and record review, the facility failed to provide Resident (R) 1 with an accurate accounting of her personal funds, when the facility overcharged R1's personal funds account by $347.89 . This placed R1 at risk for impaired autonomy and misappropriation. Findings included: - Review of R1's trust transactions as listed on the Resident Statement Landscape dated 09/01/23 to 08/26/24 documented the following duplicate charges and one charge with no receipt for R1. The withdrawals on 01/04/24 for the following amounts had handwritten receipts with R1 and Administrative Staff B's signatures for the following amounts: $20.00, $30.00, $117.89, $25.00, $30.00, and $25.00. The withdrawal on 01/31/24 for $25.00 had no receipt documented for that withdrawal. The withdrawals on 08/06/24 for the following amounts have a handwritten receipt dated from 2023 stapled to withdrawal receipts for the following amounts with receipt numbers: W000101 $117.89, W000102 $30.00, W000103 $25.00, W000104 $30.00, W000105 $25.00, and W000106 $20.00. On 08/22/24 at 04:50 PM Administrative Staff A stated that she had not reviewed the resident trust accounts. On 08/26/24 at 10:40 AM Administrative Staff B stated she did not know the job and had not received basic training to be able to handle basic situations and learned as she went. Administrative Staff B revealed she lacked understanding of the resident trust funds. On 08/26/24 at 12:15 PM Administrative Staff B looked at the trust account for R1 and realized that she entered money paid out to R1 twice, once in January and then again in August. Administrative Staff B revealed that the receipt papers had been written out by hand and then the receipts changed to a more formal form. Administrative Staff B stated that when she was putting together the receipt book for resident trust accounts earlier in August, she was entering withdrawals that Administrative Staff B thought had not been removed from R1's trust account. Administrative Staff B stated that no one looked over the resident trust accounts except for her related to the receipts and withdrawals. The undated facility policy Transactions Involving Resident Funds documented the Business Office Manager, or his/her designee, was responsible for providing residents with receipts for withdrawals and for requested or needed personal items when such funds were withdrawn from the resident's personal funds account managed by the facility. A cope of such transactions and receipts were maintained by the Business Office Manager, or designee, to verify account transactions and to reconcile resident fund balances with withdrawals and expenditures. The Business Office Manager or designee was responsible for ensuring that resident fund accounts were reconciled on a quarterly basis and discrepancies were promptly reported to the Administrator for investigations. The policy further documented that the Business Office Manager or designee would receive periodic training on this policy to ensure that receipts for resident fund expenditures were maintained. The facility failed to provide R1 with an accurate accounting of her personal funds when the facility duplicated charges to R1's personal funds account by $347.89. This placed R1 at risk for impaired autonomy and misappropriation.

The facility identified a census of 33 residents which included 23 residents with active trust accounts, held by the facility. Based on interviews and record review, the facility failed to provide Resident (R) 1 with an accurate accounting of her personal funds, when the facility overcharged R1's personal funds account by $347.89 . This placed R1 at risk for impaired autonomy and misappropriation. Findings included: - Review of R1's trust transactions as listed on the Resident Statement Landscape dated 09/01/23 to 08/26/24 documented the following duplicate charges and one charge with no receipt for R1. The withdrawals on 01/04/24 for the following amounts had handwritten receipts with R1 and Administrative Staff B's signatures for the following amounts: $20.00, $30.00, $117.89, $25.00, $30.00, and $25.00. The withdrawal on 01/31/24 for $25.00 had no receipt documented for that withdrawal. The withdrawals on 08/06/24 for the following amounts have a handwritten receipt dated from 2023 stapled to withdrawal receipts for the following amounts with receipt numbers: W000101 $117.89, W000102 $30.00, W000103 $25.00, W000104 $30.00, W000105 $25.00, and W000106 $20.00. On 08/22/24 at 04:50 PM Administrative Staff A stated that she had not reviewed the resident trust accounts. On 08/26/24 at 10:40 AM Administrative Staff B stated she did not know the job and had not received basic training to be able to handle basic situations and learned as she went. Administrative Staff B revealed she lacked understanding of the resident trust funds. On 08/26/24 at 12:15 PM Administrative Staff B looked at the trust account for R1 and realized that she entered money paid out to R1 twice, once in January and then again in August. Administrative Staff B revealed that the receipt papers had been written out by hand and then the receipts changed to a more formal form. Administrative Staff B stated that when she was putting together the receipt book for resident trust accounts earlier in August, she was entering withdrawals that Administrative Staff B thought had not been removed from R1's trust account. Administrative Staff B stated that no one looked over the resident trust accounts except for her related to the receipts and withdrawals. The undated facility policy Transactions Involving Resident Funds documented the Business Office Manager, or his/her designee, was responsible for providing residents with receipts for withdrawals and for requested or needed personal items when such funds were withdrawn from the resident's personal funds account managed by the facility. A cope of such transactions and receipts were maintained by the Business Office Manager, or designee, to verify account transactions and to reconcile resident fund balances with withdrawals and expenditures. The Business Office Manager or designee was responsible for ensuring that resident fund accounts were reconciled on a quarterly basis and discrepancies were promptly reported to the Administrator for investigations. The policy further documented that the Business Office Manager or designee would receive periodic training on this policy to ensure that receipts for resident fund expenditures were maintained. The facility failed to provide R1 with an accurate accounting of her personal funds when the facility duplicated charges to R1's personal funds account by $347.89. This placed R1 at risk for impaired autonomy and misappropriation.

The facility identified a census of 33 residents and 23 active resident trust fund accounts. The sample included five residents. Based on record review and interview, the facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for Resident (R) 3, R4, and R5. This placed the residents at risk for impaired rights and misappropriation. Findings included: - Review of the Trial Balance as of [DATE] revealed 23 total accounts with a balance of 16, 931.18. The Trial Balance documented R3 had a current trust fund balance of $233.39. R3's Electronic Medical record (EMR) recorded R3 discharged from the facility on [DATE]. The Trial Balance documented R4 had a current trust fund balance of $178.95. R4's EMR recorded R4 discharged from the facility on [DATE]. The Trial Balance documented R5 had a current trust fund balance of $20.56. R5's EMR recorded he died in the facility on [DATE]. On [DATE] at 02:40 PM Administrative Staff B stated that she was not entirely certain what she was supposed to do with residents' trust funds when the resident died. She said, when a resident died in the facility, she typically called the family and asked what funeral home and wrote a check to the funeral home and closed out the account. Administrative Staff B said that for resident accounts that were old, from last year or many months ago, she was scheduled for training on how to convey those funds. Administrative Staff B said when a resident transferred to a different facility, she wrote a check to the resident or their family and closed out the trust. When asked about the resident that had transferred and still had a trust, she stated that must have occurred before she knew what to do with the trust accounts. Administrative Staff B said she has not received any inquiries regarding balances of trust accounts for discharged residents. The undated facility policy Transactions Involving Resident Funds lacked direction for what to do upon discharge, eviction, or death of a resident with a personal fund deposited with the facility. The facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for R3, R4, and R5. This placed the residents at risk for impaired rights and misappropriation.

The facility identified a census of 33 residents and 23 active resident trust fund accounts. The sample included five residents. Based on record review and interview, the facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for Resident (R) 3, R4, and R5. This placed the residents at risk for impaired rights and misappropriation. Findings included: - Review of the Trial Balance as of [DATE] revealed 23 total accounts with a balance of 16, 931.18. The Trial Balance documented R3 had a current trust fund balance of $233.39. R3's Electronic Medical record (EMR) recorded R3 discharged from the facility on [DATE]. The Trial Balance documented R4 had a current trust fund balance of $178.95. R4's EMR recorded R4 discharged from the facility on [DATE]. The Trial Balance documented R5 had a current trust fund balance of $20.56. R5's EMR recorded he died in the facility on [DATE]. On [DATE] at 02:40 PM Administrative Staff B stated that she was not entirely certain what she was supposed to do with residents' trust funds when the resident died . She said, when a resident died in the facility, she typically called the family and asked what funeral home and wrote a check to the funeral home and closed out the account. Administrative Staff B said that for resident accounts that were old, from last year or many months ago, she was scheduled for training on how to convey those funds. Administrative Staff B said when a resident transferred to a different facility, she wrote a check to the resident or their family and closed out the trust. When asked about the resident that had transferred and still had a trust, she stated that must have occurred before she knew what to do with the trust accounts. Administrative Staff B said she has not received any inquiries regarding balances of trust accounts for discharged residents. The undated facility policy Transactions Involving Resident Funds lacked direction for what to do upon discharge, eviction, or death of a resident with a personal fund deposited with the facility. The facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for R3, R4, and R5. This placed the residents at risk for impaired rights and misappropriation.

The facility identified a census of 37 residents with three residents reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 remained free from abuse and mistreatment. On 04/26/24 at approximately 04:10 AM, R1, who had a history of trauma and Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), approached Certified Nurse Aide (CNA) M and CNA O and asked for some chocolate milk saying chocky milk. R1 attempted to retrieve the milk from the refrigerator located in the residents' dining area but CNA M and CNA O instructed R1 he was not able to get the milk from the refrigerator himself and told him staff would get him the chocolate milk if he asked for it correctly. R1 continued to pull on the refrigerator door and the two CNA staff stepped in between the refrigerator and R1 and physically obstructed R1 from opening the door, which resulted in a struggle between the staff and R1. During this physical struggle, R1 kicked at the staff, attempted to stand up from his wheelchair, and subsequently fell to the ground. The CNA staff then grabbed R1 by his legs and turned him around while the staff locked the refrigerator. As a result of this mistreatment, R1 attempted to choke himself and verbalized his intent to eventually kill himself. The facility's failure to ensure R1 remained free from abuse and mistreatment placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Huntington's disease, other lack of coordination, generalized muscle weakness, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS further documented R1 used a wheelchair and was dependent on staff assistance for eating, bathing, oral hygiene, dressing, and personal hygiene. The MDS documented R1 required substantial assistance with mobility and transfers. The MDS documented no physical, verbal, or other behavioral symptoms were exhibited. The Falls Care Area Assessment (CAA), dated 01/23/24, documented R1 had therapy services available to help with increased functional mobility and fall risk reduction. The CAA directed staff to anticipate R1's care needs so the resident would not perform unsafe activities of daily living (ADL) without staff assistance. The CAA further documented R1 had major depressive disorder, restlessness, agitation, bipolar disorder, and Huntington's disease. R1's Care Plan with an initiated date of 02/15/24, documented R1 had an ADL self-care performance deficit related to Huntington's disease and impaired balance. Interventions with an initiated date of 2/15/24 documented R1 was dependent on staff for personal hygiene and transfers. Interventions with an initiated date of 01/29/24 directed staff to assess R1's understanding of the situation and allow time for R1 to express himself and his feelings towards the situation; when R1 became agitated staff should intervene before R1's agitation escalated. Staff should engage R1 calmly in conversation, and if R1's response was aggressive staff were directed to walk away calmly and approach later. CNA M's Complaint Investigation Witness Statement of Facts dated 04/26/24 documented R1 came to the nurse's station and asked CNA O for some chocky milk. The statement documented CNA O responded to R1 that she did not know what chocky milk was and R1 then asked CNA M for the milk instead. The statement documented CNA M responded that she was not sure what R1 had asked for and R1 became upset and stated he would get the milk himself. CNA M documented in the statement that she told R1 he was not allowed into the refrigerator and that R1 propelled himself to the refrigerator as CNA M and CNA O followed him. CNA M documented in the statement that she waited for R1 to open the refrigerator to tell R1 again that he was not allowed in it, and then told R1 if he asked correctly, staff would get him the chocolate milk, but R1 refused to listen to the CNAs. The statement further documented R1 pulled at the refrigerator door and CNA M stepped between R1 and the refrigerator door to prevent R1 from opening it which led R1 to stand up with further attempts to open the refrigerator door. The statement further documented the CNAs attempted to prevent R1 from accessing the refrigerator when R1 began to kick CNA O and R1 later fell to the floor. CNA M documented in the statement that she locked the refrigerator door while R1 was on the floor and that R1 continued to kick CNA O. The statement documented Licensed Nurse (LN) I arrived to deescalate the situation and once the refrigerator was locked and R1 could no longer open the door, R1 threatened to kill himself and proceeded to choke himself with his hands. The statement documented R1 stated choking himself did not work, but that he would kill himself eventually. The statement further documented R1 was placed on a one-to-one direct observation after R1 refused to sit near the nurses' station for close observation after making suicidal statements. The statement documented CNA M sat outside his room to observe R1. The witness statement was signed by CNA M. An Incident Note dated 04/26/24 at 04:20 AM documented R1 came to the nurse's station and requested chalky milk and the CNAs requested that R1 use appropriate words for what he wanted and not to use baby words. R1 responded that other staff let him use baby words. The note further documented that staff explained it could be difficult to understand and that it would have been more beneficial for him to use real words, and that R1 refused and stated he would get the milk himself. R1 propelled himself toward the refrigerator as the CNAs followed him. The note documented that LN I heard loud noises, went to investigate, and found R1 on the floor kicking into the air and cursing. The note documented LN I attempted to de-escalate the situation and R1 stood up and attempted to unlock the refrigerator. The note further documented that R1 threatened to kill himself after he was unable to unlock the refrigerator, and he placed his hands around his neck and attempted to choke himself. The note documented that R1 then stated he would kill himself eventually. The note documented that LN I placed R1 on one-to-one close observation, contacted facility leadership for guidance, contacted R1's physician, and sent R1 to the emergency room , via ambulance, due to the suicidal statements R1 made during the incident. A Nurse Note dated 04/26/24 at 04:26 PM documented that staff spoke with R1 about the incident that occurred earlier in the morning that caused him to be sent to the emergency room . The note documented that R1 stated he was no longer suicidal and had no plan or intent to commit suicide. The note further documented staff discussed R1's triggers and his available coping skills and went over R1's trauma-informed care plan with him. The note documented R1 agreed with the care plan and voiced that he was hopeful and excited to have support from the staff. On 04/26/24 at 02:05 PM, R1 sat in his room on his bed. R1 stated that CNA M and CNA O were rough with him the night he asked for milk, and it caused him to fall. R1 stated CNA M and CNA O no longer worked at the facility and that he felt safer there as a result. On 04/26/24 at 02:15 PM a combined interview was conducted with LN G and LN H. LN G stated when she came on shift that morning R1 had been taken out of the facility by ambulance to be evaluated for the suicidal comments he made on the previous shift. LN G stated the CNAs knew to get the nurses when R1 had behaviors so the nurses could intervene. LN G and LN H stated R1 was redirectable, but it depended on the approach staff took when interacting with him. LN H stated if staff took the time to explain a situation to R1 he would typically respond better than if staff were short with him, or just told him no without an explanation. LN G and LN H stated residents are allowed to have items from the refrigerator 24 hours a day and that they only had to ask staff. LN H stated R1 should have been able to have the chocolate milk when he requested it. On 04/26/24 at 02:15 PM, CNA N stated when R1 had behaviors she would walk away and get the nurse so the nurse could intervene. CNA N stated residents are allowed to have items from the refrigerator if they ask for them. CNA N stated the refrigerator was locked for infection control reasons, but if residents ask for something from the refrigerator, then staff will get it for them. On 04/26/24 at 03:47 PM Administrative Nurse D stated from her understanding of the incident R1 asked for chocolate milk but used a slang word when he asked. Administrative Nurse D stated R1 was told by staff to use big boy words and R1 then decided to get the chocolate milk himself. Staff did not want him to get the milk himself, so they followed R1 and proceeded to physically keep him out of the refrigerator. Administrative Nurse D stated while staff attempted to physically stop R1 from getting into the refrigerator, R1 fell to the floor and kicked at staff to defend himself. Administrative Nurse D stated R1 was drug and spun around by one of the CNAs so the other CNA could lock the refrigerator. Administrative Nurse D further stated the nurse heard the commotion and came to the dining hall to de-escalate the situation and that was when R1 tried to choke himself and made suicidal statements. Administrative Nurse D stated staff should have gotten up and gave R1 the chocolate milk regardless of how he asked for it. Administrative Nurse D stated R1 drinks chocolate milk often and staff knew that. Administrative Nurse D further stated it was extremely demeaning for staff to tell R1 to use his big boy voice. Administrative Nurse D stated she reviewed the video footage from the incident, and it appeared the staff were being aggressive with R1 and not R1 being aggressive with the staff. Administrative Nurse D stated she did not want the CNAs back in the facility after she viewed the video, so the CNAs were suspended and later terminated. The facility provided an Abuse, Neglect and Exploitation policy dated 01/01/24, documented it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy further documented abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff-to-resident abuse and certain resident-to-resident altercations. Mental abuse includes but is not limited to, humiliation, harassment, threat of punishment, or deprivation. The facility failed to ensure residents remained free from abuse and mistreatment. This deficient practice placed R1 in immediate jeopardy. On 04/26/24 the facility completed corrective actions which included an all-staff in-service on preventing abuse, neglect, and exploitation and reporting abuse. The facility updated R1's care plan to include his past trauma and relevant interventions for staff to follow. CNA N and CNA O were not permitted back into the facility after the incident and were subsequently terminated. The corrective actions were completed before the onsite survey therefore the deficient practice was cited as past noncompliance at a scope and severity of J.

The facility had a census of 37 residents. The sample included 12 residents and three Certified Nurse Aides (CNAs) reviewed for yearly performance evaluations. Based on record review and interview, the facility failed to ensure three CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's performance evaluation records revealed the following: CNA O, hired 06/18/21, no yearly performance evaluations were provided upon request. CNA P had a hire date of 09/05/22. The facility could not provide any evidence that a yearly evaluation had been performed in 2023. The facility provided an evaluation dated 02/26/24 ( two days after the start of the survey). CNA Q was hired on 08/04/20. The facility provided a performance evaluation dated 02/27/24. CNA Q had no prior performance evaluations. On 02/28/24 at 11:45 AM Administrative Nurse D stated she had learned a lot during the survey and was aware that staff performance evaluations had not been completed as they should have been. Administrative Nurse D stated she had been in her position since January 2024 and would be completing the performance evaluations for the staff members in the next few days. The facility lacked a policy for Performance Review. The facility failed to ensure three CNA staff had yearly performance evaluations completed as required. This placed the residents at risk for inadequate care.

The facility identified a census of 37 residents. The sample included 12 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility failed to submit staffing hour data for all nursing personnel by the required deadline. This deficient practice placed residents at risk for impaired care due to unidentified and ongoing staffing issues. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 1 documented the facility triggered for one-star staffing and excessively low weekend staffing. Per the PBJ, the facility failed to have licensed nursing coverage 24 hours a day on 10/01/22, 10/02/22, 10/29/22, 11/24/22, and 12/26/22. The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 2 the facility triggered for one-star staffing and excessively low weekend staffing. Per the PBJ, the facility failed to have licensed nurse (LN) coverage 24 hours a day on 02/10/23, 03/02/23, 03/03/23, 03/04/23, 03/11/23, 03/13/23, 03/14/23, 03/15/23, 03/16/23, 03/17/23, 03/18/23, 03/23/23, 03/24/23, 03/25/23, 03/26. The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter Three documented the facility triggered for one-star staffing and excessively low weekend staffing. Per the PBJ, the facility failed to have LN coverage 24 hours a day on 04/06/23, 04/08/23 04/14/23, 04/15/23, 04/16/23, 04/17/23, 04/21/23, 04/28/23, 04/29/23, 04/30/23, 05/03/23, 05/08/23, 05/13/23, 05/14/23, 05/15/23, 05/16/23, 05/17/23, 05/23/23, 05/26/23, 05/30/23, 06/18/23, 06/24/23, 06/25/23. The facility failed to have Registered Nurse (RN) hours on 04/18/23, 04/19/23, 04/25/23, 04/26/23, 05/01/23, 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/16/23, 05/17/23, 05/23/23, 05/24/23, and 05/30/23. Upon review of printed staffing punch times of facility staff and agency staff provided by the facility for the dates above it was revealed that the facility had proof of LN hours for all dates. On 02/28/24 at 11:45 AM Administrative Staff A stated he was not sure what the previous management staff's process was to submit LN and RN hours information for the PBJ report. Administrative Staff A stated since he has been the administrator he makes sure he submits all staff including any agency staff's hours worked. The facility lacked a policy for PBJ reporting. The facility failed to submit complete and accurate staffing information to the federal regulatory agency through PBJ when the facility failed to submit staffing hour data for all nursing personnel by the required deadline. This deficient practice placed residents at risk for impaired care due to unidentified and ongoing staffing issues.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from February 2023 through January 2024, lacked evidence of organism identifications, duration of antibiotic prescribed, and the infections treated. The facility was unable to provide evidence of tracking upon request. On 02/28/2 at 10:41 AM, Administrative Nurse E, the facility Infection Preventionist, stated she reviewed the results of any culture and sensitivities but did not track the results. Administrative Nurse E stated she or the charge nurse completed the Mcgeer's and Lobe's criteria after a urine analysis was obtained. The facility's Antibiotic Stewardship Program last reviewed in November 2023 documented it was the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Antibiotic Stewardship Program leaders would utilize existing resources to support antibiotic stewards' efforts by working with the consultant laboratory to develop a process for alerting the facility if certain antibiotic resistant organisms are identified, providing education for nursing home staff on the differences in diagnostic tests available for detecting various infectious pathogens, and creating a summary report of antibiotic susceptibility patterns from organisms isolated in cultures. The facility failed to proactively apply the principles of antibiotic stewardship, for the residents of the facility from February 2023 through January 2024 to ensure antibiotics were administered in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance.

The facility had a census of 37 residents. The sample included 12 residents and three Certified Nurse Aides (CNAs) reviewed for in-service training. Based on record review and interview, the facility failed to ensure the four CNA staff reviewed had the required 12 hours of in-service education including the required topics per year. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's in-service records revealed the following: CNA O hired on 06/18/21 had documentation that showed in-services in the past 12 months but lacked any recorded/documented hours of in-service. CNA P hired 09/05/22, had documentation that showed in-services in the past 12 months but lacked any recorded/documented hours of the in-service. CNA Q hired 08/04/20 had documentation that showed in-services the past 12 months but lacked recorded/documented hours. The facility provided the form Annual In-Service Calendar which listed the required in-services for each month and the duration of each training which totaled 42.5 hours annually. On 02/28/24 at 09:00 AM Administrative Staff B stated that the nurse aide education information should be in a binder. Administrative Staff B stated the nurse aide's in-service hours should be tracked by the corporate nurse educator. Administrative Nurse B stated going forward the facility would ensure that in-service hours were logged for the staff members. The facility lacked a policy for in-service education. The facility failed to ensure CNA staff reviewed had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care.

The facility identified a census of 37 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to obtain consent or declinations for influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination for Resident (R) 22 and R35. The facility also failed to offer or obtain declinations for pneumococcal (type of bacterial infection) vaccination consents, declinations, or administration information for R22, R35, R17, and R32. This placed the residents at increased risk for influenza, pneumonia, and related complications. Findings included: - R22 was admitted to the facility on [DATE]. R22's clinical record lacked documentation the influenza vaccine or pneumococcal vaccine was offered or declined and lacked documentation of a historical administration. Upon request for R22's declination or administration of influenza vaccine or pneumococcal vaccine, the facility was unable to provide consent or declination. R35 was admitted to the facility on [DATE]. A review of R35's clinical record lacked documentation the influenza vaccine or pneumococcal vaccine was offered or declined and lacked documentation of a historical administration. Upon request for R35's declination or administration of influenza vaccine or pneumococcal vaccine, the facility was unable to provide consent or declination. R17 was admitted to the facility on [DATE]. A review of R17's clinical record lacked documentation the pneumococcal vaccine was offered or declined and lacked documentation of a historical administration. Upon request for R17's declination or administration of the pneumococcal vaccine, the facility was unable to provide consent or declination. R32 was admitted to the facility on [DATE]. A review of R32's clinical record lacked documentation the pneumococcal vaccine was offered or declined and lacked documentation of a historical administration. Upon request for R32's declination or administration of the pneumococcal vaccine, the facility was unable to provide consent or declination. On 02/28/24 at 10:41 AM, Administrative Nurse E, the facility Infection Preventionist, stated she had not been tracking the immunizations, but would start tracking the immunizations for the residents at the time of their admission. Administrative Nurse E stated she was not aware that immunizations consent was included in the admission paper work. The facility's Influenza Vaccination policy dated November 2023 documented it was the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunizations against influenza. The Facility's Pneumococcal Vaccine policy dated November 2023 documented it was our policy to offer residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current Centers for Disease Control guidelines and recommendations. The facility failed to obtain influenza and pneumococcal vaccination consents, declinations, or administration information for R22, R35, R17, and R32. This placed the residents at increased risk for influenza, pneumonia, and related complications.

The facility identified a census of 43 residents. The sample included 11 residents. Based on observation, record review, and interview the facility failed to develop and implement appropriate interventions to prevent falls and failed to implement planned interventions for one (#48) of three residents reviewed for falls, and failed to provide an environment free from accident hazards in an an unlocked, unattended closet and bathroom which had the opportunity to affect 8 cognitively impaired, independently mobile residents. Findings included: - The electronic medical chart on 4/21/15 at 8:42 A.M. revealed resident #48 had [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 8 (moderate cognitive impairment), required limited assistance of one staff for bed mobility, transfers, walking, locomotion, and dressing. He/she required extensive assistance of 1 staff with toilet use and personal hygiene, was not steady, but able to stabilize without staff assistance, had no functional limitation in range of motion, used a walker, had an indwelling urinary catheter, was always continent of bowel, received pain medication, had pain almost constantly which made it hard to sleep and limited day-to-day activity, rated 6 out of 10 on a 0 to 10 pain scale, had a fall within the last month prior to admission, received antidepressant medication 7 out of 7 days in the look back period, started occupational and physical therapies on 7/2/14. The Quarterly MDS dated [DATE] revealed the resident had short and long term memory problems, had moderately impaired cognition, required limited assistance of one staff for bed mobility, locomotion, required extensive assistance of 1 staff with transfers, walking, dressing and toilet use, was not steady, only able to stabilize with staff assistance, had no impairment of extremities, used a walker and a wheel chair, had a urinary catheter, was frequently incontinent of bowel, received pain medications, rarely had pain, rated 1 out of 10 on a 0 to 10 pain scale, that did not affect day-to-day activities, had 2 or more falls, one injury fall since the last assessment, received antidepressant 7 out of 7 days in the look back period, and did not receive therapy. The Care Area Assessment (CAA) for falls dated 7/14/14 revealed the resident required limited to extensive assistance with most ADL functions, including transfers and ambulation. The admission assessment revealed the resident stated he/she had a history of [REDACTED]. Staff would continue to assist the resident with transfers and ambulation. The resident would continue to receive physical and occupational therapy services to help build strength. The care plan dated 7/9/14 revealed staff used a gait belt on the resident when assisting him/her with ambulation. He/she required a walker to use for mobility, one staff member assistance with bed mobility, and transfers. The staff monitored for side effects of medications of orthostatic hypotension (drop in blood pressure when changing from a sitting to a standing position) and the new onset or increased agitation, restlessness, confusion, dizziness and falls. The intervention initiated on 3/19/15 noted the resident was confused and fell , and staff checked for a urinary tract infection. Staff initiated a new intervention of a bed alarm at all times was initiated on 10/15/14. New interventions were for the resident to see psychiatry due to confusion, and staff awaiting antibiotic orders from the doctor were initiated on 4/15/15. New interventions added on 4/20/15 revealed the resident had times when he/she was very confused, told the staff he/she saw things and tried to climb out of bed. Most of his/her falls happened when he/she had one of those episodes. Sometimes he/she was did this when he/she had a Urinary Tract Infection (UTI) but other times staff was unsure of why he/she was confused. The staff monitored closely and assist him/her during confused times to help keep him/her safe. The signed physician's orders [REDACTED]. Norvasc 5 mg by mouth every day for hypertension (HTN), hold if systolic blood pressure (SBP) less than 115, hydro/APAP (acetaminophen-for relief of pain or fever) 5/325 milligram (mg) one tablet by mouth four times daily for pain and not to exceed (NTE) 3 grams APAP in all medications in 24 hours, Macrobid (give to prevent or treat urinary tract infection (UTI)) 100 mg by mouth every day for UTI prophylactic, bed alarm at all times while in bed started 8/27/14, and apply chair alarm at all times as of 10/13/14 Record review on 4/22/2015 at 1:07 P.M. lacked orthostatic blood pressures to monitor side effects of medications as planned. The Fall Risk Assessments dated 7/1/14, 9/27/14, 3/29/15, and 4/11/15 revealed the resident was at high risk for falls. The nurse's note (NN) dated 10/12/14 at 3:50 A.M. revealed at approximately 12:20 A.M. staff overheard the resident yelling out for help. Staff entered the resident's room and found the resident on the floor. The nurse then entered the resident's room and observed the resident on the floor at the foot of his/her bed, laying on his/her back, with his legs extended outward. The resident stated he/she fell out of the bed, and hit the back of his/her head. The nurse performed active and passive range of motion of both arms and legs without the resident complaining of pain or discomfort. Two staff members assisted the resident off of the floor with a gait belt and transferred him/her to his/her recliner. The resident raised the right sleeve of his/her shirt, and stated it hurt. The nurse observed bleeding to his/her right elbow from an open, circular abrasion that measured approximately 1.0 centimeter (cm) in diameter, cleansed the area and applied triple antibiotic ointment (TAO) and covered it with a band aide. The incident investigation dated 10/12/14 provided by the facility revealed the resident had an un-witnessed fall in his/her room, and He/she stated he/she fell out of the bed. The call light was within reach. The reason the fall occurred was the resident stated he/she fell out of bed and did not explain what he/she was attempting to do prior to his/her fall. Intervention put into place immediately to prevent reoccurrence was the nursing staff provided more frequent checks with the resident. The investigations lacked witness statements or the investigation to determine the reason for the fall, and no orthostatic blood pressures (blood pressures taken while the resident was laying, sitting, and standing position). The nurse's notes (NN) dated 10/12/14 at 6:04 P.M. revealed staff found the resident located on the floor in front of his/her recliner at 2:00 P.M. He/she stated that he/she slipped trying to get to his/her phone. The resident had no complaints of pain or injuries. The physician gave new orders for: a bed and a chair alarm effective immediately. The Incident Investigation dated 10/12/14 provided by the facility revealed the resident had an un-witnessed fall in his/her room while reaching for an object and trying to stand unsupervised from his/her recliner with bare feet. The resident had a history of [REDACTED]. The intervention put into place immediately to prevent reoccurrence was to re-enforced need to use the call light and not to get up without help. The investigation lacked witness statements or investigation to determine the reason for the fall, and orthostatic blood pressures. The NN dated 10/19/14 at 11:54 P.M. revealed the doctor called back with new orders: 1) Olanzapine 2.5 milligram (mg)( medication for acute manic episodes), give 1/2 tab now (gave to the resident at 7:50 P.M.), 2) Haldol 0.25 mg give one tablet every 4 hours as needed for [DIAGNOSES REDACTED]. The resident was still agitated, hallucinating, and trying to get up. The NN incident note dated 10/20/14 at 12:02 P.M. revealed the staff found the resident sitting on the floor vertical to his/her bed at 10:45 P.M. He/she sat up with legs out in front of him/her, the bed alarm was not going off, the resident was barefoot with a brief and a shirt on, he/she yelled and was cussing to get up. The resident was able to move all arms and legs, was weak, unsteady on his/her feet. The resident received Olanzapine 2.5 mg 1/2 tab at 7:50 P.M. The nurse called the resident's family to inform them the resident had a fall. The resident's family stated that resident was hallucinating and agitated during their visit earlier in the day and staff placed a pull alarm on the resident. The Incident Investigation provided by the facility dated 10/19/14 revealed resident was in his/her room next to the bed, trying to get out of bed,the call light was in reach the bed/chair alarm on, medications the resident received listed olanzapine 2.5 mg 1/2 tab one time only at 7:50 P.M. The reason this incident occurred was due to the resident being agitated, hallucinating, and tried to get up independently all day. The intervention put into place immediately to prevent reoccurrence was staff placed a pull away alarm on the resident. The investigation lacked witness statements or investigation to determine the reason for the fall, and no orthostatic blood pressures. The NN incident note dated 3/14/15 at 7:30 P.M. staff observed the resident's call light on and the bed alarm was disarmed. The staff found the resident on the floor, on his/her back in front of his/her bathroom door. The resident stated he/she had to go to the bathroom. The Incident Investigation dated 3/14/15 provided by the facility revealed the resident had an un-witnessed fall in front of the resident's bathroom door while going to the bathroom, the call light was in reach, bed/chair was alarm on, the resident received 9 plus medications including cardiovascular medications. The fall occurred because the resident required limited assistance of 1 staff, and was up and ambulating unassisted. The intervention put into place immediately to prevent reoccurrence was the nursing staff remained with the resident 30 minutes after the fall to ensure his/her safety. The investigation lacked witness statements or an investigation to determine the reason for the fall, and there were no documented orthostatic blood pressures. The NN dated 4/11/15 at 6:10 P.M. revealed staff found the resident on the floor on his/her stomach, with his/her left arm under the recliner. He/she had a 1 centimeter (cm) x 1 cm skin tear on his/her left hand ring finger which was cleansed with normal saline and Steri strips applied. The resident had a 2 cm x 2 cm hematoma (blood filled raised bruise) found on his left elbow, and his left knee was red and measured 2 cm x 2 cm. When staff notified the resident's family, the family requested the facility check the resident for a UTI due to his/her increased agitation and increased anxiety and also requested staff to give the resident ativan. The incident investigation dated 4/11/15 provided by the facility revealed the resident had and un-witnessed fall in his/her room getting out of bed, transferring to recliner and crawling . The call light in reach, the bed/chair alarm was on, he/she received antianxiety medications. The fall occurred because the resident had been very busy and active today and last night he/she was up all night talking to him/herself, and was confused. The resident had increased agitation and anxiety. Interventions put into place immediately to prevent reoccurrence was staff ensured bed alarm was turned on, made sure the resident was comfortable in bed with call light in reach, informed the resident to use his/her call light for help. The investigation lacked witness statements or investigation to determine the reason for the fall, orthostatic blood pressures, and neuro checks. The NN dated 4/13/15 at 5:05 P.M. revealed the resident's family reported the resident complained of pain in his/her hip. The family requested an x-ray to rule out a fracture. The physician and gave an order for [REDACTED]. The NN dated 4/13/15 at 11:58 P.M. revealed the x-ray results left hip had moderate degenerative changes and a suspected fracture at the femoral neck which appears mildly shortened. The X-ray company's patient report dated 4/13/15 of the resident's left hip revealed complete 2 or more (+) views were obtained due to post fall and the resident complained of pain. The summary revealed a possible impaction fracture at the femoral head, neck junction, and moderate degenerative changes of the left hip. The NN dated 4/14/15 at 3:26 P.M. revealed the resident complained of pain in the left hip, scheduled pain medication given and was effective. The physician progress notes [REDACTED]. On 4/20/2015 at 3:43 P.M. direct care staff W repositioned the resident in bed. On 4/21/2015 at 12:15 P.M. direct care staff R asked to get the resident up out of bed to the recliner. The resident stated he/she did not want to get up due to not feeling well. On 4/20/2015 at 3:44 P.M. direct care staff LL stated he/she used the Kardex (a medical information system) to know how to take care of the resident, he/she looked in the computer, and read it to verify the interventions were listed: use a gait belt with ambulation, bed alarm, likes to eat meals sitting on side of the bed, and prop his/her legs up. On 4/22/2015 at 1:09 P.M. licensed staff K stated the nurses do not do orthostatic blood pressures after a fall. They did them if ordered from the physician or if staff noticed changes in the resident. He/she stated he/she considered falls as a change. She acknowledged resident #48's care plan stated orthostatic hypertension, and falls were side effect of medications the resident received. On 4/21/2015 at 3:52 P.M. administrative staff B stated staff talked about fall interventions they needed for the resident but was not sure if any were put into place before or after the fall. He/she said neither the bed nor the chair alarm sounded when the resident fell on [DATE]. On 4/22/2015 at 9:41 A.M. administrative nursing staff D stated the resident's care plan should have addressed his/her confusion with the resident's falls in October 2014 and again in March 2015. On 4/22/2015 at 1:20 P.M. administrative nursing staff D stated they did not do orthostatic blood pressures unless there were physician's orders [REDACTED]. The facility's fall policy dated March 2014 revealed the facility prevented the resident from falls when possible. When a fall occurred, the facility assessed the resident for injury. For a un-witnessed fall, the nurse completed an assessment which included vital signs, pain, head-to-toe assessment, range of motion and neuro checks if applicable. The incident report was given to the director of nursing (DON) for further review. The facility failed to implement interventions as planned, failed to determine the cause of the falls and failed to develop and implement appropriate and effective fall interventions for this cognitively impaired, dependent resident who experienced repeated falls and sustained a hip fracture. - On 4/22/14 at 2:20 P.M. revealed an unlocked closet in the west end resident bathroom with 2 mop buckets (identified by licensed nursing staff H) that contained chlorinated water for spills. Licensed nurse H stated he/she was not aware the door was not locked and would notify maintenance. On 4/22/14 at 2:21 P.M. observation in the west end resident bathroom revealed a chipped porcelain toilet tank cover lid. Licensed nurse H acknowledged the toilet tank lid presented a hazard to the residents on the unit and stated he/she would notify maintenance. The facility identified 8 independently mobile cognitively impaired residents in the building with access to these areas. The April 2015 Storage of Housekeeping Products policy documented: other housekeeping products such as mops buckets were stored in locked areas. The facility failed to maintain and environment as free of accidents hazards.

The facility identified a census of 41 residents. The sample included 13 residents. Based on observation, record review, and staff interview, the facility failed to identify and monitor hot water temperatures in the main dining room on 1 of 4 days onsite of survey which placed the residents in immediate jeopardy. The facility also failed to provide adequate supervision for 1 sampled resident (#47) regarding elopement placing the resident in immediate jeopardy. The facility failed to monitor bed rail gaps for 2 sampled residents (#20, #33). Findings included: - During the initial tour on 7-19-11 at 10:10 A.M., at the sink in the kitchen cabinet corner of the main dining room, direct care staff C ran water as he/she washed his/her hands. The water steamed as it hit the stainless steel sink. The water temperature on 7-19-11 at 10:12 A.M. rose to 140.1 F. Confirmation of that temperature with another thermometer confirmed the temperature of 140.1 F. On 7-19-11 at 10:10 A.M. there were four residents in the sink area of the dining room and other residents who passed through the dining room by the sink. Dietary employee A stood by the sink when this writer identified the high temperatures and said on 7-19-11 at 10:31 A.M., he/she did not realize how hot the water was until a few minutes prior so he/she did not wash their hands at that sink. Direct care staff D, the employee observed in use of the sink, said on 7-19-11 at 10:32 A.M. the water at that sink was usually that hot. On 7-19-11 at 10:43 A.M., this writer informed administrative staff A of the hot water temperatures. On 7-19-11 at 10:50 A.M., Administrative staff B stated the sink was not connected to any other sink, that it had a separate hot water heater which was in the cabinet below the sink. He/she also stated that the problem had occurred before and the facility replaced the hot water heater. Staff B said he/she did check water temperatures in the facility but did not check the temperature for this sink routinely. On 7-19-11 at 10:55 A.M., administrative staff A stated Administrative staff B turned off all the hot water in the building and also called a plumber. Administrative staff A said the hot water heater for that sink did not heat any other sink and that there was a problem about three weeks prior but maintenance staff A fixed it. Administrative staff A said that Administrative staff B checked the water temperatures regularly, he/she did not think maintenance checked the temperatures on that sink but they would now. On 7-19-11 at 11:10 A.M. Administrative staff B provided temperature logs for the facility and said he/she did not take the water temperature of the sink yet, but turned down the hot water tank under the sink several minutes before. The facility thermometer read 136.9 F. This writer's thermometer read 147.8 F. The facility Temperature logs revealed Administrative staff B checked temperatures randomly on resident halls and took the laundry temperatures and kitchen temperatures on a weekly basis. The temperature logs lacked evidence the facility checked the water temperature at the dining room cabinet sink before and/or after the previous concern with hot water temperatures at that sink. A temperature of the dining room sink on 7-20-11 at 7:15 A.M. was 105.0 F. The dining room sink temperature on 7-21-11 at 7:05 A.M. was 107.0 F. The dining room sink temperature on 7-25-11 at 8:30 A.M. was 102.0 F. The facility provided the water temperatures for the dining room sink for 7-22 -11 at 106.0 F; 7-23-11 at 103.0 F.; and 7-24-11 at 100.0 F. The facility corrective action plan was submitted on 7-20-11 at approximately 7:05 A.M. to the survey agency. The facility corrected the immediate jeopardy on 7-19-11 at 5:52 P.M. with the implementation of the new procedures. The immediate jeopardy was abated on 7/19/11 at 5:52 P.M. when the plumber repaired the hot water setting and the facility started checking the water temperatures to the dining room sink regularly. The scope and severity remains at an E. - Resident #47 admitted to the facility on [DATE]. The July 2011 physician's orders [REDACTED]. The POS also contained an order for [REDACTED]. The Minimum Data Set 2.0 ((MDS) dated [DATE] recorded the resident with intact long term memory and impaired short term memory. The MDS recorded the resident with moderately impaired decision making skills and was easily distracted, had periods of altered perception or awareness of surroundings, periods of restlessness and deterioration in cognitive status. The resident's mood had deteriorated in the last 90 days. The MDS recorded the resident was independent with transfers and ambulation. The mood state Resident Assessment Protocol (RAP) dated 8-26-10 recorded the resident was very forgetful, moderately cognitively impaired and had short term memory impairments. The resident would forget why he/she was staying at the facility, where his/her room was and that his/her family member knew where he/she was. Resident was restless throughout the day and constantly walked the halls of the facility. The resident was easily redirected and comforted by staff. The quarterly MDS 3.0 with an assessment reference date of 5-19-11 recorded the resident with a Brief Interview of Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The MDS recorded the resident displayed behaviors of inattention and disorganized thinking. The MDS recorded the resident did not wander in the last 7 days. The MDS recorded the resident was independent with bed mobility, transfer, walking in room or corridor and locomotion on the unit, and required supervision with locomotion off the unit. The MDS recorded the resident received antianxiety medication within the last 7 days. The initial care plan dated 8-13-10 recorded the resident with a Wanderguard to his/her right wrist and independent with ambulation with a rolling walker. The care plan reviewed on 6-1-11 recorded the resident walked around much of the time and was forgetful and confused at times, sometimes it helped the resident to talk to his/her family member. The care plan recorded the resident was at risk for elopement and he/she wore a Wanderguard bracelet and for staff to check the Wanderguard daily. The care plan directed nursing to comfort the resident as much as possible; reassure the resident that his/her family member was ok and that he/she would be back to see the resident and redirect the resident as much as possible with activities, coffee, and conversation. The fall care plan had an intervention added on 7-12-11 of motion sensor placed on Special Care Unit (SCU) door and staff could wire the door to the alarm panel. The initial Wandering Assessment Guide dated 8-13-10 recorded the resident as a new admission, ambulatory, able to walk alone, able to walk with walker or other assistive device or use wheelchair, without a history of wandering and with indications of dementia which indicated the need for a Wanderguard. Subsequent assessments dated 9-13-10, 2-23-11 and 5-17-11 recorded the resident with a Wanderguard in place. Nurses notes dated 6-24-11 and timed 2-10:00 P.M. shift recorded the resident was alert and oriented to person and he/she wandered in the SCU. At times the resident was tearful and continually asked about his/her family member. Nurses notes dated 6-30-11 at 6:30 P.M. recorded the resident was alert to self only and family member, ambulated on his/her own with a steady gait. Nurses notes dated 7-12-11 at 5:30 P.M. recorded staff found the resident at 3:07 P.M. outside the back door by the dining room that lead to the private parking lot. Staff checked the resident's Wanderguard and was actively and currently working. Staff checked all Wanderguard doors which were working. The social service notes dated 5-23-11 no time recorded, revealed the resident continued to live on the special care unit, was disoriented to time and place and had significant short term memory loss. He/she had episodes of anxiety and these usually occurred after 2:00 P.M. in the day. The Physician's visit documentation dated 5-19-11 recorded the resident with dementia. Review of the Maintenance Weekly Check for Wanderguard System revealed documentation that staff checked the Wanderguard alarms weekly, the last date before the elopement was on 7-11-11. Record review also revealed staff documented they checked the door alarms monthly. Review of the July 2011 TAR (Treatment Administration Record) revealed staff signed they checked the placement and function of the resident's Wanderguard each shift and staff recorded no problems with function or placement. Observation on 7-25-11 at 10:06 A.M. revealed the resident seated in a chair at the table in the living/dining room with his/her purse. The resident asked direct care staff B to go to Omaha with his/her mother and father. Direct care staff B stated the resident's family member would visit around lunch time and he/she would talk with him/her about it. The resident reported at this time that he/she needed to go to the bathroom. Direct care staff B assisted the resident with stand by assist to go to the bathroom at this time. Direct care staff B assisted the resident back to the living/dining room at 10:11 A.M. Observation revealed the resident wore a Wanderguard bracelet on his/her right wrist at this time. The resident walked with stand by assist and without any assistive devices. Observation and interview on 7-25-11 at 10:15 A.M. with Administrative staff A revealed the SCU door by room 8 had a keypad to enter the code, a 15 second delayed door alarm. Administrative staff A stated that maintenance used this door occasionally. Administrative staff A stated that from his/her understanding, the lock on the door was pushed in so the 15 seconds did not alarm. Administrative staff A stated staff found the resident knocking on the dining room door and it was not a fenced area. Observation revealed the facility was directly adjacent to the highway. During an interview on 7-25-11 at 11:21 A.M., Licensed Nursing Staff D reported he/she was not at the facility when the resident walked out on 7-12-11, but that he/she worked that morning, left for an appointment and returned to the facility at 3:10 P.M. Staff brought the resident back in the building at 3:07 P.M. Licensed nursing staff D stated that the resident was upset and agitated that morning and around 2:00 P.M. was the resident's time when sundowners set in he/she got more agitated. Every shift he/she checked Wanderguards for placement and function. Licensed nursing staff D stated there was not a Wanderguard alarm on the SCU doors prior to the resident's elopement, but you had to have a code to get out. Staff found the resident outside by the dining room door that went out to our parking lot. Licensed nursing staff D stated the resident would have to walk up the long driveway to Highway 192, and the speed limit was 30 miles per hour. The Certified Nurses Aide (CNA) working on the SCU thought the resident was lying down in bed, and didn't even hear the door open. The resident walked up to the doors and banged on them and constantly walked. The resident was on the main unit when he/she first admitted to the facility and we had problems with him/her wandering in and out of the resident's rooms and that is why he/she was moved onto the unit, he/she always looked for her family member. The resident's Wanderguard was in place when he/she left and it staff checked it that morning. During an interview on 7-25-11 at 11:41 A.M., Administrative staff B stated staff checked the door alarms and Wanderguard alarms weekly with no problems with the function of the alarms noted. Administrative staff B stated he/she did use that about 3:05 P.M. on 7-12-11 and thought the door latched. Administrative staff B stated they did not see the resident at that time. Administrative staff B continued that if the door did not latch, the door could be opened within the 10 seconds. Administrative staff B stated that the resident could have gotten to the highway from where he/she exited but that he/she would have to go all the way around to the front of the building. Administrative staff B continued that when he/she left the building and that no one was out in the parking lot at about 3:05 P.M. on 7-12-11. Licensed nursing staff A interview on 7-25-11 at 12:31 P.M. stated that the resident had falls in the past and that he/she was a high fall risk according to his/her fall risk assessment. Documentation provided by the facility revealed the temperature was 91 degrees outside at that time. During an interview at 1:02 P.M. on 7-25-11 with Direct care staff A stated he/she worked the evening the resident went out of the building, and he/she was sitting in living room talking with another resident. Direct care staff A stated the resident was extremely upset looking for his/her spouse and complained of how tired he/she was. Direct care staff stated he/she thought the resident went to lie down. A few minutes after that, Administrative staff B walked through the unit and apparently the resident went out the west door, and he/she did not hear the alarm go off. We have a lot of days where he/she is looking for his/her spouse. Administrative staff B stated it was warm outside on 7-12-11, but did not remember the temperature, there was no gate around the area where staff found the resident and the resident would have to walk a long way to get to the highway. Direct care staff stated the resident walked a lot on his/her own. An interview with Administrative staff B at 2:01 P.M. on 7-25-11 revealed he/she checked the door alarms every week when he/she checked the Wanderguards, but he/she only documented it monthly. On 7-25-11 at 2:50 P.M. during an interview with Licensed nursing staff B revealed he/she was still at the facility the evening the resident left the building and he/she heard the resident knocking on the door between the SCU and the main part of the facility before he/she left the building. The facility failed to provide adequate supervision to this resident resulting in an elopement from the facility. The facility's failure to provide adequate supervision placed the resident in immediate jeopardy for injury or harm related to heavy traffic, at risk for falls, lack of safety awareness and exposure to warm temperatures. The facility's plan of correction revealed staff immediately placed motion sensors of the Special Care Unit exterior doors at approximately 5:00 P.M. on 7-12-11. The maintenance supervisor checked the 15 second door alarm and the alarm was functioning properly. All keypads on the doors were immediately checked and the keypad code to open the doors was working. All Wanderguard doors were immediately checked and were working properly. The resident's Wanderguard bracelet sounded when coming into the building and the charge nurse also checked to ensure the Wanderguard bracelet was working, Wanderguard was actively working. Staff performed neurological checks immediately, staff performed a post-fall assessment with no injuries noted. Staff performed a full skin assessment and without new skin injuries noted. Staff notified the resident's physician and family immediately. The facility purchased an additional panic alarm and was installed on 7-14-11 at approximately 9:30 A.M. The alarm made the SCU exterior doors sound anytime they opened. The facility purchased a Wanderguard alarm system on 7-13-11. Installation of the Wanderguard system was on 7-18-11 at approximately 1:00 P.M. The system functioned on the SCU exterior doors. On 7-12-11 at approximately 5:00 P.M., the facility abated the immediate jeopardy when Administrative staff A placed a motion sensor on the exit doors of the SCU. This deficient practice remained at the scope and severity of an E. - The physician's orders [REDACTED]. The Annual Minimum Data Set (MDS) 3.0 with Assessment Reference Date (ARD) of 6/23/11 for a Staff Assessment for Mental Status revealed the resident had long/short term memory problems; was able to recognize staff names and faces; cognitive skills for daily decisions making were severely impaired; and bed mobility of total dependence. The revised care plan dated 6/29/11 revealed the resident had a low air loss mattress and full side rails; the side rails needed padding because the resident bruised her/his hands on the rails but the family/DPOA did not want the side rails padded. The Side Rail Screening Assessment with review date of 6/14/11 revealed the resident was nonambulatory; had an alteration in safety awareness due to cognitive decline; had a history of [REDACTED]. resident used full side rails due to the use of a low air loss mattress. The Side Rail Screening Assessment lack documentation of a safety assessment for the 5 inch gaps on the full length side rails. Observation on 07/19/2011 at 3:40 P.M. revealed two full length bed rails on the resident's bed when she/he was in bed. The area between the top rail and the next rail measured 5 inches. Observation on 7/21/11 at 2:43 P.M. revealed the resident lying in bed with both full length side rails in the up position; a call bell was within reach; the head of the bed elevated approximately 45 degrees; and the resident was not moving. Observation on 7/25/11 at 12:58 P.M. revealed the resident lying in bed with both side rails in the up position sleeping. Staff interview on 7/25/11 at 12:30 P.M. with Licensed Nursing Staff D stated the resident had the half side rails and would get her/his legs caught over the side of the bed; the resident was not able to get out of bed on her/his own; staff used the Hoyer lift was used to transfer the resident from the bed to the Broda chair; the resident was able to move side to side in the bed using the side rails but was not able to get out of the bed as she/he was not weight bearing. Staff interview on 7/25/11 at 12:30 P.M. with Administrative Staff B stated she/he did safety checks on side rails to see if the mattress fit snuggly against the side rails; stated she/he did not check the gaps in the rails for safety. The facility failed to monitor and assess the resident's side rails for safety - Resident #33 had [DIAGNOSES REDACTED]. The quarterly minimum data set 3.0 dated 4/6/11 recorded a BIMS (brief interview for mental status) score of 5 (severely impaired), had symptoms of delirium such as inattention and disorganized thinking which was not of acute onset, had a mood score of 9 (mild depression), had behavioral problems, needed extensive assistance with most activities of daily living except eating, had SOB (shortness of breath), had limitation in range of motion, had no falls, received an anti-psychotic and an anti-depressant medication, and had no restraints. The side rail screening assessment last revised on 4/20/11 recorded the resident now had 1/2 side rails for mobility. The care plan dated 1/7/11 did not address the resident used 1/2 side rails on both sides of the bed for mobility. An observation on 7/25/11 at 1:40 P.M. the resident lay on his/her back in the bed and had 1/2 side rails raised on both sides of the bed. The gaps between the rails measured 7 by 7 inches. An interview on 7/25/11 at 11:30 A.M. with licensed nursing staff A said the resident had 1/2 side rails on the bed, said the resident could turn in bed if he/she chose to, that since the resident returned from the hospital they had a decline, and therapy worked with the resident at this time. The staff said they did not assess the safety of the gaps between the individual rails but thought it was important to do so. The staff said the administrative staff B assessed the side rails, and had a tracking log for the side rails. An interview on 7/25/11 at 12:30 P.M. with administrative staff B said he/she did safety checks on the side rails to see if the mattress fit snuggly against the side rail but said he/she did not measure the distance between the bars for safety. At 2:00 P.M. the staff said the gaps measured 7 x 7 inches. The facility failed to ensure the environment remained free of potential accident hazards.