Every finding on record at Enterprise Estates Nuring Center

The facility had a census of 27 residents. The sample included 12 residents. Based on observation and record review, the facility failed to ensure the required annual performance reviews were completed for the three members reviewed. Findings included: - A review of the facility nurse and nurse aide performance evaluations revealed that Certified Medication Aide (CMA) R was hired on 03/21/24, Certified Nurse Aide (CNA) M was hired on 06/21/23, and CNA N was hired on 07/06/21. Randomly selected employees, who had been employed for over a year, lacked an annual review.On 09/23/25 at 11:06 AM, Administrative Staff B reported the facility had an annual review from 2023, but not for 2024. Administrative Staff B stated the facility had new administrative staff and had not performed an annual review.The facility's undated Employee Annual Performance Evaluation form included knowledge, skillset, judgement, quality of work, productivity and dependability, communication, initiative, and resident/family focus, which scored the employee for a percentage wage increase.Upon request, the facility failed to provide an Employee Performance Evaluation Policy.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain a Quality Assurance Assessment and Assurance committee (QA&A) that met quarterly and had the required membership in attendance.Findings included:- The facility provided QA&A committee attendance rosters for 01/23/25, 02/07/25, 07/02/25, and 09/11/25. Upon review of the rosters, the Medical Director signed in attendance on 02/07/25 and 09/11/25. On 09/24/25 at 02:27 PM, Administrative Staff A reported she had begun employment with the facility in July 2025 and could find limited information from the previous administrator's QA&A process. Administrative Staff A stated she had not had training related to the QA&A process but had a meeting involving the Medical Director on 09/11/25.The facility's Quality Assurance policy, dated 07/20/16, documented that the Quality Assurance Team would meet on a monthly and quarterly basis to ensure quality care and compliance with regulations. The facility shall maintain a quality assessment and assurance consisting of the director of nursing, a physician designated by the facility, and at least three members of the facility staff.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) for Resident (R) 4 and R21 urinary catheter care (tube placed in the bladder to drain urine into a collection bag). The facility also failed to have a structured Infection Control program. Finding included: - R4's Electronic Medical Record (EMR) included diagnoses of benign prostatic hyperplasia without lower urinary tract symptoms (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), major depressive disorder (major mood disorder that causes persistent feelings of sadness), overactive bladder, need for assistance with personal care, retention of urine, muscle weakness, acute kidney failure, and generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented R4 had severe cognitive impairment, was dependent on staff for toileting and personal hygiene, required substantial/maximal assistance with sitting to lying and lying to sitting, and partial to moderate assistance with bed to chair transfers and ambulating up to 150 feet. R4 had an indwelling urinary catheter and was frequently incontinent of bowel. The MDS further documented that R4 received scheduled pain medication and exhibited pain with vocal and facial expressions. R4 also received an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and an opioid (a medication to treat pain). R4's Care Plan dated 06/14/25 documented that R4 has a suprapubic catheter due to retention of urine. The Care Plan directed staff to provide catheter care every shift, empty, measure, and record urine output every shift, and monitor/record/report to the physician signs and symptoms of urinary tract infections. The Care Plan further directed staff to flush the catheter daily and change it monthly. The Physician Order dated 02/02/24 directed staff to change the indwelling catheter monthly at the urologist's (a specialist who treats disorders related to the urinary tract) office and as needed by nursing staff. The Physician Order further directed staff to cleanse the catheter site and cover with a split gauze daily. The Progress Note dated 08/25/25 at 10:46 AM documented that the urologist's catheter change was not covered by insurance, and R4's hospice services would provide the catheter change instead. On 09/23/25 at 09:56 AM, Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R donned gloves, cleansed, and placed a split gauze at the catheter insertion site on R4's lower abdomen. The staff also provided other peri-hygiene, rolled the resident from side to side, and placed a clean brief. Staff lacked the use of a barrier gown during the care of the indwelling catheter. On 09/24/25 at 11:19 AM, Administrative Nurse E stated the staff should have utilized EBP for R4's catheter care, and EBP should be included in the care plan. The facility's Evidence-Based Practice (EBP) Policy and Procedure dated 09/23/25 documented that the Administrator/Director of Nursing ensures organizational support, including resources for education and literature access. Approved EBP projects and allocated staff time. - R21's Electronic Medical Record (EMR) included diagnoses of retention of urine, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), heart failure, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), post-laminectomy (a surgical procedure to remove the bony arch of the spine bone), need for assistance with personal care, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R21's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R21 had intact cognition, required supervision or touch assistance with toileting and personal hygiene, partial to moderate assistance with bathing, and lower body dressing. R21 had an indwelling catheter and was continent of bowel. The MDS further documented R21 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine), opioid (medication to treat pain), and anticonvulsant (a class of medications use to control seizures) medications. R21's Care Plan dated 05/27/25 documented R21 had an indwelling catheter due to retention of urine. The Care Plan directed staff to provide catheter care every shift, ensure the catheter and tubing remain below the level of the bladder, and ensure the drainage bag is in a privacy bag. The staff also needed to monitor and document pain/discomfort due to the catheter. The Physician Order dated 06/09/25 directed the staff to change the catheter every month and as needed for dislodgement. The Progress Note dated 09/05/25 at 11:18 AM documented that the catheter was removed intact without difficulty, and a new catheter was inserted with immediate return of urine. On 02/23/25 at 12:06 PM, Certified Nurse Aide (CNA) M assisted R21 out of bed for the lunch meal. CNA M, without gloves, removed the urine collection bag, which had been hooked onto the bed frame, and placed the drainage bag into a privacy bag attached to the walker. On 09/24/25 at 11:19 AM, Administrative Nurse E stated the staff should have utilized EBP for R4's catheter care, and EBP should be included in the care plan. The facility's Evidence-Based Practice (EBP) Policy and Procedure dated 09/23/25 documented that the Administrator/Director of Nursing ensures organizational support, including resources for education and literature access. Approved EBP projects and allocated staff time. - On 09/25/25 at 08:00 AM, review of the facility infection control program revealed a lack of documentation for tracking infections from October 2024 to September 2025, which included the type of infection, antibiotic usage, resolution of the infection, and additional cultures. Continued review revealed a lack of identifying, tracking, monitoring, and/or reporting of infections. On 09/25/25 at 08:00 AM, Administrative Nurse E stated she had received her Infection Preventionist (IP) certification and was responsible for the Infection Prevention and Control Program, and verified she had not tracked the infections for the last few months. Administrative Nurse E stated that when she started a few months ago, she had many jobs to fill and did not track the infections. Administrative Nurse E verified the designated facility prior to IP no longer working at the facility, and they were unable to find prior documentation of the infections for the last year. On 09/24/25 at 11:10 AM, Administrative Nurse D verified the facility had not tracked infections from October 2024 to the present. Administrative Nurse D said the facility would start a system to identify infections on a map of the facility, but lacked complete documentation for the infection control programs inclusion in the policy and infection control guidelines. The facility's Infection Control policy, undated, documented the facility would facilitate safe care of all residents and staff with known or suspected communicable diseases by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy applies to all staff members from all departments of the facility, including direct and indirect care staff, contracted staff, consultants, volunteers, and others who provide care and services to residents on behalf of the facility, and students in a facility -supported training program, contracted and vendors of facility, residents residing in the facility, and visitor sin the facility. The Infection Prevention and Control Program would follow accepted Federal standards, including but not limited to the Centers for Disease Control (CDC), and is based on facility assessment and includes prevention, identification, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement. The Infection Control Program includes surveillance, investigation, controlling and preventing infections in the facility including appropriate immunizations, appropriate reporting of infection incidents, standard and transmission -based precautions to prevent spread of infection, development of procedures such as isolation and quarantine to be applied to an individual resident, circumstances to prohibit employees with communicable diseases or other infectious state from direct contact with residents or food, hand hygiene for staff involved in direct care contact, and maintaining a record of incidents and corrective actions related to infections. The infection control prevention and control program and antibiotic stewardship program is a function of the multidisciplinary, interdisciplinary team, including but not limited to the Medical Director, Director of Nursing, Infection Control Preventionist or designee, Administrator, and Consulting Pharmacist.

The facility had a census of 27 residents. The sample included 12 residents, with five residents sampled for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 8 obtain an approved diagnosis for the use of Risperidone (an antipsychotic-class of medications used to treat major mental conditions which cause a break from reality) for dementia (progressive mental disorder characterized by failing memory, confusion) or the physician's rationale for why this specific drug was necessary to treat the condition.Findings included:- R8's Electronic Medical Record documented diagnoses of Lewy body dementia (type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), recurrent major depressive disorder, and impulse disorder (sudden, forceful, irresistible urges to do something).R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented R8 had no behaviors or mood issues. The MDS documented R8 required maximum staff assistance for activities of daily living and mobility. The MDS documented R8 received antipsychotic medication. R8's Care Plan, dated 03/25/25, directed staff to give medications as ordered, obtain labs as ordered, and provide gradual dose reductions as recommended by the pharmacist. The care plan stated the consultant pharmacist and the physician were to review medications monthly and make changes as needed. The care plan documented staff were to provide one-to-one reassurance and education regarding the disease process, medications, and procedures. The care plan documented staff were to list the last gradual dose reduction attempt of Risperidone and the physician's response. The Physician Order, dated 05/15/25, directed staff to administer Risperidone, 1 milligram (mg) daily at bedtime for Lewy Body Dementia with behavioral disturbance. The Consult Pharmacist Review, dated 05/09/25, requested the diagnosis for the use of R8's medications, including Risperidone. The physician responded and indicated Risperidone was for Lewy Body Dementia with behavioral disturbance. On 09/23/25 at 08:12 AM, Certified Medication Aide (CMA) M administered medications to R8 at the dining table. She crushed all medications and put them in vanilla pudding. R8 took the medications without problem.On 09/24/25 at 10:39 AM, Administrative Nurse D verified the diagnosis for the use of Risperidone was unapproved and the physician had not written a rationale for the unapproved use. The facility's undated Psychotropic Medication Use policy stated the physician's order for a psychotropic drug would include a qualifying diagnosis for that drug and the target behaviors for each specific drug. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior.

The facility had a census of 27 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of Resident (R) 30's facility-initiated discharge to the hospital. Findings included: - R30's Electronic Medical Record (EMR) revealed diagnoses of atherosclerotic health disease (a buildup of fats, cholesterol/plaque in the walls of the arteries obstructing blood flow), 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), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), stage 3 renal failure (moderated damage to the kidneys and reduced kidney function), and hypocalcemia (abnormally low level of calcium in the blood).R30's scheduled 5-Day Minimum Data Set (MDS), dated [DATE], recorded R30 was cognitively intact. The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADL). The MDS documented R30 had frequent incontinence, required continuous oxygen, and ambulated with a wheelchair.The ADL Care Area Assessment (CAA) dated 11/13/24 recorded R30 required staff assistance with ADLs due to impaired functional ability. The CAA documented R30 had occasional incontinence of urine and required assistance with toileting, transfers, and hygiene. R30's Care Plan, dated 07/21/25, recorded R30 required staff assistance with most ADL care. R30's Care Plan documented the resident had chronic renal failure, monitored for signs and symptoms of infection. The Care Plan documented staff were to monitor the residents' heart and lung sounds as needed, document findings, and observe mental status, such as lethargy, fatigue, and tremors. The Nurse's Note on 06/09/25 at 01:02 PM documented R30 had a change in condition, was alert to orient to name and staff, but confused about place and date, and was able to feed herself without difficulty. The note documented R30 had jerking-like movement noted in the bilateral upper and lower extremities, with a heavy weight feeling to her extremities. The staff collected a blood sample for labs and a urine sample. The notes documented staff awaited a return phone call from the provider. The Nurse's Note on 06/09/25 at 03:41 PM documented the physician's office called and requested the resident to be transported to the walk-in clinic for further assessment and treatment. The resident was transported in the facility van. The Nurse's Note on 06/09/25 at 05:31 PM documented R30 was transported to the hospital and was evaluated in the emergency room.The Nurse's Note on 06/09/25 at 10:11 PM documented R30 had been admitted to the hospital for hyperkalemia.The Nurse's Note on 06/12/25 at 02:58 PM documented R30 returned to the facility at 02:30 PM, was alert and cooperative. R30 transferred into her recliner with two staff members and a gait belt.Review of the EMR documented R30 had a second hospital stay on 08/07/25. The Nurse's Note on 08/07/25 at 08:57 AM documented the resident was on an antibiotic for a urinary tract infection and was incontinent of urine. The Nurse's Note on 08/07/25 at 09:30 PM documented R30 had audible wheezing, staff elevated the head of her bed, and administered an inhaler to help with her breathing. The Nurse's Note on 08/07/25 at 11:40 PM documented the aide reported R30 had wheezing and a hard time breathing, staff administered. R30's oxygen was increased from two to four liters. Assisted with a rescue inhaler again and elevated the head of the bed. The note documented on 08/07/25 at 01:50 AM, staff called the ambulance to transport the resident to the hospital. The Nurse's Note on 08/08/25 at 04:31 AM documented R30 was admitted to the hospital for congestive heart failure exacerbations. The Nurse's Note on 08/11/25 at 09:58 AM documented R30 was discharged from the hospital and returned to the facility per the facility van. Review of the EMR noted R30's clinical record lacked documentation staff notified the LTCO of R30's discharge from the facility.On 09/23/25 at 03:10 PM, Social Service X stated they do not send any notification of discharge to the Ombudsman regarding the residents' discharge to the hospital. Social Service X verified they would notify the Ombudsman when a resident was discharged from the facility, home, or to another facility.The facility did not provide an Admission, Transfer, Discharge policy, as requested on 09/24/25.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to revise and update the care plan with Enhanced Barrier Precautions for Resident (R) 4 and R21 urinary catheters (a tube inserted into the bladder to drain the urine into a collection bag). The facility also failed to revise and update R3's falls care plan.Findings included: - R4's Electronic Medical Record (EMR) included diagnoses of benign prostatic hyperplasia without lower urinary tract symptoms (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), major depressive disorder (major mood disorder that causes persistent feelings of sadness), overactive bladder, need for assistance with personal care, retention of urine, muscle weakness, acute kidney failure, and generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R4 had severe cognitive impairment, was dependent on staff for toileting and personal hygiene, required substantial to maximal assistance with sitting to lying and lying to sitting, and partial to moderate assistance with bed to chair transfers and ambulating up to 150 feet. R4 had an indwelling urinary catheter and was frequently incontinent of bowel. The MDS further documented that R4 received scheduled pain medication and exhibited pain with vocal and facial expressions. R4 also received an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and an opioid (a medication to treat pain) medication. R4's Care Plan dated 06/14/25 documented that R4 has a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) due to retention of urine. The Care Plan directed staff to provide catheter care every shift, empty, measure, and record urine output every shift, and monitor/record/report to the physician signs and symptoms of urinary tract infections. The Care Plan further directed staff to flush the catheter daily and change it monthly. The Physician Order dated 02/02/24 directed staff to change the indwelling catheter monthly at the urologist's (a specialist who treats disorders related to the urinary tract) office and as needed by nursing staff. The Physician Order further directed staff to cleanse the catheter site and cover with a split gauze daily. The Progress Note dated 08/25/25 at 10:46 AM documented that the urologist's catheter change was not covered by insurance, and R4's hospice services would provide the catheter change instead. On 09/23/25 at 09:56 AM, Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R donned gloves, cleansed, and placed a split gauze at the catheter insertion site on R4's lower abdomen. The staff also provided other peri-hygiene, rolled the resident from side to side, and placed a clean brief. Staff lacked the use of a barrier gown during the care of the indwelling catheter. On 09/24/25 at 11:19 AM, Administrative Nurse E stated the staff should have utilized EBP for R4's catheter care, and EBP should be included in the care plan. The facility's undated Care Plan Revision policy states that documented revisions to the care plan will be the responsibility of a Licensed Nurse in collaboration with the resident, the representative/family, direct care staff, and the entire interdisciplinary team, and changes would be communicated with all staff and shifts. - R21's Electronic Medical Record (EMR) included diagnoses of retention of urine, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), heart failure, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), post-laminectomy (a surgical procedure to remove the bony arch of the spine bone), need for assistance with personal care, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R21's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R21 had intact cognition, required supervision or touch assistance with toileting and personal hygiene, partial to moderate assistance with bathing, and lower body dressing. R21 had an indwelling catheter and was continent of bowel. The MDS further documented R21 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine), opioid (medication to treat pain), and anticonvulsant (a class of medications use to control seizures) medications. R21's Care Plan dated 05/27/25 documented that R21 had an indwelling catheter due to retention of urine. The Care Plan directed staff to provide catheter care every shift, ensure the catheter and tubing remain below the level of the bladder, and ensure the drainage bag was placed in a privacy bag. The staff also needed to monitor and document pain/discomfort due to the catheter. The Physician Order dated 06/09/25, directed the staff to change the catheter every month and as needed for dislodgement. The Progress Note dated 09/05/25 at 11:18 AM documented that the catheter was removed intact without difficulty, and a new catheter was inserted with immediate return of urine. On 09/23/25 at 12:06 PM, Certified Nurse Aide (CNA) M assisted R21 out of bed for the lunch meal. CNA M, without gloves, removed the urine collection bag, which had been hooked onto the bed frame, and placed the drainage bag into a privacy bag attached to the walker. On 09/24/25 at 11:19 AM, Administrative Nurse E stated the staff should have utilized EBP for R21's catheter care, and EBP should be included in the care plan. The facility's undated Care Plan Revision policy states that documented revisions to the care plan will be the responsibility of a Licensed Nurse in collaboration with the resident, the representative/family, direct care staff, and the entire interdisciplinary team, and changes would be communicated with all staff and shifts. - R3's Electronic Medical Record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by falling memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), hypertension (elevated blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R3's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R3 had severely impaired cognition. The MDS recorded he required the assistance of one staff member for transfers and activities of daily living (ADL). The MDS further documented R3 had one fall with no injury and one fall with major injury. R3's Care Plan dated 11/01/24 recorded R3 was independent with transfers and used a walker to help maintain balance while ambulating, and would forget his walker often. The Care Plan documented the staff would intervene and assist R3 when he would be holding up items and not utilizing the walker. The care plan recorded R3 was exit seeking and would demand to leave, and staff would redirect and offer to take him out on the patio with staff supervision. The Fall Risk Assessments dated 09/24/24 noted R3 had a score of 17.0, which indicated he was at risk for falls. The Fall Risk Assessment dated 07/15/25 noted R3 had a score of 14.0, which indicated he was at risk for falls. The Nurse's Note dated 01/11/25 at 01:51 PM documented the resident was observed sitting on the floor in the dining room attempting to get up into a regular chair. Staff assisted the resident up to his feet with two staff assist and a gait belt to a regular chair. Observation revealed the resident had hit his left ear and head on the wall. Continued observation revealed the resident had a 2.5-centimeter (cm) laceration to his left temporal lobe, directly above and behind his left ear. The area was cleansed, pressure and cold pack applied for 20 minutes. R3 tolerated well and the laceration sealed on its own, reinforced with three steri-strips. R3 had 2.0 cm laceration to his superior left auricle. Staff cleansed and approximated the laceration with three steri-strips. Neuro checks were initiated, and the resident was alert and answered questions appropriately. Staff obtained the residents' vital signs that were within normal limits, and the resident was assisted to his room to lie down after staff provided incontinence cares. R3 legs were examined and equal length bilaterally, and the staff observed no external rotation. The resident denied further complaints of pain; the physician, Director of Nursing, and emergency contact were notified. The clinical record lacked documentation of a resident-centered intervention was put into place to prevent falls, and lacked documentation an investigation was completed for the fall. The Post Fall Evaluation dated 01/13/25 at 11:42 AM documented R3 had a fall on 01/11/25 at 11:15 AM that was not witnessed. The fall occurred in the dining room, and R3 had attempted to transfer himself from his wheelchair to a chair in the dining room. The notes documented the resident received a 2.5 cm laceration to his left temporal lobe and a 2.0 cm laceration to his left auricle. The note documented the resident's wheelchair was unlocked at the time of the fall. On 09/22/25 at 04:10 PM, observation revealed R3 standing in his room, then ambulated into the hall. Observation revealed the resident was unsteady and had to hold onto the door frame to steady himself as he ambulated. Staff were notified, and the resident returned to his room and sat in his wheelchair, then propelled himself to the dining room. On 09/23/25 at 11:45 AM, Administrative Nurse E stated she or Administrative Nurse D was not working at the facility at the time of the resident's fall, so was unaware if an investigation was completed, but upon review, was unable to find an investigation with witness statements. Administrative Nurse E verified the staff should report an unwitnessed fall with injury to the administration, and an investigation would be completed along with witness statements and reported to the state if indicated. On 09/23/25 at 11:45 AM, Administrative Nurse E stated she or Administrative Nurse D was not working at the facility at the time of R3's fall, so was unaware if an investigation was completed, but upon review, was unable to find an investigation with witness statements. Administrative Nurse E verified the staff should report an unwitnessed fall with injury to the administration, and an investigation would be completed along with witness statements and reported to the state if indicated. Administrative Nurse E stated the care plan should be updated with each fall, including interventions, and R3's care plan was not updated. The facility's Care Plan policy, undated, documented the care planning process includes assessment. Goal setting, intervention, referrals to other health care professionals, evaluations of resident responses to treatment, and revision of care and treatment in order to meet the resident's needs. The policy documented changes in the care plan would be required in the event the resident experienced an adverse event, including after every fall, to include specific instructions to staff based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide physician-ordered interventions to treat or prevent pressure wounds for Resident (R) 8 when staff failed to apply a pressure relief air overlay device on R8's bed. Findings included:- R8's Electronic Medical Record documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and pressure-induced deep tissue damage of the left heel.R8's Quarterly Minimum Data Set (MDS), dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented R8 had no behaviors or mood issues. The MDS documented R8 required maximum staff assistance for activities of daily living and mobility. The MDS documented R8 had one unstageable pressure ulcer (PU- 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), and interventions included pressure relief to bed and chair, repositioning, nutrition, and PU care. The MDS documented R8 received antipsychotic (class of medications used to treat major mental conditions, which cause a break from reality) medication. R8's Care Plan dated 03/25/25 directed staff to report any skin changes to the nurse, keep skin clean and dry, and provide weekly skin checks by a nurse. The care plan stated staff were to provide a Magic Cup (frozen nutritional supplement) at lunch and supper, a Mighty Shake (high-calorie nutritional supplement) or nutritional equivalent with all meals, and Arginaid (a nonprescription nutritional drink that supplies the amino acid L-arginine along with vitamin C and E) or nutritional equivalent with all meals. R8's Braden Scale for Pressure Ulcer Risk dated 06/21/25 documented R8 was at high risk of developing pressure ulcers. The Physician Order dated 04/17/25 directed staff to apply Collagen (protein derived wound treatment used to promote wound healing), Hydrofera Blue (a type of moist wound dressing which provides wound protection and addresses bacteria and yeast) Classic foam dressing, cut to wound size, and lightly moisten with saline and squeeze out excess moisture, apply to left posterior medial heel and cover with Opti foam or Alevyn dressing, and change three times weekly. The Physician Order dated 06/29/25 directed staff to offload both feet and heel pressure with a pillow, pressure relief boots, and use an air overlay on his mattress every day and night shift. The Dietary Note dated 08/23/25 documented R8 received a regular diet. His intake was variable and had orders for a MVI (multivitamin), house supplement, and Arginaid to assist with wound healing of his left heel. The Skin Check dated 08/27/25 stated R8's left heel PU was resolved. The Skin Check dated 09/11/25 stated left heel scabbing intact and documented no measurements. No measurements or wound characteristics were documented.The Skin Check dated 09/17/25 stated left heel scabbing intact, and progress stalled. No measurements or wound characteristics were documented. On 09/23/25 at 10:55 AM, Licensed Nurse (LN) G checked R8's left foot dressing. She washed her hands and gloved, but did not don enhanced barrier precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). LN G peeled the heel wound dressing back and decided to change the dressing. He had a small open area, approximately 1 x 1 centimeters (cm), on the back of his left heel. R8's left foot was very swollen, and his toes were reddish in color. LN G cleansed the wound and applied a new dressing. LN G stated she was unsure when the PU reopened. It was the same area that R8 had when he was originally admitted . LN G verified she was supposed to measure the wound, but had not. LN G stated staff were to float his feet with pillows at night, and place pressure relief booties on during the day. LN G verified R8's bed did not have an air overlay mattress on the bed as ordered. On 09/24/25 at 10:25 AM, Certified Medication Aide (CMA) R verified R8's bed had no air overlay mattress. On 09/24/25 at 10:39 AM, Administrative Nurse D verified staff should have placed an air overlay device on R8's bed as ordered, documented weekly skin assessments, and documented interventions and updates to the care plan. She stated she had attempted to get the wound clinic to come to the facility without success. The facility did not provide a policy regarding the prevention and treatment of pressure ulcers when requested on 09/25/25.

The facility had a census of 27 residents. The sample included 12 residents, with one reviewed for side rails. Based on observation, interview, and record review, the facility failed to assess the actual rail being used to assure safety for Resident (R) 7. Findings included: - The Electronic Medical Record (EMR) for R7's of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and chronic pain.R7's Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating mild cognitive impairment. The MDS documented R7 required substantial assistance with mobility and rolling left to right. The MDS lacked documentation the resident had siderails. R7's medical record lacked a Side Rail Assessment and safe use for the side rail. On 09/23/25 at 09:00 AM, observation revealed R7 lying in bed on her back watching TV. Continued observation revealed a side rail on the right side of R7's bed. The side rail on the top right side with openings approximately 12 and one-half inches wide and approximately 18 inches from the top of the rail to the mattress.On 09/23/25 at 09:10 AM, Administrative Nurse D and Administrative Nurse E verified that the staff should assess the bed rail or safety quarterly or with a significant change in the resident's status. Administrative Nurse D verified R7's bed rails had too large of openings, and R7's EMR lacked an assessment for the siderail.The facility's Bed Rails policy, undated, documented each resident has the right to be free from any physical restraint imposed for the purpose of discipline or convenience, and if the use is not required to treat the resident's medical symptoms. It is the policy of the facility to be a restraint-free environment without jeopardizing resident safety. The facility would attempt to use an appropriate alternative prior to installing a side or bed rail. If a bed rail is used, the facility would ensure correct installation, use, and maintenance of the bed rails, including but not limited to: assessment of the resident for risk of entrapment from bed rails prior to installation, review of risks and benefits of bed rails with the resident/representative, and obtain informed consent prior to installation. The policy documented to ensure that the bed's dimensions are appropriate for the resident's size and weight, follow the manufacturer's recommendations and specifications for maintaining bed rails. It is the policy of the facility to identify and reduce safety risks and hazards commonly associated with the use of bed rails or other bed mobility safety devices. The facility's regular maintenance program would include regular inspection of all bed systems, including but not limited to bed rails, bed frames, mattresses, and operational components of each bed to ensure a safe, clean, comfortable and homelike environment. The facility would also ensure bed rail assessments and evaluations are performed on a regular basis. Individual bed rail evaluations would include data collection, analysis, and determination of potential alternatives to the use of bed rails. When bed rails are deemed necessary and appropriate, the facility would provide education to residents and/or representatives pertaining to the risks and benefits of bed rail use. The facility's priority is to ensure safe and appropriate bed rail use. The purpose of the policy is to assist residents, representatives, physicians, and facility staff in determining if resident use of bed rails is safe and appropriate. The Interdisciplinary team would use data collection from regular bed inspections and individual bed rail assessments, and evaluations to assist in care planning and positive resident outcomes. The policy documented upon admission, the resident would be screened to determine if care needs may necessitate specialized beds or accessories, including but not limited to bed rails or other bed mobility devices. Assessment of need for special equipment or accessories to assess the resident to identify appropriate alternatives to installing bed rails or other bed mobility devices, and assess the resident for risk of entrapment from the bed rails prior to installation. Obtain and retain in the resident's clinical record, Informed consent for the use of bed rails and bed mobility enhancing devices. Gap measurements would be performed prior to installation and at least quarterly to ensure safety from potential entrapment following FDA guidelines for acceptable gaps: any open space between parameters of rail can present a risk of head entrapment, with the FDA-recommended space less than 4 and 3/4 inches.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review the facility's nursing staff failed to follow physician orders to obtain adequate blood samples for Resident (R) 6 's laboratory testing and further failed to obtain physician involvement for direction related to continued Coumadin (anticoagulant-blood thinning drug) and Lovenox (anticoagulant-blood thinning drug) administration without the required monitoring. Findings included:- R6's Electronic Medical Record documented diagnoses of cerebral infarction (stroke) affecting right dominant side, aphasia (condition with disordered or absent language function), hypertension (elevated blood pressure), and atrial fibrillation (rapid, irregular pulse). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R6 required staff assistance with activities of daily living, reported no pain and received anticoagulant (blood-thinning medication).R6's Care Plan dated 02/11/25 directed staff to administer medications as prescribed and monitor laboratory results. On 09/04/25, R6 was hospitalized and returned to the facility on [DATE] with physician orders for a daily INR (international normalized ratio -blood test which measures how long it takes for the blood to clot) until the goal INR was met. R6 had orders for Coumadin and Lovenox daily. On 09/11/25, R6's Medication Administration Record (MAR)/Treatment Administration Record (TAR) lacked documentation regarding the order to draw a PT (Prothrombin Time- a blood test that measures the time it takes for blood to clot)/INR, and no lab was obtained that day, and lacked evidence the physician was notified. R6 received her Coumadin and Lovenox. On 09/12/25, R6's EMR documented staff attempted two times to draw blood for INR testing, but did not draw an adequate amount for testing on the first attempt, and was unable to obtain a sample on the second attempt. Staff did not notify the physician of the failed efforts and the inability to obtain an INR result. R6 received her Coumadin and Lovenox. On 09/13/25, R6's EMR documented R6 declined to go to the lab for a blood draw until after the lab was closed. R6's clinical record lacked documentation staff attempted to draw the blood at the facility or notify the physician of the lack of an INR. R6 received her Coumadin and Lovenox.On 09/14/25, R6's EMR documented staff did not draw a blood sample for the INR because the lab was closed, though staff did not notify the physician regarding the missed INR. R6 received her Coumadin and Lovenox.On 09/15/25, R6's EMR documented R6 had a PT/INR drawn, which resulted in a critically high INR of 11.6.On 09/22/25 at 10:30 AM, R6 sat in her wheelchair visiting with a nurse at the nurse station. R6 was slow to verbalize. No abnormal bruising was observed.On 09/23/25 at 10:43 AM, Licensed Nurse (LN) G stated R6 came back from the hospital on [DATE] with orders for daily INR labwork. On 09/24/25 at 11:22 AM, Administrative Nurse D verified the daily INR labs had not been done as ordered.The facility did not provide a policy related to nursing services, as requested on 09/24/25.

The facility had a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure the consult pharmacist notified the physician or the director of nursing of the need for further documentation regarding the continued use of Risperidone (antipsychotic medication- a class of medications used to treat major mental conditions that cause a break from reality) for Resident (R) 8 related to the unapproved diagnosis.Findings included:- R8's Electronic Medical Record (EMR) documented diagnoses of Lewy body dementia (type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), recurrent major depressive disorder, and impulse disorder (sudden, forceful, irresistible urges to do something).R8's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented R8 had no behaviors or mood issues. The MDS documented R8 required maximum staff assistance for activities of daily living and mobility. The MDS documented R8 received antipsychotic medication. R8's Care Plan dated 03/25/25 directed staff to give medications as ordered, obtain labs as ordered, and provide gradual dose reductions as recommended by the pharmacist. The care plan stated the consultant pharmacist and the physician were to review medications monthly and make changes as needed. The care plan documented staff were to provide one-to-one reassurance and education regarding the disease process, medications, and procedures. The care plan documented staff were to list the last gradual dose reduction attempt of Risperidone and the physician's response.The Physician Order dated 05/15/25 directed staff to administer Risperidone, 1 milligram (mg) daily at bedtime for Lewy Body Dementia with behavioral disturbance. The Consult Pharmacist Review dated 05/09/25 requested the diagnosis for the use of R8's medications including Risperidone. The physician responded and indicated Risperidone was for Lewy Body Dementia with behavioral disturbance.On 09/23/25 at 08:12 AM, Certified Medication Aide (CMA) M administered medications to R8 at the dining table. She crushed all medications and put them in vanilla pudding. R8 took the medications without problem.On 09/24/25 at 10:39 AM, Administrative Nurse D verified the diagnosis for the use of Risperidone was unapproved and the physician had not written a rationale for the unapproved use. She verified the consultant pharmacist had not attempted to notify the physician or the director of nursing of the need for further documentation regarding the continued use of Risperidone for the unapproved diagnosis.The facility did not provide a policy on pharmacy reviews, as requested on 09/24/25.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to obtain adequate blood samples for Resident (R) 6 's laboratory testing and further failed to obtain physician involvement for direction related to continued Coumadin (anticoagulant-blood thinning drug) and Lovenox (anticoagulant-blood thinning drug) administration without the required monitoring. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke) affecting right dominant side, aphasia (condition with disordered or absent language function), hypertension (elevated blood pressure), and atrial fibrillation (rapid, irregular pulse). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R6 required staff assistance with activities of daily living, reported no pain, and received anticoagulant (blood-thinning medication). R6's Care Plan dated 02/11/25 directed staff to administer medications as prescribed and monitor laboratory results. On 09/04/25 R6 was hospitalized . R6 returned to the facility on [DATE] with physician orders for a daily INR (international normalized ratio- a blood test which measures how long it takes for the blood to clot) until the goal INR was met. R6 had orders for Coumadin and Lovenox daily.On 09/11/25, R6's Medication Administration Record (MAR)/Treatment Administration Record (TAR) lacked documentation regarding the order to draw a PT (Prothrombin Time- a blood test that measures the time it takes for blood to clot) /INR, and no lab was obtained that day, and lacked evidence the physician was notified. R6 received her Coumadin and Lovenox. On 09/12/25, R6's EMR documented staff attempted two times to draw blood for INR testing, but did not draw an adequate amount for testing on the first attempt, and was unable to obtain a sample on the second attempt. Staff did not notify the physician of the failed efforts and the inability to obtain an INR result. R6 received her Coumadin and Lovenox. On 09/13/25, R6's EMR documented R6 declined to go to the lab for a blood draw until after the lab was closed. R6's clinical record lacked documentation staff attempted to draw the blood at the facility or notify the physician of the lack of an INR. R6 received her Coumadin and Lovenox. On 09/14/25, R6's EMR documented staff did not draw a blood sample for the INR because the lab was closed, though staff did not notify the physician regarding the missed INR. R6 received her Coumadin and Lovenox. On 09/15/25, R6's EMR documented R6 had a PT/INR drawn, which resulted in a critically high INR of 11.6.On 09/22/25 at 10:30 AM, R6 sat in her wheelchair visiting with a nurse at the nurse station. R6 was slow to verbalize. No abnormal bruising was observed.On 09/23/25 at 10:43 AM, Licensed Nurse (LN) G stated R6 came back from the hospital on [DATE] with orders for daily INR lab work. On 09/24/25 at 11:22 AM, Administrative Nurse D verified the daily INR labs had not been done as ordered. She stated on Saturdays, the lab was only open until 09:30 AM, and on Sunday, 09/14/25, the emergency department would not be able to draw the lab due to the lab was not open to run it. The facility's undated Laboratory Policy and Procedure stated the facility would ensure all laboratory tests were performed accurately, safely, and in a timely manner to support resident care. Nurses were responsible for collecting, handling, and processing laboratory specimens according to standard protocol and regulations. Proper documentation and communication of results were essential for resident safety and quality care.

The facility had a census of 31 residents. The sample included 14 residents. Based on record review and interview, the facility failed to implement a water management program for waterborne pathogens including the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). This placed the residents in the facility at risk for infectious disease. Findings included: - On 01/16/34 at 03:42 PM, Maintenance Staff U stated he took over the position a couple of months ago and did not know anything about the water management process. He stated it was not implemented. On 01/17/24 at 02:45 PM, Administrative Staff A stated Maintenance Staff U probably did not know the building was at risk for Legionella. The facility's Water Management policy dated 06/20/23, documented the director of environmental services was responsible for all relevant details regarding roles and responsibilities and testing regimes contained in this policy and procedure, all results would be reported to the team on a quarterly basis and the administrator of the facility was responsible for reporting all results and findings to the board of governance on an annual basis. The facility should ensure that appropriate precautions for the control of legionella bacteria are identified through the legionella risk assessment process and appropriate control measures implemented to ensure as far as is minimum standards are met. The facility failed to implement a water management program to identify risks and manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to properly store medication and biologicals in one of two medication rooms. This placed the residents at risk of ineffective medication. Findings included: - On 01/16/24 at 02:46 PM, observation revealed the north hall medication refrigerator lacked evidence staff assessed and recorded temperatures from 01/11/24 through 01/15/24 (five days). Licensed Nurse (LN) H stated it was the night shift nurses' responsibility to check and log the refrigerator temperature. On 01/17/23 at 01:47 PM Administrative Nurse D verified the medication refrigerator temperature should have been checked daily and recorded on the log. The facility's Monitoring of Refrigerators and Freezers policy, dated 10/09/23, documented that medicine or drug refrigerators will be kept solely for the purpose of storing medications that require refrigeration according to the manufacturer's instruction. Refrigerators containing vaccines will have temperature monitored conducted and logged daily. The Charge Nurse is responsible for monitoring temperatures, appropriate logging of temperature, and appropriate discarding from all medications and specimen refrigerators/freezers. The facility failed to properly store medication and biologicals which placed residents at risk of ineffective medications.

The facility identified a census of 31 residents. The sample included 14 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination, or a physician-documented contraindication for pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - Review of Resident (R) 5, R7, R18, R19, and R24's clinical medical records lacked evidence of consent, informed declination, or physician-documented contraindication for the current pneumococcal vaccine PCV20. On 01/16/24 at 12:00 PM, Administrative Nurse E stated she had faxed the doctors about the PCV20 in November to talk about it when they came in for nursing rounds the next week and stated she had not implemented any system to address it. The facility's Annual Flu and Pneumonia Vaccines, dated 08/14, documented the flu and pneumonia vaccines would be given by a licensed staff annually and the pneumonia vaccines would be administered according to each physician's protocol. Each resident's vaccine orders would be obtained for those residents in the facility who did not have a record of having the vaccine and would be documented in the record. Permission letters would be sent to the families to show the adverse reactions of both the flu and pneumonia vaccines, as well as Influenza and Pneumonia vaccine education information. The facility failed to offer the pneumococcal PCV20 vaccination per CDC recommendations. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 4, for her diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), supplemental oxygen use and R5's care related to a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin. This placed the residents at risk for impaired care due to uncommunicated care needs. - The Electronic Medical Record (EMR) for R4 documented diagnoses of COPD and shortness of breath. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had severely impaired cognition and was dependent upon staff for toileting and showers. R4 required substantial to maximum assistance for mobility and partial to moderate assistance for personal hygiene. The MDS further documented R4 was short of breath upon exertion when resting and lying flat. R4 used oxygen and received diuretic (mediation which aids in the formation and excretion of urine) medication. R4's Care Plan lacked documentation of her diagnosis of COPD and oxygen use. The Physician's Order, dated 05/16/21, directed staff to change 02 tubing, humidifier bottle, extension tubing, and supply bag every two weeks on Sunday night shift. The Physician's Order, dated 05/16/21, directed staff to clean the oxygen concentrator filter every week on the Sunday night shift. The Physician's Order, dated 08/24/22, directed staff to administer two liters of oxygen via nasal cannula to keep oxygen saturation (percentage of oxygen in the blood) above 88% for shortness of breath. On 01/10/24 at 12:41 PM, observation revealed R4's oxygen tubing and cannula wound up inside the handle of the oxygen concentrator. On 01/11/24 at 12:15 PM, observation revealed R4's oxygen tubing and cannula unbagged, draped over a stuffed teddy bear on her nightstand. On 01/16/24 at 09:00 AM, observation revealed R4's oxygen tubing and cannula unbagged, lying on the floor. On 01/17/24 at 08:23 AM, observation revealed R4's oxygen tubing and cannula wound up inside the handle of the oxygen concentrator. On 01/17/24 at 09:15 AM Certified Nurse Aide (CNA) M stated the oxygen tubing should be in a bag when not in use. On 01/17/24 at 09:50 AM, Licensed Nurse (LN) G stated the oxygen tubing should be in a bag when not in use. On 01/17/24 at 11:15 AM, Administrative Nurse D stated the care plan should reflect the resident and diagnosis. The facility's Elder Directed Care Plan, policy, dated 08/17/23, documented the interdisciplinary team would develop a plan of services to be provided by the staff and community based on the preferences, choices, and clinical needs of the elder within seven days of completion of the comprehensive assessments, all elders will have a plan of care generated by the registered nurse responsible for the process. The plan of care would be individualized based on the diagnosis, comprehensive elder assessments, and personal goals of the elder and his/her family. The facility failed to develop a comprehensive care plan for R4, who had a diagnosis of COPD and used supplemental oxygen. This placed the resident at risk for unmet care needs. 37450 - R5's Electronic Medical Record (EMR) documented diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes melilites (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin)with kidney complications and neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), pain, hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R5 had intact cognition, required partial/moderate assistance for activities of daily living, received insulin injections (a hormone that lowers the level of glucose in the blood), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), opioid (a class of medication used to treat pain) and antiplatelet (medications used to prevent blood clotting) medications. R5's Care Plan lacked interventions related to diabetes and blood sugar monitoring. The Physician Order dated 03/07/22, directed staff to administer Novolog Insulin subcutaneously 25 units twice and day and 17 units once a day for diabetes mellitus. The Physician Order dated 07/28/23 directed staff to obtain finger stick blood sugar checks before meals and at bedtime and notify the physician if blood sugar was below 50 milliliters (ml) per deciliter (dL) or above 300 mm/dL. On 01/17/24 at 11:15 AM, Administrative Nurse D stated the care plan should reflect the resident's needs and diagnoses. The facility's Elder Directed Care Plan, policy, dated 08/17/23, documented the interdisciplinary team would develop a plan of services to be provided by the staff and community based on the preferences, choices, and clinical needs of the elder within seven days of completion of the comprehensive assessments, all elders will have a plan of care generated by the registered nurse responsible for the process. The plan of care would be individualized based on the diagnosis, comprehensive elder assessments, and personal goals of the elder and his/her family. The facility failed to develop a comprehensive care plan related to R5's diagnosis of diabetes mellitus, placing the resident at risk for impaired care due to uncommunicated care needs.

The facility had a census of 31 residents. The sample included 14 residents with seven reviewed for behaviors. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered interventions for behavioral triggers for one resident, Resident (R) 14, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). This placed the resident at risk for decreased quality of life due to uncommunicated care needs, Findings included: - The Electronic Medical Record for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and PTSD. The Quarterly Minimum Data Set (MDS), 11/22/23, documented R14 had intact cognition and was dependent on staff for transfers, toileting, and showers, and required substantial to maximum assistance with dressing. The MDS further documented R14 felt depressed and was fidgety or restless for 7-11 days and sometimes had social isolation. R14 received antianxiety (a class of medication that calm and relaxes people), and antidepressant (a class of medications used to treat mood disorders) medication and had no behaviors. The Negative Life Events or Traumatic Experiences Screening, dated 10/14/19, documented R14 did not have any negative life events. The EMR lacked evidence a trauma-informed assessment was completed for R14 after her diagnosis of PTSD. R14's Care Plan, dated 11/01/23, initiated on 11/08/19, documented R14 had a behavior problem related to crying and attention seeking and directed staff to administer medications as ordered, provide opportunities for positive interaction, provide a program of activities, report any behaviors to the charge nurse. The care plan further documented R14 got overwhelmed easily if there were too many people in her surroundings. The update, dated 4/20/22, documented R14 received behavioral health consultations. The care plan lacked identified triggers and interventions related to R14's PTSD. The Physician's Order, dated 07/28/23, directed staff to administer prazosin (a blood pressure medication), 1 milligram (mg), by mouth, daily for night terrors. The Physician's Order, dated 08/03/23, directed staff to administer propranolol hci (a blood pressure medication), 5 mg, by mouth, daily for PTSD. The Physician's Order, dated 08/24/23, directed staff to administer Trazadone (antidepressant medication), 0.5 mg, by mouth, twice daily for anxiety. The Physician's Order, dated 08/24/23, directed staff to administer duloxetine hci (an antidepressant medication), 60 mg, by mouth, twice daily for depression. On 01/11/24 at 07:30 AM, observation revealed R14 sat at the dining table and waited for breakfast. She did not speak to her tablemates. On 01/16/24 at 11:30 AM, Social Services BB verified she had not completed the trauma-informed care assessment after R14 was diagnosed with PTSD and verified the care plan lacked identified triggers related to R14's PTSD. Social Services BB stated R14 had seen a behavioral healthcare provider and would continue as needed. On 01/17/24 at 09:14 AM, Certified Nurse Aide (CNA) M stated R 14 seemed depressed at times, down on herself, and would often isolate in her room. CNA M further stated R14 could be rude and yelled at staff at times. On 01/17/24 at 09:50 AM, Licensed Nurse (LN) G stated R14 made sexual comments towards some staff and isolated herself which caused her to think about her past abuse. On 01/17/24 at 11:15 AM, Administrative Nurse D stated the care plan should reflect R14's PTSD status and a PTSD assessment should have been completed for the resident. The facility's Elder Directed Care Plans policy, Dated 08/17/23, documented it was the responsibility of every member of the team to read, understand, and follow the comprehensive elder-directed care plan and report any changes no matter how slight or significant to the team for immediate care plan revisions. Revisions were completed at 90-day intervals or more frequently based on response to the elder's condition. The team would evaluate the elder's progress toward meeting the goals of care, treatment, and services, revise the care plan, and collaborate with the elder and/or surrogate decision maker and family in reviewing and revising the plan of care for treatment and services. The facility failed to revise R14's care plans with triggers related to her PTSD. This placed the resident at risk for decreased quality of life due to uncommunicated care needs.

The facility had a census of 31 residents. The sample included 14 residents, with one reviewed for edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Based on observation, record review, and interview, the facility failed to notify the physician as ordered for Resident (R)3's weight increase. This placed the resident at risk for complications related to edema. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema, hypertension (high blood pressure), and dyspnea (difficulty breathing). The Admission Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and required limited to extensive assistance from two staff for activities of daily living (ADL). The assessment further documented R3 was short of breath upon exertion, when resting, and lying flat. R3 used oxygen and received diuretic medication (treats fluid retention and swelling). The Quarterly MDS, dated [DATE], documented R3 had moderately impaired cognition and required substantial to maximum assistance for toileting, showers, ambulation, and partial to moderate assistance for other ADL. The assessment further documented R3 was short of breath upon exertion, when resting, and lying flat. R3 used oxygen and received diuretic medication. R3's Care Plan, dated 11/29/23, directed staff to administer diuretic medications as ordered by the physician, and monitor for side effects and effectiveness every shift. The plan directed staff to obtain labs as ordered and monitor the dose as it may require modification to achieve the desired effects. The update, dated 09/27/23, documented R3 had Unna boots (a compressive dressing to aid in circulation and wound healing). (non-elastic bandages that provide high pressure when the muscles are contracted The Physician's Order, dated 06/29/23, directed staff to administer spironolactone (a diuretic medication), 25 milligrams (mg), by mouth, daily for edema. The medication was discontinued on 11/26/23. The Physician's Order, dated 09/22/23, directed staff to administer Bumex (a diuretic medication), 3 mg, by mouth, twice per day for heart failure. This medication was discontinued on 10/06/23. The Physician's Order, dated 10/06/23, directed staff to administer Bumex, 2 mg, by mouth, twice per day, for heart failure. This medication was put on hold from 01/03/24 to 01/04/24. The Physician's Order, dated 10/20/23, directed staff to take a daily weight for R3 and notify the physician for a two-pound (lb.) weight increase in 24 hours or five lb. increase in seven days for edema. R3's Medication Administration Record (MAR) dated October 2023 lacked evidence the physician was notified as ordered for a two lb. weight increase in 24 hours on the following days: 10/30/23-262.2 10/31/23-284.8- a 2.2 lb. weight increase R3's MAR dated November 2023 lacked evidence the physician was notified as ordered for the two lbs. weight increase in 24 hours on the following day: 11/07/23-264.5 11/08/23-266.6-a 2.1 lb. weight increase 11/9/23-266.1 11/10/23-268.5- a 2.3 lb. weight increase R3's MAR dated December 2023 lacked evidence the physician was notified as ordered for a two lb. weight increase in 24 hours on the following day: 12/04/23-254.4 12/05/23-258.2-a 3.7 lb. weight increase R3's MAR dated January 2024 lacked evidence the physician was notified as ordered for a two lb. weight increase in 24 hours on the following day: 01/04/2-4-263 01/05/24-269.2- a 6.3 lb. weight increase 01/15/24-265.4 01/16/24-268.3- a 3 lb. weight increase On 01/11/24 at 01:00 PM, observation revealed R3 in the hallway. He had Unna boots on both of his legs. On 01/17/24 at 09:56 AM, Licensed Nurse G verified the physician was not notified of the increased weight gain. On 01/17/24 at 11:02 AM, Administrative Nurse D stated staff should follow the physician's order if the resident had a weight increase. The facility's Edema Assessment policy, dated 01/15/23, documented the facility was committed to the quality of care to restore or maintain each resident's highest practicable level of physical mental, and psychosocial well-being including but not limited to appropriate and timely assessment and treatment of edema. The policy further documented licensed nursing staff would monitor and document on residents with edema daily to assess response to interventions, adjust care plans as needed, and notify the physician as needed for treatment. The facility failed to notify R3's physician as ordered when he had a two-pound weight increase on multiple dates. This placed the resident at risk for complications related to edema.

The facility had a census of 31 residents. The sample included 14 residents, with two reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Residents (R) 3 and R4 when staff failed to store their oxygen tubing and cannula in a sanitary manner when not in use. This placed the residents at increased risk for an infection. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema, hypertension (high blood pressure), and dyspnea (difficulty breathing). The Admission Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and required limited to extensive assistance of two staff for activities of daily living (ADL). The assessment further documented R3 was short of breath upon exertion, when resting, and lying flat. R3 used oxygen and received diuretic medication (treats fluid retention and swelling). The Quarterly MDS, dated [DATE], documented R3 had moderately impaired cognition and required substantial to maximum assistance for toileting, showers, ambulation, and partial to moderate assistance for other ADL. The assessment further documented R3 was short of breath upon exertion, when resting, and lying flat. R3 used oxygen and received diuretic medication. R3's Care Plan, dated 11/29/23, directed staff to check breath sounds and monitor/document for labored breathing, monitor/document for the use of accessory muscles while breathing, daily weight monitoring, and cardiac medications as ordered. the plan directed R3's oxygen settings via nasal cannula at two liters (L). The Physician's Order, dated 06/13/23, documented R3 required 2 L of oxygen per nasal cannula every shift for COPD. R3's EMR lacked direction to staff to staff when to change the oxygen tubing and concentrator filter. On 01/10/24 at 11:05 AM, observation revealed R3's oxygen tubing and cannula laid unbagged on the seat of his recliner, and the oxygen concentrator was running. On 01/11/24 at 07:45 AM, observation revealed R3's oxygen tubing and cannula wound around the back of his wheelchair unbagged. On 01/16/24 at 09:00 AM, observation revealed R3's oxygen tubing and cannula laid unbagged over the back of his wheelchair. On 01/17/24 at 8:42 AM, observation revealed R3's oxygen tubing and cannula laid unbagged on the seat of his wheelchair, and the oxygen concentrator was running. On 01/17/24 at 09:15 AM Certified Nurse Aide (CNA) M stated the oxygen tubing should be in a bag when not in use. On 01/17/24 at 09:50 AM, Licensed Nurse (LN) G stated the oxygen tubing should be in a bag when not in use but R3 would take it off and set it down. On 01/17/24 at 11:02 AM, Administrative Nurse D stated the residents with oxygen should have a bag to place the tubing and cannula in when not in use. The facility's Oxygen Protocol, undated, directed staff to change the connecting tubing one time a month on the Sunday night shift, and change the humidifier bottle, nasal cannula, and storage bag every two weeks on the Sunday night shift. The facility failed to provide adequate respiratory services for R3 when staff failed to store the oxygen tubing and cannula in a sanitary manner when not in use. This placed the resident at risk for infection. - The Electronic Medical Record (EMR) for R4 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and shortness of breath (SOB). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had severely impaired cognition and was dependent upon staff for toileting and showers. R4 required substantial to maximum assistance for mobility, and partial to moderate assistance for personal hygiene. The MDS further documented R4 was short of breath upon exertion, when resting and lying flat. R4 used oxygen and received diuretic (mediation which aids in the formation and excretion of urine) medication. R4's Care Plan lacked documentation of her diagnosis of COPD and oxygen use. The Physician's Order, dated 05/16/21, directed staff to change 02 tubing, humidifier bottle, extension tubing, and supply bag every two weeks on Sunday night shift. The Physician's Order, dated 05/16/21, directed staff to clean the oxygen concentrator filter every week on Sunday night shift. The Physician's Order, dated 08/24/22, directed staff to administer two liters of oxygen via nasal cannula to keep oxygen saturation (percentage of oxygen in the blood) above 88% for shortness of breath. On 01/10/24 at 12:41 PM, observation revealed R4's oxygen tubing and cannula wound up inside the handle of the oxygen concentrator. On 01/11/24 at 12:15 PM, observation revealed R4's oxygen tubing and cannula unbagged, draped over a stuffed teddy bear on her nightstand. On 01/16/24 at 09:00 AM, observation revealed R4's oxygen tubing and cannula unbagged, lying on the floor. On 01/17/24 at 08:23 AM, observation revealed R4's oxygen tubing and cannula wound up inside the handle of the oxygen concentrator. On 01/17/24 at 09:15 AM Certified Nurse Aide (CNA) M stated the oxygen tubing should be in a bag when not in use. On 01/17/24 at 09:50 AM, Licensed Nurse (LN) G stated the oxygen tubing should be in a bag when not in use. On 01/17/24 at 11:02 AM, Administrative Nurse D stated the residents with oxygen should have a bag to place the tubing and cannula in when not in use. The facility's Oxygen Protocol, undated, directed staff to change the connecting tubing one time a month on the Sunday night shift, and change the humidifier bottle, nasal cannula, and storage bag every two weeks on the Sunday night shift. The facility failed to provide adequate respiratory services for R4 when staff failed to store the oxygen tubing and cannula in a sanitary manner when not in use. This placed the resident at risk for infection.

The facility had a census of 31 residents. The sample included 14 residents, with seven reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma informed care assessment for Resident (R)14, who had a diagnosis of post -traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). This placed the resident at risk for unmet behavioral and mental health needs. Findings included: - The Electronic Medical Record for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and PTSD. The Quarterly Minimum Data Set (MDS), 11/22/23, documented R14 had intact cognition and was dependent on staff for transfers, toileting, showers, and required substantial to maximum assistance with dressing. The MDS further documented R14 felt depressed and was fidgety or restless 7-11 days, and sometimes had social isolation. R14 received antianxiety (class of medication that calm and relax people), and antidepressant (class of medications used to treat mood disorders) medication and had no behaviors. The Negative Life Events or Traumatic Experiences Screening, dated 10/14/19, documented R14 did not have any negative life events. The EMR lacked evidence a trauma informed assessment was completed for R14 after her diagnosis of PTSD. R14's Care Plan, dated 11/01/23, initiated on 11/08/19, documented R14 had a behavior problem related to crying and attention seeking and directed staff to administer medications as ordered, provide opportunity for positive interaction, provide a program of activities, report any behaviors to the charge nurse. The care plan further documented R14 got overwhelmed easily if there were too many people in her surroundings. The update, dated 4/20/22, documented R14 received behavioral health consultations. The care plan lacked identified triggers for staff related to R14's PTSD. The Physician's Order, dated 07/28/23, directed staff to administer prazosin (a blood pressure medication), 1 milligram (mg), by mouth, daily for night terrors. The Physician's Order, dated 08/03/23, directed staff to administer propranolol hci (a blood pressure medication), 5 mg, by mouth, daily for PTSD. The Physician's Order, dated 08/24/23, directed staff to administer trazadone (antidepressant medication), 0.5 mg, by mouth, twice daily for anxiety. The Physician's Order, dated 08/24/23, directed staff to administer duloxetine hci (an antidepressant medication), 60 mg, by mouth, twice daily for depression. On 01/11/24 at 07:30 AM, observation revealed R14 sat at the dining table and waited for breakfast. She did not speak to her tablemates. On 01/16/24 at 11:30 AM, Social Services BB verified she had not completed the trauma informed care assessment after R14 was diagnosed for PTSD and verified the care plan lacked identified triggers related to R14's PTSD. Social Services BB stated R14 had seen a behavioral healthcare provider and would continue as needed. On 01/17/24 at 09:14 AM, Certified Nurse Aide (CNA) M stated R 14 seemed depressed at times, down on herself and would often isolate in her room. CNA M further stated R14 could be rude and yelled at staff at times. On 01/17/24 at 09:50 AM, Licensed Nurse (LN) G stated R14 made sexual comments towards some staff, and isolated herself which caused her to think about her past abuse. On 01/17/24 at 11:15 AM, Administrative Nurse D stated the care plan should reflect R14's PTSD status and a PTSD assessment should have been completed for the resident. The facility's Trauma Informed Care policy, dated 09/18/23, documented the facility ensures that residents who are trauma survivors received culturally competent trauma informed care in accordance with professional standards of practice and accounting for each resident's experiences and preferences in order to eliminate or mitigate triggers that may cause traumatization of the resident. The policy further documented, within 48 hours of admission an initial screening for history of trauma and to determine if resident had trauma related symptoms, identification of triggers that caused traumatization, and severity of characteristics of specific trauma type. Trigger specific interventions would identify ways to decrease the resident's exposure to triggers which retraumatize the resident and identify interventions to mitigate or decrease the effect of the trigger on the resident trauma. The facility failed to complete a trauma informed care assessment for R14 who had past trauma. This placed the resident at risk for unmet mental health needs.

The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to notify Resident (R) 5's physician of elevated blood sugar per the physician ordered parameters and failed to initiate R19's prescribed bowel treatment which placed both resident at risk for impaired care and adverse medications effects. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes melilites (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin)with kidney complications and neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), pain, hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented R5 had intact cognition, required partial/moderate assistance for activities of daily living, received insulin injections (hormone that lowers the level of glucose in the blood), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), opioid (a class of medication used to treat pain) and antiplatelet (medications used to prevent blood clotting) medications. R5's Care Plan lacked interventions related to diabetes and blood sugar monitoring. The Physician Order dated 07/28/23 directed staff to obtain finger stick blood sugar checks before meals and at bedtime and notify the physician if blood sugar was below 50 milliliters (ml) per deciliter (dL) or above 300 mm/dL. R5's Electronic Treatment Administration Record (ETAR), dated January 2024 recorded the following occasions where R5's blood sugar was above the physician ordered parameter and the record lacked evidence the physician was notified. 01/03/24 at 05:30 PM blood sugar reading of 344 mm/dL and at 08:00 PM blood sugar reading of 344 mm/dL. 01/05/24 at 07:30 AM blood sugar reading of 321 mm/dL. 01/08/24 at 07:30 AM blood sugar reading of 375 mm/dL. 01/09/24 at 11:30 AM blood sugar reading of 317 mm/dL. 01/10/24 at 11:30 AM blood sugar reading of 389 mm/dL. 01/16/24 at 07:30 AM blood sugar reading of 347 mm/dL and 11:30 AM blood sugar reading of 304 mm/dL. On 01/17/24 at 10:55 AM Licensed Nurse (LN) H reported she had not notified the physician of R5's elevated blood sugars. On 01/17/24 at 10:12 AM, Administrative Nurse D verified the physician should be notified of R5's blood sugars over 300. The facility's Blood Glucose Monitoring Policy and Protocol, dated 09/12/2023, documented bedside testing will be performed only with an order from a licensed physician, an approved physician extender or by physician-approved protocol. Each physician order for bedside blood glucose testing will include physician notification parameters and hypoglycemic medication holding parameters as applicable. The facility failed to notify R5's physician of blood sugar levels outside of the physician ordered parameters placing the resident at risk of diabetes complications. 32360 - The Electronic Medical Record for R19 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) ,anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (difficulty passing stools). R19's Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had severely impaired cognition and required limited assistance of one staff for dressing, toileting, personal hygiene, and supervision and set up assistance for bed mobility, transfers, ambulation, and eating. The MDS further documented R19 received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), and antidepressant (class of medications used to treat mood disorders) medications, had no behaviors, and was continent of bowel. The Annual MDS, dated [DATE], documented R19 had severely impaired cognition and required partial to moderate assistance for showers, toileting, supervision for oral hygiene, personal hygiene. R19 was independent for transfers and mobility. The MDS further documented R19 received antipsychotic medication, had delusions and continent of bowel. R19's Care Plan dated 11/01/23, initiated on 02/18/20, documented R19 had potential for side effects related to the use of antipsychotic medication and directed staff to monitor for constipation. The Physician's Order, dated 02/17/20, directed staff to administer MiraLAX (a laxative medication), 17 grams (gm), by mouth, as needed for constipation. Mix with four ounces of water or juice once day, if no results in 24 hours, go to step two. The Physician's Order, dated 02/18/23, directed staff to administer Colace (a laxative), 100 milligrams (mg), by mouth twice a day for constipation. The Physician's Order, dated 09/11/23, directed staff to initiate bowel protocol per facility policy. R19's Bowel Monitoring Record, dated December 2023 documented R19 did not have a bowel movement (BM) for the following days: 12/22/23-12/25/23 (4 consecutive days) R19's Treatment Administration Record (TAR) dated December 2023 lacked evidence the staff provided interventions during the lack of bowel elimination on the above dates. R19's Bowel Monitoring Record dated January 2024 documented R19 did not have a BM for the following days: 01/04/24-01/08/24 (5 consecutive days) R19's TAR dated January 2024 lacked evidence the staff provided interventions during the lack of bowel elimination on the above dates. On 01/11/24 at 08:35 AM, observation revealed R19 sat at the dining room table and received his medication without concerns. On 01/16/24 at 11:50 AM, Social Services BB stated R19 had altered thought processes and said she often visited with R19 one on one. On 01/17/24 at 09:18 AM, Certified Nurse Aide (CNA) M stated residents were asked daily if they had a BM and it was recorded in the computer. On 01/17/24 at 10:00 AM, Licensed Nurse (LN) G stated R19 did not have any behaviors but was forgetful regarding family events and required cueing and reminders. LN G further stated staff asked R19 daily if he had a BM and if he had not, the bowel protocol was started. On 01/17/24 at 11:16 AM, Administrative Nurse D stated staff should have started the bowel protocol when R19 had not had a BM for three days. The facility's Bowel Protocol, dated 09/07/23, directed staff to administer the bm medications in four steps: Step 1: Administer MiraLAX, 17 grams (gm), by mouth, as needed for constipation, mix with four ounces of water or juice x one day if no results in 24 hours go to step two. Step 2: Administer Milk of Magnesium (MOM-a laxative), 400 milligrams (mg)/5 milliliters (ml), as needed, and if no bm in 12 hours go to step 3. Step 3: Administer Bisacodyl (laxative), 5 mg, every 24 hours as needed and if no bm after 12 hours go to step 4. Step 4: Administer Dulcolax (a laxative) suppository, rectally (by way of the rectum) as needed, and if no results contact the physician for further orders. The facility failed to monitor and provide interventions for bowel management for R19 as ordered by the physician This placed the resident at risk for fecal impaction and decline.

The facility identified a census of 38 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to protect residents from further abuse of staff to resident abuse. On 07/04/23 Resident (R) 1, who was cognitively impaired and had a history of wandering and /or elopement (when a cognitively impaired resident leaves the facility without staff knowledge and/or supervision) risk, attempted to exit the facility through the front door. Staff identified R1's behaviors and intervened. R1 walked aggressively, with a front wheeled walker, towards as staff member who retreated into an office. Six other staff, including Certified Medication Aide (CMA) R, surrounded R1 and tried to talk him away from the door. R1 spit at CMA R and in response, CMA R shoved R1, using his arm to R1's neck, approximately three feet until R1 was pinned against the wall by CMA R. R1, who continued to be surrounded by six staff members, was placed forcefully on the floor by CMA R. R1 landed on his right shoulder. CMA R and the other five staff present then held R1 down, on the floor, while Licensed Nurse G returned with an Ativan injection and administered the injection intramuscularly while staff restrained the resident. CMA then continued to work in the facility for the remainder of his shift on 07/04/23 and for nine other shifts until and including 07/17/23. The facility failed to protect residents from further staff to resident abuse. This placed the residents who received care from CMA R in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS documented R1 required limited assistance of one staff for dressing, toilet use, personal hygiene, and bathing. The MDS further documented R1 had delusions during the lookback period The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/07/22, documented R1 had episodes of verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) during the lookback period and had a decreased ability to understand others or to make himself understood. The Activity of Daily Living Functional/Rehabilitation CAA, dated 12/07/22, documented R1 had changing cognitive status, daily behavioral symptoms, mood decline, communication problems, physical limitations such as weakness, limited range of motion, poor coordination, and poor balance. The Behavioral Symptoms CAA, dated 12/07/22, documented R1 had verbal behaviors directed towards others and R1's behavior status, rejection of care, and wandering had worsened. The Wandering/Elopement Care Plan, initiated 06/22/22, directed staff to assist R1 with the telephone to call his significant other to try and calm and redirect R1 when he was exit-seeking. The plan directed staff to engage R1 in purposeful activity such as one on one conversation, talking about his past, farm conversation, offer R1 a diet coke or snack, or offer R1 a newspaper to read. If R1 was exit seeking and demanding to leave, staff were to remind R1 the facility was following his doctor's orders. If R1 was seeking to leave the facility, staff were to offer to take R1 outside to the patio with staff supervision and provide structured activities like walking inside. The interventions dated 07/04/23 directed staff to not have more that two staff members stand at least two arms widths away when R1 was attempting to exit seek; staff present needed to be calm and provide therapeutic communication to R1 and provide R1 with a wheelchair and take R1 to his room for any injections as needed. The Elopement Evaluation, dated 05/17/23, documented R1 had a history of attempting to leave the facility without informing staff and had a history of wandering. R1's elopement score was a three, indicating he was at risk for elopement. The Facility Incident Report, dated 07/07/23, documented at approximately 03:00 PM R1 became agitated after his guest left the facility. R1 was exit seeking and determined to leave the facility. CMA R, LN G, and LN H came to the door area when they heard a commotion by the front door. CMA R got in front of the door and would not let R1 leave. LN H tried to talk to R1 to calm R1 down. R1 continued to yell and call staff names. CMA R continued to stand between R1 and the other staff. R1 spit into CMA R's face. CMA R moved R1 towards the office door so that he could more easily control R1 and keep R1 from hitting staff. It took three to four staff to get R1's walker away from R1 so he could not use it to hurt staff. LN G went to get medication (Ativan) to give R1 and then staff moved R1 to the floor so they could hold him better to give him the injection. Staff then assisted R1 to an upright position and R1 went to the dining room to have a drink. R1 continued to yell and scream he needed out to go harvest his crops and was given two more Ativan injections before he went to his room. A Witness Statement by LN G, dated 07/06/23, documented R1 went to the front door and attempted to leave the facility. R1 began screaming, threatening, and pushing his way out the front door. Staff gathered and attempted to redirect R1. R1 continued to push his way to the front door. R1 pushed with his fists, slammed his walker repeatedly, and spit in the eyes of CMA R. Staff pushed R1 away from the door and removed R1's walker. R1 attempted to punch and claw at staff and was restrained. LN G stated she returned to the scene with an Ativan injection to calm R1 down. LN G ordered CMA R to take R1 down to the ground. R1 fought the entire time the injection was administered. After a couple of minutes of soft restraint, R1 was released and continued to yell and cuss in the dining room. The doctor called and ordered one milligram of Ativan every fifteen minutes until calm. R1 was given two more injections of Ativan before he went to his room. A Witness Statement by CNA M, dated 07/11/23, documented Certified Nurse Aide (CNA) M went to R1's room at 01:45 PM to get R1 for a movie and popcorn. R1 had a visitor so CNA M told R1 he could join the activity after his visitor left. CNA M stated at 02:45 PM, R1 came to the dining room for the activity and sat down. CNA M got R1 a bag of popcorn. At about 03:00 PM, R1 looked around and asked where his visitor had gone and then stood up and left the dining room. CNA M then heard the door alarm and saw R1 pushing on the door. Another staff member came out of the office to guide R1 away from the door and R1 started screaming, cursing and threatening the staff member. CNA M directed the staff member to go back into the office and shut the door. CNA M yelled for a nurse. CNA M walked up to R1 with her hands open and her voice lowered. CNA M asked R1 if there was anything she could do for R1. R1 screamed at CNA M to get him out of here. CNA M asked R1 if he wanted to go for a walk and R1 said he wanted the authorities called and wanted out of here. Other CNA's and nurses arrived to help. R1 was raising his fist and using his walker as a weapon. R1 then spat in CMA R's face. CMA R shoved R1 against the front office door. LN G went to call the administrator and was looking for medication orders that would help R1 calm down. R1 continued to threaten staff. LN G came up with a shot and R1 was lowered to the ground. After R1 was given the shot, staff helped him back up from the floor and R1 walked to the front part of the dining room. R1 continued to scream and cuss. CNA M got R1 to sit down and tried to get R1 to drink a coke but R1 was still yelling and screaming. An undated Witness Statement by LN H documented LN H was at the south nurses station with LN G and CMA R when she heard screaming and yelling. All three staff members went to the living room. LN H saw R1 trying to leave the building and CNA M was preventing R1 from leaving. LN H stated she tried to talk to R1 and then R1 realized LN H was not letting him out the door R1 told LN H to shut the [explicit] up. R1 continued to cuss and yell at staff. Staff cleared the living room and kept the other residents from the living room. CMA R positioned himself toward R1. R1 threatened to hit CMA R. R1 was ushered with his back to the office door. LN G called the doctor for guidance and he ordered Ativan intramuscularly. R1 continued to threaten and yell at staff. Staff took R1's walker away. CMA R was in front of R1 and R1 spit on CMA R. CMA R pushed R1 toward the door and assisted him to the floor. LN G felt this was the safest way to give R1 the injection. Once R1 calmed down, R1 sat up and was assisted to his feet. R1 ambulated to a chair next to the beauty shop. R1 continued to yell and threaten staff. R1 was given two more injections and was then assisted to his room. An undated Witness Statement by CMA R documented CMA R was at the south nurses station with LN G and LN H when a very loud commotion was heard from the direction of the living room. The three staff proceeded down the hallway to that area. Another staff yelled that she needed a nurse. Upon arriving to the living room, CMA R saw R1 screaming and cursing at another staff member that he needed to go out the door and that staff could not keep him from leaving. CMA R, LN G, and LN H approached R1 to try and redirect R1 and calm him. R1 continued to scream, cuss, and threaten staff. CMA R placed himself between R1, the other staff, and the door. R1 kept trying to grab LN H as she tried to talk to him. R1 told CMA R that he was going to hit him and spit on him. R1 spat at CMA R hitting him full in the face. CMA R decided R1 needed to be more contained and moved R1 to the office door to better contain R1. R1 continued to scream and curse at staff. LN G arrived with shot of Ativan and instructed CMA R to take R1 to the floor to administer the shot. CMA R took R1 down guarding his neck and head with CMA R's hand and continued to contain R1's neck and arms during the injection. After a few moments to let the injection kick in, R1 continued to yell and cuss. CMA R decided to move off R1 and let R1 up. R1 then proceeded to the dining room still yelling and cussing. On 07/17/23 at 09:05 AM, observation revealed video camera footage from 07/04/23 at approximately 03:00 PM, which showed R1 ambulated up to the front door with his walker and attempted to open the front door. A staff member walked out of the front office to redirect R1. R1 let go of his walker and walked towards the staff member in an aggressive manner. The staff member backed back into the office. Six other staff members came up to R1 within a couple of feet from him and surrounded him. Staff were trying to talk to R1 to get him away from the door. R1 continued to try to get to the door. R1 spit into the CMA R's face and then CMA R shoved R1 aggressively approximately three feet into the wall by the office door using an arm across R1's neck into R1's left shoulder and back. CMA R held R1 against the wall. R1 was surrounded again by five to six staff as he was held against the wall. A nurse came to the scene after she had left once and appeared to have an injection. CMA R forcefully took R1 to the floor and R1 landed on his right shoulder. Five staff, including CMA R, held R1 while the nurse gave R1 the injection. R1's upper body was obscured by a piano but R1 laid on the floor with his legs and feet unmoving for approximately five minutes. Staff then let go of R1 and R1 got to his hands and knees and attempted to get up. Staff then helped R1to his feet and R1 walked away toward the dining room. On 07/17/23 at 10:00 AM, observation revealed R1 up and walking in the hall with his walker. No behaviors or exit seeking were observed. On 07/17/23 at 10:30 AM, Administrative Staff A stated that CMA R was allowed to work the remainder of his shift after the incident occured because abuse was not reported to her by the facility staff. Administrative Staff A stated that she did not place CMA R on suspension after the incident because she spoke to both of her nurses that were on duty that day and both nurses did not feel like any abuse took place. Administrative Staff A verified that CMA R continued to work with the residents at the facility since the incident. Administrative Staff A did admit that when she watched the video play back of the incident that CMA R's actions were harsh but stated that both nurses felt like that if CMA R had not been there, the young, female CNAs would not have been able to handle R1. Administrative Staff A stated the shove was a little excessive but when the situation happened, R1 was out of control so it had to happen. On 07/17/23 at 11:20 AM, LN G stated on the day of the incident there were too many people trying to redirect R1. LN G stated R1 was very angry and wanted to leave that day and has days when he becomes angry but is more redirectable. LN G stated that she did not see CMA R shove R1 into the wall on the day that it happened as she was down the hall on the phone with the doctor and drawing up the Ativan injection. LN G stated that she saw CMA R shove R1 on video replaying what happened and felt that CMA R's actions were excessive. LN G thought that CMA R needed more training on how to handle situations like that. LN G stated that she did order CMA R to take R1 to the ground so she could safely administer the Ativan injection. On 07/17/23 at 11:45 AM, CNA M stated that she was the first staff member to come into contact with R1 on the day of the incident and she was trying to calm him down. CNA M stated she had suggested that she take R1 outside for a walk, but CMA R stated no one was going anywhere. CNA M stated that she had a good rapport with R1 and felt like she could have gotten him calmed down if all the other staff had not surrounded R1. CNA M stated when R1 spat in CMA R's face, CMA R reacted immediately and shoved R1 into the wall. CNA M thought CMA R's actions were excessive at the time but did not report it as abuse because there were nurses there that were above her. On 07/17/23 at 01:30 PM, CMA R stated he did not think that he overreacted on the day of the incident. CMA R stated he was trying to protect the girls and felt like R1 needed to be contained better so staff could handle him and explained that was the reason for pushing R1 against the wall. On 07/17/23 at 02:00 PM, CNA N stated she was in the living room on the day of the incident and saw CMA R violently shove R1 into the wall. CNA N stated that the way R1 was treated was not right and she knew it was not right. CNA N stated after CMA R shoved R1 to the wall, she was directed to go into the dining room to stay with the other residents at the activity. The facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy, reviewed 02/21/23, documented residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility has developed a system for identifying, investigating, preventing, and reporting any incident or suspected incident of abuse. It is the responsibility of the employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors including injuries of an unknown source and theft or misappropriation of resident property. Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The facility failed to protect residents from further abuse of staff to resident abuse. This placed the residents who received care from CMA R in immediate jeopardy. The following corrective actions were implemented to address the immediacy: CMA R was placed on suspension until all education/training was completed. CMA R would meet with the Administrator to discuss any issues or concerns. Anyone suspected of abuse will be suspended from work immediately until the investigation can be completed. Administrator will monitor all investigations and suspensions to ensure the process was being followed. All staff received education and retraining on Abuse and Neglect. The above corrective actions were verified by the onsite surveyor and the immediacy was removed on 07/17/23. The scope and severity remained at the level of a E

The facility identified a census of 38 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from abuse. On 07/04/23 Resident (R) 1, who was cognitively impaired and had a history of wandering and/or elopement (when a cognitively impaired resident leaves the facility without staff knowledge and/or supervision) risk, attempted to exit the facility through the front door. Staff identified R1's behaviors and intervened. R1 walked aggressively, with a front wheeled walker, towards a staff member who retreated into an office. Six other staff, including Certified Medication Aide (CMA) R, surrounded R1 and tried to talk him away from the door. R1 spit at CMA R and in response, CMA R shoved R1, using his arm to R1's neck, approximately three feet until R1 was pinned against the wall by CMA R. R1, who continued to be surrounded by multiple staff members, was placed forcefully on the floor by CMA R. R1 landed on his right shoulder. CMA R and the other five staff present then held R1 down, on the floor, while Licensed Nurse (LN) G returned with an Ativan injection (medication used to calm) and administered the injection intramuscularly (in the muscle) while staff restrained the resident. The facility failed to ensure R1 was free from staff abuse and mistreatment when staff used excessive force to physically pin the resident against the wall, force the resident to the floor, and hold him down to administer an injection. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS documented R1 required limited assistance of one staff for dressing, toilet use, personal hygiene, and bathing. The MDS further documented R1 had delusions during the lookback period The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/07/22, documented R1 had episodes of verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) during the lookback period and had a decreased ability to understand others or to make himself understood. The Activity of Daily Living Functional/Rehabilitation CAA, dated 12/07/22, documented R1 had changing cognitive status, daily behavioral symptoms, mood decline, communication problems, physical limitations such as weakness, limited range of motion, poor coordination, and poor balance. The Behavioral Symptoms CAA, dated 12/07/22, documented R1 had verbal behaviors directed towards others and R1's behavior status, rejection of care, and wandering had worsened. The Wandering/Elopement Care Plan, initiated 06/22/22, directed staff to assist R1 with the telephone to call his significant other to try and calm and redirect R1 when he was exit-seeking. The plan directed staff to engage R1 in purposeful activity such as one on one conversation, talking about his past, farm conversation, offer R1 a diet coke or snack, or offer R1 a newspaper to read. If R1 was exit seeking and demanding to leave, staff were to remind R1 the facility was following his doctor's orders. If R1 was seeking to leave the facility, staff were to offer to take R1 outside to the patio with staff supervision and provide structured activities like walking inside. The interventions dated 07/04/23 directed staff to not have more that two staff members stand at least two arms widths away when R1 was attempting to exit seek; staff present needed to be calm and provide therapeutic communication to R1 and provide R1 with a wheelchair and take R1 to his room for any injections as needed. The Elopement Evaluation, dated 05/17/23, documented R1 had a history of attempting to leave the facility without informing staff and had a history of wandering. R1's elopement score was a three, indicating he was at risk for elopement. The Facility Incident Report, dated 07/07/23, documented at approximately 03:00 PM R1 became agitated after his guest left the facility. R1 was exit seeking and determined to leave the facility. CMA R, LN G, and LN H came to the door area when they heard a commotion by the front door. CMA R got in front of the door and would not let R1 leave. LN H tried to talk to R1 to calm R1 down. R1 continued to yell and call staff names. CMA R continued to stand between R1 and the other staff. R1 spit into CMA R's face. CMA R moved R1 towards the office door so that he could more easily control R1 and keep R1 from hitting staff. It took three to four staff to get R1's walker away from R1 so he could not use it to hurt staff. LN G went to get medication (Ativan) to give R1 and then staff moved R1 to the floor so they could hold him better to give him the injection. Staff then assisted R1 to an upright position and R1 went to the dining room to have a drink. R1 continued to yell and scream he needed out to go harvest his crops and was given two more Ativan injections before he went to his room. A Witness Statement by LN G, dated 07/06/23, documented R1 went to the front door and attempted to leave the facility. R1 began screaming, threatening, and pushing his way out the front door. Staff gathered and attempted to redirect R1. R1 continued to push his way to the front door. R1 pushed with his fists, slammed his walker repeatedly, and spit in the eyes of CMA R. Staff pushed R1 away from the door and removed R1's walker. R1 attempted to punch and claw at staff and was restrained. LN G stated she returned to the scene with an Ativan injection to calm R1 down. LN G ordered CMA R to take R1 down to the ground. R1 fought the entire time the injection was administered. After a couple of minutes of soft restraint, R1 was released and continued to yell and cuss in the dining room. The doctor called and ordered one milligram of Ativan every fifteen minutes until calm. R1 was given two more injections of Ativan before he went to his room. A Witness Statement by CNA M, dated 07/11/23, documented Certified Nurse Aide (CNA) M went to R1's room at 01:45 PM to get R1 for a movie and popcorn. R1 had a visitor so CNA M told R1 he could join the activity after his visitor left. CNA M stated at 02:45 PM, R1 came to the dining room for the activity and sat down. CNA M got R1 a bag of popcorn. At about 03:00 PM, R1 looked around and asked where his visitor had gone and then stood up and left the dining room. CNA M then heard the door alarm and saw R1 pushing on the door. Another staff member came out of the office to guide R1 away from the door and R1 started screaming, cursing and threatening the staff member. CNA M directed the staff member to go back into the office and shut the door. CNA M yelled for a nurse. CNA M walked up to R1 with her hands open and her voice lowered. CNA M asked R1 if there was anything she could do for R1. R1 screamed at CNA M to get him out of here. CNA M asked R1 if he wanted to go for a walk and R1 said he wanted the authorities called and wanted out of here. Other CNA's and nurses arrived to help. R1 was raising his fist and using his walker as a weapon. R1 then spat in CMA R's face. CMA R shoved R1 against the front office door. LN G went to call the administrator and was looking for medication orders that would help R1 calm down. R1 continued to threaten staff. LN G came up with a shot and R1 was lowered to the ground. After R1 was given the shot, staff helped him back up from the floor and R1 walked to the front part of the dining room. R1 continued to scream and cuss. CNA M got R1 to sit down and tried to get R1 to drink a coke but R1 was still yelling and screaming. An undated Witness Statement by LN H documented LN H was at the south nurses station with LN G and CMA R when she heard screaming and yelling. All three staff members went to the living room. LN H saw R1 trying to leave the building and CNA M was preventing R1 from leaving. LN H stated she tried to talk to R1 and then R1 realized LN H was not letting him out the door R1 told LN H to shut the [explicit] up. R1 continued to cuss and yell at staff. Staff cleared the living room and kept the other residents from the living room. CMA R positioned himself toward R1. R1 threatened to hit CMA R. R1 was ushered with his back to the office door. LN G called the doctor for guidance and he ordered Ativan intramuscularly. R1 continued to threaten and yell at staff. Staff took R1's walker away. CMA R was in front of R1 and R1 spit on CMA R. CMA R pushed R1 toward the door and assisted him to the floor. LN G felt this was the safest way to give R1 the injection. Once R1 calmed down, R1 sat up and was assisted to his feet. R1 ambulated to a chair next to the beauty shop. R1 continued to yell and threaten staff. R1 was given two more injections and was then assisted to his room. An undated Witness Statement by CMA R documented CMA R was at the south nurses station with LN G and LN H when a very loud commotion was heard from the direction of the living room. The three staff proceeded down the hallway to that area. Another staff yelled that she needed a nurse. Upon arriving to the living room, CMA R saw R1 screaming and cursing at another staff member that he needed to go out the door and that staff could not keep him from leaving. CMA R, LN G, and LN H approached R1 to try and redirect R1 and calm him. R1 continued to scream, cuss, and threaten staff. CMA R placed himself between R1, the other staff, and the door. R1 kept trying to grab LN H as she tried to talk to him. R1 told CMA R that he was going to hit him and spit on him. R1 spat at CMA R hitting him full in the face. CMA R decided R1 needed to be more contained and moved R1 to the office door to better contain R1. R1 continued to scream and curse at staff. LN G arrived with shot of Ativan and instructed CMA R to take R1 to the floor to administer the shot. CMA R took R1 down guarding his neck and head with CMA R's hand and continued to contain R1's neck and arms during the injection. After a few moments to let the injection kick in, R1 continued to yell and cuss. CMA R decided to move off R1 and let R1 up. R1 then proceeded to the dining room still yelling and cussing. On 07/17/23 at 09:05 AM, observation revealed video camera footage from 07/04/23 at approximately 03:00 PM, which showed R1 ambulated up to the front door with his walker and attempted to open the front door. A staff member walked out of the front office to redirect R1. R1 let go of his walker and walked towards the staff member in an aggressive manner. The staff member backed back into the office. Six other staff members came up to R1 within a couple of feet from him and surrounded him. Staff were trying to talk to R1 to get him away from the door. R1 continued to try to get to the door. R1 spit into the CMA R's face and then CMA R shoved R1 aggressively approximately three feet into the wall by the office door using an arm across R1's neck into R1's left shoulder and back. CMA R held R1 against the wall. R1 was surrounded again by five to six staff as he was held against the wall. A nurse came to the scene after she had left once and appeared to have an injection. CMA R forcefully took R1 to the floor and R1 landed on his right shoulder. Five staff, including CMA R, held R1 while the nurse gave R1 the injection. R1's upper body was obscured by a piano but R1 laid on the floor with his legs and feet unmoving for approximately five minutes. Staff then let go of R1 and R1 got to his hands and knees and attempted to get up. Staff then helped R1to his feet and R1 walked away toward the dining room. On 07/17/23 at 10:00 AM, observation revealed R1 up and walking in the hall with his walker. No behaviors or exit seeking were observed. On 07/17/23 at 10:30 AM, Administrative Staff A stated that CMA R was allowed to work the remainder of his shift after the incident occurred because abuse was not reported to her by the facility staff. Administrative Staff A stated that she did not place CMA R on suspension after the incident because she spoke to both of her nurses that were on duty that day and both nurses did not feel like any abuse took place. Administrative Staff A verified that CMA R continued to work with the residents at the facility since the incident. Administrative Staff A did admit that when she watched the video play back of the incident that CMA R's actions were harsh but stated that both nurses felt like that if CMA R had not been there, the young, female CNAs would not have been able to handle R1. Administrative Staff A stated the shove was a little excessive but when the situation happened, R1 was out of control so it had to happen. On 07/17/23 at 11:20 AM, LN G stated on the day of the incident there were too many people trying to redirect R1. LN G stated R1 was very angry and wanted to leave that day and has days when he becomes angry but is more redirectable. LN G stated that she did not see CMA R shove R1 into the wall on the day that it happened as she was down the hall on the phone with the doctor and drawing up the Ativan injection. LN G stated that she saw CMA R shove R1 on video replaying what happened and felt that CMA R's actions were excessive. LN G thought that CMA R needed more training on how to handle situations like that. LN G stated that she did order CMA R to take R1 to the ground so she could safely administer the Ativan injection. On 07/17/23 at 11:45 AM, CNA M stated that she was the first staff member to come into contact with R1 on the day of the incident and she was trying to calm him down. CNA M stated she had suggested that she take R1 outside for a walk, but CMA R stated no one was going anywhere. CNA M stated that she had a good rapport with R1 and felt like she could have gotten him calmed down if all the other staff had not surrounded R1. CNA M stated when R1 spat in CMA R's face, CMA R reacted immediately and shoved R1 into the wall. CNA M thought CMA R's actions were excessive at the time but did not report it as abuse because there were nurses there that were above her. On 07/17/23 at 01:30 PM, CMA R stated he did not think that he overreacted on the day of the incident. CMA R stated he was trying to protect the girls and felt like R1 needed to be contained better so staff could handle him and explained that was the reason for pushing R1 against the wall. On 07/17/23 at 02:00 PM, CNA N stated she was in the living room on the day of the incident and saw CMA R violently shove R1 into the wall. CNA N stated that the way R1 was treated was not right and she knew it was not right. CNA N stated after CMA R shoved R1 to the wall, she was directed to go into the dining room to stay with the other residents at the activity. The facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy, reviewed 02/21/23, documented residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility has developed a system for identifying, investigating, preventing, and reporting any incident or suspected incident of abuse. It is the responsibility of the employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors including injuries of an unknown source and theft or misappropriation of resident property. Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The facility failed to prevent staff to resident abuse for R1. This deficient practice placed R1 in immediate jeopardy. The following corrective actions were implemented to address the immediacy: Resident Interventions would place to ensure R1 would be redirected by only one staff person when he was attempting to leave the facility. Staff were educated not to use mob effect redirection attempts. The facility provided Alzheimer's and Dementia education regarding proper handling of residents in situations where the resident may harm themselves or others. All staff received education and retraining on Abuse and Neglect. The above corrective actions were verified by the onsite surveyor and the immediacy was removed on 07/17/23. The scope and severity remained at the level of a G to reflect the actual harm which included psychosocial impairment based on the reasonable person concept as R1 was cognitively impaired and unable to express the impact of the situation.

The facility identified a census of 38 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff identified a situation of physical abuse and intimidation as an allegation of abuse and failed to immediately report to the facility administrator (LNHA). On 07/04/23 Resident (R) 1, who was cognitively impaired and had a history of wandering and /or elopement (when a cognitively impaired resident leaves the facility without staff knowledge and/or supervision) risk, attempted to exit the facility through the front door. Staff identified R1's behaviors and intervened. R1 walked aggressively, with a front wheeled walker, towards as staff member who retreated into an office. Six other staff, including Certified Medication Aide (CMA) R, surrounded R1 and tried to talk him away from the door. R1 spit at CMA R and in response, CMA R shoved R1, using his arm to R1's neck, approximately three feet until R1 was pinned against the wall by CMA R. R1, who continued to be surrounded by six staff members, was placed forcefully on the floor by CMA R. R1 landed on his right shoulder. CMA R and the other five staff present then held R1 down, on the floor, while Licensed Nurse G returned with an Ativan injection and administered the injection intramuscularly while staff restrained the resident. The facility failed to identify the excessive force to physically pin the resident against the wall, force the resident to the floor, and hold him down in order to administer an injection as abuse and report to the LNHA as required. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and psychosis (any major mental disorder characterized by a gross impairment in reality testing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS documented R1 required limited assistance of one staff for dressing, toilet use, personal hygiene, and bathing. The MDS further documented R1 had delusions during the lookback period The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/07/22, documented R1 had episodes of verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) during the lookback period and had a decreased ability to understand others or to make himself understood. The Activity of Daily Living Functional/Rehabilitation CAA, dated 12/07/22, documented R1 had changing cognitive status, daily behavioral symptoms, mood decline, communication problems, physical limitations such as weakness, limited range of motion, poor coordination, and poor balance. The Behavioral Symptoms CAA, dated 12/07/22, documented R1 had verbal behaviors directed towards others and R1's behavior status, rejection of care, and wandering had worsened. The Wandering/Elopement Care Plan, initiated 06/22/22, directed staff to assist R1 with the telephone to call his significant other to try and calm and redirect R1 when he was exit-seeking. The plan directed staff to engage R1 in purposeful activity such as one on one conversation, talking about his past, farm conversation, offer R1 a diet coke or snack, or offer R1 a newspaper to read. If R1 was exit seeking and demanding to leave, staff were to remind R1 the facility was following his doctor's orders. If R1 was seeking to leave the facility, staff were to offer to take R1 outside to the patio with staff supervision and provide structured activities like walking inside. The interventions dated 07/04/23 directed staff to not have more that two staff members stand at least two arms widths away when R1 was attempting to exit seek; staff present needed to be calm and provide therapeutic communication to R1 and provide R1 with a wheelchair and take R1 to his room for any injections as needed. The Elopement Evaluation, dated 05/17/23, documented R1 had a history of attempting to leave the facility without informing staff and had a history of wandering. R1's elopement score was a three, indicating he was at risk for elopement. The Facility Incident Report, dated 07/07/23, documented at approximately 03:00 PM R1 became agitated after his guest left the facility. R1 was exit seeking and determined to leave the facility. CMA R, LN G, and LN H came to the door area when they heard a commotion by the front door. CMA R got in front of the door and would not let R1 leave. LN H tried to talk to R1 to calm R1 down. R1 continued to yell and call staff names. CMA R continued to stand between R1 and the other staff. R1 spit into CMA R's face. CMA R moved R1 towards the office door so that he could more easily control R1 and keep R1 from hitting staff. It took three to four staff to get R1's walker away from R1 so he could not use it to hurt staff. LN G went to get medication (Ativan) to give R1 and then staff moved R1 to the floor so they could hold him better to give him the injection. Staff then assisted R1 to an upright position and R1 went to the dining room to have a drink. R1 continued to yell and scream he needed out to go harvest his crops and was given two more Ativan injections before he went to his room. A Witness Statement by LN G, dated 07/06/23, documented R1 went to the front door and attempted to leave the facility. R1 began screaming, threatening, and pushing his way out the front door. Staff gathered and attempted to redirect R1. R1 continued to push his way to the front door. R1 pushed with his fists, slammed his walker repeatedly, and spit in the eyes of CMA R. Staff pushed R1 away from the door and removed R1's walker. R1 attempted to punch and claw at staff and was restrained. LN G stated she returned to the scene with an Ativan injection to calm R1 down. LN G ordered CMA R to take R1 down to the ground. R1 fought the entire time the injection was administered. After a couple of minutes of soft restraint, R1 was released and continued to yell and cuss in the dining room. The doctor called and ordered one milligram of Ativan every fifteen minutes until calm. R1 was given two more injections of Ativan before he went to his room. A Witness Statement by CNA M, dated 07/11/23, documented Certified Nurse Aide (CNA) M went to R1's room at 01:45 PM to get R1 for a movie and popcorn. R1 had a visitor so CNA M told R1 he could join the activity after his visitor left. CNA M stated at 02:45 PM, R1 came to the dining room for the activity and sat down. CNA M got R1 a bag of popcorn. At about 03:00 PM, R1 looked around and asked where his visitor had gone and then stood up and left the dining room. CNA M then heard the door alarm and saw R1 pushing on the door. Another staff member came out of the office to guide R1 away from the door and R1 started screaming, cursing and threatening the staff member. CNA M directed the staff member to go back into the office and shut the door. CNA M yelled for a nurse. CNA M walked up to R1 with her hands open and her voice lowered. CNA M asked R1 if there was anything she could do for R1. R1 screamed at CNA M to get him out of here. CNA M asked R1 if he wanted to go for a walk and R1 said he wanted the authorities called and wanted out of here. Other CNA's and nurses arrived to help. R1 was raising his fist and using his walker as a weapon. R1 then spat in CMA R's face. CMA R shoved R1 against the front office door. LN G went to call the administrator and was looking for medication orders that would help R1 calm down. R1 continued to threaten staff. LN G came up with a shot and R1 was lowered to the ground. After R1 was given the shot, staff helped him back up from the floor and R1 walked to the front part of the dining room. R1 continued to scream and cuss. CNA M got R1 to sit down and tried to get R1 to drink a coke but R1 was still yelling and screaming. An undated Witness Statement by LN H documented LN H was at the south nurses station with LN G and CMA R when she heard screaming and yelling. All three staff members went to the living room. LN H saw R1 trying to leave the building and CNA M was preventing R1 from leaving. LN H stated she tried to talk to R1 and then R1 realized LN H was not letting him out the door R1 told LN H to shut the [explicit] up. R1 continued to cuss and yell at staff. Staff cleared the living room and kept the other residents from the living room. CMA R positioned himself toward R1. R1 threatened to hit CMA R. R1 was ushered with his back to the office door. LN G called the doctor for guidance and he ordered Ativan intramuscularly. R1 continued to threaten and yell at staff. Staff took R1's walker away. CMA R was in front of R1 and R1 spit on CMA R. CMA R pushed R1 toward the door and assisted him to the floor. LN G felt this was the safest way to give R1 the injection. Once R1 calmed down, R1 sat up and was assisted to his feet. R1 ambulated to a chair next to the beauty shop. R1 continued to yell and threaten staff. R1 was given two more injections and was then assisted to his room. An undated Witness Statement by CMA R documented CMA R was at the south nurses station with LN G and LN H when a very loud commotion was heard from the direction of the living room. The three staff proceeded down the hallway to that area. Another staff yelled that she needed a nurse. Upon arriving to the living room, CMA R saw R1 screaming and cursing at another staff member that he needed to go out the door and that staff could not keep him from leaving. CMA R, LN G, and LN H approached R1 to try and redirect R1 and calm him. R1 continued to scream, cuss, and threaten staff. CMA R placed himself between R1, the other staff, and the door. R1 kept trying to grab LN H as she tried to talk to him. R1 told CMA R that he was going to hit him and spit on him. R1 spat at CMA R hitting him full in the face. CMA R decided R1 needed to be more contained and moved R1 to the office door to better contain R1. R1 continued to scream and curse at staff. LN G arrived with shot of Ativan and instructed CMA R to take R1 to the floor to administer the shot. CMA R took R1 down guarding his neck and head with CMA R's hand and continued to contain R1's neck and arms during the injection. After a few moments to let the injection kick in, R1 continued to yell and cuss. CMA R decided to move off R1 and let R1 up. R1 then proceeded to the dining room still yelling and cussing. On 07/17/23 at 09:05 AM, observation revealed video camera footage from 07/04/23 at approximately 03:00 PM, which showed R1 ambulated up to the front door with his walker and attempted to open the front door. A staff member walked out of the front office to redirect R1. R1 let go of his walker and walked towards the staff member in an aggressive manner. The staff member backed back into the office. Six other staff members came up to R1 within a couple of feet from him and surrounded him. Staff were trying to talk to R1 to get him away from the door. R1 continued to try to get to the door. R1 spit into the CMA R's face and then CMA R shoved R1 aggressively approximately three feet into the wall by the office door using an arm across R1's neck into R1's left shoulder and back. CMA R held R1 against the wall. R1 was surrounded again by five to six staff as he was held against the wall. A nurse came to the scene after she had left once and appeared to have an injection. CMA R forcefully took R1 to the floor and R1 landed on his right shoulder. Five staff, including CMA R, held R1 while the nurse gave R1 the injection. R1's upper body was obscured by a piano but R1 laid on the floor with his legs and feet unmoving for approximately five minutes. Staff then let go of R1 and R1 got to his hands and knees and attempted to get up. Staff then helped R1to his feet and R1 walked away toward the dining room. On 07/17/23 at 10:00 AM, observation revealed R1 up and walking in the hall with his walker. No behaviors or exit seeking were observed. On 07/17/23 at 10:30 AM, Administrative Staff A stated that CMA R was allowed to work the remainder of his shift after the incident occured because abuse was not reported to her by the facility staff. Administrative Staff A stated that she did not place CMA R on suspension after the incident because she spoke to both of her nurses that were on duty that day and both nurses did not feel like any abuse took place. Administrative Staff A verified that CMA R continued to work with the residents at the facility since the incident. Administrative Staff A did admit that when she watched the video play back of the incident that CMA R's actions were harsh but stated that both nurses felt like that if CMA R had not been there, the young, female CNAs would not have been able to handle R1. Administrative Staff A stated the shove was a little excessive but when the situation happened, R1 was out of control so it had to happen. On 07/17/23 at 11:20 AM, LN G stated on the day of the incident there were too many people trying to redirect R1. LN G stated R1 was very angry and wanted to leave that day and has days when he becomes angry but is more redirectable. LN G stated that she did not see CMA R shove R1 into the wall on the day that it happened as she was down the hall on the phone with the doctor and drawing up the Ativan injection. LN G stated that she saw CMA R shove R1 on video replaying what happened and felt that CMA R's actions were excessive. LN G thought that CMA R needed more training on how to handle situations like that. LN G stated that she did order CMA R to take R1 to the ground so she could safely administer the Ativan injection. On 07/17/23 at 11:45 AM, CNA M stated that she was the first staff member to come into contact with R1 on the day of the incident and she was trying to calm him down. CNA M stated she had suggested that she take R1 outside for a walk, but CMA R stated no one was going anywhere. CNA M stated that she had a good rapport with R1 and felt like she could have gotten him calmed down if all the other staff had not surrounded R1. CNA M stated when R1 spat in CMA R's face, CMA R reacted immediately and shoved R1 into the wall. CNA M thought CMA R's actions were excessive at the time but did not report it as abuse because there were nurses there that were above her. On 07/17/23 at 01:30 PM, CMA R stated he did not think that he overreacted on the day of the incident. CMA R stated he was trying to protect the girls and felt like R1 needed to be contained better so staff could handle him and explained that was the reason for pushing R1 against the wall. On 07/17/23 at 02:00 PM, CNA N stated she was in the living room on the day of the incident and saw CMA R violently shove R1 into the wall. CNA N stated that the way R1 was treated was not right and she knew it was not right. CNA N stated after CMA R shoved R1 to the wall, she was directed to go into the dining room to stay with the other residents at the activity. The facility's Abuse Prevention, Intervention, Reporting, and Investigation Policy, reviewed 02/21/23, documented residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility has developed a system for identifying, investigating, preventing, and reporting any incident or suspected incident of abuse. It is the responsibility of the employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors including injuries of an unknown source and theft or misappropriation of resident property. Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The facility failed to ensure staff identified a situation of physical abuse and intimidation as an allegation of abuse and failed to immediately report to the facility administrator (LNHA). This deficient practice placed R1 in immediate jeopardy. The following corrective actions were implemented to address the immediacy: Staff were educated to notify LNHA regarding cases of suspected abuse. Staff were educated on instances when to notify administrator and what can constituted Abuse, Neglect, and Exploitation (ANE) that needed reported timely. All staff received education and retraining on ANE. The above corrective actions were verified by the onsite surveyor and the immediacy was removed on 07/17/23. The scope and severity remained at the level of a D

The facility had a census of 19 residents. The sample included 17 residents, of which 4 were reviewed for nutrition. Based on observation, record review, and interview the facility failed to develop and implement effective nutritional interventions for 1 of 4 residents sampled for nutrition, who had a severe weight loss of 18.6 (lbs) pounds/18.19% in 90 days, and 14.5 lbs/14.48% in 5 months. (#12) Findings included: - Resident #12's 3/06/2018 signed physician orders [REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 9/13/2017, recorded the resident had short and long-term memory impairment, and moderately impaired decision-making skills. The resident required extensive 2 staff assistances with bed mobility, dressing, and 1 staff assistance with transfers and eating. The resident weighed 100 lbs, was 64 inches tall, had no difficulty with chewing, and did not receive a therapeutic or mechanical altered diet. The quarterly MDS assessment, dated 3/07/2018, recorded the resident had moderately impaired cognition. The resident required extensive staff assistance of one for transfers, locomotion on and off the unit, and limited staff assistance of one for bed mobility and eating. The resident weighed 88 lbs, did not receive a therapeutic or mechanical altered diet, and had an unplanned weight loss. The Nutritional (CAA) Care Area Assessment, dated 9/13/2017, documented the resident weighed 100 lbs, received a regular diet, and ate independently with staff cueing and assistance as needed. The CAA documented the resident received Boost Breeze (liquid nutritional drink providing additional protein and calories) three times a day. The CAA documented the resident had his/her own teeth, some in poor condition, and the resident had no complaints of pain or discomfort with chewing and swallowing. The care plan, dated 11/29/2017, recorded the resident received a regular diet, Boost Breeze three times a day with meals, and required staff set up help and cueing. The care plan recorded the resident had his/her own teeth in poor condition, with missing and dental caries (decayed teeth) noted. The care plan lacked documentation for increased calorie snacks. The physician's orders [REDACTED]. The 9/29/2017 (RD) Registered Dietician nutritional assessment documented the resident's daily nutritional requirements: 1293-1409 calories, 47- 56 grams of protein, 1172 - 1407 (cc) cubic centimeters of fluid. The assessment documented the diet as ordered with Boost Breeze, 8 ounces three times a day, and documented the diet and level of intake were adequate to meet the resident's estimated needs, as evidenced by the resident's stable weight. The dietary progress note, dated 11/28/2017, recorded the resident's current weight was 98.4 lbs, a 4.8% loss in 90 days, and documented no significant weight changes. The note documented the resident's weight ranged from 96-105 lbs during the last 6 months. The note documented staff provided the resident a regular diet with Boost Breeze, three times a day, high calorie snacks in between meals, and directed staff to continue with the current dietary plan. The 1/09/2018 nurse's notes documented the facility faxed the physician regarding the resident's weight loss. On 12/12/2017 the resident weighed 98.2 lbs and on 1/02/2018 the resident weighed 94 lbs. The 1/10/2018 nurses notes, documented the physician responded, is he/she on mighty shakes, continue to monitor, no further orders. The 2/20/2018 at 6:51 AM, nurse's notes documented the dietician recommended the resident received Boost Breeze three times a day when staff delivered the snack cart, and the kitchen notified. (staff would provide the supplement 6 times a day) The facility's weight record revealed the following: 11/06/17 - 102.2 lbs 11/13/17 - 100.80 lbs 12/04/17 - 99.0 lbs 12/12/17 - 98.2 lbs 12/19/17 - 97.2 lbs 1/02/18 - 94 lbs 1/16/18 - 92.20 lbs 1/22/18 - 87.40 lbs 2/06/18 - 83.60 lbs (18.6 lbs/18.19% in 90 days) 2/13/18 - 83.60 lbs 2/21/18 - 85.40 lbs 3/05/18 - 88.0 lbs 3/26/18 - 88.40 lbs 4/03/18 - 87.40 lbs (14.5 lbs/14.48% in 5 months) The 2/20/2018 nurse's notes, documented the facility received a fax from the dietician with recommendations for Boost breeze three times a day when the snack cart is passed and the kitchen was notified. Review of the (MONTH) (YEAR) supplement intake log with meals record lacked documentation of intakes for 3 meals daily, review revealed the following: zero supplements = 6 days 1 supplement = 15 days 2 supplements = 10 days 3 supplements = zero days Review of the (MONTH) (YEAR) supplement intake log with meals record lacked documentation of intakes for the 3 meals daily, review revealed the following: zero supplements = 8 days 1 supplements = 10 days 2 supplements = 7 days 3 supplements = 3 days Review of the (MONTH) supplement intake log with meals record lacked documentation of intakes for the 3 meals daily, review revealed the following: Zero supplements = 3 days 1 supplements = 16 days 2 supplements = 8 days 3 supplements = 4 days The 2/28/2018 fax to the physician documented the resident had considerable high amounts of weight loss in the last few months and questioned if it could be due to his/her [DIAGNOSES REDACTED]. The physician stated it could likely be due to his/her dementia and questioned if the facility provided the resident with mighty shakes (frozen supplements designed to provide extra nutrition, protein, and calories) to combat the weight loss. The facility responded to the physician, the resident received Boost Breeze with his/her meals and questioned if the resident could have the nutritional supplement when the snack cart was passed. On 4/03/2018 at 12:00 PM, observation revealed the resident sat in his/her wheelchair at the dining room table. Staff served the resident meatloaf, mashed potatoes with gravy, peas, and bread with butter. Continued observation revealed the resident ate 75% of the meal. On 3/28/2017 at 11:00 AM, Nurse G verified the resident had a weight loss and the resident received Breeze nutritional supplement with meals. Nurse G verified staff documented meal intakes in the kiosk, however, when he/she pulled up the meal intakes log, it lacked meal intake documentation for the resident. On 4/02/2018 at 2:00 PM, Administrative Nurse B verified the resident had lost a significant amount of weight the last few months, verified the lack of physician and dietary interventions. Administrative Nurse B had only been in his/her Administrative position for one month. On 4/03/2018 at 2:15 PM, Dietary Staff BB verified he/she was unaware of the process in place if a resident had a weight loss. He/she started the dietary manager job 1 month ago and lacked nutritional training, however the facility enrolled him/her in a Certified Dietary Manager online course on 4/2/18. On 4/05/2018 at 12:25 PM, Registered Dietician EE stated the resident lost a significant amount of weight, he/she made recommendations for high calorie snacks (the medical record lacked a communication order or fax regarding the high calorie snacks), high calorie supplements, and he/she did not suggest fortified foods because at the time the resident was drinking better than eating. The RD verified the facility lacked documentation of his/her recommendations and stated the communication with the nursing staff at the facility was lacking for the last few months. He/she was not kept informed of the significant weight loss. On 4/05/2018 at 1:40 PM, Physician GG stated the resident lost weight. On 1/09/2018 the facility notified him/her the resident weighed 98 lbs on 12/12/17, weighed 94 lbs on 1/02/18, and at that time he/she ordered mighty shakes three times a day. Physician GG stated the next time the facility contacted him/her was 2/28/2018 regarding the resident's considerable amount of weight loss in the last few months and the physician restated the resident needed a supplement and suggested mighty shakes. Physician GG verified the facility did not contact him/her from 1/09/18 until 2/28/2018 regarding the resident's significant weight loss. The undated facility's Weight Loss policy documented all residents would be monitored for weight loss/gains and the interdisciplinary team would meet weekly (the medical records lacked documentation the facility met on a weekly basis to discuss the resident's weight loss) to ensure interventions would be in place to reduce the risk of further weight loss. The policy documented all residents would be weighed weekly, and if noted by the (DON) Director of Nursing to have a weight discrepancy, he/she requested staff re-weigh the resident the next day. Weekly notifications of a significant weight loss or gain would be sent to the physician and families and closely monitored by the Interdisciplinary team. The facility failed to implement additional interventions to prevent Resident #12 from having a 14.48% weight loss in 5 months, and notify the dietician and the resident's physician timely, for Resident #12 who had severe weight loss, placing the resident at risk for increased health concerns .

The facility had a census of 24 residents. The sample included 9 residents of which 6 were reviewed for abuse. Based on record review and interview, the facility failed to report to law enforcement physical abuse to Residents #4 and #6 and a verbal threat to want to kill someone made by Nurse Aide M. which placed all the residents in the facility at risk for abuse. Findings included: - Resident #4's significant change (MDS) Minimum Data Set assessment, dated 12/5/17, documented the resident usually understood others and was usually understood, had a (BIMS) Brief Interview for Mental Status score of 0, indicating severely impaired cognition, and required extensive assistance of 2 staff with most (ADLs) Activities of Daily Living. The 12/5/17 (CAA) Care Area Assessment for Cognition recorded the resident was alert with confusion noted, he/she was able to recognize some staff, and recently admitted to hospice services. The 12/5/17 care plan directed staff to monitor the resident's behaviors for signs and symptoms of depression, due to isolation, and to be gentle when working with the resident's left arm, as it was very sensitive. The 12/19/17 (15 days after the incident) at 2:54 PM, nurse's note documented staff faxed Resident #4's primary physician to communicate the resident was involved with a suspected abuse case which involved Nurse Aide M. On 12/4/17, Nurse Aide M was in the resident's room and placed his/her hands over the resident's mouth to keep the resident quiet. Review of Resident #4's medical record revealed no documentation staff contacted law enforcement regarding Nurse Aide M covering Resident #4's mouth with his/her hand. Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #4's mouth, because he/she screamed a lot. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she covered Resident #4's mouth with his/her hand, because the resident was screaming very loud, and he/she wanted to quiet the resident. Nurse Aide M verified he/she had not reported to the nurse or DON what he/she had done. Nurse Aide O's 12/18/17 notarized witness statement, documented he/she and Nurse Aide M were assisting Resident #4 with cares and Resident #4 cried out multiple times. Nurse Aide M took his/her hand and placed it over the resident's mouth multiple times while in the resident's room. Nurse Aide O stated he/she reported this to the nurse a couple hours later. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy documented the administrator, in conjunction with the Director of Nursing, notifies law enforcement officials if actual injury occurs. The facility failed to notify law enforcement of the physical abuse to Resident #4 made by Nurse Aide M, which placed all the residents in the facility at risk for abuse. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - Resident #6's quarterly (MDS) Minimum Data Set assessment, dated 11/7/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 6, which indicated the resident had severe cognitive impairment. The MDS documented the resident required extensive assistance from 2 staff for bed mobility, transfers, dressing, toileting, extensive assistance from 1 staff for personal hygiene, bathing, locomotion on and off the unit, and limited assistance of 1 staff for eating. The MDS documented the resident had upper and lower extremity impairment on both sides, and used a wheelchair for mobility. The annual (CAA) Care Area Assessment for cognition, dated 5/16/17, documented the resident had short and long term memory problems, frequently called out help and yelled out that he/she had to go to the bathroom, even after staff toileted the resident. The CAA documented the resident was usually able to make his/her needs known, but had thought process problems, and his/her dementia (progressive mental disorder characterized by failing memory, confusion), and behaviors placed him/her at risk for injury and unmet needs. The 11/29/17 care plan documented the resident was at risk for alteration in thought process related to dementia, [MEDICAL CONDITION] disorder ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and [MEDICAL CONDITION] (anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning). The care plan directed staff to assess the resident when he/she had hallucinations (sensing things while awake that appear to be real, but the mind created) or alterations in his/her thought process, and notify the physician. The 12/18/17 at 2:58 PM, nurse's note documented the facility notified the physician by fax, of a suspected abuse case, which involved Resident #6, when Nurse Aide M placed his/her hand over the resident's mouth to keep the resident quiet. Review of Resident #6's medical record revealed no documentation staff contacted law enforcement regarding Nurse Aide M covering Resident #6's mouth with his/her hand. Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #6's mouth, because he/she screamed a lot. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she covered Resident #6's mouth with his/her hand, because the resident was screaming very loud, and he/she wanted to quiet the resident. Nurse Aide M verified he/she had not reported to the nurse or DON what he/she had done. Nurse Aide P's 12/19/17 notarized witness statement, documented Resident #6 was crying out saying he/she had to go to the bathroom even though the resident was on the toilet. Nurse Aide M took both of his/her hands and shoved them onto Resident #6's mouth forcing the resident against the back of the toilet. Resident #6 began crying out louder from the force Nurse Aide M used while covering the resident's mouth. Nurse Aide P verified he/she did not report this occurrence to the DON. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy documented the administrator, in conjunction with the Director of Nursing, notifies law enforcement officials if actual injury occurs. The facility failed to notify law enforcement of the physical abuse to Resident #6 made by Nurse Aide M, which placed all the residents in the facility at risk for abuse. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - On 12/19/17 at 2:01 PM, Administrative Nurse D stated on 12/5/17 between 5:00 PM and 6:00 PM, Nurse Aide M stated he/she wanted to kill someone and continued to work until 9:54 PM. Administrative Nurse D verified he/she did not contact law enforcement. Administrative Nurse D's 12/20/17 notarized witness statement, documented on 12/5/17 at about 6:00 PM, he/she was getting ready to leave and Nurse Aide M stated Hey, let's kill someone. Administrative Nurse D stated No! Why would you want to do something like that? Nurse Aide M responded Because I just want to know what it would feel like to kill someone. Administrative Nurse D stated he/she was shocked, did not know what to think or do, and on 12/7/17 (2 days later) he/she reported the statement to Administrative Staff A. On 12/28/17 at 11:00 AM, Administrative Staff A verified he/she was notified on 12/7/17 of Nurse Aide M's statement that he/she wanted to kill someone and Administrative Staff A did not contact law enforcement. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy documented the administrator, in conjunction with the Director of Nursing, notifies law enforcement officials if actual injury occurs. The facility failed to notify law enforcement of a verbal threat to want to kill someone made by Nurse Aide M, which placed all the residents in the facility at risk for abuse. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F.

The facility had a census of 24 residents. The sample included 9 residents, of which 6 were reviewed for abuse. Based on observation, record review and interview, the facility staff failed to immediately report actual abuse and allegations of abuse for 5 of 6 sampled residents, to the administrator, state agency, adult protective services, or to all other required agencies, within the specified time frames. The deficient practice placed the residents in immediate jeopardy. Findings included: - Resident #4's significant change (MDS) Minimum Data Set assessment, dated 12/5/17, documented the resident usually understood others and was usually understood, had a (BIMS) Brief Interview for Mental Status score of 0, indicating severely impaired cognition, and required extensive assistance of 2 staff with most (ADLs) Activities of Daily Living. The 12/5/17 (CAA) Care Area Assessment for Cognition recorded the resident was alert with confusion noted, he/she was able to recognize some staff, and was recently admitted to hospice services. The 12/5/17 care plan directed staff to monitor the resident's behaviors for signs and symptoms of depression, due to isolation, and to be gentle when working with the resident's left arm, as it was very sensitive. Nurse Aide O's 12/18/17 notarized witness statement documented on 12/4/17, he/she was with Nurse Aide M in Resident #4's room, when the resident cried out multiple times. Nurse Aide O documented Nurse Aide M placed his/her hand over Resident #4's mouth multiple times while he/she was in the resident's room with him/her. Nurse Aide O documented he/she told Nurse Aide M to knock it off and asked Nurse Aide M if he/she would do that to his/her own grandparents. Nurse Aide O documented he/she reported the incident to the charge nurse a couple of hours after it occurred, and to Administrative Nurse D later that night. On 12/19/17 at 8:43 AM, Administrative Nurse D stated he/she was not notified about the 12/4/17 incident with Resident #4 until he/she called Nurse Aide O on 12/6/17 at approximately 11:00 PM (2 days after the incident occurred). Administrative Nurse D verified staff should stop abuse when it occurred, report the abuse to the charge nurse immediately, and the charge nurse was to report to the Director of Nursing, administrator, family, state agencies, and the resident's physician. On 12/19/17 at 3:10 PM, Nurse Aide P stated when he/she worked with Nurse Aide M, Staff M was not gentle with the residents, and Nurse Aide M would jerk the covers, and move the residents' extremities fast. Nurse Aide P stated when Nurse Aide M awakened Resident #4, he/she would grab the resident with both hands, and aggressively rocked the resident quickly from side to side, while he/she told the resident to wake up multiple times. Nurse Aide P stated when he/she reminded Nurse Aide M of his/her unnecessary roughness or poor care, Nurse Aide M would reply What are they going to do, fire me? Nurse Aide P stated he/she should have immediately reported Nurse Aide M to the charge nurse, and Administrative Nurse B. Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #4's mouth, because the resident screamed a lot. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she put his/her hands over the mouth of Resident #4 to quiet him/her when he/she was screaming. Nurse Aide M stated he/she knew what he/she had done was wrong, and he/she had not reported what he/she had done to the charge nurse or Administrative Nurse D. Nurse Aide M stated he/she received abuse training when he/she was hired, but he/she had not attended the all staff abuse in-service on 11/8/17, and verified administrative staff had not reviewed the information with him/her. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy recorded the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility staff failed to immediately report resident abuse, to the administrator, when Nurse Aide M placed his/her hands over Resident #4's mouth, when the resident was screaming, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of a F. - Resident #6's quarterly (MDS) Minimum Data Set assessment, dated 11/7/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 6, which indicated the resident had severe cognitive impairment. The MDS documented the resident required extensive assistance from 2 staff for bed mobility, transfers, dressing, toileting, extensive assistance from 1 staff for personal hygiene, bathing, locomotion on and off the unit, and limited assistance of 1 staff for eating. The MDS documented the resident had upper and lower extremity impairment on both sides, and used a wheelchair for mobility. The annual (CAA) Care Area Assessment for cognition, dated 5/16/17, documented the resident had short and long term memory problems, frequently called out help and yelled out that he/she had to go to the bathroom, even after staff toileted the resident. The CAA documented the resident was usually able to make his/her needs known, had thought process problems, and his/her dementia (progressive mental disorder characterized by failing memory, confusion) and behaviors placed him/her at risk for injury and unmet needs. The 11/29/17 care plan documented the resident was at risk for alteration in his/her thought process related to dementia, [MEDICAL CONDITION] disorder ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and [MEDICAL CONDITION] (anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning). The care plan directed staff to assess the resident when he/she had hallucinations (sensing things while awake that appear to be real, but the mind created) or alterations in his/her thought process, and notify the physician. Nurse Aide P's 12/19/17 notarized witness statement documented on an unknown date in December 2017, Resident #6 cried out and said he/she had to go to the bathroom, even though staff had toileted him/her. Nurse Aide P documented Nurse Aide M put both of his/her hands on the resident's mouth, forced the resident against the back of the toilet, and the resident cried louder. Nurse Aide P pulled Nurse Aide M's hands off the resident's mouth and told Nurse Aide M that other people could hear the resident's muffled screams. Nurse Aide P witnessed Nurse Aide M mistreat certain residents on multiple occasions, but he/she did not report the suspected abuse immediately to the charge nurse or administrative staff. Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #6's mouth, because the resident screamed a lot. On 12/19/17 at 8:43 AM, Administrative Nurse D stated the facility does not have a definite date of the incident with Resident #6, but he/she was made aware of it on 12/7/17. Administrative Nurse D verified staff should stop abuse when it occurred, report the abuse to the charge nurse immediately, and the charge nurse was to report to the Director of Nursing, administrator, family, state agencies, and the resident's physician. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she put his/her hands over the mouth of Resident #6 to quiet him/her when he/she was screaming. Nurse Aide M stated he/she knew what he/she had done was wrong, and he/she had not reported what he/she had done to the nurse or Administrative Nurse D. Nurse Aide M stated he/she received abuse training when he/she was hired, but he/she had not attended the all staff abuse in-service on 11/8/17, and verified administrative staff had not reviewed the information with him/her. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy recorded it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy documented staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy recorded the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility staff failed to immediately report resident abuse, to the administrator, when Nurse Aide M placed his/her hands over Resident #6's mouth, when the resident was screaming, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of a F. - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 12/5/17, documented the resident had short and long term memory problems, moderately impaired cognition, displayed physical, verbal and other behaviors which placed the resident and others at risk for injury, and required extensive assistance with most (ADLs) Activities of Daily Living. The annual 9/9/17 (CAA) Care Area Assessment for psychosocial well-being documented the resident was normally very pleasant, enjoyed talking to staff and enjoyed when staff gave him/her attention. The CAA documented during the evenings, the resident tended to become more depressed and exhibited behaviors, but that had improved and no longer occurred much. The 9/14/17 care plan documented the resident needed assistance of 1-2 staff with use of a gait belt for transfers, and directed staff to ensure other residents are out of Resident #3's reach when he/she was agitated. The care plan further directed the staff to explain what they were doing when working with Resident #3 and if he/she resisted cares, staff was to leave him/her for a while and then try again once the resident was calm. Nurse Aide P's 12/19/17 notarized witness statement documented he/she was with Nurse Aide M in Resident #3's room to transfer the resident into bed, when Resident #3 pinched the back of Nurse Aide M's arm, Nurse Aide M roughly grabbed the resident's feet, quickly rotated him/her, pinned the resident down, with his/her arms on the resident's chest, and Nurse Aide M shoved the resident against the bed multiple times, while stating I'm not (expletive)******* having this today. Nurse Aide P documented Nurse Aide M then aggressively threw the covers over the resident and left the room. Nurse Aide P documented he/she witnessed Nurse Aide M mistreat certain residents on multiple occasions, but he/she did not report the abuse to the charge nurse, Administrative Staff A, or Administrative Nurse D. On 12/19/17 at 1:05 PM, Administrative Nurse D verified Nurse Aide M provided cares to the resident until Administrative Staff A suspended him/her from work on 12/7/17. Administrative Nurse D verified staff reported, on 12/7/17, Nurse Aide M had physically abused the resident, at times, in the past 2 weeks. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility staff failed to immediately report, to the administrator, the suspected abuse to Resident #3, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - Resident #5's quarterly (MDS) Minimum Data Set Assessment, dated 12/12/17, documented short and long term memory problems, moderately impaired cognition, hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and had physical and verbal behaviors directed toward others. The MDS further documented the resident required extensive assistance of 1 staff with bed mobility, dressing, eating, and extensive assistance of 2 staff with transfers and toileting. The annual 9/13/17 (CAA) Care Area Assessment for cognition documented the resident had short and long term memory loss, moderately impaired cognition, but able to recognize staff faces and locate his/her room. The CAA documented conversations with the resident were difficult as he/she often talked with word salad (confused mixture of random words and phrases) and staff was not sure if the resident comprehended what was said to him/her. The CAA documented the resident could follow simple commands. The 9/26/17 care plan documented the resident liked to spend time with staff 1:1 visiting, listening to poetry, sharing a snack, sitting outdoors enjoying the fresh air, and/or singing a favorite song together, 3-4 times per week. Nurse Aide P's 12/19/17 notarized witness statement documented when Resident #5 was combative, Nurse Aide M would throw, drop, dangle by the legs, or shake the resident's baby doll, which the resident thought was his/her real baby. Nurse Aide P documented when Nurse Aide M woke the resident up, he/she would grab the resident with both hands, and move the resident quickly from side to side in a rocking motion, while he/she told the resident to wake up multiple times. Nurse Aide P witnessed Nurse Aide M mistreat certain residents on multiple occasions, but he/she did not report the suspected abuse immediately to the charge nurse or administrative staff. On 12/19/17 at 8:55 AM, Administrative Nurse D verified Nurse Aide M provided cares to the resident until Administrative Staff A suspended him/her from work on 12/7/17. Administrative Nurse D verified staff reported, on 12/7/17, Nurse Aide M had physically abused the resident, at times, in the past 2 weeks. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility staff failed to immediately report, to the administrator, the suspected abuse to Resident #5, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - On 12/19/17 at 1:05 PM, Administrative Nurse D stated on 12/5/17 at approximately 5:30-6:00 PM, Nurse Aide M stated Let's kill someone. Administrative Nurse D stated he/she asked Nurse Aide M why he/she would say something like that, to which Nurse Aide M replied, I want to know what it feels like. Administrative Nurse D stated he/she did not suspend Nurse Aide M, and Nurse Aide M was allowed to work until approximately 10:00 PM. Administrative Nurse D verified he/she left the facility not long after Nurse Aide M made the statement, and he/she did not report the incident to the administrator until 12/7/17 (2 days later). Administrative Nurse D's 12/20/17 notarized witness statement, documented on 12/5/17 at about 6:00 PM, he/she was getting ready to leave and Nurse Aide M stated Hey, let's kill someone. Administrative Nurse D stated No! Why would you want to do something like that? Nurse Aide M responded Because I just want to know what it would feel like to kill someone. Administrative Nurse D stated he/she was shocked, did not know what to think or do, and on 12/7/17 (2 days later) he/she reported the statement to Administrative Staff A. Review of Nurse Aide M's time card for 12/5/17 documented he/she worked from 3:50 PM to 9:54 PM. On 12/28/17 at 11:00 AM, Administrative Staff A verified he/she was notified on 12/7/17 of Nurse Aide M's statement that he/she wanted to kill someone, however, Administrative Staff A had not contacted law enforcement. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility failed to immediately report to administration when Nurse Aide M made the statement I want to kill someone, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - Resident #7's annual (MDS) Minimum Data Set Assessment, dated 9/20/17, documented the resident had short and long term memory problems, moderately impaired cognition, exhibited no behaviors, and required extensive assistance with most (ADLs) Activities of Daily Living. The annual 9/20/17 (CAA) Care Area Assessment for psychosocial well-being documented the resident repeatedly attempted to stand up from his/her wheelchair, was calm, cooperative with cares, often accepted staff assistance to sit down, and was not combative. The 9/18/17 care plan directed staff to provide 1:1 with the resident when he/she was anxious, position the resident in front of a table, and allow him/her to stand on his/her own to keep him/her safe. Review of Nurse Aide N's time sheet for 12/11/17, documented he/she worked from 6:05 PM to 6:11 AM on 12/12/17. Housekeeping Staff U's 12/18/17 notarized witness statement on 12/11/17, he/she saw Resident #7 place his/her hand on Nurse Aide N's arm, Nurse Aide N picked up the resident's hand, flung it across the table, told the resident not to touch him/her, and then leaned on the resident to prevent the resident from standing up. Housekeeping Staff U documented he/she did not report the incident to Administrative Staff A or Administrative Nurse D until the next morning, 12/12/17. On 12/18/17 at 1:44 PM, Dietary Staff BB stated at approximately 6:00 PM on 12/11/17, he/she observed, from the kitchen window, Resident #7 attempted to stand up at the dining room table, Nurse Aide N took the resident's arm and roughly moved the arm from the table top, and shoved it back across the resident's lap. The resident verbally indicated this action hurt his/her arm and glared at Nurse Aide N. Dietary Staff BB stated he/she did not report the incident to the charge nurse at that time, but reported it to Administrative Nurse D the next morning (12/12/17, approximately 12-14 hours after the incident occurred). On 12/19/17 at 8:43 AM, Administrative Nurse D verified Nurse Aide N worked the next 12 hours after the 12/11/17 incident with Resident #7, and Administrative Staff A suspended him/her from work on 12/12/17 at 1:30 PM. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility staff failed to immediately report, to the administrator, the suspected abuse to Resident #7, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide N on 12/12/17. The deficient practice remained at a scope and severity of an F.

The facility had a census of 24 residents. The sample included 9 residents of which 6 were reviewed for abuse. Based on observation, record review and interview, the facility failed to protect and prevent further potential abuse of the residents in the facility, when Nurse Aide M continued to work after staff witnessed him/her abuse Resident #4 and #6, allegedly abuse Resident #3 and #5, and Nurse Aide M made a verbal statement of wanting to kill someone, to see what if felt like. Nurse Aide N continued to work after Housekeeping Staff U and Dietary Staff BB observed him/her allegedly abuse Resident #7, placing all the residents in the facility in immediate jeopardy. Findings included: - Resident #4's significant change (MDS) Minimum Data Set assessment, dated 12/5/17, documented the resident usually understood others and was usually understood, had a (BIMS) Brief Interview for Mental Status score of 0, indicating severely impaired cognition, and required extensive assistance of 2 staff with most (ADLs) Activities of Daily Living. The 12/5/17 (CAA) Care Area Assessment for Cognition recorded the resident was alert with confusion noted, he/she was able to recognize some staff, and was recently admitted to hospice services. The 12/5/17 care plan directed staff to monitor the resident's behaviors for signs and symptoms of depression, due to isolation, and to be gentle when working with the resident's left arm, as it was very sensitive. The 12/19/17 (15 days after the incident) at 2:54 PM, nurse's note documented staff faxed Resident #4's primary physician to communicate the resident was involved with a suspected abuse case which involved Nurse Aide M. The note documented on 12/4/17, Nurse Aide M placed his/her hands over the resident's mouth to keep the resident quiet and the facility suspended Nurse Aide M on 12/7/17 (3 days after the incident). Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #4's mouth, because the resident screamed a lot. Review of Nurse Aide M's timesheet revealed he/she worked on 12/4/17 from 3:48 PM - 8:37 PM, and on 12/5/17 from 3:50 PM - 9:54 PM (the day after the witnessed abuse). On 12/20/17 at 11:40 AM, observation revealed Resident #4 lying in his/her bed, with his/her eyes closed. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she covered Resident #4's mouth when the resident was screaming loudly. Nurse Aide M verified he/she had not reported to the nurse or DON what he/she had done. Nurse Aide M stated Administrative Staff A suspended him/her on 12/7/17 (3 days after the incident). Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #4's mouth, as he/she screamed a lot, and staff had trouble getting the resident's attention to help the resident. Nurse Aide M documented Administrative Staff A suspended him/her on 12/7/17 (3 days after the incident). On 12/19/17 at 8:43 AM, Administrative Nurse D verified Nurse Aide M worked on 12/4/17 and 12/5/17, after the incident with Resident #4 occurred, and Administrative Staff A suspended Nurse Aide M from work on 12/7/17 at approximately 6:00 PM (3 days after the incident with Resident #4). The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented when an incident or suspected incident occurs, the Administrator, Director of Nursing, or nursing designee investigates the allegation. Residents and staff are to be protected during incident investigation by ensuring: reports are made without fear of retaliation, anonymous reports are investigated, and the administrator is immediately informed. The policy further documented the accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. The policy stated the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility failed to protect the residents who resided in the facility, when Nurse Aide M continued to work after staff witnessed him/her abuse Resident #4, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - Resident #6's quarterly (MDS) Minimum Data Set assessment, dated 11/7/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 6, which indicated the resident had severe cognitive impairment. The MDS documented the resident required extensive assistance from 2 staff for bed mobility, transfers, dressing, toileting, extensive assistance from 1 staff for personal hygiene, bathing, locomotion on and off the unit, and limited assistance of 1 staff for eating. The MDS documented the resident had upper and lower extremity impairment on both sides, and used a wheelchair for mobility. The annual (CAA) Care Area Assessment for cognition, dated 5/16/17, documented the resident had short and long term memory problems, frequently called out help and yelled out that he/she had to go to the bathroom, even after staff toileted the resident. The CAA documented the resident was usually able to make his/her needs known, had thought process problems, and his/her dementia (progressive mental disorder characterized by failing memory, confusion) and behaviors placed him/her at risk for injury and unmet needs. The 11/29/17 care plan documented the resident was at risk for alteration in his/her thought process related to dementia, [MEDICAL CONDITION] disorder ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and [MEDICAL CONDITION] (anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning). The care plan directed staff to assess the resident when he/she had hallucinations (sensing things while awake that appear to be real, but the mind created) or alterations in his/her thought process, and notify the physician. The 12/18/17 at 2:58 PM, nurse's note documented the facility notified the physician by fax, of a suspected abuse case, which involved Resident #6, when Nurse Aide M placed his/her hand over the resident's mouth to keep the resident quiet. (which the facility became aware of on 12/7/17) Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #6's mouth, because he/she screamed a lot. Review of Nurse Aide M's timesheet revealed he/she worked on 12/4/17 from 3:48 PM through 8:37 PM, and on 12/5/17 from 3:50 PM through 9:54 PM (the day after the witnessed abuse). On 12/19/17 at 9:12 AM, observation revealed Resident #6 sat in his/her wheelchair in the TV area of the facility. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she covered Resident #6's mouth with his/her hand, because the resident was screaming very loud, and he/she wanted to quiet the resident. Nurse Aide M verified he/she had not reported to the nurse or DON what he/she had done. Nurse Aide M documented Administrative Staff A suspended him/her on 12/7/17. On 12/19/17 at 8:43 AM, Administrative Nurse D verified Nurse Aide M provided cares to the resident until Administrative Staff A suspended him/her from work on 12/7/17. Administrative Nurse D verified staff reported, on 12/7/17, Nurse Aide M had physically abused the resident, at times, in the past 2 weeks. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented when an incident or suspected incident occurs, the Administrator, Director of Nursing, or nursing designee investigates the allegation. Residents and staff are to be protected during incident investigation by ensuring: reports are made without fear of retaliation, anonymous reports are investigated, and the administrator is immediately informed. The policy further documented the accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. The policy recorded the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility failed to protect the residents who resided in the facility, when Nurse Aide M continued to work after staff witnessed him/her abuse Resident #6, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 12/5/17, documented the resident had short and long term memory problems, moderately impaired cognition, displayed physical, verbal and other behaviors which placed the resident and others at risk for injury and required extensive assistance with most (ADLs) Activities of Daily Living. The annual 9/9/17 (CAA) Care Area Assessment for psychosocial well-being documented the resident was normally very pleasant, enjoyed talking to staff and enjoyed when staff gave him/her attention. The CAA documented during the evenings, the resident tended to become more depressed and exhibited behaviors, but that had improved and no longer occurred much. The 9/14/17 care plan documented the resident needed assistance of 1-2 staff with use of a gait belt for transfers, and directed staff to ensure other residents are out of Resident #3's reach when he/she was agitated. The care plan further directed the staff to explain what they were doing when working with Resident #3 and if he/she resisted cares, staff was to leave him/her for a while and then try again once the resident was calm. Nurse Aide P's 12/19/17 notarized witness statement documented he/she was with Nurse Aide M in Resident #3's room to transfer the resident into bed, when Resident #3 pinched the back of Nurse Aide M's arm, Nurse Aide M roughly grabbed the resident's feet, quickly rotated him/her, pinned the resident down, with his/her arms on the resident's chest, and Nurse Aide M shoved the resident against the bed multiple times, while stating I'm not (expletive)******* having this today. Nurse Aide P documented Nurse Aide M then aggressively threw the covers over the resident and left the room. Nurse Aide P documented he/she witnessed Nurse Aide M mistreat certain residents on multiple occasions, but he/she did not report the abuse to the charge nurse, Administrative Staff A, or Administrative Nurse D. On 12/19/17 at 1:05 PM, Administrative Nurse D verified Nurse Aide M provided cares to the resident until Administrative Staff A suspended him/her from work on 12/7/17. Administrative Nurse D verified staff reported on 12/7/17, Nurse Aide M had physically abused the resident, at times, in the past 2 weeks. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented when an incident or suspected incident occurs, the Administrator, Director of Nursing, or nursing designee investigates the allegation. Residents and staff are to be protected during incident investigation by ensuring: reports are made without fear of retaliation, anonymous reports are investigated, and the administrator is immediately informed. The policy further recorded the accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility failed to protect the residents who resided in the facility, when Nurse Aide M allegedly abused Resident #3 and continued working, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - Resident #5's quarterly (MDS) Minimum Data Set Assessment, dated 12/12/17, documented short and long term memory problems, moderately impaired cognition, hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and had physical and verbal behaviors directed toward others. The MDS further documented the resident required extensive assistance of 1 staff with bed mobility, dressing, eating, and extensive assistance of 2 staff with transfers and toileting. The annual 9/13/17 (CAA) Care Area Assessment for cognition documented the resident had short and long term memory loss, moderately impaired cognition, but able to recognize staff faces and locate his/her room. The CAA documented conversations with the resident were difficult as he/she often talked with word salad (confused mixture of random words and phrases) and staff were not sure if the resident comprehended what was said to him/her. The CAA documented the resident could follow simple commands. The 9/26/17 care plan documented the resident liked to spend time with staff 1:1 visiting, listening to poetry, sharing a snack, sitting outdoors enjoying the fresh air, and/or singing a favorite song together, 3-4 times per week. The resident's medical record lacked documentation of allegations of abuse regarding Nurse Aide M holding the resident's baby doll above the resident's head to see what kind of response he/she would get from the resident. On 12/18/17 at 4:00 PM, observation revealed Resident #5 lying in his/her bed with his/her eyes closed. Nurse Aide P's 12/19/17 notarized witness statement documented when Resident #5 was combative, Nurse Aide M would throw, drop, dangle by the legs, or shake the resident's baby doll, which upset the resident as he/she thought (the doll) was his/her real baby. Nurse Aide P documented when Nurse Aide M woke the resident up, he/she would grab the resident with both hands, and aggressively rock the resident quickly from side to side, while he/she told the resident to wake up multiple times. Nurse Aide P witnessed Nurse Aide M mistreat certain residents on multiple occasions, but he/she had not reported the suspected abuse immediately to the charge nurse or administrative staff. On 12/19/17 at 8:43 AM, Administrative Nurse D verified Nurse Aide M provided cares to the resident until Administrative Staff A suspended him/her from work on 12/7/17. Administrative Nurse D verified staff reported on 12/7/17, Nurse Aide M physically abused the resident, at times, in the past 2 weeks. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented when an incident or suspected incident occurs, the Administrator, Director of Nursing, or nursing designee investigates the allegation. Residents and staff are to be protected during incident investigation by ensuring: reports are made without fear of retaliation, anonymous reports are investigated, and the administrator is immediately informed. The policy further recorded the accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility failed to protect the residents who resided in the facility, when Nurse Aide M allegedly abused Resident #5 and continued working, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - On 12/19/17 at 2:01 PM, Administrative Nurse D verified on 12/5/17 between 5:00 PM and 6:00 PM Nurse Aide M stated to him/her that he/she wanted to kill someone. Administrative Nurse D verified he/she did not act upon this information and allowed Nurse Aide M to continue working his/her shift until 9:54 PM. Administrative Nurse D verified he/she had not reported the statement to law enforcement. Administrative Nurse D's 12/20/17 notarized witness statement, documented on 12/5/17 at about 6:00 PM, he/she was getting ready to leave and Nurse Aide M stated Hey, let's kill someone. Administrative Nurse D stated No! Why would you want to do something like that? Nurse Aide M responded Because I just want to know what it would feel like to kill someone. Administrative Nurse D stated he/she was shocked, did not know what to think or do, and on 12/7/17 (2 days later) he/she reported the statement to Administrative Staff A. On 12/28/17 at 11:00 AM, Administrative Staff A verified he/she was notified on 12/7/17 of Nurse Aide M's statement that he/she wanted to kill someone, however, Administrative Staff A had not contacted law enforcement. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented when an incident or suspected incident occurs, the Administrator, Director of Nursing, or nursing designee investigates the allegation. Residents and staff are to be protected during incident investigation by ensuring: reports are made without fear of retaliation, anonymous reports are investigated, and the administrator is immediately informed. The policy further recorded the accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility failed to protect all the residents who resided in the facility, when Nurse Aide M made the statement I want to kill someone, and continued working, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remained at a scope and severity of an F. - Resident #7's annual (MDS) Minimum Data Set Assessment, dated 9/20/17, documented the resident had short and long term memory problems, moderately impaired cognition, exhibited no behaviors, and required extensive assistance with most (ADLs) Activities of Daily Living. The annual 9/20/17 (CAA) Care Area Assessment for psychosocial well-being documented the resident repeatedly attempted to stand up from his/her wheelchair, was calm, cooperative with cares, often accepted staff assistance to sit down, and was not combative. The 9/18/17 care plan directed staff to provide 1:1 with the resident when he/she was anxious, position the resident in front of a table, and allow him/her to stand on his/her own to keep him/her safe. Review of Nurse Aide N's timesheet revealed he/she worked on 12/11/17 from 6:05 PM through 6:11 AM on 12/12/17. On 12/18/17 at 3:45 PM, observation revealed Resident #7 sat in the dining room and drank a shake with staff assistance. On 12/18/17 at 1:44 PM, Dietary Staff BB stated on 12/11/17 at about 6:00 PM, he/she observed Resident #7 attempted to stand up at the dining room table, Nurse Aide N took the resident's arm, moved it roughly from the table top and shoved it back across the resident's lap. Resident #7 verbalized pain and glared at Nurse Aide N. Dietary Staff BB verified he/she had not reported this incident to the charge nurse immediately, and he/she reported the incident to Administrative Nurse D, the next day, on 12/12/17. On 12/18/17 at 4:04 PM, Housekeeping Staff U stated on 12/11/7 at 6:10 PM, he/she observed Resident #7 placed his/her hand on Nurse Aide N's arm and Nurse Aide N picked up Resident #7's arm and flung it away, and said don't touch me. Housekeeping Staff U further stated Nurse Aide N sat down next to Resident #7 and leaned up against Resident #7 so Resident #7 could not get up from the chair. Housekeeping Staff U verified he/she received training to inform the nurse immediately of any suspicion of abuse, but did not report the incident to Administrative Nurse D and Administrative Staff A until the next morning, 12/12/17. On 12/19/17 at 8:43 AM, Administrative Nurse D verified Nurse Aide N worked the next 12 hours after the 12/11/17 incident with Resident #7, and Administrative Staff A suspended him/her from work on 12/12/17 at 1:30 PM. The facility's 2009 Abuse Prevention, Intervention, Reporting, and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The policy documented it was the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family or visitors. The policy recorded staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. The policy documented when an incident or suspected incident occurs, the Administrator, Director of Nursing, or nursing designee investigates the allegation. Residents and staff are to be protected during incident investigation by ensuring: reports are made without fear of retaliation, anonymous reports are investigated, and the administrator is immediately informed. The policy further recorded the accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. The policy documented the administrator is to be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after normal working hours, the administrator is to be called at home or paged. The facility failed to protect all the residents who resided in the facility, when Nurse Aide N allegedly abused Resident #7 and continued working, which placed all the residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide N on 12/12/17. The deficient practice remained at a scope and severity of an F.

The facility had a census of 24 residents. The sample included 9 residents, of which 6 were reviewed for abuse. Based on observation, record review and interview, the facility failed to provide a safe environment free from abuse when Nurse Aide M abused Residents #4 and #6. Nurse Aide M placed his/her hand over Resident #4 and #6's mouths multiple times. This was observed by another staff member who stated he/she did not report it to their supervisor for 1-2 hours. This deficient practice placed Residents #4 and #6 in immediate jeopardy. Findings included: - Resident #4's significant change (MDS) Minimum Data Set assessment, dated 12/5/17, documented the resident usually understood others and was usually understood, had a (BIMS) Brief Interview for Mental Status score of 0, indicating severely impaired cognition, and required extensive assistance of 2 staff with most (ADLs) Activities of Daily Living. The 12/5/17 (CAA) Care Area Assessment for Cognition recorded the resident was alert with confusion noted, he/she was able to recognize some staff, and was recently admitted to hospice services. The 12/5/17 care plan directed staff to monitor the resident's behaviors for signs and symptoms of depression, due to isolation, and to be gentle when working with the resident's left arm, as it was very sensitive. The 12/4/17 at 7:02 AM, nurse's note revealed the resident yelled and was easily agitated. The 12/19/17 (15 days after the incident) at 2:54 PM, nurse's note documented staff faxed the resident's primary physician to communicate the resident was involved with a suspected abuse case which involved Nurse Aide M. On 12/4/17, Nurse Aide M was in the resident's room and placed his/her hands over the resident's mouth to keep the resident quiet. The facility suspended Nurse Aide M (on 12/7/17, 3 days after the incident) to protect the resident and completed a physical assessment on Resident #4 with no findings of injuries or bruises. Review of Nurse Aide M's timesheet revealed he/she worked on 12/4/17 from 3:48 PM - 8:37 PM, 12/5/17 from 3:50 PM - 9:54 PM, and he/she did not work on 12/6/17 or 12/7/17. On 12/20/17 at 11:40 AM, observation revealed Resident #4 lying in his/her bed, with his/her eyes closed. On 12/18/17 at 6:20 PM, Nurse Aide O stated after supper on 12/4/17, he/she and Nurse Aide M assisted Resident #4 to get ready for bed. Nurse Aide O stated Resident #4 was crying and Nurse Aide M held his/her hand over the resident's mouth several times. Nurse Aide O stated he/she reported this to Nurse G approximately 1-2 hours later and called the (DON) Director of Nursing around 10:30 - 11:00 PM that night. Nurse Aide O verified he/she should have notified Nurse G immediately. On 12/18/17 at 6:56 PM, Nurse G stated the 12/4/17 incident with Resident #4 was reported to him/her during report on 12/5/17 around 5:00 PM and he/she didn't report the incident to the DON until the next day, on 12/6/17. Nurse G stated if Nurse Aide M had told him/her about the incident on 12/4/17, he/she would have called the DON immediately and the DON probably would have had Nurse G send Nurse Aide M home immediately. Nurse G stated he/she told the DON to contact Nurse Aide O regarding the 12/4/17 incident and other issues. On 12/19/17 at 8:43 AM, Administrative Nurse D stated he/she was not notified about the 12/4/17 incident with Resident #4, until he/she called Nurse Aide O on 12/6/17 at approximately 11:00 PM. Administrative Nurse D verified Nurse Aide M worked on 12/4/17 and 12/5/17, after the incident with Resident #4 occurred, and Nurse Aide M was suspended from work on 12/7/17 at approximately 6:00 PM (3 days after the incident with Resident #4). Administrative Nurse D verified staff were to stop abuse when it occurred, report the abuse to the charge nurse immediately, and the charge nurse was to report to the DON, administrator, family, and state agencies. Administrative Nurse D verified as soon as administration was notified about abuse, the alleged perpetrator was to be suspended immediately and an investigation completed. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she covered Resident #4's mouth when the resident was loudly screaming. Nurse Aide M verified he/she had not reported to the nurse or DON what he/she had done. Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #4's mouth, as he/she screamed a lot, and staff had trouble getting the resident's attention to help the resident. On 12/20/17 at 5:29 PM, Administrative Nurse D verified it was not appropriate to hold a hand over a resident's mouth and staff should have notified the family and physician within a day or 2 if an abusive incident occurred. The facility's 2009 Abuse Prevention, Intervention, Reporting and Investigation policy recorded residents are to be free from verbal, sexual, physical, emotional/mental abuse, neglect, self-abuse/self-neglect, medical neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion at all times. The facility failed to provide Resident #4 with an environment free of abuse, when Nurse Aide M placed his/her hands over Resident #4's mouth, when the resident was screaming, placing Resident #4 in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remains at a scope and severity of a G. - Resident #6's quarterly (MDS) Minimum Data Set assessment, dated 11/7/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 6, which indicated the resident had severe cognitive impairment. The MDS documented the resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting, personal hygiene, bathing, locomotion on and off the unit, and limited assistance of 1 staff for eating. The MDS documented the resident had upper and lower extremity impairment on both sides, and used a wheelchair for mobility. The annual (CAA) Care Area Assessment for cognition, dated 5/16/17, documented the resident had short and long term memory problems, frequently called out help and yelled out that he/she had to go to the bathroom, even after staff toileted the resident. The CAA documented the resident was usually able to make his/her needs known, but had thought process problems, and his/her dementia (progressive mental disorder characterized by failing memory, confusion), and behaviors placed him/her at risk for injury and unmet needs. The 11/29/17 care plan documented the resident was at risk for alteration in thought process related to dementia, [MEDICAL CONDITION] disorder ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and [MEDICAL CONDITION] (anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning). The care plan directed staff to assess the resident when he/she had hallucinations (sensing things while awake that appear to be real, but the mind created) or alterations in his/her thought process, and to notify the physician. The 12/18/17 at 2:58 PM, nurse's note documented the facility notified the physician by fax, of a suspected abuse case, which involved the resident, when Nurse Aide M placed his/her hand over the resident's mouth to keep the resident quiet. The 12/19/17 at 4:23 PM, nurses note documented the facility received a response from the physician's nurse practitioner that he/she would communicate the information to the resident's physician. Review of Nurse Aide M's time sheet revealed he/she worked on 12/4/17 from 3:48 PM-8:37 PM and 12/5/17 from 3:50 PM-9:54 PM. On 12/19/17 at 9:12 AM, observation revealed the resident sat in his/her wheelchair in the TV area of the facility. On 12/19/17 at 3:07 PM, Nurse Aide P stated Nurse Aide M placed his/her hands over Resident #6's mouth, when he/she was crying while on the toilet. Nurse Aide P stated he/she knew what Nurse Aide M had done to the resident was not right, but he/she was his/her friend and he/she did not want to ruin the friendship. In a signed witness statement, dated 12/7/17, Nurse Aide P stated the resident was crying out, and said he/she had to go to the bathroom, even though he/she was seated on the toilet. Nurse Aide P documented Nurse Aide M took both of his/her hands, shoved them onto the resident's mouth, and forced the resident against the back of the toilet, which made the resident cry out louder. Nurse Aide P stated he/she pulled both of Nurse Aide M's hands off the resident's mouth, and told Nurse Aide M that people could hear the resident's muffled screams. On 12/19/17 at 4:32 PM, Nurse Aide M verified he/she covered the resident's mouth with his/her hand, because the resident was screaming very loud, and he/she wanted to quiet the resident. Nurse Aide M's 12/19/17 notarized witness statement, documented he/she covered Resident #6's mouth, as he/she screamed a lot, and staff had trouble getting the resident's attention to help the resident. On 12/20/17 at 5:29 PM, Administrative Nurse D stated it was not appropriate for staff to place a hand over the resident's mouth to keep him/her quiet. Administrative Nurse D stated it would be horrifying for the resident. The facility's Abuse Prevention, Intervention, Reporting and investigation policy, dated 2009, documented residents are to be free from verbal, sexual, physical, emotional/mental abuse at all times. The facility failed to provide an environment free from abuse, when Nurse Aide M abused Resident #6, by placing his/her hands over the resident's mouth to keep him/her quiet, placing the resident in immediate jeopardy. The facility abated the immediate jeopardy on 12/22/17 at 4:00 PM, when the facility completed in-servicing to all staff on the updated abuse and reporting policy guidelines. The facility suspended Nurse Aide M at approximately 6:00 PM on 12/7/17. The deficient practice remains at a scope and severity of a G.

The facility reported a census of 34 residents. The sample included 16 residents. Based on observation, interview and record review the facility failed to thoroughly assess the skin, consistently document their findings, and prevent the development of an unstageable pressure ulcer for 3 (#9,1,46) of 3 residents reviewed for pressure ulcers. Findings included: - Review of resident #9's electronic medical record revealed the resident had [DIAGNOSES REDACTED]. The resident's annual Minimum Data Set ((MDS) dated [DATE] identified the resident scored 4 (severely impaired cognition) on the BIMS (Brief Interview for Mental Status), had no behaviors, required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, dressing and toilet use, was independent with locomotion on/off the unit and eating and required limited staff assistance with personal hygiene. The MDS recorded the resident was occasionally incontinent of urine, weighed 146 pounds, had not experienced a weight loss and was at risk for the development of pressure ulcers. The resident did not have unhealed pressure ulcers, utilized a pressure relieving device in his/her chair and on his/her bed and was not on turning/repositioning program, and used a trunk restraint on a daily basis. The 11/12/14 Care Area Assessments were not provided by the facility. The resident's quarterly MDS dated [DATE] identified the resident scored 6 (severely impaired cognition) on the BIMS, had no behaviors, required extensive staff assistance with bed mobility, transfers, toilet use, dressing, bed mobility, supervision with eating, was independent with locomotion on/off the unit, and required limited staff assistance with personal hygiene. The MDS identified the resident was frequently incontinent of urine, weighed 146 pounds and had not experienced a weight loss. The resident was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, utilized a pressure relieving device in his/her chair and on his/bed, was not on a turning/repositioning program and utilized a trunk restraint on a daily basis. The resident scored 16 on the Braden Scale (scale used to predict the development of pressure ulcers). According to the legend a score of 15-18 identified the resident was at risk for the development of pressure ulcers. The resident's 4/19/15 revised care plan reviewed revealed that on 1/4/15 the resident had a hoop placed on the outerside of his/her bed to assist with mobility and that staff should monitor for skin breakdown during interactions with this resident and report a change to the charge nurse. addressed the resident had a pressure ulcer on his/her right buttock which was first noted on 3/19/15. Licensed nursing staff performed weekly skin assessments, the resident had an alternating low pressure air mattress on his/her bed, a gel cushion in his/her wheelchair and staff performed the treatment as physician ordered and notified the resident's physician if there was no change noted with treatment in 2 weeks. The resident received Arginade (a protein supplement) twice a day. All of the above interventions had an effective date of 4/19/15. The care plan lacked evidence of interventions that were in place prior to the skin breakdown. A nurse's note dated 3/19/15 and timed 3:31 PM documented staff completed a skin assessment on the resident and the resident had an open area on his/her coccyx that measured 0.7 centimeters (cm) x 0.5 cm and staff applied a cream to the area. The resident's clinical record lacked any further documentation of the area. Review of the resident's Skin Integrity reports identified the following: 03/29/15 staff observed the resident's right upper inner buttock had a Stage 2 pressure ulcer. 03/31/15: The resident had an unstageable pressure ulcer on his/her on right upper inner buttock. The area was dry with eschar (dead tissue) and measured 1.0 centimeter (cm) by 1 cm and the peri wound measured 2 cm by 2 cm. 04/07/15: The pressure ulcer wound bed contained 100 percent (%) yellow slough (non-viable tissue), and measured 1 cm by 1 cm by 0.2 cm. 04/10/15: The pressure ulcer wound bed contained yellow slough with a small amount of pink in the center and measured 1.2 cm by 1.2 cm by 0.2 cm. 04/18/15: The pressure ulcer was a Stage 3 and measured 1.0 cm by 1.0 by 0.1 cm. 04/24/15: The pressure ulcer's wound bed contained 100% yellow slough and measured 1.0 cm by 1.0 cm. Review of the resident's weights from 2/2/15 to 4/6/15 revealed the resident's weight was stable and ranged from 143 pounds to 146 pounds. A Registered Dietician's (RD) note dated 4/1/15 documented the resident had a Stage 2 pressure ulcer on his/her buttock and recommended Arginade twice a day to promote healing. Review of a facsimile to the resident's physician dated 4/9/15 revealed staff asked for a physician's orders [REDACTED]. in the wheelchair. On 4/27/15 at 8:30 A.M., 8:40 A.M., 8:50 A.M., 8:57 A.M., and 9:00 A.M. the resident sat in his/her wheelchair at a dining room table with a seat belt in place. On 4/27/15 at 9:10 A.M., 9:17 A.M., 9:20 A.M., 9:25 A.M., 9:35 A.M., 9:45 A.M., 9:50 A.M., 10:00 A.M., 10:10 A.M., 10:15 A.M., 10:24 A.M., 10:30 A.M., 10:40 A.M., 10:50 A.M., 11:00 A.M., 11:20 A.M., 11:35 A.M., 11:45 A.M. and 11:55 A.M. the resident sat in his/her room in his/her wheelchair with a seat belt in place (a duration of 2 hours and 45 minutes). On 4/27/15 at 11:35 A.M. the surveyor asked direct care staff Q when was the last time staff repositioned the resident. Direct care staff Q stated staff repositioned the resident at approximately 9:00 A.M. prior to placing the resident in his/her room. Direct care staff Q stated he/she was unsure if the resident was on a repositioning/turning program. On 4/27/15 at 11:58 A.M. direct care staff O and R released the resident's seat belt, lifted the resident from the wheelchair and immediately sat the resident back in the wheelchair and applied the seat belt. The resident at that time pointed to the bathroom and direct care staff O and R transferred the resident from the wheelchair to the toilet via the sit and stand lift. Observation revealed during the transfer urine flowed down the resident's leg. Further observation revealed the resident's incontinent brief was saturated with urine and a dressing was intact on the resident upper inner buttock. On 4/28/15 at 7:15 A.M., 7:30 A.M. and 7:45 A.M. the resident sat in his/her room in his/her wheelchair with a seat belt in place. At 7:45 A.M. the resident beckoned for the surveyor, asked for a piece of candy and direct care staff R entered the resident's room and wheeled the resident to a dining room table. On 4/28/15 the resident continued to sit at a dining room table with the seat belt in place at 8:00 A.M., 8:15 A.M., 8:30 A.M., 8:45 A.M., 9:00 A.M., 9:15 A.M., 9:30 A.M. and 9:50 A.M. (the resident sat in the wheelchair with the seat belt in place for a duration of 2 hours and 35 minutes). During this time he/she ate breakfast, he/she consumed french toast with syrup, 2 strips of bacon, a glass of Arginade and coffee. On 4/28/15 at 10:02 A.M. licensed nurse K and direct care staff R transferred the resident from the wheelchair to the toilet via a sit to stand lift and then from the toilet to the bed via the sit and stand lift. At approximately 10:10 A.M. observation revealed the resident had a Stage 3 pressure ulcer with white/yellow slough that measured approximately 0.5 cm by 0.5 cm. After the treatment was performed staff positioned the resident on his/her left side, placed a pillow between the resident's legs but did not float the resident's heels. On 4/27/15 at 2:31 P.M. licensed nurse stated G stated the resident's pressure ulcer was facility acquired. He/she stated after the resident developed the pressure ulcer staff placed a low air loss mattress on the resident's bed. He/she stated staff repositioned the resident every 1 to 2 hours by standing them up from the wheelchair and toileted the resident every 2 hours. He/she stated the resident was incontinent of urine and identified the seat belt as a physical restraint. On 4/27/15 at 3:33 P.M. direct care staff MM stated the resident had a pressure ulcer on his/her right buttock, the resident was incontinent of urine and staff repositioned the resident every 1 to 2 hours. On 4/28/15 at 1:39 P.M. licensed nurse K stated the resident's pressure ulcer was facility acquired, staff toileted and repositioned every 2 hours. He/she stated the occupational therapist felt the pressure ulcer was due to sweat and moisture since the resident wore multiple layers of clothing and the pressure ulcer was on the upper part of the resident's buttock. Licensed nurse K stated the resident received the Arginade since the development of the pressure ulcer. On 4/28/15 at 4:20 P.M. nursing administrative staff D stated he/she thought the resident's facility acquired pressure ulcer was moisture related. He/she stated no residents were on turning/repositioning programs and residents were repositioned and toileted every 2 hours. On 4/29/15 at 4:10 P.M. nursing administrative staff D stated stated prior to the development of the resident's pressure ulcer the previous care plan dated during the month of 12/2014 did not include the resident was at risk for the development of pressure ulcers. He/she stated the resident's Braden Scale done on 11/20/14 identified the resident scored 18 (according to the legend the resident was at risk for the development of pressure ulcers). He/she stated the resident ad a seat belt in place; therefore staff repositioned the resident every 2 hours. The resident could reposition himself/herself in bed and could shift his/her weight when in the wheelchair. Prior to the development of the pressure ulcer the resident had a pressure relieving device on his/her bed and in his/her wheelchair. On 4/9/15 the facility placed the resident on a low air loss mattress and started the Arginade and protein supplement. Nursing administrative staff D confirmed the nurse's note dated 3/19/15 documented the resident had an open area on his/her coccyx. He/she stated the night shift licensed nurse documented the open area and he/she was not aware of the open area. Nursing administrative staff D stated he/she was not sure if the open area on the coccyx was the same pressure ulcer area on the resident's inner buttock. The facility's Pressure Ulcer Policy and Procedure revised April 2015 included if residents sat in a chair, staff encouraged the resident to shift his/her weight every 2 hours or more frequently if there were skin issues. If a resident developed a pressure ulcer dietary staff was notified and worked with nursing to develop a plan for increasing the resident's protein if appropriate. The facility failed to reposition and toilet this severely cognitively impaired resident with a physical restraint and developed a stage 2 pressure ulcer that increased to an unstageable pressure ulcer as planned. The facility also failed to implement the protein supplement in a timely manner after the RD's recommendation. - Resident #1 ' s Physician order [REDACTED]. The resident's annual Minimum Data Set ((MDS) dated [DATE] identified the resident scored 7 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS), had no behaviors, required extensive staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, did not walk in room/corridor and as independent with locomotion on/off the unit and eating. The MDS identified the resident weighed 181 pounds and had not experienced a weight loss. The MDS recorded the resident was at risk for the development of pressure ulcer, had no unhealed pressure ulcers, had a pressure relieving device on his/her bed and in his/her wheelchair and was not on a turning/repositioning program. The resident's quarterly MDS dated [DATE] identified the resident scored 5 (severely impaired cognition) on the BIMS, had no behaviors, required extensive staff assistance with bed mobility, transfers, toilet use, personal hygiene, the activity of walking in the room/corridor did not occur and required limited staff assistance with locomotion on/off the unit. The MDS recorded the resident weighed 168 pounds, had not experienced a weight loss and was at risk for the development of pressure ulcer. The MDS identified the resident did not have any unhealed pressure ulcers, had a pressure relieving device on his/her bed and in his/her wheelchair and was not on a turning/repositioning program. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 9/15/14 included the resident had short and long term memory problems and had a [DIAGNOSES REDACTED]. The resident's Activity of Daily Living (ADL)/Functional Potential CAA included the resident required staff assistance of 2 for transfers to the wheelchair and bed and activated his/her call light for staff assistance. The resident was wheelchair and propelled himself/herself in his/her wheelchair. The resident had a [DIAGNOSES REDACTED]. The resident's Urinary Function and Indwelling Catheter CAA dated 9/15/14 included the resident activated his/her call light for assistance to the bathroom thorough out the day and evening. At night the resident did not ask for staff assistance and was incontinent through the night. During the day the resident was also frequently incontinent of bowel and bladder. The resident's Nutritional Status CAA dated 9/15/14 included the resident received a mechanical soft and low concentrated diet and received small portion. The resident's Pressure Ulcer CAA dated 9/15/14 included the resident had no open areas at this time. The resident was able to make slight changes in her position independently. The resident required assistance of 2 staff for transfers, had a pressure relieving cushion in his chair and wheelchair and had a hand rail on the outside of his/her bed to help him/her turn with staff assistance. Staff applied moisture barrier cream after all incontinent episodes. The resident's Braden Scale (scale used to predict pressure ulcers) dated 11/26/14 identified the resident scored 16. According to the legend a score of 15-18 identified the resident was at risk for the development of pressure ulcers. The resident's clinical record lacked evidence the facility had performed a Braden Scale since 11/26/14. On 4/27/15 at 3:33 P.M. nursing administrative nursing staff D confirmed the facility had not performed a Braden Scale for the resident since 11/2/14. The resident's care plan dated 1/7/15 and revised on 4/7/15 included since 2/26/15 he resident had a wound to is/her coccyx. Staff repositioned the resident from side to side in bed as the resident allowed, encouraged the resident to lay down in the bed at night and after meals and activities. The resident had a pressure relieving cushion in his/her recliner, wheelchair and on his/her bed. The resident received Arginade twice a day (BID) for wound healing and a protein supplement three times a day. Staff performed the treatment as physician ordered and the resident required 2 staff for transfers and repositioning, All of the above had an effective date of 4/7/15. Since 1/7/15 if the resident was uncomfortable in bed, staff positioned the resident in a geriatric chair or a recliner. Effective 1/9/15 staff repositioned the resident every 2 hours and as needed. Effective 1/7/15 the resident preferred to sleep in his/her recliner during the day. Effective 1/7/15 the resident had a hand held bar on the outside of his/her bed to help with positioning. Since 10/19/13 the care plan included the resident was at risk for skin breakdown and staff applied medications as physician ordered, assessed the resident skin during care,applied moisture barrier cream during incontinent care and performed weekly skin assessments. The resident's care plan with a review date of 12/3/14 addressed the resident was at risk for skin breakdown due to history of gaulding and obesity. Interventions included the staff applied medications as physician ordered, assessed the resident's skin during care, applied moisture barrier cream during perineal care and the licensed nurse assessed the resident's skin on a weekly basis. The care plan did not include if the resident utilized pressure relieving devices nor did it include a turning/repositioning schedule or interventions to prevent skin to skin contact or protection of the resident's bony prominence to prevent the development of pressure ulcer although staff identified on the annual MDS dated [DATE] identified to be at risk for the development of pressure ulcers. The resident's care plan did not include the resident had a lipoma (slow-growing, fatty lump that's most often situated between the skin and the underlying muscle layer) and that the lipoma had shifted. The resident's care plan did not include how staff was to minimize pressure on the lipoma after it shifted. A nurse's note dated 2/26/15 and timed included the resident had a reddened unopened areas on his/her lower lumbar & both sides of his/her coccyx. Staff cleansed and continued to monitor the area. Review of the resident's skin integrity reports revealed the following: 3/6/15: The resident had a 1 centimeter (cm) by 2 cm by 0 cm Stage 1 pressure ulcer on his/her coccyx and staff applied [MEDICATION NAME]. 3/10/15: The wound on the resident's coccyx was opened into 2 small areas and measured 1.8 cm by 1.5 cm and was a Stage 2 pressure ulcer. 3/18/15: The 2 areas of the Stage 2 pressure ulcer were blended, and measured 1.3 cm by 1.8 cm. 3/23/15: The Stage 2 pressure ulcer on the resident's coccyx measured 1.5 cm by 2.0 cm. 3/30/15 The pressure ulcer on the resident's coccyx was unstageable, the wound bed contained 100 percent (%) slough (non-viable tissue) and measured 1.5 cm by 2.0 cm. 4/4/15: The pressure ulcer on the resident's coccyx was unstageable, the wound bed was covered with 100% eschar (dead tissue), was foul smelling and measured 2.0 cm by 3.0 cm. 4/7/15: The necrotic tissue was debrided and the unstageable pressure ulcer measured 3.0 cm by 2.0 cm by 1.25 cm. 4/15/15: The pressure ulcer was identified as a Stage 3 and measured 1.6 cm by 3.4 cm by 1.8 cm. The wound bed contained 80% yellow slough and necrotic black tissue was observed at deepest part of the tunneling. 4/24/15: The Stage 3 pressure ulcer wound bed contained 70% green slough, 30 pink granulation tissue and measured 2.0 cm by 1.3 cm by 1.0 cm. The skin integrity report recorded staff treated the resident's pressure ulcer with a Hydrogel cool disk covered with a foam dressing from 3/10/15 until 4/4/15 (duration of greater than 2 weeks even though the pressure ulcer deteriorated during that time). A physician progress notes [REDACTED]. Staff were trying to keep him/her from sitting as much and to lie down in bed and turn on his/her side. He/she had a stage 1 to stage 2 ulceration to the presacral coccygeal area, the area is surrounded by slight [DIAGNOSES REDACTED] (redness or inflammation of the skin) to a slight degree. The area may represent a lipoma (a fatty lump) with the ulceration nearly eroding into this. At this time staff should cover with Calcium Alginate (an absorbent wound dressing). A physician progress notes [REDACTED]. The area had been an abrasion maybe a month ago and had healed with [MEDICATION NAME] ( a moisture barrier cream) and in the last week had started to look worse with more black eschar (dead tissue). The area was cultured and culture was pending review. The note further revealed the area was open and was 2 inch (in) by 1 in, kind of black eschar with an open area the size of a pencil eraser, the area looked fairly deep with a tannish base, with no surrounding [DIAGNOSES REDACTED]. The area appeared to be tender. The progress note revealed the resident would be seen by another physician for further wound followup. A physician progress notes [REDACTED]. On 4/9/15 the facility obtained physician's orders [REDACTED]. A laboratory report dated 4/14/15 recorded the resident's [MEDICATION NAME] level at 2.8 grams/deciliter (normal reference range 3.4 to 5.0 grams/deciliter). A registered dietician note dated 3/3/15 (prior to the development of the pressure ulcer) documented the resident weighed 168 pounds. the resident ate independently and received a lo concentrated, no added salt diet with mechanical soft texture. The resident consumed 61 percent of his//her meals and staff continued to weigh the resident on a weekly basis. The resident's clinical record lacked evidence the facility thoroughly assessed the resident's nutritional status after the development of the pressure ulcer. Observation on 4/27/15 at 8:30 A.M. revealed he/she sat at the dining room table in a wheelchair and ate breakfast with assistance from staff. He/she consumed all of his/her egg sandwich and ½ banana, ate approximately 20% of oatmeal, consumed all of his/her juice and half of the water. Licensed Staff G stated that the Arginade was in his/her juice. At 9:05 A.M., therapy staff GG pushed him/her away from the table and down the hall in his/her wheelchair. At 9:18 A.M. resident remained in her wheelchair. At 9:25 A.M. resident laid in his/her low air loss mattress in bed on his/her right side. At 9:50 A.M. the resident was taken to the shower room. At 10:15 he/she was placed in bed on his/her right side and remained on the right side until 11:00 A.M. When he/she was assisted up and taken to the dining room. Observation on 4/28/15 at 7:45 A.M., he/she was placed in his/her wheelchair and taken to breakfast. He/she remained in his/her wheelchair until 9:40 A.M., when direct care staff Q and R transferred him/her with a gait belt and positioned him/her on his/her right side. Licensed nurse K measured the wound at this time, the wound measured 2.5 centimeters (cm) x 2 cm with a depth of 2.5 cm tunneling per his/her measurements. The area was cleansed and packed with calcium arginate with a Hydrogel dressing placed over it. On 4/23/2015 at 9:18 A.M. licensed nurse G stated the resident had a facility acquired Stage 3 pressure ulcer on his/her coccyx. He/she stated on 3/6/15 the resident had an area due to shearing on his/her coccyx and the facility treated the area with [MEDICATION NAME]. Licensed nurse G stated the area opened on 3/10/15 and staff changed the treatment form [MEDICATION NAME]. On 4/4/15 the facility changed the treatment to Hydrogel and covered the pressure ulcer with a foam dressing. He/she stated on 4/4/15 the pressure ulcer was black in color and was draining and the resident's saw a surgeon on 4/7/15 and the surgeon debrided the area. Licensed nurse G stated the resident had the lipoma for a while and the lipoma shifted down when the resident lost weight. An interview on 4/28/15 at 4:02 P.M., administrative nurse D revealed the area was the result of the lipoma putting pressure on the area when he/she leaned back in his/her wheelchair. The residents wheelchair cushion was changed to help reduce the pressure. He/she stated no residents were on a turning/repositioning program. The facility's Pressure Ulcer Policy and Procedure revised April 2015 included if residents sat in a chair, staff encouraged the resident to shift his/her weight every 2 hours or more frequently if there were skin issues. If a resident developed a pressure ulcer dietary staff was notified and worked with nursing to develop a plan for increasing the resident's protein if appropriate. Staff assessed resident for the risk of the development of pressure ulcers upon admission and on a quarterly with the MDS review. The facility failed to develop a care plan that included a turning/repositioning schedule and also failed to implement timely interventions to promote healing after the resident developed a Stage 1 pressure ulcer that worsened to an unstageable pressure ulcer and required debridement for this severely cognitively impaired resident that required extensive staff assistance with bed mobility and transfers. - The Electronic Medical Record (eMR) indicated the resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) was still in the process of being completed at the time of survey. The 4/19/15 Care Plan revealed the resident had pressure ulcers to his/her ankle, heel, and bilateral buttocks. Staff provided a low air loss mattress, a cushion for his/her wheelchair, nutritional supplements for wound healing, and moisture barrier cream with pericare. A licensed nurse performed weekly skin assessments. The admission nurse's note dated 4/16/15 at 2:29 P.M. revealed the resident had pressure ulcers to his/her right heel, bilateral buttocks, and one on his/her left lateral (pertaining to the side, away from the middle) ankle. The left lateral heel measured 0.3 centimeters (cm) by 0.7 cm. Nurse's notes dated 4/20/15, 4/23/15, and 4/26/15 revealed the resident remained with wounds to his/her right heel, bilateral buttocks, and left lateral ankle. The notes did not include measurements or descriptions of wound statuses. Review of the Skin Integrity Nursing Assessments dated 4/19/15 and 4/24/15 revealed assessments with descriptions and measurements were complete for the bilateral buttocks wounds and the right heel wound but lacked assessments for the left lateral ankle wound. Observation on 4/28/15 at 10:37 A.M. revealed licensed nursing staff H completed dressing changes to the resident's wounds on his/her right heel, bilateral buttocks, and left lateral ankle. The ankle wound had a red wound bed and was approximately the size of a pencil eraser. Staff H used wound cleanser, applied [MEDICATION NAME] (an antibacterial ointment) to the wound bed, and placed a dressing over the wound. Interview on 4/27/15 at 4:04 P.M. with licensed nursing staff I revealed he/she expected staff to complete an assessment and documentation on all of the resident's wounds. Interview on 4/28/15 at 11:22 A.M. with direct care staff N revealed he/she thought the nursing staff monitored all the resident's wounds. Interview on 4/28/15 at 12:58 P.M. with licensed nursing staff H revealed the resident had 4 pressure ulcers. Staff H reported the facility had a nurse that was designated to completed weekly assessments with measurements for wounds. Staff H expected the designated wound nurse to measure and document regarding the resident's left lateral ankle wound. Interview on 4/28/15 at 1:24 P.M. with administrative nursing staff D revealed he/she acknowledged the nurse responsible for completing weekly wound assessments failed to do so for this resident's left lateral ankle wound since admission. Staff D stated the wound nurse reported to him/her that he/she was unaware of the left lateral ankle wound. Staff D stated it was the responsibility of the wound nurse to review the clinical record and ensure all wound the resident had were assessed. The policy provided by the facility regarding pressure ulcer prevention and management with a revision date of April 2015 revealed any resident with pressure sores was assessed weekly by a licensed nurse and documented in the eMR under the skin record assessment and in the nurse's notes. The facility failed to assess and measure the left lateral ankle pressure ulcer for this resident admitted with 4 identified pressure ulcers.

The facility reported 34 residents with 16 residents selected for sample. Based on observation, interview and record review the facility failed to ensure effective fall interventions for 2 of the 3 sampled residents chosen for falls. (#20,40) - Resident #20's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 6 (severely impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required extensive staff assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene and the activity of walking in the room/corridor did not occur. The resident was not steady and was only able to stabilize with human assistance when moving from seated to standing position, moving on/off the toilet, surface to surface transfer, and the activity of walking and turning around and facing the opposite direction while walking did not occur. The resident had a functional impairment on both sides of his/her lower extremities and had 1 non-injury fall since the prior assessment. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 7/21/14 included the resident was occasionally confused. The resident's Fall CAA dated 7/21/14 documented the resident propelled himself/herself in the wheelchair throughout the facility. The resident reported no prior falls, scored 10 on the fall risk assessment and worked with physical and occupational therapy for gait training and activity of daily living tasks. The resident required limited staff assistance with bed mobility, transfers and ambulation. The resident's Fall Risk assessment dated [DATE] identified the resident scored 6. According to the legend a score of 10 or above represented the resident was at high risk for falls. The resident's care plan dated 1/9/15 and revised 4/17/15 addressed the resident had short term memory problems and had a potential for falls. Staff encouraged the resident to activate his/her call light for staff assistance and the resident's falls may be unavoidable due to the resident's independent nature. Staff kept the hallways and the resident's room free of clutter, placed a landing strip next to the resident's bed when the resident was in bed. The resident's main mode of transportation was a wheelchair and the resident was able to self propel. Staff ensured the resident's drinks were placed on his/her bedside table and not the night stand so that the resident could reach them. The resident wore proper footwear when getting out of bed, staff reminded the resident to lock his/her wheelchair or staff placed the resident's wheelchair against the wall so when the resident got out of it, it would not move. Staff reminded the resident to wear proper footwear when he/she ambulated and reminded the resident to wait for staff assistance with transfers. A nurse's note (NN) dated 1/26/15 and timed 7:45 P.M. documented the resident was on his/her knees next to his/her bed. Staff held onto the resident to prevent the resident from falling down any further and to prevent his/her head from hitting the night stand. The resident's bed sheets were wrapped around his/her legs and the resident's ankles were crossed. The note included the fall mat was in place. The fall investigation included an assistive device was implemented but did not identify the device. A NN dated 2/15/15 and timed 4:30 P.M. documented at approximately 3:30 A.M. the resident sat on the bedside mat on his/her buttocks with both legs out in front of him/her and leaned his/her arms against his/her legs. The resident's call light was within reach and was going off. The resident stated he/she slipped to the floor trying to get to his/her four wheeler. The resident stated he/she thought it was 3:00 P.M. and not 3:00 A.M. The fall investigation included an assistive device was ordered but did not identify the device. A NN dated 4/21/15 and timed 3:10 P.M. documented at 9:10 A.M. the resident sat on the fall mat on his/her bottom with his/her feet extended in front of him/her and his/her back was against the bed, near the foot of his bed. The resident stated he/she was trying to get into his/her wheeler and his/her feet slipped. The note included the resident had on regular socks. The fall investigation included an assistive device was ordered, and also included an assistive device was on and present at the time of the fall. The investigation did not include the type of device. The resident's clinical record lacked evidence the facility thoroughly assessed the causal factors of the resident's falls. On 4/27/15 at 8:30 A.M. the resident was in bed. Observation revealed a hand rail in place on the left side of the resident's bed and a fall mat in place. On 4/28/15 at 7:15 A.M. the resident was in bed. Observation revealed a hand rail in place on the left side of the resident's bed and a fall mat in place. Further observation revealed several pieces of candy and the resident's water pitcher on the resident's night stand and not on his/her bedside table. On 4/28/15 at 8:30 A.M. the resident sat on the side of the bed with regular socks on and the fall mat directly under the resident's feet. On 4/27/15 at 2:22 P.M. licensed nurse G stated the resident was at risk for fall, had a low bed, a hand rail and a floor mat. He/she stated the last fall occurred because the resident slid out of bed attempting to reach things in his/her dresser. On 4/27/15 at 3:32 P.M. direct care staff MM stated the resident was at risk for falls, utilized a hand rail, a fall mat and staff ensured the resident's bed was in the lowest position when he/she was in bed. On 4/38/15 at 1:23 P.M. licensed nurse K stated the resident should wear gripper socks rather than regular socks. He/she stated staff frequently checked on the resident, the resident had a low bed, a fall mat and staff kept the resident's items on the bedside table. On 4/ 28/15 at 4:16 P.M. administrative nursing staff D stated the resident was at risk for falls. He/she stated staff reminded the resident to utilize his/her call light to ask for staff assistance, staff ensured the resident's call light and bed side table were within reach. Administrative nursing staff D stated the resident had a fall mat and staff ensured the resident's bed was in the lowest position when the resident was in it. The facility's Fall Risk Assessment Policy and Procedure revised 9/2013 included staff assessed residents for falls upon admission and every 90 days. If a fall occurred the facility facility investigated the fall. The facility failed to place effective fall interventions in place for this severely cognitively impaired resident with a history of falls. - Resident #40's admission Minimum Data Set ((MDS) dated [DATE] identified the resident score 4 (severely impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion on/of the unit, dressing and personal hygiene and required extensive staff assistance with toilet use. The MDS recorded the resident was not steady and was only able to stabilize with human assistance when moved from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on/off the toilet and surface to surface transfers. The resident was frequently incontinent of urine and had not fallen prior to or since admission. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 3/13/15 included the resident was confused at times as to where he/she was and thought it was 1922. The resident had short and long term memory loss, was forgetful and hard of hearing. The resident occasionally got up by himself/herself without using his/her call light even after being reminded and the resident's gait was unsteady at times. The resident's Fall CAA dated 3/13/15 included the resident had not fallen since admission and denied falls at home. The resident was at risk for falls, got up without using his/her call light or asking for staff assistance when out in the living room. The resident's gait was unsteady at times and used a front wheeled walker and therapy worked with the resident to assist him/her to use a cane. The resident's Fall Risk assessment dated [DATE] identified the resident scored 8. According to the legend a score of 10 or above represented the resident was at high risk for falls. The resident's care plan dated 2/25/15 and revised 4/20/15 did not include the resident was at risk for falls. The care plan included upon admission staff oriented the resident to the call light system. Staff assisted the resident to the bathroom, encouraged the resident to use the call system for assistance, kept the resident's call light within reach at all times when the resident was in his/her room and monitored the resident closely to allow staff to assist him/her as needed. A nurse's note dated 3/15/15 and timed 3:12 P.M. included just before lunch the resident got out of his/her chair by himself/herself, bent down to pick up his/her slippers from the floor. When the resident stood up, he/she lost his/her balance and almost fell but this nurse was able to reach the resident in time to prevent the resident from falling. Staff reminded the resident to use the call light to ask for help and not to get up by himself/herself to prevent falls. Staff was advised to check on the resident frequently to assess for his/her needs. A nurse's note dated 4/13/15 and timed 12:20 PM included at 10:30 A.M. the resident sat on the on the floor of his/her bathroom with his/her back to the bathroom door with his/her walker in front of him/her. The resident stated he/she took himself/herself to the bathroom and was on the way back to bed. The resident stated he/she slipped on urine on the floor and lost his/her balance. The fall investigation included an assistive device was ordered and also included an assistive device was on and present at the time. The investigation did not identify the type of assistive device. A nurse's note dated 4/22/15 and timed 3:10 P.M. documented at approximately 2:45 P.M. the resident was on his/her knees in front of his/her chair, the resident's walker was next to him/her and the resident's brief was wet and the resident did not wear socks or shoes. The resident stated he/she got up to go to the bathroom. The note included staff encouraged the resident to to ask for assistance and to use the call light. The fall investigation included an assistive device was ordered and also included an assistive device was on and present at the time. The investigation did not identify the type of assistive device. On 4/27/15 at 10:41 A.M. and 11:00 A.M. the resident sat in a lift chair and the resident's walker was in front of him. On 4/27/15 at 4:38 P.M. the resident ambulated in his/her room without his/her walker. Observation revealed the resident's gait was unsteady. On 4/28/15 at 9:12 A.M. direct care staff O ambulated with the resident using the walker. Direct care staff O assisted the resident to the chair in the resident's room and placed the resident's walker in front of him/her. On 4/27/15 at 3:36 P.M. direct care staff MM stated the resident was at risk for falls, liked to get up by himself/herself and did not always ask for staff assistance. On 4/28/15 at 11:39 A.M. direct care staff N stated the resident was at risk for falls, staff reminded the resident to ask for staff assistance but the resident did not. He/she stated staff ensured the resident's call light was within reach, kept the door open to his/her room, attempted to keep the resident in the living room when activities were going on so more people could observe the resident. On 4/28/15 at 1:43 P.M. licensed nurse K stated the resident was independent by nature which placed him/her at risk for falls and the resident's cognition was impaired. On 4/28/15 at 4:21 P.M. administrative nursing staff D stated the resident was at risk for falls, and staff reminded the resident to use his/her call light, ensured the resident's walker was within reach and frequently toileted the resident. The facility's Fall Risk Assessment Policy and Procedure revised 9/2013 included staff assessed residents for falls upon admission and every 90 days. If a fall occurred the facility facility investigated the fall. The facility to place effective interventions in place for this severely cognitively impaired resident with a history of falls since admission.

The facility had a census of 37 residents. The sample included 9 residents. Based on observation, interview and record review the facility failed to assess a resident with increased bruising and change in status for 1 of 3 residents reviewed who received [MEDICATION NAME] (blood thinner) medication. (#2) This failure placed the resident in immediate jeopardy. Findings included: - Resident #2's significant change (MDS) Minimum Data Set 3.0 assessment, dated [DATE], indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 6 with inattention, disorganized thinking, and rejection of care. The MDS indicated the resident required extensive assistance from 2 staff for bed mobility, transfers and toilet use. The MDS further indicated the resident received an anticoagulant medication. The [DATE] Fall (CAA) Care Area Assessment instructed the staff the resident required assistance from 2 staff for transfers and requires assistance for bed mobility. The [DATE] Pressure Ulcer CAA indicated the resident received a full body assessment by the licensed nurse weekly. The [DATE] care plan directed the staff to assess the resident's skin during cares, notify the nurse with any abnormalities and to perform a weekly skin assessment by a licensed nurse. The care plan lacked direction to the staff regarding the resident's [MEDICATION NAME] use, although the resdient received [MEDICATION NAME] from [DATE] to [DATE] and [DATE] to [DATE] The [DATE] hospital transfer sheet included orders for the following: - Administer [MEDICATION NAME] (a blood thinner) 5 (mg) milligrams, daily to the resident - Obtain a (PT/INR) [MEDICATION NAME] Time and International Normalized Ratio (a laboratory test which measures the thickness of the blood) on [DATE] - Administer Ibprophen (a pain medication), 400 mg, every evening to the resident The [DATE] laboratory result indicated the resident had a high INR of 4.19 (normal range 2XXX,[DATE].0) (indicating the resident's blood was too thin). The [DATE] physician's orders [REDACTED]. The [DATE] at 9:33 PM nurse's note indicated the facility received new orders from the physician to hold the resident's [MEDICATION NAME] for 2 days. The note further indicated the resident did not have any new skin issues. The [DATE] skin assessment indicated a skin tear to the resident's right elbow, with no mention of bruising. The [DATE] at 8:44 PM nurse's note indicated the resident's [MEDICATION NAME] remained on hold. Review of the [DATE] (MAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. The [DATE] at 1:23 PM nurse's note indicated the resident had no new skin issues. The [DATE] skin assessment indicated a skin tear to the resident's right elbow, without mention of bruising. The [DATE] at 9:47 PM nurse's note did not mention the resident had a new onset of bruising or confusion. The [DATE] at 2:05 PM nurse's note indicated the resident with confusion. The note continued to indicate at 11:00 AM the resident was sleepy and unable to arouse for lunch. The note indicated the resident had 30 seconds of apnea (frequent and prolonged episodes in which breathing stops during sleep) at times and at 1:00 PM the resident continued to sleep. (No mention that the resident had a new onset of bruising or, additional assessment documented) The [DATE] at 3:42 PM nurse's note indicated the resident continued to sleep in his/her chair that afternoon. The [DATE] at 9:32 PM nurse's note lacked documentation of new bruising. The [DATE] at 12:38 PM nurse's note indicated the resident had multiple bruises to all 4 extremities, which included under the armpits, the front and back of the upper arms, and the right upper arm down to the mid forearm was swollen. The note further indicated the resident had a bruise to the right hip and right mid back. The resident continued to be drowsy. The note indicated the staff updated the physician on the bruises, drowsiness, use of the mechanical lift for tranfers to the recliner. The [DATE] skin assessment indicated the resident had multiple bruising on his/her hands, under arms, knees, and back. The [DATE] physician's orders [REDACTED]. The [DATE] blood laboratory result indicated the resident had a critically high INR result of 21.68. (which indicated the resident's blood was too thin) The [DATE] physician's orders [REDACTED]. The [DATE] at 10:37 PM nurse's note indicated the resident remained lethargic all shift. The [DATE] at 3:17 AM nurse's note indicated the resident was difficult to arouse, and had respirations of 24 (normal ,[DATE]) with periods of apnea (not breathing) [MEDICATION NAME] up to 20 seconds. At 1:45 AM the staff observed an approximately 4 inch circular area of bright red blood on the resident's gown and incontinent pad from the bleeding left (AC) anticubital (venipuncture site where the lab was drawn). The [DATE] at 9:40 AM nurse's note indicated the resident continued to be drowsy. He/she swallowed a Vitamin K tablet with no signs or symptoms of distress. The [DATE] at 1:47 PM nurse's note indicated the staff attempted to awaken the resident at 12:30 PM and the resident continued to snore loudly. The resident had irregular respirations at 36 per minute with ,[DATE] seconds of apnea. The note continued to indicate the staff observed a large amount of bright red blood on the resident's gown and bed on the left side and the dressing to the resident's arm was saturated in blood. Staff observed a slow bleed from the left AC venipunture site. Staff notified the physician and the facility received order to transfer the resident to the emergency room . The medical record lacked evidence that staff notified the physician after the facility received the order for Vitamin K although the resident's physical status continued to decline. The [DATE] hospital (H&P) history and physical indicated the resident was sent to the emergency room after the facility called and specified the resident had apnea spells and difficulty stopping the bleeding from his/her venipuncture site on the resident's left arm. The resident's family indicated the resident had been less responsive for a couple of days. The H&P continued to indicate the resident's physician placed him/her on [MEDICATION NAME] for [MEDICAL CONDITION] (abnormal heart rhythm ) and potentially for [MEDICAL CONDITION] (blood clot) [MEDICATION NAME] (prevention) following injury. The H&P indicated the resident's INR was slightly elevated on repeat testing and the physician instructed staff to hold his/her [MEDICATION NAME] and repeat the INR prior to resuming the [MEDICATION NAME]. The H&P indicated the facility restarted the resident's [MEDICATION NAME] without obtaining a repeat INR until the facility called the physician the day before ([DATE]) in regards to the resident having a lot of bruising. The INR indicated a result of 21.68 and an order for [REDACTED]. The note indicated in the emergency department the resident was found to be unresponsive, very pale, and had significant apnea with movement. A (CBC) Complete Blood Count was collected with a (WBC) White Blood Cell count of 19,660 (normal 5,000 to 10,000) and hemoglobin of 5.6 (normal 11XXX,[DATE].8). The (CT) Computerized Tomagraphy test did not show an acute bleed. The [DATE] physician's orders [REDACTED]. (The physician called the facility after the resident expired) On [DATE] at 11:45 AM, Administrative Staff F verified the physician notified the facility the resident's INR was to be re-drawn before restarting the [MEDICATION NAME] on [DATE], but the facility did not have an order for [REDACTED]. On [DATE] at 12:14 PM, Nurse B stated when on Monday [DATE] the Medication Aide reported to him/her the resident had increased bruising that staff reported over the weekend, but had increased in size. Nurse B stated the bruising was on the resident's arms, under his/her arm pits to his/her back, to the back of his/her arm, lower leg bruising from the left lower knee cap down to the center of the resident's lower leg. Nurse B stated the resident had some bruising on the right leg, but not as much as the left and he/she had a quarter size bruise on his/her right hip and postier mid back. Nurse B stated he/she had not heard in report that morning the resident had any bruising. Nurse B stated he/she notified the physician and received an order to draw a PT/INR, and then drew the lab from the resident's left AC. Nurse B further stated the INR came back as 21.68 and the physician gave an order to administer Vitamin K today or tomorrow. Nurse B stated the facility received the Vitamin K from the pharmacy on Tuesday [DATE] around 9:15 AM and administered it to the resident. Nurse B stated when he/she went back to the resident around lunch time to administer the resident's routine pain medication the resident was in a deep snore, and he/she found blood on the resident's gown and incontinent pad from the resident's left acticubital blood draw from the day before. Nurse B stated the resident had ,[DATE] seconds of apnea and he/she notified the physician. On [DATE] at 1:00 PM, Nurse C verified the first time he/she identified the resident had bruising was on Monday [DATE] and the floor nurse called him/her at home and stated the resident's INR came back as critically high. On [DATE], the physician's office nurse called and directed the facility to hold the [MEDICATION NAME] on [DATE] and redraw the INR in 2 days, but the facility's phone order did not show that. On [DATE] at 1:19 PM, Nurse D verified on Saturday [DATE] the Medication Aide A notified him/her the resident had some bruising, but he/she thought Medication Aide A meant bruising the resident already had so Nurse D verified he/she did not assess the resident. Nurse D stated on Sunday [DATE] the resident's routine pain medication was held because the resident was too sleepy. Nurse D further verified he/she had "spaced" off going to look at the resident's bruises on Saturday and never thought about it again on Sunday, due to the facility being short a nurse that weekend. On [DATE] at 2:19 PM, Medication Aide A stated on Saturday [DATE] he/she notified the nurse the resident had developed new bruising, and there was 2 bruises on the resident's back, bruising on his/her hands, and across 1 of his/her legs. Medication Aide A stated the resident's bruises did not appear new, but were not identified the day before, he/she notified the oncoming aide at the end of his/her shift. Medication Aide A further stated the bruising remained the same on Sunday [DATE], but he/she did not notify the nurse due to it being the same nurse. Medication Aide A stated on Sunday when the staff got the resident up the staff took him/her down to breakfast and the resident was more confused, Medication Aide A stated he/she notified the nurse and placed the resident in his/her recliner in his/her room. Medication Aide A further stated with the exception of checking on the resident, he/she did not move out of the chair for the remainder of the shift, and the resident was pretty much unresponsive. Medication Aide A stated on Monday [DATE] staff left the resident in bed, other then providing personal hygiene care. Before lunch, the nurse instructed the staff to attempt to get the resident up for the day. Medication Aide A further stated while turning the resident in bed and changing his/her clothing, the staff noticed the bruising. The resident's right arm was puffy and swollen, and the resident's skin was yellow. The staff continued to find more bruising and notified the nurse. On [DATE] at 3:11 PM, Nurse E verified he/she took the original order on [DATE] to hold the resident's [MEDICATION NAME] for 2 days and did not remember the office nurse ordering to re draw the PT/INR. On [DATE] at 8:29 AM, Nurse C verified the resident was not care planned for [MEDICATION NAME] use, including the monitoring for bleeding or bruising. Upon request the facility did not provide a policy to instruct the staff to manage care when the resident has bruising. The facility's ,[DATE] Pressure Ulcer Prevention policy instructed the staff that change in condition and any skin concerns were to be reported to the charge nurse. The facility failed to adequately provide effective assessment/ reassessment, and to notify the physician of new bruising, change in cognition and respiratory status in order to seek physician involvement for Resident #2. This failure placed Resident #2 in immediate jeopardy. The immediate jeopardy was abated on [DATE], when the facility inserviced all nursing staff on a new policy for [MEDICATION NAME] administration, including the assessment of potential side effects such as bruising, and when to notify the physician for change in residents condition, and set guidelines regarding any changes in [MEDICATION NAME] therapy. The deficient practice remains at a scope and severity of a G.

The facility had a census of 37 residents. The sample included 9 residents. Based on observation, interview and record review the facility failed to adequately assess, promptly notify the physician and provide effective pain management and monitoring for increased pain for 1 of 3 residents reviewed for pain (#2) Findings included: - Resident #2's significant change (MDS) Minimum Data Set 3.0 assessment, dated 6/6/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 6 with inattention, disorganized thinking, and rejection of care. The MDS indicated the resident required extensive assistance from 2 staff for bed mobility, transfers and toilet use and his/her balance unsteady and only able to stabilize with staff assistance, and had an injury fall prior to re-entry. The MDS further indicated the resident received scheduled and as needed pain medications for occasional level 8 pain and received an anticoagulant medication. The 6/6/14 Pain (CAA) Care Area Assessement indicated the resident sustained [REDACTED]. The CAA further indicated the resident was unable to progress with therapy due to his/her pain level and intolerance and it was discontinued on 6/10/14. The CAA continued to indicate the resident returned to the facility with [MEDICATION NAME] (a pain medication) 7.5 (mg) milligrams and he/she only requested it 4 times since the physician scheduled [MEDICATION NAME] and the staff reported pain control appeared better except when close to scheduled times he/she tended to get teary and complain of pain. The 6/11/14 care plan directed the staff to record the resident's response to pain medications and adjust as necessary and to medicate the resident before planned activities. The care plan further instructed the staff to administer medications, monitor for effectiveness, notify the physician if not effective, and to utilize the pain management program. The 3/6/14 physician's orders [REDACTED]. The 6/4/14 at 8:44 PM nurse's note indicated the resident complained of constant and horrible pain throughout the evening shift. The note further indicated the staff administered as needed pain medication twice with little relief. The clinical record lacked evidence that staff provided non-pharmalogical interventions or notified the resident's physician regarding his/her increased pain. The 6/5/14 pain assessment indicated the resident reported an aching pain, which was relieved with rest and pain medication. The resident further reported the pain increased when he/she moved around and he/she preferred not to move when in pain. The assessment stated the pain sometimes affected his/her sleep and the resident reported crying at times when in pain. Review of the June 2014 (MAR) Medication Administration Record [REDACTED] 1) 6/1/14 at 7:00 AM for a pain level of 10, with relief at a 4 2) 6/1/14 at 1:30 PM for a pain level of 10, with relief at a 4 3) 6/2/14 at 8:25 AM for a pain level of 7, with relief at a 1 4) 6/2/14 at 11:15 AM for a pain level of 9, with relief at a 0 5) 6/2/14 at 3:50 PM for an unassessed pain level and the resident was not reassessed for the effectiveness of the pain medication 6) 6/2/14 at 9:18 PM for an unassessed pain level and the resident was not reassessed for the effectiveness of the pain medication 7) 6/3/14 at 7:36 AM, for an unassessed pain level and documented as effective 8) 6/3/14 at 12:30 PM for an unassessed pain level and the resident was not reassessed for the effectiveness of the pain medication 9) 6/4/14 at 7:30 AM, for a pain level of 10, with relief at a 7 10) 6/4/14 at 11:30 AM, for a pain level of 10, with relief at a 5 11) 6/4/14 3:40 PM, for an unassessed pain level and documented as some relief 12) 6/4/14 at 7:40 PM, for an unassessed pain level and documented as effective 13) 6/5/14 at 12:20 AM, for an unassessed pain level and documented as effective 14) 6/5/14 at 5:25 AM, for an unassessed pain level and documented as some relief 15) 6/5/14 at 9:30 AM, for a pain level of a 10, with relief at a 7 16) 6/5/14 at 5:30 PM, for an unassessed pain level and the resident was not reassesed for the effectiveness of the pain medication 17) 6/5/14 at 11:05 PM, for an unassesed pain level and documented as effective 18) 6/6/14 at 3:30 AM, for an unassessed pain level and documented as effective 19) 6/6/14 at 10:00 AM, for a pain level of 10, with relief at a 0 The 6/5/14 physician's orders [REDACTED]. (The first increase in pain medication after the staff assessed the resident as tearful due to pain on 6/2/14 and on 6/4/14 when he/she complained of constant and horrible pain.) The 6/6/14 at 5:59 AM nurse's note indicated the resident received medication for complaints of pain twice. The note further indicated the resident cried early in the morning and requested medicine for his/her pain. The note documented staff reminded the resident he/she received pain medicine at 3:30 AM. The 6/7/14 at 1:23 PM nurse's note indicated the resident continued to complain of left leg pain with scheduled pain medication and he/she had no new skin issues. The clinical record lacked evidence that staff provided non-pharmalogical interventions or notified the resident's physician regarding his/her increased pain. The 6/8/14 at 11:11 PM nurse's note indicated the resident complained of lower extremity pain and scheduled pain medication education was given to the resident due to an increase of the resident's blood pressure of 196/92. (normal is 120/80, high blood pressure could indicate increased pain) The 6/8/14 at 11:54 PM nurse's note indicated the resident's blood pressure was 163/73. The 6/11/14 at 9:55 PM nurse's note indicated the resident had complained of pain this afternoon prior to the 6:00 PM [MEDICATION NAME] administration. The 6/12/14 at 9:21 PM nurse's note indicated the resident continued non weight bearing and had difficulty with transfers and complained of pain with transfers and crosses his/her legs when being transferred. The clinical record lacked evidence that staff provided non-pharmalogical interventions or notified the resident's physician regarding his/her increased pain. The 6/15/14 at 10:16 AM nurse's note indicated the resident had pain with transfers and unable to bear any weight on his/her left leg. The 6/16/14 at 2:29 PM nurse's note indicated the resident complains of pain when the staff provided cares and was tearful at times with no complaints of breakthrough pain that required more medication then what the physician prescribed as scheduled. The clinical record lacked evidence that staff provided non-pharmalogical interventions or notified the resident's physician regarding his/her increased pain. The 6/17/14 at 2:31 PM nurse's note indicated the resident became tearful when the staff provided care and complained of pain. The note further indicated the resident's pain was controlled by scheduled pain medication. The 6/19/14 at 12:20 PM nurse's note indicated the resident cried at the beginning of the shift and he/she complained of intermittent shooting pain to the top of his/her left shoulder. The note further indicated the staff folded a lap blanket and placed it under his/her shoulder which relieved some of the pain and administered schedule pain medication. The 6/20/14 at 9:48 PM nurse's note indicated the resident complained of back pain with all transfers and the resident required maximum assistance of 2 staff for transfers. The 6/23/14 at 12:38 PM nurse's note indicated the resident continued to be drowsy and complain of generalized pain. The 6/24/14 at 3:17 AM nurse's note indicated the resident moaned with turning, his/her skin was cool to touch. At 5:45 AM the staff administered pain medication. The 6/24/14 at 9:40 AM nurse's note indicated the resident made groaning noises. Review of the June 2014 (MAR) Medication Administration Record [REDACTED] 1) 6/6/14 at 3:00 PM, for a pain level of 10, with relief at a 6 2) 6/9/14 at 3:00 PM, for an unassessed pain level and documented as effective 3) 6/10/14 at 3:00 PM, for an unassessed pain level and documented as effective 4) 6/11/14 at 8:40 AM for a pain level of 10, with relief at a 6 5) 6/12/14 at 3:42 PM, for an unassessed pain level and was not reassessed for the effectiveness of the pain medication 6) 6/14/14 at 2:15 PM, for an unassessed pain level and documented as effective 7) 6/18/14 at 2:35 PM, for an unassessed pain level and was not reassessed for the effectiveness of the pain medication On 6/25/14 at 12:14 PM, Nurse B stated when the resident returned from the hospital with his/her [MEDICAL CONDITION], the staff attempted to use the mechanical lift, but the resident did not like it, so the staff used 2 staff members and a gait belt. Nurse B stated the resident had chronic pain and the facility obtained an increase his/her routine pain medication and he/she had as needed pain medication. When the resident returned from his/her [MEDICAL CONDITION], therapy attempted to provide services but the resident's pain was unbearable and therapy could not work with him/her. On 6/25/14 at 2:19 PM, Medication Aide A stated when the resident returned to the facility following his/her [MEDICAL CONDITION], and the staff attempted to touch or move him/her, the resident became hysterical. Medication Aide A stated the resident was in a lot of pain, received pain medication which had been increased once, but did not seem to help, and he/she had notified the nurse. On 6/30/14 at 11:30 AM, Nurse C verified the staff did not control the resident's pain, and should have administered as needed pain medication and/or notified the physician of the resident's uncontrolled pain. The facility's 6/2014 Pain Management policy instructed the staff that on-going pain would be monitored and documented with physician notification if the resident's medication was not effective. The facility failed to adequately provide effective pain management, assessment/ reassessment, and to notify the physician of ineffective pain management for Resident #2 after a fracture.

The facility had a census of 40 residents. The sample included 9 residents, of which 4 were reviewed for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of the 4 residents reviewed for accidents. Resident #33 sustained burns after spilling his/her hot coffee onto his/her lap. (#33) Findings included: - The 1/6/14 signed physician's orders [REDACTED]. The 1/6/14 physicians orders directed the staff to administer 0.25 (mg) milligrams of Requip (antiparkinsonian (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, forward flexion of the trunk, loss of postural reflexes and muscle rigidity and weakness) medication) daily to the resident. The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 1/1/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview of Mental Status score of 3 and required limited assistance with eating. The MDS further indicated the resident had a vision impairment and could only see large print. The 1/3/14 care plan directed the staff to use a roll and go chair (specialized rocking chair type wheelchair) pushed by staff, for the resident's mobility needs. The care plan further directed the staff to provide all (ADLs) Activities of Daily Living for the resident, the resident was to sit at the rehab table for meals, and indicated he/she fed himself/herself at times. The 1/3/14 care plan did not address Resident #33's hand tremors or supervision with hot liquids. The 1/13/14 at 4:48 PM, nurse's note indicated when the resident was sitting in the dining room alone at a regular table, Activity Staff H reported the resident had spilled his/her coffee on his/her lap. The staff assisted the resident to his/her room where staff removed his/her pants and observed a red area on both posterior upper, inner thighs. The staff also observed a blister the size of a quarter to the resident's upper right inner thigh and redness to the right lower buttocks. The nurse's note also indicated that as the night went on the blister had opened. The 1/13/14 at 11:47 PM, nurse's note indicated the staff would continue to monitor the resident's blisters from the coffee burn which occurred earlier that day, and provide treatment as ordered. The blisters to the resident's right inner groin/leg area x 4 at this time with 1 open. There is 1 blister noted to the resident's left inner groin/leg area. The 1/14/14 at 1:29 PM, nurse's note indicated the burn area on the resident's anterior right thigh, had one burn open and two with fluid filled blisters. The areas were measured and dressing applied. The burn area on the resident's upper inside left thigh was red without blisters present. The 1/13/14 at 4:20 PM, signed statement by Nurse Aide I, revealed he/she brought the resident to the table and provided him/her a cup of coffee. The 1/13/14 at 4:20 PM, signed statement from Activity Staff H, stated Resident #33 was sitting at a dining room table drinking coffee from a cup. Activity Staff H was walking past when the resident said "Oh, oh, oh, oh". On 1/13/14 at 12:10 PM, observation revealed the resident seated in the roll and go wheelchair in the activity room with his/her spouse for lunch. Observation revealed the resident attempting to eat independently and having slight hand tremors at times, with more noticeable jerking motions, causing him/her to drop his/her food from the spoon. On 1/14/14 at 10:15 AM, observation revealed Nurse J measuring the blisters to the resident's right and left groin area. Further observation revealed the resident had 3 blistered areas to his/her upper right groin/upper back thigh area. Observation revealed the top blister to be intact and measure 2.5 cm (centimeters) x 1.5 cm. The middle area open, not draining and measured 2 cm x 4 cm. The bottom blister measured 2 cm x 2 cm and was intact. The resident's left groin area revealed two areas that were bright red in color with the upper area measuring 2 cm x 5 cm and the lower area measuring 1 cm x 1.5 cm. Further observation revealed Nurse J applied triple antibiotic ointment and a loose gauze dressing to cover the area. On 1/15/14 at 7:44 AM observation revealed, Dietary Staff N, poured a cup of coffee from the coffee pot used to serve the residents. Further observation of Dietary Staff N revealed him/her obtaining the temperature of the coffee and the temperature to be 150 degree after being poured directly into the coffee cup. On 1/15/14 at 8:15 AM, observation revealed Nurse O removing the resident's dressing from his/ her upper right and left groin. The bottom blister to the resident's right groin/upper back thigh area is open and the burned areas are bright red. Nurse O reapplied the dressings to the open blister area, as well as the bright red areas. On 1/14/14 at 1:45 PM, Activity Staff H stated he/she turned around and was walking off and heard the resident say uh-oh. Activity Staff H stated the coffee cup, without a lid on, tipped part way over in the resident's hands and spilling onto his/her pants and the coffee was very warm when he/she touched it. On 1/15/14 at 10:30 AM, Nurse Aide K stated the resident should not be left unsupervised with a cup of hot liquid of any kind. On 1/14/14 at 1:50 PM, Nurse M stated staff should always supervise the residents at a table if staff served him/her hot liquids. Nurse M stated staff are suppose to put ice cubes in his/her coffee before we give it to him/her. On 1/14/14 at 10:00 AM, Administrative Nurse L stated it is a policy that staff put 2-3 ice cubes into the drinks of residents who are at risk for spilling hot liquids on themselves. He/she also verified that Resident #33 should not have been left alone with hot coffee. Administrative Nurse L verified the resident was not seated at the rehab table where he/she usually sat but staff seated him/her alone at a table where the independent residents eat. On 1/14/14 at 3:45 PM, Nurse P stated the physician started the resident on the Requip medication on 1/6/14 to help control his/her shaking. On 1/15/14 at 10:00 AM, Nurse O stated Resident #33 should not be left alone with a hot cup of coffee because he/she shakes and that might cause him/her to spill it. The resident also has dementia and sometimes forgets what he/she is doing. On 1/16/14 at 3:15 PM, Physician Q verified Resident #33 should not have been left alone with a hot cup of coffee. He/she further verified the resident did have tremors with occasional jerking motions and he/she had started him/her on Requip. The facility's August 2003 Hot Liquids policy, stated the facility will keep residents safe from burns when spilling hot liquids. When preparing hot liquids, staff will add 2-3 ice cubes for those in the assisted dining room and fill cups 2/3 full. The policy indicated that residents who eat in the main dining room rather than the assisted dining room will be served at the 160 degree temperature, and staff would monitor residents for decline, which would indicate the need to serve residents hot liquids at the 120 to 127 degree temperature. The facility failed to provide supervision or assistive devices to prevent accidents for Resident #33, who had hand tremors and sustained coffee burns to his/her thighs.